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•  (WARNING: Students can get credit for only one of Math 108, Math 111, or Math 131)

Description of the course

Concepts covered in this course include: standard functions and their graphs, limits, continuity, tangents, derivatives, the definite integral, and the fundamental theorem of calculus.  Formulas for differentiation are developed and include formulas for trigonometric, exponential, and logarithmic functions.  Applications to physics, economics and geometry are highlighted.

Successful completion of Math 111 is awarded 4 semester hours of credit. The lecture sections of the course meet 3 times a week for 50 minutes or twice a week for 80 minutes.  The fourth hour is a required class meeting in which students work additional assigned lab problems with assistance from a graduate student teaching assistant.  Both in class and in the laboratory, students use graphing calculators as tools for experimentation and visualization. The laboratory assignments complement the lectures and examine themes that run throughout the course. The lab component accounts for 15% of the course grade.

Textbook

• Single Variable Calculus with Early Transcendentals (8th edition), by James Stewart, published by Cengage Publishing.  It is in the bookstore shrinkwrappewith a WebAssign access code. The course covers most of chapters 1 through 5. 
• This book will also be used for the next course, Math 112.
• A student solutions manual may be purchased but is not required.
• Labs can be found using the links on this site. Your instructor and/or TA will let you know what labs you are responsible for and when the lab exercises must be submitted.

Calculators

• Students are encouraged to have a TI-83 or TI-84 graphing calculator for Math 111 and Math 112.  Calculators are used to complete select labs and homework.  

Students can expect to take most tests and quizzes without a calculator.

Labs

The labs for this course are found below.  You will need Adobe Acrobat Reader to open the files. You may get Acrobat for free from the Adobe site or you may go to a campus computer lab to access and print them.  Lab sessions begin on the first full week of classes.

Prerequisites

Students are expected to be proficient in the following areas that are necessary for success in calculus:

•  Algebra
•  Trigonometry
•  Logarithms

If you are worried about the level of your preparation for Math 111, you may wish to consider one or more of the following approaches:

• Math 103 (Precalculus) to Strengthen your skills. This course is designed for students who plan to take calculus but whose algebra and trigonometry backgrounds need improvement. This course does not satisfy the College's first general education requirement (GER-1).  Here is a testimonial from a student who took the course before taking Math 111:

"In my opinion, there are two types of students who would benefit from taking Math 103. The first would be any student who had a year or more away from taking any Math courses. The second would be those students who have always felt that Math wasn't their "strong suit" so to speak. I fell into both of those categories and found 103 to be a tremendous help. It helped rebuild and strengthen my algebra foundation and prepared me for the new material I would encounter in Calculus. I can strongly recommend taking this course."

• Enroll in a pre-calculus course in your home town the summer before you take Math 111.

Need only one course?

Math 111 satisfies the General Education Requirement (GER 1) and the Math Proficiency requirement under the COLL curriculum. If this is the only reason you want to take the course, you might want to think about some different options that also satisfy the requirement.

Math 104: The Mathematics of Powered Flight

The goal of this course is to study mathematics in an immediately applied context. This course is primarily aimed at non-science students and will fulfill the GER-1 requirement. This course will fulfill the GER-1 requirement.

Math 106: Elementary Probability and Statistics

This course introduces some basic ways of thinking about uncertain phenomena. Quantitative reasoning skills and statistical literacy are emphasized. An important theme is the role of probability in statistical inference. Math 106 has no prerequisites and fulfills GER 1.

Math 108: Brief Calculus with Applications

This course is an introduction to the calculus of polynomial, rational, exponential and logarithmic functions, including some multi-variable calculus, with applications in business, social and life sciences. This course will fulfill the GER-1 requirement

(Important notice: students cannot receive credit or both Math 108 and Math 111.)

For more details on individual sections of Math 111, please contact the instructor of that section. 

Tutoring for Math 111 and Math 112

Free tutoring (beginning on Sunday of the first full week of classes) is provided by graduate assistants for Math 111 and Math 112 in Jones 112 from 5:00 until 8:00 p.m. on Sunday through Wednesday evenings. Contact your instructor for details. 

Math 111 History Assignment Lesson

Math 111 history assignment1.doc

Final Exam

The test for all sections of Math 111 is administered during the math block as seen in the test schedule.   The room assignments for the final test are posted in the Mathematics Department in Jones Hall the week before the exam.

A Previous Final Examination Paper

 Any Questions?

You may direct them to Professor Zapf by clicking at [[mjzapf]].

Degrees and colleges are signals. They tell you something about the competency of a person. No wonder there is a craze and clamour for people to get into top-tier colleges - it sends a strong signal and secures their future to some extent.

The MBA isn’t immune to this. But the statistics paint a different picture. According to a study, only about 50% of MBA holders are employable. This means there are many people spending lakhs of money and getting very little in return. Moreover, the traditional MBA is rigid. You need to quit your job, take a loan and study frameworks that may not be entirely relevant to the modern world.

The final piece is measuring competency, which is very hard to measure for business roles. Most organizations still have a trial and error method, which isn’t ideal. And one wrong hire can set a business back by years.

Stoa aims to plug this gaping hole into the business education ecosystem.

The Stoa Charter is the first-of-its-kind aimed at business education. It can be pursued alongside your work and costs a fraction of a traditional MBA (₹ 2.5 lakhs + GST).

To date, the average salary for people who have completed the Stoa Program is 15 lakhs and the average hike in remuneration is 72%.

According to Aditya Kulkarni, Co-founder and CEO of Stoa, “many people want business education, but not necessarily an MBA”

But, what exactly is the Stoa Charter?

Building on the success of its online StoaMBA program, which has 600+ alumni, the Stoa Charter is a CFA-like model applied to business education. Candidates inside the Stoa program can now prove their competence and earn their Stoa Level 1 / Level 2 to earn the Charter.

L1 trains people on 'professional hygiene' (commercial awareness, writing skills, communication, and analytical thinking) and business fundamentals. To receive the L1 Charter, candidates will solve & present the case for a given business problem in front of a jury to show their problem-solving skills and thought processes.

L2 is for learning domain-specific skills and clearing this is based on how you solve business problems in a particular domain. This allows people who don't have experience in a specific field to gain knowledge and expertise to switch to that field.

“The Stoa Charter vouches for a person’s competence after we have trained them and are convinced about their abilities” Aditya goes on to elaborate.

The Charter will help professionals get all the benefits of an MBA without quitting their jobs or being burdened by exorbitant fees.

Signing up for Stoa will provide you access to 50+ learning sprints across multiple domains (Marketing, Product, Finance, Leadership, Strategy & Operations, and General Management skills). Each learning sprint is one week long with a mix of self-paced learning over weekdays and group-based learning over weekends. Candidates can choose the domains they want to specialise in and select sprints accordingly.

Each level certifies a certain competency and capability to bring value to a business. These are awarded to individuals who complete the sprints and clear the test for the respective level. One passes each level by solving case studies that mimic the challenges businesses face today and pitching solutions to a panel of judges who test for subject-specific skills, way of thinking, and communication abilities.

An interesting aspect of the Stoa program is the mentoring and coaching, which are largely absent in mainstream education. Certified professional coaches help you gain clarity on your strengths and allow you to make better decisions. Interview coaching and resume preparation workshops will help you beat the queue and stand out in your quest to get the job you want. As you clear different levels, you get access to exclusive workshops, meetups, and a network of alumni who are also at the same level.

Stoa is backed by the founders of Zerodha, CRED, Udemy, Redbus, and Myntra. The faculty comprises people who work in fast-growing business environments and have their fingers on the pulse of the ever-changing business landscape.

In short, the Stoa Program helps you become a well-rounded, competent professional. Instead of a certificate, you'll be equipped with the skills companies are looking for and have a thriving community to fall back on.

It's a worthy competitor to the traditional MBA, which is time and cash-consuming.

Benjamin Nworie writes on the exploits of the only All Progressives Congress federal legislator from Ebonyi State, Hon. Chinedu Ogah, representing Ezza South/ Ikwo Federal Constituency in the House of Representatives

Chiboy as he is fondly called has carved a niche for himself by impacting positively on the lives of others, especially the downtrodden. From childhood, this leader of youths said he imbibed the spirit of giving and philanthropy. This assertion is incontrovertibly germane, as many who have come in contact with him can attest to its veracity.

