Saturday, February 28, 2015

Does Motivational Interviewing Improve Osteoporosis Treatment? Does Motivational Interviewing Deserve Better Research?

In some of its Grand Rounds and other conference presentations, the Disease Management Care Blog likes to show a slide portraying a basic disease management business model: a nurse call center with patient calls going in the front end and piles of cash coming out the back end. That's built on a widespread assumption that if you educate persons about their health, insurance savings will accumulate faster than PCPs at a weekend "here's how you can make money with botox" seminar.

The veteran disease and population health management providers know it's not that easy. But that doesn't mean that the outbound phone model isn't still worth trying. That's why the DMCB was interested in this just released 'Online First' article by Daniel Solomon and colleagues on the "Osteoporosis Telephonic Intervention to Improve Medication Adherence" (or "OPTIMA").

The study was conducted at physicians at Boston's Partners Healthcare. The participating patients were enrolled in an unnamed Pennsylvania pharmacy benefits program. At the time of entry into the study, they were independently living, community-dwelling and low income elders. Patients who received a new prescription for any osteoporosis drug were contacted by telephone and asked about participating in the study.

If they didn't "opt out," patients were randomly assigned to one of two protocols. The intervention group (1046 participants) received telephonic coaching sessions that were based in "motivational interviewing" that reviewed attitudes about taking the osteoporosis medicine and addressed barriers to its long term use. They also received health promotion mailings. The control group (1041 participants) got just the mailings.

Both the intervention and control groups were quite elderly (average 80 years), mostly white (approximately 90%), widowed (about 67%) and already taking a lot of pills (10 medications). About 63% were on weekly oral biphosphonates, while the rest received a smattering of other types of medications.

One year later, based on a "medication possession ratio" (MPR) statistic, there was no evidence that the intervention group did a better job of taking their osteoporosis medication.

The MPR is the ratio of days that are covered by a purchased prescription versus the total number of days. The intervention group had a median MPR of 49% (in other words, they were in possession of their purchased medicine a little less than half of the eligible time) vs. 41% in the control group. While the intervention group had a higher MPR, the difference of 8% was not statistically significant. By the way, the telephonic motivational interviewing also had no impact on the self-reported rate of bone fractures (about 11% in both groups) or falls (about 37%).

To the DMCB, this looked like a solid study. The authors recruited an impressive number of patients. Their motivational interviewing and support was subjected to a lot of internal quality control. Yet, despite a seemingly strong approach, it didn't translate into patients being more compliant with their medications.

The DMCB can't say it's surprised. Based on its own experience and what it has learned in other settings, it knows that remote telephony, even if it's provided by dedicated nurses using the most modern behavioral techniques, is not going to have much of an impact if it's not accompanied by other program supports.

DMCB readers know that those supports include predictive modeling (to spot the patients at greatest risk of not taking their prescriptions), a spectrum of interventions based on that risk (including home visits, and high frequency telephonic outreach for patients most unlikely to forgo their medicines), patient incentives (including meaningful limits to any out of pocket costs) and close coordination with the patients' physicians

That multi-dimensional and synergistic approach - which is typically used in modern vendor-based telephonic disease management - was not tested here.

Motivational interviewing and osteoporosis treatment deserves better.  As previously noted by Don Berwick, dealing with complex patients involves non-linear social constructs that escape the confines of randomized trials with unidimensional interventions. They are ultimately designed to ask the unsatisfying question "what," instead of the far more important one of "how."

Last but not least, how about that fancy "OPTIMA" acronym?  The DMCB suggests this one: AFFRONT: Another Fabulous Failure of Research (to address) Osteoporosis Needing Treatment

Image from Wikipedia

CODA:  While doing the background research on this blog posting, the DMCB came across the FRAX tool to assess osteoporosis risk.  Looks like a worthy option for any population health management program that needs a guide on osteoporosis risk assessment and treatment.

A February Edition of the Health Wonk Review: Insightful Nuggets From the Best Health Policy Blogs

A valuable nugget & more on the way
Welcome to the Disease Management Care Blog's hosting of the Feb. 28 Health Wonk Review.

This HWR is a summarized compendium of submitted posts by the smartest health policy bloggers in the known universe.  The DMCB assures you that you're in for a special treat because you'll find some insightful nuggets that generally go unseen in the mainstream media and academic literature.

When it's not mining the HWR for information, the DMCB combines acumen, skepticism, modesty, peer-reviewed science and occasional humor about health policy, care coordination, population health management as well as primary care, the medical home, health insurance and the electronic record.

It's so glad you stopped by.

The DMCB has organized the posts by topic: Obamacare's key reforms, various health economists' latest divinations on health care costs, hospitals, Medicaid, the internet, California, medical education and some British humor.  The quotes that head each section should give you a hint about what you're in for.

“This is a big f—-ing deal.” – Vice President Joe Biden

What's to Know About the Go-Go Growth of ACOs?

Lots, thanks to this Health Affairs Blog post by Leavitt Partners' David Muhlestein. He counts 428 accountable care organizations (ACOs). While all eyes are on the Medicare versions, it turns out the private sector has been on a less visible parallel track with "full or partial capitation models, bundled payments, retainer agreements, in-kind services and subsidies provided by payers, and pay-for-performance incentives." Did you know that most ACOs are in the West Coast and Northeast, or that there's an even split between physician and hospital-led sponsors? Mr. Muhlestein also points out that 2015 will be the year that we'll get to see some early ACO data. David and the DMCB will be watching very carefully and, if we report Medicare's outcomes are less than expected, the DMCB is looking forward to getting a "you'll regret it" email from somewhere in the Administration.

What's to Love About the Individual Insurance Market?

Could be lots, says Nicole Fisher of Wright on Health. She wonders if there is a silver lining in the growing evidence that some employers will drop their sponsored health insurance benefit and force their workforce into the individual market. That may force the individual market to have better transparency, less discriminatory underwriting, more choice and increased competition. As result, costs could be lower than expected, consumers will better understand the true costs of health care and portability could paradoxically improve. If things go really well, we could see a self-reinforcing cycle of market demand. And, wonders the DMCB, long lines outside doctors' offices.

Maybe, But What's NOT to Love About the Individual Insurance Market?

Louise of the Colorado Health Insurance Insider blog worries that persons who aren't poor but who are also not wealthy are in for some bad news if they believe that the reformed individual market will translate into affordable health insurance.  Unlike today's market, individuals will be less able to trade lower premiums for HSAs, high deductibles and (for persons over 30 years of age) catastrophic coverage. While minimum coverage requirements are a good idea, Louise says they're also expensive. She suggests it would be good public policy to flexibly accommodate a demand for higher deductibles and lower premiums.

An economic forecaster is like a cross-eyed javelin thrower: they don't win many accuracy contests, but they keep the crowd's attention - Anonymous

Persistent Partisan Perfidy on the ACA's Costs

Maggie Mahar, over at healthinsurance.org, indicts the latest libel against Obamacare.  Her ire is directed at those repugnant conservative pundits who should have known better than to glom onto an ill-considered U.S. Internal Revenue Service document about 2016's health insurance costs. Beware, says Maggie, no one really knows what costs will be in 2016. The DMCB is shocked, shocked that economists' and actuaries' inaccurate predictions are being intentionally misinterpreted for political gain.

Numbers With A Lot of Zeros

Speaking of economists, The Hospitalist Leader has compiled a linked list of peer-reviewed references that estimates the health care costs for the big name medical conditions. He senses that there's something amiss, because adding them up is much like finding Italy's olive oil exports far exceeds that country's domestic production. He thinks science writers, patient advocates, policymakers and yes, us bloggers, should promote better numeracy and, for starters, contrast any absolute dollar figures with helpful comparisons. That's why the DMCB is pleased to post this short instructional video on some math basics courtesy of the health insurance professionals who staff the IRS:



100% Coverage of Screening Services Is Not Good Enough?

Guess what?  When health care consumers are thinking about the cost of undergoing screening for a disease, they're also thinking about the next steps if disease is found.  Quoting a study in the Journal of Health Economics, Jason Shafrin of Healthcare Economist points out that zero dollar coverage for services - while noble - will have less of an impact than anticipated unless it's linked to meaningful coverage of treatment of the underlying condition.  In other words, health screening subsidies are not enough to maximize consumer buy-in.  No wonder the DMCB spouse is unfooled by offers to screen some sales prices for a jumbotron-sized flat screen for the living room!

"Phlegm free zone" - Sign seen at a local hospital

The Riddle of Readmissions

In this posted podcast (here), David Williams asks the Robert Wood Johnson Foundation's Anne Weiss about the recent depressing report on hospital readmissions.  Based on 2010 Medicare numbers, it doesn't look like the national rate has gone down all that much and that the considerable variation between different areas of the country remains.  David and his guest also chat about some promising best practices that being used in some settings to reduce readmissions, what patients and their families can do about lowering the likelihood of a readmission and whether the practice style of hospitalists is part of the problem or a potential solution.  Despite evidence that population management can reduce readmissions, Ms. Weiss rejects for-profit vendor participation, believing that hospitals should be happy to hire more personnel in lieu of partnering.  Let the "build or buy" games continue, says the DMCB.

"Governor Brown's budget plan also counts on $488.4 million in savings from a 10% cut to Medi-Cal reimbursements. Medi-Cal is California's Medicaid program." 1/30/13 News Report.

Here's A Free Baby Elephant!

Joe Paduda can't blame many of the nation's governors for bowing to the common sense and fiscal reality of expanding Medicaid in their states, even though it can be viewed as distasteful.  The 100% federal financing is free money and their politically connected hospitals prefer Medicaid to uncompensated care.  Many states are likely to cut their Medicaid fee schedules, so providers have one more incentive to go along with testing new reimbursement strategies and delivery models.  All in all, he muses, "this is a very good thing."  Next step, muses the DMCB, is to convince the docs.

