Tuesday, September 30, 2014

The R in ER

The "R" in ER now stands for rip off.  The last few weeks have shown the ways Hospitals and of course their accomplices in crime - Doctors - pad the bills of patients.  Now we have one more way - the contract doctor.

So instead of coming into ER trying go back out and finding an urgent care clinic or go Little House on the Prairie and DIY it.

Much like most of corporate America where many are 1099'ers or Kelly Temps, the Emergency Room does the same with Doctors and in turn they can jack up the bill and avoid some of the medical malpractice often associated with such visits.  You think a conventional malpractice claim is challenging, well wait until you see how they get around that one in legal maneuverings. 

Again the idea of Obamacare was to reduce medical costs - guess not.  The medical industrial system is so entrenched in avarice and duplicity that it will take more than a Presidential order or bill or law to ever make this one functional.  He should try a pardon that may work.




Costs Can Go Up Fast When E.R. Is in Network but the Doctors Are Not

By ELISABETH ROSENTHAL
SEPT. 28, 2014

When Jennifer Hopper raced to the emergency room after her husband, Craig, took a baseball in the face, she made sure they went to a hospital in their insurance network in Texas. So when they got a $937 bill from the emergency room doctor, she called the insurer, assuming it was in error.

But the bill was correct: UnitedHealthcare, the insurance company, had paid its customary fee of $151.02 and expected the Hoppers to pay the remaining $785.98, because the doctor at Seton Northwest Hospital in Austin did not participate in their network.

“It never occurred to me that the first line of defense, the person you have to see in an in-network emergency room, could be out of the network,” said Ms. Hopper, who has spent months fighting the bill. “In-network means we just get the building? I thought the doctor came with the E.R.”

Patients have no choice about which physician they see when they go to an emergency room, even if they have the presence of mind to visit a hospital that is in their insurance network. In the piles of forms that patients sign in those chaotic first moments is often an acknowledgment that they understand some providers may be out of network.

When legislators in Texas demanded some data from insurers last year, they learned that up to half of the hospitals that participated with UnitedHealthcare, Humana and Blue Cross-Blue Shield — Texas’s three biggest insurers — had no in-network emergency room doctors. Out-of-network payments to emergency room physicians accounted for 40 to 70 percent of the money spent on emergency care at in-network hospitals, researchers with the Center for Public Policy Priorities in Austin found.

“It’s very common and there’s little consumers can do to prevent it and protect themselves — it’s a roll of the dice,” said Stacey Pogue, a senior policy analyst with the nonpartisan center and an author of the study.

While patients have complained of surprise out-of-network charges in hospitals from some other specialists — particularly anesthesiologists, radiologists and pathologists — the situation with emergency room doctors is even more troubling, patient advocates say.

For one thing, patients cannot be expected to review provider networks in a crisis, and the information to do so is usually not readily available anyway. Moreover, the Texas study found that out-of-network fees paid to emergency room physicians eclipsed the amount of money paid to those other specialists.

When emergency medicine emerged as a specialty in the 1980s, almost all E.R. doctors were hospital employees who typically did not bill separately for their services. Today, 65 percent of hospitals contract out that function. And some emergency medicine staffing groups — many serve a large number of hospitals, either nationally or locally — opt out of all insurance plans.

As more insurance plans contract with narrower networks of doctors to form offerings tailored to the Affordable Care Act, insurers have acquired greater leverage in cutting payments to physicians.

While an insurer would have little power to drive a hard bargain with a major hospital that the company needs in its network, it can often pick and choose among physicians, excluding some or offering rates so low that many doctors say their practices are unsustainable.

Dr. Jeffrey Bettinger, chairman of the reimbursement committee of the American College of Emergency Physicians, said that out-of-network emergency room doctors were an unusual phenomenon and expressed doubt that the practice was widespread. When it occurred, he added, it was typically because of insurers’ unwillingness to pay doctors a reasonable rate compared to what they pay hospitals for their services.

The average salary of an emergency room physician was $311,000 in 2014, rising from $247,000 since 2010 — a period when many other types of doctors experienced declines in salaries, according to Merritt Hawkins, a physician staffing firm.

Hospital charges for emergency care vary widely. A recent study found that hospital charges for a visit involving a serious medical issue in California varied between $275 and $6,662, just for the facility fee. “Much of the variation we observe may in fact be entirely random,” wrote the authors, emergency physicians at the University of California San Francisco Medical Center. But that variation often does not directly affect patients, since most hospitals participate in the big insurance plans in their area, and patients tend to know which are in their network, so the insurer covers most of the bill.

But it is a different matter with emergency room doctors who bill out-of-network fees, experts say.

When Dr. Michael Schwartz’s daughter went to an emergency room in the Philadelphia suburbs for a reaction to a medication in 2010, she went to an in-network hospital, Bryn Mawr. She was there for a few hours on a cardiac monitor. While most of her care was covered by his family’s insurer, Capital Blue Cross, a bill of more than $2,000 from the out-of-network E.R. physicians for cardiac monitoring was not.

“I tried to negotiate with the physician group, but they wouldn’t budge,” said Dr. Schwartz, a pediatrician, who ended up paying $1,200, the amount his plan required for his share of out-of-network care. “It was ridiculous. I’m a physician and I understand how this works. There was no sign saying, ‘Our physicians are out-of-network.’

Likewise, when Luke Adami, 6, sustained a gash to his chin on a playground, his parents rushed him to an emergency room at an in-network facility, Valley Hospital in New Jersey. The parents, Greg and Madeleine Adami, asked about a plastic surgeon to sew him up. Mr. Adami recalled: “You go to a hospital that’s in network, your kid’s bleeding. What are you going to say?”

The nurse did not mention that the surgeon she called was out of network and would charge a separate fee. Neither did the plastic surgeon say anything about costs when he came in.

He billed the Adamis $4,878 for eight stitches that were coded as “open wound, jaw, complicated.” “When I looked at the bill, I laughed and I told the surgeon’s office, ‘Process this claim with my insurer. I’m not paying out of pocket,’ ” Mr. Adami said. “The hospital has control over who they bring in. But I do not.”

Emergency physicians say they are not to blame. “In general, E.R. physicians try to align themselves with whatever networks their hospitals are in, but sometimes the rates pale compared to what is offered to the hospitals,” said Dr. Bettinger of the emergency physicians’ group. That often leads to protracted negotiations, he said, but eventually the insurers and the doctors come to agreement and sign a contract.

In the meantime, patients are stuck with out-of-pocket charges. Regulations created by the Affordable Care Act specify that insurers must use the best-paying among three methods for reimbursing out-of-network physicians dispensing emergency care: pay the Medicare rate; pay the median in-network amount for the service; or apply the usual formula they use to determine out-of-network reimbursement, which often depends on “usual and customary rates” in the area.

But in most states, doctors can then bill patients for the difference between their charge and what the insurer paid.

In months of dickering over her husband’s bill, Ms. Hopper has learned much about health insurance in Texas. Watching her travails, her husband, a lawyer, told her: “If you were my client, I’d advise you just to pay the $800 and move on with your life.”

She was too angry to take his advice.

But if she or her husband ends up in an emergency room again, she knows they will be vulnerable because only a handful of doctors in any of Austin’s emergency rooms participate in insurance plans. She sighed: “Even knowing everything I know now, it’s completely out of your control.”

Red Light

Sadly this is not the marker of the infamous district in Amsterdam, it instead marks major intersections in many towns and cities across America. They are however, a serious revenue generator in the same vein.

The use of red light cameras have long been a debated and in turn court decided issue to many cities across the country.  They have been repeatedly found unconstitutional and often when they do remain they are also debatable as to accuracy of the crime - speeding.  Just like any junk science these cameras need to be constantly tested and in turn maintained to accurately do their job.

And of course the mere presence of one should be enough to caution any driver that they are near a school or near said camera recording their illegal driving.  And that is a good thing right?  Wrong they are huge financial resources for cities and in turn eliminates or reduces the need for Police to monitor areas and issue tickets and provide more time for beating up and falsely arresting others for even less crimes.   Here in Seattle according to an SPD-provided info-sheet, West Seattle’s first speed-cam zone, Fauntleroy Way near Gatewood Elementary, was responsible for 5,500 $189 citations last school year.
 
Shame they don't have the text cam.

Declining traffic-camera revenue threatens to unbalance D.C.’s budget

Mike DeBonis
Washington Post
September 29

Revenue from tickets issued by the District’s network of traffic cameras has declined dramatically over the past year, potentially throwing the city budget out of balance, the chief financial officer warned Monday.

