The Peril of Online Physician Reviews

By NIRAN AL AGBA, MD

You may have heard that before you pick a doctor you are supposed to look them up online and see what other people have to say about them before you set up an appointment.

In the Age of Amazon this makes sense. Why wouldn’t you?

Allow me to give you a little insider information.  While they may well be a good idea in theory, Yelp.com and other online physician review sites have evolved in recent years to become the bane of my and fellow doctors existence. 

This past summer, Physicians Working Together, a non-partisan physician organization, started a petition on Change.org requesting Yelp remove online reviews of doctors.  To date, more than 30,000 physicians have signed it but I doubt Yelp will pay much attention.

Recently, the highest-level court in Germany ruled Jameda, an online physician rating site, must remove the name of a disgruntled physician.   A dermatologist from Cologne filed the case in the Federal Justice Court demanding Jameda remove her name due to the fact the anonymous nature of the rating site inspires the public to leave spiteful, vindictive comments.  Interestingly enough, in 2014, a gynecologist asked to be removed from Jameda, however the Court ruled the right of patients to be “well informed” about their doctor took precedence over freedoms of the physician.

What is the value of rating physicians online?  Are consumers becoming “well-informed?”

Patient advocates would argue rating sites for physicians improve transparency for consumers.   Physicians would counter with the argument that a medical clinic is not like a restaurant, hair salon, or shopping mall.  We engage in a highly personal way with the public that is quite different from sitting down for a meal.  The larger concern is whether or not Yelp.com patrons are actually “well-informed” by reading online physician reviews. 

After a little research, it appears the answer is no.  I used a local medical community as an example.  The reviews overall are not very good; on average the medical clinics are 3.0/5.0 stars.  Some reviews extol on physical appearance of the physician, be they female or male.  One reviewer discusses being offended by seeing a transgender physician, an element which has little to do with the provision of medical services.  At first glance, one might believe moving to Kitsap County, WA is akin to choosing between life and death.  Rest assured, most of the populace is alive and well. 

Online reviews are not a reflection of medical care quality.  Patients do not like receiving medical bills and do not like rude clinic staff.  They are unhappy if the physician disagrees with them, they abhor long wait times, and they detest prior authorizations, (news flash, so do physicians!) Yet these criticisms are not a reflection of the healthcare quality provided by the physician.  It is doubtful these grievances even have an impact on the mortality rate. 

According to “well informed” consumers, which qualities make a physician “good”?

Actually, the answer is amusing.  It is best if a physician is in fact, not a medical doctor at all.  It turns out EVERY naturopathic doctor, homeopathic doctor, chiropractor, and acupuncturist in my community is providing five-star-rated care.  One patron gave a few alternative practitioners only one star, but those reviews were more than nine years old; alternative medical practitioners were not as “well-accepted” by a “well-informed” public at that time.  As with other service businesses, the internet is unlikely to replace good, old fashioned “word-of-mouth” referrals. 

While internet ratings are not an accurate way to measure medical care quality, they are a way for angry individuals to air grievances, whether those are truth, lies, fiction, or somewhere in between.  For example, a one-star rating was left by a woman who did not like the way a staff member answered the phone at one clinic; she went on to give 5 one-star ratings to other physicians nearby at other clinics.  Interestingly enough, googling her name brings up a Yelp.com review describing her as having borderline personality disorder. 

What is the public being informed of exactly?  Not much.  Physicians may have difficulty responding to patient reviews without compromising protected health information, ultimately rendering them defenseless.  If the goal is to keep everyone accountable, where is the balance between physicians and consumers?  Should physicians have a database to rate patients?  Accountability is where the rubber meets the road and it cannot be found in online reviews of physicians.  Ironically, the lawyers in my community have very solid 5.0-star ratings, that is, unless they delivered a summons, then they were given a 1.0-star rating. 

Yelp and other physician rating sites should remove the physician reviews entirely because these entities are selling something they cannot deliver.  Until a physician wins a case against Yelp, Google, or another physician rating site, it seems wise to give every patient exactly what they ask for, never argue or tell them the truth, hire staff members who are like Mary Poppins and “practically perfect in every way”, and prioritize timely visits no matter if a patient is dying in the next room.   

Is it any wonder the U.S. mortality rate continues to fall? 

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Apple’s EHR: Why Health Records on Your iPhone is Just the Beginning

BY RYAN MARLING

Americans on average will visit a care provider about 300 times over the course of their lives. That’s hundreds of blood pressure readings, numerous diagnoses, and hundreds of entries into a patient’s medical record—and that’s potentially with dozens of different doctors. So it’s understandable, inevitable even, that patients would struggle to keep every provider up-to-date on their medical history.

This issue is compounded by much of our healthcare information being fragmented among multiple, incompatible health systems’ electronic health records. The majority of these systems store and exchange health information in unique, often proprietary ways—and thus don’t effectively talk with one another.

Fortunately, recent news from Apple points to a reprieve for patients struggling to keep all of their providers up-to-date. Apple has teamed with roughly a dozen hospitals across the country, including the likes of Geisinger Health, Johns Hopkins Medicine, and Cedars-Sinai Medical Center, to make patient’s medical history available to them on their phone. Patients can bring their phone with them to participating health systems and provide caregivers with an up-to-date medical history.

Empowering patients with the ability to carry their health records on their phone is great, and will surely help them overcome the issue of fragmented healthcare records. Yet the underlying standardization of how healthcare data is exchanged that has made this possible is the real feat. In fact, this standardization may potentially pave the way for innovation and rapid expansion of the health information technology (HIT) industry.

Growing agreement upon a standard way to store and exchange electronic healthcare information is what made Apple’s foray into health records possible in the first place. Fast Healthcare Interoperability Resources (FHIR) emerged four years ago as an interoperability standard for electronic exchange of healthcare information. It is a standard framework for the sharing, integration, and retrieval of clinical health data and other electronic health information. Enough agreement upon such a standard for health information exchange has promoted modularity.

How modularity fast-tracks innovation

A system is modular when all its components fit together in a standardized way, whether physically, mechanically, chemically or in this case digitally. This standardization enables people to design one component without having to know how everything else in the system works. An everyday example of this is the USB port. It is a standard cable connection interface upon which any number of products can connect—whether it be a keyboard, a charger, external memory, or any other device that can meet the specification. This differs from interdependent systems, in which the design of parts are customized, nuanced, and how they work together is not widely-known. Thus, a designer has to know how the whole system works to be able to design any part of it.

