Daniel A. Dougan

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Still think we can solve health care with free-market principles? Just go to the ER.

Posted by danieladougan on January 26, 2014 at 6:35 PM Comments comments (0)

I'm going to share a Fox News story that has its roots in the federal government's intrusion in health care and how it led to a man's death because he had to wait too long to see a doctor. 

But it's not the government intrusion into health care you're probably thinking of. What really killed John Verrier was not the Patient Protection and Affordable Care Act of 2009 (commonly dubbed Obamacare, but I'll shorten it to PPACA), but the Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA).

You see, this is a story about how the government intruding in health care led to the tragic death of 30-year-old ER patient John Verrier. Verrier died in the waiting room at St. Barnabas Hospital in the Bronx  more than eight hours after he checked in. Apparently the hospital did not have a policy in place to check on people in the waiting room at the ER to make sure they were still present or alive -- even after they called his name to be seen and he did not answer.

A little background: EMTALA requires all hospitals that participate in Medicare (which is essentially all hospitals period) to evaluate and stabilize any patient who comes to the emergency room, regardless of ability to pay. Sounds like a good idea, right? I mean, who wants hospitals to turn people with emergency ailments away or dump them onto county hospitals without being stabilized just because they can't pay the bill? Sadly, the law had to be written because that's exactly what was happening in the 1980s at an alarming rate. People died. There have even been plenty of cases post-EMTALA where hospitals have dumped patients due to the inability to pay. 

Why would hospitals continue to dump patients after EMTALA said they couldn't? Because, as Avik Roy of Forbes wrote, EMTALA is "one of the great unfunded mandates in American history."

So what does this have to do with John Verrier's death? According to a report on the case in the New York Post, a hospital employee said, “He died because [there’s] not enough staff to take care of the number of patients we see each day. We need more staff at Saint Barnabas.”

It makes sense, doesn't it? If the federal government requires hospitals to accept all patients regardless of their ability to pay, then you can expect two outcomes:

1) A lot of people will get care and not pay for it. In fact, according to the Centers for Medicare and Medicaid Services, 55 percent of emergency room care goes uncompensated.

2) A lot of those people who need care but cannot pay for it will end up in the emergency room because, unlike at a traditional physician practice or an urgent care, the ER has to evaluate and stabilize them BY LAW even if they can't pay. So a lot of people who end up in the ER have non-emergent conditions and would be better off if treated at a lower level of care...that is, if the primary care or urgent care practice would actually treat them since they don't have to. A study in Health Affairs revealed that:

Americans seek a large amount of nonemergency care in emergency departments, where they often encounter long waits to be seen. (emphasis added) Urgent care centers and retail clinics have emerged as alternatives to the emergency department for nonemergency care. We estimate that 13.7–27.1 percent of all emergency department visits could take place at one of these alternative sites, with a potential cost savings of approximately $4.4 billion annually.

So, here's the perfect storm that led to the death of John Verrier. The unfunded mandate of EMTALA has led to a lot of  uncompensated care at hospitals, so it's not surprising that hospitals like St. Barnabas don't dedicate enough staff to the ER -- it's a loss center for them.

From my years of graduate-level study in health administration, I have my suspicions that management best practices are to staff the ER just enough to not violate EMTALA...walk right up to the line, but don't cross it. Here in Indianapolis, we have a county safety-net hospital called Eskenazi Health. The previous facility was called Wishard Memorial Hospital.

And, according to one of my professors who would be in a position to have firsthand knowledge, there was a common saying among hospital staff and management: "Tube 'em to the Wish," which meant that the hospital's policy was to evaluate and stabilize an indigent patient just enough to not violate EMTALA and then dump the patient at the county hospital.

So, back to the understaffed ER at St. Barnabas and John Verrier's deadly wait, it's certainly worth considering that EMTALA played a role in his death. He was complaining of a rash, which on its surface would not seem like a life-threatening medical condition, but he was waiting for hours and hours just to be evaluated.

But, of course, I'm not suggesting that we stop requiring hospital emergency rooms to treat everyone without regard to their ability to pay -- I'm suggesting that if we mandate something, we need to pay for it. After all, I'm not sure whether John Verrier was insured or not...so simply repealing EMTALA might have killed him too.

And that's where the other federal law in this story -- PPACA -- can make a real difference. By passing EMTALA in 1986, we as a country established the idea that health care is a right and not a privilege and not a commodity that can be allocated by Adam Smith's invisible hand. We just refused to acknowledge the price of this belief because we didn't want to pay it. But of course there is always a price -- there is no free lunch. It comes up in higher hospital bills and higher health insurance premiums for the rest of us. It comes up in hospitals being declared tax exempt because of the amount of charity care they provide to indigent patients.

By addressing the problem of millions of Americans being uninsured, we can reduce the problem of uncompensated care for hospitals that leads to understaffing AND we can give people with non-emergent conditions more appropriate care alternatives where payment will not be a barrier to treatment. PPACA is certainly not a complete answer to the problem, but it's a big step. Maybe if Ronald Reagan had extended insurance coverage to all Americans back in 1986 instead of just mandating that hospitals see everyone in the ER without regard to ability to pay, then John Verrier and so many others in his situation might have lived.

Why Mitch Was Right to Eliminate Howard Zinn

Posted by danieladougan on July 23, 2013 at 12:55 AM Comments comments (0)

"You wanna read a real history book? Read Howard Zinn's People's History of the United States. That book'll knock you on your ass."  -- Matt Damon, Good Will Hunting



So there has been a big dustup recently about Purdue University president Mitch Daniels and some e-mails he sent back when he was the governor of Indiana in regard to eliminating a controversial history book by Howard Zinn. Zinn's book, A People's History of the United States, has a strong liberal bent that understandably frustrated a conservative like Daniels.


A lot of liberals and the faculty at Purdue University in general are concerned about whether Daniels will impede academic freedom on campus. Here's why they have nothing legitimate to worry about.


