The Moment Life Changes

This was originally written on July 17, 2017.  It took me 6 years to publish. In this interval, Dad, Mom and my only brother have gone on to glory. Grief is such an odd thing. Just like a scent or an old song, it all comes rushing back at the oddest and most unexpected moments.

Sport bikes are made to go fast. Unfortunately, sport bikes go fast wherever a rider points them.  It is difficult to imagine that at about 85 mph the rider of a small and unprotected sports bike at dusk can see clearly everything they need to see on a 6-lane highway littered with entrances and exits with very heavy traffic.

We don’t know the story of the young man who was riding the sports bike at excessive speed in the hours and minutes prior to when he collided with this car.  What I know is that my parents were sitting behind the slim sheet of metal with which he collided. He hit them directly between my father, riding on the passenger side of the front seat, and my mother, riding on the passenger side of the seat behind.  The side air curtains on the van did little to prevent breaking the ribs of both of my parents, lacerating internal organs, puncturing their lungs, and mangling my mother’s right leg and hip. They were quite literally only a few feet from being safe at home. They were coming home from a church function. 

What we have learned so far is that the bike rider was not the owner of the bike he was riding, that he was moving at excessive speed, that his wife was following him in a car trying to catch up to him and had possibly already collided with him once.

My parents have now been in the ICU and on ventilators for eleven days. Their lives and ours (the rest of the family – 4 children and their spouses, 7 grandchildren, and 15 great-grandchildren) are forever changed.  The severity of their injuries means that our parents will likely have to give up their home of 23 years. Our youngest sister has sold her home and will move to another state so that when and if my parents leave the hospital and the rehab facility that will follow, they will have assistance with tasks that they have accomplished independently for their entire lives.

We will watch for you on the road. Please ride responsibly.

Someone I love has been diagnosed with Alzheimer’s disease.

Yes, every day people all around this world are learning that someone they love has been diagnosed with cancer, or ALS, or MS or a host of other cruel and viciously unfair ailments that plague humankind.  And while it is the person who has received the diagnosis who is at the epicenter of suffering, everyone in that person’s circle of love will live with that diagnosis.

I read today that Alzheimer’s – like other degenerative diseases – is a slow packing-up of everything; getting ready to make that final journey home to heaven, where everything will be unpacked forever and restored in wholeness again. Degenerative diseases like Alzheimer’s don’t allow the luxury of packing things up in an orderly fashion.  You can’t choose to pack up directions to the store today and keep the memories of your dearest ones for later because you might want them before you travel. Some days, things will sneak back out of the suitcase for a moment or a time, and then just as soon as you get used to being able to say, “This is still good and we’ll keep it for awhile,” it sneaks off like that sock you know you put in the dryer with the other one.

I don’t know if I am ready to help my friend along this journey, or even if I know the way. But we will be grateful for as many good things we can share. We will sing songs that matter to you, and find moments of peace and calm in this storm. We will look forward to the day that the sadness and the dark moments can’t touch us anymore. And rejoice with you when that day comes that it’s all unpacked again, fresh and clean and new, for your enjoyment forever.

The Patient-Centric Revenue Cycle (is good for business)

The Patient-Centric Revenue Cycle (is good for business)

A big chunk of common sense is missing in the discussion surrounding American healthcare.  It could be that the right people are not doing most of the talking and decision-making. Talking heads around the subject of how to fix healthcare in the United States clutter up the conversation to the point that most Americans are left  just hoping that - somehow  -  everything will shake out and settle in so they can go about their lives and confront all the other worries they have in life. Many well-intentioned people have attempted to make incremental changes or tweaks. Healthcare providers are spending nearly 65% of their budgets on administrative costs and personnel to keep up – which means that less than 40% of healthcare provider resources can be dedicated to innovation.  Perhaps it’s time to think in a radically different way.

