Low Cost Health Insurance

FeedSync

January 31, 2008 on 1:52 pm | In Uncategorized | Comments Off FeedSync - I wonder why I haven't seen much buzz about this.  If Dave Winer had come up with it - would it be the cool new thing?  It's going to take a while before we see Microsoft as an innovator - eh? 

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Can we solve these problems with IT?

January 31, 2008 on 10:58 am | In Uncategorized | Comments Off

My fax machine has too many faxes in it every morning

Analog office:  .. My fax machine has too many faxes in it every morning which my staff put on a pile on my desk and then I try to read them and act on them  by scribbling illegible notes on them and putting them in piles on someone else’s desk.  Digital office:  My fax machine has too many faxes in it every morning .. which my staff scan into my EMR and then I try to read them, and act on them often using a separate system functionality – so need to leave the “reading” work stream, do the action, then return to “reading” 

Reassuring Lab Results just arrived (by fax, mail, local printer, etc)

When I get labs back – most of them are normal.  I can: Initial them (digitally or pen/paper) and put them in the chart (paper or digital) Tell the patient that “no news is good news” (which is  terrible customer service, BTW) But some will call (they should!) So the chart gets pulled (paper office) And someone calls them back (usually nurse) And sometimes answers the questions And sometimes the patient still wants to talk with the provider So now it comes to me Like 50 other ones I stay in the office until 8 PM calling my patients back And they ask other questions when we are on the phone Or they are not home so I leave a message So there is a loose end that I have to manage tomorrow. 

 I am a specialist – seeing a new patient for the first time.

I don’t have any records – so my nurse or AA calls the referring provider, pharmacy (for medication list), and hostpial (for recent H & P/Discharge summary) I wait Some of it arrives via fax Most of it arrives tomorrow I call the preferring provider’s office.  wait The provider comes to the phone Can’t remember much about the patient Asks her staff to pull the chart We wait and talk about our kids in College Our waiting rooms fill up with angry patients and well-dressed drug reps with too much cologne Chart is “not found” – it must be in a big pile somewhere We both get frustrated – referring provider hums a few bars from memory.  We hang up. I make decisions with the patient based on incomplete data I dictate my progress notes I sign them (barely review them) when they come back in 3 days from the transcriptionist They go into the chart (digital or paper) My staff faxes a copy of my note to the referring provider. 

I am a provider writing a prescription for Clarinex

The patient has seasonal allergies

Has tried “everything else”

The drug reps left a pile of these and I gave some to the patient last time she was here

They work “wonderfully”

She wants more

So I write a prescription

Which she takes to CVS 

And they want to charge her $107.50 

Because it’s not covered 

So she calls my office

And my nurse says she’ll work on it 

So she gets the chart 

So she looks up the insurance company (BlahBlah Healthcare)

And then she calls the “prior authorization” phone number 

And waits on hold 

Until a person answers  

Who sends a fax  

Which the nurse gets 4 hours later

And gets the chart again

And she fills out the form on the fax

And she puts it on my desk with a “sign here” sticky note on the signature line – and pointing to the (empty) justification section 

I get it on my desk the next morning  

I fill in the blank sections of the form and put back on the nurse’s desk

Who faxes the form   …

3 days later the patient calls and asks if this is done.

Different nurse pulls the chart and sees the copy of the fax that was sent to the insurance company – so she says yes.

Patient goes to CVS who tries to charge her $107.50 again

Patient goes home and calls the office

Nurse pulls chart again

Nurse calls BlahBlah Healthcare.  Turns out they haven’t processed it.  They will process it and will let us know if it’s denied (They won’t let us know it it’s approved).

Nurse calls patient and tells her to try CVS again in a few days.

Patient gets angry and yells at nurse

Nurse was depressed anyway and quits her job – slamming the door on her way out, hitting a child in the head as he comes in for his 3-year well-child visit.    He is conscious, but has a laceration on his forehead that will require repair.  The kid’s mother says she’ll sue the physician “for everything he’s worth” as she drags the kid off toward the emergency room.

She hits a raccoon on the way home, barely missing an Oak tree as she tries to avoid little Rocky.

She calls her physician and requests some Xanax to “calm my nerves” – beginning a life of dependence on benzodiazepines and poverty.  She stops making payments on her mortgage, loses her home, and was last seen living over a ventilation grate near the Misys offices in New York City.

