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The Fickenscher Files, Vol. 14
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Quote Of The Week

"It's pretty ugly at the moment. We've asked politicians who understand how to get
reelected by cutting taxes and raising spending to raise taxes and cut spending.
And, they have no idea how to do that,"

Douglas Holtz-Eakin, former director of the nonpartisan Congressional Budget Office
and now President of the conservative American Action Forum in comments on the efforts
of the Supercommittee who are debating the approach for reducing the federal deficit.

"Medicare reform must be part of the solution. Any attempt to reduce spending without
addressing this program would be like rearranging the deck chairs on the Titanic...[and,
to do this] we must transform our fee-for-service health care system to one that
pays for quality rather than quantity."

Senator Bob Corker (R-TN), in comments to the Supercommittee on the need for Medicare
reform.

"Transparency is a freight train that cannot be stopped."

Michael O'Boyle, President of United Health Networks, in comments to healthcare
leaders on the need to prepare for the new world of accountability in healthcare.

Consulo Indicium

Information for your Consideration...

Facing the Decline in Physician Numbers - Those of us who monitor the impending
crisis of insufficient providers took note of a California Healthcare Foundation
(CHF) report [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108623328175&s=6409&e=001T1zeaTu_TvzRUydJpFM8alaB28WSicJiG8_bVZcza6_Fb6jf6wMCLBR9TNa_YV-RNpObyskNtXr9HX4t1UpIJFEliwDU6eyfqx7zY29w1Kh-zdfJhBdTrENF4BmiVNkdq4_n32K-is1FC75zLvoz8_XlnR6aCzD-n3jtIxG_HTkhMYHsepokQfMayA2V-sgVwa3QPIFytwo62ozd3uDgOJMliSmu617XXeECsvfEjac=]
which indicated that "not only are the ranks of primary-care doctors declining but
also 25% of the nation's pediatricians, family physicians, geriatricians and internists
are 56 or older". In fact, over the next decade, we should anticipate that nearly
25% of the over age 55 physicians will retire, become disabled or die. We need focus
on the issue and the report goes on to suggest that "innovations - such as worksite
clinics, healthcare teams and telehealth - are required to address future care demands."
In fact, I would argue that the most pressing issue facing the healthcare field
- outside of the continuing escalation of costs - is the imminent insufficiency
of the workforce. I've reported it in previous issues of The Fickenscher Files.
If we believe that we can continue to provide care into the coming century using
models of care delivery that were developed in the 1950s - we are sorely mistaken.
The American healthcare system desperately needs new business and delivery models
that run the gamut from shared-savings incentives, self-care, retail clinics and
other similar initiatives which move our care delivery process toward the consumer.
The CHF report goes on to report that the barriers to innovation include poor distribution
of primary doctors, insufficient rural access to primary-care physicians, lack of
compensation for care coordination or education activities, low levels of patient
involvement and poor exchange of information. This is an issue that requires an
interdisciplinary response rather than a professionally siloed response. We'll keep
tabs on the healthcare response...

IOM Urges Congress To Investigate Risks Associated With Health IT - The IOM in a
report released last week called on Congress to create an independent federal entity
- similar to the National Transportation Safety Board - to investigate deaths or
injuries associated with the use of health information technology. The report noted
that there is a paucity of published evidence which quantifies the level of risk
that health IT poses to patients. The New York Times [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108623328175&s=6409&e=001T1zeaTu_TvzHLYc1wRe5C3D6F2D3SVw3wshVnGh1bNLtdybTK4pOnddz2IKNMM4iIy1qwosgKqKs490pDtniDMvp9UUaaQsy_0CfTn0W0T9X43imWRMbkqD1HuFXTuFoh-lX-4XNG0SUqJiW1Up-x7iXnnE_duWgfCSks36f06LZ4mfEgyQCnRTB5fiFqCWtANC7VcWNv0rA-JAhGQwPVCv_By7_3V31mP9GF-_rGS4=]
jumped on the bandwagon by reporting, "Poorly designed, hard-to-use computerized
health records are a threat to patient safety, and an independent agency should
be set up to investigate injuries and deaths linked to health information technology."
Farzad Mostashari, the National Coordinator for Health Information Technology responded
to the report by essentially agreeing with the findings when he said, "More can
and should be done to capture safety issues." I anticipate that the report will
gain some momentum on Capitol Hill after the first of the year. It actually makes
sense to me as well. Ongoing assessments and impacts of HIT on healthcare is crucial
for determining how best to manage our future investments. Just as the NTSB provides
information across the industry which results in safer flights, better management
of long-haul trucks and the like - so, we in healthcare need a similar oversight
group to manage the process. This should not be viewed as a threat but as an opportunity.
Kudos to the IOM for their efforts...