The question that none of the surveys are asking is, “How does the cost of healthcare services, the information you received prior to receiving services, and the care you received from the Finance/Billing Department after your care affect your feelings about your overall experience?”  Yet, every American family has at least one story of frustration with healthcare that has roots in costs, billing, and insurance. According to a 2012 survey¹ done by Mark Blankenship of Opinion Access for the American Health Care Association, more than 50% of Americans had a negative or very negative impression of for-profit healthcare systems, and less than 15% felt very positive about for-profit healthcare systems. Surprisingly, less than 1/3 of respondents felt positively about not-for-profit healthcare systems, too.  Everyone is purporting their expert opinions and no one – NO ONE – is listening to the angst of Americans as patients and caregivers. The fact of the matter is that a patient’s perception of their healthcare is materially related to their overall perception of healthcare services. More importantly, patient concerns and/or frustration with healthcare billing, insurance , co-pays, deductibles, and non-covered services are reflected in their overall opinions of the hospital, their doctors, and the surveys they fill out.

Americans don’t really care about the details of the ACA, AHCA, or whatever acronym is applied.  What Americans, and all of the other people in the world who count on being able to find quality care and innovative technology in U.S. hospitals, care about is to have a means to affordable, quality healthcare.

Make no mistake. Americans are passionate about how decisions and regulations made in Washington affect them personally. Who they see, however, as frustrating them are the people in front of them.  Even when patients are very pleased with their medical care and the hospital facilities, their first impressions, when they sit down to register,  and their last impressions, when they receive their bill,  color their opinions about the healthcare organization overall. 

Health is personal. Bills are personal.  When a patient has a reason to seek treatment for a health condition, their doctors and nurses are part of their team; champions and experts who comfort and cure.  Then the bills start rolling in and patients feel that suddenly they are alone and the hospital is in an adversarial relationship with them.  As industry regulations and insurance restrictions have pressured  financial positions, healthcare organizations have spent a great deal of time and effort to educate clinical staff about the revenue cycle. It is important that we also teach “bedside manner” to the Finance Department.

Medicare changed healthcare delivery and reimbursement in 1965. Medicaid changed healthcare delivery and reimbursement more expansively. Medicare part D changed healthcare delivery and reimbursement yet again;  taxing Medicare budgets substantially – as well as providing fertile ground  for  pharmaceutical and durable medical equipment costs to rise. The ACA fundamentally changed the relationship between physicians and patients, shifted control of healthcare decision-making, and added new layers of administrative burden to healthcare providers.  Good intentions all, but from 1965 forward healthcare providers have struggled to keep up with administrative costs and responsibilities.

In more than twenty years of working in healthcare, I’ve had the opportunity to talk to hundreds of patients, physicians, and healthcare workers.  The revenue cycle matters! It took years for hospitals to understand that the revenue cycle was important to the fiscal health of the organization. It seems that the fact that the revenue cycle – or at least the impact of the revenue cycle – is just as important to patients.  

Patients need to be able to make informed decisions about their healthcare, and they also need to be cared for after services are received and the bills start rolling in. In order to provide patients with realistic cost estimates for patient out-of-pocket expenses prior to care, healthcare providers need to be able to access in real-time, according to their individual contracts with insurance carriers, exactly what the patient’s benefits are for the proposed treatment plan. To underscore that statement;  that means  insurance carriers need to provide current balances for patient deductibles met and accurate assessments of coverage according to the patient’s benefits for ALL services – not just the most-utilized or the procedures paid at the highest rates. For example, cancer treatment benefits are not available on insurance websites.  

It would be awesome if insurance carriers made it possible for patients to estimate their own benefits according to their plan for the prescribed treatment ahead of their arrival for treatment.  Preferably, patients should be able to access an estimate for their out-of-pocket expenses through their insurance carrier website and/ or by telephone using current customary charges from the healthcare provider’s website and reimbursement rates based on their insurance carrier’s contract with their specific healthcare provider.  Many healthcare providers allow patients to estimate their costs based on the provider’s usual charges for a particular service, but the patient still has to then review their coverage and any claims they have already submitted in the current year and make additional calculations. Even the savviest of patients can get lost in all of that.