First of all, being a state governor is a very different job from being a university president. The e-mails in question refer to the use of Zinn's text in K-12 classrooms, not universities. And it's perfectly reasonable for a governor to be concerned with a state's academic standards. Notice that Daniels didn't say he didn't want Zinn's book published or even borrowed from the school library. He merely wanted to ensure that the book was not used as a textbook for academic credit at the K-12 level, and he did not want K-12 teachers to be able to use this textbook for professional development.


I understand the appearance of political censorship here, but perhaps a better question is why some would want a history book with an overt political agenda taught in public school classrooms in the first place.


Despite its popularity, Zinn's book has come under plenty of fire over the past 33 years, and not just from offended conservatives. Plenty of historians of all ideological stripes have panned Zinn's book too, not because of its ideology, but because of its questionable academic quality and all of its leading questions for students. This is not to say that there is no value in what Zinn wrote or that it should be kept away from students under lock and key, but using it as an official textbook ascribes an air of authority to it that it doesn't really merit.


To get a flavor for Zinn's work, let's examine a few of Zinn's questions at the end of Chapter 16:

  • Did the behavior of the United States show that her war aims were humanitarian or centered on power and profit?
  • Was she fighting the war to end the control by some nations over others or to make sure the controlling nations were friends of the United States?
  • With the defeat of the Axis, were fascism's essential elements -- militarism, racism, imperialism -- now gone? Or were they absorbed into the already poisoned bones of the victors?


These leading questions are not the stuff of normal history textbooks to be sure.


Here's another excerpt from Zinn to make it crystal clear that he writes the book with an agenda.


The mountain of history books under which we all stand leans so heavily in the other direction-so tremblingly respectful of states and statesmen and so disrespectful, by inattention, to people’s movements-that we need some counterforce to avoid being crushed into submission.


For my fellow liberals, remember that we sort of do the same thing with science textbooks, like the infamous Of Pandas and People that so many religious conservatives have fought to include as a science classroom textbook promoting intelligent design. (The conservatives lost that fight in the landmark Kitzmiller v. Dover Area School District case.) Why did the conservatives want to include that textbook in the classroom? To lend artificial credibility to intelligent design and to discredit the established science of evolution.


Now some might argue that science and history are two different beasts and that history is far more subjective than science so opposing views and controversies are much more legitimate there. But the more important lesson to me is that children, including teenagers, are impressionable, and it's important that we don't pass off propaganda as fact to them, regardless of which side the propaganda serves. Most students even at the high school level have not developed the critical thinking skills necessary to digest a book as simplistic and overtly partisan and leading as Zinn's in proper perspective; especially when it is presented as a bona fide history textbook.


Here's what liberal historian Michael Kazin -- editor of Dissent Magazine -- had to say about Zinn's book.


But to make sense of a nation’s entire history, an author has to explain the weight and meaning of worldviews that are not his own and that, as an engaged citizen, he does not favor. Zinn has no taste for such disagreeable tasks...No work of history can substitute for a social movement. Yet intelligent, sober studies can make sense of how changing structures of power and ideas provide openings for challenges from below, while also shifting the basis on which a reigning order claims legitimacy for itself. These qualities mark the work of such influential (and widely read) historians on the left as Eric Hobsbawm, E.P. Thompson, Gerda Lerner, C.L.R. James, and the erstwhile populist C. Vann Woodward. Reading their work makes one wiser about the obstacles to change as well as encouraged about the capacity of ordinary men and women to achieve a degree of independence and happiness, even within unjust societies. In contrast, Howard Zinn is an evangelist of little imagination for whom history is one long chain of stark moral dualities. His fatalistic vision can only keep the left just where it is: on the margins of American political life.


Do we liberals who have often fought so hard against the child brainwashing techniques common to organized religion really want to foist a book like A People's History on impressionable schoolchildren as a textbook?

How much computing power do you really need?

Posted by danieladougan on July 2, 2013 at 9:45 AM Comments comments (0)

Disclaimer: This one gets pretty geeky, but it might be worth a read before you buy your next computer or tablet.


Back in late 2007, I wrote a column (on MySpace!) about how upgrading from Windows XP to Windows Vista was a bad idea.


A lot has changed since I wrote that blog. The iPhone was in its infancy at that time...it didn't even work on 3G until 2008. The original iPad was released on April 3, 2010. The first Android phone was released on September 23, 2008.


Back in May I added an update to the blog that Microsoft is terminating extended support for Windows XP on April 28, 2014, so if you're still using Windows XP, you really should start to think about upgrading your Windows version now or switching to Linux for security reasons. Windows XP, after all, was first released on October 25, 2001, and even Windows Vista is more than six years old now. Windows 7 was released on October 22, 2009, and Windows 8 was released on October 26, 2012.


But the fundamental question I posed back then still remains: how much computing power do most people really need? For me, the answer is that they need more than they used to, but not nearly as much as a lot of new PCs offer. Only a select few power users will take full advantage of the high-end machines available today.


At the D8 Conference in 2010, Apple CEO Steve Jobs said, “When we were an agrarian nation, all cars were trucks, because that’s what you needed on the farm. But as vehicles started to be used in the urban centers, cars got more popular. Innovations like automatic transmission and power steering and things that you didn’t care about in a truck as much started to become paramount in cars. … PCs are going to be like trucks. They’re still going to be around, they’re still going to have a lot of value, but they’re going to be used by one out of X people.”


Another important thing happened not long after I wrote that blog entry: the emergence of the netbook. Intel released its first Atom system-on-a-chip processor in April of 2008 -- the idea was to leverage the Atom processor architecture to build small, very inexpensive laptops with long battery life.


Of course, this meant accepting some compromises in terms of performance. The Atom chips were single-core processors running at low clock speeds to conserve battery power and, of course, to save money.


A few netbooks were released with Windows Vista, which as my blog would have predicted, they could not handle. Vista was too much of a resource hog for lower-powered hardware, so the manufacturers stuck with Windows XP until Microsoft released Windows 7 Starter late in 2009. It's not necessarily that the Atom processors were too slow -- it's that they were too slow for Windows Vista.


