March 15, 2014
Slick showmanship beats serious logical argumentation every time! When this showmanship is punctuated by internet wizardry, the kind of objection that am making seems both tedious and a buzzkill. "We have the man with a plan to bring democracy right into our little city..." this is a variation of the play and film of the 1970s, The Music Man, of how a traveling flim flam man convinced poor cities to invest in bands instead of books.
Most smaller cities in the United States with less than a million people are in serious financial trouble. While cities have different issues, having various average wealth and diversity of economic-social demographics, the one common pathology is debt incurred far beyond their ability to service. Two cities in California, Bell and Stockton are examples of extreme disasters, but there are many others that are facing sacrifice of provision of vital public services to pay pension obligations that were never funded.
I will focus on my city of Encintas CA, not that it is the worse or even close. This paper is about a specific change in direction, a modification of the movement based on the belief that governance, be it of a nation or a town, is something to be relegated to professionals who will create the "glowing city on the hill" by the application of dispassionate scientific rationality. The new twist of this century old "city manager" system is that this can be improved by tapping something that really doesn't even have a name, since it is represented by technology moving so fast that just keeping up defrays the kind of analysis this essay is attempting.
The slow evolution of human communication, the glue that holds aggregations of peoples, from tribe to nation, together-- beginning with the spoken word, to cuneiform writing, the printing press, books, magazines, radio and then television--within the historical micro second of a decade has been transformed by the device we call the smart phone with universal wifi. This technological revolution is transforming our world in ways we can only begin to understand in real time. An example is "Google Translation," not just another whiz bang app, but one that is reversing God's curse on mankind for the effrontery of building the tower of Babel. This bit of technology demolishes his punishment that we would all speak languages that are unintelligible to others.
This disorienting technological revolution has consequences that are a mix of good and evil, both the promise of utopia and the danger of loss of essential parts of our very humanity. The current adaptation of this technology in Encinitas is a radical expansion of a version of E-Government, (the link to the Wikipedia article one of the efficiencies that allows this essay to incorporate tens of thousands of hours of other"s thinking and writing about this phenomenon.) The city is adopting this by not acknowledging the dangers described in the Wikipedia link and assuming, erroneously, that if it "doesn't work" it can simply be reversed when the one year contract expires. In my article that defined the specific defects of the proprietary software being installed by Peak Democracy Corp., I say that this is a tilt towards "direct democracy" where citizens decide each issue rather than elected officials.
Now, I realize this was an incorrect simplification, and that by creating an illusion of increased citizen participation it becomes antithetical to that principle by allowing actual power to reside elsewhere. True direct democracy is exemplified by last year's city Proposition A that required a referendum for certain future high density developments. This was passed by a vote of the citizens in the face of well financed unanimous opposition of the elected city council. This could be construed as an "in situ" test of the premise that representative local government actually represents the will of the people, which in this case was shown to be false. From this it follows that the adaptation of the powerful tools of E-Government that will be in the control of elected officials will not be in the spirit of direct democracy, but a potent weapon against it.
There is a further danger that is invisible to the enthusiasts of this version of E-Government; that because of the novelty and visual dynamism of this technology even the elected officials become passive, not presuming to have the ability to challenge such technological wizardry. In the long presentation by Mike Cohen the President of Peak Democracy Corp. he said that not only would he provide the technical software but would advise and train the staff on the wording of the questions to be posed to the citizens, and then will aggregate, possibly modify and deliver to the council the wide diverse communications in a condensed digestible form. He was the wizard, as the members of the council were transfixed by his promise to deliver direct democracy in a box for the mere cost of a tenth of one senior employee.
The Terms of Service (TOS) required of most computer services are often
boilerplate, such as describing reasonable warnings against using
copyrighted material that are merely informational. Given the highly
personal nature of political views that are solicited on these sites,
the protection for abuse must be iron clad, which it is not in my view.