·         Insurance companies already have access to this information, broken down by individual providers, and even by individual patient,  according to claims received and reimbursements paid.

·         Insurance plans also have access to current records on how much deductible patients have individually met at the time of estimate,

·         as well as contract information related to the patient’s specific responsibilities for co-pays, maximum out-of-pocket, etc.

·         The patient’s insurance plan sees all claims from all healthcare providers, and is therefore at an advantage to be able to relay accurate information to patients.

·         Insurance plans need to improve the knowledge-base, and in most cases improve access to their beneficiaries’ actual contracts and benefits to their customer service front line, so that communication with patients who request estimates of benefits via telephone or have questions about their benefits receive substantive and accurate information.

·         The relationship between a patient and their insurance plan is between those two entities. Insurance companies are responsible to their beneficiaries to pay claims in the manner agreed by contract.

·         Healthcare providers have a solemn responsibility to the patient to explain fully to the patient the proposed treatments, side effects and expected outcomes. They are also responsible to be accountable for questions patients have about why the cost of their care is what it is, and what plans, programs, grants, or arrangements the healthcare organization can make available to assist patients with out-of-pocket expenses. 

In defaulting all explanations to patients concerning what their insurance will and won’t pay for to the healthcare provider, the insurance companies quite deftly abdicate responsibility and patients see the healthcare provider as both their hope for care and their adversary for the cost from the beginning.

The second half of caring for our patients throughout the revenue cycle again belongs jointly to insurance companies and healthcare providers; but falls most heavily to the finance teams of the healthcare providers.  Healthcare providers need to

·         Provide clear and easily navigable information for patients to find average charges for procedures

·         Meet with patients one-on-one prior to all elective procedures to establish payment plans and outline charges for services

·         Provide access and avenues to available financial assistance; including grants, outside services, and Medicaid applications

·         Establish policies and provide copies to patients for expectations for payment and financial assistance

·         Train registrars, financial counselors, customer service, and collectors in empathy and monitor for consistent behavior aligned with organizational values

·         All Patient Access staff should be well-trained in available assistance, financial policies, and escalation for special circumstances and patient questions or concerns

·         Provide patient statements that are clear and easy to understand in layman’s terms

·         Reach out personally to patients who have outstanding bills in a friendly way to reinforce the relationship, verify that the patient is aware of pending due dates and still able to meet them, and ask if they have any questions – and reliably connect the patient with their physician’s office if medical questions come up.

 Once treatment has been delivered to the patient and the bills start rolling in, patients should already have clarity concerning their financial obligations and an established relationship with at least one (and preferably more than one) person in the finance department who is assigned to follow their account and respond to questions.  Patients should be able to pull an itemized statement of their charges on line or easily request them through a direct phone line.

A third point, though perhaps not more than wishful thinking today, would be to streamline the insurance billing process altogether.  The United States is the only healthcare system in the world that uses ICD-10 coding for purposes of healthcare reimbursement.  What would happen if patients received, as they have been requesting for at least as long as I can remember, a single statement for all services rendered – or in the case of chronic conditions one statement each month – instead of separate statements from individual providers for individual services? CMS already requires monthly claims for Medicare patients,  and coordinated care by multiple providers is already a fact. To further streamline patient billing, (and I fully expect to hear “pooh-pooh” from many voices – but just consider and humor me here) it should also be entirely possible to collect into one billing statement all care a patient receives regardless of patient status.  All physician orders and charges are already time-stamped, so in theory a patient who arrived through the ED, went to surgery, subsequently  admitted as an in-patient  post-op would still be able to receive one bill for an entire episode of care.   

In the end, the patient has to be allowed to return to the center of the equation for  American healthcare.  Regulations , ever-decreasing reimbursements, exploding demand, and insurance interests have dominated the conversation and driven the focus of healthcare providers for a generation.  The revenue cycle matters to healthcare organizations for their fiscal health, but more importantly, the revenue cycle matters to patients because to them it’s personal.

