Sunday, March 31, 2013

The Old Gray Mare

Much derision is given to the Boomer generation. We are somehow at fault for all societal ills and yet when you actually examine who seems to behave in the most incalcitrant and obstinate  manner  it are those members of the supposed "Greatest Generation" or those well into their Social Security/Medicare years or the Generation X, the product of those left out of the fun pot smoking, hippie sex that they envision all Boomers participating in. 

The two classic scolds that fit those descriptions are Alan Simpson former Senator and deficit scold and Paul Ryan, former VP candidate and Medicare scold.  Two generations with ironically the same message. I guess Boomers were out working so much that leaving the children to be raised by their Grandparents was a bad idea. And here I am the great advocate of the multi-generational home. Well maybe under one roof less division and more harmony?

But also what accompanies this is the irony that while most of the Congress are well into their dotage they seem to have no problems holding a job and despite the idiocy of their words are still re-elected year after year. Go figure.

So why are Boomers aka 'gray hairs' thought of as dull, inflexible individuals. Irony that Bill Gates and the late  Steve Jobs fit into this classification and yet were or are they so "dull?"

This is just more bull to spread on the lawn. And frankly if you spent much time with youth you see that Silicon Valley is a hub of the copy and paste icon that was developed years ago.  I need more aps and sites that say nothing and do nothing but maintain a standard of living for a select few.  Lean in baby!

The article below is a great reminder that age is like wine and it only gets better. I am back in the classroom after decades and I love it.  Who knew? Nothing changes but the politics but the kids are still the same.  I am challenging them in the same way I challenge myself and the plasticity of the brain is one terrain we have yet to fully explore and I am up for all terrain vehicles when it comes to finding ways to constantly learn and grow.

Why Innovators Get Better With Age

BY; TOM AGAN
Published: March 30, 2013

“WE need some gray hair” once referred to needing someone with more experience. But I haven’t heard that expression in a very long time.

In fact, many companies are intentionally reducing the average age of their work forces in an effort to save money. Younger employees are generally paid less and have lower health care expenses and retirement costs. As one executive remarked to me recently, “I don’t think anyone really likes this — we all know our own 50-year-old moment will be coming, too.”

There is a surprising downside, however, to encouraging older workers to leave or, at some companies, pushing them out: Less gray hair sharply reduces an organization’s innovation potential, which over the long term can greatly outweigh short-term gains.

The most common image of an innovator is that of a kid developing a great idea in a garage, a dorm room or a makeshift office. This is the story of Mark Zuckerberg of Facebook, Bill Gates of Microsoft, and Steve Jobs and Steve Wozniak of Apple. Last week, Yahoo announced that it had bought a news-reading app developed by Nick D’Aloisio, who is all of 17.

In reality, though, these examples are the exception and not the rule. Consider this: The directors of the five top-grossing films of 2012 are all in their 40s or 50s. And two of the biggest-selling authors of fiction for 2012 — Suzanne Collins and E. L. James — are around 50.

According to research by Alex Mesoudi of Durham University in England, the age of eventual Nobel Prize winners when making a discovery, and of inventors when making a significant breakthrough, averaged around 38 in 2000, an increase of about six years since 1900.

But there is another reason to keep innovators around longer: the time it takes between the birth of an idea and when its implications are broadly understood and acted upon. This education process is typically driven by the innovators themselves.

For Nobel Prize winners, this process usually takes about 20 years — meaning that someone who is 38 at the time of discovery will most likely be nearly 60 when he or she receives the prize. For most eventual laureates, that interval is spent attending and making presentations at conferences, networking with colleagues, writing additional papers, editing academic journals and talking with the press.

Let’s assume that with company resources, it will take a corporate innovator 10 years instead of 20 to educate others about the nature, implications and applications of a new idea. If that’s true, a reasonable target retention age for attaining an average level of innovation would be at least 50.

YET despite the overall aging of the work force, many organizations are heading in the opposite direction. One executive at a major investment bank remarked with concern that the average age at his firm was 32. This phenomenon is not unique to corporations. Many medical institutions and universities  have also shifted to younger workforces. But according to research by Benjamin Jones of Northwestern University, a 55-year-old and even a 65-year-old have significantly more innovation potential than a 25-year-old.

If an organization wants innovation to flourish, the conversation needs to change from severance packages to retention bonuses. Instead of managing the average age downward, companies should be managing it upward.

We can act within our own organizations to make a difference. For example, we can end policies that limit the time people are allowed to stay at a certain level in a given position. And we can stop rotating high-potential managers across different businesses. Instead, we need to encourage the best performers to stay put, giving them the years — perhaps even decades — to support and lead major innovations from inception to commercial launch.

And to encourage innovation, we must provide economic incentives to C.E.O.’s, boards of directors and investors through changes in the tax code and elsewhere that favor long-term returns driven by innovation over shortsighted pressure to reduce costs.

The journalist A. J. Jacobs has perfectly described our current situation when it comes to the relationship between age and innovation. In his book “The Year of Living Biblically,” he writes: “I’m 38, which means I’m a few years from my first angioplasty, but — at least in the media business — I’m considered a doddering old man. I just hope the 26-year-old editors out there have mercy on me.”

Relax, A. J., you still have a few more years to hit it out of the ballpark with a mega-best seller.

Leaning In, WAY IN

No one could ever accuse me of being a shrinking violet.  I have been known to lean in, over and steamroll when necessary.  A master of what I call the verbal vasectomy I have intimidated my share of male colleagues without intention, or well not, frankly.

I have found that it bit me in the proverbial ass and now as I fight for my survival and well being, no one knows better than I the deceptive nature of the male backed into the corner. It is not pretty nor easy to come out of it one piece.   I have leaned over so much I have fallen and can't get up!

We are a Patriarchal society and the few who do transcend the glass ceiling are lucky, well connected or one hell of a woman. I don't think for any reason Sheryl Sandberg, the Oprah of this new generation is the latter, but the first two I am pretty sure that if that proverbial Choo, as in Jimmy, fits then wear it.

This is from the UK Guardian and while I utterly disagree with the title, I agree with its premise. I don't see it any less here on this side of the pond.  It is no different for men.  You are born to the shoe you wear I am afraid. For some that is Manolo for others its Converse. That is is the new world economy.  But its also about the lack of Feminism as it is with the lack of Civil Rights overall, from equality in marriage,justice, immigrants, voting rights and so forth. We have failed to maintain those groups that fought hard to fight the fight and get the rights so earned. So no its not the failure in Feminism, its the failure of the current Generations X, Y, Z to maintain them.

The irony on top of irony was that accompanying this article was one asking Virgin Mobile to retract an and ad that depicted a man holding a gift while shielding the eyes of a woman, an accompanying caption asks: "The gift of Christmas surprise. Necklace? Or chloroform?" Or the one where a 14 year old girl was raped on a bus by two men.  Yes, Feminism has really failed.  Having a vagina is high risk behavior, who knew?

Feminism has failed Women
UK Guardian
March 31, 2013

Feminism has failed working-class women by focusing too much on gender equality in high-profile roles, according to new research.

While the average gap between the earnings of men and women has narrowed in the last 50 years, differences between professional and unskilled women are significantly higher than those between the same groups of men, a report by the Institute for Public Policy Research (IPPR) has found.

With or without a university degree, men continue to earn more than their female counterparts. But researchers found that women with a degree born in 1958 earned nearly three times as much (198%) as women in unskilled jobs born in the same year – compared to a difference of less than half (45%) between men in the same groups.

Dalia Ben-Galim, associate director of the IPPR, said: "While feminism has delivered for some professional women, other women have been left behind. Many of the advances for women at the top have masked inequality at the bottom.

"The 'break the glass ceiling' approach that simply promotes women in the boardroom has not been as successful in changing family-friendly working culture or providing opportunities for other women to advance.

"Gender still has a strong independent impact on women's earnings prospects – but class, education and occupational backgrounds are stronger determinants of a woman's progression and earnings prospects."

Motherhood was also a key factor, with women who had children earlier seeing their earnings prospects decrease compared to those who postponed starting a family, the study found. For men, the reverse was true, as fathers enjoyed a "fatherhood pay bonus" that saw them earn more than men without children.

The IPPR called for a more progressive parental leave system, more affordable and accessible childcare and better paid part-time jobs to address these issues.

It also warned against the "decoy effect" of focusing on women in high-profile positions, and said the breaking-down of stereotypes should be the priority.

The report found that the number of "house husbands" in Britain has trebled over the last 15 years, with 62,000 men staying at home to care for their family and remaining economically inactive. But most women (77%) said they do more housework than their husbands, with just one in ten (10%) married men doing an equal amount and 13% doing more.

And researchers discovered that British men and women increasingly marry partners from the same social group, with a decline in women "marrying up" and a small increase in women "marrying down".

Doctor Day

Apparently yesterday was National Doctor Day. They should change that date to November 1, Día de Muertos, or the Day of the Dead.  They seem to be responsible for either that or the most significant cause of bankruptcy in this country which to some families, death is preferable.

On that note I found of course numerous articles about many Physicians whose Hippocratic Oath is more hypocritical than Hippocratic.

First up this Doctor arrested for fraudulent prescriptions. The upside to this story is that he was only selling them for $125 a pop, his assistant $500. Book me an appointment with her, she seems the smart one.
Doctor and Assistant Accused in Drug Case

By Marc Santora
Published: March 28, 2013

For a certain price, according to the authorities, he would write prescriptions for oxycodone, a powerful painkiller, even if the “patient” never stepped foot in his office at the Itzamna Medical Center in the Gramercy neighborhood in Lower Manhattan. On an average day, he would write 11 fraudulent prescriptions and charge $125 per prescription, the authorities said on Thursday.

Dr. Castro’s office assistant, Patricia Valera, also had a secret.&

Unbeknown to the doctor, she was handing out sham prescriptions too, selling each prescription for $500.

“She was doing her boss one better,” Bridget G. Brennan, chief of New York City’s Special Narcotics Prosecutor’s Office, said at a news conference. “Smart businesswoman I guess.

On Thursday, both had their secrets revealed when the authorities announced their arrests for illegally selling painkillers as part of a $10 million operation that involved dozens of people throughout the Northeast.