Discontinuing Smoking and the Abysmal Failure Rate - The Centers for Disease Control
and Prevention issued a very disconcerting report last week [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108623328175&s=6409&e=001T1zeaTu_TvxolAkIYvi2gN6t1ahsZ8DZC0Oc2dQpKTpE-U-mQKoBK-U8X6JBBccDLhgq8mJtLCyFkGjmohj-zYlFwuQ14Ne42nA_MuBedrCrGyWfGDgD-Nd3r1KAGPli17IDCZH_Pr0=].
Of the nearly 69% of adult smokers who wanted to quit in 2010, just over half tried
but the success rate was only 6.2%. Of Black Americans, 76% wanted to quit, 59%
tried but the rate of success was even lower at 3.3%. Smokers with college degrees
had more success with 11.4% having success versus those with less than 12 years
of schooling only having a success rate of 3.2%. The good news is that you can double
or triple your success rate if you seek counseling or medication to assist with
the cravings of nicotine. State Medicaid programs under the healthcare reform initiative
are now required to pay for cessation services for pregnant women plus counseling
is also allowed for payment under the program. At present, only 25 states and the
District of Columbia have smoke-free laws in place. Smoking is a scourge on society.
I know how difficult it is. I was one of the lucky 6.2% when I quit back in 1982.
I did have a little encouragement; however. At the ripe old age of 31, I developed
Prinzemetal's angina (coronary artery spasm) which was caused from smoking. There's
nothing like a little chest pain to motivation you to quit!! And, I feel very lucky
to have been successful. Now, what else can we do to help the vast majority of smokers
who want to quit? I suspect it's far more than we are doing...

Appeals Court Upholds Health Reform Law - Another federal appeals panel in Washington
voted last week to uphold the Obama healthcare initiative's key provision which
requires Americans to buy health insurance or pay a penalty. But, as I've been saying
for months, the Supreme Court will ultimately have the final say. The 37-page opinion
was issued by Judge Laurence H. Silberman, who noted that the law represents the
fundamental tension between individual liberty and the legislative power of society.
There was a dissent by Judge Brett M. Kavanaugh who stated that "the courts lack
jurisdiction until the law's tax penalties take effect in 2015. Both sides of the
drama related to a Supreme Court review of the Obama legislation quickly weighed
in but, the positions were not any different than prior public releases, blogs
and statements. Adding to the drama is the fact that the Supreme Court evidently
met in private late last week to consider the arguments. We shall wait and see;
however, I place my money on the Supremes taking up the case - hopefully, sooner
rather than later...

Is Virtual Education a Harbinger of Virtual Health? - In the last two weeks, I've
had any number of articles cross my desk related to virtual education. The most
recent was the Wall Street Journal in the Review section over the weekend, "My Teacher
is an App [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108623328175&s=6409&e=001T1zeaTu_Tvyfk_M8YAcnEaHr2XdoxNnMrDvQYUiv5bM10jMuDZxI_Q5WTIErhCsRwAmlus8m52yIjZ2hMw3-9QoF3ZtEr2xdQyhPONkTdCWrz2dEV-XwvpqvdzDSfYYKJhiwh_Ygw2ARNoZgNXBdQyEEjoyNCJxP3HuYUlxdSxKEPyR8yzvix8Vf2hagjefCCpxrqkBntC1kpmp_2Y8sNKTfPbbTC_gZ]".
It seems that about 250,000 students are now enrolled in virtual schools that teach
using online services rather than classrooms. That's a jump of 40% over the last
three years. Why is this occurring? One of the primary motivators is the cost of
education. Like healthcare, about 80% of the cost of education relates to the staffing
of schools. The same can be said of hospitals, clinics, home care programs and the
like in healthcare.