From being the National President of the Ebonyi Youth Assembly (EYA), which chronic political activities has since muzzled to seeming extinction, Chinedu Ogah used the organization as a contact point between government of the immediate past governor, Chief Martin Elechi and Ebonyi people.

Under Chinedu Ogah, Ebonyi Youth Assembly was the most impactful government at the grassroots, reaching out to vulnerable people; giving jobs to the jobless, and giving hope to those who felt all hopes were lost.

No one ever met Chinedu Ogah and went back empty handed. He never dashed any hope, always doing the best within his ability to solve every problems. Many graduates got jobs in the army, police, immigration, federal and state civil services, paramilitary agencies through the instrumentality of the EYA. He devoted and utilized his influence to provide succour to many Ebonyians and non-indigenes.

In 2019, Ogah indicated interest to contest for the Ezza South/ Ikwo Federal Constituency in Ebonyi State. Many were supportive of his ambition across political divides. But uncertainty beclouded his chance of getting the seat. One, the All Progressives Congress (APC) at that time was plagued with multiple factions and internal crises in Ebonyi State. Onlookers felt he had made a terrible mistake by joining APC because of the crises in its state chapter and also knowing fully well that Peoples Democratic Party (PDP) had deep roots in Ebonyi State since 1999.

Two, considering that Ikwo council area parades the highest number of political office holders in the state, one would ordinarily feel that their collective influence will whittle down the popularity of Ogah. Some of the PDP giants in Ikwo local government area include the Deputy Governor, Kelechi Igwe; the chairman of Ebonyi Elders Council, Ambassador Frank Ogbuewu, though Ogbuewu can be excused because his people claim he has no electoral influence both from his ward to the council area. Whether Ogbuewu has electoral value or not, no one can take his “nuisance value” for granted. He can dare anybody or government if displeased.

Other bigwigs include the Ikwo council chairman, John Nnabu; Principal Secretary to the Governor, Clement Nweke. In Ikwo, there are many appointees of Umahi’s PDP administration like commissioners, Senior Special Assistants, Special Assistants, Senior Technical Assistants, Technical Assistants and others positions.

These are the personalities that Ogah triumphed over in the 2019 Presidential and National Assembly elections.

Ogah single-handedly delivered Ikwo local government area to President Muhammadu Buhari in Ebonyi State. The Federal Lawmaker fought the “big forces” of Ikwo politics to a standstill, thereby tearing their values to shreds.

After attaining such a feat, Ogah said he would continue to count his people and constituency first in the delivery of dividends of democracy. After his Appeal Court victory, there was jubilation from Ebonyi people that a “Messiah” has come. APC flags now adorn, Abakaliki, the Ebonyi State capital. People started to anticipate job opportunities. In less than two months in the House of Representatives, Ogah has secured jobs for over 20 Ebonyians.

During the Christmas celebration, Ogah’s Ikwo country home was shut down. All roads led to Ikwo as he celebrated the yuletide with widows and downtrodden. This has become an annual event. Usually, every 26th of December is a special day in the life of the family of Mr. and Mrs. Chinedu Ogah, as they use it to celebrate Christmas and empower people.

So far, last year’s event was the biggest empowerment programme by the Ogahs. Over 1000 widows went home with substantial gift. Others went home with motorcycles, tricycles, grinding machines and other items. There were tears of joy from the beneficiaries who danced with Ogah’s wife.

Item-Amagu in Ikwo has a peculiar telephony network problem but respite is coming fast. The Federal Lawmaker has petitioned Nigerian Communications Commission (NCC) to compel various network providers to provide good services in all parts of his constituency to ensure easy communication between his people and the rest of the world.

Ogah said, “I have written a letter to the NCC to make sure there is network in my constituency. There is no proper network in my constituency and I am worried about it. People in my constituency can’t use their cell phones properly because of non-availability of networks.”

“When there is proper network, people can access our constituency without any hitch and what we are doing will be transmitted to the people and the general public.”

“These massive empowerments will have a multiplier effect on my constituents because they will use them and empower others and reduce crime in the society. I can’t think of a reason for not empowering my constituents. I had to take a loan from a bank to empower them because they really tried for me by voting for me in the National Assembly elections,” he submitted.

As part of his campaign promises for supporting quality education for the youths, the lawmaker has registered over 850 indigent students from his constituency for the West African Senior School Certificate Examination (WAEC).

Adjudged as the first of its kind in the history of the state, the gesture is billed to cost over N12 million.
While addressing the students, Ogah said he did that to contribute his quota to removing the state from the category of educationally disadvantaged states.

He advised the students to work hard, shun cultism, examination malpractice, indecent dressing and other anti-social behavior that can affect their future, describing them as leaders of tomorrow.

“Joining cults cannot take you anywhere, rather it will lead you to an early grave. If you know that you are a cultist and you have not repented, go to your pastors or reverend fathers and renounce cultism. You must respect your teachers and obey your parents if you must succeed.

“We pay for WAEC every year but the only thing is that we increased the number this year. Our plan and budget was to pay for 600 candidates but we now have 850. The money I am using to pay for this WAEC is the money I suffered to get, it is my hard earned money. As I am giving it to you, it will transmit to success. It is my salary and allowances and I said I am not going to use it for any other thing other than you people.

“So, study very hard and make good results because it is the only way you can pay me back. We have given scholarship to 31 graduates to do their Masters and I am ready to assist you more,” he told the students.

Head, Exams Admin of WAEC, Mrs. Chuks Egwu-Agha who was at the event to witness the disbursement, also advised the students to study hard and make good results to make Ogah happy and encourage him to do more.

“You have to study hard and pass your exams. Do not get yourself involved in any form of malpractice. WAEC doesn’t like malpractice. Once you study hard and make good results, you have paid Hon. Chinedu Ogah one hundred fold.”

On his part, a member of the state Secondary Education Board, Okulegu Bethran commended the lawmaker for the gesture.

He said while many politicians are building hotels and wasting monies on irrelevant things, Ogah was investing in his constituents.

However, Ogah said he was not happy with the current political structure in the country as it concerns the South-east. The lawmaker was bothered that his people are playing politics that has excluded them from the national equation. He accused some leaders in the zone for sabotaging the votes of President Muhammadu Buhari from the region.

He has insisted that the current political status of Ndigbo cannot earn them any juicy position in the country, if they remain out of the mainstream ruling party. He was of the opinion that if the South-east states join forces with the APC federal government, it would create a good chance for Igbo Presidency, insisting that the highest office in the land will continue to elude Ndigbo if they remain in opposition. He also advocated for unity and support for the Buhari administration, as he meant well for Ndigbo.

QUOTE:

When Ogah indicated interest to contest for the Ezza South/ Ikwo Federal Constituency in Ebonyi State. Many were supportive of his ambition across political divides. But uncertainty beclouded his chance of getting the seat. One, the All Progressives Congress at that time was plagued with multiple factions and internal crises in Ebonyi State. Onlookers felt he had made a terrible mistake by joining APC because of the crises in its state chapter and also knowing fully well that the Peoples Democratic Party (PDP) had deep roots in Ebonyi State since 1999. Two, considering that Ikwo council area parades the highest number of political office holders in the state, one would ordinarily feel that their collective influence will whittle down the popularity of Ogah…But he triumphed over every obstacle in the 2019 Presidential and National Assembly elections

A psychic practicing session by psychics may provide you with much-needed insight into what is happening and why. They may also provide you glimpses into the future, allowing you to make decisions that will positively impact your circumstances and general life.

Good counselors can explain why certain events occurred and what might happen next using divination instruments and ancient rituals. When you are faced with a problem in your life, profound knowledge can assist you in determining which path will offer the best benefits.

Getting an online psychic practicing doesn't have to be complicated or intimidating. Numerous respectable firms provide horoscope readings, rune casting, tarot readings, dream analysis, and other similar services. All you have to do now is choose the best platform to serve you, and we'll assist you with that. We will provide you with all of the information you require to make an informed decision.

Best Online Psychic practicing Platforms

1. Purple Garden: Overall Best Online Psychic practicing Sites, Editor's Pick

2. Keen: Most Popular Psychic Reader for Career and Love Reading

3. Mysticsense: Well Known Psychic Source for Tarot Reading

4. Kasamba: Trusted Psychic Medium for Spiritual Guidance

5. Psychic Oz: Trusted Fortune Teller for Spiritual Readings

#1. Purple Garden: Overall Best Online Psychic practicing Sites, Editor's Pick

Purple Garden is an online psychic practicing service relatively new to the online psychic practicing field but has quickly gained a large following. You can select the best psychic reader for your needs from a list of over 1,500 psychics.

