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Accepted Farm Forms The Valid At ‎ ‘Īdu l-’Aḍḥā) "Festival " or "Greater Bairam" is a religious festival celebrated by Muslims all over the world. It is when Muslims sacrifice a goat, sheep, cow , camel,and bull sending part of the meat to poor people as a donation. It marks the end of the Pilgrimage hajj for the millions of Muslims who make the trip to Mecca each year and pray 5 times a day. They like to tell Allah what they are thinking and hope for him to help them, and remember Ibrahim and Ismael's courage and devotion to God. The festival is to celebrate Ibrahim's (Abraham) willingness to sacrifice his son, Ishmael, because Allah told him to do so in a dream. At the final moment,as he was swinging his axe to kill his son God told an angel to switch a lamb instead of his son, and this act of sacrificing a lamb is copied by Muslims all over the world on Eid. Ibrahim was tempted by Satan not to listen to God, and Ibrahim drove Satan away by throwing pebbles at him. This is also still commemorated by Muslims during Hajj. It consists of two Rakaah (units) with seven Takbirs in the first Raka'ah and five Takbirs in the second Raka'ah. The sacrifice of an animal, usually a cow, sheep or a goat, is a very important part of Eid. The act repeats what Ibrahim did, and also shows Muslims' devotion to God (Allah). Muslims celebrate by having a feast, and giving gifts to the poor. In some Muslim traditions gifts are also given to children. In Muslim countries the day is given as a national holiday.

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Accepted Farm Forms The Valid At When Poppy crept down the stairs of the home and stepped outside, the world slept. It was early, that was true; earlier than she’d ever been up before. Somewhere, today, for once in this big, pointless world Poppy True was needed. Of course she was often awake at this time, such was the plight of life in the home; clinging to the occasional hour of sleep which floated past in her normal tumultuous nights thrashing around under suffocatingly thin sheets. She was up, dressed, alert and ready to start her mission. The feeling hung about her shoulders like a majestic cloak, an invisible shield of beautiful, empowering strength. Of course she’d take it – they needed her – she could do anything in the world. The man with the steely gaze had never intended her to make it, had never wanted her to make it. But now, faced with the heavy breath of night still sleeping in the shadows, she hesitated. Hearing a slamming door and the rumbling of an engine from a car somewhere up the street she quickly pressed herself flat against the wall, her heart beat thumping in her chest. She was a pawn, a scapegoat he’d be able to throw away like an empty crisp packet. Entirely unaware of Poppy, oblivious to her mission it moved away from the kerb advancing slowly in the other direction. It wasn’t the old man, that was certain; his grand father stature remained in tact, his sunny aura as yet unclouded. He’d tricked her, as he’d presumably tricked the old man. She sighed with relief feeling, for the first time, the soft whisperings of day time coming to life around her. ‘Oh please, don’t let the old man be a bad guy,’ Poppy urged to herself, to whoever was out there, listening, penning the script to her super hero story; her fantastical escape from the cold, blunt reality which awaited her outside the gorse bushes. She’d need to keep walking; to fight off the need for sleep and to keep going, through the night with only the waves to talk to and the stringent light of a half clouded crescent moon to intermittently guide her. Surely, after her mission was complete, there would be someone to look at her with pride and say ‘Well done Poppy – you’ve made it! Through the dark, ominous, twenty first century night; paying no heed to shadows, to cracking twigs, to imagined murmurings and stretching, twitching fingers trying to pull her into the darkness. She pulled her hood over her head, a further layer of protection from this unfamiliar outsideness, and stepped into the street. Two days she’d boasted, when they’d asked her how fast she could make it; a new power coursing through her narrow, underfed bones as they’d looked her up and down. Indeed, the foreboding darkness was not a tempting prospect, but the vulnerable exposure of daylight now seemed so much worse. Her thoughts clung again to the old man, to his pleading eyes. ’ Opening up her rucksack Poppy fumbled for the little food she’d been able to bring with her. They’d said it was better that way – just to carry it, not to ask questions, and not to look, just to do it. She pulled out her food parcel; a cold baked potato wrapped in kitchen roll, shrunken and less hearty than it had appeared on her plate last night. Until she could find a hiding place to sleep through some of the day, when she knew the search for her would begin again? Only when she neared a road, when the threatening dazzle of headlights filled the sky did her unyielding pace falter; only then did she look about her and call on her imaginary super powers to protect her from the potential danger behind the blinding light. She was Supergirl, one of the X Men, Spiderman all rolled into one. Added to that the risk of being caught, as now she knew she could be caught; hunted and caught like a wild animal at the mercy of its hunters; the stealth of darkness offered a welcoming hand – an even bigger opportunity to be invisible. As she