In the case of the FHIR standard, the manner in which digital healthcare information is exchanged is modularized—the rules of the road are established and easy to follow. Adoption of this bit of digital standardization, by an influential group of healthcare providers, is what allowed the third-party giant, Apple, entry into the modular electronic health records game. Even though their experience in healthcare is limited, the standard lays out the rules well enough for them (and other third parties) to participate in the HIT market.

We’ve learned in the past that the creation of and agreement upon standards can expand industries by creating a new ecosystem in which third-party players can add value. In fact, the preeminent example of this type of ecosystem creation is Apple itself, and their AppStore.

Along with their AppStore, Apple created a set of standards that specified how third-parties (from companies to individual hobbyists) can more easily create applications that make use of the information on their phone and the Internet. These apps were made available to Apple’s network of users and developers were paid according to the amount of revenue the app generated Apple (based on usage). Over the span of 10 years Apple has paid AppStore developers $86.5 billion (paying out $26.5 billion in 2017). The rapid expansion of the market for creating substitutable apps in return gave everyday users the ability to harness information in any number of more convenient, simple, and potentially meaningful new ways.

What does this relatively recent and still unfolding story mean for HIT? It means that as opposed to merely viewing your health record, standardization may also allow for the creation of new tools that actually make use of your health record in new, meaningful ways. For example, developers may create an app that helps patients understand their risk of a cardiac event base pulling specific data points from the health record. In short, applications can be created by third party creators for use by the patient that make their healthcare data more accessible, easier to understand, and more actionable.

In this way, not only does modularity stand to make healthcare data more accessible to providers, researchers, and public health organizations (current consumers of health data), but to a new market—the patient. Standardization mediated by the adoption of FHIR opens up the market for innovators outside of the traditional health IT industry. These new players can then compete to reach everyday people (just as app creators did on Apple’s AppStore platform), with useful tools that empower them in their struggle for health.

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Integrating with EMR vendors? Tell us More! The 2018 Health 2.0 API Survey

By MATTHEW HOLT & KIM KRUEGER

TL;DR  Accessing and using APIs from major EMR vendors has proved a real problem in the past — in 2016, Health 2.0 (with support from CHCF) collected the data to prove it. This year, we’re updating the survey and are asking again: how hard is it for smaller tech companies to integrate their solutions with big EMR vendors? Take the survey here.  

In 2016, Health 2.0 conducted a survey of health tech startups on behalf of the California Healthcare Foundation (CHCF) to shed some light on the difficulties around integrating third party applications–mainly from a new generation of health technology companies–into major electronic medical records (EMRs). The data was revealing, and confirmed that much of the anecdotal gossip was true: it is a challenge for smaller health tech companies to integrate their solutions with the major EMR vendors. There is no clear path to integration or data access, fees are sometimes involved, and even without fees, the lengthy process is too complicated and costly for small companies to handle. Of course, the problem of integration and data access is not limited to major EMR vendors. Healthcare providers and other data custodians may well be complicating the process, too.

In 2016, this survey found an incredible diversity of experience across the major EMR vendors (i.e. working with Epic is different than working with athenahealth), as well as an incredible diversity of experience across different tech companies dealing with the same EMR vendor. We want to know more. Now, Health 2.0 is reprising our previous work, looking once again to collect concrete data around this problem. Will the data reinforce what we found in 2016 or will there be some measure of progress in the past few years?

Much has changed since the first version of this survey, including a flurry of activity around Epic and Apple’s Healthkit integration, Cerner’s Ignite initiative, and the Carin Alliance. We want to know if any of that has made an impact for those looking to integrate. If you are a tech company that has experience with these issues, take this survey. Help us understand where we stand.    

The data and commentary collected here will be used to generate a set of slides, charts, and graphs that will be shared on THCB and at Health 2.0 Conferences, and will provide another year of data and much-needed transparency around the issue of integration. Responses will be kept anonymous by Health 2.0

Matthew Holt is Publisher of THCB & Co-Chairman Health 2.0. Kim Krueger is Research Director at Health 2.0

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Why Do We Need ACOs and Insurance Companies?

By KIP SULLIVAN, JD

Six years ago Ezekiel Emanuel and Jeffrey Liebman made the foolish prediction that ACOs would eat the insurance industry’s lunch. “By 2020, the American health insurance industry will be extinct,” they wrote. “Insurance companies will be replaced by accountable care organizations….”  This would happen, they argued, because ACOs are just so darned good at lowering costs compared with insurance companies.

The first Medicare ACO programs began in 2012. Today there are 800 to 1,000 ACOs in business. [1] But ACOs aren’t even close to displacing the insurance industry. The most obvious reason is they don’t want to be insurance companies – they don’t want to bear full insurance risk. And the reason for that is they can’t cut costs. The performance of the Medicare ACOs, which are the only ACOs for which we have reliable data, illustrates both problems: Very few want to accept “downside risk” (the risk of losing money if they can’t cut costs); and they are incapable of cutting costs.

ACO hype confronts reality: Reality wins

Anyone paying attention to the research knew even before 2012 that ACOs wouldn’t cut costs for a general population (as opposed to a small slice of the population that is very sick). The Physician Group Practice Demonstration, which was widely seen as the first test of the ACO concept, raised Medicare spending. According to the final evaluation of the demonstration, the ten participating ACOs raised Medicare’s costs by 1.2 percent over the five years the demonstration ran (2005-2010), and it might have been worse if the ACOs hadn’t upcoded. [2] This failure to cut costs occurred despite the fact that the ten participating “group practices”/ACOs were very experienced in managing risk. They had names anyone who studies health policy would recognize, including Dartmouth-Hitchcock Clinic, Geisinger Clinic, and Marshfield Clinic. According to the final report on the demo, “Seven of the ten participants had currently or previously owned a health maintenance organization ….” (p. 15)

The latest reports from CMS on its Medicare ACO programs, which report 2016 data, indicate the current crop of ACOs are equally incapable of cutting costs. The data contained in the reports indicates the ACO programs are merely breaking even, and that’s only if you don’t count the costs to the ACOs of doing whatever it is ACOs do. The staff of the Medicare Payment Advisory Commission (MedPAC) prepared a graph for the commission showing how each of CMS’s ACO programs did in 2016. This graph, presented at the commission’s January 2018 meeting, appears below. (The graph appears on slide 8 here )

The graph presents the results for the 458 ACOs that participated in CMS’s three ACO programs – the Medicare Shared Savings Program (MSSP, which began in 2012), the Pioneer program (which began in 2012 and ended in 2016), and the NextGen program (which started in 2016). You’ll see that 410 of the ACOs, or 90 percent, were in “track one” of the MSSP, which means they were willing to accept only upside risk (the chance to make money if they came in under a target level of spending). We see as well that all three programs roughly broke even (again that’s not counting the cost of the interventions ACOs deploy in their attempt to cut costs).

