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Friday, June 19, 2015

The U.S. healthcare "system" in one word: "shards"

In my June 15th post, I again cited the works of Einer Elhauge, in particular his 2010 compiled/edited book "The Fragmentation of U.S. Health Care." Dr. Elhauge is neither the first nor the only critic to characterize the healthcare industry as "fragmented." I would think those of us who've spent any time interacting with it as a patient, next-of-kin/caregiver, or simply an industry employee would have to agree. Recall again my May 2009 observations:

I will by no means be the first to note that our medical industry is not really a "system," nor is it predominantly about "health care." It is more aptly described as a patchwork post hoc disease and injury management and remediation enterprise, one that is more or less "systematic" in any true sense only at the clinical level. Beyond that it comprises a confounding perplex of endlessly contending for-profit and not-for-profit entities acting far too often at ruinously expensive cross-purposes.
This blog began in 2010 in support of the federal Meaningful Use program and my REC (and subsequent HIE). I'm mainly a tech and analytic guy (if a sometimes irascible iconoclast), but, my analytic inclinations extend to "policy" -- given that "Ethics and Policy Studies" is the title of my grad degree, and given that policy and law ultimately drive and circumscribe (and may negate) progressive initiatives in tech and process QI (e.g., like "Lean").
I would also note that I extend the word "policy" implicitly to include organizational culture, which gets set by policy explicitly and/or simply as evolved, for better or worse. See my post "Talking Stick." 
Today I'm upping the allusive ante from "fragments" to the more precisely evocative "shards."

Why? It's no longer an academic/economic abstraction or organizational/business process theory for me. I've recently been diagnosed with prostate cancer: dx 185 (biopsy positive "adenocarcinoma," Gleason 3+3: 6, PSA 9.4, bone and CT scans negative for mets, MRI pending to better dx my Rad Onco options). Conflicted as I am about revealing that, I am now personally in the maw of the (non) system, a timely story worth sharing, just as was my essay about my late daughter's 1990's cancer ordeal. I now spend much time yet again episodically tip-toeing through the shards of disparate providers' fragmented workflows, referrals, and concomitant requisite pre-auths, delays ("your call is important to us..."), and inscrutable EoBs and claims denials hell wrought by clueless bureaucrats. Some days I feel like I'm traversing acres of shards, barefoot. The "One in Three" has now become "Two in Three" in my household.

More on that later. First, let's do some more pertinent excerpted Elhauge:

Evidence showing fragmentation
The chapters of this book provide considerable empirical evidence to suggest that U.S. health care suffers from excessive disintegration that worsens outcomes and thus constitutes fragmentation. At the illness level, as several chapters point out, Institute of Medicine studies show that, within any given hospital, many medical errors result because of a lack of effective data sharing and teamwork among the health care professionals working at that hospital. These studies indicate these errors are a systemic problem caused by hospital structure, rather than reflecting some rogue behavior by particular hospitals or individuals, and thus directly support greater integration within hospitals as a way of improving health care.

At the patient level, Professors Hyman points to evidence that the average Medicare beneficiary sees two physicians and five specialists a year, and that those with chronic illnesses see an average of thirteen physicians a year, “each focused on the discrete symptoms and/or body parts within their jurisdiction.” Professors Cebul, Rebitzer, Taylor, and Votruba cite similar evidence that the median Medicare patient sees eight physicians in five distinct practices, and if they have a coronary artery disease, the numbers increase to ten physicians in six distinct practices. They both point to evidence that few physicians are in multispecialty practices. Nor do Medicare and other insurers pay physicians to spend time coordinating care. Patients or family members thus end up saddled with most of the responsibility for coordinating all the physicians. But patients and family cannot do so effectively because they lack the medical expertise, authority over physicians, or control of the purse strings. The result of this lack of coordination among physicians, an Institute of Medicine report finds, is that “patients do not always receive timely care best suited to their needs.”...

One problem this fragmentation creates, as Professors Enthoven and Hyman note, is that the results of prior treatments or tests are often unavailable or treated with distrust by other providers, and that different providers lack a common information technology structure. Professors Cebul, Rebitzer, Taylor, and Votruba add that only four percent of physicians have fully functional electronic medical systems, and that government studies indicate that fragmented care leads to multiple incompatible formats for medical records. Professors Hall and Schulman focus on this issue, showing that few providers use electronic records, and when they do, their electronic records rarely interconnect with others, a problem that is getting worse over time rather than better. They also shows a clear link between the underuse of electronic records and the fragmentation of providers, by observing that electronic medical records are generally used only in integrated delivery systems that have fixed global budgets like Kaiser or the Veteran’s administration. Outside of such integrated systems, patients or family members often have to keep track of all their prescriptions and test results, but they don’t always have easy access to their medical records and the ability to persuade other providers to accept them. At best, the same records and tests keep getting redone and duplicated, achieving the same health benefit with a wasteful cost increase. At worst, pertinent records and tests end up being ignored, increasing health risks...

Unfortunately, U.S. health care couples the mother of all team production problems with the mother of all refusals to use centralized ownership structures to solve them, as the chapters in this book show. Even a single hospital stay generally means the patient is treated by multiple physicians who are independent contractors, each paid a fee for their services that is separate from the other physicians and from the fees the hospital receives for providing support. This is so even when the hospital receives flat payments from Medicare for a diagnosis- related group, because those fees cover only hospital support services and not physician fees...

Indeed, hospitals and medical staffs generally have little financial incentive to direct and monitor physicians efficiently because neither is a residual claimant that would gain any additional profit by coordinating physicians and other inputs more effectively. Instead, the hospital’s incentive is to allow case management to be controlled by the doctor who brings in the patient, like the surgeon who admits a patient for a procedure, even if the doctor has little incentive or interest in man- aging the case once the procedure is finished...

...[T]he current payment system perversely provides disincentives for any provider to invest in coordination or care that might lessen the need of patients for health care, because (as Professors Hyman and Enthoven note) such investments result in fewer payments for medical or hospital services. One nice example of this, stressed elsewhere by Professor Herzlinger, involves the case of Duke University Hospital, which adopted an integrated program to treat conges- tive heart failure that reduced health problems and cut costs by forty percent, but lost money because this meant Duke had fewer health problems to treat. In any other market, a new system that provided more value for forty percent less cost would reap enormous rewards; in our fragmented health care system, it was affirmatively penalized.