Most people who bought netbooks probably didn't expect to play hard-core games on them, but they were so underpowered that office tasks and playing high-definition video were out of the question. So when the iPad stormed onto the market in 2010 and Android tablets followed, rather than relying on Intel's x86 architecture, they used chips based on a different architecture designed by ARM Holdings (including the ARM Cortex, NVIDIA Tegra and the Qualcomm Snapdragon processor lines) that had proven to be so well suited for smart phones in terms of excellent battery life. Apple's iPod Touch, iPhone and iPad devices use ARM Cortex processors.


Even though these ARM processors were even less powerful than the Atom chips; iOS and Android were leaner operating systems that got the most out of these low-powered processors. While netbooks were seen as bargain-basement laptops, tablets were accepted by consumers are more innovative and simpler to use for reading, web surfing and watching videos. They also weighed less than netbooks and had longer battery life. Netbook sales plummeted.


Microsoft saw the advantages of ARM processors (which could not run any version of Windows) as well and released Windows RT alongside Windows 8 in late 2012...most prominently in the Surface tablet. Unfortunately, the downside of Windows RT is that it can only run apps from the Windows Store and not software programs that worked on Windows 7 or before. Windows RT products have not sold well, and


The good news is that Intel has been plugging away for years making that Atom processors better and better. The current "Clover Trail" Atom processors (you would see them on a computer label as Atom Z2760) are dual-core processors with vastly improved graphics capabilities for 1080p video and excellent battery life. They are significantly more powerful than almost all ARM processors on the market, and they can run the full version of Windows 8. They're not quite as fast as Intel's other processors (Celeron, Pentium, Core i3, Core i5 or Core i7), but they're significantly better than the Atom processors released in 2008 and might just be fast enough for your needs.


For Holiday 2013, Intel will release its new "Bay Trail" line of processors, which will apply to Atom, Celeron and Pentium. Bay Trail processors will be very capable quad-core beasts that will be able to handle all but the most demanding computing tasks quickly (read: high-end gaming and huge spreadsheets or databases) in Windows while providing all-day battery life. Intel also confirmed that the Bay Trail chips will have Wireless Display capabilities that were only available in the Core series chips. Unless you are really pushing these things, they will be almost indistinguishable from a laptop running a much more expensive Core i7 processor, and the battery will last a lot longer. If you're worried that the screen on a laptop or tablet is too small for getting work done or that you can't type efficiently on a touch screen, remember that you can always attach a laptop or a tablet to an external monitor with a simple cable or soon without a cable via Intel Wireless Display, and you can pair it to a Bluetooth keyboard and -- in Android or Windows -- a mouse.


The apps that have become so prominent on iOS and Android are based on cloud computing: the idea that the device offloads the real processing chores to an external server via an Internet connection. The device -- whether it's a smart phone, tablet or laptop -- serves as a sort of thin client; little more than a screen with an Internet connection. Thin clients are an old idea that dates back to the days of the old mainframe systems. So, as more and more computing activities move to the "cloud," the less important your individual machine's processing power will become.


Intel has announced that manufacturers will release Bay Trail Atom-based tablets for well under $199...although these will probably run Android instead of Windows. The Windows versions may add a little cost (like $50), but you will be able to get a full-fledged computer with more than enough speed to handle all but the most demanding tasks later this year for a song.


If your budget is REALLY constrained and you don't need to use your computer on the road, you might want to consider getting an Android Mini PC -- for as little as $50. All you need is an HDTV or monitor with an HDMI input. As long as your needs are not terribly sophisticated, you can accomplish the most common Office tasks for free from any web browser on any operating system (including Windows) using Google Drive.


If you do have other options, I wouldn't recommend using an Android device as a primary computer, but Android TV sticks and tablets as well as Chromebooks can make perfectly capable secondary machines for very low prices. With small credit card readers and simple financial applications available, you could even run a business on a cheap Android smart phone or tablet.


The low cost, low power consumption and small size (for easy shipping) of these Android tablets and TV sticks could bring computing power including the Internet to more people throughout the developing world, advancing their economies, improving literacy, and combating poverty.


You might not even need a new machine at all. Consider as well that a computer system is not just about the processor; it's a chain that is only as strong as its weakest link. So if you're a little low on RAM (2 GB or less for Windows) or your hard drive spins too slowly (4200 rpm or 5400 rpm is way too slow) or if you have a slow Internet connection, your system could feel a little sluggish because those components can be significant bottlenecks. You can also optimize your Windows settings for efficiency over appearance. Adding the maximum amount of RAM possible as well as swapping out your hard drive for a solid-state drive or even a hybrid hard drive with a faster-spinning platter could breathe some new life into your older computer. Doubling the factory-installed RAM from 2 GB to 4 GB, adding a hybrid drive and upgrading my Internet connection has definitely gave my old 2009 laptop, which was pretty low end even then, a shot in the arm. Now it's every bit as responsive playing HD video, performing office tasks, or surfing the web on Windows 7 Ultimate as my work computer running on a quad-core Intel Core i7 with 8 GB of RAM. Of course, newer computers are MUCH more energy efficient than their predecessors, so keeping that older machine might end up costing you more in electricity bills.


In short, we got to the moon on a Commodore 64. Do you really need an Intel Core i7 processor -- which is more than 200,000 times more powerful -- just to read your Facebook feed?

How IT Will Make the Affordable Care Act Work for Americans

Posted by danieladougan on May 29, 2013 at 9:15 AM Comments comments (0)

When speaking to the American Medical Association on June 15, 2009 about the need for health care reform, President Barack Obama cited an unlikely source. He said, "As Newt Gingrich has rightly pointed out -- and I don't quote Newt Gingrich that often -- we do a better job tracking a FedEx package in this country than we do tracking a patient's health records."


Mr. Obama's point was clear; although the debate over health care reform was intense and divisive at times along ideological lines, there was one area where almost everyone seemed to agree. In order to coordinate care, reduce costs and deliver better outcomes for patients, the United States health system needed to harness, analyze and share (within HIPAA guidelines) the data it generates. In May 2008, the non-partisan Congressional Budget Office published a report on the costs and benefits of health information technology. That report estimated an annual net savings in the healthcare sector of $80 billion. In Mr. Obama's view, it was time for the dream of interoperable electronic health records to become a reality.