 ¹    Mark Blankenship, Opinion Access, Survey Results submitted to American Health Care Association,

https://www.ahcancal.org/advocacy/Documents/Health%20Care%20Survey%20Results%20and%20Background.pdf

Heart Song

I want to see “that look” on my children’s faces again – even if only one more time. They are grown-ups now; full-blown adults with work, worries, bills, and children of their own. But my heart so wants to see -  even fleetingly, even for a moment, even if only that one more time – that look that says, “I’m so happy. I know you can protect me, make it possible, keep me safe, give me just what I need.  I trust you. I’m glad you’re my Mom.” You know that look. It’s life-affirming. Those moments in your life when your heart literally sings, when nothing else in the universe exists except for that moment and the way you feel, are not common.

I should tell you that I truly admire my children as adults. They are awesome partners, parents, friends, leaders, and mentors. Special magic - a gift of grace  -  which by definition is a good gift that comes to us undeserved – is given to parents. It happens somewhere in that fleeting moment in time between the first warm snuggle with your new baby and the day that your baby says good-bye and for the first time you are not going with them. There is a piece of my heart that will forever look through these eyes and see my babies in my arms, hear their childish giggles entwined in today’s laughter, and wonder again if I’ve given them everything they will need, as though I was packing them a lunch.

Then … there it was.  I saw that cherished look on my grandchild’s face, looking up at my child the parent. And mirrored in the face of my child.  And I am pretty sure my mother could see it on my face, too. Four generations of hearts singing the same song.  It’s a song shared by generations, resonating in every culture and recognized in every language.  It’s a song I hope you have the privilege to share.

The Prison of Everyone Knows

I would like to thank Reverend Victoria Guthrie for sharing this story.



There once was a king whose kingdom was very small. Because the kingdom was peaceful and bucolic, their treasury was also very small. All was well in the kingdom for many generations, and the people were happy.



One night things changed. A murder was committed.  The perpetrator was immediately caught and confessed to his crime. He was taken to the kingdom's only judge, who deliberated greatly, as there was no precedent in kingdom history, and pronounced a sentence of death for the criminal.



The king's advisors deliberated as to how to carry out the sentence imposed by the judge. They had no jail or jailer. They had no gallows. So the advisors consulted with the royal treasurer, who could perhaps allocate the funds needed to provide the necessary implements to build a gallows, contract an executioner, and secure a jailer to oversee the prisoner until such time as a proper gallows could be established.



The royal treasurer assured the king's advisors that funding for such an endeavor was not available. Together, they all went to see the king and ask for his advice.



Because he was a wise and good king, he did not see the logic of imposing any new taxes on the people of the kingdom to pay for a circumstance that everyone knew was not likely to occur again. So the king exercised his royal prerogative and commuted the prisoner's sentence to life in prison. He ordered that one of the storerooms in his own palace be cleared out and basic amenities, including a bed from the king's own furnishings, be placed in the storeroom for the prisoner.



So it was ordered and so it was done.



Not long after, the royal treasurer approached the king. "Sire," he said, "I have calculated carefully and pondered solutions, but if my calculations are correct - and they are - the cost of housing, feeding, and tending to the prisoner are taxing the treasury, as all of this outside of budgeted expenses. At some point, when considering the number of years that the prisoner could be expected to live, this expense will bankrupt the king's treasury."



The king pondered the royal treasurer's words. Then he ordered that the lock be removed from the prisoner's door and the guard be excused.  "When the prisoner escapes," he said, "give chase, but not too strenuously, so that the prisoner can find his own way in the world." All of the king's advisors and the royal treasurer applauded the king for his brilliant solution to their dilemma.



Days passed. Weeks passed and still the prisoner did not escape. Exasperated by the prisoner's reluctance to escape and the wearying repetition of the treasurer's warnings, the king decided to go see the prisoner himself.



