Archive for May 2013

The Council Has Spoken: May 30, 2013

Council Winners


 

 

 

 

 

 

 

  • Fourth place t with 2/3 vote – The Colossus of Rhodey – Entitlement

 

 

 

Non-Council Winners


  • First place with 2 1/3 votes! – Mark Steyn -To The Slaughter   submitted by Joshuapundit

 

  • Second place t with 1 2/3 votes – Sultan Knish –The Warrior’s Tale   submitted by The Noisy Room

 

 

 

 

 

 

 

  • Sixth place t with 1/3 vote -The Weekly Standard – Beyond the Pale    submitted by The Colossus of Rhodey

 

 

 

 

  • Sixth place t with 1/3 vote -PJ O’Rourke – Stupid   submitted byThe Watcher

Obamacare Rate Shock In California

Although I’ve been characterized as a rabid right winger on some topics, by my wife no less, when it comes to health care I’m pretty open minded and non-dogmatic. As recently as 2006 I had advocated for a single-payer system aka “socialized medicine” arguing that health care is similar a public good as fire and police protection. What changed my opinion was the government involvement in the economy in 2008-09 with the default nationalization of General Motors, AIG and a large swathe of the banking industry. While there may be good reason for government involvement in the health care industry, such involvement cannot be done in an environment whereby the government is expanding its reach in other areas. That’s why I have switched my viewpoint towards a more libertarian one whereby the federal government’s power is curtailed throughout society, and that includes in the health care industry.

But I am open to what works. Our son was born under socialized medicine in Japan, and I am familiar with its benefits and drawbacks first-hand. I remain at least in principle more accommodating to the idea than most libertarians and conservatives, as long as it works. We live in a medical system that is the most expensive in the world yet provides middling care, one that provides perverse incentives to participants that work against cost containment and better quality of care, and one with bureaucracies – that’s plural – which go beyond the Byzantine to the Kafkaesque. It’s a system that is loathed by anyone with “skin in the game,” from care givers to care receivers. It’s only the bureaucrats who delight in it and those who benefit monetarily and politically from the current regime. For most the system is collapsing, but slowly and painfully.

Obamacare makes the situation worse, which is why the conspiracy minded have viewed it as a  morphine overdose  that destroys the system and allows its replacement by socialized medicine. Honestly at this point, I’m not sure this would be a bad thing given what I’ve been seeing with Obamacare.

Last week Obamacare supporters were trumpeting cost containment. Evidently they grabbed their tin horns too quickly. It turns out that Californians, particularly the young and healthy that will be forced by law to buy insurance if its not provided by their employers, will face rate hikes as high as 146%. A catastrophic plan for a healthy 25 year old today costs roughly $92/month. After January 1, 2014 the same plan will double to $184/month.  While an extra $92 isn’t a lot to me, I remember the time particularly when I was starting my career with a young family in my late 20’s when it was. That was a week’s worth of groceries back then. Perhaps today’s 20-somethings are wealthier than I was when I was their age, but given the job climate I doubt it.

Perhaps today’s 20-somethings are much more idealistic than I was back in the day and believe Obamacare will work for them, but it seems to me that it is the continued war on the young as the rates are meant to keep costs down for older and wealthier rate payers. When I was their age I went without health insurance; that is not an option for them today.

 

 

Watchers Council Nominations: May 29, 2013

Council Submissions

The Noisy Room – Iran Deploys Long-Range Missile Launchers -– The Hawk is Set to Take Flight
Joshuapundit-Midnight In Benghazi – What Really Happened
The Political Commentator – Divorce decree for the United States of America!
The Right Planet – How the Liberal Media Would Report #Benghazi If George Bush Were President
Simply Jews – Do you need your medicine urgently? Wait till Minister Yael German stops celebrating language accessibility.
The Razor – Electronic Health Records: The $6 Billion Cure For Bad Penmanship
Bookworm Room – Sweden fiddles while Stockholm burns
The Colossus of Rhodey – Entitlement
VA Right! - Can We Just Let the Syrians and Allah Sort This Out Themselves?
The Glittering Eye -Memorial Day 2013
The Mellow Jihadi – Conversations I Almost Had Today
Rhymes With Right – IRS Official To Take Fifth Amendment Regarding Performance Of Her Job
Gay Patriot – Thoughts on the Boy Scouts & gays
GrEaT sAtAn”S gIrLfRiEnD – Sino Spookery Down Under