A total of 49 people were arrested in New York, New Jersey and Pennsylvania on Thursday after a 15-month investigation involving both federal and local authorities.

Lawyers for Dr. Castro and Ms. Valera did not return phone messages seeking comment.

The investigation began in December 2011, after a young man overdosed on oxycodone and was found dead in his home in Woodbridge, N.J.

A detective found a bottle of oxycodone at the home that had been prescribed by Dr. Castro one day before the man died.

The authorities said Dr. Castro’s name was familiar to pharmacists in New Jersey.

From September 2011 to last month, officials said, pharmacies in the state dispensed about half a million oxycodone pills based on more than 4,500 prescriptions issued out of his office.

In August 2012, after spending months conducting surveillance and interviews, an undercover officer successfully infiltrated a New Jersey drug trafficking organization and began making visits to Dr. Castro’s Gramercy office on behalf of the drug organization, the authorities said.

Dr. Castro asked the undercover agent for an M.R.I. exam, ostensibly to justify the need for painkiller, but did not question the fact that the male undercover agent provided him with a female’s imaging.

The doctor accepted a cash payment for the prescription in the office, the authorities said. While officials said Dr. Castro had flooded New Jersey with thousands of fake prescriptions, he was charged only with illegally selling 39 prescriptions, including 28 sold to the undercover officer since it would not be feasible to investigate every prescription.

Dr. Castro was arrested on Tuesday morning at his home at 540 West 52nd Street, where the authorities seized $20,000 in cash.

Shortly after the authorities started an investigation into Dr. Castro, they received information that prescriptions from his office were also flooding a rural area in Pennsylvania in the Poconos.

“The demand for oxycodone became so pronounced in this area that normal patients cannot get their prescriptions filled,” Ms. Brennan said in an interview.

It quickly became clear, according to the authorities, that it was not Dr. Castro selling the prescriptions in Pennsylvania, but rather the office manager, Ms. Valera — who was also known by her nickname, Kardashian.

She was selling prescriptions to two competing drug rings and charging a premium of $500, which included delivery from her husband, Hector Rodriguez, who was also arrested this week.

The street value of oxycodone, according to the authorities, is $20 to $30 per pill.

An average prescription yields 120 pills and is worth about $2,400 on the street.

Ms. Valera and her husband were arrested at their Bronx home on Tuesday morning and agents seized a loaded handgun, about $8,000 cash and blank prescription sheets belonging to Dr. Castro and his brother, who is also a doctor.

His brother, who helped found the Gramercy Park clinic, is not accused of any wrongdoing.

Or this, my personal favorite, the Dentist of Disease. I have no words but I love a good dose of Hep B while getting a filling. One stop shopping.

Tests Start for Patients of Dentist in Inquiry

By MANNY FERNANDEZ
Published: March 29, 2013

The unsanitary practices of a dentist in Tulsa, Okla., may have exposed thousands of patients to H.I.V. and hepatitis, forcing him to close his offices while health officials investigate and test about 7,000 people who had visited him since 2007.

Officials with the Oklahoma Department of Health began sending letters Friday to those patients, urging them to have their blood tested for H.I.V., hepatitis B and hepatitis C. The dentist, Dr. W. Scott Harrington, has offices in Tulsa and Owasso, a northern Tulsa suburb, and investigators said they found numerous health and safety violations at the Tulsa office, including non sterilized and rusty instruments.

So far, only one patient has been confirmed as having been infected — with hepatitis C — after being treated by Dr. Harrington. While officials stressed how important it was for patients to be tested, they cautioned that it was premature to characterize the situation as a widespread public health crisis. They said the transmission of H.I.V., hepatitis B and hepatitis C in a setting like a dentist’s office was unusual.

“This is certainly going to be very alarming for those patients of this dental practice, but we’re trying to assure folks that this is not an outbreak investigation,” said Leslea Bennett-Webb, the spokeswoman for the Health Department. “We know based on scientific investigations in the past that acquiring these kinds of infectious diseases in a dental practice is very rare.”

Health officials have records for Dr. Harrington’s patients only since 2007, so they do not know how many others had visited him before then and might have been exposed to the viruses. They also do not know how long the improper practices were in place, and so were recommending that anyone who had ever been treated by Dr. Harrington be tested.

Dr. Harrington, 64, has been a state-licensed dentist since 1974 and an oral surgeon since 1977. He told investigators that he had treated a large number of patients known to be infectious disease carriers.

He has voluntarily closed his two offices and surrendered his dental license for 30 days. He faces the possibility of having his license revoked, after a hearing on April 19 at the state Board of Dentistry in Oklahoma City.

Dr. Harrington and his lawyer did not respond to requests for comment.

In a 17-count complaint filed Thursday by the dentistry board, Dr. Harrington was accused of being “a menace to the public health” by using unsafe and unsanitary practices. The complaint accused him of using drug vials for more than one patient and keeping expired vials; failing to keep suitable records of dangerous drugs; leaving his drug cabinet unlocked and unsupervised; and allowing dental assistants to sedate patients though they were not licensed to do so.

Dr. Harrington told officials during one inspection that his staff handled all sterilization and drug procedures, telling investigators, according to the complaint: “They take care of that. I don’t.”

Inspectors this month also found two separate sets of instruments at the Tulsa office, each cleaned by a different method — one for those patients known to have infectious diseases and one for those not believed to have such diseases, the complaint stated. The proper approach, officials said, is for all instruments to be handled as if they contained viruses.

“This is unprecedented for us,” said Susan Rogers, the executive director of the state Board of Dentistry and a member of the team that examined Dr. Harrington’s office. “When I say he wasn’t following infection control guidelines, that’s an understatement. I will tell you that I was stunned. I’m used to seeing drug cabinets in disarray. I’m not used to seeing rusty instruments.”
A spokeswoman for the federal Centers for Disease Control and Prevention said the agency was assisting Oklahoma authorities with the investigation.

The Tulsa Health Department said it would offer free testing at a local clinic starting on Saturday.
All States have departments of health and safety and their job is to secure the safety and health of the residents of said State.  Find out if you have a "quality assurance" department or some type of division within the State that ensures the licensing, cleanliness and overall legality of medical facilities and those who practice in licensed professions exist and what they do exactly. 

I personally have had experience with said divisions and only once did I speak to someone. She ended up inadvertently helping but in reality did nothing more.  I have only had one success with a State agency and that was the Insurance Commissioner office.  Literally the phrase "debt of gratitude" is insufficient.  But to be frank our Municipalities and Agencies therein have long suffered a drought of qualified, capable professionals who can offer the kind and type of intellectual fortitude required to do a difficult and demanding job.  So basically the entire Medical Industrial Complex goes unregulated and unrepentant.

There are dozens and dozens of stories of many in the medical fields who have first done harm to their patients.   Google the phrase "Doctor arrested" there are lists of them. My favorite is this Doctor in Massachusetts who was arrested for a DUI.

And don't forget the number of "licensed" therapists who are supposed to help the most vulnerable and in need who add their special dose of crazy to the mix. Like this dude.  Maybe he could hook up with the New York Cop who wanted to cannibalize his wife or the NY Cop who was acquitted from raping a woman whom he was asked to help home one night due to intoxication.  These are the people whom we rely and yet the N.R.A is sure that only good people are not crazy and can have guns.  Its working out well.  Who would be the Judge in these cases.  Well clearly not these guys. 

A system broken. What infrastructure needs repairs first? 


Friday, March 29, 2013

Look a Bag Lady

We often avert our eyes when passing said individual on the street. Embarrassment, guilt, shame or sheer fear often propels us to pass the mentally ill, the chronically poor, the substance abuser or whatever presumed title we assign to those who live on the streets as a way of excusing or at least acknowledging those whose lives we know nothing about.

What circumstances lead those to live on the street? Well much of what I listed above covers much of the reasoning but a recent survey says that this may be more likely than once believed. Really? No, really?

Americans are one paycheck, one major crisis away from finding themselves placed into a precarious situation of risk at any time.  It can be the result of a personal issue but on average it is largely due to something outside of one's control.  The great John Galts of America are sure it is somehow a personal failing unless of course it happens to them and then all hell breaks loose as they then blame some "black guy/mexican guy/woman/immigrant/deadbeat/hophead/fill in the blank" who caused this injustice to happen. Not in my backyard! 

The survey that is below only measured those making $30K and above.. really? As there are over 15 million making below poverty wages, meaning well under that amount, it makes you wonder that their life risks are not even worth mentioning. And of course the hardest hit?  Well, see you on the corner of 3rd a Pike; Women who are over 50, divorced and what they don't mention but I can bet, those whose vagina's failed to breed.  Yes, Ladies had I known that living out of a grocery cart was the other option for not breeding I might have considered using said Vaginal for other than incoming, but alas it is too late.  No wonder Doris Duke late adopted... an adult woman but I get it.

We boomer Women who are not attached via the vagina to someone are more in need to find and secure a new kind of housing, familial relationships and restoring the idea of feminism to ensure that ALL women are secure in society. 

Fear becoming a 'bag lady' someday? Many others do, too

If you spend time worrying that you'll end up on the street in your old age with your belongings stuffed into plastic bags in a shopping cart, you have good company.
A new survey shows that almost half of American women fear they will become "bag ladies" some day, and the anxiety ripples across all income groups.

Even among women with household earnings above $200,000, 27 percent harbor the bag-lady fear, according to a new online survey issued by Allianz Life Insurance Company of North America.

While Allianz is promoting the survey to encourage women to seek more financial-planning advice, the underlying concern is valid, according to a labor economist who studies aging and income issues.

Because women typically earn less and have more sporadic work histories, their pensions and benefits are less sturdy, said Barbara Butrica, a senior research associate at the Urban Institute’s Income and Benefits Policy Center. “They are starting retirement at a disadvantage,” she said.

Women also tend to live longer than men. “So she’ll have to make that income last a lot longer time,” Butrica said.

Among the over-65 set, non-married women have the highest poverty rates. While only 4 percent of married women over 65 fell below the poverty line in 2010, that number rose to 14 percent for widows over 65 and 18 percent for divorced women over 65, Butrica said.

