The shocking truth - the birthers are almost right ...

The birther crackpots are still stumbling about. They'll never figure out the real story -- though it's been staring them in the face all along.

Of course Obama wasn't born in America, but he wasn't born in Kenya either. You see, he wasn't born at all ...

It does explain a lot.

--
My Google Reader Shared items (feed)

529 plans can be rebalanced twice in 2009

I was surprised to see this when I visited our kids 529 plans to make a contribution. I assume this extra rebalancing is to compensate for funds damaged by the crash of 2010 ...

The Treasury Department and the IRS recently announced that for 2009 only, 529 plan account owners will be allowed to change Investment Options two times per year. This means that you can reallocate your investment to different investment options in your plan up to two times this year...

I've never done any rebalancing. I didn't realize that we are normally allowed to do that once a year. Something else to learn about!

--
My Google Reader Shared items (feed)

Lipid guidelines: Sometimes the emperor really is starkers

A year ago I had to review guidelines for managing elevated blood lipids. I concluded that the guidelines were incoherent and silly. It wasn't a problem of science, it was a problem of logic.

Today, reading a JAMA editorial by Gaziano and Gaziano (brothers), I see that medicine has caught up with me. The risk calculator approach makes sense, though the models may have problems.

It's a cautionary tale of the limitations of expert panels. I suspect a lot of practicing physicians thought the guidelines were dumb, but they weren't making policy.

Hey, someone has to give me credit!

PS. There are now serious proposals to put every male over 50 or so on a statin. That's because they're so safe and cheap. The last time we did something like this it was women and estrogen. It took 10 years to learn that was a very bad idea.

--
My Google Reader Shared items (feed)

Sparta and the disturbing flexibility of human culture

I remember a cartoon of Spartan life that I learned as a child. I don't recall thinking about it much further until this week's IOT programme on Sparta.

Spartan culture is as alien to modern American life as the sacrificial cultures of the Aztecs, but it endured for hundreds of years. Men did not live with women. Children were removed from their mothers at age 7 and raised in a harsh military environment including routine sexual abuse. Contrary to some stories, it appears they did not routinely visit their mothers after that time.

The Spartans practiced active eugenics, exposing unwanted children (though some were apparently rescued by others). They enslaved, oppressed, tortured and murdered their "Helot" kin for centuries. Spartan women, paradoxically, may have had more freedom and a better life then Spartan men. Birth rates were low -- perhaps the earliest evidence that educating women leads to lower birth rates (aka "demographic transition").

This culture was not a passing thing. It appears to have been stable for centuries. Presumably, humans could do it again.

Update 11/22/09: On reflection, if you could get past losing your male children at aged 7, this might not have been such a bad arrangement for Spartan women. Exercise, education, freedom, limited exposure to Spartan men ...

--
My Google Reader Shared items (feed)

Chrome OS - the Parental Controls

I'm going to forget I read that Google imagines Chrome OS machines will sell for $400. That's clearly a ploy to sedate Microsoft.

I'll stick with my original expectation, that moderately crummy Google branded Chrome OS machines will sell for under $180 with battery.

If that happens then Chrome OS laptops will be huge in K-12 education, 23 years after I mercifully failed to sell a rural school district on a student Newton OS mini-laptop education model.

Huge, that is, if Google gets Parental Controls right. I ain't giving my kids Chromebooks unless I get full control over what they get to and what they do.

If we don't see Parental Controls emerging in Google App domains within the next six months, the Chrome OS may be missing an essential function.

When to accept an Apple OS update

I mostly agree with this Macintouch post ...

Snow Leopard

.... In my experience with Tiger & Leopard, a really usable version isn't available until around the .4 timeframe. My guess is the same will be true with SL. I play with a SL partition every now and then (whilst I test things like SoftRAID - great!), but I need a system that works.

SL ain't there yet, and once again, Steve Jobs and company thank us all very much for paying to be beta testers."

Apple's point OS updates, like 10.5 to 10.6, are dramatic; even those like 10.6 that add few marketed features.

Six months, or a .4 release, is a good rule of thumb. We're now at 10.6.2, I expect 10.6.4 after April 2010.