Honorable Mentions

Right Truth – Grinding up fetus parts in garbage disposal gets you … probation
Maggie’s Notebook – Pickering, Mullen Refuse to Testify on Benghazi? Issa: Hillary Not a Target!
SooperMexican – Mexclusive!! IRS Releases New Simplified Tax Form 1040 TEA-EZ for Tea Party Taxpayers!!
The Pirate’s Cove – Did Holder Commit Perjury?

Non-Council Submissions

Sultan Knish The Warrior’s Tale submitted by The Noisy Room
Mark Steyn – To The Slaughter submitted by Joshuapundit
FrontPage Magazine -A Memorial Day for Islamic Terror submitted by The Political Commentator
The Weekly Standard – Progressives With Bombs submitted by The Right Planet
The Passing Parade – The tenacity of Democrats, or yogurting for fun and profit submitted bySimply Jews
Le·gal In·sur·rec·tion/David Gerstman Thomas Friedman on Obamacare: It’s gonna be a bright bright bright bright sun shiny day submitted by The Razor
PJ Media/Zombie-Karl Marx Was A Tea Partier submitted by Bookworm Room
The Weekly Standard – Beyond the Pale submitted by The Colossus of Rhodey
PJ Tatler – PJ Tatler Report: 20% of Ohio’s Registered Voters are Bogus submitted by VA Right!
James Taranto/WSJ – See You in the Funny Papers submitted by The Glittering Eye
CoffeyPot My Memorial Day Feelings submitted by The Mellow Jihadi
NRO/Andrew Stiles – IRS Scandal: E-mails Suggest Findings of IG Report Delayed Until After 2012 Election submitted by Rhymes with Right
Commentary Contentions -Our Ambivalent Commander-in-Chief submitted by Gay Patriot
Douglas Murray/WSJ – The London Terror Attack Was More Than ‘Unforgivable’ submitted byThe Watcher
PJ O’Rourke – Stupid submitted by Watcher

Electronic Health Records: The $6 Billion Cure for Bad Penmanship

David Gerstman has an interesting piece up at Legal Insurrection about the IT panacea for Obamacare. He notes an op-ed by Thomas Friedman that received an endorsement by Health and Human Service Secretary Kathleen Sebelius that paints a glowing picture IT investments made under the act will have at providing better and cheaper medical care. Gerstman then follows up Friedman’s breathless piece with another that asks a simple question, if the impact of IT on health care is so wonderful Why Is Your Doctor Typing? Forbes’s Steve Denning writes about his experience at his doctor’s office where he watches his doctor typing on a computer during his exam.

Surely, I said, computerized medical records generate benefits. They are easily retrievable. They can be transferred from one practice to another and accessible to the many different service providers—hospitals, laboratories, specialists, radiology and so on—that might be involved in any one patient.

“In theory, perhaps,” he replied. “But in practice, it’s a horrible and costly bureaucracy that is being imposed on doctors. I spend less time with patients, and more time filling out multiple boxes on forms that don’t fit the way I work. Often I am filling out the same information over and over again. A lot of it is checking boxes, rather than understanding what this patient really needs.”

What about retrieving information? Isn’t that easier?

“Again, in theory, retrieval should be easy and quick,” he said, “But you can’t flip through these records the way you do with a paper file and easily find what you want.

I mentioned the articles to Dr. Wife and she said, “The only thing EHRs have done is make it easier to read a doctor’s handwriting.” Since the US is projected to spend $6 billion on EHRs by 2015, that’s a lot of money spent trying to make up for the failure of primary education to teach penmanship.

Being married to a doctor and an IT professional specializing in “big data” in the financial industry, I have watched the Wife’s experience with various EHRs with levels of amazement and dismay. It’s as if the lessons learned by the financial industry in the 1990s, such as poorly designed software that is incompatible with other software will cost more money to replace than it did to implement in the first place,  have been completely lost by the lemming-like rush towards electronic health record (EHR, also known as electronic medical records EMR) systems.

