Wednesday, December 30, 2015

Aetna's unethical cost savings are enabled by the "arbitration" laws purchased by large corporations

The New York Times did a superb series this fall on how large corporations changed American law to neutralize a major consumer protection — the class action lawsuit. Arbitration clauses mean a single consumer goes up against multi-million dollar legal teams, a hopelessly mismatched battle.

I realize that’s why Aetna can get away with cutting health insurance costs through strategic incompetence. Ten years ago if they were routinely evading their contractual obligations they’d be subject to a multi-million dollar suit. Sure, any penalties would be too small to truly impact Aetna, but a potential payoff would be big enough to fund a suit. More importantly, once a judgment was made, Aetna would need to wind the scam down — a recurring judgment might eventually amount to real money.

Today there’s really no downside for them. I’m certainly not going to take them to arbitration. So, yes, the Feds should block Aetna and Anthem’s acquisitions, but this is just one facet of a much bigger problem. The modern mega-corp has damaged our political and commercial landscape — from secular stagnation to political corruption. It may take the second coming of Theodore Roosevelt to set things right.

Monday, December 28, 2015

Why DOJ should block Aetna and Anthem acquisitions: A story of strategic pre-authorization delays

The health insurance industry is consolidating. Aetna acquired Humana and Anthem bought Cigna. That leaves UnitedHealth, Aetna and Anthem as the mega-corporate rulers of US healthcare. Unless, of course, the US Justice Department blocks these mergers. 

Like most people who pay attention to healthcare policy I very much hope the DOJ does its job properly. I’m glad we have the Obama DOJ to stand up for us, at least now we have a fighting chance. That’s not why I’m writing this blog post though, and it’s not the reason why I’ll be writing Senator Klobuchar to ask her to work against these mergers.

I’m writing this because, of course, I’m personally mad at Aetna. I think I know why Aetna and Anthem are in a position to do the acquiring, and it’s not because they’re better at delivering health care. I think they’re winning because they excel at both strategic incompetence supported by a tobacco-industry class executive culture.

In my case a physician ordered a radiology procedure for me that requires pre-authorization by my insurance company - Aetna. The order, alas, was placed in early December — perilously close to the end-of-year period. A period where cost can shift, depending on deductibles, from the insurance company to the insured, or from one carrier to another.

Aetna could decline the authorization. That might have been a reasonable act — not every physician recommended procedure is a good idea, particularly when the physician owns the imaging process. I’m guessing they don’t have grounds for denial, so instead they simply stall. Information is provided … and Aetna can’t find it. They ask for the same information several times. They will succeed in running out the clock. My physician’s staff tell me Aetna excels at this game, even by industry standards they’re good at not delivering what we pay for. Which is usually considered theft.

Aetna’s executives don’t have to write up a formalize this profitable process. They don’t need to put anything in writing. All they have to do is underfund their pre-authorization process (a “cost center”), or provide financial incentives to delay payments, or not staff for the holidays, or promote executives who are good at cost control. Most likely they do all four. 

I suspect Anthem has the same skill set, but Humana and Cigna probably aren’t quite as good at being evil. There are so many ways in healthcare to do well by doing wrong; it’s a rough rule of thumb that the more profitable a healthcare operation is the less good it’s doing.

Aetna is going to win their little battle with me. The best I can do to get even is write Senator Klobluchar (I know Senator Franken will oppose) and complete their legally mandated complaint form.

And I can write a blog post.

See also

Update 12/30/2015

After completing the official complaint form, and separately posting a public message to Twitter @aetnahelp and follow-up email to, I received this message on the morning of 12/30:

Screen Shot 2015 12 30 at 3 08 06 PM

Of course it’s too late now, Aetna ran out the clock. As we knew they would. Even though the bad guys won this one, I would try public Twitter messages and email to in future. A kind of special service track for the geek elite. 

Sunday, December 20, 2015

Growing old grudgingly: The CrossFit Inversion

Mature audiences only.

Under 45 not admitted.

You have been warned.

I was 53 when I started my CrossFit hobby. That was almost 3 years ago. I knew then, given the shape of 83, that there was a cliff ahead. I didn’t need my older friends to remind me of that, but they have. Faithfully.

Back then my gym had us post our “personal bests”, like best time for a mile, or best back squat. Since I’d never done olympic weightlifting, or even serious training, it was fun to rack up my lifetime personal bests as an old man. The gym stopped doing that, probably for a good reason, but I kept my own records. Six months ago I had another one in the deadlift.

It was the deadlift that did my latest injury. Lower back of course. Not a bad one, I’ve done this before, but aggravating. It’s the context that’s the real problem, this injury follows the knee and the shoulder. 

I get the message. My cliff started at 55; the arthritis probably moved it up a few years. Now I’m in post-cliff hang gliding mode.

