Miscellaneous, but Distressing, Crud from Recent News

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Posted in Fun

NPR: Sad State of Health Services in USVI

Nearly five months after Hurricanes Irma and Maria, medical services in the USVI are still in horrible shape, with 400 seriously ill patients receiving care in the mainland, and both major hospitals (in St. Thomas and St. Croix) unable to treat a large portion of those with chronic health problems or emergencies. From National Public Radio, Sunday, 4 February 2018.

In The U.S. Virgin Islands, Health Care Remains In A Critical State

Patients seeking cancer treatment in the U.S. Virgin Islands must now go to the mainland. The Charlotte Kimelman Cancer Institute at Schneider Regional Medical Center on St. Thomas remains closed because of extensive damage to areas like the CAT scan suite.
Greg Allen/NPR

Health care in the U.S. Virgin Islands remains in a critical state, five months after Hurricane Irma and Hurricane Maria pummeled the region.

The only hospital on St. Thomas, the Schneider Regional Medical Center, serves some 55,000 residents between the islands of St. Thomas and St. John. Schneider’s facilities suffered major structural damage, forcing a decrease in its range of services, mass transfers of its patients, staff departures and significant losses in revenue. Only about one-third of the beds are currently available for patient care.

In early September, when Irma hit the Virgin Islands, most of Schneider’s staff members were on duty. At the height of the storm, a large window on the hospital’s top floor gave out. “You had winds of 175, 180 miles per hour whipping through here,” says the hospital’s Vice President Darryl Smalls.

The screws holding the window in place failed. The window itself, made from hurricane impact glass, remained intact. It’s here, leaning against a nursing station that’s now in shambles. Ceiling panels are gone, exposed pipes and ducts are damaged and sagging in places. A large plywood barrier covers the window opening.

When the window tore off, Smalls says the staff worked quickly to evacuate some 20 patients to a safer part of the hospital. They couldn’t use the elevator in the middle of the storm, so staff transported patients from the fourth floor to the third floor using the emergency stairwells. “We literally took the patients on the mattresses, slid them down the stairs, down to the third floor, across the building and up onto the other side,” Smalls says. “We have a surgical unit which was not compromised and capable of handling patient care.”

Eventually, all of the patients who were at Schneider during the storm were evacuated off of the island. But even as staff dealt with a host of problems, the hospital remained open. In the emergency room, which flooded badly from a leaky roof, Smalls says, “You probably had about 3 to 4 inches of water on the floor in here. I had pumps. I think we probably had 50 people in here at any given time just trying to evacuate as much water out of the facility.”

Today, the hospital continues to provide surgery, labor and delivery care, radiology and lab services. But its cancer center, a $28 million facility, remains closed because of extensive storm damage. The hospital can now only provide limited services for patients requiring dialysis.

Meanwhile, Schneider Medical’s sister center, the only hospital on St. Croix, the U.S. Virgin Islands’ other major island, suffered even more extensive damage to its operating rooms.

Without adequate medical services available, Schneider Regional CEO Bernard Wheatley says most patients who evacuated St. Thomas have not been able to return. “It’s over 400 that have been transferred off island,” Wheatley says. “And to this day, we’re still transferring some patients, especially the ones requiring extensive length of stay.”

High winds blew out ceiling panels and damaged ducts and pipes at Schneider Regional Medical Center, the only hospital on St. Thomas, when a window on the hospital’s top floor blew out. Greg Allen/NPR

 

Along with the lack of facilities, another major problem is staffing. Wheatley says he’s lost 150 of the hospital’s 600 employees — many of whom left the island after the storms destroyed their homes. “The sad part of it, we’ve lost a lot of nurses,” he says. “If you ask me right now, what’s my key entity in terms of shortages, from a clinical standpoint it would be the nursing staff.”

Shanique Woods-Boschulte, who directs Schneider’s foundation says, “Every day we get one or two resignations.” After five months, Woods-Boschulte says, the daily struggle is wearing down many staff members. “The morale was really high after the storm because we saw what we were able to accomplish — no patients hurt,” she says. “But now things are trickling down and everyone is leaving a broken hospital and going home to a broken home.”

Adding to the woes, the hospital is in desperate financial straits. Revenues are half of what they were because there are far fewer patients. The government-supported hospital is projecting a $7 million loss.

With all the competing problems on the islands, CEO Bernard Wheatley says it’s not clear how much help the local government can provide. “The territory itself is projecting a $400 million loss,” he says. “They don’t have the hotel rooms, tourism is down. It’s just not the same island.”