The basic problem is that EHRs are not designed to suit the ways doctors practice. This is complicated by the fact that the way doctors practice varies between specialties, an orthopedic surgeon doesn’t practice medicine the way a primary care physician does, and by the additional complication that how doctors practice varies within the same specialty, often the same office. Even the same doctor will treat patients differently depending on what he feels works best for each patient. Yet these variances between specialties are only rudimentarily addressed within EHRs, and handle variance within specialties one of two ways, providing either a set workflow that dictates to the doctor the way she should practice, or one that provides so much flexibility that she is lost trying to get basic tasks.

The key decision in any software development is to address who the software is for and the key needs it is meant to address. Judging by the current EHR systems available none were designed for doctors. Instead they were designed for the employers of doctors such as large health systems, insurance companies and the federal government who are interested in aggregated data in order to answer questions such as “How many patients are uncontrolled diabetics?” or “How much is being spent on obesity-related illness?” These are questions which might be of interest to a doctor in general, but they are not what he’s thinking about when he’s facing his patient, say a morbidly obese, uncontrolled diabetic medicaid patient. Instead he is interested only in that particular patient’s problems. Is her agoraphobia contributing to her obesity, or is it the result of it? How can he wean her off HFCS soda and begin to move and diet when getting her into his office requires so much effort? Most of all, how can he encourage her to take an active role in her own medical care and help him treat her?

Current EHR systems will be very good at picking up his patient as an uncontrolled diabetic, and the data can be used by medicaid to threaten to cut his reimbursement for her treatment as is under discussion to control health care costs. But his patient’s needs and his attempts to deal with them will be lost in the sea of data the EHR generates because current systems are modeled on existing software developed in the financial industry which was the first to successfully integrate the technology with its existing business. Even that integration wasn’t painless, occurring over decades after many fits and starts, adoption of dead-end technologies and gargantuan piles of wasted money.

A key difference between the medical and financial industries is in the nature of the data itself. Financial data is transactional, meaning that money is traded for a good. Transactional systems are repetitive. For example, a store will sell a loaf of bread for $2.59 to every person who comes into the door and asks for it, but a doctor seeing a sore throat today knows 99% of the time her patient likely only has a viral condition, and that remaining 1% can present with a sore throat but have much more serious, perhaps even fatal, underlying conditions. Doctors are taught in medical schools to “think horses when you hear hoof beats, not zebras,” but the problem is that in reality zebras are not limited to the Serengeti Plains: they are mixed in with the horse. So while a doctor should think horses when he sees an 8 year old with a high fever and sore throat, he always must rule out he’s hearing a zebra. This is why when you see your doctor complaining of head and neck pain she makes you touch your chin to your chest: doing so rules out meningitis, a rare but very serious infection, a zebra running with horses.

The equivalent of this repetition and poor data is handling would be going to the store and buying a loaf of bread with your debit card. This bread would be tailored to your specific needs on site. Prefer no crusts? The crusts would be removed. Like thicker slices? The store would slice the bread to your exact specifications. The cash register would report the sale to your bank via fax. A person at the bank would read the fax transaction and key it into the bank’s debit card system which would then debit your account for the payment to the store. Since the store’s financial records are kept at another bank, your bank would then email the credit to the store’s systems, and someone at that bank would open the attachment, read it and add the amount to the store’s bank account. Such a transactional system would be costly to run, inefficient with the same task performed multiple times, and time consuming. A similar system already exists today with check processing, but that is limited to a handful of data elements such as the bank, amount paid and the account number of the person writing the check, and the name, the account number and bank of the payee depositing the check. That’s six pieces of data that costs banks billions to process every year. Banks hate checks which is why they have backed the current system of debit cards working to replace them.