The Internet is the most important single development in the history of human communication since the invention of call waiting. - Dave Barry

Time To Take On Medical Tourism By Getting "Lean"

Jonena Relth of Healthcare Talent Transformation points out that the times they are a changin'. The steady increase in medical tourism is challenging the notion that U.S. domiciled health care is the best, especially when international health systems are adopting U.S. methods and employing U.S. trained physicians who are using state-of-the-art electronic health records that are modeled on U.S systems. The salvation, according to Ms. Relth, is the "Lean" approach that, according to a LinkedIn discussion group, helps providers 1) put patients first, 2) cut waste and 3) eliminate tasks that don't add value.  The DMCB's experience leads it to believe that many of its physician colleagues can accomplish much of that third goal by staying away from LinkedIn.  Maybe it's time to change its mind.

"There is science, logic, reason; there is thought verified by experience. And then there is California." - Edward Abbey

California's Health Insurance Exchange Chassis Unveiled. Next Up: The Hard Part

Health reform advocate Anthony Wright of California's Health Access Blog really extols the virtues of Covered California, the Golden State's health insurance exchange web site. Anthony can be forgiven for his use of terms like "conveniently," "breakthrough," "easier" and "bold" because the site's very existence is an important step forward in having a real functioning web presence where consumers can actually buy health insurance. Whether this leads to marketplace transparency, consumer ease-of-use and increased insurance coverage for Californians remains to be seen. The DMCB took the web site's calculator for a test drive and discovered it and the spouse's unsubsidized monthly premium would be $1723 per month, which is about $700 more than it currently pays in Pennsylvania. 'Nuff said.

A Ballooning Benefit Bonanza, Courtesy of Sacramento

Speaking of California, John Goodman of his eponymously named blog examines the state's tax policy, blaming it for a plethora of generous employee benefits. Since higher wages are taxable, loopy loopholes are prompting companies to compensate their employees with home cleaning, personal trainers and the daily delivery of fresh fish. Mr. Goodman faults the unraveling of the 1980's tax reform movement and suggests now is the time for a "progressive flat tax."  Now is also the time for the DMCB Inc. Board of Directors to consider installing a tax deductible gas-powered backyard fire-pit for its two employees. 

Income from Injuries

And Calfornia doesn't stop there. Jon Coopelman of the Workers Comp Insider Blog writes that professional athletes from across the U.S. have discovered that California's generous worker's comp law allows out-of-state players to file claims long after any in-state injury that could have contributed to a disability. Thanks to clever attorneys and vague inclusion criteria, its not hard for any ex-jock who played in the state to convince a California judge that a sports team should cover all future related medical expenses. Jon says its time for the California legislature to stop the abuse and for sports teams to address this in their labor contracts. Until then, the DMCB  invites readers to pay $6 to play to enter an upcoming wiffle ball tourney in Golden Gate Park; participants will receive $1 in California taxable income, $5 worth of beer and a certificate of a compensible injury. Date TBA.

How Much Is That Hospital CEO Worth?

Roy Poses of Health Care Renewal looks at examples of small town hospital CEOs being compensated with lavish pay. Dr. Poses is particularly exasperated because the hospitals are not only public, but they've had to make tough trade-offs between being profitable and having enough nurses and docs to care for their underserved populations. Roy has little difficulty finding numerous news reports - and most are from California -  that amply demonstrate that there is little correlation between hospital administrators' $800K salaries and their institutions' financial performance. Roy blasts the gimmicky talking points that have been used justify these outlandish compensation packages, the cluelessness of hospital boards and the public's need to wake up and smell this coffee. The DMCB looks forward to what Roy discovers in 2015 when he compares ACOs' financial success with their executives' compensation packages.

 "Beware of the young doctor and the old barber." - Benjamin Franklin

Strange Bedfellows

Did you know that 15 new allopathic and 10 osteopathic medical schools have opened since 2002 and that most operate campuses located in Republican Congressional districts?  Wing of Zock's James Lewis reviews the political implications of this, pointing out that these Republicans will gain a new appreciation for the value of our national health care infrastructure. What's more, they'll probably be reluctant to go along with their House colleagues' enthusiasm to reduce the U.S. budget with sacrifices in graduate medical education funding. What delicious irony!

"Bollocks!" An oft-heard exclamation "with a long and distingished history." - Wikipedia

Merry Old En-gland?

Ouch!  The InsureBlog's Mike Feehan looks at a London Daily Mail report on the lowball rate of £20,000 that is used by the Brits' National Health Service when it needs to compensate men for a nutty type of wrong side surgery.  The DMCB points out that one historical explanation for higher U.S. jury awards is the need to compensate for future medical services.  That's less necessary, thanks to the NHS' universal coverage.  The comments that follow testily debate whether the incidence of this complication is higher in the Sceptered Isles compared to the U.S.   The DMCB will never be able to think about NHS "budget cuts" in quite the same way.

That's it for this HWR.  Mark your calendar for the next iteration, due to appear on David Williams' smartly written Health Business Blog on March 13!

Friday, February 27, 2015

Health Care Microtargeting: Just A Matter of Time

The Disease Management Care Blog is proud of its native ability to resist the highly tailored "microtargeting" of advertisers. It can confidently say this because it uses its own independently formed preferences to take advantage of on-line sales, movie placements, Twitter prompts, cable TV commercials and internet radio ads. It's not its fault that it attracts certain targeting and rejects the DMCB spouse's assertion that there's no discernible difference between Chopin and Smirnoff.

Smart DMCB readers undoubtedly feel just as secure about their native immunity to outside influencers. But that doesn't mean they won't be impressed by just how industrialized microtargeting has become when they look at this Feb 27 C-SPAN Washington Journal on Targeted Political Ads. The same decades-old science that matches a particular product to a certain profile for automobiles, accessories and aspirin is now being used as never before in the 2015 political campaigns.

The DMCB thinks there may be a silver lining here.  As this gets better every day, microtargeting is undoubtedly destined to be adopted by the disease and population health management industry. Over and beyond its ability to use details from insurance claims and electronic health records, microtargeting can also vacuum up and digest data on the magazines we subscribe to, the cable shows we watch, the credit charges we amass, the computer "cookies" we accumulate or the social media we embrace to triangulate on consumers' health profiles.

For example.... the analytics modeling could fit a known behavior (like having a lot of flat screens in the home tuned to reruns of the gluttonous Man vs. Food ) with certain conditions (like undiagnosed diabetes). It could also be used to link key health consumer attitudes (like wanting to sign up for your PCP's newly minted patient centered medical home) with a certain behaviors (such as being unable to resist viewing online images of cute puppies). Or what about leveraging the most obvious association: possessing high native intelligence and reading this blog.

Silliness aside, to the DMCB's knowledge, tapping into our public, demographic and on-line footprints for "health care microtargeting" hasn't been really commercialized - yet. It searched the published medical literature and didn't find much that was useful (though given its academic pedigree, that shouldn't be surprising), but, thanks to Google, it did find this blog post (as if we'd expect otherwise) by "Sirensong. She points out that geeks are on it, so the DMCB suspects its just a matter of time.

If any readers are aware of anything more to this, please share.

Image from Wikipedia

Thursday, February 26, 2015

More on the Failure of a Huge Medical Home Initiative to Reduce Health Care Costs

Getting the medical home back on the road
In this JAMA editorial, Thomas Schwenk agrees with the Disease Management/ Population Health Blog that the recent negative report on the medical home may have been the result of the lack of any risk stratification.

Recall that this negative report, Association Between Participation in a Multipayer Medical Home intervention and changes in Quality, Utilization and Costs of Care, compared three years' worth of clinical and economic outcomes for 32 community-based medical home clinics vs. those from 29 similar non-medical home clinics.  Claims expense, ER visit frequency, hospitalization rates and 10 out of 11 HEDIS measures were no different between the two groups.

He points out that this study....

.... has done a great service for the advocates of the Patient Centered Medical Home by effectively ending promotion of this care model as a generic, low-level, unselective approach to health care delivery for all.  The next critical phase of PCMH development should focus on its strategic deployment for the care of high-utilization patients...."

The DMCB couldn't have said it better.  The medical home should be "aimed" at patients who are most likely to benefit.

Upon further reflection, it would add two other comments:

1. Another under-recognized feature of successful population health systems is the central administration (and employment) of the non-physician care managers who are peripherally distributed throughout the primary care network.  Here's one example as well as another that suggests the central model has a better track record.

In other words, this study showed multiple independently functioning "stand-alone" medical homes is equal to the sum of its parts.

2. The study also, by the way, calls into question the return on investment of achieving NCQA Medical Home recognition.  While it's possible that it's ultimately necessary, it would appear that just having it doesn't mean a health system will save money or improve quality.

Image from Wikipedia

The Risk of (Improper) Risk Adjustment: Why The Doctor May See You Now

The stats guys go to work
The Disease Management Care Blog continues to welcome blog posts from outside authors. This is another one, courtesy of Erik Tollefson, who works in the health policy field. He can be reached at erikDOTmDOTtollefsonATgmailDOTcom

As payers increasingly pursue reimbursement strategies that share risk with health care providers, risk adjustment is emerging as an important topic in health policy research.  Indeed, for providers, the ability to properly identify the underlying health risks of a specific population could mean the difference between earning savings rather than paying penalties.  As the importance of risk adjustment ascends grows, increasing attention is being given to the robustness sophistication of adjustment methodologies. That includes including the data used to estimate the risk of a covered population risk. 

In a recent study published in the British Medical Journal (BMJ), John Wennberg and co-authors explore how under-recognized “patient observation bias” can contaminate risk adjustment results.

Previous studies have identified many pitfalls of using observational data as a proxy of a population’s true disease burden. One common example is the phenomenon of “upcoding.” This practice not only adjusts diagnostic codes to maximize reimbursement, it is a well-documented source of bias that spuriously increases variation between geographical regions and complicates risk adjustment.

Wennberg and colleagues show that patient observation bias is another potential pitfall in the science of risk adjustment that has not received such attention. The phenomenon can be quantified by using numerous proxies such as frequency of visits by physicians and the intensity of diagnostic tests (both laboratory and imaging) ordered. Previous research has shown that geographical areas with higher patient observation bias independently correlate with higher rates of comorbidity after being adjusted for all the other relevant patient factors that underlie true risk.

