Analysis: Emergency care cost estimates are too low

Public release date: 29-Apr-2013
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Contact: David Orenstein
david_orenstein@brown.edu
401-863-1862
Brown University

PROVIDENCE, R.I. [Brown University] Alternately praised in the aftermath of horrible tragedies as a heroic service and lamented in policy debates as an expensive safety net for people without primary care, emergency medicine is often a hot topic. Despite that importance, an analysis published online April 26 in the Annals of Emergency Medicine finds that national expenditures on emergency care are likely significantly higher than previously thought.

"The ER has become increasingly important as a place where people go for acute unscheduled care, however there has been little rigorous analysis of its cost structure," said paper lead author Dr. Michael Lee, assistant professor of emergency medicine in the Warren Alpert Medical School of Brown University and a physician at Rhode Island Hospital and The Miriam Hospital.

Lee, who had a prior career in economics and finance before training in emergency medicine, co-wrote the analysis with Dr. Brian Zink, professor and chair of the Department of Emergency Medicine at the Alpert Medical School, and Dr. Jeremiah Schuur, assistant professor at Harvard Medical School and director of quality and patient safety for the Department of Emergency Medicine at the Brigham and Women's Hospital.

The challenge of properly accounting for the costs of emergency care, Lee said, becomes crucial as health care financing moves from a fee-for-service model to bundled payments for patient populations or episodes of care.

Clarifying costs

The analysis first examines current estimates of aggregate spending on emergency department (ED) care. The Agency for Healthcare Research and Quality's Medical Expenditure Panel Survey (MEPS) estimates $48.3 billion of spending on emergency care in 2010, or 1.9 percent of the nation's total health care expenditures of $2.6 trillion. With the message that "The total cost is small relative to the entire health care system," the American College of Emergency Physicians has embraced the AHRQ figure in its "Just 2 percent" public relations campaign.

But Lee and his co-authors point out, based on data from other studies, that MEPS undercounts the number of ED visits and the number of ED patients who are admitted to hospitals. Adjusting for those discrepancies using data from a variety of other published sources, the authors estimate that ED costs are between 4.9 percent to 5.8 percent of total health care spending.

The authors went beyond national data sets, including the National Emergency Department Sample, to review ED spending data from a different source: a major national private insurer. The data included charges from doctors and hospitals for imaging, testing, and other procedures. But again there were accounting differences between admitted and discharged patients and a need to account fully for spending from Medicare and Medicaid. The authors' estimate based on this data is ED spending that is 6.2 to 10 percent of total health care spending.

Much of the debate in the academic literature around the expense of ED care has to do with whether the bulk of costs are fixed (e.g., expensive equipment and continuous staffing) or marginal (e.g., flexible staff time, expendable supplies). According to Lee, the cost structure of the ED remains poorly understood and is significantly more complex than what is modeled in existing studies.

As with assessments of total costs, the authors report, the studies vary widely even after adjusting for inflation. Across four major studies over the last three decades, the average cost per patient of an ED visit in 2010 dollars ranged from only $134 to more than $1,000, Lee and colleagues found. Meanwhile, the marginal cost of an ED visit (factoring out the fixed costs), ranged from $150 to $638.

Alternative accounting

The authors instead argue for an accounting based approach to ED costs using a methodology known as "Time-Driven Activity Based Costing (ABC)," which has been applied to health care by Robert Kaplan and Michael Porter, professors at the Harvard Business School.

The method maps all clinical, administrative, and diagnostic steps in a patient encounter and assigns costs to each activity, explicitly accounting for the time spent on each task.

ABC accounting might provide a more realistic and transparent measure of ED costs, Lee said, because the emphasis on time is particularly relevant for emergency medicine.

"The real cost of providing emergency care has to do with accurately measuring the resources that are used, and time is an important variable to take into account," he said.

The authors envision using the methodology to measure the cost of common ED processes or chief complaints, and to compare this to alternative sites such as primary care offices or clinics, he said. They also point out that ABC accounting gives "gives ED managers specific data they can use to improve the value of care by identifying high-cost steps in the process."

Emphasize value, not just cost

The authors acknowledge that an outcome of their analysis reporting higher overall costs for emergency care, may invite further criticism that the expense of emergency care represents unnecessary, inefficient care.

"However, we offer a more sanguine interpretation the high share of spending affirms the importance of emergency medicine within the health care system," they wrote. "With 130 million visits, 28 percent of all acute care visits, and accounting for nearly half of all admissions, emergency medicine should be expected to represent a large share of health care spending."

And Lee cautions, based on other studies, that efforts by private and government payers to divert ER care may not lead to large aggregate savings.

"Diverting nonemergency care may simply shift costs onto primary care offices and clinics which may not have the infrastructure to accommodate a large volume of unscheduled care," Lee said.

Instead there may be more potential for cost savings by focusing on reducing unnecessary diagnostic testing in the ED or unnecessary admissions that originate from the ED.

Lee and his co-authors call for the debate to include value, not just cost.

"More attention should be devoted to quantifying the value of specific aspects of emergency care," they wrote. "Rather than minimize the issue of cost, we should recognize the economic and strategic importance of the ED within the healthcare system and demonstrate that costs are commensurate with value.

Lee acknowledges that this remains a challenge for the field of emergency medicine. "The core of our business is ruling out critical diagnoses. Many of the things we look for are low probability but highly dangerous conditions. The big question is how do you quantify value when your work is often focused on trying to demonstrate the absence of something?"

###

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AAAS and EurekAlert! are not responsible for the accuracy of news releases posted to EurekAlert! by contributing institutions or for the use of any information through the EurekAlert! system.

Public release date: 29-Apr-2013
[ | E-mail | Share ]

Contact: David Orenstein
david_orenstein@brown.edu
401-863-1862
Brown University

PROVIDENCE, R.I. [Brown University] Alternately praised in the aftermath of horrible tragedies as a heroic service and lamented in policy debates as an expensive safety net for people without primary care, emergency medicine is often a hot topic. Despite that importance, an analysis published online April 26 in the Annals of Emergency Medicine finds that national expenditures on emergency care are likely significantly higher than previously thought.

"The ER has become increasingly important as a place where people go for acute unscheduled care, however there has been little rigorous analysis of its cost structure," said paper lead author Dr. Michael Lee, assistant professor of emergency medicine in the Warren Alpert Medical School of Brown University and a physician at Rhode Island Hospital and The Miriam Hospital.

