One Citizen Speaking

Donald Trump and his magic pen…

Trump Administration Preparing Executive Order on Health-Cost Disclosure

President Trump is expected to release an executive order as early as next week to mandate the disclosure of prices in the health-care industry, according to people familiar with the discussion.

[OCS: this is where I ask, So What? So consumers and others can see a price list, now what?]

The order could direct federal agencies to pursue actions to force a host of players in the industry to divulge cost data, the people said. The administration is also looking at using agencies such as the Justice Department to tackle regional monopolies of hospitals and health-insurance plans over concerns they are driving up the cost of care, according to two people familiar with the discussions.

The White House declined to comment on its plans. Industry groups said the initiatives under consideration are an executive overreach and legal challenges are possible.

<Source: Wall Street Journal>

Nothing angers me more than politicians and “experts” saying “all you have to do is …” followed by some government-imposed administrative rule …

It appears that the Department of Health and Human Services will receive an executive order to issue a proposed rule regarding price-transparency, ostensibly to make purchasing medical care more like the rest of the economy, and less like today’s secretive and frustrating morass.

Saying it is not the same as doing it…

The four areas of emphasis are the following: giving consumers greater control over health information through interoperable and accessible health information technology; encouraging transparency from providers and payers; using experimental models in Medicare and Medicaid to drive value and quality throughout the entire system, and removing government burdens that impede this value-based transformation.

[OCS: Electronic Health Records has been a costly boondoggle and has yet to provide any semblance of value to consumers. In most cases, patient portals are little more than email messaging systems that allow access to limited information. In many cases, these systems have been a burden on physicians – many of whom are now followed by a “scribe” to capture impressions, prescriptions, and procedural information.

Encouraging, but not mandating, price transparency is a bureaucratic joke.]

The key theme uniting these four priorities is the recognition that value is not accurately determined by arbitrary authorities or central planners. It is best determined by a marketplace of many players — in the case of healthcare, patients and, where necessary, their third-party payers. Each piece of our plan for value-based transformation recognizes this, and it’s the main reason I am optimistic that we may have more success, and sooner, than past efforts.

[OCS: The statement “value is not accurately determined by arbitrary authorities or central planners” appears to be oxymoronic since the legislation and administrative rules and regulations are crafted behind closed doors in Washington, D.C. Has anyone noticed that the major third-party payers still cling to regional monopolies and do not compete across state lines? ]

In recent years, we’ve seen substantial advances in terms of adoption of electronic health records by providers, but all too often, this simply meant putting in electric form what had been on paper, at great expense and burden to the provider. Useful, but hardly realizing the promise of health IT. And this shift almost entirely left the patient out of the picture. It’s not just that the benefits of health IT aren’t always apparent to patients—it’s that unless we put this technology in the hands of patients themselves, the real benefits will never arrive.

[OCS: I am an IT expert and my electronic health records may prompt questions on abnormal test results, but otherwise they contain no actionable information. Many times I am frustrated that information captured over multiple visits to multiple doctors conflicts with the information displayed and there is no reasonable or rational means for correcting mistakes.]

Empowering consumers and individuals has been key to the advances of the information age. Think about how we now often make restaurant reservations, through apps like Open Table. From the restaurant’s perspective, there was nothing wrong with a ledger of reservations or, maybe, a business-focused program for tracking tables. But as a consumer, you had to call from restaurant to restaurant to understand when and where there were tables available. Now, if I pull out my smartphone to make a reservation for dinner on a Saturday night, I have all that information at my fingertips. I’m not depending on the person who answers the phone to get it right. I’m the one in control of the whole process: I can see the available choices, I make an informed decision, and I’ve got the record in my hands.

[OCS: I am willing to bet that restaurants honor their reservations far better than physicians and facilities honor their appointment times. In a number of cases, the automated systems will show multi-month waits for available appointments and make no allowances for urgent matters. I have yet to see a flag for an urgent appointment on any of the larger portal systems.]

We already have the technological means to offer this power to patients, but it hasn’t yet happened. The key to this administration’s approach will not be micromanaging the standards and processes used.

[OCS: Available technology does not always drive consumer acceptance. It is driven by need, convenience, and availability.]

<Source> Remarks on Value-Based Transformation to the Federation of American Hospitals by the Secretary of Health and Human Services, Alex M. Azar II, to the Federation of American Hospitals, March 5, 2018, Washington, D.C.