The U.S. Virgin Islands is now looking to Congress to help decide what to do about its battered hospitals. The local government is in talks with FEMA and the Army Corps of Engineers to determine whether the hospitals can be rehabilitated, or if new facilities will be needed.

Posted in Climate Change, Development, Disaster Management, Health, Small Island

Gerrymandering: The Root of All Evil [NOT]

This deep analysis of gerrymandering, from a joint study by “FiveThirtyEight” and the “Cook Political Report” is from Dan Balz’s The Sunday Take political analysis column in the Washington Post.

Gerrymandering is the root of all political evil. Or is it? 


Protesters demonstrate in front of the Supreme Court while the justices hear arguments on gerrymandering, on Oct. 3, 2017. (Bill O’Leary/The Washington Post)

Chief correspondent January 29 at 2:23 PM
 
The combined talents of the team at Nate Silver’s FiveThirtyEight and the Cook Political Report have performed a valuable service. With a study that is creative in design and rich in data, they have cast doubt on the idea that there is a straightforward solution to the controversy over the partisan gerrymandering of congressional district boundaries.

The gerrymandering issue is front and center in the courts.

The Supreme Court has taken two cases: one challenging a Republican-drawn map in Wisconsin, the other a Democratic-drawn map in Maryland. The justices will rule later this year on the constitutionality of district boundaries that appear to unduly favor the party that drew them.

Meanwhile, the Pennsylvania Supreme Court just ruled the congressional boundaries there violate the state constitution by giving Republicans more districts than the partisan split of the state should allow. The state court ordered the lines be redrawn by early next month. In North Carolina, a federal court tossed out the boundaries there for the same reason. That ruling was stayed by the Supreme Court as the justices deliberate over the cases already before it.

Partisan gerrymandering is often seen as the root of much of what is wrong with current politics, from the lack of competitive districts to the rise of ideological extremes, particularly on the right, and the ensuing gridlock in Washington. Most Americans recoil at the contorted shape of some districts and see malevolent hands at work.

The authors of the Gerrymandering Project at FiveThirtyEight acknowledge the problems. But they are candid — and back it up with multiple demonstrations — that if partisan gerrymandering is eliminated, the question of what comes next is not easy to answer.

“It’s easy for opponents of gerrymandering . . . to argue what districts shouldn’t look like,” writes David Wasserman, who oversees House elections at the Cook Political Report. He adds, “But it’s much more difficult to say what districts should look like, because reformers can disagree on what priorities should govern our political cartography.”

Harry Enten of FiveThirtyEight, another member of the team that spent months on the project, writes that gerrymandering “is a far more complex topic than some analysts and partisans care to acknowledge. . . . There’s no ‘right’ way to draw a district. Prioritize one goal — competitiveness or nonwhite representation, for example — and you have to sacrifice others.”

The team set out to show how different goals produce dramatically different maps. In all they drew 258 different state congressional district maps and a total of 2,568 district maps, using a free, Web-based application. The results are all available for viewing at FiveThirtyEight.com.

They produced maps that heavily favored Democrats, with 263 districts where that party would have a clear advantage. They did another that heavily favored Republicans. In that case, there were 275 districts tilted toward the GOP. In both cases, fewer than 30 districts of the 435 were considered competitive.

But then they showed what the breakdown between the parties would look like if the mapmaking process sought to closely match the distribution of seats to the allegiances of the electorate. In another case, they drew boundaries to produce the maximum number of closely competitive districts; in another, they maximized the number of majority-minority districts. They produced one set of maps with districts that followed county boundaries as much as possible. In one case, they turned the process over to an algorithm designed to produce the most compact districts possible.

Redistricting is inherently a political process, and in most states it remains in the hands of politicians. After the 2010 elections, Republicans held the upper hand in far more state legislatures than the Democrats, which is one reason the GOP has the advantage in the House. But Democrats have not been exactly pure in their approach, either. In states where they controlled the process, they sometimes produced districts that were similarly designed to give themselves an advantage.

 

However, if Democrats were to control more state legislatures and governorships after the 2020 Census, and therefore have a freer hand in many states to draw new boundaries, they would face some obstacles that Republicans have not faced, according to the study.

Democratic voters are far more clustered in and around urban areas than are Republicans, making it easier to pack them into districts. Republicans are more spread out. This geography of politics favors Republicans in the construction of congressional districts.

Another factor is the role of the Voting Rights Act. Democrats can’t maneuver their voters into particular districts so easily because that could reduce the number of majority-minority districts. In the past, Republicans have worked with minority (and Democratic) legislators to create more majority-minority districts, reaping the benefit of making surrounding districts more Republican in their leanings.