From a physician’s perspective, what should an electronic medical records system do? It should provide her with the treatment plan from the previous encounter. Most systems hide this information from a doctor, making her search for the notes from the last visit. The system should provide lab work and test results directly from the laboratory providing the test results. Currently labs do not have set data standards, and electronic medical records systems do not have the capability to receive these records directly. Instead the records are either faxed or sent via email where they are “attached” to a patient record. This is akin to attaching a picture to an email, meaning that the contents of the picture remain completely unreadable by the system. The email system doesn’t know if the picture is a snap from your trip to the beach, whether its of a sunset or a personal portrait. Data in a picture or as commonly sent PDF format cannot be read and translated into a data record directly. Instead either the doctor, mid-level or medical tech must look at the results in the attachment and physically key them into the system.

Dr. Wife tells me her current system, one of the top used in the US, can only report weight and BMI results from last visit. Lab values and other pertinent information is hidden in attachments or non-indexed patient notes. Prior to the EHR she would open a patient’s chart and look at the lab result for a patient’s hemoglobin a1c result. Since the labs were in a separate section of the paper chart she could open it up then flip backwards through the stack to immediately find the results of previous tests. Similarly she could open the chart and see the notes from the patient’s last visit to see what recommendations she had then, or flip back further to see how the patient’s condition had changed with time. To do this in her current EHR is much more difficult than flipping through pieces of paper. Instead she has to search for and find lab result attachment which may not only be located in the lab result folder, but which may have been filed mistakenly by a medical tech into the fax folder because the lab result may have arrived via fax, and was scanned and added as a patient communication. Since the information is not indexed, there is no way for the physician to type in a search box “hemoglobin a1c” and have all documents that contain the phrase pop up. Instead she has to open each attachment to determine what it is and whether it’s the lab result she is looking for. Since EHRs are rarely known as fast and responsive, opening each attachment takes 5-15 seconds depending on size and EHR file complexity, making a search which would have taken three or four seconds flipping through a paper charts several minutes to complete. When a doctor is allotted 15 minutes per patient, anything that makes a doctor’s job harder for no benefit to him or his patient whatsoever will not be appreciated. Yet hospital administrators and software companies wonder why medical practitioners loathe electronic medical records systems?

Here’s what Dr. Wife described as her dream medical records system. First, the entire encounter would be recorded to protect her from future litigation or in case anyone needed to review or document anything from the patient encounter later. Next she would be able to choose from a set of predefined dropdowns or checkboxes the treatment plan for the patient. Lab values would be available on the right side of the screen, and she would be able to click on any one of them to see details or trends. These would be automatically populated by the labs themselves without any input from the doctor or practice staff, and could be signed off by the doctor simply by clicking the value. It would be a simple app that would run on an iPad. Suri would be used to transcribe a brief note after the visit, which would allow Dr. Wife to spend more time with her patients and doing what she is paid to do, diagnose illnesses and develop treatment programs, instead of typing, filing and other busy work skills that is so devalued in today’s workplace that much of it is offshored.

Another alternative would be to hire scribes, medical technicians who are trained to enter data into the EHRs. Many optometrists who must use their hands and eyes in concert use scribes already to notate lens dimensions and other key patient facts, so their presence in the exam room wouldn’t be completely new. Such positions would pay $12-15/hour with benefits, about what medical technicians commonly earn today, and would offer advancement thanks to the coding skills and familiarity with the software developed with experience. Of course adding a scribe for each physician would increase personnel costs, but ask yourself, does it make sense to pay someone $75 an hour to do a job that can be done by someone making $15 an hour? And from the patient’s perspective, would they rather pay an extra $4 a visit to have the undivided attention of their doctor for 15 minutes instead of watching him divide his attention between them and his computer?

 

Memorial Day Weekend 2013

Remember.

From 2012: Remembering Douglas E. Sloan

2012 Memorial Day Drudge Report Sloan Headstone

What Government Intimidation Looks Like

Peggy Noonan writes:

But the most important IRS story came not from the hearings but from Mike Huckabee’s program on Fox News Channel. He interviewed and told the story of Catherine Engelbrecht—a nice woman, a citizen, an American. She and her husband live in Richmond, Texas. They have a small manufacturing business. In the past few years she became interested in public policy and founded two groups, King Street Patriots, and True the Vote.