With less than two days left in the city’s fiscal year, CFO Jeffrey S. DeWitt said in a letter to District officials that revenue from fines and forfeitures may end up more than $70 million under projections if the trends hold — a significant chunk of a $6.3 billion local budget. The bulk of the shortfall comes from fines issued through red-light and speeding cameras, which have been the subject of rancorous public debate as their use has proliferated in recent years.

The city expected to collect $93.7 million through automated traffic enforcement in the fiscal year ending Sept. 30, but as of the end of August, the cameras had generated only $26.1 million, according to preliminary cash reports issued by DeWitt’s office. That is a drop-off of 62 percent from the nearly $70 million the city had collected by that point in 2013.

DeWitt didn’t pinpoint a reason for the lagging revenue, noting only that fine revenue had been “projected to increase because of the rollout of new automated enforcement equipment.”
Doxie McCoy, a spokeswoman for Mayor Vincent C. Gray (D), said in an e-mail that fewer tickets have been issued this year for a variety of reasons, including delays in deploying some new devices, higher speed limits on some streets and more motorists obeying the law.

“And we don’t view any of this as a bad thing,” McCoy said. “As we’ve said all along: the purpose of automated traffic enforcement is to improve public safety and save lives, not to raise money.

But the implications for the District’s budget are considerable: The city had projected it would collect $156 million in camera revenue in the coming fiscal year. Should final tallies expected in December confirm a precipitous decline this year, officials may have to cut $50 million to $70 million in spending from next year’s budget.

The news prompted D.C. Council Chairman Phil Mendelson (D) to take his fellow city leaders to task for being too dependent on ticket revenue in balancing the District’s budget.

In a statement, Mendelson said the revenue projections “add to the black eye” around the camera program delivered by a recent D.C. inspector general’s report that suggested it was more about filling city coffers than maintaining public safety. He noted that the council tried to lower camera fines in 2012 but “couldn’t reduce the fines as much as we wanted because of the revenues that would be lost.”

“The District’s budget should not be dependent on the fines of speeders,” he said.

Police Chief Cathy L. Lanier, an outspoken defender of camera enforcement, said in a statement that she saw in the new figures proof that the cameras are working: “As I have said many times, we usually see significant reductions in citations issued in the first few months of deployment. This demonstrates that drivers are changing their behavior.”

“Our goal is traffic safety,” she continued. “The fact that infractions are going down is a good thing in my view. Automated traffic enforcement is and always has been about safety. We deploy technology as needed.”

News of the declining fine revenue came on the same day city leaders learned of a more welcome financial development: Two of three Wall Street bond-rating agencies said Monday that they were upgrading the city’s general obligation debt. Standard &Poor’s and Fitch both raised their ratings to the “AA” level, matching the rating previously issued by the third firm, Moody’s.

Monday, September 29, 2014

Voice of Reason

Social Media is great fun but I question in reality what it actually accomplishes. I realize what I excel at is investigation and research and am utterly incapable of networking and that is what I see it as but in reality it is advertising and marketing and nothing more. And that is both sides of that coin - the users and the owners of the data. Facebook has just opened up its data trove to more than the NSA.


Every week there is another editorial, complaint or article on Facebook or some app and the associated fallback or realization that it is a distraction, a tool but often a weapon and in turn it makes me wonder if that is why the sudden push for more laws to oversee, govern or remove free speech under the guise of revenge porn or hate speech in which to protect the ever increasing whine me me generation. We have truly raised a generation of complainers, doers not so much. I listened to a young man complain about how my generation put lead into paint and I pointed out that it was not mine the ubiquitously blamed boomers for the asbestos, lead and mercury in everything from insulation to teeth fillings that was his great generational grandparents, ours was the one that actually fixed that.

And yet the NY Times had an article that praised the app that helps you pack and send packages for for the lazy moron too busy or too lazy to go to the post office.   Once again I cannot believe the idiocy and laziness of the MEMEME generation.  Can you not take it to a UPS or private shipping store as they do that too - SHOCKING, I know!  Which means it is a legitimate business with operational costs, profit margins and actual employees not some beleaguered  underemployed person working in the supposed sharing economy.

As for the current climate I recall the Indian of my youth stopping pollution but Gen X gave us the proverbial FU when they elected Reagan and Bushes version 1.0 and 2. So bitch please. I  came home  later that day to watch Bill Moyers and his amazing young guest who is 18 and leading the way in climate revolution. Reminding me that is this new generation that will be the ones whose backs are against the wall who will save the planet, the country and themselves as they have no choice. Or I hope as they need to disengage from the technology that they are so addicted.

Why a leading professor of new media just banned technology use in class it speaks volumes. Kids play with toys and these are largely toys.

I am sure that once in a blue moon actually going to a library, actually talking to a stranger, actually living away from the screen will not kill you. Or it could but living is just that living.

Why a leading professor of new media just banned technology use in class


September 25

Clay Shirky is, as he explains below, a “pretty unlikely candidate for Internet censor.”

Shirky is a professor of media studies at New York University, holding a joint appointment as an arts professor at NYU’s graduate Interactive Telecommunications Program in the Tisch School of the Arts, and as a Distinguished Writer in Residence in the journalism institute. He is a leading voice on the effect technology has had on society — and vice versa — and has been writing extensively about the Internet for nearly a decade.

For years Shirky has allowed his students to bring laptops, tablets and phones into class and use them at will. But he just told students to put them away. He explains why below in a piece below


By Clay Shirky

I teach theory and practice of social media at New York University, and am an advocate and activist for the free culture movement, so I’m a pretty unlikely candidate for Internet censor. But I have just asked the students in my fall seminar to refrain from using laptops, tablets, and phones in class.

I came late and reluctantly to this decision. I have been teaching classes about the Internet since 1998, and I’ve generally had a laissez-faire attitude towards technology use in the classroom. This was partly because the subject of my classes made technology use feel organic, and when device use went well, it was great. Then there was the competitive aspect. It’s my job to be more interesting than the possible distractions, so a ban felt like cheating. And finally, there’s not wanting to infantilize my students, who are adults, even if young ones. Time management is their job, not mine.

Despite these rationales, the practical effects of my decision to allow technology use in class grew worse over time. The level of distraction in my classes seemed to grow, even though it was the same professor and largely the same set of topics, taught to a group of students selected using roughly the same criteria every year. The change seemed to correlate more with the rising ubiquity and utility of the devices themselves, rather than any change in me, the students, or the rest of the classroom encounter.

Over the years, I’ve noticed that when I do have a specific reason to ask everyone to set aside their devices (“Lids down,” in the parlance of my department), it’s as if someone has let fresh air into the room. The conversation brightens, and more recently, there is a sense of relief from many of the students. Multi-tasking is cognitively exhausting; when we do it by choice, being asked to stop can come as a welcome change.

So this year, I moved from recommending setting aside laptops and phones to requiring it, adding this to the class rules: “Stay focused. (No devices in class, unless the assignment requires it.)” Here’s why I finally switched from “allowed unless by request” to  “banned unless required.”
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We’ve known for some time that multi-tasking is bad for the quality of cognitive work, and is especially punishing of the kind of cognitive work we ask of college students.

This effect takes place over more than one time frame — even when multi-tasking doesn’t significantly degrade immediate performance, it can have negative long-term effects on “declarative memory”, the kind of focused recall that lets people characterize and use what they learned from earlier studying. (Multi-tasking thus makes the famous “learned it the day before the test, forgot it the day after” effect even more pernicious.)

People often start multi-tasking because they believe it will help them get more done. Those gains never materialize; instead, efficiency is degraded. However, it provides emotional gratification as a side-effect. (Multi-tasking moves the pleasure of procrastination inside the period of work.) This side-effect is enough to keep people committed to multi-tasking despite worsening the very thing they set out to improve.

On top of this, multi-tasking doesn’t even exercise task-switching as a skill. A study from Stanford reports that heavy multi-taskers are worse at choosing which task to focus on. (“They are suckers for irrelevancy”, as Cliff Nass, one of the researchers put it.) Multi-taskers often think they are like gym rats, bulking up their ability to juggle tasks, when in fact they are like alcoholics, degrading their abilities through over-consumption.
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This is all just the research on multi-tasking as a stable mental phenomenon. Laptops, tablets and phones — the devices on which the struggle between focus and distraction is played out daily — are making the problem progressively worse. Any designer of software as a service has an incentive to be as ingratiating as they can be, in order to compete with other such services. “Look what a good job I’m doing! Look how much value I’m delivering!”
This problem is especially acute with social media, because on top of the general incentive for any service to be verbose about its value, social information is immediately and emotionally engaging. Both the form and the content of a Facebook update are almost irresistibly distracting, especially compared with the hard slog of coursework. (“Your former lover tagged a photo you are in” vs. “The Crimean War was the first conflict significantly affected by use of the telegraph.” Spot the difference?)