When the FiveThirtyEight team sought to make districts as compact as possible — and they note that there are scores of measures of what constitutes compactness — they ended up reducing the number of ­majority-minority districts. When they sought to draw maps proportionate to the breakdown of the electorate, they had to engage in some partisan gerrymandering to get there.

When they sought to produce the maximum number of competitive districts, geography again became a factor. “In an era when Democrats and Republicans are choosing to live next to like-minded neighbors, drawing lots of competitive districts can be tricky,” Wasserman writes. “In fact, in some cases, it requires conscious, pro-competitive gerrymandering.”

That particular effort produced a map with 242 competitive districts: a remarkable number that would put the political parties on the edge of breakdowns and enrich a new class of political operatives. It also could result, for better or worse, in a House whose members were reactive to the mood swings of an electorate influenced by 24/7 cable news and the power of social media. The “competitive” map also ended up with non-compact districts and a reduced number of majority-minority districts.

The lack of competitiveness in House districts has come gradually and steadily and not simply as a result of partisan gerrymandering. The Cook Political Report has calculated that the number of competitive districts declined from 164 after the 1996 election to just 72 after the 2016 election. Cook’s team earlier concluded that less than a fifth of that decline was caused by redistricting.

One factor in reducing the number of competitive House districts is that fewer and fewer counties are balanced politically. Enten cites statistics showing that in the 1996 presidential election, 1,111 counties — about a third of the total nationally — were decided by margins of 10 percentage points or fewer. In 2016, “that number had plummeted to just 310.” That makes it all the more difficult to produce competitive House districts without trampling on the goal of keeping counties and communities as intact as possible.

All of this may be a bit wonky for the average person. But there’s a larger message in all the data. As people judge the current state of politics, there is more at fault than partisan gerrymandering, as distasteful as it might be. As Wasserman puts it: “Gerrymandering is a really easy practice to condemn and a really complex problem to solve. And just as there are not permanent majorities in American politics, there may never be such a thing as a perfect map.”

Correction: An earlier version of this article misstated the number of U.S. House districts. There are 435, not 538.

Posted in Fun, Governance, politics

National Action Plan for Open Government, version 4.0

[Not sure that this news represents a vote of confidence in the Open Government movement or support for it by the US Government . . . At the least, the less-than-24-hours advance notice of the postponement of the meeting evinces a degree of disrespect for the “Open Government community.” . . . For other, sporadic notice of information about the Open Government movement by the US Government and a few civil society organizations and individuals, check the web site at <https://groups.google.com/group/us-open-government>

For non-US organizations and agencies that are affected by elements of the US Open Government programs (I’m thinking, for example, of disaster and international health issues, such as satellite imagery or up-to-date epidemiological reports), contact me at <bpottter@irf.org>, and we’ll see if we can find a channel for introducing your concerns in the formulation of version four of the US National Action Plan. . . . .  bp]

Good morning Open Government community,

 We’re writing with a few updates regarding the National Action Plan for Open Government.

First, due to a combination of factors, we will need to delay tomorrow’s meeting by approximately two months. Please hold Tuesday March 27 at 10:00 am on your calendars.  As stated in the United States’ official delay letter (available: open.usa.gov,opengovpartnership.org), the delayed delivery of the fourth National Action Plan and related materials is allowing USG additional time to ensure that the plan is as substantive and aligned to national priorities as possible. The delay in this month’s meeting reflects that approach. We appreciate everyone’s patience and remain committed to full participation in the partnership.

On an administrative note, we wanted to make sure that everyone saw that, as a result of the delayed delivery of the fourth National Action Plan, the Open Government Partnership has moved the United States from the “odd year” to the “even year” cohort of participating countries. The new deadline for delivery of NAP4 is August 31, 2018You can read OGP’s official letter here.

Thank you,

Alycia on behalf of the Open Gov Team

 

U.S. General Services Administration

Alycia Yozzi
<Alycia.piazza@gsa.gov>
Office of Government-wide Policy

202-219-1487


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Posted in Access, Dissemination, Governance, Information

When “Alternate Truth” Starts to Drive US Government Policy — e.g., today. . .

[There’s a point at which I stop being bemused by the blunders and lies — which cannot be distinguished from each other, because the perpetrators themselves DO NOT KNOW the difference — of the New Regime. This report from the January 16th Washington Post is much too oblique in calling out the embedded fake stats. ]

Trump administration links terrorism and immigration, but an expert doubts the math


In this courtroom drawing, defendant Sayfullo Saipov, right, addresses the court during his arraignment on federal terrorism charges. The Uzbek immigrant is charged in the Oct. 31 truck rampage in New York that left eight people dead. (Elizabeth Williams/AP)

January 16

A new Justice Department report issued Tuesday suggests that, since 9/11, 73 percent of terrorism convictions in the United States have involved individuals who were born in other countries. An expert on terrorism data, however, said that what is most alarming about the document is its math.