I’m good at taking clearly delivered feedback like this. So I’m updating my list of personal bests and filing it away. Been there, done that. In its place I’m making up a list of personal “safe limits”. For my deadlift I’m afraid that will be low even for a little guy like me — something like 235. Safe limits go up very carefully.

Personal best replaced by personal max. That’s my CrossFit inversion. Now I’ll see how far that gets me…

Tuesday, December 15, 2015

Smartphone calendaring: a brief survey

i’m collecting some data on how people do calendaring on their smartphones to support my special needs smartphone for independent living book project. If you’re reading this before December 20th 2015, can you please fill out this 2-3 min, 3-7 question survey? Thanks!

Calendaring in iOS, OS X, Outlook 2010 and Google Android/Chrome are all very different.

If you’ve ever wondered why healthcare institutions can’t easily share data between computer systems, just take a look at Calendaring in iOS, OS X, Outlook 2010 and Google Android/Chrome.

Google went down the road of calendar overlays. You can have as many calendars as you like and you can share them across a Google Apps domain or between Google users. Public calendars are available for subscription. My current Google Calendar calendar list holds twenty distinct calendars of which 8 belong to my family. (One for each family member, one for entire family, a couple of parent-only calendars that the kids don’t see.) In Google’s world, which is consistent across Chrome and Android, shared calendars can be read-only or read-write. Google supports invitations by messaging.

I love how Google does this, but I’m a geek.

I’ve not used any modern versions of Outlook, but Outlook 2010 also supported Calendar subscription. They didn’t do overlays though, every Calendar stood alone. I never found this very useful.

Apple did things differently. Not only differently from everyone else, but also differently between iOS, OS X, and iCloud.  OS X supports calendar overlays and subscriptions, but the support of Google Calendar subscriptions is  weird (there are two ways to view them and both are poorly documented). iOS has a very obscure calendar subscription feature that I suspect nobody has ever used, but it does support “family sharing” for up to 6 people/calendars (also barely documented). There’s an even more obscure way to see multiple overlay Google calendars on iOS, but really you should just buy Calendars

iCloud’s web calendar view doesn’t have any UI support for Calendar sharing, I’ve not tested what it actually does. Apple is proof that a dysfunctional corporation can be insanely profitable.

All three corporations (four if you treat Apple as a split personality) more-or-less implement the (inevitably) quirky CalDAV standard and can share invitations. Of course Microsoft’s definition of “all-day” doesn’t match Apple or Google’s definition, and each implements unique calendar “fields” (attributes) that can’t be shared.

Google comes out of this looking pretty good — until you try to find documentation for your Android phone and its apps. Some kind of reference, like Google’s Android and Nexus user guides. As of Dec 2015 that link eventually leads to a lonely PDF published almost five years ago. That’s about it.

I don’t think modern IT’s productivity failure is a great mystery. 

Saturday, December 05, 2015

Arthritis - the feeds and queries (reference post)

I feel like I’m tied to a railroad track, and see the light of the train approaching. And I don’t know if it’s one mile away, or 500. 
Anonymous, a patient three years into leukemia remission.

Cancer will give many of us that oncoming train feeling, but of course the light is always there. We’re just good at denial. When we’re young and healthy the train is probably far away. When we’re 93 it’s pretty close. In between we try not to look.

There’s only one “train”, but there are lots of smaller hits along the way. Bicycles and cars maybe. One of them ran into me recently, so I’ve renewed an old interest in the so-called “rheumatic disorders” (misleadingly named after bodily fluid flow).

It really is an old interest. Before I figured out how to do medical school [1], I closely read the 1982 version of the Arthritis Foundation’s “Primer on the Rheumatic Diseases”. Within the broad bounds of unreliable memory I recall that osteoarthritis was a “wear and tear” disorder of aging, rheumatoid arthritis and a handful of other disorders were “auto-immune” diseases, gout and non-gout crystal deposition were relatively well understood, and many viral and non-viral diseases (Gonorrhea and, a bit later, Lyme) caused arthritis. Steroids (not the androgen variety!) worked very well on the auto-immune disorders, but the long term side-effects were horrible and inevitable. We had reasonable drugs for Gout, gold for Rheumatoid arthritis (some value [7]), and nothing for osteoarthritis. Okay, so we had NSAIDs like ibuprofen, but we already suspected they were a mixed blessing. We’ve kind of given up on them.

Things aren’t that much different 33 years later. Relatively recently we’ve realized that “osteoarthritis” covers a multitude of evils, some or all of which, like “psoriatic” arthritis, are more than “wear and tear”. We still don’t have any great treatments for Systemic Lupus Erythematosis, though we now do less harm with the treatments we have. Rheumatoid arthritis has seen the most care improvements, but, amazingly, we can’t actually cure it or any other auto-immune arthritis [3]. We still wonder about the role of infectious agents in creating or sustaining auto-immune disorders but we have few leads [2][6]. The most recent (2005) edition of the Primer on Rheumatic disease says of Osteoarthritis “It is clear that this … includes a variety of different conditions, but we have made less progress …”.