Lee, who had a prior career in economics and finance before training in emergency medicine, co-wrote the analysis with Dr. Brian Zink, professor and chair of the Department of Emergency Medicine at the Alpert Medical School, and Dr. Jeremiah Schuur, assistant professor at Harvard Medical School and director of quality and patient safety for the Department of Emergency Medicine at the Brigham and Women's Hospital.

The challenge of properly accounting for the costs of emergency care, Lee said, becomes crucial as health care financing moves from a fee-for-service model to bundled payments for patient populations or episodes of care.

Clarifying costs

The analysis first examines current estimates of aggregate spending on emergency department (ED) care. The Agency for Healthcare Research and Quality's Medical Expenditure Panel Survey (MEPS) estimates $48.3 billion of spending on emergency care in 2010, or 1.9 percent of the nation's total health care expenditures of $2.6 trillion. With the message that "The total cost is small relative to the entire health care system," the American College of Emergency Physicians has embraced the AHRQ figure in its "Just 2 percent" public relations campaign.

But Lee and his co-authors point out, based on data from other studies, that MEPS undercounts the number of ED visits and the number of ED patients who are admitted to hospitals. Adjusting for those discrepancies using data from a variety of other published sources, the authors estimate that ED costs are between 4.9 percent to 5.8 percent of total health care spending.

The authors went beyond national data sets, including the National Emergency Department Sample, to review ED spending data from a different source: a major national private insurer. The data included charges from doctors and hospitals for imaging, testing, and other procedures. But again there were accounting differences between admitted and discharged patients and a need to account fully for spending from Medicare and Medicaid. The authors' estimate based on this data is ED spending that is 6.2 to 10 percent of total health care spending.

Much of the debate in the academic literature around the expense of ED care has to do with whether the bulk of costs are fixed (e.g., expensive equipment and continuous staffing) or marginal (e.g., flexible staff time, expendable supplies). According to Lee, the cost structure of the ED remains poorly understood and is significantly more complex than what is modeled in existing studies.

As with assessments of total costs, the authors report, the studies vary widely even after adjusting for inflation. Across four major studies over the last three decades, the average cost per patient of an ED visit in 2010 dollars ranged from only $134 to more than $1,000, Lee and colleagues found. Meanwhile, the marginal cost of an ED visit (factoring out the fixed costs), ranged from $150 to $638.

Alternative accounting

The authors instead argue for an accounting based approach to ED costs using a methodology known as "Time-Driven Activity Based Costing (ABC)," which has been applied to health care by Robert Kaplan and Michael Porter, professors at the Harvard Business School.

The method maps all clinical, administrative, and diagnostic steps in a patient encounter and assigns costs to each activity, explicitly accounting for the time spent on each task.

ABC accounting might provide a more realistic and transparent measure of ED costs, Lee said, because the emphasis on time is particularly relevant for emergency medicine.

"The real cost of providing emergency care has to do with accurately measuring the resources that are used, and time is an important variable to take into account," he said.

The authors envision using the methodology to measure the cost of common ED processes or chief complaints, and to compare this to alternative sites such as primary care offices or clinics, he said. They also point out that ABC accounting gives "gives ED managers specific data they can use to improve the value of care by identifying high-cost steps in the process."

Emphasize value, not just cost

The authors acknowledge that an outcome of their analysis reporting higher overall costs for emergency care, may invite further criticism that the expense of emergency care represents unnecessary, inefficient care.

"However, we offer a more sanguine interpretation the high share of spending affirms the importance of emergency medicine within the health care system," they wrote. "With 130 million visits, 28 percent of all acute care visits, and accounting for nearly half of all admissions, emergency medicine should be expected to represent a large share of health care spending."

And Lee cautions, based on other studies, that efforts by private and government payers to divert ER care may not lead to large aggregate savings.

"Diverting nonemergency care may simply shift costs onto primary care offices and clinics which may not have the infrastructure to accommodate a large volume of unscheduled care," Lee said.

Instead there may be more potential for cost savings by focusing on reducing unnecessary diagnostic testing in the ED or unnecessary admissions that originate from the ED.

Lee and his co-authors call for the debate to include value, not just cost.

"More attention should be devoted to quantifying the value of specific aspects of emergency care," they wrote. "Rather than minimize the issue of cost, we should recognize the economic and strategic importance of the ED within the healthcare system and demonstrate that costs are commensurate with value.

Lee acknowledges that this remains a challenge for the field of emergency medicine. "The core of our business is ruling out critical diagnoses. Many of the things we look for are low probability but highly dangerous conditions. The big question is how do you quantify value when your work is often focused on trying to demonstrate the absence of something?"

###

---

[ | E-mail | Share ]

?

AAAS and EurekAlert! are not responsible for the accuracy of news releases posted to EurekAlert! by contributing institutions or for the use of any information through the EurekAlert! system.

Source: http://www.eurekalert.org/pub_releases/2013-04/bu-aec042913.php

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Colossal hot cloud envelopes colliding galaxies

Apr. 30, 2013 ? Scientists have used Chandra to make a detailed study of an enormous cloud of hot gas enveloping two large, colliding galaxies. This unusually large reservoir of gas contains as much mass as 10 billion Suns, spans about 300,000 light years, and radiates at a temperature of more than 7 million degrees.

This giant gas cloud, which scientists call a "halo," is located in the system called NGC 6240. Astronomers have long known that NGC 6240 is the site of the merger of two large spiral galaxies similar in size to our own Milky Way. Each galaxy contains a supermassive black hole at its center. The black holes are spiraling toward one another, and may eventually merge to form a larger black hole.

Another consequence of the collision between the galaxies is that the gas contained in each individual galaxy has been violently stirred up. This caused a baby boom of new stars that has lasted for at least 200 million years. During this burst of stellar birth, some of the most massive stars raced through their evolution and exploded relatively quickly as supernovas.

The scientists involved with this study argue that this rush of supernova explosions dispersed relatively high amounts of important elements such as oxygen, neon, magnesium, and silicon into the hot gas of the newly combined galaxies. According to the researchers, the data suggest that this enriched gas has slowly expanded into and mixed with cooler gas that was already there.

