Monday, June 29, 2020

A Comprehensive Case Management Program - Free Essay Example

JOURNAL OF PALLIATIVE MEDICINE Volume 12, Number 9, 2009 ? Mary Ann Liebert, Inc. DOI: 10. 1089=jpm. 2009. 0089 Original Article A Comprehensive Case Management Program To Improve Palliative Care 1 1 Claire M. Spettell, Ph. D. , Wayne S. Rawlins, M. D. , M. B. A. ,2 Randall Krakauer, M. D. ,3 Joaquim Fernandes, M. S. , 2 2 2 Mary E. S. Breton, B. S. , J. D. , Wayne Gowdy, B. S. , Sharon Brodeur, R. N. , B. S. , M. P. A. , Maureen MacCoy, B. S. N. , M. B. A. ,2 and Troyen A. Brennan, M. D. , M. P. H. 4 Abstract Objective: The objective of this study was to evaluate the impact of comprehensive case management (CM) and expanded insurance bene? s on use of hospice and acute health care services among enrollees in a national health plan. Study Design: Retrospective cohort design with three intervention groups, each matched to a historical control group. Methods: Intervention groups were health plan enrollees who died after 2004: 3491 commercial enrollees with CM; 387 commercial enrollees with CM and expanded hospice bene? ts; and 447 Medicare enrollees with CM. Control groups consisted of enrollees who died in 2004 prior to the start of the palliative care CM program. The main outcomes measured were the proportion using hospice, mean number of hospice days, and number of inpatient days measured through medical claims. Results: Hospice use increased for all groups receiving CM compared to the respective control groups: from 30. 8% to 71. 7% ( p 0. 0001) for commercial members with CM and from 27. 9% to 69. 8% ( p 0. 0001) for Commercial members with CM and enhanced hospice bene? ts. Mean hospice days increased from 15. 9 to 28. 6 days ( p . 0001) and from 21. 4 to 36. 7 days ( p 0. 0001) for these groups, respectively. Inpatient stays were lower for all groups receiving CM services compared to their respective control groups. Conclusions: Comprehensive health plan CM and more liberal hospice bene? t design may help to break down barriers to hospice use; ben e? ts might be liberalized within the context of such case management programs without adverse impact on total costs. Introduction ospice care helps to meet the needs of patients with advanced illness by providing effective pain and symptom management and support for the emotional and spiritual needs of patients and their caregivers. Such care allows patients to achieve a sense of control over dying, many of whom would prefer to die at home. Hospice utilization among Medicare decedents increased dramatically in the last decade, to approximately 40% in 2005. 1 However, the current rate is considered less than ideal to fully meet the needs of those with advanced illness, and there is substantial variation in the use of hospice by age, race, diagnosis and geographic location. 2–5 Many individuals enter hospice shortly before death, substantially limiting the bene? t they might obtain 1 2 H from hospice services. In 2006, the median length of stay in hospice was 20. 6 days, down from 26. 0 days in 2005, and little changed from the 2001 rate of 20. 5 days. 6 Among Medicare decedents, the median length of stay was 15 days in 2005. 1 Barriers to election of hospice care include preferences for aggressive curative treatment among patients, families, and physicians, physician’s discomfort and dif? culty in initiating conversations about advanced illness choices, Medicare regulations requiring the patient’s physician to certify that the patient has a life expectancy of 6 months or less, limits on hospice bene? s, and the need to forego curative medical treatment in order to qualify for hospice. 7,8 In 2004, a national health plan launched a comprehensive case management (CM) program targeted speci? cally to patients with advanced illness and their families. The health Aetna Informatics, Aetna, Blue Bell, Pennsylvania. Aetna Government Health Plan, Aetna, Hartford, Connecticut. 3 National Care Management, Aetna, Hartford, Connecticut. 4 CVS Car emark, Woonsocket, Rhode Island. 827 828 plan also piloted a bene? t design change among 13 large employers that liberalized hospice and respite bene? s for seriously ill patients and families. The purpose of this article is to describe the impacts of the case management program and the liberalization of bene? ts on use of hospice and acute health care services in commercially insured and Medicare Advantage populations. Methods Program description A comprehensive case management program termed the ‘‘Compassionate Care Program’’ was launched at the end of 2004 and included comprehensive case management services provided by health plan nurse case managers who received extensive training in palliative care. This specialized case management program supplemented the traditional case management services available to all health plan members. Members were identi? ed as candidates for the program through the health plan’s process of concurrent review of in patient admissions, physician referral, self-referral, and monthly use of a proprietary predictive model examining medical and pharmacy claims to identify individuals whose claims history suggested a terminal illness. Case management services were available to all eligible members and few individuals declined these services. Physicians in the health plan network were noti? ed of the program at the time it was implemented via an article in the physician newsletter sent out by the health plan. Case managers reached out by telephone to identi? ed members and conducted a comprehensive assessment of their needs and developed individual plans of care that addressed the members’ needs and preferences. The number and frequency of contacts with the member was established with the member=caregiver during the initial outreach. The case manager assisted the member and family by addressing issues such as the need for education of the disease process for member and family=caregiver, understanding of advanced directives and assistance with obtaining these documents, understanding their preferences for care, identifying community resources for member and caregiver support, social work support, pain control, medication management, and home or respite care. The case manager worked with the member’s physician to coordinate care and with the hospice agency if hospice was in place. The case manager handled an average caseload of 40–45 health plan members, all in various stages of need for support. Members with advanced illness made up a small percentage of that caseload at any given time. The internal cost for a nurse case manager to manage a member with advanced illness was approximately $400. In January 2005, a pilot program was launched for 13 large employers whereby, in addition to the provision for case management support, insurance bene? ts for hospice and respite were expanded. The expansion included extending the durational de? nition of te rminal illness from 6 months to 12 months; continued receipt of curative treatment while also receiving hospice services; removal of length of stay for inpatient hospice and maximum dollar limits for outpatient hospice; provision of 15 days per year of respite bene? ts for family members; and availability of bereavement services through employer assistance programs. Study design and population SPETTELL ET AL. The study was a retrospective cohort design using matched historical control groups. Data for the analysis came from the health plan’s eligibility, claims and utilization management systems. Members who died during 2005, 2006, and the ? rst quarter of 2007 were identi? ed through the health plan case management database. These members comprised three groups: 1. Case Management (CM) Group (n ? 3491): Commercially insured members with usual hospice bene? ts who received comprehensive case management (CM) services. 2. Enhanced Bene? ts CM Group (n ? 387): Commercially in sured members whose bene? s were provided by one of the 13 large employers participating in the pilot program for which hospice and respite bene? ts were liberalized. These members also received the comprehensive CM services. 3. Medicare CM Group (n ? 447): Medicare Advantage members with Centers for Medicare Medicaid Services (CMS)-de? ned hospice bene? ts who received comprehensive CM services. Control groups Historical control groups were created for each of the groups above. Health plan members who died in 2004 were identi? ed from the Social Security Death Index ? es by matching on Social Security Number and two of the following: date of birth, gender and full name. 9 Control group members had been eligible for the health plan’s usual case management services in place prior to the specialzed training program in palliative care. Each member receiving CM was matched to a control group member on age, severity of illness score, presence of health plan pharmacy bene? ts, and diagnosis using information available in the health plan’s claims and eligibility systems. Severity of illness of each member was quanti? d using the Ingenix Episode Risk GroupO (ERGO) Score software. 