Worse, the designers of operating systems have every incentive to be arms dealers to the social media firms. Beeps and pings and pop-ups and icons, contemporary interfaces provide an extraordinary array of attention-getting devices, emphasis on “getting.” Humans are incapable of ignoring surprising new information in our visual field, an effect that is strongest when the visual cue is slightly above and beside the area we’re focusing on. (Does that sound like the upper-right corner of a screen near you?)

The form and content of a Facebook update may be almost irresistible, but when combined with a visual alert in your immediate peripheral vision, it is—really, actually, biologically—impossible to resist. Our visual and emotional systems are faster and more powerful than our intellect; we are given to automatic responses when either system receives stimulus, much less both. Asking a student to stay focused while she has alerts on is like asking a chess player to concentrate while rapping their knuckles with a ruler at unpredictable intervals.
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Jonathan Haidt’s metaphor of the elephant and the rider is useful here. In Haidt’s telling, the mind is like an elephant (the emotions) with a rider (the intellect) on top. The rider can see and plan ahead, but the elephant is far more powerful. Sometimes the rider and the elephant work together (the ideal in classroom settings), but if they conflict, the elephant usually wins.

After reading Haidt, I’ve stopped thinking of students as people who simply make choices about whether to pay attention, and started thinking of them as people trying to pay attention but having to compete with various influences, the largest of which is their own propensity towards involuntary and emotional reaction. (This is even harder for young people, the elephant so strong, the rider still a novice.)

Regarding teaching as a shared struggle changes the nature of the classroom. It’s not me demanding that they focus — its me and them working together to help defend their precious focus against outside distractions. I have a classroom full of riders and elephants, but I’m trying to teach the riders.

And while I do, who is whispering to the elephants? Facebook, Wechat, Twitter, Instagram, Weibo, Snapchat, Tumblr, Pinterest, the list goes on, abetted by the designers of the Mac, iOS, Windows, and Android. In the classroom, it’s me against a brilliant and well-funded army (including, sharper than a serpent’s tooth, many of my former students.) These designers and engineers have every incentive to capture as much of my students’ attention as they possibly can, without regard for any commitment those students may have made to me or to themselves about keeping on task.

It doesn’t have to be this way, of course. Even a passing familiarity with the literature on programming, a famously arduous cognitive task, will acquaint you with stories of people falling into code-flow so deep they lose track of time, forgetting to eat or sleep. Computers are not inherent sources of distraction — they can in fact be powerful engines of focus — but latter-day versions have been designed to be, because attention is the substance which makes the whole consumer internet go.

The fact that hardware and software is being professionally designed to distract was the first thing that made me willing to require rather than merely suggest that students not use devices in class. There are some counter-moves in the industry right now — software that takes over your screen to hide distractions, software that prevents you from logging into certain sites or using the internet at all, phones with Do Not Disturb options — but at the moment these are rear-guard actions. The industry has committed itself to an arms race for my students’ attention, and if it’s me against Facebook and Apple, I lose.

The final realization — the one that firmly tipped me over into the “No devices in class” camp — was this: screens generate distraction in a manner akin to second-hand smoke. A paper with the blunt title Laptop Multitasking Hinders Classroom Learning for Both Users and Nearby Peers says it all:

We found that participants who multitasked on a laptop during a lecture scored lower on a test compared to those who did not multitask, and participants who were in direct view of a multitasking peer scored lower on a test compared to those who were not. The results demonstrate that multitasking on a laptop poses a significant distraction to both users and fellow students and can be detrimental to comprehension of lecture content.

I have known, for years, that the basic research on multi-tasking was adding up, and that for anyone trying to do hard thinking (our spécialité de la maison, here at college), device use in class tends to be a net negative. Even with that consensus, however, it was still possible to imagine that the best way to handle the question was to tell the students about the research, and let them make up their own minds.

The “Nearby Peers” effect, though, shreds that rationale. There is no laissez-faire attitude to take when the degradation of focus is social. Allowing laptop use in class is like allowing boombox use in class — it lets each person choose whether to degrade the experience of those around them.

Groups also have a rider-and-elephant problem, best described by Wilfred Bion in an oddly written but influential book, Experiences in Groups. In it, Bion, who practiced group therapy, observed how his patients would unconsciously coordinate their actions to defeat the purpose of therapy. In discussing the ramifications of this, Bion observed that effective groups often develop elaborate structures, designed to keep their sophisticated goals from being derailed by more primal group activities like gossiping about members and vilifying non-members.

The structure of a classroom, and especially a seminar room, exhibits the same tension. All present have an incentive for the class to be as engaging as possible; even though engagement often means waiting to speak while listening to other people wrestle with half-formed thoughts, that’s the process by which people get good at managing the clash of ideas. Against that long-term value, however, each member has an incentive to opt out, even if only momentarily. The smallest loss of focus can snowball, the impulse to check WeChat quickly and then put the phone away leading to just one message that needs a reply right now, and then, wait, what happened last night??? (To the people who say “Students have always passed notes in class”, I reply that old-model notes didn’t contain video and couldn’t arrive from anywhere in the world at 10 megabits a second.)

I have the good fortune to teach in cities richly provisioned with opportunities for distraction. Were I a 19-year-old planning an ideal day in Shanghai, I would not put “listen to an old guy talk for an hour” at the top of my list. (Vanity prevents me from guessing where it would go.) And yet I can teach the students things they are interested in knowing, and despite all the literature on joyful learning, from Marie Montessori on down, some parts of making your brain do new things are just hard.

Indeed, college contains daily exercises in delayed gratification. “Discuss early modern European print culture” will never beat “Sing karaoke with friends” in a straight fight, but in the long run, having a passable Rihanna impression will be a less useful than understanding how media revolutions unfold.

Anyone distracted in class doesn’t just lose out on the content of the discussion but creates a sense of permission that opting out is OK, and, worse, a haze of second-hand distraction for their peers. In an environment like this, students need support for the better angels of their nature (or at least the more intellectual angels), and they need defenses against the powerful short-term incentives to put off complex, frustrating tasks. That support and those defenses don’t just happen, and they are not limited to the individual’s choices. They are provided by social structure, and that structure is disproportionately provided by the professor, especially during the first weeks of class.

This is, for me, the biggest change — not a switch in rules, but a switch in how I see my role. Professors are at least as bad at estimating how interesting we are as the students are at estimating their ability to focus. Against oppositional models of teaching and learning, both negative — Concentrate, or lose out!—and positive — Let me attract your attention! — I’m coming to see student focus as a collaborative process. It’s me and them working to create a classroom where the students who want to focus have the best shot at it, in a world increasingly hostile to that goal.

Some of the students will still opt out, of course, which remains their prerogative and rightly so, but if I want to help the ones who do want to pay attention, I’ve decided it’s time to admit that I’ve brought whiteboard markers to a gun fight, and act accordingly.

Judgment Day

Today the Tarot Card of Race was thrown down in the local Judicial elections. When all else fails that one is a trusty handy one to use. The irony is that this is a Municipal race with little more to actual judicial review to what is classified as Misdemeanors - gross or not so. In other words the big three - DUI, Drugs, Traffic Violations that are other than parking infractions.  And the color of most of those defendants are anything but white.  Anything requiring heavy lifting - as in intelligence, competence and diligence - is relegated to the County courts (not that many in that group are brain trusts).   This is the lowest of the low courts and as one who sat through many a visit there over the last two years I can truly attest that finding one out of the three is shocking, I know!

So after I stopped laughing I read the op ed piece in the NY Times that discusses the issue of electing Judges. Well nothing new there. We should not be electing them at all nor appointing them for life either.

We also need to step up what exists with regards to boards and bureaus that do take complaints and put teeth in their jaws so they actually can speak up and not just be the mouthpieces for the interests that they especially represent. There is a lot of conflict there when you are a Bar Association leader and in turn reviewer of your members for Judiciary positions. But my favorite is the selective assessments that barely represent the lawyers registered to practice in the area. Wow 55 evaluations of a Judge who sees hundreds of cases means they are mostly indigent and the Public Defender is not biting that hand that feeds either. What a fucked up system.


Judges on the Campaign Trail


By ADAM LIPTAK
SEPT. 27, 2014



WASHINGTON — FEDERAL judges are appointed for life and insulated from politics, and most of them do not think much of the distinctively American practice of electing judges. They make this clear by insisting that those elections, which take place in 39 states, be as political as possible.