During the extended baby boom, shorter bursts of star formation have occurred. For example, the most recent burst of star formation lasted for about five million years and occurred about 20 million years ago in Earth's timeframe. However, the authors do not think that the hot gas was produced just by this shorter burst.

What does the future hold for observations of NGC 6240? Most likely the two spiral galaxies will form one young elliptical galaxy over the course of millions of years. It is unclear, however, how much of the hot gas can be retained by this newly formed galaxy, rather than lost to surrounding space. Regardless, the collision offers the opportunity to witness a relatively nearby version of an event that was common in the early Universe when galaxies were much closer together and merged more often.

In this new composite image of NGC 6240, the X-rays from Chandra that reveal the hot gas cloud are colored purple. These data have been combined with optical data from the Hubble Space Telescope, which shows long tidal tails from the merging galaxies, extending to the right and bottom of the image.

A paper describing these new results on NGC 6240 is available online and appeared in the March 10, 2013 issue of The Astrophysical Journal. The authors in this study were Emanuele Nardini (Harvard-Smithsonian Center for Astrophysics, or CfA, Cambridge, MA and currently at Keele University, UK), Junfeng Wang (CfA and currently at Northwestern University, Evanston, IL), Pepi Fabbiano (CfA), Martin Elvis (CfA), Silvia Pellegrini (University of Bologna, Italy), Guido Risalti (INAF-Osservatorio Astrofisico di Arcetri, Italy and CfA), Margarita Karovska (CfA), and Andreas Zezas (University of Crete, Greece and CfA).

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Story Source:

The above story is reprinted from materials provided by Chandra X-ray Observatory.

Note: Materials may be edited for content and length. For further information, please contact the source cited above.

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Journal Reference:

1. Emanuele Nardini, Junfeng Wang, Giuseppina Fabbiano, Martin Elvis, Silvia Pellegrini, Guido Risaliti, Margarita Karovska, Andreas Zezas. The Exceptional Soft X-ray Halo of the Galaxy Merger NGC 6240. The Astrophysical Journal, March 10, 2013 DOI: http://arxiv.org/abs/1301.5907

Note: If no author is given, the source is cited instead.

Disclaimer: Views expressed in this article do not necessarily reflect those of ScienceDaily or its staff.

Source: http://feeds.sciencedaily.com/~r/sciencedaily/top_news/~3/e1pM4S1vtDI/130430151549.htm

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Cern to re-create first web page

30 April 2013 Last updated at 03:09 ET By Pallab Ghosh Science correspondent, BBC News, Cern

A team at the European Organisation for Nuclear Research (Cern) has launched a project to re-create the first web page.

The aim is to preserve the original hardware and software associated with the birth of the web.

The world wide web was developed by Prof Sir Tim Berners-Lee while working at Cern.

The initiative coincides with the 20th anniversary of the research centre giving the web to the world.

Continue reading the main story

?Start Quote

I want my children to be able to understand the significance of this point in time: the web is already so ubiquitous - so, well, normal - that one risks failing to see how fundamentally it has changed?

End Quote Dan Noyes Cern web manager

According to Dan Noyes, the web manager for Cern's communication group, re-creation of the world's first website will enable future generations to explore, examine and think about how the web is changing modern life.

"I want my children to be able to understand the significance of this point in time: the web is already so ubiquitous - so, well, normal - that one risks failing to see how fundamentally it has changed," he told BBC News

"We are in a unique moment where we can still switch on the first web server and experience it. We want to document and preserve that".

The hope is that the restoration of the first web page and web site will serve as a reminder and inspiration of the web's fundamental values.

At the heart of the original web is technology to decentralise control and make access to information freely available to all. It is this architecture that seems to imbue those that work with the web with a culture of free expression, a belief in universal access and a tendency toward decentralising information.

Subversive

It is the early technology's innate ability to subvert that makes re-creation of the first website especially interesting.

While I was at Cern it was clear in speaking to those involved with the project that it means much more than refurbishing old computers and installing them with early software: it is about enshrining a powerful idea that they believe is gradually changing the world.

I went to Sir Tim's old office where he worked at Cern's IT department trying to find new ways to handle the vast amount of data the particle accelerators were producing.

I was not allowed in because apparently the present incumbent is fed up with people wanting to go into the office.

But waiting outside was someone who worked at Cern as a young researcher at the same time as Sir Tim. James Gillies has since risen to be Cern's head of communications. He is occasionally referred to as the organisation's half-spin doctor, a reference to one of the properties of some sub-atomic particles.

Amazing dream

Mr Gillies is among those involved in the project. I asked him why he wanted to restore the first website.

"One of my dreams is to enable people to see what that early web experience was like," was the reply.

"You might have thought that the first browser would be very primitive but it was not. It had graphical capabilities. You could edit into it straightaway. It was an amazing thing. It was a very sophisticated thing."

Continue reading the main story

?Start Quote

One of my dreams is to enable people to see what that early web experience was like... It was an amazing thing?

End Quote James Gillies Co-author, How the Web Was Born

Those not heavily into web technology may be sceptical of the idea that using a 20-year-old machine and software to view text on a web page might be a thrilling experience.

But Mr Gillies and Mr Noyes believe that the first web page and web site is worth resurrecting because embedded within the original systems developed by Sir Tim are the principles of universality and universal access that many enthusiasts at the time hoped would eventually make the world a fairer and more equal place.

The first browser, for example, allowed users to edit and write directly into the content they were viewing, a feature not available on present-day browsers.

Ideals eroded

And early on in the world wide web's development, Nicola Pellow, who worked with Sir Tim at Cern on the www project, produced a simple browser to view content that did not require an expensive powerful computer and so made the technology available to anyone with a simple computer.

According to Mr Noyes, many of the values that went into that original vision have now been eroded. His aim, he says, is to "go back in time and somehow preserve that experience".

"This universal access of information and flexibility of delivery is something that we are struggling to re-create and deal with now.

"Present-day browsers offer gorgeous experiences but when we go back and look at the early browsers I think we have lost some of the features that Tim Berners-Lee had in mind."

Mr Noyes is reaching out to ask those who were involved in the NeXT computers used by Sir Tim for advice on how to restore the original machines.

