-----Original Message-----
From: California Healthline [
mailto:CALIFORNIAHEALTHLINE@ADVISORY.COM]Sent: Thursday, October 23, 2003 10:36 AM
Schwarzenegger Names Health Net Executive as Chief of Staff
10/23/2003
Gov.-elect Arnold Schwarzenegger (R) on Wednesday named Patricia Clarey, vice president for government affairs at the HMO <
http://www.healthnet.com/> Health Net, as his chief of staff, the <http://www.sacbee.com/24hour/politics/story/1034303p-7262339c.html> AP/Sacramento Bee reports (AP/Sacramento Bee, 10/22). The chief of staff position is a key role in a California governor's administration because he or she has a role in appointing other government officials. Clarey, a deputy to former Gov. Pete Wilson's (R) chief of staff, worked in the administrations of former presidents Reagan and Bush before joining Health Net, the state's third-largest HMO ( http://www.californiahealthline.org/members/basecontent.asp?contentid=50041&collectionid=3&program=1 California Healthline, 10/21). Clarey also served as Schwarzenegger's deputy campaign manager (Ostrom/Marimow, <http://www.bayarea.com/mld/mercurynews/news/local/7082616.htm> San Jose Mercury News, 10/23). Several top aides in the Schwarzenegger campaign recommended Clarey's appointment, the <http://www.californiahealthline.org/members/Los%20Angeles%20Times> Los Angeles Times reports (Morain, Los Angeles Times, 10/23). Several people close to Schwarzenegger's transition team said that Clarey's experience in Sacramento and in the private sector "make her a good choice for a neophyte politician like Schwarzenegger," the Mercury News reports (San Jose Mercury News, 10/23). Schwarzenegger said Clarey "has a wealth of experience in executive government" and "has a very good understanding of how the governor's office works" (AP/Sacramento Bee, 10/22). According to the <http://www.bayarea.com/mld/cctimes/7082571.htm> Contra Costa Times, Clarey's appointment was praised by many Republicans but drew criticism from the <http://www.consumerwatchdog.org/> Foundation for Taxpayer and Consumer Rights, which said in a statement that "HMO lobbyists should not be part of an administration that pledged to govern for the people, not for special interests" (LaMar, Contra Costa Times, 10/23). Beth Capell, a lobbyist for consumer advocacy group <http://www.health-access.org/> Health Access, said that Health Net "worked really hard to kill most HMO reforms proposed during Davis'" tenure as governor (Martin, http://www.sfgate.com/cgi-bin/article.cgi?file=/chronicle/archive/2003/10/23/MNGFS2HCM91.DTL San Fran! cisco Chronicle, 10/23). But Lisa Haines, Health Net's vice president for corporate communications, said the HMO industry will not necessarily benefit from Clarey's appointment (Los Angeles Times, 10/23). Clarey said in a prepared statement, "It is an honor to return to public service and work for Gov. Schwarzenegger during such an important period in California's history. I am committed to the governor's goal of strengthening California's economy and bringing jobs back to the state." Clarey's appointment does not require confirmation, and she will begin work immediately, Schwarzenegger's transition team said (AP/Sacramento Bee, 10/22).Brian Potts
Managing Editor, CAL/AAEM News Service
MS-IV, UC-Irvine
Do you Yahoo!?
Exclusive Video Premiere - Britney Spears --0-448659464-1067799159=:21000-- From pottsbri@yahoo.com Wed Nov 5 00:24:36 2003 From: pottsbri@yahoo.com (CAL/AAEM News Service) Date: Tue, 4 Nov 2003 16:24:36 -0800 (PST) Subject: CMS Announces 2004 Cut of 4.5% in Medicare's Physician Reimbursements Message-ID: <20031105002436.72633.qmail@web41308.mail.yahoo.com> --0-1185921686-1067991876=:71768 Content-Type: text/plain; charset=us-ascii -----Original Message----- From: California Healthline [mailto:CALIFORNIAHEALTHLINE@ADVISORY.COM] Sent: Friday, October 31, 2003 10:01 AM CMS Announces 2004 Cut of 4.5% in Medicare's Physician Reimbursements 10/31/2003
-----Original Message-----
From: California Healthline [
mailto:CALIFORNIAHEALTHLINE@ADVISORY.COM]Sent: Friday, October 31, 2003 10:01 AM
CMS Announces 2004 Cut of 4.5% in Medicare's Physician Reimbursements
10/31/2003
<
http://www.cms.gov/> CMS Administrator Tom Scully on Thursday announced that the agency will reduce Medicare's physician reimbursements by 4.5% in 2004, the http://www.lasvegassun.com/sunbin/stories/archives/2003/oct/30/103006426.html?scully AP/Las Vegas Sun reports (Sherman, AP/Las Vegas Sun, 10/30). In March, Bush administration officials announced that the provider payment cut for 2004 would likely be 4.2%, despite a provision in the 2003 omnibus spending package that provided $54 million over 10 years to avoid such cuts. That law also blocked a proposed 4.4% reduction for 2003 ( http://www.californiahealthline.org/members/basecontent.asp?contentid=48291&collectionid=3&program=1 California Healthline, 3/26). Scully said that the 2004 cut will be higher than the forecasted 4.2% because CMS is legally required to follow the current payment formula, which is based on actual Medicare spending, the rate of medical inflation and economic growth. CMS will revise the formula next year to "make it more reflective of doctors' costs," according to agency officials, the AP/Sun reports. The <http://www.ama-assn.org/> American Medical Association said the cut will make physicians reluctant to acc! ept new Medicare beneficiaries. AMA President Dr. Donald Palmisano said physicians are already limiting their number of new Medicare patients because reimbursements do not match service costs. He added that the new reimbursement cuts will exacerbate the problem and "make it even harder for seniors to get the health care they need." The cuts come amid negotiations to reconcile the House and Senate Medicare bills ( <http://thomas.loc.gov/cgi-bin/query/z?c108:h.r.1:> HR 1 and <http://thomas.loc.gov/cgi-bin/query/z?c108:s.1:> S 1); the House bill would cancel reimbursement reductions for 2004 and 2005 and boost physician payments by 1.5% (AP/Las Vegas Sun, 10/30).Brian Potts
Managing Editor, C! AL/AAEM News Service
MS-IV, UC-Irvine
Do you Yahoo!?
Protect your identity with Yahoo! Mail AddressGuard --0-1185921686-1067991876=:71768-- From pottsbri@yahoo.com Wed Nov 5 06:29:14 2003 From: pottsbri@yahoo.com (CAL/AAEM News Service) Date: Tue, 4 Nov 2003 22:29:14 -0800 (PST) Subject: Subject: Member Alert: Medicare to Cut Physician Payments Message-ID: <20031105062914.59749.qmail@web41312.mail.yahoo.com> --0-2047558004-1068013754=:59101 Content-Type: text/plain; charset=us-ascii -----Original Message----- From: AAEM [mailto:info@aaem.org] Sent: Tuesday, November 04, 2003 9:14 AM To: akazzi@attglobal.net Subject: Member Alert: Medicare to Cut Physician Payments *** MEDICARE TO CUT PHYSICIAN PAYMENTS BY 4.5% IN 2004 *** On October 30th, the Centers for Medicare and Medicaid Services (CMS) released its final Medicare payment rule calling for a physician payment cut of 4.5% in 2004. This cut comes on top of a 5.4% payment cut in 2002. With only weeks remaining before congressional adjournment for the year, Congress must act now to stop the Medicare payment cuts before additional resources are stripped from our EDs. THE TIME TO ACT IS NOW! FAX, CALL, or E-MAIL your Senators and Representative TODAY. Urge them to ensure that Section 601 of H.R.1, Revisions of Updates for Physicians' Services, which increases the Medicare physician fee schedule reimbursement rate by at least 1.5% per year for the next two (2) years, is retained in the final passage of the Medicare Prescription Drug Act. PERSONALIZE YOUR MESSAGE BY TELLING THEM WHAT EFFECT AN ADDITIONAL MEDICARE CUT WOULD HAVE ON YOU, YOUR PATIENTS, AND THE FACILITY IN WHICH YOU WORK. Go to AAEM's Legislative Action Center for detailed information, a template letter/talking points, and all the contact information you will need. To access the Action Center, click here: http://capwiz.com/aaem/home/ When you are on the Action Center's HOMEPAGE, please take the time to sign up for AAEM's "E-Mail Alerts." These "Alerts" will provide you with strategic information to affect key policy issues of concern to emergency medicine. AAEM 611 East Wells Street Milwaukee, WI 53202 800-884-2236 Fax: 414-276-3349 E-mail: info@aaem.org Website: www.aaem.org Brian Potts Managing Editor, CAL/AAEM News Service MS-IV, UC-Irvine --------------------------------- Do you Yahoo!? Protect your identity with Yahoo! Mail AddressGuard --0-2047558004-1068013754=:59101 Content-Type: text/html; charset=us-ascii
-----Original Message-----
From: AAEM [
mailto:info@aaem.org]Sent: Tuesday, November 04, 2003 9:14 AM
To: akazzi@attglobal.net
Subject: Member Alert: Medicare to Cut Physician Payments
*** MEDICARE TO CUT PHYSICIAN PAYMENTS BY 4.5% IN 2004 ***
On October 30th, the Centers for Medicare and Medicaid Services (CMS) released its final Medicare payment rule calling for a physician payment cut of 4.5% in 2004. This cut comes on top of a 5.4% payment cut in 2002. With only weeks remaining before congressional adjournment for the year, Congress must act now to stop the Medicare payment cuts before additional resources are stripped from our EDs.
THE TIME TO ACT IS NOW!
FAX, CALL, or E-MAIL your Senators and Representative TODAY. Urge them to ensure that Section 601 of H.R.1, Revisions of Updates for Physicians' Services, which increases the Medicare physician fee schedule reimbursement rate by at least 1.5% per year for the next two (2) years, is retained in the final passage of the Medicare Prescription Drug Act. PERSONALIZE YOUR MESSAGE BY TELLING THEM WHAT EFFECT AN ADDITIONAL MEDICARE CUT WOULD HAVE ON YOU, YOUR PATIENTS, AND THE FACILITY IN WHICH YOU WORK.
Go to AAEM's Legislative Action Center for detailed information, a template letter/talking points, and all the contact information you will need. To access the Action Center, click here:
http://capwiz.com/aaem/home/When you are on the Action Center's HOMEPAGE, please take the time to sign up for AAEM's "E-Mail Alerts." These "Alerts" will provide you with strategic information to affect key policy issues of concern to emergency medicine.
AAEM
611 East Wells Street
Milwaukee, WI 53202
800-884-2236
Fax: 414-276-3349
E-mail: info@aaem.org
Website:
www.aaem.orgBrian Potts
Managing Editor, CAL/AAEM News Service
MS-IV, UC-Irvine
Do you Yahoo!?
Protect your identity with Yahoo! Mail AddressGuard --0-2047558004-1068013754=:59101-- From pottsbri@yahoo.com Thu Nov 6 07:22:44 2003 From: pottsbri@yahoo.com (CAL/AAEM News Service) Date: Wed, 5 Nov 2003 23:22:44 -0800 (PST) Subject: St. Joseph hopes fee will reduce ER visits Message-ID: <20031106072244.30753.qmail@web41315.mail.yahoo.com> --0-254361461-1068103364=:30596 Content-Type: text/plain; charset=us-ascii >From EMED-L..... ========== St. Joseph hopes fee will reduce ER visits By JOE MANNING jmanning@journalsentinel.com Last Updated: Oct. 23, 2003 For the first time in southeast Wisconsin, a hospital is adding a fee for emergency room care in an attempt to stop a flood of patients who walk through the doors seeking treatment for such minor ailments as runny noses and ingrown toenails. St. Joseph Medical Center Photo/Michael Sears: Mark Mitchell examines a patient's chart Thursday at St. Joseph Regional Medical Center. The hospital sent 5,000 letters telling uninsured former patients of a minimum $150 fee on emergency room visits.The Numbers The American Hospital Association says 67% of emergency rooms are either at or over capacity. At inner-city hospitals, that number jumps to 80%. U.S. emergency room visits jumped to an average total of 107.7 million in 2001 and 2000, up 16.3% from 1996 and 1997. People covered by Medicare visited emergency rooms 16 million times, a 10% increase. Visits by uninsured patients rose 10.3% to 18 million. Source: Center for Studying Health System Change; Associated Press St. Joseph Regional Medical Center has sent 5,000 letters telling uninsured former patients who owe the hospital for emergency care that their next trip to the emergency room will cost them a minimum of $150. Hospital officials said care will not be denied to anyone coming to the emergency department, but the $150 is intended as a "financial incentive" to discourage people from seeking emergency care for conditions that would be better handled in primary care clinics. "We are an emergency department and not a primary care giver. We have to make sure that we continue to have these resources available to provide care to those who present with true emergencies," said Mark Mitchell, the physician in charge of the emergency department at St. Joseph. The decision comes as the use of emergency rooms is soaring in the region and across the United States. The American Hospital Association says 67% of emergency rooms are either at or over capacity. At inner-city hospitals, that number jumps to 80%. Increased use of hospital emergency rooms is a contributing factor in the rising cost of care, which has sent health insurance premiums soaring by double-digit percentages for four straight years in southeast Wisconsin. "There is an ever-worsening problem with inappropriate use of emergency departments," said Bill Bazan, vice president of the Wisconsin Hospital Association. "St. Joseph is communicating important information to patients in an attempt to educate and inform them on using appropriate levels of clinical care. It is not meant to discourage appropriate emergency department use," he said. It's a cost-shifting issue, Bazan said, as hospitals shift emergency room expenses onto paying customers. In the Milwaukee area last year, Bazan said, there were more than 83,000 visits by uninsured people to hospital emergency rooms, "and 60% of those medical encounters could have been better handled in a primary care setting. This is a communitywide problem that nearly every hospital is facing." Everyone will be charged The new policy at St. Joseph, a member of the Covenant Healthcare System, applies to anyone seeking care in the emergency department. People with insurance will be asked to pay a portion of the charge when discharged. A patient's insurance would be billed for the difference. Those without insurance "will be asked to make a minimum deposit starting at $150 for the most basic care," the letter says. Mitchell said if patients cannot afford to pay the $150 - which is assessed after patients receive care and not as a condition of receiving care - they will be referred by financial counselors to community programs that help with medical costs. "We are trying to make people aware that our emergency department is not the best place to come to for primary care," said Rosemary Anton, senior vice president of mission and ethics at St. Joseph. Inappropriate use of the emergency room interferes with the delivery of care to people who actually have life-threatening conditions, she said. "It's a bad utilization of resources. It's like taking a baseball bat to a flea. People come to the emergency department for something that is thoroughly well cared for at a primary care clinic." Anton said people will still be treated for primary care ailments in St. Joseph's emergency department, but the intent is to get them into treatment at clinics where care is cheaper. She said hospital emergency rooms have high overhead in expensive equipment and on-duty personnel as well as hours of operation. The cost of primary care in an emergency department is estimated to be four times as expensive as the same care given in a clinic or doctor's office. "We are advising people in advance of what is expected in the emergency department," she said. "We are a faith-based system founded by sisters concerned about people getting health care. We agonize over people being cut out of the system. We want everyone to get medical care. It is very important to us," Anton added. Covenant Healthcare System spokeswoman Anne Ballentine said an emergency room fee policy will be instituted soon at St. Michael Hospital, also a Covenant facility. Primary care crunch The overuse of emergency rooms has to do with a lack of primary care available in the community, said the hospital association's Bazan, who is working with other health care executives to get a $4 million federal grant to build additional primary care clinics and increase clinic hours. Bazan said the problem has to do with historic patterns in the central city in which patients view emergency rooms as primary care providers. Other hospitals may be following St. Joseph's and St. Michael's lead. Aurora Sinai Medical Center has begun a policy of referring patients who come to the emergency room for primary care to community clinics. Aurora Sinai officials said the hospital is considering beginning "a cash disincentive" similar to St. Joseph's. "Every hospital in Milwaukee is looking at strategies to assist patients in finding appropriate levels of clinical care. This is extremely serious. It's a growing challenge in Milwaukee County, and no end is in sight," Bazan said. Anton said the $150 level was selected because the hospital did not want to set a minimum fee too high to scare away people who need legitimate emergency care. "We are trying to make sure that we provide care for people who cannot afford it and don't get waylaid in providing care to people who can pay for it," she said. Brian Potts Managing Editor, CAL/AAEM News Service MS-IV, UC-Irvine --------------------------------- Do you Yahoo!? Protect your identity with Yahoo! Mail AddressGuard --0-254361461-1068103364=:30596 Content-Type: text/html; charset=us-ascii
From EMED-L.....
==========
St. Joseph hopes fee will reduce ER visits
By JOE MANNING
jmanning@journalsentinel.com
Last Updated: Oct. 23, 2003
For the first time in southeast Wisconsin, a hospital is adding a fee for emergency room care in an attempt to stop a flood of patients who walk through the doors seeking treatment for such minor ailments as runny noses and ingrown toenails.
St. Joseph Medical Center Photo/Michael Sears: Mark Mitchell examines a patient's chart Thursday at St. Joseph Regional Medical Center. The hospital sent 5,000 letters telling uninsured former patients of a minimum $150 fee on emergency room visits.The Numbers The American Hospital Association says 67% of emergency rooms are either at or over capacity. At inner-city hospitals, that number jumps to 80%. U.S. emergency room visits jumped to an average total of 107.7 million in 2001 and 2000, up 16.3% from 1996 and 1997. People covered by Medicare visited emergency rooms 16 million times, a 10% increase. Visits by uninsured patients rose 10.3% to 18 million. Source: Center for Studying Health System Change; Associated Press
St. Joseph Regional Medical Center has sent 5,000 letters telling uninsured former patients who owe the hospital for emergency care that their next trip to the emergency room will cost them a minimum of $150.
Hospital officials said care will not be denied to anyone coming to the emergency department, but the $150 is intended as a "financial incentive" to discourage people from seeking emergency care for conditions that would be better handled in primary care clinics.
"We are an emergency department and not a primary care giver. We have to make sure that we continue to have these resources available to provide care to those who present with true emergencies," said Mark Mitchell, the physician in charge of the emergency department at St. Joseph.
The decision comes as the use of emergency rooms is soaring in the region and across the United States. The American Hospital Association says 67% of emergency rooms are either at or over capacity. At inner-city hospitals, that number jumps to 80%.
Increased use of hospital emergency rooms is a contributing factor in the rising cost of care, which has sent health insurance premiums soaring by double-digit percentages for four straight years in southeast Wisconsin.
"There is an ever-worsening problem with inappropriate use of emergency departments," said Bill Bazan, vice president of the Wisconsin Hospital Association.
"St. Joseph is communicating important information to patients in an attempt to educate and inform them on using appropriate levels of clinical care. It is not meant to discourage appropriate emergency department use," he said.
It's a cost-shifting issue, Bazan said, as hospitals shift emergency room expenses onto paying customers.
In the Milwaukee area last year, Bazan said, there were more than 83,000 visits by uninsured people to hospital emergency rooms, "and 60% of those medical encounters could have been better handled in a primary care setting. This is a communitywide problem that nearly every hospital is facing."
Everyone will be charged
The new policy at St. Joseph, a member of the Covenant Healthcare System, applies to anyone seeking care in the emergency department. People with insurance will be asked to pay a portion of the charge when discharged. A patient's insurance would be billed for the difference.
Those without insurance "will be asked to make a minimum deposit starting at $150 for the most basic care," the letter says.
Mitchell said if patients cannot afford to pay the $150 - which is assessed after patients receive care and not as a condition of receiving care - they will be referred by financial counselors to community programs that help with medical costs.
"We are trying to make people aware that our emergency department is not the best place to come to for primary care," said Rosemary Anton, senior vice president of mission and ethics at St. Joseph.
Inappropriate use of the emergency room interferes with the delivery of care to people who actually have life-threatening conditions, she said. "It's a bad utilization of resources. It's like taking a baseball bat to a flea. People come to the emergency department for something that is thoroughly well cared for at a primary care clinic."
Anton said people will still be treated for primary care ailments in St. Joseph's emergency department, but the intent is to get them into treatment at clinics where care is cheaper.
She said hospital emergency rooms have high overhead in expensive equipment and on-duty personnel as well as hours of operation. The cost of primary care in an emergency department is estimated to be four times as expensive as the same care given in a clinic or doctor's office. "We are advising people in advance of what is expected in the emergency department," she said.
"We are a faith-based system founded by sisters concerned about people getting health care. We agonize over people being cut out of the system. We want everyone to get medical care. It is very important to us," Anton added.
Covenant Healthcare System spokeswoman Anne Ballentine said an emergency room fee policy will be instituted soon at St. Michael Hospital, also a Covenant facility.
Primary care crunch
The overuse of emergency rooms has to do with a lack of primary care available in the community, said the hospital association's Bazan, who is working with other health care executives to get a $4 million federal grant to build additional primary care clinics and increase clinic hours.
Bazan said the problem has to do with historic patterns in the central city in which patients view emergency rooms as primary care providers.
Other hospitals may be following St. Joseph's and St. Michael's lead.
Aurora Sinai Medical Center has begun a policy of referring patients who come to the emergency room for primary care to community clinics. Aurora Sinai officials said the hospital is considering beginning "a cash disincentive" similar to St. Joseph's.
"Every hospital in Milwaukee is looking at strategies to assist patients in finding appropriate levels of clinical care. This is extremely serious. It's a growing challenge in Milwaukee County, and no end is in sight," Bazan said.
Anton said the $150 level was selected because the hospital did not want to set a minimum fee too high to scare away people who need legitimate emergency care.
"We are trying to make sure that we provide care for people who cannot afford it and don't get waylaid in providing care to people who can pay for it," she said.
Brian Potts
Managing Editor, CAL/AAEM News Service
MS-IV, UC-Irvine
Do you Yahoo!?
Protect your identity with Yahoo! Mail AddressGuard --0-254361461-1068103364=:30596-- From pottsbri@yahoo.com Thu Nov 6 23:42:13 2003 From: pottsbri@yahoo.com (CAL/AAEM News Service) Date: Thu, 6 Nov 2003 15:42:13 -0800 (PST) Subject: Tenet Ordered To Pay $253 Million to Former Executive in Contract Dispute -and- GAO: Number of U.S. physicians climbs 26% in decade Message-ID: <20031106234213.99445.qmail@web41302.mail.yahoo.com> --0-34007765-1068162133=:98132 Content-Type: text/plain; charset=us-ascii Well, they sure do get due process protection, don't they? -----Original Message----- From: California Healthline [mailto:CALIFORNIAHEALTHLINE@ADVISORY.COM] Sent: Friday, October 31, 2003 10:01 AM Tenet Ordered To Pay $253 Million to Former Executive in Contract Dispute 10/31/2003 The 2nd District Court of Appeals in Los Angeles on Tuesday ruled that California-based
Well, they sure do get due process protection, don't they?
-----Original Message-----
From: California Healthline [
mailto:CALIFORNIAHEALTHLINE@ADVISORY.COM]Sent: Friday, October 31, 2003 10:01 AM
Tenet Ordered To Pay $253 Million to Former Executive in Contract Dispute
10/31/2003
The 2nd District Court of Appeals in Los Angeles on Tuesday ruled that California-based <
http://tenethealth.com/TenetHealth> Tenet Healthcare must pay $253 million to a former executive for failure to honor a compensation contract in 1993, the <http://www.latimes.com/business/la-fi-tenet31oct31,1,6164915.story> Los Angeles Times reports (Vrana, Los Angeles Times, 10/31). In the case, John Bedrosian, a co-founder of Tenet predecessor National Medical Enterprises, filed a lawsuit over allegations that the company failed to provide him with stock benefits when he was terminated without cause in 1993. Bedrosian has not received any of the benefits, which were due from the start of fiscal year 1994 through September 1! 995, Bedrosian attorney Richard Hodge said. A lower court had awarded $9.2 million to Bedrosian, based on a share price of $19 and no subsequent stock splits. The appeals court decision, written by Justice Roger Boren, calculated a share price of $52.50, the highest market value within a "reasonable" time limit, and included subsequent stock splits. Tenet officials plan to appeal the decision. "We do not believe the evidence in this case justifies this huge award, and we will ask the court to promptly review," Tenet Deputy General Counsel Gary Robinson said (Dunn, <http://www.philly.com/mld/inquirer/business/7145651.htm> Bloomberg/Philadelphia Inquirer, 10/31). The award, equal to about one-third of Tenet earnings in 2002, would represent a "severe financial blow" for the company, the Times reports. Tenet officials have said that the company wo! uld take the award as a one-time charge in the third quarter (Los Angeles Times, 10/31). Tenet currently faces several state and federal investigations. Since October 2002, the <http://finance.senate.gov/sitepages/committee.htm> Senate Finance Committee, the <http://www.sec.gov/> Securities and Exchange Commission, the HHS <http://www.oig.hhs.gov/> Office of Inspector General, the <http://www.usdoj.gov/> Justice Department and the <http://www.ftc.gov/>! Federal Trade Commission have launched separate investigations into Tenet related to alleged Medicare fraud and other issues. The company also faces an investigation by the http://myfloridalegal.com/pages.nsf/0/ebc480598bbf32d885256cc6005b54d1?OpenDocument Florida Medicaid Fraud Control Unit (http://www.californiahealthline.org/members/basecontent.asp?contentid=50017&collectionid=3&program=1 California Healthline, 10/20).
===================================
AHA NEWS NOW
The Daily Report for Health Care Executives
www.ahanews.com===================================
Monday, Nov. 3, 2003
+++
4) GAO: Number of U.S. physicians climbs 26% in decade
The U.S. physician population increased 26% between 1991 and 2001, or twice the rate of total population growth during the period, according a report released today by the General Accounting Office. The average number of physicians per 100,000 people increased from 214 to 239, while the mix of generalists and specialists remained about one-third generalists and two-thirds specialists. The number of physicians per 100,000 people in non-metropolitan areas increased 23% from 1991-2001, while the number of physicians in metropolitan areas increased 10%. However, metropolitan areas continued to have about 145 more physicians per 100,000 people than non-metropolitan areas, the study indicates. The report can be found at
http://www.gao.gov==================================
Copyright 2003 by the American Hospital Association. All rights reserved. For republication rights, contact Craig Webb. AHA News is a registered trademark of the American Hospital Association. The opinions expressed in AHA News Now are not necessarily those of the American Hospital Association.
Brian Potts
Managing Editor, CAL/AAEM News Service
MS-IV, UC-Irvine
Do you Yahoo!?
Protect your identity with Yahoo! Mail AddressGuard --0-34007765-1068162133=:98132-- From pottsbri@yahoo.com Mon Nov 10 06:27:19 2003 From: pottsbri@yahoo.com (CAL/AAEM News Service) Date: Sun, 9 Nov 2003 22:27:19 -0800 (PST) Subject: Subject: Renew Your AAEM Membership Online Message-ID: <20031110062719.45006.qmail@web41306.mail.yahoo.com> --0-706587027-1068445639=:43972 Content-Type: text/plain; charset=us-ascii -----Original Message----- From: AAEM [mailto:info@aaem.org] Sent: Monday, November 03, 2003 1:20 PM To: akazzi@attglobal.net Subject: Renew Your AAEM Membership Online Dear AAEM Member, With your continued support, AAEM has surpassed the 4,000-member mark and we are continuing to have a major impact as we work toward the goal of a physician-run specialty. To help AAEM continue its efforts, take a moment and renew your membership now at www.aaem.org. Below are some of the accomplishments we've achieved with your help and others which are on the horizon. This list should make you proud to remain a member. * February 20-22, 2004, Miami. Based on feedback from the membership, the Board voted to continue free registration for AAEM's 10th Scientific Assembly. * November 1-2, 2003. AAEM sponsored its first-ever JAM Session Reviews for the Written Board certification and re-certification exams in Chicago, Dallas, and East Brunswick, NJ. Plans call for an additional offering in Los Angeles in 2004. * September 2003. After the success of the 2001 conference in Italy, AAEM and EuSEM co-sponsored the 2nd Mediterranean EM Congress in Sitges/Barcelona, Spain. The record-breaking event attracted more than 1,200 attendees from 65 countries. * AAEM will continue to co-sponsor the popular cadaver-based airway course developed by Richard Levitan, MD FAAEM. A total of seven sessions will be held in 2004. Visit www.aaem.org for more details. * The AAEM Resident Section unveiled its new guide for medical students planning on a career in EM: AAEM's Rules of the Road for Medical Students. * AAEM continues to offer its Written Board Review Course along with eight annual sessions of our highly-popular Oral Board course. In 2004, the East Coast section of the Oral Board course will expand to accommodate double the number of participants. * Common Sense and the Journal of Emergency Medicine continue as the official publications of AAEM. * AAEM is continuing its public education website, 911emergency.org. If your department isn't included, contact AAEM to request a registration form. * AAEM continues to monitor and support legislative efforts that are in line with our mission. * Members have access to AAEM's Template System at a reduced price. You will also note that there is no increase in AAEM dues for 2004. Payment of your 2004 dues will allow you to vote for the positions open in the upcoming election - President, Vice President, Secretary/Treasurer and three At-Large Board seats. Your ballot and voting information will be sent to you with the January/February 2004 issue of Common Sense. As always, there will be a Candidates Forum at the Scientific Assembly to allow you to question the candidates before casting your vote. To renew your membership online, click on the following link: https://ssl18.pair.com/aaemorg/membership/application.html Your continued support of AAEM's mission and principles allows us continue our work on behalf of the working emergency physician. Sincerely, Joseph Wood, MD JD FAAEM President AAEM 611 East Wells Street Milwaukee, WI 53202 800-884-2236 Fax: 414-276-3349 E-mail: info@aaem.org Website: www.aaem.org Brian Potts Managing Editor, CAL/AAEM News Service MS-IV, UC-Irvine --------------------------------- Do you Yahoo!? Protect your identity with Yahoo! Mail AddressGuard --0-706587027-1068445639=:43972 Content-Type: text/html; charset=us-ascii
-----Original Message-----
From: AAEM [
mailto:info@aaem.org]Sent: Monday, November 03, 2003 1:20 PM
To: akazzi@attglobal.net
Subject: Renew Your AAEM Membership Online
Dear AAEM Member,
With your continued support, AAEM has surpassed the 4,000-member mark and we are continuing to have a major impact as we work toward the goal of a physician-run specialty. To help AAEM continue its efforts, take a moment and renew your membership now at
www.aaem.org.Below are some of the accomplishments we've achieved with your help and others which are on the horizon. This list should make you proud to remain a member.
* February 20-22, 2004, Miami. Based on feedback from the membership, the Board voted to continue free registration for AAEM's 10th Scientific Assembly.
* November 1-2, 2003. AAEM sponsored its first-ever JAM Session Reviews for the Written Board certification and re-certification exams in Chicago, Dallas, and East Brunswick, NJ. Plans call for an additional offering in Los Angeles in 2004.
* September 2003. After the success of the 2001 conference in Italy, AAEM and EuSEM co-sponsored the 2nd Mediterranean EM Congress in Sitges/Barcelona, Spain. The record-breaking event attracted more than 1,200 attendees from 65 countries.
* AAEM will continue to co-sponsor the popular cadaver-based airway course developed by Richard Levitan, MD FAAEM. A total of seven sessions will be held in 2004. Visit
www.aaem.org for more details.* The AAEM Resident Section unveiled its new guide for medical students planning on a career in EM: AAEM's Rules of the Road for Medical Students.
* AAEM continues to offer its Written Board Review Course along with eight annual sessions of our highly-popular Oral Board course. In 2004, the East Coast section of the Oral Board course will expand to accommodate double the number of participants.
* Common Sense and the Journal of Emergency Medicine continue as the official publications of AAEM.
* AAEM is continuing its public education website, 911emergency.org. If your department isn't included, contact AAEM to request a registration form.
* AAEM continues to monitor and support legislative efforts that are in line with our mission.
* Members have access to AAEM's Template System at a reduced price.
You will also note that there is no increase in AAEM dues for 2004.
Payment of your 2004 dues will allow you to vote for the positions open in the upcoming election - President, Vice President, Secretary/Treasurer and three At-Large Board seats. Your ballot and voting information will be sent to you with the January/February 2004 issue of Common Sense. As always, there will be a Candidates Forum at the Scientific Assembly to allow you to question the candidates before casting your vote.
To renew your membership online, click on the following link:
https://ssl18.pair.com/aaemorg/membership/application.htmlYour continued support of AAEM's mission and principles allows us continue our work on behalf of the working emergency physician.
Sincerely,
Joseph Wood, MD JD FAAEM
President
AAEM
611 East Wells Street
Milwaukee, WI 53202
800-884-2236
Fax: 414-276-3349
E-mail: info@aaem.org
Website:
www.aaem.orgBrian Potts
Managing Editor, CAL/AAEM News Service
MS-IV, UC-Irvine
Do you Yahoo!?
Protect your identity with Yahoo! Mail AddressGuard --0-706587027-1068445639=:43972-- From pottsbri@yahoo.com Mon Nov 10 20:42:08 2003 From: pottsbri@yahoo.com (CAL/AAEM News Service) Date: Mon, 10 Nov 2003 12:42:08 -0800 (PST) Subject: IOM panel recommends changes to nursing work hours, environment , -and- FDA advises physicians of adverse events associated with stent Message-ID: <20031110204208.36399.qmail@web41313.mail.yahoo.com> --0-1339102372-1068496928=:35789 Content-Type: text/plain; charset=us-ascii =================================== AHA NEWS NOW The Daily Report for Health Care Executives www.ahanews.com =================================== Tuesday, Nov. 4, 2003 1. IOM panel recommends changes to nursing work hours, environment STORIES: 1) IOM panel recommends changes to nursing work hours, environment A report released today by an Institute of Medicine panel recommends work hour limits and other changes to the work environment for nurses to strengthen patient safety. The report proposes limiting nurses' working hours to less than 60 hours per week and 12 hours in any 24-hour period. It also recommends health care organizations reduce their use of temporary nursing staff, invest more in training and continuing education for nurses, and increase nurses' role in management and decision-making. The panel says regulators and health care leaders also should work to reduce workplace inefficiencies, such as excessive paperwork and documentation, which reduce the time nurses have to spend with patients. Pamela Thompson, CEO of the American Organization of Nurse Executives, said the report "highlights some important areas that we've already begun to address. Hospital and nurse leaders are working to redesign the work environment -- through technology, training and retention efforts! -- to better support nurses as they work to deliver quality care to patients." AONE is the AHA's nursing affiliate. The IOM report is available at http://www.national-academies.org/. +++ 3) FDA advises physicians of adverse events associated with stent The Food and Drug Administration has informed physicians about adverse events associated with a drug-coated stent approved in April for patients undergoing angioplasty procedures to open clogged coronary arteries. The FDA said it has received more than 290 reports of thrombosis, or clotting, occurring one to 30 days after implanting the Cordis Corporation's Cypher Coronary Stent. In more than 60 of the reports, use of the device was associated with the death of the patient. The FDA said it also has received more than 50 reports, including some deaths, of possible hypersensitivity reactions to the stent. It is encouraging doctors and patients who have experienced an adverse event related to the stent to report the incident to the FDA. For more information, go to http://www.fda.gov/bbs/topics/ANSWERS/2003/ANS01257.html. +++ ================================== Copyright 2003 by the American Hospital Association. All rights reserved. For republication rights, contact Craig Webb. AHA News is a registered trademark of the American Hospital Association. The opinions expressed in AHA News Now are not necessarily those of the American Hospital Association. Brian Potts Managing Editor, CAL/AAEM News Service MS-IV, UC-Irvine --------------------------------- Do you Yahoo!? Protect your identity with Yahoo! Mail AddressGuard --0-1339102372-1068496928=:35789 Content-Type: text/html; charset=us-ascii
===================================
AHA NEWS NOW
The Daily Report for Health Care Executives
www.ahanews.com===================================
Tuesday, Nov. 4, 2003
1. IOM panel recommends changes to nursing work hours, environment
STORIES:
1) IOM panel recommends changes to nursing work hours, environment
A report released today by an Institute of Medicine panel recommends work hour limits and other changes to the work environment for nurses to strengthen patient safety. The report proposes limiting nurses' working hours to less than 60 hours per week and 12 hours in any 24-hour period. It also recommends health care organizations reduce their use of temporary nursing staff, invest more in training and continuing education for nurses, and increase nurses' role in management and decision-making. The panel says regulators and health care leaders also should work to reduce workplace inefficiencies, such as excessive paperwork and documentation, which reduce the time nurses have to spend with patients. Pamela Thompson, CEO of the American Organization of Nurse Executives, said the report "highlights some important areas that we've already begun to address. Hospital and nurse leaders are working to redesign the work environment -- through technology, training and retention effo! rts -- to better support nurses as they work to deliver quality care to patients." AONE is the AHA's nursing affiliate. The IOM report is available at
http://www.national-academies.org/.+++
3) FDA advises physicians of adverse events associated with stent
The Food and Drug Administration has informed physicians about adverse events associated with a drug-coated stent approved in April for patients undergoing angioplasty procedures to open clogged coronary arteries. The FDA said it has received more than 290 reports of thrombosis, or clotting, occurring one to 30 days after implanting the Cordis Corporation's Cypher Coronary Stent. In more than 60 of the reports, use of the device was associated with the death of the patient. The FDA said it also has received more than 50 reports, including some deaths, of possible hypersensitivity reactions to the stent. It is encouraging doctors and patients who have experienced an adverse event related to the stent to report the incident to the FDA. For more information, go to http://www.fda.gov/bbs/topics/ANSWERS/2003/ANS01257.html.
