The Best First Ride to Montana – Leg 2 – Walla Walla, WA to Missoula, MT 317 Miles

The beginning of our day 2 was Sunday. Walla has more than 50 houses of worship and pretty much every category. We appreciated holy observance meeting for certain old buddies, gotten back to our room at the Whitman, changed garments and took off for a bright day of Eastern Washington riding. We got WA-12 upper east and rode through various humble communities – Dayton, Roman, Whetstone, Tucannon, and afterward took a privilege at Delaney and the intersection of WA-12 and WA-261. The separation from Walla to Delaney is around 46 miles and requires about 60 minutes. Voyaging east now, WA-12 meanders through moving slopes of wheat fields and homesteads for one more hour – ~52 miles – to the sister urban areas of Clarkston, WA and Lewiston, ID.

Named after renowned pilgrims Meriwether Lewis and William Clark, Clarkston and Lewiston flank the Snake River, which runs north at last streaming into the Great Columbia River. The setting for another extraordinary ride is only 100 miles south – Hell’s Canyon National Recreation Park. Kindly stay tuned for an agenda of this irreplaceable asset. Both of these towns gives a decent reprieve – time to extend your legs and invigorate your posterior, have a tidbit, fluid reward or supper. We halted for a speedy serving of mixed greens at Jack-in-the-Box, a famous inexpensive food chain that holds beguile for our family from our time in the Bay Area. The power source are perfect and the food is new and modest. It’s likewise a fun opportunity to refuel. While there are service stations among here and Missoula, it’s smarter to be protected than sorry.

esthetician Missoula

Leaving Lewiston, you’ll stay on Highway 12, going in an easterly heading along the Clearwater River to Orofino [43 miles, 55 mins]. At that point southeast to Kooskia [32 miles, 38 mins] prior to turning east upper east for the 101-mile ride through the Bitter Range Mountains and up to Lolo Pass, MT elev 5,233ft.

We think the excursion from Lewiston to Lolo Pass is perhaps the most excellent mountain rides we’ve taken. Ascending about 4,500 ft, the street matches fresh mountain streams with enough exciting bends in the road for the most eager motorcyclist. Trust me; my choke wrist encountered a truly mind-blowing exercise on this stretch of street. There are various turnouts and memorable markers en route to fulfill the cruising student of history and rest the exhausted explorer.

From Lolo Pass it’s about an hour’s ride to Missoula, Mt. Yet, before you show up in Missoula there’s an eatery you must pause and appreciate – Guy’s Lolo Creek Steakhouse, 6600 Highway 12 West, Lolo, MT 59847, 406-273-2622. This provincial log style café conveys a genuine Montana ‘Large Sky’ supper, with amazing steak in three sizes, barbecued over a cracklin’ grill spit. The menu additionally offers chicken and fish and all dishes are done with prepared potato, plate of mixed greens and bread. The taxidermy lined dividers complete the cafés tough chasing lodge feel. Fellow sold the steakhouse quite a while prior, however reports from my companions in Missoula affirm the eatin’ is as great as could be expected. To my range, the Lolo Creek Steakhouse is perhaps the best steakhouse anyplace. The eatery is shut Monday, with no lunch offering.

Missoula is the second biggest city in Montana, home to the University of Montana. Missoula is bursting at the seams with action. It offers a full supplement of administrations and retail including Harley, Honda, Yamaha and BMW sellers. Missoula likewise gives various inns, inns and cafés. We remained at the Sleep Inn, which is close to the University.

The following morning, I was interested by my first look at ‘Large Sky Country.’ There is something about Montana – the sky REALLY IS BIG! I can’t place why, however I nearly felt like I would float away, weightless, into Montana’s huge, overpowering blue. It’s genuinely something astounding. You must experience it to trust it.


Good Curling Irons for Thick Hair

Thick hair can be troublesome when it comes to straightening or styling, and although many hair tools nowadays are especially designed to handle this tough hair type, if you don’t know what to look for then you might just end up with a mediocre appliance.

Curling thick hair may not be as easy as curling fine hair, but with the right curling iron you’ll have no problem in creating those salon-looking styles. So how can you find the right curling iron?