The graph’s most discouraging news, from the point of view of ACO advocates, is the underwhelming performance of the eight diehard ACOs that remained in the Pioneer program in 2016. The graph indicates those ACOs cut Medicare’s costs by a mere seven-tenths of one percent in 2016, the fifth and last year of the program. Like the ten ACOs that participated in the Physician Group Practice demo, those eight ACOs were the crème de la crème – the entities most likely to succeed at the ACO game. They were the crème de la crème of the cohort of 32 ACOs that CMS selected to enter the Pioneer program in 2012, and those 32 ACOs were in turn the crème de la crème of all ACO candidates in 2011 when CMS accepted applications for the Pioneer program.

Because ACOs in the Pioneer program would have to accept both up- and downside risk, CMS was very selective in choosing the original 32 Pioneer ACOs. As the Advisory Board  put it in an article published just before the Pioneer program began, “The 32 Pioneers underwent a rigorous evaluation – including a comprehensive review of applications and in-person interviews….” And yet by 2016 only eight of these rigorously evaluated ACOs remained. The dropouts were those who lost money or expected to lose money. Thus, if we were to take an “intent to treat” approach in evaluating the Pioneer program and asked how well all 32 performed, the result would probably be worse than the 0.7 percent savings achieved by the eight diehard ACOs that participated for all five years.

Why did we need ACOs in addition to insurance companies?

What were ACO proponents thinking would happen? We know they thought ACOs would perform much better than they have. But how much better? Did they agree with Emanuel and Liebman? Did they think ACOs would gradually accept total insurance risk and go on to outcompete the insurance industry? We don’t know. We don’t know because ACO proponents never bothered to ask an elementary question: “Are we proposing to create an ACO industry because we think the HMOs and the managed care tools they popularized have failed, and if so, why do we think ACOs will succeed where HMOs and managed care plans have failed? What tools will ACOs use that the insurance industry hasn’t already experimented with?”

ACO proponents never indicated that they had given a moment’s thought to that question. They never came right out and said, “Managed care plans have had their day in the sun, they haven’t worked, and now we need to replace them with a new entity we’re calling the ‘accountable care organization,’ and here’s why.” They just demanded that Congress authorize CMS to set up an ACO program in Medicare alongside the Medicare Advantage program, and that private-sector payers create a private-sector ACO industry alongside the insurance industry.

Congress, with even less forethought, agreed. Congress inserted provisions into the Affordable Care Act authorizing CMS to set up Medicare ACO programs, President Obama signed the ACA in March 2010, and CMS implemented the Pioneer and MSSP programs early in 2012. In 2015, Congress did it again: They enacted MACRA, which encourages the formation of even more ACOs. At no time in this higgledy-piggledy ACO-creation process did any of the participants publicly address the question, “How will ACO magic differ from HMO magic, and if there is no difference, why are we doing this?”

A handful of ACO advocates did attempt to distinguish ACOs from HMOs after the ACA was enacted, but their distinctions were meaningless or misleading. Of these after-the-fact distinctions, the three most frequently heard were: (1) Doctors will be running ACOs, not “distant,” uncaring HMOs; (2) ACOs do not limit patients to a network of “preferred” providers as HMOs do; and (3) modern information technology makes it possible for ACOs to provide much better care than HMOs ever did. Emanuel and Liebman, for example, trotted out all these distinctions. [3]

The first claim – that doctors are running ACOs, not HMOs – is laughable. HMOs and other insurers are setting up their own ACOs, and even the ACOs that were not established by insurers have very little physician involvement in management. [4] The claim that ACOs do not limit choice of provider is, strictly speaking, true at this moment, but that is changing because ACOs are not happy with the enormous “leakage” they suffer because they can’t force their “attributees” to stay in network. Finally, the argument that information technology improves quality of care is an exaggeration of IT’s impact on quality, and in any event, the insurance industry has as much access to IT as ACOs do.

But even if these false distinctions between ACOs and HMOs were true, they wouldn’t tell us what it is ACOs do that HMOs don’t do. So what if doctors really are running ACOs? So what if ACOs have yet to force patients to stay within ACO networks? What does that tell us about what ACO doctors are doing that doctors micromanaged by the insurance industry are not doing?

Comparing one black box to another

The failure of ACO proponents to answer the question, Why do we need both ACOs and insurance companies, is creating problems for Medicare which now has to administer three separate programs – the traditional fee-for-service program, the new ACO program, and the Medicare Advantage (MA) program. Life for CMS, and for MedPAC (which has to advise CMS and Congress), was difficult enough when CMS had to administer just the FFS and MA programs. It has become infinitely more difficult with the insertion of the ACO program in 2012 and the enactment of MACRA in 2015. The complexity of today’s Medicare program has driven up CMS’s administrative costs, and has forced MedPAC into long discussions about how to ensure that all three programs are paid fairly.

The same problem now afflicts state Medicaid programs that were forced by their legislatures to balkanize into the same three sectors – a FFS sector, a privatized Medicare-Advantage-like sector, and an ACO sector.

In my next post, I will discuss the attempts MedPAC and Minnesota’s Medicaid program have made over the last few years to apply more uniform payment rules to their ACO and managed-care-plan programs. MedPAC and Minnesota’s Department of Human Services (DHS), which runs the Minnesota Medicaid program, apparently want to answer the question ACO proponents never bothered to ask: Are ACOs more efficient than insurance companies? MedPAC seems to want to answer that question by forcing all three Medicare sectors to compete on a level playing field to see which ones are driven to extinction by the others. Minnesota’s DHS seems to want to answer that question by forcing its ACO and MA-like sectors to compete on a level playing field. I use the word “seems” because MedPAC and DHS can’t bring themselves to come right out and say they expect ACOs to beat the insurance industry or vice versa. But they are willing to say they want to create competition between the two types of entities under uniform payment rules.

As we shall see, MedPAC’s attempts to create a level playing have failed, and DHS’s attempt appears to be well on its way to failing.

[1] Our knowledge about Medicare ACOs is very limited, but at least we know how many of them there are. We don’t even know the number of entities that call themselves ACOs that contract with private-sector payers (insurance companies and self-insured employers). The estimates are all over the map. A directory of ACOs claims to list 800 of them. Elliott Fisher, who invented the ACO label in 2006 with MedPAC, alleges there are 1,000 .