Outside of a single hospital stay, the problems are even worse. A patient with any complex problem has to visit a series of physicians and care providers, each of which is paid separately and acts autonomously, and who usually are not even in the same building. The patient’s primary physician can provide some help in referring the patient to the right specialists. But the primary physician is not a residual claimant who pays those specialists, and thus has little incentive to manage them optimally and little power to do so anyway. Each physician and specialist bills only for its separate services, and no one is paid to manage the case or based on the results of the case. Indeed, the payment system affirmatively discourages the physicians from coordinating with each for the same reason noted above: if coordination lowers the need for services that can be billed, then the physicians will earn less money.

Nor can we count on patients orchestrating the various contributors that will achieve the desired health results, the way we can count on, say, hotel guests to choose the restaurants and activities that will make their vacations enjoyable. The problem is that, unlike consumers in other markets, patients lack the knowledge, power, and incentives to make such decisions optimally. They lack the knowledge because what they are buying is knowledge about what health care they need. They lack the power because often they cannot order medical services  or products without provider or insurer consent. And they lack incentives to make sensible tradeoffs because an insurer generally covers the lion’s share of the cost...
Causes of Fragmentation
Fragmentation might have various causes, and it pays to understand which are the actual causes because that bears on the appropriate solutions. Given that we are talking about medicine, it makes sense to begin by asking: are there sound medical or scientific reasons for the current fragmentation of U.S. health care? Certainly none that appeared in any of the chapters of this book. The fact that other nations have far more integrated health care systems and hospitals dominated by salaried doctors, and achieve similar or better health results at lower cost, belies any claim that medicine or science inherently requires U.S. levels of disintegration. This same fact seems inconsistent with the claim that the sociology of the medical profession inherently requires such fragmentation. Further, Institute of Medicine studies of the U.S. system have condemned fragmentation because it leads to more medical errors, meaning that, if anything, sound medicine and science cuts in the opposite direction and is being overwhelmed by other causes.

This much may seem obvious, but it has an important implication. If medical or scientific reasons are not driving current health care fragmentation, it is unlikely that fragmentation is going to be cured by studies that show how it leads to medical errors, by analyses demonstrating medically optimal team methods, or by new information technologies that help hospitals and physicians coordinate better. Those may help at the margins, but to really tackle fragmentation we are going to have to address the underlying structural cause that has been driving U.S. health care to levels of disintegration that are medically harmful.

Can the current fragmentation of U.S. health care be explained by sound eco- nomics or business reasons? Again, none of the chapters offers any support for that possibility. To the contrary, the evidence that fragmentation raises costs, worsens outcomes, and deters efficient investments in long-term health suggests that the economics are to the contrary. And the fact that hospital organization deviates from the sort of business organization used to address team production for other businesses suggests the absence of any sound business rationale for fragmentation either.

Again, this may not be particularly surprising, but it has the important implication that we cannot expect economic or business studies on optimal payment schemes or organizational methods to solve the fragmentation problem. For example, while payment for performance is a popular business strategy for dealing with some of the problems caused by fragmentation, it amounts to trying to cure the fact that core incentives are not producing appropriate conduct by making (or withholding) payments to reward (or punish) some types of conduct. This strategy is unlikely to help much for two reasons. First, it presupposes, contrary to fact, that we do not have a team production problem where contributions are difficult to assess without observation. It basically tries to use a market mechanism to deal with the problem—paying for particular conduct—even though the problem is precisely that market mechanisms are less efficient than ownership monitoring and control...

The dominant cause of fragmentation instead appears to be the law, which dictates many of the fragmented features described above and thus precludes alterative organizational structures. The law is the culprit even though the payment system is also an important cause of health care fragmentation…

Private insurer efforts to directly manage care have likewise been curbed by the ban on corporate practices of medicine and the threat of tort liability. In addition, states have adopted laws requiring insurers to pay for any care (within covered categories) that a physician deemed medically necessary, banning insurers from selectively contracting with particular providers, and restricting the financial incentives that insurers can offer providers...

To me, then, the absence of good quality measures provides no reason to favor preserving physician autonomy because today uncoordinated autonomous providers worsen medical quality. Moreover, paying a firm for a set of treatments and making that firm responsible for it would make it easier to measure quality because then one can just measure the outcomes, without getting into complex issues about the extent to which each participant contributed to those outcomes...

Although the above laws seem to be the proximate cause of current fragmentation levels, one might wonder what causes those laws. This I take to be the deeper challenge posed by the two chapters that conclude this book. The chapter by Mr. Johnson and Professor Kane argues that the health fragmentation we get reflects core U.S. values such as individualism and faith in markets and competition. Professor Marmor’s chapter argues that our health care system is driven by larger political forces, and that fragmentation has played a modest role in those political debates. If true, these positions indicate that any quest to defragment the health care system may be futile or relatively unimportant. My view is to the contrary, but if one wants to fully understand the skeptical view, one could hardly do better than reading their illuminating chapters.

To me, the problem with saying that current health care fragmentation reflects U.S. values or politics is that this position doesn’t explain why those same values and politics do not produce similar levels of fragmentation for other markets like education, air travel, hotels. We don’t view individualism or market competition as inconsistent with the fact that we usually buy our products and services from integrated corporations that perform team production functions. The faith in market competition is, after all, a faith in competition among integrated corporations. It also seems to me that the above evidence and theory suggests that the role of fragmentation is large, not modest, and indeed that the fundamental legal framework of fragmented, autonomous, separately-paid providers has undermined many other reform efforts. Even if some of our values and political pressures favor fragmentation, our values and political interests also favor better and more efficient care, so that I think defragmentation reforms can overcome resistance based on values or political interests, though such resistance will no doubt be formidable.

But, assuming such defragmentation reforms are politically possible, what should they be?

Defragmenting Reforms
The most promising reforms, it seems to me, involve ending the legal obstacles to integrated care...

...I would not favor reforms that try to require some specific type of integration. For example, laws that require Medicare or other insurers to pay physicians to coordinate care seem unwise. They presuppose we know what sort of coordination is optimal and impose it as a centralized choice. A better strategy would be to simply make sure that the total payments to a collection of autonomous providers providing some joint treatment are no higher than the same payment to an integrated firm doing so, and then leave competition between autonomous and integrated providers to determine which forms of coordination are optimal...