The survey was conducted by the Justice Department and the Department of Homeland Security in response to a specific requirement in the Trump administration’s travel-ban order issued in March. It found 549 individuals charged with terrorism. Of them, 254 were not U.S. citizens, 148 were born abroad but later received U.S. citizenship and 147 were U.S. citizens by birth, the report says.

President Trump has called for an end to the practice of letting naturalized U.S. citizens bring their relatives into the United States — critics call this “chain migration” — and for abolishing the “diversity lottery’’ for green cards. In releasing the report, administration officials said the figures underscore a need for tougher immigration standards to keep terrorists out of the United States.

Karen Greenberg, director of Fordham University’s Center on National Security, said the figures instead show there is a need for applying tougher statistical standards to government reports. [I think she means the report is wrong, by almost any standard of interpretation for its errors . . . bp]

“It’s an awfully thin report for an absolutely important topic,” she said. “There’s almost no rhyme or reason to the things they choose to include or not include — they don’t explain it.”

The report considers only those incidents motivated by international terrorist groups — so instances of domestic terrorism are not counted. Moreover, individuals captured overseas, extradited and brought to the United States to face trial are included in the same category as people who emigrated to the United States and were charged with terrorism offenses years later.

For example, Ahmed Abu Khattala, convicted in November in connection with the deadly 2012 attack on a U.S. diplomatic mission in Benghazi, Libya, is counted in the same category as someone who successfully applied for a visa to enter the United States.

“Doing that intentionally confuses the threat of domestic terrorist attack with the number of foreigners, by increasing the number of foreigners,” Greenberg said. Extradited terrorism suspects are not immigrants, she said, and should be taken out of the sample.

Trump’s executive order specifically seeks “information regarding the number of foreign nationals in the United States who have been charged with terrorism-related offenses while in the United States (or) convicted of terrorism-related offenses while in the United States.”

That would appear to exclude those, such as Abu Khattala, who were brought to the United States for the sole purpose of charging them with terrorism crimes committed overseas, but the report issued Tuesday said it includes “those who committed offenses while located abroad, including defendants who were transported to the United States for prosecution.”

A Justice Department spokesman would not say how many such extradition or overseas-capture cases were included in the report. 

Greenberg, whose center at Fordham issues reports analyzing terrorism prosecutions, said there are about 80 such cases.

Greenberg also questioned the time frame examined in the report, saying that looking back to 2001 paints a misleading picture of today’s terrorist threat.

Online indoctrination and recruitment by the Islamic State and other terrorist groups over the past few years has led to an increase in the number of U.S.-born terrorism suspects. About 54 percent of those charged with supporting the Islamic State in recent years were born in the United States, Greenberg said.

Senior Democrats on two House committees accused the Trump administration of misrepresenting terrorist crimes to fit anti-immigration policy goals.

Reps. Jerrold Nadler (D-N.Y.) and Bennie Thompson (D-Miss.) called the report an attempt “to vilify the immigrant community and justify an exclusionary immigration policy,” adding in their statement, “The American people will not be fooled by such naked bigotry, and we should not allow this administration to get away with its abuse of the facts to further its extremist, xenophobic agenda.”

The top Republican on the House Judiciary Committee, Rep. Bob Goodlatte (R-Va.), said in a statement that the report “confirms what we already know: our current immigration system is broken, and it fails to protect the American people.’’ 

Posted in Fun, Governance

Why You Pay Lots for Emergency Care: “Duh, It’s a Monopoly, Dude.”

[This article is from the exemplary on-line magazine Vox, by Sarah Kliff, who is a super interpreter of public policy in the health arena. Follow her regularly, including especially her daily VoxCare column. ]

Emergency rooms are monopolies. Patients pay the price.

New data shows how emergency rooms take advantage of their market share, at the expense of their patients.

Amanda Northrop/Vox
Around 1 am on August 20, Ismael Saifan woke up with a terrible pain in his lower back, likely the result of moving furniture earlier that day.

“It was a very sharp muscle pain,” Saifan, a 39-year-old engineer, remembers. “I couldn’t move or sleep in any position. I was trying laying down, sitting down, nothing worked.”

Saifan went online to figure out where he could see a doctor. The only place open at that hour was Overland Park Regional Medical Center in his hometown of Overland Park, Kansas.

