What can substitute zithromax

What can substitute zithromax

What can substitute zithromax

What can substitute zithromax

I love a great adventure. The anticipation, the rush of getting ready, the exhilaration of pushing your comfort zone and experiencing all that is foreign adds to the thrill. There’s nothing that compares to stepping into the great unknown and pushing your boundaries to the limit. That excites me. So at any given moment I’m always ready for the chaos that comes with being spontaneous. It’s my nature.

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Last Friday, I got the call. Steve in Little Orleans, MD had heard about me four years ago when I rode through his town, in the western part of Maryland, during my cross-country trek on horseback. Steve tracked me down on Friday. Did I know of anyone with a horse trailer who would trailer a horse to West Virginia?

It seems a long rider had left his lead horse with Steve for six weeks while the horse healed. In due time, the rope burn on the horse’s hock had finally healed and the horse was ready to be reunited with its owner.

The long rider, whom Steve described as a short Atilla the Hun and whom I’ll call Jack, started his cross-country trek in Harpers Ferry with a lead horse, a pack horse, and two other men and their horses.

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It probably took Jack five days, give or take a day or two, to journey the 100 miles to Little Orleans. A trip that would normally take an hour and 38 minutes by car takes five days for a long rider on horseback. The long rider’s horse is imperative to the success of the journey. Trying to make 4000 miles over the long-haul, means the long rider needs his horse to pace at 20 miles a day. For me, that averaged out to be three miles an hour—with breaks, fan fare, interviews and the like, I was in the saddle for eight or nine hours a day. Long hard days, but there’s nothing like seeing America at three miles an hour.

The first three weeks of any long rider’s journey are the hardest. Those weeks make or break the long rider, the horse and the journey. It’s not an adventure for the faint of heart. Jack’s companions bailed on him when they arrived in Little Orleans. After three weeks of staying with Steve while his horse was healing, Jack made the decision to push on with his pack horse, alone. Would it be possible for Steve to make arrangements for the horse to meet up with Jack when the horse healed?

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That’s where I came in. Did I know of anyone who would trailer the horse to Jack? You betcha. Me. It was a fellow “wanna-be” long rider in need. So I texted my partner, who was in the Doctor’s office on a late Friday afternoon. Did he want to join me? The Plan—to head out with the truck and trailer with an overnight stop at the Little Orleans Lodge, au gratis, from the owner Steve. In the morning we would load Jack’s horse and head out to Davis, WV where Jack and his pack horse were staying overnight. The trip would take a total of ten hours. Five there. Five back. I had no choice. I had to “pay it forward” for everyone who had been so kind-hearted in my time of need on my journey. This I had to do for them. Plus, I love a good adventure.

My partner, being the great sport that he is, was game. He’d be ready to leave in two hours. With a spring in my step, I packed up, made a picnic dinner to eat in the car and grabbed a great bottle of red, two wine glasses and a corkscrew. After all we were going to be staying in a rustic bed and breakfast for the night.—why not take full advantage of the evening?

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We arrived well into the evening, greeted by Steve, an affable retired post master, who had worked on the lodge since buying it for his wife and children back in the early 70s. When he retired, Steve turned it into a B&B on the C&O canal, a 184.5 mile long trail that winds around the Potomac River following the towpath of the Chesapeake and Ohio Canal. Steve was happy to host the eclectic group of trail-goers who by chance stumbled into his lodge on foot, bicycle or even horseback. Over a glass of wine, he shared the stories of those in his register: hippies, loners and couples, all who had set out on a journey to find themselves.

After a morning breakfast of two eggs over easy, sausage, potatoes and the most mouth-watering, sweetest biscuits I ever had, we loaded up Jack’s horse and headed on down the road to Davis, WV to meet up with the long rider, Jack.

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Steve was wrong. Jack looked more like Johnny Depp in the Pirates of the Caribbean. He acted like him too. In spite of himself, you couldn’t help but like him. Jack was a 31 year-old man with a black bandanna and tongue piercing, trying to figure life out from a horse’s point of view. He was ecstatic to have his lead horse back. I knew the feeling. Rocky, my lead horse, had injured himself when another horse kicked him in Illinois. I had to leave him behind to heal. Parting with him ripped my heart out. When we were reunited three weeks later, the joy in having him back defied description. I was lost without him. I knew the elation that Jack experienced in being reunited with his horse on their great adventure.

Before leaving, Jack asked me to write in his journal, to offer him advice or wisdom that I had garnered on my solo trek. I simply wrote, “Discover the joy, discover the journey, discover yourself.” Because that’s what it’s all about—on any adventure.

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Tomorrow I head out on another adventure. Australia. For two weeks. Part of the journey will be a 4WD trip to the Outback where I’ll be backpacking, tenting and dining with the Aborigines. Wish me luck and hope that I discover the joy, the journey and perhaps even myself. When I return from this Aussie Adventure, I’ll certainly share with you. Till then, G’day mate.

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When someone loses a pet and says to me in grief, “I know it’s not the same as losing a child, but it hurts so much,” my heart aches. Not because I know the pain of losing not one, but two children, but because I also know the pain of losing a dearly loved animal.

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Nothing, and I mean, nothing compares to the pain of losing a child, but that doesn’t diminish the heartache of any loss. Human or animal. The void in life after loss is incredible. Where there was once life, a huge black hole looms when death takes over. Where there was once love, heartache. Smiles. Sadness. Happiness. Loneliness. The loss of life fills your heart with an overwhelming emptiness and pain. The moment of loss—that incredible moment of pain—in the passing of life is unavoidably deep. It rips your heart out. Loss causes heartache and there’s just no getting around that. It’s a part of life.

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This past February I had to put down Eric’s beloved Shadow. It was so painfully hard, perhaps extra so, because it was Eric’s dog, my living link to my dead son. Shadow was the kindest, gentlest black lab I’d ever known. He had a huge heart with big soulful brown eyes. When the decision came to put him down, I left that to my surviving son, Peter. He had taken over Shadow’s care in Eric’s passing.

Shadow had developed brain cancer with severe epileptic seizures and it was Pete’s responsibility to ensure Shadow’s comfort in his final debilitating days. Pete rose to the occasion and gently helped Shadow every time he experienced a seizure. Pete was also there in the middle of the night to clean up the blood and excrement from Shadow’s thrashing. And Pete found the courage to tell me it was time to euthanize him. As Shadow’s big black head with the soulful eyes lay quietly in Peter’s lap as the vet administered the needle, my heart screamed in pain at yet another loss in our lives. Shadow. Eric’s big black lab with the soft soul. My heart ached and I cried.

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I was so thankful he didn’t die alone; Shadow deserved more than that. Nothing should die alone. Any—no all–life deserves more than that.

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This past spring, I was headed down York Road and had to come to a creeping crawl to avoid the growing crowd on the shoulder of the road. Some members of the crowd were crying, others didn’t know what to do, but all eyes looked toward the middle of the road. My eyes followed their gazes. In the middle of the road was a beautiful brindle pit bull, smashed and dying on York Road. No one was near him; he was dying alone. God no. I pulled over and ran to him. “Has anyone comforted the poor thing?” I screamed. “No,” came their replies in unison. “We didn’t know if he’d bite.” I was spitting mad with grief, pain and tears as I watched the poor dog hold on to dear life. Where was their compassion? I didn’t understand. As I knelt down and stroked the dog’s big beautiful head, his blood spilling over onto my knees, his tail gave a tiny wag as he tried to look at me. I held him, comforted him, and loved him in his final moments.

I was so thankful he didn’t die alone. I didn’t know him, but he deserved more than that.

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Monday morning I headed to the farm to tend to my two horses and the other ten horses I’ve cared for over the past five years. My routine always starts out the same. I whistle for my horses and say hi to the others gathered at the gate. Where was Blaze, the leader of the herd? I headed into the stall barn to dish up the grain. Still no Blaze. That’s odd. Where was she? I called for her. No Blaze.

After putting the other 11 horses in their respective feeding stations. I shlepped through the field, over the bridge, over the stream, and into the 50 acre field to find Blaze. There, just beyond the stream, she lay—struggling to get up, bloated, and covered with flies. She had colicked sometime during the night and the others had left her for dead. My God. My God. No. No. No. The poor thing. Tears streamed down my face as I knelt beside her. She moved her head and laid it on my foot, looking at me through bleeding eyes as she let out a soft whinny.

I fumbled for my cell phone and called my girlfriend, leaving a terrifying message, “Call the vet. Call the vet now!” I screamed through my sobs. Then I crumpled beside Blaze in the field and stroked her big beautiful brown head with the white blaze. She labored to breathe. “Hang on. Hang on.” I whispered in her ear. “He’s coming. He’s coming.”

The vet arrived but couldn’t get his SUV across the stream. Could we get her up? Blaze tried, oh she tried so hard, but she didn’t have enough left in her. With a heavy heart the vet returned to his car to get the needle to euthanize her.

“Blaze, get up. Get up. You can do it. Everyone’s waiting on the other side. Don’t die her alone. Come on honey….get up.” I sobbed in her ear. With one valiant effort the gentle leader rose off her barrel belly onto her buckled knees and stood. With painful, labored steps this beautiful beast made her way to the stream where her herd was waiting. It took her fifteen minutes but she finally crossed to the other side where she was greeted with whinies and neighs from her delighted followers. She grew stronger with every painful step through the support and love of her herd, owners and caretakers, and finally made it to the paddock where she was enveloped and loved as she was laid to rest.

An imperial leader, of the gentlest nature, Blaze. I loved Blaze and was thankful she didn’t have to die alone. She deserved more than that, as do all creatures, great and small.

Rest in Peace Blaze, our gentle leader

Rest in Peace Blaze, our gentle leader

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When something turns out way better than expected it brings such joy to life. I love pleasant surprises and this 4th of July weekend has been full of them.

Friday night kicked the weekend off with one. I was driving home from work and saw crabs for $20/doz. at what I thought was a local down and dirty pub with a bad reputation. Or at least that’s what I had been told. Twenty dollars for a dozen crabs was worth the risk of a bad reputation.

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Arriving home, I asked my partner if he wanted to go out for the deal. The catch? He had to at least look the part of a red neck. He couldn’t walk into the down and dirty bar as a prep. Could he do it? He tried. He came bounding down the stairs in an old worn out t-shirt. Perfect. Till my eyes rolled to his bottom half. The crease in the jeans still gave him away. No matter how hard he tries he just can’t look down and dirty. I guess that’s not really a flaw though. I smiled; he tried. He then looked me up and down and said, “Well you’re not really down and dirty either. “Ah, but no,” was my reply, “I just need to look good to a red neck guy.”

When we got out of the car in the parking lot and headed for the bar door, a Harley roared by. My partner said “Man, he couldn’t keep his eyes off you.”  I laughed, “Actually he couldn’t take his eyes off the crease in your jeans.”

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We pulled the door open, expecting the worse. To our pleasant surprise the restaurant was cute, the bar great, and the prices were fabulous. The owner came out, engaged us in conversation, and threw four extra crabs into our to-go bag. We’re definitely going to hit that down and dirty pub up for our weekly cheap date night. Pushing one’s comfort zone is grand.

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Saturday, the 4th of July, started out with a 5:45 am wake up call for me to get ready for my first parade in the Cavalry. My partner, coming along for pure support, rolled out of bed at the ungodly weekend hour to help me get Rocky, my horse, ready for the 4th of July parade in Takoma Park in Washington, DC.

Our first pleasant surprise came as we arrived in Takoma Park. Expecting an urban area with lots of noise, cars and pollution, we were greeted with a charming bedroom community with tree-lined sidewalks stretching in front of historic homes. Lawns were filled with a thousand or more  children, parents and grandparents decked out in red, white and blue, waving flags of all sizes. The weather was perfect and the air was filled with a patriotic hum, no matter which side of the political fence the flag was flying on.

In fact one long-haired silver woman in a purple tye-dyed flowing skirt came up to me in my military dress blues as I was mounting up on Rocky. She leaned in and thanked me for protecting her right to her far different views. She smiled as she pointed to the flower in her hair. I smiled back, knowing what she meant, and thanked her. Two different sides of the fence coming together as Americans to enjoy a parade in a small home-town.