searched, her hand stroked the surface of ‘the package’, sending butterflies fluttering into her hungry stomach. Blistered feet in broken shoes walked, marched, trampled, stumbled, over 40 miles – although she didn’t know it – before the screech of seagulls welcomed in the day time and the first rays of sun climbed out of the sea. How hard could it be to carry such a small thing for sixty miles? A memory in soft focus had sang in her head, golden edged and smelling of summer, of cut grass and of a granddad putting a warm, steady hand around her shoulders. Her orders were to hug the coast line, to stay away from the major roads, from any roads at all where a twelve year old girl wandering on her own might arouse suspicion, arouse temptation. With the sound of passing cars reassuringly distant, and the lure of an upside down rowing boat, swollen, and lichen covered before her, Poppy True knew, at last, it was time to rest. The old man had smiled, had nodded, had believed in Poppy with all of his might, with his seventy three years of wrinkled, stooped hope that this girl could do it, that she could deliver this thing and make things right. He’d stared at her, stared into her, stared through her, an unbending face like cold steel but for a twitch beneath his left eye. No, she was to follow the frills of rock and foam, the sands and hills and smaller villages all the way from Edinburgh in the hope that, at some point within the next 48 hours she’d arrive at a house somewhere in the North East of England, a big house, a house rooted into a cliff top, firm against the salty retaliation of the North Sea; a house that ‘she’d know was the one when she saw it,’ where she was to deliver her package. Melt into insignificance once more, dissolve into the sands she was about to tread, go back to how it was? She crawled beneath the hull, wood worm and bugs seeming like welcome comfort, and slept. She pushed all thoughts of ‘afterwards’ from her head, and headed towards the sea, an unassuming secret agent in second hand jeans. It snapped against Poppy’s skin like a rough leather strap. So deep was her slumber, so surprisingly void of haunting dreams and restless movements, that it was only the sound of the waves lapping ever closer to her resting place that stirred Poppy. ’ she asked herself as she opened her eyes to the thick, damp darkness of her tomb, but as she moved her legs and felt the sudden ache of her exhausted muscles, she remembered. An unsung super hero carrying the future in a purple rucksack with a fraying strap. It knows how to act, how to react, how to intuitively take care of itself, often without our conscious input. If she gets there, well – you’re history, I’m history, we’re both history.’ ‘I’ll find her. Whatever time it was, however long she had rested had to be enough – she had to finish her mission. When it feels threatened, exhilarated, ready for a challenge, a battalion of extra adrenalin is shipped in pulsating through the limbs providing almost cartoon Popeye strength. Maybe this is how a child of twelve could march, relentlessly along the coast; sharp, wet rain cutting into her face, rocks slippery under foot, at such a tempo; such determination to complete her mission, to prove that she had been a wise choice. In the end.’ Such had been the mantra of Poppy True throughout her entire life. Fumbling for her rucksack, and feeling reassured by the weight of the package still inside, she crawled from beneath the boat. Maybe this is why, in the soft yawning of dusk, when a white car broke all of the normal boundaries and drove slowly across the beach towards her, a tired young girl who had been walking all day found enough new energy sizzling in her legs to run, to head in land, to fight against the gluey pull of the sand dunes as she made her escape. Today, if only for today, she prayed that it was so. It’s just a matter of time.’ ‘Well, time we don’t have my stupid friend. The tide was in, the carpet of foam reaching almost to the boat wreck, and in the distance she could see the distant twinkle of street lights in some of the fishing villages she’d passed. Through a shrill, deafening heart beat she ran, the echoes of slamming doors, of masculine swearing and arguing like a warped, underwater cry swimming towards her. How long Poppy sat, crouched in the gorse bushes, she wasn’t sure; long enough to feel the groan of walking in the soles of her feet; long enough to feel a pang of hunger in her belly; long enough for the two men chasing her to grow tired and even more angry, spitting shards of blame at one another as they trampled the dunes. She must have about 10 hours left to get to the house on the cliff. With leaden limbs she started to walk, calling upon the energy she had earlier to come back and help her to complete her journey. She wove through the dunes, tearing her legs on splinters of dried grass, running for the safety of the gorse bushes, tunnelling through their inconvenient pathways to find a dark, secret place that could embrace her for a couple of hours, to stroke her hair and tell her everything would be ok. But the sand had been kind to Poppy, pouring itself into her footsteps, masking her tracks, helping Miss Invisible to truly disappear. The familiar face of darkness was soon back to accompany her, as slowly her muscles warmed up, her stride regained its strength and fluidity of the night before and she began, slowly but surely to pull the house on the cliff towards her, inch by determined inch. ‘I am a super