Off-base optimism: Part 1

I like to view myself as an optimist, but two recent reports demonstrate the danger of misplaced or premature optimism.  I fear that they are influenced by what the authors hope will be the case rather than what has proven to be the case.  I find this generally to be the situation in the health care arena, where public policy is often based on shallow interpretations of data and on people's political wishes rather than rigorous analysis.

The first comes from Karen Davis at the Commonwealth Fund, in a blog post entitled, "Health Spending Continues to Moderate, Cost of Reform Overestimated."  We should know from the title alone that the conclusions cannot be accurate:  It is just too soon to reach them.  It would be like drawing a picture of climate change from one year of data about temperatures.

Here's an excerpt:

A recent report from the Centers for Medicare and Medicaid Services (CMS) shows that national health spending grew at a historically low rate of 3.9 percent in 2010, almost paralleling the 3.8 percent increase in our gross domestic product (GDP) last year. This is . . . good news for the federal government as the slowdown indicates that the cost of health reform has been overestimated.

Now, let's look at the possible reasons: 

First . . . continuing declines in employment and private health insurance coverage have contributed to fewer people receiving both essential and nonessential treatment. [F]ewer people have received needed preventive and acute care. And people have increasingly gone without prescriptions, tests, and elective procedures.

Let's see, is this good news or bad news?  Health spending is down because insurance coverage has become more limited.  But, what proposition does it actually support?  Answer, as universal coverage is restored under the new federal law, costs will rise again.  As we found in Massachusetts, when you give people insurance, they use it.  Indeed, that is the purpose.  Thus, this statement offers no support to the proposition that the cost of health reform has been overestimated. 

Some of the slowdown in 2009 and 2010 may be related to the uncertainty surrounding the enactment and implementation of the Affordable Care Act. During earlier reform efforts . . . health care cost growth abated as cautious hospital and other health care leaders held back on hiring decisions until the implications of proposed changes were clearer. In 2009 the health care industry—including hospitals and pharmaceutical companies—also pledged to achieve voluntary savings. 

Let's start with the last line first.  Those "voluntary savings" are vacuous estimates related to the trends that might have occurred.  They are not absolute savings.  They are not measured.  They are not enforced.

But, it may be the case that hiring has slowed down.  In hospitals, though, it would be due to reduced earnings as states and the federal government have cut Medicaid and Medicare payments because of their budget woes.  This goes back to President Obama's misrepresentation as to the nature of cost savings that would result from the Act.  These were not cost savings derived from increased efficiency in the health care system, as most economists would define that:  There were reductions in governmental appropriations that have led to reduced earnings, slowly decapitalizing hospitals and forcing reductions in staff.

There is a parallel in the private insurance market, as rate increases from those companies have also leveled off because of pressure from employers and individual subscribers.  Again, this is not an efficiency gain in the health care system.  It is simply a price reduction forced by payers who have more market leverage than the providers.

Health spending trends may also reflect almost a decade of voluntary efforts to improve patient safety and quality, and eliminate waste—cutting costs while improving health outcomes. The Institute for Healthcare Improvement has completed several successful campaigns to improve patient safety and continues to support widespread initiatives that encourage efficiency. The Commonwealth Fund’s own Commission on a High Performance Health System has been publicizing approaches to reduce hospital readmissions, implement medical homes, and improve the quality of nursing home care. Some hospitals are now using “Lean” techniques used by other industries to improve care and cut out waste. 

Now, here we might have something, if it were true and could be proven.  As my regular readers know, I certainly hope it would be the case, but there is a paucity of data to show that this has occurred on a wide scale.  There are industry leaders and early adopters.  Among the large systems, Ascension Health, Gundersen Lutheran, Thedacare, and several others show the way.  In Boston, the fact that hospitals like BIDMC and Mt. Auburn Hospital can achieve earnings comparable to their counterparts in the much more highly paid Partners Healthcare System is a demonstration of the virtuous feedback loop between improving patient quality and safety and reducing waste.

I would dearly love to engage in the kind of wishful thinking that would suggest that these efforts have made a noticeable blip in the health care cost trajectory.  But, as I speak to front-line staff people in hospitals around the country, it is clear that there are miles to go on this front.  The most common reaction I get from enthusiastic doctors and nurses and managers to my presentations at national conferences is this:  "We believe in what you say.  How can I get my -- fill in the blank -- CEO, CFO, CMO, Chief of Service -- to provide leadership on this, to focus on it, to provide training and resources to make it happen."

