13 August 2013
Improving the Functioning of Government - Part 1
To really address some of the more egregious flaws in the manner with which our federal government does things, there are some ways to stop wasting our tax money by adding some simple rules. These recommendations would require political courage that may be lacking in the Congress or in the Executive. What might be possible:
- Require OMB approval of any contract exceeding $50 million that is being sole-sourced or otherwise not subject to a competitive RFP process including a minimum of three proposals; This requirement must include the DOD, DOS, DOI, DHS, DHHS, DOE and most federal agencies such as the FAA, NOAA, NSA, CIA and NASA (with exceptions that Congress oversees with security requirements). OMB should report to Congress at least sem-annually on contracts reviewed and actions taken.
- Require full budget funding allocations for federal inspectors, auditors and other regulatory compliance functions; Enforcement of laws and regulations is pathetic. Congress passes a law to address a public need, yet the first victims of tight budget allocations usually eliminate the function whose job is to see whether the law is being followed.
- Require full funding of our Judicial System and the DOJ; For our system of justice to function as designed, to minimize lengthy trials, arbitrations or torts, we need more judges, more public defenders, more local prosecutors and better information systems to support them.
- Require public member appointments be filled for all Executive and Congressional Commissions before they are chartered. The absence of a public member enables the lobbyist-indebted Congressional or Executive department members to function irrespective of the opinions that a non-political appointee might offer.
Undermining a President-The Republican Party Agenda #1
It seems to me that there is a soto voce smear campaign being wages against the President, not because he is a Democrat, not because he is of the other party, but because of his race. I am listening to an intense series of Republican representatives from Iowa, Florida, expressing such shock and insinuating the President's complicity in alleged irregulatities that all of a sudden became dire national issues within the eight months following Barack Obama's inauguration.
See what the House is dealing with while the Senate is struggling with 554 amendments to to the Senate Bill on health care reform. According to Republicans and news media stars (who talk without breathing) President Obama should be held accountable for the following:
Suddenly, the past eight years of the Bush/Cheney administration never existed. George Bush paid for the Iraq and Afghanistan wars with money the Congress approved as supplemental funds outside of the official government budgets. Who gave Wall Street a trillion dollars to prevent a world-wide economic collapse, but did not have any accountability for how those federal funds should be used?President Obama brought those extra-budgetal items into the formal budget process. There is no mention of the huge budget surplus left to President Bush by President Clinton, especially with the Republicans having controlled Congress throughout the Clinton years and the White House for 12 of the prior two decades.
John Boehner in a CNN interview referred all questions about a Republican health care plan to the party's web site: gop.org. I looked at it and I am embarrassed for Republicans seeking a cogent, coherent health care plan alternative to the Democratic Party's plan moving through Congress. The web site makes me sad while reading comments in their Forums. Comments therein are dominated by some people who believe in a literal Constitution as the only legitimate way to evaluate the federal government's actions since 1787. Most predominant in the health care forum is the argument that the 10th amendment prohibits the federal government from regulating insurance providers. The prohibition derives from their view that the insurance industry is by governed and controlled by State law so therefore the insurance industry is by definition not interstate commerce. The majority of comments refer to most federal government programs as unconstitutional.
In response to one post asking whether we should leave people to die in the streets, another post said that "if you don't have health insurance- get a job." Nothing of substance was evident in any of the Forums I read, except for one written by a marine in Afghanistan. Most of his comments were ignored or dismissed as unrealistic, too much government and not worth doing. George W. Bush did not get much mention except that he was a liberal and undisciplined in his spending.
I could not find anything like the information Republican House leader Boehner asserted was there to read nor was there anything else worth reading. I did find remarkable that they had a list of Republican Accomplishments and a list of Republican Heros. Most of the accomplishments occurred during Reconstruction after the Civil War or prior to World War I. Most predominant were those Republicans who were African-Americans, mostly during Reconstruction in the South, sponsors of anti-KKK legislation, Voting Rights Act and Civil Rights legislation. Weirdly slanted commentaries of these hallmark achievements as due to Republicans and were accompanied by biographical material about an African-American legislator elected during Reconstruction while Grant was President. One would conclude, according to this line of thinking, that the entire Civil Rights Movement following World War II was unnecessary. Who can swallow that?
Their propaganda is pathetic.