Awe

The machines were the most advanced of their time. Sir Tim used two of them to construct the web. One of them is on show in an out-of-the-way cabinet outside Mr Noyes's office.

I told him that as I approached the sleek black machine I felt drawn towards it and compelled to pause, reflect and admire in awe.

"So just imagine the reaction of passers-by if it was possible to bring the machine back to life," he responded, with a twinkle in his eye.

The initiative coincides with the 20th anniversary of Cern giving the web away to the world free.

Continue reading the main story

?Start Quote

Keeping the web free and freely available is almost a human right?

End Quote Prof Nigel Shadbolt Southampton University

There was a serious discussion by Cern's management in 1993 about whether the organisation should remain the home of the web or whether it should focus on its core mission of basic research in physics.

Sir Tim and his colleagues on the project argued that Cern should not claim ownership of the web.

Great giveaway

Management agreed and signed a legal document that made the web publicly available in such a way that no one could claim ownership of it and that would ensure it was a free and open standard for everyone to use.

Mr Gillies believes that the document is "the single most valuable document in the history of the world wide web".

He says: "Without it you would have had web-like things but they would have belonged to Microsoft or Apple or Vodafone or whoever else. You would not have a single open standard for everyone."

The web has not brought about the degree of social change some had envisaged 20 years ago. Most web sites, including this one, still tend towards one-way communication. The web space is still dominated by a handful of powerful online companies.

But those who study the world wide web, such as Prof Nigel Shadbolt, of Southampton University, believe the principles on which it was built are worth preserving and there is no better monument to them than the first website.

"We have to defend the principle of universality and universal access," he told BBC News.

"That it does not fall into a special set of standards that certain organisations and corporations control. So keeping the web free and freely available is almost a human right."

Follow Pallab Ghosh on Twitter @bbcpallab

Source: http://www.bbc.co.uk/news/technology-22249490#sa-ns_mchannel=rss&ns_source=PublicRSS20-sa

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How does pregnancy reduce breast cancer risk?

Monday, April 29, 2013

Being pregnant while young is known to protect a women against breast cancer. But why? Research in BioMed Central's open access journal Breast Cancer Research finds that Wnt/Notch signalling ratio is decreased in the breast tissue of mice which have given birth, compared to virgin mice of the same age.

Early pregnancy is protective against breast cancer in humans and in rodents. In humans having a child before the age of 20 decreases risk of breast cancer by half. Using microarray analysis researchers from Basel discovered that genes involved in the immune system and differentiation were up-regulated after pregnancy while the activity of genes coding for growth factors was reduced.

The activity of one particular gene Wnt4 was also down-regulated after pregnancy. The protein from this gene (Wnt4) is a feminising protein - absence of this protein propels a foetus towards developing as a boy. Wnt and Notch are opposing components of a system which controls cellular fate within an organism and when the team looked at Notch they found that genes regulated by notch were up-regulated, Notch-stimulating proteins up-regulated and Notch-inhibiting proteins down-regulated.

Wnt/Notch signalling ratio was permanently altered in the basal stem/progenitor cells of mammary tissue of mice by pregnancy. Mohamed Bentires-Alj from the Friedrich Miescher Institute for Biomedical Research, who led this study explained, "The down-regulation of Wnt is the opposite of that seen in many cancers, and this tightened control of Wnt/Notch after pregnancy may be preventing the runaway growth present in cancer."

###

Parity induces differentiation and reduces Wnt/Notch signaling ratio and proliferation potential of basal stem/progenitor cells isolated from mouse mammary epithelium

Fabienne Meier-Abt, Emanuela Milani, Tim Roloff, Heike Brinkhaus, Stephan Duss, Dominique S Meyer, Ina Klebba, Piotr J Balwierz, Erik van Nimwegen and Mohamed Bentires-Alj

Breast Cancer Research (in press)

BioMed Central: http://www.biomedcentral.com

Thanks to BioMed Central for this article.

This press release was posted to serve as a topic for discussion. Please comment below. We try our best to only post press releases that are associated with peer reviewed scientific literature. Critical discussions of the research are appreciated. If you need help finding a link to the original article, please contact us on twitter or via e-mail.

This press release has been viewed 28 time(s).

Source: http://www.labspaces.net/127977/How_does_pregnancy_reduce_breast_cancer_risk_

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Karzai?s ?ghost money??he warned us in 2008

Afghan President Hamid Karzai and Finnish Prime Minister Jyrki Katainen in Helsinki on April 29. (Martti Kainu??Word that the CIA gave Afghan President Hamid Karzai's office tens of millions of dollars in cash over a decade is a weird blend of shocking and entirely unsurprising. After all, when it comes to dollars, Karzai made his goals pretty clear as far back as December 2008.

The New York Times reported Monday that the CIA dropped suitcases, backpacks and shopping bags full of money for Karzai in a bid to purchase influence. The cash instead helped fuel Afghanistan?s raging corruption epidemic and empowered warlords, the Times said.

"The biggest source of corruption in Afghanistan," one American official said, "was the United States." (Karzai recently said that, too.)

But here?s Karzai, letting everyone in on the plan during a joint December 2008 press conference in Kabul with then-President George W. Bush.

Karzai had been asked by Steven Lee Myers of The New York Times whether he hoped for a withdrawal timetable?a date certain when American troops would be gone.

Afghanistan won't let the "international community" leave "before we are fully on our feet, before we are strong enough to defend our country, before we are powerful enough to have a good economy, and before we have taken from President Bush and the next administration billions and billions of more dollars,? Karzai said. The transcript records ?(laughter),? but it was more awkward and disbelieving than appreciative. ?No way that they can let you go,? Karzai added. A joke? Half-joke? Moment of candor?

Bush?s response? ?Yes, you better hurry up, in my case.?

Source: http://news.yahoo.com/blogs/ticket/karzai-ghost-money-warned-us-2008-161728884.html

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Pakistan Taliban bomb politicians' offices, kill 9

PARACHINAR, Pakistan (AP) ? Pakistani Taliban detonated bombs at the campaign offices of two politicians in the country's northwest on Sunday, police said, killing at least nine people in an escalation of attacks on secular, left-leaning political parties.

In first attack, on the outskirts of Kohat city, a bomb ripped through the office of Syed Noor Akbar, killing six and wounding 10 people, police official Mujtaba Hussain said.