Notwithstanding her optimistic lede, though, we finally get to Dr. Davis' real conclusion:

Despite the slowdown, U.S. health care spending per person is still more than twice that in other major industrialized countries, and costs are projected to rise though 2020. The retirement of “boomers” born after World War II will continue to cause health care expenditures and federal budget outlays to increase as a percentage of the economy.

Yes, that is certainly true. But it is not an issue facing the US alone.  Other developed economies in Europe and elsewhere are seeing a similar trend.  Their overall expenditures as a percentage of GDP will be growing even more rapidly than ours as public pressures emerge that push them in the direction of trying to replicate aspects of the tertiary care system that exists in the US.  (See Denmark as one example.)

But then Dr. Davis returns to unsupported hoping:

It is important to implement key cost-saving provisions of the Affordable Care Act, including value-based purchasing, shared-savings incentives for accountable care organizations, innovative payment pilots such as patient-centered medical homes, and creation of the Independent Payment Advisory Board. 

I have previously addressed the underlying structural problem of ACOs under the Medicare rules, which is that the PPO character of Medicare would not change:

"The provider may not require a beneficiary to obtain services from another provider or supplier in the same ACO."

How can you be held accountable, as a provider group, if you cannot control the management of care of your patients? I'm not blaming CMS for this contradiction. The agency is simply implementing what Congress and the President ordered it to do. There is no way Congress will limit choices among the Medicare population.

Meanwhile, too, the IPAB is under political assault, as Congresspeople figure out that it, too, could limit constituents' choices and have other unintended consequences:

Quite simply, IPAB has so many opponents because it embodies centralized planning from Washington, D.C., and enables unelected bureaucrats to make decisions about people's health care. The contrast couldn't be more clear: a new government body (IPAB) charged with taking resources away from the beloved Medicare program.

Further, IPAB is a threat to critical medical treatments and services for all Medicare beneficiaries. Proponents of the board have argued that IPAB will improve the quality of care as a result of the cost-cutting measures it enacts in order to save. However, it is doubtful this will happen because the board will have to make cuts that reach annual targets. Thus, standard line item cuts will result, which will only reinforce systemic problems, not fix them, and create unsustainable savings.

What about new pricing regimes?   This leads me to my next example of overly hopeful analyses, in the post below.

Off-base optimism: Part 2

In the post above, I present a review of a recent blog post from the head of the Commonwealth Fund that, to me, represents an all-too-common analysis of health care issues, one driven by desire rather than clear-headed thinking.  I promised a second example, and here it is, using a recent article in the New England Journal of Medicine.  It was again brought to my attention by this teaser from the Commonwealth Fund:

New Study: Innovative System for Paying Health Care Providers Slows Spending, Improves Patient Care

Findings from a Harvard University study conducted with Commonwealth Fund support reveal that a recently implemented global payment system for physicians and hospitals in the Blue Cross Blue Shield of Massachusetts network is lowering medical spending and improving the quality of patient care.

This is delicate as I offer comments, in that I know several of the authors and have the greatest respect and fondness for them.  But the fault lies not in their analysis.  I quibble more with the Commonwealth Fund's interpretation of the results than with the study itself.  The Fund seems to be looking for a "quick win" on the issue of capitated, or global, payment contracts.  As noted above, drawing any conclusions from one year of data is problematic.

The title of the article is "Health Care Spending and Quality in Year 1 of the Alternative Quality Contract," and the authors clearly lay out the limitations of their analysis.  Here is a section of the discussion, upon which the Commonwealth Fund seems to base its teaser:

The AQC was associated with modestly lower medical spending and improved quality in the first year after implementation. The savings derived largely from shifting outpatient care to providers who charged lower fees and were seen primarily among high-risk enrollees. Savings were larger among providers who were previously paid by BCBS in a fee-for-service system.

The improvements in quality are probably due to a combination of substantial financial incentives and BCBS data support. AQC quality bonuses are much higher than those in most pay-for-performance programs in the United States, since they apply to the entire global budget rather than to physician services alone or PCP services alone.