By the time of the President’s address to the American Medical Association, he had already signed the landmark Health Information Technology for Economic and Clinical Health (HITECH) Act into law as part of the American Recovery and Reinvestment Act of 2009. Among its many provisions, the HITECH Act established $20 billion in federal funding for electronic health records systems that satisfy “meaningful use” criteria. Yet, as Obama pressed Congress to pass a comprehensive health care reform bill, he made expanded use of health information technology part of his agenda.


The final healthcare reform law, the Patient Protection and Affordable Care Act, took the next step after the HITECH Act by instituting new electronic billing standards, requiring health plans to implement electronic health information exchanges, and creating new health insurance marketplaces called exchanges. It is perhaps even more critical to understand the law’s indirect impact on health information technology through its emphasis on value-based purchasing, physician quality reporting, accountable care organizations and patient-centered medical homes. If there is one common thread among the myriad changes brought about by PPACA, it is an increased dependence on health information technology.


Billing and insurance reforms


PPACA is primarily a law about expanding access to health insurance. Beginning in 2014 (with open enrollment starting October 1, 2013), individuals and small businesses will be eligible to purchase private insurance from multiple carriers through exchanges. Because health insurance is regulated at the state government level, each state will have its own marketplace. PPACA gives state governments the option to either operate their own exchanges, work in a state-federal partnership or defer to the federal government to operate their state’s exchange. Regardless of the governance structure (whether states choose to implement their own exchanges is driven largely by partisanship), exchanges will be heavily dependent on the Internet and on standardized electronic transactions to facilitate insurance purchasing.


On the surface, a health insurance exchange website may seem analogous to a travel booking website like Expedia.com. Different private insurers could simply list and explain their offerings and let consumers choose. However, because PPACA includes means-tested subsidies for private insurance and a lengthy list of eligibility requirements for government programs (specifically Medicaid and CHIP), the data collected from insurance applicants is far more extensive.


Also, insurers that participate in the exchanges will be required to report to the government on quality measures, provider network adequacy, essential health benefits, claims payment, medical loss ratios, individual mandate compliance and many other details. That is why the law mandates standardized, secure electronic transactions (including financial transactions) maintained by the Department of Health and Human Services to facilitate these reporting requirements and simplify administrative tasks.


The task of setting up the exchanges is mammoth, and the Department of Health and Human Services has been working closely with states to make sure that residents of every state have access to a functioning exchange when open enrollment begins. However, deadlines continue to be pushed back to account for a lack of readiness by the states that have opted to operate their own exchanges. (This does not even account for the states where Republican governors who oppose PPACA are actively trying to derail its implementation.) Because PPACA was challenged in federal court (and ultimately at the US Supreme Court) and because candidate Mitt Romney vowed to repeal PPACA, a common attitude among governors was to wait until after the election to make any major decisions.


Health IT for clinical data


In order to minimize the cost impact of expanding health coverage to millions of Americans, PPACA also includes provisions designed to “bend the cost curve” by measuring and improving the quality of health care. PPACA depends heavily on expanded health information technology to collect, disseminate and analyze clinical data in the hopes of improving outcomes and reducing costs.


Just as third-party health payers will have new reporting requirements through the insurance exchanges, PPACA also includes provisions to expand health information exchanges for clinical data from the health care delivery system. Where the HITECH Act included grants to finance the health information technology infrastructure for electronic medical records, PPACA established quality reporting and public health data collection requirements that will employ the new infrastructure to measure quality and track population health. In the spirit of the HITECH Act, PPACA also provided additional funding for long-term care facilities to implement electronic medical records systems.


Indirect health IT impacts


Some of the most significant health IT impacts of PPACA are indirect -- that is, provisions that do not explicitly cover health IT nonetheless incentivize investments in information systems.


Two of the more significant provisions of PPACA are the creation of two new voluntary health care delivery models for Medicare: accountable care organizations and patient-centered medical homes. Although the rules governing these new models are extensive, the concept behind them is essentially shifting reimbursement away from a fee-for-service structure toward a structure of bundled payments that reward providers for managing patients’ health across the whole continuum of care.


Accountable care organizations (established through the new Medicare Shared Savings Program) are required to use health information technology for electronic health records, disease registries, eHealth solutions, health information exchanges and advanced data analytics. Naturally when an accountable care organization is charged with keeping a population of patients healthy (regardless of where they go for their health care), it will have an incentive to participate in a health information exchange so the patient can be tracked. This can be particularly useful in the case of disease registries for chronic conditions such as diabetes.


Because PPACA requires healthcare providers to report their quality measures to the Department of Health and Human Services and bases reimbursement levels on performance against these measures, health information technology adoption will become more critical. PPACA extended the Medicare Physician Quality Reporting Initiative, which provides additional compensation to physicians who report quality measures and meet or exceed quality benchmarks (an example of value-based purchasing). Failure to report on these quality measures will result in penalties (reductions in Medicare reimbursement) beginning in 2015.


Not only can health IT enable providers to meet their reporting requirements, it can also help them improve their quality scores so that they can achieve higher reimbursement levels. Electronic health records systems often include decision support tools for physicians to help them practice evidence-based medicine. With the expanded reporting requirements from PPACA, the Department of Health and Human Services can use the data collected to continually improve decision support systems as new evidence and analytics become available. EHR systems also frequently include e-prescribing tools, which can substantially reduce prescription drug errors. Research has shown that handwritten prescriptions have a 37 percent error rate vs. a 7 percent error rate for electronic prescriptions.


Where are we now?


Nearly three years after Mr. Obama signed PPACA and nearly four years after the HITECH Act, health IT adoption in the United States is substantially higher than before, but still very low when compared to other developed nations. A 2012 survey of U.S. primary care doctors by the Commonwealth Fund found that 69 percent reported using an electronic health records system compared with 46 percent in 2009. By contrast, the United Kingdom has an adoption rate above 90 percent. Only 27 percent of U.S. primary care providers reported having access to electronic health records with “multifunctional” capabilities.*


As health IT adoption continues to increase over time, the United States should expect to see positive impacts on cost and quality, but how effective PPACA will be at controlling costs is a matter of intense debate. With health insurance exchanges set to go live for open enrollment on October 1, 2013, an enormous of amount of information technology work must be completed in a short timeframe. How successful the exchanges will be depends in large part about how effectively the technology is implemented -- especially in terms of usability by people looking to enroll in health coverage.