...I would make some exceptions to the general policy of not forcing forms of integration that cannot succeed on the market. First, assuming we maintain a market system where insurer incentives to provide certain forms of care depend on the extent to which individuals switch insurers, then I think optimal health care will require centralized risk adjustments to the payments those insurers receive. Otherwise, insurers would have incentives to provide care in a way that induces low-risk individuals to enroll (say by emphasizing sports medicine) and high-risk individuals to disenroll (say by giving them poor care). However, such risk-adjustments will necessarily require some centralized group-level decisions about how resources should be allocated among various health care needs...

...A better solution would be providing centralized funding for care with long-term health benefits, with the funding amount reflecting the expected gain in health outcomes produced.

Third, I agree with Professors Cebul, Rebitzer, Taylor and Votruba that we should mandate or subsidize the creation of a common system of electronic medical records. The reason is that, although integrated providers are certainly more likely to use electronic medical records than nonintegrated plans, Professors Hall and Schulman’s analysis indicates that an integrated provider still has incentives to make its electronic records incompatible with other integrated producers because doing so makes it harder for patients to switch providers. Left to its own devices, a free market will thus not produce the optimal common system of electronic medical records, and government regulations to require or induce a common system will help make the market more competitive. Although Professors Hall and Schulman are certainly right to advocate legal changes allowing patients to authorize use of their medical records for a fee, and Professors Cebul, Rebitzer, Taylor, and Votruba are right that insurers and patients can try to assemble some of the data, I doubt that either alternative will be sufficient given providers’ affirmative incentives to create incompatible records...

Leaving aside such exceptions, I would lift legal obstacles to integration, but not adopt legal changes that would mandate particular forms of integration...

In short, for defragmenting health care to really work, we are going to have to couple (1) reforms lifting laws that bar integrated firms from monitoring and controlling a team of medical professionals with (2) payments for the output produced by those integrated firms that give their owners incentives to optimize the coordination of medical professionals. Payments per treatment or for prom- ises to treat are not really payments for output, and respectively incentivize overcare or undercare. We could pay per medical improvement provided if it is measurable and we have a sufficient consensus on how to define it. Or we could define the output as attracted enrollees, and pay per enrollee attracted. Either payment approach would require repealing or preempting laws that require insurers to pay for any “medically necessary” care within a category they cover, and allowing insurers to instead pay per health improvement or be paid per enrollee they can attract with their method for allocating care. But if the above legal restraints were lifted, then this sort of approach could be used by employers or insurers under our current system, as well as by the government in a more thorough reform.
Much to consider. The foregoing seems like a lot, but it comprises just a small sample from that one chapter in the book, which btw, Mr. Elhauge has posted publicly here (pdf).

You might find this more recent Elhauge paper of interest as well (pdf). Pretty much the same riff, Cliff Notes edition.

Noted in the paper:


Einer's numerous works provide rather extensive analysis of the myriad salient aspects of the fragmentation issue in health care delivery. Less clear are what rational reform proposals might actually fly in terms of legislation and regulation in this hypercontentious political era. Republicans are overwhelmingly hell-bent on repealing or otherwise neutering "ObamaCare," in case you hadn't noticed. GOP proposals regarding alternatives don't go beyond vague platitudes that would fit on a campaign button lapel pin or a bumper sticker.

Moreover, notwithstanding all of recent years' progressive policy push (including those contained in the PPACA) toward "P4P" (Pay for Performance), "ACO's" (Accountable Care Organizations), "PCMHs" (Patient Centered Medical Homes), "patient-centered continuity of care," etc, the legacy FFS (Fee For Service) paradigm and the inertia of industry incumbency will not go quietly into the sunset. Moreover, I have to wonder whether, despite all the news in recent years of healthcare space "consolidations" and "M&A's" (mergers and acquisitions), the fragmentation is actually getting worse, not better. More shards strewn about, and sharper around the edges. Corporate acquisitions are driven by near-term profit potential, not by noble, altruistic notions of materially improved care delivery unwaveringly focused on patients. The cheery exhortations I see clamoring from the expressway billboards here around Contra Costa County -- all replete with beautiful and handsome, smiling models in scrubs exuberantly intoning cliches like "You Talk, We Listen" -- constitute just so much marketing copywriter crap.

apropos of all of this fragmentation and increasing, often maddening complexity, some of David Graeber's observations come to mind.

...[I]t is becoming almost impossible to say what is public and what is private. This is not just due to the much-noted outsourcing of one-time government functions to private corporations. Above all, it’s due to the way the private corporations themselves have come to operate.

Let me give an example. A few weeks ago, I spent several hours on the phone with Bank of America, trying to work out how to get access to my account information from overseas. This involved speaking to four different representatives, two referrals to nonexistent numbers, three long explanations of complicated and apparently arbitrary rules, and two failed attempts to change outdated address and phone number information lodged on various computer systems. In other words, it was the very definition of a bureaucratic runaround. (Neither was I able, when it was all over, to actually access my account.)

Now, there is not the slightest doubt in my mind that, were I to actually locate a bank manager and demand to know how such things could happen, he or she would immediately insist that the bank was not to blame— that it was all an effect of an arcane maze of government regulations. However, I am equally confident that, were it possible to investigate how these regulations came about, one would find that they were composed jointly by aides to legislators on some banking committee and lobbyists and attorneys employed by the banks themselves, in a process greased by generous contributions to the coffers of those same legislators’ reelection campaigns. And the same would be true of anything from credit ratings, insurance premiums, mortgage applications, to, for that matter, the process of buying an airline ticket, applying for a scuba license, or trying to requisition an ergonomic chair for one’s office in an ostensibly private university. The vast majority of the paperwork we do exists in just this sort of in-between zone— ostensibly private, but in fact entirely shaped by a government that provides the legal framework, underpins the rules with its courts and all of the elaborate mechanisms of enforcement that come with them, but— crucially— works closely with the private concerns to ensure that the results will guarantee a certain rate of private profit...

Consider the word “deregulation.” In today’s political discourse, “deregulation” is— like “reform”— almost invariably treated as a good thing. Deregulation means less bureaucratic meddling, and fewer rules and regulations stifling innovation and commerce. This usage puts those on the left-hand side of the political spectrum in an awkward position, since opposing deregulation— even, pointing out that it was an orgy of this very “deregulation” that led to the banking crisis of 2008— seems to imply a desire for more rules and regulations, and therefore, more gray men in suits standing in the way of freedom and innovation and generally telling people what to do...