The psychics' complete profiles are published on their websites to make things easier for you. Take your time looking through the profiles until you find one that connects with you. You can make your decision easier by categorizing the psychics according to their readings.

Purple Garden's success can be attributed to its extensive psychic screening process. Psychics must complete an application and provide a reading. They will not be hired if their practicing is inaccurate. As a result, your chances of receiving accurate online psychic readings are increased. Depending on the psychic you choose, you can expect to pay anywhere from $0.99 to $14.99 each minute.

If you are unhappy with the services you have received, you can ask for a refund. To get your refund, you must email customer support and explain why you require it.

Features

Astrology and horoscopes, dream interpretation, psychic readings, palm readings, tarot cards, angel insights, and oracle guidance are among them. Their preferred online psychic practicing methods are phone calls, chat, and live video.

Access to a psychic

Purple Garden acts as a middleman that connects renowned psychics with regular individuals interested in their services. Purple Garden serves as a matchmaker in this role. Out of the more than a hundred currently available psychics, you can choose one who is an excellent match for your requirements.

In addition, the website provides a bio for every psychic reader and a video that introduces them and provides an overview of the services they may provide for you. With the help of these profiles, it is easy to determine whether or not the individual in question is fit for your requirements and possesses the appropriate abilities.

Transparency

Purple Garden takes excellent satisfaction in that all interactions between its psychics and customers are kept open and honest. Psychic readings at Purple Garden may be obtained by calling the number on their website.

This is only one of the numerous reasons Purple Garden has attained such a high level of success. Customers can view both favorable and unfavorable reviews of a psychic and the total number of times that person has performed readings.

Because of this, you can select the reader from whom you would want to receive your reading, and you also have the chance to leave feedback regarding the experience.

Pros

- All psychics utilize a variety of channels for their communication

- The platform has a good reputation for providing reliable readings

- User-friendly website and user interface

Cons

- No free readings

Customer reviews

Customer feedback for this online psychic practicing network is excellent. Furthermore, they are the outcome of exceptional customer service and high-quality readings. Purple Garden's online psychic readings have a reputation for providing life-changing readings.

Purple Garden also aims to provide people with psychic services at a reasonable price. Whether you're willing to spend a lot of money on psychic readings or you're on a budget, this site won't let you down.

=> Click here to visit the official website of Purple Garden

#2. Keen: Most Popular Psychic Reader for Career and Love Reading

Keen is a leading online psychic site with over 20 years of experience. On Keen’s website, there are roughly 1700 psychic readers to pick from, so you'll have lots of options. Spirituality, work, and relationships are all areas of specialization for these spiritual counselors.

Some of Keen's top psychic readers have over 40 years of expertise, making them extremely dependable and trustworthy. You can also look at the psychic readers' unique and detailed profiles. Depending on your preference, you can call or chat with a psychic reader on Keen. However, video calls are not available.

One of the greatest payment policies is offered by Keen. You can pay for a psychic reader consultation with PayPal, credit, or debit cards. Clients can also pay using gift cards, which hurry accepts.

You'll also like Keen's satisfaction guarantee, which allows you to request a refund of up to $25 if you're not happy with the reading. hurry also takes refund requests, so don't be shy about contacting the helpful customer service team.

Features

On Keen, a psychic practicing might cost anything from $1.99 to $49.99 each minute. Some of the most well-known psychics on this site are rather expensive, but they are also known for providing accurate readings.

Availability of resources

When it comes to available resources, Keen’s psychics hold an advantage. When it comes to love, tarot cards, and many other themes, this psychic platform has authored numerous blogs on them.

The Keen-specific blog contains a wealth of information for you. Another feature worth mentioning is Keen's free daily horoscope, which is available to anybody, irrespective of whether or not they have joined the platform. You will also value that hurry has a mobile application for both the iOS and Android operating systems.

Ease of use

Even if you're a first-time user, Keen's website is simple to navigate. The platform's registration process is simple. You may also sort your favorite psychic readers according to their reviews, talents, availability, specialty, and pricing.

This online tarot practicing website also has several articles that you may find useful. If you're interested, Keen also offers a lucrative affiliate program through which you may earn money by introducing others to the site.

Pros

- Psychic readers with a lot of experience

- Accurate readings provided

- Psychic readings are quite reasonably priced

- The readers can be contacted in a variety of ways

- On the site, there is a free horoscope as well as several useful tools

Cons

- There are no video consultations available

- Some tarot readers charge an exorbitant fee

Customer reviews

Keen is one of the most user-friendly psychic apps on the market, making it simple to get a psychic practicing wherever and anytime users choose. While the hiring procedure isn't as rigorous as other platforms, Keen's access to over 1,700 distinct psychics with diverse expertise is one more plus.

With Keen's three free minutes for every new customer, they get a free psychic practicing online, which they consider a great deal.

=> Click here to visit the official website of Keen

#3. MysticSense: Well Known Psychic Source for Tarot Reading

Mysticsense is an online psychic practicing site featuring a broad selection of legitimate practicing types from which users can choose. The website is intended to assist customers in screening out psychics that offer the psychic practicing online that they desire and the type of practicing they seek.

There are many different sorts of online psychics and readings to choose from, so try as many as you can before finding the right fit. The length of the sessions is determined by you and what you can afford.

Depending on your comfort level, you can also choose how your psychic sessions or online psychic readings are conducted (by phone, chat, etc.). The pricing on Mysticsense is transparent and straightforward, so you will never pay more for free psychic practicing online than what is stated. On the internet, you receive exactly what you see.

Based on your budget and the reputation of the psychics you choose, you can pay as little as $0.99 per minute for practicing or as much as $5 per minute. If you are a member of their site, you receive free access to daily horoscopes. They also provide away free minutes of readings to new customers.

Features

Different channels of communication

You can talk to psychics on Mysticsense using text-based chat, voice conversations, or even video calls if you like. It is among the few psychic sites where online psychic readers offer video practicing options, which is a great feature.

Transcripts are also offered for chat psychic readings so that consumers can refer back to them quickly. While you want to glance at the transcripts while you are moving around, such as when you are traveling, you can do so discreetly and conveniently, thanks to the fact that they are entirely secret.

Different kinds of presentations

The psychics at Mysticsense are all experts in different subjects. Various possibilities are open to you, including tarot card readings, energy healing, and angel card readings. There's a section on Mysticsense dedicated to angel card readings.

Spiritual psychics are also available on this site to assist you in finding lost belongings, overcoming grief, and having a thorough understanding of LGBTQ relationships. Psychics on this platform employ astrology, crystals, numerology, chakras, and a crystal ball, among other equipment, to deliver the most accurate psychic readings.

Pros

- Mobile application available

- Accurate psychic reading

- Different specializations

Cons

- Customers must be over the age of 18 to join

Customer reviews

We discovered that many psychics are well-liked by their consumers, with pleasant comments praising them and their services. Many of the advisors who have helped clients have been direct and quick to respond, and they tend to connect.

Mysticsense has evolved to be an online psychic giant with millions of delighted consumers from all over the world by charging a reasonable price in line with industry standards. They even have a free trial option and will provide you the first five minutes of your paid session for free.

=> Click here to visit the official website of MysticSense

#4. Kasamba: Trusted Psychic Medium for Spiritual Guidance

Kasamba is a name you should never forget in the field of online psychic readings. For over 16 years, this company has been a prominent force in the business, providing outstanding psychic services to millions of subscribers.

Not only do you receive a 3-minute free psychic practicing with your first advisor, but you can also expect the same ensure with practically every other advisor. For some customers, these counselors act as therapists, mystic cupids, and empaths. You can trust their instincts about romantic relationships when selecting what to do next.

Kasamba also stands out among free psychic readings online in terms of dependability and convenience. For all psychic readings, the organization offers various payment choices, a mobile app for free psychic readings on the move, and a 100% customer satisfaction guarantee.

If you have any problems with your psychic readings, you can contact Kasamba's customer support staff, which is available 24 hours a day, 7 days a week. To address any concerns, you can call or chat with the friendly psychic service department.