Spacecraft Falling! Get Set to Duck?

January 30, 2008 on 6:15 am | In Uncategorized | Comments Off

Correction Appended: Jan. 29, 2008

If you're the kind inclined to worry, here's a real hand-wringer for you: Sometime as early as February, 7,000 lbs. of flaming metal are going to start raining out of the sky, and nobody can say exactly where on Earth it's going to happen. The upside is, there's almost no rational reason you should give it a second thought.

The approaching fireball of debris comes to us courtesy of an unnamed U.S. spy satellite launched in December 2006, which reached orbit perfectly well, but then suffered a breakdown that caused ground controllers to lose communication with it. "It's not necessarily dead, but it's deaf," John McDowell, an astronomer with the Harvard-Smithsonian Center for Astrophysics unhelpfully told The New York Times. A deaf satellite, after all, is almost as bad as a dead satellite, when it comes to telling it to fire its thrusters so that it can stay in orbit, or at least come down in a safe place like the middle of the ocean. Without communications, the satellite becomes a falling cannonball colliding with the atmosphere at 17,500 mph.

That very atmosphere, however, helps ensure that we're in very little danger from being struck by this craft or any other incoming junk. Even billions of years after the formation of the solar system, space is still something of a shooting gallery, with meteors careening everywhere. The Earth is a very fat, very slow target for such flying rubble, but the high speed of the approaching rocks and the density of the planet's air cause anything but the biggest pieces of debris to burn up on their way down, producing nothing more dangerous than shooting stars.

That's not to say we're at zero risk from space junk. In the 50 years since the launch of Sputnik, the world's first satellite, and Explorer I, America's first satellite, rocket builders from all over the world have fired so much heavy hardware into space that the planet is now surrounded by a belt of litter consisting of some 10,000 objects four inches or more in diameter and many tens of thousands of smaller ones. Taken together, they're estimated to represent more than 900,000 lbs. of flying — and possibly falling — rubbish.

In 2006, wreckage from a plummeting Russian spy satellite whizzed dangerously close to a Latin American Airbus carrying 270 passengers. That near-miss took place over the Pacific Ocean, which is considered among the safest places in the world to bring down satellites due to its unpopulated vastness. The worst uncontrolled reentry in history occurred in July 1979, when Skylab, America's abandoned, 78-ton space station — which had long since run out of maneuvering fuel — came down earlier than planned, raining debris across the Australian outback.

Often, however, satellites and other spacecraft are brought down in a much more controlled way, their trajectories tweaked and adjusted before their terminal plunge so that they strike a precisely selected — and safely empty — spot. In 2000, the 17-ton Compton Gamma Ray Observatory was gently steered back to earth this way. In 1970, one of the most storied spacecraft of all — the Apollo 13 lunar module, which served as a lifeboat for the crew when their command module was crippled by an explosion — sparked fears of nuclear contamination since it was on a return path to collide with Earth still carrying radioactive instruments that were supposed to have been left on the surface of the moon. As reentry approached and the astronauts clambered back into the command module through the tunnel that linked the two ships, the soon-to-be-jettisoned lunar module was already being targeted for a landing in a deep ocean trench off the coast of New Zealand. There it splashed down and sank — and there it remains.

The comparatively small spy satellite now wobbling its way home will not have nearly so precise a landing — but it is likely to have an equally uneventful one. Seventy percent of the Earth's surface is water, meaning that there ought to be a 7 in 10 chance that the craft will drop in the drink. The fact that satellites are usually targeted for flight over land narrows those odds some, but the equally important fact that the majority of the Earthly land mass is uninhabited widens them back up. That plus the small size of the doomed craft probably means its death will be nothing more than a pleasant sky show for the few people lucky enough to see it. If you're the kind inclined to worry, you might have to pick another problem.

The original version of this story incorrectly stated that the U.S. spy satellite expected to fall back to Earth weighs 20,000 lbs. It weighs 7,000 lbs.

Is Congress Finally Ready to Go Green?