The doctor checked his blood pressure, asked about the pain, and gave him a muscle relaxant. The visit was quick and easy, lasting about 20 minutes.

But Saifan was shocked when he received bills totaling $2,429.84.

The bill included a $3.50 charge for the muscle relaxant. The rest — $2,426.34 — was from “facility fees” charged by the hospital and doctor for walking into the emergency room and seeking care.

Because Saifan’s health spending is still within his plan’s deductible, he is responsible for the entire amount.

“I called the insurance company to make sure the bill was real,” he says. “They said it was a reasonable price, and gave me a breakdown.”

Spending on emergency room fees has increased by $3 billion — even though the number of fees is declining slightly

There are 141 million visits to the emergency room each year, and nearly all of them (including Saifan’s) have a charge for something called a facility fee. This is the price of walking through the door and seeking service. It does not include any care provided.

Emergency rooms argue that these fees are necessary to keep their doors open, so they can be ready 24/7 to treat anything from a sore back to a gunshot wound. But there is also wide variation in how much hospitals charge for these fees, raising questions about how they are set and how closely they are tethered to overhead costs.

Most hospitals do not make these fees public. Patients typically learn what their emergency room facility fee is when they receive a bill weeks later. The fees can be hundreds or thousands of dollars. That’s why Vox has launched a year-long investigation into emergency room facility fees, to better understand how much they cost and how they affect patients.

Saifan’s bill was so expensive, it turns out, because the hospital used the facility fee typically reserved for complex, intensive emergency room visits.

Emergency room facility fees are usually coded on a 1 to 5 scale, to reflect the complexity of care delivered to the patient. Saifan’s visit where he received a muscle relaxant was coded by the doctor as a level 4 visit — the second highest — and came with hefty fees as a result.

The hospital billed a separate facility fee (!) and chose level 3, typically reserved for moderately complex visits.

Saifan’s experience isn’t an anomaly: A new Vox analysis reveals that emergency rooms all across the country are increasingly using these higher-intensity codes, and that the price of these codes has increased sharply since 2009.

Vox worked with the nonprofit Health Care Cost Institute (HCCI) to analyze 70 million insurance bills for emergency room visits from between 2009 and 2015. We focused on the prices that health plans paid hospitals for facility fees, not the hospital charges (which can often be inflated well above what patients actually pay).

We found that the price of these fees rose 89 percent between 2009 and 2015 — rising twice as fast as the price of outpatient health care, and four times as fast as overall health care spending.

Overall spending on emergency room fees rose by more than $3 billion between 2009 and 2015, despite the fact the HCCI database shows a slight (2 percent) decline in the number of emergency room fees billed in the same time period.

“It is having a dramatic effect on what people spend in a hospital setting,” says Niall Brennan, executive director of the Health Care Cost Institute. “And as we know, that has a trickle-down effect on premiums and benefits.”

Javier Zarracina/Vox

The HCCI data shows that prices are rising dramatically and that, increasingly, hospitals have gravitated to using the most expensive billing codes — the level 4 and 5 charges, typically reserved for the most complex visits.

The rising price of emergency room facility fees coupled with growing usage of the most expensive codes mean it’s significantly more expensive to go to an emergency room now than it was six years ago.

Hospitals argues that these increases are due to an aging, sicker population.

“If you have a monopoly — and when it comes to the ER, it’s a monopoly — you can set any price you want,” says Robert Derlet, a professor emeritus in emergency medicine at the University of California Davis, who has been critical of ER billing in the past.

“What is going to deter me from increasing my price? Who can stop me? If I’m the financial officer for the hospital, I might even get a bonus for doing this.”

Hospitals increasingly code emergency room visits as complex

David Overton knows what strep throat feels like. He comes down with it once or twice every year. He typically goes to urgent care or a drug store clinic when his achy throat and fever symptoms start.

But his most recent strep throat infection flared up on Memorial Day, and those clinics were closed. So he went to Legacy Emergency Room & Urgent Care outside of Dallas.

Overton walked in the door for urgent care, but staff there said his case was severe enough to move him to the emergency room side of the clinic.

“I felt terrible, and I wasn’t up for debating it,” he says. “So I was like okay, I guess we’ll do this.”

The emergency room performed a CT scan and used IV medications to treat Overton. He immediately felt better, and left with a prescription for antibiotics. Three days, later he saw another doctor who confirmed it was a simple case of strep throat.

But because of the complex intervention — the CT scan, the IV drugs, the long visit — the hospital coded Overton has having the most complex visit possible, a level 5. They billed him a $1,900 facility fee. Because he has a high-deductible plan, he’s responsible for all of it.

