demonstration

Unorganised workers federation protests New Labour Codes with demonstration




demonstration

Demonstrations in Thailand? No Problem, Travelers Say.

Filed under: ,

Shutterstock
The political protests currently taking place in parts of Bangkok don't seem to be affecting travel to and within Thailand. And that should be no surprise. Despite events -- a coup, floods and protests that closed an airport among them -- that have rocked the country in recent years, travelers remain unfazed about visiting Thailand.

Quartz reports:

Not only are tourists still coming, but they've been arriving in increasing numbers in recent years, according to government data.

The story adds:

Continue reading Demonstrations in Thailand? No Problem, Travelers Say.

Demonstrations in Thailand? No Problem, Travelers Say. originally appeared on Gadling on Mon, 02 Dec 2013 11:26:00 EST. Please see our terms for use of feeds.

Permalink | Email this | Comments




demonstration

CSB issues guidance on safety during science demonstrations

Washington – Three recent incidents that left both children and adults with burn injuries have prompted the Chemical Safety Board to issue a safety bulletin on educational science demonstrations that use flammable chemicals.




demonstration

Steakholder Foods Opens Demonstration Center

The facility offers live demonstrations of the company's 3D printers, showcasing real-time production of plant-based meat and seafood alternatives and promoting customer engagement.




demonstration

Demonstration of full polarization control of soft X-ray pulses with Apple X undulators at SwissFEL using recoil ion momentum spectroscopy

The ability to freely control the polarization of X-rays enables measurement techniques relying on circular or linear dichroism, which have become indispensable tools for characterizing the properties of chiral molecules or magnetic structures. Therefore, the demand for polarization control in X-ray free-electron lasers is increasing to enable polarization-sensitive dynamical studies on ultrafast time scales. The soft X-ray branch Athos of SwissFEL was designed with the aim of providing freely adjustable and arbitrary polarization by building its undulator solely from modules of the novel Apple X type. In this paper, the magnetic model of the linear inclined and circular Apple X polarization schemes are studied. The polarization is characterized by measuring the angular electron emission distributions of helium for various polarizations using cold target recoil ion momentum spectroscopy. The generation of fully linear polarized light of arbitrary angle, as well as elliptical polarizations of varying degree, are demonstrated.




demonstration

Demonstration of neutron time-of-flight diffraction with an event-mode imaging detector

Neutron diffraction beamlines have traditionally relied on deploying large detector arrays of 3He tubes or neutron-sensitive scintillators coupled with photomultipliers to efficiently probe crystallographic and microstructure information of a given material. Given the large upfront cost of custom-made data acquisition systems and the recent scarcity of 3He, new diffraction beamlines or upgrades to existing ones demand innovative approaches. This paper introduces a novel Timepix3-based event-mode imaging neutron diffraction detector system as well as first results of a silicon powder diffraction measurement made at the HIPPO neutron powder diffractometer at the Los Alamos Neutron Science Center. Notably, these initial measurements were conducted simultaneously with the 3He array on HIPPO, enabling direct comparison. Data reduction for this type of data was implemented in the MAUD code, enabling Rietveld analysis. Results from the Timepix3-based setup and HIPPO were benchmarked against McStas simulations, showing good agreement for peak resolution. With further development, systems such as the one presented here may substantially reduce the cost of detector systems for new neutron instrumentation as well as for upgrades of existing beamlines.




demonstration

tna to bring full snack food line demonstration to SNAXPO

The global processing and packaging provider will highlight its start-to-finish solutions for the snack industry via an interactive booth experience at SNAXPO in Houston.




demonstration

Experience the Best in NDI|HX3 PTZ cameras at ISE 2023 with BZBGEAR's live demonstrations

BZBGEAR plans to showcase their AI auto-tracking NDI®|HX 3 PTZ camera series during the show. The company is also offering demonstrations of the AI auto-tracking and network-based production functions of the camera series live on the show floor.