10 This score was derived from weights assigned from a normative insurance claims database for each diagnosis group found in medical episodes constructed from medical and pharmacy claims data. Study period The date of enrollment in the CM program was determined for each member and the number of days between this index date and the person’s death was calculated. The number of days prior to death was used as the observation period for each matched pair. Primary outcome measures The primary outcome measures were rates of hospice use and mean number of days in hospice, which were expected to be higher in the groups receiving case management and expanded hospice bene? ts compared to the control groups. Hospice use measures were calculated from health plan claims data for t he commercial members and included the proportion of members using hospice in both inpatient and outpatient settings and the length of service in hospice. For the Medicare CM Group for whom hospice claims were paid directly by CMS, hospice use was calculated based on an CASE MANAGEMENT TO IMPROVE PALLIATIVE CARE indicator ? ag on the CMS Monthly Member Eligibility Files. The number of days in hospice was not available from this source. The ? ag indicating hospice in the health plan utilization management system was not available for the Medicare control group, thus, the hospice use rate was not calculated for this group. Secondary outcome measures The acute care utilization measures were calculated from health plan claims data, and included the proportion of members with acute care hospital admissions, the rate of acute hospital inpatient days per 1000 members, proportion of members with an intensive care unit (ICU) stay during an acute hospitalization, proportion of members w ith emergency visits, the rate of emergency department visits per 1000 members, and rate of primary care and specialist vists per member. No directional hypotheses were made for these measures. Measures expressed as days per 1000 members were calculated as the number of days divided by the number of members in the CM Group multiplied by 1000. Statistical analysis Generalized linear models were used to compare outcome variables between groups with a subject effect variable to adjust for the paired nature of the data. McNemar’s test was used for comparing proportions. A generalized linear model assuming a two parameter Poisson probability distribution was employed for comparing rates represented as counts per thousand. The two-parameter Poisson was chosen for the response probability distribution so that the scale parameter 829 could model the overdispersion in the data. Kaplan-Meier methods were used to estimate the number of days between hospice enrollment and death, an d group differences were tested using a two-sided log rank test. All models included a variable for the geographical region where the member resided to adjust for regional differences in hospice use. Results of statistical tests yielding p values 0. 5 were considered statistically signi? cant. All analyses were done using SAS v. 9. 0 (SAS Institute, Cary, NC). Results Table 1 shows sociodemographic characteristics of each CM group compared to its control group. There were no statistically signi? cant differences on the variables used in the matching process. Table 2 lists the top 15 diagnoses for each group. Within each cohort, the CM and Control groups varied in the geographic distribution of members; therefore, geographic region was used as an adjustor in the analyses of outcomes. Table 3 presents the use of health care services by the Enhanced Bene? ts CM Group, the CM Group and the Medicare CM Groups compared to their respective control groups, adjusted for differences in ge ographic region. The average number of days in the CM program was 42. 3 days (Enhanced Bene? ts CM Group), 39. 6 days (CM), and 56. 7 days (Medicare CM). For each group receiving CM, the percentage of members using hospice more than doubled compared to its control group (Enhanced Bene? ts CM 69. 8% versus 27. 9%, p 0. 0001; CM 71. 7% versus 30. %, p 0. 0001). The mean number of days with hospice increased from 21. 4 days to 36. 7 days ( p 0. 0001) for the Enhanced Bene? ts CM group, and from Table 1. Characteristics of Case Management (CM) Groups Enhanced Bene? ts CM Study group 387 59. 47 18. 19 18. 1% 74. 4% 61. 5% 96. 6% 9. 8% 20. 9% 4. 1% 9. 8% 39. 3% 8. 3% 7. 8% Control group 387 59. 04 17. 76 18. 1% 74. 4% 55. 8% 98. 2% 10. 3% 22. 0% 9. 3% 9. 8% 19. 4% 8. 8% 20. 4% Study group 3491 56. 52 19. 79 62. 4% 80. 7% 49. 7% 65. 1% 20. 3% 16. 4% 12. 7% 24. 7% 10. 3% 9. 8% 5. % CM Control group 3491 56. 87 19. 65 62. 4% 80. 7% 48. 1% 74. 9% 14. 9% 16. 6% 14. 0% 14. 4% 12. 1% 10. 0% 1 7. 9% Study group 447 77. 14 24. 83 100% 57. 5% 44. 5% 0% 47. 9% . 2% 48. 5% . 2% 0% 3. 1% 0% Medicare CM Control group 447 77. 36 24. 17 100% 57. 5% 44. 5% 0% 43. 0% 0% 34. 7% 0% 0% 22. 4% 0% n Matching variables Mean age Comorbidity risk scorea Health plan pharmacy Bene? t % with cancer as terminal condition Descriptive variables % Female % PPO Health plan geographic Region Mid-Atlantic North Central Northeast Southeast Southwest West Unknown a value 0. 45 0. 5582 1. 00 1. 00 0. 1086 p value 0. 1266 0. 5824 1. 00 1. 00 0. 1880 p value 0. 6588 0. 4181 1. 00 1. 00 1. 00 Episode Risk GroupO Score. PPO, preferred provider organization. 830 Table 2. Top Fifteen Conditions by Case Management Group Enhanced case management Lung cancer Gastrointestinal cancer Colorectal cancer Neoplasms—other Brain cancer Breast cancer Gynecologic cancer Neurologic disorders Hodgkin’s lymphoma COPD Hepatobiliary disorders Head and neck cancer Heart failure Malignant melanoma Sepsis 15. % 10. 6% 9. 0% 7. 2% 6. 2% 6. 2% 5. 2% 3. 9% 3. 1% 2. 6% 1. 8% 1. 6% 1. 3% 1. 3% 1. 0% Commercial case management Lung cancer Gastrointestinal cancer Breast cancer Neoplasms—other Colorectal cancer Gynecologic cancer Brain cancer Hodgkin’s lymphoma Hematologic cancer Hepatobiliary disorders Head and neck cancer Prostate cancer COPD Respiratory failure Malignant melanoma 20. 1% 12. 7% 9. 2% 7. 9% 7. 5% 5. 0% 3. 8% 2. 2% 2. 1% 1. 8% 1. 5% 1. 5% 1. 4% 1. 3% 1. 2% SPETTELL ET AL. Medicare case management Lung cancer Gastrointestinal cancer Congestive heart failure Neoplasms—Other COPD Colorectal cancer Breast cancer Prostate cancer Chronic renal failure Diabetes mellitus Respiratory failure Cerebrovascular disease Hematologic cancer Pneumonia Hypertension 19. 5% 9. 6% 6. 7% 6. 5% 6. 0% 4. 9% 3. 4% 3. 1% 2. 9% 2. 9% 2. 9% 2. 2% 2. 2% 1. 6% 1. 6% 15. 9 days to 28. 6 days ( p 0. 0001) for the CM group. The rate of use of hospice in the Medicare CM Group was 62. 9%. The percentages of members with an acute inpatient stay after program enrollment were reduced for the Enhanced Bene? ts CM Group (16. % versus 40. 3%, p 0. 0001), CM group (22. 7% versus 42. 9%, p 0. 0001), and Medicare CM group (30. 0% versus 88. 4%, p 0. 0001) compared to their respective control groups. The number of acute inpatient days was reduced for the Enhanced Bene? ts CM group (1549 versus 3986 days per thousand members, p 0. 0001), CM Group (2311 versus 3858 days per thousand members, p 0. 0001), and Medicare CM Group (2309 versus 15,217 per thousand members, p 0. 0001) compared to their respective control groups. The proportion of members with ICU stays during an acute inpatient admission was signi? antly lower for all of the groups receiving CM compared to their respective control groups, as was ICU days per thousand member (Enhanced Bene? ts CM Group 899 versus 2542, p 0. 0001, CM Group 1356 versus 2162, p 0. 0001, Medicare CM Group; 1189 versus 9840, p 0. 0001) c ompared to the control groups. Table 3. Adjusted Utilization of Health Care Servicesa Enhanced Bene? ts CMb Pilot Group Study group Average days in 42. 3 CM program Percent Using 69. 8% Hospice Mean days from hospice 36. 7 claim and death Hospice inpatient 1,424. days=1000 Hospice outpatient 14,607. 0 days=1000 Percent with acute 16. 8% inpatient stay Average Length of 5. 84 Stay Inpatient Percent With Emergency Visit 9. 8% Percent With ICU Stay 9. 6% Acute inpatient days=1000 1,549. 4 Emergency visits=1000 94. 4 ICU days=1000 898. 8 Primary care physician 0. 53 visits per Member Specialist visits per Member 1. 44 a c b CM Group Study group 39. 6 Control group p value Medicare CM Group Study group 56. 7 Control group p value Control group p value 27. 9% 21. 4 601. 2 3,914. 5 40. 3% 6. 91 15. 2% 23. 0% 3,986. 4 159. 3 2,541. 6 1. 00 2. 09