But, the Commonwealth Fund failed to mention this most significant finding:

The savings associated with the intervention do not imply that total payments made by BCBS declined. Total BCBS payments must take into account quality bonuses and end-of-year budget surpluses paid to the AQC groups. In 2009, quality bonuses were generally between 3% and 6% of the budgets. Additional BCBS support for information technology, staffing, and other needs was between 0% and 2% of the budgets. Moreover, all AQC groups spent less than their 2009 budget targets, earning, on average, 3% in budget surpluses (consistent with our estimates). Taken together, these first-year investments and payouts exceeded our average estimated savings of 1.9%, suggesting that total payments by BCBS to AQC groups rose for AQC groups in the first year.

I have discussed aspects of this before, citing an article in Commonwealth Magazine:

Blue Cross padded first-year global payment budgets to entice hospitals and doctors to sign on.... [T]he current goal is not to actually reduce costs, but to cut in half the rate of growth in medical costs after five years.

An insurance company has a major incentive to shift actuarial risk to providers and away from itself.  It also has an interest in price stability, for competitive and earnings reasons.  We cannot fault BCBS or otherwise for behaving in a manner consistent with its corporate goals.  But we can fault policy advocates who take incomplete results and use them in an unrigorous manner to support a policy agenda.

In memoriam: Rita McCafferty McQueeney

In these days of unfortunate denigration of people who choose a career in state government, it is important to recognize those who devote their lives to public service -- not in a flashy or ostentatious way -- but in just doing their job thoughtfully and well every day of the week.  Rita (McCafferty) McQueeney was one such person, and she passed away peacefully and quietly this week.

Rita was a secretary in the state's Department of Public Utilities, working for a succession of Commissioners in that regulatory agency.  She lived in Mansfield, south of Boston, and would take the train to work every day.  I don't ever recall her missing a day of work.  Even during the worst snow storms, she would show up bundled up with boots on.  But beyond that, her attitude and approach to work and life was always positive.  She had a marvelous sense of humor and excellent judgment about people, which never got in the way of her being inevitably polite, respectful, and helpful to all.

I was fortunate to work with her during my two terms in the agency, from 1977-78, and then again from 1983-1987.  During the second term, my young daughters would often come to visit the office, and they adored Rita.  I have wonderful memories of their laughing together about some secret that they were keeping from their father and boss!

Rita and I stayed in touch after I left the DPU, but irregularly.  She always knew about my latest job and would have astute observations about the political environment within which I was working.  But she mainly wanted to know how "her girls" were doing and would have the pride of an honorary aunt when I would tell her of their accomplishments.

She will be missed by all who knew her.

How to be a good sales associate at any store?

My best advice to be a sales associate from any store: kill with kindness! Be open to receive advice and be almost too nice to any customer has the opportunity to interact with. Do not let anyone enter the store without a greeting, or leave a thank you. Be sure to be as helpful and knowledgeable about the store and merchandise as possible. good luck

How to start Dog Walking business?

Very simple. Place ads in the newspaper. Put adds in trees or walls or anywhere that you can put these things. So one thing you can also go online to look for people who need someone to take care of the dogs for a while, and you can talk to them about it, and if you do a good job, they will tell their friends, and so on, and by the time you know it, you'll have a lot of business. But wait, it will not happen overnight.

What are good ways to protect your savings in a devaluation of the US dollar?

Reminiscent of the movie Barb Wire in negotiating the reward and asked that currency and in Canadian dollars. The U.S. dollar can devalue, devaluation of the currency of nations is a common trick to encourage people to buy domestic goods and people stop buying imported products and to stimulate the economy and jobs as domestic firms more competitive on the world market, but overall it is a strategy that is effective only for smaller countries.
 
U.S. is the largest economy in the world of rich
 
And therefore, the devaluation has fewer benefits to the U.S. after being abroad. If your expenses are mostly in the domestic products to buy Washington State apples, not from Chile and buy watermelons from California or Texas instead of from Mexico, then you have little to fear a devaluation of the currency but if you buy are from foreign countries, then the costs will rise.
 
This can be a good time
 
To check if most of your expenses are domestic or foreign. As for the protection of their investments from one currency devaluation, the products can help, but there is little intrinsic value in something like gold, investing in foreign companies can help and of course there are foreign bonds.
 
Moreover,
 
As Warren Buffet says, do not bet against America. Also the quote from Winston Churchill, "Americans can always be counted on to do the right thing ... after they have exhausted all other possibilities" .. It may take a while, but everything goes by itself.

Finding Joy and Creativity in Infrastructure

I apologize to my regular health care constituency for the recent spate of postings about infrastructure and other urban planning topics, but it just seems to be one of those times that many of those stories have ripened. To get this out of my system before returning to hospitals and health care next week, I offer this compendium of stories.