Using a sample of Medicare claims data, the authors computed two different risk adjustment measures: 1) using standard methods; 2) adjusting for potential observation bias.  Overall, the adjusted method (using visit intensity) emerged as a more accurate predictor of the population’s underlying burden of illness. Thanks to their ability to identify a source of bias that explained a greater portion of variation in important categories such as sex, age, and race, but was the authors were able, compared to the usual risk adjustment methods, to reduce the variation levels between different geographic regions.

The importance of accurate risk adjustment is not just limited to its potential impact on increasingly high financial stakes in the health care sector. The ability of policy makers to understand why variation occurs in health care costs and utilization across geographical areas has emerged as one of the key questions that may ultimately improve delivery and cut costs in a bloated health care system. This study offers important evidence that part of the answer may indeed lay in the supply-inducing doctors self-referring patients for unnecessary diagnostic procedures that littered Atul Gawande’s account of rising health care costs in McAllen, Texas.

Another important take home lesson, however, also applies: the quality of underlying data. With continued histrionics surrounding access to ever greater amounts of health care data, it helps to remember that qualitatively understanding what one is actually measuring is still as important as the accuracy of the underlying statistical methods.

Qnexa for Obesity: Should It Ever Be Prescribed Without Concurrent Lifestyle Counseling? The Role of Disease and Population Health Management

Physician waiting room chair
for Qnexa candidates?
It's that time of year again. A political as well as cinematic blur of uninspiring candidates are being manipulated by an opaque, unaccountable and moneyed white male nomenklatura that foists "winners" on an unsuspecting public. The Oscars, the primary election year.... what's the difference?

So the Disease Management Care Blog distracted itself by turning its bloggy eye to newsmaker "Qnexa." This is a combination of two well known appetite suppressant drugs, phentermine and topiramate, that was just reviewed by an FDA expert panel. Their 20-2 vote in favor of approval makes it likely the Qnexa will be released to the market for the treatment of obesity sometime after a final Agency review in April.  Investors in Vivus like what it means for the company's prospects.

Population health management service providers should also like the prospects.

That's because Qnexa hasn't been tested as a stand-alone drug and, based on the published evidence, there is no evidence that it works without concurrent lifestyle counseling: 

The CONQUER Trial: "...assessed the efficacy and safety of two doses of phentermine plus topiramate controlled-release combination as an adjunct to diet and lifestyle modification for weight loss and metabolic risk reduction in individuals who were overweight and obese, with two or more risk factors."

The EQUIP Trial: "All patients were provided with standardized lifestyle counseling."

The SEQUEL Study: "All subjects participated in a lifestyle-modification program."

As the DMCB understands it, the FDA expert panel has recommended that Qnexa's release be tied to careful monitoring for an approximate 5% absolute risk of heart valve abnormalities. The DMCB believes they got it half right.

Access to Qnexa, based on the evidence, should also be explicitly tied to concurrent lifestyle counseling.  Assuming physicians are still unable to incorporate this into their usual clinic work flows, that leaves pharmacy benefit managers (who have supported patients with diabetes), patient centered medical homes and, last but not least, disease and population health management vendors.

Image from Wikipedia

Wednesday, February 25, 2015

A Huge Medical Home Pilot Fails: the Pennsylvania Chronic Care Initiative

Back in 2007, Pennsylvania Governor Ed Rendell created the "Chronic Care Management Reimbursement and Cost Reduction Commission."  Months later, the Commission presented its strategic plan to the Governor, which then led to the Pennsylvania Chronic Care Initiative (PACCI). The "Rx for PA" was launched, promoting the medical home as a means of increasing quality and lowering costs for Pennsylvanians with diabetes and pediatric asthma.

The Commission recognized that one of the problems with the medical home was that not all health insurers covered its services the same way.  That left the primary care practices with the dilemma of having to offer different services to different patients depending on insurance status.  As only big Ed Rendell could do in his "discussions" with the Commonwealth's health insurers, the PACCI "leveled" the playing field by getting Medicaid and the dominant Pennsylvania health insurers to similarly "cover" the medical home. This minimized - outside of Medicare - the impact of multiple insurers with different benefit and coverage standards.

The PACCI was a statewide, multipayer medical home pilot that was started in southeast portion of the state.  It started in June of 2008 involved six health plans (3 commercial and 3 Medicaid) that agreed to give NCQA-recognized clinics additional yearly practice support payments and other bonuses.

Three years later, 32 out of 34 of the originally selected southeast Pennsylvania practices completed the pilot, of which 6 were independently managed by nurse practitioners; at the end, about half had achieved high "Level 3: NCQA status. 

The PACCI clinics and their approximately 64,000 patients were compared to a parallel group of 29 comparison practices that were similar in size, specialty and patient mix; they had approximately 56,000 patients.  Of the six health plans, only four could supply claims data that went back to 2007.

Results?  The article is here, but the short version is as follows:

Using 2007 as the baseline, there was no difference in any change in hospitalization rates, ED visit rates, primary care visits, visits to specialists or overall costs of care. In fact, the medical home clinics had MORE "ambulatory sensitive" hospitalizations. 

Ouch.

Of 11 HEDIS® quality measures (blood sugar testing and control, cholesterol testing and control, monitoring for kidney or eye disease in diabetes, childhood asthma treatment, plus the health maintenance chlamydia screening and breast, cervical and colon cancer testing) only the kidney monitoring was statistically significantly improved compared to the non-pilot clinic populations.

Double ouch.

The DMCB's take:

This is bad news for the medical home community. While the methodology is not pristine (the clinics were not randomly assigned, opening the possibility of bias and some of the data were not available), this is a real world study that should have detected some cost savings or quality improvement. Instead, none were found. 

The DMCB and AHRQ have worried about this before, but the DMCB remains open minded:

Medical home is necessary but not sufficient? The authors points out that there were no other economic incentives to reduce costs and that there was no feedback on performance.  The DMCB agrees that had the practices known which patients were at greatest risk, they might have been able to better target their services.  In other words, medical homes may be more likely to succeed if they are paired with predictive modeling to proactively identify and intervene on their patients who were most likely to have ambulatory-sensitive hospitalizations

Not really "all payer." As the DMCB understands it, Medicare was not a participant in PACCI, and its failure to cover medical home services could have repressed its complete adoption throughout the practice.  Small wonder, since Medicare can account for half of a doctor's income.

Generalizability to small physician-owned practices? Medical homes arguably work in "closed" integrated or Medicaid care systems.  It may be that the sum of smaller independent practices is equal to all its uncoordinated parts.

Nurse practitioners? It sure would be nice to know how the nurse practitioner-led PACCI practices fared vs. physicians.

Image from Wikipedia

Cool Gossip On Celebrities images

Cool Gossip On Celebrities images

A few nice gossip on celebrities images I found:

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Image by movietvtechgeeksnews Funniest Memes from Movie TV Tech Geeks movietvtechgeeks.com

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Image by movietvtechgeeksnews Funniest Memes from Movie TV Tech Geeks movietvtechgeeks.com

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A few nice male celebrity images I found:

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Image by Wanda Wisdom Learn more about this sassy siren at wandawisdom.com

Candi and Wanda male celebrity
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Nina, Blanche, Wanda, RyRy, Bunny male celebrity
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Nice Celebrity Pregnancies photos

Nice Celebrity Pregnancies photos

Some cool celebrity pregnancies images:

4 celebrity pregnancies
Image by Wanda Wisdom Watch the entire film at tinyurl.com/auntcarol Wanda’s crazy Aunt Carol is on the loose again from Sobriety Acres. This time she’s skipping through the countryside, saving cute woodland creatures and dodging celebrity-driven death mobiles! wandawisdom.com adamlessordinary.com

21 celebrity pregnancies
Image by Wanda Wisdom Watch the entire film at tinyurl.com/auntcarol Wanda’s crazy Aunt Carol is on the loose again from Sobriety Acres. This time she’s skipping through the countryside, saving cute woodland creatures and dodging celebrity-driven death mobiles! wandawisdom.com adamlessordinary.com

WorldFest 2011, LA's biggest "green" eco-friendly festival

WorldFest 2011, LA's biggest "green" eco-friendly festival

A few nice celebrity skin images I found:

WorldFest 2011, LA's biggest "green" eco-friendly festival celebrity skin
Image by Mary Cummins Sunday, May 22nd, 2011, 10:30 a.m. to 7:00 p.m. at WorldFest 2011 Earth Day Festival. It will be held at the beautiful outdoor setting of Woodley Park in Lake Balboa at 6350 Woodley Ave., Van Nuys, CA 91406. We welcome our attendees to a magnificent day filled with entertainment, education and enlightenment. Now in its tenth year, WorldFest has established itself as LA’s premiere solar powered pet and family-friendly "green" event. With more than 100 exhibitors, a global vegetarian and vegan food court, entertainment areas for children, and an eclectic blend of live music and engaging speaker line-up, WorldFest promises a day of entertainment and inspiration. Stars from television, film, music and sports will be joined by healthy living experts and culinary maestros to bring issues near and dear to their hearts to a broad audience, and to inspire festival-goers to embrace compassionate living. A few of our speakers include Emmy and Genesis award winning journalist Lu Parker of the Lu Parker Project, Leilani Munter professional race car driver and the Carbon Free Girl and Shannon Keith producer of "Skin Trade" and "Behind the Mask." Sponsors spanning the green spectrum include Lagunitas Brewing company, VegNews Magazine, Sun Flour Baking Co., Animal Cruelty Investigations, 100.3 fm The Sound, Follow Your Heart, Culture and Animals Foundation, Sun Cafe, Klean Kanteen, Town & Country event rentals, Lake Balboa Neighborhood Council and Mike the printer. Check out our website for a current list of Celebrities, Sponsors, Musicians, Speakers and more. Toward Freedom is a 501 3c non-profit dedicated to educating, inspiring, and supporting people on their quests to live more compassionately. For more information on WorldFest 2010, visit WorldFest at www.WorldFestEvents.com or call (310) 477-7887. Check the website for the latest updates on WorldFest’s musical entertainment, exhibitors, and speakers.