+++
==================================
Copyright 2003 by the American Hospital Association. All rights reserved. For republication rights, contact Craig Webb.
AHA News is a registered trademark of the American Hospital Association. The opinions expressed in AHA News Now are not necessarily those of the American Hospital Association.
Brian Potts
Managing Editor, CAL/AAEM News Service
MS-IV, UC-Irvine
Do you Yahoo!?
Protect your identity with Yahoo! Mail AddressGuard --0-1339102372-1068496928=:35789-- From pottsbri@yahoo.com Wed Nov 12 08:07:30 2003 From: pottsbri@yahoo.com (CAL/AAEM News Service) Date: Wed, 12 Nov 2003 00:07:30 -0800 (PST) Subject: GAO: Number of U.S. physicians climbs 26% in decade Message-ID: <20031112080730.23866.qmail@web41307.mail.yahoo.com> --0-254210563-1068624450=:23163 Content-Type: text/plain; charset=us-ascii I thought some of you would be interested in this data. Also, you can pull the report off the web. Antoine Kazzi A. Antoine Kazzi, MD, FAAEM Vice-President, The American Academy of Emergency Medicine Vice-Chair, Department of Emergency Medicine University of California, Irvine =================================== AHA NEWS NOW The Daily Report for Health Care Executives www.ahanews.com =================================== Monday, Nov. 3, 2003 +++ 4) GAO: Number of U.S. physicians climbs 26% in decade The U.S. physician population increased 26% between 1991 and 2001, or twice the rate of total population growth during the period, according a report released today by the General Accounting Office. The average number of physicians per 100,000 people increased from 214 to 239, while the mix of generalists and specialists remained about one-third generalists and two-thirds specialists. The number of physicians per 100,000 people in non-metropolitan areas increased 23% from 1991-2001, while the number of physicians in metropolitan areas increased 10%. However, metropolitan areas continued to have about 145 more physicians per 100,000 people than non-metropolitan areas, the study indicates. The report can be found at http://www.gao.gov. +++ ================================== Copyright 2003 by the American Hospital Association. All rights reserved. For republication rights, contact Craig Webb. AHA News is a registered trademark of the American Hospital Association. The opinions expressed in AHA News Now are not necessarily those of the American Hospital Association. This e-mail/fax message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail/fax and destroy all copies of the original message. To unsubscribe, send the command "SIGNOFF EMED-L" to LISTSERV@ITSSRV1.UCSF.EDU Brian Potts Managing Editor, CAL/AAEM News Service MS-IV, UC-Irvine --------------------------------- Do you Yahoo!? Protect your identity with Yahoo! Mail AddressGuard --0-254210563-1068624450=:23163 Content-Type: text/html; charset=us-ascii
I thought some of you would be interested in this data. Also, you can pull the report off the web.
Antoine Kazzi
A. Antoine Kazzi, MD, FAAEM
Vice-President, The American Academy of Emergency Medicine Vice-Chair, Department of Emergency Medicine University of California, Irvine
===================================
AHA NEWS NOW
The Daily Report for Health Care Executives
www.ahanews.com===================================
Monday, Nov. 3, 2003
+++
4) GAO: Number of U.S. physicians climbs 26% in decade
The U.S. physician population increased 26% between 1991 and 2001, or twice the rate of total population growth during the period, according a report released today by the General Accounting Office. The average number of physicians per 100,000 people increased from 214 to 239, while the mix of generalists and specialists remained about one-third generalists and two-thirds specialists. The number of physicians per 100,000 people in non-metropolitan areas increased 23% from 1991-2001, while the number of physicians in metropolitan areas increased 10%. However, metropolitan areas continued to have about 145 more physicians per 100,000 people than non-metropolitan areas, the study indicates. The report can be found at
http://www.gao.gov.+++
==================================
Copyright 2003 by the American Hospital Association. All rights reserved. For republication rights, contact Craig Webb.
AHA News is a registered trademark of the American Hospital Association. The opinions expressed in AHA News Now are not necessarily those of the American Hospital Association.
This e-mail/fax message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail/fax and destroy all copies of the original message.
To unsubscribe, send the command "SIGNOFF EMED-L" to LISTSERV@ITSSRV1.UCSF.EDU
Brian Potts
Managing Editor, CAL/AAEM News Service
MS-IV, UC-Irvine
Do you Yahoo!?
Protect your identity with Yahoo! Mail AddressGuard --0-254210563-1068624450=:23163-- From pottsbri@yahoo.com Fri Nov 14 06:08:51 2003 From: pottsbri@yahoo.com (CAL/AAEM News Service) Date: Thu, 13 Nov 2003 22:08:51 -0800 (PST) Subject: CRNAs - Wow! Did anesthesia ever dig themselves a hole!, -AND- CMA Launches Fundraising for Its Emergency Care Initiative Message-ID: <20031114060851.43863.qmail@web41312.mail.yahoo.com> --0-1263621568-1068790131=:42321 Content-Type: text/plain; charset=us-ascii > -----Original Message----- > From: McNamara, Robert > Sent: Tuesday, November 04, 2003 10:02 AM > Subject: CRNAs > > Wow! Did anesthesia ever dig themselves a hole! > RMM (McNamara, Robert) > > ALASKA HAS BECOME THE TENTH STATE TO REQUEST THAT MEDICARE EXEMPT IT FROM A PHYSICIAN SUPERVISION REQUIREMENT FOR NURSE ANESTHETISTS. > > Alaska Governor Frank Murkowski told the Centers for Medicare & Medicaid Services that his state was opting out of the physician supervision Medicare regulation because the requirement may be severely limiting the ability of rural hospitals to treat emergencies and provide other services requiring anesthesia care to Medicare patients. Alaska joins nine other states that have opted out of the requirement: North Dakota, Washington, Iowa, Nebraska, Idaho, Minnesota, New Hampshire, New Mexico and Kansas. American Association of Nurse Anesthetists, October 30, 2003 ======================================== -----Original Message----- From: cma_alert@cmanews.org [mailto:cma_alert@cmanews.org] Sent: Thursday, November 06, 2003 3:16 PM 2. CMA Launches Fundraising for Its Emergency Care Initiative CMA and the Coalition to Preserve Emergency Care have begun fundraising efforts to support the 2004 Trauma and Emergency Care Initiative. The initiative would increase the 911 surcharge to 3.7 percent on telephone calls made within California to fund 911 emergency dispatch, hospital emergency rooms, trauma centers, emergency doctors, and on-call physician specialists. CMA's goal is to raise $900,000 to support the initiative. While this may sound like a lot of money, the return on the investment for physicians will be great. The initiative, if successful, is expected to raise $500 to $800 million annually for trauma and emergency services, $200 million of which go to reimburse emergency and on-call physicians for services provided to uninsured and underinsured patients. CMA needs your help to reach its $900,000 goal. Many CMA members will receive donation forms with their 2004 CMA/county medical society dues statements. Donation forms can also be downloaded online
> -----Original Message-----
> From: McNamara, Robert
> Sent: Tuesday, November 04, 2003 10:02 AM
> Subject: CRNAs
>
> Wow! Did anesthesia ever dig themselves a hole!
> RMM (McNamara, Robert)
>
> ALASKA HAS BECOME THE TENTH STATE TO REQUEST THAT MEDICARE EXEMPT IT FROM A PHYSICIAN SUPERVISION REQUIREMENT FOR NURSE ANESTHETISTS.
>
> Alaska Governor Frank Murkowski told the Centers for Medicare & Medicaid Services that his state was opting out of the physician supervision Medicare regulation because the requirement may be severely limiting the ability of rural hospitals to treat emergencies and provide other services requiring anesthesia care to Medicare patients. Alaska joins nine other states that have opted out of the requirement: North Dakota, Washington, Iowa, Nebraska, Idaho, Minnesota, New Hampshire, New Mexico and Kansas.
American Association of Nurse Anesthetists, October 30, 2003
========================================
-----Original Message-----
From: cma_alert@cmanews.org [
mailto:cma_alert@cmanews.org]Sent: Thursday, November 06, 2003 3:16 PM
2. CMA Launches Fundraising for Its Emergency Care Initiative
CMA and the Coalition to Preserve Emergency Care have begun fundraising efforts to support the 2004 Trauma and Emergency Care Initiative. The initiative would increase the 911 surcharge to 3.7 percent on telephone calls made within California to fund 911 emergency dispatch, hospital emergency rooms, trauma centers, emergency doctors, and on-call physician specialists.
CMA's goal is to raise $900,000 to support the initiative. While this may sound like a lot of money, the return on the investment for physicians will be great. The initiative, if successful, is expected to raise $500 to $800 million annually for trauma and emergency services, $200 million of which go to reimburse emergency and on-call physicians for services provided to uninsured and underinsured patients.
CMA needs your help to reach its $900,000 goal. Many CMA members will receive donation forms with their 2004 CMA/county medical society dues statements. Donation forms can also be downloaded online <
http://www.calphys.org/html/bb428.asp> . For information on how you, your medical staff, or your medical group can help, please contact CMA Government Relations at the number below.CMA leaders express their gratitude to those who have already donated to this important effort. Special thanks go out to Beaver Medical Group and the medical staff of Fountain Valley Medical Center, which contributed $6,000 and $10,000 respectively.
For more information about this initiative, click <
http://www.calphys.org/html/bb428.asp> here.Contact: CMA Government Relations, 916/444-5532 or dcorcoran@cmanet.org <
mailto:dcorcoran@cmanet.org>Brian Potts
Managing Editor, CAL/AAEM News Service
MS-IV, UC-Irvine
Do you Yahoo!?
Protect your identity with Yahoo! Mail AddressGuard --0-1263621568-1068790131=:42321-- From pottsbri@yahoo.com Sat Nov 15 20:41:58 2003 From: pottsbri@yahoo.com (CAL/AAEM News Service) Date: Sat, 15 Nov 2003 12:41:58 -0800 (PST) Subject: Malpractice: FROM THE PRESIDENT (of the AMA), -AND- FW: Malpractice: Florida's New Tort Reform Law Delivers Unintended Consequence Message-ID: <20031115204158.72635.qmail@web41310.mail.yahoo.com> --0-744269897-1068928918=:71966 Content-Type: text/plain; charset=us-ascii Why we should still join the AMA... And the CMA... Antoine Kazzi ============== FROM THE PRESIDENT (of the AMA) Donald J. Palmisano, MD AMA eVoice, October 2, 2003 At last week's North Dakota Medical Association meeting, I was reminded once again of the obstinacy with which trial lawyers continue to ignore the facts surrounding our nation's medical liability crisis. I sat on a panel with two trial lawyers who claimed that today's increasing medical liability premium rates are due to insurance companies' stock market losses. AM Best, an independent authority, clearly documents that the return on investments has been positive for the past five years. The sad fact is, more money is paid for claims than is received in premiums, and that is what is driving physicians out of practice! Yet in every debate, trial lawyers continue to put forth misinformation as if they have never been disproved. Imagine if, in medicine, someone touted a cancer-curing treatment, even after it had been repeatedly debunked. I reminded the legislators in the audience that they have a grave responsibility to listen to all viewpoints, but the decision should be based on the facts and in the public's best interest. Go to the best evidence, the actual source material, and not junk math interpretations. =============================== Press Release Source: GE Medical Protective Florida's New Tort Reform Law Delivers Unintended Consequence Friday October 3, 10:01 am ET GE Medical Protective is Unable to Renew Physicians Whose Policies Expire January, 2004 FORT WAYNE, Ind.--(BUSINESS WIRE)--Oct. 3, 2003--GE Commercial Insurance's Medical Protective (MedPro) announced today it has regretfully been forced to issue non-renewal notices to physicians whose medical malpractice insurance policies expire in January 2004. MedPro had filed for a rate increase more than two months before the Florida legislature passed its recent tort reform measure, but that rate filing had not been approved prior to the passage of the new legislation. This new law mandated a rate freeze, which required MedPro to withdraw its rate filing. MedPro is unable to resubmit its request for new rates until Florida's Office of Insurance Regulation (OIR) calculates its "presumed rate factor," which could be as late as mid-November. Unfortunately, Florida's insurance regulations require 60 days notice of any price increase to policyholders. Given this time frame it is impossible for MedPro to create a new rate filing in time for its January 1, 2004 renewal policies. "MedPro remains strongly committed to the State of Florida and its health care providers," said Timothy Kenesey, President and Chief Executive Officer of MedPro. "However, we cannot write business today at rates that are inadequate, or worse, unknown to us. Our ability to charge the right rates for our coverage has allowed us to provide peace of mind to physicians for more than 100 years. We owe it to all of our policyholders to ensure we are charging adequate rates in every state where we do business so we can be here for the next 100 years." "Florida's legislators and its insurance regulators understand our concerns, and we are working with them to devise an acceptable solution to this problem," said William Daley, Executive Vice President and Chief Counsel of MedPro. "We plan to file new rates as soon as possible and hope to have approval to use those rates prior to our physicians' renewal dates in January." Source: GE Medical Protective Brian Potts Managing Editor, CAL/AAEM News Service MS-IV, UC-Irvine --------------------------------- Do you Yahoo!? Protect your identity with Yahoo! Mail AddressGuard --0-744269897-1068928918=:71966 Content-Type: text/html; charset=us-ascii
Why we should still join the AMA... And the CMA...
Antoine Kazzi
==============
FROM THE PRESIDENT (of the AMA)
Donald J. Palmisano, MD
AMA eVoice, October 2, 2003
At last week's North Dakota Medical Association meeting, I was reminded once again of the obstinacy with which trial lawyers continue to ignore the facts surrounding our nation's medical liability crisis. I sat on a panel with two trial lawyers who claimed that today's increasing medical liability premium rates are due to insurance companies' stock market losses. AM Best, an independent authority, clearly documents that the return on investments has been positive for the past five years.
The sad fact is, more money is paid for claims than is received in premiums, and that is what is driving physicians out of practice! Yet in every debate, trial lawyers continue to put forth misinformation as if they have never been disproved. Imagine if, in medicine, someone touted a cancer-curing treatment, even after it had been repeatedly debunked. I reminded the legislators in the audience that they have a grave responsibility to listen to all viewpoints, but the decision should be based on the facts and in the public's best interest. Go to the best evidence, the actual source material, and not junk math interpretations.
===============================
Press Release Source: GE Medical Protective
Florida's New Tort Reform Law Delivers Unintended Consequence Friday October 3, 10:01 am ET GE Medical Protective is Unable to Renew Physicians Whose Policies Expire January, 2004
FORT WAYNE, Ind.--(BUSINESS WIRE)--Oct. 3, 2003--GE Commercial Insurance's Medical Protective (MedPro) announced today it has regretfully been forced to issue non-renewal notices to physicians whose medical malpractice insurance policies expire in January 2004.
MedPro had filed for a rate increase more than two months before the Florida legislature passed its recent tort reform measure, but that rate filing had not been approved prior to the passage of the new legislation. This new law mandated a rate freeze, which required MedPro to withdraw its rate filing. MedPro is unable to resubmit its request for new rates until Florida's Office of Insurance Regulation (OIR) calculates its "presumed rate factor," which could be as late as mid-November. Unfortunately, Florida's insurance regulations require 60 days notice of any price increase to policyholders. Given this time frame it is impossible for MedPro to create a new rate filing in time for its January 1, 2004 renewal policies.
"MedPro remains strongly committed to the State of Florida and its health care providers," said Timothy Kenesey, President and Chief Executive Officer of MedPro. "However, we cannot write business today at rates that are inadequate, or worse, unknown to us. Our ability to charge the right rates for our coverage has allowed us to provide peace of mind to physicians for more than 100 years. We owe it to all of our policyholders to ensure we are charging adequate rates in every state where we do business so we can be here for the next 100 years."
"Florida's legislators and its insurance regulators understand our concerns, and we are working with them to devise an acceptable solution to this problem," said William Daley, Executive Vice President and Chief Counsel of MedPro. "We plan to file new rates as soon as possible and hope to have approval to use those rates prior to our physicians' renewal dates in January."
Source: GE Medical Protective
Brian Potts
Managing Editor, CAL/AAEM News Service
MS-IV, UC-Irvine
Do you Yahoo!?
Protect your identity with Yahoo! Mail AddressGuard --0-744269897-1068928918=:71966-- From pottsbri@yahoo.com Sun Nov 16 22:48:50 2003 From: pottsbri@yahoo.com (CAL/AAEM News Service) Date: Sun, 16 Nov 2003 14:48:50 -0800 (PST) Subject: "Whistleblower physicians face harsh reprisals from some hospitals" Message-ID: <20031116224850.61545.qmail@web41304.mail.yahoo.com> --0-358003500-1069022930=:60395 Content-Type: text/plain; charset=us-ascii Interesting reading. I am not sure how and why it ended up in the Internal Medicine Professional Society (ACP = American College of Physicians) electronic bulletin... -----Original Message----- Sent: Thursday, November 06, 2003 2:21 PM To: 'akazzi@attglobal.net' Subject: FYI: whistleblower emergency physicians >From American College of Physicians, mentions reprisals against emergency physicians: "Whistleblower physicians face harsh reprisals from some hospitals" Physicians who complain to hospital administrators about substandard care or staffing problems sometimes face retaliation that includes the loss of their practice, drawn out investigations and no protection from whistleblower regulations that safeguard professionals in other industries. According to the Oct. 26 Pittsburgh Post-Gazette, a 1998 survey found that more than 20% of emergency department physicians who brought up concerns about patient care had either been threatened with losing their job or lost their position. The article said that some physicians who raise concerns are labeled "disruptive" by their hospitals. They are also subjected to protracted peer-review investigations, and they often can't take their disputes to court or have legal representation. Sources quoted in the article claim that as more physicians are employed by hospitals, the objectivity of the peer-review process is being threatened-particularly in an era when hospitals are struggling for profitability and marketing clout. Some experts recommend that hospitals reconfigure their peer review process so it includes outside representatives, and not just members of the hospital staff. That move, they say, would help protect whistleblower physicians. The Pittsburgh Post-Gazette article is online at http://www.post-gazette.com/pg/03299/234499.stm. Brian Potts Managing Editor, CAL/AAEM News Service MS-IV, UC-Irvine --------------------------------- Do you Yahoo!? Protect your identity with Yahoo! Mail AddressGuard --0-358003500-1069022930=:60395 Content-Type: text/html; charset=us-ascii
Interesting reading. I am not sure how and why it ended up in the Internal Medicine Professional Society (ACP = American College of Physicians) electronic bulletin...
-----Original Message-----
Sent: Thursday, November 06, 2003 2:21 PM
To: 'akazzi@attglobal.net'
Subject: FYI: whistleblower emergency physicians
From American College of Physicians, mentions reprisals against emergency
physicians:
"Whistleblower physicians face harsh reprisals from some hospitals"
Physicians who complain to hospital administrators about substandard care or staffing problems sometimes face retaliation that includes the loss of their practice, drawn out investigations and no protection from whistleblower regulations that safeguard professionals in other industries.
According to the Oct. 26 Pittsburgh Post-Gazette, a 1998 survey found that more than 20% of emergency department physicians who brought up concerns about patient care had either been threatened with losing their job or lost their position.
The article said that some physicians who raise concerns are labeled "disruptive" by their hospitals. They are also subjected to protracted peer-review investigations, and they often can't take their disputes to court or have legal representation.
Sources quoted in the article claim that as more physicians are employed by hospitals, the objectivity of the peer-review process is being threatened-particularly in an era when hospitals are struggling for profitability and marketing clout.
Some experts recommend that hospitals reconfigure their peer review process so it includes outside representatives, and not just members of the hospital staff. That move, they say, would help protect whistleblower physicians.
The Pittsburgh Post-Gazette article is online at
http://www.post-gazette.com/pg/03299/234499.stm.Brian Potts
Managing Editor, CAL/AAEM News Service
MS-IV, UC-Irvine
Do you Yahoo!?
Protect your identity with Yahoo! Mail AddressGuard --0-358003500-1069022930=:60395-- From pottsbri@yahoo.com Tue Nov 18 00:53:47 2003 From: pottsbri@yahoo.com (CAL/AAEM News Service) Date: Mon, 17 Nov 2003 16:53:47 -0800 (PST) Subject: The CMA - Physicians Must Be Allowed to Sue Health Plans for Unreimbursed ER , -AND- CMA Files Suit Against State Over Scheduled Medi-Cal Reimbursement Rate Reductions Message-ID: <20031118005347.80822.qmail@web41302.mail.yahoo.com> --0-1353404946-1069116827=:80687 Content-Type: text/plain; charset=us-ascii -----Original Message----- From: cma_alert@cmanews.org [mailto:cma_alert@cmanews.org
-----Original Message-----
From: cma_alert@cmanews.org [
mailto:cma_alert@cmanews.org <mailto:cma_alert@cmanews.org> ]Sent: Thursday, November 13, 2003 2:45 PM
> Physicians Must Be Allowed to Sue Health Plans for Unreimbursed ER Claims CMA on Friday filed a letter with the California Supreme Court, urging it to review yet another appellate court decision that allows health plans to evade payment responsibility for emergency services. In this case, Chase Dennis Emergency Medical Group Inc. v. Aetna U.S. Health Care of California, the 2nd District Court of Appeal in Los Angeles ruled that while California law requires health plans to pay for emergency services, unpaid providers cannot sue health plans to recover payment for services provided to enrollees because neither the language of the statute nor its legislative history "clearly indicates the Legislature intended to create such a right to sue for damages."
> This is just one of three recent cases in which the courts have allowed HMOs to absolve themselves of the very function for which licensure is required under the Knox-Keene Act-to reimburse providers (in this case, for life-saving emergency services)-so long as they contract away that responsibility to failing third parties that are generally unlicensed and not subject to regulatory control.
> The appellate court said in its ruling that the responsibility to enforce the Knox-Keene Act lies with the Department of Managed Health Care (DMHC). CMA's letter to the Supreme Court pointed out that despite literally millions of dollars in unreimbursed physician claims for emergency services, there has not been a single enforcement action brought by DMHC. Nor has DMHC taken any actions taken against HMOs that have failed to ensure the financial viability of their arrangements with contracting intermediaries, as required by law. All of this has occurred while HMOs are enjoying record profits and demonstrates a "profound need" for enforcement action, wrote CMA legal counsel Astrid Meghrigian in the letter. "The [appellate court's] opinion leaves physicians treating emergency conditions wholly uncompensated for their services and remediless."
> CMA's letter argues that the appellate court in this case applied an overly mechanical analysis of a prior Supreme Court decision (Moradi-Shalal v. Fireman's Fund Insurance Companies). The appellate court did not, as it should have, look at the purpose of the law-ensuring that providers get paid so that enrollees can receive continuous, accessible care-to determine whether a private remedy was required to achieve that purpose.
>
-----Original Message-----
From: California Healthline [
mailto:CALIFORNIAHEALTHLINE@ADVISORY.COM]Sent: Monday, November 10, 2003 10:40 AM
CMA Files Suit Against State Over Scheduled Medi-Cal Reimbursement Rate Reductions
11/10/2003
The <
http://www.cmanet.org/> California Medical Association and 11 other plaintiffs representing Medi-Cal providers on Friday filed a lawsuit in U.S. District Court in Sacramento to halt the implementation of a 5% Medi-Cal reimbursement rate cut, the <http://www.sacbee.com/content/politics/story/7748079p-8687384c.html>Sacramento Bee reports (Furillo, Sacramento Bee, 11/8). The rate reduction was approved by the Legislature as part of the fiscal year 2003-2004 budget to save the state $115 million and help close a $38 billion budget deficit. The lawsuit claims that the reduction violates the federal Social Security Act, which requires that Medicaid rates "attract enough doctors to serve the program's patients," the <
http://www.latimes.com/news/local/la-me-docsuit8nov08,1,1570658.story>Los Angeles Times reports (Halper, Los Angeles Times, 11/8). The suit says that the rate reduction "is being imposed on a system already in crisis" and that low reimbursement rates have led to "a scarcity of willing providers, creating serious access hurdles for Medi-Cal beneficiaries." The suit also alleges that the state did not hold a "properly noticed" public hearing on the rate reduction, which is scheduled to begin Jan. 1, the Bee reports. Joining the CMA in the suit are the <
http://www.aidshealth.org/> AIDS Healthcare Foundation, the <http://www.aap.org/> American Academy of Pediatrics, the <http://www.acog.org/> American College of Obstetricians and Gynecolog! ists, the Brain Injury Policy Institute, the <http://www.calacep.org/> California chapter of the American College of Emergency Physicians, the <http://www.cda.org/cgi-bin/htmlos.cgi/beta/index.html> California Dental Association, the <http://www.cfilc.org/> California Foundation for Independent Living Centers, the <http://www.cpha.com/> California Pharmacists Association, the Long Term Care Management Council, the <http://www.ltcpa.org/public/> Long Term Care Pharmacy Alliance and the <http://www.opsc.org/> Osteopathic Physicians and Surgeons of California.
Reaction
"By reducing the reimbursement, the state is greatly injuring the most vulnerable Californians," Jack Lewin, CEO for the CMA, said, adding, "Unfortunately, these kinds of cuts, by virtue of sending these people to emergency rooms, will actually increase the (budget) burden in the long run." Lewin said that CMA surveys found that up to 15% of doctors currently treating Medi-Cal beneficiaries would likely stop doing so as a result of the rate reduction. Chris Perrone, senior program officer for the <
http://www.chcf.org/> California HealthCare Foundation, said that it is too soon to determine how the 5% cut would affect access to care. "I think the impact of this will be felt over time," Perrone said, adding, "I think it will continue to color the picture of Medi-Cal that physicians have, both existing and new physicians, and whether or not to participate. Many physicians al! ready are doing it for reasons beyond getting paid" (Sacramento Bee, 11/8). Hilary McLean, a spokesperson for Gov. Gray Davis (D), said that Davis raised reimbursement rates in "good times," but the "very harsh reality is in the last few years, California has been buffeted by sharp declines in revenue. We had to make a lot of tough decisions in order to eliminate the budget shortfall" (Los Angeles Times, 11/8). Ken August, a spokesperson for the <http://www.dhs.cahwnet.gov/> Department of Health Services, added that the cuts do not apply to inpatient or outpatient services, nursing homes or county clinics (Sacramento Bee, 11/8). H.D. Palmer, a spokesperson for Gov.-elect Arnold Schwarzenegger's (R) transition team, said that the team has not yet reviewed the suit and has no comment, the <http://www.bayarea.com/mld/cctimes/living/health/7213254.htm> Contra Costa Times reports (Kleffman, Contra Costa Times, 11/8). <http://www.csus.edu/npr/NprModules/newsroom.html> Capital Public Radio on Friday reported on the lawsuit (Montgomery, Capital Public Radio, 11/7). The full segment is available <http://www.csus.edu/npr/localnews/mm031107.ram> online in RealPlayer.Brian Potts
Managing Editor, CAL/AAEM News Service
MS-IV, UC-Irvine
Do you Yahoo!?
Protect your identity with Yahoo! Mail AddressGuard --0-1353404946-1069116827=:80687-- From pottsbri@yahoo.com Tue Nov 18 23:33:49 2003 From: pottsbri@yahoo.com (CAL/AAEM News Service) Date: Tue, 18 Nov 2003 15:33:49 -0800 (PST) Subject: EMTALA Rules, -AND- CMS issues EMTALA enforcement guidance Message-ID: <20031118233349.76336.qmail@web41304.mail.yahoo.com> --0-1218017942-1069198429=:75166 Content-Type: text/plain; charset=us-ascii -----Original Message----- From: AAEM [mailto:info@aaem.org] Sent: Wednesday, November 12, 2003 7:59 AM To: akazzi@attglobal.net Subject: EMTALA Rules To: AAEM Members, Thomas R. Barker, Esq., the Health Policy Counselor to the Administrator of CMS has released a PowerPoint presentation outlining the major provisions of final regulation for EMTALA. To view the presentation please visit the AAEM website at www.aaem.org/emtala/emtalaupdate.ppt AAEM 611 E. Wells Street Milwaukee, WI 53202 800-884-2236 Fax: 414-276-3349 E-mail: info@aaem.org Website: www.aaem.org =================================== AHA NEWS NOW The Daily Report for Health Care Executives www.ahanews.com =================================== Monday, Nov. 10, 2003 Today's headlines: 1) CMS issues EMTALA enforcement guidance The Centers for Medicare & Medicaid Services today issued a memorandum providing interim guidance to CMS regional offices concerning enforcement of the Emergency Medical Treatment and Labor Act (EMTALA) final rule, which takes effect today. The guidance summarizes the provisions of the final rule, published Sept. 9, and clarifies CMS' policy regarding when a patient is "stabilized" as well as the hospital's EMTALA obligation to inpatients. CMS said surveyors will use the interim guidance and CMS' current Interpretative Guidelines for EMTALA to assess whether a hospital is in compliance with the final rule until it issues Revised Interpretative Guidelines. It said enforcement of EMTALA will continue to be initiated only by a complaint. CMS said the guidance will be posted in the next few days at http://www.cms.hhs.gov/medicaid/survey-cert/letters.asp. +++ Copyright 2003 by the American Hospital Association. All rights reserved. For republication rights, contact Craig Webb. AHA News is a registered trademark of the American Hospital Association. The opinions expressed in AHA News Now are not necessarily those of the American Hospital Association. ============================ Brian Potts Managing Editor, CAL/AAEM News Service MS-IV, UC-Irvine --------------------------------- Do you Yahoo!? Protect your identity with Yahoo! Mail AddressGuard --0-1218017942-1069198429=:75166 Content-Type: text/html; charset=us-ascii
-----Original Message-----
From: AAEM [
mailto:info@aaem.org]Sent: Wednesday, November 12, 2003 7:59 AM
To: akazzi@attglobal.net
Subject: EMTALA Rules
To: AAEM Members,
Thomas R. Barker, Esq., the Health Policy Counselor to the Administrator of CMS has released a PowerPoint presentation outlining the major provisions of final regulation for EMTALA. To view the presentation please visit the AAEM website at
www.aaem.org/emtala/emtalaupdate.pptAAEM
611 E. Wells Street
Milwaukee, WI 53202
800-884-2236
Fax: 414-276-3349
E-mail: info@aaem.org
Website:
www.aaem.org===================================
AHA NEWS NOW
The Daily Report for Health Care Executives
===================================
Monday, Nov. 10, 2003
Today's headlines:
1) CMS issues EMTALA enforcement guidance
The Centers for Medicare & Medicaid Services today issued a memorandum providing interim guidance to CMS regional offices concerning enforcement of the Emergency Medical Treatment and Labor Act (EMTALA) final rule, which takes effect today. The guidance summarizes the provisions of the final rule, published Sept. 9, and clarifies CMS' policy regarding when a patient is "stabilized" as well as the hospital's EMTALA obligation to inpatients. CMS said surveyors will use the interim guidance and CMS' current Interpretative Guidelines for EMTALA to assess whether a hospital is in compliance with the final rule until it issues Revised Interpretative Guidelines. It said enforcement of EMTALA will continue to be initiated only by a complaint. CMS said the guidance will be posted in the next few days at
http://www.cms.hhs.gov/medicaid/survey-cert/letters.asp+++
Copyright 2003 by the American Hospital Association. All rights reserved. For republication rights, contact Craig Webb.
AHA News is a registered trademark of the American Hospital Association. The opinions expressed in AHA News Now are not necessarily those of the American Hospital Association.
============================
Brian Potts
Managing Editor, CAL/AAEM News Service
MS-IV, UC-Irvine
Do you Yahoo!?
Protect your identity with Yahoo! Mail AddressGuard --0-1218017942-1069198429=:75166-- From pottsbri@yahoo.com Thu Nov 20 00:20:04 2003 From: pottsbri@yahoo.com (CAL/AAEM News Service) Date: Wed, 19 Nov 2003 16:20:04 -0800 (PST) Subject: Capacity constrained in many EDs, some hospitals -AND- U.S. Nursing Shortage Likely To Continue Despite Recent Increase in Nurse Employment Message-ID: <20031120002004.56204.qmail@web41310.mail.yahoo.com> --0-218399428-1069287604=:54829 Content-Type: text/plain; charset=us-ascii =================================== AHA NEWS NOW The Daily Report for Health Care Executives www.ahanews.com =================================== Wednesday, Nov. 12, 2003 3) Capacity constrained in many EDs, some hospitals, study finds A new study by the Center for Studying Health System Change examines hospital capacity in 12 U.S. communities and the factors contributing to constrained services and hospitals' responses. Most of the hospitals studied reported emergency capacity problems, while other hospital services were constrained for some local hospitals from time to time. The nurse shortage was perceived as a major contributor to capacity problems. Hospitals were implementing various strategies to expand or convert capacity, better manage capacity, attract and retain nurses, and work locally to better coordinate emergency department care and reduce diversions. The authors said more research was needed to determine the extent of capacity constraints nationally and whether efforts to address them are working. Caroline Steinberg, vice president health trends analysis, commented, "As a nation, we need to take a hard look at our capacity issues to care for our communities -- from disaster readiness to incr! eased use of health services as the baby boomers age. Increasing capacity goes beyond adding bricks and mortar, it involves training more nurses and pharmacists and equipping hospital caregivers with tools to help them do their jobs more easily. As a health care field, we're committed to ensuring that Americans have access to the care they need, in the right setting and at the right time." For more on the study, go to http://www.hschange.org/CONTENT/624/. ================================== Copyright 2003 by the American Hospital Association. All rights reserved. For republication rights, contact Craig Webb. AHA News is a registered trademark of the American Hospital Association. The opinions expressed in AHA News Now are not necessarily those of the American Hospital Association. -----Original Message----- From: California Healthline [mailto:CALIFORNIAHEALTHLINE@ADVISORY.COM] Sent: Thursday, November 13, 2003 10:27 AM U.S. Nursing Shortage Likely To Continue Despite Recent Increase in Nurse Employment, Study Finds 11/13/2003 The number of registered nurses employed in the United States increased by about 100,000 from 2001 to 2002 because of an "influx of nurses from other countries and the return of older nurses to the field," but "that is only a temporary fix" to the U.S. nursing shortage, according to a study in the latest issue of the journal Health Affairs, the
===================================
AHA NEWS NOW
The Daily Report for Health Care Executives
www.ahanews.com===================================
Wednesday, Nov. 12, 2003
3) Capacity constrained in many EDs, some hospitals, study finds
A new study by the Center for Studying Health System Change examines hospital capacity in 12 U.S. communities and the factors contributing to constrained services and hospitals' responses. Most of the hospitals studied reported emergency capacity problems, while other hospital services were constrained for some local hospitals from time to time. The nurse shortage was perceived as a major contributor to capacity problems. Hospitals were implementing various strategies to expand or convert capacity, better manage capacity, attract and retain nurses, and work locally to better coordinate emergency department care and reduce diversions. The authors said more research was needed to determine the extent of capacity constraints nationally and whether efforts to address them are working. Caroline Steinberg, vice president health trends analysis, commented, "As a nation, we need to take a hard look at our capacity issues to care for our communities -- from disaster readiness to i! ncreased use of health services as the baby boomers age. Increasing capacity goes beyond adding bricks and mortar, it involves training more nurses and pharmacists and equipping hospital caregivers with tools to help them do their jobs more easily. As a health care field, we're committed to ensuring that Americans have access to the care they need, in the right setting and at the right time." For more on the study, go to
http://www.hschange.org/CONTENT/624/.==================================
Copyright 2003 by the American Hospital Association. All rights reserved. For republication rights, contact Craig Webb.