But more important than my own concerns is that as of this date there
has been no mention of this TOS being subjected to a rigorous evaluation
of whether they meet the higher bar of the Ralph M. Brown open meeting
act. One example of is clause 7.3 which is a right to modify filter or
refuse any comment by a citizen, which as of now they are doing in a
responsible way, but need not according to this agreement. Section 8.2
gives SD the right to use your comments to promote their software
program. Section 13 explains that on the pages that describe the issue
to be discussed on this site, they may insert advertisements for their
own income, and furthermore they will be targeted individually to you
based on your profile garnered from your own comments. It's amazing
what software venders can get away with when no one reads these
The contract for the software and services of Peak Democracy Corp. was
signed without the knowledge of two or possibly the entire elected
member of the city council. Some were mildly surprised that this
presentation was only delivered after the fact, while others were
clearly disturbed. Two members voted to abstain, and were told by the
city attorney that such an abstention in these circumstances would be
recorded as a yes vote. Ironically, this abrogation by the city's
elected officials of their responsibility for this major change is done
in the name of increasing trust in government. Mr. Cohen presentation
was riding on a wave of illusions and truisms that seemed to possess all
the magic of the smart phone-Internet-WiFi era. Not one of the elected
officials made any reference to the body of literature exploring the
criticism of this movement, and there was absolutely no evaluation of
the nature of the contract required between every citizen and the owners of the
new Peak Democracy software.
In this discussion there was no reference to the treading on the edges of the Ralph M. Brown open meeting laws, which can only be avoided by great effort by all concerned with using this product. And even if there is no lawsuit, the limited use of this product by excluding those who do not choose to allow Peak Democracy to use their words to target advertisements to them will further divide and alienate the citizenry, all in the name of improving the image of city hall. If read carefully, their required Terms of Service go beyond the legitimate boilerplate, which makes this an illegal requirement to address a public municipal meeting.
Hundreds of thousands of dollars of staff time was spent
exploring various venders of E-Government products and services, with
minimal involvement by elected members of the council or citizens. With
no sense of embarrassment over the hubris of making such a decision
unilaterally, the City Manager closed the deal, and the City Council to
this date has not begun to have the vital discussion over how this city
shall engage the revolution of technology that is upon us.
-------------------
Extensive links to published articles about Peak Democracy and details of the council action are appended to "Peak Democracy" --unexamined effects on City of Encinitas"
President Obama's profiling edict may have lost even liberals
This is the headline article on January 16, 2014, in the N.Y. Times, U.S. to Expand Rules Limiting Use of Profiling by Federal Agents. I'll quote from the first paragraph,
The Justice Department will significantly expand its definition of racial profiling to prohibit federal agents from considering religion, national origin, gender and sexual orientation in their investigations, a government official said Wednesday.
I often comment on Times articles, frequently being the voice of dissent on some serious issues, specifically their biased reporting on social issues and the ACA. They are not spurious comments, as on at least one occasion the public editor agreed and forwarded my observations to the person who approved a clear non-fact based OpEd. Usually, when it is a partisan issue, the reader comments are highly in favor of the Democratic position, unless it is a clear political sell out, such as not prosecuting the malefactors who engineered the financial depredations that almost brought down the world's economy in 2008.
This was my comment on the current profiling article:
We have one group, Arab Muslims, who happen to have reason to resent our invasions, drone attacks and support of one country in a region that is often at war with them. They also believe that exercise of the first amendment freedom of speech, even invidious ridicule that is protected under the Constitution, is cause for murder.
This group represents some one percent of this country's population. While no one is suggesting random arrests, focusing surveillance on this group specifically is like mining in an area with known ore deposits.
If such religious profiling is eliminated, then our investigatory efforts will be diluted to about a tenth of effectiveness, or conversely would require ten fold to prevent the same amount of potential terrorist attacks.
Sometimes reality isn't pretty, but it's still reality.
What is notable is that it received a high number of recommends, agreements with my sentiments, which were echoed in other comments with high reader approvals. What I didn't have space for in my printed comment was to describe the contradiction- the President's moral obtuseness of self righteous abrogation of an investigatory tool for tracking potential terrorists; while defending drone based execution of targeted individuals, including innocent bystanders. In this procedure, unlike the investigations that have now been denied tools for effectiveness, there is absolutely nothing remotely like "due process," no defense at all, simply the sum total of damning reports of nefarious purposes that condemns the individual, and innocents around the explosion, to death.