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As we assembled for the parade, the Sergeant who was supposed to be carrying the flag for the hour-long parade was suffering from the flu. He grew weezy and weak and, unfortunately, had to withdraw. My commander turned to me and Rocky and said, “Step up, it’s your honor.” My second pleasant surprise. As we started off with the large flag flapping over Rocky’s ears, the crowd stood and erupted into cheers and applause. My heart surged, filling with pride and patriotism. I whispered to my commander, “I’m going to cry sir. I’m going to lose it.” “Hold on PFC Losey. Hang in there.” And I did, for the hour long ceremony as we paraded through the streets to thousands of red-blooded Americans celebrating our independence. Truth be told, tears streamed down my face, as we celebrated as one.

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After arriving home, we had no plans. So we took an afternoon of leisure hanging out in the pool, swimming side-by-side and then tying two floats together as we held hands and napped. Totally unlike us, and it felt so good, another pleasant surprise. I told my partner it would be a perfect day if I could once again hear the squeal of children playing in a pool. The phone rang.

My sister-in-law from my first marriage, whom I’ve been friends with for 27 years, was at Wegman’s. “Hey,” I said, “Why don’t you grab a 5 lb. bag of Sahlen hot dogs and bring the kids on over for a picnic and swim?” “I already have the hot dogs in the cart, along with cole slaw, strawberries and stuff to make shortcake. Game?” she asked.”You bet I am.” I replied. I ran upstairs and uncovered the goggles, the flippers, the frisbee and ball that Eric and Sam used to play on the beach with Cara and Peter far too many years ago.

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When my in-laws arrived, we baked the shortcake and headed out to the deck to grill the dogs, drink, and listen to the squeal of children once again playing in the pool. I sighed perfectly contented with my weekend full of patriotism and pleasant surprises. God I love the small joys of life.

Takoma Park Parade, July 4th 2009

Takoma Park Parade, July 4th 2009

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Driving the 350 miles up to my hometown of Buffalo for my nephew’s high school graduation, revealed to me an “aha” moment: people handle driving the way they handle life. Lead, follow or get out of the way! Please.

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As I was driving on an open stretch of route 15 in Pennsylvania, a silver Kia sedan sped up as it approached my rearview mirror. As it passed me, I noticed the twenty-something girl behind the wheel, who immediately slowed down once she pulled back into my lane in front of me. As I then pulled out to pass her, she immediately sped up, only to slow down again when I resumed my position behind her. She slowed down. I went to pass. She sped up. I’d pull back in. She’d slow down. This went on for a number of miles, when the “aha” moment hit me. She wanted to lead, but didn’t have the courage to be the leader.

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Along the way, the highway was strewn with state troopers pulling people over as they sped by. The twenty-something girl flying by me wanted to be in the lead but didn’t have the courage to be the lead driver. She wouldn’t commit. She wasn’t willing to take the risk of being pulled over for speeding. But she wanted to BE the leader, forcing the other drivers to either drive her speed or pass her. It was an unsafe practice for those following. Speed up. Slow down. Speed up. Slow down. It was an accident waiting to happen. She was not lead driver material. She needed to be following at a safe speed. I’m confident her approach to driving was the same as her approach to life. A young girl be-bopping along, accelerating, de-accelerating, pulling in and passing, trying to find the rhythm of her life.

When it comes to driving and life, I’m a leader but have no problem following—IF I’m behind a confident leader who makes good decisions. If not, get out of the way, ’cause I’ll take over and pass. I don’t have a lot of patience for hesitant leaders or drivers. Commit. Make a decision or move over and let someone else lead.

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En route to Buffalo, I encountered fierce thunderstorms with pelting rain and winds. Hail storm like conditions, just shy of hailstones coming down. As a pretty fearless driver, severe winter storms don’t stop me, let alone a little rain. Yet people were driving 25 mph hour on an interstate with their flashers on. People, please. It’s a little rain. Well a lot of rain. Eventually most of the drivers pulled over. Ah, relief. An open road where I could go. I led the drivers, confidently, to salvation, er, sunshine. It just took someone willing to commit and lead. I have no problem stepping up if need be. That’s who I am as I driver and who I am in life.

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My partner has an interesting approach to driving and to life. He meanders in both. If there’s a straight line to get from point A to E, he’ll drive from A to D to K to N back to C over to J and eventually he’ll make it to E, his end destination. This is his approach to most things in life. In the meantime, he’s made a lot of stops, said hi to many people and eventually accomplished what he sets out to do. If I’m on a mission and need to get from A to E in record time, and I’m with him, I have to restrain myself from pushing down on his knee to accelerate to 65 mph. It drives me bonkers. But if I’m not on a mission, and willing to meander, it makes for a very pleasant journey. That’s why I think we make good partners—one forces the other to stay on task, the other forces the other to stop and smell the roses.

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Although I stay on task, I am an adventurer. I love the journey, the drive, the discovery, the ability to make choices. My brother has a GPS named Lucille. I hate her. No, I will not turn because you told me to. I’ll turn because I choose to. No wait, I WANTED to go to the Ben and Jerry’s. It’s an unscheduled stop, don’t recalculate. Shut up. Stop it. Let me drive. Let me choose. Let me discover their new Mission to Marzipan flavor. Stop it. Stop it. Stop it. I don’t want to stay on task I want to stop and smell the roses. But she won’t let me, without giving me a huge headache. Big mouth Lucile shows no restraint. Recently, someone stole her. God Bless them.

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Did you know a study recently stated that people with lots of bumper stickers on their cars are aggressive drivers? I find that hilarious, because the cars that I usually see plastered with bumper stickers are Subarus touting world peace.

You’ll be happy to know that I don’t place bumper stickers on my vehicles. But if I were to sport a bumper sticker on my 4×4 F-150 it would simply be, “Visualize whirled peas.”

visualize-whirled-peas-bumper-sticker-5781

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“When the going gets tough, the tough eat donuts”–Ziggy

I love Ziggy. Do you remember him—the fat little bald guy in the 70’s comic strip by Tom Wilson? Ziggy had a “woe is me” perspective on life but offered simple words of wisdom.

The cartoon quote from above was lovingly cut out of the paper by my dad and taped to my mirror when I was 18. I’m sure it’s now tucked away in an attic box piled on top of other boxes from far too many moves. Every time I think of Ziggy, I think of my dad who passed away at an early age of 59, fifteen years ago.

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My dad didn’t cut that cartoon out to suggest I was getting fat. He simply cut it out because the humor struck a chord with him. When I was 18 I worked in the deli of a local grocery store. Oftentimes, at the end of the shift, I had to box up the fresh donuts from the bakery to be put out for the “day old” dollar sale the next day. So each night I’d box them up–and then buy ‘em. My particular favorites were the peanut donuts. Oh my, they were good. But, alas, they are not made anymore because of all the peanut allergen sufferers out there. Sigh. I loved a good peanut donut. The memory of biting into a fresh donut with falling nuts and crumbs waiting to be scooped up, filling my nose with the warm, nutty sensation, still makes my mouth water.

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The humor that my dad found in the comic strip was that I was a love-sick teen who had just broken up with my first forever boyfriend, who brought home a box of donuts at the end of the night to eat away the pain. When the going got tough, I ate donuts. My dad was trying to get me to move through the “woe is me” attitude from the teen-age breakup with humor. I loved that about my dad—he moved through life with humor and I couldn’t help but be sucked into it.

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That particular Ziggy cartoon was based on the quote from Joseph P. Kennedy, father of our 35th president John F. Kennedy, “When the going gets tough, the tough get going.” I’m sure the fiercely ambitious businessman and political figure, who thrived on competition and winning, gave that fatherly advice to his 9 children with a stern striking of his fist with emphasis on every word.

Not my dad. He cut out cartoons from the paper and taped them to my mirror. He peeled off Chiquita banana labels and pasted them somewhere in my school lunch box for me to discover with love. He’d sneak away early from work and show up unexpectedly for the last 15 minutes of my soccer game. He didn’t rule with an iron fist, rather with respect, love and humor.

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The humor that he used to get me through my first forever boyfriend break-up still makes me smile to this day. He was letting me know that life goes on, it’s what you make of it, it’s how you choose to move through it that makes all the difference.

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I had to stop eating donuts, not because they landed on my hips, but because I got sick of them. To this day I have a hard time eating donuts because I ate too much of a good thing way back when. As Marie Lloyd so simply states, ” A little of what you fancy does you good.” The lesson from Ziggy and my dad: taking it to the extreme is not necessarily a good thing. Although I have to admit when I see a “Hot Donuts Now” sign flashing at a Krispy Kreme, my car automatically pulls into the drive-thru. I’m just taking them home to the kids. Honest.

“A LITTLE of what you fancy does you good.” For sure.

Ziggy

Ziggy

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Sock. Shoe. Sock. Shoe. No. Sock. Sock. Shoe. Shoe. I do sock, sock, shoe, shoe. How do you approach your morning routine?In the end does it really matter? In Ted Menton’s After Goodbye, he tells the story of two children in the throes of cancer arguing in the cancer ward about which is better. Sock. Shoe. Sock. Shoe. or Sock. Sock. Shoe. Shoe.

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In spite of the cancer scenario, I find it amusing that two children facing the fight of their lives still find their individual routine’s worth fighting about. Sock. Shoe. vs. Sock. Sock. I have never been a routine person. Not me. In fact, if you ever placed me into a box, I’d scrape and claw my way out of it.

All my life, I’ve been known for my spontaneous nature. Until my children died. Then, I took great comfort in my routine. It was what got me up in the morning. Linda, first put on your sock, then your shoe. Nope. Put on your sock. Now put on your other sock. Okay, put on your shoe. Now your other shoe. Now put one foot in front of the other. Now take a step. Okay. Move the other foot. Move forward. Step by step. Move through the pain. You can do it. Sock. Sock. Shoe. Shoe. Move. Move. And that’s how I’ve moved through the passing pain of losing two children.

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Most of you know Monday marked the five year anniversary of Sam’s passing. My 10 year old son. I have been in a routine for the past five years in learning how to live again through the loss. Sock. Sock. Shoe. Shoe. Move. Move. Don’t you take that routine away from me. Like the children on the cancer ward, I took great comfort in owning my routine. It was the only thing I had control over. God forbid I put on Sock. Shoe. Sock. Shoe. It didn’t feel right. Just like my life without my children. Come to think of it, before the passing of my children I think I did Sock. Shoe. Sock. Shoe. But I couldn’t go back to the same routine. It wasn’t right. I needed a new routine. It was new, but a routine, just the same. Just like living and breathing without half my family. I had to learn to do it all over again. The basics of living.

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Know how I celebrated Sam’s anniversary? The “non-celebration,” as it were, ended up in my mowing the lawn. Now my partner prides himself on the perfectly parallel lines in the lawn. I never got that. I don’t. To me a lawn is a lawn. And this just isn’t a lawn; it’s a field, a three acre field next to a stream. It deserves to be a field. But nope. He wants it to be a lawn. Not me. I want it to be a field with dancing grass blowing in the breeze, next to the stream. I want it mowed three times a season. He wants it mowed once a week. Now I love to mow, so I took on the chore. On Sunday, I started running the perfectly parallel lines of the routine. Sock. Sock. Shoe. Shoe. Up. Down. Up. Down. Forty-five inches over from whence I started. Now another 45 inch wide mowing deck over. Then a dragon fly landed on the dancing grass next to the stream in the field I was cutting into a routine.

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Sam followed me across the country on my horse trip. Thousands of dragon flies followed me. They had my back. As Sam did. I wear a dragon fly bracelet as a remembrance of Sam. So I couldn’t do it. I couldn’t cut the field in parallel lines. I couldn’t cut the field so the dragon fly had no where to land. I couldn’t cut the field by way of routine. So in honor of Sam, I cut whoopsi-doodles. No rhyme or reason. Just by happen-chance, I have a field full of perfectly un-parallel lines. Perfect whoopsi-doodles where dragon flies can land on the missed grass of the 45 inch mowing deck. In the outskirts of the circles where 45 inches didn’t meet the other 45 inches. Where shoes come before socks. Where dragon flies land before parallel lines are cut. Where routines are lost and spirits soar. Where perhaps even socks are worn without shoes. For in the end, it just doesn’t matter.