“Did I need the CT scan? No. Did I need the IV antibiotics? No,” he says. “I could have been treated with oral antibiotics.”

He’s currently paying off the bill by $50 each month. So far, he’s paid $300.

Emergency billing guidelines offered by the American College of Emergency Physicians typically reward doctors for providing a higher level of medical care. They instruct hospitals to use the more expensive billing codes for cases where they have to perform multiple scans and examinations.

Two different hospitals trips for the same condition may be treated and billed quite differently. A case of strep throat treated with oral antibiotics — a simple visit — would likely be coded as a level 1 or 2 visit. But a visit with multiple scans and an IV drip could come out to a 4 or 5.

The HCCI data set suggests that Overton’s experience may not be atypical. It shows that more and more emergency rooms are billing the severe, expensive facility fee charges.

What’s more, there are no federal guidelines on how to code even the exact same visit. This is left up to a hospital’s billing staff, meaning that if two patients receive identical care in different emergency rooms, one may be coded as a level 3 and another as a level 4.

“There are charges that people could look at differently,” says David McKenzie, reimbursement director for the American College of Emergency Physicians. “Reasonable people could disagree on severity.”

These discrepancies can be expensive for patients, as emergency rooms charge hundreds of dollars more for the more severe codes.

The HCCI database shows that the average price of a level 3 facility fee (in medical coding, this is billed as 99283) is $576. Go up to the next severity code, level 4 (or, in medical codes, 99284), and the price rises to $810.

The price of facility fees has risen steadily in recent years. A level 3 code (99283) now costs, on average, $576. A level 4 code (99284) averages $810.
Christina Animashaun/Vox

“Hospitals can make a lot of money charging for all the extras — CT scans, MRIs, laboratory fees, even starting an IV,” Derlet, the emergency physician, says.

In 2009, 50 percent of all emergency room facility fee charges were for level 4 and 5 codes. In 2015, that number rose to 59 percent.

How to interpret that trend isn’t fully clear. Some say it could signal hospitals charging higher rates for similar care. But the current data makes it impossible to rule out the fact that emergency room visits may just be getting more serious.

Medicare tried to simplify facility fees. It failed.

The government has tried to crack down on high emergency room fees before — but ultimately was scared off by intense push back from health care industries.

In 2012, an investigation by the Center for Public Integrity showed that hospitals had earned an additional $1 billion in Medicare revenue by using the most expensive facility fees — the level 5 codes.

This meant that the public insurance program that covers Americans over 65 was suddenly spending significantly more money on these routine fees.

Christina Animashaun/Vox

In response, the Obama administration proposed eliminating the facility fee levels entirely, to get rid of any incentives to bill for a higher price. It suggested one flat fee for all visits.

“A single code and payment for clinic visits is more administratively simple for hospitals and better reflects hospital resources involved in supporting an outpatient visit,” Medicare argued in November 2013.

But that rule never saw the light of day. After intense pushback from hospitals and doctor groups, the issue was dropped and the fee levels remain today.

“I remember we got an onslaught of comments, hospitals being very frustrated, emergency room doctors being upset,” one former Medicare official involved with the rule said. “It definitely got pulled, and it was just about the amount of commenting and concerns from the industry.”

At the time, Medicare issued a statement saying it “intends to consider options to improve the codes for these services in future rulemaking.” So far, the agency has taken no actions to re-regulate these codes.

Some patients, however, have had success taking matters into their own hands.

Last winter, John Shelbourne ended up with a small gash above his eye from a basketball game with friends.

“It was just big enough that it needed to be closed,” Shelbourne, 37, says. “It was probably 9 at night, so I had to head to the emergency room.”

The doctors at Swedish Covenant Hospital glued the wound shut and covered it with Steri-Strips. Shelbourne estimates the visit took about 15 minutes.

A few weeks later, he received a bill with a $899 facility fee. (Incidentally, the Steri-Strips — which cost $1.49 for a box of 12 at Target — were billed at $14.)

Shelbourne’s visit was coded level 3, a medium-intensity facility fee. He showed the bill to his father, a doctor.

“I was able to ask him what these levels were, and he asked his nurses, who knew the difference,” he says. “They said level 3 is a complex procedure, and once I found that out, I knew there was no way this was a complex visit.”

Shelbourne started calling the hospital, arguing that his visit should be coded level 2 instead of 3. He made 25 separate calls over two months. He kept records of all of them, on sticky notes around his desk at work. The hospital eventually agreed with him and lowered his visit from a level 3 down to a level 2.

That change lowered his portion of the bill from $441 down to $305.