A study done in Georgia showed that the cost of educating the average student dropped
from $7,650 per year to about $3,200 per year through the use of the Georgia Cyber
Academy. Florida has realized similar savings of about $1,500 per year for each
student who is enrolled in an online program. In fact, Former Florida Governor Jeb
Bush (R-FL) has become one of the primary sponsors through his new initiative, Digital
Learning Now, which wants to remove the legal barriers to public funding for virtual
classrooms. But, does it work? Well, there is a huge debate about that issue and
it would take pages of discussion to go through all of the arguments. However,
long story short is that in a hybrid program it seems to work well. A totally virtual
education program however, most likely results in poorer performance by students.

So what does this mean for healthcare? As a proponent of new technologies, I believe
that virtual healthcare is on the horizon. However, I also believe that removing
healthcare providers from the picture is most likely not the best approach. In
fact, we need to consider the hybrid models which seem to work in education. Using
handhelds, computers and other interactive media to engage individuals in their
own healthcare, using kiosks to manage certain elements of the healthcare process,
having patients help manage their patient records are all technology initiatives
that move us toward virtual healthcare. We need to embrace these approaches, learn
from education and other sectors which may be ahead of us so that we can derive
better quality, lower costs and enhanced service within the healthcare sector. This
is a trend that will sweep around healthcare if we don't embrace it...

SuperStress On The SuperCommittee

Thanksgiving is just around the corner with no Supercommittee solution in sight...

While members of the Supercommittee - charged by Congress with defining an approach
toward reducing the federal deficit by $1.2 trillion dollars - have not yet given
up hope, many are expressing pessimism at finding a solution. The Washington Post
reported that there is a sense of "gloom" among the negotiating members on both
sides of the aisle. With just 10 days left before Thanksgiving - the date where
a debt reduction deal must be presented to Congress - stress and anxiety are increasing
on Capitol Hill. If the Supercommittee fails, across-the-board, automatic cuts in
spending will occur which many politicians on a bipartisan basis feel would be devastating.
If that were to occur, the Pentagon would be hit with a $54.7 billion cut, healthcare
would get an additional $11 billion cut and, $38 billion would be cut from other
agencies forcing massive federal layoffs - all of this in 2013 alone. As we say
out on the farm, it's time to fish or cut bait...

Clearly Medicare and Medicaid are part of the solution along with the Social Security
entitlement. We should fully expect that driving further efficiency and effectiveness
will be the name of the game in healthcare for the coming decade - something I've
been talking about for a couple of years now. In fact, healthcare must embrace the
accountable care movement. Healthcare represents about one-fourth of the entire
federal budget so if we think that we will not be touched by the current debate,
we are absolutely wrong.

However, what looms larger than the issue of cuts in real dollars for healthcare
is the issue of the impact of an impasse on the global financial markets. Much
of the attention of financial analysts in recent months has been on the Euro, the
French-German compromise for managing the European debt crisis, and the political
/ economic implosions in Greece and Italy. With those issues now much clearer -
in terms of how the issues will be managed - attention is now turning to the elephant
in the room or, the USA economy and the Supercommittee discussions. Pundits are
noting that the USA could face yet another downgrade of its credit rating which
would not only fuel further implosion of business and consumer confidence but would
also, no doubt, cause chaos in the financial markets. I've already decided that
I need to work until I'm at least 70 given the current market situation...