demonstration

BlackKite sensor flies on U.S. Army Group 4 UAS at EDGE 23 demonstration event

Wide-area motion imagery (WAMI) system tested as payload for Air-Launched Effects platform




demonstration

5G Proof-of-concept demonstrations

5G Proof-of-concept demonstrations




demonstration

Introducing Be My Eyes' Virtual Volunteer: A Demonstration of Some Game Changing Real-World Use Cases

In this episode of our podcast, Thomas Domville demonstrates the power of the Virtual Volunteer feature, set to come to the Be My Eyes app in late Q3 2023. Currently in beta testing, this feature, powered by OpenAI's GPT-4 model, has the potential to be a game changer for people with visual impairments. It offers a virtual sighted assistant that can generate context and understanding for images, allowing for a greater degree of independence in everyday tasks.

During the episode, Thomas showcases a variety of real-world use cases for the Virtual Volunteer, including identifying clothing; getting information from food packaging; describing greeting cards, photos from your photo library or places such as Facebook, and weather maps; reading restaurant menus, and more.

We thank the Be My Eyes team for allowing us to record and share this demonstration of the Virtual Volunteer.




demonstration

A Demonstration of Cisco Packet Tracer for Mac, a Powerful Network Simulation Tool

In this episode, Majid Almaadeed gives us a demonstration of Cisco Packet Tracer for Mac, a versatile network simulation and visualization tool designed for learning and practicing networking concepts. It provides a virtual environment where users can create, configure, and simulate network topologies and devices, enabling them to gain hands-on experience with networking technologies without the need for physical hardware.

Cisco Packet Tracer for Mac allows individuals to design and simulate complex network setups. It supports a wide range of Cisco devices, such as routers, switches, and wireless access points, enabling users to configure and interconnect them to create functional networks. You can explore various networking concepts, including routing, switching, wireless communications, and network security. It facilitates the simulation of network protocols and their behaviors, allowing users to understand how data flows through different network layers and devices.

In addition to its simulation capabilities, Cisco Packet Tracer for Mac offers a range of learning resources and activities, making it an ideal tool for educational institutions and self-paced learning. It allows users to test their network configurations, troubleshoot issues, and visualize the impact of changes before implementing them in real-world scenarios.




demonstration

A demonstration and Walkthrough of Safari Web Apps on macOS

In this episode, Tyler demonstrates how to create and use Safari website shortcuts or "Web apps" on macOS.

This feature allows you to create shortcuts to websites on your dock that when opened, behave as if the website was its own app. This may be useful for VoiceOver users, as web apps are included when pressing Command-Tab to cycle through open apps, making them easy to switch to and from. In addition, these web apps can be mapped to commands in Keyboard Commander so they can be accessed with a single keystroke.

To create a web app, go to a website in Safari and choose File > Add to Dock. Change the name and icon of the web app if you wish, and click Add. It can then be accessed via the Dock, or in the Applications folder in your Home folder, accessed by choosing Go > Home in Finder, or pressing Command-Shift-H. To map the web app to a command in Keyboard Commander, open Voiceover Utility > Commanders > Keyboard, click Add, type the key that you want to open the app when pressed, choose "Custom commands > Open application" from the menu, and navigate to and select the web app in the Open dialog.




demonstration

A Demonstration and Walkthrough of VoiceOver Command Customization on macOS

In this episode, Tyler demonstrates some of VoiceOver's command customization capabilities on macOS.

If you find a particular VoiceOver command difficult to perform, or discover a function in the Commands menu that doesn’t have a default command, you can assign your own custom command to it. In addition, you can configure commands to open apps and run scripts, so you don’t have to locate them manually.

Commands can be configured by going to VoiceOver Utility > Commands, selecting the “Command set: user” radio button, and clicking “Custom commands edit.” For ease of navigation, you can choose the type of commands you want to view or change, such as numpad, trackpad, keyboard, etc from the "Filter commands" popup menu, or use the search field to locate a particular command.