Sherfdog
See what the House is dealing with while the Senate is struggling with 554 amendments to to the Senate Bill on health care reform. According to Republicans and news media stars (who talk without breathing) President Obama should be held accountable for the following:
- ACORN irregularities that are alleged to involve importing young girls to be prostitutes, abusing its 501(c) 3 tax status to commit gross election violations such as same-day registrations;
- Irresponsibility with spending that have us with such a huge deficit, with such wasteful spending to bail out the economy that the dollar is in danger of losing its status as the world currency.
- Creating a health care system that will create generate such tax burdens that we will bankrupt the country.
- Anything else that people feel that is bad about our country since January 21, 2009.
The Republicans no longer control all three branches of government. Let's see how these Republicans react to a Supreme Court ruling that goes against their agenda. Will they again decry the decision as judicial activism? Looking at the record of the SCOTUS in 2009 and 2010, a number of decisions have reversed prior decisions, gone beyond the written legislation or seem to show a libertarian activism. Why are only the liberal-tinged decisions proclaimed as examples of judicial activism?
To me, allegations and insinuations of this sort coming from the Luddite Republican congress are indicative of the thinly veiled, social and institutional racism still entrenched in our country. Assumptions of guilt, of slackness of incapability appear in media reporting and especially in video and photographs that accompany news online and in print. Earlier this year, we heard comments about people feeling that they just didn't trust President Obama's judgment. Then, he became responsible for the huge level of the National Debt, for the failures of the banking system, the failure of our public education system and now for the skyrocketing health care costs that are entirely the fault of Medicare.
Suddenly, the past eight years of the Bush/Cheney administration never existed. George Bush paid for the Iraq and Afghanistan wars with money the Congress approved as supplemental funds outside of the official government budgets. Who gave Wall Street a trillion dollars to prevent a world-wide economic collapse, but did not have any accountability for how those federal funds should be used?President Obama brought those extra-budgetal items into the formal budget process. There is no mention of the huge budget surplus left to President Bush by President Clinton, especially with the Republicans having controlled Congress throughout the Clinton years and the White House for 12 of the prior two decades.
John Boehner in a CNN interview referred all questions about a Republican health care plan to the party's web site: gop.org. I looked at it and I am embarrassed for Republicans seeking a cogent, coherent health care plan alternative to the Democratic Party's plan moving through Congress. The web site makes me sad while reading comments in their Forums. Comments therein are dominated by some people who believe in a literal Constitution as the only legitimate way to evaluate the federal government's actions since 1787. Most predominant in the health care forum is the argument that the 10th amendment prohibits the federal government from regulating insurance providers. The prohibition derives from their view that the insurance industry is by governed and controlled by State law so therefore the insurance industry is by definition not interstate commerce. The majority of comments refer to most federal government programs as unconstitutional.
In response to one post asking whether we should leave people to die in the streets, another post said that "if you don't have health insurance- get a job." Nothing of substance was evident in any of the Forums I read, except for one written by a marine in Afghanistan. Most of his comments were ignored or dismissed as unrealistic, too much government and not worth doing. George W. Bush did not get much mention except that he was a liberal and undisciplined in his spending.
I could not find anything like the information Republican House leader Boehner asserted was there to read nor was there anything else worth reading. I did find remarkable that they had a list of Republican Accomplishments and a list of Republican Heros. Most of the accomplishments occurred during Reconstruction after the Civil War or prior to World War I. Most predominant were those Republicans who were African-Americans, mostly during Reconstruction in the South, sponsors of anti-KKK legislation, Voting Rights Act and Civil Rights legislation. Weirdly slanted commentaries of these hallmark achievements as due to Republicans and were accompanied by biographical material about an African-American legislator elected during Reconstruction while Grant was President. One would conclude, according to this line of thinking, that the entire Civil Rights Movement following World War II was unnecessary. Who can swallow that?
Their propaganda is pathetic.
Sherfdog
Patient-centered Care
The new management theme in health care is "Patient-centered Care." In a recent article in the LinkedIn.com group Patient-centered Care, a prominent physician-educator wrote a very supportive article to build up her colleagues who were feeling bashed by their patients. I did not consider her positive article went far enough for explaining why patients might feel antagonistic towards their physicians.