Let's hope the politicians come up with a compromise and that both sides do not
succumb to the pressures of the extremes. Both the left and right are facing inordinate
pressures from their respective constituencies to hold firm. At some point, the
politicians need to decide to do what's right for the country rather than what's
right for their political future. That's easy to say and difficult to execute -
I realize it!! But, it needs to be done. So, in an effort to support their ego
needs, I propose that we create a new monument on The Mall which will be dedicated
to the 10 politicians who stepped forward to solve the problem. The monument would
consist of 15 foot tall statues of the ten saviors kibitzing as a group - sort of
like the disciples. While I jest - to some degree - this is serious business. We
need resolution of the debt crisis. Any reasonable person knows that resolution
requires BOTH cost reduction AND increased taxes. What's so ironic in the current
debate is that the SILENT MAJORITY are in the middle and wanting resolution. We
are captive to the extremes and need to unshackle ourselves from those fringe perspectives.
We need a BOTH/AND solution. Let's hope the Supercommittee realizes it and moves
forward with a solution rather than simply punting. The American people deserve
better than a punt at this point.

Navigating Stark Legislation in the New ACO Environment

A sea of waivers to pave the way...

Several weeks ago, the Centers for Medicare and Medicaid Services (CMS) released
the 696 page final rule [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108623328175&s=6409&e=001T1zeaTu_TvyLpVWJuS3spKwYN5KMExgP_dusD-C4aWxWZgT-LehIJVj8mBBh3_A2K4xBDyhFksJh5_xKlyNmVFF0x3MFyfwpWNYZdu9NZMggMK7lS5ECag12EAEug9PD3KppcHZrfnw=]
for establishing Federal Accountable Care Organizations (ACOs) which sets the standards
for participation in the Medicare Shared Saving Program (MSSP). The initial set
of proposed rules released in March, 2011 prompted a plethora of concerns from a
myriad of stakeholders and actually seemed dead on arrival in most health policy
circles. However, CMS listened - as they said they would and responded by easing
some of the more controversial requirements of participation. In a November issue
of The Fickenscher Files, I highlighted these differences - ACOs: A Final Regulation
But An Evolving Concept [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108623328175&s=6409&e=001T1zeaTu_TvxrurOaY6r4l_JNBVZi02iEvsjd_nvP7FZvpO-bV5sYqJrWo3LGh8P_lPDZkRiCXTIurEZPCGCq2SZLUAJvDxCe2nPAZAuL4sXDnx484MI0T0NdheuHnSAM6wvKeZVA3d_KgTD95wkvZBlgbDrfAdp1gZTqthnvNOnALYMxNS7mbeCn7oUcYSo9HuYhLKBFIc8=].
But, I thought it would be helpful to go beyond the ACO rules of participation to
consider the impact of anti-trust legislation and the potential impediments of existing
regulatory standards which may pose as obstacles to ACO integration, care coordination,
and shared savings.

Of all the laws on the books the Stark Laws - which date back to the Omnibus Budget
Reconciliation Act of 1989 (OBRA 1989) and took effect January 1, 1992 - are the
most important. The law, known as Stark One (Stark I) barred physicians from making
self-referrals for laboratory services under the Medicare program but also included
a number of exceptions in order to accommodate legitimate business arrangements.
The Omnibus Budget Reconciliation Act of 1993 (OBRA 1993) expanded those initial
restrictions to include additional health services beyond lab testing. Stark Two
(Stark II) applied the regulations to both Medicare and Medicaid, as well.

In essence, the Stark Law [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108623328175&s=6409&e=001T1zeaTu_TvzPlyL712KHuUOCQG83WS3LdQW6QjjdTtm1m2sSvfKXkSw-W0zN7r0Ka2CWH_ibKeo3HBfpc60wTZ4U5AROPqirQIgTjl2FIEx857ToP5lSyBuxHCLKqJEaIx1PD2MyhyM5DYsUNCGnkbZWJi_87vkSQBVRoCPP-iC2dDBEfwUnh2UYuDeix9bnd2hiiJR-5B4=]
prohibits physicians from making a referral to any entity for the provision of designated
health services (DHS) that may be payable to Medicare or Medicaid (and commercial
insurers in most states) if the physician, or an immediate family member of the
physician, has a direct or indirect financial relationship with the entity. The
only exceptions to the Stark regulations are very explicit and, few and far between.
In a review of the ACO regulations, they included cost-saving collaboration related
to inpatient and outpatient hospital services; radiology services including CT scans,
MRIs and ultrasound, radiation therapy; and, outpatient prescription drugs. Under
the Stark rules these types of physician-hospital relationships which involve financial
ties are prohibited financial relationships for physicians to engage in because
of ownership and compensation considerations.