More recent publications have even undone old certainties; we’re no longer confident that the various flavors of psoriatic and osteoarthritis are primarily “arthritic” (greek: Arthron, joint). Disorders along the osteoarthritis - psoriatic arthritis spectrum may begin as diseases of the tendons. Some of them may be lifelong disorders of tissue healing; small injuries accumulate due to a healing defect, perhaps with later onset of an auto-immune component reacting to disordered tissues.

My medical school interest became personal as I watched my mother go through the arthritis experience for about 35 years, ending as “rheumatoid arthritis” (our classifications are imprecise). It wasn’t pretty.

Which is all by way of introducing this “reference post”; a blog post that I’m going to be revising and extending. It’s a post supporting my surveillance of our historically limited knowledge base. I’ll revise it periodically over the next year or two. Sometimes I’ll post/tweet about updates to this reference post, but most of the interesting results will appear in a pinboard RSS stream tagged “arthritis” [4].  

My surveillance relies on PubMed [5] (National Library of Medicine) RSS feeds. Anyone can create these, but I’ve never seen anyone but me write about them. I’ll list them by topic below, but first I’ll describe what I’m not monitoring.

I’m not monitoring care guidelines or the cutting edge of rheumatologic practice. I see a rheumatologist for that; that’s his job. If I want an update on current practices I’ll take a look at FP Notebook’s Rheumatology Book. I’m not interested in alternative or complementary therapies — that way lies madness. I’m only mildly curious about lifestyle factors; mostly because we know so little and very little research is going to get funded.

I am curious about tolerance induction — the Holy Grail of the rheumatic disorder treatment. We’ve been hammering on this decades, but we have new tools now. This is what we really want - a cure for at least some of these diseases. I’m looking for articles on disordered healing and secondary arthritic conditions, but I’ve yet to figure out a good search for that one. Likewise I’m looking for articles that relate loss of self-tolerance to a dysfunctional pseudo-neoplastic component of the immune system (yeah, this is definitely fuzzy). More concretely anything about the role of infections organisms in precipitating or maintaining arthritis.

Here are the RSS feeds and “similar articles” queries I’m revising and using for each of these topics. I wish there were RSS feeds for the “similar to” queries, as I learn the topics i’ll put create RSS feeds with similar results.

tolerance induction

tendon injury (enthesitis) and arthritis

microbiome and role of infection in creating and maintaining arthritis
Immune system and neural networks (because I figure the immune system is a form of neural network)

- fn -  

[1] The way to do the didactic portion medical school is to maintain a relentless focus on examinations. If you’re doing well you may then indulge your passion and curiosity. 
[2] As a still distractible student I read the first speculative article written on an association between bugs living in the high acid stomach and gastric ulcer disease. Before then we thought the stomach was sterile; nothing could live in such a disagreeable environment. That probably contributed to my extremophiles and auto-immune disease post.
[3] Juvenile Rheumatoid Arthritis does resolve about half the time. Which is curious.
[4] Like all things Pinboard it has an RSS Feed: Sadly there are no RSS feeds for “similar article” queries and “My NCBI” doesn’t show feeds.
[5] My medical informatics career began in Family Medicine residence as a beta tester of the “Grateful Med” software. I believe the product manager, Rose Marie Woodsmall, was a dead head. I was among the last generation of medical students to use the paper Index Medicus to do journal research.
[6] I’d wondered years ago why we weren’t mining synovial fluid for foreign DNA. Turns out this was done in 2001 with interesting results, but the follow-up was limited until “microbiome” became a funding source.
[7] Gold was used to treat Rheumatoid arthritis from at least 1945 through the early 1990s. I seem to remember it was sometimes associated with extended remissions. I can find almost nothing on it written after 1965 or so, and nothing at all on how it worked. There’s very little on long term outcomes. Which is, you know, profoundly weird.

Update 12/18/2015

I have a hunch that whatever is afflicting me now is the end-stage of a congenital defect with soft tissue/tendon formation. I’ve always been prone to calcium deposits along tendons and to overuse tendonopathies. It would not be surprising that as I’ve aged my body’s ability to manage this problem, and heal from injury, has declined. That in turn could lead to some secondary auto-immune issues (prolonged inflammatory/antigen spill issues). I haven’t come up with a search criteria yet to explore this idea; it would probably show up in whole genome analyses. I would need to look for discovery of a gene associated with auto-immune arthritis/osteoarthritis that was important for tendon formation.