For men over 65 living in poverty, 4 percent were married; 11 percent were widowers and 12 percent were divorced. The gender differences are even more striking, Butrica said, when you consider that in 2010, only 29.5 percent of men age 65 or older were not married, compared with 56.3 percent of women. Those numbers come from the Social Security Administration's 2012 report on “Income of the Population 55 or Older, 2010.”

But should even women with very good jobs fret about being homeless one day?

“It’s highly unlikely. But it could happen,” Butrica said, citing the likelihood that a catastrophic illness is more likely to strike as you get older. “The fact that these women are thinking about it is a good thing.”

And indeed more women are planning for retirement, especially since the financial crisis of 2008-2009, according to the Allianz survey.

More than 90 percent of the women who responded to the survey said women need to be more involved in financial planning. The strongest agreement, 96 percent, came from divorced women.

Overall, 57 percent of the respondents said they both "have more earning power than ever before" and 60 percent said they are the primary breadwinner in their household

The Women, Money & Power Study was conducted by Larson Research + Strategy in December 2012 as an opt-in, online survey with 2,213 women, ages 25 through 75, with an annual household income of at least $30,000. The numbers are representative of the U.S. female population based on age and geographic distribution and are weighted to reflect the most recent and accurate available U.S. Census proportions.

Justice For All?

Watching this week's Bill Moyer's show I was reminded of the book I read in school called Gideon's Trumpet. The writer of the piece died this week and ironically in the same  the world watches this Supreme Court and its case regarding Marriage Equality.

The word "equality" is the connection between the legendary case of Gideon who argued that under the Constitution being poor does not relegate one to having a lack of representation when facing criminal charges.  The landmark decision that resulted was that it required States to establish a public defender system to ensure that poor have available legal representation at no cost. This is what established the Public Defender system, a system that exists now 50 years later in only 27 states. So much for equal justice for all.

The show is below and I urge you to watch the entire program as the second section is regarding the death penalty another punishment that has no logic, equality and reasoning other than retribution.

We are not equal. We are not just. We have two systems of parity in America. The one for the rich and  the other for the poor.  It is not just criminal, literal or figurative, but it is in the  civil side as well.  I have already written about that side of jurisprudence and  until you realize how irrefutably broken, corrupt and damaged it is, more will find themselves victims to it while little is done to improve it or the quality of our lives and society as a whole.


Code Blue,STAT!

In the ever increasing Unicorn Mythology that describes America the one that healthy but uninsured are littering the ER rooms with demands for routine care or are waiting until absolutely necessary to get care causing an increase in costs and treatment as a result.

I have long said that was not the case and once again ER's are not the hallowed halls of George Clooney with his Caesar bangs.  They have their own admit history of bias and trauma which passes onto Patients who are neglected, ignored, misdiagnosed and mistreated. 

The article below addresses many of these issues and the findings? Not shocking in the least.

Costs of Emergency Room Cost-Cutting


By PAULINE W. CHEN, M.D.
Published: March 28, 2013


It was the dead of winter, high season for viral gastroenteritis, so it was with a certain degree of wariness that the harried doctor and nurse finally got around to seeing the patient, a man in his late 60s who had come to the emergency room complaining of belly discomfort.

“I think I’ve got the stomach bug,” he said when they approached.

The nurse moved him to a far corner of the emergency department reserved for less critical cases. The doctor’s plan was to infuse a liter of intravenous fluids then send the man home.

But a couple of hours later, mid-infusion, the patient suddenly turned blue, then gray and passed out.

The patient’s belly pain, it turned out, was the result of a life-threatening aneurysm, a ballooning of the abdominal aorta that had been leaking blood internally for several hours.

Thanks to emergency surgery, the patient survived. But his sudden downturn, his dramatic brush with death and the cavalier initial response of the staff were powerful reminders of an aphorism I had heard since my first weeks of internship; “Assume nothing.”

I remembered that patient after reading a new study that analyzed an assumption underlying a perennially popular cost-cutting measure: reduce emergency room visits for non-urgent care, which can cost up to five times more than care provided in a doctor’s office.

For close to 50 years, emergency rooms have been fingered as a major source of excessive health care costs. And while some newer research has challenged the idea that a large proportion of patients visit the emergency room for routine problems, many payers and policy makers continue to focus on these patients as a major source of wasteful spending.

Not long ago, for example, in an effort to cut back on Medicaid expenditures, several states zeroed in on these so-called “unwarranted visits” and proposed a policy so apparently logical that it was hard to resist the temptation to slap yourself on the forehead. The proposal was to reimburse for an emergency room visit based on the urgency of the discharge diagnosis.

Bills would be paid for true emergencies, like a heart attack or ruptured aneurysm. But payment would be reduced or denied for visits that turned out to be less serious, like heartburn, constipation or an insect bite.

It sounded like an obvious way to discourage unnecessary and expensive visits to the E.R.

But according to the new study, published in The Journal of the American Medical Association, such a policy relies on a huge, and erroneous, assumption: that patients can predict the urgency of their diagnosis based on initial symptoms alone.

Researchers reviewed the records from almost 35,000 patient visits to emergency departments across the country. In 6 percent of cases, the patient was discharged and could have been treated in a doctor’s office.

The researchers then combed through the initial symptoms or complaints of these non-urgent cases and discovered that in nearly 90 percent of the other, more urgent cases, patients came to the emergency room with the same primary presenting symptoms, complaints like abdominal discomfort, chest pain or fever. In addition, more than 10 percent of these urgent patients ended up requiring hospital admission, surgery or intensive care.

In other words, basing reimbursement on discharge diagnoses is just Monday morning quarterbacking, health care policy style.

“Patients don’t have their diagnosis taped to their forehead when they come into the emergency department,” said Dr. Renee Y. Hsia, senior author of the study and an assistant professor of emergency medicine at the University of California, San Francisco. “They present with symptoms or complaints.”

It is not the first time that limiting payments based on discharge diagnoses has been proposed. During the 1980s and ‘90s, private insurers imposed similar restrictions, requiring patients to obtain “pre-authorization” for emergency room visits, then denying payments to those whose discharge diagnosis turned out not to be an emergency. In response, several states at the time passed “prudent layperson mandates” requiring insurers to pay for the emergency room visit of any patient who presented with symptoms that an average person might consider urgent, even if the final diagnosis was not.

The mandates helped to ensure that patients could get care. But the recent interest in once again basing payment on discharge diagnosis could limit patient access. “It’s easy to see why paying for non-urgent problems might make a policy maker’s blood boil,” Dr. Hsia said. “But is it right to make patients shoulder the entire burden and associated risk of figuring out whether their presenting complaint meets the payer’s criteria for reimbursement?”

One state that did consider such a policy now appears to have found a different solution that, while complicated, does not assume that patients know the true seriousness of their condition before they head to the hospital. Since July of last year, emergency departments in Washington state have established programs to educate patients on how to access care as well as other measures designed to improve care, including statewide guidelines on prescribing narcotics, shared electronic health and prescription information, and regularly updated reports on how emergency department resources are utilized. The policy has already resulted in significant changes and a projected savings of over $31 million by the end of the fiscal year.

Dr. Hsia believes that the policy’s success, as well as the degree of work and cooperation required, only confirm what her study showed: that when it comes to caring for patients, the best approaches are neither simple nor assumed.

“A policy that requires more coordination and more tailoring means more work than one that slashes benefits across the board,” Dr. Hsia said. “But it’s the right thing to do for patients.”



Wednesday, March 27, 2013

Moby Dick

Ah the eponymous tale of Ahab and his fight to conquer the whale. A modern day version may well be that of JP Morgan Chase's own Jamie Dimon and the Federal Regulators whom he and his own "whales" have long ignored as Jamie courted and flirted and mocked his way through both parties, as in political ones. Ah Moby was a Dick of another kind and a sperm whale too elusive for the ever obsessed Ahab, is this one as well?

This week the Captain battened down the hatches and lead a full on assault to the elusive Dick as they have these past weeks. The last Senate hearing, Mr. Dimon was not invited as he is believed to be a distraction and not yet ironically a curse with regards to Chase's outstanding problems of which there are many.

The article below summarizes the current battles of this Ahab and their Dick and perhaps this might mean getting bailed may include a balling out. But given our climate, our fear of those too big to fail and the sheer power the banks hold over Government one wonders if this is simply just a storm that we must batten down the hatches and Ahab once again loses to the Dick, the mighty whale of this ocean.

We shall see who goes down with the ship.

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JPMorgan Chase Faces Full-Court Press of Federal Investigations


By JESSICA SILVER-GREENBERG and BEN PROTESS
Applewhite/Associated Press

Jamie Dimon is chief of JPMorgan Chase.As the nation’s strongest bank, JPMorgan Chase used to be known for carrying special sway with regulators. Now it increasingly finds itself in the cross hairs of federal authorities.

At least two board members are worried about the mounting problems, and some top executives fear that the bank’s relationships in Washington have frayed as JPMorgan becomes a focus of federal investigations.

Still federal prosecutors are examining whether JPMorgan failed to fully alert authorities to suspicions about Bernard L. Madoff, according to several people with direct knowledge of the matter. And nearly a year after reporting a multibillion-dollar trading loss, JPMorgan is facing a criminal inquiry over whether it lied to investors and regulators about the risky wagers, a case that could accelerate when the Federal Bureau of Investigation and other authorities interview top JPMorgan executives in coming weeks.

All told, at least eight federal agencies are investigating the bank, including the Federal Deposit Insurance Corporation, the Commodity Futures Trading Commission and the Securities and Exchange Commission. Federal prosecutors and the F.B.I. in New York are also examining potential wrongdoing at JPMorgan.

A recent misstep points to the growing friction between JPMorgan and regulators as well as to the concerns within the bank. JPMorgan misstated how the bank may have harmed more than 5,000 homeowners in foreclosure, according to several people briefed on the matter. The bank’s primary regulator, the Office of the Comptroller of the Currency, is expected to collect a cash payment from the bank to remedy the flawed review of loans, these people say.

The bank acknowledges its broad regulatory challenges. “We get it, and we are dealing aggressively with these issues,” said Joe Evangelisti, a JPMorgan spokesman.