Tuesday, May 26, 2020

Asian Students and Colleges Essay - 1386 Words

Many people assume that Asians have it the easiest of all the races when it comes to applying to top tier schools. Not only are they â€Å"naturally intelligent†, they are also a minority meaning they can reap the benefits of affirmative action; therefore, they must be able to easily stand out against White applicants with a comparably high academic record. Surprisingly, studies show that the opposite may be true. Asians admission rates in top tier schools like Harvard suggest that White applicants may be chosen over an Asian applicant with the same qualifications due to higher expectations for Asian students. These unofficial discriminatory policies have the exact opposite effect of affirmative action: giving advantaged Whites preference over†¦show more content†¦Yet despite numerous roadblocks, the emphasis on hard work and education in most Asian cultures has allowed them to excel above and beyond expectations. On average, Asians score higher than any other race on the SAT (Washington, 2011). In highly selective High Schools that require application based on merit there is often an Asian population that is disproportionate to the Asian population in the surrounding county. In Thomas Jefferson High School in Fairfax County, one of the top high schools in the nation for math and science, subjects Asians generally excel in, Asians have surpassed Whites in enrollment. The student body of Thomas Jefferson is fifty-four percent Asian, an astounding figure when compared to the mere nineteen percent Asian population in Fairfax County (Shapiro, 2013). n.d.). Unfortunately, this success also led to the stereotype that Asians are naturally intelligent as well as create a higher standard for Asians, undermining the hard work and dedication many put into academics. 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Tuesday, May 19, 2020