AHA News is a registered trademark of the American Hospital Association. The opinions expressed in AHA News Now are not necessarily those of the American Hospital Association.
-----Original Message-----
From: California Healthline [
mailto:CALIFORNIAHEALTHLINE@ADVISORY.COM]Sent: Thursday, November 13, 2003 10:27 AM
U.S. Nursing Shortage Likely To Continue Despite Recent Increase in Nurse Employment, Study Finds
11/13/2003
The number of registered nurses employed in the United States increased by about 100,000 from 2001 to 2002 because of an "influx of nurses from other countries and the return of older nurses to the field," but "that is only a temporary fix" to the U.S. nursing shortage, according to a study in the latest issue of the journal Health Affairs, the <
http://business.bostonherald.com/businessNews/business.bg?articleid=771> Boston Herald reports (Heldt Powell, Boston Herald, 11/13). In the
study, Peter Buerhaus, senior associate dean for research at <
http://www.mc.vanderbilt.edu/nursing/> Vanderbilt University School of Nursing, and colleagues examined data in the Current Population Survey conducted by the U.S. Census Bureau Survey for U.S. residents ages 21 to 64 who reported their occupation as registered nurse between January 1994 and December 2002. Over the nine-year period, the study found that RN employment increased by 17%, about half the rate of increase in the previous ten years. The study found that between 1994 and 2002, the number of RNs ages 35 to 49 increased by 12% -- 4.5% between 2001 and 2002 -- and the number of RNs ages 35 and younger decreased by about 17%-- 8.3% between 2001 and 2002; the study also found that between 1994 and 2002, the number of RNs ages 50 and older increased by about 60% -- 15.8% between 2001 and 2002. In addition, the study found that the number of foreign-born RNs employed in the United States increased by about 71% between 1994 and 2002 -- 13.8% between 2001 and 2002 (Buerhaus et al., Health Affairs, November/December 2003). According to the study, the short-term increase in the number of RNs employed in the United States may have resulted from increased wages -- wages for RNs in hospitals increased by about 5% between 2001 and 2002 -- or the recent economic downturn, which may have prompted some RNs who left the profession to return to work, the <
http://www.bayarea.com/mld/cctimes/news/7251075.htm> AP/Contra Costa Times reports. The study concluded that the current nu! rsing shortage, which began in 1998, will likely continue because older RNs will retire earlier. According to the AP/Times, the United States will have an estimated shortage of 500,000 nurses by 2015 (Neergaard, AP/Contra Costa Times, 11/13). The study recommended that lawmakers consider proposals to increase the number of RNs in the workforce, to retain older RNs and to prepare for an increased number of foreign-born RNs in the U.S. workforce (Health Affairs, November/December 2003).
Reaction
Buerhaus said that despite the "very large infusion of RNs" into the U.S. workforce between 2001 and 2002, "there is no evidence that the shortage is over" (Boston Herald, 11/13). Cindy Price, a spokesperson for the <
http://www.nursingworld.org/> American Nursing Association, said, "What will be important to see is if hospitals are able to retain nurses over the long term. You need to change the working conditions of nurses in order to tackle the larger problem" (AP/Contra Costa Times, 11/13). An abstract of the study is available <http://content.healthaffairs.org/cgi/content/abstract/22/6/191> online.
Brian Potts
Managing Editor, CAL/AAEM News Service
MS-IV, UC-Irvine
Do you Yahoo!?
Protect your identity with Yahoo! Mail AddressGuard --0-218399428-1069287604=:54829-- From pottsbri@yahoo.com Thu Nov 20 13:57:21 2003 From: pottsbri@yahoo.com (CAL/AAEM News Service) Date: Thu, 20 Nov 2003 05:57:21 -0800 (PST) Subject: MEDICARE TO CUT PHYSICIAN PAYMENTS 4.5% IN 2004 Message-ID: <20031120135721.21380.qmail@web41303.mail.yahoo.com> --0-1830914415-1069336641=:20291 Content-Type: text/plain; charset=us-ascii -----Original Message----- From: Kathleen A. Ream [mailto:aaemgov@aol.com] Sent: Tuesday, November 04, 2003 3:54 AM To: aaem_list@capwiz.mailmanager.net Subject:
-----Original Message-----
From: Kathleen A. Ream [
mailto:aaemgov@aol.com]Sent: Tuesday, November 04, 2003 3:54 AM
To: aaem_list@capwiz.mailmanager.net
Subject: <b><c>MEDICARE TO CUT PHYSICIAN PAYMENTS 4.5% IN 2004</c></b>
Take Action. Now! <
http://ffs.capwiz.com/img/sc/template1_top.gif>MEDICARE TO CUT PHYSICIAN PAYMENTS 4.5% IN 2004
On October 30th, the Centers for Medicare and Medicaid Services (CMS) released its final Medicare payment rule calling for a physician payment cut of 4.5% in 2004. This cut comes on top of a 5.4% payment cut in 2002. With only weeks remaining before congressional adjournment for the year, Congress must act now to stop the Medicare payment cuts before additional resources are stripped from our EDs.
THE TIME TO ACT IS NOW!
FAX, CALL, or E-MAIL your Senators and Representative TODAY. Urge them to ensure that Section 601 of H.R.1, Revisions of Updates for Physicians' Services, which increases the Medicare physician fee schedule reimbursement rate by at least 1.5% per year for the next two
(2) years, is retained in the final passage of the Medicare Prescription Drug Act. PERSONALIZE YOUR MESSAGE BY TELLING THEM WHAT EFFECT AN ADDITIONAL MEDICARE CUT WOULD HAVE ON YOU, YOUR PATIENTS, AND THE FACILITY IN WHICH YOU WORK.
Go to AAEM's Legislative Action Center for detailed information, a template letter/talking points, and all the contact information you will need. To access the Action Center, <
http://capwiz.com/aaem/utr/1/NCYZCGIMPB/IVTQCGIMXN/> click here.*********************************
Kathleen A. Ream
Director, Government Affairs
American Academy of Emergency Medicine
To Unsubscribe: You may unsubscribe from our mailing list at any time by visiting here <
http://capwiz.com/aaem/lmx/u/?jobid=26653719> .Brian Potts
Managing Editor, CAL/AAEM News Service
MS-IV, UC-Irvine
Do you Yahoo!?
Free Pop-Up Blocker - Get it now --0-1830914415-1069336641=:20291-- From pottsbri@yahoo.com Sat Nov 22 00:43:55 2003 From: pottsbri@yahoo.com (CAL/AAEM News Service) Date: Fri, 21 Nov 2003 16:43:55 -0800 (PST) Subject: FW: Doctor alleging misuse of ER sues over firing Message-ID: <20031122004355.33389.qmail@web41313.mail.yahoo.com> --0-1627054700-1069461835=:33208 Content-Type: text/plain; charset=us-ascii ------------------------- >From the Indianapolis Star Doctor alleging misuse of ER sues over firing. Suit says he tried to stop hospital visits by Medicare, Medicaid patients for minor ills. By Fred Kelly fred.kelly@indystar.com November 13, 2003 A former Indiana doctor says he was fired after he blew the whistle on a hospital that allowed Medicare and Medicaid recipients to use costly emergency room care for minor illnesses such as colds. Taxpayers needlessly are paying for Medicaid and Medicare recipients to visit hospital emergency rooms for routine care, Dr. John Chomer says in a federal lawsuit, but after he tried to stop the visits at Logansport Memorial Hospital, he lost his job. The outcome of his case could affect how Indiana hospitals deal with thousands of poor people who go to emergency rooms for illnesses such as sore throats, the flu and runny noses, attorneys and medical officials said. And no matter how the suit is resolved, it underscores a major flaw in the health care system. "This is a big problem," said Bob Morr, vice president of the Indiana Hospital and Health Association. "The emergency room is the most expensive part of the health care delivery system. It is the most inappropriate place for people with the sniffles and sneezes." Hospitals can do little to stop abuses by patients because federal law requires them to see anyone who comes into their emergency rooms, they said. The Indianapolis Star could not reach Logansport Memorial Hospital or Logan Emergency Physicians officials for comment. Their attorney, David Honig, called Chomer's allegations absurd and said they are based on a misunderstanding of the Medicaid billing system. A 1986 federal law requires hospitals to assess any person who visits their emergency rooms, he noted, adding that Medicaid allows medical providers to bill the government for such assessments. Indiana pays more than $23million annually through Medicaid for emergency room visits. Medicaid is a state-federal program for the needy. Medicare covers older Americans. An ongoing study started recently by the state Family and Social Services Administration has found thousands of Medicaid recipients who have made "inappropriate" emergency room visits for minor illnesses. Some of them have made repeated visits to the hospital, said John Barth, director of managed care programs for the state agency. He said it is not known how much the state spends on unnecessary emergency room trips. In a lawsuit filed this spring in U.S. District Court, Chomer claims he was dismissed from his duties at Logansport Memorial Hospital after he tried to stop Medicaid and Medicare patients from coming to the emergency room for simple illnesses. He accuses the hospital of providing treatment in the emergency room even after doctors determined patients weren't facing a serious health problem. Chomer's suit alleges that his firing by the hospital and Logan Emergency Physicians followed complaints he made to patients and after he reported abuses to the Family and Social Services Administration. The firing, he argues, violated the state's whistle-blower protection act, which forbids employers from retaliating against employees reporting wrongdoing. Logan Emergency Physicians, which also is named in the court action as a defendant, has a contract to provide doctors to Logansport Memorial Hospital. Last week, U.S. District Judge Sarah Evans Barker rejected a motion by the hospital to have the suit dismissed. It will go to trial at a date to be determined. Chomer, who now has a job in Florida, began work at the hospital in early 2002. Soon after, he told Medicaid and Medicare patients it was "inappropriate" for them to visit the emergency room for colds and other minor illnesses. In the suit, Chomer, who declined to comment this week, claims that Logan Emergency Physicians President Lazo Krszenski warned him to stop deterring the patients. Krszenski told him "(you) are taking money out of (the hospital's) pocket," the suit says. In August, Chomer filed a complaint with the Family and Social Services Administration. Krszenski warned Chomer never to file another complaint, the suit says. A short time later, Chomer was fired. If Chomer wins the case, "every emergency room in America would have to change the way it operates," said Honig, the hospital's attorney. "Taken at face value, it would allow hospitals to determine that a patient doesn't need (care) and throw them out of the emergency room." There is no way the hospital provided treatment to Medicaid and Medicare recipients to bolster its finances, he said, because treating them is not profitable. But advocates for the poor say low-income residents often are forced to go to emergency rooms for routine care. Many private physicians will not see Medicaid and Medicare recipients because the government does not reimburse them fully for the services, said Dr. Michael Carius, former president of the Dallas-based American College of Emergency Physicians. Americans made 108 million emergency room visits in 2001, Carius said, compared with 95 million three years earlier. About 9 percent of emergency visits are for "nonurgent" illnesses, reports the Centers for Disease Control and Prevention in Atlanta. "The emergency room has become the safety net of the health care system," Carius said. Brian Potts Managing Editor, CAL/AAEM News Service MS-IV, UC-Irvine --------------------------------- Do you Yahoo!? Free Pop-Up Blocker - Get it now --0-1627054700-1069461835=:33208 Content-Type: text/html; charset=us-ascii
-------------------------
From the Indianapolis Star
Doctor alleging misuse of ER sues over firing. Suit says he tried to stop hospital visits by Medicare, Medicaid patients for minor ills.
By Fred Kelly
fred.kelly@indystar.com
November 13, 2003
A former Indiana doctor says he was fired after he blew the whistle on a hospital that allowed Medicare and Medicaid recipients to use costly emergency room care for minor illnesses such as colds.
Taxpayers needlessly are paying for Medicaid and Medicare recipients to visit hospital emergency rooms for routine care, Dr. John Chomer says in a federal lawsuit, but after he tried to stop the visits at Logansport Memorial Hospital, he lost his job.
The outcome of his case could affect how Indiana hospitals deal with thousands of poor people who go to emergency rooms for illnesses such as sore throats, the flu and runny noses, attorneys and medical officials said. And no matter how the suit is resolved, it underscores a major flaw in the health care system.
"This is a big problem," said Bob Morr, vice president of the Indiana Hospital and Health Association. "The emergency room is the most expensive part of the health care delivery system. It is the most inappropriate place for people with the sniffles and sneezes."
Hospitals can do little to stop abuses by patients because federal law requires them to see anyone who comes into their emergency rooms, they said.
The Indianapolis Star could not reach Logansport Memorial Hospital or Logan Emergency Physicians officials for comment.
Their attorney, David Honig, called Chomer's allegations absurd and said they are based on a misunderstanding of the Medicaid billing system.
A 1986 federal law requires hospitals to assess any person who visits their emergency rooms, he noted, adding that Medicaid allows medical providers to bill the government for such assessments.
Indiana pays more than $23million annually through Medicaid for emergency room visits. Medicaid is a state-federal program for the needy. Medicare covers older Americans.
An ongoing study started recently by the state Family and Social Services Administration has found thousands of Medicaid recipients who have made "inappropriate" emergency room visits for minor illnesses.
Some of them have made repeated visits to the hospital, said John Barth, director of managed care programs for the state agency. He said it is not known how much the state spends on unnecessary emergency room trips.
In a lawsuit filed this spring in U.S. District Court, Chomer claims he was dismissed from his duties at Logansport Memorial Hospital after he tried to stop Medicaid and Medicare patients from coming to the emergency room for simple illnesses. He accuses the hospital of providing treatment in the emergency room even after doctors determined patients weren't facing a serious health problem.
Chomer's suit alleges that his firing by the hospital and Logan Emergency Physicians followed complaints he made to patients and after he reported abuses to the Family and Social Services Administration.
The firing, he argues, violated the state's whistle-blower protection act, which forbids employers from retaliating against employees reporting wrongdoing.
Logan Emergency Physicians, which also is named in the court action as a defendant, has a contract to provide doctors to Logansport Memorial Hospital.
Last week, U.S. District Judge Sarah Evans Barker rejected a motion by the hospital to have the suit dismissed. It will go to trial at a date to be determined.
Chomer, who now has a job in Florida, began work at the hospital in early 2002. Soon after, he told Medicaid and Medicare patients it was "inappropriate" for them to visit the emergency room for colds and other minor illnesses.
In the suit, Chomer, who declined to comment this week, claims that Logan Emergency Physicians President Lazo Krszenski warned him to stop deterring the patients.
Krszenski told him "(you) are taking money out of (the hospital's) pocket," the suit says.
In August, Chomer filed a complaint with the Family and Social Services Administration.
Krszenski warned Chomer never to file another complaint, the suit says. A short time later, Chomer was fired.
If Chomer wins the case, "every emergency room in America would have to change the way it operates," said Honig, the hospital's attorney. "Taken at face value, it would allow hospitals to determine that a patient doesn't need (care) and throw them out of the emergency room."
There is no way the hospital provided treatment to Medicaid and Medicare recipients to bolster its finances, he said, because treating them is not profitable.
But advocates for the poor say low-income residents often are forced to go to emergency rooms for routine care.
Many private physicians will not see Medicaid and Medicare recipients because the government does not reimburse them fully for the services, said Dr. Michael Carius, former president of the Dallas-based American College of Emergency Physicians.
Americans made 108 million emergency room visits in 2001, Carius said, compared with 95 million three years earlier.
About 9 percent of emergency visits are for "nonurgent" illnesses, reports the Centers for Disease Control and Prevention in Atlanta.
"The emergency room has become the safety net of the health care system," Carius said.
Brian Potts
Managing Editor, CAL/AAEM News Service
MS-IV, UC-Irvine
Do you Yahoo!?
Free Pop-Up Blocker - Get it now --0-1627054700-1069461835=:33208-- From akazzi@uci.edu Sat Nov 22 02:31:50 2003 From: akazzi@uci.edu (Kazzi, A. Antoine) Date: Fri, 21 Nov 2003 18:31:50 -0800 Subject: FW: MEDICARE CONFERENCE AGREEMENT IN FINAL STRETCH ? CONTACT YOUR CONGRESSIONAL DELEGATION NOW! Message-ID: <59CDD9FF884EAE4AB86132E86110D72202E096B6@wicket.ndc.mc.uci.edu> This message is in MIME format. Since your mail reader does not understand this format, some or all of this message may not be legible. ------_=_NextPart_001_01C3B0A0.C8FC26D0 Content-Type: text/plain; charset="iso-8859-1" -----Original Message----- From: Kathleen A. Ream [mailto:aaemgov@aol.com] Sent: Wednesday, November 19, 2003 2:14 AM To: aaem_list@capwiz.mailmanager.net Subject: MEDICARE CONFERENCE AGREEMENT IN FINAL STRETCH ? CONTACT YOUR CONGRESSIONAL DELEGATION NOW! Take Action. Now!
From: Kathleen A. Ream [mailto:aaemgov@aol.com]
Sent: Wednesday, November 19, 2003 2:14 AM
To: aaem_list@capwiz.mailmanager.net
Subject: MEDICARE CONFERENCE AGREEMENT IN FINAL STRETCH ? CONTACT YOUR CONGRESSIONAL DELEGATION NOW!
| ||||||||||||||||||||||||
This e-mail/fax message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail/fax and destroy all copies of the original message.
------_=_NextPart_001_01C3B0A0.C8FC26D0-- From pottsbri@yahoo.com Sat Nov 22 17:04:05 2003 From: pottsbri@yahoo.com (CAL/AAEM News Service) Date: Sat, 22 Nov 2003 09:04:05 -0800 (PST) Subject: Medical Board Defines "High Risk" Specialties for Settlement Disclosure - EM is Medium Risk... See PDF Attachment Message-ID: <20031122170405.9658.qmail@web41311.mail.yahoo.com> --0-732887805-1069520645=:9105 Content-Type: multipart/alternative; boundary="0-1774449408-1069520645=:9105" --0-1774449408-1069520645=:9105 Content-Type: text/plain; charset=us-ascii The PDF file that is attached is safe to open. See the 3 categories. Interesting data... Antoine Kazzi A. Antoine Kazzi, MD, FAAEM CAL/AAEM Executive Director Vice-President, The American Academy of Emergency Medicine Vice-Chair, Department of Emergency Medicine University of California, Irvine -----Original Message----- From: cma_alert@cmanews.org [mailto:cma_alert@cmanews.org] Sent: Thursday, November 13, 2003 2:45 PM Medical Board Defines "High Risk" Specialties for Settlement Disclosure [Posted 11/13/03] For More Information ClickThe PDF file that is attached is safe to open.
See the 3 categories. Interesting data...
Antoine Kazzi
A. Antoine Kazzi, MD, FAAEM
CAL/AAEM Executive Director
Vice-President, The American Academy of Emergency Medicine Vice-Chair, Department of Emergency Medicine University of California, Irvine
-----Original Message-----
From: cma_alert@cmanews.org [
mailto:cma_alert@cmanews.org]Sent: Thursday, November 13, 2003 2:45 PM
Medical Board Defines "High Risk" Specialties for Settlement Disclosure
[Posted 11/13/03]
For More Information
Click <
http://www.calphys.org/assets/applets/high_low_comments.pdf> here to download a copy of CMA's comments.Click <
http://www.calphys.org/assets/applets/carrier_risk_data.pdf> here for CMA's chart of risk classifications.The Medical Board of California recently issued proposed regulations specifying which physician specialties would be classified as high risk and low risk under the malpractice settlement disclosure provisions of SB 1950.
SB 1950, signed by the governor last year, allows the board to disclose on its website when a physician in a low-risk specialty has three malpractice settlements above $30,000 in a 10-year period. For high-risk specialists, disclosure is allowed after four such settlements.
The board's initial proposal classified only neurosurgeons, plastic surgeons, and orthopedists as high-risk specialties. CMA, the Academy of Obstetrics and Gynecology, and the California Association of Physician Liability Insurers vigorously opposed this limited definition of high risk. CMA submitted to the board a chart of risk classifications, combining data from four malpractice insurance carriers, which indicated that obstetrics and any specialty that encompasses surgical procedures should be classified as high-risk specialties.
