Category Archives: Government and Politics

Hacking by Russia is a serious matter: here’s why

Pinpointing why Russia’s desperation led to their meddling in American democracy to get Trump elected – and how that is now playing itself out through the appointment of Rex Tillerson.

It is well known that Russia is in an economic funk because of super low oil prices. Russia’s national reserves have shrunk by two-thirds since the start of hostilities with Ukraine in 2014, falling from roughly $88 billion) that year to roughly $30 billion. In August, their real incomes dropped 8.3% from a year earlier.

Russian troubles are made worse by two Obama policies – which Secretary Clinton would have maintained: 

1 Sanctions on trade with Russia
2 Reduce dependence on foreign oil

As to dependence on foreign oil, the energy security policies of the Obama administration are also well known, and have achieved amazing success over the recent past. The emergence of natural gas and alternative energies have essentially freed America from being held hostage to foreign oil interests, including Russia. 

As to sanctions, two facts are not well known. First, Exxon leases a staggering 63.7 million acres of Russian land.  This is over 5 times the amount of land it leases in the US. Second, Exxon inked a “deal” with Russia – a gigantic $500 billion deal – which was blocked by sanctions in 2014. The deal was central to Russia getting out of their economic funk, and they subsequently went with a fallback plan: to sell a 19.5% stake in their state-owned oil company Rosneft for $11.3 billion to Qatar and others (announced last week). Many speculate that Trump’s election and the potential for an improved Russia investment climate made this deal possible.

Could the decision by Russia to meddle in American democracy lead to a lifting of sanctions and a thawing of Russia’s awful investment climate? In exchange, could Exxon Mobil get there $500 billion deal back on the table? 

Is it an accident that Robert Gates, for sure, was the person who advised Trump to look at Tillerson, and that Gates is on the payroll of Exxon Mobil?

Could this be the scandal of the century? You can’t make this up!

Please …. check my sources and correct the record if you can. I think I have the facts right!

CREDIT: https://thinkprogress.org/trump-putin-and-exxonmobil-team-up-to-destroy-the-planet-fb88650acfa1#.euuvdrjjq

CREDIT Russia’s $500 billion oil deal with Exxon was killed by U.S. sanctions. Wall Street Journal, 9/11/2014.

CREDIT: https://www.washingtonpost.com/politics/trump-wasnt-happy-with-his-state-department-finalists-then-he-heard-a-new-name/2016/12/13/0727658e-c161-11e6-8422-eac61c0ef74d_story.html?utm_term=.4e5d59c79a9a&wpisrc=nl_az_most

CREDIT: http://oilprice.com/Latest-Energy-News/World-News/Oil-Price-Collapse-Pushing-Russias-Economy-To-The-Edge.html

CREDIT: http://www.forbes.com/sites/timdaiss/2016/10/28/why-u-s-oil-production-trumps-any-russian-opec-deal/2/#71646c9b165d

CREDIT: http://fortune.com/2016/12/10/twenty-first-century-fox-sky-bid/

CREDIT: https://www.bloomberg.com/news/articles/2016-12-14/what-could-trip-up-tillerson-on-capitol-hill-a-viewer-s-guide

CREDIT: https://www.bloomberg.com/view/articles/2016-09-26/russian-economy-takes-hit-fron-putin-s-grip

CREDIT: http://www.forbes.com/sites/realspin/2016/11/02/russias-road-to-economic-ruin/#2de337cc5a30

CREDIT: http://blogs.ft.com/beyond-brics/2016/11/24/could-trump-help-revive-russias-economy/

“Direct Primary Care”

Its pretty clear that a coalition of “direct primary care” providers is pushing Congress to recognize subscription services as a service reimbursable under Medicare.

I believe they are differentiating themselves from “concierge” care, for political reasons. The coalition says concierge care is $2000-$5000, instead of under $2000. One of the main advocates for direct primary care says that it does not seek third party reimbursement, while concierge services might.

“The Primary Care Enhancement Act of 2016” has been brought to the Ways and Means Committee, where is was referred in September, 2016 to the Health Sub-Committee.

Sponsor: Rep. Paulsen, Erik [R-MN-3] (Introduced 09/13/2016)
Committees: House – Ways and Means
Latest Action: 09/19/2016 Referred to the Subcommittee on Health. (All Actions)

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Direct primary care could get a big boost next year. Under the federal health care law, these practices will be able to operate in state-based health insurance exchanges. However, insurers on exchanges must offer a basic benefits package that includes hospital, drug and other coverage, so direct primary care practices will likely team up with other health plans.
If you’re considering a direct primary care practice, get a list of provided services and talk with a physician in the practice. Also, some practices that are similar to concierge care may accept insurance but charge a monthly fee for extra services. For options in your area, visit the Web site of the Direct Primary Care Coalition (www.dpcare.org).

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The Primary Care Enhancement Act of 2016  proposes to amend the tax code so consumers can use their health savings accounts (HSAs) to pay physicians in direct primary care (DPC), bypassing insurance. H.R. 6015 would also enable Medicare enrollees to pay for direct primary care using Medicare funds, rather than pay out of pocket.

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http://www.dpcare.org

Senators Bill Cassidy, MD (R-LA) and Maria Cantwell (D-WA) have introduced bipartisan legislation which clarifies that DPC is a medical service for the purposes of the tax code regarding Health Savings Accounts. The bill also creates a new payment pathway for DPC as an alternative payment model (APM) in Medicare. “Co-sponsors are important. They show Senate leaders that there is widespread support for the legislation,” said Sen. Cassidy when he addressed the DPCC Fly-in Sept. 24. We need your help today to ensure that S.1989 moves forward.  Please contact your Senators and urge them to co-sponsor the Primary Care Enhancement Act today.

On the Move in the States with DPC
16 States Move to Clear Regulatory Hurdles for DPC 
Legislation  defines DPC outside of Insurance.
 
As of June, 2016, 16 states have adopted Direct Primary Care legislation which defines DPC as a medical service outside the scope of state insurance regulation. 
 
The DPCC has developed model legislation to help guide legislators and their staffs on the best way to accomplish  this important reform. Click here to see the model bill.
States With DPC Laws:

• Washington – 48-150 RCW
• Utah – UT 31A-4-106.5
• Oregon – ORS 735.500
• West Virginia – WV-16-2J-1
• Arizona – AZ 20-123
• Louisiana – LA Act 867
• Michigan – PA-0522-14
• Mississippi – SB 2687
• Idaho – SB 1062
• Oklahoma – SB 560
• Missouri – HB 769
• Kansas – HB 2225
• Texas – HB 1945
• Nebraska – Leg. Bill 817
• Tennessee – SB 2443
• Wyoming – SF0049

Current as of June, 2016

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Direct Primary Care is an innovative alternative payment model in primary care model embraced by patients, physicians, employers, payers and policymakers across the United States.The defining element of DPC is an enduring and trusting relationship between a patient and his or her primary care provider. In DPC unwanted fee-for-service incentives are replaced with a simple flat monthly fee. This empowers the doctor-patient relationship and is the key to achieving superior health outcomes, lower costs and an enhanced patient experience.
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http://medicaleconomics.modernmedicine.com/medical-economics/news/bill-could-allow-health-saving-account-use-dpc

Direct primary care physicians charge patients a monthly fee for care and access to a package of services rather than by fee-for-service or insurance. The subscription model can grant patients increased access to doctors, discounted drugs and laboratory services. 
According to Meigs, the proposed law will allow people with high deductible plans to use their HSA to pay for primary care, given that people with high deductible insurance plans can use their insurance for catastrophic coverage and hospitalizations, and cost-effectively tap their HSAs for primary care.  

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Direct primary care and concierge medicine: They’re not the same

Direct primary care and concierge medicine: They’re not the same
SAMIR QAMAR, MD | PHYSICIAN | AUGUST 24, 2014
Samir Qamar
Direct primary care (DPC) and concierge medicine are rapidly growing models of primary care. Though the terms are used interchangeably, both are not the same. Such liberal use of terms, many times by even those within the industry, confuses those who are attempting to understand how these primary care models operate. As former concierge physician for the Pebble Beach Resorts, and subsequent founder of one of the nation’s largest direct primary care companies, I have attempted to differentiate the two based on extensive personal knowledge and experience.

First, concierge medicine. Born in the mid 1990s, this practice design was first created by wealthy individuals who were willing to “bypass” the woes of the current fee-for-service system by paying a subscription to access select primary care physicians. This access consists of same-day appointments, round-the-clock cell phone coverage, email and telemedicine service, and sometimes, as in my previous practice, house calls. Although some high-end practices charge as much as $30,000 a month, most charge an average monthly fee of $200.
In return, to allow such unrestricted access, physicians limit their patient panels to several hundred patients at most, a significant drop from the typical 2,500-plus panel size most doctors are used to. Many concierge doctors also bill insurance or Medicare for actual medical visits, as the monthly “access fee” is only for “non-covered” services. This results in two subscriptions paid by patients — the concierge medicine fee, and the insurance premium. Importantly, a few concierge practices do not bill insurance for medical visits, as the monthly fees cover both access and primary care visits.
Direct primary care started in the mid 2000s, and was created as an insurance-free model to serve a new patient population: the uninsured. In DPC, patients, and now their employers, are also charged a monthly fee, but the fee can be as low as $50 per month and there is typically no third-party payer involvement. Consumers pay physician entities directly (hence, direct primary care), and because the insurance “middle man” is removed from the equation, all the overhead associated with claims, coding, claim refiling, write-offs, billing staff, and claims-centric EMR systems disappears.

Patient panels can be as high as 1,500 patients per doctor, and there is typically no physician cell phone access or house call service. Similar to higher-priced concierge practices, DPC practices also allow for longer patient visits and telemedicine. The most important characteristic of DPC practices, however, is that insurance claims are not filed for medical visits.

Direct primary care’s definition, therefore, is any primary care practice model that is directly reimbursed by the consumer for both access and primary medical care, and which does not accept or bill third party payers.
Confusion arises from similarities that exist in both models, such as decreased patient panels, monthly subscriptions, and longer visits. There is added confusion when a DPC physician offers house calls or email access, typical of concierge practices. Confusion is maximized when a physician is by definition practicing direct primary care, yet calls the practice a “concierge practice.” Similarly, a concierge practice may decide to abstain from participating in third party payer systems, and thus would also be a DPC practice.
The distinction is important because direct primary care is explicitly mentioned in the Affordable Care Act, while concierge medicine is not. Several state laws have also recognized direct primary care as medical practice models, and non-insurance entities. In addition, the term “concierge medicine” causes visceral reactions in select social and medical circles, drawing criticism such as elitism and exacerbation of physician shortage.
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In summary, not all direct primary care practices are concierge practices, and not all concierge practices are direct primary care practices. The terms are not synonymous, and even the basic fundamentals of either model do not overlap. The key to differentiation is whether or not a third party payer is involved. If not, then the model is a direct pay, or direct primary care model, no matter what the fees.
Samir Qamar is CEO, MedLion and president, MedWand. He can be reached on Twitter @Samir_Qamar.

Corridors

This idea of corridors has occurred to me over the last few months. I know of no references for the way of thinking that I will try to describe here. I am sure these references exist, but I do not know where they are.

Applications of Corridors
Corridors have application in law, and its sister concept of regulation; in design, and its subset applications of architecture, landscape architecture, interior design, and fine arts, such as drama, art, music, and dance; in policy, and its subset applications of corporate policy, or global, national, regional, and local policy (bodies of legislation and accompanying case law and precedent is a broad variant on this idea); in education, when schools ask students to specify a major, to join a department, or to specialize in a field; and in careers, when individuals define their own professional corridors, e.g. in engineering, software design, medicine, law, business, etc.

The Core Idea of Corridors
The core idea is this: productivity is a function of well-designed corridors. Design a corridor that is too narrow, and productivity is stifled. Design a corridor too wide, and productivity suffers from too many permutations and combinations of possibilities.

If any given project is vague, then the progress of the project managers is limited as they attempt to find a path forward that makes sense. Once found, a clear path forward leads to progress in leaps and bounds. If the path forward is not found, among a myriad of possibilities, then project teams flounder and are frustrated.

Corridors in Law
A law is a corridor hammered out by the legislative body. Designed well, a law specifies the corridor by which activity is “legal”. And conversely, a law specifies which activity is “illegal”. Along with the idea of illegal comes the the sanctions applied to those unfortunate enough to be caught doing something illegal.

Corridors in Regulation: the Sister Concept to Corridors in Law
A regulation reflects the desire of a law-making body to avoid making the law itself too narrow (where the language of the law effectively gets into counter-productive micro-management). It reflects the delegation of authority from the law-making body to an agency. The agency is charged with coming up with “regulations’ that define the tactics of the law. Done well, regulations always remain within the corridors outlined in the law. They reflect the intention of the law, and are an executional element of the law. Done poorly, regulation stray beyond the corridors outlined in the law, and can serve to confuse the public and frustrate the law-makers.

An example of Corridors in Law and Regulation: Social Security
FDR is known for making Social Security the law of the land. The US Congress, in adopting Social Security, effectively defined a corridor for aging in the US. From its adoption forward, older citizens who qualify for Social Security are entitled to a “safety net” of income. Because Congress recognized that this entitlement would require dynamic adjustment over time, it authorized the Social Security Administration to publish regulations that would tactically implement, and to adjust over time, the intentions of the law.

Corridors in Design
Creatives focus. The really great ones define corridors for their work. The corridors are broad enough to be highly motivating to the creative – who yearns for freedom of thought and expression. At the same time, they are narrow enough to allow the creative to be highly productive, by applying and reapplying their creative concepts within a relatively narrow scope.

An example of Corridors in Design: Steve Jobs and Apple
An example is Steve Jobs and Apple – a brilliant example of choosing a corridor for creativity and productivity. Apple defined the personal computer as their corridor – with stunning success. As they achieved preeminence in this field, Apple was able to see a larger corridor, which the world now sees as the ipod, iPad, iPhone, and – now – the iWatch. Are these new consumer appliances different than a “personal computer” – the corridor of the original vision? I would argue that they are not different: they are applications of the personal computer corridor, brilliantly subsuming appliances from other corridors into the corridor of personal computing.

Corridors in Policy
I mentioned that policy is an area where the notion of properly chosen, well-defined corridors can lead to high productivity. Corporate, Global, National, Regional, and Local Policy-Makers must constantly struggle to define corridors within which citizens and institutions within their sphere of influence must operate.

Urban Policy as an Example of Corridors in Policy
Take urban policy as an example. Urban design policies found in comprehensive plans and zoning ordinances. These plans and regulations reflect policies about where a given city wants to grow. How much growth should be in industrial, commercial, and residential ? Where are the geographies slated for each? Where does mixed-use fit? What procedures allow for changes over time?

Corridors in Education
Education is probably the most classical application of the example of a “corridor”. It is impossible to know everything. So educators attempt to guide students in narrowing their field of study. An undergraduate education might well define “liberal arts” or “engineering” as a corridor of study. A graduate program might define “public administration” or “mechanical engineering” as a corridor. Unfortunately, however, there are far too many examples of students getting lost in a corridor as large as “liberal arts”. Out of frustration parents and students alike may well force a narrower corridor. Chosen well, such a narrower corridor, e.g. history, can focus the mind and increase productivity and creativity. At the same time, there are far too many examples of those who define an educational corridor that is too narrow, e.g. automotive mechanics.

Example of Corridors in Education
90%+ of US students follow a corridor path that is well-known. They might, for example, take liberal arts as an undergraduate, and major in a science, social science, language, or fine arts. But US students may well have the sites set on graduate school, and so they stay very broad in undergraduate courses so they do not limit their choices in graduate school. A law or medicine graduate student does well to stay broad in undergraduate classes. The medicine corridor in graduate school would naturally expect more science course. The law corridor in graduate school would be inclined to expect high proficiency in writing and communication and analysis as an undergraduate.

Corridors in Careers
What is my career path? Virtually everyone struggles with this question. It is a corridor question and brings with it the same perils of other corridor choices. Choose a corridor that is too narrow, e.g. cost accounting, and the person runs a real risk that opportunities will rapidly fall outside the chosen corridor. The result will be career confusion, as job choices can be endless, and dead-end job choices are everywhere. At the same time, choose a career corridor that is too broad, e.g. systems design, and the person runs a real risk that no employers trusts that the applicant is qualified for a specific job that is available.

Example of Corridors in Careers
Sales is a reasonably common example of a career corridor filled with endless possibilities, and yet it is very specific in the eyes of an employer. “Show me proof that you can sell”, they might say. And with that proof, they may well not care if they have proof that the person can sell a specific widget or software or product or service.