Features

If you're having trouble sleeping because of concerns about your love life, try spending your nights more productively by visiting Kasamba's website. You can read articles about love, spirituality, destiny, and more while browsing through hundreds of qualified advisors for free.

Free minutes

Although many online psychic businesses may provide free minutes to their clients, in most cases, this perk is reserved exclusively for the customer's initial reading. However, Kasamba is different.

Each customer of Kasamba is allowed to speak with a new psychic for three minutes at no additional cost. Customers looking for a new psychic who is compatible with their demands may benefit from this. In addition, you will receive a discount of 50% off your first reading.

Safety first

Kasamba's dedication to security is one of the reasons it has become such a popular platform for online psychic readings. It has a specialized team of security professionals that are continually monitoring the systems for any potential attacks.

They protect users' data with cutting-edge security technologies and tight protocols to ensure that all user information is kept safe and secret at all times. Kasamba also provides a secure payment method, allowing consumers to be certain that their financial information is always protected. The moderators take all necessary precautions to ensure that the safety of the users is always a top priority.

Pros

- There is a wide range of psychic readers available

- The platform is simple to navigate and use

- Consultations by text and calls are available

- Excellent deals for first-time users

Cons

- Some tarot readers are quite pricey

Customer reviews

Kasamba's platform is incredibly user-friendly, so even newcomers will have no trouble navigating it. Signing up with Kasamba is simple, but users must create a username and password before they can begin talking with a psychic reader. They may then choose a psychic reader and begin conversing straight away.

Users also love that Kasamba includes several articles that may aid them in their spiritual path.

=> Click here to visit the official website of Kasamba

#5. PsychicOz: Trusted Fortune Teller for Spiritual Readings

Psychic Oz has been since 1989, making it the platform with the most experience in our review section. The network has been improving its services and presenting some of the most skilled psychics in the world for more than 30 years.

The psychics are chosen following a rigorous process, and you may note that the network has fewer advisors than other sites. However, this is not a disadvantage; on the contrary, Psychic Oz safeguards its hiring practices and the consultants' validity.

Remember that you may only get a refund in free credits if you want to provide the platform another opportunity. You have to ask for a refund within 24 hours of the session, and the session shouldn't go on for more than 20 minutes.

When looking for the finest online psychic reading, you'll see that you have the option of sorting the psychics by rating, price, and type of reading. Additionally, clicking on their profile reveals their online psychic practicing subjects, abilities, and psychic instruments. Finally, the first three minutes are free with Psychic Oz, and there are a few enticing promotional deals.

Features

Informative tutorials

Psychic Oz psychics include instructional videos in their profiles, one of the most distinguishing characteristics that set them apart from other psychics. Some psychics will provide their clients good advice on how to Strengthen themselves.

It enables their psychics to acquire a following and become more than just psychics; they can also become content creators. Furthermore, you are permitted to research a psychic before investing credits in them. There are paid versions of some of these videos and free performances of others.

Psychic convergence

Choosing the ideal psychic reader among the many psychics currently accessible through the Psychic Oz’s website may be difficult.

You will be given a few quick questions about what you're seeking, and in a matter of seconds, the platform will offer the best psychics accessible, depending on your responses to those questions. The questions will be about what you're searching for.

Pros

- For new users, the first three minutes are free

- Psychics are subjected to a rigorous screening process

- Prices are lower than on other sites

- Guaranteed satisfaction

- Free minutes as a form of compensation

Cons

- No mobile app

Customer reviews

Customers like that Psychic Oz gives its customers easy access to a tool that facilitates communication with psychics, which is a significant differentiator for the company.

When it comes to customer happiness, Psychic Oz provides a satisfaction ensure that allows you to request a refund if you are not satisfied.

=> Click here to visit the official website of Psychic Oz

How We Made the List of Tarot practicing Online?

Screening process

When you look for a free psychic online without completing your research, you are likely to come upon a hoax. Many websites offer free psychic readings without verifying the psychics' credentials or reputation.

Examining how well the website filters its readers was a big consideration for us in determining the best psychic practicing sources. Each of our top five platforms goes through a thorough screening and analytical procedure to vet psychic readers, guaranteeing that you always get professional and reliable results.

Our recommended websites evaluated their quality scores, client feedback, and honesty even after hiring the top psychics, and they still do that. We also discovered that the finest free psychics had no issues about displaying all of their reviews online.

User reviews

Analyzing a free psychic website's reviews was an excellent approach to judging its credibility. When it comes to accuracy, payment, and overall success, customer reviews can tell you a lot.

There was a lot that goes into getting great evaluations for a company. Customer support, website maintenance, and communication were all part of this activity, which goes beyond the efforts of the free psychics.

Positive feedback indicates that paying for a psychic practicing online is a pleasurable experience that is well worth your money. Each service on our list has earned multiple good feedback from clients. The psychics on these portals, as well as the portal itself, have earned hundreds of positive evaluations from their pleased users.

Prices

When looking for online psychic readings, the cost of the practicing is also a major factor for many people. The majority of websites charge per minute.

While a cheap psychic practicing may appear to be more appealing, keep in mind that if a price appears to be too good to be true, it could be a fraud. For example, if a website offers free psychic readings with no time limit, you should think about how good the psychics are.

Psychic specialties

A website must first demonstrate that it can provide a wide range of psychic readings. Sticking to the basics, such as tarot card readings, fortune telling, psychic forecasts, and so on, is, of course, a solid plan.

Kasamba had the widest range of specialties of any psychic network we looked at. Just keep in mind that the site may appear to be overpowering at first. Furthermore, the types of psychic readings available will be determined by which online psychics are taking bookings.

Factors to Consider While Choosing Psychic practicing Websites

Channels of contact

When you want to take a psychic practicing session, you want to know that the psychic will be able to speak with you. The more communication ways an online psychic service has, the more likely you are to be able to reach them when you require their services.

Many firms provide email addresses as their primary contact method. However, this isn't always the most trustworthy way to get out to your psychic. Instead, make sure the psychic has a phone number and possibly even a chat box on their website. Additionally, check for online psychics that state how long they've been in business and what kind of experience they have.

Trial minutes offered

One of the most important elements to consider when looking for internet psychics is whether or not they provide free trial minutes. The best online psychic practicing websites are at the top in providing users with a host of online psychics with live chat and a significant amount of free trial minutes, according to these psychic reviews.

The main advantages of free psychic readings are that they allow you to try out a reputable online psychic, learn how they work, and obtain answers to your queries. If you've never had an online psychic practicing before, look for a deal that includes free trial minutes when deciding which one to utilize.

Surprisingly, online psychics provide more benefits than phone psychics. When looking for online psychics, they will usually provide you with a larger selection of options.

Satisfaction guarantee

Regardless of the psychic platform's legitimacy, the psychic readers' accuracy cannot be guaranteed. The spiritual advisor's experience is what determines the accuracy of the psychic reading. Nonetheless, the greatest psychic practicing online guarantees your complete delight.

If you are not happy with the reading, you will typically receive a full or partial refund. You will, however, receive reimbursement in your psychic practicing platform account. These free credits can then be used to book a psychic practicing with a reader of your choice.

Years of experience

Expertise is crucial when it comes to choosing an online psychic. Our top picks have been in the business for nearly two decades. As company critics and reviewers, we want them to have figured out what works best for individuals seeking psychic services in this length of time.

Even the most current psychic services have been available for at least ten years. These websites are well-established, and it's reasonable to assume that they have a strong grasp of how things work.

Psychic readers have all been learning for decades, and many have learned that this new internet domain is a convenient method to extend their business on a global scale. On each site, you can find psychics with a wide range of expertise, including some who have been in business for over 45 years.

Benefits of Online Psychics

Save your time

There's no denying that we've all considered receiving psychic readings to be confident about some aspects of our lives, like our future, relationships, and financial security. Our hectic schedules, on the other hand, are a stumbling obstacle, limiting the amount of time we can spend with the psychics. Online psychic practicing services have proven to be very useful for people who are busy in their day jobs.

Cost-effective

When compared to online psychic readings, it is evident that offline psychic services are more expensive. The reason for this is due to factors such as rent and other operating costs that businesses must incur to stay in business.

Because everything is done online, online services tend to be more cost-effective for your wallet. The sessions are also shorter than in-person meetings, which helps to reduce the overall cost of services you will have to pay.