After considerable discussion, the board agreed to include obstetrics as a high-risk specialty, but did not add other surgical specialties. The amended proposal will be reissued for a 10-day comment period.
Contact: Sandra Bressler, 415/882-5171 or sbressler@cmanet.o <
mailto:sbressler@cmanet.org>Brian Potts
Managing Editor, CAL/AAEM News Service
MS-IV, UC-Irvine
Do you Yahoo!?
Free Pop-Up Blocker - Get it now --0-1774449408-1069520645=:9105-- --0-732887805-1069520645=:9105 Content-Type: application/pdf; name="carrier_risk_data.pdf" Content-Transfer-Encoding: base64 Content-Description: carrier_risk_data.pdf Content-Disposition: attachment; filename="carrier_risk_data.pdf" JVBERi0xLjMNJeLjz9MNCjkgMCBvYmoNPDwgDS9MaW5lYXJpemVkIDEgDS9P IDExIA0vSCBbIDgzNiAyMDMgXSANL0wgNDYzNDMgDS9FIDQ0MzcxIA0vTiAx IA0vVCA0NjA0NiANPj4gDWVuZG9iag0gICAgICAgICAgICAgICAgICAgICAg ICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICAgICB4cmVmDTkg MTYgDTAwMDAwMDAwMTYgMDAwMDAgbg0KMDAwMDAwMDY2NSAwMDAwMCBuDQow MDAwMDAxMDM5IDAwMDAwIG4NCjAwMDAwMDExOTMgMDAwMDAgbg0KMDAwMDAw MTM0MCAwMDAwMCBuDQowMDAwMDAxNTUyIDAwMDAwIG4NCjAwMDAwMDE5NzUg MDAwMDAgbg0KMDAwMDAwMjAxNCAwMDAwMCBuDQowMDAwMDAzMzkyIDAwMDAw IG4NCjAwMDAwMDM2MTQgMDAwMDAgbg0KMDAwMDAwNDA3NSAwMDAwMCBuDQow MDAwMDE5OTc0IDAwMDAwIG4NCjAwMDAwNDE1MzkgMDAwMDAgbg0KMDAwMDA0 NDIxNiAwMDAwMCBuDQowMDAwMDAwODM2IDAwMDAwIG4NCjAwMDAwMDEwMTkg MDAwMDAgbg0KdHJhaWxlcg08PA0vU2l6ZSAyNQ0vSW5mbyA3IDAgUiANL1Jv b3QgMTAgMCBSIA0vUHJldiA0NjAzNyANL0lEWzwwMjA5MDc5OGE4ZTY1MDI0 MTJlNDAxNjAwNzA1OWFkMT48YTk1ZGI0YjZhZWE1ZjFhMTlmMGRlYzAzMjZj MWFmMWU+XQ0+Pg1zdGFydHhyZWYNMA0lJUVPRg0gICAgIA0xMCAwIG9iag08 PCANL1R5cGUgL0NhdGFsb2cgDS9QYWdlcyA2IDAgUiANL01ldGFkYXRhIDgg MCBSIA0vT3BlbkFjdGlvbiBbIDExIDAgUiAvWFlaIG51bGwgbnVsbCBudWxs IF0gDS9QYWdlTW9kZSAvVXNlTm9uZSANL1BhZ2VMYWJlbHMgNSAwIFIgDS9P dXRsaW5lcyAxIDAgUiANPj4gDWVuZG9iag0yMyAwIG9iag08PCAvUyAzNiAv TyA4NSAvTCAxMDEgL0ZpbHRlciAvRmxhdGVEZWNvZGUgL0xlbmd0aCAyNCAw IFIgPj4gDXN0cmVhbQ0KSIliYGDgY2BgdmEAghXfGbABDigtAMQ8UMzAoM7A z/CMcQNrhgQDA6PfgejGZdUvAyKCCpgKwNJiDAxrrIE0MxCfBmIWBoa1bECa CYg9AAIMAHyhDRQNZW5kc3RyZWFtDWVuZG9iag0yNCAwIG9iag04NiANZW5k b2JqDTExIDAgb2JqDTw8IA0vVHlwZSAvUGFnZSANL1BhcmVudCA2IDAgUiAN L1Jlc291cmNlcyAxMiAwIFIgDS9Db250ZW50cyAxNiAwIFIgDS9Sb3RhdGUg OTAgDS9NZWRpYUJveCBbIDAgMCA2MTIgNzkyIF0gDS9Dcm9wQm94IFsgMCAw IDYxMiA3OTIgXSANPj4gDWVuZG9iag0xMiAwIG9iag08PCANL1Byb2NTZXQg WyAvUERGIC9UZXh0IF0gDS9Gb250IDw8IC9UVDIgMTQgMCBSIC9UVDQgMTgg MCBSID4+IA0vRXh0R1N0YXRlIDw8IC9HUzEgMjIgMCBSID4+IA0vQ29sb3JT cGFjZSA8PCAvQ3M2IDE1IDAgUiA+PiANPj4gDWVuZG9iag0xMyAwIG9iag08 PCANL1R5cGUgL0ZvbnREZXNjcmlwdG9yIA0vQXNjZW50IDkwNSANL0NhcEhl aWdodCAwIA0vRGVzY2VudCAtMjExIA0vRmxhZ3MgMzIgDS9Gb250QkJveCBb IC02MjggLTM3NiAyMDAwIDEwMTAgXSANL0ZvbnROYW1lIC9GUEJEQ0MrQXJp YWwsQm9sZCANL0l0YWxpY0FuZ2xlIDAgDS9TdGVtViAxMzMgDS9Gb250Rmls ZTIgMTkgMCBSIA0+PiANZW5kb2JqDTE0IDAgb2JqDTw8IA0vVHlwZSAvRm9u dCANL1N1YnR5cGUgL1RydWVUeXBlIA0vRmlyc3RDaGFyIDMyIA0vTGFzdENo YXIgMTIxIA0vV2lkdGhzIFsgMjc4IDAgMCAwIDAgMCAwIDAgMzMzIDMzMyAw IDAgMCAwIDAgMCAwIDAgMCAwIDU1NiAwIDAgMCAwIDAgMCAwIDAgDTAgMCAw IDAgNzIyIDAgNzIyIDAgMCAwIDAgNzIyIDAgMCAwIDYxMSA4MzMgMCAwIDAg MCA3MjIgNjY3IDAgMCANMCAwIDAgMCAwIDAgMCAwIDAgMCAwIDU1NiAwIDU1 NiA2MTEgNTU2IDAgNjExIDYxMSAyNzggMCA1NTYgMjc4IA04ODkgMCA2MTEg NjExIDAgMzg5IDU1NiAzMzMgNjExIDAgNzc4IDAgNTU2IF0gDS9FbmNvZGlu ZyAvV2luQW5zaUVuY29kaW5nIA0vQmFzZUZvbnQgL0ZQQkRDQytBcmlhbCxC b2xkIA0vRm9udERlc2NyaXB0b3IgMTMgMCBSIA0+PiANZW5kb2JqDTE1IDAg b2JqDVsgDS9JQ0NCYXNlZCAyMSAwIFIgDV0NZW5kb2JqDTE2IDAgb2JqDTw8 IC9MZW5ndGggMTMwMyAvRmlsdGVyIC9GbGF0ZURlY29kZSA+PiANc3RyZWFt DQpIiYRWy3bbNhDd8ytm0x6qJ+IDfGrRhZO4dnqayE2YdlF3AVOwhIYEFIC0 o7/vAHxLdSr7UDYxz3tnBvO6cPyiIBBC8egEEEZemsO6+wogSj0SQxQSL4Wi dvw3OoVS44H50aVw/JtPIew1ahaleTw77qcjKzmtmhN85PoLvKEN20vFmYZV 8Y+zJl4ekxBdeCSNCBRvHffejeE9rY6Klg0vGaoolFcarmpa7WmNFnb3K6ON AYZelqK2/QogI16IwUfEy4iJ8C/3N/nMdGN9r9ZZkCde5sJ/f96zHW9rI7r6 u/jVuS6cr04IHJw09DA0kodebBCJ8ZkECIFizp8gnNfFS4HEJPHyMIhMKO4X EzEa/f07Ckmw8WKSdQovhAlwy/eHPqne5iLQJEi9MB0jTYyD/w01Rbk8COPL ULEe4qEeNsgWrO0T/9lAknpxh/PVruaC60bRhj8xi2XJBVutQ2KA27jI4o7L Su5PoNsHzRqNZ3EUZV7o/kJrXp38GyaYohXcDcw/8+YA29eWjsDWSBxtTI2g v6piCm1RsYN3dd0Ka9q4CzHxzQieNUHFnstXUFL8+0fAGIWuWowXfR2VLNmu VcyEk2WJl7jbB//mJKzT4ifjSiDYCDincO9uBUM7tiDhZ6htyWAxrjOSII6j 2yMe0EbxEq2mebRxP7Vqz9SU+2T9CQW5FHPIkiCIZ8ZsDoruOkEDW0bSRR2/ wewVKxtaTYZngD/70jTeAaSCK4MFJiKkWHPxRDXSZRKISJZi8m+Zwgbr1Yzf ih+lbsvec2DQjWeeF/I+sAqjMAVQSl0zJHEWj+L4P638z4iEaExbz+tkk5n+ erkUfEDCMH78bcUO0U9+WK1JlGMxzsLp9Savy/ikTcfYuAx0HcexoX8ypjvO DIUZyReAY4Gwcsz6MtlrsZOl4mNVpoll9LpmJvnyNGc7ShZsY39jUU+mXkJE SL9DZAwTmyNANGaxTZ0W5Ti805mTD6xVclAdnd1QbGGJ9DA1hJ6EWbDQlKI6 GQBMWmGYzpoNYIsh+u/pt8niLRvwNw2WBEuIrS0uHplqeMUbIxOTfFliW1Sn 6iT2s6r8Tp3dSn3k2Ak4jNBaTixz78SuxczwIpojH58jv1XNQZrends7HZl6 oNjLC9K6FvzApOjT8+8YEj7lGprajGbG7yoEd24Zg2JHhg/sBmsao7v+hnQj 09gQAY7kyLU89Sbzc2iKg8RyWNp8NMjIVsNbrhnVNs/UUrg9HpoDrerz2iDR JlxEWija1nQR6Dl6tpnKfqbY+bpap2kYLNjtJxd7tDWLbE0dFZgRN5f9bLM0 GMz9Yh2Kudc1mLlVjqMNB2+W5Rcux/I4dphPjrN0cT0A/EF12WJ9+d28nJwP jJjGQxPaZkxrYTLFOx3bKXQ/0vM77UJ9K8qBvjjfRB5Z3OtyOB31PrDjYSQ8 y0h2poHj5qULbLSxLcv2aC+LZb2TjMSLcQmAl8peyHldnpWJ5blvMsP1GZtm U7BKZ0061xrA70XvsGq6BIcXw2WpxzeKPWFXLDaJ4UifyoMRn9Tbhwq93DLc Mg/TS0xAYEQXBj4eWDuOpP4dXBA54DNKjB/FUFbs4ZFXtZ1flyITqK9A4bLW wIFR1bwg3WGlumhndF4Iiras0I7dOuYZzSQktBWWh5Z4R/ZLXBqYdY3kgdnh 43TjJbj84dqdm6XwsT82cxm3xctj3Ihw5c/M/mverdMs8xLSnf07AATAdA8K ZW5kc3RyZWFtDWVuZG9iag0xNyAwIG9iag08PCANL1R5cGUgL0ZvbnREZXNj cmlwdG9yIA0vQXNjZW50IDkwNSANL0NhcEhlaWdodCA3MTggDS9EZXNjZW50 IC0yMTEgDS9GbGFncyAzMiANL0ZvbnRCQm94IFsgLTY2NSAtMzI1IDIwMDAg MTAwNiBdIA0vRm9udE5hbWUgL0ZQQkRGRytBcmlhbCANL0l0YWxpY0FuZ2xl IDAgDS9TdGVtViA5NCANL1hIZWlnaHQgNTE1IA0vRm9udEZpbGUyIDIwIDAg UiANPj4gDWVuZG9iag0xOCAwIG9iag08PCANL1R5cGUgL0ZvbnQgDS9TdWJ0 eXBlIC9UcnVlVHlwZSANL0ZpcnN0Q2hhciAzMiANL0xhc3RDaGFyIDEyMSAN L1dpZHRocyBbIDI3OCAwIDAgMCAwIDg4OSA2NjcgMCAzMzMgMzMzIDAgMCAy NzggMzMzIDAgMjc4IDAgMCAwIDAgMCA1NTYgMCAwIA0wIDAgMCAwIDAgNTg0 IDAgMCAwIDY2NyA2NjcgNzIyIDcyMiA2NjcgNjExIDc3OCA3MjIgMjc4IDAg MCAwIDgzMyANNzIyIDc3OCA2NjcgMCA3MjIgNjY3IDYxMSA3MjIgNjY3IDAg MCAwIDAgMCAwIDAgMCAwIDAgNTU2IDU1NiA1MDAgDTU1NiA1NTYgMjc4IDU1 NiA1NTYgMjIyIDAgMCAyMjIgODMzIDU1NiA1NTYgNTU2IDAgMzMzIDUwMCAy NzggNTU2IA01MDAgNzIyIDUwMCA1MDAgXSANL0VuY29kaW5nIC9XaW5BbnNp RW5jb2RpbmcgDS9CYXNlRm9udCAvRlBCREZHK0FyaWFsIA0vRm9udERlc2Ny aXB0b3IgMTcgMCBSIA0+PiANZW5kb2JqDTE5IDAgb2JqDTw8IC9GaWx0ZXIg L0ZsYXRlRGVjb2RlIC9MZW5ndGggMTU4MDggL0xlbmd0aDEgMzE3ODggPj4g DXN0cmVhbQ0KSIl8VQtUVNcV3ee++2YQARFRGEDzhhFCBTQQP6ioCAxKVUQx Bvx1RgYDCkoisUoSiYi1HU0j0di0fqpGI/GTPpRGg1ExXWYl1h/LT4w1Ccto /ERWqcZqjczrmdFa7VrNvevBueeee84+3wEBCMTrUJA7Nq9P8vTz+ZXAK5uZ m1NY5iyvHd3lWWD+6wA1FM6r0P7+1KqjfHcBMA+aUf5Cmd/VxjjALxxQv3ih dMGMpjPrTgIpO4CYuuIip+v4RWsd6/uB3/QvZkbIwhCDDbbxuWdxWcX8Dabk NUBQKBARVzqn0IkbpSuAaRP4nFDmnF8eWEMr+X0Ny2uznWVFqY2l/YFKvqc+ 5XPmVjBuXpV9vfflLxWVD7e6mBOXCgTPURsR5fu2IkrGIgowLv3n85QYl7x3 3v/iOmvr/uB7uHZhB76gONKwm+4hDHfJQknIhsQdtvgntONthGICVlMIeqIb nkM2SZaJx3JaY8wzrmEI3sImYw9VG9v4/k18iruM4GtJGIAcln8ORbimXEaB 8Qf4YSk6YjDGUzc4cZb3bcawEqtwgF417rLVUFSzvlQMx3DjkHEfvbBcrlDP dfgzarGPTEahUYIeiIZbxBtnjW8QiwK8ix2MKZ6a5EhYMQtL8A5ZlE+Zehub 4aEAMVXJUA+ypWxMxGz8Em5swxEKoVz1nNpmvGJcgQldEMeYSnCN+tEYsUUG GEON85iMj/AZ++vdTXKy3KpO9gwz1hmfoCv2kD99TIfUZPW37YuMjcYHCGA8 SRyRHLYzHYtxCJ/jH7gpqowqjEQeWz5M3UmjWI74WWERC8VC5RR6s7dTGe3L +CN0zkgj9mE/x+ZvaMFlCqVI+jlNp1q6KQKES5xQ1igNymlJ8n2Otw0xHKMK bMGHOIpjOEEq63+GcmkmzaHf0TpqEbq4Ie5IP7lY/ijb1VhPi+dHI8e4jXBE YDQqUcWxfRe70YDjOIObuIV/UjClUDFtJJ1a6IboIKLFWFEuVostYqeSo9Qq h2Q/mS5nyWPyvPordZnZafbcf8+z0rPT02zsMZq5doJYfyyyOKKLuCq24CBO sfYv8RUueuuH9Q+mSTSNrcylX9Mq2kmHqZmus5fw7WgxWGSy1TniJY5TtVgp VrH1E7xPivPiK/G9uK2oSrTSX3lR2ajoyl7lpPKdDJaxsrdMkmPlJGlwZpLV EWqeWqduVz9R20ypJpep3HTVXG2u8Tva3qv9aw88xR7ds5tr148rqZIjsR6b uO4bOAdHOKLHGXELfuAsRJCVnmbcAymLRtEYep6mUBFV01J6i96hNbSJPmAP 2AdhZuzxYrjIE05RJGrEUvGGaODdKD4XZ8U50crIwxSbEq8kKdnKJGWyMpt9 qFAWKjUc2Vplm3JCOaVcUa4qrZy1MNlDviwr5e/lVtkgm9XRahnvTepBtUlt Vu+r903CFGGKMvUxzTTVmS6aTeb+5lzzb8ynzbf8yimKejFyDY8tYeEe7CG2 iVBZRa3M6E4SndjzeM5DHnfFLQxTPJyXIO89Y+sqLLKL96UpTer8voL2oR8d RpVJKDxVZQt20QXRIv8ihuAMOcgityqz1SPCiu08jVaIj8U+SkeDSBUTxVoF dJnqcJnrfT5W0Syai+3USoPoNRpAVTgtuil5VINUY5OQ1IGyqQ2MAIukC9Pw k4sG8rS+5lkvA+WrPJ/2YjVndAe+ofdxj1TjBk83haeRk6fMcq73JfBOvanc Z1XcjxaeIKWmE2ggE0/8AaahshJt+BeuqY1cUek8Sa94SuR6+a0xwEjkDuMu Qx33XTFGcMdc5irZz2fvaQp3uj/PkmTu6lxMgguv8dSrNXRjrbHYWGDMwV/5 7T1KoHu0gTtiL79IxWe838SXtIz7cMRP+/n/lseFJlyncIqhZO6HVnWeukLd pjaoB9RjpiSOdg3WcEVf5Gr2Zw8K0YzruEN+nBsLEtCX8aYw9nyUigJlPzIo AuXcs3E8x9MfejKXtVRz9NZyP+/n3mjjOTEFB3COBIWxR4Vs34/1jOI4/4Kl 3+MMLqbdzHHx1O6F79nvIEoRFWwvjTWt5qnVxJgu4DuOtuHDlcBzIZMmsq47 eB4uttAfuVTPGfgQA3myZipHOd49KRjpFE2b+Z2DOzQI3TFQ/ZYEEjw5Rooo Ufbzb4zB/A386xWJIfQio+jEfrSjK41FP894xnAKSBs+IW3Y0CGpgwcNTBnQ r++zyUnP9OmdmBDf62dxT8fG9LRFW7WnenSPioywhId16xraJaRzcKegwICO /h38zCZVKoKQYLdlOTQ91qHLWNvIkYnes83JDOdjDIeuMSvrSRldc/jEtCcl 01hyxv9Ipj2QTHskScFaKlITEzS7TdOPZdq0vTRpXD7Tb2TaCjS91UeP8dEr fHQg01YrP9Ds4cWZmk4Oza5nzSt22x2ZrK6+o3+GLaPIPzEB9f4dmezIlB5m K6+nsKHkI0SYfVC9gF8gg9IjbJl23WLL9CLQlRi706Xnjsu3Z0ZarQWJCTpl FNqm67Cl653ifSLI8JnRTRm62WdGK/F6g2VafUKTe/neYEx3xAe4bC7nlHxd cRZ4bXSOZ7uZeljlpfD/Hll5SEb+0sdvIxW3PbxE8x7d7qWa3jQu//Fbq/dv QQHr4LciJsvhzmLTyzmIo/I0tiaWFOTrtIRNal5PvF498K/IZvdyHDM1vYMt 3Vbsnung1ES4dYxfYN0VEZH2kdGCCLvmnpBvs+rDIm0Fzsyo+lC4xy/YbUnT LE/eJCbUB3d+ENj6oE4PiYDAx4miR3c+yifupUaNfxRZ8iKyZXNB6Fqhxkjy /8191QdFdV3x8967772V2GRTC1WYxCUbiAgUNfELra4yUhsmBBBwQSdB/GjU ttIwcWJnQmimrWSR1o+oKGht0sQETLsY/1jBtmvTqdGUJjMJacZmMhZrqqKd ZqJNCpHX37nvvXVZtTbN9J/u8OPce84995577u9+PD/mNIP/rZxBoeUz0Ay/ KgVe4RVYkdXhUQU1IW8+69k/rGd4/b7QZQID/BcvjNQsczRGhvcycZF5EqMa 7G45nJ0dnjiRKWIWYE0R4xxZn5qbsz6iTvPXeX0QSB+VILfLqvLzkP70dF7g 5kiAalEJN5YG7bqPatMOUiAvuyqs1rAl6lqSK9jS6Fpi7jV+MPkQ8aM+OezJ jP3d5k0Zs+CR/LCS8m/MK2170SJ/UWl10LcgVOPktqh8RM22z4jZnFJ4TEFQ S1OdkpqmSStIuTTWmCvB0WGRgT9DknpFWAMppULxFYa9NQvt/1VJ6ek39ImY njiniPV39pLiqpsTZTg/e2R91oj6iOhGhzTEKzLVovLqUChphK0QB1AoVOj3 FYZqQssiVmOt3+f1hw6r+9X9oboFNe6CRqzu5rRw4aYqTOIRJR9kVWl+l19p Ku0KKE2LqoOHvfhSaSoPHlQVtaBmflXX3bAFD+MpEpBaNablmo9rVKSA6AdV jzSlHQ4QNUqrkApZXx5RSOo8rk6h5RHV1nmlDr9c4rU35wwXU4GXBgeHM71S E/8zQoajUmc66KCI9jrViXr6IlBo3kFV+jGqVv5KS2FbCxRod+Ab6wBVoP1j qNdDblNnWlfQvhJ4FrgXeADIBJYAix0sAubB5zjQgT4e5n6kPE1rzF76KsYi YAewDHhGr6TtsO00ZlIt6zHWJvThR3kX9HuMDtqCcivsVdxWSvavpPthz0F5 m15pWWYLmdARylegT8H4WzlmyEyMXy/qrYsoT0TfX4d9I2QFZLkT71hZPs0+ cq48x6e5jPw0QL8FKAOagSXID/tPgt941FtQvgVxjYIcDdwqiO5Cm9l4K4Yh czF+gTNvkvPGPGJzQvwypuuDczovHoiJ53UO6AXejIstES0jUI9Xxb1y/XjO XwBmqb00H3kZ5nnpZ6yPGR6idzGvHkDHe3Syh6wOxDlXP0StqE8BZkvUkyLa aZ12CWtwiL5r7KCfQk/qZOAflKFeoFQjg6Yjf0H0vxhYiT5flXxYwTFYFyDH izOUir5qgDUY+7ibJ84N6guxrkG0/RRlPGrp+8Bq5KAVeJTjw/h5nHOs+8dK 5fBLaHsK4xQxMOZ4CczdXld6DP7fQV+KHMdeB1sCsK9BTn8O/Bo4yjG4kDxz IPvqIE3tsD6CHAOkAr3AFuYbUAPs4zYYPwntkyRfwRnmJvODuaEfk1xdxLHb c5B7odnZM9+C/xJgHDDBOEBLHUxAW85PLXOW94vbN3OLee1Kyem1zHvlPM+T ORUnn9GjVMoxyHHBLVfyvkO/G1jiu4Rj2q310WbmLPPNlZwX5hrvR94TjiyJ m2uOs0dy4H+n5Dq46Eo3FzH5Bu1Gn5XGFvB0gIrFSSrGS7hY3wC5FfM7DB3m I/BFoWXTg54oZWEtH4TvrgTZyjD7lDUY68eiE7nooz0yr33qXaJP0fVO65xO ynG9U22Q5WtkIpSobWPJiLd9Vv1/A/UdvZNWoXxe77MszGcr7wlzQJkE+FwJ /UGgEZjoyVZaPWuViFlBXnzyXQLWiQDl6wGaLqI0VyRTAHnKgL7C+Jo8dzej /2PKALVgvX5oJpNfO4ezEWOp7+B+ALh/yAfieDSCc4lccqXL10TJnOFzF1KH HId91w30ACcd/BnoBx+/Lfcv7gY+n+X9gDMaaLH5al2M8fM4tUP+yOVnAk8n JvDTTORlouS7hc93ebdgnyKOFnf+fD7yGcdnJJ9zfPe57RNlnP92nB1/lOdw L1U7+zoLmATkoY8jzjnSo0WsS9ijZ423rB5zrtWjnbB6jF3WC+Za6zXjkNWO eWfF7tSofZbxfnLvUs4T34vuPapn0irnPNst22J8eY9WynOAjA3Yf2uoFv3+ nu9V3odaO/Yd8on+nhIv0jdFP21G7Ldpv7D1YhEV85ko1qMMPc50tt+ibZb2 MvERrRdZKL8I2Ua3GyatN37DPlav1J22bazTq2kneJcnnqaf6V0U5LXieahT rRO89tjzqZ5G2mMSONxPu8Ug5hzFHI9J2Sb5xL6vWIM8P3MWfVnXMD9uA7CP vod8Tj52yFxEZY62Sw4jF9yn8bZ8b5D+Ltr/hJ7wJNFuzz04ny5TqomzRI7V RYs9AZl3Ie/rD7E/BsCxCmrSv2T9U/L/gGVpg9hDA9hfDDzt9GQapw9QG/ZS k8yPLZt5/2gDlMwcwfzK5XtiABx/nh41OmmTEQXv+nAX9GHdBjCXtTQD5S2i 0xpC2wXog3hs6Evl+4TvqYD1Ju8XM0pjzQDGRxuOQb7/MK52BvFuoyacJfM8 A/Sc4eN3jaKAe3cCk23I+pNAA7DJhtR5bamko48npH4lvaZ2aCr4zfbj4iXs vTaap+2nJLEK74fz9JSaRxu1YvDuIu4MDX6oixyaoF2kIu0Tef9s1JNoumyX gnv8LJWIKvhHaYU4SCs0C+WxwHbwEX56hKr15XhnPYR+HKjT4DOKSoxmlPOs A9xOjvGJlcIQG2iK9IuDjNUFx/xsXMzbkdvvgQ8cL8rx8XKssTidGK8Xn5wn 9ws/2eZPNI/Ieg/IsOVwqdpCncA+9STe4VFqUHZY3Uo7FSpngHYHL9NCKbuA UioUDUoTUAII0UB7IXMhzwN9QDtwBPibmEo/QN9HIV/h7wKG+iucXZCwPw/8 EnjftcWDx7qePh7iA6s7vq5PoZkMNQdnes5Im2y/l+4Tj+McnmR1M7T1lMQw bqUs00NZaj/0lfBLqOsTaKdYh3Y3iedmUN6gSTKHNgLxc3TXAzLlP8B7cdLH Evsrl+/nzxvjZwXW90ngGzL/++grkkNn8SY3rVeVI/SQcsoaxHluMOw6pcp8 7qXb3XWCvknqE9YPXJmmlZGWqEd5NsOtJ67rzerod3U8XB64MKdQgCHeR3sg sY77IMAwmGM519Zj494I5XQf8lQoyhFL/7V1w0t5DLUO9VbYP6B7GLF6OWUx uC0DufUzkOtuhtpP6QytDLYy2X4OIy6vQc6rFmVf6S/Xx+V54vrAl8RvcR79 BW/mckpNlDF+O+fFCM6X2nyP1fksOZPQ5uqeuLo3sFdu1Of/E7B3TgDHgN/9 T8cBzxUCVwEv4U33Ft4bYbxVn8M35uvUQnSliWjoKNGnD+Mcmgz5MnQVKGdC fgiMhW41JG6joVMo18H2NtAL7BNp9LjzrhyH+gLb98oLTn8Ztj/7DeK1MzTN 9h/aCLSh/AcALBv6F+3lG9vkccfx+2P8PEmT2IRgXEK4pwmOiUMazw0zDCl5 HCjVmk1xIUXJGKpH20nbtGKNpGzQkpQpEgkl9dZNWtep8SYtQmI0Tx6X1FnC 4o5VQq0YXqdqMGmaX7AX06jgRdk0ic773tlGyIym6TZZ3+d79zz3ubvn7vHd 787DfwC/ifIWuAH4Udw7Bu9APgrtRP53yHdCDOnPQX+F0M9bCGNutYN/DXpW xiP/4Rz6v/V7nD8+qaOPX4f2qZgT/S0/Q3xiL83nEl5+1ijN/1JeOkvc5cVx QMz3jtQdZ5+PPeOUHPP5z6I+hK47xvIfIabUVByNWFbF3DJ+LLqKt99X8SRV MWXRMZ6yH1UydpbxK/wn6px3Cf05SL6Afu1R/SrtI3esrWwTeRryFIV1j2xH mffQnxv0FHHRU/mbiC0TUnJvU/sYhH33XbgLa+4iXcjfhF9EvgF7WUVpTyut rXetsXfvaf/X/HL3yE+xp/YW9bUyle5/tajy5+1FNUqV78XL1VJ796fey++x R9+5T/+3+dI+X9JScWl5HLBUfqn6lpsvjzvuyM9IfcxzlS+PS0r5ct31/O5v rxDPrMX/raSy/91yhf9pt+NA/krp/1rqQ/n/+Pb/rXRGGCY7oIdLjvVjI9aR FujF4rmrCWnsgfnDcn/Tb5GQfoaEkD8Lzco1Bz5Q2PvyL9I3EEv/A4E9+dco 8prjoirbX9TAUt9z+Xcr43MVH2LMVN8TmIsPSTu0DaqFZqBv3p5rnCHR9gWO nVeec/nV/E3UdfNeseC9HOe8b8nzHvIu5F2/In38x1g6KRH5DP9Ryl0XMtP8 lZRrVciMuPkPSRRixOJfJBmIkQP8e2QYYijeY7d9JjQnE6nKmpAb5U8QAxqB OEniSlXehGT5E6lVHln9d23XSsUdsYMdhUTK7Q1FI3X824Typ/kzpIkIfhS+ Hv4kvAG+nz9FqlU/zZTLHRpBe10o3sVXkxY8jnAP5kTwHfju6lWxIbum0M6Q vTEQilTy7dyrirh4NemA61yzQ8KY5yZ6avLjqYr7ZP+O2+7VoXN8lGukDqVG UGqNcJ3jlaQdkm/Sl6qoDiUiVbwPr9mHYRHoIyWT6mryZ2xUhPYe5uuIB8++ wRvIavhOvt5eLTLz/GVV7PuyFrTXaesPSUtV14QykQreiacWn8CIT6jWEqnm LSESaeYbSRBiGNRhpIaRcvNxpMYxTeOYmnFMzTh6MY5Yk/AxPBlDmXZ+mMT5 IZKAJpF2oMrVNkZwTiU2bAzN8fu5FyPhnsfYUdxdm6qokT3z2rWrVDFvqqom 1HWOHyS9EEPnB1NrvKED8zygXmVTylsvgbhdUYWhW1OYC4AeOQfn+Dq+Xo1E gxoBKyKQp8TFBaHsHZaVo8N+z96X88suIS/93aJfLPpvC57PsGwKrZhp9p70 XGQd+wsqe4L9iUwixdg8O0+CAP7I0rIX7AqbI13wy8g/BZ+DPwT/pf3ABZFm 6RQMfX/VrvbIl2Xn7db2YkL4iok19cVErScU8bFfs7fIOlTxB/gG+FssQxrh i3AvPMMGyQX4WbaZbIO/UfTfsAX5TbM32SzZAk/ZNbILlq1Jm7ad0l63SSEX bRcL7HV2mqxF0TN281rcPZVq3iBc86iPsp+zQbtB1EYq2U9pP5YLwZLksnRS y35mh2UlCXvBEHMswRKmN2z6zDZzigd9wbbgFDd8RpsRNqaMiJtNkBUYPPxh 2Qlcw8Rg+HogE0qwMdsRtiIf4Z3kezEygmtSpWK4xlWK4Oq+/fSGSnWxUYQc o0gl2FFoGBqBXiAOXA9DR6DnoOfVnUFoCDqE5SMOIg4iDiKuiDiIOIg4iLgi 4qr1IUgSMRAxEDEQMUXEQMRAxEDEFCH7GwMRU0QURBREFERUEVEQURBREFFF REFEQUQVYYIwQZggTEWYIEwQJghTESYIE4SpiCCIIIggiKAigiCCIIIggooI ggiCCCrCAGGAMEAYijBAGCAMEIYiDBAGCEMRbhBuEG4QbkW4QbhBuEG4FeFW 8zMESSIHIgciByKniByIHIgciJwiciByIHLs0AzPRt4GkgWSBZJVSBZIFkgW SFYhWSBZINniqw+qwWD4bI5Cw9AIJNkM2AzYDNiMYjPq8xqCJGuBsEBYICxF WCAsEBYISxEWCAuEpYgkiCSIJIikIpIgkiCSIJKKSKoPdwiSxPI/ymVPDXuB 9uvYXNkIbVE+TK4pP0ouK3+ezCh/jkwpP0KOKT9MwsoPkWblqE/5IBE6tUXY FfFgCeiFnoAOQJPQNLQIaSp1CfozlGebzUaHS+vVJrVpbVFbMa3lNOZy9jon ndPOReeKaWfOyYxIPatW6yiWFvKSug7jeh3CJoJrl0p1sQ6024F1djN+HazD XPmBcT1ALwXoYoBOB+hLARqpYI9Qh1rpDBJm6DjtN6uaO8VlKNzs78TKNDF7 bY2wmz8r0nShYC1mK/waNANNQcegMBSC2iAfJNS9AMr3m43FKhcgP/QAZMgm iMeDWK12pW7OsWo6lXq7mlTIdvwbwc3b/iAsbft7YW/a/v0iUkFniV+GQfQs Zu40fNoWV/H4TMF+YYt52ClbdMD22f4HYXtt/0URqaaPE+GQaF/Rd+O9pe+y xR4Ue8wWLbBW298sSwfQkA9PW2g/uQr3FakNhZaabLEN1miLrbK0Tvxy4qmT tKnurYCk8xQ6dH2O9juoeZ/4QLwsrgH/GwYWn8cVI+2AXfKl6R6zUiy0vYbC EWFHKmV57A8zRbeknxVTvjHxKuqivlnxinhQTLSlddw+iX6PqSZsccxIs9Pm KjEigmKw7ao4KB4VXxG7xD4f7tviy2JBdpMM0H52elZEUeHn8RY+WzziS6su 7hTfEabwi63GghxfsqVQb7htQY4ACRVa34TxDfjS8ht/PJymK82AdkNLaHu1 bm2b1qQ1auu1Bq1Or9Xdeo1epVfquu7UHTrTiV6XzufMVoLPtg7HOZjTIa8O lXYzecUFV8KozsijxFrFe1jP7m7aY2WeJD37Devvu5vStPKxL1krmrqpVdtD evq6rS2tPWktv8sKt/ZYWnRv/wylEwO4a7HjaUr6+tM0L2+N1lu12/GQjJ6s nyOU3j96cmCAeD3Pdnm7ajtXbt2549+kV31sFMcVn5md3b3Z2/Xt2cY+Dhvv +XLng6uxDTaO4eDW5g4lde1AHKV3JEdNqMEBqcWxD9KqMY4ShdAghUotNEIR rvhyUUXONqW2G4IrKG1aRW3UKHHUVkEtLQnCATUOiYBb982eDUT1f53dfW92 3m/mvX3z5u3MHKR9hobvFc/91dLMgea2ROZkaTKzlFemS5PNmefbjCcTo8RF tHhslORxlkyM0h3EFX+Ut9MdsSTALtswiOY8gKEKzgDmaEIGh0E+aeIwmKMc LgjdAefjDHCKhoI2LqhoNo5ijhucMOKxQcOwMXCMmrAxEwF0HwYiBvrGBoNB G+U3cIKjcMJv2IYtsgcqKwNIZZkNwbCvswcqw7ayTNU9SGAGUncXUmfrEvA9 TFkOUxiaxRSGABP+P0tHUxgP16R7z8c7/PF2f7wDnvbMKzs7PZm+pwxjsDfN BUZGCLY/tbmT800dmbS/I5bp9ceMwZrzc4jPc3GNPzaIzscfSwyeNztiQzVm Tdy/KZYcjkYSjV/RtfeurkRkjsEifLAE1xVtnEPcyMVRrquR62rkuqJm1NYV f5rH/brEoAM1Jdc8mePDxKlADLcv8CWbivQdq3lAj670eXoXjFGEB5AznMyo /qaMBg8XVTZWNnIRrDMuyoNm14zI07vSt2AMD8yIdGh2+5vQrGsRBzVn6tY3 Z3xtGxI8VDLmprnnrJsXW+xB8adjcMN7j/3AdT8Sdc9ZeuYq6XS6m5N0uBuh 5szitubM8vVgiSyDqvZYEtqWzLYJgt02yFh8ZHochGEwAvdwdbwWxmHwoKnA qUsm/VK/TPhRoWfYW7r0u2fhD74bHjjHkV1DVTX2KWLXcHmAn196hqvqchzO p5wPeX1LQcNwPXTlPJDjprsSKvsD+yv31/cH+iv76yVoPXMcGsuO81/pUNVx AfWEu2cdAdWeJDgbzOL6fjZUUmor7ueVcDgZ7sa2v/7X2XjW6Xcd2z0zarc9 fM/shOTau1EOnBOG07Od0jNdbGHa7mIrhNQLKViEC3ZTMmo6TbAlySMkahYg kVoCUmRqYTTfIYkWEd7EQcRwBnuQJ6zfjGQjrfpUpCUbQVGo63eA1FT73D53 AAgkenTHEMbvmCK6jQw6zjP9dms96RT/gnS01swLuU4IxMEwYjrKd5zF5YhB mi4Hm35sKuwz9ZBBqymhI+TAsPvYdq4xNZmdmtQnUTSqR3TQhVPYHyR1esHy +mWEzCvMLy4iHb95rX/z4y+O7926qs5vrb+C//MJ9mFy6az1rvXNT49aA4e2 cEvWgCWmbcnDpqeCVChbyVblIDlBBvJk5tAR3Pk6twnBF9s2nXZ8Jh5SuTX5 29Zwayazl79qTMFqoa6WCMuK8ucVykSIt8VWlGzZe+7giabmX1jrh9768qP0 p/jnuOoDa+GX7163pqzbMC4KIkRj4jhSkIY+MhtUQ2tg6nw1rLap29V/qNKk hiVaRAM0pD2kPaGd0H6lXdQYhj+sKmmyqDg1Gamqpo3gU6ZXoIWCQAWiUk3Q CFWQbGrj2p/h5dc4hBww3afPIEqhA4L92mnxVQUrI5iY+TrsRc/Jgux1Rclu Qsj8vDH8DfwQTHSrfrkLXN8ylYrwmY7ClGdTEezOb8hvaEA22yMuCdPn9Asu l2tQImseS5jOSnWV2qK+o/5dFVEqyb2TQqkwxEUdXuZeNs/vxm5MerMD5AfX zpyxblhv4IqbwpE7G7+wPiQL8eeW094bIPGcOAZxqeDGUSRPT5isvqFWCgGR +TJkobpayQQCbxPmOl8FyIAsQovpYjGkVKkPonoxqm5D20iHsEXsdGxVPhZc X5cwDztBYYzKDGMDyYUIyRKj1BClQlGUHIrpLV2tcBVOb2mtEiCCIFG+YTXz JJmIFPZqDrW42ItGyCbYSsEYuBr3YQGPkAdMVsZwNetjhI2RBxAFBDNELM53 btzMvTmVasnOv5nqmkp1ebKt8Y7Yv2H5QARFIy2T4M2qSDYcjnCP7nnuwp4l Hs5kPRLZc+FCzrenWS3TalGYO7U544ScuBBy4igSpq0hB1XGpi3w1J1BiT7I SxJ3pXIpwOcT4MK+AkEQz1lv9WXPfM+6SFbihsV/uIhbrGFx7M4PiZG9xFfH pukr4kZYHV70vtn6EttbuLfoMPqp9Dv2nvCe83OBBVhIDWmLChcVpcU0e0l0 yAVycXFBcfEislgIiHJIfE08yN4WfusUo/gRTPCjOsKX0A2YVJ5G3Z5amyvw HSN4g1nsqaSOPDMvvzav+Vsu/IgLu8x5nlrXCA6Z5fmViuC6nvc4uo7sobzV JbhkXkW/jF1ymVwNMTtC9g0v6G3LOberZbJVT0G8Tk7B2sxOhVNdl8Oc80qq phqlIBRTWJSo30BuHfmM4qJiMRj0l0tuvWjZ0uU0isuarHeuWX+zXsbfx7VY G/j2Uuuv3mM7j/zx9/07T5IFT9z4BL+KN+Dv4J8c3phZ+8yLV61b1tVrB7jn gIiLIWad6IgZYFRUBMKUAM1/Q8CCgCRRJJjIDocTOUSHIf1JxmD9K2a5qa3T 2jVhh9anEUOr1vph1VKNOA2Izmo0DskZYMNqTTr3kTzptuiprmdupmbyrx1A QCCAUvwvA+EwPlTaIICbh7w2GyxogChIwiIWRJ1DIWctc/vuXgdwiMRwyJrI vimOZc+RxltryfPZ3fBNr0OGOiaegp/EKtO7ToY5IBRmGTmo6IU8l7OR2BZK NaP3LGzVLW4a1KJ2frS1zXsd9FwST91++Avurx8hJM0Hf6nEYzqdQtARdEL+ wmBwn8lKVtQqxoqVtQxOEsMz3DxasgRagUjMofyTXVMoZYpSQEqozsoUP/ka NVgVpPNO2sG2KbvIs/QoO6n8ko0pN9ktpegw3c8OKxfZ28oHZIK+zz5UrpCP 6b/YVUXbxZ5VXiD76Atsn7KfyAlnB9lGt7LO/1JdNbBNnGf4vvP5zne+P1/s O5//Yvucvzo/4Fx+HNLmGGlKEtaACCEucgmiCYRqC0alkEqUgroEtnaFDtHR oZGpFCiVJggjJFDGzzTaVZpArKVUXdfRso2fBaQKdWw0zt7Pzn6wdffefffJ vu99n/d5no97nhykmGaynWpm27mljqVsN8d4uSrRJBsok53DNYkMplyaZTkP 6aM0lpmhwUJIFMfaeYZJ0CKfAJGVQfIWOgTTiU+5VYpOwXRYYonpxCcY2mvJ +MLpsIGGAlo44G2obVOjS9GS+V5Oo6pJ+aNJPOAfn55jVcC/hCkHyybyAgC+ kUvYSLgk4WdsPEWSPAd8xzgKRSSOI+EYQ9upk2Q9YYc2XJY27ZjrtMWdpj3B WMxmB3Kc3gxVOO0MO3lynKy3FPAJFkwkLJhEJAp5xOOfETAi5XuZyXhcbrwj N/p0eSozlWn0eWWgMRgA8YCXl3PwhLd9mNdmOKxgMeDVMf3no84wJqx07pNZ l3dEGQwbhDBCQcddO9EpxCEGvZedzH6e/Sr7J6Atr+3Gv1qorQ9exAcAEfcg YJjwEBHivrU1KbVKS5k1zjX8YfagOGKMiVdZjnbQnOZQuVqxRWyRGIfMutyi W3LLtWKt9IS0XhyU/8A5N7Ib9eeD29ht+lCQZlU3y0viYnG9+LK4S3xLtIth gXcLAi/xHkFTiwpkN+pxj7hJt5sIR4qgTQRR9BAOEQtHCSHIAil85C8ZoY/Q Z+lLNEUPrzVQ2JhlkEbE8/9dFJ298n9dBG0OxudeevI/XT6Va/IMRCzCyeHK eFoE8UWunBrnGC6TxllLqKrHTTOqqhVEbJWkYbhcwG+1NWZxSbFh7CYHbn/8 0vlzPZvWHMv+/Mq6zqf7Gj/7eE1jx/zYr/5mP9nx4da3PwnUD72b/RI1vZuK TO21PRnr/k7bMhB06Nu26b9SX4NClKNL1qMTrvHgWOmFcgpkwAMy4PHGe+29 pc/RG4XnSj/lrxh8ilsiLommjNV8n7Iq0l+6qnxDcCi4O8IrBu7tUKGJo9Wr +8xF0UXGueg5g8pEM8aW6BbjWvSaQce5R4RYNGYkBdNo59qF5ug8Y43QawwK L0S3Cz+MHuAOCoeiBSzHCnSUNnROF9QoEzU4gUJal9fSw+aAFw1493lJ70my l/AD3nlfstCP/BVuGzEf4QZo9YXNWchCC1EP2oFGwOmeRQ50h7J8SZlCVMUj rPfutIY0q0AztXampNhXWVgyIh+RSbkd3XXlC6hXXJ6RovbF3UcJqz71XVy9 J+VvIMbXYVHKxO+l49fzcV38OvRFHu854o5CPvzBxyAfl2biV6MFySikBwLc /W5UwXeXLElJCmElyeUOCY/dsEQexoQk58VHQfKhrURqhpQ8DVyDUBOtgTy2 CvOiLcYB7p0ol3NpRDoDNrZIxTqYgwn+1pi1tdVhKi+SDO1xayqVQxZW0DYU 9u0bfm3nowvMiTs9w5vvvoPcSGOyVws2bdrSWlVej45cXP/KNHEmeyt7BX0e 2LltcJHZ6lcq53QN/nLtb/q+/lDIrKyJJs2iqr7vnf7Ri398FiHsilunb1CV 1GOEQSRQxlrN+BwBe1D1tfnnB1qLPpO/cLG1eou+tLhPX1U8VPy6/hPfAd+E /33fB36epgWPSutqCV3mSekbyCHyAH2cvkDzZ8xPZTIYS8x2lQsxK15pxqxo KZz0oDkQ+zZGxlqCGAWzRMl8NIiIoBw8EvxnkAoGy1E1YcGoRBTCqy2JWAFX U8Tyy3Dy+swIbBSPUwwvcOXY1MCzXITHuQgzymGGZbmdodnFjjK2VEgV8vt4 Ejh0GmjUElWT93WYyOyBvvrxLIRQdVlkuYa+0FCHtlwb0GyaXt0/d8berAMU ZSbT2OPE83fXsQEAAo43NTYB6eawlWOIeL7go1VBlElN5m8miNj02RP+oNkZ eyZGpuMp7A6BNmwiGAKs0pk0BkEJlBzTh82tahGMApo2ojkk1NXWATLALSGa xmAAqMBQbQ3qnY5fvvjeeLvNX5S95ZQZ2/z96f2nu372+m8XLBxo70RP196K 1XU3L3i8WnaSX1a+uSu1/UR2/JUfLAjU6Y6WltFtT73aHigKBxY9Pid7WUl4 SxrndCWK62K9kJUlgIYmQINOXLMWdUspJaWulvqVfnWTd1B/g3yDvyBf8H4i X/HepG86bhbc9NynC+oL6j1tSpva4k3x/TzToNSpdV7bBvsGadg+JG3XDykH 1QllTGXFXJX8Jo7HFbcpVgt4RA+ZuSi5TOEkoggOaqi4nIQFUwkL5hHVO6BW JwGvFDwKawzCoyhCVAn4Qoh0gNb6/EzErfu68+XD3hRb0/i9yTg2p+nr8bw3 hZjvvgxY05wZzWW2ts6OE499KpSDmp29La7s6N+0+dmFfR7kjt/7/c3sbaRO nv8L+ffE4s6dh0/vXTZQ9evzqBhRoJFFB3EndULuVoAaSkSA2GFVKCk6xaWU