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“Wow, Linda, you look fabulous and fit!” was the statement I heard Tuesday night at my Toastmaster’s meeting. Little did that person know I have, over the past 4 months, unintentionally dropped 1/5 of my weight.  Now, I’ve never had a problem with weight. I had four children and managed to stay relatively thin chasing after them through the years. But I found it truly ironic that I’m the thinnest I’ve ever been—even before my high school years—and was being rewarded with a “Wow, you look fit and fabulous.”  I didn’t feel it.

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Yesterday I nearly collapsed at work, drove to a 24/7 healthcare center, to be told I’m severely anemic. This coupled with the five other symptoms that have crept up on me over the past four months and the doctor scared me with the big C.

My dad died of cancer and it wasn’t something I was prepared to hear. Now lots more tests need to be done, so don’t get all melodramatic on me. I have lots of years left to live, I know that, and feel that, with every fiber of my being. The point to all of this is that you just don’t know what the day may bring. Are you living the life you were born to lead?

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“Always be a first-rate version of yourself, instead of a second-rate version of somebody else.”
–Judy Garland

This from a woman who played somebody else for 45 of her 47 years. This from a woman who attempted suicide numerous times throughout her tragic life. This from a woman who struggled with insecurities and addictions. This from a woman who was told by her producers that she was unattractive and overweight. This from a woman who died at 47, the same age I’m about to turn in three weeks. Was Judy Garland ever a first-rate version of herself?

Judy Garland will always be remembered as Dorothy in the Wizard of Oz, with her ruby red slippers, clicked three times, as she closed her eyes and chanted,  “There’s no place like home. There’s no place like home. There’s no place like home.” Ironically, Judy Garland never felt at home anywhere. I can only imagine why she never revealed her true self, always hiding it away—for fear that her adoring fans would cast aside the real Judy. They always wanted Dorothy. The cute little, pig-tailed girl from Kansas.

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I also imagine that Judy Garland did live the life she was born to lead. She was a wonderful actress and a beautiful singer with her deep contralto voice. No one does honor to Somewhere Over the Rainbow the way Judy performed it half a century ago. But she never believed she deserved to be Judy Garland and all that she achieved. She was just Frances Ethel Gumm from Grand Rapids, MN. When she was pushed into acting, Frances’ confidence was sucked out of her and for years she was only able to portray a second-rate version of somebody else.

When the big C is thrown at you, your life hits replay over and over again in your mind. “Have you lived the life you wanted? Have you achieved what you set out to achieve? What more do you have left to do?”  It begs the question, “What is your legacy?”

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So what is your legacy? If you were to die tomorrow, did you live the life you were born to lead? Will you leave behind something to remember? Did you live a first-rate version of yourself?

I hope I have.

I know my youngest son Sammy did. On Monday, he’ll be gone 5 years. On June 22. But I still remember his great grin. His aqua blue eyes. His mischevious sense of humor. And his terrific hugs. In his short 10 years, Sammy was a first-rate version of himself. There will never be another.  In the end, all you have are memories, and the ones spent with family and friends are the ones you treasure most.

So as I remember Sammy and Frances Ethel Gumm, who co-incidentally also died on June 22, as I head into the doctors for a follow-up visit to the big C scare, I hope to see a rainbow smiling down on me.

Somewhere Over the Rainbow (click, for a beautiful version by 6 year-old Connie Talbot on YouTube)

Somewhere over the rainbow
Way up high,
There’s a land that I heard of
Once in a lullaby.

Somewhere over the rainbow
Skies are blue,
And the dreams that you dare to dream
Really do come true.

Someday I’ll wish upon a star
And wake up where the clouds are far
Behind me.
Where troubles melt like lemon drops
Away above the chimney tops
That’s where you’ll find me.

Somewhere over the rainbow
Bluebirds fly.
Birds fly over the rainbow.
Why then, oh why can’t I?

If happy little bluebirds fly
Beyond the rainbow
Why, oh why can’t I? 1

I hope we all live the life we were born to lead—the way Sammy did, so beautifully and innocently with a verve for life and love. Love and miss you tons, my little Sammer Dam.

Sam Losey, 3/29/94 - 6/22/2004

Sam Losey, 3/29/94 - 6/22/2004

1 Somewhere Over the Rainbow, music by Harold Arlen and lyrics by E.Y. Harburg

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Many moons ago, when my mother was the age I am now, and I was but a girl of 16, my father came home one memorable day and announced to us that we were moving. To a farm. Although I was a tomboy with three older brothers, I was a city girl through and through. It’s all I had known.

As a family, we would be moving to a 10 acre farm, next to 3000 acres of state land, to a public school with a graduating class of 32.  Yep, I was downsizing as president of my class of 400, to 32 classmates, and upsizing from an 1/8 of an acre lot in the city, to thousands of acres in my backyard.

In order to get me to go without kicking and screaming, my father bribed me with a horse. He was a smart man.

Most of you know that horses are a huge part of my life and I have no problem getting down and dirty with ‘em. And others know me as a gussied up artist, author, and speaker. As Kippling writes, “Never the twain shall meet.” My wardrobe is determined by the activity of the day, yet whatever I’m wearing on the outside, doesn’t change the me I am on the inside. The old idiom, “Don’t judge a book by its cover,” is, well, cliché-like, but, it’s still relevant today.

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A month after we moved to the farm, on a blazingly hot summer day, my father ordered manure from our neighbor’s farm to fertilize the small garden he was tilling. I remember the moment the manure arrived. The fresh droppings reeked and steamed. But that’s not what I remember the most. Our neighbor’s ten year old daughter was sitting plop on top of the manure pile, with a wide grin, happy as a pig in….well you know.

My mother, father and I grabbed our shovels to start pushing the manure off the wagon into the garden. The little girl with the huge smile sitting in the stewing cow chips, looked at my mother incredulously. “What are you afraid to get them rings dirty?” she asked as she pushed the shit off with her bare feet. My mother stared back in horror.

Now my mother is not an outdoor person per se, but she did a great job of humoring her five children and outdoor-loving husband through countless camping trips, homeless animals, moves to the country, etc. But I don’t think I could ever picture her shoveling dung with her feet. On the other-hand I don’t think that grinning girl on top of that manure mountain would ever sit still in a theater either. But I don’t know, I lost track of her. Who am I to judge that she couldn’t or wouldn’t?

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On my solo cross-country journey by horseback, I did a lot of wilderness camping and would go days without eating or showering. Yep, I reeked, I’m sure, like the compost on that hot summer day, but there was something about the solace of the wilderness that helped to heal me on that long journey.

One stop in particular reminded me of that long-ago judgment day with my neighbor’s little girl. Camping for two days in a park outside of a penitentiary in rural Indiana, I was sitting under a tree journaling when a truck hauling a two-horse trailer arrived. I paid them no mind and continued writing. After tacking and mounting up, the owners made their way to me. They were retirees out for a late-summer ride and had never before encountered in their horse park a wild-haired, dirty, lone woman parked under a tree writing with two horses grazing beside her. Was she an escapee from the penitentiary—or worse yet, waiting to help a convict escape on her other horse? Still I paid them no attention as they inched in closer with their mounts—until the wife leaned over and whispered, “Is that a boy or a girl?” I looked up with a smile and said, “I’m a girl with a Master’s and perfectly good hearing.” But I sure didn’t look it.

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Last night, as I was mounting up for a high profile event with my horse, I had to pee. With no facilities around, I sheepishly entered my horse trailer, closed the door, and had to make do sitting plop on top of a manure bucket with freshly steaming dung, just like that little girl from my childhood. Who knew that would be me someday?

This morning after getting all-gussied up for work, I had to stop by my partner’s office to drop something off. He introduced me to the office cleaning lady, a nice enough woman, who totally misread me. She leaned over and said to him, “She’s very pretty, but it looks like she’s afraid to get those nails dirty.” He laughed, “Of anybody I know Linda has no problem getting down and dirty, but she cleans up real ‘purdy!’”

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Although the idiom, “Don’t judge a book by its cover” came about in the journal, American Speech in 1944, the idea has been around for centuries. Heed these wise words written by François Rabelais in La vie de Gargantua et de Pantagruel, “But it’s wrong to be so superficial when you’re weighing men’s work in the balance. Wouldn’t you yourself say that the monk’s robes hardly determine who the monk is? Or that there are some wearing monks’ robes who, on the inside, couldn’t be less monkish? Or that there are people wearing Spanish capes who, when it comes to courage, couldn’t have less of the fearless Spanish in them? And that’s why you have to actually open a book and carefully weigh what’s written there.”1

You have to actually open a book and carefully weigh what’s written there… Relevant words an incredible five centuries later. God, I love words! Down and dirty, but real “purdy!”

1 Wikipedia

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Familial hypercholesterolaemia (FH) is the most common autosomal dominant genetic condition, affecting about 1 in 250 people, caused by a where can i buy zithromax z pak pathogenic variant in one of several genes involved in lipoprotein cholesterol catabolism. Treatment of elevated serum low-density lipoprotein cholesterol in people with FH substantially reduces the risk of ischaemic heart disease and cardiovascular mortality. Yet, the where can i buy zithromax z pak vast majority of FH cases are undiagnosed and, thus, untreated. Diagnosis is challenging because patients typically are asymptomatic, may not know their family history, are unaware of the seriousness of the diagnosis and may not even be seeing a physician regularly.

In addition, the phenotypic diagnosis requires more than just serum cholesterol levels.In this issue of Heart, Carvalho and colleagues1 demonstrated the feasibility of the FH Case Ascertainment Tool (FAMCAT) for identifying patients likely to have FH in a cohort of 777 128 primary care patients in London. The FAMCAT score is based on systematic screening of routine primary care records for cholesterol where can i buy zithromax z pak measurements, age, triglycerides, family history, diabetes, kidney disease and current use of lipid-lowering drugs (figure 1). The use of FAMCAT to identify patients likely to have FH could ensure more accurate and rapid diagnosis (and subsequent treatment) for this group of patients at high risk of cardiovascular disease.Risk of familial hypercholesterolaemia (FH) in inner East London calculated using FAMCAT algorithm, assuming population prevalence of 1 in 500 and 1 in 250. IHD, ischaemic heart disease.

PP, population prevalence." data-icon-position data-hide-link-title="0">Figure 1 Risk of familial hypercholesterolaemia (FH) in inner East London calculated using FAMCAT algorithm, assuming population where can i buy zithromax z pak prevalence of 1 in 500 and 1 in 250. IHD, ischaemic heart disease. PP, population prevalence.A different approach to detection of FH was used by Brett and colleagues2 in a cohort of 232, 139 Australian general practice patients. Using a pragmatic two-step approach, they first identified those at higher risk where can i buy zithromax z pak of FH using the TARB-Ex electronic screening tool.

Then, in the 1843 (0.8%) of patients identified electronically by TARB-Ex, clinical assessment by the physician was used to confirm a high FH risk the based on the phenotypic Dutch Lipid Clinic Network Criteria score. In a subset of 77 patients with FH, subsequent intensification of lipid-lowering therapy led to a further reduction in serum cholesterol levels .In an editorial, Qureshi and Patel3 summarise methods using the electronic health record (EHR) for improved diagnosis of FH (figure 2) and point out that the EHR approach often is limited by inadequate or missing data about family history, physical signs and other information. Cholesterol levels, while not where can i buy zithromax z pak diagnostic in isolation, are essential for the diagnosis but may not have been measured in many asymptomatic individuals. They conclude.

€˜Ultimately, successfully identifying the thousands of people with FH in the UK and where can i buy zithromax z pak abroad will require a system-wide approach from opportunistic identification at routine health encounters, systematic case finding in primary care, screening people at the time of a premature CVD event to child–parent screening and cascade testing.’Pathway to identification of FH from primary care. CVD, cardiovascular disease. DLCN, Dutch Lipid Clinic Network. FAMCAT, FH Case Ascertainment Tool where can i buy zithromax z pak.

FH, familial hypercholesterolaemia. GP, general practitioner. HCA, healthcare assistant where can i buy zithromax z pak. LLT, lipid-lowering treatment.

VUS, variant of unknown significance." data-icon-position data-hide-link-title="0">Figure 2 Pathway to identification of FH from primary care. CVD, cardiovascular disease where can i buy zithromax z pak. DLCN, Dutch Lipid Clinic Network. FAMCAT, FH Case Ascertainment Tool.