January 30, 2008 on 6:15 am | In Uncategorized | Comments Off

Correction Appended: January 29, 2008

As concern over global warming became more and more prominent in the U.S. over the past several years — in the media, in opinion polls, in business and in state governments — the one place where the issue seemed all but invisible was the one place that could really do something about it: Congress. But that began to change in 2007, and nowhere more so than in the Senate's key committee on the environment and public works, which drafts much of the country's environmental legislation. Up until last January, the committee was chaired by Oklahoma Sen. James Inhofe, a Republican who memorably called global warming "the greatest hoax ever perpetrated on the American people." When the Democrats took over Congress in the 2006 midterm elections, however, the chairperson's gavel was handed over to Sen. Barbara Boxer of California, and the floodgates opened. Boxer began a series of open hearings on the science of global warming, giving airtime to the sort of experts — including former Vice President Al Gore — who had been suppressed under Inhofe. "As soon as the change took place, I realized that this was going to be one of my number one goals," says Boxer. "Elections have consequences, and this was one of the consequences."

Hours and hours of hearings finally led to a legislative breakthrough in December: the passage out of the committee of the first bill that would put carbon caps on the U.S. economy. Co-sponsored by the Republican Sen. John Warner and the Independent Sen. Joseph Lieberman, the America's Climate Security Act would cap U.S. carbon emissions at 15% below 2005 levels by 2020, with a 70% cut projected for 2050. If enacted, those carbon caps would all but force U.S. businesses to invest in cleaner technology and greater energy efficiency, and would help the country take a leadership role in international climate negotiations.

Similar bills had been put forward over the past several years, only to die in committee. This time, however, Boxer was able to help pull together not only Democrats but a Republican as well, giving the bill some bipartisan support. That's key — given how narrowly divided Congress has become, meaningful climate change legislation only has a chance if its supporters can draw allies from across the political aisle. Boxer is confident she can. "The environment has been an issue that has pulled together Republicans and Democrats in the past," she says. "Everyone has to breathe the same air."

The Climate Security Act has passed the first barrier to becoming law, but the road is only going to get tougher. To have a chance in the Senate, the bill needs at least 60 votes — anything less, and opponents can stop it with a filibuster. That will require winning over more conservative Senators, while at the same time ensuring the bill doesn't become so watered down that it loses all effectiveness. And even if the bill were to pass the Senate, and then the House of Representatives, it still has to make it through President George W. Bush, who has shown little inclination to support it. Bush favors what he calls technological solutions to global warming, but without the pressure of carbon caps. "That's like saying let's meet at the field and play baseball, but you don't bring a mitt or a ball," says Boxer. "You can't play the game."

Critics like Bush tend to focus on the economic costs of reducing carbon emissions — through increased energy prices — but Boxer, and many of her supporters, believe that combating climate change can have a net positive effect on the economy. Boxer hails from California, which has already passed the strongest state legislation on climate change, cutting carbon emissions to 1990 levels by 2020. Far from hurting the state economically, Boxer notes, the carbon bill has helped California become the center for green innovation in the U.S., with Silicon Valley venture capitalists pouring billions into alternative energy start-ups. Those businesses will create new, green jobs that should make up for the short-term costs of cutting carbon. "The cure for global warming is positive," says Boxer. "That makes it easy for me to approach it with hope."

Emphasizing the hope, the positive possibilities of dealing with climate change, should also help Boxer broaden the appeal of the Climate Security Act. Americans are worried about global warming, but they're also worried about Iraq, the economy and health care. Make global warming into an economic issue, or an issue of national security, not just an environmental one, and there's a better chance of achieving broad, bipartisan support. Not all environmentalists are happy with the Climate Security Act — it has been criticized by the Sierra Club, among other groups, as too weak. While it could be tightened, the reality is that only a moderate bill is likely to pass soon, and with science telling us that we may have less than 15 years to turn around carbon emissions, we can't afford to hold out for a perfect law. "The longer we wait to do what we need to do, the harder the transition will be," says Boxer. "We're running out of time." She's absolutely right, but at least Congress is no longer standing still.

The original version of this article stated that Senator James Inhofe represented Alaska. He actually represented Oklahoma.

The Amazon Gets Less and Less Green

January 27, 2008 on 3:55 am | In Uncategorized | Comments Off

Despite the alarms about global warming, the news concerning Brazil's crucial Amazon jungle is not good. Once again, satellites are showing deforestation is on the rise. And once again the government has announced a package of measures aimed at halting it. If you think you've heard this story before, you're not wrong. It's depressingly familiar. "This is only a surprise if you believe in Father Christmas," said Roberto Smeraldi, director of Friends of the Earth's Brazil office.