Reliable results

When doing a practicing in person, there are a few elements that can either help or hurt your reading. When you visit a psychic reader for the first time, you may feel worried, and as a result, you may provide the wrong signals to your reader.

Because your facial expressions, body motions, and overall body physique can all be used to connect with your future, it pays to be calm and concentrated; however, this is less important for people using online services. Without as many indications to go on, the psychic will rely on characteristics like your voice to provide you a more accurate reading.

FAQs on Psychic practicing via Phone or Chat

Is it true that some psychic readings are fake?

Unfortunately, some fake psychics are out there, tarnishing the reputation of many genuine and ethical psychics. Choosing one of the five greatest sites from this list is the safest decision. You can trust these sites to provide you with a practicing from a screened, professional psychic, and you can also trust them to compensate you if you are dissatisfied with your reading.

What should I take a psychic practicing session?

People get psychic readings to answer their queries about their lives and futures. Others seek to find their soulmate or communicate with a loved one who has passed away. Preparing a list of questions ahead of time will help you get the most out of the reading.

Is online practicing safe?

Yes, online psychic practicing platforms are generally safe. The majority of psychic practicing websites take great precautions to protect both your privacy and your financial information.

Customers are aggressively advised not to provide their personal information. That said, it's preferable to stick to reliable sites that have been operating for a while for your protection and peace of mind.

Concluding on Tarot Card and Psychic practicing Online

As you are all aware, life can be stressful, especially if you have a demanding job, a complex relationship, or financial problems. A psychic practicing can be quite beneficial and can Strengthen your overall quality of life.

Reading can also assist you in adjusting your perspective on a situation and making the necessary changes to resolve it. All of the services featured in this article are reputable and provide good promotional deals to new users.

Therefore, we suggest you choose one of the recommended sites and then live without a doubt.

Disclaimer: This article is a paid publication and does not have journalistic/editorial involvement of Hindustan Times. Hindustan Times does not endorse/subscribe to the content(s) of the article/advertisement and/or view(s) expressed herein. Hindustan Times shall not in any manner, be responsible and/or liable in any manner whatsoever for all that is stated in the article and/or also with regard to the view(s), opinion(s), announcement(s), declaration(s), affirmation(s) etc., stated/featured in the same.

This story was originally produced by the New Hampshire Bulletin, an independent local newsroom that allows NHPR and other outlets to republish its reporting.

Executive councilors have voted 4-1 to deny funding to the state’s largest providers of low-income reproductive health care three times in less than a year. On Wednesday, the Department of Health and Human Services will ask them to reconsider – again.

Democratic Councilor Cinde Warmington continued Monday to publicly support the family planning contracts. Republican Councilor Joe Kenney indicated he’s likely to continue to oppose them. The other three councilors, Republicans Janet Stevens, David Wheeler, and Ted Gatsas, did not return messages.

What is certain is the department’s next step if the contracts fail a fourth time.

“If we run into a wall every single time, we are going to continue bringing it forward and run into that wall,” said Commissioner Lori Shibinette in an interview last week. “We won’t stop.”

The $1 million in proposed contracts with Planned Parenthood of Northern New England, Lovering Health Center, and Equality Health Center would serve nearly 17,600 Granite Staters, with a focus on people who are low-income, uninsured, underinsured, adolescents, LGTBQ+, refugees, and people at risk of unintended pregnancy because of substance abuse.

The proposed money can be used for basic reproductive health care, such as cancer screenings, STD testing and treatment, birth control, annual exams, and education on abstinence and safer sex. Under the contracts, providers may answer questions about abortion and refer patients to centers that provide abortions, but they cannot use contract funding to perform abortions.

None of the providers have violated that rule, according to statements and information provided to councilors by Heath and Human Services, which is now required by the Legislature to audit providers. The Attorney General’s Office has confirmed those findings, but the assurances have not been persuasive.

Kenney reiterated his concerns Monday about misuse of public money.

“If (reproductive health care services) are all under one tent, one umbrella, I have a hard time supporting funding going to an organization that provides abortions,” he said. Kenney said he would feel differently if the organizations had created separate spaces and budgets for their abortion work and the other reproductive health care.

Republican lawmakers had sought the same operational divide during budget negotiations last year but agreed to the requirement that the providers be audited in a compromise proposed by Sen. Jeb Bradley, a Wolfeboro Republican.

Kenney said he will have additional questions for the department Wednesday about the state’s obligation under the new abortion law, which he said “allows abortions up to 25 weeks, I believe.” The law prohibits abortions after 24 weeks with two exceptions: risk to the mother’s life and a fetus that will not survive on its own after delivery.

On Friday, the Joint Legislative Fiscal Committee passed a related funding request from the department that sought to accept and spend about $1.4 million in federal money for family planning.

Questions about what the money can – and can’t – be used for led Sen. Gary Daniels, a Milford Republican, to vote against it.

The department had not yet made public that it hoped to direct some of that money to Planned Parenthood of Northern New England, Lovering Health Center, and Equality Health Center, all of which provide abortions as part of their reproductive health care using private money.

When Daniels asked Trish Tilley, director of the Division of Public Health Services at Health and Human Services, what the money could be used for, she answered that none of the money can fund abortions. The money can be used only for reproductive health care such as contraception, cancer and STD screenings, and education, Tilley said.

While the department did not ask the fiscal committee to approve particular contracts Friday, Daniels said he was upset to see the three providers identified a few hours later on the Executive Council agenda, after being told during the meeting the providers’ names were not yet public.

“‘None of the money is going to abortion services,’ means different things to different people,” Daniels said Monday. “Does that mean none of the money will be used to pay for someone who is referring for abortion? Those kinds of things weren’t answered. I think the answers that were given were very vague and pretty broad.”

The department’s request passed the fiscal committee, 9-1.

Until recently, the state’s “Family Planning Program” provided low-cost, high-quality reproductive health care to people in all parts of the state.

The council’s votes in 2021 and in January to defund Planned Parenthood of Northern New England, Lovering Health Center, and Equality Health Center did not close those centers but eliminated them from the program, leaving just four sites supported with state contacts in Berlin, Laconia, Manchester, and Nashua. The contracts before the council Wednesday would expand that network to Derry, Exeter, Keene, Concord, and Greenland.

Sandi Denoncour, executive director of the Lovering Health Center in Greenland, said the family planning contract represents 20 to 30 percent of her center’s budget. It is expected to pay for care for about 370 people between now and December 2023.

“Choice of providers contributes to the success of statewide programs like family planning,” she said in an email. “While other providers on the Seacoast CAN provide services, none are obligated to provide them to the extent required by sites under contract. Having more providers in the network ensures high-quality, robust care models that the state can reinforce to best meet the current and emerging needs of our communities statewide.”

Denoncour said the funding loss led her center to eliminate a position dedicated to outreach and education. “We have worked hard to maintain our presence at community events,” she said, “but it is a strain on an already very small staff.” Despite the loss, the sliding fee has remained, she said.

“New Hampshire taxpayers and legislators have prioritized funds for this program to meet the needs of the lowest income citizens,” Denoncour said. “And while the Executive Council is empowered to approve or deny the contracts, the result of denial is stigmatizing and removes important freedoms of choice in health care for those seeking sexual and reproductive health care services.”

The proposed contract with Planned Parenthood of Northern New England says it would provide care to nearly 16,240 people over two years. After the council rejected the provider’s contract for the third time in January, it received $500,000 in federal money at the request of the federal delegation to cover some of that loss. Kayla Montgomery, vice president for public affairs at Planned Parenthood of Northern New England, said in a statement Monday that access to affordable health care remains critical and fragile.

“The fact is, with Roe v. Wade being overturned, the reproductive health care landscape in this country is (in) chaos,” she said. “Ensuring access to critical preventative health care – including birth control, cancer screenings, and STI testing and treatment – for our most vulnerable populations has never been more important. For over a year, access to affordable, quality family planning care has been in jeopardy for thousands of Granite Staters because of three consecutive votes to defund reproductive health providers.”

Warmington echoed that urgency Monday in an email.

“I have been holding this Governor and Executive Council accountable for defunding health care services … since they first rejected family planning funds last summer,” she said. “It is my hope that these councilors finally understand the impact their rejection has had on the thousands of Granite Staters in their districts seeking care, and I hope they will join me on Wednesday in supporting these vital services.”