Stevie Ryan and Clint Catalyst celebrity skin
Image by The_Scene_Is_Dead picture from www.clintcatalyst.com, photographer unknown, happy birthday clint!!, www.stevieryan.tv she is funny

Nice Celebritys photos

Nice Celebritys photos

Check out these celebritys images:

Chevrolet Celebrity two door sedan celebritys
Image by dave_7 Chevrolet Celebrity in two door sedan form. The four doors are much more common but haven't seen a two door for a while. This one has the 2.5L four cylinder engine as well.

Singer Celebrity Cheryl Cole Visits British Troops in Afghanistan celebritys
Image by Defence Images Singer Cheryl Cole shelters from the downwash of a Chinook helicopter during her morale boosting trip visiting British troops in Afghanistan. On the 14 September 2011 Cheryl Cole paid the British Troops in Afghanistan a morale visit where she presented the British Forces with the Pride of Britain Award. Here she can be seen taking part in a demonstration by 42 Commando Royal Marines conducting a compound clearance followed by a casualty evacuation via a Chinook helicopter. She exclaimed that she had never experienced so much dust in her life before after the helicopter came in to extract the casualty. Photographer: LA(Phot) Dave Hillhouse Image 45153211.jpg from www.defenceimages.mod.uk Follow us: www.facebook.com/defenceimages www.twitter.com/defenceimages

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Some cool celebrity homes images:

DSC09632n celebrity homes
Image by vfk

DSC09544n celebrity homes
Image by vfk

Nice Celebrities That Smoke photos

Nice Celebrities That Smoke photos

Some cool celebrities that smoke images:

2010 Millennium XLII, #9399 - SOLD celebrities that smoke
Image by MillenniumLuxuryCoaches 2010 Millennium XLII, #9399 Sildes: 2 - Rear Super Slide (Prevost) MILLENNIUM UNIT #9399 2010 XLII S2 REAR SUPERSLIDE CHASSIS SPECS GENERAL LENGTH, OVERALL 45.0 FT. WHEELBASE 314.0 IN. WIDTH, OVERALL 102.0 IN. HEIGHT, OVERALL 140.0 IN. FLOOR-TO-CEILING HEIGHT 86.0 IN CABIN FLOOR HEIGHT (FROM THE GROUND) 48.5 IN. USABLE CABIN FLAT FLOOR LENGTH (NO WHEEL HUMPS) 34.75 FT. UNDER-FLOOR STORAGE (WITH DRIVER A/C) 407 CU.FT. UNDER-FLOOR COMPARTMENTS DOORS WIDTH 60.5 IN. ENTRANCE DOOR WIDTH 30.0 IN. STEP HEIGHT 15.0 IN. GROUND CLEARANCE 11.0 IN. OVERHANG (INCL. BUMPER) â€" FRONT 68.75 IN. OVERHANG (INCL. BUMPER) â€" REAR 107.75 IN. TURNING RADIUS 41.8 FT. BODY CONSTRUCTION (STRUCTURE) INTEGRAL BODY CONSTRUCTION (STAINLESS / RUST PROTECTED MILD STEEL) (OUTER SHELL â€" UP TO WINDOW LEVEL) STAINLESS STEEL BODY CONSTRUCTION (SUB-FRAME) LOW-ALLOY/HIGH TENSILE STEEL FUEL TANK (US GALS.) 208 FUEL FILLER NECKS ON BOTH SIDES GROSS VEHICLE WEIGHT RATING (LBS.) 54,500 AXLE DESIGN LOAD CAPACITY (LBS.) â€" FRONT 18,000 AXLE DESIGN LOAD CAPACITY (LBS.) â€" DRIVE 22,500 AXLE DESIGN LOAD CAPACITY (LBS.) â€" TAG 14,000 WET WEIGHT - WITH DRIVER A/C (LBS.) 31,150 WET WEIGHT - WITH FULL A/C (LBS.) 31,850 DRIVER-ONLY A/C 2 TIRES AND WHEELS MICHELIN 315/80R22.5 (DRIVE) MICHELIN 365/70R22.5 (FRONT & TAG) ALCOA ALUMINUM RIMS 22.5 X 10.5 IN. (FRONT & TAG AXLES) 22.5 X 9 IN. (DRIVE AXLE) POWERTRAIN DETROIT DIESEL SERIES 60 W/EGR 14L-515HP (5-YR. WARRANTY) 3-SPEED ENGINE COOLING FAN ALLISON WORLD B500, 6-SPEED AUTO. TRANS. (5-YR. WARRANTY) CRUISE CONTROL ALLISON HYDRAULIC TRANSMISSION RETARDER PNEUMATIC DRIVE BELTS TENSIONERS TURBO BOOST GAUGE ENGINE COOLANT FILTER RACOR FUEL FILTER BRAKES ALL-DISC BRAKES WITH ABS FRONT WHEELS BRAKE BOOSTERS TYPE 27 DRIVE WHEELS BRAKE BOOSTERS TYPE 24-24 TAG WHEELS BRAKE BOOSTERS TYPE 14-16 PARKING BRAKE BOOSTER ON TAG WHEELS STEERING AND SUSPENSION PNEUMATIC TILT & TELESCOPIC STEERING WHEEL ZF SERVOCOMTRONIC VARIABLE POWER STEERING INDEPENDENT SUSPENSION SYSTEM STEERING SLAVE CYLINDER FRONT & DRIVE AXLES SWAY BARS INTEGRATED PNEUMATIC LEVEL-LOW LEVELING SYSTEM LIFTABLE TAG AXLE 3 ELECTRICAL SYSTEM FULLY MULTIPLEXED ELECTRICAL SYSTEM 12-VOLT EXT. LIGHTING 24-VOLT MAIN SYSTEM SHELL ALTERNATOR (DRIVER A/C) 140 AMPS FACTORY-INSTALLED OPTIONAL EQUIPMENT FACTORY SLIDE-OUTS (ALL-ELECTRICAL) 2 SLIDES W/ REAR SUPERSLIDE ROADSIDE FRONT ROADSIDE REAR (SUPERSLIDE) KIDDE DUAL SPECTRUM FIRE PROTECTION SYSTEM HIGH-INTENSITY HEADLIGHTS FOG LIGHTS RAMCO REMOTE HEATED REARVIEW MIRRORS CENTRAL ELECTRICAL DOOR LOCKING SYSTEM REMOTE KEYLESS LOCKING (ENTRANCE DOOR) REMOTE KEYLESS LOCKING (COMPARTMENT DOORS) TRAILER HITCH PACKAGE (20,000 LBS.) LOW FUEL WARNING LIGHT COURTESY LIGHTS BLINKER SWITCH ENGINE AND COMPARTMENTS LIGHTING ISRI AIR ADJUSTABLE (6800) FACTORY EXTERIOR PAINT W/SPECIAL EFFECT BACK-UP SOUND ALARM HEADLAMPS CLEANING GENERAL XENON HEADLAMPS AIR POCKET DOORS WITH ROD LESS CYLINDERS FLEXFOIL INSULATION ON INTERIOR OF SHELL MARINE GRADE ELECTRICAL WIRE LUTRON HOMEWORKS ILLUMINATION CONTROL SYSTEM WITH REMOTE DIAGNOSTICS OPTION 5 CRESTRON TOUCH SCREEN CONTROLLERS LINKED TO LUTRON HOMEWORKS OPERATING SYSTEM WITH IPHONE / I-TOUCH AND LAPTOP CONTROLS FULLTIME INTERNET WI-FI NETWORK CONNECTION 4 RUSSOUND CAV6.6 SIX-ZONE A/V PROCESSOR DVD/VCR RECORDERS WITH DIGITAL TUNERS (2) SATELLITE DVR RECEIVERS (1) ESCIENT MEDIA SERVER WITH 500GB STORAGE CEILING LED ROPE LIGHTING THROUGHOUT MARINE GRADE BRASS LED OVERHEAD LIGHTS MULTI-ZONE AQUA HOT HEATING SYSTEM WITH DUAL 1500 WATT ELECTRIC ELEMENTS INTERIOR AND EXTERIOR LED LIGHTING MOTORIZED HUNTER DOUGLAS CELL SHADES FRONT AND REAR CUSTOM SPOILERS STATEROOM MAIN VANITY 32” FLAT SCREEN LCD MONITOR AIPHONE INTERCOM WITH BUILT IN MONITOR TO VIEW ENTRY DOOR MASTER LIGHTING SWITCH ON THE REAR NIGHTSTAND AND FRONT ELECTRIC BLACK-OUT SHADES PRE-WIRE FOR CEILING FAN CARBON MONOXIDE DETECTOR SMOKE DETECTOR SPECIAL LIGHTWEIGHT SOUND INSULATION PACKAGE FABRICA CARPETING WITH HIGH DENSITY PADDING TEMPER-PEDIC KING SIZED ADJUSTABLE BED LEFT AND RIGHT END TABLES AT HEAD OF THE BED DRAWER BENEATH THE FOOT OF THE BED MIRRORED CEILING CUSTOM BEDDING CARPET LINED WARDROBE CABINETS WITH CEDAR CEILINGS LAVATORY 120-VOLT VANITY LIGHTING 120-VOLT OUTLET IN BOTTOM AND INSIDE UPPER VANITY CABINET FANTASTIC VENT OVER SHOWER AREA WITH COVER FANTASTIC VENT WITH COVER IN COMMODE ROOM 5 AQUAHOT HEATER GRANITE FLOORING GRANITE COUNTERTOPS SHAMPOO AND SOAP HOLDER LOWER VANITY CABINET WITH FLUSH DOORS AND DRAWERS HEADHUNTER ELONGATED COMMODE WITH HOMETECH BIDET CUSTOM CURVED SHOWER MEDICINE CABINET GALLEY GE SIDE BY SIDE FULL SIZED REFRIGERATOR WITH 23.3 CUBIC FEET OF STORAGE BREW EXPRESS COFFEE MAKER (RECESSED AND HARD PLUMBED) TWO BURNER COOK TOP STACKED BOSCH WASHER AND DRYER UNITS MARINE-GRADE POWER PANEL SHARP INSIGHT PRO MICROWAVE DRAWER AQUAHOT HEATERS CENTRAL VACUUM GRANITE STARBURST MEDALLION INLAY IN PORCELAIN FLOOR LOUNGE BAR WITH ELECTRIC LIFT COMPUTER/TV/CRESTRON TOUCH SCREEN, WIRELESS KEYBOARD/MOUSE SMOKE DETECTOR AUTOMATIC INTERIOR LED CABINET LIGHTS GRANITE FLOORING WITH ELECTRIC FLOOR HEAT FRANKE BEECH SINK SYSTEM WITH ACCESSORIES SINGLE HANDLE FAUCET WITH BUILT-IN SPRAYER UNDER COUNTER PULL OUT TRASH CONTAINER FULL SIZED PANTRY LIGHTWEIGHT CABINET CONSTRUCTION WITH WOOD VENEER AND POLYESTER FINISH FISCHER PAYKEL DISH DRAWER EXTENDABLE ISLAND FRONT LOUNGE PRE-WIRE FOR FAX IN THE C/S LOWER CABINET (120-VOLT OUTLET, CELLULAR, AND LANDLINE TELEPHONE JACKS FIBERGLASS WINDOW SILLS MOTORIZED HUNTER DOUGLAS CELL SHADES 6 SOFA (ELECTRIC FRAME) ON DRIVER’S SIDE WITH STORAGE BELOW 42” DROP DOWN LCD PILOT AND CO-PILOT SEATING AREA TIRE PRESSURE MONITORING SYSTEM 110 VAC AND 12 VDC OUTLETS KENWOOD/GARMIN AM/FM/DVD/GPS/MP3 MAPPING SYSTEM 15” ADJUSTABLE MONITOR AT PASSENGER SEAT COLOR LCD BACKUP MONITOR WITH I-CONTROL FUNCTION CB RADIO MAP LIGHTS FOR CO-PILOT AND DRIVER MASTER CONTROL SWITCHES ELECTRIC PRIVACY SHADES MAP STORAGE AND DRINK HOLDER CARPETING BELOW THE DRIVER’S SEAT ISRINGHAUSEN AIR RIDE DRIVER’S SEAT CUSTOM WOOD DASH PANELS CUSTOM ENTRY DOOR DESIGN SLIDE STEPWELL COVER OPEN SHOE STORAGE IN STEPWELL CUSTOM SMART STEERING WHEEL VILLA 28” WIDE CO-PILOT SEAT WITH THE FOLLOWING OPTIONS: RECLINE, FOOTREST, ELECTRIC SIX WAY POWER BASE, MASSAGE, HEATING, MAP STORAGE AND DRINK HOLDER EXTERIOR GENERAL EQUIPMENT UPPER AND LOWER LUMINESCENT BLUE ROPE LIGHTING CB ANTENNA CELLULAR PHONE ANTENNA AM/FM ANTENNA GPS ANTENNA GLOMEX SAUCER-TYPE AMPLIFIED TV ANTENNA INMOTION TRACSTAR SATELLITE DISH WITH (2) DVR RECEIVERS COLOR DIRECTIONAL BACKUP CAMERA ON REAR OF COACH 7 AIPHONE DOORBELL / CAMERA NEXT TO ENTRANCE DOOR 4 FULL LENGTH ROOF MOUNTED AWNINGS WITH WIND MOTION SENSORS (6) LED CURB LIGHTS 4 HIGH POWERED AIR HORNS IN NOSE FOR WIND NOISE REDUCTION HWH ONE-TOUCH LEVELING SYSTEM GENERATOR ROOF EXHAUST CUSTOM PAINTED REAR WINDOW GRAPHICS AQUAHOT ROOF EXHAUST SIDE MARKER LIGHT TRIM CHROME PLATED HEATED SIDE MIRRORS LICENSE PLATE HOUSING-POLISHED S/S MICROWAVE VENT LED LIGHTS ON TOP AND BOTTOM OF COACH BAY COMPARTMENTS 1ST BAY 101.75 CUBIC FEET OF STORAGE (CURBSIDE OR ROADSIDE) (8) 8D MARINE DEEP CYCLE BATTERIES (4) 3500 WATT OUTBACK INVERTERS 100 AMP VANNER BATTERY EQUALIZER BATTERY TIE-IN RELAY (CONNECTING HOUSE BATTERIES TO CHASSIS BATTERIES AND CHASSIS BATTERIES TO HOUSE BATTERIES) (4) BATTERY DISCONNECT SWITCHES GLENDINNING ELECTRIC REEL FOR SHORELINE CORD (WITH WIRELESS REMOTE) SHORELINE CORD (60’) ADAPTORS FOR SHORELINE FOR 30A AND 20A SERVICE SHORELINE REVERSE POLARITY MONITOR TELEPHONE AND CABLE TV CONNECTORS NEAR SHORELINE REEL COAX CORD AUXILIARY AIR COMPRESSOR WITH TWO SERVICE AIR CONNECTIONS (D/S AND C/S) COSMETIC PANELS TO COVER ELECTRICAL EQUIPMENT 120 VOLT GFCI RECEPTACLE IN THE PLUMBING COMPARTMENT 330 AMP AIR COOLED ALTERNATOR FOR HOUSE SYSTEM 140 AMP AIR COOLED ALTERNATOR FOR CHASSIS SYSTEM 8 HVAC AQUAHOT HEATER WITH THERMOSTATS IN PLUMBING COMPARTMENT (4) ROOFTOP A/C UNITS LOW PROFILE (15,000 BTU’S EACH) 120 VAC CERAMIC HEATER IN FIRST, SECOND AND PLUMBING BAYS ELECTRIC FLOOR HEAT GENERATOR POWERTECH ULTIMATE 17.5 KW TURBO GENERATOR GENERATOR AUTO-START FEATURE (CONTROLLED BY LUTRON AND CRESTRON SYSTEMS) GENERATOR BATTERY BOOST CIRCUITRY GENERATOR PRIMARY FUEL FILTER START/STOP SWITCHES AT THE FOLLOWING LOCATIONS: * GENERATOR * DRIVER’S AREA POWER PANEL * INVERTER PANEL * CRESTRON TOUCHSCREENS * ANY REMOTE ACCESS COMPUTER ROOF MOUNTED GENERATOR EXHAUST ROOF MOUNTED COOLING SYSTEM FOR GENERATOR FOUR INVERTER BYPASS SWITCHES PLUMBING AQUAHOT WATER HEATING SYSTEM WITH (2) 1500 WATT ELECTRIC HEATING ELEMENTS HEADHUNTER 120 VOLT WATER PUMP WATER PRESSURE REGULATOR CARTRIDGE WATER FILTER SYSTEM 2 HOSE CARRIERS FOR DUMPING HOLDING TANKS PAPER TOWEL AND SOAP DISPENSER PLASTIC PLUMBING WITH FLEXIBLE LINES FOR VIBRATION ISOLATION MANIFOLD SYSTEM WITH SHUT OFF VALVES TO ALL PLUMBING EQUIPMENT. (NO SHUTOFFS INSIDE THE COACH INTERIOR; CONTINUOUS LINES RUN FROM THE MANIFOLD TO THE FIXTURE) STAINLESS STEEL COVER POLYPROPYLENE FRESH WATER TANK WITH CLEAN OUT (180 GALLONS) POLYPROPYLENE GREY WATER TANK WITH CLEAN OUT (80 GALLONS) 9 POLYPROPYLENE BLACK WATER TANK WITH CLEAN OUT (80 GALLONS) ELECTRIC OPERATED DUMP VALVES TANK LEVEL MONITOR GAUGES AT ALL CRESTRON PANELS CITY WATER INLET WITH MILLENNIUM AUTOMATIC FRESH WATER FILL SYSTEM GRAVITY FILL FOR FRESH WATER TANK MANUAL TANK CLEAN OUT VALVES FOR GREY AND BLACK TANK HOSE BIB STAINLESS STEEL COSMETIC PANELS TO COVER PLUMBING EQUIPMENT BUILT IN PRESSURE WASHER WITH 75’ LINE ON REEL (1450 PSI) BUILT IN DEIONIZER WITH BYPASS FOR SPOT FREE RINSE MODE MACERATOR WITH ELECTRIC HOSE REEL ABS PLASTIC UNDER THE PLUMBING EQUIPMENT BAY ENTERTAINMENT CENTER ENTERTAINMENT CABINET WITH STORAGE DRAWERS REFRIGERATOR BOSE WAVE AM/FM/CD/MP3 STEREO 42” LCD FLAT SCREEN MONITOR ON PULLOUT ADJUSTABLE SLIDE SYSTEM (4) ZIP DEE LAWN CHAIRS KENYON CUSTOM SMOKELESS INFRA RED GRILL

Cool Celebrity Clothing Lines images

Cool Celebrity Clothing Lines images

Some cool celebrity clothing lines images:

Sandy Tejada celebrity clothing lines
Image by Clothes, Bags & Accessories Photographer: Genesis Gideon Gonzales Model: Sandy F. Tejada , Eco Park , Quezon City

Sandy Tejada celebrity clothing lines
Image by Clothes, Bags & Accessories Photographer: Genesis Gideon Gonzales Model: Sandy F. Tejada , Eco Park , Quezon City

Cool Celebrity Style images

Cool Celebrity Style images

Some cool celebrity style images:

Millennium’s Signature Styling celebrity style
Image by MillenniumLuxuryCoaches Sometimes you know you’re looking for a change, but not sure where to start. Other times, you may have ideas, but need help with designs or refinements, and in ultimately making them a reality. That’s where Millennium Luxury Coaches’ design team can lend a hand. Our Complimentary design consultations are the perfect no risk opportunity to talk to our professional interior designers about your unique ideas, and receive a host of possible options for your all of your specific requests. With thousands of fabric, wood, tile and accessories samples onsite, we make the process fast, easy, and fun.