A little extra … Azar is a politician (former Deputy Secretary of Health and Human Services), lawyer (Yale Law School), pharmaceutical lobbyist (Biotechnology Innovation Organization), and former drug company executive (Eli Lilly and Company).

An informed decision, my ass.

In response to Trump’s proposed action, I saw one of those nonsensical headlines in the conservative National Review, “Liberate Americans to Shop for Medical Care.”

Most Americans struggle with the decision about what vehicle to purchase and how much they are willing to pay. They are guided through this transaction by sales people who quickly realize that they need to kill to eat – or be terminated. They practice deception, role-playing, and meeting objections. They hand you a standard price list containing the Manufacturer’s Suggested Retail Price (MSRP) and a copy of what they purport to be an actual invoice for the vehicle in question. It is up to you to negotiate an acceptable initial offer – over which the haggling begins. Of course, they never tell you about the spiffs (bonuses) they receive for pushing a particular vehicle, not about the “dealer-holdback” which is paid to the dealer by the manufacturer, nor about the financing incentives, or the true cost of accessories – many added on by the local dealer to up-price the vehicle, nor any of the tricks involving your “trade in.”

At least with a vehicle, there is a common understanding of function, utility, and the result may not be life-threatening unless they lack the skill to drive the vehicle you purchase.

The truth about medicine: is it is a matter of trusting your physician and the facilities and services within your local environment. With few exceptions, you will seek the care, and use the specialists, recommended by your physician.

Not everybody is as fortunate as I am to be located in an area where world-class hospitals (UCLA, USC, CEDARS-SINAI, ST. JOHNS, PROVIDENT) and renown medical specialists abound. And not everybody can project their medical requirements in advance to ensure that they actually can afford the care they may desperately need.

One need only look at the pricing shenanigans involving pharmacy benefit managers, durable medical equipment providers, and hospitals who use “allocated overhead” to grossly inflate the price for their services. You cannot compete against these people. Hell, even Medicare cannot compete against these people considering the amount of waste, fraud, and abuse that is rampant in the medical environment. And, in many cases, it is not only the patients, but the physicians, who are being systemically screwed as they are given patient volume quotas, hospital admissions quotas, and the necessity to “sell” particular goods and services or risk their own compensation.

Knowing the price of something and attempting to use that information are two different things.

Another joke from HHS, “The public plays an important role in the rulemaking process by commenting on proposed rules. Your comments can help shape the Department’s decisions.” Read the submissions and you will find that most of the formal comments come from special interest groups, many with lobbying clout, or activists with media access. Most rules are written in a language that resembles English in that you can read and understand the meaning of the words – but, use dense legalese or reference other rules and regulations down to the sub-sub-sub-paragraph and sentence level, often changing a single word. A million-dollar change from “shall” to “may” would be clearly understandable to the policy wonks and special interests but be totally opaque to the average individual.

Bottom line …

All it takes is a ruling from a partisan activist judge to bollix up the works. Especially if the proposals come from the Trump Administration and appear to conflict with Obama’s signature medical monstrosity.

We are so screwed.

-- steve

"The object in life is not to be on the side of the majority, but to escape finding oneself in the ranks of the insane." -- Marcus Aurelius

“A people that elect corrupt politicians, imposters, thieves, and traitors are not victims... but accomplices” -- George Orwell

Before House Speaker Nancy Pelosi shoots off her mouth suggesting that the President of the United States threw an unjustified temper tantrum at a meeting of Congressional leaders conferring on infrastructure spending…

“Another temper tantrum, again, I pray for the president of the United States. I wish that his family, the administration, and his staff would have an intervention for the good of the country."

One might consider that Pelosi, just prior to the meeting, told the media …

“The president’s behavior in terms of obstruction of justice, the things that he is doing, it’s very clear. It’s in plain sight. It cannot be denied. Ignoring subpoenas, obstruction of justice, yes, these can be impeachable offenses.”

And the President was completely justified in not negotiating with the same Congressional leaders who tried to spy on his campaign, bring criminal charges against him personally, continued to mount a historic cover-up of a silent coup d'état, and vilified him daily in the media…

“I walked into the room and I told Senator Schumer and Speaker Pelosi: ‘I want to do infrastructure. I want to do it more than you want to do it. I’d be really good at that, that’s what I do. But you know what? You can’t do it under these circumstances. So get these phony investigations over with.”