One value of looking at this ruling is that it is done under the rubric of fairness, opposing "discrimination"-- a word that when over-generalized negates the differentiation between when such a sorting process is rational and when it is used to perpetuate unjustified harm to a given group. "Discrimination" so distorted, is always seen as invidious, as an extension of another common term that is unfortunately not explored with the full appreciation of its violence to our language, to critical thinking, and in this case, vital pubic policy. That term is "political correctness," or simply PC. It is too often simply a joke, a punch line, something for late night comedians to garner a chuckle.
In combating terrorist attacks, President Barack Obama continues to defend our vast investment in NSA procedures that tease out by phone-based "meta data" patterns that often mirror religious connections. Perhaps such individuals will have accumulated guilt-by-connections with such groups, or too many calls to a vocal advocate of violence against America. And by the decision of a single individual, without any legal defense or even opportunity to explain his/her action, a lethal attack may be authorized.
If this suspect person had been investigated, perhaps his group infiltrated by covert FBI agents based on criteria now disallowed, there may have been an indictment, then a trial, an appeal-- the entire array of what we promise all who live in this country, "due process." Our President with a stroke of his pen, without any concurrence by our elected legislators, has weakened this process that begins with an investigation and ends with a trial; while preserving his right to issue edicts of remote execution.
And yes, this is too much, even for liberals. Actually, especially for liberals.
Medicare Annual Wellness Visit- A Critical Analysis
January 1, 2014
This is written on the first day that ACA, also known as Obamacare, takes effect, an issue so controversial that readers of this essay will have to accept that this is neither an attack or defense of the underlying law. I will argue that this analysis is important, yet has only been addressed in academic and professional circles. This essay is about the elderly, those on Medicare, which now begins with the patient being offered this Welcome to Medicare" preventive visit (WTM ref. 1) with an annual followup that is described below.
There is an immediate semantic challenge that must be addressed. The followup, the Medicare Annual Wellness Visit-or AWV is an interaction between patients, also called "beneficiaries" because they are recipients of a Medicare insurance benefit, and a physician controlled office, yet it is not what usually occur in this setting. This memo from Empire Blue Cross announcing that they are discontinuing annual examinations explains what AWV is not: "These services are preventive focused and should not be mistaken for a routine physical." The term used under this law which is "visit" is used even though the word itself implies a casual non-official interaction. I will use the word Visit to describe AWV with quotations understood, as it is a misuse of the deeper meaning of the word.
I will be presenting the case against AWV, and will only briefly define the consensus of government and medical interests that support it, as to the best of my knowledge there has been no openly published dialogue on the perspective I am presenting. I am taking the position that this Visit, far from being a casual get together, has profound implications for our society on many levels. There has been no previous examination of the adverse effects expressed in this essay, therefore the refutation, the opposing argument is not conveyed as such. Unlike a legal arguments with briefs from both sides, this is one side of the issue, that while written to make a point, is also an invitation for a substantive rebuttal, that will lead to a further public discussion. For these reasons this essay is a polemic that will focus on the unfounded assumptions inherent in the official expanation, the obfuscation of them to the beneficiary-patient, and the long term effect this augers for societal and individual perception of aging.
AWV is representative of a larger movement of expansion of public health interests over that of the individual. Ironically, this larger issue has only captured the public's attention over one element of the initial visit, "Welcome to Medicare" which is now described as: "An offer to talk with you about creating advance directives." Because this issue became politicized during the legislation, characterized as part of a death panel, of all the evaluations, tests, and discussions that are mandated in WTM-AWV series, only this one must be first described to the patient, and permission obtained before proceeding. I happen to agree that this information for every patient is important to have on record, and it certainly is not a conspiracy defined by the words, "Death Panel." Yet, the treatment of the question of advanced directives illustrates how easily it would be to have considered the autonomy by the patient, the need for them to be ready to discuss a given issue with a given professional.