If you buy a system released after a point OS release, and stick with Apple or very mainstream products, you can probably get by with a .3 release.

If you have an older system that's still supported, you may need to wait for .5 or .6.
--
My Google Reader Shared items (feed)

Google's failures - and recent improvements

Good list of Google's more prominent failures. They are far from perfect, as any heavy duty Google user knows.

Time for me to update my Google Quick, Sick and Dead list. Here's the current list, I use pretty much everything except Android. I'm surprised to see that there have been more promotions than demotions over the past 10 months ...

The Quick

• Search and Scholar
• Android
• Google Reader
• Google Reader Comments and Shares
• Gmail
  
• Google Contacts
• Google Mobile Sync
• Chrome browser
• Chrome OS
• Picasa and Picasa Web Albums
• Calendar
  
• Maps
• Earth
  
• News
• Browser toolbars
• Translate
  
• Gmail Tasks (promoted)
• Custom search engines (promoted)
• YouTube (promoted)
• Mobile (promoted)
• Google Talk (promoted)
• Books (because they keep trying)

The Sick

• Google Voice (iPhone web app frozen in time)
• Google Sites
• Google Apps
• Google Video Chat (demoted)
• Blogger (demoted)
• Shopping
• Google Checkout
• Google Base
  
• Orkut
• Desktop
• iGoogle
• Knol (all-but-dead)

The Dead

• Google Notebook
• Google Page Creator
• Google Browser Sync
• Google Video
  
• Google Groups (demoted)
• Google Web Accelerator
• Google Name Verification (Knol)
• Google Gears

Update 12/4/09: I've added a few more items, such as Google Gears in the Dead category.

--
My Google Reader Shared items (feed)

Fans of Glenn Beck

By their fans ye shall know them ...

Glenn Beck - Salon.com

... every person in the last 2 years that I have introduced to the WN [White Nationalist] Philosophy have come largely from Alex Jones, Glen Beck and the Scriptures for America founder Pastor Pete Peters ... Baby steps are required for people like these, but the trio Beck, Jones, Peters are the baby food that feeds potential Nationalists… Glenn Beck is not far behind as his Mormon background indicates to me as most Mormons I have met are not friends of Jews like the Church was years ago...

--
My Google Reader Shared items (feed)

Twilight of the mail

It's been a couple of months, so I went through my home paper mail. As usual there were about 3 items of interest, 3 periodicals for the bathroom, and a 2 journals for the office.

We know the periodicals and journals are going to move to some form of "ePad" in the next year or two. At that time I will get valued paper mail less than six times a year -- mostly from family over 80.

I get nothing at work.

Of course there's a trick. Emily gets all the bills and the Netflix DVDs, but fairly soon vendors will stop mailing paper. We're fed up with broken Netflix DVDs, so that will end within a few months time. (Suck it Netflix.)

Paper mail is going the way of paper news.

--
My Google Reader Shared items (feed)

Health IT Standards - what I would do

I almost never blog about anything that's work related. For example, if you visit my blog page you'll see a "label cloud" with 360 posts on Economics, but I'm no economist.

This post, written as a private citizen, is different. I'm going to write about something that I really do know quite well. It's a sufficiently obscure topic that there are probably only a handful of people who know it as well as I, and I doubt any of them have been invited to participate in the Health and Human Services IT standards process.

I wasn't invited, but I feel a moral obligation to contribute anyway. I can't see a good way to do that, so I'll post my contribution here. Sometimes these posts travel in odd ways.

My unusual expertise is in combining the realms of healthcare "accounting" (ICD-9-CM, HCPCS, CPT) and the realms of industrial ontology (gritty knowledge representation) such as SNOMED. I've been personally grinding these pieces together for over twelve years in various software systems. I know them rather better than I'd like.

The accounting systems matter. Their idiosyncrasies distort health care statistics, change people's insurance, impede and break computerized decision support, dictate care and determine how most clinicians define disorders. They are fashioned in obscure dark rooms, and they alter health care as surely as technical accounting dictates corporate software development.

They matter so much that they are deeply embedded and almost impossible to displace. ICD-9 was obsolete 30 years ago, but it staggers on. ICD-10-CM is a merely improvement that will cost many fortunes to implement.