So what are people actually referring to when they talk about “deregulation”? In ordinary usage, the word seems to mean “changing the regulatory structure in a way that I like.” In practice this can refer to almost anything. In the case of airlines or telecommunications in the seventies and eighties, it meant changing the system of regulation from one that encouraged a few large firms to one that fostered carefully supervised competition between midsize firms. In the case of banking, “deregulation” has usually meant exactly the opposite: moving away from a situation of managed competition between midsized firms to one where a handful of financial conglomerates are allowed to completely dominate the market. This is what makes the term so handy. Simply by labeling a new regulatory measure “deregulation,” you can frame it in the public mind as a way to reduce bureaucracy and set individual initiative free, even if the result is a fivefold increase in the actual number of forms to be filled in, reports to be filed, rules and regulations for lawyers to interpret, and officious people in offices whose entire job seems to be to provide convoluted explanations for why you’re not allowed to do things...

Graeber, David (2015-02-24). The Utopia of Rules: On Technology, Stupidity, and the Secret Joys of Bureaucracy (pp. 14-17). Melville House. Kindle Edition. 
My experience of late (recounted in more detail in what follows), while necessarily anecdotal (albeit one that now includes my participation in a prostate cancer support group full of stories of frustration), leaves me wondering about all this fragmentation -- these "shards" --  and skeptical that things will get cleaned up.

I return briefly to a gripe I aired in my January Health 2.0 "WinterTech" post.

I am effectively without a Primary these days. After I retired from the REC, sold the house in Vegas in September 2013, and moved over to Contra Costa County, I ended up in the Muir system. My new doc there is a nice young Internal Med D.O. whose answer to everything is to refer me to a specialist -- even to get a dad-gumbed scrip refilled! (He referred me to a "pain management specialist.") e.g., from one of my TCHB comments:

It's Tramadol 50 mg. I have some bulging disks and pinched nerves ("cervical and lumbar spondylosis with myelopathy"), in part the upshot of too many years of getting the crap knocked out of me while pursuing my absurd decades-long full-court Hoop Dreams, (I have the attestational eyebrow suture scars, and torn meniscal and MCL vestiges), followed by too many recent years of too much sitting, reading, and blogging for hours and days on end.

I usually took one Tramadol a day, in the early morning upon arising (even though the scrip said 'one every 4-6 hours as needed'). On bad days, I'd drop a 2nd one mid-day. They helped. Materially.

Given that DEA recently "rescheduled" Tramadol, I can't help but wonder whether my young doc wants to keep his fingerprints off the Rx. I'd given him my entire longitudinal Hx from my Vegas Primary, dumped from the EHR. I fail to see the point of doing an expensive encounter with yet another physician -- one who doesn't know me, and who will have to redundantly (and expensively) read the chart, listen to (or blow off) my CC Subjective, and either bless or deny the simple Rx request.

I note on the EOB that Muir charged me and my BC/BS $436 for each primary care visit (Cheryl and I are now on high-deductible HSA). I dutifully underwent the PT regimen he wrote me for (it helped a bit). I dutifully do my exercises. My cut of the nearly $3k for that was just shy of $1,200. My paid OOP for 2014 came to about $3,600 (welcome to the ACA). For a lot of people, that might be extremely painful in its own right.

Knowing that I would have another annual visit coming up, I went into Muir's portal to schedule it and request a lab draw order (blood and UA panels) to avoid another $436 charge for a pleasant (MU-compliant) 30 minute 99213 chat just to essentially pick up a lab slip and incur yet another charge for the f/up.

He refused. Had some Muir employee call me the following week with the news. Didn't respond (for the record?) to my portal email.

I told the caller to just cancel my appointment request.

That's just a mild episode. The real frag fun began in the wake of my first elevated PSA result at Muir. Stay tuned.

From THCB:
A House subcommittee recently voted to eliminate the Agency for Healthcare Research and Quality (AHRQ) as of Oct. 1, 2015, the start of fiscal 2016...

The GOP-led House Subcommittee on Health, Employment, Labor and Pensions (HELP) first voted to ax AHRQ back in 2012, along with other big government cuts; the agency escaped thanks to political gridlock that led to continuing budget resolutions instead of individual appropriations bills. Now, with the GOP in control of both houses of Congress, AHRQ has again been “terminated,” to quote the legislative language...

One problem is that while clinical research and fighting epidemics are popular causes that will also pump money into various Congressional districts, eliminating health care “waste” brings no local political benefit. If anything, the effect is the opposite. Clamping down on waste can look an awful lot like bureaucratic interference to those whose income is jeopardized...
Interesting. I'm not an unalloyed fanboy of AHRQ, and I've had a bit of REC Blog sport with them, here, and here back in 2012. But, their current funding of about $440 million is a rounding error, just in terms of Iraq and Afghanistan.
"Clamping down on waste can look an awful lot like bureaucratic interference to those whose income is jeopardized."
apropos of the general theme of this post, no? Or, as my old mentor Dr. Brent James joked to us some 21 years ago: "every misspent dollar in the health care system goes into somebody's paycheck."

"Elevated PSA of 7.4. Referred to urologist to rule out cancer"

My first Muir labs came back fine, all panel parameters solidly in the normal ranges (as usual) with the exception of this one. Elevated PSA. My Primary referred me.

I dutifully made my appointment with this urology practice in Concord, which I was told "is part of the Muir system." A few days out, I logged into the "MyJohnMuirHealth" patient portal just to confirm the date and time.


I called. "Oh, yes, we're not on the Muir system, so it wouldn't be there. We don't have a patient portal."

While "part of the Muir system," they're an acquisition yet to be integrated into Muir, and still go by their original practice name. Their EHR is NextGen, not Muir's Epic. None of the scheduling, billing, or encounter results appear in the Muir patient portal. No "interoperability" here.

My urology visits always began with a clipboard. Okee-Dokee...

We opted to re-test every few months for a while, given the inexactitude and high false positive rates that beset the PSA.

My subsequent assays went 7.8, 7.1, and, finally, 9.4 earlier this year. The latter finding, combined with the concomitant low "Free PSA %" made the exigent case for biopsy. We tee'd one up.

A "transrectal prostate biopsy" is not much fun, but it's a relatively quick outpatient px. A bunch of quick, sharp bee stings inside your butt. Cheryl and I were at Starbuck's in Concord an hour later.

My urologist:

"There's about a 1% chance of an infection that could put you in the hospital. If you run a fever of more than 101.5, go to the ER."