LrXLmwr8lNnD3mfZtaGXQmSDzeQbPKbeZmvm2zzN+h6WdQNuR+1OH4av6GRE CUrBaWWiUIzGUZklSYTvtRAKyRGHHuxu/O8KM9/AVmaqEe9r4DvZNDmjSfO6 LaGf7uf6lT61z9sfoNOpSKRmZoFKdUIDoQdyyXMPpIBakX0w9+hTJ7IPsudH tyJ9SqlqfmHFtpdXPTO8d1kKlQA3i0jfRcrfrj284Ptv7z/xi32w3rmw3hLA ipsIoLcmCHn6vtXiTO5h3xR2y4fsB7lT7Clh3OdwuNF88gm6hesIHRLG6DHf +9wH/BXuKn+f+YcgBKSAx4Iu8Viiy5Q8ZzwXPTZPDg2hplwUNYjkqxYYAmWh 2COSolfBGjKm+01UreS2N8FwfpsTLcvHeEU+egO5aElAKSOQUkKG116uKJDm Y5RT8eJ0x5wMEUFVnjyIqkLLQwOhfSEqJEUcliCZkPAZRog/tN/5N9nVAhTV dYbPOfd99+7r7nsBYR/sZRcVCItKxexFcaNx4jMSoRKJjSgxJWBGTdqqTDS+ R2IyCMEXcdqKja0UNSNJMzrNtKaTztROx840rTHTmsFMw6htRU3YS/9zFzSd znA5u3fv7jn/43v8wyAhutuvF7lTfn2SHf4BDfkpX5kKkMqYEqPCIeAJlR4G HlLH6YquAxOPAtWYqmF+AcEHaiU99ICPLv1nJflx8211KAUmDZ6/QVmkwdze pkOWbHRTG90eBjtfCpk/ag63IHTgXMrpRNCGGooxbfECkBna44gJmeLjymqN j3yN/dO+PGP88/Vm7P7TMFb5jM689tzseo15pXZlVRXGS0t63jl/8Br0QrFx 2fhwy755+MUfbJsz52Wz940lbKOpIiV4ob56c96uPKIq1tayndb2MrYAg/Ni SnE5KWd0PIfMYb5rr3PXFdbGa+Go6+33nfdd6kxruXdmUflksBzeBUU1k28r GZ98AHjbolgtCcWq2bw+zxSrAqLoj9IOOG92gFlom9NM0lmLkl2LEtkGiBRm 17JkthEkT45J/qs4Crh8u0YXmzyFNoLFI/gDfCJuiQX9FHRSIBAMdpThMoDg BV1G5dGQGih9iL7/jOPPMezI3EBZ+AHDbMhagAkNQObhzM0HJCVplg/TaYI6 yEp6gSMGNUBARw1tJm7tze7mwrXxpuLmEsAtavBxXt8E91cAhMcL6KsIgZEm kQIQC5f7EZZfxdViXlFty/RCl3XrpT9vWY3xxd+0Y+Hx1g86jH/9fXR749oD u9et2Z7WZngmhbxlkWcPnz7fcRVbcPDnnaNP/Or9F6oGD9jI9lNH3zn2k96j kKw3YSqtA17zogG92I7zcSUtpGM2nu38DD/AksB5uShZ4Vzn5DAmLrdTdTFu gu00qXmMADOj2yN7EbLIMVHSC6LJMxIek7AEaYaSeMPR5Bv+Xj9p9d/2k1t+ 7EfumNdjwhae7fXg2x7sCfhS2cSDe8tOvNTHjYy/M/mPWvZhyKnPlFiRSiwo LHaCvk4iHphqkibd8/Qlfnf3h88dWZRnDBUsmZVuKTfAh2e+OD6vdXdH5iAp O1lfUbNnZ+YrCBp6+y2w4afhJYMEtHkQSXCylFNO6dJiibRL/dIl6Yp0S+Ly pUZpm9QLNziGFxDHMsDiOrqCPodvNhCMeI4XWJkIoBlmL4aiSTYgjsf1KA6Y O2DmYDgHjShrFDYUu+ih4XoLB4whHGDfw6wx+s2TbOybT6FCe6BCq+CEFvTv QcSMXTtrdaYYuseWwJSkwDgYF69JTfwZ+aL8sfSJ/KksL2MaGWIV/FKaf0bc xHPvSdfZYXaUvctzC4WFYhO/hd3PHmaPcD18j9AjyvmsyhezxVyCTwgJscS6 gF3AyeBLYAwQZU6WGJ61cCwPUSKLRRRkRpYt7AXyfT3IlYiV+QIW1liJJYbb Ec6HAweU1A/HbRaNO+AYafMDouj0OjF8ZadYEeYtsWoCTczYxwNSKInMcZaO rmgDuKry7MQKf4JzDw7g+bje6MSvG3807m6HoXUEbzJ+lHkWX9tjnIatH1Vz 2SDiIEdxWktuMUfauX7uEneFu8Vx+Vwjt43rhRschMSAJWFiGE1UDQXY/6va eJ3KszXi3v86DXttRYjvBlbU8MxBFIdvN8BewMKKh/cqSSYpJv3JSA2ZK871 10SUAqYkvkxqjLfHj8d/zJ8Ufqqc588r/fEr8c/jNhQviS+GDy7Gr8f5uB7M Tabgfbv5ISeEWCGY56VkJgvUJeuTWMHhdGo5ubkxTYbWsztiqlOvr2h04peg kS6QtG4P5sTycuHeS7m4MRfnwr1zhbGYRh3HAEKaKcJSiq76NDi3Bo9qejVc VXBFtaSmf2dWskT7g3ZdY+xavtauMUgr0Eq1MY3VAkX/qJow0uNjUZYrq0ZA 76pgaWugywR0HSZ8U8NAjiY3Qj43FFOLjItdIQ/1yD7TKfu8JpS1h1B+hOqt mNl3qelQafrEyo0nigDbedqSmeumGkOTUtOq100xhtjYwVNPL1/+9KqVNd2Z OrLq2NSqefsOGYSkD9dPTu94OzMKaF8KrqYHamYFD9ylz7uJh8R7rnse9jK5 yRE1wAUkUueoddV66/xdpJvvFruUC9JV8lfub9JVZYgb4m9aHSfFT8jv+Y/E 3yrcRnEPv0NknGZtLD5aGzcruCuFYGNOaw7JsYXQ/5jWNhhe0biVm9AEqdnR BE6u2c9iKggwOCZVyAXyuFEkHI0Vfov9l+7NHLmDk8bvvnrTuLcXFxxqaens bGk5RML7Mb/XuHzrjvHRjrG+Y319vUf6+ii77TNeZLsgXge41h596gzXPBdR k0yltdKVzKlh5lvnu2pyHuRItXztQzc7IjzIEaGrgqZtFah71b0Wi8Nu84XE YCs4VWfcZrPHHA7TvlpaUTvsFMhLZeNse2q4ChrBcWMi3Kx4TjA2VcEmvunb 7hU10CagMYNBh/lIowb2UdT7MF/+ixcGMTFGB1d0LAKG9B5oWv3azu+t3c3G jix+3vjMyBgjxl/SyzNfMoNn3z169uSJ44DPXQgx083Y+/SiLg5LNryMa+I2 ckyJusK2ztaqsrJkV/IV0qGMKSSlLFKIcoFs1uOCAAadIbxchCSHVCq1SqwU 3KYeV8kqdZt6Rr2isqoDxTBjxk9IO+7FBAecqUGci7JJGIcDVbKRhsBTN5A/ 6+IBMJWPZVPRhhb0+5Yt6K9YUr/il/JjMyAPoZAzmwmfYPa9E/dCuNyc9TWN dc88MWvm0hI21rW+puLu1OqfGXcgxlLoZwfEmCC/1i/xTj4iaj6nL9Ktdru7 tM6EJLjTbqJ+YB20XQ59EblvHQnzcety6xprp6VLPRkeVITqiB6tia0NPx/b pe5y7wxvj0rTY3P5tOVJ6yJ7OjQ7LISjWmy6UhGqCFdEKqICL3NOKeS3ako4 HI4I0bA++WXlFfernk3xjYndnh2JHk9n4lz4XMTajjt8+/1vJ04l+ifzvpBX D0WSXj03P5nvxde92FsuhhYXdhSSQv2/7FdrbBxXFT535s7szmNnXzM7u2PH 3l3H603WwQ5eO1nXxJM4ddz4USepm7jg2nkrSkJwUIhbIZoi0aStQKWiUYpA jVAFqEWqYxvioCIFiIRQQVRt8yNRf1iqKVVEhRWZkJTsLufObAK0KqYIIX7M 3fnuPWfmzN25585855z4sny91ci4yEQuGmwkzY2kqZE01qSaQyTUgsVgha+c EU1ctpYCyNa5iVnm8tvIQZi3jb9fSR5y40xDdnof3ABjt4qEiCRGMum2VHfq ATJs7iEHzBtEJiZHrVSay0YDKpe1Rimh3Vll0CJWd9TXWRzBgyV1dzAyXnUB 0uXXWB6amnXH9Gx5brpmOdPnpmuXu3rCcnS7CoWDAdKW7k6fCXwrfSn9VlpM pdUApRZUMl1oYTnvtLmqk1TKAkdP1+fZaC/DiACkmdhkkNAxcoIsEB5ICLUx LFGZZTSGloTY/UDJKF2gHFtCzMapYy2mjfOaNk5q2q1r8qad+xR29Suww3mD Zq05ah4xqTlk2ZiuBS0yaJUtrrL48dziiMvw8zmmLuYqnM8qFeYM9+KwEyJh HNvIiFPsLC//2paUSGcwix364Y8/CRRUXS0wcUotoIeunVMKTkFD8H7kw2h9 zEmFWzEANOBL15p3YoLgFjEG1rQUA4SOWXKmmViRz+8+vKZeN+4r/eizX7n6 +6tvZUt/CY/uONKcrM6Qnw/vWPzTlSJpym0dylY3JQ093LvuweefevUbT69e t6E2VldjVO/b3PvEs29M4ldUW36P+6bwXYwJv7VXJAELGnlFsF3brA0HfQkD 4nzMADMS1YkZ4XQS5yWf7FPjzN1BMM+akyY/hsNFkzdnCZ0yCKPMaTBEH6NO TVWkJrkJsHYaRZZACzsb5zNmZMjo1F/QX9H5Mf2E/oz+ur6gC6CH9KTerFM9 YU2cvRNieyfXIE/cgzxxAfTyxbXDHf23MboujnSEFhOMWpBekXHRdB6Da7gl iI1xDDHqwrrjU5M5LYMuDde1trTWh7lHLyoN1Q2b47u+3PdoQZEef5xYNDNX euCrueqqqytbtty7+jnyu7k3Xyw9if75OrLMNprBGuE7trk9vD98WuAlMSF2 cB3hXq43/AfO59QDYarEQDZ0XZbEqJ4xDGAEqcWcsiBGyvjNf1xZICsZyX+3 LPCTBT/xf3xZ4IaYu8kkC6cYOFOtorPMVkwcnGW3tTGRH2j/2YGDL/WRRO3W zp6jK0nihaFdD790mjtbis/tvef+Y/PkIibauE4JM7q1uE6Va7BXg0JkEDnZ J0hVEONqaFiwfLpUI4dVNZLjc2KdUuALYg/fI57hz4iSxp5+onFTXgaFUoFK ikzVKrBoTNClhGyoah1kaYOwSsrKDepqWCOsk7phE7dJ6PHdJx2HCXpcmJAm 5OPqSThFTwqnpFPySfUKXKGXhcvSFfmyeg2u0XlhXromz6u34Ba9Idz03ZBu yTfUVcJs+U1bqmrP0wx20mz5qqPJTFPvXAOmiYwtEu15VkGcx1GxsXMZcsZP tIBzHdNwp8IwUFBspikiEo6PElEC2c3q2NfPvl1W5lbN/EKhQnK23D8tyhKO ffaneVCTeBevAkeoyguy4pP8ot/nEwRKOY6IqixLOFuT1qlxmmla/vUS0SCJ Pj8MCsIGnmgzSZIIXLpALDeuWon+ohUvFq1EMT5w796N747gwzjZZSXLDHU4 D4RH2Okh7Dwl0hO4ROPwDbIWMJaaUexAAVd8cypQwAXfRIpSbJWdWUCK4t0B tbkphWlzdwjLYTwWw1MkFY2yg6R4ngyXJkn4V+dJ8NxrxCi9XLp+foZmij3c LMNfr3IvF4fwLdNKW+hWfMuiJD8TyQokymJEXA3m/bFAMO9jncg6IYbnOLYN tVZ7HgsLGlA0McRBVKRRjuL/YZIWHcMAOUtesSNKMNCkZSFpNBtjBr9gEMOJ IJk8G+1IdU3eQCfTAm/HE/nHeJa8NNgS52gc4ZgWIQWwq9vySWhmGZ1+qcJA uf5iAns84kXH67nc+NH+0OI85rIjTa7rCRKPk9s7rvdpoQ7mctfhI72TISSw diSwKRqCn5YXgJQXzvEhshbbsBMuhPJ7toaVbTQUTWAXiXfiO70wjQobp1B3 5xp23e3T+Lp0QwP7yNdoJFe6SepKT3bVd21/bHDLQGJD666HE+h6jbt+m7sw susz6fDbgS8OQ6Ud+gS4gcRw4t8H9+1PDqq7EAY+CjH9IWDV6X/jo5DbANTT /xm0F10E5wBCrwNE3nahzwIYiNhDLswnENcBEt93YeG9Vc+6qP4SQO2rAEm8 L3XJxfKVLup/6MGDBw8ePHjw4MGDBw8ePHjw4MGDBw8ePHjw8P8B4IAAazrw TCIWQoQlG18ZFfXv58x/NFgOGTbkEE3NTGpt+6cJNkL3ph7Y3NsHA/cPwtZt MPTg9h3wEHxu6f/+nzQKZ7FPQxIlDvsVkIf10AU90A/bYCfshQNwGL4Ax+A4 PFIuo20Ssndt+mAr2uyG/XAQjsBR16b8zr/+VXZiqcYvaeGHfZW5eAhjTyor CuPPlUWU0mzHqYRn0tBSkTnQYKgi83h+d0WmKH+tIoso/6B7cMPGrq7c+qMH dh5q3HDk0J6lT0A3DMIG3Pgu/OXQUUfRhTvhEDTi2SM47kGn7UWXHUN5J15d 2v6/YcE8Ij4F16EDT4jogRA0oQ9AHMBd5VHHxZNnQAA/RYlpd0bYx0Xw9rvt w9vQiQ1sfC8e8bNpfuM3KFfZDe7d/aVfrl47Guz4sz/hd6y/907HMjZeuPzj 6Acf3C6GwG+gyvbHmflvAwCCgD+ZCmVuZHN0cmVhbQ1lbmRvYmoNMjAgMCBv YmoNPDwgL0ZpbHRlciAvRmxhdGVEZWNvZGUgL0xlbmd0aCAyMTQ3NCAvTGVu Z3RoMSA0MDI2OCA+PiANc3RyZWFtDQpIiVxUC1hU1xH+55x7d5GXaFBgMfGu V4jyiIoxolJEYdFUUB6aLFYjy0PAiIBPSPAVo9j1EeNnqOAjsWrEmJiLRYtW W5OYxH4KWJMmMU19xVTNFyPt9xmtxr2dXa3V3vnuvTNzZs7M/GfOgAAEYQkk sibkDkgoqHRWAZuPsXZ8YbmrcmXHp8FAQydAmwvnz9XqY07P57VvAMvA6ZUl 5Sdr8hoBayDLs0pm1kzvdTOxJ5BwHMi4XVrsKmrfGL0e2BLKPs+UsqL74O4m B6xluW9p+dzq4KedKSy/Bdj6zawodNGlbbeAxRzfFlfuqq4MGEtNnM8Ottdm ucqLF2yM7ApsepflW5UVc+Zy3vxsWu1dr5xdXJnjOXYVeJLj+5vqIUTwa1N3 IUKJRjhgXub3ivfvKTOveNe9f/E9e7fef4EmvEdleA9/wofUyV7v4yBacBxh SMNm1GID6mDBZNb8GjlMKus3UITZggHYxvlsQxvbPo9FOISeFG5exWIsl5+x 13JGug9GIQsVWEMZ5jxMwTllGYYiA7NQSUtMp7nWXG/uwE4clMfNuwiADYVM beaP6lfmN4hnjzfQgHO0vst+pHCUJWy5BbPRKKcqZJaYtzkDOxZwDgoy0UZH RSzvXozLFE61MpV32W4a5jG26oWpKEUjDtEQGiPs6hQz02xDT45Rzbs2YB8O MLXiCL6mQLXT3GF2IgJxeJbraUE7HZWeu0s9IxkxlVHqj2G8UoE/4lOcIp0+ EBVqoJqgpqgvmZ8jFIMwibPdxZ7/oJtiEdNi+YmSbo5GMOPyuhdtfIwLZKMB NIGeE/1FhdgqZ8OPIw5iKkIZ472Rdz9LsXRABIoOuV3Zo9yxPO45bwbziURj E7bgAwriSjWaQ6/QF/StSBXTxCZxUW5QdiunrS6u+gWUYw324CZ1p0TKpl9R KdVSHb1ODdRGp+iKGCUmihfFdVkqq+QRZTRTrjJHWaauUFdZrnicnmOev3hu mgnmCmRzPyzl7N/AVq7sIDpwhukcLpJKARTMpJGdJtHLTItoDf2Wmmg3tXCU U3SRrtK/6AbdEWCyiEhhF32YdDFbLBAbxGbRwXRK/CD+LcNkHxkrh8gkmScr OKs6uY5pv7yg2JQOxWScE9R69U21Sd2jfqh2WgKtr/jB7+TP2+/G3D3rgWel p96zz9NiXkAPPkMbo9AbSZy9i2kGn3c9d9z7+IwCGTsbxVAyZTAy02gGVVE1 I/kqNdJOX+576TCj9CVd55yDRC9fzk+JIWK0mMD0gigWVWKdWC9axBfitrTK ANlV9pAxcoycKovlXFkj66UhT8q/y4vyJ/kzk6n4K72VPkq0EquMUaYp85St ymXlsjpFPaF+Z/G3lFtWWFot/7Q+Y022ZlmzrVOtr1kPWD/3y+fu/Aj78Xs8 9NB5uVQ65H6sFYOVCNEu2rmfp6FIZgruVNFEK8VCahF91WrLCDGCxqNTiWas PxFvip/ECJlJ4ygXM8Sge7tZQpV3+JekfIRrymGurZ13rrYE0iJx3RKIfQQx jGN+LAcqsfIEvpbnyKpsw98Ufwqja2KXzOIuOKIkq07Y5WbslVW0EPuFg6fT Hb/V3Mfj6R2eCxMpgW5JE1KM5y4aKr/FMrwovsI1vscr8RsqUkqwFoOpFpfx Nt+K/uosS4ylB/1ZlClu8Ri1QCi7ubph1JekGopXaapstFwXZzAPHYo/zsp3 OfsOsVdmKp1qDpXyDViIFagyl6JGdSqnqQSSnkOUcp6nW61MUOz8X8xTZQrP tAN8uw/xHBglM1kTzp2TwX0xiSdEI9NGnhMKd1AZ3/HneYq1o8UyUbSiRA0m njqAcsKTg8nm22gwSzDLXI94ngd1Zi3v2ITv8BqaaLnnZVTiCb45ZylDTRcd aroZL9zijMgV9Y+eL6MdReH4nmkvC8nqH+BWvkQuRpqrzb9yd/fjCduAAvwS l7jKHznCWHkUgz3jRbOZLiu53nPINneZvckfpeZMTMBh7LSqcFljU1InTRyV MjL5F0kjhg9LHDrk6cEJgwYOeCo+Ljamf78no6P66n3sWu8nHu8VaYsID+vZ I/Sx7t1CugYHBQb4d/GzWlRFCkKcQ0/P14zofEOJ1seOjffKuosVrocU+YbG qvRHbQwt32emPWqZwpbT/88y5Z5lygNLCtGSkBQfpzl0zWhL07VWmpztZH5N mp6nGdd8fKaPX+fjg5i329lBc4SXpmkG5WsOI31+qduRn8bbNQf4p+qpxf7x cWj2D2A2gDkjTK9sprBk8jEizDG8WcAviJMybHqaw4jQ07wZGDLK4SoysrKd jrRIuz0vPs6g1EK9wIA+2uga6zNBqi+MYUk1rL4wWpm3GqzSmuOOule3hqAg PzawSC9yTXEa0pXnjdEtluOmGWEvXQr/n8ibd0911j28GindjvAyzSu63XWa 8Va28+FVu/ebl8d7sK+ISs93p3Po1QziuFyNo4nleU6DlnNIzVuJt6p79RXr Dq8mf4ZmdNFH66XuGfl8NDa3gZwa+z6bLeWgeR42h+ae6NTtxshIPc+V1qs5 FO6cmt9FpGgRj67ExzWHdLsHbHNw1/tMYNDDTPGDNR/nM/dy43IeIEvejPRn uSEMrVDjTJw615To/RQnwl2YyGb85BF7GUV8ImVGl9R8d8hwr97rb6hRIbrm vgHuAP3aD49qXPc1lqiQG/Cy3j550Gq8/l/eiI01YmK8LWJN5TPlHJN98pD4 uPmtQtcrQzT+MXzIYmxdecMHMPx2u/eAV7WmoIAFY0m2856soSDyP9xXfXBU 1RU/77373i4IZSEsFTJIYhI+hECA4bNIVgIBkoKGZJNNpCV81FJXKjXV2g7K ZiIhLKTT2sLEgDRJsdCEDhuMNcnYGpjRFDvK1GmwrfTDj8xU02nVQTuC5PV3 7ntv2X1hDLXtP83sL797zv0699xz7r3vNAXmzCyPqZVc0+PU+INcE3Fq4t0r MxDJHcRPWX/MOzX+G+ObkLJq+9KYMuFTqr9i1RcWZxQWVYTSVkUrbd8WliRJ Vv3ieJ1diqXkhbRU1S6pqZqsRVBujDdmITQqJrLwM2RQb+v0eBGVUqOk5cd8 lWus/+Uj09NvsFOn+R73knStm21mbOnMZPkLSXKSeaOiGgzGNVhYUhGNjkyq Q6hZE661CRFPJaH0tLwYBZGZWfh1mj2LGeWpsQBclscNEH+WyhaTGqba5XL8 cXRmz8rHQReN5mek5Ucro5s7zciWjDRfRrRLPaueje5cVekETqfZvT81ln+g HL7arixFUqi0oj1DqStqDyh1xRWhLh++A+pKQqdVRc2rXFHenom6UFcaUUBq VdaykoU0FqhQwSJPq17ZPrULXyMRWSukQspbOxWSOq+jU2hrp2rpfI5OhU5Y uoDU8R+fMXklocTokSlZns1XGb6clg+upzwfXT41ONUnNYl/RtSwVfzOsBFT X6MviyryA2s9k+lbeimFlL1UobbSLoY2mQLiJD2Atq2Q7wB3c1+0DwJ/BpYB pcAkW7cO2AwUs4y2XdwXY+zkcSRXUYV3Ct2vl5pXMd8hvZfuAY6i3CLeohPG EtoB+Rj6PS+IFnEb9DlktFID9EdQvxW6o+AQ5GaUN6Jfjl0e4anHtxoYMKCf gXH22+udpp2hhaLKfANrKceYBUAt5rgLnA8Uok0KeAWwV+mlOqXXbEE9mGow /17WAyttXoNx9qA+F/0yIdegPAl2GOAxQDowXT1JS9Tx9Bx4DtZfZq0b6KXt vOb4mmC/bdNQWDYWJgJz/gLIUJeY/eARCba5UePCWm0+RcBhIBUoUl+mHeKL pMBfT+j9pDG8ROynPwG3i220HrICO4v1DmpkGVgnUWVeFUeoSbtEi1H3HeMQ 1rEN/sbLV/2I5qh/o2wji3YjvlZi/GrgKMb8q4yHbVSC+WeD54t+GUO1wAHM 9Q/HT+wbyNXY1w2Y6xMvx3ArFQOrsS8R4D62B/PPYZ/zviulg0vQ9m202ciA /vMSWDvHJPfh/hgry47DlmtMLWhTD7/+BSwAP9vgQMaZDdS9iHEmAgYwGZgN 9AMtQBhYCjwLTMfchHk1Ga+IGY5NGR+IDb0XPoRtMmatNRyV+2nlTLM9Fs+T bpyksI10HpPzhWMWtrQ7Y3NOccw4LOM7zHGvvM/r5JiKM3JPDNBqtkHmIGLL Yc472Mz5cEgNUh24EXFcwzHL9jnMfuFYkz5BTti8LGGtOTJHwBpRhh3rNQ47 vojzdjqGMSuNLThTmmiN+Cbe3t+nLeI9WqnNoNl6DnRYD9rG1AHa4MW7HHt5 J+QnXNzA8PQp9+o9WGcb/NlHT8Kn3xB96q2iT9H1NvMdnZRzepv6qCwPYTeU HquOmZFY9+/qPwvUC3obzsw28129zzSxnsc5JzwDSg6Q5jD0p4EIcJt3ptLg DSudniD5DKJLwP0iQEv1AC0SPdgfP8555AL0Qf0Nel6rp32iz/y9EqGI2ke1 Hj9txvfTGJ5LvUA1DB4fvDMhjpJizh1LDjvx6mY+8+2YmgI2kH+v2HjbxkfA h4ijHyvWHIv4fJb3A85ooNaKV/NyPD7P0VPg/U58uuI07IrPUe64dLO8W3C+ O3kKO/Y56+fzkc84PiP5nONzxmnv5oT+UbUVcczn8MtUYef1rTYKYOObdu7j HMZ+l5mmkW8eNzrME9o484QxD+XfAbp5HOt+OH6nhsxB+z6d4dyllp5ucu5R fT7tsM+zY/K8+YB+KO/RUmnfCOMU7davYN9xBkp7m+wchD9hd1hUwueNdADr mKjtRT5CD2xkn8i9ILqZ7wW+E7WD8DPfRfVUo72O9wL3nU9j5X2RS2Ww/ZzU 4U5lZp1eRi3GAM0TQZy1PbSN94rXwfbw3nsfpNFeP86JPporfoo2fhqJdk3S BwE6LuOC+4aJ2BeereRBzK5HGx6vWfYJ0DjbH8ekL2R/vEU4vtgXGNPw0wb5 nhigH+lBKkMONXsi1GwEkXN+OoExnkK/INuCfpPkfX2Q7kZ+1eFsqsOZQzL+ K8wrWhvW8zDOdUCLwEdtdLMegQ/Dcu0rhXXG7uX80VppKseIcRDnML8nDlJU zKRVRpjqoavXcU5i3v3QPYb8zUHu7kP/Kfa5TZh7H/TcN5ffMvxG4HzxBCjF iMh3AEkb+J2C+bV3qFkroDrE8R3eg/DDHsrGfaEg9m4B5lqQ8qM2DliQOp/F Srrmo0ekfj69qrZqNyFu+Q7tEtX0NVFK87S5NFGMpWzxG+Tqx3RYG0ObxEt0 WHTSAZZFCk3X8ErXOvC2ZP15uov16quQG6hCLEP/Ovq62ERVWjti77c0UtyD vUY//buIk0z0/wDj2lDeogqtFLlVi/LH5kluJ+foMMsYYg1ly34JkLY6cNms FsJvBdhT2MvlJHtha9xOx8br2CfXyeOiH7cRh2kZkXkRyLJ4sEitpzagSf0D 5Wnr6NvKCbNbOUL5Sj9wxMbPaI3kdqAId/wCZRcwWyygZ4FqlGeBfwmcsmS8 3RbQ68AejH0G/DR/FzDUFbSQGbqjQAPwa6cuETzX9fSJ0FPN7iT5Gdw1gHIJ a7iUXCfnrMa7fAFwu9nNQCwWMIzdNN7zEI3XpkF/C/q5ZD0V+fQMZQ5nz3BQ zlOO9KGFQOIanf0AT7gBXEzgNGb7bviP7PsswP7uBr4k/ft38lsxRJ9TLpgX waXKBfJpDyIGAcjZkFMcfzr7BP0PpN61f4gV0sj8p1vvlt37OpysPk2bEuHE QTweHqflDJGL9oBb9p6j5QzjBdS9MFQWx4dBBd2mNbJNiMFpQ2XjTprGUDNh 6yTug5wD4vJ5nBEAt5X9R9NqhsxdQO3A9xoQr19AqxgJfl3IftUarXpnf5x9 ce8P7AuIV2gteCp4CbgYXOBwPL7t8yIp5ouseI/LfJb0u9pcy4lruXGe75rr j/n/BOTOS0Av8OL/ei6FEKuADzAu4h2Si3dkH94nd1MN0VWcJZ/MAX6Cc6gE /Bp0uL0HZwCjUR4L3VfBTxJd+RDlB6Dvs2CqIpWa7HflROh+bvf12uMVW/2v /Iro8iXglNX/SitwL8rvA4+g/EfwGXAD2r+Lfo+Bz1r1VzdBfgh4DvIA5PuA EMrfA/vBs4AUYBz6H2Lwe2TId+h/na///XGjjDfLVtg5BdwN3uX+hrhhdvZz GHZ/azj7Pxzr9rfEULb8gG+mN/HuiyV++3zaN86/WC//2CaPM47fnR37TUKw 40HixI7f10lsIKYETFgIofHrYC9Qa0qAQOMsJeFHJAadYHJCtEmFl2moQy0E MYltTKoRmqZpHeobe80cQEqmdN2aFahWxjT6i3b7Y/0jS6kKHRrU+97ZDhBA Gd3y5vP8uHveu/O99949b07jeX5xL8ZN6TvIKefwPJrnsjx/FvljVovvN5HH ol9C5uU0xpPP81eeO/P8FZq3/7wpT4xnE8bVI8aVPTfu3VvpZ+QlYAWOrN6N mFtsQfoiziYL9tQbyDV/xhFnGz/XANb9JVF/JT3KY6AvwK+AvpE703J76wN7 7Cxn2v/bf9wz8kucqf4s3TN4VHmOlVnWcWaexY/LbGf3lz7LH3FG33tO/69+ 7pzPMVte+kAeMIs/W3uP68/MOx7bn5GX5PyZPFA/c+3l8plyUj7NjPfuceHf FsZX7+b+uTHMfI+n37fcN8IBEr4X7AMLs2foaewXS0EFwBmVPo6y/dJt4pfO ED/8VwHOzS8moXfwOug4PUIIu5m+A/978K3GCyK2I8uO2dbzzHXL83ORH2LO xD54jI+f1IJGYAND4Fu5Z82/IdH3XxlOXf6da+xM3zBeBDNywFn1CvJtcAa+ Bb5lqN0SrDSUkimQBgYiQ9aCVtANBkEcmIglW7IHHACj4BNRoxpKE8eXqymo F4RK7nrWL9ytGbfrGeEmn45m9NfXZ3RoXSZsVSZsWV2meElzRi9YnNE2j1/j uqDIPxYsMZSQtwAjeyEpew07PyUyOWWYT3TADKZsiWqwJau9/viowUiogRko 2UHk9JiBJoqK/cEClmZTxIYz/59sMlPDJpNzi/3x4FPsI/IKGAUG9hGuD9mH +MC6htzNChkAcTAKLoEpYGLXcH2A6332PrGw90gtCIBuEAejYAqY2XuQVvYu /94UktsBwNi7kFb2Dn7WO5AWdhXWVXYVQ3s7Ud/gHxGGrzZryJ6sUerIGrYS f4r9KXFrkZxif0sqPvlUcCm7THTA0NllNH6ZKKAN9IC9wATrCqwrRAPHwCmg AxPuwZcjUNgEeBNcIUuBCtqAxN5KoJsUu5TwNsvBEnaR/Z6UYlIvsD8I/SZ7 Xeg/st8J/Qa0C3qCvZ5wySRYiHqCe6zQVuha1Oex3yarbXI6WMxGMT0yZC0I gFbQDQaBiY2yysQO2YZGzpEJJLkyS5CPhf45OS0RdZesetdgjSlceFc9CQsi rsS9TPWe+AlcLrxHj8Piwvv9F2Fx4f3uQVhceJ/dB4sL745dsLjwdnbD4sLb 2g4LIsVe+k31Arm+dTdVghY2gFkawCwNYJYGiJEN8IvcMvKx/TRRU4MZO6n6 FtXI2lmqnafaBqqdplov1fZT7SDVVlNtC9V8VHNSzUU1lWrn6EpMhUbVX9/n Nqh2qk1Q7QzVYlTzUs1DtWqqKbReTTF3Yt1yocJCJYP8vYJ+sslvwRjdmFE3 lrUbr/0o5CWQFp6KIKUyE1zm4royWRPI+EtW+fcE17Jx3DiOxzBOPgBGPKBx LKNxNDKOBiyQAdANxsAUSAMToisx8EEhLZC1IAC6wQEwBUxiOFOAkT3ZIb4i BlabHXQr99g4rkpcbuZWK6xOq8+61jDopBYXbXWlXayelJQQQmzFUnGKFg1/ XvSvz4tIfjCfHWWDpAIP4lhWDyZuVcgp+uOE95wcnE9/RFxGrDraQLzUA72S xIS/gjglruuIk70M7U84N+M2S8K7WD5L5/K7huVbzr/LHztTDOY/nOfkvygp I03If0bJy8PyZedh+Y3alISS894UhTqriNAR50r5zIQIPYiKkwl5P1fD8nPO Fnm3U1T0Ziq2xOCpFnmDt1Nei/ZCzm2yGkObw3LAuUVenYlawe8ZlpdiCL6M WYPBLnKKTqtcosFN9Sm6U11sPmHuMLeav2r2mxeb3WbZXGF2mOdJNskqzZXm SAWSJJkko8QkIs1Lpa+pPoJHN89k5Yp/fFBiFLaVcQkh9jUqMfIU0b9iiLDI xmYa0ce2k8g2Rb+5sSpFC9Z36nlVzVS3RUikvVlf6YukzOkNer0vopvbvtEx ROnRKEp19oMUJe0dKZrmRYccum1NxwihtPjQEQfXCw8diUaJvWRfwB6wNRU3 fC30ENGTlb67f/b77Ar9RGRjh/7Liqju50a6IhrRf7hR6eoYoZ/ST8KhEXqd q2jHiKGJfhrewMsNTaFoNJKim0UcUeh1xGHFXBdxkosoPI4okisTdzIT58H9 iKvmCnH5+cQj4jz5+SLOSHncUKw6HBqqrhYxpQqJiZhYqXJvzIQHMR6PiCnR yISImSjReIzeJEKcToS4nCKElhOnCHHSchGy+W5IbTbk8HTIYdGTgd6NcWZi iq7lYoquIcb33/71Nvt8NNkY3d4V7q0K91SFe0GP/sK+nXZd26YoQ9ujvELR Dd6ebdt3cr21V49W9Yb07VUhZaix6yHVXby6sSo0RLrC7R1DXWpvKNGoNoar toaiyZa2uvr7+jo83Vdd20Maa+ON1fG+WuofUl3Pq1t4X/W8r3reV4vaIvoi Yo23dQxJpDm6piujk6ywAOu1x+GONpdY9zaJxdvotu93nEVC8gtS6Ivqc6qa 9SLAq54IPhHkVXineNVcFFuyVfb9jW4HsvVslRXFxVXNxNfXH+sn9vA3Q5n/ GP5Q1NfPJzwjfbFH/aEurKtbQ7E+QiJ6zcaIHljf2TFkNqO0h/8kfVWurLAw nEqPZQqXoHAVLzQYpgN52Wpelp+fDXzw+fdn9Rr+FmjsXJKqLtpHYlGD7oq0 M2wF7Z34rV2dHWeRLvHjIRbFD4xRH43l2hDDJhmb8N+bo68/a2XnoS+rM3fh llhuOqb/+CzxfQr7VR4uHC5mQtzF7mIPBPY0clsxjN1W88i/iWIc40ED6QlT PO9tUohExkEWkOXUrBYcKztWznZK5Q4HP9Et9rJ5dnuZ3THfUla+zGc7z+Ik n/aSOSyuFhrKy8oM1GG3exbychnlS1g84Sl0nmcniQ8jWcZOJit/tcLE/fnw LWgyX8FU9Nc93Wn3WW8+M/nZpPUmBAlM3pm0rrauDgArbFpsa2jgPL/E95z1 tWVL7Wu+o26gyxe5fPJ/6K7y4CauM/7e29WujtVqda3lQ5cVJGxhS7Z8V8Qb DjOUMVcwYAcZGMZcKYMvksGlg8EEp8aAQ4oTwoBN26GQQBKIAWGcwW0cQppx KelMOoGEY8bN0UYZEjyUQiT1e7LzR9uppH3vt/ue9n3v+37f8VDIVeDEeV5A gScA6YnBidJYqxMbtYDMakC59qmQ0dzQTPPlO1HQA42IBSeWVdBIOpMTTiLQ oB/1h38EO3DEXFQSKpStFs6T7cXZnNUihwpLiou8DA5h/H/Gnj/a23Xuwu4X zuDymbV1M2bBxWQf+OEu/tvRV2CgEwYq6MPZtXVs3ZHP3r88+OEV/H7r4b0t ra/ta3nUwmn+9U+87+hNOvABHmk93N1KB8COy5O3VD6wkxNNg9PVdOVqm7VZ bk5ry28L7JaPBz5H6l77b2Tyy0BHCenI2uUmAzJelbbaTWSrIm9EzOuOGzJp yWqxky0ZzZlkC/q5TLrSOjLJSeubMulwdLlIl7Yji3zkuuIjo/IfMslgxhUL 2VAyKJMNaQ0h0hDAS0MrSkhVqM5JquUZmSSYUe4k3swnXATl5Tny8rValCnL dqtLll2uQW2eRavN8+ZIuCjHUcHoMnfbPfWrzI3mfjMTMCtmYv7Mvt+GbVFS p2SlP+lodtmxvawsp75fj/X9BfUuHvMbS5tenWRIJCaNR8bGYxHoAI+hyrFY ZaxTzPeLwAxeDHeKtJPCKVAQxJH//aDJfgoHdvN5i4tKSr20TZlShUtK0zhe TuO9uITa0pOyaxrG3KR9mdHaj9vu7nr2rTfXzLh2pPdy4h+Yz0u/FFzc0L51 U8KxZfbKOXNXezy4OnH+wNp9OxedPr1mzavbDr148+nmfTN2vRfdcf1XiTPL W6cOb9v9zP4q5oXZ6yvnrayflT0vN16MDy07OLd2uAHcYltiEVkFlpbQdEXr M0ANYuLVkhTFoXdQn6iGXjHyfWI9YiTGxTDMKeOR7pSS4g+oG6FKcB+6f+wl xqLSktIQx8PXKmF8++CfquuGdmz1TfcA0xOLhvBDLH57I/74z7VdvZfeTTgT rv9Yv0ERppKpEtFoJYxMGiqBto/B0A+gPqZejCbvDUgSqQHwcMBgSIGxAb0+ Bb5RDFotqTGITpGIp0yTMlLf+i85zR5kLPJ54RuS02SrROI7wA2zp/vadgzV VV9LLMJ38N2hi71ddR8/jt/4NvF9Qg1Svp64hTvQKNKi+ee0EObe4KJ4oeLF TJgQrMVhpCUM3CCujK9YgFaizWg76od41687Rik1Hhkfk2IQZiDmpIKNNBFt CoKh4hD4Ne8rKSk9P7pwWWE52H20aY+3On31M7DuUzhKNpJN4JHTlPRG0siQ alwNS3oQyVA1woR0tnGvzT9fGotIX6BAdawgiJpgk8Vu61MkB0fPnUuVkskv STnomEFPX0RM8tZZSzmJJm8pLkv5KwwmTB/zFkOY5xC2wGwI5wzSMl8h8hXo /iS8gH2nDfYQliBuTuixU5Xvj/xigvd+v5VGqJM9ieXpqm8e0TegmuSXrFt1 HDnw0jOEzFxC683ksKKntsJZotZhtWaZouSSojOwrCNLL2LE26LJv6esmgJ0 pi3g948GRgOgs8qYqTwQH5FG/AXBTCXHJOj1XI0h1c7L2Grvsveaf2d+T/hE uJmp1phtYm4GowmqgrrB5B3Y7x1FMmutJrP5j6LBIpotokEfJb9VzFQQRewH wogGxYonhbpgYPFfFNhFFNsUFxXPuFLaLG2X9kus1M632BS3pyhow8gm2QgI O36BimHrcZmG4HhjwAeRHpedFc/hQTj1INi2Dua7kAJlfQ8cdQ6c2TNBTchA NBH5I00AI5QZ8chYaqMRI1zAkbFOdb5fBXpGKargMvjgJtB4rblUnkwBEDZ4 n9ltdTMQV5DVwtMcUfOu9dDPdg6c7l7WPfXkPvJp/MKCXS8NY3Xr3vGrcdwu de0Z+fVrZxdUyuS7U4nnViQeXP/gpbN3IJOjZnyMrWC5VCafo/hUHGZ5KK8Z PIUh/BSW5aYECe4j1wghl1UoQ4PT1TSrAv8m6BdpilF2h4Ep2AjJtJzK7S6G cqDYzVb8UMZcpRdTfyJ++ASsl4xDUVCrGoTVRLzuPBYN4N9Aze8HJsHDAapc AONKrSBwNRqBtqpUG5CC0jr1es0q6UWmR/pQdYUblu5JOrWqFi8lC6X1urel +8J9/X1RwwqsnhUZnVajYllBL6o5nhcAqzmBB++AZRSDIJAa5OIFCwwRhqHP rPQZ42IFC/xL41Cp1A6O4aKkUdEgtfC1QjAhg1gHZyidYhJcqIFnFi9kr7G3 WaaHxSycExXdQmGYvy0wPQIW6L1k4K/xZDvfzhP+ZcMnf03FhqZ0uOBnA61l pEuxGLJVhjNilWNhGjNi1NtoPdKZb0v1E2UKVCnSyIg4MtKpmuhB0fPe1kEV 6YAqcoA1MGp+MHkPGPiQ8qYWNzdFJooND/irh3EzZjfj9XE8Q0LXyfLP34gf PvYp/u5QVXZWSDX4qAoPJWaROtx78fm9e2hl1wtx4GuwlBHZUS42X0Qs2GSO TsfVsGyVZ6lnradFs0vDbcjYomrUtOg6VB06zidrGJsv1yHbNRqzyZGbm5OD suwO0JvT4TAitc3LCTSic9HkF0qIOj9nop7PcVTznJq+nUvZmrNQHnBLpniF LPoPQUvnCZQXVjpLyJhmd7gwTSguOg42fZCKJilA5wJ4NJAy8gTgKLinaOl7 UcT/kxXUKycUFAnHw/NTN9Wx8ckKjQa+eJhe4KBhKR4uDxhprYhNaZTikOz9 IaO7UKZVGk9bkXiwu7A0ldu9HnCAwtInyQTuJd4TH7WsXffC/mXtv+9OvIyn 7yj76byqnUcTN/Gmeu/MuoolB7sTp1WDtRcb6o+HfEPt686sKmAWG+W11XM3 5zzu54WyZ6sWby2gsXbtv0mv1uAmrit8791d6WpXu9qVZOtlyStsywZB8Qs7 KqTslIQ2AQc30xiMUXDiSdtpQssjQx+ZBGUGAm3aAZM2BUKBoZCYAYaXcYxJ C3UzhYa0MG0CTJNMmBYodAphUk+g2F567l3JOPCHTmV092glpHPO/c53v+/W P6SlwO1x9JeDHeTbcYJ7b13qZj2B+i5Z81lkolq1Ay1Ez8ZzaHl8Ddog7RS2 q4eEbvWYegqdj/87bmj+uBGPC+NcVca4ErP0K2pLcHZRS+Rb0tPx5/wv+zcI 67UNJV14G+ky3tcCKIiielCPiuwY2V+Vgd88ak2oyug+hMVYIOEVYgnRo6d8 D6OUiTGOloZSJsXUy7KhkUTHPMYZA+ls0xVoNKxcjU+9YvBmwg5kF0FD03gx DrnEsjHl0Dh/eV2tCGqJMR4pCvoZ/4nd/ffbv7twxT7z2h48rf9DPH7ykbr+ V3b8fd6Ciy/96m+E1Hwy+Fv8nT9fwI/tO3diwpa1W+1POg/bl3/8FuO6TcA9 cwHRPujdBWuiWYqnUQedhp7wIQope3CpxcDj4aDyyAxRnjC/w6HHKSlaGtfv GXrXC9C7UYBe4k7o5ePsbcjVVIMRaRBibuqiEhWp6IqEo2HiUmSYA1lwFRUH iwPFgismhJLYr8ESpiVJXCwbScRdxjh4gMdgCA2B6vEXBQngsyJZ2+AAtBJQ uQn/Z+fcF1qfXfLIDzv/uMIGT9G5vebBpl8888hu+12pryg+80n75Ntv2PaO J2p3N9Q8ePn1i9fHJaDqrcAMl6CPCvq5VeSSEpS63UgQWSNlT0JB1M3QEdf9 9e6vCw+bsqkSOaqKnv9jXL2T2xwA5ZvWxAc22zRwPn3nnILEMuB4zD+3iuVD m4T00PvCcqlvtz11l63uZlMEh5G4AmrwoJ9aaV7DajAEhTKghI0mMRVCoso9 5G0pPHFvfgjtu9KXJ88blf6o/MFn5FPP3pl7l/DR0AWyd7iZ5f3F3cPfgBwW wOwfgtmvwAErGgvGikh7JX6cBrBfKC9HSX+IVKAE4cNpshzAXIQSmpBMuDwY pyorykHQQ12V7UQgTEuzSvjpyyqB4K98B/jpG2P/nyzOVeLKeMqUsayzG3Ik 1dE2MspNevazfD2QPJDjiHRLT+GvGV/Ck4kZAPQDYlmsJFoSKRFc3pReUZQq TdEKMVVWEVbjSVTsCyThw8GA6YZXY6SKJC5RANlBA5aEJ5lE5QIsiP0gIBzk 6ZR04cGwjrJ4UoXxOfYAs/UFAvTB/EnQLwKBNBrCTLJgtX1qy1l7c/cB3PzB ZozXpvYkn+z57or+7yXvW4lJ5wvXvkSm7sLD5xYvOYQfP3saL+n+Zu/Pqhfm mr62fNaqzW/bN3JPNGID9mMbMMoYPglnDyEVuh4NFNWLQsIjb5FPyUSWCFEo TLDpdsORd5X3G4JPLYWfejo/9XpBr4b5yYf5yZfNgUMlioM6tpUyfOk9wI/m 4TeKcYrz02Oq2FSb1XZ1oSpObg2DBC3wT56BnH1MMwxywZ/JTuQ0hOGQA0jC swzWbf3kZn//sEvqG36dzL05nRwYboIcj8BAvQhdENC7B9nsEAmyPnDf/fX8 WlfvXCdUO9eqsc61rMK5xhPONRzlV2ucqteb0hppjwRYBbG2GnzVXiROBEHd jD5G15DkN+HmGiTwj/NOgjR3uvOvQneuFrrzmaU7So93Z6t4unUU+U6bN2d/ DuRctnXR4inD2UJLoAdT2SjWGUf6mTSCGtch5PJBjTo5X3A4FL6bd55qqsGn Bn4UAkjrqlXFIq+fvS35vIIHbBb1KBqiHiIrLpatorMMFdi/HvYpRYdkL3bn 67hRqGPIqQOcEVgjtkBqR4/qp04dNUCIpNP89Eyj2D4XS8oqdfM6XXwV+Cry VeIrZdgrYxHhZAWDyKZcu620Zb66C0KcMhSVsiglYa8p++t9fJG8AsIaUD0F zmeFs2/jAf+Sw6QF+aFXLZaaZ0VXAZP8axFmtQxMBELkcJviFJN1quEPPufp mLUMER8NkhgVl3pf8h6HVnof8j7kE8aKFep4bY7QJi5Vv6+tVKlCJJpRG7RZ ZIbwgNuiTeqXNXkdWS+86n6VdglvuF1+4tO0aokEJYlQ8JLVEoWQeh/1PYot kPaUemQF8KRpOtundn/OT/x9pAv8Xc1+yaS9uMaSvR7ZtLzLFKz0QZEaVuAd 0guGwOODM8K3UMd6L2l505TapZwEECVdBww2chHQ/eD6wjBsXPNDHB15cT4L DgDaoI/6i4IvYE5g5fPcCMClphrdFvy/Rt5bg4DB02CqTnO9P2OvF96rgvcY F93Yp8nsLkCcvXyvJ5nRxiczai+EjRmttpGHByfA3QkZp+Wt4BjQoixMQyvM PC4ONTTiJAw+LsPGOlyO26qLI5PwfCwdtlv22HOkvsFPO7/a/JowdHO6eGJw knhukDHWRuDEUnay4uf3+ZUCf9Gwtxi8FVOoSRZRsFymm4L5osQtCNQjEuJx