I write these in tribute to those public servants who, over the years, joyfully and creatively built or improved the infrastructure that serves the public every day. You might be surprised to think of those activities as either joyful or creative, especially during periods of tight budgets. But, there have been several people who have thrived in the environment, pursuing investments for the public good.Their stories might provide inspiration to current and future generations of public officials.

The Librarian

Notable among this group was Theodore Mann, the longest-serving Mayor of Newton, a suburb west of Boston.  While he did a lot for the City, his pet project was the construction of a new library.  I met with him in the early 1990s, just before the ground-breaking.  He was bubbling with enthusiasm and with the glee of a Depression-era child who had just gotten something for nothing.

“I was able to get a third floor,” he said.  “I only had approval for two floors, but I put an alternate into the bid document.”  Ted knew the public construction laws well enough to understand that you did not have to re-bid a building project if you put a provision asking bidders to scope out an optional extra additional item.  As the City prepared the bid documents, he was alert to the fact that the construction market was a bit soft, and so the bids for the two-story building would likely come in under the architect’s estimate.  What if he could get a third floor added, and still have the whole thing come in under budget?

It worked.  The bids, including the third-floor alternate, were low enough to expand the scope of the library substantially.  “We’ll need that space eventually,” he told me.  “But if we don’t get it built now, it will never happen.”

The Dairy Farmer

When Bill Geary took over as Commissioner of the Metropolitan District Commission in 1983, he noticed an odd traffic phenomenon.  About once a week, a truck would enter Storrow Drive or Memorial Drive and attempt to go under the Mass. Avenue underpasses.  It would get stuck, and the roof of the truck would roll up like the top of a sardine can.  Traffic would back up to Watertown.  The MDC police and road crews would go to work, rescue the truck driver, deflate the tires, and tow the truck away.  Meanwhile, thousands of commuters would be late to work.

On the Cambridge side, the freshmen women living in MIT’s McCormick Hall would jump with a start when they heard a crash and would watch the rescue operation.  By second semester, they had become so accustomed to this pattern that they didn’t even look up from their homework.

Bill brought his team together and suggested that having a truck crash into a bridge every week was not acceptable.  Couldn’t something be done?  “No, Commissioner,” he was told.  “Besides, we have a routine all worked out.  The police handle the traffic.  We bring in the tow truck, the Jaws of Life, whatever we need.  We clean out the whole problem within an hour.”

“What if,” he said, “we put signs up at every entrance to the river roads, at the height of the underpasses, with a pictogram warning taller trucks to stay out?”

“Commissioner,” they replied. “Can you imagine the liability if our sign breaks a windshield and sends glass flying into the face of a truck driver?’

“Well, what if we make the signs out of rubber so they don’t break the windows?”

“Rubber signs, Commissioner?  There is no such thing.”

Shortly after this conversation, Bill was driving his car along the Mass Turnpike and was approaching the toll booth that displayed an elevated sign saying, “Cars only.”  He looked closely.  The sign appeared to be made of rubber.   He stopped in the toll plaza, climbed up onto the hood of his car, and grabbed the sign.  It was made of rubber!

He got on the phone and called Jack Driscoll, then head of the Turnpike Authority, and found out where he had purchased the signs.

At the next meeting with his staff, Bill reported that he had found rubber signs and suggested that they be ordered.

“But Commissioner,” someone said, “What good is a rubber sign?  Truck cabs are noisy places.  A trucker will just hit the sign and drive right through without even hearing that he has hit it.”

“Well, then, let’s hang cow bells on each sign, so drivers will hear a noise as they approach our roadway if their vehicle is too high to go through the underpass.”

“Where will we get cow bells?” he was asked.

“I don’t know.  Call a dairy farmer and ask where they get their cowbells.”

The signs were installed, cow bells and all.  The frequency of crashes in the underpasses went from one per week to less than one per year.

The water guy

Boston was growing rapidly in the late 1800s, with the population surging to staff local industries and commerce.  But public officials were worried.  Where would the city get sufficient drinking water?  Local supplies were in danger of contamination from sewage in the city streets.  As reported at the time, “Under certain conditions . . . especially on summer evenings, a well defined sewage odor would extend over the whole south and west ends of the city.”  The danger of typhoid and cholera epidemics was persistent and real.