[2] According to the final report on the Physician Group Practice Demonstration, “[T]he demonstration saved Medicare .3 percent of the claims amounts, while performance payments were 1.5 percent of the claims amounts.” (p. 64)

[3] Here’s an excerpt from the Emanuel-Liebman op-ed  in which they sought to persuade readers that ACOs are not your father’s HMOs. “ACOs are not simply a return to the health maintenance organizations of the 1990s. Although in both models patients are members of a provider network with a specific group of doctors and hospitals, and both are paid primarily per member rather than per procedure or test, there are big differences between them. HMOs were often large national corporations far removed from their members. In contrast, ACOs will consist of local health care providers working as a team to take care of patients who are likely to be members for years at a time. HMOs often cut costs not by keeping people healthy but by denying patients services and by forcing doctors and hospitals to take lower payments. In the 1990s, we lacked the information technology and proven models of integrated care delivery that we have now. These advances will allow ACOs to simultaneously improve health outcomes and reduce costs.

“A final bonus of A.C.O.’s is that they will lead to a better form of competition in health care markets. Today, consumers have to choose among insurance plans with a bewildering array of copayments, deductibles and annual out of pocket maximums — choices that few of us are any good at making. In the A.C.O. model, consumers will choose a primary care physician and the team of doctors and hospitals that are in the same group.”

[4] Claudia Schur and Janet Sutton report that only a tiny fraction of all doctors in Medicare ACOs play leadership roles, and up to half are unaware of who their ACO patients are or whether they are eligible for shared savings.

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Health in 2 point 00, Episode 3

Here’s the third episode of Health in 2 point 00, hosted by Jessica DaMassa. This week the tech and parties of HIMSS18 are looming on the horizon and she asks me as many questions as I can answer in two minutes. Hope you enjoy it! And if you have questions please leave them in the comments–Matthew Holt

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Consider This Speculative Amazon Scenario

By TORY WOLF

Amazon has many puzzled about its plans for healthcare. Arguably, Amazon is just as puzzled, but is – in effect — running a massive Delphi process to sort out the plan. Amazon is, after all, the Breaker of Industries, Destroyer of Margins. Allow rumors to float, hire some people, have meetings, seek a few regulatory approvals, start a vaguely missioned non-profit with other business titans. Fear and greed do the rest.

Stock prices gyrate as investors bet and counter bet on who is vulnerable, incumbent CEOs promise cooperation or competitive hostility, analysts speculate, “old hands” pontificate, and consultants send megabytes of unsolicited slide decks to South Lake Union. All that information gets exposed without any material commitment.

Disrupting the roadblocks to healthcare innovation

Proper strategic planning requires consideration of a few disruptive (if less likely) scenarios. Amazon getting into hospital supply or creating yet another benefits buying group is easy to imagine but conservative in scope. And we know Bezos thinks long-term and that profits are secondary to platform building.

 

We also know that the biggest target for disruption–complex, opaque, and inefficient care delivery – remains largely undisturbed despite wave after wave of innovations: ACO and bundle payment models, transparency initiatives (e.g., Castlight), private exchanges, direct contracting models, telemedicine, alternative primary care models (concierge, medical home) – all have all fallen short of their promise.

Why is that? Healthcare is a goldmine of textbook market failures thriving on (1) incentive misalignment (2) information asymmetry and (3) a system frozen by byzantine contracting and regulatory structures, highly scaled incumbents operating highly scalable processes and local market entry barriers which ensure that share shifts are glacial. Innovation is kept comfortably on the margins.

How could Amazon fix this?

The Luxury to Choose

By TRAVIS BIAS, MD

The 80 year-old woman lay on her mat, her legs powerless, looking up at the small group that had come to visit her. There were no more treatment options left. The oral liquid morphine we had brought in the small plastic bottle had blunted her pain. But, she would be dead in the coming days. The cervical cancer that was slowly taking her life is a notoriously horrible disease if left undetected and untreated and that is exactly what had happened in this case.

We had traveled hours by van along dirt roads to this village with a team of health workers from Hospice Africa Uganda, the country’s authority on end-of-life care, to visit the woman. She was the second patient of a similar condition I would see that afternoon.

Back home, seeing an 80 year-old woman with advanced cervical cancer, let alone two in the same day, was exceedingly rare. In high-income countries, cervical cancer is a largely treatable disease, especially when caught in the early stages. And it is now preventable thanks to a widely accessible vaccine against Human Papillomavirus (HPV), the infectious agent that causes most cervical cancers, called Gardasil, which is recommended for all pre-teens in the United States.

“If only she had had access to Gardasil,” I thought to myself.

Just months earlier I was busy in my private primary care practice in suburban Austin, Texas. In one of the richest countries on the planet that spends more on healthcare per person than anywhere in the world, I was putting forth my best effort to explain to a mother why her 14-year-old daughter, who had never before had any sexual contact, needed the series of 3 shots against HPV. “So this HPV is sexually-transmitted, and she still needs the vaccine even though she is not sexually active? And she does not need this shot to attend school?” Gardasil was a difficult sell in the conservative state that was careful about adopting what government, or anyone for that matter, recommended an individual take on for the sake of public health.

It is now February 2018 and news reports are sounding the alarm about the strain of influenza making its way around the US causing remarkably high rates of hospitalization and death. This disease can be easily prevented by one vaccine each flu season, yet patients decline this vaccine due to any number of excuses. “Won’t I be sick or sore for several days after?” “I am very careful about what I put in my body.” And the online “anti-vax” echo chamber encourages this behavior, turning one anecdote of syncope into several cases of harm attributed directly to a single shot in the arm.

What a luxury to choose from a menu of technological advances to protect one’s health. What a luxury to have an employer or taxpayer fund these ubiquitous means of preventing disease; whether it is a vaccine, a blood test, or a basic treatment. High-income societies have applied the Kantian ethical tenant of autonomy like pros and, sometimes without the rational or even conscious decision-making bit, taken for granted life-saving resources. All to the detriment of their communities. What a luxury.

Considering the Centers for Disease Control and Prevention’s list of the top ten greatest public health feats of the last 100 years, we are on an incredible backslide to the year 1899. Measles was declared eliminated from the United States in 2000 thanks to widespread immunization, yet we now have outbreaks at Disneyland and anticipated future outbreaks due in part to conscientious objectors to the vaccine. Thanks to advancements in water treatment we no longer have major outbreaks of diarrheal disease, yet we now have entrepreneurs selling “raw water.”

What a luxury.