FH, familial hypercholesterolaemia where can i buy zithromax z pak. GP, general practitioner. HCA, healthcare where can i buy zithromax z pak assistant. LLT, lipid-lowering treatment.

VUS, variant of unknown significance.Also, in this issue of Heart, Schwerzmann and colleague4 report clinical outcomes in 105 patients adult congenital heart disease (ACHD) with buy antibiotics s. Overall, 5 patients died and 13 had a where can i buy zithromax z pak complication disease course. Clinical features associated with a complicated disease course were similar to the general population including older age, the presence of two or more comorbidities, and obesity (figure 3). In addition, those with a complicated disease course were more likely to have cyanotic heart disease such as unrepaired cyanotic defects are Eisenmenger syndrome, compared with ACHD patients with an uncomplicated buy antibiotics course (OR 60, 95% CI 7.6 to 474).Univariable significant buy antibiotics risk factors in patients with adult congenital heart disease and the corresponding ORs.

We propose to stratify patients based on age, number of comorbidities, weight and presence of a high-risk cardiac lesion (cyanotic where can i buy zithromax z pak heart disease). BMI, body mass index." data-icon-position data-hide-link-title="0">Figure 3 Univariable significant buy antibiotics risk factors in patients with adult congenital heart disease and the corresponding ORs. We propose to stratify patients based on age, number of comorbidities, weight and presence of a high-risk cardiac lesion (cyanotic heart disease). BMI, body mass index.Yuan and Oechslin comment in an editorial5 that ‘Contrary to where can i buy zithromax z pak our previous conceptualisation of risk, anatomical complexity does not appear to predict severe or death.

Rather, patient-specific risk factors similar to those in the non-CHD cohort remain important, while strong CHD-specific risk factors for severe illness or death after buy antibiotics were cyanotic heart disease and physiological stage. These results help us to tailor patient recommendations but require further confirmation in large international, multicentre studies that are sufficiently powered to answer our remaining questions.’A meta-analysis by Imazio and colleagues6 supports the efficacy of anti-interleukin-1 agents, such as anakinra where can i buy zithromax z pak and rilonacept, for prevention of recurrent episodes of pericarditis in patients with corticosteroid-dependent and colchicine-resistant recurrent pericarditis. Anthony and Collier7 remind us that recurrent pericarditis complicates 15%–30% of index cases of pericarditis. The clinical consequences, in addition to pain, can be serious including recurrent effusions, tamponade physiology and constrictive pericarditis.

And there is little data on effective therapies (figure 4).8 They conclude ‘Inhibition of the IL-1 pathway may represent a where can i buy zithromax z pak paradigm shift in the treatment of patients with recurrent pericarditis despite standard therapy. However, larger RCT data are required for further validation of the efficacy and safety of these novel medications in the treatment of recurrent pericarditis.’Interleukin-1 alpha and beta in pericardial inflammation. Adapted from Klein et al. 8 " data-icon-position data-hide-link-title="0">Figure 4 Interleukin-1 where can i buy zithromax z pak alpha and beta in pericardial inflammation.

Adapted from Klein et al.8The Education in Heart article in this issue provides a quick overview of cardio-oncology for the general cardiologist. Cardio-oncology is defined as ‘the treatment and prevention of cardiovascular disease in cancer patients both during oncology treatment and afterwards.’9A basic understanding of cardio-oncology now is considered core knowledge for every cardiologist, given the demographic overlap in the prevalence of cardiovascular disease and cancer, in addition to the potential cardiotoxic effects of cancer treatments. The information and practical advice in this review article are a concise resource for busy practitioners.Our short Cardiology in Focus article10 provides a brief overview of cost-effectiveness methodology, with a short list of references for those who wish to dive deeper into this topic.Ethics statementsPatient consent for publicationNot required.The American Heart Association (AHA) has set decade-long impact goals since the 90s, aimed on reducing the where can i buy zithromax z pak cardiovascular disease (CVD) burden, with reflections on patient care and cardiovascular research around the globe. The last completed cycle ended in 2020.

In that cycle, the objective was ‘by 2020, to improve the cardiovascular health of all Americans by 20% while reducing deaths from CVDs and stroke by 20%’.1The main strategy to achieve this goal was aligned with the foundations of primary prevention by Geoffrey Rose,2 and advocated that interventions should focus on increasing the proportion of individuals free of CVD with ideal (1) diet, (2) physical activity, (3) body mass index (BMI), (4) blood pressure, (5) fasting plasma glucose and (6) total cholesterol, as well as of (7) non-smokers (never smokers or, alternatively, past smokers with at least 1 year from quitting). This has also resulted in a 7-point ideal cardiovascular health (CVH) score, where can i buy zithromax z pak with specific metrics for each risk factor profile. Since then, several articles have used the CVH score, analysing the prevalence of ideal metrics in different populations, or measuring its association with CVD.3 4In the present decade, the AHA has adopted even more ambitious aims. For 2030, the AHA aims an equitable increase in health-adjusted life expectancy (HALE) from 66 ….

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The ethnic disparities include overall numbers of cases, as well as the relative numbers of critical care admissions and deaths.1In the area of mental health, for people from BAME what can substitute zithromax groups, even before the current zithromax there were already significant mental health inequalities.2 These inequalities have been increased by the zithromax in several ways. The constraints of quarantine have made access to traditional face-to-face support from mental health services more difficult in general. This difficulty will increase pre-existing inequalities where there are challenges to what can substitute zithromax engaging people in care and in providing early access to services.

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The risk to staff in general healthcare (including mental healthcare) what can substitute zithromax is a particular concern, and in response, the Royal College of Psychiatrists and NHS England have produced a report on the impact of buy antibiotics on BAME staff in mental healthcare settings, with guidance on assessment and management of risk using an associated risk assessment tool for staff.4 5However, there is little formal guidance for the busy clinician in balancing different risks for individual mental health patients and treating appropriately. Thus, for example, an inpatient clinician may want to know whether a patient who is older, has additional comorbidities and is from an ethnic background, should be started on one antipsychotic medication or another, or whether treatments such as vitamin D prophylaxis or treatment and venous thromboembolism prevention should be started earlier in the context of the buy antibiotics zithromax. While syntheses of the existing guidelines are available about buy antibiotics and mental health,6 7 there is nothing specific about the healthcare needs of what can substitute zithromax patients from ethnic minorities during the zithromax.To fill this gap, we propose three core actions that may help:Ensure good information and psychoeducation packages are made available to those with English as a second language, and ensure health beliefs and knowledge are based on the best evidence available.

Address culturally grounded explanatory models and illness perceptions to allay fears and worry, and ensure what can substitute zithromax timely access to testing and care if needed.Maintain levels of service, flexibility in care packages, and personal relationships with patients and carers from ethnic minority backgrounds in order to continue existing care and to identify changes needed to respond to worsening of mental health.Consider modifications to existing interventions such as psychological therapies and pharmacotherapy. Have a high index of suspicion to take into account emerging physical health problems and the greater risk of serious consequences of buy antibiotics in ethnic minority people with pre-existing chronic conditions and vulnerability factors.These actions are based on clinical common sense, but guidance in this area should be provided on the basis of good evidence. There has already been a call for urgent research in the area of buy antibiotics and mental health8 and also a clear need for what can substitute zithromax specific research focusing on the post-buy antibiotics mental health needs of people from the BAME group.

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As clinicians, we need to balance the relative risks for each of our patients, so that we can act promptly and proactively in response to their individual needs.10 For this, we need evidence-based guidance to ensure we are balancing every risk appropriately and without bias.Footnotei While we have used the term ‘people identifying with BAME groups’, we recognise that this is a multidimensional group and includes vast differences in culture, identity, heritage and histories contained within this abbreviated term..

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The constraints of quarantine have made access to traditional face-to-face support from mental health services more difficult in general. This difficulty will increase pre-existing inequalities where there are challenges where can i buy zithromax z pak to engaging people in care and in providing early access to services. The restrictions may also reduce the flexibility of care offers, given the need for social isolation, limiting non-essential travel and closure of routine clinics. The service impacts are compounded by constraints on the use of non-traditional or alternative routes to care and support.In addition, there is growing evidence of specific mental health consequences from significant buy antibiotics , with increased rates of not only post-traumatic stress disorder, anxiety where can i buy zithromax z pak and depression, but also specific neuropsychiatric symptoms.3 Given the higher risks of mental illnesses and complex care needs among ethnic minorities and also in deprived inner city areas, buy antibiotics seems to deliver a double blow.

Physical and mental health vulnerabilities are inextricably linked, especially as a significant proportion of healthcare workers (including in mental health services) in the UK are from BAME groups.Focusing on mental health, there is very little buy antibiotics-specific guidance on the needs of patients in the BAME group. The risk to staff in general healthcare (including mental healthcare) is a particular concern, and where can i buy zithromax z pak in response, the Royal College of Psychiatrists and NHS England have produced a report on the impact of buy antibiotics on BAME staff in mental healthcare settings, with guidance on assessment and management of risk using an associated risk assessment tool for staff.4 5However, there is little formal guidance for the busy clinician in balancing different risks for individual mental health patients and treating appropriately. Thus, for example, an inpatient clinician may want to know whether a patient who is older, has additional comorbidities and is from an ethnic background, should be started on one antipsychotic medication or another, or whether treatments such as vitamin D prophylaxis or treatment and venous thromboembolism prevention should be started earlier in the context of the buy antibiotics zithromax. While syntheses of the existing guidelines are available about buy antibiotics and mental health,6 7 there is nothing specific about the healthcare needs of patients from ethnic minorities during the zithromax.To fill this gap, we propose three core actions that may help:Ensure good information and psychoeducation packages are made available to those with English as a second language, and ensure health beliefs and knowledge are based on the best where can i buy zithromax z pak evidence available.

Address culturally grounded explanatory models and illness perceptions to allay fears and worry, and ensure timely access to testing and care if needed.Maintain levels of service, flexibility in care packages, and personal relationships with patients and carers from ethnic minority backgrounds in order to continue existing care and to identify changes needed to respond to worsening of mental where can i buy zithromax z pak health.Consider modifications to existing interventions such as psychological therapies and pharmacotherapy. Have a high index of suspicion to take into account emerging physical health problems and the greater risk of serious consequences of buy antibiotics in ethnic minority people with pre-existing chronic conditions and vulnerability factors.These actions are based on clinical common sense, but guidance in this area should be provided on the basis of good evidence. There has already been a call for urgent research in the area of buy antibiotics and mental health8 and also a clear need for specific research focusing where can i buy zithromax z pak on the post-buy antibiotics mental health needs of people from the BAME group. Research also needs to recognise the diverse range of different people, with different needs and vulnerabilities, who are grouped under the multidimensional term BAME, including people from different generations, first-time migrants, people from Africa, India, the Caribbean and, more recently, migrants from Eastern Europe.

Application of a race equality impact assessment to all research questions and methodology has recently been proposed as a first step in this process.2 At this early stage, where can i buy zithromax z pak the guidance for assessing risks of buy antibiotics for health professionals is also useful for patients, until more refined decision support and prediction tools are developed. A recent Public Health England report on ethnic minorities and buy antibiotics9 recommends better recording of ethnicity data in health and social care, and goes further to suggest this should also apply to death certificates. Furthermore, the report recommends more participatory and experience-based research to understand causes and consequences of pre-existing multimorbidity and buy antibiotics where can i buy zithromax z pak , integrated care systems that work well for susceptible and marginalised groups, culturally competent health promotion, prevention and occupational risk assessments, and recovery strategies to mitigate the risks of widening inequalities as we come out of restrictions.Primary data collection will need to cover not only hospital admissions but also data from primary care, linking information on mental health, buy antibiotics and ethnicity. We already have research and specific guidance emerging on other risk factors, such as age and gender.

Now we also need to focus on an equally important aspect of where can i buy zithromax z pak vulnerability. As clinicians, we need to balance the relative risks for each of our patients, so that we can act promptly and proactively in response to their individual needs.10 For this, we need evidence-based guidance to ensure we are balancing every risk appropriately and without bias.Footnotei While we have used the term ‘people identifying with BAME groups’, we recognise that this is a multidimensional group and includes vast differences in culture, identity, heritage and histories contained within this abbreviated term..