In this dialog, commands can be presented in either column view, which organizes commands into categories like general, information, and navigation, or table view, which displays a list of all VoiceOver commands, including user-configured ones, which you can navigate with the up and down arrow keys. To add a command, in column view, locate the command, interact with the table of assignments, and specify your new one using the "Add input" popup menu. To add a command when in table view, click the Add button, interact with the table, and specify the input assignment from the popup menu labeled "None: edited." Then, press VO-Right-Arrow passed an empty cell to another popup menu, and choose the command you want your new input assignment to perform.

transcript:

Disclaimer: This transcript is generated by AIKO, an automated transcription service. It is not edited or formatted, and it may not accurately capture the speakers’ names, voices, or content.: Hey, Apple Vissers.

Tyler here.

With a demonstration and walkthrough of VoiceOver command customization on macOS.

Prior to macOS Sequoia, VoiceOver included several user configurable sets of commands, known as commanders, for the numpad, trackpad, keyboard, and quick nav.

With macOS Sequoia, these commanders have been consolidated into VoiceOver's broader command set, meaning in addition to the existing modifiers that you could use, like the option key for keyboard commander, you can also create your own command assignments using the VoiceOver modifier, which may be useful if you find a particular VoiceOver command difficult to perform, if you find a command in the commands menu, for example, that lacks a default assignment, or if you want to create a custom command to open an application.

So to demonstrate this, I'm going to open VoiceOver utility on my mac with VoF8.

Opening VoiceOver utility.

VoiceOver utility.

VoiceOver utility.

Window.

Utility categories.

C for commanders.

Commands.

Commands.

VRA.

VoiceOver modifier.

Control option or caps lock.

VoiceOver modifier.

VoiceOver modifier.

This is the setting that was located in the general category in prior versions of macOS, but options are the same.

Control option, caps lock, or control option, or caps lock, which is the default.

VRA.

Also control VoiceOver with.

Also control VoiceOver with.

Numpad.

Uncheck.

Checkbox.

Numpad, which was formerly known as Numpad Commander.

If you want to use, if you have a…




demonstration

A Demonstration and Overview of iPhone Mirroring

In this episode, Tyler demonstrates the basics of using iPhone Mirroring, a feature that allows you to use your iPhone from your Mac, with VoiceOver. Topics covered in this demonstration include:

  • General description of the feature and its current issues and limitations
  • System requirements and setup
  • Navigating and dealing with various elements of the iOS user interface, such as the Home Screen, rotor actions, and context menus, using macOS
  • Controlling which iPhone apps can forward notifications to your Mac

More general information about this feature can be found in the Apple Support article "iPhone Mirroring: Use your iPhone from your Mac."

Transcript

Disclaimer: This transcript was generated by Aiko, an AI-powered transcription app. It is not edited or formatted, and it may not accurately capture the speakers’ names, voices, or content.

Hey Apple visitors, Tyler here, with a demonstration and overview of iPhone mirroring. iPhone mirroring is a feature that allows you to essentially use your iPhone from your Mac.

This may be useful if you, for example, prefer a given service's mobile app over its desktop or web equivalent, or if what you're using doesn't have a desktop app or website.

In addition, as notifications from your iPhone can be forwarded to your Mac via iPhone mirroring, you may find it more convenient to receive and respond to the notification on your Mac than to switch devices if you're working on your Mac when the notification comes in.

With the initial release of Mac OS Sequoia 15.0, this feature was completely inaccessible with voiceover.

With the subsequent 15.1 update, it has become accessible to a point.

I say to a point because at the time of recording, October 2024, there are several issues that, in my opinion, make the experience less than refined from a voiceover perspective, which I'll elaborate on later in this demo.

To use iPhone mirroring with voiceover, you'll need an iPhone with iOS 18.1 or later and a Mac with Mac OS 15.1 or later.

All iPhones capable of running iOS 18 work with iPhone mirroring, as do all Macs capable of running Sequoia, with the exception of the 2019 iMac, as that model lacks the T2 security chip or Apple silicon.