On the other hand, SNOMED, a language for healthcare, is a very rich tool. Buggy, yes. Imperfect, yes. Even so, it's a powerful tool for anyone who wants to provide cost-effective decision support that will make all health care providers smarter and faster.

So why don't we implement things like SNOMED now? Are there technical issues? Well, there are some technical challenges, but they're not too big. The real problem is the deadweight of ICD-9, CPT and all that layers upon them, such as vast "medical necessity" (LRMP, medical coverage) databases. Since payment is closely bound to ICD and CPT coding, the easiest route to legal maximization of reimbursement is to stay close to ICD and CPT.

I don't think we have the energy to move America quickly to better health care standards like SNOMED CT. Maybe we do, but this kind of change is very hard. Even so, I think we can do it gradually. The trick is to keep the current system in place, while incrementally building up an alternative approach.

For example, consider the "coverage determination" database. This is a reasonably complex set of tables that define relationships between ICD-9-CM (aka "ICD" in the US) codes and CPT codes (AMA owns CPT btw). The tables express rules such as "we will pay for procedure X (CPT) if a patient has condition Y" (ICD).

I think those tables would be simper, and more internally consistent, if the rules were expressed using SNOMED CT. Medicare (CMS) could then publish rules in both SNOMED and, through things called "mappings", ICD-9-CM and CPT too. The transaction systems would still use the ICD and CPT codes of old, but developers could represent the rules internally using SNOMED, thereby facilitating SNOMED use in their clinical systems. This alone would remove a very large hurdle.

State governments could encourage clinicians to include SNOMED CONCEPTIDs (codes) in a new class of public health and/or payor transactions. This would be entirely optional, but transactions could have come with small payments and regulatory rewards.

We could express new ARRA reporting requirements in SNOMED as well as in the traditional ICD and CPT code sets. Again, accept either data set.

Lastly, we could accelerate implementation of SNOMED-founded ICD-11, perhaps even foregoing ICD-10-CM plans and doing an early partial implementation of the full ICD-11 vision.

It's very hard to move things as deeply embedded as ICD-9-CM and CPT. This deadweight is heavy weight. We can't do it all at once, but we could take doable steps that would provide us with better decision support and more portable electronic health records.

We now return you to the regular amateur hour ...

--
My Google Reader Shared items (feed)

How much is the gBook in the Window?

So yesterday Google does a presser on their coming Chrome OS ("chromestellation") netbook. Buried away, and rarely reported, Google's Sundar Pichai says ...

Q: Do you know what this Chrome OS netbooks will cost?
SP: You will hear that from our partners. They will be in the price range that people are used to for netbooks today. But it’s hard to predict a year from now. Also remember, they will be bigger.

Huh?

The price range people are used to netbooks today?!

Err, that wasn't what I was expecting. What am I, wrong?!

Who cares about "bigger", we want cheap, cheap, cheap! We want that sucker under $150 (battery extra).

Not everyone heard Mr. Pichai ...

What ChromeOS Means For Netbooks And Why Microsoft Needs To Be Scared

... ChromeOS may not be powerful, it may not play Far Cry and it may not run Microsoft Office but it’s a game changer. The underpowered laptops that limped along under Vista, XP, or 7 will fly under a new ChromeOS regime and thin-and-light laptops will fall below the vaunted $199 mark as the so-called “Microsoft Tax” – basically the small cost manufacturers pay for OEM licenses – disappears."..

The XP tax, by the way, is less than $25.

If Google intends to sell a Netbook at $400 then Microsoft can relax.

I hate being wrong.

--
My Google Reader Shared items (feed)

A smart mind is a dangerous thing to waste

When I did my undergrad the USSR was a going concern. The military-industrial complex sucked in a lot of smart grads. Their work would be classified, and would add little to the greater good.

Then came the fall of the wall. For a magical decade smart minds had good work to do.

Somewhere along the way, though, smart minds started working on novel financial instruments, malign pricing innovations, games with insurance plans, and other emergent frauds. Instead of building better bridges and inventing new conservation strategies and clean energy sources, too many of our brightest minds have been investing in complexity attacks.

We need a cultural reform movement that values people not by what the money they take, but by the worth they make. Anyone see signs of this anywhere?