At this point it is important to understand this essay is about societal norms that transcend health care policy. These two interactions, initial and subsequent, will be between a patient and a medical professional. If every such interaction were with a familiar, knowledgeable, unhurried, idealized physician, this would hardly be an issue. Such a Doctor internalizes the sensitivity and concern for his/her patient that negates many of the issues I raise. Yet the reality is often quite different, and will be more so given the changes of systems, group practice and other mandates of ACA. The epitome of the impersonal nature of the questioning is that companies are offering to do a part of these session on line, to relieve the physician of spending time with patients and increasing profits (their sales pitch, not my evaluation) How closely will the physician "directly supervise" the registered dietitian or nutrition professional" who may do the mandated assessments such as for depression or cognitive decline? These are complex subjective experiences for the patient, and a challenge even for neurologists and clinical psychologists who have years of specific training.
My argument is buttressed by an exacting analysis of a document on AWV now on line by CMS, Center for Medicaid and Medicare Services, which is the major operating agency under Health and Human Services: Providing the ANW. (ICN 907786 July 2012). ANW is described in another CMS document, the 32 page manual (CMS 10110) available on line, Your Guide to Medicare Preventive Services.
My criticism of ANW is that by its structure, incentives to providers along with the unarticulated assumptions in the presentation to users, it has the effect of exacerbating one of the most debilitating effects of aging. This is psychological dependency, a relinquishing of autonomy to others-- in the case of AWV, to an amorphous collection of medical providers selected as much by their political clout, than by evidence of professional efficacy. This service, under the rubric of "preventive care," is so favored that the usual co-payment is waived, so providing a greater incentive to the patient. It is an all or nothing offer (except for the one item described above) , with the patient not being given the option in advance of evaluating what elements to be reviewed, who will be making what could be life altering assessments. Beyond this major societal adverse effect, at least one of these assessments with dire emotional life changing consequences may be performed by individuals with no appropriate academic background. Here is a description from CMS (linked above pg 5) of who can provide this visit:
This is written on the first day that ACA, also known as Obamacare, takes effect, an issue so controversial that readers of this essay will have to accept that this is neither an attack or defense of the underlying law. I will argue that this analysis is important, yet has only been addressed in academic and professional circles. This essay is about the elderly, those on Medicare, which now begins with the patient being offered this Welcome to Medicare" preventive visit (WTM ref. 1) with an annual followup that is described below.
There is an immediate semantic challenge that must be addressed. The followup, the Medicare Annual Wellness Visit-or AWV is an interaction between patients, also called "beneficiaries" because they are recipients of a Medicare insurance benefit, and a physician controlled office, yet it is not what usually occur in this setting. This memo from Empire Blue Cross announcing that they are discontinuing annual examinations explains what AWV is not: "These services are preventive focused and should not be mistaken for a routine physical." The term used under this law which is "visit" is used even though the word itself implies a casual non-official interaction. I will use the word Visit to describe AWV with quotations understood, as it is a misuse of the deeper meaning of the word.
I will be presenting the case against AWV, and will only briefly define the consensus of government and medical interests that support it, as to the best of my knowledge there has been no openly published dialogue on the perspective I am presenting. I am taking the position that this Visit, far from being a casual get together, has profound implications for our society on many levels. There has been no previous examination of the adverse effects expressed in this essay, therefore the refutation, the opposing argument is not conveyed as such. Unlike a legal arguments with briefs from both sides, this is one side of the issue, that while written to make a point, is also an invitation for a substantive rebuttal, that will lead to a further public discussion. For these reasons this essay is a polemic that will focus on the unfounded assumptions inherent in the official expanation, the obfuscation of them to the beneficiary-patient, and the long term effect this augers for societal and individual perception of aging.
AWV is representative of a larger movement of expansion of public health interests over that of the individual. Ironically, this larger issue has only captured the public's attention over one element of the initial visit, "Welcome to Medicare" which is now described as: "An offer to talk with you about creating advance directives." Because this issue became politicized during the legislation, characterized as part of a death panel, of all the evaluations, tests, and discussions that are mandated in WTM-AWV series, only this one must be first described to the patient, and permission obtained before proceeding. I happen to agree that this information for every patient is important to have on record, and it certainly is not a conspiracy defined by the words, "Death Panel." Yet, the treatment of the question of advanced directives illustrates how easily it would be to have considered the autonomy by the patient, the need for them to be ready to discuss a given issue with a given professional.