The new statistics show that deforestation for the last five months of 2007 was 3,235 sq. kilometers (1,250 sq. miles or about the size of Rhode Island), a rise from the previous year's figure and alarming because deforestation normally drops in the final rainy months of the year. In a world panicked by its own carbon footprint, the forests of the Amazon are the planet's largest absorber of carbon dioxide.

Even more disturbing was an alert from another government agency warning the true figure is closer to 7,000 sq. km. (2,700 sq. miles) "It is a completely new and very worrying development," Joao Paulo Capobianco, executive-secretary at the Environment Ministry, admitted at a press conference to announce the figures on Thursday. So worrying that President Luiz Inacio Lula da Silva brought together several ministers to discuss measures designed at halting the destruction.

Lula, elected with the support of green groups who later accused him of kowtowing to Brazil's powerful agribusiness lobby, called for a complete ban on deforestation in the 36 worst-hit municipalities and said he would next month send 800 federal police officers to ensure the moratorium is respected. He also told landowners they would have to register their properties and prove they comply with existing environmental legislation, something very few currently do. Those not in compliance will be ineligible for government credit or prohibited from selling their property. Measures will also be introduced to stop non-compliant businesses from selling their produce.

The measures are thorough and hard-hitting and many environmentalists approve. However, in a remote region like the Amazon, where laws are more suggestions than commandments, perpetual question marks surround enforcement. The Lula administration has to truly want to bring landowners into line, which is a big if, especially in a year of municipal elections, said Paulo Adario, coordinator of Amazon campaigns of Greenpeace.

What is even more frightening is that the government may not even be able to implement the laws, even if it wanted to. "These measures are very difficult to implement," Adario said. "But the problem is that while the government knows where the deforestation is taking place it doesn't know who is doing it. They don't know who owns what out there. Lots of people don't have legal papers, some of the land has been taken in land grabs and it is hard pinning down the culprits."

Environmental groups also believe the government's commitment is questionable because it needs the income from Brazil's booming agriculture sector. Brazil is the world's biggest beef and soy exporter and it leads the global race to turn sugar cane into fuel. When commodities like soy, beef and grains are sought after on world markets, farmers have more incentive to hack away and create fields. Environment Minister Marina Silva said the recent rise in deforestation is due in large part to increased commodity prices. Deforestation fell along with food prices in 2005 and 2006 and now both are on the rise. Silva, however, meets counter-arguments from within the government. The minister of Agriculture has rejected that theory and argued that the amount of land given over to soy has remained constant for four years.

Until the government operates from the same premises, real and concerted change will remain elusive, said Carlos Alberto Scaramuzza, thematic conservation director at the World Wildlife Fund-Brasil. "The government needs to recognize that agribusiness, especially cattle ranching, is part of the problem," Scaramuzza said. "If we keep hearing the agriculture minister saying that agri-business has nothing to do with the problem then we are always going to be chasing our tail."

Another worrying aspect comes in the westerly shift of deforestation. Thursday's figures show a large increase in forest degradation in Rondonia, a remote state bordering Bolivia. Rondonia had avoided much of the destruction but the new figures show that deforestation there is almost equal to that in Para, a state five times the size.

Smeraldi put the rise down to a controversial government decision to license two hydro-electric dams on the Madeira river, the longest tributary of the Amazon. The dams could provide as much as 8% of Brazil's energy needs but they have been compared to China's Three Gorges project because of the potential ecological damage. Lula dismissed claims by his own environmental agency that the dams could cause serious harm to the environment and ordered a shake up that resulted in the ousting of officials who opposed the project. The tender process went ahead last year, prompting a land grab nearby, Smeraldi said. "This is the result of the speculation boom over land that started in July 2007 when the Madeira dams were given the go ahead without even studying the impact on deforestation and land issues," he said.

Whatever the cause, Smeraldi and his colleagues in the environmental lobby are gearing up for more bad news when the annual figures are released later this year. Most of them swear they are optimistic by nature. But they know how this story goes. They've seen it before. And it rarely has a happy ending.