The classic statement of this attitude, one she has come to regret, came from Justice Sandra Day O’Connor, who joined a 2002 decision allowing judges running for office to take stands on political and legal issues. “If the state has a problem with judicial impartiality,” she wrote, “it is largely one the state brought upon itself by continuing the practice of popularly electing judges.”

The idea seemed to be that states would think better of their decision to hold judicial elections once they were subjected to the full diet of venom and nonsense that accompanies regular political campaigns. It has not worked out that way.

Soon after Justice O’Connor retired, in 2006, the Supreme Court embarked on a run of campaign finance decisions amplifying the role of money in politics. Those rulings are also helping transform state judiciaries.

“At a time when concerns about the conduct of judicial elections have reached a fever pitch, the court today unleashes the floodgates of corporate and union general treasury spending in these races,” Justice John Paul Stevens wrote in his dissent in the 2010 Citizens United decision, which concerned spending in a presidential primary.

The last three election cycles included $152 million in spending in judicial races, according to Justice at Stake, a research and advocacy group that says it seeks to protect judicial independence. “Judicial campaign cash is burning a hole in the Constitution,” said Bert Brandenburg, the group’s executive director. “You cannot pour millions of dollars into our courtrooms without having an effect.”

But James Bopp Jr., who played a leading role on the winning side in both Citizens United and the 2002 case of Republican Party of Minnesota v. White, said robust judicial campaigns are protected by the First Amendment and allow voters to discipline errant judges. “There is no perfect system,” he said. “The balance is between the need for judicial independence to faithfully follow the law and to be held accountable if they do not follow their function and become activist.”

The larger battle is over the proper conception of the judicial role. Is it detached and marked by technical skill, an even temperament, a certain elitism and the political connections needed to secure an appointment? Or does it share characteristics with the elected officials who run campaigns based on charisma, populism and promises, and who are responsive to their supporters’ agendas?

At their private conference on Monday, the Supreme Court will consider whether to hear a case that could take another step toward reshaping judicial elections. The question now is whether candidates for judicial office may personally solicit campaign contributions.
Continue reading the main story Continue reading the main story
Continue reading the main story

Thirty of the states that elect judges ban such personal requests. Every state supreme court to address the bans has said they are justified by the need to protect the integrity of the judiciary and public confidence in the judicial system.

But federal appeals courts are split on the issue. Four of them, collectively covering 23 states, have struck down solicitation bans. In May, for instance, the United States Court of Appeals for the Ninth Circuit, in San Francisco, struck down Arizona’s ban, at least as applied to candidates for judicial office who are not yet judges.

“A state sets itself on a collision course with the First Amendment when it chooses to popularly elect its judges but restricts a candidate’s campaign speech,” Judge Richard A. Paez wrote, citing Citizens United. “To the extent states wish to avoid a politicized judiciary,” he added, “they can choose to do so by not electing judges.”

The new case comes from Florida, where Lanell Williams-Yulee, a candidate for the county court in Hillsborough County, which includes Tampa, was reprimanded and made to pay $1,860 in court costs for signing a fund-raising letter.

In the process, the Florida Supreme Court upheld the state’s solicitation ban, saying it helped “ensure that judges engaged in campaign activities are able to maintain their status as fair and impartial arbiters of the law.”

The decision acknowledged that many federal judges have ruled differently but noted that they “have lifetime appointments and thus do not have to engage in fund-raising.”

The Florida Bar, which filed the complaint against Ms. Williams-Yulee and successfully defended the state’s solicitation ban, told the justices that “there is a national need for resolution.”

The splits among lower courts make it likely that the Supreme Court will hear the case. So does the fact that the winning side has joined Ms. Williams-Yulee in urging the justices to intercede.

Ms. Williams-Yulee is represented by Yale Law School’s Supreme Court clinic, which says the solicitation bans do a poor job of ensuring impartial judges. In barring not only one-on-one requests but also mass mailings and speeches to large groups, the clinic’s brief said, the bans censor speech unlikely to give rise to judicial corruption.

The bans also do too little, the brief continued, by allowing candidates to raise money through campaign committees and personally thank their donors.

Should the Supreme Court agree to hear the case, Williams-Yulee v. The Florida Bar, No. 13-1499, most signs point to a ruling that will further loosen campaign restrictions.

But one points in a different direction. In 2009, the Supreme Court required the chief justice of the West Virginia Supreme Court to recuse himself from a case in light of $3 million of campaign spending on his behalf by an interested party.

Such spending, Justice Anthony M. Kennedy wrote, could give rise to “a debt of gratitude.” Seven months later, in Citizens United, Justice Kennedy suggested that politicians were more trustworthy than judges. As to politicians, he said, “There is only scant evidence that independent expenditures even ingratiate.”

James Sample, a law professor at Hofstra University, said the 2009 decision Caperton v. A. T. Massey Coal Co. “has elevated the notion that there is something other than the First Amendment in the discussion when it comes to judicial elections.”

But Mr. Bopp said Citizens United was the more pertinent ruling. “There is no judicial elections exception,” he said.

Justice Antonin Scalia, at least, seems to agree.

“Maybe you shouldn’t have judicial elections,” he said during the argument of the 2002 case. “It may be a very bad idea. But as long as you have it, I don’t see the interest in keeping the electorate from being informed.”

I'm with Stupid

I wanted to write some pity observations, some snark but this comes after Friday's Bill Maher and Alexander Pelosi's visit to a parking lot with regards to the coming elections. As it is an off year one would expect some lack of interest but her interviews with people regardless of political party advocacy the respondents were utterly clueless. To say idiotic would be nice to say stupid would be more appropriate.

I think this op ed says it all - smile you're on candid camera. Or as Forrest Gump says "stupid is as stupid does" which explains why we have what we have in America. And we have a lot of it. Shit piles up as they also say. Maybe it needs its own composting can.


The Opinion Pages | Op-Ed Contributor
Curses, Fooled Again!

By PETER FUNTSEPT. 26, 2014

I SPENT the summer producing new “Candid Camera” shows, and among the many things I observed after a 10-year hiatus was that people are more easily fooled than ever.

That may seem counterintuitive, but I’m certain it’s true. Much has to do with multitasking. When my dad, Allen Funt, introduced the show over six decades ago, he had to work at distracting people. Nowadays they do it to themselves.

Many people we now encounter are fiddling with cellphones and other devices, tackling routine activities with less-than-full focus. That makes them easier targets for our little experiments, but also more vulnerable to personal mishaps and genuine scams.

I worried briefly that people are now so tech-savvy that some of our props and fake setups wouldn’t be believed. Instead, we found that the omnipresence of technology has reached a point where people will now accept almost anything.

We showed customers at a salon an “un-tanning machine” that ostensibly sucked off dark pigment in seconds. We told residents in a Denver suburb that they would be getting mail delivery via drone. We gave patients at a dentist’s office an iPad and said they’d now have to conduct their own “online dental exam.” In each case, just about everyone bought in. At the dental office, several people were even prepared to give themselves a shot of Novocain before we intervened.
Continue reading the main story Candid Camera: Drone Mail Video by TV Land

I don’t necessarily believe 21st-century Americans are more gullible, but they tend to give that impression by protesting life’s little insults without taking time to fully digest the situation.

For instance, we told shoppers in Seaside, Calif., they would be charged a “$10 in-store fee” for not buying online. We told customers at a New York food store that to pay with a credit card they would need “three forms of photo ID.” We hired a cop in Scottsdale, Ariz., to enforce a “2 m.p.h. pedestrian speed limit.”
Continue reading the main story Candid Camera: 2 MPH Video by TV Land

Virtually everyone took these propositions to be true. They shot back quickly at big government, big business or any other entity that seemed to have too big a role in managing their lives.

We tried a few political experiments and the results were all too predictable. We showed New Yorkers petitions to recall state officials, but the names were all fictitious. Most people supported the effort, among them a lawyer who carefully explained that one should never sign anything without complete knowledge of the facts, and then signed anyway. In California, our actress posing as a candidate obtained dozens of campaign signatures without ever stating a position, a party or even her last name.
Continue reading the main story Candid Camera: Recall Petition Video by TV Land

In Arizona, we hired two actors to portray “illegal immigrants.” One played a well-dressed gentleman from England, the other a blue-collar worker from Mexico. The British fellow got plenty of signatures to “vouch for good character,” while the Mexican guy had difficulty just getting people to stop and listen to his plea.