A second bomb targeted a campaign office of another candidate, Nasir Khan Afridi, in the suburbs of Peshawar city. That attack killed three people and wounded 12, police official Saifur Rehman Khan said.

Both politicians, who were not in the offices at the time of the blasts, are running as independent candidates for national assembly seats to represent constituencies in Pakistan's lawless tribal areas, where scores of militant groups operate including some with links to al-Qaida. The general elections will be held on May 11.

Pakistani Taliban spokesman Ahsanullah Ahsan claimed responsibility for both attacks, as well as two others against secular political parties in the southern port city of Karachi.

"We are against all politicians who are going to become part of any secular, democratic government," he told The Associated Press by telephone from an undisclosed location.

The Taliban previously announced a strategy to target three political parties, including the Awami National Party (ANP), the Muttahida Quami Movement (MQM) and the Pakistan People's Party (PPP). All three are perceived as liberal, having earned the Taliban's ire by opposing the insurgency and extremism during their time in the outgoing government.

The onslaught has forced many of the parties to change their campaign strategy and has raised questions about whether the vote can be considered valid if some mainstream parties can't properly take part.

Such attacks have killed at least 28 people in just last four days.

One of the most serious attacks occurred on April 21, when a suicide bomber blew himself up outside a meeting of the ANP in the northwestern city of Peshawar, killing 16 people. The Taliban said the target of the attack was Haroon Ahmad Bilour, whose father, a senior party leader, was killed in a suicide bombing in Peshawar in December. He escaped unscathed, but his uncle, Ghulam Ahmad Bilour, suffered minor injuries.

In the capital, Islamabad, Pakistani officials said they planned to seal the border with Afghanistan and restrict the movement of Afghan refugees on election day.

Officials at the Interior Ministry and the election commission have said that the measure is aimed at preventing terrorist attacks during the vote. However, officials did not say how they would restrict the movement of hundreds of thousands of people spread out across the country or block crossings along the porous border. Pakistan announced similar measures in the past but failed to take action.

The officials spoke on condition of anonymity because they were not authorized to brief reporters.

The Islamist and center-right political parties have been spared by the Taliban and have been holding big public rallies without fear of being attacked. They largely support peace talks with the Taliban instead of military offensives.

The leaders of the political parties under Taliban attack have said the violence amounts to election rigging. But they have, so far, decided not to boycott the vote.

____

Associated Press Writers Riaz Khan and Rasool Dawar in Peshawar contributed to this report.

Source: http://news.yahoo.com/pakistan-taliban-bomb-politicians-offices-kill-9-125711860.html

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Rolling Stones To Play Echo Park's Echoplex In Secret Show - Echo Park-Silver-Lake, CA Patch

echopark.patch.com:

This is not a joke.

The Rolling Stones will play the Echoplex in Echo Park Saturday night. Owner Mitchell Frank says the show will begin at 9 p.m., with access extremely limited. The LA Weekly says capacity is 700.

Read the whole story at echopark.patch.com

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Filed by Sasha Bronner ?|?

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1. HuffPost
2. Los Angeles

?

Source: http://www.huffingtonpost.com/2013/04/27/rolling-stones-to-play-ec_n_3171829.html

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World markets climb on central bank expectations

SEOUL, South Korea (AP) ? World stock markets mostly rose Monday as weaker-than-expected U.S. growth added to expectations that central banks will continue easy monetary policies to support economic recovery.

In early European trading, Britain's FTSE 100 was up 0.1 percent at 6,433.02 and Germany's DAX added 0.6 percent to 7,862.89. France's CAC 40 rose 0.8 percent to 3,839.31.

Futures augured gains on Wall Street. Dow futures rose 0.3 percent to 14,694 and S&P 500 futures advanced 0.3 percent to 1,581.60.

The U.S. government said Friday that world's largest economy expanded 2.5 percent in the first quarter over a year earlier, falling short of expectations of 3 percent growth and compounding worries about the strength of global growth.

The report came after Japan said its consumer prices fell 0.9 percent in March, underlining challenges to the government's efforts to pull the economy out of a long spell of debilitating deflation. Earlier this month, China reported a slowdown in growth for the first quarter.

The downbeat reports were tempered by expectations the European Central Bank will either lower interest rates or expand financial support for the 17-country euro area at its meeting Thursday, said Lim Ho-sang, a Seoul-based economist at Samsung Futures. The U.S. growth figure also reinforced the view that the Federal Reserve won't rush to end its current policy of record low interest rates.

The easy money polices of central banks have boosted stock markets because returns on bonds and other fixed interest assets are at low levels.

In Asia, Australia's S&P/ASX 200 gained 0.6 percent to 5,125.80 and Hong Kong's Hang Seng edged up 0.3 percent to 22,580.77. South Korea's Kospi lost 0.2 percent to 1,940.70. Markets in mainland China and Japan were closed for holidays.

Investors are also waiting for more data to better assess the health of the U.S. private sector as the weaker-than-expected growth of the U.S. economy largely stemmed from lower government spending. U.S. March housing sales and April employment figures are scheduled to be released this week.

Benchmark oil for June delivery was up 15 cents to $93.16 per barrel in electronic trading on the New York Mercantile Exchange. The contract fell 64 cents to $93 a barrel on Friday.

In currencies, the euro rose to $1.3090 from $1.3029. The dollar fell to 97.69 yen from 98.03 yen.

Associated Press

Source: http://hosted2.ap.org/APDEFAULT/f70471f764144b2fab526d39972d37b3/Article_2013-04-29-APFN-World%20Markets/id-b77f7994ff0549a4a691e2f9fc573f5a

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NBA vet Jason Collins is first openly gay player in U.S. sports

(Refiling to add additional codes)

* NBA Commissioner praises Collins for breaking barrier

* Free agent Collins says hopes to find a new team

By Julian Linden

April 29 (Reuters) - Jason Collins, a veteran center in the National Basketball Association (NBA), announced on Monday that he was gay, becoming the first active player from any U.S. professional sports league to publicly reveal his homosexuality.

Collins, a free agent who played with the Washington Wizards and Boston Celtics during the NBA's 2012-13 regular season, made the announcement in an interview with Sports Illustrated that was published on Monday.

"I didn't set out to be the first openly gay athlete playing in a major American team sport. But since I am, I'm happy to start the conversation," he said.