In July 2010 she sent applications to the IRS for tax-exempt status. What followed was not the harassment, intrusiveness and delay we’re now used to hearing of. The US government came down on her with full force.

In December 2010 the FBI came to ask about a person who’d attended a King Street Patriots function. In January 2011 the FBI had more questions. The same month the IRS audited her business tax returns. In May 2011 the FBI called again for a general inquiry about King Street Patriots. In June 2011 Engelbrecht’s personal tax returns were audited and the FBI called again. In October 2011 a round of questions on True the Vote. In November 2011 another call from the FBI. The next month, more questions from the FBI. In February 2012 a third round of IRS questions on True the Vote. In February 2012 a first round of questions on King Street Patriots. The same month the Bureau of Alcohol, Tobacco and Firearms did an unscheduled audit of her business. (It had a license to make firearms but didn’t make them.) In July 2012 the Occupational Safety and Health Administration did an unscheduled audit. In November 2012 more IRS questions on True the Vote. In March 2013, more questions. In April 2013 a second ATF audit.

All this because she requested tax-exempt status for a local conservative group and for one that registers voters and tries to get dead people off the rolls. Her attorney, Cleta Mitchell, who provided the timeline above, told me: “These people, they are just regular Americans. They try to get dead people off the voter rolls, you would think that they are serial killers.”

This week Ms. Engelbrecht, who still hasn’t received her exemptions, sued the IRS.

So in case you are keeping score that’s:

FBI visits: 9

IRS Audits: 4

ATF Audits: 2

OSHA Audit: 1

Now the tendency is for liberals to discount this intimidation, but as has been said before by people far smarter than me, life is like a wheel and it all comes round. There will come a time when Conservatives rule, and unless they want liberal groups to be harassed the same way as conservative groups have been, they might want to consider this as a true bipartisan issue. If not, they might want to start reviewing their tax returns and preparing for the full wait of the federal government to come down on them.

The Council Has Spoken: May 24, 2013

Congratulations to this week’s winners. Full voting here.

Council Winners


Non-Council Winners


Oregon Study: Medicaid ‘Had No Significant Effect’ On Health Outcomes vs. Being Uninsured

This is surprising, even to me. Maybe it’s because I still have a left0ver Socialist streak in me from my liberal days when it comes to health care.

So, what did the Oregon study authors find? They found no statistically significant difference in elevated blood pressure (1.33 percent less incidence in Medicaid vs. control, p=0.65); high cholesterol (2.43 percent less than control, p=0.37); high HbA1c (0.93 percent less, p=0.61); or Framingham risk score (0.21 percent less than control, p=0.76). According to the p values, the blood pressure result has a 65 percent chance, the cholesterol result a 37 percent chance, the HbA1c result a 61 percent chance, and the Framingham score a 76 percent chance of being statistical noise. Again, statistical significance requires a p value of less than 0.05.

I think it’s critical for those of us who tend to be political ideologues to try to act based on the evidence and not on our beliefs whenever possible, to maintain a balance between completely closed minds and those that are so open our brains fall out. It isn’t easy, and we’re only human, but we need to try.

Scandal Scorecard

I have promoted this article to a page at the top of this website. Further updates will appear there.
Page current as of 21:00 EST 2013-05-23.

Please refer to it at its new location.
 

Benghazi


 

IRS


 

Press Monitoring/DOJ Wiretaps


 

Gross Incompetence


Islam: A Religion of Pieces

It’s so easy to confuse them these days…
Islam a Religion of Pieces

Watcher’s Council Nominations: May 22, 2013

Council Submissions


Honorable Mentions


Non-Council Submissions


Jay Carney’s Shifting Excuses for IRS

A few weeks ago I referenced Blazing Saddles, today I get to reference another comedy classic, The Blues Brothers.

Jay Carney’s shifting excuses for the IRS reminds me of another famous Ja(ke), although this one has a heart of gold and is a helluva lot funnier.