Top 5 Supreme Court Scandals

If your knowledge of Supreme Court scandals begins and ends with the tumultuous Senate confirmation process of Justice Brett Kavanaugh in October 2018, you will either be relieved or horrified to learn that he was by no means the first jurist with a less-than-pristine reputation. From the judge who refused to listen to cases argued by women, to a former KKK member, bad behavior on the nations highest court is not that uncommon. Here are a few of the juiciest scandals.   Supreme Court Fast Facts The Supreme Court is the highest court in the federal judicial system of the United States.The Supreme Court is composed of nine judges, including eight Associate Justices and the Chief Justice of the United States. Supreme Court justices are nominated by the President of the United States with the approval of the United States Senate. The Supreme Court has appellate jurisdiction (right to consider) over all federal and state court decisions dealing with questions of constitutional or statutory law, as well as original jurisdiction over lawsuits between the states.The Court also has the power of judicial review, the authority to overturn laws that violate the Constitution or unlawful acts of the executive branch. Wishing Washington Dead, Justice Rutledge Gets the Boot Appointed by President George Washington in 1789, John Rutledge was one of the Supreme Court’s first justices. He was also the first and so-far only justice to be kicked off the court. In June 1795, Washington issued a â€Å"recess appointment† temporarily making Rutledge Chief Justice. But when the Senate reconvened in December 1795, it rejected Rutledge’s nomination because of what John Adams called his â€Å"Disorder of the Mind.† Still not recovered from the unexpected death of his wife in 1792, Rutledge gave a rant-filled speech on July 16, 1795, in which he reportedly suggested that it would be best if Washington died rather than sign the Jay Treaty with England. In Justice Rutledge’s case, that was where the Senate drew the line. Justice McReynolds, the Equal-Opportunity Bigot Justice James Clark McReynolds served on the court from 1914 to 1941. After he died in 1946, not a single other living current or former justice attended his funeral. Reason being, they had all come to hate his guts. Justice McReynolds, it seems, had established himself as an unabashed bigot and all-around hater. A vocal anti-Semite, his other favorite targets included African Americans, Germans, and women. Whenever Jewish Justice Louis Brandeis spoke, McReynolds would leave the room. Of Jews, he once declared, â€Å"For 4,000 years the Lord tried to make something out of Hebrews, then gave it up as impossible and turned them out to prey on mankind in general—like fleas on the dog.† He would often refer to African Americans as â€Å"ignorant,† possessing â€Å"but a small capacity for radical improvement.† And in the rare (in those days) event a woman attorney appeared to argue a case before the court, McReynolds would exclaim, â€Å"I see the female is h ere again,† before grandly gathering his robe and leaving the bench. Justice Hugo Black, Ku Klux Klan Leader Though widely recognized as a staunch supporter of civil liberties during his 34 years on the bench, Justice Hugo Black was once an organizing member of the Ku Klux Klan, even recruiting and swearing in new members. Though he had left the organization by the time President Franklin D. Roosevelt appointed him to the Supreme Court in August 1937, public knowledge of Black’s KKK history resulted in a political firestorm. Supreme Court Justice Hugo Black. Getty Images Archive On October 1, 1937, less than two months after taking his seat on the court, Justice Black was forced to give an unprecedented nationwide radio address to explain himself. In a speech heard by an estimated 50 million Americans, he said in part, â€Å"I did join the Klan. I later resigned. I never rejoined,† adding, â€Å"Before becoming a Senator I dropped the Klan. I have had nothing to do with it since that time. I abandoned it. I completely discontinued any association with the organization. I have never resumed it and never expect to do so.† Hoping to reassure African Americans, Black said, â€Å"I number among my friends many members of the colored race. Certainly, they are entitled to the full measure of protection accorded by our Constitution and our laws.† However, in 1968, Black argued in favor of limiting the scope of the Civil Rights Act as it applied to the protection of the rights of activists and protesters, writing â€Å"unfortunately there are so me who think that Negroes should have special privileges under the law.† Justice Fortas Denies Taking Bribes but Still Quits Justice Abe Fortas suffered a fatal flaw for judges. He liked to take bribes. Appointed to the Supreme Court by President Lyndon Johnson in 1965, Fortas had already faced serious allegations of improperly promoting LBJ’s political career while serving on the highest court in the land. Things got a lot worse for Justice Fortas in 1969, when it was revealed that he had accepted a secret legal retainer from his former friend and client, infamous Wall Street financier Louis Wolfson. Under their agreement, Wolfson was to pay Fortas $20,000 a year for life in return for special help and â€Å"consultation† during his pending trial on charges of securities fraud. Whatever Fortas did to help Wolfson failed. He ended up in federal prison and Fortas saw the handwriting on the wall. Though he always denied taking Wolfson’s money, Abe Fortas became the first and so far only Supreme Court justice to resign under threat of impeachment on May 15, 1969. Clarence Thomas, Anita Hill, and the NAACP The two most-watched TV events of 1991 were probably the First Gulf War and the Clarence Thomas vs. Anita Hill Supreme Court Senate confirmation hearings. Spanning 36 days, the bitterly fought hearings centered on accusations that Thomas had sexually harassed attorney Anita Hill when she had worked for him at the Department of Education and the EEOC. In her testimony, Hill vividly described a series of instances in which she claimed Thomas made sexual and romantic advances toward her, despite her repeated demands that he stop. Thomas and his Republican backers contended Hill and her supporters had made the whole thing up to prevent President Ronald Reagan from placing a conservative African American judge, who might vote to weaken civil rights laws, on the Supreme Court. Justice Clarence Thomas During Senate Hearings. Corbis Historical / Getty Images In his testimony, Thomas vehemently denied the allegations, stating, â€Å"This is not an opportunity to talk about difficult matters privately or in a closed environment. This is a circus. It’s a national disgrace.† He went on to liken the hearings to â€Å"a high-tech lynching for uppity blacks who in any way deign to think for themselves, to do for themselves, to have different ideas, and it is a message that unless you kowtow to an old order, this is what will happen to you. You will be lynched, destroyed, caricatured by a committee of the U.S. Senate rather than hung from a tree.† On October 15, 1991, the Senate confirmed Thomas by a vote of 52–48. Justice Brett Kavanaugh Overcomes Sexual Assault Claims People who remembered Clarence Thomas and Anita Hill probably got feelings of dà ©jà   vu watching the Senate confirmation hearings of Justice Brett Kavanaugh in October 2018. Soon after the hearings began, the Judiciary Committee was told that research psychologist Dr. Christine Blasey Ford had formally accused Kavanaugh of sexually assaulting her at a fraternity party in 1982 when she was in high school. In her testimony, Ford claimed that a visibly drunken Kavanaugh had forced her into a bedroom where he pinned her on a bed while attempting to remove her clothes. Expressing her fear that Kavanaugh was going to rape her, Ford added, â€Å"I thought he might inadvertently kill me.† Brett Kavanaugh Sworn In As 114th Supreme Court Justice. Getty Images News In his rebuttal testimony, Kavanaugh angrily denied Ford’s allegations while accusing Democrats in general—and the Clintons specifically—of attempting â€Å"a calculated and orchestrated political hit, fueled with apparent pent-up anger about President Trump and the 2016 election.† After a controversial supplemental FBI investigation found no evidence proving Ford’s claim, the Senate voted 50-48 to confirm Kavanaugh’s nomination on October 6, 2018. Sources and Further Reference Flanders, Henry. The Life of John Rutledge. J.B. Lippincott Co.Glass, Andrew. Abe Fortas resigns from Supreme Court May 15, 1969. Politico (May 15, 2008)James C. McReynolds. Oyez Project Official Supreme Court media. Chicago Kent College of Law.The Thomas Nomination; Excerpts From Senates Hearings on the Thomas Nomination. The New York Times (1991)Pramuk, Jacob. Trump Supreme Court nominee Brett Kavanaugh categorically denies sexual misconduct accusation detailed in New Yorker report. CNBC (September 14, 2018)