"Why are you still here? Everyone knows that freedom is preferable to imprisonment. There is no jailer here, nor lock to prevent you from regaining your life. Do you fear that you would be harmed if you were to try to leave this place?"



The prisoner responded, "Sire, I have no reputation, no skills, no work, no family, and no home. There is nothing outside of these walls that tempts me. I am comfortable here and well-cared for. I have no need or desire to leave this place."



There is another story about what everyone knows. John 9:1-41 tells the story of a day when Jesus restored the sight of a man who had been blind from birth. Conventional wisdom of the time dictated that physical afflictions were the result of the sin of the afflicted person or their parents. As Jesus and his disciples came upon the blind man, his disciples asked him (because "everyone knew") whether this man had sinned or his parents had sinned. Jesus told them that this man was not born blind because his parents had sinned, nor because he had sinned, but to show God's glory. Then Jesus spit on the ground to make some mud, put the mud on the man's eyes, and told him to go to the wash in the pool of Siloam (which means "sent"). The blind man did as Jesus said and his sight was restored.



Now the Pharisees of that time were something akin to  a cross of the Supreme Court and Congress today. The Torah was the written law, and the Pharisees interpreted the written law and the oral law (what "everyone knew") under the principle that men must use their reason in interpreting the Torah and applying it to contemporary problems. Because the blind man was healed on a Sabbath day, and word travelled fast, the Pharisees took this matter upon themselves to investigate for a potential violation of law. They sent for the previously blind man so that they could question him.



The Pharisees had already heard about Jesus, and the majority did not like what they had heard. The Pharisees asked the man before them if he was the same man who had previously been blind, and he assured them he was. They asked him how it was possible that his sight had been restored. He replied that he did not know, but Jesus put mud on his eyes and told him to wash, and when he did, he could see. So the Pharisees wanted to know where Jesus was, and the man told them he did not know. Some of the Pharisees decided that Jesus could not be a man of God, because he did this on a Sabbath day, and some said a sinner could not have done this, so they were divided. They drew the conclusion that this man could not be the same man who was blind, so they sent for his parents to testify.



Intimidated is not a strong enough word to describe how the parents of the previously blind man felt about being summoned by the Pharisees. They could be cast out, excommunicated, from their church and their community; cut off from all resources. So they told the Pharisees that yes, this was their son; but since he was of age and they didn't know anything the Pharisees should talk to their son.



So the Pharisees sent for the previously blind man again. This time they said to him that they knew Jesus was a sinner because they didn't know where he came from, and wanted him to say so. The man who had been blind said he didn't know whether the man who healed him was a sinner or not. All he knew was that he had been blind from birth and now he could see. And they asked him the same questions again, but even more insistently. The man said, "I have already told you. Why do you want me to tell you all of this again? Do you want to be his disciples?...Never before has anyone heard of sight being restored to someone who was blind, yet this man restored my sight. If this man were not from God, he could do nothing." Of course this infuriated the Pharisees, who pronounced the man who had previously been blind a sinner and cast him out.



When Jesus heard that the man had been cast out, he went to find him. He asked him if he believed in the Son of Man. The man said, "Who is he, Sir, that I might believe?" Jesus said, "You have seen him, and he is talking to you." The man said, "Lord, I believe."



Not only did word travel quickly, but some of the Pharisees were never far from where Jesus and/or his disciples were; and some overheard this exchange. Being men accustomed to entitlement, they immediately addressed Jesus directly and asked, "Are we also blind?" Jesus said to them, "If you were blind, you would have no guilt; but now that you say, 'We see,' your guilt remains."



There is a powerful lesson in these stories. We need our communities, and some of what "everyone knows" is useful information instinctive to us through generations of shared wisdom. We know, for example, that roller skating on broken glass, jumping out of airplanes without a parachute, or drinking Drano is not good for us. We do not need to test these theories to know that they are true for us.  However, group-think can also lead us like lemmings to our destruction. David Koresh, Charles Manson, Adolph Hitler and Kim Jung Un come to mind as recent examples of dictating group-think in evil and destructive ways. Many of us have experienced mean-girl cliques who dominate the behavior of entire groups of people through intimidation.