Behind the Scenes with Avedaâ„¢ â€" Osklen SS14 â€" Mercedes-Benz Fashion Week New York Spring Summer 2014 â€" #MBFW #NYFW â€" September 17, 2013 â€" Creative Commons (cc) photos distributed by Mainstream via Aveda Corporation celebrity style
Image by goMainstream ███████████████████████████████████ Mercedes-Benz Fashion Week New York Behind the Scenes with Avedaâ„¢ â€" Osklen SS14 at MBFW NYFW ████████████ AVEDA CORPORATION Avedaâ„¢, The Art and Science of Pure Flower and Plant Essencesâ„¢, was founded in 1978 with the goal of providing beauty industry professionals with high performance, botanically based products that would be better for service providers and their guests, as well as for the planet. Aveda manufactures plant-based hair care, skin care, makeup, Pure-Fumeâ„¢ and lifestyle products. Aveda is available in Aveda stores, and in nearly 7,000 professional hair salons and spas in 29 countries worldwide. aveda.com twitter.com/aveda ████████████ DESIGNER On Wednesday, September 11th at 7:00 PM at The Stage at The Tents at Lincoln Center, creative director Oskar Metsavaht of Osklen debuted his women's Spring/Summer 2014 collection. For Spring/Summer 2014 Metsavaht takes inspiration from the cut, color, vibrancy and transparency of gemstones, translating these influences into a collection of innovative fabrications and original prints. The Osklen aesthetic represents the lifestyle of modern men and women in a world where the urban and the naturalistic, the global and the local, the organic and the technological co-exist. This balance is further exemplified by the brand's use of eco-friendly "e-fabrics". This season, Metsavaht utilizes ecological silk, formed by use of cocoons discarded by the industrial process and environmentally safe vegetable dyes. osklen.com twitter.com/Osklen twitter.com/osklenUSA ████████████ EVENT Mercedes-Benz Fashion Week New York Mercedes-Benz Fashion Week is New York City's single largest media event, taking place twice a year (February & September) at Lincoln Center, one of the most well known arts and cultural institutions in the world. The event provides top designers an international platform to showcase their collections to more than 100,000 industry insiders from around the world, including buyers, editors, retailers, celebrities, VIPs, and more. With more than 80 designers shows over 8 days, it is known as the premier event worldwide where style, beauty, supermodels, and celebrities come together to celebrate the best in fashion. mbfashionweek.com ████████████ PUBLICITY Photos added to the Creative Commons (cc) by Aveda Corporation aveda.com twitter.com/aveda ███████████████████████████████████ Images licensed with the following Creative Commons license on September 12, 2013 creativecommons.org/licenses/by/2.0/deed.en_CA ████████████ Mainstre.am Mainstream makes images available to the independent press, the mainstream press, open media such as Flickr, Creative Commons, and Wikipedia. We will soon launch with a service for content creators, publicists, and publishers around the world. mainstre.am ████████████ Contact Questions can be sent to: Tamara McCartney (Assistant Producer) twitter.com/tamaramccartney and Jason Hargrove (Founder) twitter.com/jasonhargrove jasonhargrove.com

Behind the Scenes with Avedaâ„¢ â€" Osklen SS14 â€" Mercedes-Benz Fashion Week New York Spring Summer 2014 â€" #MBFW #NYFW â€" September 17, 2013 â€" Creative Commons (cc) photos distributed by Mainstream via Aveda Corporation celebrity style
Image by goMainstream ███████████████████████████████████ Mercedes-Benz Fashion Week New York Behind the Scenes with Avedaâ„¢ â€" Osklen SS14 at MBFW NYFW ████████████ AVEDA CORPORATION Avedaâ„¢, The Art and Science of Pure Flower and Plant Essencesâ„¢, was founded in 1978 with the goal of providing beauty industry professionals with high performance, botanically based products that would be better for service providers and their guests, as well as for the planet. Aveda manufactures plant-based hair care, skin care, makeup, Pure-Fumeâ„¢ and lifestyle products. Aveda is available in Aveda stores, and in nearly 7,000 professional hair salons and spas in 29 countries worldwide. aveda.com twitter.com/aveda ████████████ DESIGNER On Wednesday, September 11th at 7:00 PM at The Stage at The Tents at Lincoln Center, creative director Oskar Metsavaht of Osklen debuted his women's Spring/Summer 2014 collection. For Spring/Summer 2014 Metsavaht takes inspiration from the cut, color, vibrancy and transparency of gemstones, translating these influences into a collection of innovative fabrications and original prints. The Osklen aesthetic represents the lifestyle of modern men and women in a world where the urban and the naturalistic, the global and the local, the organic and the technological co-exist. This balance is further exemplified by the brand's use of eco-friendly "e-fabrics". This season, Metsavaht utilizes ecological silk, formed by use of cocoons discarded by the industrial process and environmentally safe vegetable dyes. osklen.com twitter.com/Osklen twitter.com/osklenUSA ████████████ EVENT Mercedes-Benz Fashion Week New York Mercedes-Benz Fashion Week is New York City's single largest media event, taking place twice a year (February & September) at Lincoln Center, one of the most well known arts and cultural institutions in the world. The event provides top designers an international platform to showcase their collections to more than 100,000 industry insiders from around the world, including buyers, editors, retailers, celebrities, VIPs, and more. With more than 80 designers shows over 8 days, it is known as the premier event worldwide where style, beauty, supermodels, and celebrities come together to celebrate the best in fashion. mbfashionweek.com ████████████ PUBLICITY Photos added to the Creative Commons (cc) by Aveda Corporation aveda.com twitter.com/aveda ███████████████████████████████████ Images licensed with the following Creative Commons license on September 12, 2013 creativecommons.org/licenses/by/2.0/deed.en_CA ████████████ Mainstre.am Mainstream makes images available to the independent press, the mainstream press, open media such as Flickr, Creative Commons, and Wikipedia. We will soon launch with a service for content creators, publicists, and publishers around the world. mainstre.am ████████████ Contact Questions can be sent to: Tamara McCartney (Assistant Producer) twitter.com/tamaramccartney and Jason Hargrove (Founder) twitter.com/jasonhargrove jasonhargrove.com

2008 Millennium H3-45 - Double Slide - SOLD

2008 Millennium H3-45 - Double Slide - SOLD

A few nice sell celebrity photos images I found:

2008 Millennium H3-45 - Double Slide - SOLD sell celebrity photos
Image by MillenniumLuxuryCoaches 2008 Millennium H3-45, #0683 Slides: 2 Year: 2008Mileage: 23,602 Make: Millennium Engine: Detroit Series 60 Model: H3-45 2 Prevost Slides Trans: Allison 6 Speed VIN: 2PCV3349261710683 Type: Prevost Exterior Colors: Black â€" Blaze Gold â€" Gold Beige â€" Bordeaux Red Entry/Helm: â€" St. Cecilia New Venetian Granite entry w/no slip brass strips â€" matching Bone leather on Pilot and Co-pilot seats with Black Stingray inserts - eight-way power adjustments â€" massage and heating - Hunter Douglas power cell shades â€" power air-slide step cover â€"Burlwood veneer console â€" Karadon solid surface counter tops â€" color and adjustable back-up monitor â€" AM/FM CD player - Pioneer N3 Navigation system - cruise, tilt steering wheel - dash and aux dash A/C â€"auto leveling system - Allison transmission retarder â€" Uniden CB â€" Crestron Audio/Visual controls near pilot seat - 15” Co-pilot LCD Salon: Beautiful gold colored Chenille sofa â€" 2 leather recliners with built in footrest and occasional table â€" Fabrica beige carpet with winding St. Cecilia New Venetian granite walkway - designer fabric window treatments w/ - 42" plasma TV on fold down liftâ€" Hunter Douglas power cell shades â€" (4) roof AC’s â€" Denon surround sound system â€" DVD - VCR - In-motion SAT system Galley: Adjustable J-Lounge with Dark Brown Leather seat and Gold Chenille fabric backrest - large storage drawers below â€" Karadon Solid surface counter tops â€" Motorized extendable counter top - stunning crushed glass tile backsplash â€" Olive Ash Burl wood veneer cabinetry - Advantium Microwave/convection oven â€" St. Cecilia New Venetian granite floor w/ glass tile inserts â€"- Hunter Douglas power cell shades - Franke Beach galley sink â€" Fisher Paykel dish drawer - 2 burner Princess stove top â€" 22.2 cubic ft double door with freezer drawer refrigeratorâ€" large pull out pantry - glass display cabinets. Bath/Passage: Large full hanging closets with shelves in hallway â€" Stacked Bosch Washer/ Dryer â€" separate private lavatory with vanity â€" St. Cecilia New Venetian granite shower w/glass tile floor and wall design and seating bench â€" large main vanity with Karadon solid surface countertop and beautiful vessel sink - mirrored ceiling with rope lighting - additional cabinet storage - exhaust fan - privacy door front and back Stateroom: Mirrored ceilings inlays with rope lighting - ceiling fan â€" custom made designer bedding and collection of décor pillows â€" electric shades - 32” plasma TV â€" Denon surround sound system - DVD, VCR - Satellite system - camera door bell and monitor â€" Crestron touch screen station â€" large hanging closet and bank of drawers in rear. Exterior: Stainless Steel accents - 4 air horns â€" Chrome wiper blades - S/S chrome mirrors with heat - front lower S/S inserts - driving lights with S/S trim - polished wheels with chrome lug covers - bay lights â€" LED exterior side lighting - mud flaps with S/S trim and stiffeners S/S exhaust on Detroit - rear S/S package - 4 Zip Dee power awnings - painted engine â€" powder coated piping and air filter housing - Driver’s side: Bay #1 Full open bay, Bay #2 1/4 storage bay with 2 drawers, Bay #3 drawers, Bay #4 battery and Inverter bay, Bay #5 plumbing bay. Passenger side: Bay #1 open for storage, Bay #2 entertainment package with 32” LCD TV & Bose Wave radio, refrigerator and drawer storage, Bay #3 generator, Bay #4 Aqua Hot and Infrared LP Grill, Bay #5 plumbing bay â€" Bays 1, 2, 3, 5 are heated Tanks: Diesel-235 Grey-100 Fresh-200 Black-100 Systems: Powertech 17.5 KW generator â€" 270 amp alternator â€" (8) 8D house batteries â€" (4) Outback 3500 watt inverters â€" (4) roof AC units - Aqua Hot with 3 zones - Tracstar In Motion Satellite Systems â€" 60’ Glenn Denning power shore cord - water manifold - built in 1550 psi pressure washer - heated granite floors â€" Lutron Homework’s operating system with (6) Crestron touch screen controllers (controls functions including: lighting, shades, audio/visual, water management, heating, generator, and awnings While every attempt has been made to provide an accurate equipment listing and mileage statement Millennium is not responsible for errors or omissions.