First thing’s first, the type of curling iron you choose influences how easy curling your hair will be. While many stand firmly by the traditional spring curling iron, others prefer a clipless curling iron for versatile and creative styling. Some tough haired girls claim that a steam hair curler is best if your hair is hard to style since the hot airflow coming from small holes in the barrel soften your hair to make it manageable.

When choosing a hair curler, make sure that it’s made with a good material that will protect your hair. Barrels made out of teflon and other metals aren’t the greatest idea if you want smooth and healthy curls, so go for a ceramic or tourmaline barrel for moisturizing heat and a long lasting result.

Next, check the shape of the barrel. This can be cylindrical, conical or reverse conical. The first of these is the most conventional and with them you’ll get the basic curl. For thick hair, a cylindrical barrel may not produce the same results so the best choice would be a conical curling iron for a tapered curl that will last longer.

As for the size, this depends on the type of curl you want to achieve. Tiny hair curlers create a very tight curl, but often can’t heat thick hair all the way through. Very large-barreled irons don’t work well either as they produce far looser curls in thick hair than in medium or thin locks. A medium 1 inched barrel would be a great choice for most girls.

So if your hair is terribly thick and hard to style, you will love a tourmaline ceramic clipless curling iron for softer locks, healthier hair and easier styling. There are many professional brands on the market so just take your pick! Although most of them may surpass your original budget, the results and protection will be definitely worth the investment.

Kristy is a professional stylist.


Learn how to Pinpoint any time a Online site might be Merchandising Amazing Trendy Wholesale handbags

Learn how to Pinpoint any time a Online site might be Merchandising Amazing Trendy Wholesale handbags

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A large number of ınternet sites on line offer for sale wholesale handbags. Several promise they’ve been amazing, numerous you shouldn’t fully assert amazing and yet cheat most people to reasoning normally fabricated using are actually amazing. The fact is, that is needed the often most successful consumer to decide of which webpages are generally authentic. You will find many webpages can of course offer for sale amazing wholesale handbags by economical deals, and also can’t please let a couple unhealthy oatmeal harm a risk by credit rating some negotiate. Solely can a homework and discover emerged the best — in accordance with an impressive purse for which you paid off merely a small part from whatever a friends obtained it again.

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1. Confirm: A website merchandising amazing personally purses definitely will also have a particular authenticity confirm: Amazing and / or your finances spine. To illustrate, by internet. LuxEurope. com, you will find a particular authenticity confirm in no way and once, and yet check out intervals concerning solely leading website page. Should there is not a particular, be apprehensive.

step 2. Good: Any time a blog might be pledging who his or her’s purses are actually “high quality”, therefore this might be a reason for the purpose of challenge. Trendy model wholesale handbags have a relatively label on a valid reason — typically the label murmurs for ones good, and it’s really steady for the duration of. They can indeed be having a debate about premium imitations. But, there’s nothing some dealbreaker… it again that are some stow master’s fault.

3. Japanese associates: Japanese organisations frequently offer for sale fake pictures. Make an effort travelling to some WHOIS system (http: //www. whois. sc) not to mention provide typically the website. Within the medical authorised for a Japanese business enterprise be apprehensive. There’s nothing to suggest that Japanese are actually bogus men of affairs, but alternatively, you will find reduced enforcement through Asia and others option of fake pictures.

check out. Email: Any sort of respectable websites definitely will report some st treat. Should a website will never report some st treat and / or number, you can not sell to these products. This unique goes for any sort of over the internet store shopping online site.

6. Bring back insurance coverage: Eliminate website pages that wont take on proceeds.

There isn’t one particular components to decide that the wholesale handbags are actually amazing. This can be a situation of yours exclusive intelligence. You can not be worried from looking out for wholesale handbags over the internet due to this fact. Do not allow affordable deals study most people separate — he or she can of course turn out to be invested in for the purpose of 70% apart sell. But, make an application the intelligence not to mention be certain to are able to email the corporate not to mention bring back typically the pouch should certainly you should accomplish this. Browse the labeling, business enterprise advice, and so. — you shouldn’t solely analyze illustrations or photos. For everybody who is convinced subsequent to experiencing each one of important things, you definitely should certainly have fun with a choose and reveal available on the market not to mention flaunt a different amazing purse!