It is a cruel reality of inequality and resource mismatch across the globe when those without resources are clamoring for them and those with resources refuse. Whether based on religious or individuality protests in conservative communities or “natural” ways of life in more liberal communities, the result is the same ignorance of science and reason. What a luxury.

But a heavily and densely populated globe interconnected by the increasing ease of international travel means that one person’s declined influenza vaccine might mean another person’s influenza death. The case of Ebola Virus Disease transported from Liberia to Dallas, Texas in 2014 highlighted how quickly and easily infectious diseases can spread across borders.

When does a society refusing to take advantage of superfluous means present such an egregious affront to the other ethical tenant of justice. In a world of finite resources (yes even in America) when does the conversation about personal responsibility turn to demand that individuals implement what is available to him or her to benefit their global community?

In a decade as a Family Medicine physician in the States I had never before seen a death due to cervical cancer. With our suite of widely used screenings, diagnostic technology, and range of surgical solutions, cervical cancer-related deaths are exceedingly rare. And now that we have deployed the vaccine, Gardasil, cervical cancer rates worldwide have been cut in half.

“If only this woman had had access to Gardasil,” I thought to myself. Instead, the 82-year-old matriarch tried to maintain her dignity in the face of a spreading cervical cancer, urinating on a plastic tarp in her niece’s concrete open-air house and controlling her pain with ibuprofen and oral liquid morphine. If only she had had access to that luxury to prevent her cancer. With a little public will, perhaps her great-granddaughters, and mine, will.

Travis Bias, DO, MPH, DTM&H is a Family Medicine physician in California and medical and public health educator. Connect with him at his blog, The Global Table, or on twitter @Gaujot.

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A National Health Encounter Surveillance System

By ADRIAN GROPPER, MD

Trust is essential for interoperability. One way to promote trust is to provide transparency and accountability for the proposed national system. People have come to expect email or equivalent notification when a significant transaction is made on our personal data. From a patient’s perspective, all health records transactions involving TEFCA are likely significant. When a significant transaction occurs, we expect contemporaneous notification (not the expectation that you have to ask first), a monthly statement of all transactions, and a clear indication of how an error or dispute can be resolved. We also expect the issuer of the notification to also be accountable for the transaction and to assist in holding other participants accountable if that becomes necessary. Each such notification should identify who accessed the data and how the patient can review the data that was accessed. Each time, the patient should be informed of the procedure to flag errors, report abuse, and opt-out of further participation at either the individual source or at the national level.

Recommendation 1 :  Add Principle 2D as: Every transaction over the TEFCA network, including bulk access, is to be accompanied by a contemporaneous email to each individual patient and a monthly statement delivered via email or post if there is activity in that month.

Make Patient-Directed Exchange the Baseline for a National API

Application Programming Interfaces (APIs) are the future of interoperability and mandated by law applicable to TEFCA. The scope of APIs is broad. An API can serve inside a single legal entity to connect one information system to another, it can provide access to one patient per transaction or to a batch of patients, it can connect under the direction of an authorized entity, or it can connect two parties directly on demand by the patient herself. We are familiar with patient-directed interoperability as the paper Release of Information Form submitted to hospital records departments. This fundamental patient right must be preserved and enhanced as we move from paper and Fax to APIs. Using a separate API for entity-directed vs. patient-directed exchange increases the attack surface, confuses patients, and increases cost. If separated, the patient-directed exchange API is likely to be less supported and less functional that the entity-directed API. Errors and security breaches in both APIs are likely to be harder to detect if the two APIs are separate.

Specify that the same API is to be used for both entity-directed and patient-directed exchange. Treat bulk transfers of multiple patients in one transaction as a special case of the API that is not patient-directed, but still notifies the individual patients involved. Ensure that the API does not require more paper-based or in-person processes for patient-directed exchange than are required for entity-directed exchange.

Recommendation 2 : Amend Principle 3A to specify that the same API is to be used for both entity-directed and patient-directed exchange.

Recommendation 3 : Amend Principle 5A to specify that the same API is to be used for both entity-directed and patient-directed exchange.

Recommendation 4 : Amend Principle 6A to clarify that the multiple patient record functionality does not reduce the responsibility to contemporaneously notify individual patients.

Recommendation 5 : Definition of Individual Access 2) is confusing. The API Task Force was clear that blocking of any patient-directed sharing other than one that endangers other patients is prohibited. For example, a patient directed-request to move information to a destination via plain, unsecured email or to a foreign country is acceptable under Applicable Law.

Separate Identity and Authorization Standards from Data Model Standards

Introducing interoperability into a system as large and diverse as healthcare is a tremendous challenge that the draft TEFCA clearly recognizes and seeks to address. Much of this regulation is, quite appropriately, devoted to standards. Some of the standards relate to how health records are encoded. Let’s call this the data model. Other standards relate to how access to a record is controlled. Let’s call this authorization. It is common practice for standards-dependent efforts such as SMART or Argonaut or TEFCA to combine both data model and authorization concerns because there is some overlap in their scope. For example, the data model includes demographic information that is critical to the discovery aspects of authorization around an encounter. Unfortunately, blending projects that seek to standardize the data model with those that seek to standardize the authorization model makes scaling interoperability much harder because it makes healthcare practices less able to benefit from large-scale authorization standards outside of the healthcare domain.

Identity, demographics, and authorization standards are not specific to healthcare. To achieve broad interoperability on a national scale, adopt the Postal Service model of separating what’s on the envelope (authorization) from what’s in the envelope (the data model) and manage the corresponding standards, policies, and practices separately.

We are especially mindful of the multiple portals problem that forces patients to manage consent separately by accessing every separate provider using different protocols and procedures. Just as TEFCA seeks to provide a single on-ramp for providers as End Users it should encourage and ideally offer a single on-ramp for individual patients by allowing the patient to specify their preferred UMA / HEART Authorization Server.

Recommendation 6 : Amend Principle 1A to encourage separation of authorization and data model standards.

Recommendation 7 : Reference Kantara UMA and the profile work of Health Relationship Trust (HEART) as components of ISA.

Recommendation 8 : Any QHIN, Participant, or End User that offers access to Individuals via an API, including the TEFCA-specified API, must allow the Individual to specify and delegate control to a standards-based authorization server of their choosing.

Be Clear About Creating a National Health Encounter Surveillance System

TEFCA is creating a national health encounter surveillance system under the control of the Federal Government. Regardless of the reasons why this might be desirable, the Federal Government needs to be clear that this is a new national agency that manages personal information on substantially everyone just like the IRS, TSA, and FBI. The draft TEFCA is very confusing in this respect. It is hard to draw an analogy to existing systems of identity. State drivers’ licenses are the only common example of a distributed identity system that allows for broadcast queries to some extent, but it is operated by government, founded on coercive biometric databases, and controversial when subject to federal policy like Real ID.