To set up iPhone mirroring, just open the iPhone mirroring app on your Mac and follow the on-screen instructions.

I've already done that, so now I'm going to demonstrate the feature.

I'm going to open iPhone mirroring on my Mac.

So here I am prompted to authenticate.

By default, whenever you open the iPhone mirroring app, you are prompted to authenticate as a way to verify your identity before it gives you control of your iPhone.

If you'd rather, it didn't prompt you to authenticate each time you open the app, you can change this in iPhone mirroring settings.

Just choose settings from the menu bar or press command comma and it should be there.

But I'm going to authenticate with touch ID now.

Close button.

Okay, so here I am in the iPhone mirroring window.

Okay, so we have home screen and app switcher.

Now you can use those buttons to get to those locations, or I find it more convenient to use the view menu or keyboard shortcuts.…




demonstration

News24 | Teargas, smoke in Maputo as police crack down on demonstrations

In some parts of the capital, protesters negotiated with police. In other parts there was no talking.




demonstration

Amsterdam police detain pro-Palestinian protesters at banned demonstration




demonstration

Amsterdam police detain pro-Palestinian protesters at banned demonstration 

THE HAGUE, Netherlands —  Police detained several people Sunday for taking part in a demonstration in central Amsterdam that had been outlawed following violence targeting fans of an Israeli soccer club, a local broadcaster reported.  Amsterdam Mayor Femke Halsema banned all demonstrations over the weekend in the aftermath of the grim scenes of youths on scooters and on foot attacking Maccabi Tel Aviv supporters on Thursday and Friday in what was widely condemned as a violent outburst of antisemitism in the Dutch capital.  Israel's ambassador to the Netherlands said that 2,000 Israelis were brought home on special flights from Amsterdam over the past few days  Before the match against Ajax, Maccabi fans also tore a Palestinian flag off a building in Amsterdam and chanted anti-Arab slogans on their way to the stadium. There were also reports of Maccabi fans starting fights.  Video on local broadcaster AT5 showed police detaining one man Sunday who was taking part in a small demonstration on the central Dam Square. The protesters yelled slogans including "Free, free Palestine." AT5 reported that about 20 people were detained.  Amsterdam Municipality said on X that police had begun arresting demonstrators who refused to leave the square, which is in the heart of the city's downtown shopping area and close to the historic canal network.  Organizers of the protest went to court on Sunday morning seeking an injunction to allow the demonstration, but a judge upheld the ban imposed by the municipality.  At the hearing, senior Amsterdam police officer Olivier Dutilh said that there were again incidents overnight targeting people thought to be Jewish, including some being ordered out of taxis and others being asked to produce their passports to confirm their nationality.  Police launched a large-scale investigation Friday after gangs of youths conducted what Amsterdam's mayor called "hit and run" attacks on fans that were apparently inspired by calls on social media to target Jewish people. Five people were treated at hospitals and more than 60 suspects were arrested.  Israeli Foreign Minister Gideon Saar rushed to the Netherlands on Friday and offered Israel's help in the police investigation. He met on Saturday with Dutch Prime Minister Dick Schoof and said in a statement that the attacks and demands to show passports "were reminiscent of dark periods in history." 




demonstration

Police detain dozens in Amsterdam after demonstrations banned

Police detain dozens in Amsterdam after demonstrations banned




demonstration

The Ultimate Demonstration of God’s Love

God’s love for sinners is a well-documented historical fact. Its verification doesn’t hinge on the consensus of theologians, nor does its validation rest on something we feel. The apostle John points us to the cross as the consummate and undeniable proof of divine love.