hero’ she repeated her sacred mantra to the beat of a frightened pulse, ‘I am Miss Invisible. ‘I thought you said she was scrawny, wouldn’t make it past Aberlady! Although walking in the right direction, she was lost in a sea of time and space, not knowing where she was, how far she had to travel and how long she had left. The only consolation was that the car had not re-found her, and had little chance of doing so along the route she took. It was only when she realised she’d reached Berwick upon Tweed that she knew she really could make it. Desperately sifting through her memory for things the old man had said, she remembered the house was only another few hours walk from there. Hope bolstered her step once more, ‘Poppy True, super hero – makes it’, she congratulated herself. Little did she realise that she was not the only one with such determination. That somewhere, closer than she could have feared, someone else was still looking for her. It was just as she’d imagined it; to the point where she began to question whether it really was the first time she’d seen this place; the grey whiteness of the walls, the heavy slates of the roof, the old tree, sculpted into stooped submission by the wind which bullied it day after day. Her heart lunged forward, both with the pang of familiarity and with the final roar of achievement. She’d beaten everything – the distance, the darkness, the men in the car, not having any food. Her stomach was cavernously empty, her limbs were screaming in pain, her blisters burned the soles of her feet like white hot embers, but still, for those last 200 metres, she broke into a run. ‘Poppy True – you’ve done it’, she panted to herself, the package in her rucksack bouncing up and down against the notches of her spine. She could only have been a mere 50 metres from the door when she caught a glimpse of whiteness out of the corner of her eye; when she heard a door slam and the yell of a man, like the howl of a wolf who hasn’t eaten for days. She dared to turn, to see him running towards her – the man with the twitch, his face twisted with hate, his body, undoubtedly fresher than Poppy’s, contorted into a vicious, lung bursting sprint, his hand clasped around something small and dark. She couldn’t quite make out what it was, until he pointed it at her, with clenched teeth, taking a desperate, uncalculated aim. The thunderous echo of the shot reverberated across the cliff top as it ricocheted off the wall of the house, followed by another and another. Poppy froze, midway between the house and her predator, her legs shaking uncontrollably, suddenly unable to push them forward as she had for the last sixty miles. Had she come so far only to be killed on the door step of safety? ‘Come on Poppy True,’ she whispered to herself, ‘You can do it Poppy True. The good guys always win.’ The man was fast approaching, his gun still pointed at Poppy as she turned her back on him for one last time and gathering every last ounce of energy in her tiny body, pushed herself towards the sanctity of the house. A final shot exploded into the air, and then there was silence; a slow motion silence where all Poppy felt was a bursting pressure at her back, as her body was thrown face forward into the grass at the steps of the house; a soothing, melting silence filled with white light as she felt herself float above it all to watch the man with the gun stop deadly still, and a woman – a woman she’d never seen before - standing on the steps of the house, over Poppy’s limp body, the glowing light emanating from her, and from the thing she was holding. A sea shell - a shiny, silver seashell, just the right size for a package in a rucksack. Poppy looked at what was now left of her rucksack – a heap of frayed purple fabric torn apart by the bullet? The man with the gun stared helplessly at the woman, at the glowing sea shell she held out towards him, and sank to his knees, his body convulsing in sobs. ‘Please no,’ he wailed, ‘I’m sorry, I’m so, so sorry.’ The glow of the sea shell in her hand stretch forward in one solid beam of light until it covered the man too, wrapping his sobbing body in brilliance. It stretched beyond the man to the car, to the cowering figure of his accomplice hiding behind it, until both were wailing again, this time in pain, writhing on the ground, convulsing as their shape started to change, to mutate, to shrink until the only thing remaining were two fat, black slugs; one crawling across the cold steel trigger of a gun, the other crawling beneath the tyre of a car. The woman on the steps turned to Poppy’s body, her serene expression unchanged as she placed the glowing shell back into Poppy’s rucksack, and Poppy felt herself sinking, the cool, salty air pulling her down from the sky and back into her earthly body, with tired limbs and aching stomach. A flash of blinding light from the sea shell was the last vision she had of her own body. Opening her eyes again, the vision that greeted her was far lovelier than she could ever have imagined – a woman’s face, almost identical to the one she’d seen from above, but warmer, not bathed in white light, more homely somehow. Poppy’s head was in her lap and she was stroking her matted hair away from her brow. ‘Well done Poppy’, the woman smiled, ‘You’ve made it. The rucksack, which appeared to be completely in tact, had been unstrapped from Poppy and was on the step. Welcome home.’ ‘I knew I would,’ Poppy muttered before falling into the deepest sleep of her young, turbulent life.

