Sunday, July 29, 2018

MEDICINE AND RACKETEERING


We are, after all, all humans. We share a common ancestry. If you know a bit of molecular medicine, you would know that there is a “Mitochondrial Eve.” That, all share the same mitochondrial DNA from the “Last Common (Human) Ancestor,” a woman. And yet there are legions of humans who believe otherwise. Perhaps their greed beckons them, or shades their eyes, or perhaps it blinds them to their common end. But there is no doubt that such a progeny of the bureaucrats has arisen and continues to flourish and grow, like weed, to overtake the once plush garden of that Eve.

On looking at the definition of the word, “Racketeering,” one finds this, “dishonest and fraudulent business dealings.” Hmm…simple enough, right?
It is if you have your eyes wide open.

But alas, all the goodness is interred in the sub-level surfaces of human activity, it seems. We define success as the men and women with the best toys. The race to that top of the mountain seems apace at breakneck speed. People climbing on other’s shoulders not to see further in the adventures of innovation and productivity but in the act of stomping on other’s heads to crush and bury them and their meek protests. And if protests do arise, they quickly demonize and or vilify the broadcaster of such protest. Charlatans have indeed gained a copious landscape and a highly visible lectern to pontificate the “Benefits” of their managerial swag.

Kris Held, MD @kksheld and Alieta Eck, MD @AlietaEck deserve the credit to bring this video across my visual horizon. It details the cozy relationship between the government and the private sector all cobbled together by the money bag exchange. It is all about self serving heuristics of those with the power to do so. The politicians want money to keep their enriched power base and other perks of “legal insider trading,” free jet-service to the Cayman Islands and the French Riviera all in the name of “Public Good.” Indeed, any and most actions doled out by these power-hungry trolls in the private sector and the government are marquee events under the euphemistic banner of “Public Good.” So, watch out for those words.

https://youtu.be/aQhsPLcFwN8


This video, encapsulates the racketeering in one sector of Medicine today; Cost of Medicines. And by the way, we are at the pinnacle of this act since the total cost of healthcare in the United States currently stands at $3.4 Trillion and escalating. That number alone is juicy enough to invite the eyeballs of some very wealthy individuals like Buffett, Bezos and Dimon to the stage. After all, why not partake in the health-palooza while the going is good to raise the topline and bottomline of their respective businesses.

Patients meanwhile are being told that their medical care is not “preauthorized” because of such and such reasons…mostly pointing fingers to doctors who it appears never seem to make the correct decisions for their patients. And if should one of those services be rendered then an automatic denial of 12%+ is served up by the insurance company, for the doctor to fight over for the next few months to get “reimbursed." The doctors meanwhile are forced to hire legions of paper pushers in their low revenue offices just to get paid. And that, dear fellow if you do a look back, is the reason why in 2014 thru 2016 the fastest gains in employment, while the whole rest of the world was asunder, was the medical field, was awash with new applicants, (that and bar tenders it seems) lowering the spurious unemployment rate.

Meantime the costs of medicines, if you surely have noticed, was going up. A hoax that seemed to have inadvertently been exposed by the greediest of all the hedge fund and Pharma bro, by the name of Martin Shkrelli.


But he wasn’t alone. He was closely followed by Heather Bresch the CEO of Mylan who did the same with the Epipen; an emergent supply of epinephrine for children and adults in the throes of an Hyperallergic reaction. 


Recently thais was followed by another pretty face called Elizabeth Holmes of Theranos. All these and many more in the business of racketeering, it seems. You guessed it, these people have no virtues, save, extract lives and money, just like a over-taxing, over-regulating, mightier than thou governments.

https://www.vanityfair.com/news/2018/06/elizabeth-holmes-is-trying-to-start-a-new-company