READ MORE




demonstration

Loan No. 2606-PRC: Shanxi Small Cities and Towns Development Demonstration Sector Project [B-YY-01-01]




demonstration

Shandong Qixia Ecological Function Conservation Demonstration Project

Extending across seven provinces and two autonomous regions, the Yellow River Ecological Corridor (YREC) comprises the second largest river basin in the People's Republic of China (PRC) with a population of 120 million. The basin is critical for food security yet faces complex ecological and environmental challenges. The region suffers from severe water scarcity, impacts from climate change and environmentally unsustainable development.





demonstration

Database on U.S. Department of Energy Budgets for Energy Research, Development, and Demonstration (1978–2025R)

The July 2024 update to our database on the U.S. government investments in energy research, development, demonstration, and deployment (ERD3) through the U.S. Department of Energy.




demonstration

First demonstration of in situ Lu–Hf dating using LA-ICP-MS/MS applied to monazite

J. Anal. At. Spectrom., 2024, 39,2703-2715
DOI: 10.1039/D4JA00258J, Technical Note
Shitou Wu, Junlong Niu, Yueheng Yang, Hao Wang, Jinhui Yang, Fuyuan Wu
Monazite is a LREE-rich accessory mineral in various igneous and metamorphic rocks; therefore, monazite geochronology has the potential to answer a range of important geological questions.
The content of this RSS Feed (c) The Royal Society of Chemistry




demonstration

Thowheed Jamaath members stage demonstration against Bill




demonstration

Demonstrations at Co-op facilities affecting Sask. producers: APAS

The Agricultural Producers Association of Saskatchewan (APAS) is the latest organization to weigh in on the Co-op Refinery labour dispute, saying demonstrations at Co-op facilities could negatively affect farmer’s seeding.




demonstration

Demonstrations in Thailand? No Problem, Travelers Say.

Filed under: ,

Shutterstock
The political protests currently taking place in parts of Bangkok don't seem to be affecting travel to and within Thailand. And that should be no surprise. Despite events -- a coup, floods and protests that closed an airport among them -- that have rocked the country in recent years, travelers remain unfazed about visiting Thailand.

Quartz reports:

Not only are tourists still coming, but they've been arriving in increasing numbers in recent years, according to government data.

The story adds:

Continue reading Demonstrations in Thailand? No Problem, Travelers Say.

Demonstrations in Thailand? No Problem, Travelers Say. originally appeared on Gadling on Mon, 02 Dec 2013 11:26:00 EST. Please see our terms for use of feeds.

Permalink | Email this | Comments




demonstration

AITUC to stage demonstration

THANJAVUR The All India Trade Union Congress will be organising a demonstration on May 11 to press the Union and State governments to expedite the pro




demonstration

CryoEM at 100 keV: a demonstration and prospects

100 kV is investigated as the operating voltage for single-particle electron cryomicroscopy (cryoEM). Reducing the electron energy from the current standard of 300 or 200 keV offers both cost savings and potentially improved imaging. The latter follows from recent measurements of radiation damage to biological specimens by high-energy electrons, which show that at lower energies there is an increased amount of information available per unit damage. For frozen hydrated specimens around 300 Å in thickness, the predicted optimal electron energy for imaging is 100 keV. Currently available electron cryomicroscopes in the 100–120 keV range are not optimized for cryoEM as they lack both the spatially coherent illumination needed for the high defocus used in cryoEM and imaging detectors optimized for 100 keV electrons. To demonstrate the potential of imaging at 100 kV, the voltage of a standard, commercial 200 kV field-emission gun (FEG) microscope was reduced to 100 kV and a side-entry cryoholder was used. As high-efficiency, large-area cameras are not currently available for 100 keV electrons, a commercial hybrid pixel camera designed for X-ray detection was attached to the camera chamber and was used for low-dose data collection. Using this configuration, five single-particle specimens were imaged: hepatitis B virus capsid, bacterial 70S ribosome, catalase, DNA protection during starvation protein and haemoglobin, ranging in size from 4.5 MDa to 64 kDa with corresponding diameters from 320 to 72 Å. These five data sets were used to reconstruct 3D structures with resolutions between 8.4 and 3.4 Å. Based on this work, the practical advantages and current technological limitations to single-particle cryoEM at 100 keV are considered. These results are also discussed in the context of future microscope development towards the goal of rapid, simple and widely available structure determination of any purified biological specimen.