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Winchester Writers’ Festival provides an abundance of networking opportunities for creative writers – attendees can book up to four appointments with literary agents and editors of their choice in order to pitch their ideas and gain valuable feedback or a market appraisal. The annual Festival offers three days of talks and workshops for writers at all levels of experience, working in a wide variety of forms and genres,including contemporary fiction, writing for children or young adults, life-writing, fantasy, crime fiction, historical fiction, poetry, short fiction and script. Katherine Rundell (right), prize-winning author of five novels for children and a renowned academic scholar, has been announced as the keynote speaker for this year’s University of Winchester Writers’ Festival. Established in 1980 Authors who have appeared previously include: Lemn Sissay MBE, Joanne Harris, Julian Fellowes, Terry Pratchett, Jasper Fforde, and Carol Ann Duffy, Sebastian Faulks (right). Katherine’s keynote speech, titled ‘Why You Should Read Children's Books, Even Though You Are So Old and Wise’, takes place at 9am on Saturday 15 June 2019 and will explore how children’s books ignite, and can re-ignite, the imagination; how children's fiction, with its unabashed emotion and playfulness, can awaken old hungers and create new perspectives on the world. Other speakers always include top literary agents, commissioning editors and award-winning novelists, poets and scriptwriters. Past speakers at the Festival include Patrick Gale, Sebastian Faulks, Joanne Harris, Meg Rossoff, Julian Fellowes, and Terry Pratchett, to name a few. University of Winchester, Sparkford Road, Winchester, Hampshire SO22 4NR Who? For details of the full programme and how to book, along with information about the competitions and Festival Scholarship Scheme, visit The 2019 Festival takes place between 14th-16th June at the University of Winchester. Highlights of the 2019 Festival include workshops with historical crime writer William Ryan, best-selling fantasy novelist Jasper Fforde and children’s writer Ross Montgomery; a reading by novelist Beth O’Leary, as well as dozens of talks on the craft of writing with the likes of novelist Claire Fuller, BBC writer and producer Vanessa Amberleigh and forensic archaeologist Anna Chaussée. Friday night events are free to attend and include an open mic and two industry panels.