"I wish I wasn't the kid in the classroom raising his hand and saying, 'I'm different.' If I had my way, someone else would have already done this. Nobody has, which is why I'm raising my hand."

In the ultra-scrutinized world of U.S. professional sports, there had never been an openly gay player in any of America's major professional sports leagues, although some had revealed their sexual orientation after retiring.

In a country with openly gay politicians, entertainers and even soldiers, professional sports had become a final frontier and questions were being asked why sports, which helped play a key role in changing public opinion on racial discrimination, was out of step with the rest of American society.

Former U.S. President Bill Clinton, whose daughter Chelsea was a classmate of Collins at Stanford University, applauded Collins for coming out.

"Jason's announcement today is an important moment for professional sports and in the history of the LGBT community," Clinton said in a statement.

"It is also the straightforward statement of a good man who wants no more than what so many of us seek: to be able to be who we are; to do our work; to build families and to contribute to our communities. For so many members of the LGBT (lesbian, gay, bisexual, transgender) community, these simple goals remain elusive.

"I hope that everyone, particularly Jason's colleagues in the NBA, the media and his many fans extend to him their support and the respect he has earned."

NBA Commissioner David Stern also praised Collins for breaking the barrier.

"Jason has been a widely respected player and teammate throughout his career and we are proud he has assumed the leadership mantle on this very important issue," Stern said in a statement.

Collins, 34, has played for six NBA teams since entering the league in 2001 and twice appeared in the playoffs. He said he wants to continue playing and hopes to find a new team.

It had seemed like only matter of time until an active player said he was gay after the issue had become one of the hottest topics in North America, no more so than in the National Football League (NFL), the most macho of America's pro sports.

In the days leading up to this year's Super Bowl in New Orleans, San Francisco 49ers cornerback Chris Culliver told reporters he would not welcome a homosexual teammate into the locker room.

He later retracted his comments but reports have since emerged of NFL teams asking college players about their sexuality at a scouting combine in February.

This prompted the New York State attorney general to send a letter to the NFL, urging the league to take action and adopt a formal policy of sexual discrimination.

Culliver's comments are not typical of the attitude of all professional sportsmen. Indeed, there are several high-profile NFL players, most notably Chris Kluwe and Brendon Ayanbadejo, who have advocated for gay rights.

Both believe it was only a matter of time before a professional player came out publicly. (Reporting by Julian Linden in New York; Editing by Frank Pingue)

Source: http://news.yahoo.com/nba-collins-comes-first-openly-gay-player-u-154748772.html

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PFT: 'Phins owner blames Sparano for dysfunction

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After analyzing?the draft needs of all 32 teams, PFT will review how well each team addressed those needs. Up next: The Oakland Raiders.?

What?they?needed: Defensive line, quarterback, offensive line, cornerback, tight end, wide receiver.

Who they got:
Round 1: D.J. Hayden, CB, Houston.
Round 2: Menelik Watson, OT, Florida State.
Round 3: Sio Moore, LB, Connecticut.
Round 4: Tyler Wilson, QB, Arkansas.
Round 6: Nick Kasa, TE, Colorado.
Round 6: Latavius Murray, RB, UCF.
Round 6: Mychal Rivera, TE, Tennessee.
Round 6: Stacy McGee, DT, Oklahoma.
Round 7: Brice Butler, WR, San Diego State.
Round 7: David Bass, DE, Missouri Western.

Where they hit: Hayden, who survived a freakish life-threatening internal injury suffered in November, could be the Raiders? top cornerback in short order. With the second-rounder acquired from Miami, the Raiders added Watson, a tackle prospect with upside. Moore is a good scheme fit, and Wilson could prove a very good value if he plays to his best collegiate form.

Where they missed: The Raiders didn?t draft a defensive lineman until Round Six. There?s playing time to be had for ends Bass and Jack Crawford (2012 fifth-rounder) and tackles McGee and Christo Bilukidi (2012 sixth-rounder) behind the Raiders? veteran starters, but Oakland could use a little more help at both line positions. In McKenzie?s defense, the Raiders have numerous needs, and on first analysis, he did quite well to add talent and depth in this draft.

Impact rookies: Given the state of the Raiders? roster, all 10 drafted rookies have a chance to make the team, and several could earn game-day snaps of consequence in Year One. Hayden has the best shot to start. He should compete with Tracy Porter and Mike Jenkins right off the bat. Moore is also a player to watch; the Raiders have revamped their LB corps this offseason but don?t have any standouts. A talented fresh face has a chance to make an impact early at this position. Watson?s best opportunity to start in 2013 is at right tackle, but that?s no sure thing, given his lack of experience. Rivera is a potential sleeper, given the Raiders? lack of a clear-cut top target at tight end after the departure of Brandon Myers. Murray also is an interesting addition; can he challenge backup Rashad Jennings for snaps? And then we come to Wilson. Matt Flynn will get first run at the starting job, and Wilson will have to be a quick study to beat out him and Terrelle Pryor for playing time. However, it?s not out of the realm of possibility.

Long-term prospects: Watson is talented enough to play in Year One if he quickly develops, but his best football could be down the road.?If Wilson doesn?t win the starting job in 2013, the question becomes whether he shows enough to be one of the primary contenders or the heir apparent in 2014. The Raiders used a mere fourth-round pick on him, so he?s going to have to show at least a little promise in Year One. Kasa is a converted defensive end who could need some time to continue learning the TE position.

Source: http://profootballtalk.nbcsports.com/2013/04/27/ross-blames-sparano-for-dolphins-dysfunction/related/

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Spotify Quietly Starts Rolling Out The Discover Tab In Its Web App In The UK And Nordic Markets

Back in December 2012, music streaming service Spotify provided an update on how it was going to double down on social recommendations to increase music listening on its platform by launching two new features, Follow and Discover. While the Follow feature, aimed at friends, started to get rolled out in March and April, it turns out that Spotify has also been rolling out the Discover feature, too.

Source: http://feedproxy.google.com/~r/Techcrunch/~3/Ao4VYFaow1Q/

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Gunmen surround Libya Foreign Ministry

TRIPOLI, Libya (AP) ? A Libyan military official says about 200 armed men are surrounding the Foreign Ministry building in Tripoli, demanding the ministry to reform and hire former fighters who helped overthrow former dictator Moammar Gadhafi.