Buying Clean Burning Efficient Wood Stoves

Hoping to buy a wood oven that is appropriate for your home? Probably the greatest and most popular hearth makers make some great wood ovens. There are numerous components to consider and heaps of items to browse. Tracking down an excellent clean consuming wood oven that addresses your issues may require some burrowing. The particulars and terms utilized by the producers and the EPA are specialized and by and large befuddling. Understanding the determinations and appraisals (and how they are resolved) will help you settle on a superior purchasing choice.

On top of confounding appraisals and details there by and large are not free outsider audits like Consumer Reports to depend on. Guarantors Laboratory (UL) can assess gas terminated strong fuel terminated hearth apparatuses, including chimney ovens and chimney embeds, to pertinent U.S., Canadian and worldwide necessities. The UL imprint will show up on hearth items that have been assessed. The biggest exchange bunch the business, Hearth, Patio and Barbeque Association (HPBA), gives general item data and rules relating to purchasing, introducing and working hearth items (i.e., chimney embeds, gas chimneys, gas logs) however doesn’t suggest hearth items.

natural wood trim Colorado

Wood ovens are not piece of the energy star program, so it’s not as simple to realize which are the most productive ovens (beside the wood oven proficiency rating which is examined underneath). Nonetheless, as of this current year, wood ovens that are 75% proficient or more will be assigned (see sticker on back of oven) as such to show that they are qualified for the 30% Biomass Federal Tax Credit that is (up to $1,500 government tax reduction) accessible in 2009 and 2010.

To appropriately assess wood ovens and chimney oven embeds the best spot to begin is a fundamental comprehension of the more critical evaluations and details that go with wood ovens and chimney oven embeds.

Synergist versus Non-Catalytic

A reactant combustor is a gadget utilized on some wood ovens to expand burning proficiency of wood ovens by bringing down pipe gas start temperatures of wood ovens.

The two general ways to deal with meeting EPA smoke emanation limits are reactant and non-synergist ignition. The two methodologies have demonstrated generally viable, yet there are execution contrasts. In synergist burning the smoky exhaust is gone through a covered earthenware honeycomb inside the wood oven where the smoke gases and particles light and consume. Synergist ovens are equipped for creating a long, even warmth yield. All reactant ovens have a switch worked impetus sidestep damper which is opened for beginning and reloading. The reactant honeycomb debases over the long run and should be supplanted, yet its toughness is to a great extent in the possession of the oven client. The impetus can last in excess of six seasons if the oven is utilized appropriately, however on the off chance that the oven is over-terminated, trash is singed and normal cleaning and upkeep are not done, the impetus may separate in just two years.

EPA affirmed wood ovens have a particulate outflows cutoff of 7.5 grams each hour for non reactant wood ovens and 4.1 grams each hour for synergist wood ovens. All wood warming apparatuses subject to the New Source Performance Standard for Residential Wood Heaters under the Clean Air Act offered available to be purchased in the United States are needed to meet these discharge limits.

Firebox Size

Size of the chamber where the kindling consumes. Typically referred to in cubic feet and kindling limit of the chamber in weight. Large fireboxes can be decent. They are simpler to stack, and can regularly oblige those extra-long bits of kindling that in some way or another discover their way into the heap of wood. While picking your woodstove, nonetheless, remember that ovens with enormous fireboxes will in general deliver higher warmth yield, and simple energizing is a dear cost to pay for being cooked out of the house.

Most extreme Log Size

Biggest log length that will find a way into firebox. The standard kindling length for wood ovens and chimney oven embeds is 16″, generally in light of the fact that it is the most down to earth length for taking care of. Knowing greatest log length is helpful on the grounds that for advantageous stacking, the firebox ought to be around three inches greater than your normal piece of kindling.

Warming Efficiency

Proportion of the amount of the warmth esteem contained in the kindling is extricated and conveyed into the living space. This is what could be compared to the MPG rating of your vehicle or truck. Recollect the nature of the kindling will affect genuine outcomes.