One reason for 'doctor bashing' is the process by which patients get access to a physician, however caring the physician may be. A patient has to establish his or her financial ability to pay for access, so financial stress can produce a negative reaction in the caller or at the registration desk. Second, the patient's financial resources, i.e. insurance coverage, must meet the requirements policed at the check-in window. Third, an empathetic, dedicated physician often cannot limit patient personal access to the time slot established by the practice or HMO, so patients may have to wait over 30 minutes-often more- for a 10-15 minute appointment. Patient waiting areas are not healthy places because no one knows what reasons for appointments the other occupants have. The lack of infectious disease controls in private practices and in most HMO registration, waiting and pharmacy facilities is appalling and unregulated by the UBC (Uniform Building Code) or accrediting agencies. Is it little wonder that the patient may not feel nurtured in the physician's office?
Dr. Rotering's supportive opinion piece most likely describes the best intentions of practicing physicians today. Of that I have no doubt. Patient-centered care, however, is less about the physician's expertise, attitude and empathy than it is about the environment within which the physician must practice. The members of the LinkedIn.com group are mostly health care professionals, not patients. Their perspective tends to focus on what to do for patients rather than to start from the patient's perspective of the patient expectations of them.
Patient-centered care is about nursing, about office staff and about financing of health care more than it is about the physician per se. Such a care model must include an awareness of the patient's time constraints, too. Working, single parents with an ill infant or child, a worker seeking access for a non-work related illness or injury, patients seeking psychological and other behavior/mood professionals and any patient without a working knowledge of English or with any cognitive impairment (such as with age) have not been the starting points for designing a patient-oriented care practice today.
The physician is the last person to encounter such patients and I believe that is a 180-degrees wrong design for health care. Imagine how differently our system might be if patients met first with the physician. The physician's ability to diagnose and to establish treatment modalities would determine the steps taken by the clinic or office staff on behalf of the patient as prescribed by the physician. Perhaps certain tests would be needed or medications prescribed for follow-up with the patient. If so, the tests might be chosen more specifically to the patient's state of health and initial medications might address symptoms while an underlying illness is being diagnosed. As I see it, the only reason physicians require testing results before seeing a patient is so that the physician can see more patients per shift. That is not patient-centered care. That is practice-centered care.
Physicians are bashed these days because the public sees the profession as having become greedy (remember, these are perceptions not reality); in charge of the entire health care system-other than the insurers-and, therefore, as able to make any changes physicians want in the delivery of health care. Yes, bashing for these reasons is not only unfair to individual physicians, it is also unfair to other patients' perceptions of their health care options. Patients requiring particularly expensive interventions often find themselves waiting for an insurance review of their physician's request for covering the procedure and patients may find themselves calling their insurer to speed up the approval process.
Certainly, insurers want to minimize patient care costs and insurers occasionally may prevent an unnecessary procedure. The role of private health care insurance providers, however, is to support the patient's ability to pay for services, not to function as a professional practice review board. Further, private insurers establish their reimbursement rules according to those promulgated by the public insurers. Public insurers like Medicare and Medicaid, though, seem to limit a physician's professional discretion through enforcement of the DCM-10 coding mechanism of reimbursement for services rendered. I think this effort to control health care costs by the Centers for Medicare and Medicaid Services (CMS) inhibits innovation in diagnosis and treatments and, rather, encourage physicians to find the best ways to help their patients get well and remain well.
And, part of this issue lies with each and every physician who tolerates sub-standard professional care by other physicians, who will not police their own ranks of bad actors, who subsume their medical ethics below financial support from third parties like pharmaceutical suppliers, and who refuse to criticize the judgment or actions of other physicians in formal arbitration and courts. If local and state medical boards were more pro-active in correcting unprofessional or inadequate performance by those they have licensed and granted membership to their medical societies, then I believe the public image of physicians would improve by a great amount. Physicians also need to know how their staff treat the patients.