This post would not be complete without mentioning one of my favorite bloggers, a cardiologist Dr. Westby Fisher @Doctorwes who has exposed the many virtue-signaling harms committed by the ABIM and ABMS against the physicians. And these organizations have amassed many millions of dollars in all the fine places for their “Annual and semi-annual Retreats,” all at the altar of “Public Good.” These organizations have never been able to show benefit of their quasi-knowledge tests undertaken under the strict scrutiny of “physical and virtual guards,” in confined spaces. Meanwhile by extracting large sums of money from the physicians they have their lobbyists, lobby the government to mandate their scheme to gain a universal order of such money extraction in perpetuity. So, please extend your kudos to him and Charles Kroll CPA @CharlesPKroll. As the war against these self-appointed middlemen wages on, the outcome is eagerly awaited by most of the physicians whose main concern remains; delivering good patient care.

http://www.changeboardrecert.com/anti-moc.html
https://www.policymed.com/2017/06/anti-moc-laws-picking-up-steam-across-the-united-states.html
https://practicingphysician.org/moc/
https://www.medscape.com/viewarticle/881274

These organizations ABIM, ABMS are fighting back with their “representativeness heuristics” to cobble together estimates of dubious harm and probability outcomes couched in their falsified estimates. It is important to remember that the incidental, anecdotal, irrelevant perceptions and other such haphazard cognitions can and do effect judgment and behavior of those at the higher echelons of power with “No Skin In The Game” (SITG). To the power-hungry crowd only money bags matter. So stay alert at the next signal that repeats the words, ”FOR THE PUBLIC GOOD.”

But as Shakespeare once said, “Mischief, thou art swift.”

Where did we go wrong?
When did we refuse to follow the path of “Above All do No Harm?”
How did we come to this?

We forget the patients, whose misadventured piteous overthrows in finding a sanctuary against illness do with their death, bury the GPOs and PBMs and other hidden bureaucrats between the money-sheets racketeering schemes to keep from visible light. Thus they remain alive and with their viper poisonous tongues and sharp fangs, clot the blood of all civility, confuse the mind’s messages and normal human discourse.

It seems that when the many who rushed to acquire MBA degrees from prestigious universities and got hired at institutions rolling with cheap and free printed paper money, these new hires were expected to come up with their “algorithms” to determine the best mechanism of monetary extraction from the tax payer funded largesse. An endeavor that was quickly replicated across the private industry. There were others as well, especially those educated in the “Streetonomics” of how to get rich schemes, duly exploited the loop-holes in the framework of morality and deceit was writ large. The damage these few have unleashed on the framework of this Great Nation is telling in where we are in our daily dialog. Anger and distrust breeds with equal fervor in our society today.

We have turned into a country of Lobbyists and other large “money baggers.” The bigger the pot, the more “say.” The more the say, the more regulations. The more the Regulations, the more stifling of the “Free Market.” The more stifling of the Free Market, the more the horns of the Socialism dilemma grow. The more of that and we are no different that Venezuela, Cuba and the rest of the totalitarian regimes across the globe. Give that a moment to sink in.

All beings emanating from the Mitochondrial Eve must face the same Common End!! 

So...

For now, ”Live Long and Prosper.” -Spock

Saturday, July 21, 2018

Aircraft LANDINGS Made Easy

Let us talk about landing an aircraft, shall we?



Apparently from what I seem to find when flying with another person and even with another pilot, nothing seems so satisfying as greasing the landing. The rest of the flight blurs and is captured into this singularity called landing. You might have dodged a thunderstorm, you might have experienced a wind shear, you might even have encountered a gusty crosswind, but if, and that is the biggest if, if you didn’t chirp the landing, well then, you just displayed your incompetence.

In fact, several weeks ago, I was a passenger in seat 29A in a B737 on a very gusty day, landing at KEWR. The pilot up ahead behind the bolted doors must have been very good, he touched down smoothly without a lurch. Hmm… I thought, I had fallen into the same trap? Actually no. You see most of the flight on this large aluminum tube was on the triple redundant autopilot, but the landing was definitely the pilot’s, so he gets the award.

On the other hand in our tinier aluminum or composite bodied transportation devices, we can and do use “George” at cruise and sometime through descent but once in the 5-mile vicinity of the airport, it is all on the left seat driver. To put it gently, “You’re it!”