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Accepted Farm Forms The Valid At Tomorrow, May 30th, it will be released, and EA has been kind enough to give us a early access review copy. We were already excited about this pack, so we are really happy to let you know what we thought of it. This new game pack brings a lot of new gameplay with it, so to make it more readable, this part is divided by a few sections: Parenting skill, Character Values and Teaching Moments. Not everyone is a natural parent, not even your Sims. Luckily, they can learn to be a better parent by developing the Parenting skill. Leveling the parenting skill can be done by “browse Parenting Forums” and “Research Parenting Methods” on a pc, or certain interactions with your Sims children. Giving parenting tips also raises your skill level bar. I also had this really cute thing happening in my game. She had found her spirit animal and only wanted to be in a bear costume from then on. It even went as far that when she took a bath, it was “Un-bearable” to be without the costume. My parent Sim then had the option in the Parenting menu to “ask about the phase”. My child Sim basically said, I just like being a bear, deal with it, you could join me by wearing a bear costume too. And after that the option appeared for my parent Sim to also wear a bear costume. Toddlers, Children and Teens have Character Values to build and learn as they grow up. It’s only available for toddlers to teens, once they age up to Young Adult, their Character Values meters disappear from the menu. And depending on how low or how high a Character Value is, your Sim can be awarded a positive or negative trait, but you have to work on them to get those traits. There are 5 different Character Values: Building the Character Values can be done by Parents rewarding or punishing certain actions, or your kids can perform good actions themselves, like clearing the dishes will reward manners, doing homework builds up responsibility. A new items is the journal, and your Children or Teens can write in them to gain Emotional Control, it also raises Creativity (Children) or the Writing Skill (Teens and up). But keep your journal hidden or on you, because other Sims can snoop in them as well! There are no new traits in the sense that you can pick them in CAS, only the ones you can earn by either have bad Character Values, or good, but there is a new Aspriation! This focuses on raising your children and their Character Values and of course, the parenting skill. Sometimes you get a pop up screen where your Sims Child asks a question, to get some advice. Depending on your parenting skill the amount of options vary, or how much information you get what answer has what sort of impact on the child’s development. These moments raise one Character Value, and lowers another. This pack is already quite full when it comes to game play, but they didn’t forget about the builders either. There’s actually a full new kitchen set dining set, new sofas and coffeetables, desk for you Sims to do homework, and lots of items to clutter your house with. Working on this also builds on Responsibility, and depending on the project, different skills. The next images were made with only The Sims 4 Parenthood items. Parents can also assist their children with school projects. Builds on Emotional Control, and Creativity/Writing skill. No other packs or basegame items were used, except for the floors (there is no new flooring with this Game pack) items include: A building table, to build on. Kids have to start the project themselves, parents can’t do that, but parents can finish the projects for them. Night Owl Toy Night Light, is a toy, a night light and it helps Children and toddlers to control their Emotions. It focusses on family play and offers a lot for it. It doesn’t build on any skill though, just can give the emotion buff “Construction Collaboration”. There are 2 designs for this one, the Tumm Tumm Teddy and the Boo Boo Billy, They build on Empathy and can only be used by children. Compared to the other things, CAS feels a bit bare, but that doesn’t mean there is nothing! There are new hairs for children, teens and up, full outfits, pants, and tops. You can now also give your Sims some facial imperfections, like pimples! There are new school projects your kids can do, together with their parents even.

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Accepted Farm Forms The Valid At KID INFO saves YOU valuable time by providing for FREE - in ONE website directory - the BEST Preschool and K-12 educational websites, videos, and powerpoints to help you with homework assignments! Important Facts about Plant Varieties, Plant Structure, Plant Care, Plant Types, Plant Cells, Photosynthesis, Plant Reproduction, Trees, Gardening, Carnivorous Plants, a Plant Glossary, and a Plant Image Library Remember to bookmark and return to KID INFO often! KID INFO saves you "valuable time" and allows you to spend "quality time" by eliminating the chore of sifting through hundreds of search engine results! Kid provides YOU with a FREE educational website directory that provides the BEST Pre K-12 quality educational websites, videos, and powerpoints. Kid also provides informative, interesting, and challenging educational game websites. Make your first stop for Homework Help, Teacher Lesson Plan Resources, Parenting Resources and Parenting Tips, and Challenging Educational Game Websites so you can become the BEST possible student, teacher, or parent! Disclaimer and Terms of Use - Privacy Policy Copyright 2014 - Linda Guterba.