U1EwXS6pMMfSCFVKziQBuVlRDuesqWBTaVbalYVKTpEUCqc0J0sVfuzejmvx br4cOa5HkUQ6m+YMuWjgcwwJlowZ3pUi3yFn/A4h4da5N71GPTVhAQS31lSz wwr2oJta0zNQ/tGe6Rlq1TphbcY9JpJhkronAmGtE7K7ZTy0lLKMWwvCM8Be D/QEIIw7YRzCIhbe2FeU3780HjU6sIV1mPE2NjYeE0jfsSEbNuxFcRlsVm4w x/RwB6iJj6T3kIZi6B2rOerDQT0YjIViMVHUxaASUmLijlCP9ntNCIXCMWLG LWNWYFbIis6R5nhm648Z8wNzQ/PDLdHZsZdD64keSQiCP6F4ilImiClmS9gm uAtsDME1LjAg+CdnDAgGOCG42bYkOfVEc3Ec96XYHrpGUUekpOAhHBORLXB4 k+MkmCcDDwFGIqCjZK3IJC/XAo06qqtFRj0BI4E68CrccAJP39lt9xw5afd1 HcfxMx/g2A8ud/7JPkPewQvwL/vt7R9+bG85eBzP/Y193T6J63HsAFZesS84 HkIcBnSrKIz2W+OfMp4Okhn6jGCb3hYUFW8CGAaFwo6G9Kcod61Uz3NvXlXR qBnF8C8aVv9XaXm3Mo6MdhN5J7so63jZEXHpnOUgkbghSICdIsmkAfGIFyBj 1zY9s7b1qv0HexV+7q1N2Zk1y+0fSX2a/6meBYft4eFdAv7Jsnn/ZbxaYJs4 7/h957vz+XEPO/b5ET/j89mOCU5wQjAEcu1IeJRHJpYCBY/Q8n6nAQZIbEEM SugDNG1UXTtRhlQVJgSDAhmtVIbQRqd2VN1EBxpSx9IVNKKxlk3jkWT//2cb Ok2TFuf8/X332d/d9/2+32OnV0LkHII9DnEV5qCGPDTjbodM3GNDz0SXiWuj EAOpctB3K33XAex04SVcbyyclcJRKdz9IzdOuYON0N45VZNqdOHncKpRLbdK uYXrfzgVNkrXob9abvG6OQ2KpDw9ND02x7EwtDb0vG2LvFXZZd+jvCodUfqV m/IXigpqF3MpHpdLcSlOm7uajQc1u+B2qZKT99tsmi8YiPiQSgI46T4fE6+h 6+n3K4osRgz5DQGhXfZypaWiJq6G2jkBn1goxvQNeq9u0Wv8/+8aC/+TjxIT 3v6v+FDeAIEBP8ZGFIzyWmfhWkshB4JKXL7CC/LoLL9dvYjLn/36H1P2P6Zd NJWCoo53uccjbZBuqhgysE8wUHABP7nhkM1QQa3xwBGF4xHhoE6M0TSvR7BC yvRVJSyjWYBTgkILsZWIH2L3Xvxw229+NzPdOWPk7oXOdXPr4k/9iRzadWDW q4eH6/lzsy9tfeNKOKnP2jTcTRq+/9I4h3VokyXfvHXKit2Y1BaOfMH9FTJP Pes1U89ZnuN6LBs5LplqshRC37BMs84It0Un6+2pOZb51oXhuem+KjmBkQbn W68UyUphVIpUpUjQpSh1LhXJSmFUihT6yHas0pKhs7ollRyrNCYmJ9tyz8Se TnQm1zhWSavlZZ6l/q2ObdI2Zbu6Se9J7rbsdfRJe5WX1V36zuQPpAPKAW+k 7NTq4oa72gjajAwxGCYTdHNjGgxmKWwuqW5rdV81W53UpLpIKkmSvMYjd1Bn xkfqbJGIZqGcl4VsVSzFLGyKBG1UbrD0qjbrkrosOfh4KBypFq0CZ2EFktRr 4BwE3uq6oImw2wc8NKgxdTQ0UpVVSYx0kC6ygewnAuknJ8yqOhwSh4Y7nm4z mAzJIIXLMtuZwVuT8HuZ4Bh4JmK4Ub7xkrsCcjdiWaG7/Fu4FwIN5RBZnDkA KBpUgc//San8bonMVfDiA/h2F58IYOxCuYUSBJUpdj9GMXB+VXOEzZfQljL0 lGE0NY4dmwdU+qwGUD4kP5/G+ShIBdADY+FZadGl7euPzulYOGF4zTdXLv/u lz88fG83f045duTEocI4cnVe77bdD37y6+GvXiOfqutenvtkz+S25Qnf4mzz 4aXrf7lk5Yc75Bdf2bFgdj6/Oj3h9OZNl3s23kKk1oM2nANWtDJ9psSzEZhw Buad52z9bM+pGEe4fkLOCjHC5izEAvVpUs54N00HpQexzA1fUkqE4kaFJB5W SGG4ZKDxF8Uzr30ty7TAdII7GSj+BcmgRP0N9XFXvCnujbvYquEwt3e4mpeO Hbv/Fd7tIVB/zK4e5qppN5R53DzxA5HTEAYaeKhGboLYzk0XNytv8TcVq5Nh Xf3su+8INo/BVvwZ+8ifsTRksciCIRovijGNxLQOje3SNmi9mkWTjJid2Ct2 0E7p0F6hQ3sFKfZHdGjnypGiRIf2R3RoL3rRnj2mw2xxcKYKuk8nouQGqNpl mSLJu8ouoAmskEfTACguruvCkuEHv//t8P0NF6Yc237lDH/u4c+vDz88/AqR bllmPzz5/ulnLxAPzpENdK4d5shOJpVSn+nmCQRcVHc7w9tEnrB87vpH6vWP XPk8zHkrALWhvtrUczypZdKWpD3nrHd2OfvEPtt+53nnHacj5uxwshzrENkS E5y1EScEKfjJ1laCOIdv2222mMh7RJGHcBpjeQ/L8jYY6lbMDslkqUiWsiJO pSNd6BBJr7hfhM+EmBJrpguLWLKPPciyLJ5xxfgOnq2HNLKfP8/f4XlIJHtO ObreLiWS7gHYTXj4VdiFICTBwKC/tQVzB4gG5g5oSCl1eCBZnGQUWIm/n7S5 CTYQzMDcjaN/GEDS0G0sDSDMyPlx8+dTUwa2Y36c5Et5Ik/YJ4YufUK2j47W 1JGXfjV0AVzpp70btmzhMvfb0VtMH7nJhbhJTJppZuvMUTbJVhuQgrUZqbYW 4p23uXp87bTaolSsXSWtrO2q3yvtzvxYez14RPKmUZYRNSncUVS93wocTZ8J vJu+GLic/sR7PS1O1kgEGcuFoHK7KaVSYm1C7HZiFfVF/dlRtY0FrjBqGjd1 1NPi/OwycWV2s/MF5wfOe9K9rKu5USacmtMbfWPiHv+izPoMmwnl5FZ5n3xQ HpH5g/Jx+W+yRXYiuGWkSoS7jAN7VVXolJ2IZFlQFHiXQxZfP3v0jP9HnlDI ymCnIN3sbSn7mJDFkVmsLmYEygPJuI57ryxtt0t7T+dwv8DnAXh4WtylswDF H5FXoKID6RUW0fvZBaacMhlDNWJGvXHc4Avo0JCzQfKunKFFQ4HGqUiisb5w vsC+WSAFH97bE/iLvqS/Jqe/L1wW2KjQKrCCTO2Qk3ohP/VBTrwZgRpXQaae SMXBhYZxj91qNxB+FqJVFtl/8NGGbhnKfv457uOBbOvg0IALXU25f3dJ7gpU 6lAMqAp0Q8N0J5HgKf0301dTYwoFwJqaxFI90Lxej+ZLGBbBKoMFRjKATpaW Jb9Ydfy9KT1Tm1ZfW07ybXu+tzV8wr/u4749RztUm6/mvZDv2YvrF45Zu3LF T43wzs72n+2atWOWR5aCetK+rm7i/G5/94tPmYunj95y58GuiePI9XRITc/M Te1aMHvidwDRuwHRUWARlQmTXvN1wjsVnW/i23i+NXoiykajNaF86MnQhuj+ qDC+qkVrCc7QZgSLYlGapxS1bwdXiWukFco6bV3wfPSq85rvWuBG1W3f7cCf w59FR6KBGJ9Tcp56vlUx+RlKB7+Mvxb+B3dfdapemRNYpjokWIndG5Idfv1j B1EdpqPL0evgoiauloNi1OGnNdJw2ZXfoRii9hzBA8VnFDx4xszhejo2Qr5k KPgYjopS3pJk2fMEfMOb5AS5Q7goaSWziYWgbCFooXhohhFehEKFUNkgboQK oVCBHv96BxFGu2o4NPHjuMSDQ5BAZErzf5A/ouL5lpnqEJwBy/D4JBUC+HcV KCeDGEBHpjueACUAfwAhSGUSNal/c101wFGUZ/j79uf2dvf2dvdubzd32eSS XI4E7spP7hJ+JiOLSKwGQiAELGM0iChCW5IUMviDhFIBK2rqjI6KmjAgRYsS JCKktFwLQ2csTOIITota6Bha1AlkGExtIEm/99sAqTN3+3c7t/u9z/v8vCyJ Byk6B5FWwT/6bWfTgYf2NzrDV/9wdDWTrv1N87631zXv47uGvntx/osf/2L4 yvBnb+JXjtU+d/qvPSdPE4+oHrnE9hG9iuClox6R9m9UsSpjB1WjBsQiLmDL QpbNydgfEryweoGuXvDB6gUNVi/QDj995qSbf07UlcAXrORu0Yej9uzgbKsm WGPVB+utHcwO9nVlt7Y74vMqYWkV8xi7il/na1BalD2+D8VD0oc+n+nb4vuK Yf0FD6pr1I0qq2IiMc7jkxG8VD15rVbUji6gfmJxqiqj2+9ok1cv9HupPhVk k/UVyokoxsSHsEMBcig6P6aYRCgm99ihwm4BR4WZAiP44SZBgpsEKq/ClOz0 idGcQlBxyV/XVFkTq6ROgcEp+pquJfqa6NoJ2fXpk7S6XvKhaY/g9hNsAbeR ng5AtLuV7AA5tvxAzpX3zw3/p+nrZ9/7Iro/vHHptnd3/2rVC/gZ66NunIOl fZjZtH9n9uqfHv/0sz//EjymgmB2njBSJ4ysdXZLDKfElbRyl8KXGqX2EmaR tNCosR9lHuZXiMuNejsTPcOfDX4Zvhi8aFyxvg1fpMwzo9FEBOhaGQHuChOZ QmWiOYMpVSqZOUqFcY+9RFqsPKpc9PzbHMTX/BoOsX5ZUwkjZUFHhJKsnJXC KK6rcU3r0bGmO3q93qITakJPuATVA8AcnZoWUFX3QAfplLA6DWBQcd0PFSfn lylLdYhLdwI6+tpA4TGhWzgvjAgcQDRfYIVc2nJUp4VctxUpbNSWBOo+Qjg3 XT2GaXWN8/qGxpKunCSGofJeGrfge5tnxPEb80tBi4kYu4ARzmHjNs/YaStO bDy7btWZzfWvTDo4lLdvXfPbe59cv3PLW9uv72rD7K8XzGL8gxVM4NTHfzp5 7tQJwKySqGgu4VmIYFbjWFFkh5hato6vE2vlFexqfo24QvaGwAXpssmBsxCO cmzYFgX+zg8aAxFuSmBGeIo9KzAvMsteELg/vNBeFvhZZJm93rM+NMAMZGnI xKpiWdUmJFfWtNVWrV1jNI3LtiUBdTHvQsfeVLMMYQOpu0bY8XKQsMdyFOK6 NMoqgAU8WgH/h5IqcL9YNCHdoWAlEiVnB+Pj0rB3ZoHNRnHUTGmFglM4IX0T qbwxSNkUKZdgNsXIpHgRpMZqYl1i3lBvlUampIHGW5GYzFKJXkquuvKhxnIa NAEuXEctFDc23aSYhlIlSDeEfJqWcf44aqLsA13Jy0e+Hr6CjS/OYj++cUn6 4Jnl24fOMQt80xY/+9Q7eLG1qxNHidj7cPHwP4b/q+Xt71qJX94ye+UeoiJB AmEL/ymysOLkGiJWw5PCk8NOuCG8w/eG8o7ijSjFSkc4E+bCUI/iSDSd41VY n2pLOMQkjCDHepDUZmBjJOhwVpxDLPMShtkpc3DKtDTsnYQdTbciHHaAJmFH ITRBBp2riulcVQDEQcnRieqqO2cgA+qJ3IxGD/5FDY8cDH5EY9iurPBR3IXy 0QCWUFYiMZAYQwMSVrRrZN4i6bmvDoaucjJ2zeybrpPazn7cMTTdIwoeL0lI mhjIRrpHzcYJnJiwaRNOEJ40pfRYaao0PRVGViJroGqhVCimf9DWFoxsbp57 f/a0koV3dXezr29vXJ2uWBJ4U6qof2j7jUcII+4cXsB+QxiRiybgNU69LPNG Uo4bc+U5hkfMCeck5XFGMjZdLjPulSuMxcJ98kp5UPou5J8YSxbdEbujaG5R a7I9KZTll42fmayQK/LnjF+Uv2j8Y8Ly/OXj65MtyXNFl/Ivx64U6ZbpCR1m DnQW20GBOomWR8Zd8JEWlEE9ZOQ9zGxwSnjbVqU5BbZPMkOpeEqKZ2X1WFiz HKvearG4JCk5U5uksmZRWbNuyZpFZc0y6W8EDVfW4C4PnLuyZkEouBea3lqr 4jgqiBYeU7vV8+qIykXVmep8YnSUMWoEsFUL4N9UOpGqVNtUqm1qOJFcmw/y lqgaI2/X+rQfKNxQ70A5IU8v8KcX9nSwbCSmZFmm5QbIIsIaxtU5q5QMmTSE BseI3SP75ZLZazdsy/Lj5o7P+3/+yfNHn9iz4vP2P37z2p4NT+1974n1e++L LIiXPLx0asdzuPzLVzHe/mrLjVXfd6//HTvhk8yxU8dPHodpdCtC7CXiWgZe dgSZpPFDVpqFsYXG6zhXys5huxSOXpphhdOWV/fpBksmVtXmBUOWfHHRSZWl R0ScEbFJPcZ0AAaxmG4NgECEwUKHwok024kRuI9cHXAhEQ2ARASDkeG5ogR0 gd8PQW3FKhO4aKXL0h1mv8k0mO1mhzliciZjxClfHY28Qz9ZD8ojnXMBcUA1 Kqhw4FiUpW6s9MKjETfK0EE3DyKG0pKhkbMqdHf1aLgYRY1MD+UwUoxJiPQy TLduHJyOAy47/R6/EPd7fNlY8RJeIkLMxCZESI0TKTclmmZIj+kURk9I39r5 dKb5/crOdaurny8nkfDqS3W73xh6kNm59cmaFzYM/Z5wchsBivxEUp+ATjsP iGWwgvliq9gudogZ8bzYLwpIjIoNYovYNnrpgjgiSlGRZCyBY1jRwz6NkYf3 cJJHiPOIa+PauQ4uw13gPBmun2MQl8f1kDOOc7MyU8vdqhtH68ZJ8FSOKht3 U9k4COFQMw5IJEENuSrvD6vXRKoHMjazj1oEfKHlmxoTwdJUiCVV2dbZ2cl9 2919PcSNu34O+nIz2Uyla/7qEE8XzIMsT52Wpvt0qbufPMXdF8Tp3omT9lX5 KN/Gn+e5+WTTz7NRvoFv4Ud4jnSHxLBuw8A/0cYJEaVsQzhDYisztnu+v909 OWO6h1ZhVN+9o+LuloAcjFBBQbdqgaq4/68FFANGUSgHZX2Texk6Y3Mn3zVY McpJzziiwTH8lyNIIcMS/L338OgBYcXfnHmyko5zvVyv+E/rYh5/lh/IYyxv XkzMys4TWTaWa3tCIFEC9sQiYU3qiePWeHuciVtWxB9v1bHO0QSYRdMfsFP+ H93VAtvEecfvO599vvPZ/s5n38OXx+FniMPLSchIKTaULJRHaKFjEOyCGGmX QLYEKKMCJlJBs66MUhiinbYVaARbO4kQAoJqaNEESDyqZupe1cRgWsaqoVRR hdCm1sm+/3dxCHRDwfnf5e678//3/X8P6gCD8CXJ8adZDb6ozFIfKFEf6IJB kWGuim5w3BWhfFbS4wdNZNLlzInlTLocOf4sK8NyJp06kxp5cnbUHnZTgoXJ 8Zd0YRPWUxm2OhpHgwyCTMGWMxlmOdkLcI+NBqaKS6MeI1FM1PGJ/rKoufez QTraNhSUzxgjFr+Adpyd0jiZp4t5rzA0KQLmhyfHwUJTQ8vCuyTrgRiTrbyM GNVhWZsDG7o4+FJQSQQl2UQBb6g4+ONWiOAbmk1NK3zY4091eTIRHE+fbNt+ tPz713/+3tlobl7Hj/tXb1zaVc8ljjSt27D6g9PnC0n2Z5vX1R/pKRxl+3bs eOYnbxY+KXL4XbJfVLQ7qzgdLoX9Bb6A/+74pzLieKC4yGyOZOeSDfMyRm/h Qf2OPqZzljvoC6oBwuHIpXpFr0/yxXTK2zrlcA9lbw9lb88Ee3voEHgi9Aro MGVvD2VvcvwfG1APZW8PsDtNax4qEB5EfjxNOgxdGJhcH9HZDv2Y3qsP6Jzu YKtDKp3NB/2ybE/e/yZw8TEClycRODc+iQPZwOOC0KThB/nOh5iSKbxPSf2R s+TfMLFewOuZ4YesrrpkQXSLvOhw4QRJSybyi4FxkCu7QL7JFqIoA79rj0Dc feKlW+uPP4PF/spNi7ae4hJHTzd0LEvvLmxlX/1O+/xDNwu/hiyykGSRJEHR yxho0/mQDt9EIZNIh8wPI7kVKoP+IcCLhtToWuRe5VrjftHV6nbX4PpAvVqr N+AlgSVqg55z5oQVOB/Iqyv0dme7sBG3B9rVjfr3UEhwOb1rHc85nxPXSpsd Lc4WcbMkaiUcLxPKCMZM6qVMug14cE3US/E0HPJ4/OxIP40MUNC8AAXgQAua IwAEJRavmckjhse8RYLHrNuEI+D80xBNSO2LMZIPbHSAjrNE8S2h+NJIMj61 lH8YlSKcJUsCHbDMrDBEFALqQ+RIQMk/yOcnYQlRcphQLeTHp3Krs8JK50ph g3ODwKH8GgYuUXAdAY0JUZPFTDZZC3teu/IXpO689/rt0eGLfd2v9p3d193H Kih5YPvo3wof3nsFlSHvzRs3f3flxnXyQt2jrdwUgmCAKUMbsgckPA0/iZdg LmP1Wmy5NVWKlqZD6dIFpR3WQctdr9Wbi7XF5hr3Wimn5cw29yapFbdrm8wB 6+PgLf1W+OOyoeBQ2R1rzFKjXAqnQrVcPf46txg343947pWOYo/sI2GyBFhe LfF5GJ8RGxQRFrPienGPyFkUQovCKZIMkvUAkKI+fgw8TovPKJYiCAxAKMJe i0KzxW1IqWarA3GGGUDoIDqGetEI4spRBi0noQx0jrIxomyMKBsjukOQBEsi GGbAjl5KjRaSYGFCkQRXZJQ31unoYcosEjEu3B96aJvznQRFAiPMI4wjkwfh ZDqVIqmqoSALBjkpOyah191Tf+jbPxhse+n2zuY3pssnt+94/9S2rWdGW52X fvjss/vH3np39IvXl9YXvnD0fHj5xh9uXP8TcOk+MopXCYYycy37xAwFYQ5F uRruKW4l9wK3jXMJsltwC15FFryMw408tPmMKFQcdCN3xFKQwkbk/+9JJ1zF v7PyJEpz0S3/iHbZttRF97zbtqWBxstfsaVDOH9/yxDpD3SH2FCqSHMYfK3b t/sy9GoLyhfVx86CPKGkfSfmtWbWPj9vwYInng+WcYnjnYvqTyUbM+u3FH4P XciMfeo4Q7ow06Fld3KRYKReWCwsjK2KtER2CQeEvbGTyvtVv3V4BS2sazOX VP1Rc5rsN1gWp5Go59w5ISfmPDkp521ztwltYpunTWrz9if6k/5kIpaMTZ0d axbXeDYmNlZsi26L7YkdFn8qHao4WnVkZo/4S+ndZE/F2cSVhFpR9DyRYhEt FrFiQa+BLkWKRbRYxIpF6YWxv2YDZXOa3cm4JHJhKxHiPNNLwxA6I0YVNL/c yBjLjXXGaeMjw+U3yo3vGrcNrtx4w2CNSwSbENkX7zGIoBqEyzHKIhajQcQy CCMWgaMMqjWIwu6TaxCanivdXMqWloR4Dl6Dmmcyg0XbfDerAMBcyXRPeRiF Y0ZW0WvScPsMGFJDtz9hrgwV9ohhwZ2GBXcZGL6VoVI9uMCu7eNjleTWcyVz BitRJTwF7qgE8YBlaAF3kOJf5+GmyjB91JRkZc369ECazaT3pNk0RgjFGN12 VnTLWXaXCYlAAS8ARdaAl7Bifjrqfvp6fgsu84MeW/BMvw8e6JeoeEVuMwgM HMsYs4CzycDnO5eND/0w+Y/Jry1NVIzhVGdq2ST3NUxcF1yUGe4MzJlhe2hC D/QX2ezkh+x5zdbpbHJaWdQZrErIOIAV7HBFvJbJCBW8iZzTyEdZkBxO8UVN JhL1Su6pookqkoLoSnEmU45LQdFTmOi//YHg8ZWprq4uZhJBQXLJK3WqTTXJ RHI6W1szu86mIjJjVPWDGnEBWhlry0oi0+d/beeuHbXxw1ffXj7/a5Vvrtx9 qVnulba27mpT1Rnm3t8cXdV6dfdHn6AnSzZtaVn4ZFSPp5/uamp8uaI8tWjn i/qK3Iq6aEmpIsaq5+/KNb/zzV/BnMbGPmcrnW8zGvPni4xI9mA0USMAsvNJ sccg6U/yisjBqFhI+UUiEg6PH0eYCPIG4hIa490NQsN6voPfwx/kOYZo9DG+ lx/gB3kXD7IAXMXbskCLz/uBs3jb+Y8XAD5vezVb/UFlSOUaNwG2f+E/YNsY Hc0+88JjcYgQ/TBxYnjo/lyQalICycvV1fgaBKRUKq5B/xK1crS2Wq4jTBaV g9B6FoeXzt2wuWrv3rPnzimpirLj7+B5LSfYb+1H/ObRH+0vHF5WFaZJknDZ HS5Bnr78IhMmvRFIRmQtRa3xw9tWB4I1KQXF3IoqIUX1EDKXSZuYajWua2Bc w9QVa9QPawFogEYDDnRAo/StTThhjTphDeidOmGNRhsNnLAX+jGmoQENaU1h mjzBBIdHwmxH+Fi4NzwW5sJSXJgQDgExgiUMCncETigKhzAhHAJ9siDCUwVY n+qFQF2wwNKc2GQ8Ej7JcA1/1e4SBYG+Z+baykGHKMxhn9f/X76rPTaK44zP zL5nH7Ozt7bPvjOcrxw+fAi7so05cOUtpOJhIUOglCO5NpUqI8QrqC0E5PCQ aExoSpT+kZg+1KqRCkhVwfjJow1qKaKkbmkEpHXrijZO4qK4aiWHKnV97jfr syFSldub597uzXzf7/t9v7GJqumqruggeWUrhmydx5AQvDU1xyAFw7NVjaFr qsE59RwALwJiqehLLR13v/h6m2v2mnzPxo2nVvR+r3fN7rbGr5JvT/V869Or N256+QTJTg6Dd8BF0hh4h+IH3YSs2rw1KFN0RHUVqxQphq5goiwQ8FNqMyND 7sgQQENkO7HU2ECjglGSZ6ngd5tnDTjQNOiiIsB0PdDiYgu/+ENgzKtqQGmo QoVjJFMNqBQqGA0Hh9NLGlACKmYtQmljIc2iRroGraZb8BaS07ca7bid7NB3 GM+hA/gAOag/ZxygnbiTvCC9qJ3QTxrfR13GK/Qn6Ef0Z2hA66a/Rr+iw+gu /QC9QyfRBF0M26FRVErTaCFtom0ooIYSeKUNCkCloVsN927AfsTWkRBjARNu pCjkUGELMRcKJ2GVcJYoimWC22pHMmAbKEOZoQyqbWkJXRkLmqim6ymD+oZB kUQICBMfY1gIBcmi64RgVaOGhLBSa2ErqQdBYBw1iDGIY32BclQhCvQCI0EC nDQfvCXQNF5RPpWfyldEx0fzQmoItdHSLOiyBUK3U1mS6Xz+eueSqGhyIEAy GdDejx+vUD5XhesjpWVLmyL1GP+0sOvno6n50cwHlwp75IVTx7fv3byfnABw ADpUhJQBQIcnV86g4xLywAjhWVRTw0SlFtXsnV7LDlPsWGCKHk9YMzeu9Tpu eANSq+jxIBxTLmFkgRrCKgNr2JYqAsrimMhU5lQM+CzRccg6Q0PuvSH3TmZI oE8YWGScYloQwRCDCPRxjbyIknX8KX6KSzwR+m9w+n5IgfJshwvaMeZXNbjx ympB1/8MBuYvaJBVy4ioMaPcU2Qkq6ZhOrrnoojka3E9ZlbCWSml1egZpwE1 asv1Fc4T0mo10NbrreYqtpqv855iT3o7ta/o272D6iHta/ol9TLr9z5UJ420 ydMobVc7aVbt1frLUJN3QH9B75Jes87gs+Ss+WOrD/Wrl52b8j31j8aYPMbe 9ybU/xhxUxUrtsLaDWsnrFlYe0XYxqjDZA9xXdNTGks54sDgaJKNrZQ9OH0v aBIsZQP6asJTgY39iEpNvpBm+Gb5Sfo038U7+ElOOZUBi8IdM455ZOp8KGtr MxPwFWN3VFwz2R++scCXFAUIS1MMSnXTsqjLOfB7a4+CPNAsa4N2ypzEL7mm JzTueRlF8xVFc8DPKdvxbdvR4ZSboboPjyNlLlIQwZon64xbjh0uzwMe13VN E6HjMeY4iPoPXRs/Yz9rH7UlexCfCWiijeK99AgldJB8PjDaON7Lj3DCxch0 FfyM8iwElwTBdaYPP4w8bA8lUfn6iXw+CroGviLI8tH35iLLLV6wdVyMOh7W nesfD7iPN4DKTse9rjlusyiiL0rrhfmbtvbaCStBrk7fB017HznTt3tRHUt4 gFG8rPjJtV5o2AQRp0/f7tbqcDhRtan1Qv3GbeHs/W4tMTPrwey8cBZe1A9S EN4NbHX7olYn3ngRLSOXZ/5p7uVzz5WFz/Hp+z00ISeQuAG0gVc9Hb7tTr+X RYuhQIB3R7Kwo9zsMVFQidCKcBoMCSXkk0iZIJVPSdUSbi1cuXyuRa4/d+kH jZ/pP1/ovXJu0dtAMN8d5bfInqmuN4dI++Qw6ej77++AaRjkoX8B07j4z8U8 VMKwqcrEUIlqAyJZqMhZbSYEJS8L8w/zMEuWZ1WRfzaUZ7exV+VX9dPOd9g1 5Zp6TXuTGSwozVZIEaPErnAb8XLzGD5l6rXeF+ScljO3Oq/hLtplDpBB66Z5 y/mNOyzdNX5v/8l9l3qzwWVayOMsaoOwUAW7OaLHVERsRCmBGBHEC0gAGhJN LGhXVUnTDQOrqqHIEkg+BvncxozZrgmigtimZLlUZYRR9wa6YRA3hQwfIUMi 9g0b2ylL8i1LooYhSUSFk4BlIdrmYW+tfdhKUvZl1TgcUMgMA4G6QT2qSuog WRU4CekwSbaBLdfyjvCgmp+YSRaQK9x33Ynx9/Ifw7PIFfkiWvPPu9eRWD5j nXqI0pkaGgHdZr25CIpeJ1qZNYW9zcqslSzLSlDE+GJV1hUcT0uyOFmVNYJ4 djbj5PL7UAZyEAAFEk59mUg9TdADmGCGjxdO//X1JfHFqZ63C6/gb44MLy/8 naRx4aPVdSvrJwvW1G/xulwhD/uqKmyU/gEYqcD/LmKkkvpMMqV4OfNUU40E HkuYgZUoYqW8NlMxUhEdqih3RSOAMx6mjVgPi2MmNrE7nk37W9h5KgV2AA5J pOsaXFFpluGV2lGv2qy2qu2l1lK70TnNzbSXjqwpzXm5SK5kh7cjsqPkoLrf PsgP+YdKvmGf5C95L0Ve9LvoWfOqe4Vf9h/Q9/0P7Sn3I386Pm8WUaURMx6T 2RPsOJNY+dzyw/WBD/JFHDUxZrnAlaAcyv1IJOVRHwbMAjJMmdQ3TRrxPMsy VfECFHfjpDb+RpzEB0lLHwNbBP4g2RyYLV7gkS95b3jEG8Qr+xlOos/FqLgV WitIWHVWmyVtsKYtYsEvemoZ2Ia09MYSHUCMYLypfXBcBBBBdzzqToyWu6P5 feMVUXc87KGoODjMIkoHJEEbzThFSHWG+AHWc4BtosA2V5A1PYbM6TH8ONf4 03/pb8rSZFPWgSjrK8nyZEm2iB5gGtAwAJ9ItdC4TeJ6JGEgVYEOPuKvWNy8 powvVMzC7l+MZJLzM+/0FnZ9dkFdx5aGwvZzbnpBbCerlNNTp79+rGM/2Tl5 8/zK3CY096n55ILfAoa6OlPkZih/e1SUbVB+OFNU9/8X7dYnl/+xWwarTURR GP6SiXFi0yQUqUEDFmmatEmtTY2ttZKmxKSNFWPEWLUgEWwpZCFBgxVxWURc uHTdF3AjgjsRceXWJ6gL1wULBjQ9N46WCqG6ERfnhO/ef84MZ+5/7jATe3I3 vk/Q9RD8r6D7u3zP30LwPvKRh56AsLmb3ggceg/hJuZPfZtIDY72Cu+g7zMc W/xzosch5of4G7F/F5IpGF6DkQaMSvFUYIexA5CWNY/LPSdknZNrPzjzFDIn YXoBsluQk5fc7CMorsN8U1EURVEURVEURVEURVEURVEU5f8ANy5MHMQyynVY 8LJnWGawfXT5IRiip50MOyf7hP7oQCw+OJRIij4xmhojfWp84vROgdy5fGF2 rnh+Hi6WLpUvc6VydeHa9RuLe9/7n4SHxzJGCIlVvzgaYJBhRkhzljlKVFjh DqutFsZvlDhJ52yWC5SpUqPearU2Ov2cvncOa8812iw5VcwacbRHtN/RXlFh s7Men2TC9DvaTYApR1uSLzraI/qWo72iH+RLM7l8IZGtr1RrnTR56ccMOZkL JMR/XXpj/Je5zTL3RFUl1+mqv82LM+8TGTI02C9OQtL3itjulr2w5FhMuJ6x D9sjyhz9nFlyy3Pq+hW/tzMjwbTs5qptynyw/dZzp6uyF6HNr42bwakv9hG7 ffX6RmzIzK8/vtxqvvi2HMI2e2D63K68LcAAensojAplbmRzdHJlYW0NZW5k b2JqDTIxIDAgb2JqDTw8IC9OIDMgL0FsdGVybmF0ZSAvRGV2aWNlUkdCIC9M ZW5ndGggMjU3NSAvRmlsdGVyIC9GbGF0ZURlY29kZSA+PiANc3RyZWFtDQpI iZyWeVRTdxbHf2/JnpCVsMNjDVuAsAaQNWxhkR0EUQhJCAESQkjYBUFEBRRF RISqlTLWbXRGT0WdLq5jrQ7WferSA/Uw6ug4tBbXjp0XOEedTmem0+8f7/c5 93fv793fvfed8wCgJ6WqtdUwCwCN1qDPSozFFhUUYqQJAAMKIAIRADJ5rS4t OyEH4JLGS7Ba3An8i55eB5BpvSJMysAw8P+JLdfpDQBAGTgHKJS1cpw7ca6q N+hM9hmceaWVJoZRE+vxBHG2NLFqnr3nfOY52sQKjVaBsylnnUKjMPFpnFfX GZU4I6k4d9WplfU4X8XZpcqoUeP83BSrUcpqAUDpJrtBKS/H2Q9nuj4nS4Lz AgDIdNU7XPoOG5QNBtOlJNW6Rr1aVW7A3OUemCg0VIwlKeurlAaDMEMmr5Tp FZikWqOTaRsBmL/znDim2mJ4kYNFocHBQn8f0TuF+q+bv1Cm3s7Tk8y5nkH8 C29tP+dXPQqAeBavzfq3ttItAIyvBMDy5luby/sAMPG+Hb74zn34pnkpNxh0 Yb6+9fX1Pmql3MdU0Df6nw6/QO+8z8d03JvyYHHKMpmxyoCZ6iavrqo26rFa nUyuxIQ/HeJfHfjzeXhnKcuUeqUWj8jDp0ytVeHt1irUBnW1FlNr/1MTf2XY TzQ/17i4Y68Br9gHsC7yAPK3CwDl0gBStA3fgd70LZWSBzLwNd/h3vzczwn6 91PhPtOjVq2ai5Nk5WByo75ufs/0WQICoAIm4AErYA+cgTsQAn8QAsJBNIgH ySAd5IACsBTIQTnQAD2oBy2gHXSBHrAebALDYDsYA7vBfnAQjIOPwQnwR3Ae fAmugVtgEkyDh2AGPAWvIAgiQQyIC1lBDpAr5AX5Q2IoEoqHUqEsqAAqgVSQ FjJCLdAKqAfqh4ahHdBu6PfQUegEdA66BH0FTUEPoO+glzAC02EebAe7wb6w GI6BU+AceAmsgmvgJrgTXgcPwaPwPvgwfAI+D1+DJ+GH8CwCEBrCRxwRISJG JEg6UoiUIXqkFelGBpFRZD9yDDmLXEEmkUfIC5SIclEMFaLhaBKai8rRGrQV 7UWH0V3oYfQ0egWdQmfQ1wQGwZbgRQgjSAmLCCpCPaGLMEjYSfiIcIZwjTBN eEokEvlEATGEmEQsIFYQm4m9xK3EA8TjxEvEu8RZEolkRfIiRZDSSTKSgdRF 2kLaR/qMdJk0TXpOppEdyP7kBHIhWUvuIA+S95A/JV8m3yO/orAorpQwSjpF QWmk9FHGKMcoFynTlFdUNlVAjaDmUCuo7dQh6n7qGept6hMajeZEC6Vl0tS0 5bQh2u9on9OmaC/oHLonXUIvohvp6+gf0o/Tv6I/YTAYboxoRiHDwFjH2M04 xfia8dyMa+ZjJjVTmLWZjZgdNrts9phJYboyY5hLmU3MQeYh5kXmIxaF5caS sGSsVtYI6yjrBmuWzWWL2OlsDbuXvYd9jn2fQ+K4ceI5Ck4n5wPOKc5dLsJ1 5kq4cu4K7hj3DHeaR+QJeFJeBa+H91veBG/GnGMeaJ5n3mA+Yv6J+SQf4bvx pfwqfh//IP86/6WFnUWMhdJijcV+i8sWzyxtLKMtlZbdlgcsr1m+tMKs4q0q rTZYjVvdsUatPa0zreutt1mfsX5kw7MJt5HbdNsctLlpC9t62mbZNtt+YHvB dtbO3i7RTme3xe6U3SN7vn20fYX9gP2n9g8cuA6RDmqHAYfPHP6KmWMxWBU2 hJ3GZhxtHZMcjY47HCccXzkJnHKdOpwOON1xpjqLncucB5xPOs+4OLikubS4 7HW56UpxFbuWu252Pev6zE3glu+2ym3c7b7AUiAVNAn2Cm67M9yj3GvcR92v ehA9xB6VHls9vvSEPYM8yz1HPC96wV7BXmqvrV6XvAneod5a71HvG0K6MEZY J9wrnPLh+6T6dPiM+zz2dfEt9N3ge9b3tV+QX5XfmN8tEUeULOoQHRN95+/p L/cf8b8awAhICGgLOBLwbaBXoDJwW+Cfg7hBaUGrgk4G/SM4JFgfvD/4QYhL SEnIeyE3xDxxhrhX/HkoITQ2tC3049AXYcFhhrCDYX8PF4ZXhu8Jv79AsEC5 YGzB3QinCFnEjojJSCyyJPL9yMkoxyhZ1GjUN9HO0YrondH3YjxiKmL2xTyO 9YvVx34U+0wSJlkmOR6HxCXGdcdNxHPic+OH479OcEpQJexNmEkMSmxOPJ5E SEpJ2pB0Q2onlUt3S2eSQ5KXJZ9OoadkpwynfJPqmapPPZYGpyWnbUy7vdB1 oXbheDpIl6ZvTL+TIcioyfhDJjEzI3Mk8y9ZoqyWrLPZ3Ozi7D3ZT3Nic/py buW65xpzT+Yx84ryduc9y4/L78+fXOS7aNmi8wXWBeqCI4WkwrzCnYWzi+MX b1o8XRRU1FV0fYlgScOSc0utl1Yt/aSYWSwrPlRCKMkv2VPygyxdNiqbLZWW vlc6I5fIN8sfKqIVA4oHyghlv/JeWURZf9l9VYRqo+pBeVT5YPkjtUQ9rP62 Iqlie8WzyvTKDyt/rMqvOqAha0o0R7UcbaX2dLV9dUP1JZ2Xrks3WRNWs6lm Rp+i31kL1S6pPWLg4T9TF4zuxpXGqbrIupG65/V59Yca2A3ahguNno1rGu81 JTT9phltljefbHFsaW+ZWhazbEcr1FraerLNua2zbXp54vJd7dT2yvY/dfh1 9Hd8vyJ/xbFOu87lnXdXJq7c22XWpe+6sSp81fbV6Gr16ok1AWu2rHndrej+ osevZ7Dnh1557xdrRWuH1v64rmzdRF9w37b1xPXa9dc3RG3Y1c/ub+q/uzFt 4+EBbKB74PtNxZvODQYObt9M3WzcPDmU+k8ApAFb/pi4mSSZkJn8mmia1ZtC m6+cHJyJnPedZJ3SnkCerp8dn4uf+qBpoNihR6G2oiailqMGo3aj5qRWpMel OKWpphqmi6b9p26n4KhSqMSpN6mpqhyqj6sCq3Wr6axcrNCtRK24ri2uoa8W r4uwALB1sOqxYLHWskuywrM4s660JbSctRO1irYBtnm28Ldot+C4WbjRuUq5 wro7urW7LrunvCG8m70VvY++Cr6Evv+/er/1wHDA7MFnwePCX8Lbw1jD1MRR xM7FS8XIxkbGw8dBx7/IPci8yTrJuco4yrfLNsu2zDXMtc01zbXONs62zzfP uNA50LrRPNG+0j/SwdNE08bUSdTL1U7V0dZV1tjXXNfg2GTY6Nls2fHadtr7 24DcBdyK3RDdlt4c3qLfKd+v4DbgveFE4cziU+Lb42Pj6+Rz5PzlhOYN5pbn H+ep6DLovOlG6dDqW+rl63Dr++yG7RHtnO4o7rTvQO/M8Fjw5fFy8f/yjPMZ 86f0NPTC9VD13vZt9vv3ivgZ+Kj5OPnH+lf65/t3/Af8mP0p/br+S/7c/23/ /wIMAPeE8/sKZW5kc3RyZWFtDWVuZG9iag0yMiAwIG9iag08PCANL1R5cGUg L0V4dEdTdGF0ZSANL1NBIGZhbHNlIA0vU00gMC4wMiANL1RSMiAvRGVmYXVs dCANPj4gDWVuZG9iag0xIDAgb2JqDTw8IA0vQ291bnQgMSANL1R5cGUgL091 dGxpbmVzIA0vRmlyc3QgMiAwIFIgDS9MYXN0IDIgMCBSIA0+PiANZW5kb2Jq DTIgMCBvYmoNPDwgDS9UaXRsZSAoU2hlZXQxKQ0vUGFyZW50IDEgMCBSIA0v QSAzIDAgUiANPj4gDWVuZG9iag0zIDAgb2JqDTw8IA0vUyAvR29UbyANL0Qg WyAxMSAwIFIgL1hZWiAwIDAgbnVsbCBdIA0+PiANZW5kb2JqDTQgMCBvYmoN PDwgDS9TIC9EIA0+PiANZW5kb2JqDTUgMCBvYmoNPDwgDS9OdW1zIFsgMCA0 IDAgUiBdIA0+PiANZW5kb2JqDTYgMCBvYmoNPDwgDS9UeXBlIC9QYWdlcyAN L0tpZHMgWyAxMSAwIFIgXSANL0NvdW50IDEgDT4+IA1lbmRvYmoNNyAwIG9i ag08PCANL1Byb2R1Y2VyIChBY3JvYmF0IERpc3RpbGxlciA1LjAgXChXaW5k b3dzXCkpDS9UaXRsZSAoQ2FycmllciBSaXNrIENsYXNzIERhdGEueGxzKQ0v QXV0aG9yIChzYnJlc3NsZXIpDS9Nb2REYXRlIChEOjIwMDMxMTExMTYzMDE0 LTA4JzAwJykNL0NyZWF0aW9uRGF0ZSAoRDoyMDAzMTExMTE2MzAwMi0wOCcw MCcpDS9DcmVhdG9yIChBY3JvYmF0IFBERk1ha2VyIDUuMCBmb3IgRXhjZWwp DT4+IA1lbmRvYmoNOCAwIG9iag08PCAvVHlwZSAvTWV0YWRhdGEgL1N1YnR5 cGUgL1hNTCAvTGVuZ3RoIDEwNzcgPj4gDXN0cmVhbQ0KPD94cGFja2V0IGJl Z2luPScnIGlkPSdXNU0wTXBDZWhpSHpyZVN6TlRjemtjOWQnIGJ5dGVzPScx MDc2Jz8+PHJkZjpSREYgeG1sbnM6cmRmPSdodHRwOi8vd3d3LnczLm9yZy8x OTk5LzAyLzIyLXJkZi1zeW50YXgtbnMjJyB4bWxuczppWD0naHR0cDovL25z LmFkb2JlLmNvbS9pWC8xLjAvJz48cmRmOkRlc2NyaXB0aW9uIGFib3V0PScn IHhtbG5zPSdodHRwOi8vbnMuYWRvYmUuY29tL3BkZi8xLjMvJyB4bWxuczpw ZGY9J2h0dHA6Ly9ucy5hZG9iZS5jb20vcGRmLzEuMy8nIHBkZjpDcmVhdGlv bkRhdGU9JzIwMDMtMTEtMTJUMDA6MzA6MDJaJyBwZGY6TW9kRGF0ZT0nMjAw My0xMS0xMlQwMDozMDowMlonIHBkZjpQcm9kdWNlcj0nQWNyb2JhdCBEaXN0 aWxsZXIgNS4wIChXaW5kb3dzKScgcGRmOkF1dGhvcj0nc2JyZXNzbGVyJyBw ZGY6Q3JlYXRvcj0nQWNyb2JhdCBQREZNYWtlciA1LjAgZm9yIEV4Y2VsJyBw ZGY6VGl0bGU9J0NhcnJpZXIgUmlzayBDbGFzcyBEYXRhLnhscycvPgo8cmRm OkRlc2NyaXB0aW9uIGFib3V0PScnIHhtbG5zPSdodHRwOi8vbnMuYWRvYmUu Y29tL3hhcC8xLjAvJyB4bWxuczp4YXA9J2h0dHA6Ly9ucy5hZG9iZS5jb20v eGFwLzEuMC8nIHhhcDpDcmVhdGVEYXRlPScyMDAzLTExLTEyVDAwOjMwOjAy WicgeGFwOk1vZGlmeURhdGU9JzIwMDMtMTEtMTJUMDA6MzA6MDJaJyB4YXA6 QXV0aG9yPSdzYnJlc3NsZXInIHhhcDpNZXRhZGF0YURhdGU9JzIwMDMtMTEt MTJUMDA6MzA6MDJaJz48eGFwOlRpdGxlPjxyZGY6QWx0PjxyZGY6bGkgeG1s Omxhbmc9J3gtZGVmYXVsdCc+Q2FycmllciBSaXNrIENsYXNzIERhdGEueGxz PC9yZGY6bGk+PC9yZGY6QWx0PjwveGFwOlRpdGxlPjwvcmRmOkRlc2NyaXB0 aW9uPgo8cmRmOkRlc2NyaXB0aW9uIGFib3V0PScnIHhtbG5zPSdodHRwOi8v cHVybC5vcmcvZGMvZWxlbWVudHMvMS4xLycgeG1sbnM6ZGM9J2h0dHA6Ly9w dXJsLm9yZy9kYy9lbGVtZW50cy8xLjEvJyBkYzpjcmVhdG9yPSdzYnJlc3Ns ZXInIGRjOnRpdGxlPSdDYXJyaWVyIFJpc2sgQ2xhc3MgRGF0YS54bHMnLz4K PC9yZGY6UkRGPjw/eHBhY2tldCBlbmQ9J3InPz4KZW5kc3RyZWFtDWVuZG9i ag14cmVmDTAgOSANMDAwMDAwMDAwMCA2NTUzNSBmDQowMDAwMDQ0Mjk0IDAw MDAwIG4NCjAwMDAwNDQzNzEgMDAwMDAgbg0KMDAwMDA0NDQzNSAwMDAwMCBu DQowMDAwMDQ0NDk3IDAwMDAwIG4NCjAwMDAwNDQ1MjcgMDAwMDAgbg0KMDAw MDA0NDU2OSAwMDAwMCBuDQowMDAwMDQ0NjM0IDAwMDAwIG4NCjAwMDAwNDQ4 NzcgMDAwMDAgbg0KdHJhaWxlcg08PA0vU2l6ZSA5DS9JRFs8MDIwOTA3OThh OGU2NTAyNDEyZTQwMTYwMDcwNTlhZDE+PGE5NWRiNGI2YWVhNWYxYTE5ZjBk ZWMwMzI2YzFhZjFlPl0NPj4Nc3RhcnR4cmVmDTE3Mw0lJUVPRg0= --0-732887805-1069520645=:9105-- From pottsbri@yahoo.com Sun Nov 23 23:06:03 2003 From: pottsbri@yahoo.com (CAL/AAEM News Service) Date: Sun, 23 Nov 2003 15:06:03 -0800 (PST) Subject: NYT: For Middle Class, Health Insurance Becomes a Luxury Message-ID: <20031123230603.36951.qmail@web41309.mail.yahoo.com> --0-674979979-1069628763=:35893 Content-Type: text/plain; charset=us-ascii Submission by Paul Windham. ====================== --------------------------------- November 16, 2003For Middle Class, Health Insurance Becomes a LuxuryBy STEPHANIE STROM ALLAS — The last time Kevin Thornton had health insurance was three years ago, which was not much of a problem until he began having trouble swallowing. "I broke down earlier this year and went in and talked to a doctor about it," said