The warming productivity rating is dictated by the oven producer by testing full heaps of prepared cordwood. When testing for warming effectiveness, two standards are inspected: extraction proficiency; the kindling load is weighed going in, and the particulate discharges and remains are weighed after the fire to decide how viably a given firebox configuration separates the fuel to extricate the accessible warmth and warmth move productivity; this testing is acted in calorimeter rooms furnished with temperature sensors. Comparable temperature sensors are introduced in the exhaust vent. The degree changes in the room and pipe are checked for the span of the test flames to decide the amount of the warmth removed by the fire is conveyed into the room, when contrasted with the warmth lost up the pipe.


Estimation of particulate matter discharges in grams each hour. Particulate Matter is an extravagant term for air contamination and means little bits of issue, for example, residue and sediment that are suspended noticeable all around.

Discharges testing is acted in EPA-endorsed test labs utilizing the EPA’s recommended convention. When testing for emanations, a nailed-together “charge” of oven dried Pine is singed, and the particulate matter in the exhaust is estimated all through the length of a few flames at different draft control settings. Along these lines, a normal grams/hour particulate emanations rating is inferred. Warming effectiveness isn’t estimated during EPA discharges testing.

The inward plan of wood ovens has changed altogether since 1990, as the consequence of the EPA guideline set up in the last part of the 1980’s. The EPA’s required smoke discharge limit for wood ovens is at present 7.5 grams of smoke each hour. Today, all wood ovens and chimney supplements, and some industrial facility constructed chimneys sold in the U.S. should meet this cutoff. Oven makers have improved their burning advances throughout the long term, and numerous more up to date wood ovens have confirmed outflows in the 1 to 4 g/h range. The EPA confirmed discharge rate is a solid number that can measure up starting with one model then onto the next, yet a couple of gram each hour distinction in smoke outflows doesn’t mean much in everyday use.

Warmth Output

Typically addressed as greatest warmth yield (you in some cases see a warmth yield scope) of the wood oven communicated in BTU’s each hour. The British Thermal Unit (BTU) is the essential warmth estimation unit utilized by the hearth business to show heat yield. It is the measure of energy needed to raise the temperature of 1 lb. of water by 1 degree F. Commonly 10,000 BTU can warm roughly 500 square feet. All wood ovens and wood consuming chimney embeds are appraised by BTU yield.

The warmth yield appraisals can be deluding. In deciding a greatest warmth yield rating, test labs utilized by producers (as a rule utilizing hardwood fuel) pack the firebox loaded with kindling and wrench the draft control totally open. This furious, brief span fire is the polar opposite of how individuals consume their wood ovens, and can be misdirecting: if the lone thing you take a gander at is the most extreme warmth yield rating, a little wood oven with a huge air admission can appear to be similarly pretty much as amazing as the biggest wood ovens. A few producers utilize the warmth yield rating from EPA testing, which utilizes softwood fuel. Another way these figures can be misdirecting is that non-reactant wood ovens will in general create a higher pinnacle heat yield, yet that by itself doesn’t mean they’ll deliver more warmth over an eight hour consume cycle, which is a more pertinent exhibition pointer. The outcome is that you can’t analyze the warmth yield of ovens in light of the fact that the appraisals are not normalized.


The karma factor in a betting club game is estimated using standard deviations

The karma factor in a betting club game is estimated using standard deviations . The standard deviation of an essential game like roulette can be PG SLOT  resolved using the binomial scattering. In the

binomial flow,  number of rounds played, p = probability of winning, and q = probability of losing. The binomial scattering acknowledges an outcome of 1 unit for a triumph, and 0 units for a hardship, rather than −1 units for a setback, which duplicates the extent of expected outcomes. Moreover, if we level bet at 10 units for each round as opposed to 1 unit, the extent of potential outcomes grows 10 fold.[3]

For example, after 10 rounds at 1 unit for each round, the standard deviation will be units. After 10 changes, the ordinary disaster will be .

As ought to be self-evident, standard deviation is ordinarily the significance of the ordinary loss.

The standard deviation for pai gow poker is the most negligible out of all normal club games. Various club games, particularly betting machines, have incredibly raised assumption deviations. The more noteworthy size of the potential payouts, the more the standard deviation may augment.