Consider approaching the 45-degree entry for the downwind. It is important to scan traffic and look at the departure end of the runway for traffic and potential landing zones if on a later flight the engine decides to pull a fast one. (VSO specified in this example as 60 kts – adjust Vso and tailor the advice to your specific aircraft accordingly). So on 45-degree approach to runway, Speed Vso * 1.6 (in most cases 95-100kts). Stabilized with the appropriate power settings. Left downwind stabilized at 1000 feet (midfield) above the runway threshold keep the speed to VSo *1.5 (In most cases 90-92 kts). Turning Base reduce to Vso * 1.4 (in most cases between 82-85 kts). Turning final reduce power for Vso *1.3 (in most cases 78 kts). The last 500 feet on final are a matter of experience and practice. In short field approaches reduce speed to Vso *1.2 ( in most cases 72 kts).



Ok, ok, I realize the above rhetoric looks kind of pedantic, but now here is the key to the puzzle. Let’s say you are in a Cessna 172 or Archer aircraft where the power settings are by means of the RPM only. The trick is to set the power setting to the most appropriate setting (Maybe 1600-1700 RPM) and then use the flap settings to realize the speed reductions. This is easily done at altitude on level flights. Go out there in the wild blue and practice this to figure out at LEVEL ALTITUDE say around 1000-2000 feet and see what the aircraft delivers. Start with 2000 RPM and reduce your way to 1500 RPM with increasing flap settings to realize the speeds the aircraft delivers, to figure out what works for the aircraft you are commanding. Once the appropriate speed is determined. Write the power settings and configurations down and voila you have a winning strategy. In the Arrow , Mooney, Bonanza and other Manifold (MP) yielding complex aircraft the idea is similar but slightly different. Establish the power setting with a 17 MP and a 2400 RPM (should get you to gear speed) Put the gear down and trim for level flight and then use the flaps for future speed reductions. Further reduction in power starts at 500 feet on final. Hmm…QED.



Flaps are a great addition to the wings; they provide drag and 30 degree flaps essentially are like barn doors that decrease air speeds and allow us to fly deeper descents to the field without increasing the air-speed. Pretty smart thinking by Edward F. Zaparka in 1932. They also by virtue of the increased camber of the airfoil (wing) help reduce the stall speed. A double advantaged whammy, so to speak. Lower Airspeeds, Lower Stall speeds and viola you can hover down to a chirper landings...most of the time. Except that one time when the Airbus 321 pilot decided to flair 10 feet above the runway and darn near took my teeth out. I can still some days hear that chatter.



Nuance: In gusty winds add HALF the gust (say 320 10G20) or 5 kts to your speed by adjusting upwards the MP or RPM as the case maybe.

Another nuance: The Dreaded, sweaty and bile eating last 500 feet. How do we address that? Simple. My dear Watson!



The power is in your hand. Get your aircraft visually aligned with the runway. Put the nose of the aircraft right on the approach end of the runway and KEEP it there (as if you are in a shallow dive), now adjust the power (MP or RPM) to maintain the Vso *1.3 till you know you have the runway made (which means in case of complete loss of power at that altitude, you can glide to a safe landing on to the runway). But please make sure if this format is different than your instructor’s advice, practice what your instructor says and if any of the above is helpful to your thought process, incorporate while he or she is stuck in the right seat.



As always… Safety is no accident, so FLY SAFE!

Ahhhh...

A short video of 7 Landings in 7 minutes for your viewing pleasure...

https://youtu.be/ozrowvQYv_M



Monday, July 9, 2018

"PERMITS, LICENSES & CERTIFICATIONS"

Humans have a neural substrate of imagined sounds. In music sometime anticipation is used. At times, the musician will withhold a much-anticipated note to increase the desire to hear it by the listener. In fact, our mind predicts such imminent structural pauses as whetting the desires of the potential future. Ringo Starr of the Beatles did that masterfully in his drumbeats. But what happens when that note fails to materialize? It simply jars the mind. 