I had dutifully taken my Cipro, self-administered the requisite pre-px enema, and my biopsy procedure was done on Monday morning March 30th. By Thursday morning my temp upon awakening was 102.3 (along with a skull-crushing headache).

Off to the Muir Medical Center ER in Walnut Creek. 

Another clipboard. I fill it out, and present my ID and BCBS/RI and Medicare-A insurance cards.

After a couple of hours in the ER waiting area, I'm called back and put into an ER exam bay.

More waiting. I recall the old ER joke: "be glad that you're having to wait; it means you're not dying."

Finally, the ER doc appears. I recount my biopsy. He laughs.

"Welcome to the club."

Lordy. I'd recently played a birthday party band gig down in Pacifica with a bass player who is a prominent Marin County plastic surgeon. Told him about my pending biopsy while we were chatting at the bar.

"Been there; done that. No biggie. the main problem with prostate cancer is the PSA test"


The ER doc orders more labs, specifically to include blood and UA cultures, which, he explains will take several days to grow, and are necessary to try to ID the bugs so as to more precisely Rx the most effective antibiotic.

Nice guy. Our interaction took less than 5 minutes (and for which I would subsequently be billed separately by his "independent contractor" ER medical group for $623). I am to be admitted for tx of "Sepsis" (the Admit will be formally written up by the Muir Hospitalist, with whom I will subsequently visit). I will further undergo a pelvic CT (also billed separately, $1,286.75, "Neuroscan" 3rd party) and cardiac echo.

From walking into the ER through arriving at MedSurg floor 5 took not quite four hours (and included an interim gurney jaunt down to Nuke Med from the ER for the CT). Not bad, as these things go. They put me in a private room, likely owing to the Sepsis, I guess. 'Can't wait to see the charge for that,' I recall thinking.

Friday morning they wheeled me down for the cardiac echo. I made small talk with the tech as he pecked away at his Epic EHR screen. "So, how do you like Epic?"

"It's a great tool. For tracking our every move."

Friday afternoon my iPhone barks at me. Incoming secure message alerts from the Muir Patient portal, apprising me of my "upcoming" pelvic CT and cardiac echo "appointments."

Lordy. Seriously, people?

My urologist showed up briefly to pat me amiably on the shoulder (have to say, I do like him), look at my labs in the Epic EHR, and offer some ($429 inpatient rounds encounter) words of encouragement.

I got discharged on Saturday. Cultures were negative for anything identifiable. Just stay on the amoxicillin I'd been written for.

Subsequent self-study puts the post-prostate biopsy sepsis risk at more like 4% (or worse), not "1%."


April 10th, biopsy results dx Day. Cheryl and Danielle insisted on going with me. As I've already alluded to, I'm found positive for "adenocarcinoma." Six of 12 cores positive, all on the left side of the gland. He'd ordered a full-body bone scan (w/contrast), principally in deference to my anxiety over my low back pain and any possible mets involvement. It, like my pelvic CT at Muir, was negative. My lumbar spinal problems indeed look orthopedic. I can now pretty much rule out that concern.

We traverse the list of tx/px options. Fairly lurid descriptions of the surgical prostatectomy process and plausible outcomes (including likely side-effects).

Not goin' there.

The Radiation Oncology menu options. External beam or "Brachytherapy."

Next stop, a Radiation Oncologist referral visit.


I'm referred by my urologist to a Rad Onco doc not far from my house (walking distance, actually). Not part of the Muir system, as far as I can tell (I'm not ID'ing these various docs and clinics). I look him up online; nice "sheet," very well known for successful brachytherapy in particular.

Very nice, obviously astute man. He too walks me through the litany of my px/tx options and their relative pluses and minuses. We pencil in "active surveillance" for now -- repeat the PSA in ~3 months, maybe another biopsy in 6 (or, alternatively a pelvic/prostate MRI). I'm pretty comfortable with this doc. He spends just under an hour with me and my wife.

Soon, the EoBs and bills start to arrive. My Rac Onco statement reads "99245, Office Consult Onc5, Charge, $694.35, Adjustment, -$340.03, Payment, -$319.89, Balance, $35.14."

Is the "$694.35" an accounting fiction (e.g., akin to the much-mocked "chargemaster"), or is that what I'd have been charged "retail" as a cash self-payer?

I'm on a high-deductible PPO HSA plan through my wife's employer (and I'm a Medicare Part-A "secondary payer" bene), so I'm starting to meet my deductible for the year, and I have no doubt I will surpass my max OOP for the year once this is all done.

I finally get an aggregated bill from my urologist, my net cut is $908.56. Guys, your revenue cycle is glacial.

Insurance absurdities begin to ensue. Muir informs me that BCBS/RI denies my hospitalization claim, on the grounds that I'm "no longer insured."

I'm not making that up.

NOTWITHSTANDING that I'd presented both of my active current ID cards at the ER.

The geniuses at BCBS/RI issue new beneficiary cards every year. They change the Subscriber ID numbers. So, reposing vestigially in the Muir billing system, last used for my fall 2014 PT sessions at the Brentwood facility, is my old number. Which, of course, is the expired ID the geniuses at Muir used to file my April 2015 hospitalization claim.

Everybody sing! "NOTWITHSTANDING that I'd presented both of my active current ID cards at the ER."

Medicare then denies "secondary payer" coverage for some of the things done while I was at Muir. For one thing, I guess the ER workup is not "inpatient." You are pending at that point.

They were filed as Medicare Part-B (outpatient encounter charges).

Multiple phone calls and Muir and BCBS/RI portal visits later, these Best and Brightest get their respective acts together, and my hospital stay claim issue gets resolved.
"Your call is important to us. All of our representative are busy helping other customers. Please stay on the line, and someone will be with you as soon as possible."

The other day I got an EOB statement from Medicare, in which they noted that they paid Muir $14,195.86 for my 2-night hospitalization (Part-A"), and that I might still be on the hook for up to $1,260.

Whatever. Muir made bank on me this time around.

BTW, I am now in my 3rd billing cycle disputing the ER doc group's $623. They claimed that they'd submitted it to BCBS/RI.

There is no record in my BCBS/RI portal claims history of their having done so. I finally had to send them a letter, for the record.