Frederic Stearns, a civil engineer working for the City’s Engineering Department, designed a system capable of disposing of sewage for the metropolitan area.  The system was later cited by Scientific American as “important advance in sanitary engineering." Later, as chief engineer for the Metropoltan Water and Sewerage Board and later, the state’s Board of Public Health, he devised a plan for providing adequate supplies of clean drinking water.  He envisioned a series of reservoirs to the West, capturing pristine rainwater from central Massachusetts rivers and streams.  The led to the construction of the 65-billion gallon Wachusett Reservoir in 1906 and the 412-billion gallon Quabbin reservoir in the 1920s and 1930s.

Remarkably, all of that water flows by gravity to Boston and its suburbs, avoiding energy costs associated with pumping.  Also, the reservoirs have unheard of levels of reserves – over five years’ worth of supply, even if it totally stops raining for that length of time.  Finally, thousands of acres comprise the catchment area around Quabbin.  These forests, now called “the accidental wilderness”, ensure that this supply is protected from contamination.

Stearns’ attentiveness to detail was legendary.  His 1901 “Report of the Chief Engineer,” to the MWSB stretched to 91 pages, ranging from the “force employed on works” to “removal of soil” to “culverts and crossings” to “consumption of water” to the “quality of the water.”  His management skills with regard to construction were prodigious.  In 1906, he was able to report, “The design of the Wachusett Dam and the contract for its constructions . . . was made . . . on October 1, 1900. . . . There has been no material change in the plant or in the methods.”

Just an engineer

Fred Salvucci’s prowess as a transportation planner is well known, but as Secretary of Transportation, he also played a lead role in shepherding public works projects through the political labyrinth of Beacon Hill.  His tenacity is legendary, but it is based on a substantive knowledge that can only be described at encyclopaedic. An example:

One day, I boarded a flight at Logan Airport, headed to Washington, DC.  I found myself in a row with Fred, with another fellow in the center seat.  This was around the time that people were trying to decide how to design and build the Charles River Crossing of the new Central Artery Project.  It was a tricky engineering problem, with lots of environmental and political ramifications, as well.  The design had been through many revisions, and they were up to number 26, or “Scheme Z.”  As we sat on the tarmac in Boston, I casually asked Fred, “Can you tell me about Scheme Z?”

He started talking, and I started listening.  He stopped talking as we taxied up to the gate at National Airport.  I learned more in that hour-and-a-half about the history of the highway project than I had learned before or have learned since.  I still wonder, though, about the poor guy sitting between us!  I sure hope he was interested in the topic.

I recall a radio interview with Fred during that time, as he engaged in a long discourse with the reporter about the many aspects of the Central Artery project – financial, engineering, work force, and politics.  The interviewer was clearly impressed and started to end the interview by complimenting Fred on his political acumen in creating and maintaining support for this major public works project.   Fred modestly replied, “I’m just an engineer.”  The reporter, tongue fully in cheek, ended the segment, “Thank you, Fred Salvucci, engineer.”

Training the IG to be practical

The office of the Inspector General was created in 1980 by the legislature after the publication of the Ward Commission report.  Officially entitled, the Special Commission Concerning State and County Buildings, this body of experts determined that there had been a pervasive pattern of corruption in the design and construction of state buildings.   The idea was that there should be an office distinct from the Attorney General and the State Auditor:

A "vast middle ground". . . between the ability to review all state transactions to a limited degree without the power to investigate [i.e., the Auditor], and the power to investigate allegations of fraud on a case-by-case basis [i.e., the Attorney General]. . . .

The value of such an office is incontrovertible, but some of us engaged in building major infrastructure projects sometimes found the IG and his staff to be meddling and troublesome interlopers in our plans to be creative with public funds.  I say creative advisedly.  We had no intention or interest in doing anything that would come even close to being illegal.  But sometimes you just have to think outside of the box if you want to actually get infrastructure built.

While at the MWRA running the Boston Harbor Cleanup Project, I needed to build a pier in the Squantum section of Quincy to serve as a ferry terminal for thousands of construction workers who would head to Deer Island every day to build a $3 billion sewage treatment plant.  The ideal site was owned by the local electric company, Boston Edison, which did not want to sell it.  While we had sufficient money to purchase the land and build the pier, my agency did not have eminent domain powers.  But Bill Geary’s MDC did have eminent domain powers.