One thing that surprised us is the frequency with which people now whip out phones to record whatever strange situation we create. When we rigged a self-serve yogurt machine to start but never stop, one young customer took video for two full minutes. When we arranged to have a store in Arizona institute a “gays- only” policy, one startled patron conducted (and recorded) his own interview with our actor — essentially producing the “Candid Camera” show without realizing he was on it.
Continue reading the main story
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Continue reading the main story Candid Camera: Yogurt Video by TV Land
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I recall the scenarios on Candid Camera years ago as being less about trying to find something close to believable and seeing if the people...
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I haven't laughed this consistently in a long time.What in the world is "TV Land"?I did find it on our cable listing.I hope we can find out...
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I think a lot of it, compared with 50 years ago, is that people are now exposed to so much more bizarre stuff on TV, and that things seem to...

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I don’t mind the smartphone obsession in our scenes; it’s rather funny. It is a shame, though, that so many people now interrupt real life — in effect hollering “cut” — to record what could be called Act One. In doing so they spoil their own Act Two.

Much hasn’t changed over the years. For example, I expected to encounter more profanity in everyday conversation, but it’s really not there. I also wondered whether young people would be less spontaneous and engaged when caught in our scenarios, yet there’s no hint of that whatsoever. I thought in these litigious times fewer people would sign a waiver to appear on our show, but the percentages have stayed about the same over the years.

I do note that today more people step out in public looking a bit disheveled and unkempt and are then hesitant to sign because they’re not happy with their appearance.

Fortunately for our show, people are still, for the most part, willing to engage a stranger and to smile when a little joke is revealed. That said, many folks are feeling the weight of the world’s problems, perhaps more than before.

It seems the less able we are to control the macro aspects of our lives, the more we dwell on minutiae. That might explain why strangers stood on a street corner for many minutes to help our actress select the best cellphone picture of her dog. Folks listened with surprising curiosity as our actor explained why he needed change for a dime.

Posing as a sanitation worker, I told residents in Queens, N.Y., that they would now be required to separate household trash into eight different color-coded bins. I can’t imagine someone being more passionate about any world controversy than the gentleman who was incensed about a bin devoted to “poultry waste.” “How,” he asked, “am I going to eat enough chicken in two weeks to fill that up?”

Double Edge

I have long commented on the way law enforcement seems to have the exception to the rules part down well when it comes to enforcing the law and in turn being held to the standards of the law as citizens. And once again that beast raises their head in this case out of Maryland.

The story is familiar, cop beats individual, lies about it and surprise a video appears that contradicts the lies the liars, whoops I mean police, tell. Criminal charges becomes civil suit and the police now become defendants criminally. The punishment was made and of course one that was less jail and more community service, as if anyone else had committed a class one felony as these officers would have found themselves wearing jumpsuits, but that is the joke about mandatory minimums when it comes to non drug related offenses. Those are quite specific yet a violent beating by an officer of the law that leaves the victim with a head injury gets home detention and even better yet expunged from his record in what is record time too!

Expunging records are possible in most cases (and yes the exceptions are DUI, Sex Offense and Domestic Violence- social crimes that have little to do with protecting the community but shaming the defendant for life that is way more important) but they are costly with little guarantee unless of course you are a cop in Maryland.  Love the spokesperson comments she seems to think this is just a regular occurrence - no there are actual lawyers who specialize in this field.

 And now thanks to the Judge, this lying abusing but retired officer likely on full pension, in a few years will find this "indiscretion" off the record faster than checking the box! As a result he won't be needing to check same box and no one will ever know or care. Retired cops usually take security jobs of which I am sure he will excel.

This Judge is amazingly expedient or well just another idiot whom was elected to the Bench and clearly has demonstrated her allegiances. Was she elected to the bench? And if so I am sure the Police Guild aka Union will be donating to her next campaign. No.bias.what.so.ever.

What are the total costs to the taxpayers of Maryland?  As it includes not just that Cops pensions,  but the costs of the civil suit and the "suits"  that negotiated the settlement;  and in turn all the secondary and other related criminal court costs, including the jail time for the original defendant now plaintiff.   I am guessing that this is now in double digit millions but hey he is a cop right?

I would love to move to Maryland assault someone so severely they were placed in the hospital, get 30 days home detention then in less that 4 years expunged from my record.  Who's with me?


ETA: Since I posted this this a.m, Radley Balko of the Post adds some very pertinent but not surprising comments to this very case - including such treasures as the Campus security officer lost the video and was of course married to one of the assaulting whoops I mean arresting Officers, and the Judge was formerly married to a cop. Why did I not even speculate that this might be the case as I have come to observe over the last few years that nothing shocks me anymore with regards to the corruption and collusion of the units in charge of "justice."

Former Prince George’s officer convicted of beating U-Md. student can clear record

By Lynn Bui
Washington Post
September 29, 2014


Long before John McKenna enrolled at Catholic University law school, he learned how unpredictable the legal system can be.

In March 2010, McKenna, then a junior at the University of Maryland, was beaten by two Prince George’s County police officers as he headed to a bar with his friend.

One officer was acquitted and has returned to duty. Another spent 30 days in home detention for second-degree assault and 18 months on probation. It was a disappointing outcome for McKenna, who hoped for harsher punishments. But, he thought, at least he received a modicum of justice.

Now, McKenna says he has been let down by the legal system again. Earlier this month, a Prince George’s County Circuit Court judge ruled that the guilty verdict and sentence James Harrison, 50, received be stricken from his record. Judge Beverly Woodard’s decision means that as long as Harrison, who has retired from the force, keeps a clean criminal record, the case will be expunged from his files in 2017 as if he had never been found guilty of assault.

“The people of Prince George’s County should be upset about this and worry that the justice system can’t police their own cops,” said McKenna, 26, now in his second year of law school.

McKenna’s case dates back to a raucous celebration of the school’s victory over Duke in a men’s basketball game. McKenna was skipping down the street with a friend when, according to video capturing the scene, they ran into a police line and encountered an officer on horseback. As McKenna backed away from the horse, officers, including Harrison, are shown running toward McKenna and then beating him with batons.

McKenna suffered a concussion and was arrested for allegedly beating an officer. Those charges were dropped after video emerged contradicting the police account.

“The injustice is incredible,” said McKenna’s attorney, Terrell N. Roberts III. McKenna “was not only beaten, he spent the night in jail. This guy [Harrison] found guilty of assault gets no jail time . . . while his conviction is wiped away.”

Phone messages and other attempts to reach Harrison’s attorney were unsuccessful.

Prince George’s agreed to pay McKenna $2 million in a civil settlement and about $1.6 million to nine others who were falsely arrested or physically assaulted the same night. The case also spurred several changes within the police department. For example, officers deployed in the Civil Disturbance Unit now have their ID numbers prominently displayed on their helmets. And the department ordered more cameras to record events.

John Erzen, a spokesman for the Prince George’s County State’s Attorney’s Office, said prosecutors are also disappointed with the judge’s decision.

“Ultimately, we believe that these officers’ actions were criminal, which is why we took the case to trial,” Erzen said. “We believe that the jury spoke loud and clear as to the type of policing they feel is acceptable in Prince George’s County.”

Angelita Plemmer Williams, a spokeswoman for the Maryland judiciary, said it is common for judges to allow convictions to disappear from records — known as probation before judgment — if people request that they be removed and “otherwise have an unblemished record.”

Plemmer Williams said that Woodard did not overturn Harrison’s conviction but issued a “stay,” meaning that when Harrison applies for a job, the misdemeanor conviction won’t appear on his record.

Harrison’s attorney indicated to the judge that Harrison would not apply for police jobs, a condition of his departure from the Prince George’s Police Department, Plemmer Williams said.

Domenic Iamele, a Baltimore attorney who has significant experience in police use-of-force cases, said based on video footage of McKenna’s assault, it was clear the officers did not have justification to beat him up. But Iamele said it was reasonable for the judge to grant Harrison probation before judgment, especially because Harrison had served his sentence, was not convicted of a felony, left the police force and had a clean record before the conviction.

“There is no good and cogent reason to continue the punishment of this man,” Iamele said, “particularly if he has a job opportunity. Why should his record be blemished that he may not be able to get the job or keep the job?”

McKenna worries that erasing this conviction for Harrison won’t deter other officers from carefully thinking about when they use force against civilians in the future. As a law student, McKenna said there is little he can do about the judge’s decision other than to keep telling people about his experiences and use his future degree to help others.

“I was thrust into a media frenzy during my junior year of college all because I skipped down the street somewhat jovially after a basketball game,” McKenna told the judge as he asked her to deny Harrison probation before judgment. “Mr. Harrison committed a serious, violent crime against me, was found guilty of that crime by a jury of his peers, and he needs to pay for that crime.”