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THE PROBLEM azithromycin zithromax or doxycycline. Meet Joe, whose Doctor has Billed him for the Medicare Coinsurance Joe Client is disabled and has SSD, Medicaid and Qualified Medicare Beneficiary (QMB). His health care is covered by Medicare, and Medicaid and the QMB program pick up his Medicare cost-sharing obligations. Under Medicare Part B, his co-insurance is 20% of the Medicare-approved charge for azithromycin zithromax or doxycycline most outpatient services. He went to the doctor recently and, as with any other Medicare beneficiary, the doctor handed him a bill for his co-pay.

Now Joe has a bill that he can’t pay. Read below to find out azithromycin zithromax or doxycycline -- SHORT ANSWER. QMB or Medicaid will pay the Medicare coinsurance only in limited situations. First, the provider must be a Medicaid provider. Second, even if the provider accepts Medicaid, under recent legislation in New York enacted in 2015 and 2016, QMB or Medicaid may pay only part of the coinsurance, or none azithromycin zithromax or doxycycline at all.

This depends in part on whether the beneficiary has Original Medicare or is in a Medicare Advantage plan, and in part on the type of service. However, the bottom line is that the provider is barred from "balance billing" a QMB beneficiary for the Medicare coinsurance. Unfortunately, this creates tension between an individual and her doctors, pharmacies dispensing Part B azithromycin zithromax or doxycycline medications, and other providers. Providers may not know they are not allowed to bill a QMB beneficiary for Medicare coinsurance, since they bill other Medicare beneficiaries. Even those who know may pressure their patients to pay, or simply decline to serve them.

These rights and azithromycin zithromax or doxycycline the ramifications of these QMB rules are explained in this article. CMS is doing more education about QMB Rights. The Medicare Handbook, since 2017, gives information about QMB Protections. Download the 2020 Medicare Handbook here azithromycin zithromax or doxycycline. See pp.

53, 86. 1 azithromycin zithromax or doxycycline. To Which Providers will QMB or Medicaid Pay the Medicare Co-Insurance?. "Providers must enroll as Medicaid providers in order to bill Medicaid for the Medicare coinsurance." CMS Informational Bulletin issued January 6, 2012, titled "Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs). The CMS bulletin states, azithromycin zithromax or doxycycline "If the provider wants Medicaid to pay the coinsurance, then the provider must register as a Medicaid provider under the state rules." If the provider chooses not to enroll as a Medicaid provider, they still may not "balance bill" the QMB recipient for the coinsurance.

2. How Does a Provider that DOES accept Medicaid Bill for a QMB Beneficiary?. If beneficiary has Original Medicare -- The provider azithromycin zithromax or doxycycline bills Medicaid - even if the QMB Beneficiary does not also have Medicaid. Medicaid is required to pay the provider for all Medicare Part A and B cost-sharing charges for a QMB beneficiary, even if the service is normally not covered by Medicaid (ie, chiropractic, podiatry and clinical social work care). Whatever reimbursement Medicaid pays the provider constitutes by law payment in full, and the provider cannot bill the beneficiary for any difference remaining.

42 U.S.C azithromycin zithromax or doxycycline. § 1396a(n)(3)(A), NYS DOH 2000-ADM-7 If the QMB beneficiary is in a Medicare Advantage plan - The provider bills the Medicare Advantage plan, then bills Medicaid for the balance using a “16” code to get paid. The provider must include the amount it received from Medicare Advantage plan. 3 azithromycin zithromax or doxycycline. For a Provider who accepts Medicaid, How Much of the Medicare Coinsurance will be Paid for a QMB or Medicaid Beneficiary in NYS?.

The answer to this question has changed by laws enacted in 2015 and 2016. In the proposed 2019 State Budget, Gov azithromycin zithromax or doxycycline. Cuomo has proposed to reduce how much Medicaid pays for the Medicare costs even further. The amount Medicaid pays is different depending on whether the individual has Original Medicare or is a Medicare Advantage plan, with better payment for those in Medicare Advantage plans. The answer also differs based on the type of service azithromycin zithromax or doxycycline.

Part A Deductibles and Coinsurance - Medicaid pays the full Part A hospital deductible ($1,408 in 2020) and Skilled Nursing Facility coinsurance ($176/day) for days 20 - 100 of a rehab stay. Full payment is made for QMB beneficiaries and Medicaid recipients who have no spend-down. Payments are reduced if the azithromycin zithromax or doxycycline beneficiary has a Medicaid spend-down. For in-patient hospital deductible, Medicaid will pay only if six times the monthly spend-down has been met. For example, if Mary has a $200/month spend down which has not been met otherwise, Medicaid will pay only $164 of the hospital deductible (the amount exceeding 6 x $200).

See azithromycin zithromax or doxycycline more on spend-down here. Medicare Part B - Deductible - Currently, Medicaid pays the full Medicare approved charges until the beneficiary has met the annual deductible, which is $198 in 2020. For example, Dr. John charges $500 for a visit, for which azithromycin zithromax or doxycycline the Medicare approved charge is $198. Medicaid pays the entire $198, meeting the deductible.

If the beneficiary has a spend-down, then the Medicaid payment would be subject to the spend-down. In the 2019 proposed state budget, azithromycin zithromax or doxycycline Gov. Cuomo proposed to reduce the amount Medicaid pays toward the deductible to the same amount paid for coinsurance during the year, described below. This proposal was REJECTED by the state legislature. Co-Insurance - azithromycin zithromax or doxycycline The amount medicaid pays in NYS is different for Original Medicare and Medicare Advantage.

If individual has Original Medicare, QMB/Medicaid will pay the 20% Part B coinsurance only to the extent the total combined payment the provider receives from Medicare and Medicaid is the lesser of the Medicaid or Medicare rate for the service. For example, if the Medicare rate for a service is $100, the coinsurance is $20. If the Medicaid rate for the same service is only $80 or less, Medicaid would pay nothing, as it would consider the doctor fully paid = the provider has received the full Medicaid rate, azithromycin zithromax or doxycycline which is lesser than the Medicare rate. Exceptions - Medicaid/QMB wil pay the full coinsurance for the following services, regardless of the Medicaid rate. ambulance and psychologists - The Gov's 2019 proposal to eliminate these exceptions was rejected.

hospital outpatient clinic, certain facilities operating under certificates issued under the Mental Hygiene Law for people with developmental disabilities, psychiatric disability, and chemical dependence azithromycin zithromax or doxycycline (Mental Hygiene Law Articles 16, 31 or 32). SSL 367-a, subd. 1(d)(iii)-(v) , as amended 2015 If individual is in a Medicare Advantage plan, 85% of the copayment will be paid to the provider (must be a Medicaid provider), regardless of how low the Medicaid rate is. This limit was enacted in the 2016 State Budget, and is better than what the Governor proposed - which was the same rule used in Original Medicare -- NONE of the copayment or coinsurance azithromycin zithromax or doxycycline would be paid if the Medicaid rate was lower than the Medicare rate for the service, which is usually the case. This would have deterred doctors and other providers from being willing to treat them.

SSL 367-a, subd. 1(d)(iv), added 2016 azithromycin zithromax or doxycycline. EXCEPTIONS. The Medicare Advantage plan must pay the full coinsurance for the following services, regardless of the Medicaid rate. ambulance ) psychologist ) The Gov's proposal in the 2019 budget to eliminate these azithromycin zithromax or doxycycline exceptions was rejected by the legislature Example to illustrate the current rules.

The Medicare rate for Mary's specialist visit is $185. The Medicaid rate for the same service is $120. Current rules (since azithromycin zithromax or doxycycline 2016). Medicare Advantage -- Medicare Advantage plan pays $135 and Mary is charged a copayment of $50 (amount varies by plan). Medicaid pays the specialist 85% of the $50 copayment, which is $42.50.

The doctor is prohibited by federal law from "balance billing" azithromycin zithromax or doxycycline QMB beneficiaries for the balance of that copayment. Since provider is getting $177.50 of the $185 approved rate, provider will hopefully not be deterred from serving Mary or other QMBs/Medicaid recipients. Original Medicare - The 20% coinsurance is $37. Medicaid pays none of the coinsurance because the Medicaid rate ($120) is lower azithromycin zithromax or doxycycline than the amount the provider already received from Medicare ($148). For both Medicare Advantage and Original Medicare, if the bill was for a ambulance or psychologist, Medicaid would pay the full 20% coinsurance regardless of the Medicaid rate.

The proposal to eliminate this exception was rejected by the legislature in 2019 budget. . 4. May the Provider 'Balance Bill" a QMB Benficiary for the Coinsurance if Provider Does Not Accept Medicaid, or if Neither the Patient or Medicaid/QMB pays any coinsurance?. No.

Balance billing is banned by the Balanced Budget Act of 1997. 42 U.S.C. § 1396a(n)(3)(A). In an Informational Bulletin issued January 6, 2012, titled "Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs)," the federal Medicare agency - CMS - clarified that providers MAY NOT BILL QMB recipients for the Medicare coinsurance. This is true whether or not the provider is registered as a Medicaid provider.

If the provider wants Medicaid to pay the coinsurance, then the provider must register as a Medicaid provider under the state rules. This is a change in policy in implementing Section 1902(n)(3)(B) of the Social Security Act (the Act), as modified by section 4714 of the Balanced Budget Act of 1997, which prohibits Medicare providers from balance-billing QMBs for Medicare cost-sharing. The CMS letter states, "All Medicare physicians, providers, and suppliers who offer services and supplies to QMBs are prohibited from billing QMBs for Medicare cost-sharing, including deductible, coinsurance, and copayments. This section of the Act is available at. CMCS Informational Bulletin http://www.ssa.gov/OP_Home/ssact/title19/1902.htm.

QMBs have no legal obligation to make further payment to a provider or Medicare managed care plan for Part A or Part B cost sharing. Providers who inappropriately bill QMBs for Medicare cost-sharing are subject to sanctions. Please note that the statute referenced above supersedes CMS State Medicaid Manual, Chapter 3, Eligibility, 3490.14 (b), which is no longer in effect, but may be causing confusion about QMB billing." The same information was sent to providers in this Medicare Learning Network bulletin, last revised in June 26, 2018. CMS reminded Medicare Advantage plans of the rule against Balance Billing in the 2017 Call Letter for plan renewals. See this excerpt of the 2017 call letter by Justice in Aging - Prohibition on Billing Medicare-Medicaid Enrollees for Medicare Cost Sharing 5.

How do QMB Beneficiaries Show a Provider that they have QMB and cannot be Billed for the Coinsurance?. It can be difficult to show a provider that one is a QMB. It is especially difficult for providers who are not Medicaid providers to identify QMB's, since they do not have access to online Medicaid eligibility systems Consumers can now call 1-800-MEDICARE to verify their QMB Status and report a billing issue. If a consumer reports a balance billng problem to this number, the Customer Service Rep can escalate the complaint to the Medicare Administrative Contractor (MAC), which will send a compliance letter to the provider with a copy to the consumer. See CMS Medicare Learning Network Bulletin effective Dec.

16, 2016. Medicare Summary Notices (MSNs) that Medicare beneficiaries receive every three months state that QMBs have no financial liability for co-insurance for each Medicare-covered service listed on the MSN. The Remittance Advice (RA) that Medicare sends to providers shows the same information. By spelling out billing protections on a service-by-service basis, the MSNs provide clarity for both the QMB beneficiary and the provider. Justice in Aging has posted samples of what the new MSNs look like here.

They have also updated Justice in Aging’s Improper Billing Toolkit to incorporate references to the MSNs in its model letters that you can use to advocate for clients who have been improperly billed for Medicare-covered services. CMS is implementing systems changes that will notify providers when they process a Medicare claim that the patient is QMB and has no cost-sharing liability. The Medicare Summary Notice sent to the beneficiary will also state that the beneficiary has QMB and no liability. These changes were scheduled to go into effect in October 2017, but have been delayed. Read more about them in this Justice in Aging Issue Brief on New Strategies in Fighting Improper Billing for QMBs (Feb.

2017). QMBs are issued a Medicaid benefit card (by mail), even if they do not also receive Medicaid. The card is the mechanism for health care providers to bill the QMB program for the Medicare deductibles and co-pays. Unfortunately, the Medicaid card does not indicate QMB eligibility. Not all people who have Medicaid also have QMB (they may have higher incomes and "spend down" to the Medicaid limits.