Friday, May 15, 2020

Legal Mechanisms for Foreign Institutional - Free Essay Example

Sample details Pages: 10 Words: 3110 Downloads: 8 Date added: 2017/06/26 Category Law Essay Type Analytical essay Level High school Tags: India Essay Did you like this example? Abstract The paper seeks to lay down the existing legal mechanism for the foreign institutional ( portfolio ) investors in India and draws out its merit and demerit. I then seeks to draw outline to the current response of the Indian state both, legislature and judiciary to the foreign institutional investors. It then seeks to draw out the existing dichotomy between the income tax department and the government policies about the FPIs. Don’t waste time! Our writers will create an original "Legal Mechanisms for Foreign Institutional" essay for you Create order Introduction Foreign institutional investors have not been defined in the income tax. The term in economic sense means an investment that is made into a country without a permanent establishment. Whether or not the investor has a permanent establishment in India is an important factor to determine before giving them tax benefit. There can be many definitions of the same, one of the standard definition that is used is given in the Article 7 of the DTAA between India and UK. It defines that a person has a permanent establishment if he maintains a stock is goods or merchandise from where he actually delivers goods or merchandise for or on behalf of the enterprise.[1] Simply because one carries out a business in another country through a middle man does not mean that one has a PE in another country. One company has to exercise effective control on the portfolio company for it to be considered as their company. [2] The power to define and name an investor as FIIs has been given to t he Central Government under section 115 AD (3) (a). In 1995 Government of India listed 65 FIIs and they were treated to be foreign institutional investors (hereinafter referred to as FIIs).[3] The Foreign portfolio in investors (FPIs) registered with the SEBI are also be referred to as FIIs for the purpose of section 115 AD.[4] They have an advanced tax liability as per the provisions of Part C of Chapter XVII of the Income Tax Act 1961. They can claim Tax deduction at source (TDS) or avoid tax as per the DTAA. Section 115 AD elaborates what would constitute total income for a FII and it includes: (1) income received in respect of securities other than the income received from dividends. [5] Or units referred to in section 115 AB, i.e. income received in respect of units purchased in foreign currency or long term income arising from the transfer of foreign currency. (2) Income by the way of short term capital gain arising from the transfer of such securities. The amount of income ta x is to be calculated in the following manner: (1) For securities, it is to be calculated at the rate of 20 percent with an exception mentioned in section 194 LD. [6](2) For short term capital gain, it is to be calculated at 30 percent except for the income in section 111 A which is to be calculated at the rate of 15 percent[7]. (3) For long term capital gain , it is to be calculated at the rate of 10 percent[8] (4) the amount taxed had the income been reduced by the amount of income for which the FIIs are charged.[9] This difference in tax rate for the short term capital gain and long term capital gain exists as the latter contributes more to the economics of the state. No deduction are offered to the gross income of the FIIs in respect of securities under section 28 to 44C or in clause (i) and (iii) of section 57 or under section 57 or under Chapter VI-A.[10] the first and the second g provisos of section 47 relating to the computation of charges will not apply in case of a transf er of the aforesaid securities by the FIIs. Any capital gains arising from transfer of long-term capital asset which is either equity shares or units of equity oriented shares shall be exempt from income-tax[11]. This is subject to any transaction relating to the sale of securities on which the securities transaction tax (hereinafter referred as STT) is applicable.[12] As per new STT the short-term capital gains is taxable at the rate of 10%.[13]. It also envisages that neither deduction under Chapter VI can be claimed nor the rebate under section 88 be claimed. Thus after 2005 for short term transaction of securities 10% tax is charged either under section 111 A or 115 AD. Section 196 D elaborates that where an income in respect of securities referred to in section 115 is payable to a Foreign institutional investors, the person responsible for making the payment shall deduce income tax at the rate of 20 percent at the time of credit of such income to the account of the payee or at the time of the payment thereof in cash or y issue of a cheque or draft or any other mode. FIIs can enter into transactions relating to the securities or by entering in to derivate contracts. Derivative contracts are bilateral contracts which determine the content of obligation from a reference value. The performance of the contract is done in future. The reference value of the derivate contract can be anything starting from a real economy to any future event. In Indian the extent of these derivates contracts are regulated by SEBI and RBI and take place through a registered intermediary, like stock exchange board of India.[14] Thus this is a very important financial tool which is used by the FIIs to invest into a country. As the obligation is based on a reference value the fluctuates in a very short interval of time and thus the income is only generated In respect of the purchase and sale of the derivate and not on dividend as is the case with the securities. Section 10 (38) exempts any income that arise out of the transfer of long term capital asset being an equity share in a company or unit of an equity oriented fund and section 115 AD charges 10 percent tax from the long term capital gain arising out of the transfer of securities. This give rise to two peculiar questions. Firstly, whether the securities are held as stock in trade or as capital assets of the FIIs and Secondly, whether they would attract the provision of section 115 AD or Section 10(38), or 111 A. This a determinative factor as the investor has various rate benefits and rates under various heads. In the case of 115 AD the FIIs would be taxed at the statutory rate in 10(38), full tax exemption and in 111 A partial exemption. The first question is important because it uses the term capital asset and thus creating a doubt on whether such exemption is applicable to securities as capital asset only or does it extent to securities held as stock in trade. The legislative intent behind s ection 115 AD would through light on the purpose for which such specific section for FIIs was enacted. This was to encourage more and more foreign investors to invest in India, to fix the tax rate and to establish certainty regarding the tax rates and thus allowing the investors to assess all possible variables before designing their investment strategy in India. The purpose of section 115 AD is to provide for special concessional rate of taxation in relation to securities received from or arising from the income of FIIs. There was no particular reason why the income on account of trading in securities was excluded from the purview of section 115 AD. The fact that the transfer of securities gave rise to capital gains was dealt with clause (b) was not a valid reason to hold that the transfer of securities in the course of trading in them was outside the ambit of section 115 AD.[15] Even though it cannot be denied that the securities held by the FIIs are held in nature of Stock in trade and thus should come under the head of profit and gain from business and profession but is such proposition is accepted than the purpose for which a special section was in acted would be defeated. Also it is a general principal of law that specific provision (Section 115 AD) are considered over the general provisions ( 10 (38) and 111 A) Thus securities held by the FIIs have to be considered not as stock in trade but as capital asset for them to fall under the ambit of section 115 AD and both long term and short term capital gain by the FIIs will be taxed under section 115 AD. In India a lot of investment is done by the FIIs from the countries that India has signed a Double Tax Avoidance treaty (DTAA) with. Generally there is always clause which provides that such investors will pay tax only in the country where they have a permanent establishment. Thus the provisions of section 115 AD will not be applicable with such investors. In XYZ/ABC Equity Fund,[16], there was a holding company in Mauritius. Its main business was to hold securities and selling them at profit. The capital had been raised from obtaining money by acquiring large block of shares in Indian companies (portfolio companies). The investment strategy was through investment advisors who were acting as the nominee directors in this portfolio companies .Thus the assessing officer charged income tax on the profit and gain from business and profession. It was contended that the sales from the proceeds resulted in the business receipt and not capital gains. It was argued that the presence of the nominee director in the portfolio company made those portfolio companies the PE of the holding company in India. The question was whether the capital gain arising