I would like for your company to be paid appropriately without further delay for your service rendered to me on 04/02/2015 at John Muir Hospital in Walnut Creek CA, but issues remain that require clarification. When I got your initial bill, last cycle, I called immediately to inquire. I’d had an issue with Muir itself, given that they had initially denied my BCBS/RI claim because someone in their billing department used an expired member ID number (BCBS/RI issues new cards every year, and the numbers change; my old number was obviously still in their system from 2014 encounters I’d had). This despite the fact that I presented my current, valid card at the hospital when I presented at the ED (photocopy attached). The Muir claim error was subsequently rectified.

Your call center person assured me that it would be resubmitted and cleared up. Now I get an identical second bill in the amount of $623, which contains the line item “04/24/15 DOS: 04/02/15 – Blue Shield-OUT .00 CO-INS.”

I logged into my BCBS/RI member portal and I find no such claim processing entry anywhere in the claims history. Again, photocopy of that screen attached.

The most charitable explanation for this is that the incorrect ID was used. Please advise. We are on a high-deductible HSA PPO plan, and if I truly owe this amount, so be it. But claims go against our annual maximum out-of-pocket and must be processed accurately. Given that I am now faced with a serious illness and have already incurred significant 2015 OOP expense, I again ask that you clear this up. All of my other encounter claims show up in my BCBS/RI portal in the wake of my 2015 episodes of care, and I need a satisfactory explanation as to why this one does not. I have alerted BCBS/RI of this circumstance.

Thank you.


Robert E. Gladd
cc: file
Someone from the ER doc group's billing department called me late last week after they got the letter. NOW they assert that the claim error problem owed to the fact that my wife's BCBS/RI mailing address is that of her post office box in Walnut Creek (a vestige of the period when Cheryl was working here and apartment-hopping and I was still living and working in Vegas), not our street address in Antioch.

Yes, Cheryl still has her P.O. box just down the street from her office (and she uses her "maiden" name). So what? You have my name, my Social, my DoB, my BCBS/RI Subscriber ID, my street address (where you obviously sent the bills), and my phone number, and you're gonna gum things up interminably over a post office box number?

They tell me they've put "a hold" on it, and to just ignore the latest bill while they "re-submit" the claim.
Still an open question with BCBS/RI is whether this independent ER docs group is "out of your network." You show up in the ER with an acute condition worthy of admission, and you're supposed to know this precisely how at the exigent point of  care? You can't just opt for a different ER "vendor." You're not at Walmart in search of Everyday Low Prices.
Shards, man. These are some of the reasons we in the U.S. pay double.

Not finished with the Frag Follies. Stay tuned.



I'm asked to come back in for a further consult with my urologist. Having gotten word from Rad Onco in Antioch regarding my "active surveillance" decision, he's concerned that I'm not fully understanding and perhaps glossing over the potential risk of doing so, that my "6 of 12 cores positive" determination (coupled with my mid-range Gleason Score) puts me at somewhat elevated risk of potential tumor aggressiveness and growth that may preclude some preferred tx options down the line.

I explained in reply that my "active surveillance" decision was only "penciled-in" tentatively that day at Rad Onco, that upon subsequent reflection and conversation with my wife, I was leaning toward doing something sooner rather than later anyway, particularly since the radiation oncologist had stated frankly that I would most likely have to be having some sort of tx intervention at some point.

In any event, I told him, I'd reached out for a second opinion consult with a radiation oncologist who'd successfully treated a close Vegas show producer friend of mine via "Calypso" radiation therapy in Berkeley last year.

He replied, rather weakly and unconvincingly, "well, yes, you should do that."

An interesting little dustup followed that visit. Without asking me, my urologist sent my biopsy to a company that performs "OncoType dx" genetic assays of biopsies for several cancers, including prostate. He simply wanted to know whether mine was a good candidate for this type of test.

They just went ahead and ran it, without the urologist's green light order, or my knowledge or consent. I got a call out of the blue one day from a lady wanting to verify my insurance information, and advising me that this test might be "out of your network," leaving me on the hook for some $400, worst case (I subsequently came to learn that it's a ~$4,000 test). I thought it odd, and thought I'd follow up with my doc.

My urologist called me. He was embarrassed and pissed. A young rep from the OncoType dx vendor also called me shortly thereafter. He was in fear of losing his job, having tee'd up the test absent explicit auth.

I've yet to hear anything further. I think they're all just trying to make this one go away. Though, it would not surprise me one whit to see a charge pop up in my BCBS/RI portal one of these days.

The OncoType test result merely served to confirm (expensively -- for someone) what my urologist already suspected. The malignancy aggressiveness in my case is in a sort of "grey zone." The merging composite picture is "don't dally with this."


This doc had moved on from his medical group in Berkeley, and was now at Stanford, practicing in their Radiation Oncology Department and serving as a Professor of Clinical Medicine.

He was not easy to contact. Stanford Medical Center may indeed be world-class, but their automated attendant phone tree system is abysmal.

"Your call is important to us. All of our representatives are busy helping other patients. Please stay on the line, and the next available representative will help you. Or, you may press '1' to leave a callback number..."

Over and over. On my first try I sat on the line for a good half hour.

I finally got through, explained my situation, and was told I'd be put in the system for a "new patient request," and that someone would follow up within a couple of days. I was given a tracking number.

No one ever called back.

So, I composed a hardcopy snailmail letter addressed specifically to the doctor, playing the close friend card.

Shortly thereafter, I got an account setup and login "secured email" request from Stanford. The "New Patient Coordinator" needed my insurance, demographic, PCP, and emergency contact info "so I can register you into the Stanford System."


I was also emailed a pdf of a HIPAA release form, and advised to fill it out forthwith and return it to expedite release of my records from Muir, my urologist, and radiation oncologist.

I immediately printed it out, filled it out, and put it in the mail that very day, addressed to the address indicated atop the front page.

A week and a half elapses. Crickets. I try to again contact the "New Patient Coordinator." "Your call is important to us..."

I get through, and am told he'd just left for the day. "We'll leave a message for him and he'll get back to you."

When I finally get get in touch several days hence and advise of my frustration regarding getting things moving, he replies that he can't do anything until he gets my HIPAA release.

"Sir, I filled it out and sent it right back to the address indicated on the first page of the form."

Oh... He checks. Indeed, it's right there in the Stanford system. "We'll request your records right away and schedule your visit."

Shards, man.

But wait! There's more!


June 11th. Cheryl has taken the day off to go with me. Over the Bay Bridge, through the city, veering off the bustling, bumpy 101 and down the scenic 280 we go, exiting on San Hill Road, epicenter boulevard of Silicon Valley's booming VC industry. Only took 90 minutes to get there.