All of this new data infrastructure brings with it new challenges for privacy and security. In addition to the requirements set forth in the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Department of Health and Human Services is building new capacity to enhance -- and enforce -- information security beyond the original HIPAA provisions. According to the National Coordinator for Health Information Technology, These added privacy and security protections are an integral piece of the government’s increased efforts to broaden the use of IT in health care.”


Efforts by the U.S. government to expand health information technology are very much in their infancy. Although some significant progress has been made, most of the work lies ahead. Whether all of this effort and cost will be worthwhile remains to be seen, but early signs of bending the cost curve are positive.



Obama, B. Remarks to American Medical Association, Chicago, 6/15/2009. Available: www.politico.com/politico44/perm/0609/obamas_ama_speech_d856ddc1-eaeb-44f4-9010-2fd4b8473d99.html

Congressional Budget Office. “Evidence on the Costs and Benefits of Health Information Technology,” May 2008. Available: www.cbo.gov/sites/default/files/cbofiles/ftpdocs/91xx/doc9168/05-20-healthit.pdf

The White House. “Deficit-Reducing Health Care Reform.” Available: www.whitehouse.gov/economy/reform/deficit-reducing-health-care-reform

U.S. Department of Health and Human Services. “Key Features of the Affordable Care Act, By Year.” Available: www.healthcare.gov/law/timeline/full.html.

Kaiser Family Foundation. “Explaining Health Care Reform: Questions about Health Insurance Exchanges.” April 2010. Available: www.kff.org/healthreform/upload/7908-02.pdf

National Association of Insurance Commissioners. “Patient Protection and Affordable Care Act of 2009: Health Insurance Exchanges.” April 2010. Available: www.naic.org/documents/committees_b_Exchanges.pdf

Angle, J. “Administration scrambling to set up ObamaCare exchanges.” Fox News, 1/30/2013. Available: www.foxnews.com/politics/2013/01/30/administration-scrambling-to-set-up-obamacare-exchanges

Goodnough, A. and Pear. R. “With Obama Re-Elected, States Scramble Over Health Law.” The New York Times, 11/8/2012. Available: www.nytimes.com/2012/11/09/health/states-face-tight-health-care-deadlines.html?pagewanted=all&_r=0

Ungar, R. “New Data Suggests Obamacare is Actually Bending the Healthcare Cost Curve.” Forbes, 2/12/2013. Available: www.forbes.com/sites/rickungar/2013/02/12/new-data-suggests-obamacare-is-actually-bending-the-healthcare-cost-curve

Healthcare Information and Management Systems (HIMSS). “The Patient Protection and Affordable Care Act: Summary of Key Health Information Technology Provisions.” Available: www.himss.org/content/files/ppaca_summary.pdf.

Impact Advisors. “The Role of Health Information Technology in Accountable Care,” January 2012. Available: www.himss.org/content/files/ImpactAdvisorsWhitePaper_ITImplicationsofACOs.pdf

Schmittdiel J et al. “BRIEF REPORT: The Prevalence and Use of Chronic Disease Registries in Physician Organizations.” J Gen Intern Med. 2005 September; 20(9): 855–858. Available: www.ncbi.nlm.nih.gov/pmc/articles/PMC1490197

Mather, R.C. et al. “Penalties coming under PPACA, PQRI,” from American Academy of Orthopaedic Surgeons. Available: www.aaos.org/news/aaosnow/jan11/advocacy2.asp


Stross, R. “Chicken scratches vs. electronic prescriptions.” The New York Times, 4/28/2012. Available: www.nytimes.com/2012/04/29/business/e-prescriptions-reduce-errors-but-their-adoption-is-slow.html

Terry, K. “EHR Adoption: U.S. Remains the Slow Poke.” InformationWeek, 11/15/2012. Available: www.informationweek.com/healthcare/electronic-medical-records/ehr-adoption-us-remains-the-slow-poke/240142152


Office of the National Coordinator for Health Information Technology. “Federal Health Information Technology Strategic Plan: 2011 - 2015.” Available: www.healthit.gov/sites/default/files/utility/final-federal-health-it-strategic-plan-0911.pdf


*The generation of patient information, such as lists of patients' medications; the generation of patient registry and panel information, such as a list of patients due for preventive care; order entry management, such as electronic prescribing; and decision support, such as alerts about potential adverse drug interactions. To be counted as a user of a multifunctional EHR, a practice had to report that its system had at least two functions in each of these four domains.




When it comes to dating, honesty is such a lonely word

Posted by danieladougan on December 9, 2012 at 1:40 PM Comments comments (0)

Think of this song as a promise you can do what you want,

If you decide you wanna move into a new stage,

Deleting me from pages in your mission statement,

My love is unconditional, make no mistake,

I don't ask for much, just be honest, with me.

Jason Mraz, "Be Honest"

So after a four-year courtship, a six-year marriage and a three-year relationship, I am out on the dating scene -- really for the first time ever. (I don't think high school counts.)

Of course there are opportunistic people out there -- men who lie so women will have sex with them; women who use sex to get something else they want -- but, for the most  part, I think people want to treat others with at least respect. No man wants to be thought of as an asshole, and no woman wants to be considered a bitch.

So what unfortunately happens is that people behave insincerely to spare the feelings of less desirable candidates who approach them. It's hard to do what Jennifer Garner did in The Invention of Lying when she answered the door and told Ricky Gervais that she was "equally depressed and pessimistic about [their] date tonight."

Most of us were taught by our parents that, if we couldn't say anything nice, not to say anything at all. So sometimes we tell little white lies just to be nice. And sometimes it means we really don't say anything at all.

While it certainly makes us feel less guilty when we say something nice (but meaningless) or when we say nothing, perhaps this may be the cruelest approach of all. Allow me to demonstrate with the dialogue at the end of a date.