from the transfer of securities held in an Indian company (the portfolio company) be taxable in India? and whether the FII have a PE in India ? The court held that the presence of the nominee director did not make those portfolio compan ies as PE of the holding company in India. Hence not taxable under the head of business and gain and under Article 5 of DTAA (double tax avoidance agreement) of India Mauritius , the provision of section 115 AD and 10 (38) will not be attracted. The reason why DTAA is given preference over 115 AD or 10 (38) is because of section 90 (2), which says that the provisions shall apply to the extent they are more beneficial to the tax payer. Hence when a situation arise where the applicability of one of the two is in question. DTAA will prevail as it is more beneficial to the taxpayer. There is no provision in the Income tax Act which taxes the income generated in derivative contracts. Derivative has been recognized as a security under Securities Contract (Regulation)Act Now the same question arises whether the income from derivative contract is taxed under Income from business and profession or under capital asset. There are two views in this regards: First was given in the Morgan Stanley international limited [17] case where it was pointed that in order to determine this it is imperative to determine the extent of trade that is undergone with respect to the asset. At times it is important to determine the intension of the party to put them under of the income heads. The intension is determined from their action,. i.e. the substantial nature of their transactions and the quantum of purchase and sale. Thus there is no set rule of whether transaction in derivative contracts will be taxed under capital gain or profit from business and profession. It has to be determined on case to case basis Second view was taken recently in the case of Platinum Investment management A.c Platinum International Fund v DDIT [18]where the tribunal taxed the income from transaction of derivatives as capital gain. It scrutinized the SEBI regulations 1995 with section 115 AD and laid that in light of the Memorandum explaining the provisions of the Finance Bill, 1993, a FII is allowed to invest only in securities and thus the income from securities as to taxed only under section 115 AD. It said that as derivative has been made part of the securities and the marginal note of Chapter XII in which section 115 AD falls reads determination of tax in special cases. Thus a special provision overrides the general provision. I further went on state that speculative transaction, under section 43 (5) does not have an application to the FIIs in regards to the securities mentioned in section 115 AD. It said that the variable of the speculation and non speculation does not play any role and the income for al l the aforementioned reason. Both the views are important, they are not contradictory, one leaves it on the fact so each case, and other instills certainty in the regards to the taxation of the derivative contracts. The second view favors the investor more as it categorizes all transactions of FIIs securities as investment transactions and not as business transactions which allows them to invest more in India as they have to pay less tax. Further whenever there is a question in regards of the applicable law, DTAA will prevail and FIIs will not be taxed in respect to the Derivatives contracts but where there is no DTAA signed with the Country to which the FII belong then it will be taxed under section 115 AD. European financial transaction tax A lesson can be learned from the EU which has come up with an extensive policy regarding the taxation of Financial transaction. This tax was brought to ensure that the financial institutions make a fair contribution to covering the cost of the recent crisis an d to ensure a level playing field with other sectors from taxation point of view. Under this tax the insurance contracts, mortgage lending, consumer credit and primary market transactions are excluded. Also currency transactions on spot markets are outside the scope of FTT, which preserves the free movement of capital. The scope of this tax is wide enough to incorporate instruments which are negotiable on the capital market, money market instruments, units and share in collective investment undertaking (including UCITS and alternative investment funds) and derivate agreements. It covers the over the counter trade. It is not only limited to the transfer of ownership but rather represents the obligation entered into. The definitions of financial instruments is wide and includes investment firms, organized markets, credit institutions, insurance and reinsurance undertaking and their managers, pension funds and their managers, holding companies financial leasing companies, special purpo se entities, and where possible refers to the definitions provided by the relevant EU legislation adopted for regulatory purpose. [19] Additionally other persons carrying out certain financial activities on a significant basis are considered to be financial institutions. [20] The principal of taxation in this residential principal, in order for the financial transaction to be taxable in the EU, one of the parties to the transaction needs to be established in the territory of the member state. Moment of chargeability is defined as the moment when the transaction occurs.[21] FTT is payable by each financial transaction institutions which fulfill any of the following conditions: It is a party to the transaction, acting either for its own account or for the account of another person It is acting in the mane of the party to the transaction The transaction has been carried out on its account. When one FI act s on the behalf of the account of another FI only that other financial institutions shall e liable to pay FTT. In case the transaction is carried out by electronic means the tax is due immediately at the time of chargeability.[22] Thus now when India looks at reforming it tax policies it is imperative that he lessons are drawn for the EU which ensures that tax is levied on the investors but the investors but they are not overburdened. There is some line that has to be drawn and it should be visible so that there is certainty in the market and the investors can access the market and its regulatory framework before they are investing into a country. In the globalized world today the importance of the FPIs cannot be undermined and if they decide to invest in India , it is symbiotic relationship that both share and till it can remain that not turn parasitic from either side, a healthy marker will flourish. The regulatory mechanism in our country screens a lot of investment strategy and the tax regime make is even worse. The tax regime as w e have understood does provide with incentive to the FIIs but there has always been confusion on what head they would taxed. That fosters uncertainty in the minds of the investors. Recently due to the change in government there was a lot a hope that India will be opening itself to the foreign investment and the unfriendly ground created by the Vodafone case will be cleared but the tax department has recently issued a notice to the portfolio companies that a minimum alternative tax shall be levied on them. Minimum alternative tax (MAT )is a tax that was levied on the companies and the firms who were earning a lot of profit but due to the various deductions and incentive were not paying proportionate tax. It is charges to some fixed rate on the books of account and it varies from companies to LLPs. The FPIs will be charges at the rate fo 20 % on ling term capital gain. India is one of the few countries in the world that levies tax on the non residents. This additional tax on the long term capital gain will disinterest the investors from investing into India.[23] FPIs before this notice pay zero tax for long capital gains but now it will change to 20 %, such an addition will surely hamper the already deteriorating investment attractiveness of India. As per the reports FPIs have been net buyers of 84, 988. 54 Crore in Indian equity market.[24] This projects the existing dichotomy within the government itself and reminds us that there is dire need to reform the tax system in India especially with respect to the FPIs. A [1] Article 7 [2] Morgan Stanley Co International Limited, 272 ITR 416. [3] Notification No. SO 282 (E)/ 31-3-95.Available at : // [4] Notification No: SO 199(E) / 22-1-2014. Available At : [5] Section 115 (O), Income tax Act, 1961. [6] Section 115AD (i) [7] Section 115AD(ii) [8] Section 115 AD (iii) [9] Section 115AD (iv) [10] Section 115 AD (2) (b) [11] Section 10 (38), Finance (No. 2) Act, 2004. [12] Chapter VII, Finance (No. 2) Act, 2004. [13] Section 111A, Finance (No. 2) Act, 2004. [14] Section 2(a) (a ), Securities contract Regulation Act, 1956. [15] Royal Bank of Cannada, IN re, (2010) 323 ITR 380 (AAR). [16] XYZ/ABC Equity Fund, (2001) 250 ITR 194 [17] Morgan Stanley Co. International Limited, (272 ITR 416). [18] Platinum Investment management A.C Platinum Int ernational Fund v DDIT ( ITA No 3598/ Mum / 2010 ). [19] Thornton Matheson, Taxing financial transactions: issues and evidence, 2011 IMF Working paer WP /11/54 . [20] Article 2(7), FTT [21] Article 4, FTT. [22] Article 10, FTT. [23] Bijal Ajinkya, partner Khaitan and Company, Business standard. ( 17 September 2014). Available At : [24] Business standard ( 17th September ) Available At :