The final part of patient-based health care models is the heretofore unrecognized fact that in health care, the primary stakeholder is the patient. Using a football analogy, the patient hires the team, the primary physician can be the general manager, head coach or quarterback. Consulting physicians or temporarily-designated attending physicians are the coaches. Nurses are the teams, often the special teams needed to make the quarterback successful and to make up for an embattled quarterback. I hope this concept is clearer using the analogy. The patient is the owner is patient centered care. QED
One reason for 'doctor bashing' is the process by which patients get access to a physician, however caring the physician may be. A patient has to establish his or her financial ability to pay for access, so financial stress can produce a negative reaction in the caller or at the registration desk. Second, the patient's financial resources, i.e. insurance coverage, must meet the requirements policed at the check-in window. Third, an empathetic, dedicated physician often cannot limit patient personal access to the time slot established by the practice or HMO, so patients may have to wait over 30 minutes-often more- for a 10-15 minute appointment. Patient waiting areas are not healthy places because no one knows what reasons for appointments the other occupants have. The lack of infectious disease controls in private practices and in most HMO registration, waiting and pharmacy facilities is appalling and unregulated by the UBC (Uniform Building Code) or accrediting agencies. Is it little wonder that the patient may not feel nurtured in the physician's office?
Dr. Rotering's supportive opinion piece most likely describes the best intentions of practicing physicians today. Of that I have no doubt. Patient-centered care, however, is less about the physician's expertise, attitude and empathy than it is about the environment within which the physician must practice. The members of the LinkedIn.com group are mostly health care professionals, not patients. Their perspective tends to focus on what to do for patients rather than to start from the patient's perspective of the patient expectations of them.
Patient-centered care is about nursing, about office staff and about financing of health care more than it is about the physician per se. Such a care model must include an awareness of the patient's time constraints, too. Working, single parents with an ill infant or child, a worker seeking access for a non-work related illness or injury, patients seeking psychological and other behavior/mood professionals and any patient without a working knowledge of English or with any cognitive impairment (such as with age) have not been the starting points for designing a patient-oriented care practice today.
The physician is the last person to encounter such patients and I believe that is a 180-degrees wrong design for health care. Imagine how differently our system might be if patients met first with the physician. The physician's ability to diagnose and to establish treatment modalities would determine the steps taken by the clinic or office staff on behalf of the patient as prescribed by the physician. Perhaps certain tests would be needed or medications prescribed for follow-up with the patient. If so, the tests might be chosen more specifically to the patient's state of health and initial medications might address symptoms while an underlying illness is being diagnosed. As I see it, the only reason physicians require testing results before seeing a patient is so that the physician can see more patients per shift. That is not patient-centered care. That is practice-centered care.
Physicians are bashed these days because the public sees the profession as having become greedy (remember, these are perceptions not reality); in charge of the entire health care system-other than the insurers-and, therefore, as able to make any changes physicians want in the delivery of health care. Yes, bashing for these reasons is not only unfair to individual physicians, it is also unfair to other patients' perceptions of their health care options. Patients requiring particularly expensive interventions often find themselves waiting for an insurance review of their physician's request for covering the procedure and patients may find themselves calling their insurer to speed up the approval process.
Certainly, insurers want to minimize patient care costs and insurers occasionally may prevent an unnecessary procedure. The role of private health care insurance providers, however, is to support the patient's ability to pay for services, not to function as a professional practice review board. Further, private insurers establish their reimbursement rules according to those promulgated by the public insurers. Public insurers like Medicare and Medicaid, though, seem to limit a physician's professional discretion through enforcement of the DCM-10 coding mechanism of reimbursement for services rendered. I think this effort to control health care costs by the Centers for Medicare and Medicaid Services (CMS) inhibits innovation in diagnosis and treatments and, rather, encourage physicians to find the best ways to help their patients get well and remain well.
And, part of this issue lies with each and every physician who tolerates sub-standard professional care by other physicians, who will not police their own ranks of bad actors, who subsume their medical ethics below financial support from third parties like pharmaceutical suppliers, and who refuse to criticize the judgment or actions of other physicians in formal arbitration and courts. If local and state medical boards were more pro-active in correcting unprofessional or inadequate performance by those they have licensed and granted membership to their medical societies, then I believe the public image of physicians would improve by a great amount. Physicians also need to know how their staff treat the patients.
The final part of patient-based health care models is the heretofore unrecognized fact that in health care, the primary stakeholder is the patient. Using a football analogy, the patient hires the team, the primary physician can be the general manager, head coach or quarterback. Consulting physicians or temporarily-designated attending physicians are the coaches. Nurses are the teams, often the special teams needed to make the quarterback successful and to make up for an embattled quarterback. I hope this concept is clearer using the analogy. The patient is the owner is patient centered care. QED