Man: I had a nice time with you. Would you like to do this again Saturday night?

Woman (lying): I had a nice time too. 

Woman thinks: But you have a heinous breath problem. And you're cheap.

Man thinks: Maybe I should swoop in for a kiss.

Woman: Oh, I'm sorry. I have a cold, and I don't want to pass on any germs.

Man: Oh, I see. Well, good night. See you soon.

Woman (lying by omitting when she will see him again): Good night. 

Woman thinks: See you never.

The man walks away from the exchange thinking that the woman is just not feeling well but wants to see him again (at some indeterminate time). He wonders why he does not hear from her. And then he wonders why other women don't respond to him either.

If the woman had the courage to be honest with him instead of trying to spare his feelings, he wouldn't waste his time waiting for her to make a call she will never make and he might become aware of what is holding him back with women in general: his breath and his flintiness. If a woman asks how her really bad hairstyle looks, should you compliment her (thus encouraging her to keep getting the same bad hairstyle)? Was withholding the difficult truth really more humane?

Of course, there is a difference between things a person can control/improve and things they cannot. There's certainly no point in telling someone that you are not interested because he or she has been gruesomely disfigured. What is that person going to do about that problem?

So, all of you ladies out there, in order for me to become a more complete, appealing person -- please do me this one favor. I don't ask for much, just be honest with me.

Marketplace bullies strangleholding innovation

Posted by danieladougan on November 16, 2012 at 9:45 AM Comments comments (0)

Progress is almost always a good thing for humanity. But there are always winners and losers. The automobile not only made travel much faster and more efficient, but it improved public health by reducing the need for horses to get from point A to point B. (Horses are beautiful animals and usually enjoy being ridden, but their leavings presented real disease problems in large cities when everybody needed one.) Unfortunately, for blacksmiths, the demand for horseshoes dropped significantly as more and more people bought cars. Such is the price of progress, but I think most people will agree it was worth it.

Fast forward to 2012, and we are faced with innovation happening at breakneck speeds. If you purchased a then-revolutionary iPad in 2010, you are now three versions behind. All in all, this rapid innovation brings us better and better consumer products. Couple that with changes in how content is delivered, and you can find most things to watch on demand, from pretty much any device for a low subscription price. (And, of course, there are plenty of people who use the Internet to download content illegally, but that is a different conversation.)

Unfortunately there is one industry that does not like this at all: the cable/satellite providers. For decades they have had a cash cow in requiring people to pay hefty fees for a lot of channels that they don't watch. Some monthly cable bills are higher than an annual subscription to Amazon Prime.

So why doesn't everybody just cut the cord on cable and satellite? The barrier that comes up for most people is the ESPN family of networks and, to some extent, the NFL Network.

I get it. People want to watch live sports. So do I. But what I dislike is the business model. Rather than giving consumers what they want, which is a direct subscription to the content provider, ESPN is choosing to milk the cash cow by only allowing cable and satellite subscribers access to content. They have even built the online architecture to enable live streaming, so they know it can be done.

I get that ESPN pays handsomely for its exclusive rights to televise big-time sporting events, and they need to earn good returns on that investment in intellectual property. But they are not serving their true customers -- the viewers -- well by refusing to offer other subscription models because they would rather deal with the cable and satellite companies who know how crucial ESPN is to their very survival.

Why can't Amazon Prime or Netflix try to negotiate a deal with ESPN? Why can't ESPN sell online live streaming plans directly to consumers who want the access?

If ESPN decides to wield some monopoly power and gouge customers, it should present an opportunity for a new competitor to emerge who can bid for some of these broadcast contracts and create a pricing model that is more efficient for everyone.

But ESPN (actually its parent company Disney) will fight it tooth and nail, flexing its muscles to preserve its stranglehold on the market for sports broadcasting. Consumers will lose, and there may be justification for antitrust action just like what happened with Microsoft bundling Internet Explorer with Windows to drive out Netscape in the 1990s.

New contenders emerged in the browser wars, and now we have real choices like Google Chrome and Mozilla Firefox. Hopefully new contenders will emerge that allow us to cut the cable cord forever. Anybody want to watch Monday Night Football on Hulu?

Would you like some eternal salvation with that?

Posted by danieladougan on August 26, 2012 at 5:25 PM Comments comments (0)

This morning I was walking on the trail at a local park. I had my cell phone with me and my earphones in, absorbed in my music and the natural scene. During my walk, a runner came toward me on the opposite side of the trail. He said, "Here you go," handed me a business card and kept running.


At least it looked like a business card. It was actually a gospel message about "the most important day of your life." It apparently wasn't my graduation day, my wedding day (which, admittedly was not my finest hour) or the day my children (who do not exist) were born. But instead it will be Judgment Day.


Of course, this sort of message is old hat to me as a former evangelical Christian. I am used to getting gospel tracts, knocks on the door, etc. But what struck me about this particular man was that he just handed me the card, said, "Here you go," and left.


What if I wanted to talk to him about what was written on the card? What if I were hurting and needed help -- or even prayer? What if I had deep philosophical questions about faith?


Nope. The only contact information was a website: www.redeemedscoundrels.com, and that tells me that I am, like everyone else, a bad person who deserves to be killed in a tsunami. I wish I were making this up, but you can see for yourself.


Apparently this fellow got it into his head that Jesus wanted him to spread the good news not by healing the sick, feeding the poor or even having real conversations with people but instead by doing guerilla marketing as if he were trying to create a buzz for a new smart phone model at a tech convention or hand out coupons for the latest sandwich at McDonald's.


Of course, if you've read any of my other blog entries, you will know that I am incredulous toward all religions, but this kind capitalist Christianity -- uniquely American, I might add -- is particularly offensive to me. It insults the intelligence of the audience, and it reinforces the idea that these people care more about increasing their numbers than actually meeting people's needs. It's as if Jesus hired an advertising agency. 


When asking, "What would Jesus do?" I hope the answer is not, "run by a stranger and hand them a gospel message printed on a business card."