Esam al-Naas said 38 trucks, some mounted with machineguns, had surrounded the ministry on Sunday. The men allege that many supporters of the old regime are still occupying senior positions in the ministry and its missions abroad.

He said negotiations with the protesters are underway and that no one has entered the ministry building.

Associated Press

Source: http://hosted2.ap.org/APDEFAULT/cae69a7523db45408eeb2b3a98c0c9c5/Article_2013-04-28-ML-Libya/id-a0e0219e6e6c4f8b8a695485454d0937

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SMALL-BUSINESS SPOTLIGHT: Bid of History, Chesterton ? The ...

CHESTERTON | The name, Bid of History, tells the story.

Robert Zahkar and Vince Kisala?s business, an in-house and online auction house, handles property from estates, of collectors or just those who need to dispose of items they no longer want or need. Auctions are held live at the seller?s premises, at the auction house or online.

The latter is what sets them apart from their local competitors.

?We wanted to do something different,? said Vince Kisala, the owner of an eBay store in Chesterton. ?We decided to be a high-tech house.?

The partners opened the business in December after almost a year of preparation that included renovating a commercial building owner by Zakhar and earning state certifications as auctioneers.

?We went to Indianapolis in February (2012) for 10 days to auctioneering school,? Kisala said. ?It was a lot more involved than either of us thought. Indiana is very strict. We had 90 hours of schooling, passed three exams inside the school and had to go to the Indiana State building to pass the final certification test. We both passed and got our licenses in March (2012.)?

Besides renovating the building at a cost of $275,000, the men spent another $200,000 buying the computer system that allows them to video and audio stream their auctions live via the internet.

The partners and their appraisers evaluate each item

We recommend you visit the following site for more complete information and related topics. Article source: http://www.nwitimes.com/business/local/small-business-spotlight-bid-of-history-chesterton/article_c9818c34-b914-57bf-99cb-f00a6e577a4c.html

Source: http://leomoo.com/2013/04/small-business-spotlight-bid-of-history-chesterton-the-times/

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Koyim bisiklete: Structured settlement

A?structured settlement?is a?financial?or?insurance?arrangement, defined by Internal Revenue Code as periodic payments; a claimant accepts to resolve a personal injury?tort?claim or to compromise a statutory periodic payment obligation. Structured settlements were first utilized in?Canada?after a settlement for children affected by?Thalidomide.^[1]?Structured settlements are widely used in product liability or injury cases (such as the birth defects from Thalidomide). Benefits of a structured settlement can be to reduce legal and other costs by avoiding trial.?^[2]?Structured settlement cases became more popular in the United States during the 1970s as an alternative to?lump sumsettlements.^[3]?The increased popularity was also due to several rulings by the IRS, an increase in?personal injury?awards, and higher interest rates. The IRS rulings changed policies such that if the requirements were met then claimants could have federal income tax waived.^[4]?Higher interest rates resulted in lower?present values, hence annuity premiums, for deferred payments versus a lump sum. Structured settlements have become part of the statutory tort law of several?common law?countries including Australia, Canada, England and the United States. Structured settlements may include?income tax?and spendthrift requirements as well as benefits and are considered to be an?asset-backed security.^[5]?Often the periodic payment will be created through the purchase of one or more?annuities, which guarantee the future payments.^[6]?Structured settlement payments are sometimes called periodic payments and when incorporated into a trial judgment is called a ?periodic payment judgment."

In the United States

The United States has enacted structured settlement laws and regulations at both the federal and state levels. Federal structured settlement laws include sections of the (federal)?Internal Revenue Code.^[7]?State structured settlement laws include structured settlement protection statutes and periodic payment of judgment statutes. Forty-seven of the states have structured settlement protection acts created using a model promulgated by the National Conference of Insurance Legislations ("NCOIL"). Of the 47 states, 37 are based in whole or in part on the NCOIL model act.?Medicaid?and?Medicare?laws and regulations affect structured settlements. To preserve a claimant?s Medicare and Medicaid benefits, structured settlement payments may be incorporated into ?Medicare Set Aside Arrangements? ?Special Needs Trusts." Structured settlements have been endorsed by many of the nation's largest disability rights organizations, including the American Association of People with Disabilities?^[8]?and the National Organization on Disability.^[9]

Definitions

Congress adopted special tax rules in Public Law 97-473, the?Periodic Payment Settlement Tax Act of 1982?to encourage the use of structured settlements to provide long-term financial security to seriously injured victims and their families. These structured settlement rules, as codified in sections 104(a)(2) and 130 of the Internal Revenue Code of 1986, 26 U.S.C. 104(a)(2) and 130, have been in place working effectively since then. In the Taxpayer Relief Act of 1997, Congress extended the structured settlements to worker?s compensation to cover physical injuries suffered in the workplace. A ?structured settlement? under the tax code's terms is an "arrangement" that meets the following requirements:

The structured settlement tax rules enacted by Congress lay down a bright line path for a structured settlement. Once the plaintiff and defense have settled the tort claim in exchange for periodic payments to be made by the defendant, the full amount of the periodic payments constitutes tax-free damages to the victim. The defendant then may assign its periodic payment obligation to a structured settlement assignment company (typically a single purpose affiliate of a life insurer) that funds its assumed obligation with an annuity purchased from its affiliated life insurer. The rules also permit the assignee to fund its periodic payment obligation under the structured settlement via U.S. Treasury obligations. However, this U.S. Treasury obligation approach is used much less frequently because of lower returns and the relative inflexibility of payment schedules available under Treasury obligations. In this way, the defense can close its books on the liability, and the claimant can receive the long-term financial security of an annuity issued by a financially strong life insurance company.

To qualify for special tax treatment, a structured settlement must meet the following requirements:

• A structured settlement must be established by:
  • A suit or agreement for periodic payment of damages excludable from gross income under Internal Revenue Code Section 104(a)(2) (26 U.S.C.???104(a)(2)); or
  • An agreement for the periodic payment of compensation under any workers? compensation law excludable under Internal Revenue Code Section 104(a)(1) (26 U.S.C.???104(a)(1)); and
• The periodic payments must be of the character described in subparagraphs (A) and (B) of Internal Revenue Code Section 130(c)(2) (26 U.S.C.???130(c)(2))) and must be payable by a person who:
  • Is a party to the suit or agreement or to a workers' compensation claim; or
  • By a person who has assumed the liability for such periodic payments under a qualified assignment in accordance with Internal Revenue Code Section 130 (26 U.S.C.???130).