Mr. Thornton, who lives in Sherman, about 60 miles north of Dallas. A barium X-ray cost him $130, and the radiologist another $70, expenses he charged to his credit cards. The doctor ordered other tests that Mr. Thornton simply could not afford. "I was supposed to go back after the X-ray results came, but I decided just to live with it for a while," he said. "I may just be a walking time bomb." Mr. Thornton, 41, left a stable job with good health coverage in 1998 for a higher salary at a dot-com company that went bust a few months later. Since then, he has worked on contract for various companies, including one that provided insurance until the project ended in 2000. "I failed to keep up the payments that would have been required to maintain my coverage," he said. "It was just too much money." Mr. Thornton is one of more than 43 million people in the United States who lack health insurance, and their numbers are rapidly increasing because of ever soaring cost and job losses. Many states, including Texas, are also cutting back on subsidies for health care, further increasing the number of people with no coverage. The majority of the uninsured are neither poor by official standards nor unemployed. They are accountants like Mr. Thornton, employees of small businesses, civil servants, single working mothers and those working part time or on contract. "Now it's hitting people who look like you and me, dress like you and me, drive nice cars and live in nice houses but can't afford $1,000 a month for health insurance for their families," said R. King Hillier, director of legislative relations for Harris County, which includes Houston. Paying for health insurance is becoming a middle-class problem, and not just here. "After paying for health insurance, you take home less than minimum wage," says a poster in New York City subways sponsored by Working Today, a nonprofit agency that offers health insurance to independent contractors in New York. "Welcome to middle-class poverty." In Southern California, 70,000 supermarket workers have been on strike for five weeks over plans to cut their health benefits. The insurance crisis is especially visible in Texas, which has the highest proportion of uninsured in the country — almost one in every four residents. The state has a large population of immigrants; its labor market is dominated by low-wage service sector jobs, and it has a higher than average number of small businesses, which are less likely to provide health benefits because they pay higher insurance costs than large companies. State cuts to subsidies for health insurance to help close a $10 billion budget gap will cost the state $500 million in federal matching money and are expected to further spur the rise in uninsured. In September, for example, more than half a million children enrolled in a state- and federal-subsidized insurance program lost dental, vision and most mental care coverage, and some 169,000 children will lose all insurance by 2005. "These were tough economic times that the legislature was dealing with, and the governor believed in setting the tone for the legislative session that the government must operate the way Texas families do and Texas businesses do and live within its means," said Kathy Walt, spokeswoman for Gov. Rick Perry. She noted that the legislature raised spending on health and human services by $1 billion this year, and that lawmakers passed two bills intended to make it easier for small businesses to provide health insurance for their employees. Those measures, however, will not help Theresa Pardo or other Texas residents like her who have to make tough choices about medical care they need but cannot afford. Ms. Pardo, a 29-year-old from Houston, said that having no insurance meant choosing between buying an inhaler for her 9-year-old asthmatic daughter or buying her a birthday present. The girl, Morgan, lost her state-subsidized insurance last month, and now her mother must pay $80 instead of $5 for the inhaler. Rent, car payments and insurance, day care and utilities cost Ms. Pardo more than $1,200 a month, leaving less than $200 for food, gas and other expenses. So even though her employer, the Harris County government, provides her with low-cost insurance, she cannot afford the $275 a month she would have to pay to add her daughter to her plan. When Morgan's dentist recently wanted to pull a tooth, Ms. Pardo hesitated. The tooth extraction proceeded, but: "I had to ask him, if you pull this tooth, will it cause other problems? Because if it does, I can't afford to deal with them." Lorenda Stevenson said her choice was between buying medicine to treat patches of peeling, flaking skin on her hands, arms and face and making sure her son could continue his after-school tennis program. "There's no way I will cut that out unless we don't have money for food," she said. Mrs. Stevenson's husband, Bill, lost his management job at WorldCom two years ago, when an accounting scandal forced the company into bankruptcy. They managed to pay $900 a month for Cobra, the government policy that allows workers to continue their coverage after they lose their jobs, but when the cost rose to $1,200, they could no longer afford it. When their son, a ninth grader, needed a physical and shot to take tennis, Mrs. Stevenson turned to the Rockwall Area Health Clinic, a nonprofit clinic in Rockwall, a city of 13,000 northeast of Dallas. The clinic charged her $20 instead of the $400 she estimated she would have paid at the doctor's office. "I sat filling out the paperwork and crying," she said, tears streaming down her face. "I was so embarrassed to bring him here." A salve to treat her skin condition costs $27, and she pays roughly $50 a month for medications for high blood pressure and hormones. She does without medication she needs for acid reflux, treating the conditions sporadically with samples from the clinic. Carol Johnston cannot afford even doctor visits. A single mother in Houston, she lost her job in health care administration in May and said she was still unemployed despite filling out 500 to 600 applications and attending countless job fairs. Cobra would have cost $214 a month, or more than one-fifth of the $1,028 in unemployment she gets a month. As it is, her monthly bills for rent, car, utilities and phone exceed her income. She got a 12-month deferral on her student loans, and Ford pushed her car payments back by two months. The Johnstons rely on television for entertainment and almost never use air-conditioning, despite Houston's muggy, hot climate. Now Ms. Johnston's 16-year-old son is losing the portion of his insurance that covered treatment for his learning and emotional disabilities because of state cutbacks. Ms. Johnston herself does not qualify for Medicaid, the government insurance program for the indigent, because her income is too high, the same reason she qualifies for only $10 a month in food stamps. "I worry, I worry so much about making sure my son is safe," she said. As for her own health, Ms. Johnston has two cysts in one breast and three in another but has had only one aspirated because she cannot afford to check on the others. "Do I have to move to Iraq to get help?" she asked. "They have $87 billion for folks over there," she said, referring to money Congress allocated for military operations and rebuilding. Experts warn that allowing health problems to fester is only going to increase the costs of health care for the uninsured. "As Americans, when are we going to realize it's cheaper to save them on the front end than when they get cancer and show up in the emergency room?" said Sandra B. Thurman, executive director of PediPlace, a nonprofit health clinic in Lewisville, Tex. Many hospitals and neighborhood clinics here say that the well-heeled are now joining the poor in seeking their care. Emergency rooms are particularly hard hit, since federal law requires them to treat anyone who walks through their doors for emergency treatment, regardless of whether they can pay. Public hospital emergency rooms are even harder hit, since private hospitals will move quickly to shift uninsured patients to them. And clinics for the poor are also seeing an increase in demand. A clinic run by Central Dallas Ministries charges patients $5 for a doctor visit, $10 for medication and $15 if laboratory work is needed, but often settles for no payment from many of the 3,500 patients it treats each year. "I'm not real optimistic it will get a lot better," said Larry Morris James, executive director of Central Dallas Ministries. "Demographic and economic trends tell you that it's probably going to get worse." For Irma Arellano, the problem has already hit home. Mrs. Arellano is a secretary in the Royse school district northeast of Dallas, which provides her health insurance for $35 a month but offers no discounts for her three children or husband. Two years ago, the Arellanos paid $269 a month to insure the family. The price jumped last year to $339 and this year to $780, more than their monthly mortgage payment. Her husband works for a small landscaping company that does not offer insurance. So Mrs. Arellano is insured, but her husband, Jose, and their three children — Jackie, 16; Joe, 15; and Anthony, 13 — are going without insurance. The Arellanos' income, which ranges from $2,800 to $3,200 a month, makes them ineligible for state-subsidized insurance. Their basic expenses run $2,000 a month or more. "I'm one of those people in the middle," Mrs. Arellano said. "We don't make enough to pay for insurance ourselves, but we make too much to qualify for CHIP," the government-subsidized program for children. So her children were recently at the Rockwall clinic for the physicals they need to participate in after-school sports, paying $25 instead of the $100 or more Mrs. Arellano would have paid at the doctor's office. The family has catastrophic insurance, but Mrs. Arellano is uncertain how much longer she can afford it. Mr. Arellano's income typically drops in the winter, and his wife is hoping the children will then qualify for the state insurance program. Even so, newly initiated regulations require families to reapply for the insurance every six months, rather than once a year, so they are not likely to qualify for long. "I'll take what I can get," Mrs. Arellano said. Copyright 2003 The New York Times Company | Home | Privacy Policy | Search | Corrections | Help | Back to Top Brian Potts Managing Editor, CAL/AAEM News Service MS-IV, UC-Irvine --------------------------------- Do you Yahoo!? Free Pop-Up Blocker - Get it now --0-674979979-1069628763=:35893 Content-Type: text/html; charset=us-ascii
  November 16, 2003For Middle Class, Health Insurance Becomes a Luxury
"I broke down earlier this year and went in and talked to a doctor about it," said Mr. Thornton, who lives in Sherman, about 60 miles north of Dallas. A barium X-ray cost him $130, and the radiologist another $70, expenses he charged to his credit cards. The doctor ordered other tests that Mr. Thornton simply could not afford. "I was supposed to go back after the X-ray results came, but I decided just to live with it for a while," he said. "I may just be a walking time bomb." Mr. Thornton, 41, left a stable job with good health coverage in 1998 for a higher salary at a dot-com company that went bust a few months later. Since then, he has worked on contract for various companies, including one that provided insurance until the project ended in 2000. "I failed to keep up the payments that would have been required to maintain my coverage," he said. "It was just too much money." Mr. Thornton is one of more than 43 million people in the United States who lack health insurance, and their numbers are rapidly increasing because of ever soaring cost and job losses. Many states, including Texas, are also cutting back on subsidies for health care, further increasing the number of people with no coverage. The majority of the uninsured are neither poor by official standards nor unemployed. They are accountants like Mr. Thornton, employees of small businesses, civil servants, single working mothers and those working part time or on contract. "Now it's hitting people who look like you and me, dress like you and me, drive nice cars and live in nice houses but can't afford $1,000 a month for health insurance for their families," said R. King Hillier, director of legislative relations for Harris County, which includes Houston. Paying for health insurance is becoming a middle-class problem, and not just here. "After paying for health insurance, you take home less than minimum wage," says a poster in New York City subways sponsored by Working Today, a nonprofit agency that offers health insurance to independent contractors in New York. "Welcome to middle-class poverty." In Southern California, 70,000 supermarket workers have been on strike for five weeks over plans to cut their health benefits. The insurance crisis is especially visible in Texas, which has the highest proportion of uninsured in the country — almost one in every four residents. The state has a large population of immigrants; its labor market is dominated by low-wage service sector jobs, and it has a higher than average number of small businesses, which are less likely to provide health benefits because they pay higher insurance costs than large companies. State cuts to subsidies for health insurance to help close a $10 billion budget gap will cost the state $500 million in federal matching money and are expected to further spur the rise in uninsured. In September, for example, more than half a million children enrolled in a state- and federal-subsidized insurance program lost dental, vision and most mental care coverage, and some 169,000 children will lose all insurance by 2005. "These were tough economic times that the legislature was dealing with, and the governor believed in setting the tone for the legislative session that the government must operate the way Texas families do and Texas businesses do and live within its means," said Kathy Walt, spokeswoman for Gov. Rick Perry. She noted that the legislature raised spending on health and human services by $1 billion this year, and that lawmakers passed two bills intended to make it easier for small businesses to provide health insurance for their employees. Those measures, however, will not help Theresa Pardo or other Texas residents like her who have to make tough choices about medical care they need but cannot afford. Ms. Pardo, a 29-year-old from Houston, said that having no insurance meant choosing between buying an inhaler for her 9-year-old asthmatic daughter or buying her a birthday present. The girl, Morgan, lost her state-subsidized insurance last month, and now her mother must pay $80 instead of $5 for the inhaler. Rent, car payments and insurance, day care and utilities cost Ms. Pardo more than $1,200 a month, leaving less than $200 for food, gas and other expenses. So even though her employer, the Harris County government, provides her with low-cost insurance, she cannot afford the $275 a month she would have to pay to add her daughter to her plan. When Morgan's dentist recently wanted to pull a tooth, Ms. Pardo hesitated. The tooth extraction proceeded, but: "I had to ask him, if you pull this tooth, will it cause other problems? Because if it does, I can't afford to deal with them." Lorenda Stevenson said her choice was between buying medicine to treat patches of peeling, flaking skin on her hands, arms and face and making sure her son could continue his after-school tennis program. "There's no way I will cut that out unless we don't have money for food," she said. Mrs. Stevenson's husband, Bill, lost his management job at WorldCom two years ago, when an accounting scandal forced the company into bankruptcy. They managed to pay $900 a month for Cobra, the government policy that allows workers to continue their coverage after they lose their jobs, but when the cost rose to $1,200, they could no longer afford it. When their son, a ninth grader, needed a physical and shot to take tennis, Mrs. Stevenson turned to the Rockwall Area Health Clinic, a nonprofit clinic in Rockwall, a city of 13,000 northeast of Dallas. The clinic charged her $20 instead of the $400 she estimated she would have paid at the doctor's office. "I sat filling out the paperwork and crying," she said, tears streaming down her face. "I was so embarrassed to bring him here." A salve to treat her skin condition costs $27, and she pays roughly $50 a month for medications for high blood pressure and hormones. She does without medication she needs for acid reflux, treating the conditions sporadically with samples from the clinic. Carol Johnston cannot afford even doctor visits. A single mother in Houston, she lost her job in health care administration in May and said she was still unemployed despite filling out 500 to 600 applications and attending countless job fairs. Cobra would have cost $214 a month, or more than one-fifth of the $1,028 in unemployment she gets a month. As it is, her monthly bills for rent, car, utilities and phone exceed her income. She got a 12-month deferral on her student loans, and Ford pushed her car payments back by two months. The Johnstons rely on television for entertainment and almost never use air-conditioning, despite Houston's muggy, hot climate. Now Ms. Johnston's 16-year-old son is losing the portion of his insurance that covered treatment for his learning and emotional disabilities because of state cutbacks. Ms. Johnston herself does not qualify for Medicaid, the government insurance program for the indigent, because her income is too high, the same reason she qualifies for only $10 a month in food stamps. "I worry, I worry so much about making sure my son is safe," she said. As for her own health, Ms. Johnston has two cysts in one breast and three in another but has had only one aspirated because she cannot afford to check on the others. "Do I have to move to Iraq to get help?" she asked. "They have $87 billion for folks over there," she said, referring to money Congress allocated for military operations and rebuilding. Experts warn that allowing health problems to fester is only going to increase the costs of health care for the uninsured. "As Americans, when are we going to realize it's cheaper to save them on the front end than when they get cancer and show up in the emergency room?" said Sandra B. Thurman, executive director of PediPlace, a nonprofit health clinic in Lewisville, Tex. Many hospitals and neighborhood clinics here say that the well-heeled are now joining the poor in seeking their care. Emergency rooms are particularly hard hit, since federal law requires them to treat anyone who walks through their doors for emergency treatment, regardless of whether they can pay. Public hospital emergency rooms are even harder hit, since private hospitals will move quickly to shift uninsured patients to them. And clinics for the poor are also seeing an increase in demand. A clinic run by Central Dallas Ministries charges patients $5 for a doctor visit, $10 for medication and $15 if laboratory work is needed, but often settles for no payment from many of the 3,500 patients it treats each year. "I'm not real optimistic it will get a lot better," said Larry Morris James, executive director of Central Dallas Ministries. "Demographic and economic trends tell you that it's probably going to get worse." For Irma Arellano, the problem has already hit home. Mrs. Arellano is a secretary in the Royse school district northeast of Dallas, which provides her health insurance for $35 a month but offers no discounts for her three children or husband. Two years ago, the Arellanos paid $269 a month to insure the family. The price jumped last year to $339 and this year to $780, more than their monthly mortgage payment. Her husband works for a small landscaping company that does not offer insurance. So Mrs. Arellano is insured, but her husband, Jose, and their three children — Jackie, 16; Joe, 15; and Anthony, 13 — are going without insurance. The Arellanos' income, which ranges from $2,800 to $3,200 a month, makes them ineligible for state-subsidized insurance. Their basic expenses run $2,000 a month or more. "I'm one of those people in the middle," Mrs. Arellano said. "We don't make enough to pay for insurance ourselves, but we make too much to qualify for CHIP," the government-subsidized program for children. So her children were recently at the Rockwall clinic for the physicals they need to participate in after-school sports, paying $25 instead of the $100 or more Mrs. Arellano would have paid at the doctor's office. The family has catastrophic insurance, but Mrs. Arellano is uncertain how much longer she can afford it. Mr. Arellano's income typically drops in the winter, and his wife is hoping the children will then qualify for the state insurance program. Even so, newly initiated regulations require families to reapply for the insurance every six months, rather than once a year, so they are not likely to qualify for long. "I'll take what I can get," Mrs. Arellano said. |
ALLAS — The last time Kevin Thornton had health insurance was three years ago, which was not much of a problem until he began having trouble swallowing.Brian Potts
Managing Editor, CAL/AAEM News Service
MS-IV, UC-Irvine
Do you Yahoo!?