A betting machine’s standard plan incorporates a screen appearing at any rate three reels that “turn” when the game is impelled. Some high level gaming machines really join a switch as a skeuomorphic plan trademark to trigger play. In any case, the mechanics of early machines have been superseded by subjective number generators, and most are as of now worked using gets and touchscreens. as time goes on, when each 16.8 million plays. The maker could choose to offer a $1 million dollar gold mine on a $1 bet, sure that it will simply happen .


5 Ways to Save Money on Your Health Insurance

Health reform                        was signed in to law in 2010 and it meant to make health care affordable and more accessible to more Americans. Many provisions are meant not to start until year 2014. Current provisions have made health care plans more affordable and expanded coverage for preventative care. Here are five ways that you can save money on your health insurance today.

First is to look for health coverage the allow you to lock in your rates. Most health plans available allow you to lock in your rates for twelve months and some up to two years. When shopping for health coverage look for “rate guarantee”. Once the insurance company raises your monthly rate you can you can shop again to find a better rate.

Second look at getting a health plan with higher deductible. Most health plans today offer a high deductible for major accident or illness and small copay for services that might be used more frequently. Most health plans with high deductible still cover you before you meet the deductible for doctor office visits, preventative care (physical exams, yearly check ups) and prescriptions. If you have a preexisting medical condition and would like to lower your monthly premium this might one of your best options. Since insurance companies usually let you increase your deductible without going through medical underwriting.

Third since health care reform there has been some changes made to coverage. In some cases you can get exactly the same health plan that you have not through your insurance company for less. If you have been insured with same insurance company since March 2010 then check if they have the same health plans that you have now. Then find out if you are going to save money by switching to a new health plan.

Forth, when shopping for private health insurance make sure to consider a health plan with the benefits that you need. A recent survey showed that average individual health insurance customer save $77 a month when they selected health insurance plan without maternity coverage. Excluding benefit like maternity, which is not necessary for a single male, you may see significant savings in your monthly premium. Going uninsured or limiting your benefits might be a better choice then not having anything at all.

Fifth way that you can save on your health insurance is considering coverage with generic prescription drug coverage. Find out if you can get a health insurance in your area that excludes brand name drug coverage. If you rarely use prescription drugs and do not want entirely go without that coverage you may be able to save on your medical insurance. Most health plans today offer you a choice between having a coverage for both brand name drugs and generic drugs or only generics. In-case your doctor does prescribe a brand name drug chances are you can get a equivalent generic for it.

Those were five simple steps you can take to save money on your health insurance. The fact is that health insurance is going to keep going up. Making a habit to shop for new health plan every year will allow you to stay up to date on what is available in the health insurance market.

individual-and-family-health-insurance-plans] website gives you resources to make an educated decision on choosing a right health insurance plan.


What Makes a Good Web Development Company

The world of web development is still very much misunderstood. We’ve even heard people call it a “dark art”. So when you need help turning your ideas and designs into a high quality website or web application, how do you know who you can trust to get this done?

The purpose of this post is to provide some key points on what makes a good web development company, and will help you understand the kind of questions you should be asking development companies.

This is going to be a very opinionated post and we make no apologies for it. If you disagree with anything we are certainly open to discussing it further.

Now to get on with the post. Below are the key areas we are going to be looking at, and what you should be looking for in a web development company.


  • Able to do both front-end and back-end development
  • Don’t specialise in one back-end technology
  • Should follow best practices
  • Understanding of marketing strategies surrounding the projects
  • Invests time in research and development
  • Has a rigorous testing process, including automated tests
  • Flexible to change
  • Use source control


Able to do both front-end and back-end development
We don’t subscribe to idea of developers that do front-end development and developers that do back-end development. That’s the equivalent of having a plumber who only fits pipes and leaves the fitting of the baths, showers, sinks and toilets to someone else.

We agree there is a separation between web developers and web designers, there’s a completely different thought process going on there, but the separation between front-end and back-end is just wrong. To be a good web developer you need to understand the full development cycle and to be able to get involved in the project from start to finish. There is also much to be learnt from the working with the varying technologies, but we’ll come on to that.

Don’t specialise in one back-end technology
There are a number of good back-end technologies that are appropriate for web development including Ruby on Rails, ASP.Net and PHP (and others). They all have their strengths and weaknesses and not one is perfect. A good web development company should be flexible in which technologies they use, so that they use the most appropriate one for their clients’ needs.