New Hampshire Bulletin is part of States Newsroom, a network of news bureaus supported by grants and a coalition of donors as a 501c(3) public charity. New Hampshire Bulletin maintains editorial independence. Contact Editor Dana Wormald for questions: info@newhampshirebulletin.com. Follow New Hampshire Bulletin on Facebook and Twitter.

Investment Thesis

Omega Healthcare Investors, Inc. (NYSE:OHI) is the largest Skilled Nursing Facility focused REIT, with 700+ SNF properties leased to 60+ tenants who actually operate the Skilled Nursing Facility (SNF).

Many investors view SNFs as an attractive segment of the health care real estate markets, perhaps associating skilled care with higher revenue, and aware of the $28 billion Medicare paid for SNF services in 2021.

However, an analysis of the SNF business in general, and OHI specifically, indicate that the tenants primarily provide long term care to indigent Medicaid patients, with very low revenue per patient-day, less than half that paid by Medicare.

This appears to be the root cause of recurrent problems with tenants inability to pay rent; the tenants are in a fundamentally low margin business, leaving the tenant's business viability at risk from even minor management mistakes, unforeseen events, or regulatory changes.

Investors should be careful to understand the genuine business mix of OHI's tenants. I view this business mix as intrinsically unattractive, and choose to avoid it.

Introduction

In this article, we will discuss the general SNF business, what constitutes "skilled" care, the role of Medicare vs. Medicaid, the REIT footprint in the business, OHI specifics, and finally how an investor might think about all this. There is some detail required, so bear with me.

Be aware that terminology in this area is often imprecise.

There is often minor inconsistency in the numbers, among and even within sources, and not all data is from the same reporting period, but I believe it is generally inconsequential to this analysis. Note also that some numbers for 2020 and 2021 are impacted by COVID, and significant but temporary COIVD related payments.

The Medicare Payment Advisory Commission (MedPAC) is a permanent U.S. government commission which provides analysis and recommendations to Congress; it is a public domain data and analysis resource. They issue reports twice a year.

Chapter 7, Skilled Nursing Facility Services, from MedPAC's March 2022 Report to the Congress: Medicare Payment Policy contains a great deal of information and analysis on the SNF business. For anyone considering investments in the SNF area, this chapter is worth reading.

The National Investment Center for Seniors Housing & Care (NIC), collects and analyzes a great amount of data. This data and analysis is available to corporate partners like OHI, is sometimes reported to the public, but is not generally freely available for use. Occasionally elements of this data become available in news stories.

Professional service vendors may also provide useful information. The CLA annual report on SNF costs for example, provides a quantitative view of the 25-50-75 percentile variance for many SNF operational and financial metrics.

The Skilled Nursing Facility Business

The data in this section is from the MedPAC's March 2022 report, unless otherwise noted.

Some Basic Numbers

There are about 15,000 certified SNFs; more than 94% are dual certified as nursing homes in order to accept Medicaid. Almost all (> 90%) nursing homes are Medicaid certified.

In 2020, 96 percent of SNFs were freestanding (not hospital affiliated). For-profit facilities accounted for 71 percent of providers. The median size is 100 beds.

Skilled Care

The U.S. government Center for Medicare and Medicaid Services (CMS) defines skilled care as "nursing and therapy care that can only be safely and effectively performed by, or under the supervision of, professionals or technical personnel."

CareTrust (CTRE) provides a definition for SNFs in its exact Investor Presentation:

Licensed healthcare facility the provides restorative, rehabilitative and nursing care for people not requiring the more extensive and sophisticated treatment available at an acute care hospital or long-term acute care hospital. Treatment programs include physical, occupational, speech, respiratory, ventilator, and would therapy.

Operationally, one could say this involves at least daily attention from a licensed nurse, possibly almost daily from a licensed therapist, and some involvement from higher level medical personnel. Tasks might include medical monitoring, wound care, catheter management, delivery of antibiotics or other medications via IV, and management of prescription narcotics for pain management. The intensity of care may vary significantly.

One can contrast this with the level of care provided in an Assisted Living Facility (ALF), which provides help with the six Activities of Daily Living (e.g. eating, moving, dressing, personal hygiene, continence, toileting). ALFs may also include help with medication management.

Any parent will immediately recognize that the six ADLs are a fair description of what's involved in taking care of 18 month old. I've described this as "Mom care". While it's critical to the recipient, this level of care is not prescribed by or delivered by medical personnel, and is not considered "skilled" in that sense.

However, a combination of multiple ADL functional disabilities, health issues, cognitive impairment, and behavior issues may tip the scale for a doctor to prescribe long term "nursing home level of care" in a nursing home as medically necessary.

This difference in intensity of care is reflected in cost. Genworth reports that the national median cost in 2021 for a private room in an ALF is $4500 per month, or $148 per day. This is 50% of the cost for a private room in a nursing home.

This comparison can be extended to SNF care. As we will see below: $148 per day for ALF, $225 for Medicaid long term care, $539 for traditional Medicare rehabilitation care. These are different products; this conclusion doesn't rely on extreme precision in the numbers; these are large differences.

Medicare vs. Medicaid

It's worth briefly summarizing the difference between Medicare and Medicaid.

Medicare is funded entirely by the U.S. Federal government, and is generally limited to persons 65 years and older. Medicare is not means tested.

If you qualify for Medicare Part A, and require skilled care, Medicare will pay 100% of the costs for days 1-20, all but a copay of $194.50 per day for days 21-100, and nothing after that. The average length of stay in a SNF in the US is, remarkably, about 28 days.

Traditional Medicare is also referred to as FFS Medicare (i.e. fee-for-service), to distinguish it from Medicare Advantage (sometimes called managed Medicare), an alternative insurance program available to Medicare beneficiaries.

Medicare does not generally pay for long term care or Assisted Living care.

Medicaid is a joint state-federal program, targeted toward low-income patients, with funding split about 30/70 state/federal. Excluding federal passthrough funds, Medicaid gets about 18% of state spending, second only to education; it is thus in direct competition with all other state budget items.

Each state manages Medicaid in their state, and has some discretion to define eligibility, covered services, and reimbursement levels.

Medicaid provides Nursing Facility Services if medically necessary, including long term care. In general, one has to be indigent (minimal assets and income) to qualify for Medicaid long term care; see for example the Florida requirements here.

Medicaid may pay some of the cost for Assisted Living care.

Certification and Licensing

To receive payment under the Medicare or Medicaid programs, a skilled nursing facility (SNF) or nursing facilities (NF) must be certified, demonstrating compliance with U.S. regulations as defined under Title 42 CFR Part 483, Subpart B. These regulation covers issues such as staffing, quality of care, medical services, liability, etc. for both SNFs and NFs.

State inspectors perform the genuine on the ground inspections and certify compliance, with Center for Medicare and Medicaid (CMS) approval required for SNFs. SNF and NF are actually licensed by the states.

The REIT Footprint in the SNF Business

A SNF includes both the physical real estate and the operator certified and licensed to provide medical services. In some cases the real estate owner and the operator are the same entity (i.e. an owner/operator), in some cases company A owns the real estate and leases it to company B, the operator.

According to a May 2022 report in the Journal of the American Medical Association, in 2021 REITs own 1870 (12%) of SNF properties. These properties are leased under triple-net terms to operators (in some instances the REIT holds a mortgage instead).

CareTrust CEO David Sedgwick recently pointed out that the triple net leases typically used in this area by REITs create an “impenetrable wall” between the REIT and the operator, leaving the REIT with zero control over SNF operations.

It's notable that in spite of the high cap rates available, none of the largest healthcare REITs - Welltower (WELL), Ventas (VTR), or Healthpeak Properties (PEAK) - now choose to own material SNF real estate, although Welltower and Ventas have very large investments in senior housing. Nor do the large and widely diversified triple net REITs chose to own SNF real estate.

Acquisition volume indicates public companies such as REITs have backed away from SNF acquisitions in exact years.

Among the public REITs active in the SNF market, Sabra Health Care (SBRA) identified a peer group of four with >50% NOI from SNF properties - including OHI, SBRA, CareTrust, and LTC Properties (LTC).

There is some variance in the industry among both properties and operators. Two examples from the CLA report; average age of the physical plant:

And operating margin:

REITs seldom disclose information at this level of detail for their properties or operators, individually or at the REIT level. However, it seems reasonable to assume that REIT properties and operators are median or better.