Wednesday, May 6, 2020

Kurt Vonnegut s Slaughterhouse Five - 902 Words

I. Introduction A. Hook 1. PTSD, or post-traumatic stress disorder, is an anxiety disorder that develops in some after they experience extremely traumatic events, such as combat. Those with PTSD may relive the event via intrusive memories, flashbacks and nightmares; they would do anything to avoid memories of trauma, including inventing an alternate planet. 2. Billy, the main character in Kurt Vonnegut’s novel Slaughterhouse-Five, experienced firsthand the trauma of war during the firebombing of Dresden. After this event, Billy created Tramfaladore, the planet where time does not exist. B. Summary 1. In Kurt Vonnegut s novel, Slaughterhouse-Five, he waves a story of destruction, war, mental health, and time travel to demonstrate the†¦show more content†¦There were sounds like giant footsteps above.† (Vonnegut 177) b. â€Å"A guard would go to the head of the stairs every so often to see what it was like outside, then he would come down and whisper to the other guars. There was a firestorm out there. Dresden was one big flame. The one flame ate everything organic, everything that would burn.† (Vonnegut 177). c. Events that are more emotionally difficult are focused on less; instead of time travelling to the bombing, Billy remembers it (Harris). This makes the traumatic event less immediate, allowing for distance between the horrors of war and the present. 3. Non-linear fashion of SHV a. No specific climax or chronological order: events do not follow the traditional ‘linear’ fashion of novel. 1. Time is not a linear progression of events, but a constant condition: â€Å"All moments, past, present, and future, all have existed and always will.† → Tralfamadorian principle 2. The Tralfamadorians provide Billy with the concept of nonlinear time, which becomes the foundation for a mode of living (Vanderwerken). 3. â€Å"I am a Tralfamadorian, seeing all time as you might see a stretch of the Rocky Mountains. All time is all time. It does not change. It does not lend itself to warnings or explanations. It simply is. Take it moment by moment, and you will find that we are all, as I’ve said before, bugs in amber.† (Vonnegut 86) b. Events are seemingly randomized: the reader can interpret

Loss of Innocence in A Long Way Gone Memoirs of a Boy...