Free Pop-Up Blocker - Get it now --0-674979979-1069628763=:35893-- From pottsbri@yahoo.com Mon Nov 24 22:18:40 2003 From: pottsbri@yahoo.com (CAL/AAEM News Service) Date: Mon, 24 Nov 2003 14:18:40 -0800 (PST) Subject: House passes Medicare Prescription Drug Bill conference report; AHA applauds Message-ID: <20031124221840.29166.qmail@web41308.mail.yahoo.com> --0-1714217798-1069712320=:26818 Content-Type: text/plain; charset=us-ascii =================================== AHA NEWS NOW Special Report House passes Medicare Prescription Drug Bill conference report; AHA applauds November 22, 2003 =================================== After intense debate and a vote that lasted nearly three hours, the House voted 220-215 before dawn Saturday to approve the Medicare prescription drug bill conference report. Soon after, the AHA issued a statement describing the vote as "a step that America's hospitals applaud" and sent a bulletin to members urging them to contact their senators and urge passage. "This legislation provides an historic addition to the Medicare program - a long overdue prescription drug benefit," Executive Vice President Rick Pollack said in the AHA statement. He added: "In America's hospitals, more than 4.7 million people go to work; more than 3 million babies are born; and more than 100 million people are treated for emergencies every year. This bill is vitally important for that care to continue. It provides significant relief for rural hospitals, eliminates reductions in payments to teaching hospitals, and provides much needed relief to hospitals that serve a large number of the poor and uninsured. "We encourage Senate passage of this agreement that addresses important health care needs of the elderly while improving the underlying system upon which they depend," the statement concluded. At roughly the same time as the AHA spoke out, the Senate began its debate on the measure Saturday morning. That chamber was expected to continue talking through the rest of the weekend and then vote late Monday. Before House debate began Friday, the AHA sent a letter to all members of Congress urging them to pass the bill. It also has published several ads in Washington publications supporting the legislation. Aside from numerous financial provisions affecting hospitals, the bills also includes language addressing concerns with CMS' proposed changes to the 75% Rule on Medicare inpatient rehabilitation facilities. Specifically, the conferees directed the Government Accounting Office to issue a report looking into how the rule must be updated, and urged the Secretary of HHS "to delay implementation of the rule ... until the report is finished." For details on what's in the legislation and how the House voted, go to http://www.aha.org and click on the "Medicare Prescription Drug Bill" icon on the home page. ***** Feel free to talk to AHA News Now's editors with your feedback, stories and suggestions: * Executive Editor: Jim Reiter, jreiter@aha.org, 202-626-2364 * Business Manager: Craig Webb, cwebb@healthforum.com, 202-662-2435 * Managing Editor: Mary Ann Costello, mcostello@healthforum.com, 312-893-6877 * For information on sponsoring AHA News Now, contact Agatha Abbinanti at aabbinanti@healthforum.com. Visit AHA News Now and its print version, AHA News, at http://www.ahanews.com/ ================================== Copyright 2003 by the American Hospital Association. All rights reserved. For republication rights, contact Craig Webb. AHA News is a registered trademark of the American Hospital Association. The opinions expressed in AHA News Now are not necessarily those of the American Hospital Association. Brian Potts Managing Editor, CAL/AAEM News Service MS-IV, UC-Irvine --------------------------------- Do you Yahoo!? Free Pop-Up Blocker - Get it now --0-1714217798-1069712320=:26818 Content-Type: text/html; charset=us-ascii
===================================
AHA NEWS NOW Special Report
House passes Medicare Prescription Drug Bill conference report; AHA applauds
November 22, 2003
===================================
After intense debate and a vote that lasted nearly three hours, the House voted 220-215 before dawn Saturday to approve the Medicare prescription drug bill conference report. Soon after, the AHA issued a statement describing the vote as "a step that America's hospitals applaud" and sent a bulletin to members urging them to contact their senators and urge passage.
"This legislation provides an historic addition to the Medicare program
- a long overdue prescription drug benefit," Executive Vice President Rick Pollack said in the AHA statement.
He added: "In America's hospitals, more than 4.7 million people go to work; more than 3 million babies are born; and more than 100 million people are treated for emergencies every year. This bill is vitally important for that care to continue. It provides significant relief for rural hospitals, eliminates reductions in payments to teaching hospitals, and provides much needed relief to hospitals that serve a large number of the poor and uninsured.
"We encourage Senate passage of this agreement that addresses important health care needs of the elderly while improving the underlying system upon which they depend," the statement concluded.
At roughly the same time as the AHA spoke out, the Senate began its debate on the measure Saturday morning. That chamber was expected to continue talking through the rest of the weekend and then vote late Monday.
Before House debate began Friday, the AHA sent a letter to all members of Congress urging them to pass the bill. It also has published several ads in Washington publications supporting the legislation.
Aside from numerous financial provisions affecting hospitals, the bills also includes language addressing concerns with CMS' proposed changes to the 75% Rule on Medicare inpatient rehabilitation facilities. Specifically, the conferees directed the Government Accounting Office to issue a report looking into how the rule must be updated, and urged the Secretary of HHS "to delay implementation of the rule ... until the report is finished."
For details on what's in the legislation and how the House voted, go to
http://www.aha.org and click on the "Medicare Prescription Drug Bill" icon on the home page.*****
Feel free to talk to AHA News Now's editors with your feedback, stories and
suggestions:
* Executive Editor: Jim Reiter, jreiter@aha.org, 202-626-2364
* Business Manager: Craig Webb, cwebb@healthforum.com, 202-662-2435
* Managing Editor: Mary Ann Costello, mcostello@healthforum.com, 312-893-6877
* For information on sponsoring AHA News Now, contact Agatha Abbinanti at aabbinanti@healthforum.com.
Visit AHA News Now and its print version, AHA News, at
http://www.ahanews.com/==================================
Copyright 2003 by the American Hospital Association. All rights reserved. For republication rights, contact Craig Webb.
AHA News is a registered trademark of the American Hospital Association. The opinions expressed in AHA News Now are not necessarily those of the American Hospital Association.
Brian Potts
Managing Editor, CAL/AAEM News Service
MS-IV, UC-Irvine
Do you Yahoo!?
Free Pop-Up Blocker - Get it now --0-1714217798-1069712320=:26818-- From akazzi@uci.edu Mon Nov 24 22:25:47 2003 From: akazzi@uci.edu (Kazzi, A. Antoine) Date: Mon, 24 Nov 2003 14:25:47 -0800 Subject: FW: Take Action Now on Medicare Bill - *** MEDICARE BILL BEING D EBATED IN SENATE - CONTACT YOUR SENATOR NOW! *** Message-ID: <59CDD9FF884EAE4AB86132E86110D72202E09712@wicket.ndc.mc.uci.edu> -----Original Message----- From: AAEM [mailto:info@aaem.org] Sent: Monday, November 24, 2003 2:25 PM Subject: Take Action Now on Medicare Bill *** MEDICARE BILL BEING DEBATED IN SENATE - CONTACT YOUR SENATOR NOW! *** The Medicare Bill/Conference Report passed by the House Saturday morning contains three provisions on which AAEM has been actively lobbying: - It blocks the 4.5% cut in physician payments and substitutes an increase of 1.5% in 2004 and 2005. - It provides physicians with unrestrictive access to billings submitted on their behalf by the entity with which they have contracted. - It contains $1 billion mandatory spending for hospitals, ambulances, and physicians providing services to illegal immigrants under an EMTALA related admission. The Senate started its debate on the bill at about 12:30 p.m., today. Debate can not go longer than 30 hours at which time the vote will occur. ACT NOW TO ENSURE PASSAGE OF THE MEDICARE CONFERENCE AGREEMENT BY THE SENATE! FAX or CALL your Senators TODAY! Ask them to adopt the Medicare Conference Agreement and pass H.R.1. PERSONALIZE YOUR MESSAGE. TELL YOUR CONGRESSIONAL DELEGATION HOW THESE ISSUES EFFECT YOU, YOUR PATIENTS, AND THE FACILITY IN WHICH YOU WORK. Should you choose to call your Senators (Go to the AAEM Legislative Action Center for individual office phone numbers.), please highlight the following in your conversation: **You are a constituent and an emergency medicine physician. **The status quo is unacceptable to patients and their physicians. **The Conference Report includes numerous provisions that will improve seniors' access to medical services as well as provide critical support to the emergency medical community. **You strongly advocate the Senate's adoption of the Medicare Prescription Drug and Modernization Act's Conference Report. Go to AAEM's Legislative Action Center for detailed information, and all the contact information you will need. To access the Action Center, go to the AAEM homepage
-----Original Message-----
From: Kazzi, A. Antoine [
mailto:akazzi@uci.edu]To: Potts, Brian
Yes, it does. AAEM was able to get this inserted into the bill at the last minute...
Please call and send emails to your representatives. This is a great victory for EM, for the individual EPs, and puts an end to the effort of some powerful non-AAEM entities who tried, in the original draft in front of the Legislature, to get the reassignment of professional fees inserted into Medicare law to accommodate the needs and interests of contract holders and practice management groups.
That was why they met with the OIG...
Call and help us make this bill pass.
It is indeed a great victory for Fairness in EM and the result of AAEM's initiative.
Antoine Kazzi
-----Original Message-----
From: Potts, Brian
Dr. Kazzi,
"It provides physicians with unrestrictive access to billings submitted on their behalf by the entity with which they have contracted.".... Is this provision really part of the upcoming Medicare Bill? This would be an amazing step in efforts against the CMGs.
Brian
-----Original Message-----
From: calaaem-admin@uci.edu [
mailto:calaaem-admin@uci.edu] On Behalf Of Kazzi, A. AntoineSent: Monday, November 24, 2003 2:26 PM
To: CAL/AAEM News Service
Subject: FW: Take Action Now on Medicare Bill - *** MEDICARE BILL BEING DEBATED IN SENATE - CONTACT YOUR SENATOR NOW! ***
Importance: High
-----Original Message-----
From: AAEM [
mailto:info@aaem.org]Sent: Monday, November 24, 2003 2:25 PM
Subject: Take Action Now on Medicare Bill
*** MEDICARE BILL BEING DEBATED IN SENATE - CONTACT YOUR SENATOR NOW!
***
The Medicare Bill/Conference Report passed by the House Saturday morning contains three provisions on which AAEM has been actively lobbying:
- It blocks the 4.5% cut in physician payments and substitutes an increase of 1.5% in 2004 and 2005.
- It provides physicians with unrestrictive access to billings submitted on their behalf by the entity with which they have contracted.
- It contains $1 billion mandatory spending for hospitals, ambulances, and physicians providing services to illegal immigrants under an EMTALA related admission.
The Senate started its debate on the bill at about 12:30 p.m., today. Debate can not go longer than 30 hours at which time the vote will occur.
ACT NOW TO ENSURE PASSAGE OF THE MEDICARE CONFERENCE AGREEMENT BY THE SENATE! FAX or CALL your Senators TODAY! Ask them to adopt the Medicare Conference Agreement and pass H.R.1. PERSONALIZE YOUR MESSAGE. TELL YOUR CONGRESSIONAL DELEGATION HOW THESE ISSUES EFFECT YOU, YOUR PATIENTS, AND THE FACILITY IN WHICH YOU WORK.
Should you choose to call your Senators (Go to the AAEM Legislative Action Center for individual office phone numbers.), please highlight the following in your conversation:
**You are a constituent and an emergency medicine physician. **The status quo is unacceptable to patients and their physicians.
**The Conference Report includes numerous provisions that will improve seniors' access to medical services as well as provide critical support to
the emergency medical community.
**You strongly advocate the Senate's adoption of the Medicare Prescription Drug and Modernization Act's Conference Report.
Go to AAEM's Legislative Action Center for detailed information, and all the contact information you will need. To access the Action Center, go to the AAEM homepage <
www.aaem.org> and then click on "Legislative Action Center."When you are on the Action Center's homepage, please take the time to sign up for AAEM's "E-Mail Alerts." These "Alerts" will provide you with strategic information to affect key policy issues of concern to emergency medicine.
This e-mail/fax message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail/fax and destroy all copies of the original message.
_______________________________________________
List-Info:
https://maillists.uci.edu/mailman/listinfo/calaaemBrian Potts
Managing Editor, CAL/AAEM News Service
MS-IV, UC-Irvine
Do you Yahoo!?
Free Pop-Up Blocker - Get it now --0-1873887112-1069824953=:24450-- From pottsbrian@yahoo.com Thu Nov 27 18:00:40 2003 From: pottsbrian@yahoo.com (B Potts) Date: Thu, 27 Nov 2003 10:00:40 -0800 (PST) Subject: NYT: Flu Vaccine Faces Unexpected Strain Message-ID: <20031127180040.56198.qmail@web60310.mail.yahoo.com> --0-238595769-1069956040=:55092 Content-Type: text/plain; charset=us-ascii --------------------------------- November 18, 2003Flu Vaccine Faces Unexpected StrainBy LAWRENCE K. ALTMAN he influenza vaccine now being given was not developed to protect against a strain of the virus that has surfaced in this country this fall, but the government is optimistic that this year's vaccine will stave off outbreaks, a top federal health official said yesterday. The reason is that animal studies suggest that the strains of virus included in the vaccine are close enough to the new one that the vaccine will still protect, said the official, Dr. Julie L. Gerberding, the director of the Centers for Disease Control and Prevention in Atlanta. Still, she warned, the United States could face a severe epidemic this year, given that the flu season began unusually early and has hit Texas and Colorado particularly hard. "It's a little too early to say whether or not this portends the worst flu season we have had in a long time," Dr. Gerberding said in a telephone news conference. Her agency is responsible for tracking and controlling influenza and other infectious diseases. She said she was "sounding the alarm" to urge more people to get flu shots to "nip this problem in the bud." The center does not know how many people have received flu shots this season. "People have the impression we are doing better this year than last year, but we do not have the data to back that up at this point in time," she said. The flu vaccine includes three strains of influenza virus, but was not designed to protect against a new one that has appeared in a number of countries over the last year. It is known as the Fujian strain, a variant of the Panama strain that is included in the current vaccine. Both are categorized as H3N2 strains that have been linked to higher rates of serious illness requiring admission to a hospital and to death, Dr. Gerberding said. Each year, influenza causes 114,000 hospital admissions and 36,000 deaths. The influenza virus mutates frequently. Health officials change the strains of virus put in the flu vaccine each year as they try to keep up with mutations. But matching strains in the vaccine with those circulating among humans during a flu season is a notoriously unpredictable exercise. The World Health Organization committee that makes the recommendations for the flu vaccine knew about the Fujian strain in February, said Dr. Klaus Stöhr, an influenza expert at the organization. But Dr. Stöhr said in a recent interview that the committee decided not to include the Fujian strain because scientists could not make it pure enough in time for a human vaccine. The flu vaccine is prepared in eggs. Decisions about the components of the vaccine have to be made months in advance in part because manufacturers and farmers need to know how many eggs to prepare in anticipation of demand. Influenza typically occurs during the winter in each hemisphere, and the vaccines are prepared at different times. The vaccine being prepared for use in the Southern Hemisphere will include the Fujian strain, Dr. Stöhr said. "There may be less than optimal protection against H3N2" in the Northern Hemisphere, "but no vaccine failure has been reported" there, he said. "So there is no reason to discourage people from getting vaccinated." Dr. Gerberding said it was common for the circulating influenza to gradually change genetically — known as "drift" — as it spread to infect more people. Tests at the center found that 84 percent of the 55 strains of influenza virus isolated this fall are the Fujian strain, Dr. Gerberding said. But she emphasized that protection could still occur even without a perfect match. Dr. Gerberding said that an earlier than usual onset of the flu had occurred in some European countries but that "this is not a pandemic." Copyright 2003 The New York Times Company | Home | Privacy Policy | Search | Corrections | Help | Back to Top --------------------------------- Do you Yahoo!? Protect your identity with Yahoo! Mail AddressGuard --0-238595769-1069956040=:55092 Content-Type: text/html; charset=us-ascii
November 18, 2003Flu Vaccine Faces Unexpected Strain
The reason is that animal studies suggest that the strains of virus included in the vaccine are close enough to the new one that the vaccine will still protect, said the official, Dr. Julie L. Gerberding, the director of the Centers for Disease Control and Prevention in Atlanta. Still, she warned, the United States could face a severe epidemic this year, given that the flu season began unusually early and has hit Texas and Colorado particularly hard. "It's a little too early to say whether or not this portends the worst flu season we have had in a long time," Dr. Gerberding said in a telephone news conference. Her agency is responsible for tracking and controlling influenza and other infectious diseases. She said she was "sounding the alarm" to urge more people to get flu shots to "nip this problem in the bud." The center does not know how many people have received flu shots this season. "People have the impression we are doing better this year than last year, but we do not have the data to back that up at this point in time," she said. The flu vaccine includes three strains of influenza virus, but was not designed to protect against a new one that has appeared in a number of countries over the last year. It is known as the Fujian strain, a variant of the Panama strain that is included in the current vaccine. Both are categorized as H3N2 strains that have been linked to higher rates of serious illness requiring admission to a hospital and to death, Dr. Gerberding said. Each year, influenza causes 114,000 hospital admissions and 36,000 deaths. The influenza virus mutates frequently. Health officials change the strains of virus put in the flu vaccine each year as they try to keep up with mutations. But matching strains in the vaccine with those circulating among humans during a flu season is a notoriously unpredictable exercise. The World Health Organization committee that makes the recommendations for the flu vaccine knew about the Fujian strain in February, said Dr. Klaus Stöhr, an influenza expert at the organization. But Dr. Stöhr said in a recent interview that the committee decided not to include the Fujian strain because scientists could not make it pure enough in time for a human vaccine. The flu vaccine is prepared in eggs. Decisions about the components of the vaccine have to be made months in advance in part because manufacturers and farmers need to know how many eggs to prepare in anticipation of demand. Influenza typically occurs during the winter in each hemisphere, and the vaccines are prepared at different times. The vaccine being prepared for use in the Southern Hemisphere will include the Fujian strain, Dr. Stöhr said. "There may be less than optimal protection against H3N2" in the Northern Hemisphere, "but no vaccine failure has been reported" there, he said. "So there is no reason to discourage people from getting vaccinated." Dr. Gerberding said it was common for the circulating influenza to gradually change genetically — known as "drift" — as it spread to infect more people. Tests at the center found that 84 percent of the 55 strains of influenza virus isolated this fall are the Fujian strain, Dr. Gerberding said. But she emphasized that protection could still occur even without a perfect match. Dr. Gerberding said that an earlier than usual onset of the flu had occurred in some European countries but that "this is not a pandemic." |
he influenza vaccine now being given was not developed to protect against a strain of the virus that has surfaced in this country this fall, but the government is optimistic that this year's vaccine will stave off outbreaks, a top federal health official said yesterday.Do you Yahoo!?
Protect your identity with Yahoo! Mail AddressGuard --0-238595769-1069956040=:55092-- From pottsbri@yahoo.com Sun Nov 30 16:21:17 2003 From: pottsbri@yahoo.com (CAL/AAEM News Service) Date: Sun, 30 Nov 2003 08:21:17 -0800 (PST) Subject: Senate Passes Medicare Legislation 54-44; President Bush Expected to Sign Message-ID: <20031130162117.18406.qmail@web41306.mail.yahoo.com> --0-1265601636-1070209277=:18105 Content-Type: text/plain; charset=us-ascii -----Original Message----- From: California Healthline [mailto:CALIFORNIAHEALTHLINE@ADVISORY.COM] Sent: Tuesday, November 25, 2003 10:34 AM Senate Passes Medicare Legislation 54-44; President Bush Expected to Sign 11/25/2003 The Senate on Tuesday morning voted 54-44 to approve a bill (HR 1
-----Original Message-----
From: California Healthline [
mailto:CALIFORNIAHEALTHLINE@ADVISORY.COM]Sent: Tuesday, November 25, 2003 10:34 AM
Senate Passes Medicare Legislation 54-44; President Bush Expected to Sign
11/25/2003
The Senate on Tuesday morning voted 54-44 to approve a bill (HR 1 <
http://thomas.loc.gov/cgi-bin/query/z?c108:h.r.1:> ) that would add a prescription drug benefit to Medicare as "part of the biggest revision in the program since it was created in 1965," the <http://www.nytimes.com/2003/11/25/politics/25CND-MEDI.html?hp> New York Times reports. The bill now goes to President Bush, who has said he will sign it into law (Pear/Hulse, New York Times, 11/25). The vote came after the Senate on Monday in two separate votes ended a filibuster and then defeated a measure to delay the bill over budget concerns (Kuhnhenn, <http://www.philly.com/mld/inquirer/news/nation/7342811.htm> Philadelphia Inquirer, 11/25). The Senate on Monday voted 70-29 to end a filibuster led by Sen. Edward Kennedy (D-Mass.) and supported by some Democrats and a "handful" of Republicans, the <http://www.washingtonpost.com/wp-dyn/articles/A12583-2003Nov25.html> Washington Post reports (Dewar/Goldstein, Washington Post, 11/25). In the roll call, 22 Democrats, 47 Republicans and Independent Sen. James Jeffords (Vt.) voted to end the filibuster and invoke cloture on the bill, CongressDaily reports. Three Republicans -- Sens. Lincoln Chafee (R.I.), Chuck Hagel (Neb.) and John McCain (Ariz.) -- voted to continue the filibuster; Sen. Richard Shelby (R-Ala.) was the only absentee (CongressDaily, 11/25). Democrats then called for a vote to st! op the bill over allegations that it violates congressional budget rules because it allows for more spending in fiscal year 2004 than was allocated in the 2004 budget and that it violates committee jurisdiction rules, the <http://www.washingtontimes.com/national/20031124-112318-1208r.htm> Washington Times reports (Fagan, Washington Times, 11/25). The 61-39 vote to exempt the bill from the budget rules, which needed 60 votes to pass, came only after Sens. Trent Lott (R-Miss.), Lindsey Graham (R-S.C.) and Ron Wyden (D-Ore.) changed their votes, according to the Post (Washington Post, 11/25). In all, 49 Republicans, 11 Democrats and Jeffords voted to waive the Budget Act rules (CongressDaily, 11/25). The House, after a three-hour roll call vote, early Saturday morning approved the legislation in a 220-215 vote largely along party lines ( http://www.californiahealthline.org/members/basecontent.asp?contentid=50347&collectionid=3&program=1 California Healthline, 11/24). President Bush on Monday said, "It's time to modernize Medicare and make the system better. It will enable us to help millions of seniors."
Proponents Hail Legislation
Senate Majority Leader Bill Frist (R-Tenn.) said, "For the first time under Medicare, 40 million seniors and individuals with disabilities will finally have the prescription drug coverage they need and the Medicare choices they deserve" (New York Times, 11/25). HHS <
http://www.hhs.gov/> Secretary Tommy Thompson, who was present in both the House and Senate during votes to lobby legislators to support the bill, said, "We are right there for a touchdown for our seniors all across America" (Hirschfeld Davis, Baltimore http://www.sunspot.net/news/nationworld/bal-te.medicare25nov25,0,4500463.story?coll=bal-home-headlines Sun, 11/25). Sen. John Breaux (D-La.), who along with Sen. Max Baucus (D-Mont.) was one of the two Democrats involved in the conference committee, said, "I think we have a once-in-a-lifetime opportunity today to complete our work on this bipartisan Medicare bill." Bill Novelli, executive director of AARP <http://www.aarp.org/> , which supports the bill, said that "this bill is going to go a long way to help" the United States prepare for an increasing number of residents ages 65 and older (Lipman, http://www.ajc.com/tuesday/content/epaper/editions/tuesday/news_f33c201e565b62db0006.html Palm Beach Post/Atlanta Journal-Constitution, 1! 1/25).
Opponents Vow To Continue Objections
Democrats who had opposed the bill said they would continue to fight the bill through alternate measures, the
http://www.latimes.com/news/nationworld/nation/la-na-medicare25nov25,1,2788481.story?coll=la-home-headlines Los Angeles Times reports (Kemper, Los Angeles Times, 11/25). Senate Minority Leader Tom Daschle (D-S.D.) said, "This is the beginning of the end; it is not the end. We will see many, many more votes. I predict that we will be back within the next 12 months. Seniors will demand that we respond to the many deficiencies of this bill, and they will not rest until we address them" (New York Times, 11/25). Kennedy said the bill "starts the unraveling of the Medicare system" (Heldt Powell, <! http://news.bostonherald.com/national/national.bg?articleid=43> Boston Herald, 11/25). Sen. Debbie Stabenow (D-Mich.) said that although supporters have called the bill a first step, "it's a first step off a cliff" (Barfield Berry, Long Island Newsday, 11/25). Some Republicans in the Senate opposed the bill, which they said includes "huge, perpetual annual expenditures," the http://www.chicagotribune.com/news/nationworld/chi-0311250257nov25,1,7688374.story?coll=chi-newsnationworld-hed Chicago Tribune reports (Zuckman, Chicago Tribune, 11/25). McCain said, "It's like the ancient! medieval practice of leeching. Every special interest is attaching itself to this bill and bleeding Medicare dry" (Long Island Newsday, 11/25). Sen. Bill Nelson (D-Fla.) said he plans to introduce legislation that would allow Medicare to negotiate prescription drug prices with pharmaceutical manufacturers (Los Angeles Times, 11/25). The current legislation prohibits the federal government from using bulk purchasing techniques to bargain with drug makers "in order to promote competition" (California Healthline, 11/24).
Future
Although the legislation will likely be signed into law, the "lack of consensus" over some issues -- in particular a 2010 pilot program in which private insurers would directly compete with Medicare in six metropolitan areas -- will "make it harder to reach the compromises that will be needed to put the bill into action in coming years," the Wall Street Journal reports. Thomas Mann, a congressional scholar at the Brookings Institution <
http://www.brook.edu/> , said, "[W]hen this passes, it will be the beginning of a massive political struggle to define the meaning of this bill. Rather than resolve something, it will keep it very much in play. The outcome of subsequent elections will have a tremendous impact." Some Republican lawmakers have said they want to re-examine cost-containment measures in the bill, while Democrats "already vow they will reopen the legislation soo! n," according to the Journal. Daschle said, "There will be efforts to go back over and over again" to make the prescription drug benefit more generous. Kennedy said opponents will "fight [the legislation] in the congressional elections and in presidential elections as well." While Democrats "have been longtime supporters of a Medicare drug benefit," the current legislation is "viewed as a Republican product -- and Republicans plan to take full credit in the next year's campaign," the Journal reports. CMS <http://www.cms.gov/> Administrator Tom Scully said, "This thing is always a work in progress. Unfortunately, it's a politicized issue. ... The fact is, a lot of this is politics, not substance. You've got conservative Republicans who don't like it, you've got liberal Democrats who don't like it" (McGinley et al., Wall Street Journal, 11/25).Bri! an Potts
Managing Editor, CAL/AAEM News Service
MS-IV, UC-Irvine
Do you Yahoo!?
Free Pop-Up Blocker - Get it now --0-1265601636-1070209277=:18105-- From pottsbri@yahoo.com Sun Nov 30 16:22:49 2003 From: pottsbri@yahoo.com (CAL/AAEM News Service) Date: Sun, 30 Nov 2003 08:22:49 -0800 (PST) Subject: Impact of Medicare Legislation Examined Message-ID: <20031130162249.19403.qmail@web41313.mail.yahoo.com> --0-1938235910-1070209369=:18203 Content-Type: text/plain; charset=us-ascii -----Original Message----- From: California Healthline [mailto:CALIFORNIAHEALTHLINE@ADVISORY.COM] Impact of Medicare Legislation Examined 11/25/2003 The Medicare legislation (HR 1
-----Original Message-----
From: California Healthline [
mailto:CALIFORNIAHEALTHLINE@ADVISORY.COM]
Impact of Medicare Legislation Examined
11/25/2003
The Medicare legislation (HR 1 <
http://thomas.loc.gov/cgi-bin/query/z?c108:h.r.1:> ) approved by the House and Senate this week will have an impact on beneficiaries, the drug industry and the 2004 campaigns of Democrats and Republicans, http://www.usatoday.com/money/industries/health/2003-11-25-medicare-side2_x.htm USA Today reports. The following summarizes media coverage analyzing the impact of the legislation.
Beneficiaries
Analysts say the bill would "aid millions of seniors nationwide" in paying for prescription drugs, but the "degree to which it would help varies from one person to another," the
http://www.orlandosentinel.com/news/nationworld/orl-asecmedicareimpact25112503nov25,1,1130317.story Orlando Sentinel reports (Suriano/Kunerth, Orlando Sentinel, 11/25). Under the legislation, relatively healthy seniors "could actually find their drug expenses increase," but "many seniors, especially those who are seriously ill or suffer chronic conditions," would see their expenses drop, according to the Wall Street Journal. However, the plan would "require seniors to become much more savvy consumers," the Journal reports (Lueck, Wall Street! Journal, 11/25). Some seniors say they do not understand all the provisions in the bill and whether they would benefit under the legislation (Mondics, <http://www.philly.com/mld/philly/news/7342794.htm> Philadelphia Inquirer, 11/25). According to an AARP <http://www.aarp.org/> survey released last week, 75% of its members supported the measure, but polls performed by other groups found that about 50% of seniors opposed the plan after learning its details (Martelle/Goldman, http://www.latimes.com/news/nationworld/nation/la-na-seniors25nov25,1,1661746.story Los Angeles Times, 11/25).
Drug Industry
With the passage of the Medicare legislation, the drug industry appears "on the cusp of an enormous victory, gained in part by millions in political donations and an expensive lobbying campaign," the <
http://www.nytimes.com/2003/11/25/politics/25DRUG.html> New York Times reports (Harris, New York Times, 11/25). Under the plan, the industry would "reap a multibillion bonanza in the form of millions of new customers and limits on foreign competition," according to Long Island http://www.newsday.com/business/local/newyork/ny-bzmedi253558654nov25,0,7056167.story Newsday. Of the 40 million Medicare beneficiaries, 10 million currently have no drug coverage; by offering a drug benefit, consumption would increase. The bill is also favorable to the drug industry because it would require a safety certification from HHS before allowing the reimportation of U.S.-made prescription drugs from Canada by U.S residents. HHS Secretary Tommy Thompson has said he is not likely to do so. The bill also would prohibit price controls on the drugs, a move that the industry supports (Toedtman, Long Island Newsday, 11/25). However, "some investors already are starting to fret" about the bill's long-term side effects, including the possibility that the drug industry could become "very subject to the whims of Congress," the Wall Street Journal reports (Hensley et al., Wall Street Journal, 11/25). In addition, drug makers still face pressure to reduce the prices of their treatments, and some drug executives predict the additional sales volume will be balanced by discounts they will have to pr! ovide to health plans and insurers that negotiate prices (Harris, New York Times, 11/25).
Political Campaigns
President Bush's "bid to break the historic political alliance between Democrats and senior citizens" could affect the 2004 elections and "perhaps long-term partisan patterns in this country," the <
http://www.washingtonpost.com/wp-dyn/articles/A11573-2003Nov24.html> Washington Post reports. However, the effect of the legislation remains "difficult to predict," according to the Post (Broder/Connolly, Washington Post, 11/25). Officials from both parties have said they will use the Medicare bill to "clobber the opposition" during 2004 congressional races, the <http://www.hillnews.com/campaign/112503_medicare.aspx> The Hill reports (Savodnik, The Hill, 11/25). Republican strategists are "convinced! " that they have reached a "transformational moment in American politics, creating a historic improvement for a constituency that Democrats had long claimed as their own," the <http://www.nytimes.com/2003/11/25/politics/25ASSE.html> New York Times reports (Toner, New York Times, 11/25). The legislation could hurt Democrats, who have previously "slammed Republicans for failing to produce a prescription drug benefit," and could "inoculate[e]" the GOP from "accusations that it doesn't care about seniors," according to The Hill (The Hill, 11/25). However, Democrats expect that seniors will be "sorely disappointed when they realized the limits of the new coverage and the complexity of the system," according to the Times (New York Times, 11/25). Because the House vote is "likely to affect congressional races across the country next year," incumbent Demo! crats in the House who won their seats by slim margins in the last election "weighed their options carefully before voting yea or nay" and conservatives who were "torn between politics and principle" tried to demonstrate that they had "extracted concessions" from Republican leaders, according to The Hill (The Hill, 11/25).Brian Potts
Managing Editor, CAL/AAEM News Service
MS-IV, UC-Irvine
Do you Yahoo!?
Free Pop-Up Blocker - Get it now --0-1938235910-1070209369=:18203--