Cool Shop Celebrity Style images

Cool Shop Celebrity Style images

Check out these shop celebrity style images:

Nikki Phillips shop celebrity style
Image by Eva Rinaldi Celebrity and Live Music Photographer Mercedes-Benz Fashion Week; Cruise Bar hosts famous fashion event; MBFWA business wheels in motion Cruise Bar Hosts Fashion Week... When it comes to style the Cruise Bar and Restaurant is a perfect host partner for the prestigious Mercedes-Benz Australian Fashion Week. For the first time in many years, Cruise Restaurant is open to the public everyday of fashion week for lunch and dinner. Fashion Week is Sydney’s premier fashion and lifestyle event showcasing some of our most talented and contemporary designers. The beautiful waterfront location of Cruise Bar in Circular Quay is an ideal location to enjoy gourmet food, decadent wines and delicious cocktails while enjoying the cultural surrounds that is Fashion week. For more information visit their official website. Mercedes-Benz Fashion Week: Business, fashion, beauty, deals and gossip... Sydney will be enjoying a bevy of catwalk shows and party like events as Mercedes-Benz Fashion Week Australia commences tomorrow. But unlike the increasing number of fashion festivals across the country where people can buy tickets to events, MBFWA is invitation only. Today was media registration day, which was quite an event in its own right. Over five days, fashion designers show their latest collections to media reps, celebrities and retail buyers, and the response can be paramount to the bottom line. This year happens to mark Mercedes-Benz’s return to Fashion Week as the title sponsor, which many media and fashion commentators have welcomed. “The strong link between Mercedes-Benz and fashion was initiated in Australia with the launch of Mercedes-Benz Fashion Week in 1995, so it’s come full circle,” advised Mercedes-Benz senior manager of corporate communications David McCarthy. The car maker’s Fashion Week events have spread around the world to places such as New York and Berlin, and to Swim Fashion Week in Miami. The Mercedes-Benz’s sponsorship deal was not exactly a secret last year as Rosemount’s (wine) five-year run came to an end. The new deal is understood to be valued at million over three years but McCarthy says the details are confidential. MBFWA comes with a many change. A key change from the festival organisers is that IMG Fashion have reduced the price of on-site venue fees. A trend over the past few years. This year, it set back exhibitors ,250 to use the newly returned Tent at the Overseas Passenger Terminal as a catwalk venue, 00 to be a part of Fashion Week but show off-site and between 00 and 00 to showcase collections at The Rocks Pop-Up suites. Two of the festival’s biggest names, Josh Goot and Dion Lee, pulled out a fortnight before their respective shows. The designers who have fallen by the wayside in the lead-up to the five-day event have either opted to concentrate on upcoming overseas shows (Lee), to focus on getting collections out to coincide with northern hemisphere seasons (Goot) or have chosen to disregard Fashion Week from the get-go, with Fairfax Media pointing to Alex Perry as the example. For Melbourne Business School associate professor of marketing Mark Ritson, having Australian designers drop out is a “tricky” scenario. “On the one hand, you have to respect any Australian designer focused on building their reputation overseas,” he says. “We are perilously under-represented in Paris and Milan. “But at the same time, a designer has to be careful of burning branding bridges back home. That said, if Goot or Lee make it in Europe they’ll be welcomed back home in 2013 with open arms.” Fashion Week is serious business. Alongside Mercedes-Benz, sponsors that have signed on this year include DHL, EYE, HP, Maybelline NY, Redken, Shangri-La Hotel Sydney, Pentax, Keystone Hospitality and Getty Images. The NSW government, Destination NSW and Austrade are also supporting the event. In addition, designers are obtaining their own sponsorships. Jayson Brunsdon’s show, for instance, is being presented by Myer and sponsored by Qantas, Woolmark, TRESemme, MAC Cosmetics and Joh Bailey. Couture designer Johanna Johnson is the virgin Australian designer to showcase her collection at the prestigious Mercedes-Benz Presents show, which has previously featured big fashion names such as Herve Leger by Max Azria, Carolina Herrera and Badgley Mischka. “To do [the Presents show] during our first year back was a priority,” McCarthy says. Johnson recently found international success, with Hollywood actresses Christina Hendricks and Maya Rudolph wearing her feminine creations on the red carpet. The show will have the same feel â€" glamour, lots of hand-beading and detailed finishes. “I hadn’t really considered doing it and was focusing more on overseas expansion this year,” Johnson says. “But we’re having so much feedback from Australians wanting to know more now, it will be really good to showcase our luxury lifestyle line and red carpet ready-to-wear.” She initially signed on to show in the smallest of the three catwalk venues, the Box, but had to move the show to the Tent (the biggest) as the number of outfits she wanted to parade expanded. “It’s our debut show so we want it done as well as it possibly can be,” she says. Australian accessories giant Oroton is launching its first ready-to-wear collection. But for creative director Ana Maria Escobar, the clothes are there to show off the accessories â€" be they handbags, jewellery or shoes. “The biggest thing is when I walked into the stores, I saw they needed something soft to highlight the accessories,” she says. Customers can expect “understated quality” from the new Oroton clothing range. “To me, functionality is important,” Escobar says. “So are the materials . . . it can be a simple singlet but made out of really beautiful silk or customised fabrics. There’s a tone of heritage as well.” While Oroton views Fashion Week as important, Escobar says there is also “life beyond those 15 minutes on the catwalk”. For the retailer, it’s about reminding people of the brand. “We want to talk a little louder about the product we design,” she says. “Fashion Week gives us that space without having to scream.” This year, a great spread of overseas buyers will be in attendance, many from online retailers such as Net-A-Porter, My Wardrobe, Shopbop, Moda Operandi and ASOS. Department store Harvey Nichols and Hong Kong-based Joyce will also have buyers present. The retail picture in Australia is not particularly strong, and IBISWorld analysts are predicting growth for the local rag trade over the coming financial year will be flat at just 0.5 per cent. IBISWorld general manager Karen Dobie says the high Australian dollar is a double-edged sword for retailers, as local vendors can buy overseas at a favourable rate, but increasingly tech-savvy competition is straining profit margins. New to MBFWA: Dylan Cooper; Flowers for a Vagabond; Toi et Moi Sydney; By Johnny; Oroton; Watson x Watson; An Ode to No One; Jenny Kee; Aje; Roppa Pemmaraju; Bless’d Are The Meek and Nana Judy Not present this year: Dion Lee; Josh Goot; Alex Perry; Arnsdorf; Morrison; Friend of Mine; Flannel; Karla Spetic; Lover; Therese Rawsthorne; Ms Couture; Rachel Gilbert; Little Joe Woman (voluntary administration); Nookie; Amber & Thomas; Marnie Skillings; Kate Sylvester; Shakuhachi; Bianca Spender; Dhini; Camilla & Marc; White Suede; Yeojin Bae; Lisa Blue; Limedrop; Stolen Girlfriends Club; Alistair Trung; Saint Augustine Academy (which shut up shop late last year) Returning to the show: Romance Was Born; Camilla; Aurelio Costarella; Ksubi; Jayson Brunsdon; Akira Camilla... Since launching her label eight years ago, Camilla Franks continues to receive global recognition as an Australian designer who has a unique approach to creating colorful, playful and luxurious lifestyle fashion. Her unique ready-to-wear and resort wear designs are becoming highly sought after products, capturing the attentions of celebrities and fashionistas alike. Camilla’s global fan club (which includes the likes of Beyonce Knowles, Miranda Kerr, Kate Hudson, Lily Allen and Gwen Stefani) reached new heights 2 years ago when the queen of television, Oprah Winfrey, glowed in one of her designs while taping her ‘down under’ series. The general public and the fashion world gushed and stock sold out overnight. Camilla is definitely a brand on the move. So, how did Camilla Franks become one of Australia’s most iconic fashion designers? This iconic brand came to be whilst Camilla was exploring her passions for theatrical artistry. Here, she embraced her inner creative spirit to craft beautiful elaborate costumes for the various characters in her productions. It wasn’t long before the Australian fashion market caught eye of these imaginative, easy-to-wear designs and catapulted Camilla on this amazing journey. Today, Camilla has evolved from beach and resort fashion into ready-to-wear clothes that cater to all her client’s needs. Globally, Camilla has begun weaving into the various fashion niches, resulting in a kaleidoscope of high-end editorial and extending an already growing customer database. Over eight years, Camilla has produced nine collections: these include the highly anticipated 2011/12’s Spring Summer Collection, Labyrinth; which has received significant media attention and 2012’s Autumn Winter Collection Caravanserai, Camilla’s second winter season. The success of her brand is derived from Camilla’s philosophy that “all women have the right to look and feel beautiful no matter their age, colour, size or origin”, this is also a testament to the company’s popularity and growing awareness. Camilla is a brand that celebrates women, self-expression, beauty and individuality. The signature ‘Camilla’ piece is a statement of brilliant colour, graphics and material rhythm. It is a celebration of shapes that can be tailored to individual styles and that follow global trends. Mercedes-Benz Fashion Week Australia Announces Preliminary Line-up... Mercedes-Benz Fashion Week Australia Announces Preliminary Line-upfor Spring/Summer 2012/13 Collections Sydney, Australia (February 29, 2012) Mercedes-Benz Fashion Week Australia is excited to announce cult label Ksubi, celebrity favourite Camilla, Zimmermann, Lisa Ho, Toni Maticevski, Aurelio Costarella, Jayson Brunsdon, Ellery, and Carl Kapp will be amongst the line-up of designers showcasing their Spring/Summer 2012/13 Collections at Sydney’s Overseas Passenger Terminal, April 30 to May 4, 2012. "MBFWA is a fantastic opportunity for emerging Australian designers to join already well established designers in showcasing their creations not just in venues that people expect but in venues and spaces that will reflect the diversity and vibrancy of the Australian fashion scene. The shows, presentations and locations demonstrate that MBFWA has a flavour and style that can more than hold its own around the world" says Gavin Allen, General Marketing, Mercedes-Benz Australia/Pacific. A stand out on the 2012 schedule is expected to be Romance was Born. The label is showcasing their polished ready to wear collection combining art and wearable fashion in a sophisticated Spring Summer range. Johanna Johnson will also attract hype as she hosts an intimate salon show for her debut at MBFWA. Mixing old Hollywood charm and modern simplicity, Johnson is renowned for her recent Oscar’s role dressing starlets in her eponymous label. Iconic Australian brand, Oroton will also debut on the runway at MBFWA for the first time demonstrating the brand is as skilled at creating Ready to Wear women’s wear as well as their well known luxury accessories. Joining this incredible line up of iconic designers are Magdalena Velevska, Alice McCall, Lisa Maree, Gary Bigeni, Bec and Bridge, Miss Unkon, Bowie, Kooey Australia, Michael Lo Sordo, Kirrily Johnston and Talulah. New talent showcasing for the first time, Watson x Watson are sure to excite international buyers and media with their collections, providing new ‘ones to watch’ for our global audience. Watson x Watson focus on everyday luxury and easy glamour, with a relaxed, sexy appeal that has become synonymous with Australian fashion. Other newcomers joining the MBFWA family: We are Handsome, Aje, Elliot Ward Fear, Roopa Pemmaraju, Flowers for a Vagabond, Suboo, An Ode to No One and Project Runway Australia winner Dylan Cooper and alumni by Johnny. Designers involved in the 2012 New Generation, Fashion Design Studio and Raffles emerging talent shows will be announced shortly. “We’re extremely excited by the response from designers and brands and are looking forward to showcasing the new seasons Spring Summer Collections in our world class facilities on site as well as sharing more of the city of Sydney’s wonderfully unique locations with our expanded off site program of shows and presentations’” says Jarrad Clark, Global Production Director, IMG Fashion. Leveraging our global network, Mercedes-Benz Fashion Week Australia is introducing new showroom spaces, exciting venue upgrades and unique presentation spaces to ensure our line up of designers have innovative way to communicate their artistic vision for 2012. For the first time on Australian soil, many designers will showcase their collections via a studio style presentation space known as The Box. Having established itself at MBFW in NY and Berlin, designers are redefining how they showcase their collections using this blank canvas. Australian designer Dion Lee recently used a presentation style space to showcase his collection at London Fashion Week and wowed crowds with his use of lighting to create drama and engagement around his collection without the confines of the runway. 2012 will also see the much anticipated return of The Tent. Synonymous with international fashion events, the sheer scale of The Tent showroom set on the Sydney harbour foreshore will create an incredible billboard for MBFWA and the Australian Fashion Industry for our attending local and international guests. Key buyers will have the opportunity to get up close with designer collections during the week via a unique offering of Designer Showrooms via The Rocks Pop-Up Suites, utilising retail spaces within The Rocks historical precinct, designers will be able to house their collections off runway, and meet buyers and media in one on one appointments. It is here that designers are encouraged to create consumer offerings around the Fashion Week schedule to create more retail opportunities for our participating designer brands. MBFWA hosts the world’s most influential buyers, media and industry players during the 5 day event and bring Sydney city to life with Fashion Week fever. With the support of our official partners, and showcasing designers, the 2012 season will be a standout year showcasing the creative energy and raw talent that Australia has to offer. Title sponsor Mercedes-Benz is proudly supported by Government partners Destination NSW and Austrade, Maybelline New York, DHL, HP/Intel, Redken 5th Avenue NYC and EYE and as well as media outlet Getty Images. Mercedes-Benz Fashion Week Australia is an IMG event. The Spring Summer 2012/13 Collections will take place April 30 to May 4, 2012, Press and Industry Registration opens March 1, 2012. For more information please visit us online at mbfashionweek.com Follow us on Twitter @MBFWA and on the Mercedes-Benz Fashion Week Facebook Websites Mercedes-Benz Fashion Week (Australia) australia.mbfashionweek.com IMG Worldwide www.imgworld.com Cruise Bar www.cruisebar.com.au Eva Rinaldi Photography Flickr www.flickr.com/evarinaldiphotography Eva Rinaldi Photography www.evarinaldi.com