Friday, September 26, 2014

Daddy's Home

When I read this article this morning, I thought "well we will all be in some type of jail in our lives including ones for the elderly."

This is another grab for money by the medical industrial complex to take whatever is left - blood or money - preferably the former versus the latter when it comes to caring for the ill and elderly (not always the same btw).

The reality is we have a dual problem: The one where home health care workers are poorly paid and trained but desperately in need and two - an increasingly elder aging population that will be in heavy denial about aging and the needs which that requires.

We have this idea that we will age perfectly and will die in our beds, that science will of course retain our health in some quasi state of acceptance and in turn then appropriately die of "old age." What we have in reality is an end of life care that is both exploitative and in turn not adequately addressed and handled by either the medical field and the families as they come to this crossroads in life. And this too is another issue that must be addressed as it will too lead to further hysteria, debate and some absurd laws that do nothing to help those move forward.

Fighting to Honor a Father's Last Wish: To Die at Home

By: Nina Bernstein
September 26, 2014


Joseph Andrey was 5 years old in 1927 when his impoverished mother sold him to the manager of a popular vaudeville act. He was 91 last year when he told the story again, propped in a wheelchair in the rehabilitation unit of a nursing home where it seemed as though age and infirmity had put a different kind of price on his head.

Craning his neck, he sought the eyes of his daughter, Maureen Stefanides, who had promised to get him out of this place. “I want to go home, to my books and my music,” he said, his voice whispery but intense.

He was still her handsome father, the song-and-dance man of her childhood, with a full head of wavy hair and blue eyes that lit up when he talked. But he was gaunt now, warped like a weathered plank, perhaps by late effects of an old stroke, certainly by muscle atrophy and bad circulation in his legs.

Now she was determined to fulfill her father’s dearest wish, the wish so common among frail, elderly people: to die at home.

But it seemed as if all the forces of the health care system were against her — hospitals, nursing homes, home health agencies, insurance companies, and the shifting crosscurrents of public health spending.

Her father had been discharged by a hospital to a nursing home like this one, supposedly for rehabilitation, so many times that even she had lost count. The stays, long or short, had only left him weaker, harder to care for at home with a shrinking allotment of help from aides and more prone to the infections that sent him back to the hospital.

This time she had fiercely opposed his being discharged to anywhere but home, a small walk-up apartment in Manhattan that her parents shared for half a century before her mother’s death. Yet over her protests and his own, he had been transferred here anyway, to Jewish Home Lifecare in Morningside Heights, a sprawling institution an hour from where she lived. Later, he would ask, “Are you sure you didn’t put me here?”

“No matter what I do, they want you in a nursing home,” Ms. Stefanides told him, promising the placement would be temporary. “I think they’re making money off you.”

Records would show that her father’s case let the nursing home collect $682.48 a day from Medicare, about five times the cost of a day of home care.

By now Ms. Stefanides was a veteran of battles with the health care system, but it still baffled her. A public-school teacher, she could not afford out-of-pocket home care, and though her father qualified for both Medicaid and Medicare, the flow of money seemed to bypass what he actually wanted at the end of life.

Home care agencies abruptly dropped or refused high-needs cases like her father’s as unprofitable under changes in the state’s Medicaid program. Hospitals, eager to clear beds, increasingly sent patients to nursing homes. The nursing homes were often too short-staffed to reliably change diapers but still drew premium Medicare rates, ordering hours of physical therapy and other treatment that studies showed was often useless or harmful.

Continue reading the main story Even hospice was limited. Now mostly for-profit, hospice companies would provide supervision and visits at home a few times a week through Medicare if a doctor certified that Mr. Andrey had only six months to live. The hidden catch: He would lose all Medicaid home care, the daily help he needed to be home at all.
Ms. Stefanides smoothed her father’s hair and touched his cheek, preparing him for her exit.

At 54, she was still slim as a girl and fragile-looking. For most of the past year, she had lifted and rolled and washed her father by herself after the home care aide’s eight-hour shift ended. She would rush to her father’s place from the East Harlem school where she taught fifth grade, feed him supper and get him in pajamas, leave him sleeping under a neighbor’s eye, and then head home, 35 blocks away, to her waiting husband and the dogs she rescued from animal shelters.

She was prepared to do as much again, but she could not quit her job. And now the home care agency had refused to reinstate her father’s aide services.

“He’s in and out of the hospital too much,” an office manager for the agency said when she demanded an explanation. “This is not allowing our girls to make any money.”

Her father was a World War II veteran who had paid taxes all his life, working the night shift in the Murray Hill post office. She was his health care proxy and had power of attorney. But what good was all that?

“It’s a terrible situation they’ve put us in,” Ms. Stefanides said in an agitated phone message left on this reporter’s voice mail. “My father wants to die at home, he knows he’s dying. And here I am proving I’m power of attorney, that I’m guardian, and it means nothing, it falls on deaf ears.”

Her recorded voice continued, rising in anger and resolve as she rushed to explain her father’s straits before being cut off in midsentence.
The message was left at 4:46 p.m. on May 23, 2013, the day after he was taken by ambulance to his fourth or fifth nursing home stint in two years. She would have eight months and eight days to fight for her father before he died.

Dying in America
While Joseph Andrey’s daughter battled the health care system, a national panel appointed by the federally funded Institute of Medicine was preparing a sweeping critique of how the system handles just such cases. The report, “Dying in America,” released last week, calls for a fundamental overhaul of the country’s end-of-life care.

For most people, death does not come suddenly, the report points out. With 48 times as many people reaching 85 more than a century ago, and triple the number who turn 65, the likely course of death is long and unpredictable. In the new demographic reality, the immediate family is older, too, often literally unable to do the heavy lifting for the long haul.
Yet the system was never engineered to support families through this, and its financial incentives reward harmful transitions among homes, hospitals and nursing homes, said Dr. Joan M. Teno, a gerontologist and one of the report’s authors.

“We have these frail older people moving about in the medical-industrial complex that we’ve constructed,” Dr. Teno said. “It’s all about profit margins. It’s not about caring for people.”

Many geriatric experts say that if the wasteful medical spending on this stage of life could be redirected, it could pay for all the social supports and services actually needed by today’s fragile elders and their families. Instead, public money has been shuffled in the same system, benefiting health care businesses but not necessarily patients.

A prime example is the abuse of short-term rehabilitation in nursing homes, improper charges that cost the public more than $1.5 billion a year, federal inspectors for the Department of Health and Human Services reported in 2012. Medicare will pay premium rates for up to 100 days of services in a nursing home to rehabilitate patients. While such efforts can be beneficial, government investigations and lawsuits document a pattern of excessive or fraudulent orders for such services, often just before death.

As for dying at home, “you can’t believe the forces of the system that are arrayed against it,” said Jack Resnick, once a health system executive and now a doctor with a geriatric house-call practice on Roosevelt Island. “The way the reimbursement system works, these decisions are not made on the basis of what the individuals need. They’re based on what the institutions need.”

A nursing home is frequently the only place to find coverage for 24-hour care. But the care itself often falls short. In an analysis this year, federal inspectors found one in three Medicare patients who went to a nursing home from a hospital suffered harm, including preventable infections and medication errors.

Other national research confirms that pressure sores, falls and malnutrition are endemic in many nursing homes, and strongly linked to inadequate staffing. A 1987 law required enough staff to prevent such harms, but states’ enforcement has been weak in the face of a hugely profitable, politically powerful nursing home industry.

To Dr. Joanne Lynn, a veteran hospice physician consulted for the Institute of Medicine report, the problem goes beyond perverse financial incentives. Most developed countries spend much less on medical care over all than the United States, but nearly twice as much on social supports.

“Why can I get a $100,000 drug but I can’t get supper?” she asked, pointing to the budget sequestration that slashed federal spending on meals for seniors last year.

In the end, only a humane case-by-case approach can provide the right care for the last chapter of a long life like Joseph Andrey’s, added Dr. Lynn, who directs the Center for Elder Care and Advanced Illness at the Altarum Institute, a research organization based in Ann Arbor, Mich.

In 1927, a New York newspaper published a request that “a prosperous family” adopt Mr. Andrey, far left, then 5, and a brother.

Poor Childhood, Rich Marriage
Mr. Andrey was the oldest child in a family so poor they begged in the street. His mother appealed to one of New York’s newspapers. “Wants Her Sons Adopted,” the front-page headline said on Aug. 7, 1927, above a family photograph “taken before domestic dissension set in.”