Why I bring that up is simply to explain the nuances in our current state of society that have subverted the naturally occurring structural pauses into dead ends. Permits and licenses and certifications are everywhere! The pedigree of these chaotically semi-predictable meanderings has long been passed down as pedogogical constructs. We expect them. We know them to happen as the laws of Nature and civility.



Imagine if you will, a 9-year old sitting on a bare-bone furniture of chair beside a table with the following set of artifacts. A Pitcher filled with Lemonade, some plastic cups and a sign “50c Lemonade.” People come and go in front some with a glance and a smile and others willing to partake in the offering. Soon the child has accumulated $8.00 as her revenue and starts on the second pitcher when a blaze of blue and red lights filter across the horizon and stop in front of her lawn. By then, the child is in tears and the parents are answering legal questions to protect their child and themselves. Far-fetched imagination, you think? Nope. It happens in most of the “ultra-intellectual” states of the United States today.

In fact, the other day there was woman aptly termed “Permit Patti” who upon seeing a 8-year old selling water called the police. Ah yes, she was the whistleblower against the 8-year old child. Permit Patti was looking to put an end to the child’s entrepreneurial spirit and dashing all hopes of an innovative mind of the future. A shame!

Yes, we as a society of the “developed and civilized” world have become the most developed “permit, license, certification needs” hungry society of all times. The legion of Rent-seekers are burgeoning to fill the void where common sense once prevailed. A pity! You want to cut a tree down, get a permit. you want to put up a fence, get a permit. You want to add plumbing to your house, get a permit. In fact, you want to have a garage sale, get a permit. Our lives revolve around the “Permit Alleys” of the Municipal buildings and other such Regulatory bodies daily. Still, I haven’t yet seen a permit for practicing witchcraft yet. But I have seen one for landscapers, pest catchers, pet groomers and all other sort of occupations. It appears, the authorities are at the threshold of every mode of work one can do, collecting fees.

via Charles P Kroll CPA


Case in point, once again; Medicine. You need a license to practice medicine governed by a small cadre of physicians and others called the Board of Medical Examiners (BME) (Hmm... The others include; lawyers, lay people, nurses, insurance liaisons and others sought fit to deem if the physician is fit to practice medicine). Each State in the United States has one. (Then there is a Federation of the Board of Medical Examiners a quasi-non-governmental organization that seeks to rent-seek at the National level and recently tried to acquire a large multi-million dollar building in Washington DC near the seat of power to exact some for itself, but failed). Well okay then, that is the law of the land. And away we go to the proverbial “paddy-fields.”

Next, we get to some off-the shelf, quasi-self-appointed-governing body that has coopted some of the BME power over the physicians by crafting a net over the entire nation and wishes to exact its authority and the physician's financial resources around the globe as the global authority in physician knowledge testing. It is a not for profit organization. Using their “(esoteric-)knowledge-based examination certifying that the physician had achieved a level of knowledge above the rest of his or her peers, they claimed, was a badge of excellence, . No support for this excellence in patient benefit or physician benefit has EVER been found. Yet the drum beat goes on. That examination, initially, was voluntary and would cost around $2000.00. But as time went on and conflicted Authors from that Board wrote self-serving papers trying to prove the validity of the need for that examination as a corollary to a physician’ s competence in caring for the patients, the cost now seems well in advance of $10,000.00-$15,000.00 (if you factor in all associated costs). Soon ABIM/ABMS were awash with money, enough to lobby and win the governmental seal of approval. The Certification Examination being a very expensively generated and with proprietary set of statistical modelling tools, was held in “prison-like environment to prevent physicians from copying the questions. See Dr. Westby Fisher’s podcast. 