“I’m stubborn,” Shelbourne says. “Once I found out what a level 3 visit was, I got pissed off about it. I was on a mission. I went from not knowing the difference between ER visit levels to seeing how these things could get totally slipped by you.”

Saifan, the engineer in Kansas who received the $2,429.84 bill for the muscle relaxant, is disputing his bill as well.

“We’ll see how the dispute goes, but I’m not expecting it to change,” he says. He says the hospital told him he could get a 10 percent discount if he paid the bill in full rather than installments over time, which he’ll do if his dispute is unsuccessful. His family has enough money to pay off the bill.

“It’s not easy to pay $2,500, but it won’t be life or death,” he says. “It would be a pretty frustrating disappointment.”


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Posted in Fun, Governance, Health

US Fisheries Regulation: States’ Rights, except When the Emperor Says NO

Really important example of how to kneecap regulatory processes. Result will certainly be over-exploitation of fisheries resources for the seventh largest fishery on the East Coast (summer flounder) . Needless to say, this is being led by national, Trump administration, regulatory agencies over-ruling state and regional authorities. Painful to see …

From the Washington Post 

Local

Trump administration dives into fish fight

November 21 at 2:27 PM
WASHINGTON — An unprecedented Trump administration decision over the summer that overruled an interstate fishing commission has drawn the ire of critics who worry that keeping a healthy and viable supply of flounder in the Atlantic Ocean is being sacrificed to commercial profits.While the fight over fish largely has been out of the public eye, it has implications for Maryland and other coastal states. Critics charge the controversy further underscores environmental backsliding by a White House beholden to business interests seeking fewer restrictions on the potentially harmful exploitation of natural resources.In July, Secretary of Commerce Wilbur Ross overruled a recommendation by the Atlantic States Marine Fisheries Commission finding New Jersey out of compliance with proposed 2017 harvest limits of summer flounder along the Atlantic coast.The reversal marked the first time since passage of the Atlantic Coastal Act in 1993 that the Department of Commerce overruled the commission’s finding of noncompliance, said commission spokeswoman Tina Berger.

It was a big surprise that the commission’s authority would essentially be disregarded by the Commerce Department,” said Maryland Del. Dana Stein, D-Baltimore, one of the fisheries commissioners. “I was very disappointed upon hearing about this.”

Former commission Chair Douglas Grout at the time said the “commission is deeply concerned about the near-term impact on our ability to end overfishing on the summer flounder stock, as well as the longer-term ability for the commission to effectively conserve numerous other Atlantic coastal shared resources.”

The commission, formed by the 15 Atlantic coastal states in 1942, provides a platform for states to coordinate management plans to conserve fishing stocks.

Each state is represented by three commissioners, including a member of the state legislature, an industry representative and a state official.

Fisheries management is a complicated and difficult field that uses a number of measurements to estimate the number of fish of a particular species in the ocean.

Much of the data is collected by the National Marine Fisheries Service, a part of the National Oceanic and Atmospheric Administration (NOAA).

The data includes fish size, recreational and commercial harvest amounts and assessments of the habitat and movement of species. Also measured is spawning stock biomass, defined as the total weight of male and female fish in a population that contribute to reproduction.

The focus of the dispute is New Jersey’s plan for summer flounder, also known as fluke, a large, flat fish that in Maryland is caught both in the Chesapeake Bay and on the Atlantic seaboard.

At issue is how many fish of any species can be taken in a season without tipping the balance toward a steady decline in the overall stock, as occurred years ago with striped bass.

Growing up to four feet long, summer flounder is the seventh most-fished in Maryland and is particularly prized by recreational fishermen.

The flounder reach spawning age at around two years, by which time a mature fish should measure approximately 10 inches long.

New Jersey proposed allowing the harvest of approximately 93,000 more fish this year – roughly double the previous quota limit. The state contended that it was possible to reduce the number of undersized flounder that die after being released back into the ocean by anglers, using an angler education program.

New Jersey’s “discard mortality” was rejected by the fisheries commission in its technical report as unquantifiable. But the Commerce Department said Ross accepted NOAA’s judgment that New Jersey’s plan would work “while also preserving jobs supported by the recreational summer flounder industry” in the state.

It is unclear what NOAA told the Commerce Department. Officials with NOAA declined requests for comment.

However, an earlier report by NOAA contradicts the position the Commerce Department took on the health of the summer flounder supply. In short, that report said that summer flounder was experiencing overfishing and noted that spawning stock biomass of the species decreased significantly between 2013 and 2016.

The NOAA report also noted that, “as the result of the 2016 assessment update, reductions in catch and landings limits were required for 2017 and 2018.”