At this point it is important to understand this essay is about societal norms that transcend health care policy. These two interactions, initial and subsequent, will be between a patient and a medical professional. If every such interaction were with a familiar, knowledgeable, unhurried, idealized physician, this would hardly be an issue. Such a Doctor internalizes the sensitivity and concern for his/her patient that negates many of the issues I raise. Yet the reality is often quite different, and will be more so given the changes of systems, group practice and other mandates of ACA. The epitome of the impersonal nature of the questioning is that companies are offering to do a part of these session on line, to relieve the physician of spending time with patients and increasing profits (their sales pitch, not my evaluation) How closely will the physician "directly supervise" the registered dietitian or nutrition professional" who may do the mandated assessments such as for depression or cognitive decline? These are complex subjective experiences for the patient, and a challenge even for neurologists and clinical psychologists who have years of specific training.
My argument is buttressed by an exacting analysis of a document on AWV now on line by CMS, Center for Medicaid and Medicare Services, which is the major operating agency under Health and Human Services: Providing the ANW. (ICN 907786 July 2012). ANW is described in another CMS document, the 32 page manual (CMS 10110) available on line, Your Guide to Medicare Preventive Services.
My criticism of ANW is that by its structure, incentives to providers along with the unarticulated assumptions in the presentation to users, it has the effect of exacerbating one of the most debilitating effects of aging. This is psychological dependency, a relinquishing of autonomy to others-- in the case of AWV, to an amorphous collection of medical providers selected as much by their political clout, than by evidence of professional efficacy. This service, under the rubric of "preventive care," is so favored that the usual co-payment is waived, so providing a greater incentive to the patient. It is an all or nothing offer (except for the one item described above) , with the patient not being given the option in advance of evaluating what elements to be reviewed, who will be making what could be life altering assessments. Beyond this major societal adverse effect, at least one of these assessments with dire emotional life changing consequences may be performed by individuals with no appropriate academic background. Here is a description from CMS (linked above pg 5) of who can provide this visit:
The AWV must be furnished by a health professional, meaning:A physician; A physician assistant, nurse practitioner, or clinical nurse specialist; (I interpret this to mean that the two para-professional groups may operate without direct supervision by a physician, unlike below)
or
A medical professional (including a health educator, a registered dietitian or nutrition professional, or other licensed practitioner) or a team of such medical professionals, working under the direct supervision of a physician.
Here is the list of the elements of AWV
----------------
Addendum and Notes:
Note 1 My text reads "It (AWV) is an all or nothing offer, with the patient not being given the
option in advance of evaluating what elements to be reviewed" There is one exception to this which illustrates the political nature of this AWV, for better and for worse. One element of the initial Welcome to Medicare visit was to be a discussion of end of life care, whether the individual wanted all efforts to be made to prolong life if he/she were unresponsive in a terminal condition or to be allowed to expired. This is the single element that became controversial, as it was depicted as part of the accusation of the legislation having "death panels." A solution was that this discussion must be prefaced by approval by the beneficiary, who could decline to engage in this discussion-this compromise is documented but is not in the current instructions linked above. Evaluation of depression, something that is inherently part of the deepest levels of an individuals values, relationships, experiences and beliefs, is not optional, and is mandated to be part of the AWV.
Note 2 There is a large literature of explanation of how the cognitive assessment is to be performed, including on-line testing services. Some are described in this article that I wrote. All of the formal assessments are based on standardized memory tests- the assumption being that these correlate with the ability of the individual to function, which is formalized in Activities of Daily Living (ADL) which is a legal concept for long term care insurance. This N.Y. Times article,Vitamin E Slows Decline of Some Alzheimer’s Patients in Study on the possible therapeutic effects of multidoses of vitamin E, showed no correlation between cognitive tests and ability to function without assistance, ADLs.
Note 3 This link is an addendum with connection my article in The Humanist focusing on the adverse consequences of cognitive assessment requirement of AWV. There are two reports, one from the International Journal of Alzhiemer's Disease that supports my contention that the default option should not be disclosure of decline of cognition. What is fine with approval by patient based on his/her evaluation of the relationship between medical provider, should not be general rule under all circumstances.
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