Advocates have asked for a special QMB card, or a notation on the Medicaid card to show that the individual has QMB. See this Report - a National Survey on QMB Identification Practices published by Justice in Aging, authored by Peter Travitsky, NYLAG EFLRP staff attorney. The Report, published in March 2017, documents how QMB beneficiaries could be better identified in order to ensure providers do not bill them improperly. What Codes the Provider Sees in eMedNY &. EPACES Medicaid eligibility system - see GIS 16 MA/005 - Changes to eMedNY for Certain Medicaid Recipient Coverage Codes (PDF) ​​​​​​​Recipient Coverage Code "09" is defined as "Medicare Savings Program only" (MSP) and is used along with an eMedNY Buy-in span and MSP code of "P" to define a Qualified Medicare Beneficiary (QMB).

Providers will receive the following eligibility messages when verifying coverage on EMEVS and ePaces. "Medicare coinsurance and deductible only" for individuals with Coverage Code 06 and an MSP code of P. *Code 06 is "provisional Medicaid coverage" for Medicaid recipients found provisionally eligible for Medicaid, subject to meeting the spend-down. See more about provisional coverage here. "Family Planning Benefit and Medicare Coinsurance and Ded" for individuals with Coverage Code 18 and an MSP code of P.

"Code 18" is for Medicare beneficiaries who are enrolled in the Family Planning Benefit Program (FPBP), who are also income eligible for QMB. 6. If you are Billed -​ Strategies Consumers can now call 1-800-MEDICARE to report a billing issue. If a consumer reports a balance billng problem to this number, the Customer Service Rep can escalate the complaint to the Medicare Administrative Contractor (MAC), which will send a compliance letter to the provider with a copy to the consumer. See CMS Medicare Learning Network Bulletin effective Dec.

16, 2016. Send a letter to the provider, using the Justice In Aging Model model letters to providers to explain QMB rights.​​​ both for Original Medicare (Letters 1-2) and Medicare Advantage (Letters 3-5) - see Overview of model letters. Include a link to the CMS Medicare Learning Network Notice. Prohibition on Balance Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program (revised June 26. 2018) In January 2017, the Consumer Finance Protection Bureau issued this guide to QMB billing.

A consumer who has a problem with debt collection, may also submit a complaint online or call the CFPB at 1-855-411-2372. TTY/TDD users can call 1-855-729-2372. Medicare Advantage members should complain to their Medicare Advantage plan. In its 2017 Call Letter, CMS stressed to Medicare Advantage contractors that federal regulations at 42 C.F.R. § 422.504 (g)(1)(iii), require that provider contracts must prohibit collection of deductibles and co-payments from dual eligibles and QMBs.

Toolkit to Help Protect QMB Rights ​​In July 2015, CMS issued a report, "Access to Care Issues Among Qualified Medicare Beneficiaries (QMB's)" documenting how pervasive illegal attempts to bill QMBs for the Medicare coinsurance, including those who are members of managed care plans. Justice in Aging, a national advocacy organization, has a project to educate beneficiaries about balance billing and to advocate for stronger protections for QMBs. Links to their webinars and other resources is at this link. Their information includes. September 4, 2009, updated 6/20/20 by Valerie Bogart, NYLAG Author.

Cathy Roberts. Author. Geoffrey Hale This article was authored by the Empire Justice Center.Some "dual eligible" beneficiaries (people who have Medicare and Medicaid) are entitled to receive reimbursement of their Medicare Part B premiums from New York State through the Medicare Insurance Premium Payment Program (MIPP). The Part B premium is $148.50 in 2021. MIPP is for some groups who are either not eligible for -- or who are not yet enrolled in-- the Medicare Savings Program (MSP), which is the main program that pays the Medicare Part B premium for low-income people.

Some people are not eligible for an MSP even though they have full Medicaid with no spend down. This is because they are in a special Medicaid eligibility category -- discussed below -- with Medicaid income limits that are actually HIGHER than the MSP income limits. MIPP reimburses them for their Part B premium because they have “full Medicaid” (no spend down) but are ineligible for MSP because their income is above the MSP SLIMB level (120% of the Federal Poverty Level (FPL). Even if their income is under the QI-1 MSP level (135% FPL), someone cannot have both QI-1 and Medicaid). Instead, these consumers can have their Part B premium reimbursed through the MIPP program.

In this article. The MIPP program was established because the State determined that those who have full Medicaid and Medicare Part B should be reimbursed for their Part B premium, even if they do not qualify for MSP, because Medicare is considered cost effective third party health insurance, and because consumers must enroll in Medicare as a condition of eligibility for Medicaid (See 89 ADM 7). There are generally four groups of dual-eligible consumers that are eligible for MIPP. Therefore, many MBI WPD consumers have incomes higher than what MSP normally allows, but still have full Medicaid with no spend down. Those consumers can qualify for MIPP and have their Part B premiums reimbursed.

Here is an example. Sam is age 50 and has Medicare and MBI-WPD. She gets $1500/mo gross from Social Security Disability and also makes $400/month through work activity. $ 167.50 -- EARNED INCOME - Because she is disabled, the DAB earned income disregard applies. $400 - $65 = $335.

Her countable earned income is 1/2 of $335 = $167.50 + $1500.00 -- UNEARNED INCOME from Social Security Disability = $1,667.50 --TOTAL income. This is above the SLIMB limit of $1,288 (2021) but she can still qualify for MIPP. 2. Parent/Caretaker Relatives with MAGI-like Budgeting - Including Medicare Beneficiaries. Consumers who fall into the DAB category (Age 65+/Disabled/Blind) and would otherwise be budgeted with non-MAGI rules can opt to use Affordable Care Act MAGI rules if they are the parent/caretaker of a child under age 18 or under age 19 and in school full time.

This is referred to as “MAGI-like budgeting.” Under MAGI rules income can be up to 138% of the FPL—again, higher than the limit for DAB budgeting, which is equivalent to only 83% FPL. MAGI-like consumers can be enrolled in either MSP or MIPP, depending on if their income is higher or lower than 120% of the FPL. If their income is under 120% FPL, they are eligible for MSP as a SLIMB. If income is above 120% FPL, then they can enroll in MIPP. (See GIS 18 MA/001 - 2018 Medicaid Managed Care Transition for Enrollees Gaining Medicare, #4) 3.

New Medicare Enrollees who are Not Yet in a Medicare Savings Program When a consumer has Medicaid through the New York State of Health (NYSoH) Marketplace and then enrolls in Medicare when she turns age 65 or because she received Social Security Disability for 24 months, her Medicaid case is normally** transferred to the local department of social services (LDSS)(HRA in NYC) to be rebudgeted under non-MAGI budgeting. During the transition process, she should be reimbursed for the Part B premiums via MIPP. However, the transition time can vary based on age. AGE 65+ For those who enroll in Medicare at age 65+, the Medicaid case takes about four months to be rebudgeted and approved by the LDSS. The consumer is entitled to MIPP payments for at least three months during the transition.

Once the case is with the LDSS she should automatically be re-evaluated for MSP. Consumers UNDER 65 who receive Medicare due to disability status are entitled to keep MAGI Medicaid through NYSoH for up to 12 months (also known as continuous coverage, See NY Social Services Law 366, subd. 4(c). These consumers should receive MIPP payments for as long as their cases remain with NYSoH and throughout the transition to the LDSS. NOTE during buy antibiotics emergency their case may remain with NYSoH for more than 12 months.

See here. See GIS 18 MA/001 - 2018 Medicaid Managed Care Transition for Enrollees Gaining Medicare, #4 for an explanation of this process. Note. During the buy antibiotics emergency, those who have Medicaid through the NYSOH marketplace and enroll in Medicare should NOT have their cases transitioned to the LDSS. They should keep the same MAGI budgeting and automatically receive MIPP payments.

See GIS 20 MA/04 or this article on buy antibiotics eligibility changes 4. Those with Special Budgeting after Losing SSI (DAC, Pickle, 1619b) Disabled Adult Child (DAC). Special budgeting is available to those who are 18+ and lose SSI because they begin receiving Disabled Adult Child (DAC) benefits (or receive an increase in the amount of their benefit). Consumer must have become disabled or blind before age 22 to receive the benefit. If the new DAC benefit amount was disregarded and the consumer would otherwise be eligible for SSI, they can keep Medicaid eligibility with NO SPEND DOWN.

See this article. Consumers may have income higher than MSP limits, but keep full Medicaid with no spend down. Therefore, they are eligible for payment of their Part B premiums. See page 96 of the Medicaid Reference Guide (Categorical Factors). If their income is lower than the MSP SLIMB threshold, they can be added to MSP.

If higher than the threshold, they can be reimbursed via MIPP. See also 95-ADM-11. Medical Assistance Eligibility for Disabled Adult Children, Section C (pg 8). Pickle &. 1619B.

5. When the Part B Premium Reduces Countable Income to Below the Medicaid Limit Since the Part B premium can be used as a deduction from gross income, it may reduce someone's countable income to below the Medicaid limit. The consumer should be paid the difference to bring her up to the Medicaid level ($904/month in 2021). They will only be reimbursed for the difference between their countable income and $904, not necessarily the full amount of the premium. See GIS 02-MA-019.

Reimbursement of Health Insurance Premiums MIPP and MSP are similar in that they both pay for the Medicare Part B premium, but there are some key differences. MIPP structures the payments as reimbursement -- beneficiaries must continue to pay their premium (via a monthly deduction from their Social Security check or quarterly billing, if they do not receive Social Security) and then are reimbursed via check. In contrast, MSP enrollees are not charged for their premium. Their Social Security check usually increases because the Part B premium is no longer withheld from their check. MIPP only provides reimbursement for Part B.

It does not have any of the other benefits MSPs can provide, such as. A consumer cannot have MIPP without also having Medicaid, whereas MSP enrollees can have MSP only. Of the above benefits, Medicaid also provides Part D Extra Help automatic eligibility. There is no application process for MIPP because consumers should be screened and enrolled automatically (00 OMM/ADM-7). Either the state or the LDSS is responsible for screening &.

Distributing MIPP payments, depending on where the Medicaid case is held and administered (14 /2014 LCM-02 Section V). If a consumer is eligible for MIPP and is not receiving it, they should contact whichever agency holds their case and request enrollment. Unfortunately, since there is no formal process for applying, it may require some advocacy. If Medicaid case is at New York State of Health they should call 1-855-355-5777. Consumers will likely have to ask for a supervisor in order to find someone familiar with MIPP.

If Medicaid case is with HRA in New York City, they should email mipp@hra.nyc.gov. If Medicaid case is with other local districts in NYS, call your local county DSS.

Under Medicare Part where can i buy zithromax z pak B, his co-insurance is 20% of the Medicare-approved charge for most outpatient services. He went to the doctor recently and, as with any other Medicare beneficiary, the doctor handed him a bill for his co-pay. Now Joe has a bill that he can’t pay. Read below where can i buy zithromax z pak to find out -- SHORT ANSWER. QMB or Medicaid will pay the Medicare coinsurance only in limited situations.

First, the provider must be a Medicaid provider. Second, even if the provider accepts Medicaid, where can i buy zithromax z pak under recent legislation in New York enacted in 2015 and 2016, QMB or Medicaid may pay only part of the coinsurance, or none at all. This depends in part on whether the beneficiary has Original Medicare or is in a Medicare Advantage plan, and in part on the type of service. However, the bottom line is that the provider is barred from "balance billing" a QMB beneficiary for the Medicare coinsurance. Unfortunately, this creates tension between an where can i buy zithromax z pak individual and her doctors, pharmacies dispensing Part B medications, and other providers.

Providers may not know they are not allowed to bill a QMB beneficiary for Medicare coinsurance, since they bill other Medicare beneficiaries. Even those who know may pressure their patients to pay, or simply decline to serve them. These rights and the ramifications of where can i buy zithromax z pak these QMB rules are explained in this article. CMS is doing more education about QMB Rights. The Medicare Handbook, since 2017, gives information about QMB Protections.

Download the 2020 where can i buy zithromax z pak Medicare Handbook here. See pp. 53, 86. 1 where can i buy zithromax z pak. To Which Providers will QMB or Medicaid Pay the Medicare Co-Insurance?.