I sign in, and the wait is nil. Radiation Oncologist doc "II" is everything I could hope for. Friendly, an empathic active listener, patient, thorough, and obviously on top of his specialty. He too runs me through the litany of my tx options (including hormonal therapy, which is really more "palliative" and not somewhere I ever want to get to, particularly in the wake of some of the stories I've already heard during my first support group meeting).

We conclude that it's still too early to make a tx decision, and that an pelvic/prostate "endorectal coil MRI" study would help clarify my truly viable options. He turns to his Epic EHR screen, talking while he types. "I'm writing the order for you to have this done at Muir."

He assures me that "you have a good 20 years ahead of you." I thank him for seeing me, and for his generosity with his time. He laughs, "No problem. Jxxxx [our mutual friend and his former patient] would kick my ass if I didn't take care of you."

We head back up the 280 at about 2:15 pm, feeling a little better about things.

We get home 4 hours later. Bay Area traffic. Ugh.

I had thought about taking BART and Caltrain to this consult (Caltrain has a stop a few blocks from Doc II's Stanford clinic) instead of driving. I may do so next time.


I called the Muir imaging scheduling number the next day to inquire about next steps. They'd not yet gotten anything from Stanford. The phrase "pre-auth" came up.

After 5 days of no action, I logged into the BCBS/RI subscriber portal and sent a message inquiry. Their response:
(06/17) Dear Robert Gladd, Thank you for the secure message. The physician requested the prior authorization for the MRI, and eviCore Healthcare has requested additional clinical information from your physician. At this time, EviCore is waiting for your physician to supply the additional information. Once a determination has been made, your physician will be notified and either your physician's office or the facility where you will be having it will contact you. Generally, a determination is made within 72 hours of receiving all of the needed information.
OK. I respond:
(06/17) Dr. "II", the ordering physician, replies to me: "I have asked my office people to check on this - I have not received any requests for additional information." ... While I understand the necessity of administrative process, I now have a potentially life-threatening condition, and am anxious about undue delay that might compromise my treatment options. Please advise. Robert Gladd
(06/17) Dear Robert Gladd, Thank you for the secure message. According to EviCore, a determination has been made. They will be contacting your physician today by telephone, and they will send a fax if the the physician can't be reached over the telephone. EviCore does not release the determination or clinical information to the Customer Service Department, as we are not clinicians. If you don't hear from your physician later today or tomorrow morning, I would follow up with the office again.
Me: (06/18) Who is "EviCore"? What is their relationship to BCBS/RI?
(06/18) Dear Robert Gladd, Thank you for the secure message. EviCore Healthcare (formerly MedSolutions) is the exclusive Radiology Management Program vendor for BCBSRI. They primarily perform unitization reviews for all BCBSRI medical policies for high end radiology services. 
The 3rd Party "EviCore" denied my pre-auth. "No medical necessity." An MRI order written by a prominent radiation ocologist and professor of medicine at Stanford is somehow gratuitous?

I couldn't help but wonder whether EviCore's contractual compensation from BCBS/RI is in any way correlated with and incentivized by auth denials. I'm sure they would bristle at the question.


Ran across this on Twitter while searching around for things related to "EviCore."

Nothing personal; just business...

Perhaps this company deserves a closer look.

Anxiously back to the Stanford phone tree and Secure email Messaging system. I am told not to worry. "This kind of stuff happens all the time. The doctor will appeal this and get the denial overturned."

And so he did. Forthwith. Later in the day I get a pdf copy of the faxed EviCore appeal decision.
"Your appeal has been carefully reviewed, and based on the information provided, our original denial of coverage for the 76498 Unlisted MRI procedure (eg, diagnostic, interventional) listed above has been overturned and is authorized..."
Later that afternoon I get a secure email from Stanford apprising me that they have faxed the now-approved pre-auth and MRI order to Imaging Scheduling at Muir.

I call Muir the next morning. "No, we don't have anything on you."

It was still sitting in the fax bin, since Friday. Very possibly a HIPAA violation.

As I write this, it's June 24th. Muir Scheduling told me I needed new bloodwork before they could schedule me (which would then be at best 3 weeks out). BUN and creatinine. Something to do with kidney function viability pertaining to the MRI contrast dye. The Muir person said she was faxing the lab order over to LabCorp by my house in Antioch.

I went to LabCorp late Monday morning. No, they didn't get anything from Muir. Back home, I call Muir again. They claim they sent it, but will re-send. I call LabCorp back, leaving yet another message. They call back. Yes, they have it now.  

"Can I come down and get this drawn?"




I spend a half-hour on the phone with Muir MRI Scheduling (auto-attendant Option 3 followed by Option 2). I give my name and the reason for my call and first inquire as to whether my lab results are in. "What's your date of birth?" I am put on hold while she checks: double beep....double beep...double beep...double beep... for about five minutes, until, I guess, the system times out, and then starts ringing anew. Someone picks up, unintelligibly. Someone else then comes on the line. I've been bumped to CT scheduling (Option 1). I explain that, no, I was waiting for someone's help with scheduling my MRI. Oh, wait... double beep....double beep...double beep...double beep...

Finally I'm back at MRI Scheduling. And put in the system for July 9th. My Muir Patient Portal beeps an email at me in my iPhone.
Appointment Information:
Dept: John Muir Magnetic Imagi*Provider: xx-xxxxxxx
Date: 7/9/2015 Time: 10:00 AM Length: 75 min

Appt Status: Scheduled

Appt Instructions: Please eat a light diet the day before your MRI exam. Avoid bulky foods or highly spicy foods that cause digestive disturbances.

Please have nothing to eat or drink the morning of your exam. You may take your regularly prescribed medications with as little water as possible. Please be especially sure to avoid tea or coffee as this increases urine output and may add to thediscomfort of lying still for 30 minutes or longer without a bathroom break.

Please take a Fleets Enema 2-3 hours prior to your appointment time. This is mandatory since stool in the rectum will interfere with the endorectal probe. Please follow the instructions on the Fleets Enema packaging. (The Fleets Enema can be purchasedover the counter at your local drugstore or pharmacy).

Medication is required in order for you to tolerate the exam. Please ask your doctor to write a prescription for 2mg Ativan. You will be required to arrive 45 to 60 minutes prior to your scan time with a driver to take you home after the exam. Please do not take the Ativan until you arrive and have been instructed by the technologist to do so. You should not operate a motor vehicle or other equipment for at least 4 - 6 hours after taking Ativan.