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Accepted Farm Forms The Valid At Two years ago, Margaret O’Neill brought her 5-year-old daughter to Children’s Hospital Colorado because the band of tissue that connected her tongue to the floor of her mouth was too tight. The condition, literally called being “tongue-tied,” made it hard for the girl to make “th” sounds. It’s a common problem with a simple fix: an outpatient procedure to snip the tissue. During a pre-operative visit, the surgeon offered to throw in a surprising perk. O’Neill’s first thought was that her daughter seemed a bit young to have her ears pierced. Wasn’t that something done free at the mall with the purchase of a starter set of earrings? “I didn’t think you did ear piercings.” The surgeon, Peggy Kelley, told her it could be a nice thing for a child, O’Neill said. All she had to do is bring earrings on the day of the operation. Her daughter emerged from surgery with her tongue newly freed and a pair of small gold stars in her ears. In fact, O’Neill said it dug in, telling her to pay up or it would send the bill to collections. “There are a lot of things we’d pay extra for a doctor to do,” she said. Only months later did O’Neill discover her cost for this extracurricular work: ,877.86 for “operating room services” related to the ear piercing — a fee her insurer was unwilling to pay. Her daughter hadn’t needed her ears pierced, and O’Neill would never have agreed to it if she’d known the cost. “This is not one of them.” Kelley and the hospital declined to comment to Pro Publica about the ear piercing. Surgical ear piercings are rare, according to the Health Care Cost Institute, a nonprofit that maintains a database of commercial health insurance claims. The institute could only find a few dozen possible cases a year in its vast cache of billing data. But O’Neill’s case is a vivid example of health care waste known as overuse. Into this category fall things like unnecessary tests, higher-than-needed levels of care or surgeries that have proven ineffective. Wasteful use of medical care has “become so normalized that I don’t think people in the system see it,” said Dr. Vikas Saini, president of The Lown Institute, a Boston think tank focused on making health care more effective, affordable and just. “We need more serious studies of what these practices are.” Experts estimate the U. health care system wastes 5 billion annually — about a quarter of all the money that’s spent. Of that, an estimated 0 billion goes to unnecessary or needlessly expensive care, according to a 2012 report by the National Academy of Medicine. Pro Publica has been documenting the ways waste is baked into the system. Hospitals throw away new supplies and nursing homes discard still-potent medication. Drugmakers combine cheap ingredients to create expensive specialty pills and arbitrary drug expiration dates force hospitals and pharmacies to toss valuable drugs. senators introduced a bill this month to reduce what they called “colossal and completely preventable waste.” But any discussion of waste needs to look how health care dollars are thrown away on procedures and care that patients don’t need — and how hard it is to stop it. Arenas, 34, has a history of noncancerous cysts in her breasts so last summer when her gynecologist found some lumps in her breast and sent her for an ultrasound to rule out cancer, she wasn’t worried. We also reported how drug companies make oversize eyedrops and vials of cancer drugs, forcing patients to pay for medication they are unable to use. But on the day of scan, the sonographer started the ultrasound, then stopped to consult a radiologist. They told her she needed a mammogram before the ultrasound could be done. Arenas, an attorney who is married to a doctor, told them she didn’t want a mammogram. She didn’t want to be exposed to the radiation, or pay for the procedure. But sitting on the table in a hospital gown, she didn’t have much leverage to negotiate. So, she agreed to a mammogram, followed by an ultrasound. As Arenas suspected, she had cysts, fluid-filled sacs that are common in women her age. The radiologist told her to come back in two weeks so they could drain the cysts with a needle, guided by yet another ultrasound. But when she returned she got two ultrasounds: one before the procedure and another as part of it. The radiologist then sent the fluid from the cysts to pathology to test it for cancer. That test confirmed — again — that there wasn’t any cancer. Her insurance whittled the bills down to ,361, most of which she had to pay herself because of her insurance plan. Arenas didn’t like paying for something she didn’t think she needed and resented the loss of control. “It was just kind of, ‘Take it or leave it.’ The whole thing. You had no choice as to your own care.” Arenas, sure she’d been given care she didn’t need, discussed it with one of her husband’s friends who is a gynecologist. She learned the process could have been more simple and affordable. Then bill collectors got involved, so she demanded a refund and threatened legal action. Her demand was routed to an attorney, who declined her request because there was “no inappropriate care.” She also complained to her insurance company and the Washington, D. Arenas complained to The George Washington Medical Faculty Associates, the large Washington, D. C., attorney general’s office, but they declined to help reduce the bill. Overtreatment related to mammograms is a common problem. The national cost of false-positive tests and overdiagnosed breast cancer is estimated at billion a year, according