Perverse incentives and unintended consequences everywhere

Posted by danieladougan on June 30, 2012 at 4:20 PM Comments comments (0)

I'm a big fan of the books Freakonomics and SuperFreakonomics, co-authored by economist Steven Levitt and journalist Stephen Dubner. I especially like them in audiobook form because the reader, Dubner, throws his voice into a high shrill to demarcate when he is quoting someone else. But I digress.


The books consist of a series of anecdotes that are shocking, bizarre and occasionally inspiring. In the prologue to SuperFreakonomics, the authors tie all of the stories together with this theme. "People respond to incentives, although not necessarily in ways that are predictable or manifest. Therefore, one of the most powerful laws in the universe is the law of unintended consequences."


I firmly believe that government has an important role to play in making society more just, equitable and civil than it would otherwise be. Whether it's a police force protecting citizens from the threat of crime or Social Security protecting the elderly and disabled from the threat of poverty, the government is in a unique position to solve certain problems that might otherwise go unsolved.


Yet both of these books include story after story of well-intentioned government policies that went terribly awry because their authors did not predict how they would play out in the real world. In a scathing indictment of government intervention, the authors point out that Franklin Roosevelt -- the progressive hero who brought us Social Security -- chose to donate his personal funds to the private sector research on curing polio while he was sitting in the Oval Office instead of relying on Uncle Sam. Roosevelt suffered from polio himself, so his contributions to the organization that ultimately became the March of Dimes were the ultimate example of his personal health incentives outweighing his incentives for political gain. Even though he did not live to see it happen, Roosevelt bet on the right horse because it was a private sector team led by Jonas Salk that ultimately invented the polio vaccine.


If you've spent any time with me at all in recent years (or if you have read some of my other blog entries), you will know that I am particularly passionate about health care reform. Indeed I was quite pleased when the Supreme Court decided to uphold the Patient Protection and Affordable Care Act, albeit by the narrowest of margins. I see this as an issue of justice since more than 50 million Americans have no health insurance, and millions more are underinsured.


Yet I am a person who tries to listen to the ideas of those who do not share my views. And I have heard a lot of objections to the law. The strongest one that I have heard, though, was the law of unintended consequences. Levitt and Dubner made the best case for this when sharing stories of other government policies gone wrong in decades past. For example, the authors demonstrated how the Americans with Disabilities Act actually discouraged employers from hiring disabled people because they feared lawsuits if they were to ever discipline or fire a bad employee who happened to be disabled.


So, if government is not the answer, what is one to do when faced with a difficult societal problem -- especially one as complex and emotional as health care? Simply accept the problem as inevitable?


PPACA is undoubtedly fraught with problems. One unintended consequence of the law has already cropped up: some insurers have responded to the law's prohibition against denying coverage to children for pre-existing conditions by not offering child-only policies at all. (This is a temporary problem since the law prohibits this practice for all ages starting in 2014 -- insurers surely cannot stop selling policies altogether.)


But why would insurers make this tradeoff, even in the short term? Why would they stop selling policies to the parents of healthy kids just because they will have to cover sick kids too? Because health care itself is expensive, and the sick children who can now qualify for insurance are really expensive to cover.


This turn of events should not have come as any surprise to smart policymakers because when there is a lot of money on the line, rational humans invariably will game any system. This goes for insurers, hospitals, doctors, pharmaceutical companies, medical device manufacturers and patients. There is no way to make everybody happy. Any meaningful reform will have big winners and big losers.


Many smart patients will likely choose to pay the individual mandate penalty and go without health insurance until they get sick because the penalty is less than the cost of insurance and the insurance companies will be required to accept them regardless of health status. The higher premiums these gamers will create for everyone else will become what economists call a negative externality -- a consequence of one person's actions that is borne by another person. At least the penalty provides some counterweight to that natural inclination.


So why doesn't the law go harder after making health care itself cheaper so insurers won't have such a strong incentive to deny coverage to sick children? Sure, there are some provisions in the law like comparative effectiveness research, accountable care organizations, and health information technology investments, but I suspect the real reason for the kid-gloves approach to costs in the system is because politicians respond to incentives too.


When President Obama and congressional Democrats started working on this law in 2009, they knew that they would face a tough political fight. It was made tougher by Republicans who decided it was in their best political interests to oppose the law unanimously, no matter what provisions it contained. Plus, as politicians who run for re-election, everyone owed a sort of legislative debt to whoever contributed to their campaign funds if they hoped to continue raising said funds.


Since we have already established that health care is expensive, any attempt to reduce costs is invariably going to lead to some belt tightening. And, as humans who respond to incentives, everybody wants somebody else to do the most belt tightening. Are health insurance companies earning too much profit? Are pharmaceutical and medical device companies to blame? What about those high-paid doctors and huge hospital bills? Naturally, with that much money at stake, the biggest players were willing to sink millions of dollars into lobbyists and advertising campaigns to protect their interests.


So, President Obama struck deals -- some might say dirty, backroom deals -- with PhRMA, the American Medical Association and the American Hospital Association by shielding them from deep cost cutting provisions in exchange for their political allegiance. The Republicans were no better -- they partnered with America's Health Insurance Plans, the U.S. Chamber of Commerce and the Medical Device Manufacturers Association to campaign against the law since these players had so much to lose and the Republicans. Rather than making deals across the aisle, both sides drew lines in the sand and built up their arsenals for an ugly, televised fight that included phrases like "death panels" and "pull the plug on Grandma." No matter what your ideology, the second half of 2009 was a low point in American politics.


This is another important concern -- is it possible for anyone on either side of the aisle to do honest policymaking anymore? Won't even the most well-intentioned bill authored by the most honest legislator ultimately be corrupted by the time it reaches the President by lobbyists who have become so endemic to the political process?  


Perhaps the federal government has a role to play after all, but it is not the role that anybody on the left or right expects. It is neither a role of command and control and micromanagement nor a role of laissez faire, but a role of creating the right incentives for people to do the right thing.


Maybe we should offer big incentives for health insurance companies to cover people with pre-existing conditions instead of penalizing them for denying it. Maybe the pharmaceutical industry should be required to prove the cost-effectiveness of their drugs before the FDA along with safety and efficacy data. Maybe the government can issue huge award checks for the best ideas to solve the health care cost problem.