I called Bill and laid out the issue.  Would he have a way to receive and spend money from the MWRA, without legislative appropriation, take the land from Boston Edison, and permit us to build a pier?  I was operating under a strict Court-ordered schedule and therefore could not await a lengthy and uncertain legislative process.  Without a moment’s hesitation, Bill informed me that he had a parkland renovation trust fund that could be used for such a purpose, on the condition that the acquired land and pier would be available for public use.  “It’s a deal,” I said, and the next day our lawyers codified the transaction.

The Inspector General blew a gasket.  We had no authority do such a thing, he argued.  He threatened that would hold a press conference and otherwise raise a ruckus about our action.  Bill and I quietly suggested that instead, he should make his case before the Federal Judge in the Boston Harbor case, and we would abide by the result.  Silence quickly reigned.

Can you become a millionaire with the stock market ?

Yes .. but can also lose your shirt. Those who make wise investments with a long-term asset allocation and risk management, and clear investment objectives can become rich in time.

Consider this

Those who go for easy money usually end up losing most or all of what you put inside. If you want to do well, however, start with some good basic books, like Investing for Dummies.

Call centers in the Philippines are good choice for sales campaigns?

I have been using outsourcing call centers for years and I can use from the Philippines and India. I can tell you from my experience in India will cost a little more, but it's better for sales. They have a less thick accent and a soft spoken tone.

Consider this

I use in the Philippines to manage my customer service, then sales in India, which saves me money. I've been using a service called inso for a while because the management of both types of schools (you can find them and other google services outsourcing call centers).

How to start a business of saree?

It depends on the amount you can invest for your business. All you have to do your own market introduction of the softness of business and advertising your business to attract more customer has the choice to do enough for them and remember to focus on all categories of the range of client high or low. 

And most importantly you have to sell good quality materials to meet people, it's a good way to wear saree business.

How to make good process outsourcing services ?

This is a very important question as it is their money and the representative of the line. I have been using outsourcing for years and have learned something useful from my experiences. (I currently use a company called insoluble, but you can easily find them and other online providers by searching for them).

Here are some things to look

1. Flexible billing - unrounded
2. The daily reports to
3. Experience in your industry
4. Quality Reports
5. Short timeout
6. Internal Project Manager

Thanks for riding the T: Have a drink on us.

While we are on the topic of signs, I thought a previous Secretary of Transportation had made a commitment that the MBTA (Boston's transit system) would turn down advertisements that sold alcoholic beverages.  Instead, the T seems to be targeting those ads to the poorer sections of town and near colleges and universities.

At least one state representative recognizes the public health implications of this practice and has filed a bill to ban it.  But, shouldn't the Governor take this issue on without legislation?  It would be a good time to just say no.

Naming rights and wrongs

The thing I liked best about Mitt Romney as governor was that he refused to put his name on signs throughout the state.  You know, like the ones that say "Welcome to Massachusetts" as you cross the border. Why? Well, he felt that those signs were public property, not private bulletin boards for elected politicians trying to get more name recognition.  He also, I think, was offended by the idea of spending public money every time a new person was elected governor.

This is very unusual.  I recently drove through a number of states, and at virtually every border crossing, I saw the governor's name attached to the welcome sign.  Like this one:

In times of tight budgets, why are we spending taxpayer money on this kind of self-aggrandizement?  But even in more prosperous times, why should any elected person's name be placed in a public way like this?

Shouldn't there be a general rule that the names of elected officials should not be included in signs on public ways?

About the Financial Markets

A broad term that describes any market where buyers and sellers involved in the trade of assets such as stocks, bonds, currencies and derivatives. Financial markets are usually defined as having price transparency, basic rules on trade costs and fees and market forces determine the prices of securities that trade.
 
Some financial markets
 
They only allow participants to meet certain criteria, which may be based on factors such as the amount of money held, the geographical location of investors, market knowledge and profession of participants.
 
Investopedia says:
 
Financial markets can be found in almost every nation in the world. Some are very small, with only a few participants, while others - like the New York Stock Exchange (NYSE) and the currency markets - trillions of dollars trade journals.
 
Most financial markets
 
Have periods of heavy trading and demand for securities in such periods, prices can rise above historic norms. The reverse is true - the recession could cause prices to fall earlier levels of intrinsic value, based on low levels of demand or other macroeconomic forces such as tax rates, domestic production or employment levels.

Transparency
 
The information is important to increase the confidence of participants and therefore promote an efficient financial market.

What kind of work can be obtained with a computer-aided design ?