demonstration

Exploring the secrets to success in sustainable-technology demonstration projects

Demonstration projects can represent a critical intermediate step between research and development (R&D) and large-scale commercialisation; yet many involving new sustainable technologies fail. In order to map the internal and external factors that enable or prohibit demonstration projects from reaching their goals, a case study of 21 projects was conducted. Qualitative data collected from funding applications and interviews were analysed to identify key themes. Based on these findings, the study proposes a process model outlining the key activities for setting up a new demonstration project.




demonstration

Desert View Watchtower Hosts Second Annual Cultural Demonstration Series

Local artisans will share their culture and crafts with Grand Canyon National Park visitors at the Desert View Watchtower. https://www.nps.gov/grca/learn/news/dv-cultural-demonstrations.htm




demonstration

Desert View Watchtower Set to Host the Last Cultural Demonstration of 2015

The Desert View Watchtower at Grand Canyon National Park will host the final artist in the annual Cultural Demonstrator Series. https://www.nps.gov/grca/learn/news/last-2015-desert-view-demonstration.htm




demonstration

Sialendoscopy demonstration apparatus

Models, kits and methods useful in the demonstration of sialendoscopy devices and techniques are described. An exemplary demonstration apparatus comprises a support structure, an insert structure contacting the support structure, and a duct structure contacting the insert structure. The insert structure has a top surface defining a first opening and a bottom surface defining a second opening, and defines a channel with a first end in communication with the first opening and a second end in communication with the second opening. The duct structure comprises an elongate tubular member and has a first end in fluid communication with the first opening of the insert member, a second end, and defines a lumen extending from the first end to the second end. A portion of the duct structure is releasably disposed within the channel defined by the insert structure.




demonstration

Demonstration vor dem Reichstag – Attila Hildmann abgeführt

In Berlin, Stuttgart, Frankfurt, München und Köln gab es am Samstag erneut Proteste gegen die Einschränkungen wegen der Corona-Epidemie. Vor dem Reichstag nahm die Polizei 30 Personen vorläufig fest. Unter den Teilnehmern war auch Vegankoch Attila Hildmann.





demonstration

Warwick Academy Students Hold Demonstration

Friday, February 28 marked the 20th consecutive Friday morning that a small group of Warwick Academy students demonstrated on Middle Road to raise awareness about climate change, with the students holding the demonstration before school started. A spokesperson said, “Friday, February 28 marked the 20th consecutive Friday morning that a small group of concerned Warwick Academy students […]

(Click to read the full article)




demonstration

Group Counter Protests Paid Democrat Demonstration

Christi Gibson June 28, 2017 DES MOINES- With health insurance premiums on the rise and deductibles skyrocketing, not to mention the majority of insurance companies in Iowa abandoning the Affordable Care Act (Obamacare), Iowans are growing increasingly concerned about healthcare for themselves and their family members. The impending vote on […]




demonstration

Electrical and anatomical demonstrations : delivered at the School of Massage and Electricity, in connection with the West-End Hospital for Diseases of the Nervous System, Paralysis and Epilepsy, Welbeck Street, London. A handbook for trained nurses and m

London : J. & A. Churchill, 1887.




demonstration

Ellis's demonstrations of anatomy : being a guide to the knowledge of the human body by dissection.

London : Smith, Elder, 1887.




demonstration

Impact of Pediatric Exclusivity on Drug Labeling and Demonstrations of Efficacy

Most therapeutic products used in children have not been studied in that population. There is a need for special incentives and market protection (pediatric exclusivity) to compensate drug sponsors for studying these products in children.