The mortgage errors, while by themselves relatively minor, have heightened concerns within JPMorgan because they come on top of the other investigations. The increased scrutiny presents a challenge for the bank and its influential chief executive, Jamie Dimon, who was widely praised for steering JPMorgan through the 2008 financial crisis, leaving it in far better shape than its rivals. Among some executives at the bank, the worry is that the unwanted attention will undercut Mr. Dimon’s authority in Washington.

“Jamie and other executives feel terrible that the bank’s self-inflicted mistakes have put regulators in an awkward position,” Mr. Evangelisti said. He added, “We are wholly to blame for our errors and are fully cooperating with all authorities to make things right.”

Mr. Dimon has already testified before Congress and apologized for the trading losses. In response to last year’s trading blowup, the bank has also worked to root out the problems, shuffled its top executives, bolstered its risk controls and brought in a new head of compliance.

The bank’s board, which halved Mr. Dimon’s compensation in January, recently reiterated its support for him as both chairman and chief executive. JPMorgan, whose shares have soared in recent months, has recorded record profits for the last three years.

But as JPMorgan seeks to address its legal woes and restore its credibility in Washington, the bungled review of troubled mortgages could present a setback for the bank. The problems stem from January, when JPMorgan and other big banks agreed to a multibillion-dollar settlement over foreclosure abuses. As part of the pact, the bank agreed to comb through each loan file to spot potential errors, a process that the regulators will use to help determine the size of the payouts to homeowners.

While assessing 880,000 mortgages, JPMorgan overstated the potential harm for more than 5,000 loans, the people familiar with the matter said. The mistakes were not deliberate, according to a person with direct knowledge of the review, who also noted that the extent of the problem was small and that other banks were encountering their own issues with the review.

To ensure those errors didn’t cheat homeowners out of relief, JPMorgan offered additional compensation for borrowers, according to one person familiar with the matter. Still, the comptroller, which is growing impatient with JPMorgan’s mistakes, could also fine the bank, another person said.

Tensions between JPMorgan and its primary regulator were highlighted in a recent Senate report that examined the $6.2 billion trading loss. The report, by the Senate Permanent Subcommittee on Investigations, portrayed a somewhat defiant stance by Mr. Dimon, showing how during a brief period in August 2011 the chief executive stopped providing regulators with profit-and-loss reports about the investment bank.

Jamie Dimon, left, at headquarters. His occasional defiance of regulators may have emboldened his employees to do likewise.Although the bank says Mr. Dimon was merely concerned about a security breach, the report says he took an adversarial tone with regulators, pushing them to explain why they needed that level of information. Mr. Dimon’s approach seemed to influence other executives, including one employee who once screamed at examiners and called them “stupid.”

Those episodes, combined with the current investigations, are costing the bank some of its influence in Washington, according to government officials who would speak only anonymously. The legal problems also pose a test for Stephen M. Cutler, the bank’s general counsel, who is advocating for the bank to take a respectful approach with regulators.

In April, according to people briefed on the matter, senior executives are expected to meet with investigators who are examining the trading loss. A handful of executives have already met with authorities, but the second round will include Mr. Dimon. While he is not suspected of any wrongdoing, the officials hope Mr. Dimon will help build a case against traders in London suspected of lowballing their losses.

The investigators will also seek information about whether some top bank executives misled investors and regulators about the severity of the losses. Even as losses mounted last year, the bank did not publicly disclose the problem for months. The bank has said that “senior management acted in good faith and never had any intent to mislead anyone.”

But the S.E.C. is also examining such disclosures. And under the Dodd-Frank regulatory law, the F.D.I.C. is investigating the trading loss, according to people briefed on the matter.

The S.E.C., F.D.I.C., Comptroller’s office and F.B.I. all declined to comment.

JPMorgan has separately come under fire for lax controls against money-laundering. In January, the comptroller hit JPMorgan with a cease-and-desist order for failures that threatened to allow tainted money to move through the bank’s vast network.

Mr. Evangelisti, JPMorgan’s spokesman, has said the bank has “been working hard to fully remediate the issues identified.”

Still, federal prosecutors in Manhattan are examining JPMorgan’s actions in the Madoff case, suspecting the bank may have violated a federal law that requires banks to alert authorities to suspicious transactions. The comptroller’s office is investigating similar issues.

“We believe that the personnel who dealt with the Madoff issue acted in good faith in seeking to comply with all anti-money-laundering and regulatory obligations,” Mr. Evangelisti said.

The federal investigation echoes claims in a 2010 lawsuit against the bank brought by Irving H. Picard, the bankruptcy trustee gathering assets for Mr. Madoff’s victims.

The suit cited internal JPMorgan e-mails sent 18 months before Mr. Madoff’s arrest, in which one employee acknowledged that a bank executive “just told me that there is a well-known cloud over the head of Madoff and that his returns are speculated to be part of a Ponzi scheme.”



Tuesday, March 26, 2013

Churn Baby Churn

That refers to the practice of insuring that a bill is generated in excessive amounts as it relates particularly to the legal field. In my most recent dealings with the Legal Industrial Complex they are not inherently different than the Medical one, in every way, including killing you (see the post on the death sentences applied to those with crap Attorneys).   But unlike MMC the LIC can be sued for excessive billing. The option with Medical care is personal bankruptcy which is also possible if you assume that many legal bills but even they stop when they realize that the buck stopped with you, medicine not so much.  The band plays on.

Today the cover of the New York Times discusses one client's attempt to expose the fraud and the deception that comes along with the incompetence when dealing with Law firms.  As one who has found that this is a group that will do as little as possible for as much as possible nothing shocks me.  I often say they bill by the word.  To ask an Attorney to actually write a brief or file a motion is akin to asking them to sacrifice their first born if that Attorney is not on an hourly basis; I should know that as well. I got one to actually write one and I think even the Judge seemed shocked.  And then people wonder why I chose to go per se when it came to filing my Medical Malpractice Complaint.  I have nothing, literally, nothing to lose.

I wonder if we as a Country have finally reached the nadir of corruption and greed and finally like the Gilded Age we are awaiting its fall.  Nero fiddled when Rome burned, I wonder if Andrea Botticelli could be an acceptable substitute.

Suit Offers a Peek at the Practice of Inflating a Legal Bill


By PETER LATTMAN
Published Mar 26, 2013

They were lawyers at the world’s largest law firm, trading casual e-mails about a client’s case. One made a sarcastic joke about how the bill was running way over budget. Another described a colleague’s approach to the assignment as “churn that bill, baby!”

The e-mails, which emerged in a court filing late last week, provide a window into the thorny issue of law firm billing. The documents are likely to reinforce a perception held by many corporate clients — and the public — that law firms inflate bills by performing superfluous tasks and overstaffing assignments.

The internal correspondence of the law firm, DLA Piper, was disclosed in a fee dispute between the law firm and Adam H. Victor, an energy industry executive. After DLA Piper sued Mr. Victor for $675,000 in unpaid legal bills, Mr. Victor filed a counterclaim, accusing the law firm of a “sweeping practice of overbilling.”

.Mr. Victor’s feud with DLA Piper began after he retained the firm in April 2010 to prepare a bankruptcy filing for one of his companies. A month after the filing, a lawyer at the firm warned colleagues that the businessman’s bill was mounting.

“I hear we are already 200k over our estimate — that’s Team DLA Piper!” wrote Erich P. Eisenegger, a lawyer at the firm.

Another DLA Piper lawyer, Christopher Thomson, replied, noting that a third colleague, Vincent J. Roldan, had been enlisted to work on the matter.

“Now Vince has random people working full time on random research projects in standard ‘churn that bill, baby!’ mode,” Mr. Thomson wrote. “That bill shall know no limits.”

A DLA Piper spokesman said the firm did not comment on pending litigation.

Legal ethics scholars said that it was highly unusual to find documentary evidence of possible churning — the creation of unnecessary work to drive up a client’s bill.

Stephen Gillers, who teaches professional responsibility at New York University Law School, called the e-mails a troubling example of lawyers’ flip attitudes toward a client’s escalating fees. And he noted that they had come to light at a time when corporations are increasingly rejecting the billable hour standard and becoming vigilant about controlling skyrocketing legal expenses.

William G. Ross, a law professor at Samford University’s Cumberland School of Law who specializes in billing ethics, said that the DLA Piper e-mails appeared to support what several of his studies had shown: that churning, while not endemic, is an insidious problem in the legal profession.

In a survey of about 250 lawyers that Professor Ross conducted in 2007, more than half acknowledged that the prospect of billing extra time influenced their decision to perform pointless assignments, such as doing excessive legal research or extraneous document review. There is also the issue of “featherbedding,” he said, or throwing armies of bodies at every problem.

“Lawyers sometimes conflate their own financial interests with the interests of the client who pays the bills,” Professor Ross said. “Of course, most lawyers are ethical, but the billable hour creates perverse incentives.”

The three DLA Piper lawyers who wrote the e-mails have since left the firm. Mr. Eisenegger and Mr. Roldan, who now work for other law firms, did not respond to requests for comment. Mr. Thomson, now a government lawyer, declined to comment. Their departures had nothing to do with the Victor case, according to people briefed on the matter.

The fee dispute centers on DLA Piper’s representation of Mr. Victor in a Chapter 11 filing for one of his holdings, Project Orange Associates, the operator of a power plant in Syracuse that provided steam to Syracuse University. Mr. Victor, the chief executive of TransGas Development Systems, which is based in New York, said that his fight over the Project Orange bill was the culmination of a relationship that had deteriorated over the last decade as DLA Piper undertook a breathtaking expansion.

He said that when he first started working with DLA Piper in the late 1990s, the firm was a modest size and went by the name Piper Rudnick. Mr. Victor had a point person at the firm, Nicolai J. Sarad, a partner in the energy industry practice.

But as DLA Piper grew, Mr. Sarad began spending less time on his assignments, Mr. Victor said. Mr. Sarad did not respond to a request for comment.

Through acquisitions, joint ventures and the aggressive hiring of partners from other firms, DLA Piper has grown into a global monolith of 4,200 lawyers in more than 30 countries, making it the world’s largest firm by lawyer count. Last year, it posted revenue of $2.25 billion, according to The American Lawyer magazine.