The companies I can think of are the companies manufacturing or machining companies. Many companies use CAD programs to design products and everything that is manufactured is designed first. If you look at companies that do things, you will surely need someone who has these skills.

How to maintain motivation and productivity in yourself ?

Exercise. Not only is it good for the muscles, but also good for the brain. Ideas flow like a river after a trot. Meditate and get in touch with my goals and dreams.

How to receive paypal payments and how to take out the amount in cash ?

The money will go into your Paypal account. You know it's there when you sign into Paypal and look at your account balance and see the money there.

Withdraw money

Withdraw money from your Paypal account by clicking the "Cash Out" button. You can have money sent to you in the form of a check or a prepaid debit card, or can be transferred to your linked bank account.

Mayor Menino and Nicole deliver Hubway

BIDMC team at opening day of New Balance Hubway

I just returned from an opening ceremony for Boston's bike share program, entitled New Balance Hubway.  This is a citywide installation or bikes for hire.  You pick up a bicycle at one set of racks, ride to your location, and leave it any another.  The bike locations are also closely coordinated with the local transit system, to provide a mutual feeder system.

The program is the brainchild of Nicole Freedman, Mayor Thomas Menino's biking tsarina.  With the Mayor's encouragement and support, Nicole had already succeeded in expanding the number of bicycle lanes on city street and installing dozens of bike racks in public spaces.

But they had bigger plans.

A couple of years ago, Nicole came to me in my capacity as CEO of BIDMC and asked if we would sponsor a couple of the stands for Hubway, at a cost of $100,000 each.  Our hospital and staff already had volunteered to help other biking programs that Nicole had organized, like being medical providers for Hub on Wheels, and so I had great confidence in her vision and ability.  I immediately committed to the effort and promised to solicit other hospital CEOs to do the same.  Today, many of those hospitals were announced as partners, along with the Boston Red Sox, housing developer Steve Samuels, and others. Later, my successor at BIDMC, Eric Buehrens, committed to a third station as well.

New Balance, the Boston-grown and run athletic shoe company, tossed in funds to become the naming sponsor of the program, and now it is up and running.  Here's Matthew Lebretton, director of Public Affairs, at the opening ceremony on behalf of the company.

What is the best bank to get Home Loan in the US ?

Best bank / lender for a mortgage loan is that your application is approved for a mortgage loan. After earning his initial loan from your bank / lender or broker the opportunity to have heard of that bank would be very slim. The company that would get your home loan is normally called an author. These authors will sell your loan to an investor like Fannie Mae or Freddie Mac
 
There are many things you should do
 
The first thing to do is contact a mortgage broker that does FHA and VA mortgage loans and pre-approved. This is the first step. Once you have your pre-approval contact a realtor to search the house based on what is qualified to buy.
 
Also
 
You will need proof of income to be available pay stubs, W-2, bank statements and other items from your mortgage broker will be required. He will tell you what you need once you contact them.
 
Consider this
 
This pre-approval will tell you how much house you are qualified to purchase and the interest rate, the monthly mortgage payments and other necessary things you need to know about your mortgage. If you can not buy a house before the pre-approval letter expires you can go back and reissue another.

How to find an apartment in Los Angeles

Web sites are a good place to find an apartment or house for rent, if you want to go through the entire list to find one in your state and city. The best place to look for places to rent is to go to the yellow pages of your telephone book, look at the property managers. These rental properties list of people in certain areas, so be sure to select the areas you wish to hire.
 
Call several of the managers of the property list,
 
Say you want a list of properties that are for rent. Some of fax, email or mail the list of local places to rent along with the address, number of bedrooms and bathrooms, amenities available, such as washers and dryers or gyms, the monthly rent of the unit . Most include a rental application. This list will include the monthly rent is necessary, if a lease or month to month agreement will be signed. Also indicate whether they accept Section 8 vouchers. It also indicates that you have disabled access, laundry service and if so let the guy.
 
Consider this
 
That could indicate a website you can visit to get your list of places to rent. No cost to get a list of rental from a property manager in good standing. Make sure you do not fall for the fraud and the purchase of a list by 70% -80% of these lists consist of a list without ever compiled. They are not the property managers of any property in most cases.
 
Also
 
I could google and property managers in any city or community that wants to live and see what happens. Again, do not have to pay for this information because it is free of reliable property managers. Each city has its own club in the area. You can change your party scene each week until he found a regular meeting point.