Of 189 products studied under pediatric exclusivity, 173 (92%) received new labeling information. Pediatric efficacy was not established for 78 (42%), including 81% of oncology drugs. Probability of demonstrating efficacy was related to therapeutic area and year exclusivity was granted. (Read the full article)




demonstration

Demonstration facility for non-destructive inspection and non-contact 3D metrology systems established in Yokohama




demonstration

Free cooking and food demonstrations at Delaware State Fair

Visitors to the Delaware State Fair can learn how to cook Japanese foods, carve a chicken, eat healthy on a budget and make a watermelon banana split – all in one place, at the Department of Agriculture’s Education Building. Starting Friday, July 19, DDA and its partners will offer a lineup of free food and cooking demonstrations every day of the fair.



  • Department of Agriculture

demonstration

MHK risk assessment tool set for demonstration in London this month

Offshore Renewable Energy (ORE) Catapult and consultancy firm Frazer-Nash, both based in the UK, will perform a live demonstration of their marine hydrokinetics (MHK) energy project risk assessment tool during the International Tidal Energy Summit pre-conference risk and reliability workshop in London on Nov. 23.
 




demonstration

The Ultimate Demonstration of God’s Love

God’s love for sinners is a well-documented historical fact. Its verification doesn’t hinge on the consensus of theologians, nor does its validation rest on something we feel. The apostle John points us to the cross as the consummate and undeniable proof of divine love.

READ MORE




demonstration

ADB Approves Green Financing, River Restoration Demonstration Project in Anhui, PRC

ADB has approved a $100 million loan for a demonstration project that will help clean up the Xin’an River in Anhui Province in the PRC. The project will also pilot an innovative financing mechanism to reduce rural pollution...




demonstration

Medical staff praised for silent counter-protest in Colorado as anti-lockdown demonstrations erupt across US

Defiant US healthcare workers have been praised after silently blocking cars during coronavirus anti-lockdown demonstrations in Colorado.




demonstration

A controversial new demonstration in Medicare: Potential implications for physician-administered drugs


According to an August 2015 survey, 72 percent of Americans find drug costs unreasonable, with 83 percent believing that the federal government should be able to negotiate prices for Medicare. Recently, Acting Administrator of the Centers for Medicare and Medicaid Services (CMS) Andy Slavitt commented that spending on medicines increased 13 percent in 2014 while health care spending growth overall was only 5 percent, the highest rate of drug spending growth since 2001.

Some of the most expensive drugs are covered under Medicare’s medical benefit, Part B, because they are administered by a physician. They are often administered in hospital outpatient departments and physician offices, and most commonly used to treat conditions like cancer, rheumatoid arthritis, and macular degeneration. Between 2005 and 2014, spending on Part B drugs has increased annually by 7.7 percent, with the top 20 drugs by total amount of Medicare payments accounting for 57 percent of total Part B drug costs. While overall Part B drug spending is a small portion of Medicare drug spending, the high growth rate is a concern, especially as new expensive breakthrough cancer drugs enter the market and have a negative effect on consumers’ pockets.

Unlike Part D, the prescription drug benefit, there are fewer incentives built in to Part B for providers to consider lower cost treatments for patients even if the lower cost drug may be clinically equivalent to the more expensive drug, because prior to budget sequestration, providers received 6 percent on top of the Average Sales Price (ASP) of the drug. Larger providers and hospitals often receive discounts on these drugs as well, increasing the amount they receive directly on top of the out-of-pocket cost of the drug.

This leads to more out-of-pocket costs for the consumer, as patients usually pay 20 percent of Part B services. The Government Accountability Office (GAO) estimated that in 2013, among new drugs covered under Part B, nearly two-thirds had per beneficiary costs of over $9,000 per year, leading to out-of-pocket costs for consumers of amounts between $1,900 and $107,000 over the year. On top of these high costs, this can lead to problems with medication adherence, even for serious conditions such as cancer.

A New Payment Model

To help change these incentives and control costs, CMS has proposed a new demonstration program, which offers a few different reimbursement methods for Part B drugs. The program includes a geographically stratified design methodology to test and evaluate the different methods. One of the methods garnering a lot of attention is a proposal to lower the administration add-on payment to providers, from current 6 percent of ASP, to 2.5 percent plus a flat fee of $16.80 per administration day.