to a 2015 study in Health Affairs. Some of this is fueled by anxious patients, some by doctors who know that missing a cancer diagnosis can be grounds for a medical malpractice lawsuit. But advocates, patients and even some doctors note the screenings can also be a cash cow for physicians and hospitals. With Arenas’ permission, we shared her case with experts, including Dr. Barbara Levy, vice president of health policy for the American College of Obstetricians and Gynecologists and three radiologists. Levy said there’s a standard way to treat a suspected breast cyst that’s efficient and cost-effective. If the lump is large, as in Arenas’ case, a doctor should first use a needle to try and drain it. If the fluid is clear and the lump goes away there’s no cause for concern or extra testing. If the fluid is bloody or can’t be drained, or the mass is solid, then medical imaging tests can determine if it’s cancerous. However, doctors often choose to order imaging tests rather than drain apparent cysts, Levy said. “We’re so afraid the next one might be cancer even though the last 10 weren’t,” she said. “So, we overtest.” Levy and the radiologists agreed that at least some of Arenas’ care seemed excessive. But their opinions varied, which shows why it can be difficult to reduce unnecessary care. Standards are often open-ended, so they allow for a wide range of practices and doctors have autonomy to take the route they think is best for patients. The American College of Radiology recommends an ultrasound for a 32-year-old — Arenas’ age at the time of the procedure — with an unidentified breast mass. Mammograms are also an option, but “most benign lesions in young women are not visualized by mammography,” the guidelines state. Phillip Shaffer, a radiologist who’s practiced for decades in Columbus, Ohio, said he didn’t think Arenas needed the mammogram. “If I did an ultrasound and saw cysts, I’d say you have cysts. In 32-year-olds the mammogram does almost nothing.” Dr. Jay Baker, chair of the American College of Radiology breast imaging communications committee, agreed that the ultrasound alone would have “almost certainly” identified the cyst. But, he said, maybe something about the lumps concerned Arenas’ radiologist, so a mammogram was ordered. None of the radiologists consulted by Pro Publica could explain why two ultrasounds on the return visit would be necessary. According to Arenas’ medical records, the practice told one reviewer that two were done to make sure the cysts hadn’t changed. “They just billed her twice for one thing,” he said. Levy, the gynecologist, said it’s “excessive” to do two ultrasounds. And, she said, there was no need to send clear fluid to pathology. Arenas offered to waive her privacy rights so the practice that provided her treatment could speak to Pro Publica. Her medical records show that in response to reviews by her insurance company and the attorney general’s office, her doctors said the care was appropriate. Since then she has her cysts drained without images in her gynecologist’s office for about 0. But Arenas said on two occasions she’s used a needle at home to do it herself. (Doctors do not recommend this approach.) She admits it was an extreme choice, but at the time she worried she would be subjected to more unnecessary tests. “I was taken advantage of because I was a captive audience,” she said. In a brick-and-glass office park just outside Roanoke, Virginia, Missy Conley and Jeanne Woodward have battled on behalf of hundreds of patients who believe they’ve been overtreated or overcharged. The two work for Medliminal, a company that challenges erroneous and inflated medical bills on behalf of consumers in exchange for a share of the savings. The two women excitedly one-up each other with their favorite outrages. How about the two cases involving unnecessary pregnancy tests? One of the patients was 82 —decades past her childbearing years. The other involved a younger woman who no longer had a uterus. Another case involved an uninsured man who fell off his mountain bike and hurt his shoulder. The first responders pressured him to take an air ambulance to a hospital when it would have been faster for his friends to drive him. Such unexpectedly pricey flights — and the aggressive billing that comes with them — have been featured in stories by NPR, The New York Times and The Atlantic. Medliminal gets dozens of calls a week from consumers who are fed up with the medical system. Woodward, a nurse and certified medical auditor, regularly sees patients billed for unnecessary lab tests. A man with diabetes may only need his glucose measured, but the doctor may order a bundle of 14 unnecessary tests, she said. If there’s a billing dispute it can take months of phone calls and emails to get a case resolved, said Conley, who gained an insider’s knowledge during years working for insurance companies. Patients fighting bills on their own often give up and pay the bill or let it go to collections, she said. Saini, president of The Lown Institute, said profit is a major driver of overuse. “Providers are getting constant messages from superiors or partners to maximize revenue,” Saini said. That’s business as usual.” Patients aren’t true health care consumers because they typically can’t shop by price and they often don’t have control over the care they receive, Saini said. The medical evidence may support multiple paths for providing care, but patients are unable to tell what is or is not discretionary, he said. Time pressure adds urgency, which makes it difficult to discuss or research various options. “It’s sort of this perfect