Recommendation 9 : State clearly in the introduction of the proposed regulation that it is national in scope and subject to federal government policy. State also that the system is identity-based, and that a person can have zero, one, or multiple identities in the system.

Recommendation 10 : Definition of Broadcast Query to make clear that it is a national in scope and may include encounters outside of HIPAA Covered Entities.

Recommendation 11 : Definition of Recognized Coordinating Entity (RCE) to make clear that it is controlled by the federal government and subject to the policies of the federal government.

Recommendation 12 : In section 3.3, describe how patients can choose to be tracked, identity-matched, and notified of a match, in a voluntary and non-coercive way.

Recommendation 13 : In section 6.2.4, describe how patients identified only as “known to the practice” under HIPAA or receiving an anonymous service from a laboratory may voluntarily participate, without Identity Proofing in the national system.

If TEFCA is Voluntary, Explain How Patients Can Opt-Out

TEFCA is introduced as voluntary but the draft document is not clear about how a patient can avoid participation in the national surveillance system. Consider, for example, a 15 year old with a severe anxiety attack requiring mental health care. Will this patient be entered into the national system by the emergency department, the psychiatrist, the laboratory, the pharmacy, the insurance company, or all of the above? When this patient turns 18, will he or she have the ability to delete the record of this episode of care from the national system and the process to effect this deletion?

Define how the system is voluntary from the perspective of the patient and describe how a patient opts-out of having an encounter from being entered into system, how a patient is notified when an encounter is added to the system, and how an encounter is deleted from the system.

Recommendation 14 : Amend Principle 5B to replace the reference to Qualified HIN and replace it with a broad statement of participation in the national health encounter surveillance network.

Avoid Introduction of a Hidden Data Brokerage Layer

Current patient rights regulations tend to focus on the right of access to a service provider such as a HIPAA Covered Entity combined with a limit on the ability of Business Associates to aggregate information about an individual across multiple service providers. When a data aggregator or broker is introduced, as for example some state health information exchanges or the Surescripts network, these entities are not well-known to the patient and have no customer relationship with the patient. The result is that these intermediary data brokers are effectively hidden from the patient and not accountable to the patient.

By analogy, we are familiar with the national surveillance system of credit bureaus. Equifax, Experian, and TransUnion are limited in number to three so people can know of all of them, they are regulated to be accessible and responsive to people, and they are required to accept and redistribute comments from the individual. The credit surveillance system also has benefit of a unique person identifier, the Social Security Number, in order to reduce the number of errors that are propagated. Nonetheless, having to deal with three separate data brokers in cases such as identity theft to impose a credit freeze is a major hardship for the individual.

There is, however a major difference between credit surveillance and health surveillance. As individuals we access credit voluntarily but we are compelled to access health care by illness, accident, and misfortune. At a time of suffering and stress, US patients already have to worry about the scope of their insurance network, large unknowable out-of-pocket costs, the impact of their misfortune on employment, disability, and life insurance. These are all hidden consequences of seeking health care. It’s imperative that TEFCA not add another hidden layer to an already stressful system.

To the extent TEFCA envisions a layer of QHINs responsible for managing the location of encounters and consent to access personal information, it is critical that they be accessible and accountable directly to the individual at least as much as the hospitals and service providers are. To the extent TEFCA is establishing a single national data brokerage system like the TSA or the IRS, it is imperative that people know exactly who they are dealing with and how they are identified in the system. Decentralized, private-sector surveillance such as we have for advertising tracking is not appropriate for healthcare.

Recommendation  15 : In Section 7, Access, make RCE the single patient-facing entity, accountable for a consistent policy and a consistent patient identifier across all hospitals, labs, payers, and other service providers. To avoid coercion, allow patients to have multiple, separate RCE identifiers in order to voluntarily segment sensitive encounters from routine one

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Fear and Loathing in Pay-For-Performance Land

KIP SULLIVAN & STEPHEN SOUMERAI

Pay for performance, the catchall term for policies that purport to pay doctors and hospitals based on quality and cost measures, has been taking a bashing.

Last November, University of Pittsburgh and Harvard researchers published a major study in Annals of Internal Medicine showing that a Medicare pay-for-performance program did not improve quality or reduce cost and, to make matters worse, it actually penalized doctors for caring for the poorest and sickest patients because their “quality scores” suffered. In December, Ankur Gupta and colleagues reported that a Medicare program that rewards and punishes hospitals based on arbitrary limits on the number of hospital admissions of heart failure patients may have increased death rates. On New Year’s Day, the New York Times reported that penalties for “inappropriate care” concocted by Veterans Affairs induced an Oregon hospital to deny acute medical care to its sickest patients, including an 81-year-old “malnourished and dehydrated” vet with skin ulcers and broken ribs.

And just three weeks ago, the Medicare Payment Advisory Commission recommended that Congress repeal a Medicare pay-for-performance program, imposed by Congress in 2015, because the program is costly and ineffective.

This bad news comes on top of a decade of less-publicized research indicting policies intended to reward and penalize doctors based on measures — most of them inaccurate — of their cost and quality. That research demonstrates that penalties against doctors:

Do not improve the health of patients

Harm sicker and poorer patients

Encourage doctors and hospitals to avoid or “fire” sicker patients who drag down quality scores due to factors outside physicians’ control

Cause some doctors to stop using lifesaving treatments if they don’t result in bonuses

Create interruptions in needed medical care

Reduce job satisfaction and undermine altruism and professionalism among doctors

Cause doctors to game quality measures. For example, a Medicare program that punished hospitals for hospital-acquired infections actually induced some hospitals to characterize infections acquired after admission as “present upon admission” or to simply not report the infection rather than reduce actual infection rates.

Subjecting doctors and hospitals to carrots and sticks hasn’t worked for several reasons. The most fundamental one: Clinician skill is not the only factor that determines the quality of care. Consider one widely used performance measure: the percent of patients diagnosed with high blood pressure whose blood pressure is brought under control. Doctors who treat older, sicker, and poorer patients with high blood pressure will inevitably score worse on this so-called quality measure than doctors who treat healthier and higher-income patients.

The Intractable Debate over Guns

By, SAURABH JHA

When Russian forces stormed the school held hostage by Chechen terrorists, over 300 people died. The Beslan school siege wasn’t the worst terrorist attack arithmetically – the fatalities were only a tenth of September 11^th. What made the school siege particularly gruesome was that many who died, and died in the most gruesome manner, were children.