Policymakers, physician organizations, and patient advocacy organizations have voiced major concerns raising the alarm that this initiative will negatively affect patient access to vital drugs and therefore produce poorer patient outcomes. The sequester will also have a significant impact on the percentage add on, reducing it to closer to an estimated .86 percent plus the flat fee. But we believe the goals of the program and its potential to reduce costs represent an important step in the right direction. We hope the details can be further shaped by the important communities of providers and patients who will deliver and receive medical care.

Geographic Variation

Last year, we wrote a Health Affairs Blog that highlighted some of the uses and limitations of publicly available Part B physician payment data. One major use was to show the geographic variation in practice patterns and drug administration, and we particularly looked at the difference across states in Lucentis v. Avastin usage. As seen in Exhibit 1, variation in administration is wide among states, even though both are drugs used to treat the same condition, age-related macular degeneration, and were proven to have clinically similar outcomes, but the cost of Lucentis was $2,000 per dose, while Avastin was only $50 per dose.

Using the same price estimates from our previous research, which are from 2012, we found that physician reimbursement under the proposed demonstration would potentially change from $120 to $66.80 for Lucentis, and increase from $3 to $18.05 for Avastin. Under the first payment model, providers were receiving 40 times as much to administer Lucentis instead of Avastin, while under the new proposed payment model, they would only receive 3.7 times as much.

While still a formidable gap, this new policy would have decreased financial reimbursement for providers to administer Lucentis, a costly, clinically similar drug to the much cheaper Avastin. As seen in Exhibit 1, a majority of physicians prescribe Avastin, thus this policy will allow for increased reimbursement in those cases, but in states where Lucentis is prescribed in higher proportions, prescribing patterns might start to change as a result of the proposed demonstration.


Source: Author’s estimates using 2012 CMS Cost Data and Sequestration Estimates from DrugAbacus.org

The proposed demonstration program includes much more than the ASP modifications in its second phase, including:

  • discounting or eliminating beneficiary copays,
  • indication-based pricing that would vary payments based on the clinical effectiveness,
  • reference pricing for similar drugs,
  • risk-sharing agreements with drug manufacturers based on clinical outcomes of the drug, and
  • creating clinical decision tools for providers to help develop best practices.

This is all at the same time that a new model in oncology care (OCM) is being launched, which could help to draw attention to total cost of care. It is important that CMS try to address rising drug costs, but also be sure to consider all relevant considerations during the comment period to fine-tune the proposal to avoid negative effects on beneficiaries’ care.

We believe CMS should consider offering a waiver for organizations already participating in Center for Medicare & Medicaid Innovation (CMMI) models like the OCM, because financial benchmarks are based on past performance and any savings recognized in the future could be artificial, attributable to this demonstration rather than to better care coordination and some of the other practice requirements that are part of the proposed OCM. Furthermore, because this demonstration sets a new research precedent and because it is mandatory in the selected study areas rather than voluntary, CMS must try to anticipate and avoid unintended consequences related to geographic stratification.

For example, it is possible to imagine organizations with multiple locations directing patients to optimal sites for their business. Also, without a control group, some findings may be unreliable. The proposed rule currently lacks much detail, and there does not seem to be enough time for organizations to evaluate the impact of the proposed rule on their operations. Having said that, it will be important for stakeholders of all types to submit comments to the proposed rule in an effort to improve the final rule prior to implementation.

The critical question for the policymakers and stakeholders is whether this model can align with the multitude of other payment model reforms — unintended consequences could mitigate all the positive outcomes that a CMMI model offers to beneficiaries. Helping beneficiaries is and should be CMS’ ultimate obligation.

Authors

      




demonstration

Affordable housing project in UK is a demonstration of Radical Simplicity

Architype demonstrates that simple forms and careful window choices are the way to build efficient, affordable homes.




demonstration

Cepezed's new offices are a demonstration of circular design

Design for deconstruction out of low-carbon materials is the way of the future.