The intent of both Stark I and II legislation was to remove conflicts of interest
from physician decision making. However, in an ACO environment where integration
is the name of the game, the legislation has caused major concerns, particularly
in rural environments where there are fewer providers and fewer entities to provide
"designated health services". Sharing ancillary services and revenues across networks
of physicians and hospital/physician joint venture entities in order to constrain
growth in capacity costs simply will not work from a Stark perspective. And, the
likelihood that a physician has some type of financial relationship with a lab,
home health agency or other entity, for example, increases dramatically in less
populated areas. So, clearly, something will need to be done about the Stark rules.

To address some of the barriers that Stark I and II pose to ACO implementation,
the Antitrust Division and the Federal Trade Commission issued a joint Statement
of Antitrust Enforcement Policy Regarding Accountable Care Organizations Participating
in the Medicare Shared Savings Program [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108623328175&s=6409&e=001T1zeaTu_TvyXb45w8RRyqfg4ftnO1MIQ91iD8tdDhr3jc6ZCclpz41lFNFyp4gapeFBoNiAqfFSOFoAiCKMVfBVI5iigkmVHaVtoa9HOc7gA4NE2sgiuCecNmXbJQy412-J7RuYu53s_VL0zh6m67L406vlNxiRXGNttOaueRvk=].
The report notes that in addition to providing the HHS Secretary the ability to
authorize ACOs under statutes of the legislation, it also provides the Secretary
the authority to "waive" certain Medicare requirements, such as the Stark rules.
Specifically, the ACO waiver authority applies to Sections 1128A, 1128B and Title
XVIII of the Social Security Act which means that compliance with Stark (in Title
XVIII) can be waived. In conjunction with the release of the ACO Final Regulations,
CMS and the DHHS Office of the Inspector General jointly released an interim final
rule [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108623328175&s=6409&e=001T1zeaTu_TvxJMGqPeIZjvmP1yQmYx1koPvF_SykF3F3GGSXJAGmhHYgxZkPDhDxzgS5VDoC2kq09jgle7E9OPkNKJ2h9r6TT2-FRArVQ_S9xhhu0uqrMl4bCkqlRcUr_JGXWHWHao1yHqhywFBAZo0NuF7o88OONgYZx9MVpUKH9uzrJCX4B0Xjcl71tNyhP]
establishing waivers of the application of certain health care fraud and abuse laws
to specified arrangements involving ACOs' participating in the Medicare Share Savings
Program (MSSP). It's an interim final rule so there is an opportunity to respond
over the next 60 day which will extend to January 3, 2012.

In their ruling, the Department set forth five waivers for which ACOs may qualify.
The five separate, independent waivers are intended to afford flexibility to ACOs
in structuring their operations to share costs and revenues. Furthermore, the waivers
are intended to be self-implementing (i.e., no separate grant or approval of a waiver
to an ACO by CMS or OIG will be necessary assuming all requirements are met). The
waivers include:


1. ACO pre-participation waiver
2. ACO participation waiver
3. Shared savings distribution waiver
4. Compliance with the Stark law waiver
5. Waiver for patient incentives

We're not lawyers at The Fickenscher Files so we encourage everyone to engage in
due diligence. However, we found a nice summary of the qualifications and parameters
of the waivers in a chart [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108623328175&s=6409&e=001T1zeaTu_TvwUZKKRNH3wiRJvXT1pOS0ePkAWCWOIBreOrXSCaqHYxM02UyDoG-9MsGAKNysq9JvwHfW-wNm1s8Ov1y6CNTdhVDBYj-SpKJfMdZdcAZMIn8_xIcha92DtvhxNLlrBeQRpD6r7cBJitevAKXoqa0SfpdRW-fqIK6q1rPE1E4MHjy17wpgBf1nBxncgh8yVM7ta1WvliZTQddwOQ2EWjUEH28F6qeEFT2hJFzZ034gSz-gsZl6RC93n]
issued by McKenna, Long, and Aldridge, a healthcare law firm. It is important to
note however, that while a provider only need satisfy one of these waivers in order
to be protected from fraud and abuse liability, the waivers are limited in scope
and apply in a variety of different circumstances. As a result, we anticipate that
ACOs may end up applying for more than one waiver to ensure complete protection.
But, again, we're not lawyers...