[edit]Legal Structure

The typical structured settlement arises and is structured as follows: An injured party (the claimant) settles a?tort?suit with the defendant (or its insurance carrier) pursuant to a settlement agreement that provides that, in exchange for the claimant's securing the dismissal of the lawsuit, the defendant (or, more commonly, its insurer) agrees to make a series of periodic payments over time.^[10]?The defendant, or the property/casualty insurance company, thus finds itself with a long-term payment obligation to the claimant. To fund this obligation, the property/casualty insurer generally takes one of two typical approaches: It either purchases an?annuity?from a life insurance company (an arrangement called a "buy and hold" case) or it assigns (or, more properly, delegates) its periodic payment obligation to a third party ("assigned case") which in turn purchases a "qualified funding asset" to finance the assigned periodic payment obligation. Pursuant to IRC 130(d) a "qualified funding asset" may be an annuity or an obligation of the United States government. In an unassigned case, the defendant or property/casualty insurer retains the periodic payment obligation and funds it by purchasing an annuity from a life insurance company, thereby offsetting its obligation with a matching asset. The payment stream purchased under the annuity matches exactly, in timing and amounts, the periodic payments agreed to in the settlement agreement. The defendant or property/casualty company owns the annuity and names the claimant as the payee under the annuity, thereby directing the annuity issuer to send payments directly to the claimant. If any of the periodic payments are life-contingent (i.e., the obligation to make a payment is contingent on someone continuing to be alive), then the claimant (or whoever is determined to be the measuring life) is named as the annuitant or measuring life under the annuity. In some instances the purchasing company may purchase a life insurance policy as a hedge in case of death in a settlement transfer.^[11]

In an assigned case, the defendant or property/casualty company does not wish to retain the long-term periodic payment obligation on its books. Accordingly, the defendant or property/casualty insurer transfers the obligation, through a legal device called a qualified assignment, to a third party. The third party, called an assignment company, will require the defendant or property/casualty company to pay it an amount sufficient to enable it to buy an annuity that will fund its newly accepted periodic payment obligation. If the claimant consents to the transfer of the periodic payment obligation (either in the settlement agreement or, failing that, in a special form of qualified assignment known as a qualified assignment and release), the defendant and/or its property/casualty company has no further liability to make the periodic payments. This method of substituting the obligor is desirable for defendants or property/casualty companies that do not want to retain the periodic payment obligation on their books. A qualified assignment is also advantageous for the claimant as it will not have to rely on the continued credit of the defendant or property/casualty company as a general creditor. Typically, an assignment company is an affiliate of the life insurance company from which the annuity is purchased.

An assignment is said to be "qualified" if it satisfies the criteria set forth in Internal Revenue Code Section 130?[1]. Qualification of the assignment is important to assignment companies because without it the amount they receive to induce them to accept periodic payment obligations would be considered income for federal income tax purposes. If an assignment qualifies under Section 130, however, the amount received is excluded from the income of the assignment company. This provision of the tax code was enacted to encourage assigned cases; without it, assignment companies would owe federal income taxes but would typically have no source from which to make the payments.

[edit]Financing

The nature of structured settlements requires people to wait to obtain funding. However, there are options to cash out or obtain a cash advance on one's structured settlement. Various?legal financing?companies can offer to buy part or all of one's structured settlement (or other fixed annuity payments) in return for a lump sum cash upfront. Basically, such companies allow one to switch, for example, a structured settlement payment of over 20 years to one (lesser-valued) payment now. Such financing can be used to pay for a house, send a child to college, or pay off one's debts. Such financing will need the approval of a judge and the insurance company.^{[citation needed]}?In 2012, a Tennessee Chancery Court issued an order denying a payee's transfer of workers' compensation settlement payments under a structured settlement agreement. Judge William E. Lantrip held that (i) workers' compensation payments are not within the definition of "structured settlement " under the Tennessee Structured Settlement Protection Act, Tenn. Code. Ann. ?47-18-2601?^[12]

[edit]Purchasers of Structured Settlements

A purchaser of a structured settlement is an individual or company who buys a pre-existing structured settlement. These settlements can include lottery winnings, annuities, etc.

An example: There's a court ordered structured settlement which pays five thousand dollars a year, to individual A, for twenty years. Individual A doesn't want to wait for twenty years to receive their money so they approach purchaser A, a SS purchaser. Purchaser A offers them fifty thousand dollars for their SS. In this case Indiv. A receives less money than they would if they waited twenty years, however they get more money immediately which they might need.

This type of transaction is pretty basic and easy.^{[citation needed]}?Things become more complicated if individual A only wants to sell some of their SS, or if the purchaser A buys this SS and then sells it to purchaser B and keeps a percentage. This could extrapolate to an unlimited number of individuals and purchasers. While the purchasing of SS has been around for a while, it has become a larger industry in recent years, probably because of the risk-free incentive. These purchasers are essentially buying loans which are guaranteed to be paid off. Because of the growing market and the growing complexities, SS purchasers are finding it more and more difficult to track their settlements(loans).^{[original research?]}?Because of this, there is a growing market of loan servicing software being used by SS purchasers to keep track.^{[dubious???discuss]}

[edit]See also

Source: http://byuzun.blogspot.com/2013/04/structured-settlement.html

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Boston suspects' father postpones trip to U.S.

MAKHACHKALA, Russia (AP) ? The father of the two Boston bombing suspects says he is postponing a trip to the United States because of poor health.

Anzor Tsarnaev told The Associated Press on Sunday that he is "really sick" and his blood pressure had spiked.

Tsarnaev said last week that he planned to travel from Russia to the U.S. with the hope of seeing his younger son, who is under arrest, and burying his elder son, who was killed in a clash with police.

Tsarnaev confirmed that he is staying in Chechnya, a province in southern Russia, but did not specify whether he was hospitalized.

Until Friday, he and the suspects' mother had been living in the neighboring province of Dagestan.

Source: http://news.yahoo.com/boston-suspects-father-postpones-trip-us-124041600.html

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