It's A Low Margin Business

Operating a SNF today is, on average, a low margin business. The all payer, all business line profit margin for 2019 was 0.6% and 3.0% in 2020. This is a long standing problem.

Here's a Long Term Care News 2020 comment on the general SNF business, pre-COVID:

SNF operators are on average in a break-even business. The median net profit margin for 2018 was just a quarter of 1%. That largely reflects the fact that low-paying Medicaid patients still account for over 50% of SNFs payer mix. While Medicare had an average net margin of 20%, its patients only account for 15% of SNF utilization.

Who Pays

There are four sources of payment to SNFs - FFS Medicare, Medicare Advantage, private pay, and state Medicaid.

One 2019 snapshot reported by Skilled Nursing News (data from 2016, 2017) shows the distribution of patient days by payor, illustrating the dominant role of Medicaid. This is still the case today.

What They Pay For

Medicare (both FFS and Advantage) pay for short-term skilled nursing and rehabilitation services for Medicare beneficiaries.

The MedPAC report says:

Skilled services are defined as ordered by a physician, requiring the skills of technical or professional personnel, and furnished directly by or under supervision of such personnel.

To qualify for Medicare coverage, a beneficiary must require daily skilled nursing or rehabilitation services and have had a preceding hospital stay of at least three days. (This hospital stay requirement was temporarily suspended between March 2021 and April 2022 due to COVID.)

The five most common conditions leading to SNF admission for post-acute care from hospital — septicemia, heart failure and shock, joint replacement, respiratory infections, and hip and femur procedures - account for a quarter of admissions.

Medicare does not generally pay for care after 100 days.

Medicaid does pay for long term care; eligibility is means tested. MedPAC notes:

... a facility that provides skilled care often also provides long-term care services that Medicare does not cover. The less intensive long-term care services typically make up the bulk of a facility’s business, and Medicaid pays for the majority of this care.

Patient Days by Payer

Medicaid paid for 63% of SNF patient days in 2020. FFS Medicare paid for 10%. The remaining 27% of patient days were split between Medicare Advantage and private pay.

The Kaiser Family Foundation (KFF) reports that the fraction of Medicare eligible people who choose Medicare Advantage rather than traditional FFS Medicare has been growing for many years, and reached 42% in 2021. It is projected to reach 50% by 2030.

FFS Medicare Payments and Profits

In 2021 the median FFS Medicare payment for SNF services was $539 per day. FFS Medicare accounted for 17% of SNF revenue in 2020.

The MedPAC table below gives some data on median payments, costs, margins, and of the impact of efficiency on performance measures for 2020. About 9% of the 4,256 SNFs in this demo were rated "relatively efficient", with a median Medicare margin of $133 per patient-day, or 23%; the other 91% of SNFs had a margin of $78 or 16%.

FFS Medicare stays are usually short term, according to the Kaiser Foundation, the average stay for an FFS Medicare patient in a SNF is about 25 days.

The genuine operator cost to provide care for Medicare patients was estimated to be in the $450-480 range in 2020, with $480 typical.

The Medicare profit margin was 11.9% in 2019 and 16.5% in 2020. MedPAC reports that for the 21st consecutive year, the aggregate Medicare margin was above 10 percent.

FFS Medicare payments are considered adequate to motivate providers to accept Medicare patients; in 2020 the marginal profit for the incremental Medicare patient was 25%.

Medicare Advantage Payments and Profits

In 2021 the Medicare Advantage (managed Medicare) rate was about 80% of the FFS Medicare rate (see the last row in report Table 7.6 below). The lower payments "are unlikely to be explained by the differences in patient characteristics."

MedPAC does not quantify Medicare Advantage profitability for SNFs, but notes "Some publicly traded post-acute care firms with SNF holdings report seeking managed care patients as a business strategy, indicating that the MA rates are attractive."

However, if Medicare Advantage patients are paying 20% less than FFS Medicare patients, it seems reasonable to think the profit margin for Medicare Advantage patients is low to very low.

Both SNF usage and length of stay are also lower for Medicare Advantage than FFS Medicare, and provide an obvious benchmark for FFS Medicare.

Private Pay and Medicaid Payments and Profits

Medicaid pays for the vast majority of long-term care patient days provided in nursing homes, but some are private pay.

Genworth reports that the national median cost in 2021 for a semi-private room in a nursing home is $260 per day, and for a private room, $297 per day.

The American Council on Aging reports that "private pay residents pay approximately 25% more for nursing home care than Medicaid pays. In 2022, the nationwide average private payer pays approximately $255 per day for nursing home care while Medicaid pays approximately $206 per day". Note that Medicaid rates vary by state.

The Medicaid.gov website explains one scenario:

For example, commonly an individual will enter a Medicare SNF following a hospitalization that qualifies him or her for a limited period of SNF services. If nursing home services are still required after the period of SNF coverage, the individual may pay privately, and use any long-term care insurance they may have. If the individual exhausts assets and is eligible for Medicaid, and the nursing home is also a Medicaid certified nursing facility, the individual may continue to reside in the nursing home under the Medicaid NF benefit.

Medicaid long term care is very low margin. The non-Medicare (i.e. Medicaid and private payer) SNF margins in 2020 were -0.3%, an improvement from the -2.4% ,-2.4%, -3.2%, and -2.2% margins in 2015-2019.

A 2020 Skilled Nursing News report on SNF finances noted that

The financial viability of long-term care services is directly correlated to Medicaid funding, and negative operating margins in many regions of the United States suggest more facilities may be forced to close.

The OHI 2021 Annual Report notes that:

Since our operators’ profit margins on Medicaid patients are generally relatively low, more than modest reductions in Medicaid reimbursement and an increase in the number of Medicaid patients could place some operators in financial distress, which in turn could adversely affect us.

About OHI

OHI's April 2022 Investor Presentation provides a convenient summary of OHI. Their 2021 Annual Report provides additional details. The numbers in this section come from these two sources.

Two key slides tell much of the story for their SNF tenants:

OHI emphasizes that they are the "largest Skilled Nursing Facility focused REIT".

They own about 940 properties (685 SNFs, 133 Assisted Living Facilities (ALF), 20 Independent Living Facilities, 16 rehabilitation and acute care facilities and two medical office buildings, and hold mortgages on an additional 59 SNFs, 2 ALFs, and 2 specialty facilities) with 96 thousand beds.

These are leased to 63 third-party operators under long term triple-net lease terms. Average occupancy is 74%.

These operators serve over 150,000 Medicare and 80,000 Medicaid patients annually, with 53% of revenue from Medicaid, 14% from Private Pay, and 33% from Medicare. Their average length of stay for Medicare patients is 20-25 days, and for Medicaid patients 18 months. Their revenue per patient-day is $450-575 for Medicare, and $240 for Medicaid.

Seeking Alpha indicates OHI has a current market cap of $6.7 billion (5th largest among Health Care REITs) and a dividend yield of 9.2%. OHI debt is S&P rated BBB-, the lowest investment grade.

Problems with Operators

There have been recurrent problems with operators paying rent. This is neither new, rare, or confined to a few small operators. For example, compare the table of OHI's largest operators from the 2019 Annual Report, highlighted to note those that appear on the problem operators list detailed below from the 2021 Annual Report:

From the 2021 Annual Report:

• In 2021, we terminated the Daybreak Ventures, LLC (“Daybreak”) master lease and fully exited our relationship after transitioning 14 Daybreak facilities to existing operators and selling the four remaining Daybreak facilities.

• In the second quarter of 2021, Gulf Coast stopped paying contractual rent under its master lease agreement for 24 facilities because of on-going liquidity issues.

• From August 2021 through October 2021 and December 2021, Agemo Holdings, LLC (“Agemo”) failed to pay contractual rent and interest due under their lease and loan agreements

• From October 2021 through December 2021, Guardian Healthcare (“Guardian”) failed to make contractual rent and interest payments under its lease agreement for 26 operating facilities and on its $112.5 million mortgage loan agreement, bearing interest at 10.81%, for nine facilities, due to ongoing liquidity issues.

• We wrote off straight-line rent receivable balances of $5.9 million... from... four other operators. We determined that collection of substantially all contractual lease payments with these operators was no longer probable.

• In January and February 2022, an operator, representing 3.4% of total revenue (excluded the impact of write-offs) for the year ended December 31, 2021, did not pay its contractual amounts due under its lease agreement.