“As the firm got bigger, there were all of these lawyers who I didn’t know suddenly showing up on my bills,” Mr. Victor said.

He said he was particularly irked by the routine practice of DLA Piper partners farming out assignments to the firm’s junior lawyers. He complained that this resulted in higher bills and often subpar work.

Internal DLA Piper e-mails from the Project Orange bankruptcy appear to corroborate that criticism. Lawyers on the case openly discussed the inefficient use of junior lawyers, who are known as associates. Mr. Thomson, a DLA Piper lawyer, wrote that although the firm had reduced the amount of a bill for Mr. Victor, he expected his fees to escalate.

“DLA seems to love to lowball the bills and with the number of bodies being thrown at this thing it’s going to stay stupidly high and with the absurd litigation P.O.A. has been in for years it does have lots of wrinkles,” Mr. Thomson wrote.

Later, Mr. Thomson complained that DLA Piper associates were taking too long to complete assignments. “It took all of them four days to write those motions while I did cash collateral and talked to the client and learned the facts,” Mr. Thomson wrote. “Perhaps if we paid more money we’d have skilled associates.”

The e-mails were included in the 250,000 pages of documents that were turned over to Mr. Victor by DLA Piper as part of pretrial discovery in the case. Mr. Victor said that the e-mails confirmed his worst suspicions.

His lawyer, Larry Hutcher at Davidoff Hutcher & Citron, amended the countersuit last week to include a fraud claim and a request for $22.5 million in punitive damages, a number representing 1 percent of DLA Piper’s reported revenue last year.

“For the past decade, I have fought with DLA to reduce their legal bills,” Mr. Victor said. “And now I’m going to keep on fighting.”



Monday, March 25, 2013

Need Help, Don't Ask

I posted a dialog about the DSM and the repercussions as a result of the diagnosis provided by Psychiatrists and Psychologists who find reliance on extraneous factors, versus actually talking to and spending time with a Patient, to ensure that they are finding the right kind of help they need.  In that exchange I saw a response by a Paula J. Caplan and in turn found this article and her book on the subject of mis-diagnosis of mental illness, particularly to women.

Note that the woman in Ms. Caplan's article was caretaking both an ill elderly adult and a small child, alone.  As you read it, you note that the ER Admit Dr. was of no use, not shocking, he was simply going off the 15 minute admit/quit/move on list but the one who most significant in her trip down the rabbit hole, the Hospital Social Worker. 

I have spoken to others who have had similar experiences and one ER Doctor I met recently said the Hospital Social Worker is largely part of the problem, not the solution. Instead of finding her resources to aid her in home, from support networks to other in home care services, this Social Worker recommended entering the Service network of Disability, a life of drugs and dependency on low income and few  resources.  That is a vicious circle of which once entered you cannot escape.  Put them on the list of utter idiots with degrees that don't match the skill set. 

I have also included another article also about the dangers of the new DSM.  Both are below.  I for one will never set foot in any "licensed" therapy office regardless of need.  No one needs anything that badly.  

This is our system, a Patriarchal one that began with Lobotomy, then to Valium, to Aderall and other drugs that keep women and children medicated and obliterated to the point of compliance. It's much easier after a hard day right?

This is our system of incompetence and ineptitude. Scary movies have less dangerous assholes than the Medical Industrial complex.
 

New mental health manual is "dangerous" say experts



LONDON | Thu Feb 9, 2012 2:24pm EST
 
(Reuters) - Millions of healthy people - including shy or defiant children, grieving relatives and people with fetishes - may be wrongly labeled mentally ill by a new international diagnostic manual, specialists said on Thursday.

In a damning analysis of an upcoming revision of the influential Diagnostic and Statistical Manual of Mental Disorders (DSM), psychologists, psychiatrists and other experts said new categories of mental illness identified in the book were at best "silly" and at worst "worrying and dangerous."

"Many people who are shy, bereaved, eccentric, or have unconventional romantic lives will suddenly find themselves labeled as mentally ill," said Peter Kinderman, head of Liverpool University's Institute of Psychology at a briefing in London about widespread concerns over the manual.
"It's not humane, it's not scientific, and it won't help decide what help a person needs."

The DSM is published by the American Psychiatric Association (APA) and has symptoms and other criteria for diagnosing mental disorders. It is used internationally and seen as the diagnostic "bible" for mental health medicine.

No one from the APA was immediately available for comment.

More than 11,000 health professionals have already signed a petition calling for the development of the fifth edition of the manual to be halted and re-thought.

Some diagnoses - for conditions like "oppositional defiant disorder" and "apathy syndrome" - risk devaluing the seriousness of mental illness and medical zing behaviors most people would consider normal or just mildly eccentric, the experts said.

At the other end of the spectrum, the new DSM, due out next year, could give medical diagnoses for serial rapists and sex abusers - under labels like "paraphilic coercive disorder" - and may allow offenders to escape prison by providing what could be seen as an excuse for their behavior, they added.

RADICAL, RECKLESS, AND INHUMANE
Simon Wessely of the Institute of Psychiatry at King's College London said a look back at history should make health experts ask themselves: "Do we need all these labels?"

He said the 1840 Census of the United States included just one category for mental disorder, but by 1917 the APA was already recognizing 59. That rose to 128 in 1959, to 227 in 1980, and again to around 350 disorders in the fastest revisions of DSM in 1994 and 2000.

Allen Frances of Duke University and chair of the committee that oversaw the previous DSM revision, said DSM-5 would "radically and recklessly expand the boundaries of psychiatry" and result in the "lexicalization of normality, individual difference, and criminality."

David Pilgrim of Britain's University of Central Lancashire said it was "hard to avoid the conclusion that DSM-5 will help the interests of the drug companies."

"Madness and misery exist but they come in many shapes and sizes," he said. "We risk treating the experience and conduct of people as if they are botanical specimens waiting to be identified and categorized in rigid boxes.

"That would itself be a form of collective madness for all those complicit in the continuing pseudo-scientific exercise."

Nick Craddock of Cardiff University's department of psychological medicine and neurology, who also spoke at the London briefing, cited depression as a key example of where DSM's broad categories were going wrong.

Whereas in previous editions, a person who had recently lost a loved one and was suffering low moods would be seen as experiencing a normal human reaction to bereavement, the new DSM criteria would ignore the death, look only at the symptoms, and class the person as having a depressive illness.

Other examples of diagnoses cited by experts as problematic included "gambling disorder," "internet addiction disorder" and "oppositional defiant disorder" - a condition in which a child "actively refuses to comply with majority's requests" and "performs deliberate actions to annoy others."

"That basically means children who say 'no' to their parents more than a certain number of times," Kinderman said. "On that criteria, many of us would have to say our children are mentally ill."

Psychiatry’s bible, the DSM, is doing more harm than good

By Paula J. Caplan, 
April 27, 2012
About a year ago, a young mother called me, extremely distressed. She had become seriously sleep-deprived while working full-time and caring for her dying grandmother every night. When a crisis at her son’s day-care center forced her to scramble to find a new child-care arrangement, her heart started racing, prompting her to go to the emergency room.

After a quick assessment, the intake doctor declared that she had bipolar disorder, committed her to a psychiatric ward and started her on dangerous psychiatric medication. From my conversations with this woman, I’d say she was responding to severe exhaustion and alarm, not suffering from mental illness.

Since the 1980s, when I first made public my concerns about psychiatric diagnosis, I have heard from hundreds of people who have been arbitrarily slapped with a psychiatric label and are struggling because of it.

About half of all Americans get a psychiatric diagnosis in their lifetimes. Receiving any of the 374 psychiatric labels — from nicotine dependence disorder to schizophrenia — can cost anyone their health insurance, job, custody of their children, or right to make their own medical and legal decisions. And if patients take psychiatric drugs, they risk developing physical disorders such as diabetes, heart problems, weight gain and other serious conditions. In light of the subjectivity of these diagnoses and the harm they can cause, we should be extremely skeptical of them.

Psychiatric diagnosis is unregulated, so the doctor who met briefly with the aforementioned patient wasn’t required to spend much time understanding what caused her heart to race or to seek another doctor’s opinion. If he had, the patient would have realized that her bipolar diagnosis wasn’t necessary or appropriate. Neither on her ER trip nor in later visits to therapists did anyone explain how sleep deprivation impairs the body’s ability to handle pressure.

In our increasingly psychiatrized world, the first course is often to classify anything but routine happiness as a mental disorder, assume it is based on a broken brain or a chemical imbalance, and prescribe drugs or hospitalization; even electroshock is still performed.

According to the psychiatrists’ bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM), which defines the criteria for doling out psychiatric labels, a patient can fall into a bipolar category after having just one “manic” episode lasting a week or less. Given what this patient was dealing with, it is not surprising that she was talking quickly, had racing thoughts, was easily distracted and was intensely focused on certain goals (i.e. caring for her family) — thus meeting the requisite four of the eight criteria for a bipolar diagnosis.

When a social worker in the psychiatric ward advised the patient to go on permanent disability, concluding that her bipolar disorder would make it too hard to work, the patient did as the expert suggested. She also took a neuroleptic drug, Seroquel, that the doctor said would fix her mental illness.

Over the next 10 months, the woman lost her friends, who attributed her normal mood changes to her alleged disorder. Her self-confidence plummeted; her marriage fell apart. She moved halfway across the country to find a place where, on her dwindling savings, she and her son could afford to live. But she was isolated and unhappy. Because of the drug she took for only six weeks, she now, more than three years later, has an eye condition that could destroy her vision.

This patient is well-educated and white, and before her illness, she was wealthy. Research reflects that she was more likely to be diagnosed as mentally ill than a man in her circumstances. Racism, classism, ageism and homophobia can also affect who receives a psychiatric diagnosis.

It would be less troubling if such diagnoses helped patients, but getting a label often hinders recovery. It can lead a therapist to focus on narrow checklists of symptoms, with little consideration for what is causing the patient’s suffering.