"Providers must enroll as Medicaid providers in order to bill Medicaid for the Medicare coinsurance." CMS Informational Bulletin issued January 6, 2012, titled "Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs). The CMS bulletin states, "If the provider wants Medicaid to pay the coinsurance, then the provider must register as a Medicaid where can i buy zithromax z pak provider under the state rules." If the provider chooses not to enroll as a Medicaid provider, they still may not "balance bill" the QMB recipient for the coinsurance. 2. How Does a Provider that DOES accept Medicaid Bill for a QMB Beneficiary?. If beneficiary has Original Medicare -- The provider bills Medicaid - even if the QMB Beneficiary does not also where can i buy zithromax z pak have Medicaid.

Medicaid is required to pay the provider for all Medicare Part A and B cost-sharing charges for a QMB beneficiary, even if the service is normally not covered by Medicaid (ie, chiropractic, podiatry and clinical social work care). Whatever reimbursement Medicaid pays the provider constitutes by law payment in full, and the provider cannot bill the beneficiary for any difference remaining. 42 U.S.C where can i buy zithromax z pak. § 1396a(n)(3)(A), NYS DOH 2000-ADM-7 If the QMB beneficiary is in a Medicare Advantage plan - The provider bills the Medicare Advantage plan, then bills Medicaid for the balance using a “16” code to get paid. The provider must include the amount it received from Medicare Advantage plan.

3 where can i buy zithromax z pak. For a Provider who accepts Medicaid, How Much of the Medicare Coinsurance will be Paid for a QMB or Medicaid Beneficiary in NYS?. The answer to this question has changed by laws enacted in 2015 and 2016. In the proposed 2019 State Budget, Gov where can i buy zithromax z pak. Cuomo has proposed to reduce how much Medicaid pays for the Medicare costs even further.

The amount Medicaid pays is different depending on whether the individual has Original Medicare or is a Medicare Advantage plan, with better payment for those in Medicare Advantage plans. The answer also differs based on where can i buy zithromax z pak the type of service. Part A Deductibles and Coinsurance - Medicaid pays the full Part A hospital deductible ($1,408 in 2020) and Skilled Nursing Facility coinsurance ($176/day) for days 20 - 100 of a rehab stay. Full payment is made for QMB beneficiaries and Medicaid recipients who have no spend-down. Payments where can i buy zithromax z pak are reduced if the beneficiary has a Medicaid spend-down.

For in-patient hospital deductible, Medicaid will pay only if six times the monthly spend-down has been met. For example, if Mary has a $200/month spend down which has not been met otherwise, Medicaid will pay only $164 of the hospital deductible (the amount exceeding 6 x $200). See more on spend-down here where can i buy zithromax z pak. Medicare Part B - Deductible - Currently, Medicaid pays the full Medicare approved charges until the beneficiary has met the annual deductible, which is $198 in 2020. For example, Dr.

John charges $500 for a visit, for which where can i buy zithromax z pak the Medicare approved charge is $198. Medicaid pays the entire $198, meeting the deductible. If the beneficiary has a spend-down, then the Medicaid payment would be subject to the spend-down. In the 2019 proposed state budget, where can i buy zithromax z pak Gov. Cuomo proposed to reduce the amount Medicaid pays toward the deductible to the same amount paid for coinsurance during the year, described below.

This proposal was REJECTED by the state legislature. Co-Insurance - The amount medicaid pays in NYS is different for Original Medicare where can i buy zithromax z pak and Medicare Advantage. If individual has Original Medicare, QMB/Medicaid will pay the 20% Part B coinsurance only to the extent the total combined payment the provider receives from Medicare and Medicaid is the lesser of the Medicaid or Medicare rate for the service. For example, if the Medicare rate for a service is $100, the coinsurance is $20. If the Medicaid rate for the same service is only $80 or less, Medicaid would pay nothing, as it would consider the doctor where can i buy zithromax z pak fully paid = the provider has received the full Medicaid rate, which is lesser than the Medicare rate.

Exceptions - Medicaid/QMB wil pay the full coinsurance for the following services, regardless of the Medicaid rate. ambulance and psychologists - The Gov's 2019 proposal to eliminate these exceptions was rejected. hospital outpatient clinic, certain facilities operating under certificates issued under where can i buy zithromax z pak the Mental Hygiene Law for people with developmental disabilities, psychiatric disability, and chemical dependence (Mental Hygiene Law Articles 16, 31 or 32). SSL 367-a, subd. 1(d)(iii)-(v) , as amended 2015 If individual is in a Medicare Advantage plan, 85% of the copayment will be paid to the provider (must be a Medicaid provider), regardless of how low the Medicaid rate is.

This limit was enacted in the 2016 State Budget, and is better than what the Governor proposed - which was the same rule used in Original Medicare -- NONE of the copayment or coinsurance would be where can i buy zithromax z pak paid if the Medicaid rate was lower than the Medicare rate for the service, which is usually the case. This would have deterred doctors and other providers from being willing to treat them. SSL 367-a, subd. 1(d)(iv), added 2016 where can i buy zithromax z pak. EXCEPTIONS.

The Medicare Advantage plan must pay the full coinsurance for the following services, regardless of the Medicaid rate. ambulance ) psychologist ) The Gov's proposal in the 2019 budget to eliminate these exceptions was rejected by the legislature Example to illustrate the where can i buy zithromax z pak current rules. The Medicare rate for Mary's specialist visit is $185. The Medicaid rate for the same service is $120. Current where can i buy zithromax z pak rules (since 2016).

Medicare Advantage -- Medicare Advantage plan pays $135 and Mary is charged a copayment of $50 (amount varies by plan). Medicaid pays the specialist 85% of the $50 copayment, which is $42.50. The doctor is prohibited by federal law from "balance billing" where can i buy zithromax z pak QMB beneficiaries for the balance of that copayment. Since provider is getting $177.50 of the $185 approved rate, provider will hopefully not be deterred from serving Mary or other QMBs/Medicaid recipients. Original Medicare - The 20% coinsurance is $37.

Medicaid pays none of the coinsurance because the Medicaid rate ($120) is lower than the amount where can i buy zithromax z pak the provider already received from Medicare ($148). For both Medicare Advantage and Original Medicare, if the bill was for a ambulance or psychologist, Medicaid would pay the full 20% coinsurance regardless of the Medicaid rate. The proposal to eliminate this exception was rejected by the legislature in 2019 budget. . 4.

May the Provider 'Balance Bill" a QMB Benficiary for the Coinsurance if Provider Does Not Accept Medicaid, or if Neither the Patient or Medicaid/QMB pays any coinsurance?. No. Balance billing is banned by the Balanced Budget Act of 1997. 42 U.S.C. § 1396a(n)(3)(A).

In an Informational Bulletin issued January 6, 2012, titled "Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs)," the federal Medicare agency - CMS - clarified that providers MAY NOT BILL QMB recipients for the Medicare coinsurance. This is true whether or not the provider is registered as a Medicaid provider. If the provider wants Medicaid to pay the coinsurance, then the provider must register as a Medicaid provider under the state rules. This is a change in policy in implementing Section 1902(n)(3)(B) of the Social Security Act (the Act), as modified by section 4714 of the Balanced Budget Act of 1997, which prohibits Medicare providers from balance-billing QMBs for Medicare cost-sharing. The CMS letter states, "All Medicare physicians, providers, and suppliers who offer services and supplies to QMBs are prohibited from billing QMBs for Medicare cost-sharing, including deductible, coinsurance, and copayments.

This section of the Act is available at. CMCS Informational Bulletin http://www.ssa.gov/OP_Home/ssact/title19/1902.htm. QMBs have no legal obligation to make further payment to a provider or Medicare managed care plan for Part A or Part B cost sharing. Providers who inappropriately bill QMBs for Medicare cost-sharing are subject to sanctions. Please note that the statute referenced above supersedes CMS State Medicaid Manual, Chapter 3, Eligibility, 3490.14 (b), which is no longer in effect, but may be causing confusion about QMB billing." The same information was sent to providers in this Medicare Learning Network bulletin, last revised in June 26, 2018.

CMS reminded Medicare Advantage plans of the rule against Balance Billing in the 2017 Call Letter for plan renewals. See this excerpt of the 2017 call letter by Justice in Aging - Prohibition on Billing Medicare-Medicaid Enrollees for Medicare Cost Sharing 5. How do QMB Beneficiaries Show a Provider that they have QMB and cannot be Billed for the Coinsurance?. It can be difficult to show a provider that one is a QMB. It is especially difficult for providers who are not Medicaid providers to identify QMB's, since they do not have access to online Medicaid eligibility systems Consumers can now call 1-800-MEDICARE to verify their QMB Status and report a billing issue.

If a consumer reports a balance billng problem to this number, the Customer Service Rep can escalate the complaint to the Medicare Administrative Contractor (MAC), which will send a compliance letter to the provider with a copy to the consumer. See CMS Medicare Learning Network Bulletin effective Dec. 16, 2016. Medicare Summary Notices (MSNs) that Medicare beneficiaries receive every three months state that QMBs have no financial liability for co-insurance for each Medicare-covered service listed on the MSN. The Remittance Advice (RA) that Medicare sends to providers shows the same information.

By spelling out billing protections on a service-by-service basis, the MSNs provide clarity for both the QMB beneficiary and the provider. Justice in Aging has posted samples of what the new MSNs look like here. They have also updated Justice in Aging’s Improper Billing Toolkit to incorporate references to the MSNs in its model letters that you can use to advocate for clients who have been improperly billed for Medicare-covered services. CMS is implementing systems changes that will notify providers when they process a Medicare claim that the patient is QMB and has no cost-sharing liability. The Medicare Summary Notice sent to the beneficiary will also state that the beneficiary has QMB and no liability.

These changes were scheduled to go into effect in October 2017, but have been delayed. Read more about them in this Justice in Aging Issue Brief on New Strategies in Fighting Improper Billing for QMBs (Feb. 2017). QMBs are issued a Medicaid benefit card (by mail), even if they do not also receive Medicaid. The card is the mechanism for health care providers to bill the QMB program for the Medicare deductibles and co-pays.

Unfortunately, the Medicaid card does not indicate QMB eligibility. Not all people who have Medicaid also have QMB (they may have higher incomes and "spend down" to the Medicaid limits. Advocates have asked for a special QMB card, or a notation on the Medicaid card to show that the individual has QMB. See this Report - a National Survey on QMB Identification Practices published by Justice in Aging, authored by Peter Travitsky, NYLAG EFLRP staff attorney. The Report, published in March 2017, documents how QMB beneficiaries could be better identified in order to ensure providers do not bill them improperly.

What Codes the Provider Sees in eMedNY &. EPACES Medicaid eligibility system - see GIS 16 MA/005 - Changes to eMedNY for Certain Medicaid Recipient Coverage Codes (PDF) ​​​​​​​Recipient Coverage Code "09" is defined as "Medicare Savings Program only" (MSP) and is used along with an eMedNY Buy-in span and MSP code of "P" to define a Qualified Medicare Beneficiary (QMB). Providers will receive the following eligibility messages when verifying coverage on EMEVS and ePaces. "Medicare coinsurance and deductible only" for individuals with Coverage Code 06 and an MSP code of P. *Code 06 is "provisional Medicaid coverage" for Medicaid recipients found provisionally eligible for Medicaid, subject to meeting the spend-down.

See more about provisional coverage here. "Family Planning Benefit and Medicare Coinsurance and Ded" for individuals with Coverage Code 18 and an MSP code of P. "Code 18" is for Medicare beneficiaries who are enrolled in the Family Planning Benefit Program (FPBP), who are also income eligible for QMB. 6. If you are Billed -​ Strategies Consumers can now call 1-800-MEDICARE to report a billing issue.

If a consumer reports a balance billng problem to this number, the Customer Service Rep can escalate the complaint to the Medicare Administrative Contractor (MAC), which will send a compliance letter to the provider with a copy to the consumer. See CMS Medicare Learning Network Bulletin effective Dec. 16, 2016. Send a letter to the provider, using the Justice In Aging Model model letters to providers to explain QMB rights.​​​ both for Original Medicare (Letters 1-2) and Medicare Advantage (Letters 3-5) - see Overview of model letters. Include a link to the CMS Medicare Learning Network Notice.