In the picture, little Joseph stands solemnly with a younger brother before their father, a Greek immigrant. His Irish Catholic mother holds a baby on her lap. “As a result of her husband’s failure to support her and the children,” the caption says, she had decided “to seek a good home with a prosperous family for the two older boys.”

The publicity drew the show business agent for the Loomis Twins, singing sisters looking for a sidekick. Money changed hands. And just like that, 5-year-old Joseph went from hunger in the tenements to room service at the Waldorf-Astoria and beyond, to the dining cars of trains speeding to vaudeville stages around the country.

“It was the best thing that happened in my life,” he rasped from his wheelchair last year, recalling the highlight of his childhood: Dancing the leading toy soldier in a Christmas show at Radio City Music Hall.

Just as abruptly, at age 7, the idyll ended. His mother demanded him back, or else more money. He was returned to finish out a ragged childhood. To support the family, he left school at 14 for menial jobs, always longing to get back to the stage.

The draft took him instead to the Pacific theater in World War II. It was the ultimate escape from his parents’ squalid fights, as he told it. Still in uniform, he met Florence Agnew, his future wife, at New York’s Roseland Ballroom.

“They danced together all the time,” their daughter remembered. “They danced around the house, for no reason at all. And then he danced with me.”

A photo of Mr. Andrey, his wife, Florence, and their daughter, Maureen, taken in a photo booth. Just for fun, all three would pile into a photo booth at Woolworth’s, her father cracking them up with his Mighty Mouse voice when the shutter lights flashed.

By then he was sorting mail all night and working in hotel security on the side. He regretfully gave up his Broadway dreams. But he had achieved another fervent childhood goal: a happy marriage.

“It was like a dream,” his son-in-law, Dean Stefanides, would say later, recalling how the couple laughed at their own infirmities.

The medical histories repeated again and again in hospital records were not such a big deal. Yes, she had an early hysterectomy, and in his 50s, he lost the tip of his penis to a cancer that never recurred. Yes, he had a stroke before 70; he seemed to recover completely, though five years later he would have to take medication daily to control seizures, and by 80, began having trouble with his legs.

But for years love and humor seemed to trump the toll of aging. Unable to extract each other from a cab one day, they told a funny story about it. Hard of hearing, they made fractured conversation another comedy routine.

Then Alzheimer’s changed everything. At the couple’s 50th wedding anniversary party, two weeks after the Sept. 11 attacks, relatives drew Ms. Stefanides aside: “Something is wrong with your mom.” She had been calling a cousin from her apartment at 3 a.m., saying she wanted to go home.

Continue reading the main story She was 80. Her steep decline would last eight years.
Like many of the 15 million Americans caring for a relative with Alzheimer’s, Ms. Stefanides and her father learned that Medicare does not cover long term day-to-day help, in any setting. They would have to turn to Medicaid, the shared state and federal program for poor and disabled people.

They were lucky. Under New York’s unusually expansive version of Medicaid, a home attendant went daily to their fourth-floor walk-up in the Yorkville neighborhood to provide eight hours of unskilled “personal care assistance.” Eventually, it was not enough.

The calls from her father would start at 5 a.m.: “I’m scared. What is it with your mother?”

She sometimes brought her mother to her place so her father could sleep, but that put new strains on her marriage.
She and her husband, an art director, had bought their duplex near Beekman Place in the early 1990s, before the advertising industry imploded. Now the apartment doubled as his freelance work space.

One day in 2007, her father broke down. Florence was banging on other tenants’ doors, seeking her childhood room.
“I can’t take it anymore,” he said. “I can’t run after her. Is there like a really nice place where we can put her?”
No. But there was DeWitt Rehabilitation and Nursing Center, a for-profit nursing home on East 79th Street.
“I was so ignorant of what nursing homes are,” Ms. Stefanides would say later. “My mother kept holding on to my sleeve, saying, ‘Take me out of here.’ ”

One day the nightgown slipped off her emaciated shoulders, revealing a mass of bruises. The woman in the next bed confided that Ms. Andrey, then wordless, had been beaten by an aide when she resisted some daily routine.

“The roommate told me that she cried under the covers when she heard my mother’s screams,” Ms. Stefanides recalled.
Now, the nursing home declines to discuss the case. At the time, her own complaints to the administration, the State Health Department and the police went nowhere. Fruitlessly, she hunted for a better place until her mother died.

‘Where’s My Dad?’

“I want to go home, to my books and my music,” Mr. Andrey said while in a nursing home and as his daughter continued to try arrange care for him at home. Credit Victor J. Blue for The New York Times Mr. Andrey’s health worsened after he was widowed in 2009. But the less he could walk, the more he loved being home after brief hospital stays, nested with his Nat King Cole albums, cared for by live-in aides through Medicaid.

Ms. Stefanides was not prepared for the abrupt end of that way of life. Her father was in Lenox Hill Hospital for a urinary tract infection in spring 2011 when a discharge worker called her at school: He would not be sent home, because his home health agency, Excellent, had ended his services, and no one was there to care for him. Instead, he was to go to a nursing home for rehabilitation.

“Absolutely not,” Ms. Stefanides declared, rushing over. His hospital bed was empty. “Where’s my dad?” she cried.
He had been whisked to Kateri Residence, a Catholic nursing home on West 87th Street. And for more than a year, as his legs atrophied and he begged to go home, she was unable to get him out: No home health agency would take him.
Continue reading the main story Agencies like Excellent no longer wanted high-hours home care cases like her father’s, explained Jack Halpern, the chief executive of MyElderAdvocate.com, when she briefly hired him to try to get her father home. Such cases were no longer lucrative.

She came to realize that it was the start of a larger upheaval. The administration of Gov. Andrew M. Cuomo was shifting billions in public spending on long-term care to private managed-care companies, which were paid a flat Medicaid rate for each enrollee. Key players were shunning fragile clients like her father in favor of seniors robust enough to bike to a social adult day care center for table tennis.

“They don’t want heavy-care people, so they’re denying them services,” Mr. Halpern said later. “Everyone’s getting shoved into nursing homes.”

The nursing home, Kateri (which has since been sold and renamed), had financial incentives to keep Mr. Andrey: For up to 100 days, Medicare would pay roughly double Medicaid’s daily rate for regular nursing home care. Later, he was relegated to a unit with so little staff that he rarely left bed. Finally, in spring 2012, when he was showing signs of dementia, Kateri declared him a permanent resident and moved to take his whole income.

At the last moment, Ms. Stefanides cobbled together his escape: She persuaded Gentiva Health Services, a national company, to provide eight hours of home care on weekdays — much less than the live-in care he had before — while her husband, still freelancing, signed papers promising to do the rest. In reality, the schedule relied on her visits and a neighbor’s vigilance.

They managed, barely, for a year. But in 2013, they faced the same problem, only worse. The home care company, under new ownership, dropped her father, and NewYork-Presbyterian Hospital sent him for rehabilitation — to DeWitt.

“When the elevators open, you get this terrible stench,” Ms. Stefanides said of DeWitt’s upper floors at night. “I was hearing people screaming for help and nobody coming. My father was on the verge of tears — in his defecation for three hours, and he kept ringing the bell.”

(DeWitt’s lawyer, Neil Ptashnik, now says: “The only comment the facility has is: We’re well run, adequately staffed, we’ve had no problems with the Department of Health, and our residents seem quite happy.”)

The nursing home sent him to the hospital after 10 days, with a recurrent infection from an improperly placed catheter, medical records show. The hospital soon discharged him to the next nursing home, Jewish Home Lifecare, where orders for therapy and skilled services brought the price of his care up to $682.48 daily under Medicare.

Ben Taylor, a lawyer at the New York Legal Assistance Group, thought he could break the cycle. By law, he said, the state should require Gentiva to reinstate eight hours of daily home care pending a fair hearing. Meanwhile, Ms. Stefanides should contact managed-care plans, which were not supposed to rule out round-the-clock home care.
Continue reading the main story But she reached receptionists who said 24-hour care was unavailable. Jewish Hom
e insisted her father could not safely go home with less. And day by day in the nursing home, he was sinking.

On arrival May 22 last year, Mr. Andrey was “alert and verbal,” with a good appetite, clinical notes said. Less than a week later, he was eating only half his food. On Day 12, he was found on the floor: He had fallen from bed, hurting his knee.

By Day 14, when Medicare had spent nearly $10,000 on his care, a pressure sore was eroding the flesh of his right heel. Despite treatment, ulcers later covered his left buttock and feet. When physical therapy ended, the wounds became another reason for the institution to extend his stay, now costing Medicare $585.49 a day.