Problems with operators was a major syllabu on the Q1 2022 Earnings Call, with several questions about operators with EBTIDAR ratios below 1, who account for 30% of rent, as disclosed in the Supplemental;

This extended exchange from the Q1 Earnings call goes directly to the point of operator robustness (edited for brevity):

Analyst:

... somebody asked earlier about your optimism on some of these low coverage ratios, ... with almost a third of the portfolio below one-time. Again, do you see a path for a lot of these guys to get back to where the rents are? Do you think this is a portfolio that really just about everybody here needs to be restructured ...?

OHI

It’s -- all -- it’s predominantly driven by occupancy recovery. And so if you assume occupancies will recover to pre-pandemic levels at 84%, then the vast majority of those operators climb back out of that under one coverage scenario and we should be in decent shape.

But that’s why there’s so much focus on the velocity of occupancy recovery, and ultimately, who knows what that will be. We feel highly confident that the demographics will eventually drive us there. But is it eight months or 24 months, we don’t know the answer to that yet.

Analyst

... when I look at the coverages and occupancy, do you think this is indicative of the industry overall or do you think your portfolios either outperforming or maybe this experience causing you to kind of re-examine the portfolio in a specific way, like geography [or] other things?

OHI

... it’s hard to compare to the world as a whole. But I would say our portfolio is doing as well, if not better than other portfolios that we see and other operators outside of our world.

Analysis

Let's recap the situation, and then summarize the bull case and the bear case, and consider what might change.

The SNF business has two market segments, long term care and short term post-acute rehabilitative care. There are four payers - Medicaid, private pay, FFS Medicare, and Medicare Advantage.

SNFs are actually a long term care Medicaid business, measured by either patient-days (~ 65%) or revenue (>50%). The private pay long term care business adds about another 10% to patient-days, at better rates than Medicaid.

Short term rehabilitative care includes FFS Medicare patients, accounting for ~ 11% of patient-days and ~ 20% of revenue, and Medicare Advantage, ~ 8% of patient-days but less profitable.

FFS Medicare patients are the only clearly profitable patients. Overall, the SNF operator business is ~ break-even; this has been the case for years.

OHI's tenants appear fairly similar to the general SNF business, with 53% of revenue from Medicaid, ~8% from private pay, and 33% from Medicare (FFS and Advantage).

The REITs who own these physical properties are dependent on the success of the operators. However, low margins leave little profit on the table for the operators, sometimes not enough to pay the rent. Leasing to these SNF operators does not look like a very robust or attractive business.

We can summarize the main points of the bull and bear cases.

The Bull Case For OHI

• Demographics - a tsunami of elderly patients will eventually flood SNFs, increasing occupancy and profitability, and particularly the profitable FFS Medicare patient-days.
• It offers a high yield, currently over 9%.

The Bear Case for OHI

• The larger health care REITs have chosen to avoid the SNF business.
• Above average yield, and property cap rates, implies above average risk.
• SNF is, and has been for years, a low margin business for operators.
• A history of significant operator problems, i.e. inability to pay rent.
• While the 80+ population will increase, there are factors at work (e.g. home health care) to divert many of these patients from SNFs.
• THE SNF patient and revenue mix is predominantly long term Medicaid; this will be hard to change.
• SNF operator efficiency will be hard to improve.
• The public REITs with large SNF exposure have only limited ability to further high-grade their current portfolio.

What Might Change The Bear Case

What could change this situation? Some of the possibilities include:

• more patients leading to higher occupancy
• improved payor mix
• improved operator efficiency
• increased reimbursement rates from Medicare and Medicaid
• for a specific REIT, a better portfolio of properties and operators

More Patients

The 80+ population, which reflects the SNF patient age, is increasing by about 4% per year, with some variation by state.

However, as OHI notes, only 20% of FFS Medicare patients are currently discharged from acute care hospitals to SNF. Further, the growing percentage of patients with Medicare Advantage are less likely to be discharged to SNF and to have fewer days per stay than FFS Medicare patients.

Robert Hartman, founder of Symphony Post Acute Network, speaking in 2020 about future baby boomer clients, said:

They will do everything humanly possible not to come into a nursing home

Improved Payor Mix

The operator's margin is a function of patient and payor mix. A SNF that served only FFS Medicare patients, and maintained 85% occupancy, should certainly be profitable.

However, FFS Medicare patients today fill only about 10% of SNF beds, with Medicare Advantage filling perhaps another 8%. Just to reach 50% combined Medicare beds would require 2-3 times today's number of short term care patients.

It's not easy to shift the existing patient mix from long term Medicaid to short term FFS Medicare. It takes 22 FFS Medicare patients, each with average stay of 25 days, to fill the bed occupied by one long term care Medicaid patient with an average stay of 18 months.

Improved Operator Efficiency

Because personnel account for about 65% of costs, it seems unlikely that operators will achieve material efficiency improvements. This is likely to be particularly true for operators already at or above median efficiency; the low hanging fruit has already been harvested.

There are also forces acting to decrease efficiency, e.g. a push for private rather than shared rooms. This 2021 article reports that "two multi-facility licensed skilled care organizations saw an average increase in operating costs ranging from $16 to $25 per patient day and capital costs increased from $20 to $40 per patient day after transitioning to single-resident rooms."

Increased Reimbursement Rate from Medicare and Medicaid

Medicare and Medicaid fund 85-90% of SNF revenue. It's admittedly a judgement call, but I expect Federal and State budgetary constraints on Medicare and Medicaid funding are likely to continue, and in fact may increase.

The August 2021 Medicare Trustees Annual Report states that the Medicare trust fund that pays for SNF care is projected to be depleted in 2026, and that under current law the trust fund is not adequately financed.

The only recommendation that MedPAC made in regard to SNFs in their March 2022 report is that for fiscal year 2023, the Congress should reduce the 2022 FFS Medicare base payment rates for skilled nursing facilities by 5 percent.

Indeed, on June 8, 2022, the Medicare Payment Advisory Commission (MedPAC) wrote to Congress noting:

the Commission recommended in its March 2022 report that the Congress reduce the 2022 Medicare base payment rates by 5 percent for FY 2023. The aggregate Medicare margin for freestanding SNFs in 2020 was 16.5 percent, the 21st consecutive year that this margin has exceeded 10 percent.

The high level of Medicare’s payments indicates that a reduction is needed to more closely align aggregate payments to aggregate costs.

Medicaid funding from the States is in direct competition for state budget dollars with education, public employee pension obligations, and all other state expenditures.

My expectation is that the equilibrium point is for funding to be set at the lowest level possible that avoids widespread operator failures, and that while Congress and the States may sustain operations, they will feel no need to set payments at a level that will leave the operators, or their landlords, with any profit.

All in all, it's hard to see a path that leaves much more on the table for either operators or their landlords.

A Better Portfolio

One might imagine a public REIT creating a boutique portfolio of extraordinary properties and operators drawn solely from the top 20% of their current portfolio, but this reduction in scale seems unlikely.

For the public REITs, their current operators and properties already reflect a decade or more of active portfolio management by highly skilled and experienced management teams.

I think it's fair to assume that given the REIT's demand to grow and maintain a large portfolio - hundreds of properties and dozens of operators - they have done as well as is practical. However, that also suggests it will be difficult to do materially better in the future.

Investor Takeaway

OHI has delivered commendable results over the last 10 years, comparable to WELL, the largest health care REIT, and Realty Income (O), the largest triple-net REIT. Per OHI, 84% of OHI's 10-year return is from dividends.

Dividend growth has slowed in exact years, predating COVID effects (there is a glitch in the YCharts data, so the data below is from the OHI website):

I bought OHI at $33.85 in July 2015, and sold at $32.00 in August 2018, an exception to my usual buy and hold preference. I bought based on an initial enthusiasm for the SNF business, and sold after learning more about the business and concluding my enthusiasm was misplaced. It was, for me, a good lesson in the value of understanding the fundamentals of the business one is buying.

Looking forward, my assessment of the current bull and bear cases have been detailed above. Overall, I find the bear case more compelling, largely reflecting the genuine business mix of OHI's tenants, I view the reward vs. risk as unattractive.

I have no opinion as to whether OHI's stock price will be higher or lower a year from now. However as a long-term investor with no current position, I choose to avoid the stock. As Seeking Alpha does not offer an Avoid rating, I have rated it Hold.