The loudest voices are not always speaking truth. What "everyone knows" can be turned on it's head.



Phillipians 4:8 gives us the test that we can apply:



Finally, brothers and sisters, whatever is true, whatever is noble, whatever is right, whatever is pure, whatever is lovely, whatever is admirable—if anything is excellent or praiseworthy—think about such things.



If a belief or a behavior recommended to us is not the fruit of the test of truth, pureness, nobility, and right; in turn creating something beautiful - no matter how many people around you support it - it does not pass the test and cannot become part of what "we know."







Related References



John 9:1-41

https://www.britannica.com/topic/Pharisee

How to make PlayDoh

How to make PlayDoh

What you will need:

1.      Permission and help from an adult who loves you

2.      Ingredients:

·         1 cup of water

·         ½ cup of salt

·         1 tablespoon of vegetable oil

·         1 tablespoon of cream of tartar

·         Food coloring

·         1 cup of flour

3.      1 saucepan

4.      1 wooden spoon or heat-resistant spatula

5.      Plastic gloves

6.      Zip-lock freezer bags or airtight container(s)

Directions:

Measure water, salt, vegetable oil, and cream of tartar.  Add these ingredients to a saucepan. Add as much food coloring as you need to get a color that you like. Stir everything together and heat the mixture.  Remove the saucepan from the heat and add the flour. Continue stirring until it is well-mixed. Turn out onto a flat surface and knead the mixture until it is smooth. Put on plastic gloves if you want to add more coloring, and just knead the extra coloring into the dough. The dough will cool as you knead it. Once cooled, store in an airtight container.  Resist the urge to omit the cream of tartar, as the cream of tartar will extend the storage life up to six months.

One storage idea is to use the leftover plastic containers that frosting comes in (washed out and dried). The colored lids can indicate the playdoh color stored inside.

Even Better S'Mores

Even Better S’Mores

In less than the time it would take you to go to the store (and, as far as I know, you can’t even BUY these because no one markets them commercially) you can make your own appropriately-sized  s’more marshmallows that will make you the envy of the campfire and fire pit crowd. There’s even a bonus: these marshmallows will be square and cover every corner of your s’mores…..which definitely works for our crowd.

The recipe is below. You will want to make your s’mores marshmallows the day before or at least three hours ahead of your campfire fun.  I do want to mention that the basic marshmallow recipe is from Food.com; the caramel and/or peanut butter  and/or chip twist is my invention – which I share with you because EVERYONE who’s tasted them loves them.  These twisted marshmallows also work well with hot chocolate (something to tuck away in the memory banks for fall!) and leftover sauces for twists *may* have been added to certain cups of coffee at our house….please don’t judge.

Ingredients

Yield  96 1-inch marshmallows or 48 2-inch s’more size marshmallows.  

·         1 cup confectioners' sugar

·         2 tablespoons unflavored gelatin

·         2 ¹⁄₂ teaspoons unflavored gelatin (3.5 envelopes)

·         ¹⁄₂ cup cold water

·         2 cups granulated sugar

·         ¹⁄₂ cup light corn syrup

·         ¹⁄₂ cup hot water (about 115 F)

·         ¹⁄₄ teaspoon salt

·         2 large egg whites

·         1 teaspoon vanilla

Twists:  

Caramel Sauce – Use about ½ of an 11.75 oz jar of your favorite ice cream caramel and refrigerate the rest OR make your own. Pinterest is full of recipes you can try, but here’s an easy one that I make to flavor homemade caramel frosting and for caramel-twisted marshmallows:

·        1 cup brown sugar

·        ½ cup butter

·        ¼ cup milk

·        1 teaspoon vanilla extract

Bring  brown sugar, butter, and milk to a gentle boil and cook until the mixture thickens – about 1-2 minutes. Remove from heat. Add vanilla. The mixture will thicken as it cools.