In late July, Mr. Taylor won a state directive for Gentiva to restore home services, if the doctor approved. Separately, a social worker at one managed-care company, GuildNet, told Ms. Stefanides that Mr. Andrey might be accepted for home care if the nursing home agreed.

But the nursing home said he was too weak to be released. Instead, it transferred him to a long-term-care wing.
Nursing Home Limbo

Mr. Andrey in the cafeteria of Jewish Home Lifecare in August 2013. Credit Nina Bernstein/The New York Times On a Wednesday evening in mid-August 2013, in the dining room, Mr. Andrey poked at the lid of his ice cream cup with a fork. Beside him, a blind woman fumbled to find the food on her tray, the staff too short-handed to help. At the next table, a woman with dementia kept screaming. Mr. Andrey’s voice could not be heard above the din.

On this wing, emaciated Alzheimer’s patients wandered into his shabby room. From a skinny 138 pounds on admission, he was dwindling to 128.

“Why am I with these people?” he would ask his daughter. “Why am I losing this weight?”

“Dad, this is all through atrophy,” she told him. “We have to get you moving again.”

“They never move me,” he answered. “I’m lucky if they come to change me.”

On some days he went hungry, he told his daughter. Rushed workers left his food tray on the air-conditioner, where he could not reach it. Several times, he fell out of bed trying.

Medicaid now paid the home $307.70 a day for his care, much less than Medicare did before. On Aug. 20, two days after his Medicare stint ended, so did his protein supplements. If his daughter wanted him to drink Ensure, the staff told her, she should buy it herself.

In rehab, a psychologist had noted that Mr. Andrey brightened when he spoke of “the pleasure he derived from the arts.” Now there was not even a television in his room. Visitors found the bathroom filthy, garbage uncollected and Mr. Andrey left half-covered in a diaper. A friend, Dyandria Darel, was so appalled that she documented the scene in photos.
(Jewish Home’s chief medical officer at the time, Mark Levy, who secured Ms. Stefanides’s permission to discuss the case, strongly defends the care provided, calling it “professional, compassionate and well done.” At the same time, he said, “if you fit it all together from the perspective of Mr. Andrey, I don’t think the United States health care system did a great job of meeting his needs.”)

Continue reading the main story Mr. Andrey’s only hope of escape now was GuildNet, the managed-care company. He was interviewed; the apartment was inspected; both passed. But the nursing home’s assessment was missing.

One Sunday evening that summer, Ms. Stefanides and her husband found her father falling from bed, in agony from his contracted legs. His pain medication, Oxycodone, had been halted over the weekend — “doctor’s orders,” the head nurse said when Ms. Stefanides confronted her, adding something about preventing kidney damage.

“My father’s dying, put him on goddamn morphine!” Ms. Stefanides cried. The flustered nurse gave her a number to reach a doctor. But the one who picked up said angrily that he was off the clock, and hung up. Not until Monday could a doctor be found.

By then, Ms. Stefanides felt as though she were petitioning for her father’s release from prison. Another month went by. All told, four months, 11 days and $61,033.62.
But at 6:45 p.m. on Oct. 2, 2013, Joseph Andrey left the nursing home by stretcher as a GuildNet enrollee, his daughter at his side. He was carried up the stairs to the old apartment, newly equipped with a special bed. Soon the smell of good cooking filled the air. An aide fed him with a spoon.
The first week, his daughter crowed, he gained five pounds

More Than Aides Can Handle
Maureen Stefanides in her father's bedroom after he died. Credit Victor J. Blue for The New York Times It was the aides who mattered most and earned the least, Ms. Stefanides reflected. The primary care physician whom GuildNet assigned to her father never met him. The nurses who showed up to treat his deep ulcers kept changing. Yet the two aides who split the week as “live-ins” were paid so little by a subcontractor that they had to take second jobs, they told her.

Both aides seemed nurturing, but one, a recent immigrant, was inexperienced in washing a bed-bound patient. The other rebuked Mr. Andrey when he woke her up, his daughter later learned.

Nearly immobile now, his skin frayed and flesh gaping, he needed more care than they could give, especially at night. When an aide asked for more help, Ms. Stefanides first called the subcontractor, Allen Home Care, and then the GuildNet case manager.

The case was already too costly, she was told. In fact, a caseworker confided, the only reason GuildNet had taken her father was that he was not expected to live long.

(GuildNet declined to comment. Calls to the chief nurse and marketing director at Allen Home Care were not returned, but a team coordinator said, “We basically do what we’re told by the insurance company.”)
In theory, GuildNet was now coordinating all of her father’s care. In practice, he careened between the sleep-deprived aides and a dozen different doctors at NewYork-Presbyterian Hospital.

When he had trouble breathing, his aide called 911, and he went by ambulance to the emergency room. The aide was told to check back in three days for the results of a urine culture, but she forgot. The bad news reached the family 10 days late: The bacteria were resistant to his prescribed antibiotic. By then he had a septic ulcer in his scrotum.
Continue reading the main story The result: Emergency surgery, a different antibiotic, 13 days in the hospital ($108,895.37), followed by a brief discharge home without pain pills or a refill for his antiseizure medicine — and a seizure that sent him back. Two days in medical isolation while doctors ruled out multidrug-resistant bacteria ($20,721.82). Home again, increasingly incoherent.

On Christmas Eve, suffering chills, fever and mental confusion, he went back to the hospital for the third time in three months.

A Father’s Question
“Thank you for keeping me alive,” he told his daughter, teary with gratitude, when he emerged from days of delirium. “When are you taking me home?”

He still wanted to live, she realized. But the doctors said there was nothing more to be done. Now they wanted him sent somewhere else to die.

She felt they were bullying her to disregard her father’s wishes. “They almost told me I was wasting their oxygen and their medicine,” she said.

His sepsis would keep recurring. His system, likely colonized by bacteria acquired in health care institutions, was breaking down. Demented, contracted, hurting — he had no quality of life, doctors said, urging hospice.
But as the hospital’s own social workers had explained, hospice benefits from Medicare came with a catch: Her father would lose all Medicaid home care. In home hospice, that would leave huge gaps, unless she could tend to him around the clock. The alternative was hospice in a nursing home.

Not that, she vowed, vividly recalling her mother’s monthlong death in hospice at DeWitt, after a doctor said withholding liquids was “the humane way.” Once, arriving for her daily visit, she had unthinkingly carried in a cup of tea. Not quickly enough, she hid it behind a curtain, seeing her mother pass her tongue over parched lips.

“She was suffering, and I contributed to that,” she said, sobbing. “I will never forgive myself.”

For her father, she was determined to do better. She told the doctors she needed more time to consider home hospice, and wrestled with her inability to make the open-ended commitment. School administrators had long since lost patience with her absences, and all but accused her of using her parents’ health as an excuse to miss work. She had weeks to go until early retirement, and she had been postponing surgery to replace a hip injured in an icy fall.

The hospital finally proposed another option: Haven, a hospice inside Bellevue Hospital Center run by Visiting Nurse Service of New York. On Jan. 29, with her father unintelligible again, she reluctantly signed the papers.

The people who met them wore masks. Suddenly alert, her father grabbed her sleeve. “Don’t leave me here,” he said. “Something’s going to happen here. Why did you bring me to Bellevue?”

A hospice worker strapped him down, looking for a vein. As the painkiller reached his bloodstream, his daughter saw him gasp for life. She ran out in distress, asking for a priest.

“My God, the last rites, you’re at a hospice!” Ms. Stefanides said later. “No priest to be found.”
Continue reading the main story Continue reading the main story Continue reading the main story (A Haven official later expressed deep concern, saying, “We are reviewing this case to make sure this is the isolated case we believe it is.”)

As she and her husband took turns at his side, Ms. Stefanides’s father lived on — one day, two days. Death came the third morning, before she arrived, on Feb. 1 of this year, three weeks before his 92nd birthday.

At a Manhattan funeral home. Mr. Andrey died on Feb. 1, three weeks before his 92nd birthday. Credit Victor J. Blue for The New York Times The funeral home director told her the deep pressure ulcers on her father’s body were the worst he had ever seen. The records she obtained showed that in the last year of his life, his care cost at least a million dollars. Was that the best, she wondered, that a million dollars could buy?

“He didn’t die in his bed, and that’s what he wanted,” she said. “I still feel that I let him down.”
After the wake, she stayed behind with his body. In a last rite of her own, she placed her hand on his chest and said the act of contrition: “Please forgive my father for all his sins.”

Nearby, on display, was his life in pictures: dashing soldier, dancing husband, loving and demanding father. Through the winter gloom, it still gleamed.