The deadline for submitting comments to CMS on the fraud and abuse waiver interim
final rule is 5:00 PM on January 3, 2012. I'm absolutely convinced that any concerns
or comments that you share will be heard - now is the time to speak. I was with
representatives of CMS last week. They are truly attempting to make the legislation
work and understand that the historical impediments we put in place for a volume-based
healthcare system are no longer applicable in a value-based healthcare system. From
my perspective, CMS has done a great job incorporating a variety of stakeholder
concerns into the final ACO rules. Kudos to Don Berwick, MD, Rick Gilfillian, MD
and the other members of their team for listening and responding. I have considerable
confidence that the CMS administrators will act in a similar fashion to any critiques
or perspectives we share related to the fraud and abuse waivers issue which will
clearly pave the way for ACO implementation.

Readings for Your Consideration

Amid the sea of thoughts and perspectives, here are a few you should consider reading...

The Central Question for Health Policy in Deficit Reduction [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108623328175&s=6409&e=001T1zeaTu_Tvy9NkHum3buI-8Jd3SINIyZ2V1JTCvbYcFh1FJCY4FU9YPq9XhEA8N0_0kLY6Bo1QmBVpsoNZi9HPkdYH_VECjXBqtLZexMuVCNsK_yHiDp5omt36xY-H-_lWXo3F4qepCHg8BKETL4YGJOuLQkiy9W]-
is an editorial by Henry Aaron, Ph.D. from the Brookings Institute in the November
3, 2011 issue of the New England Journal of Medicine (365:18 - p 1655). The essence
of the overview is that if we think we can reduce the deficit by $1.2 trillion and
not touch healthcare - we are wrong. Furthermore, he makes the argument that $1.2
trillion in cuts is insufficient over the longer term and that if we don't make
substantial redirections in societal allocations, we will be having the current
debate every couple of years for the foreseeable future. I think that everyone should
read it.

Beyond the PC [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108623328175&s=6409&e=001T1zeaTu_Tvy4lO9FRB8gUrtzj-_SKaBufCZJVR_d0czoU4SL2jpRh8D77Y83voiFTZua5tMIazN0auj9RVxL3MIr16vmAMBDjZcoSYhN65DbrEG-NBKDduHj7htIF1hWCNWcpN2fyc8=]
(The Economist) - provides an excellent overview on the impact of mobile technologies
on the future of everything. From my perspective, healthcare is at the forefront
of this revolution of empowerment for consumers. We need to take note and consider
how it will change who, what and where healthcare services will be delivered.

The Role of Interprofessional Collaboration in Creating and Supporting Health Care
Reform [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108623328175&s=6409&e=001T1zeaTu_TvzdqD6HOk0taOOuB2pLAhgPd7NFlrtF2ehpLDTMOiensX1-pMYIxTFPAtWGjNqEC6YPIqMJBL07Of1tr8ua3g5i3bRd4BvYBDNzb52HBO0TGKYQhbb8MXnT1yI1R0BcOIU7daxb2abKQP0Ius6D0-PX_QTS5RW2aGUwG94bOT0aIA==]-
is a very good article that deserves discussion and debate. I firmly believe that
if we do not move toward a more collaborative, interdisciplinary approach to healthcare
that the system under any type of accountable care model will NOT work.

The Weekly Whisk

Musings from a foodie...

The listing for the top 50 restaurants recently came out in Washingtonian, the local
style magazine. Washington, DC has truly become more a culinary scene in the last
decade. One of my favorites is located in my neighborhood of Cleveland Park. Palena
Restaurant [****] is owned by the former Sous Chef for The White House, Rank Ruta,
during the Reagan / Bush I years. He served at The White House at the personal request
of Nancy Reagan, serving from 1988 through the remainder of the Reagan Administration
and for the first 15 months of the Bush presidency. He started cooking alongside
his mother and grandmother - much like me!