A prominent theme in A Long Way Gone is about the loss of innocence from the involvement in the war. A Long Way Gone is the memoir of a young boy, Ishmael Beah, wanders in Sierra Leone who struggles for survival. Hoping to survive, he ended up raiding villages from the rebels and killing everyone. One theme in A long Way Gone is that war give innocent people the lust for revenge, destroys childhood and war became part of their daily life. In the A Long Way Gone, Ishmael Beah, a twelve-year-old explains how he used to go on a swim with his friends and his love for rap music and hip-hop dance. When Ishmael and his friends went to visit Mattru Jong, they visited Ishmaels grandparents in Kabati. While staying at the Mattru Jong, they†¦show more content†¦Then, the boys were caught by a group of guarding villagers and they were sent to the chief of the village. When the chief is decides to drown the boys, the rap tape in Ishmaels pocket leads them to discover that they arent a th reat and only innocent boys. The boys stayed in Kamator for one month until it was finally attacked. Ishmael and his brother were seperated and never seen him again even his friends. Surviving alone in the forest for a month, Ishmael was able to find the exit of the forest and joins a group other boys. When the boys reach seashore, they were caught by fishermen. The fishermen gave the boys shoes because of their severe burn feet on the hot sand. After two weeks, the villagers caught the boys and when the chief saw Ishmaels rap cassette, they allows them to leave. When they are travelling to the next village, Saidu became sick and quiet. When they boys arrived, A woman was able to tell Ishmael about his family in the next village. 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Role of Methodology in Project Management †

Question: Discuss about the Role of Methodology in Project Management. Answer: Project Management Methodology Project Management methodology is a model or concept or approach which is being adopted by team members of the project irrespective of type, size and objective of the project(TutorialsPoint, 2017). It has a set of pre-defined steps or sequences of executing the project, which are required to be followed by the project manager for the proper success of the project and prevent it from any delay in time, cost overrun, additional resource requirements along with proper quality standards. Role of Methodology in Project Management Project management is a schedule of activities which are required to be followed for properly managing the project without affecting any of the three projects constraints. The methodology is analytically proven with full success rate(McConnell, 2010). It must be strictly followed by all the project managers to get a sure success in project management. It helps in taking proper and quick decisions by the project managers. The methodology helps in quick realization of the self-responsibilities by the team members. It provides a common understanding among the team and helps in managing the roles of senior management and creating effective governance and so the decisions(Naybour, 2016). Different Methodologies available There are various different approaches by which the project can be managed. So the project manager first needs to know all the methodologies for making the perfect choice among many. The different types of project management methodologies are: PRINCE2: according to this methodology, the members of board takes lead in project in place of the project manager, governance is given the higher priority for effective execution and controlling of the project(Wrike, 2017). The project manager acts as daily site coordinator. SDLC: is the traditional methodology of executing any project Waterfall: in this method the activities and the stages within the project are linked with finish to start relationship, so successor cannot start unless the predecessor activity or stage has completed fully. Agile: it depends on the people centric comments or the type of projects like IT or marketing Scrum: in this methodology the project management teams always keeps on targeting the hurdles present in the project and acts for removing them only to facilitate the smooth execution of the project PRiSM: is the approach of reducing the environmental footprint while executing the project activities Lean: according to this approach, the whole project team acts towards the common aim of reducing the number of resource utilization But it is the sole responsibility of the project team and manager to decide which approach is required to be adopted for the right type of the project, because all methodologies do not suit all projects. Two Methodologies To compare between the two methodologies, let us select the two famous methodologies Agile and Waterfall for the discussion: Agile Waterfall Advantage: for people related project which is always capable of going under changes(Palmquist, Lapham, Miller, Chick, Ozkaya, 2013) Advantage: for the projects where the resources and the cost is limited and need to be tracked throughout the project phase Disadvantage: generally there are chances of getting cost overrun for the project Disadvantage: cannot be applied for the project where the scope is not fixed since beginning Useful for: the project like IT and marketing, which requires many comments from different stakeholders to develop the final outcome Useful: for the projects where scope is rigid and confirmed from the beginning stage itself Similarity: both the approaches are derived from the same goal of achieving the quality product within the given time and cost. Both usages the same steps within the stages. Both has defined time frame to complete the stages or the project. Both the methodologies uses the approach of finalizing the scope at the very first stage of the project by conducting multiple levels of reviews. Methodologies and Project Life Cycle (PLC) The basic stages involved in the project life cycle are the initiation, planning, execution and closing and all these stages are well defined in the respective methodologies. The Agile methodology tells about organizing the high level meetings from the start and the end of each stages or steps to reorganize the requirement and plan the future execution stages for proper closing. The stakeholder management by fulfilling all the required expectations is the important stage in the project management which is being taken care in Agile and Waterfall models by arranging regular multilevel review meetings. So after all the study it can be concluded that the PLC must be executed according to any of the suitable methodology and its strictly defined steps. References McConnell, E. (2010, July 22). Project Management Methodology: Definition, Types, Examples. Retrieved August 30, 2017, from Naybour, P. (2016, May 24). The benefits of following a project management method. Retrieved August 30, 2017, from Palmquist, M. S., Lapham, M. A., Miller, S., Chick, T., Ozkaya, I. (2013). Parallel Worlds: Agile and Waterfall Differences and Similarities. Massachusetts: Carnegie Mellon University. TutorialsPoint. (2017). Project Management Methodologies. Retrieved August 30, 2017, from Wrike. (2017). Retrieved from II. Choose Your Project Management Methodology: