Apparently, it’s newsworthy that the medical office uses iPads. No, not really.

Um, we went to the store, paid $whatever, and then turned it on. Just like anybody else could. In fact, I didn’t even go to the store. Steve did that.

I don’t understand why people are so excited about who is buying iPads and why. Yes, iPads are useful tools, and I like them, but buying one doesn’t make you a genius. More importantly, an iPad isn’t going to somehow make your money my money in zero words or less which is my standard criteria to judge anything that isn’t somehow producing healthcare for patients. However, the iPad did seem effective at making my money Apple’s money before we even got an iPad, so that is impressive —for Apple.

Medicare has cut its already low rates… or simply refuses to pay claims. Private insurance is increasingly not paying claims. Credit is not available to anybody, general operating expenses continue to rise, and all spending —especially individual spending— continues to fall.

Meanwhile, state and federal governments continue to “address” this “issue” by forcing new legislation and escalating enforcement —further compounding economic stress with abstruse legal liability.

Financial panic, plus denial, plus institutional instability, plus a confusing blob of new laws that nobody understands but supposed to be really scary and have impressive acronyms?

This here is Scam Season.

Home Health Care: “Healthcare” is now apparently both a “growth industry” and “recession proof,” and in “times like these,” you too can “control your own destiny by starting your own business in healthcare.” Just buy these books, attend these seminars, sign here here and here… and congratulations! You are not officially (empowered to be) a Healthcare Entrepreneur! Now… if only you could somehow clutter my office with your glossy trifold brochures with old people on them, you’ll be rich… wait, you did!? You win! The Economy!

Do the math: Free Money. From The Government. You can’t lose!

I think so far we’ve had four individual “new exciting firms” solicit our very small, very under-publicized medical office to… you know what? I’m not really sure what these people are selling. It’s something to do with old people and glossy brochures and old people on glossy brochures.

Yah, I do make it very awkward on purpose when you ask me to “exchange business cards,” and then when I pretend that you’re a patient who has confused an appointment? Yah, I know that you’re not really a patient. In fact, basically, everything out of my mouth will be rambling worthless nonsense until you dread even the suspicion that I could be in the office. (Also see: common responses to “can you fix my wireless Internet?” “Well, that depends.”)

Aside: I have bad news for you aspiring “healthcare entrepreneurs”: unless you can make diagnosis or prescribe drugs, I promise you, your “new career” is already obsolete because 1) computers do it 2) or your compensation scheme is already targeted for fraud by Medicare. Unless… you new career is selling “career opportunities.” That business seems to be booming.

Hospital-Sponsored-But-Independent-Seriously-Trust-Us Physician Organizations: the fad of Independent Physician Associations from two decades ago is back, but this time, it’s not your good buddies the HMOs, it’s your friendly local medical conglomerate! and they’re really excited to spend the all the money they don’t have to buy … well, they don’t know what exactly they will buy, but it will be expensive, and everybody is doing it, and MOST ESPECIALLY, whatever it is, it will NOT fall into the claws of Evil Neighboring Medical Conglomerate and their corrupt schemes for total domination. Just, um, you know, computers and efficiencies and stuff. Just… trust us. We went to Yale / Columbia / um, we’re rich? Yah… that physician restrictive covenant? That’s just boilerplate. Don’t be such a sorry sally. My business school professor was totally like, eludicated, that you’re supposed to buy up all the providers in a down economy, and there was a Microsoft Excel Spreadsheet, so now what, you’re better than Yale / Columbia / um… don’t you like money?  Yah, dats wat I THOUGHT.

Do the math: Free Money. From The Government. You can’t lose!

I don’t think I need to elaborate here. You know who you are. Please print more copies of my website and continue pester me with tattling. In exchange, I’ll continue to try and estimate the immediate liquidity and regulatory exposure of your operations. Thanks.

No law, no precedent, no damages, no crime, no jurisdiction, no evidence, no proof?

No problem!

For Law is the Strange Game of Kings, who worry not about trifles like these, as the winning move is not to play, but he loses least survives the most to play, and play again!

Shall we play a game?


EXECUTE LAWGAMES

10: PROMPT: Are you a King? If True, GOTO 20; else GOTO 30;

20: Do whatever you want. It's not your time, money, or problem. GOTO 100;

30: PROMPT: Are you a Minion? If True, GOTO 40; else GOTO 60;

40: PROMPT: Do you have a legitimate, documented legal grievance with a clear cause of action and the jurisdiction to pursue? If True, GOTO 50, else GOTO 50;

50: Spread rumors in the guise of dispassionate bureaucratic proceedings to defame and distress the opposing party. Constantly demand an "ongoing discussion" at the opposing party's expense in a context you control. Cobble together obscure, irrelevant details which often you yourself manipulated into existence into some complaint only vaguely related to the actual grievance but with consequences so dire and reasoning so abstruse that the opposition cannot ignore you. Continue to reap the well-deserved fruit of your laborious and highly specialized administrative career by surfing Google for obscure bureaucratic material to fight for people you don't know over matters you don't understand ---nor would ever want to. Swallow your tears and grind out that last extra hour in document review like the fired hardened rockstar that you are as you reminisce about that one time your date didn't return your calls after you slipped into that impassioned soliloquy about the Cost Savings Initiatives (CSI) you championed in the Big TPS Coversheet Section 13 Article 43 Debacle at the office. Secretly hope that the opposition simply disappears. Think about your cat. GOTO 100;

60: GOTO 100;

100: LAWGAMES CONCLUDED. WINNER: NONE


Apple + Google* runs my primary care medical practice. Patients enter their information in Google Form on an Apple iPad in the waiting room or at home on their computer. A Google Calendar displays the patient appointments on a big screen in the waiting room on the web alerts the patient when an appointment is ready. The patient records, plus any paper or insurance cards scanned into Dropbox using Fujitsu Scansnap, are wirelessly available to Dr. Steven Murphy’s iPhone, iPad, and HP Touchsmart office desktop for his reference during examination while moving about the examination rooms. After medical service, Steve enters the CPT and ICD (medical service and diagnosis codes, respectively) into a Google Spreadsheet for billing. In the background, software using Gdata uses these records to bill insurance and the patient’s credit card via Authorize.net and MDonline. Later, Steve dictates his complete medical note using Dragon into a Google Docs template. In the afternoon, Steve makes rounds on patients at Greenwich Hospital and Greenwich Woods nursing home using his iPad and a Google Spreadsheet to keep logs while always on call via Gmail on his iPhone.

In the meantime, calls, faxes, and emails to the Office are routed through RingCentral and Google Voice, MyFax, and Gmail respectively to Gmail accounts which process, filter, and route messages to my sister and her roommate at University of Toledo for reception. Spam is filtered, and patients are scheduled by phone or email using Google Calendar, and clinical messages are forwarded to the doctor’s or patient’s attention. Because Gmail automatically archives all messages, the computer automatically and securely files, sorts, and stores all communications for easy future reference, transmission, and processing. (Are you an insane backcountry Greenwich narco addict with delusions of aristocracy who soaps up my little sister for hours over the phone because we don’t jump around like dogs to get you drugs because “somehow” you “lost” them and you simply “cannot” schedule an appointment? One button, poof! You are spam. Good bye. Tell it to your horses.)

Medical inventory is managed by rolling “drawer carts” assembled from clear plastic drawers and metal shelving purchased at Home Depot. Each transparent drawer is labeled with a QR code of a URL to be scanned by your iPhone to go to the McKesson or Amazon webpage for that drawer’s restock. (Actually, I’ve paused the QR scanning project because inventory projects cost money and I’ve been busy with collections. I can’t program websites when I’m busy telling old ladies with uncontrolled diabetes that their medical insurance doesn’t cover $100 in copays and that I’ve dropped them from the practice when they threaten me about it to me over the phone.)

For medical reference, why, we use Google.com Search of course! Why go to “school” to be a “medical biller” when Wikipedia has the world’s best diagnostic reference online for free?

Of course, we never use Google Health which is Silicon Valley’s second** most embarrassing politico boondoggle of worthless garbage —even though Google pushes Google Health to the top of search results. Where are the ICD codes? Oh, you mean the magical language that standardizes pages of indecipherable handwritten notes and legacy medical terminology into an easy-to-type-and-process tokens understood worldwide which are required for all medical billing? Oh no, Google Health is more about FACETIME for flawless resumes. (Where are the faces of the people who made Gmail, Search, and Docs?)

All of this is for you —any person, patient, or doctor— to purchase and assemble yourself with no evil bizdev blueshirts and their stupid websites at consumer prices. Need something really fancy not mentioned here? Google Shopping or Amazon.com. Hell, go visit Best Buy in person if you want that procrastinaty retro consumertime vibe for the day.

You can see this for yourself if you are in the Fairfield County, CT area. Schedule an ordinary, boring physical or sick visit by email at 9hh@hhdocs.com. We accept most medical insurances.

Currently, I’m working on patient accounts for billing and medical records in Python Google Apps and networking and billing tools for the independent Greenwich Physician Association which is headquartered in the office adjacent to mine. Also, I ordered a Counsyl genetic test for myself and am waiting for the results. If the results are good, then I’m unilaterally applying Counsyl to our regular medical physical procedure for all patients of childbearing age. SO: HA! Genetics as standard primary care! Eat me, 23andMe! (but… do need to wait for results before applying…)

PS: My sister and I will be at Google I/O this May. Ideally, I can get the hell out of this horrible, horrible town and do some real engineering remotely where I don’t have to deal with detachments of worthless, decaying dependents to retired millionaires who tattle to Grandpa, fucking President of Whatever, about every $76 bill for coinsurance.

*Enterprise edition with no advertisements: selling patient data for marketing is evil, dishonest, and unlawful in medicine)
** #1 is 23andMe. Special recognition is in order for a medical genetics test which not only is hostile to medical use by design, but EXPLICITLY FORBIDS medical use in its Terms of Service.

Yes, I get it. You want to “free” the “masses” from the “evils” of International Classification of Diseases (ICD) and Current Procedural Terminology (CPT).

Yeah, just like how AOL wanted to “free” the “masses” from the “evils” of Universal Remote Location (URL).

Yes, I agree that the American Medical Association is obnoxiously aggressive about CPT copyright… but ICD? You have a problem with the World Health Organization (WHO)?

I was in elementary school during the first dot-com boom, but even I know the “redefine words” game from way way back when AOL and every other obnoxious portal site tried to redefine reality in the vocabulary of their own private text box.

ICD-9 is moving to ICD-10, and Google Health, you could have done the world good by easing the transition by understanding ICD as a domain addressing system for medicine like its intent. But no. Google Health, you wanted to play the greedy “newspeak key word game” with the entire Google search engine. Never mind that medical vocabulary is spread over multiple millennia, languages, and cultures and can’t be trusted for credible medical documentation for any purpose including billing. Right? So you’re just going to “help” “simply” the “vocabulary.”

Assholes.

Thank God for Wikipedia.

Same billing codes. One month ago.

If you thought $.45 on the dollar was bad… well, now it’s $.20. I posted this just in case you thought “oh, maybe Cigna had a good reason to not cover your service.”

And why does Cigna not pay us? Oh, I’m sure it’s somehow “our fault.” I’m sure I could spend two hours fighting on the phone, fax, and snowmail to learn nothing about why we’re not getting paid.

Hey, did you see? They have a website! All I need to do is fax their registration form, and they’ll send a “team of healthcare representatives,” to “install” their website on my computers, and then I can learn why their not paying me in Internet Explorer 6 via a Java plugin which doesn’t work on their usually broken website exactly as slowly as receiving Cigna’s snowmail! Aren’t computers great?

I guess we didn’t study hard enough to make the Cigna grade this time. I guess we’ll just have to Try Harder. Will I be able to bare the shame of not meeting my obligations as a loved and trusted member of the Cigna family? No. Also, it’s almost certainly a violation of “contracts” and “HIPPA” (misspelled, of course) to post this sentiment and these bills on a public website.

Here’s how much of your thousands of dollars in medical insurance premiums actually go to the medical doctors who do the work.

This is a settlement from Cigna for $89.57 of a $475.00 medical bill including a complete medical physical and a new patient office consult of moderate complexity. This represents about one to two hour of our medical and administration time providing service including review of records, intake, and documentation. A full roster of patients like this (which we don’t have, thank God…) works to be about $30 per hour per doctor. That’s gross revenue… not salary, not profit, and this is for one of “America’s most exclusive communities” (gag)… At 160 hours of work per month, that’s $4800 per month in sales, which is just barely enough to make minimum payments and rent.

Let me tell you what happens now:

Either:

1) I debit this patient’s payment card for the remaining unsettled balance ($250). Unfortunately, more and more people provide to us completely maxed payment accounts. Either this charge will clear and ruin this patient’s monthly financies, or this patient will be denied due to abject poverty, or because this is Greenwich, Connecticut, this patient is on Trust Fund Welfare, whomever is the “poppa/mamma bear” of this family will try to confront the medical doctor directly and complain. If bear already (unfortunately) knows me by name, they will demand that I am disciplined.

I assure you 100% that this patient is completely convinced that he “saves money” by buying medical insurance and would simply not believe that not only is all insurance —especially medical insurance— an almost guaranteed financial loss in all expected circumstances, but also, that his “fiscal responsibility” doesn’t protect him from being billed twice —once for “insurance,” and again because insurance refused to pay.

Aside: isn’t it funny how much money we spend trying to “save money?”

2) I don’t debit this patient. I inform the patient that he may apply for financial assistance, the patient has a private freak out about how “everything is circling the drain,” and I never hear from the patient again. Meanwhile, the office itself either:

a) goes bankrupt (“acquired”) and nobody gets any medical care outside of the hospital meatgrinder (and hospital collections are far more ruthless and expensive)

b) increasingly charges fewer patients with some financial support for the poor while people in the middle —enough to pay something but not enough to qualify for financial assistance— …get no service whatsoever.

Healthcare is diverging: either you get Private Flight service, or you get the DMV factory line. If you are somewhere in the middle: I have news for you, you better pick a side now, because it’s not so much that flight is impossibly expensive… it’s that it’s not for sale… to you.

Note: there is little correlation between quality of insurance and socioeconomic status —unless you are an informatic or organized labor.

At university, an exchange student fresh from Shanghai and I were watching television during dinner –but she was confused. Why all the political commercials? Wasn’t this considered crude in America?

“Oh yes, that’s why they work.” I told her. “You see, in America, nobody is better at propaganda than other Americans. It is our primary export! (Though we usually call it finance or marketing or business development.)

So excellent are Americans at propaganda —because, remember, Americans themselves pride themselves in ‘media savvy’— that the only kind of propaganda that really works is propaganda so painfully obvious that Americans could not believe that we ourselves could be fooled by such an attempt to fool us. We think we know better. Then, we are fooled.”

So unlike China or any places in the world, American propaganda is always true! —assuming you mean “true” to mean “not a lie.” To learn the real truth, simply assume all reported facts must be true, invert the connotation, and voila: the truth! Isn’t that great? A culture so dishonestly honest that all you have to do to know reality is to believe what is bad is good and what is good is bad for the exact same reasons why everyone else will disagree with you.”

“So…” she tries, “that’s how to be successful in America?”

“Oh no.” I laugh. “That’s how to be sure everybody will hate you. If you already aren’t wealthy, then you’ll almost certainly never be, because that’s the way the world is and always has been everywhere no matter what.”

And… that relationship didn’t last long.

By the way, did you hear? 23andMe is hiring. That is a fact.

…and thank goodness, because you know what else is a fact? That your medical insurance won’t pay for healthcare anymore. Nope! That was all those “cost saving initiatives” you all have been so excited about recently. Good thing that now you’re “empowered” to figure out medicine for yourself on the Internet. So long, and thanks for all the fish money intellectual property!

I can’t speak authoritatively for any state except for Connecticut and by word of mouth for New Jersey, but ATTENTION INTERNET: MEDICARE STOPPED PAYING CLAIMS.

The official “recommendation” from “various agencies” is to “not submit claims” until “the government” rules on a “planned” 10-30% rate cut for Medicare’s already frighteningly low reimbursement rates at a time when many healthcare providers are already operating at a loss with no liquidity.

Apparently, Medicare can’t pay outstanding claims at full value now, and regional Medicare processors were struggling to process the regular flow of claims before… but now all providers are sitting on their Medicare claims to all be submitted in One Big Run on the Bank of CMS.

We are. The physician association billing service claims to be doing this for all area physicians “as recommend.” So are other major providers like nursing homes.

So the healthcare system was already stressed, and now all creditors (healthcare providers) are sitting on Medicare claims to all submit “some time” in the “near, unspecified future.”

This is bad.

Aside:

A letter from Practice Fusion’s CEO, Ryan Howard:

The money is on the table… Practice Fusion guarantees that our EHR will be certified and available to all physicians who want to qualify for 2011 HITECH payments.

There several million people over the age of 65 who would like to know where this “table” is on which “the money is on,” Ryan Howard.

Source: Medical Group Management Association

Basically: you can try to collect $.80 on the Medicare dollar now, or you can wait to see how this bill bounces around —and in the meantime, you don’t get paid.

Senate sends amended payment freeze bill back to House

Earlier this afternoon, the Senate passed an amended version of H.R. 4851, the Continuing Extension Act of 2010 by a vote of 59 – 38. The bill freezes Medicare physician payments at the current level through May 31. Because the Senate failed to pass identical legislation addressing the extension of the Medicare physician payment freeze by last night, Medicare contractors may begin processing held claims today with the 21.3 percent cut in place. Since the Senate version of this extenders legislation is different than the version passed by the House on March 17, the House must also pass this bill before sending it to the president for his signature. The House Rules Committee has already approved a rule allowing for swift consideration of this amended version of H.R. 4851. The House is expected to act on this bill later this evening.

Spoiler alert: a small, one-time payment in “Medicare Bonuses” are not going to cover a 20% cut in reimbursement.

Hey! Do the math! I’ll pay you about $20,000 (in medicare bonuses) now…. and you agree to a 20+% cut in all claims forever! What a deal!

Rachel Lehmann-Haupt writes about Counsyl

I’d like this to sit on the Internet for the next fifty years —just in case Rachel feels like it is ever personally expedient for her to pretend this article was never published should fashions and politics in reproductive medicine ever shift like they tend to do…

Title: Want a Perfect Baby? Counsyl Says: Just Spit

Translation: Eugenics is bad, but Counsyl isn’t Credible

Breakdown: Spitting is considered crude in all cultures, but especially European cultures. The idea of a “Perfect Baby” is taboo because it is an allusion to eugenics. However, all parents want “perfect babies.” Thus, Rachel allusion is that Counsyl promises something both impossible and taboo —but as immature upstarts who need gentle correction and merit little actual attention.

1: Counsyl is a me-too scam

Every expecting parent wants to have a perfect kid. Counsyl, a new Redwood City, Calif.- based genetics company, hopes to profit off this fantasy by selling a cheap(er) genetic test that claims to screen out 100 dangerous genetic anomalies.

Breakdown: [everybody wants something perfect but that's impossible.] Counsyl: “new” “hopes” “profit” “fantasy” “cheap(er)” (even less credible than other already low-value tests) “claims” [something vague, dubious, but scary].

Photo: Little Child Spitting Water

flickr for “Spit”

Caption:

“Water play in my bathroom. -Homage to rebekka’s “talk” series

Translation: First word Rachel associated with “Counsyl” is “spit.” What a buccal DNA sample has anything to do with “water play in my bathroom” is: nothing. Rachel doesn’t care because she doesn’t take Counsyl seriously. She didn’t even bother to post a picture of the logo, company, or product. Flickr “spit,” copy-paste… next!

2: Counsyl is Heterodox

Even with the creepy Gattaca undertones, Counsyl’s technology could potentially save lives and health care dollars as a kind of preventative medicine. But the accuracy of the new technology is still in question, and it’s unclear if the masses really want to know these answers to such questions — even if insurance is willing to pay. Accuracy and large-scale adoption is the formula Counsyl needs to make its business model work.

Breakdown:

Even with the creepy Gattaca undertones,

First: “creepy” is intelligentsia for “heterodox.” Also: a movie reference. Pop culture. Not serious.

Counsyl’s technology could potentially save lives and health care dollars as a kind of preventative medicine.

[dubious... unrecognized technology] “could” “potentially” [dubious... impossible promise] [dubious... includes profit motive] “kind of” [dubious] [dubious].

Also: there is no such thing as “saving health care dollars.” YOU DON’T PAY FOR HEALTH CARE! There is only “insurers not paying claims with money they’ve already collected from your employer.” Any “savings” is money already paid by you to pay the margin calls for your big broke investment bank medical insurer (Aside: Medicare of Connecticut flat refused to pay providers for all claims this month. Your “cost saving initiatives” in action.)

But the accuracy of the new technology is still in question

This is a baldfaced lie so astounding that it breaks my concentration just to read it. The Counsyl “technology” is extremely accurate —especially by medical standards —and you can rerun tests if necessary. It’s the immediate clinical application of this extremely accurate data which is not well understood —which is not especially problematic considering the low cost and immutability of your genotype. I don’t expect Rachel to understand the distinction —in fact, she would probably be insulted if you challenged her casual dismissal of the entire core substance of the product —because “she’s more about the people-side” and “I don’t ‘do’ math.” I’m not an idiot, but the shear sophistication behind Counsyl humbles me, and I’m a complete asshole. Calling Counsyl “inaccurate” is like calling Idaho “the Moon.”

and it’s unclear if the masses really want to know these answers to such questions — even if insurance is willing to pay.

1) the masses don’t care about rs230492384, but they do care such questions including “how I not have retard baby?” 2) the opinion of the masses is irrelevant because first, even if 99% of people didn’t want this test, that shouldn’t restrict the remaining 1%, and second, the masses don’t have any coherent or useful medical opinion, and third, the masses don’t pay for health care — insurers do— but Rachel doesn’t consider that relevant because she already has decided that genetic testing is heterodox in the same way that I have already decided that homeopathy is heterodox —your insurer’s reimbursement policy be damned.

Accuracy and large-scale adoption is the formula Counsyl needs to make its business model work.

No. All Counsyl needs to do is

1. Not be 23andMe
2. Not engage in expensive lawsuits
3. Have more money than they spend —which largely amounts to: 1) sales higher than debt service 2) not hiring anybody who ever expects to participate normal salaryman society, or really, to ever work at any other company ever again, and probably will (should) kill themselves if the company catastrophically fails (not official medical recommendation) 3) unix, which is apparently cheap in dollars but impossibly expensive in humans

Large-scale adoption is the EXACTLY WRONG formula, because a dozen 30-somethings cannot compete dollar for dollar with big providers which have almost unlimited credit and a monopoly on distribution. All a Labcorp would have to do would be add checkbox to their superbill —as so goaded by an army of blueshirt blabbermouths screaming about “widespread adoption” in the press, and… whoops! Counsyl just missed one payment on its “world domination sales numbers” to service all that pushed debt to buy “widespread adoption.” Knock knock! Hello! It’s me! Your friendly pharma VC bagman! I would like to sit on your board now. Would you like an Xbox to play while you sit out this forced acquisition?

The market point for a generic genetic test is about the cost of a vaccine. You may as well try to compete in the medical gauze market —at least cotton has a longer shelf life. Go for the impossible-to-replicate speciality test in public, while building a local vertical for complete medical testing in private. What’s the big difference between a genetic test and all other medical labs? Another machine? It’s not the technology that makes a medical test: it’s the distribution! Your own single-internist medical center can be bought for about $200,000 if you already know a doctor who’d work there. Why would you want to know about that terrible business? Because you know which test the doctor orders in real practice? The one on the superbill. You know who puts which labs on which superbills? I do. (actually, Steve uses Google Docs to make his own forms) The risk is: which is more expensive, the liability of launching a medical practice (probably illegal, as in “American in China” illegal), or the liability of missing the market for your product (certain death)?

to be continued…

Rachel Lehmann-Haupt writes about Counsyl:

Even with the creepy Gattaca undertones, Counsyl’s technology could potentially save lives and health care dollars as a kind of preventative medicine. But the accuracy of the new technology is still in question, and it’s unclear if the masses really want to know these answers to such questions — even if insurance is willing to pay. Accuracy and large-scale adoption is the formula Counsyl needs to make its business model work.

“Creepy Gattaca undertones?” Tell me more, Rachel Lehmann-Haupt, about who you are to declare what “The Masses” think. From Rachel’s Lehmann-Haupt’s website:

I [Rachel Lehmann-Haupt] graduated with honors in English Literature from Kenyon College and attended The Graduate School of Journalism at The University of California at Berkeley. While at UC Berkeley I was the founding editor of F magazine, a post-feminist zine for which I received a fellowship from Women in Communications, Inc. I was also an assistant editor to Clay Felker, the founder of New York magazine, at The Felker Magazine Center.

Oh right. Kenyon College, UC Berkeley, “post-feminist zine,” New York magazine. I see that neither your subsidized intelligentsia education nor your vagina crippled your ambitions to write about your ambitions to write as a Woman who Writes. Good for you. If not for your harrowing quest to achieve your superior understanding of cultural justice, how else would you credibly justify your plea that “The Masses” may not be ready to not die from Tay Sachs?

Oh. Because genomics is “creepy.” Fuck you.

Fact: any plea on behalf of “the masses” is bullshit —unless your car is on fire —and even then, bet on an accident. “The Masses” don’t move around much anymore.

In fact, a lot of idiots seem to think that prenatal disease screening is the de facto harbinger of some lock ‘n stock B+ “Write about a Dystopia” 10 pager for ”Composition and Social Issues” 205. A quick Google search:

• counsyl brave new world
• counsyl gattaca

The hilarious part is that “The Masses” don’t want this “help” —and you are not “The Masses.” Think: when was the last time you read anything by anybody who self-identified as a member of “The Masses?” I bet it was about Jesus and published as a YouTube comment.

Listen: the primary complaint of “The Masses” is that television commercials are so loud that you have to turn down the TV, but then the show comes back on and you can’t hear it so you have turn up the TV… and what if you can’t find the channel changer?

That’s right: “The Masses” have no useful opinion on any subject —most people don’t even know what DNA is, let alone read books almost 100 years old. If The Masses did have a coherent collective opinion, it would be that they hate you —Rachel Lehmann-Haupt, The People’s Champion— for the excellent, all-purpose reason that you are a “know-it-all fag bitch.” (Nothing personal about you, that’s just the reason.) Either that, or they’d be obsequiously picking stray clutter during casual conversation which will include “Um, Sorry for [triviality]” and “Uhh… did you need help with [errand]?”

But why DNA, Rachel? What is so “creepy” about an esoteric biomedical laboratory for fatal inheritable diseases?

Because The Big Cultural Taboo in America is that you could not free to be who you want to be. That there could exist some universal, standardized report —never “mandatory,” always “understood”— which the inalterable, indisputable broadcast to the entire world exactly your place and where you belong, and to behave otherwise is blasphemy.

The real taboo is that record already exists: it’s called:

a “RESUME.”

Nobody cares about your DNA unless daddy is a big customer for The Firm . What people DO care about is 1) degree caste 2) occupational class 3) have you admitted to anything which could cast doubt on your suitability for your appointed social track.

No? Oh, right… I forgot. That’s not how this debate is suppose to go, right? Yes, please save us from all the scary DNAs! Save us Rachel! [My Employment Owner] paid [my wages] to the Death’s Protection Racket, but now I can’t cash out for a CT scan because my rs2384234 was an A and not a T! *GASP* I dropped an eyelash —my  precious FICO! I missed the resume screening for my own television sitcom fantasy —all because nobody could save me from evil DNA testing! O brave new world, that has such people in’t —like creepy geneticists! If only somebody had published skeptical op-ed and put these creeps back in their place! Society wasn’t ready!

Keep your minitruth doublespeak to yourself and leave genomics alone, Rachel. It’s already a Brave New World, but some of us still really do want to be astronauts.

“Ralph J Williamson MD” (alias?) seems to be confused about how health law enforcement actually works (in my thankfully limited experience.)

… 30,000 physicians can’t be wrong. If practice fusion was an illegal product, or an unethical product, it would have already been shut down. Put your money where your mouth is and challenge them, Mr. Yates. Report them to the feds, call the police, call your politician, tell the press, sue them. … So I would like you to bring them down before I make the move.

First, I don’t think I’ve been ambiguous about “putting my money where my mouth and challenging them.” I do publish on a public website under my own name, and I do file reports with the appropriate agencies when it’s my business to do so (for whatever that is worth, which is zero), but I don’t know what you’re expecting… a bazooka? The Men in Black? Harvey Birdman, Attorney at Law?

Second, you know what the big problem in healthcare is right now? Medicare in Connecticut stopped all payment this month. Yah, oops! the government healthcare payers missed a payment. “Immediate Financial Catastrophe” is probably higher on the checklist of things for “the government” to “fix” right now over some snipity Blueshirt MD super douche throwdown over a blog comment about some new Website! …dot com run by 10 people in California.

Third, every big provider in region that I know about is currently being audited for “compliance.” “Big” means “hospitals” and “nursing homes the size of hospitals.” “Compliance?” You know how that works? Here’s how: Government Auditors: “We’ll get back to you.” You know what that means? Doesn’t matter! Do you think that the government is in the “Free Audits for Fun” business? “Hey guys, um, we couldn’t find anything wrong even though we don’t audit you without knowing that you’re already guilty of something largely because we are the sole arbitors of what and who is guilty whenever when and why, but could you, like, please try harder to not bill medicare now? Cause, we don’t have any money to pay you, and you’re probably guilty as hell anyways? Is that cool? Thanks guys.”

Yah, they’re fucked.

But the good news for idiot medical students who think that a free and easy Practice Fusion account and a fresh MD makes them a “threat” to the “establishment” is: “No, you’re not. Please continue to avoid regular employment despite your expensive educations by the grace of there actual problems real adults have to solve now. We are not worried that sometimes you smoke pot and may own a Che Guevara t-shirt because he is dead and because buying t-shirts can be positive consumer activity which we as Americans endorse and appreciate. Thank you.”

Fourth, selling patient data is wrong, even if you don’t get caught or get in trouble. It’s also stupid if you don’t even get paid for it in cash.

Fifth, even a single lawsuit is expensive. Very expensive. And one lawsuit means you’re on the Law Menu. If you lose, it’s feeding season. Would you take a bet to earn an extra $1k per month if, in exchange, you had to pilot an explosion on wheels while half asleep twice a day at speeds which would instantly kill you over several miles also swarming with other explosions on wheels also piloted by other half asleep people whom you’d recognize at the DMV? Yes. So… never mind.

Six, law is slow. Even if God told George W. Bush right now that everybody at Practice Fusion had to be assassinated immediately, practicefusion.com would still probably accept your new user registration. In practice, the law is going to be even slower than that. So, I think I’m not going to be able to “save” you this time from big bad Practice Fusion, Dr. Ralph. Sorry.

Aside: I have no idea what motivated this comment, but if “Ralph” were a sock puppet, I am struggling to fathom the poor judgement of engaging me in some blog comment defense of Practice Fusion. My motive is usually provoked adolescent rage. It’s not complicated or dishonest. If I don’t have any new reason to like something I hated before, why would I change my mind later given that same information? In fact, the only new information I have is that somebody thinks that by repeating the same information is itself veiled threat. Like, if this was a clever attempt to get me to post more about Practice Fusion, it worked, but I don’t see how me not liking Practice Fusion and saying so changes the law I cited, the moral hazards of medical privacy I described, and the fact that other companies including Google already offer better, similar services for similar prices with more honest terms. For example, mdon-line.com is OK, and they’ll process your billing, and they seem to be doing OK, even though I’ve never been pestered by their blueshirts or blog spam. Like, it’s not that hard. Just ignore me. Then, I do other things. Problem solved.

For $10/month/seat, we get almost unlimited storage, unlimited instant search of all messages and contacts, custom forms which enter directly into spreadsheets, video chat, the world’s best online calendar, the world’s best email, a collaborative document editor into which we dictate medical notes, the world’s best API for integration, Google App Engine for custom applications, and it all works on any computer, iPhone, or iPad without installation or support —all secure, legal, and private. No blueshirts, no bullshit —it just works.

Ralph Williamson MD writes:

You know, I wouldn’t be surprised if Mr Andrew Yates is an investor/partner/etc in a competing EMR corporation. In fact, I wouldn’t be surprised if this post is removed.

30,000 physicians can’t be wrong. If practice fusion was an illegal product, or an unethical product, it would have already been shut down. Being the fastest growing EMR is the country puts you under the lime-light, and practice fusion is out in the open for all to see…and it keeps growing.

Put your money where your mouth is and challenge them, Mr. Yates. Report them to the feds, call the police, call your politician, tell the press, sue them. If you shut them down, I will eat my words and apologize to you for being so naive and stupid.

All I ask is that you do it quick, because I am on the verge of signing up. So I would like you to bring them down before I make the move.

First: yes, 30,000 physicians can be wrong. Second, what idiot would invest in a business whose business plan is to “sell” a free and unlawful version of Google Spreadsheets implemented in Adobe Flash? Not me. I don’t work for Google, and I don’t care about nerd shit like “EMRs.” Not even actual computer nerds are nerdy enough to care about EMRs.

As for enforcing the law: I’m not the law. The federal and state government can prosecute whomever they want —they don’t need my help. You want to use Practice Fusion? Go ahead (dumbass).

Also: 30,000 physicians? There are only about 300,000 physicians in the United States total. 10% of physicians in the United States use Practice Fusion? Really? I’d be surprised if 10% of physicians regularly use email for clinical use.

Here is how I would apply existing genomic technology  in my own primary care practice(s) given feasible economic availability today.

Ancestry, Ethnicity, and Sex Screening

Technology: ancestry, ethnicity, and sex screening is the greatest strength of all genomic testing and can be performed using commodity SNP chip technology

Price I Would Pay: $15 if included with a common blood test pannel, $10 if stand-alone blood test, $2 if buccal kit —it is expensive for the medical office to use oragene spit kits in serial medical procedure because they can consume up to twenty minutes of supervised provider time to fill. Thus, they must be forked to a parallel procedure which adds overhead.