There’s something particularly distressing about kids being massacred, which can’t be quantified mathematically. You either get that point or you don’t. And the famed Chechen rebel, Shamil Basayev, got it. Issuing a statement after the attack Basayev claimed responsibility for the siege but called the deaths a “tragedy.” He did not think that the Russians would storm the school. Basayev expressed regret saying that he was “not delighted by what happened there.” Basayev was not known for contrition but death of children doesn’t look good even for someone whose modus operandi was in killing as many as possible.

There’s a code even amongst terrorists – you don’t slaughter children – it’s ok flying planes into big towers but not ok deliberately killing children. Of course, neither is ok but the point is that even the most immoral of our species have a moral code. Strict utilitarians won’t understand this moral code. Strict utilitarians, or rational amoralists, accord significance by multiplying the number of life years lost by the number died, and whether a death from medical error or of a child burnt in a school siege, the conversion factor is the same. Thus, for rational amoralists sentimentality specifically over children dying, such as in Parkland, Florida, in so far as this sentimentality affects policy, must be justified scientifically.

The debate over gun control is paralyzed by unsentimental utilitarianism but with an ironic twist – it is the conservatives, known to eschew utilitarianism, who seek refuge in it. After every mass killing, I receive three lines of reasoning from conservatives opposed to gun control: a) If you restrict guns there’ll be a net increase in crimes and deaths, b) there’s no evidence restricting access to guns will reduce mass shootings, and c) people will still get guns if they really wish to. This type of reasoning comes from the same people who oppose population health, and who deeply oppose the sacrifice of individuals for the greater good, i.e. oppose utilitarianism.

When the fetish of pro-gun conservatives for utilitarianism started I don’t know, but utilitarianism became sexy in the gun debate by the work of John Lott – an econometrician who showed that crime was lower in places which allowed adults to carry concealed weapons. Lott, who published a book with a catchy title: “More guns less crime,” would regularly surface on TV after a mass shooting, and with an affect of a rational amoralist – which is an indifference which comes from uncompromising deference to numbers – he would warn a bifid nation partly in mourning that gun control would lead to net harm.

Lott, a rational data-driven economist, transformed the debate over gun control. The gun debate no longer was just about constitutional law, but science. Suddenly, conservatives became deferent to data. The fight for gun control would no longer take place over sloppy sentimental musings, but over calculus and matrix algebra. I haven’t analyzed Lott’s econometric models which showed “more guns less crime.” But casual acquaintance with econometrics has lead me to conclude that any econometric model can be debunked with sufficient time, knowledge and will. And with even more will, the debunking can be debunked.

And Lott’s science was debunked – not by conservatives. I don’t know for sure the political theology of the debunkers of Lott, suffice to say that the debunking was widely covered in left-leaning publications. Lott responded to the debunking and defended his research. Unlike Chechen terrorists, the rational amoralists know no moral codes – only codes in Stata and SPSS. The gun debate was reduced to arguing about surrogates, missing variables and disputed codes on statistical software.

True to form the data-driven progressives, who are usually utilitarian to their core, have once again fallen for the utilitarian trap. They have hoped to inform policy on firearms by data, by numbers, what is called “rational policy.” It should be easy showing that restriction to guns reduces deaths by guns – this is naked common sense. But the science of gun control falls in the dominion of social sciences whose methods are inherently flawed, and whose flaws can selectively be exposed, the type of science that conservatives have an instinctual distrust of, unless it’s about gun control.

Even though utilitarianism, which is ultimately about numbers, should settle public debates, it doesn’t. This is partly because social sciences are too methodologically weak to settle anything. And partly because new lines of argument sprout. I’ll give you one example – pointing out that many gun-related deaths are suicides and that gun control ought to reduce the number of suicides, which is good in a utilitarian sense, should be a potent argument for gun control. But it’s not and actually weakens the argument for gun control, or leads to more arguing. Why so? Because then some clever clog says “duh, it’s not a gun issue but a mental health issue and the gun problem can’t be solved unless we solve the mental health problem. We need more psychiatrists, not fewer guns.”

The arguing continues. If the issue isn’t a mental health issue then it’s a family value problem – families no longer dine together, or a moral problem, or a problem of too few jobs, or a problem of lack of optimism, or of violent Hollywood movies – but never a problem of easy access to guns. Thus, gun control gets relegated by deeper societal root causes, real or imaginary, of gun deaths.

The emphasis on data has driven the anti-gun progressives off the moral thrust that they so badly need. The gun debate reaches depths of churlishness that is unprecedented in the public space. One example is the ban placed on the CDC from researching about guns. I’m not sure what’s more absurd – the ban or the reaction to the ban. But it feeds well into the utilitarian fallacy that only if we had more and better data we could employ the right policy to reduce mass killings.

After every mass killing there’s an editorial bemoaning the ban on the CDC, as if were it for CDC’s ability to research gun violence we’d have gun control. This is a typical fallacy in which the rationalist fails to appreciate that the quest for fine policy merely defers the enactment of blunt policy, without delivering the finer policy.

The utilitarian mindset leads to technocratic solutions which are prescriptively useless. Another one in this genre is “guns are a public health issue.” The logic for making guns a public health issue is taut – guns lead to death and disability. But the logic of involving physicians in the gun debate is less clear. If you’re not moved by the chilling voices of children screaming in Parkland as the assailant shot with reptilian indifference you’re hardly going to be moved by somber-looking physicians proclaiming “gun control leads to better health,” pointing to some UN charter on health to make their point.

Another absurdity was a law, now struck down, in Florida which prohibited doctors from questioning patients about gun safety. The law was idiotic but what is also absurd, though not as idiotic as the law, is an MD-MPH pediatrician trained in the Acela corridor quizzing a gun enthusiast from flyover country about gun safety. The trouble with involving doctors in the gun debate is that they’ll view shootings as a safety problem – the Parkland massacre didn’t happen because the Parkland murderer hadn’t attended a gun safety seminar.

Making gun control scientific leads to a paralyzing granularity and gun advocates, who generally know more about firearms than the gun control brigade, play granularity to their advantage. If you ever propose gun control, the pro-gun brigade will instantly ask “so, what’s your solution?” and then relentlessly quiz you on your proposed solution. Here’s an example of the argument you can get into:

Ban semi-automatics – people can still get Glocks. Ban large guns – actually large guns can’t be concealed, you’re better off banning small guns. Ban small guns – Second Amendment. Restrict access to AR-15 – there are other guns. Restrict access to other guns – good luck confiscating guns. But it’s not the guns per se, but the size of magazines. But it’s not a gun issue but a mental health issue, etc, etc, etc.