The marketing of the DSM has been so effective that few people — even therapists — realize that psychiatrists rarely agree about how to label the same patient. As a clinical and research psychologist who served on (and resigned from) two committees that wrote the current edition of the DSM, I used to believe that the manual was scientific and that it helped patients and therapists. But after seeing its editors using poor-quality studies to support categories they wanted to include and ignoring or distorting high-quality research, I now believe that the DSM should be thrown out.

Sunday, March 24, 2013

Cancer, Not Just a sign in the Zodiac

This article stood out for many reasons: One the Emanuel's are infamous family in many circles. I will let you Google them to read more on who is who in the family tree and what they do now.

Two: This is about Cancer care. Why not all medical care? There is so little effective and appropriate communication and collaboration in medicine leaving many misdiagnosed and/or mistreated at immense costs, both financial and psychological, you wonder if anything will ever improve this broken system.  It has its own cancer and it seems terminal

The irony is that the fixes he proposes are those partially apparent in the Affordable Care Act, which he was one of its primary authors and given that its ironic that little of it is actually implemented in the final act that of 1000 pages does nothing to really ensure affordable care. 

A Plan To Fix Cancer Care

By EZEKIEL J. EMANUEL

This year, more than 1.6 million Americans — 0.5 percent of the population — will receive a diagnosis of cancer. Their treatment will consume at least 5 percent of the country’s health care spending, at a cost that is growing faster than all other areas of medicine. Doctors and patients recognize that this is unsustainable and that we need to change the way we deliver care.

But we need help, and that is why more than 20 prominent members of the oncology community contributed to the drafting of this essay (their names appear below).

Many cancer patients, after getting a diagnosis of a terrifying disease, pursue any potentially promising therapy, regardless of the price. But the main cost driver is the fee-for-service payment system. The more doctors do for patients, the more reimbursement they receive. Surgeons earn more for every procedure. Oncologists typically make more money if they use newly approved drugs and the latest radiation treatments than if they use cheaper, older alternatives that work just as well. (This is because they get paid back the cost of the drug, in addition to an extra 6 percent of that cost — the more expensive the drug, the higher the compensation.

Some of these new therapies are rightly heralded as substantial advances, but others provide only marginal benefit. Of the 13 anticancer drugs the Food and Drug Administration approved in 2012, only one may extend life by more than a median of six months. Two extended life for only four to six weeks. All cost more than $5,900 per month of treatment.

Significant costs also come from hospitalizations and emergency room visits that could be prevented with better management of common symptoms. Unfortunately, doctors earn more treating patients for serious problems in the hospital than they do preventing those problems from occurring in the first place.

Five major changes need to occur:

First, over the next few years, the payment system needs to move away from fee-for-service toward a system of bundled payments, in which doctors are paid one fee for all the treatments involved in caring for a cancer patient. This would remove the incentive to prescribe more expensive drugs when older generics are equally effective.

Second, insurers have to give physicians information about where they are spending money. As crazy as it sounds, most physicians have little ability to track the care they deliver, or how they compare with other physicians who care for similar patients. Costs vary wildly for patients with identical cancers. One study of patients with cancers that had spread throughout their bodies showed that the costs of four months of scans varied from $1,800 to $6,400 per patient. Doctors don’t have a clear sense of whether the money is going to chemotherapy, hospitalizations or follow-up M.R.I. scans. Armed with better data, physicians can learn how to improve care at lower cost.

Third, any change in payment methods must be accompanied by rigorous quality monitoring to ensure that there is neither under- nor over-utilization of care.

Fourth, we need more “high touch” oncology practices. In these practices, nurses manage common symptoms before they escalate to the point that they require visits to the emergency room, and doctors talk with patients about palliative-care services and end-of-life preferences early on — not in the weeks before death. These services are frequently not paid for by insurers but can improve the quality of care and save significant money by averting repeated tests, hospitalizations and futile, toxic chemotherapy. Insurers need to share the resulting savings, enabling physicians to invest in providing these services.

Fifth, we need better incentives for research. Many expensive tests and treatments are introduced without evidence that they improve survival or reduce side effects, and with poor information about which patients should receive them. For instance, while more than 800,000 robotic surgeries, mostly for cancer, have been performed in the last two years, there is no reliable evidence that the robots either improve survival or reduce side effects — despite the fact that they cost more than traditional surgery. Once interventions are paid for, the incentive for research disappears.

The oncology community cannot make these changes alone. The government is deeply involved and has to help. Today, 60 percent of cancer diagnoses are made in patients who are eligible for medicare. By 2030, that number will rise to over 70 percent. Medicare and the other payers need to work with oncologists. The secretary of health and human services should organize a working group representing Medicare, private insurers, oncologists, quality experts and patients to figure out how to develop these proposals — with no increase in costs — and start implementing them by the end of 2015. Everyone engaged in cancer care needs to help improve it.

Rubbers Anyone?

When I saw this new competition by the Gates Foundation I did not know whether to laugh or just shake my head in disgust.  In another attempt to re-invent the wheel this year's competition reminds me of the one to make a composting toilet... aka the "outhouse".

This reeks of male patriarchy and arrogance with just a touch of Eugenics.  To think the fake chicken was laughable, this one shows that a fool and his money is frequently misspent just in triple digits. 




Develop the Next Generation of Condom

Grand Challenges Explorations Round 11
March 2013

Opportunity:

Male condoms are cheap, easy to manufacture, easy to distribute, and available globally, including in resource poor settings, through numerous well developed distribution channels.  The current rate of global production is 15 billion units/year with an estimated 750 million users and a steadily growing market. Condoms have almost universal product recognition. There are few places on earth where condoms are not recognized or not available. When used properly, they reliably protect females from pregnancy and both partners from numerous STIs, including HIV transmission, making them a prime example of a multi-purpose prevention technology (MPT). Their use does not require a prescription, a skilled health provider or in fact any healthcare provider or healthcare delivery system.  There are no adverse events associated with their use, a statement that cannot be made for any other contraceptive or STI-preventive product. They are user controlled, user applied devices that are simple to use and easily transported. These characteristics make male condoms the perfect MPT product, especially for low resource settings.  

The one major drawback to more universal use of male condoms is the lack of perceived incentive for consistent use. The primary drawback from the male perspective is that condoms decrease pleasure as compared to no condom, creating a trade-off that many men find unacceptable, particularly given that the decisions about use must be made just prior to intercourse.  Is it possible to develop a product without this stigma, or better, one that is felt to enhance pleasure?  If so, would such a product lead to substantial benefits for global health, both in terms of reducing the incidence of unplanned pregnancies and in prevention of infection with HIV or other STIs?
Likewise, female condoms can be an effective method for prevention of unplanned pregnancy or HIV infection, but suffer from some of the same liabilities as male condoms, require proper insertion training and are substantially more expensive than their male counterparts.  While negotiating use of female condoms may be easier than male condoms, this need for negotiation precisely illustrates the barrier preventing greater use that we seek to address through this call.

The Challenge: 

Condoms have been in use for about 400 years yet they have undergone very little technological improvement in the past 50 years. The primary improvement has been the use of latex as the primary material and quality control measures which allow for quality testing of each individual condom. Material science and our understanding of neurobiology has undergone revolutionary transformation in the last decade yet that knowledge has not been applied to improve the product attributes of one of the most ubiquitous and potentially underutilized products on earth. New concept designs with new materials can be prototyped and tested quickly.  Large-scale human clinical trials are not required. Manufacturing capacity, marketing, and distribution channels are already in place.

We are looking for a Next Generation Condom that significantly preserves or enhances pleasure, in order to improve uptake and regular use. Additional concepts that might increase uptake include attributes that increase ease-of-use for male and female condoms, for example better packaging or designs that are easier to properly apply. In addition, attributes that address and overcome cultural barriers are also desired.  Proposals must (i) have a testable hypothesis, (ii) include an associated plan for how the idea would be tested or validated, and (iii) yield interpretable and unambiguous data in Phase I, in order to be considered for Phase II funding.  
A few examples of work that would be considered for funding:
  • Application of safe new materials that may preserve or enhance sensation;
  • Development and testing of new condom shapes/designs that may provide an improved user experience;
  • Application of knowledge from other fields (e.g. neurobiology, vascular biology) to new strategies for improving condom desirability.
We will not consider funding for:
  • Exclusively non-technological, social, or educational interventions;
  • Testing of existing commercially available products;
  • Proposals without a clearly articulated hypothesis or plan for testing the proposed product’s value in overcoming adherence issues;
  • Concepts that are inherently too expensive for a developing world setting;
  • Concepts that would sacrifice the value of condoms for prevention of either unplanned pregnancy or HIV infection.



Alone Together Naturally

I have been railing against the overwhelming reliance, expectancy and surrogacy of technology to do all, from solve society's ills to being the best friend, babysitter, worker, teacher and be all end all savior in America.

That "we are saving the world" is the biggest bullshit PR phrase to ever come out of Silicon Valley aka Wall Street West since the mushroom cloud of mass destruction one just 10 years ago this past week.

After my interesting encounter with the Student who felt that technology had all the answers to all the problems and that the greatest fallacy was the belief in Human Rights I began to either wonder or worry.  This next Generation Idiot may be a little more nuts than I thought. The same Student professed that all invaders of the Americas and Australia need to leave and return to their homeland of origin.  I asked if it included taking our Technology with us since we "invented and built" it, he responded, "yes." And that would do what I asked.  He went on then with another rant about how we should all just kill ourselves if we cannot fix the problems that we created. Honestly, after about 5 minutes I couldn't tell if he was utterly bullshitting me or was insane, either way I stopped listening. What can you say? Nothing.

But this generation will be the most "wired" in every sense of the word.  Sorry but I see it solely as a tool which "we" operate.  We can build a house with nails and a hammer or we can use a nail gun, doesn't make it "better" just faster.  But this generation can't see the forest for their smart phones. They should implant them in the womb at birth and that would really enable Silicon Valley to hook them immediately.  Sort of like Pimps and Dealers only without the fun attire and physical abuse.

I read this today and it reiterates what I have been proselytizing about, technology is not saving us its destroying us one byte at time.



Your Phone vs. Your Heart

By: Barbara L Fredrickson
Published: March 23, 2013 s

CAN you remember the last time you were in a public space in America and didn’t notice that half the people around you were bent over a digital screen, thumbing a connection to somewhere else?