In addition, a memo from the Commerce Department to the Atlantic States Marine Fisheries Commission said that while it was possible New Jersey’s proposal would result in equal conservation, it recognized that “there is some uncertainty about how effective the New Jersey measures will be.”

“There’s a serious question here of transparency,” said Molly Masterson, project attorney at the National Resources Defense Council, a non-profit organization focused on long-term management of natural resources.

“… We don’t know, but if commerce and the technical advisors at NOAA were at odds on this that’s really important for the public to know and as it currently stands we just don’t know,” she said.

According to Kiley Dancy, program manager for summer flounder at the Mid Atlantic Fishery Management Council — one of six federally mandated regional councils — summer flounder was one of the “best assessed” species managed by the commission.

“Almost all of the input into the assessment have shown pretty substantial declines of summer flounder over the years, so although there may be some uncertainties in exactly where the biomass is right now, we’ve seen trends in declines in these indices for almost all of the indices that are in the assessment,” Dancy told Capital News Service.

Her assessment was shared by Maryland officials familiar with the issue.

“The flounder stock has shown a kind of extended period of decline over the last decade from a high point, you know, ten years ago, to a point in time now where the stock is approaching the threshold level for which more significant management action would have to happen,” said Michael Luisi, program director at the Maryland Department of Natural Resources.

But New Jersey officials say their approach was quantifiable and based on hard data.

“At the end of the day, we’re the Department of Environmental Protection,” said that agency’s assistant commissioner, David Glass. “We’re a science-based agency and were able to ultimately be successful by providing sound science and data to the secretary of commerce and NOAA fisheries.”

“We’ve contracted with Montclair State University.here in New Jersey, to conduct a survey,” Glass added. “They did a preseason survey for us, and they’re doing a post-season survey to show, ultimately was our campaign effective? Did it change angler behavior? Did it help save more fish in the water?”

Officials in Maryland were cautious about the approach taken in New Jersey.

“It’s not that New Jersey wasn’t acting in the best interest of conservation,” Luisi said. “They just did it in a different way and maybe it was a little less quantified based on the hard science, but it doesn’t mean it was wrong.”

“I think there was just a difference of opinion regarding the management actions that one particular state was presenting as something that they felt was equal to that of the other states,” Luisi added.

The fisheries commission tends to err on the side of caution, Masterson said, noting that with a vulnerable population such as summer flounder, “it’s really critical that the managers get it right based on a really robust scientific and management strategy evaluation process.”

Luisi agreed: “The stock is approaching the threshold level for which more significant management action would have to happen…Managers need to be conservative in how they deal with quotas.”

A statement from the Department of Commerce maintains that the decision was in keeping with the available data and with recommendations from the National Marine Fisheries Service.

“The long-term sustainability of American fishing stocks and the jobs that rely on them are of the utmost concern to Secretary Ross,” said a statement provided by the department.

But the matter also seems to be one of political and commercial interest taking precedence over economic and environmental sustainability according to NRDC’s Masterson.

She insisted that “the secretary’s decision had absolutely no technical support or analysis from a conservation standpoint as to why that it warranted…overturning the commission’s decision and why New Jersey’s proposal would be enough basically for conservation.”

The future of sustainability efforts now appears to be in a state of uncertainty, according to state fishery managers, with the strict limits imposed by the commission suddenly open to question.

“There’s a real concern of states coming out sort of at the last minute and saying, ‘Oh, we want to do something totally different and… because of political influence, we have the guys at the commerce that are going to support us,’” said Masterson.

If others states are able to lobby the Commerce Department directly for changes to fishing regulations, as New Jersey has done, Stein said he doesn’t want Maryland to lose out.

“I would hope that Maryland wouldn’t be the next state (to loosen regulations), but if it seems like that’s the trend, Maryland would feel it’d have to defend its own interests,” the lawmaker said.

“The decision by Commerce – it makes the whole compliance conservation equivalency a little bit gray. How that translates into future management, it’s yet to be determined,” Luisi said.

But the decision may be popular with fishermen, who contend the fisheries commission’s zeal to protect the fish supply often exceeds its technical knowledge.

“I’m glad to see that somebody stood up to the commission,” said Robert Brown, president of Maryland Watermen’s Association, which represents commercial fishermen in the state.

“The best science that they say is available — it isn’t such a thing,” Brown said. “It’s the best assessment, the best guess. There’s no way you can tell how many fish are out there.”

Brown’s elation could be short-lived.

Berger, the fisheries commission spokeswoman, said that if summer flounder reaches an overfished status, more stringent federal laws could impose fishing moratoriums on the species.

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