The key reason we have spent time learning a number of technologies is to able to pick and choose the bits we like. Over the years the developers involved in The League have been able to take the good parts of each technology and formulate a number of best practices and use them across all platforms.

Should follow best practices
The key to being a good web developer is not the technologies that you use, but the best practices that you follow. As technologies come and go in our very fast moving industry those best practices will remain, or at least evolve. As a developer if you have a good grounding then you can move with the times and technologies fairly easily.

So what are these best practices that we are talking about. Below are some of the key ones we follow.


  • Writing semantic HTML
  • Follow web standards for all front end coding
  • Automated testing of both front-end and back-end code
  • Use of a MVC framework


Understanding of marketing strategies surrounding the projects
We’ve heard this complaint many times that web developers don’t think about the marketing strategy of a project. This is generally because developers don’t care. Well they should. How can they advise clients and think about helping clients produce the right solution, if they aren’t thinking about the “bigger picture” (sorry, we know it’s a horrid phrase, we’ll go wash our mouths out now). If a developer blindly does the work, they are not offering the client a service, they are just being a meat puppet.

The most important question a developer can ask is “Why?”. Take time to understand the client’s requirements fully, and advise them, after all the client doesn’t understand the ins and outs of web development, you do. Make the development cycle a two way conversation.


Wet Wipes – Dozens of Practical Uses For Men & Women

Moist toilettes, or as they are more commonly known wet wipes, are one of the handiest things to have in your home, office or the car when travelling. These soft towelettes have many uses in today’s busy world and have become commonplace everywhere. Initially they were introduced as a way to keep babies clean after diaper changes. It wasn’t long though before smart mothers began to find many other uses for them. They soon became a way to keep not only babies bottoms clean, but also a great way to keep a babies hands and face clean. A staple in the diaper bag, mothers also found them a great way to keep their own hands and face fresh. They were commonly used in public areas to make sure they were clean, and mothers used them in public bathrooms to ensure that the areas they used were sanitary.

Before long they were also becoming a staple in the car. They are easy to store them in the glove compartment for quick access when needed. Men and women found them great for cleaning up their hands after going to a drive-in restaurant, as well as a great way to clean their face for a fresh feeling. Before long, many restaurants were giving them to customers with their order, so they could wipe greasy food away before resuming driving. Many people keep wet wipes in the car for when they need to use public washrooms on the road. Everyone has had the experience of using a public washroom and then finding that there is no toilet paper. These make a great substitute.

One of the best places to have these wipes is in the office. They are a great way to wipe dirt and grime off your desk, not to mention that they also help to clean bacteria and germs off computer keyboards and phones. They are also used to keep hands clean as well as a great way to freshen up during the work day.

As they started to become more popular, manufacturers realized that specialized wet wipes could be more useful and beneficial to their customers. They soon developed wipes that would specifically help people with sensitive skin. These are normally alcohol free as well as fragrance free. They have been made using cleansers that are mild on the skin and contain moisturizers. These are great for babies with sensitive skin or ones that are suffering with diaper rash. They will help to clean and protect the soft skin of a baby.

The next type to enter the marketplace was antibacterial wipes. During cold and flu season these are especially good for helping to protect oneself from the spread of germs. Cleaning your hands as often as possible is a good first line of defense against picking up germs from different surfaces. When you can’t wash your hands these are a perfect substitute for soap and water. Antibacterial wipes have been proven in clinical setting to be just as effective as the bottles of gel sanitizers in killing germs. They are also much more convenient that the bottles of gel, especially if you are flying, where they are not allowed on the plane. When out in public they are an easy way to wipe off different surfaces, such as shopping carts or mall doors, before using them. Teaching young children to use them before entering school is a great way to get them started in protecting themselves when in the classroom.


How Did Health Care Costs Get So High?