Maybe the federal government can dispense money to each state government (proportionate to their populations), give a few simple constraints on the results they must achieve (like covering 95 percent of their residents and not denying people for pre-existing conditions) and then create 50 laboratories for health reform plus regular workshops so that state lawmakers can learn from each other's successes and failures. If one state can achieve the results at a lower cost than what has been allocated, they get to refund taxpayers the difference. And if you don't like what your state is doing, you can easily move to another state.


I don't have all the answers. Whatever the government does -- or doesn't do -- there will certainly be some unintended consequences.






Anger is a helpless feeling

Posted by danieladougan on June 25, 2012 at 12:55 AM Comments comments (1)

"Get rid of all bitterness, rage and anger, brawling and slander, along with every form of malice." -- Ephesians 4:31, NIV

When writing a blog entry about anger, I deliberately sought out a quote from the Bible, a book (or, rather, a collection of books) that normally triggers angry feelings in me. The goal was to try to find something positive in there despite my instincts to the contrary. Amid all of the verses about God unleashing his anger -- and there were many of them -- it was nice to find some good advice about human anger. I suppose the Bible is not all bad.

You see, I've been feeling tremendous amounts of anger lately directed at a variety of sources.

When I found out that a jury convicted Jerry Sandusky on 45 counts of child sex abuse, I reacted the way most people probably did: seething at a man who used his influence to take advantage of so many trusting children, including his own adopted son. When I found out that a jury convicted financier Tim Durham and his business associates on fraud charges, I had similar feelings: perhaps gleefully imagining the horrible things that are sure to befall all of these men in prison. They surely deserve it, right?

But this feeling accomplishes nothing. Revenge does not in any way compensate a victim or undo the damage that these men did. Instead, it perpetuates the tragedy and causes more pain. It might feel satisfying for a moment, but once the moment passes, you are still left with the memory of terrible tragedies for which there is no possible resolution or restitution.

What about political or ideological anger that motivates us to fight for a particular cause? Surely that is more productive, right?

It is certainly a step up from revenge on the grand scheme of things, but that is somewhat like ascending into a higher circle of hell from a lower circle. You are still (metaphorically) on fire. And you're probably so distracted by your emotions that your effectiveness wains. Nothing changes, you get angrier, and the downward spiral continues.

I've been taught before that "anger is a secondary emotion." The lesson, of course, is that in order to address it in a healthy way, we must identify what emotion is behind the angry cloak.

For me, I believe the true emotion is helplessness. There is absolutely nothing I can do to help the children who were assaulted by Jerry Sandusky. There is nothing I can do to compensate the people who lost their savings as a result of Tim Durham and his associates. That much is obvious, and that is what makes me really foam at the mouth.

What was less obvious is that there is also very little I can do affect the way the larger world works. If the Supreme Court strikes down the health care reform law and returns the United States to the status quo, I will be deeply disappointed and, yes, angry, but I have to realize that these are decisions being made by people whom I have never met and likely do not care what I think anyway. I can vote, I can make small campaign contributions and I can share my views with others, but I ultimately cannot control the outcome in any meaningful way by myself. It is what it is.

I have found some solace in the Tao Te Ching when I experience these emotions. Maybe I should practice it a little more so that I can be more centered.

Therefore the Master

acts without doing anything

and teaches without saying anything.

Things arise and she lets them come;

things disappear and she lets them go.

She has but doesn't possess,

acts but doesn't expect.

When her work is done, she forgets it.

That is why it lasts forever.

Progressive relationship norms and human nature collide

Posted by danieladougan on February 6, 2012 at 8:25 PM Comments comments (0)
Thanks that was fun
Don't forget, no regrets
Except maybe one
Made a deal not to feel
God, that was dumb

-- Barenaked Ladies, "Thanks That Was Fun"

2012 bears almost no resemblance to 1912. We have technologies now that our forefathers never even dreamed of. Thanks in large part to the advent of contraception, we also have what seems like a million new options for how to define our sexual relationships. Traditional marriages. Same-sex marriages (where legal). Civil unions. Commonlaw marriages. Open marriages. Domestic partners. One-night stands. Friends with benefits.

I'm a pretty progressive guy, and I have no moral objection to any of these options. I certainly don't like it when religious (or, worse, governmental) authorities try to dictate sexual behavior. Do what you want to do. Knock yourself out. 

The problem with some of these options, however, is the murkiness. Call it hubris if you like, but I've watched so many people who thought they could defy the odds end up in a world of emotional pain when things don't work out according to a neat little plan. Friends who attempt to add in "benefits" often shatter their friendships. 

The fact is that people are not robots, and we invariably become emotionally  invested in our sexual partners to some degree. Sex is an intensely intimate thing, and it can get really messy really fast. No set of rules and no sophisticated contract can cover up our human need to have and to hold.

This is not to say that you cannot possibly sustain a string of meaningless sexual dalliances, but A) that can leave you feeling empty and B) you can't assume that the other participants feel as detached from you as you do from them. (I also happen to think those who pretend that their sexual encounters are meaningless are just kidding themselves.) And today's absolution from obligation can quickly become tomorrow's jilted lover or even a stalker. 

I believe the sexual revolution has been a positive thing overall, but it does come at a cost. In addition to the precautions we take to protect ourselves from diseases and unintended pregnancies, I believe we must also be more sensitive to one another's emotional needs. 

I have a tendency to talk about a lot of issues in the abstract sense, but there is a huge chasm between my "in theory" philosophy about sex and my actual behavior / desires. I don't fault someone for pursuing the kind of sex life that he or she wants, but for some reason -- probably a combination of my traditional upbringing and my  emotional makeup -- what I actually want for myself is a far more traditional bond than my 2012 beliefs would dictate. I suspect being detached would make my life a lot easier, but the reality is that I'm still looking for a specific her to wake up next to.

Addendum: I started to write this post back in February but couldn't quite complete the thought. Some recent discussions I have had plus my new foray into the dating world bring this issue back to the forefront of my mind.