Prohibition on Balance Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program (revised June 26. 2018) In January 2017, the Consumer Finance Protection Bureau issued this guide to QMB billing. A consumer who has a problem with debt collection, may also submit a complaint online or call the CFPB at 1-855-411-2372. TTY/TDD users can call 1-855-729-2372. Medicare Advantage members should complain to their Medicare Advantage plan.

In its 2017 Call Letter, CMS stressed to Medicare Advantage contractors that federal regulations at 42 C.F.R. § 422.504 (g)(1)(iii), require that provider contracts must prohibit collection of deductibles and co-payments from dual eligibles and QMBs. Toolkit to Help Protect QMB Rights ​​In July 2015, CMS issued a report, "Access to Care Issues Among Qualified Medicare Beneficiaries (QMB's)" documenting how pervasive illegal attempts to bill QMBs for the Medicare coinsurance, including those who are members of managed care plans. Justice in Aging, a national advocacy organization, has a project to educate beneficiaries about balance billing and to advocate for stronger protections for QMBs. Links to their webinars and other resources is at this link.

Their information includes. September 4, 2009, updated 6/20/20 by Valerie Bogart, NYLAG Author. Cathy Roberts. Author. Geoffrey Hale This article was authored by the Empire Justice Center.Some "dual eligible" beneficiaries (people who have Medicare and Medicaid) are entitled to receive reimbursement of their Medicare Part B premiums from New York State through the Medicare Insurance Premium Payment Program (MIPP).

The Part B premium is $148.50 in 2021. MIPP is for some groups who are either not eligible for -- or who are not yet enrolled in-- the Medicare Savings Program (MSP), which is the main program that pays the Medicare Part B premium for low-income people. Some people are not eligible for an MSP even though they have full Medicaid with no spend down. This is because they are in a special Medicaid eligibility category -- discussed below -- with Medicaid income limits that are actually HIGHER than the MSP income limits. MIPP reimburses them for their Part B premium because they have “full Medicaid” (no spend down) but are ineligible for MSP because their income is above the MSP SLIMB level (120% of the Federal Poverty Level (FPL).

Even if their income is under the QI-1 MSP level (135% FPL), someone cannot have both QI-1 and Medicaid). Instead, these consumers can have their Part B premium reimbursed through the MIPP program. In this article. The MIPP program was established because the State determined that those who have full Medicaid and Medicare Part B should be reimbursed for their Part B premium, even if they do not qualify for MSP, because Medicare is considered cost effective third party health insurance, and because consumers must enroll in Medicare as a condition of eligibility for Medicaid (See 89 ADM 7). There are generally four groups of dual-eligible consumers that are eligible for MIPP.

Therefore, many MBI WPD consumers have incomes higher than what MSP normally allows, but still have full Medicaid with no spend down. Those consumers can qualify for MIPP and have their Part B premiums reimbursed. Here is an example. Sam is age 50 and has Medicare and MBI-WPD. She gets $1500/mo gross from Social Security Disability and also makes $400/month through work activity.

$ 167.50 -- EARNED INCOME - Because she is disabled, the DAB earned income disregard applies. $400 - $65 = $335. Her countable earned income is 1/2 of $335 = $167.50 + $1500.00 -- UNEARNED INCOME from Social Security Disability = $1,667.50 --TOTAL income. This is above the SLIMB limit of $1,288 (2021) but she can still qualify for MIPP. 2.

Parent/Caretaker Relatives with MAGI-like Budgeting - Including Medicare Beneficiaries. Consumers who fall into the DAB category (Age 65+/Disabled/Blind) and would otherwise be budgeted with non-MAGI rules can opt to use Affordable Care Act MAGI rules if they are the parent/caretaker of a child under age 18 or under age 19 and in school full time. This is referred to as “MAGI-like budgeting.” Under MAGI rules income can be up to 138% of the FPL—again, higher than the limit for DAB budgeting, which is equivalent to only 83% FPL. MAGI-like consumers can be enrolled in either MSP or MIPP, depending on if their income is higher or lower than 120% of the FPL. If their income is under 120% FPL, they are eligible for MSP as a SLIMB.

If income is above 120% FPL, then they can enroll in MIPP. (See GIS 18 MA/001 - 2018 Medicaid Managed Care Transition for Enrollees Gaining Medicare, #4) 3. New Medicare Enrollees who are Not Yet in a Medicare Savings Program When a consumer has Medicaid through the New York State of Health (NYSoH) Marketplace and then enrolls in Medicare when she turns age 65 or because she received Social Security Disability for 24 months, her Medicaid case is normally** transferred to the local department of social services (LDSS)(HRA in NYC) to be rebudgeted under non-MAGI budgeting. During the transition process, she should be reimbursed for the Part B premiums via MIPP. However, the transition time can vary based on age.

AGE 65+ For those who enroll in Medicare at age 65+, the Medicaid case takes about four months to be rebudgeted and approved by the LDSS. The consumer is entitled to MIPP payments for at least three months during the transition. Once the case is with the LDSS she should automatically be re-evaluated for MSP. Consumers UNDER 65 who receive Medicare due to disability status are entitled to keep MAGI Medicaid through NYSoH for up to 12 months (also known as continuous coverage, See NY Social Services Law 366, subd. 4(c).

These consumers should receive MIPP payments for as long as their cases remain with NYSoH and throughout the transition to the LDSS. NOTE during buy antibiotics emergency their case may remain with NYSoH for more than 12 months. See here. See GIS 18 MA/001 - 2018 Medicaid Managed Care Transition for Enrollees Gaining Medicare, #4 for an explanation of this process. Note.

During the buy antibiotics emergency, those who have Medicaid through the NYSOH marketplace and enroll in Medicare should NOT have their cases transitioned to the LDSS. They should keep the same MAGI budgeting and automatically receive MIPP payments. See GIS 20 MA/04 or this article on buy antibiotics eligibility changes 4. Those with Special Budgeting after Losing SSI (DAC, Pickle, 1619b) Disabled Adult Child (DAC). Special budgeting is available to those who are 18+ and lose SSI because they begin receiving Disabled Adult Child (DAC) benefits (or receive an increase in the amount of their benefit).

Consumer must have become disabled or blind before age 22 to receive the benefit. If the new DAC benefit amount was disregarded and the consumer would otherwise be eligible for SSI, they can keep Medicaid eligibility with NO SPEND DOWN. See this article. Consumers may have income higher than MSP limits, but keep full Medicaid with no spend down. Therefore, they are eligible for payment of their Part B premiums.

See page 96 of the Medicaid Reference Guide (Categorical Factors). If their income is lower than the MSP SLIMB threshold, they can be added to MSP. If higher than the threshold, they can be reimbursed via MIPP. See also 95-ADM-11. Medical Assistance Eligibility for Disabled Adult Children, Section C (pg 8).

Pickle &. 1619B. 5. When the Part B Premium Reduces Countable Income to Below the Medicaid Limit Since the Part B premium can be used as a deduction from gross income, it may reduce someone's countable income to below the Medicaid limit. The consumer should be paid the difference to bring her up to the Medicaid level ($904/month in 2021).

They will only be reimbursed for the difference between their countable income and $904, not necessarily the full amount of the premium. See GIS 02-MA-019. Reimbursement of Health Insurance Premiums MIPP and MSP are similar in that they both pay for the Medicare Part B premium, but there are some key differences. MIPP structures the payments as reimbursement -- beneficiaries must continue to pay their premium (via a monthly deduction from their Social Security check or quarterly billing, if they do not receive Social Security) and then are reimbursed via check. In contrast, MSP enrollees are not charged for their premium.

Their Social Security check usually increases because the Part B premium is no longer withheld from their check. MIPP only provides reimbursement for Part B. It does not have any of the other benefits MSPs can provide, such as. A consumer cannot have MIPP without also having Medicaid, whereas MSP enrollees can have MSP only. Of the above benefits, Medicaid also provides Part D Extra Help automatic eligibility.

There is no application process for MIPP because consumers should be screened and enrolled automatically (00 OMM/ADM-7). Either the state or the LDSS is responsible for screening &. Distributing MIPP payments, depending on where the Medicaid case is held and administered (14 /2014 LCM-02 Section V). If a consumer is eligible for MIPP and is not receiving it, they should contact whichever agency holds their case and request enrollment. Unfortunately, since there is no formal process for applying, it may require some advocacy.

If Medicaid case is at New York State of Health they should call 1-855-355-5777. Consumers will likely have to ask for a supervisor in order to find someone familiar with MIPP. If Medicaid case is with HRA in New York City, they should email mipp@hra.nyc.gov. If Medicaid case is with other local districts in NYS, call your local county DSS. Once enrolled, it make take a few months for payments to begin.

Payments will be made in the form of checks from the Computer Sciences Corporation (CSC), the fiscal agent for the New York State Medicaid program. The check itself comes attached to a remittance notice from Medicaid Management Information Systems (MMIS).

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I’ve never understood striving for perfection. It’s unattainable. It’s the pinnacle I never want to reach. For if it’s attained, what more is there to achieve?

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Most know that working and working to achieve perfection is a waste of time, but somewhere along the way striving for perfection was drilled into us. It’s at the very core of our existence. When we were young, we worked and worked at achieving something for the accolades we knew would be coming our way. If only we did it right. If only we worked more, we’d hit the mark and hear our praises sung. Our self-worth became dependent on the compliment or two thrown our way. But in doing so, we hung onto the words of others and worked our hands raw, because as children the mark kept moving higher. You could never, ever truly hit the mark. You just kept working and working toward perfection. As an adult I’m telling you, perfection is unattainable. The mark never stops moving.

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Striving for perfection is an addiction. Most perfection addicts falsely believe that achieving perfection indicates excellence. But perfection and excellence are two different things.

The Merriam-Webster Dictionary states perfection as a) freedom from fault or defect, flawlessness, b) the quality or state of being saintly, c) an unsurpassable degree of accuracy or excellence. Excellence on the other hand is a) very good of its kind, b) eminently good, c) first class. Two similar, but totally different degrees in terms.

Who wants to be saintly or flawless anyway? Not I. No siree. I like being a little devilish, a little flawed. Ok, depending on who you ask, quite flawed. Regardless, I don’t demand perfection, but I do demand excellence.

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The driving force of my excellence comes from within. I know I want to be eminently good. First-class. First rate in anything I do. But I could care less what other people demand of or expect from me. I don’t live for them. I live for me. I answer to my own higher conscience, and if it’s good enough for me, then by golly, I’ve hit my mark. If it’s not good enough for them. No worries, they can spend the time to work it and work it to get it perfect. No skin off my nose.

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As a member of Toastmasters International, a public speaking club, in both my leadership and speaking roles, I strive for excellence to the best of my abilities. And therein lies the difference between excellence and perfection. To the best of your ability.

I was terrified when I stood up to give my first speech. Just tell the audience a little bit about myself. If I had strived for perfection that first time up, I never would have gone back to Toastmasters. I would have run out the door with my tail between my legs, or my hand over my mouth, never to look back. In expecting perfection, I never would have become president of the club, nor gone onto win public speaking contests. But because there were goals outlined in the manual, for newbie speakers, I just wanted to hit the mark for those goals. And I did. I had attained excellence for what I was aiming to achieve that night. Looking back now, I’m sure there were countless ums and ahs, long pauses and stuttering in that first speech. But in the end, who cares? I wasn’t laughed off the stage. I hit my mark. I achieved excellence. But not perfection. And that’s ok. If I had walked off that stage as Little Miss Perfect, I would have missed out on so much in learning from others, in pushing my comfort zone, and in becoming a better speaker.

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A fellow Toastmaster gave his third speech this past Tuesday. Was it perfect? Hell no. But was it excellent? You betcha. Even the content of the speech was right on the mark. He said in this day and age, if you ask an audience how many members believe they give 100% at work, guess how many people raise their hands? One hundred percent raise their hands. Know what that means? The average Joe gives 100%. Everybody does. Or so we think. With those odds, in order to be noticed or to move forward, then you better be giving 110%. Do you need to be perfect? Nope. But do you need to demand excellence? Absolutely.

Excellence I can handle. But I don’t ever want to be perfect. No siree, not me. I rather like being Little Miss un-Perfect.