Two-plus years of his President’s programs delayed by the progressive socialist democrats who are trying to impeach him based on a phony document concocted by the Hillary Clinton campaign and the Democrat National Committee – with the full knowledge and cooperation of the White House. So what incentive does President Trump have to assist progressive socialist democrats in delivering additional pork to their districts and special interest friends like the anti-Trump unions?

Something stinks…

"[Attorney General] Barr stated: The thing that’s interesting about this is that this was handled at a very senior level of these departments. It wasn’t handled in the ordinary way that investigations or counterintelligence activities are conducted. It was sort of an ad hoc, small group — and most of these people are no longer with the FBI or the CIA or the other agencies involved. I think there’s a misconception out there that we know a lot about what happened. The fact of the matter is, Bob Mueller did not look at the government’s activities."

Special Counsel Robert Mueller was a partisan hack whose activities were not only malfeasant but criminal fraudulent.

Ex-FBI lawyer: Carter Page FISA application approved in 'unusual' way by McCabe, Yates, and Baker

In front of a joint session of the House Judiciary and Oversight committees on Aug. 31, 2018, former FBI Deputy General Counsel Trisha Anderson said she was normally responsible for signing off on Foreign Intelligence Surveillance Act applications before they reached the desk of her superiors for approval. Anderson said the “linear path” those applications typically take was upended in October 2016, with FBI Deputy Director Andrew McCabe and Deputy Attorney General Sally Yates signing off on the application before she did. Because of that unusual high-level involvement, she didn’t see the need to “second guess” the FISA application.

The Page FISA application was filed by the Justice Department and FBI with the Foreign Intelligence Surveillance Court in October 2016. A surveillance warrant was granted and three renewals were subsequently approved. The FISA application relied heavily on unverified research in British ex-spy Christopher Steele's dossier on President Trump's ties to Russia, which was compiled through his employment with opposition research firm Fusion GPS with funding from the Hillary Clinton campaign and the Democratic National Committee through the Perkins Coie law firm.

Anderson said all FISAs need to be signed off on in the FBI’s National Security Law Branch, where she was assigned at the time. Anderson said she was the Senior Executive Service approver for the “initiation” of the Page FISA, including determining whether there is legal sufficiency.

But Anderson stressed “in this particular case, I'm drawing a distinction because my boss and my boss’ boss had already reviewed and approved this application.” She emphasized “this one was handled a little bit differently in that sense, in that it received very high-level review and approvals — informal, oral approvals — before it ever came to me for signature.”

[OCS: Anderson signed the document under penalty of perjury and now she should be held accountable. She failed to perform her sworn duty.]

"Because there were very high-level discussions that occurred about the FISA," Anderson said she believed that meant “the FISA essentially had already been well-vetted all the way up through at least the Deputy Director [McCabe] level on our side and through the DAG [Yates] on the DOJ side.” Yates had already signed the application by the time it made it to Anderson’s desk.

The publicly available Page FISA documents show then-FBI Director James Comey also signed off on it.

Because the FISA application had already been approved at such high levels, Anderson said she did not look at the Page FISA application with much skepticism. “I wouldn't view it as my role to second-guess that substantive approval that had already been given by the Deputy Director [McCabe] and by the Deputy Attorney General [Yates] in this particular instance," she said.

[OCS: Malfeasance, at the minimum, that can be attributed to blind loyalty to her superiors.]

Asked why this FISA application was different, Anderson said she believed “the sensitivity level of this particular FISA resulted in lots of very high-level attention both within the FBI and DOJ.”

“The General Counsel [Jim Baker] … personally reviewed and made edits to the FISA, for example,” Anderson said. “The Deputy Director was involved in reviewing the FISA line by line. The Deputy Attorney General over on the DOJ side of the street was similarly involved, as I understood, reviewing the FISA application line by line.”

Baker recently defended the FBI’s handling of the FISA process, saying “we took [the dossier] seriously” but “we didn’t necessarily take it literally” and did not treat it as “literally true in every respect.” Baker also said, “I am not going to go into details with respect to what investigative steps we actually took to try to validate it.” Former FBI Director James Comey still referred to the dossier as “salacious and unverified” even in 2017.

[OCS: Time to see the entire FISA applications – all four of them, including the three renewals after sufficient time has passed to know that Carter Page was innocent of colluding with the Russians and the Steele material was corrupt.]