Krynica, Stary Dom Zdrojowy shop celebrity style
Image by Małopolski Instytut Kultury fot. Marcin Klag II Małopolskie Dni Dziedzictwa Kulturowego, wrzesień 2000 Krynica Stary Dom Zdrojowy Krynica jest jednym z największych i najbardziej znanych polskich uzdrowisk. Rozsławiły ją wody lecznicze, a także odbywający się tu Europejski Festiwal im. Jana Kiepury, który przyciąga latem do Krynicy miłośników opery, operetki i baletu. Krynica pojawiła się w zapiskach w 1547 r., jako osada Krzenycze. Była wówczas niewielką, podgórską wsią. Już w 1721 r. jezuita Gabriel Rzączyński pisał o właściwościach leczniczych tutejszych wód, które stały się jednak znane dopiero pod koniec XVIII w., kiedy to wzrosło zainteresowanie górami. W 1790 r. profesor Uniwersytetu Lwowskiego i znawca Karpat, Baltazar Hacqueta, zbadał tutejsze wody mineralne i spopularyzował ich walory. Na początku XIX w. Krynicę uznano urzędowo za zdrój kąpielowy i w 1807 r. uruchomiono pierwsze łazienki kąpielowe. Budowano drewniane pensjonaty, restauracje i kawiarnie, sklepy, powstał teatr, a w 1889 r. Krynica otrzymała prawa miejskie. W 1876 r. uruchomiono linię kolejową z Tarnowa do Muszyny, a w 1911 r. doprowadzono ją do samej Krynicy. Bywali tu Jan Matejko i Henryk Sienkiewicz oraz Helena Modrzejewska. W latach międzywojennych Krynica była ekskluzywnym kurortem, a swoją niezwykłą popularność zyskała po II wojnie światowej. W 1884 r., z inicjatywy hr. Alfreda Potockiego, podjęto decyzję o budowie Dworca Zdrojowego, czyli obecnego Starego Domu Zdrojowego. Zarządzająca wówczas Krynicą lwowska Dyrekcja Domen i Lasów rozpisała międzynarodowy konkurs na projekt tegoż domu gościnnego. Pierwszą nagrodę przyznano krakowskiemu architektowi, Janowi Zawiejskiemu (1854-1922). Stary Dom Zdrojowy (nazywany tak po wybudowaniu w 1939 r. Nowego Domu Zdrojowego) jest wybitnym dziełem architektury neorenesansowej. Wzniesiono go jako murowany i tynkowany, dwupiętrowy budynek z ryzalitem środkowym i dwoma bocznymi. Ryzalit środkowy, pełniący rolę reprezentacyjną, mieści klatkę schodową prowadzącą z parteru do sali balowej na piętrze. We wnętrzach Starego Domu Zdrojowego znajduje się także restauracja, cukiernia, kawiarenka i sklep oraz ponad 200 pokoi. W elewacji tylnej powstały na parterze otwarte werandy wsparte na ozdobnych, żeliwnych słupach. Po dobudowie dwóch skrzydeł w latach 1923- -1924, budynek zyskał plan litery U; jego modernizacji dokonano w latach 1950-1970. Zewnętrzny wygląd Domu Zdrojowego nie uległ większym przekształceniom, wnętrza zaś zachowały wspaniały wystrój architektoniczny z końca XIX w. --- Old Spa Lodge in Krynica Krynica is one of the oldest and better-known Polish spas. It was made famous by the medicinal properties of its mineral waters, and by the Jan Kiepura European Festival, which brings opera, operetta, and ballet lovers to the resort every summer. Krynica features in historical records in 1547 as the Krzenycze settlement, back then merely a tiny village near the mountains. As early as 1721, a Jesuit of the name of Gabriel Rzączyński wrote about the healing properties of the Krynica waters, which however became famous only towards the end of the 18th century, at the time when mountain trips became fashionable. In 1790, a professor of Lviv University and connoisseur of the Carpathians, Baltazar Hacqueta, tested and advocated the use of the waters. At the beginning of the 19th century, Krynica was officially proclaimed to be a balneotherapy resort, and in 1807, the first baths were opened. Wooden inns, restaurants, cafes and shops grew around them, even a theatre was established, and in 1889 Krynica received municipal status. In 1876 a railway line was opened between Tarnów and Muszyna, and it 1911 it was extended all the way to Krynica. Among frequent visitors to the spa, there were such celebrities as the painter Jan Matejko, writer Henryk Sienkiewicz, and actress Helena Modrzejewska. Between the world wars it was a chic resort, and after the second world war, its popularity grew universal. In 1884, Count Alfred Potocki initiated the construction of the Spa Hostelry, today’s Old Spa Lodge. The Lemberg (Lviv) Domains and Forests Administration, which governed Krynica at the time, held an international competition for the design of the hostelry. Kraków architect Jan Zawiejski (1854-1922) was the winner. The Old Spa Lodge (as it came to be called after the construction of a new one in 1939) is a remarkable building in neo-Renaissance style. The two-storey brick edifice is covered with plaster, with projections at the centre and the sides. The central projection contains a grand staircase leading from the ground floor to a ballroom on the upper floor. In addition to over 200 rooms, the interiors accommodate a restaurant, a cake shop, a café, and a boutique. In the back elevation, at ground floor level, open verandas are raised upon decorative, cast-iron steles. With the addition of two side wings between 1923-1924, the building received the shape of the letter ”U”; it was renovated and upgraded between 1950-1970. The outer appearance remained largely unchanged, and also the interiors retain their original, grand late 19th century style.