via Charles P Kroll CPA

The ABIM/ABMS revenue stream was increasing at a geometric scale but not as fast as the salaries of these “esteemed” board member individuals and their lucrative pension plans. They decided that the initial examination was not enough to sustain their avarice and thus the new dictum came down; “all physicians needed to take the recertification examination every 10 years.” There was another revenue spike to the delight of these few. Soon the Cayman island resorts and associated “free-from the prying jurisdiction of the IRS,” banks were frequented for annual, semi-annual and quarterly “Retreats.” A nice multimillion dollar condo in Philly fully furnished with a Mercedes Limousine and Tax-exempt cash stored offshore for safe-keeping became a “brilliant scheme” away from the prying eyes of physicians and others, didn’t it? Or so they thought, till it was brought to light. They concocted the scheme to have a continuous “Maintenance of Certification” operation inflicted upon the physicians, because, well, physicians, they implied, seem to lose their grasp of medicine pretty quickly and their care could not be trusted, because, well, jumbo jets filled with physician mistakes were crashing and causing a high mortality...see the Susannah Fox piece  virtual patient-loaded-jumbo-jets crashing every week. 

Meanwhile the MOC as it was named generated oodles of money to the tune of $160+ million for the so called Not for Profit organization, yet the handsome salaries, bonuses and pension liabilities of these few, continue to exceed the revenue streams. “What to do?” they must have thought? More pseudo-scientific papers were written to convince the need for the maintenance of certification (MOC). Those with vested interests and no SITG (Skin in the Game) http://www.medtees.com/content/MedicareBilling.pdf sang praises as they lined their pockets,while, in the meantime the physician force was getting despondent, depressed and with the burdens imposed upon it from this organization and other governmental Regulatory initiatives, there was a rash of physician suicides. “No, don’t look there!” they implied, “Look here, where we are doing so much “public good,” by testing the competency of the physicians constantly.” But the gig seems to be up!

A few physicians have seen the charade and the façade behind the whole scheme. More are learning daily. And, the dollar-lined walls of these organizations are starting to show deep cracks. 

“Permits,” it’s all about permits and licenses and certificates Oh My!

A society so constrained from achieving its potential will ultimately die from starved ideas. The bureaucratic hold on innovation and entrepreneurship always destroys the desire of the few lurching towards the “Next Frontier.” Only the few crooked ones make out fortunes for a while until the hammer comes down on them: Theranos and her Holmes face, to name one. Where exactly were the permit-granters, allowing $9 billion investor money and hundreds if not thousands of patient harmed based on inexact diagnostic report generation. Where were these “expert permit granting authorities?” Nowhere close because Elizabeth was smart enough to fill her Board seats with well-known politcos and power-brokers so no one dared, until John Carreyrou, a recalcitrant health-care reporter from The Wall Street Journal did. 

So you see dear reader, this charade of “Permits, Licenses and Certifications” is a game for the thrones. Decrees to pay up and shut up. Who thrives is known. Who gripes, who cares?

By the way, I forgot to mention the Medical Organization… It is the American Board of Internal Medicine (ABIM) and American Board of Medical Specialties (ABMS). Other agencies and organizations usurping physician’s abilities to give good care to their patients also include the now famous American Medical Association with 12% membership and most (Almost $200 million) revenues coming from the CPT coding needed for the Electronic Medical Records and Billing… @CharlesPKroll (twitter) a stalwart researcher CPA, adds these miniature bites to inform us:

AMA Membership Dues vs CPT Royalties 2008 - 2016
☐Total Dues: $362.3 million ☐Total Royalties: $673.9 million
☐2016 Dues Down $5.0 million (-11.3%) from 2008
☐2016 Royalties Up $53.5 million (+97.1%) from 2008
☐2017 Dues Down Another $2.5 million

 The American College of Physicians and other specialties with the word “American” before it, all appear in cahoots with raising their revenues thru these quasi-ponzi authoritarian schemes without concern about the harm to patients.

The "note" of humaneness and harmony is missing and there is grave dissonance in the society these days. Maybe it will pass and maybe it won’t. But it won’t be for the want of telling the truth.

Because Dear Reader, remember, if you harm the physician, you also harm the patient! 

I wonder how they (the rent seekers) can live with that?

https://www.vanityfair.com/news/2016/09/elizabeth-holmes-theranos-exclusive