Peanut Butter Sauce – Again, there are tons of recipes for peanut butter sauce on Pinterest, but here is one of our favorites. Please do be conscientious, though, if your guest list includes persons with peanut allergies, to label clearly and keep separated any marshmallows with peanut butter sauce.

·        ½ cup creamy peanut butter

·        ½ cup sweetened condensed milk (refrigerate in a covered container the leftover to make other sauces or use for Sunday morning coffee)

·        1 teaspoon vanilla extract

·        5 tablespoons of water

Stir the peanut butter and condensed milk together over low heat until smooth.  Add the water and continue stirring to incorporate. Add vanilla. Pour into a jar or large measuring cup to cool. It will thicken as it cools. Cover and refrigerate any leftover sauce.

Chocolate Sauce – You can use any commercially prepared chocolate sauce – but thicker is better. Hersheys will work, but be rather sparing, as it is quite liquid. Smuckers hot fudge sauce – or any hot fudge sauce, really, will be thicker and richer.

Peanut Butter Hot Fudge Sauce – Just a note, this is also a great ice cream sauce. And ditto for the peanut allergy precaution above. You can purchase this commercially or try our homemade version:

·        ¼ cup creamy peanut butter

·        ¼ cup chocolate fudge sauce

·        2 tablespoons corn syrup

·        1 teaspoon vanilla flavored extract

Stir together, adding vanilla last. You can substitute 12 oz (1 small bag) of chocolate chips for the hot fudge sauce, but you would then use 1 can of sweetened condensed milk + 2 tablespoons milk instead of corn syrup, and you would want to heat the condensed milk, milk, peanut butter and chocolate chips together over low heat to melt the chocolate chips and add vanilla once removed from heat.

***Chocolate chips, mint chips, caramel chips, peanut butter chips or any combination you like/have on hand also work in a pinch. Just sprinkle on top of the hot marshmallow mixture and cut through with a knife just like you would the sauce.

MARSHMALLOW Directions See How It's Made

1.      Oil bottom and sides of a 13x9x2-inch rectangular metal baking pan and dust bottom and sides with some confectioners' sugar.

2.      In bowl of a standing electric mixer or in a large bowl sprinkle gelatin over cold water and let stand to soften.

3.      In a 3-quart heavy saucepan cook granulated sugar, corn syrup, hot water, and salt over low heat, stirring with a wooden spoon, until sugar is dissolved. Increase heat to moderate and boil mixture, without stirring, until a candy or digital thermometer registers 240°F., about 12 minutes. Remove pan from heat and pour sugar mixture over gelatin mixture, stirring until gelatin is dissolved.

4.      With standing or a hand-held electric mixer beat mixture on high speed until white, thick, and nearly tripled in volume, about 6 minutes if using standing mixer or about 10 minutes if using hand-held mixer. In a large bowl with cleaned beaters beat whites (or reconstituted powdered whites) until they just hold stiff peaks. Beat whites and vanilla into sugar mixture until just combined. Pour mixture into baking pan and Add your preferred twist: Drizzle your preferred flavor of twist over the top of the hot marshmallow mixture and then cut it in with a knife the way you would with cake batter.

5.      Sift 1/4 cup confectioners' sugar evenly over top.

6.      Chill marshmallow, uncovered, until firm, at least 3 hours, and up to 1 day.

7.      Run a thin knife around edges of pan and invert pan onto a large cutting board. Lifting up 1 corner of inverted pan, with fingers loosen marshmallow and let drop onto cutting board. With a large knife trim edges of marshmallow and cut marshmallow into roughly 1-inch cubes. Sift remaining confectioners' sugar into a large bowl and add marshmallows in batches, tossing to evenly coat. Marshmallows keep in an airtight container at cool room temperature 1 week.