storm where no one is really evil but the net effect is predatory,” Saini said. Once the service or treatment is provided, the bill is on its way, with little forgiveness. Dong Chang, the director of the medical intensive care unit at Harbor-UCLA Medical Center, a public hospital in Los Angeles, decided to see whether the care being delivered in his ICU was appropriate. Resources were scarce in his ICU, and he suspected it might be possible to manage them better. So, he and his colleagues reviewed the records of all the patients in the unit over the course of a year to see whether the patients might have been either too sick, or too healthy, to benefit from intensive care. They determined the care may not have been beneficial to more than half of the patients. “ICU care is inefficient, devoting substantial resources to patients less likely to benefit,” their study, published in the February edition of JAMA Internal Medicine, concluded. Chang and his team also reviewed the use of intensive care at 94 hospitals in two states, Maryland and Washington, focusing on four common conditions that can lead to treatment in an intensive care unit. They found wide variation in the types of patients hospitals determined needed intensive care. One hospital put 16 percent of patients with diabetic ketoacidosis, a serious condition that can result in a coma, in intensive care, while another hospital did so with 81 percent of such patients. The range for patients with pulmonary embolisms was from 5 percent to 44 percent and for those with congestive heart failure, it was 4 percent to 49 percent. Chang attributes the difference to doctors using intensive care based on their habits, hunches or training. Profit, he said, may also be a motive, but it didn’t appear to be a driving force. “We really don’t have good standards and a good discussion going on about who should receive ICU care,” Chang said. The unnecessary intensive care can also be harmful. The study found intensive care patients underwent more invasive procedures, like the insertion of catheters, including central lines, which carry the risk of infection. Overuse of the ICU is bad for patients who don’t need it, Chang said. Survival rates were also no better at the hospitals that used intensive care the most. Reducing unneeded intensive care stays would save big money. Intensive care costs about ,000 for a typical stay and accounts for 4 percent of national health care expenditures, according to research cited by Chang’s team. If the hospitals in Maryland and Washington with the highest rates of intensive care use had behaved more like those with lower use, it would save around 7 million, the study estimated. That’s the savings for fewer than 100 hospitals in two states. There are about 4,000 hospitals nationwide, suggesting that reducing unnecessary intensive care use could save billions of dollars a year. Chang hesitated to call the overuse of intensive care “wasted” health care spending. He said the medical literature calls it “non-beneficial” care, which is maybe a nicer way of saying the same thing. For O’Neill, her dispute of the fee for her daughter’s ear piercing was a trip into the hell of medical billing. O’Neill is an attorney, so she knows how to weed through fine print. But it took her untold hours and phone calls to the hospital and her insurance company to root out the issue. The hospital had initially billed her insurer for the ,877.86 for “operating room services” related to the ear piercing. The company rightly rejected payment for the cosmetic procedure. So, the hospital billed the family, according to her medical and billing records and correspondence. The surgeon billed the family an additional 0, which O’Neill paid. The operative report describes the piercing in obscure technical terms: “The bilateral lobules were prepped with betadine and a 18 gauge was used to pierce the left lobule in the planned position …” O’Neill said she got nowhere in several conversations with the manager of the hospital’s team that deals with payments directly from consumers. Then in mid-July, O’Neill wrote a letter to the manager explaining that they were at an impasse and urged the hospital to cancel the bill. In early August, Pro Publica contacted the hospital and surgeon to inquire about the ear piercing. The hospital spokeswoman replied in an email that, generally speaking, ear piercings during surgery are rare and only done at the request of a family. (The medical records say O’Neill requested the ear piercing.) It would not result in a separate operating room charge, she wrote. The spokeswoman’s explanation didn’t jibe with the hospital’s bill, which even listed the billing code for ear piercing. She declined to discuss O’Neill’s case or explain the discrepancy. In mid-August, the self-pay manager sent O’Neill a letter saying, “the remaining balance of ,877.86” would be removed “as a one-time courtesy adjustment.” The manager added that the hospital hadn’t done anything wrong. The account was “correctly documented, coded, charged and billed according to industry standards,” she wrote. The hospital’s ,877 bill for the ear piercing within industry standards. As for O’Neill, she and her daughter had to endure one additional insult. The surgeon’s piercing of one ear was off-kilter so it had to be redone. This time O’Neill had it done at the mall, for about 30 bucks. 4, 2017: A caption on the original story misidentified the image Christina Arenas was looking at on her computer screen. The caption said it was a mammogram, but it is an ultrasound.

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