Most of us are well aware of the convenience that instant electronic access provides. Less has been said about the costs. Research that my colleagues and I have just completed, to be published in a forthcoming issue of Psychological Science, suggests that one measurable toll may be on our biological capacity to connect with other people.

Our ingrained habits change us. Neurons that fire together, wire together, neuroscientists like to say, reflecting the increasing evidence that experiences leave imprints on our neural pathways, a phenomenon called neuroplasticity. Any habit molds the very structure of your brain in ways that strengthen your proclivity for that habit.

Plasticity, the propensity to be shaped by experience, isn’t limited to the brain. You already know that when you lead a sedentary life, your muscles atrophy to diminish your physical strength. What you may not know is that your habits of social connection also leave their own physical imprint on you.

How much time do you typically spend with others? And when you do, how connected and attuned to them do you feel? Your answers to these simple questions may well reveal your biological capacity to connect.

 My research team and I conducted a longitudinal field experiment on the effects of learning skills for cultivating warmer interpersonal connections in daily life. Half the participants, chosen at random, attended a six-week workshop on an ancient mind-training practice known as metta, or “lovingkindness,” that teaches participants to develop more warmth and tenderness toward themselves and others.

We discovered that the meditators not only felt more upbeat and socially connected; but they also altered a key part of their cardiovascular system called vagal tone. Scientists used to think vagal tone was largely stable, like your height in adulthood. Our data show that this part of you is plastic, too, and altered by your social habits.

To appreciate why this matters, here’s a quick anatomy lesson. Your brain is tied to your heart by your vagus nerve. Subtle variations in your heart rate reveal the strength of this brain-heart connection, and as such, heart-rate variability provides an index of your vagal tone.

By and large, the higher your vagal tone the better. It means your body is better able to regulate the internal systems that keep you healthy, like your cardiovascular, glucose and immune responses.

Beyond these health effects, the behavioral neuroscientist Stephen Porges has shown that vagal tone is central to things like facial expressivity and the ability to tune in to the frequency of the human voice. By increasing people’s vagal tone, we increase their capacity for connection, friendship and empathy.

In short, the more attuned to others you become, the healthier you become, and vice versa. This mutual influence also explains how a lack of positive social contact diminishes people. Your heart’s capacity for friendship also obeys the biological law of “use it or lose it.” If you don’t regularly exercise your ability to connect face to face, you’ll eventually find yourself lacking some of the basic biological capacity to do so.

The human body — and thereby our human potential — is far more plastic or amenable to change than most of us realize. The new field of social genomics, made possible by the sequencing of the human genome, tells us that the ways our and our children’s genes are expressed at the cellular level is plastic, too, responsive to habitual experiences and actions.

Work in social genomics reveals that our personal histories of social connection or loneliness, for instance, alter how our genes are expressed within the cells of our immune system. New parents may need to worry less about genetic testing and more about how their own actions — like texting while breast-feeding or otherwise paying more attention to their phone than their child — leave life-limiting fingerprints on their and their children’s gene expression.

When you share a smile or laugh with someone face to face, a discernible synchrony emerges between you, as your gestures and biochemistries, even your respective neural firings, come to mirror each other. It’s micro-moments like these, in which a wave of good feeling rolls through two brains and bodies at once, that build your capacity to empathize as well as to improve your health.

If you don’t regularly exercise this capacity, it withers. Lucky for us, connecting with others does good and feels good, and opportunities to do so abound.

So the next time you see a friend, or a child, spending too much of their day facing a screen, extend a hand and invite him back to the world of real social encounters. You’ll not only build up his health and empathic skills, but yours as well. Friends don’t let friends lose their capacity for humanity.

Got A Union? Get a Job

I have long been writing about the wonderful way this economy finds and employs workers. There are of course "Interns" those are usually young people fresh out of college, fresh with debt, no ties, ambition and fear all rolled into one desperate for servitude.  Work for free much? Good you will be.

Then we have the "McJob" individual. This is the person who in need of work, regardless of skill set, finds themselves in a largely transitory job.  You think of it as only temporary and somehow your hard work ethic, super smarts and ambition will translate into a better job higher up the corporate ladder or to another company impressed with your ability to make lemonade out of lemons. Enjoy the lemonade there the 100K Receptionist.

We have the "Solopreneur." This is the individual who was once full time employed but now seen as "too old" "out of the loop" "atrophied skills" or simply not "like us" decides to form their own business out their garage with the belief that they will be either the next Jeff Bezos or Steve Jobs or someone will eventually hire them thinking they have shown and proven their merit.  Garages are for cars, but that is okay as you had to sell yours to make ends meet.

We have the "H1B1 Visa" holder. This unlike the card that never expires really has a limit of a coupled of years filling a job where there are no American citizen holders qualified and able to do the job. The job description vague and of course the pay less they are lured with the idea that perhaps the path  to Citizenship and long term employment is all possible. Get the hulu hoop and start swinging. 

And lastly the "1099er."  This is the contracted temporary employee. Either they worked at the Company before the great recession or simply was told that the budget did not allow for a permanent hire but in time that could change.   This of course like the Visa holder has no benefits, no job security, no pension, no nothing.  It's the modern day Kelly Girl only without the cute moniker.

I started my "career" in the age of Reagan. The 80s when the Recession was not called that. But like all those today, when you leave college at a point where you start at the low end of the totem pole don't expect to climb to the top soon, if ever, especially if a woman.  I actually was fine with that for that time in my life, I had no college debt and lived with my Parents. So all my income was disposable and I used the time to travel. That was the best experience and education more than any job could provide and it taught me a valuable lesson about independence that has bode me well over the years.  I also lowered any expectation financially as when you learn early on that money will be tight you learn to live less on less.

I started with Olsten Temporary Service and frankly I look back on that also a paid internship as I learned a lot about Corporate dynamics and politics. I worked for some of the largest and most prestigious companies and saw first hand some great Management and some not great Management. I was very much on the inside but not.  It suited me and frankly as I am a Substitute Teacher it still suits.  I am very much a self manager and task doer.  I can work independently and my worth is not determined from an extraneous source,  such as a Supervisor and Manager. Which to some might be thought of as "hard to manage" because we seem to rely so much on what "others" think that we have no sense of self or self worth.  I see it with kids in schools, Pavlovian Dogs who need the reassurance of grades, scores and other means to assess their value. There should be a healthy balance but in this age of heavy Parental management to neglect you see why.  I feel bad for this next generation they are going to be great foot soldiers which I have always thought was the point.

But this brings me to the article below regarding a Freelancers Union. Now it seems to function less as a Union in a classic definition but more of a Co-op to provide a opportunity to get health care and commiserate.  There is no actual wage negotiations, teaching said skills, other contract and job skills and a sense of defining what salaries and other information is needed to help their members ensure that they are getting a "fair deal."  Why I commend them for the overall concept they need to start a place of Salary exchanges, Corporate informational exchange and even working with other Organizations to build a strong presence to both lobby and find a place at the table be it the Government or Corporate one. 

That said, it is needed. And it can only go up from there. We need to restore the idea that Unions have a place in this free market and no one can work for free.



Tackling Concerns of Independent Worker 

By STEVEN GREENHOUSE"
Published: March 23, 2013


SOON after landing a job at a Manhattan law firm nearly 20 years ago, Sara Horowitz was shocked to discover that it planned to treat her not as an employee, but as an independent contractor.

“I saw right away that something wasn’t kosher,” Ms. Horowitz recalls. Her status meant no health coverage, no pension plan, no paid vacation — nothing but a paycheck. She realized that she was part of a trend in which American employers relied increasingly on independent contractors, temporary workers, contract employees and freelancers to cut costs. Somewhat bewildered, somewhat angry, she and two other young lawyers who were also hired as independent contractors jokingly formed what they called the “Transient Workers Union,” with the facetious motto, “The union makes us not so weak.” &lt; Ms. Horowitz’s grandfather was a vice president of the International Ladies’ Garment Workers’ Union, and her father was a labor lawyer. So it was perhaps not surprising that she responded to her rising outrage by deciding to organize a union. What she organized, however, was a newfangled version. The Freelancers Union, with its oxymoronic name, is a motley collection of workers in the fast-evolving freelance economy — whether lawyers, software developers, graphic artists, accountants, consultants, nannies, writers, editors, Web site designers or sellers on Etsy.

Today, the Freelancers Union is one of the nation’s fastest-growing labor organizations, with more than 200,000 members, over half of them in New York State. Ms. Horowitz, who has never lacked audacity, says she expects to expand the organization to one million members within three years. For some perspective, the United Automobile Workers union currently has 380,000 members. Of course, while hundreds of thousands of auto jobs have disappeared, the country is awash in freelancers and other independent workers. Studies by the Bureau of Labor Statistics and the Government Accountability Office show that there are more than 20 million of them. Many companies, including The New York Times, employ these workers.

The Freelancers Union, which is based in Brooklyn, doesn’t bargain with employers, but it does address what is by far these workers’ No. 1 concern, by providing them with affordable health insurance. Its health insurance company covers 23,000 workers in New York State and has $105 million in annual revenue. Impressed by that success, the Obama administration recently awarded Ms. Horowitz’s group $340 million in low-interest loans to establish cooperatives in New York, New Jersey and Oregon that will provide health coverage to freelancers and tens of thousands of other workers.

Having health insurance makes it far easier to be a part of what Ms. Horowitz calls the “gig economy.” But many freelancers would prefer not to participate in that economy at all. They would rather have regular jobs, but companies will often hire them only as independent contractors. Companies find these workers less painful to dismiss and generally less costly because they rarely receive severance pay or benefits like health insurance or paid vacations.

“There are some freelancers for whom this is great — they love the flexibility,” Ms. Horowitz said. “And there are some freelancers for whom this is the worst thing in the world.”

While being an independent worker allows certain advantages — you can go to yoga class or on vacation whenever you want — it also means economic vulnerability. An internal Freelancers Union survey found that 58 percent of the group’s members earn less than $50,000 a year from freelancing and that 29 percent earn less than $25,000. The survey also found that 12 percent of members, many of them college graduates in their 30s and 40s, received food stamps during the recession.