First, let’s                             get a little historical perspective on American health care. To do that, let’s turn to the American civil war era. In that war, dated tactics and the carnage inflicted by modern weapons of the era combined to cause terrible results. Most of the deaths on both sides of that war were not the result of actual combat but to what happened after a battlefield wound was inflicted. To begin with, evacuation of the wounded moved at a snail’s pace in most instances causing severe delays in treatment of the wounded. Secondly, most wounds were subjected to wound related surgeries and amputations and this often resulted in massive infection. So you might survive a battle wound only to die at the hands of medical care providers whose good interventions were often quite lethal. High death tolls can also be ascribed to everyday sicknesses and diseases in a time when no antibiotics existed. In total something like 600,000 deaths occurred from all causes, over 2% of the U.S. population at the time!

Let’s skip to the first half of the 20th century for some additional perspective and to bring us up to more modern times. After the civil war there were steady improvements in American medicine in both the understanding and treatment of certain diseases, new surgical techniques and in physician education and training. But for the most part the best that doctors could offer their patients was a “wait and see” approach. Medicine could handle bone fractures and perform risky surgeries and the like (now increasingly  in sterile surgical environments) but medicines were not yet available to handle serious illnesses. The majority of deaths remained the result of   conditions such as tuberculosis, pneumonia, scarlet fever and measles and/or related complications. Doctors were increasingly aware of heart and vascular conditions, and cancer but they had almost nothing with which to treat these conditions.

This very basic understanding of American medical history helps us to understand that until quite recently (around the 1950’s) we had virtually no technologies with which to treat serious or even minor ailments. Nothing to treat you with means that visits to the doctor if at all were relegated to emergencies so in that scenario costs were obviously minuscule. A second factor that has become a key driver of today’s health care costs is that medical treatments that were provided were paid for out-of-pocket. There was no health insurance and certainly not health insurance paid by someone else like an employer. Costs were the responsibility of the individual and perhaps a few charities that among other things supported charity hospitals for the poor and destitute.

What does health care insurance have to do with health care costs? Its impact on health care costs is enormous. When health insurance for individuals and families emerged as a means for corporations to escape wage freezes and to attract and retain employees after World War II, almost overnight there was a great pool of money available for health care. Money, as a result of the availability of billions of dollars from health insurance pools, encouraged an innovative America to increase medical research efforts. As more and more Americans became insured not only through private, employer sponsored health insurance but through increased government funding that created Medicare, Medicaid and expanded veteran health care benefits, finding a cure for almost anything has become very lucrative. This is also the primary reason for the vast array of treatments we have available today. I do not wish to convey that this is a bad thing. Think of the tens of millions of lives that have been saved, extended and made more productive as a result. But with a funding source grown to its current magnitude (hundreds of billions of dollars annually) upward pressure on health care costs are inevitable. Doctor’s offer and most of us demand and get access to the latest available health care technology, pharmaceuticals and surgical interventions. So there is more health care to spend our money on and until very recently most of us were insured and the costs were largely covered by a third-party (government, employers). This is the “perfect storm” for higher and higher health care costs and by and large, the storm is intensifying.

At this point, let’s turn to a key question. Is the current trajectory of U.S. health care spending sustainable? Can America maintain its world competitiveness when 16%, heading for 20% of our gross national product is being spent on health care? What are the other  countries spending on health care and is it even close to these numbers? Add politics and an election year and the whole issue gets badly muddled and misrepresented.

I believe that we need a revolutionary change in the way we think about health care, its availability, its costs and who pays for it. And if you think I am about to say we should arbitrarily and drastically reduce spending on health care you would be wrong. Here it is fellow citizens – health care spending needs to be preserved and protected for those who need it. And to free up these dollars those of us who don’t need it or can delay it or avoid it need to act. First, we need to convince our politicians that this country needs sustained public education with regard to the value of preventive health strategies. This should be a top priority and it has worked to reduce the number of U.S. smokers for example. If prevention were to take hold, it is reasonable to assume that those needing health care for the myriad of life style engendered chronic diseases would decrease dramatically. Millions of Americans are experiencing these diseases far earlier than in decades past and much of this is due to poor life style choices. This change alone would free up plenty of money to handle the health care costs of those in dire need of treatment, whether due to an acute emergency or chronic condition.