Ideal Application: include with scheduled vaccinations, a new patient complete physical, and other unique-in-life medical services

Clinical Application: Most scientific research and clinical recommendations assume that a patient’s ethnicity is obvious to the medical provider: it’s not obvious. First, patients themselves often do not know their own ethnicity. Second, patients produce vague or contradictory answers which are not clinically ideal, e.g. “Asian American.” (really? what part of “Asia”?) Third, patients may not be the children of whom they believe or or whom they imply to be their parents. This is far more common than you may think. Fourth, patients lie —especially about culturally taboo topics which they do not feel are immediately relevant to their primary medical complaint. Fifth, any intake from patient interview is expensive because it requires provider attention, because any patient intake from forms or verbal interview incurs data entry overhead, and because patients tend to produce poor quality data in response to any question —in particular, responses without a definite answers— due to errors, typos, omissions, a simple attitude of evasiveness, and often, from sheer ignorance and illiteracy. I think that people on the Internet do not realize that about half of all people are functionally illiterate for the purposes of medical intake —especially the elderly. Sixth, patient sex is critical data in clinical application, and 99.9% confidence for a genomic SEX TEST is almost certainly higher than the existing confidence derived from asking the patient or trusting existing records.  Aside: I think it is hilarious to read about criticism of genomic data accuracy, because people have no idea how inaccurate actual medical data can be in real practice.

Abstract, complex medical reports are the new new financial derivatives.

See the New York Times today: How Washington Abetted the Bank Job

…Complexity was what made it possible [for banks] to hide debt, avoid capital requirements and evade taxes. Thus the [regulatory agency] statement said that banks should document their reasons for concluding that each complex instrument developed and sold would be used for a legitimate purpose and not to evade the law. It also said that financial institutions should ensure that the buyers of complex instruments understood how they worked and what risks they entailed.

The financial industry would have none of that. It bombarded the agencies with comments denouncing the proposal. Banks did not want the responsibility of explaining to customers the risks inherent in these instruments. And, while banks couldn’t say it directly, how they could document that products that were valuable specifically because they could get around laws were not being bought for that purpose?

Replace a few words…

…Complexity was what made it possible [for labs] to hide risk, avoid public health regulations, and evade duty. Thus the [regulatory agency] statement said that labs should document their reasons for concluding that each complex instrument developed and sold would be used for a legitimate purpose and not to evade the law. It also said that genomic institutions should ensure that the buyers of complex instruments understood how they worked and what risks they entailed.

The genomic industry would have none of that. It bombarded the agencies with comments denouncing the proposal. Labs did not want the responsibility of explaining to customers the risks inherent in these instruments. And, while labs couldn’t say it directly, how they could document that products that were valuable specifically because they could get around laws were not being bought for that purpose?

Now consider the 23andMe Terms of Service:

3. Description of What the Services Are and Are Not: 23andMe Service Is For Research and Educational Use Only. We Do Not Provide Medical Advice, And The Services Cannot Be Used For Health Ascertainment or Disease Purposes

Still waiting from an opinion from “top genomics lawyer” Dan Vorhaus. I guess every aspiring Enron needs an aspiring Arthur Andersen? It’s a shame, too. The stakes are so low. I mean, if you’re going to be dishonest, why not go all the way? Arbitrage the California power grid. Now that took some balls. I can appreciate that. Spit parties and Oprah? That’s just depressing.

Remember this picture? April Fools!

complete legal opinion regarding “gene patents invalid” ruling: http://www.aclu.org/files/assets/2010-3-29-AMPvUSPTO-Opinion.pdf

“illegal”

reference: Dan Vorhaus, “The New York Times vs. Personal Genomics: Much Ado About Not Very Much”

A commenter at Gene Sherpas writes:

It seems to me that the service Pathway offers is closely modeled on 23andMe’s products, so why do you consider them to be so much more responsible? On the surface, I can’t see much difference in how the two services work? And Pathway seems to have a more invasive privacy policy?

Short answer: pick your battles

Long answer: 23andMe is anti-medicine —lies. Navigenics is “integrative medicine” —noise. Both companies have had many years and many executive teams to demonstrate any motive otherwise. They have not.

But readers are absolutely correct. Pathway tries similar hey-bro-just-kidding garbage in their Terms of Service and in their product design. I know.

Pathway Genomics and the Services do not provide medical advice or diagnosis or treatment recommendations for diseases or other health conditions.

For the obtuse: My agenda is that “business problems” of 23andMe and Navigenics are correctly attributed to dishonesty and not “the market” or “needz more bizdev to doctors.” I prefer to believe that people care about their work and want to make it better for the greater good.

That said, of Silicon Valley genomics, only Counysl seems to have any inkling that its work is critical human medicine and not a mere toy with “scalable economics” in a “fundable market.”

“Oh but Navigenics is Serious!” Boring toys are still toys.

Aside: If —hypothetically— you were to solicit a genetic test in my medical office that was like 23andMe —”only better!” … keep it clean. I am watching.