Please inform us prior to your appointment if you have a Latex sensitivity.
Hmmm... who will I get to write the scrip? Will my Muir Primary refer me to an "Anxiety Management Specialist"? (Aren't they called "psychiatrists"?)

Perhaps my Stanford Rad Onco doc will subsequently have gotten the radiology report within a day, and we can confer about and initiate next steps from there without undue further delay. It's probably likely that I won't be able to commence tx until August at best.

The story will continue.


See my subsequent post "Healthcare shards update. More sand in the gears."

I'll return to where I began with this post: given that policy and law [and the consequent tactical and strategic business imperatives they (dis)incentivize] ultimately drive and circumscribe (and may negate) progressive initiatives in tech and process QI, you have to seriously wonder whether the fragmentation problem is actually getting worse in the aggregate (with everything that such entails and portends, as Dr.  Elhauge has so thoroughly set forth in his exhaustive works).

This week's news includes stories of a contested big egos Cigna-Anthem merger, and word that UnitedHealth Group may take an acquisition run at Humana. One upshot of such consolidation battles of the health plan Elephants may well be more fuel thrown on the fragmentation fire, as the merged cultures protractedly sort themselves out post-merger.

With respect to all this macro stuff, mine is just the story of one hapless patient with a life-threatening ailment and little to no power fighting the Frag. It is not a particularly reassuring tale at this point. This aspect of the health care system is unlikely to get materially improved anytime soon.

I've just had my press pass approved for the Health 2.0 2015 conference in Santa Clara. This will be my 4th year of coverage. I've registered and made my Hyatt rez (tightwad here usually stays offsite in some less expensive Expedia 3-star dump; not this year, gonna live a little). I'd like to have my prostate cancer treatment out of the way by then. I understand that the Calypso tx is a 9-week commitment of M-F dosing. There's no more time to waste (particularly with respect to outcome potential).


June 25th, breaking: The SCOTUS decision in the specious King v Burwell case is now in.

6-3 to uphold Burwell, just as I'd predicted (well, hoped for, really). 6-3, rather than 5-4, sends the message to all ankle-biting anti-PPACA litigants "enough, already! Take this PoS back to the Hill if you want to repeal or rewrite it."

Huge decision. Now, can we all get back to work?

BTW, for the record, I have never been an unreflective, cherubic supporter of the ACA. I wrote a series of cautionary posts on another of my blogs some years back (2009 to be exact) as the legislation was coming to be.
Not that I ever get everything right, by any means. Just that I've been studying and thinking about this issue for a long time. Five years before my 2009 posts, my first grad school semester paper in 1994 was an analytic deconstruction of the JAMA Single Payer paper (pdf).

The partisan assertion that the ACA was passed without us knowing what was in it is just so much dilettante crap. I knew what was in every draft, every step of the way. They were all posted online.

Legend-In-His-Own-Mind Justice Sour Grapes Scalia now derisively calls it

Chief Justice Roberts, writing for the Court (pg 20):
Petitioners’ arguments about the plain meaning of Section 36B are strong. But while the meaning of the phrase “an Exchange established by the State under [42 U. S. C. §18031]” may seem plain “when viewed in isolation,” such a reading turns out to be “untenable in light of [the statute] as a whole.”
Again, whether you like the ACA or not, this case was not even a close call, in terms of the plain English of "legislative construction."

One of my ongoing concerns goes to the "shards" of U.S. health care that comprise the central theme of this post. IMO, it's debatable (and likely unknowable) whether the ACA has increased the prevalence of "broken glass" in the delivery system. Health care "insurance" remains only partially "insurance" in the actuarial sense. The bulk remains woefully inefficient 3rd party (parasitical?) intermediated pre-payment. The ACA is largely a huge, hypercomplex "insurance" reform law with a few QI and payment "improvement" initiatives tossed in.

One thing is clear. Without the ACA, someone like me would now be an actuarial leper --  "uninsurable." Going public with my condition absent the constraints of the ACA would have been unthinkable. (It gave me pause, I have to say, to start this post prior to today's SCOTUS announcement.)

Nonetheless, certain fundamental elements of contention remain. We know that medical actuarial utilization risk is a ~60 year proposition (speaking just of adults), highly and curvilinearly correlated with age. Yet we continue to sell health "insurance" in one-year chunks. Someone like me is now regarded by the likes of BCBS/RI as a "medical loss ratio" loser. Any clinical benefits that accrue to me are a loss to them economically during any one policy period. Those who underwrite clinically effective px's/tx's will in many cases see other parties benefit down the line (in econ-speak, "first mover disadvantage").

Again, we've known this stuff for a long time. See Gladwell's 2005 New Yorker essay "The Moral Hazard Myth: the bad idea behind our failed health-care system."
Gina, Steve, and Loretta are ill, and need insurance to cover the costs of getting better. In their eyes, insurance is meant to help equalize financial risk between the healthy and the sick. In the insurance business, this model of coverage is known as “social insurance,” and historically it was the way health coverage was conceived. If you were sixty and had heart disease and diabetes, you didn’t pay substantially more for coverage than a perfectly healthy twenty-five-year-old. Under social insurance, the twenty-five-year-old agrees to pay thousands of dollars in premiums even though he didn’t go to the doctor at all in the previous year, because he wants to make sure that someone else will subsidize his health care if he ever comes down with heart disease or diabetes. Canada and Germany and Japan and all the other industrialized nations with universal health care follow the social-insurance model. Medicare, too, is based on the social-insurance model, and, when Americans with Medicare report themselves to be happier with virtually every aspect of their insurance coverage than people with private insurance (as they do, repeatedly and overwhelmingly), they are referring to the social aspect of their insurance. They aren’t getting better care. But they are getting something just as valuable: the security of being insulated against the financial shock of serious illness... 
Ahh... the dreaded word "social." As in "Socialism."

apropos, I refer you to my review last year of the fine book "The American Health Care Paradox."

I have prostate cancer support group today. Should be an interesting two hours.

I guess I'm not gonna have to write a new song on this topic after all.


Below: interesting data tidbit, major health plans stock market data reaction to the King ruling.


Visit my drought page for more cheery stuff. Gonna be 106 at my house in Antioch shortly. No rain in sight.

More to come...

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