Over the years, Chef Ruta has received many acclamations for his culinary talents.
I recently made the decision to stop in at the dining room which is separate from
the front end informal dining area. It had been some time since I had stopped in
and, I was not disappointed. The dinner started with a horseradish mouse with minted
cream - an absolute delight and wonderful way to start a culinary experience. The
dinner is a price fixe approach with one of two choices - either the three or six
entre approach. So, we decided to go the six course route by splitting two three
course meals. The dinner started with a mushroom and squash puree soup. Again,
outstanding. The soup was followed by smoke tuna with artichoke hearts and a small
saddle of rabbit stuffed with chard, all accompanied by candied and vinegar infused
tomatoes. Then there was an interlude of wood pigeon raviolini with turnip root
layered over a consommé with red peppercorns sprinkled with Brussels sprouts and
pomegranate seeds. The second interlude was equally wonderful with fresh garbanzo
beans (which are vastly different than the canned type) and a sweet red beet ravioli
in a walnut butter sauce. By this time, I was getting to edge of satiety but - there
were two more courses to follow. They included halibut with a caper butter sauce,
sautéed celery over a celery puree. The final dish was veal loin with varietal mushrooms
(Portobello, chanterelle and others) along with steamed parsnips. Following last
two dishes, I couldn't go on so I demurred on dessert and committed to a long walk
the next day to rid myself of the calories!!

I know it's in my neighborhood but I believe Palena's is the most understated and
underrated restaurant in all of Washington, DC. Everyone who visits out nation's
capital should try them out. Plus, the neighborhood is a wonderful DC experience
as well. It's close to the zoo! You can find Palena's - 3529 Connecticut Ave, NW
(between N Ordway St & N Porter St) - Washington, DC20008 - (202) 537-9250 - http://www.palenarestaurant.com
[http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108623328175&s=6409&e=001T1zeaTu_TvykXcNln-pgPNzvFkCXBjIIWKSn5nJbY4NjqeuwDZ5AmcuiKDgyEKy-XHDD3A1G1NfkMHwmA62xbedVLGo3AaMqBasAdzAUTzD1-WOLTziioS855LUnlPjs].
It's just off the Cleveland Park Metro Station on the Red Line so; it's also an
easy jaunt from pretty much anywhere in the District. Consider Palena's - you will
NOT be disappointed...

The Good, The Bad, And The Ugly

The ongoing saga...

The Good - This is the season that brings us together with family and friends and,
a time for thoughtful consideration on the bounty that most of us have enjoyed over
the last year. It is also a season that begins to prepare us for the New Year. Enjoy
it. Share wisely and give thanks for the abundance you have received...

The Reflection - We should all give tribute to our troops who manage the front line
while we enjoy the comforts of home and hearth. Our veteran's deserve our very special
support.

The Bad - The continuing strife in Syria causes angst among the leaders and peoples
of the world - as it should. The Arab League spoke out in opposition to Syria's
ongoing tyranny against its people. While that is good, the ongoing suppression
within Syria is bad. The despots are no longer in control and the government of
Syria should recognize the right of the people to govern themselves, as they see
fit. Those of us in healthcare need to recognize the results of despotism; however,
since the guilds (i.e. medicine, nursing) are no longer in control. In fact, they
are dead. If we don't adapt to the new world, we will all be overthrown as well...

The Ugly - The up and down of the Euro is causing market fluctuations that are not
for the faint of heart - one day huge losses, the next day big gains. All told;
however, it's been a year of losses for most of us. Oh well, retirement gets extended
for another couple of decades. At least I enjoy what I do...
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Founding Sponsor
Dearborn Advisors, LLC [http://r20.rs6.net/tn.jsp?llr=svyssnfab&et=1108623328175&s=6409&e=001T1zeaTu_TvxBGvtttthlwjDhrz0twuzw5S-LZ_cfcqw1bduZIK6UGm_tv3m1PqnoLqVhBOx43Wb5IBI_hWJl1NzqdFrJFO6_TAx_ImdO6NAMq1T_51JddKY3xvW416Kf]
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

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In This Edition

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