The non-scientific arguments against gun control are at least dressed in some scholarship, the most potent being the rationale behind the Second Amendment, which one understands with historical context. But history is history, and though one must pay heed to George Santayana’s advice that “those who cannot remember the past are condemned to repeat it,” it’s also important not overplaying history. The value of a “well-armed” militia in keeping a free state was no doubt important when it was not clear if King George would return with the British Armada, but it’s unlikely that Charles or William, and least of all Harry, have any intentions in recapturing Fort McHenry.

The idea that the Second Amendment keeps the government at bay is romantic and plays well with constitutional purists. But guns are hardly keeping the government at bay – Americans are progressively getting more and more regulated despite “well-armed militias.” And then there’s Facebook – a de facto digital surveillance state which even the Stasi would have envied. The importance of guns for the citizen militia cannot be more forthrightly diminished than was by the passengers on hijacked United Flight 93, who on September 11^th saved the White House by taking the control of the plane from the terrorists – none of the passengers had an AR-15 with them.

Guns are incidental to the American economic system, though a contrived and shaky trajectory tries to link freedom, free market and the Second Amendment. It’s as if Adam Smith’s invisible hand is perennially trigger happy. How such muddy thinking rose to the surface is bewildering. I suspect the error here is the juxtaposition of two beliefs – that markets work best with minimum government intrusion, arguably correct, and that the Second Amendment is what minimizes government intrusion, unarguably absurd.

But the Second Amendment is not absolute, any more than the First Amendment – the right to bear arms isn’t the right to a personal rocket launcher – so really we’re quibbling about the price not principle, and if people recognize the limitations of the First Amendment, both in the letter and spirit of the law, what’s so complex in recognizing the limitations of the Second Amendment? Why is restriction to guns so objectionable to conservatives? How does restricting access to AR-15 violate the Second Amendment? Why are the same activists, who rally energetically against Obamacare without worrying whether their alternatives are really solutions (they’re not, BTW), suddenly become mute after mass killings? How is it when it comes to gun control the conservatives are suddenly incontinent with “nuance”?

A common logic advanced by conservatives explaining why they are against gun control is that if you trade freedom for security you get neither freedom nor security. I like this rationale. But if conservatives are so worried about this lose-lose trade why did they not object to the personal intrusions for the sake of security after September 11^th? The Patriot Act affected ordinary Americans, too, not just aspiring terrorists. Where are the calls for freedom over security when airports make travel unpleasant for all?

Another rationale is that restricting access to guns won’t abolish mass killings. Of course, it won’t. Antibiotics for meningitis don’t reduce the death toll from meningitis to zero. If we stopped all interventions which only reduced the outcome probabilistically, not with certainty, medicine would grind to a halt.

Another stonewalling technique when one proposes restricting access to guns is what should be done with those who already have the restricted, or banned, guns. “Good luck confiscating guns,” the clever clog will smugly challenge. But anyone who understands the difference between prevalence (existing cases of a disease) and incidence (new cases of a disease) will recognize a sophomoric flaw in such logic. Sure – gun restriction won’t reduce the access to existing firearms to zero, nor should it, but it’ll make it a tad more difficult getting access to new firearms.

Still another rationale is that there’s no evidence that restricting access to guns will reduce the frequency of mass killings. This logic is usually advanced by born-again-empiricists on the right, the same ones who deride deference to data over common sense in other domains. I doubt a randomized controlled trial is practical in this realm. But there’s some epistemic confusion here. Policy doesn’t operate on science – yes, I know it should but it can’t – policy operates on will. There was no evidence that invading Afghanistan, or capturing Osama Bin Laden, would have improved long term outcomes, or was cost effective, or had a high probability of success, but those interventions were still deemed necessary.

There’s a chance that the policy will work and a chance it won’t – and no one has the information to know whether any policy will succeed. The reason for enacting policy is if you believe the situation is dire enough to merit it. I think the mass killings in general, and killing of school children in particular, in the US merits urgent policy, and debating which is the best policy only stalls decision making.

The most specious argument against gun control is “guns don’t kill, people kill.” This cute aphorism, emphasizing that people not guns have moral agency, misses the point which is that all things being equal, ceteris paribus, restricting access to guns could reduce the chances that people will kill using guns which don’t kill. I’m amazed that the same people who advance this logic in the very next breath blame clunky EHRs for medical errors. Perhaps I should say – doctors, not EHRs, go to medical school but then you’d flag me for catastrophically missing the point.

A proposed alternative to gun control in protecting school children from gun attacks is abolishing the “gun free zones” that schools have and in equipping every school with armed guards. Leaving aside the costs of this venture, and the fact that it’d make the country literally a banana republic, this would be parody if it wasn’t about such a tragedy. The irony of requiring the military to protect children because citizens have easy access to guns to protect themselves from government, is depressing.

The choice seems clear though – arm all or disarm some. To be fair passing gun control laws isn’t easy. Partly, this is because the National Rifle Association has become a convenient bogey man and like the Koch Brothers are now folklore – evil forces who manipulate the politicians like puppets. The citizens rarely ask whether they are simply a convenient excuse for lily-livered politicians to do nothing. The Democrats achieved jack $hit in terms of gun control when they commanded DC a few years ago.

The progressives have not advocated smartly for gun control. The obsession over the 45^th President’s Russian connections isn’t helpful. Nor does calling the current regime “Nazis” make a logical case for restricting access to guns. The best hope for gun control lies with President Trump. It’s probably not a good idea calling this thin-skinned president names if you want gun control.

After the Beslan school siege Basayev’s colleague, Aslan Maskhadov, distanced himself, calling the attack a “blasphemy.” Maskhadov recognized, amongst other things, that one sure way of losing support for his cause is by killing children. The episode was a turning point in Russian history. Putin’s power increased and the Chechen struggle became just that tad more unimportant.

The Parkland shooter wasn’t killing kids for political reasons. But Maskhadov would instantly have seen what American conservatives seem unable to see. That children being massacred doesn’t look good for a nation. Massacre of kids tears the nation’s psyche. The case for restricting access to guns isn’t a utilitarian case about net deaths. Its enactment doesn’t depend on data. It’s a policy and like all policies it is heavily drenched in faith and spurred by the exigencies of the moment. Its rationale is based on common sense – tightening access to certain types of guns might, just “might,” reduce frequency of mass killing of kids – “might” might not be right but “might” is good enough.

About the author

Saurabh Jha is a contributing editor to THCB and can be reached @RogueRad

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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