NJ Teacher Not Angelina Jolie Is The Brave One

Update 5/22/2013: As Julianne points out in the comments, Debbie Gentile-Abbood, Dr. Wife and I are all wrong when it comes to insurance coverage. The Women’s Health and Cancer Rights Act of 1998 mandates insurance coverage for the preventative removal of the breasts as well as their reconstruction. I have confirmed this here and here. I still haven’t been able to confirm whether Medicaid/Medicare covers these procedures, but with the law on the books I’d be surprised if they didn’t. Given the daily battles Dr. Wife faces with the insurance companies, and my cynicism towards anything that stinks of corporate or bureaucrat involvement in healthcare  we both assumed such coverage was not available to women. In this case, I’m very happy to be wrong. I know too many women who have been cut down early by the disease, and if there’s any chance of preventing it I’m all for it.
——
A New Jersey teacher has taken issue with Angelina Jolie’s decision to remove her breasts before contracting breast cancer. Evidently Jolie tested positive for the BRCA gene mutation that makes one likely to develop breast cancer and had mastectomies before the cancer developed. Debbie Gentile-Abbood says “It upsets me… That’s good for her; she’s got the best health care and she’s got money. She doesn’t have to worry about taking off of work.”

I discussed Jolie’s decision with Dr. Wife who said it was a smart idea – if you had the money. She pointed out that a positive BRCA mutation test would likely not convince an insurance company to cover the cost of the  radical mastectomies without evidence of cancer beforehand, and they would definitely not cover the reconstructive surgery Jolie underwent at the Pink Lotus Breast Center, considering it purely cosmetic. While many have commended Jolie for her courage to face a positive test and then act upon it, her actions seem less commendable for those of us who struggle getting tests pre-authorized, or writing letters to insurance companies on behalf of patients whose life-saving medicines aren’t covered in the company’s formulary. Gentile-Abbood won’t even take the test because doing so would put her family into a predicament caused by a positive result. Get the life-saving surgery and ruin the family financially, or play the odds and hope she doesn’t develop cancer. It is an appalling choice, but one that is faced every day by hundreds of women nearly all of whom lack Jolie’s means.

I don’t begrudge Jolie for her decision, but I don’t laud her either. Instead I would hope that cancer detection and treatments improve so that all women regardless of their economic background could live life without fear. Now that would be truly worth noting.

The Sublime Beauty of Stepping Stones: Germany’s Stolpersteine

The Economist’s sister publication Intelligent Life has a fascinating article about stolpersteine, stepping stones memorializing those murdered in the Holocaust with stones placed in the pavement in the neighborhoods where they last lived. Artist Gunter Demnig has been laying the stones, each wrought by hand, since 1996. Each is handmade, he says, because “any form of mass-manufacturing would remind him of the mechanized and bureaucratic murder at Auschwitz.” His work has even earned him three death threats, proof that he must be doing something right.

It’s a fascinating read, and an even more fascinating memorial to view, with thousands of his brass plates embedded in streets throughout Germany. Just something to keep in mind on your next visit.

Book Review: Cannon the Brown Bear: An Illustrated Children’s Fable

I usually don’t review books, let alone children’s books, but every once in awhile something comes a long that deserves my admiration.

Cannon the Brown Bear: An Illustrated Children’s Fable is a very simply story about a bear who begins free and happy and who provides for himself. But then he starts to receive food handouts and even his den is dug out for him, and he begins to find himself unhealthy and bored and unhappy. So one day he takes back his independence and begins to rely on his own resourcefulness to provide for himself, and his life is much fuller because of this.

I enjoyed the book very much. Some may find this message to be political which is a shame. Maybe it’s because I’m old but I didn’t find the message very “political” at all. Is it right wing to teach children the value of reaping what you sow? Is it Republican for children to read fables that could have been read 2,500 years ago by a Greek like Aesop? Since when is learning to provide for yourself a political act?

And I particularly enjoyed the fact that the illustrations were done by a child. As a fan of the classic illustrators like the Wyeths, I appreciate the artistry of the medium, and seeing it done with a child’s hand adds authenticity to the work.

If you are looking for a book for those in the 3-7 range, consider this one. It’s Kyle’s first work, and honestly, it’s one of the better first books I’ve read as of late. Kudos to Michaela for a job well done illustrating the work.