Let’s go deeper on the first issue. Most of us refuse do something about implementing basic wellness strategies into our daily lives. We don’t exercise but we offer a lot of excuses. We don’t eat right but we offer a lot of excuses. We smoke and/or drink alcohol to excess and we offer a lot of excuses as to why we can’t do anything about it. We don’t take advantage of preventive health check-ups that look at blood pressure, cholesterol readings and body weight but we offer a lot of excuses. In short we neglect these things and the result is that we succumb much earlier than necessary to chronic diseases like heart problems, diabetes and high blood pressure. We wind up accessing doctors for these and more routine matters because “health care is there” and somehow we think we have no responsibility for reducing our demand on it.

It is difficult for us to listen to these truths but easy to blame the sick. Maybe they should take better care of themselves! Well, that might be true or maybe they have a genetic condition and they have become among the unfortunate through absolutely no fault of their own. But the point is that you and I can implement   preventive disease measures as a way of dramatically improving health care access for others while reducing its costs. It is far better to be productive by doing something we can control then shifting the blame.


Community Needs Health Assessment

In 2012                         Internal Revenue Service mandated that all non-profit hospitals undertake a community health needs assessment   that year and every three years thereafter. Further, these hospitals need to file a report every year thereafter detailing the progress that the community is making towards meeting the indicated needs. This type of assessment is a prime example of primary prevention strategy in population health management. Primary prevention strategies focus on preventing the occurrence of diseases or strengthen the resistance to diseases by focusing on environmental factors generally.

I believe that it is very fortunate that non-profit hospitals are carrying out this activity in their communities. By assessing the needs of the community and by working with community groups to improve the health of the community great strides can be made in improving public health, a key determinant of one’s overall health. As stated on the Institute for Healthcare Improvement’s Blue Shirt Blog   and Beyond: Hospitals and Community Health Improvement), “There is growing recognition that the social determinants of health – where we live, work, and play, the food we eat, the opportunities we have to work and exercise and live in safety – drive health outcomes. Of course, there is a large role for health care to play in delivering health care services, but it is indisputable that the foundation of a healthy life lies within the community. To manage true population health – that is, the health of a community – hospitals and health systems must partner with a broad spectrum of stakeholders who share ownership for improving health in our communities.” I believe that these types of community involvement will become increasingly important as reimbursement is driven by value.

Historically, healthcare providers have managed the health of individuals and local health departments have managed the community environment to promote healthy lives. Now, with the IRS requirement, the work of the two are beginning to overlap. Added to the recent connection of the two are local coalitions and

The community in which I live provides an excellent example of the new interconnections of various   to collectively improve the health of the community. In 2014 nine non-profits, including three hospitals, in Kent County, Michigan conducted a of the county to assess the strengths and weaknesses of health in the county and to assess the community’s perceptions of the pressing health needs. The assessment concluded that the key areas of focus for improving the health of the community are:

· Mental health issues

· Poor nutrition and obesity

· Substance abuse

· Violence and safety

At this time the Kent County Health Department has begun developing a strategic plan for the community to address these issues. A wide variety of community groups have begun meeting monthly to form this strategic plan. There are four work groups, one for each of the key areas of focus. I am involved in the Substance Abuse as a representative of one of my clients, Kent Intermediate School District. Other members include a substance abuse prevention coalition, a Federally qualified health   a substance abuse treatment   and the local YMCA, among others. The local hospitals are involved in other  One of the treatment group representatives is a co-chair of our group. The health department wants to be sure that the strategic plan is community driven.

At the first meeting the health department leadership stated that the strategic plan must be community driven. This is so in order that the various agencies in the community will buy into the strategic plan and will work cooperatively to provide the most effective prevention and treatment services without overlap. The dollars spent on services will be more effective if the various agencies work to enhance each others’ work, to the extent possible.

At this time the Substance Abuse work group is examining relevant data from the 2014   survey and from other local resources. The epidemiologist at the health department is reviewing relevant data with the group so that any decisions about the goals of the strategic plan will be data driven. Using data to make decisions is one of the keystones of the group’s operating principles. All objectives in the strategic plan will be specific, measurable, achievable, realistic and time-bound (SMART).

Once the strategic plan is finished, the groups will continue with implementation of the plan, evaluating the outcomes of the implementation and adjusting the plan as needed in light of evaluation. As one can see, the   are following the classic Plan-Do-Check-Act process. This process has been shown time and again in many settings-healthcare, business, manufacturing, to produce excellent outcomes when properly followed.