“In today’s economy, there’s a huge chunk of the middle class that’s being pushed down into the working class and working poor,” Ms. Horowitz says, “and freelancers are the first group that’s happening to.”

Historically, through the power of collective bargaining, labor unions helped reverse that equation, enabling many unskilled workers to earn middle-class incomes. But as traditional labor unions have steadily declined in size and power, groups like the Freelancers Union, the New York Taxi Workers Alliance and Domestic Workers United have stepped up, trying to give collective voice and power to often-marginalized workers. &lt; Some union old-timers argue that the Freelancers Union is more like an association than a union and will not be able to achieve truly significant gains for workers. Its members don’t pay union dues, which means that joining requires no sacrifice, and the Freelancers Union doesn’t negotiate contracts with employers or represent freelancers when they have grievances. (Under the National Labor Relations Act, freelancers are considered independent contractors, not employees, and employers thus have no obligation to bargain with them, even when they form a union.) &lt; Ms. Horowitz, 50 and a Brooklyn native, insists that her organization is indeed a labor union because, like other unions, it is a large, influential, self-supporting organization of workers that pushes to advance their interests, although its members work for numerous employers in many industries.

“It reminds me of the old guilds” — the precursors of modern-day labor unions — “that focused on workers’ individual autonomy, trying to build their own careers, with the backing of a collective organization to assist them,” says Janice R. Fine, a professor of employment relations at Rutgers University. “Sara is terrific at adapting old ideas to help today’s work force.”

ON a recent rainy morning, a half-dozen members of the Freelancers Union met in a large yoga and meditation studio. The studio was inside a 6,000-square-foot health clinic in Downtown Brooklyn that the union opened for its members in November. It is in a century-old loft building, with bright lights and blond-wood floors, its walls covered with the Freelancers Union’s posters featuring its logo of buzzing bees around a hive.

The freelancers were there to talk with Ms. Horowitz about how the clinic was doing and how it could be improved. They seemed to like a lot: the on-site nutritionist and acupuncturist; the fact that they rarely had to wait more than 10 minutes to see a doctor; and that they could consult with a doctor from home using Skype if necessary. They also liked that there were no co-pays.

Using the clinic is free for those have signed up with the Freelancers Insurance Company; premiums range from $225 to $603 a month — 40 percent less than individual plans available in New York, according to a comparison by the union.

“It’s nice to have one place where I can focus on health care,” Dani Simons, a communications and strategic consultant, said at the meeting, “instead of having to go one place to see this doctor and another place for that doctor.”

The clinic has an unusual team approach. There are two full-time doctors and eight “health coaches,” who serve as liaisons between patient and doctor. Ms. Horowitz says this focus on primary care will save money over time. By tracking members who have special diets or are taking medications, for example, the health coaches can help patients stay healthy and avoid costly hospital stays for failing to follow a treatment plan.

“If we were a for-profit insurance company, we would not be able to provide all these services,” Ms. Horowitz says. “We’re able to steer the profits back into serving the freelancers.”

About 2,200 of the insurance company’s policy holders have signed up for the clinic, while the other 21,000, much like members of other insurance plans, see doctors through a network, Empire Blue Cross, with which the Freelancers Union contracts.

When Ms. Horowitz started the union, her main concern was the here-today, gone-tomorrow insecurity of freelance jobs. But after listening to many freelancers, she changed her mind. “I saw that their overwhelming concern was the lack of health insurance, even though I hadn’t seen that as a major issue,” she says.

To create the Freelancers Insurance Company, Ms. Horowitz needed to persuade investors to put up $17 million. The Rockefeller Foundation and others gave $7 million in grants, and other foundations joined in, agreeing to lend the rest at a 3 percent interest rate.

“She saw that labor unions basically haven’t innovated for several generations, and in the meantime the world has changed and there were tremendous needs that weren’t being met,” says Bill Drayton, founder of Ashoka, a nonprofit foundation that invests in social entrepreneurs.

The health insurance profits that don’t go toward repaying lenders go into a reserve to strengthen the company’s finances, though some future profits will eventually be recycled into running the daily operations of the Freelancers Union and future projects, like a planned health clinic in Manhattan. The union gets $2 million a year from application and enrollment fees its members pay to get discounted life, dental and disability insurance that the union arranges through an outside insurer.
Together, the union and its health insurance company have a staff of 80, and Ms. Horowitz receives a salary of $272,000 for her dual role as head of the union and the insurance company. She notes proudly that while health insurance premiums rose by 5 percent, on average, for Americans this year, the Freelancers Insurance Company is not raising premiums at all for its policy holders.

Jo-Ann Mort, who worked for many years in communications for labor unions and foundations, said it was thanks to the new insurance company that she was able to start her own communications and fund-raising firm. “I was scared to go out on my own because I was worried I couldn’t find affordable insurance elsewhere,” she said. “Sara made that possible.” &lt; In many ways, Ms. Horowitz operates more like an entrepreneur than an old-style union leader, says Kyle Zimmer, chairwoman of the health care cooperative that the union is forming in Oregon.

“She identified that health insurance was a gigantic gaping hole for these workers,” said Ms. Zimmer, who is also president of First Book, a nonprofit group that provides access to books for children in need, “and she stepped into that space, navigated through difficult waters and created a successful insurance company that takes on traditional insurers.”

“She did this in a way,” Ms. Zimmer added, “that would make anyone who believes in private enterprise proud.”

While the union is praised for helping to deliver health and other benefits to its members, some employment experts question whether it can make real headway in raising incomes of independent workers. “All the self-help they do seems good and creative,” says Gordon Lafer, a professor of labor relations at the University of Oregon. “The question is can they get any leverage to get a fair shake from employers, to get companies to give a fair share of their profits to freelancers? They may need to be more creative to do that.” &lt; The freelancers assembled in the yoga studio had plenty of suggestions, large and small, for Ms. Horowitz. Why schedule yoga classes on Monday mornings when people are already feeling mellow from the weekend? Shouldn’t the doctors have a checklist when they see patients? Why can’t freelancers who shun junk food and alcohol pay lower premiums? Can the Freelancers Union build affordable housing for financially squeezed freelancers? “It would be great if there were a network of clinics like this in big cities around the country,” said Ms. Simons, the communications consultant. “It would be really cool. We often have to travel to other cities.” Ms. Horowitz, her hands folded, listened.

ON the wall in front of Ms. Horowitz’s desk is a dusty, decades-old photo of Sidney Hillman. The head of the Amalgamated Clothing Workers of America from 1914 to 1946, Hillman is the model for an idea Ms. Horowitz is talking about a lot these days, something she calls “the new mutualism.”

Hillman was an influential adviser to Franklin D. Roosevelt and spent much of his life translating his mutualist vision into reality. He built low-cost housing and a health clinic for garment workers as well as a union-owned bank and insurance company.

“How did Sidney Hillman know to do housing and insurance?” asks Ms. Horowitz, who has a degree in labor relations from Cornell. “He just listened to people and helped solve their problems.”

Ms. Horowitz’s new mutualism is based on a simple premise: freelancers should band together to set up social-purpose institutions to serve their mutual needs. That, she says, would be far better than relying on corporations and private investors who might have different priorities, not to mention a desire for substantial profits. &lt; This idea, she acknowledges, is not new. But with the changing economy, the decline of organized labor, the end of paternalism among employers and the shrinking role of government, she says, the conditions are ripe for embracing mutual aid societies anew. “The social unionism of the 1920s had it right,” she says. “They said: ‘We serve workers 360 degrees. It’s not just about their work. It’s about their whole life.’ We view things the same way.” “Whether you like it or don’t like it, it’s unlikely we’re going to see growth in government over the next few years,” she says. “But we’re not going to see any reduction in social needs for workers. And we need these social-purpose institutions in place to serve their growing social needs.” Her ideas have gained traction beyond the usual worker-advocacy crowd. She received a “genius” grant from the MacArthur Foundation in 1999. She has been invited to speak at the World Economic Forum in Davos, Switzerland, the Aspen Institute and the Harvard Business School. She was recently appointed to the board of the Federal Reserve Bank of New York.

Ms. Horowitz’s new mutualism also benefits from her political connections. She has close ties to Senator Kirsten E. Gillibrand of New York, and to Sheldon Silver, speaker of the New York State Assembly. Senator Gillibrand, for instance, at Ms. Horowitz’s request, is pushing to have the Bureau of Labor Statistics count the number of independent contractors and freelancers nationwide. And the State Assembly, though not the Senate, passed a bill that would authorize the State Labor Department to crack down on companies that fail to pay freelancers as promised.

A few years ago, the union persuaded New York City to eliminate the unincorporated business tax for independent workers who earn less than $100,000 a year — a move that saves freelancers up to $3,400 annually. (Mayor Michael R. Bloomberg said later that he had “successfully advocated for reducing or eliminating the unincorporated business tax” for “freeloaders and contractors,” a verbal stumble that Ms. Horowitz found hilarious.)

MS. HOROWITZ has seen how the post-New Deal model of employers providing health insurance, pensions and other benefits is breaking down. More and more workers, and not just freelancers, have been left to fend for themselves in dealing with sickness, accidents and old age. One result, she says, is that many workers feel trapped, hesitant to change jobs or start a business for fear of losing health insurance or other benefits.

“We want people to have meaningful independence,” Ms. Horowitz says. “And that means freeing them of this insecurity to give them the ability to take risks because somebody has your back. That’s what this is about. That’s what the new mutualism is.”

In this new mutualism, she sees another, largely unrecognized benefit for freelancers, those supposedly pajama-clad workers who often spend their days toiling at home alone. “People feel mentally and physically better when they feel connected to each other,” she says. “What we’re doing brings people together without them losing any individual aspects of themselves.”

At times, she has been accused of arrogance, and that perhaps stems from her often speaking with self-certainty. “What I’m good at is intuition,” she says. “I have a sense of what’s going to work and what’s not going to work.”

In discussing her family’s labor legacy, Ms. Horowitz noted that her daughter was born on the birthday of Samuel Gompers — the father of the modern American labor movement. Ms. Horowitz sees him, too, as a role model.

“If Gompers were alive today,” she says, “he’d be trying to figure out what the next models are for today’s workers.”