--
My Google Reader Shared items (feed)

Paul Graham on the price of the App Store

Apple needs to fix the App Store ...

Apple's Mistake

... I suppose Apple has a third misconception: that all the complaints about App Store approvals are not a serious problem. They must hear developers complaining. But partners and suppliers are always complaining. It would be a bad sign if they weren't; it would mean you were being too easy on them. Meanwhile the iPhone is selling better than ever. So why do they need to fix anything?

They get away with maltreating developers, in the short term, because they make such great hardware. I just bought a new 27" iMac a couple days ago. It's fabulous. The screen's too shiny, and the disk is surprisingly loud, but it's so beautiful that you can't make yourself care.

So I bought it, but I bought it, for the first time, with misgivings. I felt the way I'd feel buying something made in a country with a bad human rights record. That was new. In the past when I bought things from Apple it was an unalloyed pleasure. Oh boy! They make such great stuff. This time it felt like a Faustian bargain. They make such great stuff, but they're such assholes. Do I really want to support this company?

Start with allowing Google's products.

--
My Google Reader Shared items (feed)

Health insurance: we're defeated by a complexity attack

It's time again to play spin the insurance wheel.

This year my employer is offering only a "HRA" (Consumer directed) plan. What we used to call a "medical savings account plan". My employer self-insures, so presumably this saves them money.

So we tried to figure out what plan makes sense. My wife and I are both physicians. I'm a wee bit of a computer geek. We have, between us, at least 35 years of post-secondary education.

The enemy has hundreds of analysts and extensive simulations. They can throw up pages of unreadable and meaningless computer generated descriptions.

It's really no contest. The best we can do is run the provided simulations through optimal, average, and disastrous scenarios and assume that the strange seeming results are accurate. The simulations, of course, don't ask about tax brackets, and they mix pre-tax dollars (our premiums) with post-tax dollars (out-of-pocket expenses).

We can offset the post-tax dollars by gambling on Flex dollars -- but then we run the risk of sending the Flex money back to yet another gambling corporation (and probably, eventually, to my employer).

In the end we'll probably pick the middle option and go light on the Flex.

This, like mobile phone services, is a complexity attack. I'm guessing if I worked this one through I'd put it in the large class of emergent frauds - an echo of the crash of '08.

We must, as a nation, figure out a way to beat this stuff back.

Update: EL has been working with pencil, and it now looks like

• The graphical portion of the simulation is probably wrong.
• Disregarding the graphical part, and parsing out rollover of the "HRA" part, and factoring in various combination of pre-tax and post-tax contributions and Flex guesses the plans are more similar than the appear -- but the numbers may be wrong
• The numbers in one resource are quite different from the simulation/web site numbers. They don't add up. On the other hand, one of the simulation numbers is probably wrong.

See also:

• Gordon's Notes: Employment benefit complexity: we are sheep
• Gordon's Notes: The hidden insurance problem: they can play the game better than we can

Update 5/28/10: Our sense of doom was well justified. Midway through the year we found that mental health payments were not handled in the MSA-like plan. They're handled through a separate, traditional, indemnity plan. Since these payments constitute our major healthcare expense, our entire analysis was rendered moot. Needless to say, in all of our review neither my wife nor I saw this in the materials we were given.

AT&T “A List” – the gift that’s not

AT&T markets a new “A List” feature…

Enjoy unlimited calls to and from the phone numbers in your A-List. Your A-List can include valid domestic phone numbers for any domestic service provider - wireless or landline.

I’ve added my corporate conference call number to my AT&T “A List”. The list already includes my home landline and, especially, the Google Voice number that connects me to Canada for free.

Once this is effective my corporate conference calls shouldn’t use any of my minutes (even toll-free calls use minutes).

Since Google Voice and Google Talk combined with the A List mean my whole family uses less than 300 minutes a month, we no longer need our family plan of 1,400. I’ve be fine with only 550 minutes.

Wow! I could drop my bill from $80 to $40. What a great feature …

Ahh. But you know there’s a hook, don’t you?

The A list feature is only available for plans with 1,400 minutes and up.

AT&T isn’t stupid. Crooked, sure. Stupid, no.