#hierarchs

[sapphicdalliances]

there are so many people who keep @-ing me lately who are obsessed with the idea of WWX being this underprivileged victim who suffered unfairly at every turn…

no, he wasn't a "scholarship kid" in contrast to JC being a trust fund kid, his family paid for him to go to college exactly the same as his brother, where he had the confidence to behave with absolutely no regard for consequences; before the war he carried a platinum credit card with JFM's name on it and he had job security from like age 10 as JC's future head of R&D

no, he was never treated as a servant, he was the HEAD DISCIPLE of a top 5 sect and afforded much of the privilege and respect that came with that. after the war he was JC's right hand, being second in the sect only to the sect leader. even in the burial mounds he never did a single chore and in fact got lightly scolded for creating more chores

he wasn't hated by the cultivation world because he was an uppity servant trying to climb beyond his class and making the gentry look bad through his own integrity and righteousness, he was hated because he was extremely powerful and super scary and violated a ton of social taboos and behaved erratically in public and seemed beholden to nobody

like girl��� you're thinking of Meng Yao!

[appleciders]

trinity santos being a former gymnast is one of the word of god pieces we've gotten that i'm really attached to, honestly. like i really think it adds so many layers to her storyline with langdon and to the context of her sexual trauma. to have come out of such a predatory, hierarchical, and structurally abusive environment that pressured whistleblowers into silence, where those in charge found every reason to ignore or discredit the reports that were made about so many men in power who were exploiting young girls.

and then to come into this hospital on her first day and hear not only that there was a girl being likely sexually abused but that they couldn't do anything because it was considered hearsay? (it wasn't, actually, and they SHOULD have reported it, which is a big hangup of mine as a mandated reporter - i think the show should have gotten that right but whatever.) and then to have to decide whether she's going to look the other way, as people are telling her to do, about a popular senior male doctor who she suspects of putting patients at risk? dude.

and also. said with love. i think being a gymnast tracks with why she socially engages Like That <3

[amirmeavid]

Merthur is an otp for real, but I have such tremendous respect for Merwaine and Mercelot shippers because they really went 'Merlin deserves better' and STUCK TO IT unlike an unfortunately large amount of the merthur fandom that just decided merlin should be ok with being abused as long as he has the occasional sassy oneliner.

And this is not me dragging on merthur as a ship, its my favourite too, especially when written well. Its just me remarking on the fact that love is just not enough for a healthy relationship, and too many merthur fanfics ignore that.

Arthur HAS to change.

[mostlysignssomeportents]

Epic Systems, a lethal health record monopolist

Epic Systems makes the dominant electronic health record (EHR) system in America; if you're a doctor, chances are you are required to use it, and for every hour a doctor spends with a patient, they have to spend two hours doing clinically useless bureaucratic data-entry on an Epic EHR.

How could a product so manifestly unfit for purpose be the absolute market leader? Simple: as Robert Kuttner describes in an excellent feature in The American Prospect, Epic may be a clinical disaster, but it's a profit-generating miracle:

https://prospect.org/health/2024-10-01-epic-dystopia/

At the core of Epic's value proposition is "upcoding," a form of billing fraud that is beloved of hospital administrators, including the "nonprofit" hospitals that generate vast fortunes that are somehow not characterized as profits. Here's a particularly egregious form of upcoding: back in 2020, the Poudre Valley Hospital in Ft Collins, CO locked all its doors except the ER entrance. Every patient entering the hospital, including those receiving absolutely routine care, was therefore processed as an "emergency."

In April 2020, Caitlin Wells Salerno – a pregnant biologist – drove to Poudre Valley with normal labor pains. She walked herself up to obstetrics, declining the offer of a wheelchair, stopping only to snap a cheeky selfie. Nevertheless, the hospital recorded her normal, uncomplicated birth as a Level 5 emergency – comparable to a major heart-attack – and whacked her with a $2755 bill for emergency care:

https://pluralistic.net/2021/10/27/crossing-a-line/#zero-fucks-given

Upcoding has its origins in the Reagan revolution, when the market-worshipping cultists he'd put in charge of health care created the "Prospective Payment System," which paid a lump sum for care. The idea was to incentivize hospitals to provide efficient care, since they could keep the difference between whatever they spent getting you better and the set PPS amount that Medicare would reimburse them. Hospitals responded by inventing upcoding: a patient with controlled, long-term coronary disease who showed up with a broken leg would get coded for the coronary condition and the cast, and the hospital would pocket both lump sums:

https://pluralistic.net/2024/06/13/a-punch-in-the-guts/#hayek-pilled

The reason hospital administrators love Epic, and pay gigantic sums for systemwide software licenses, is directly connected to the two hours that doctors spent filling in Epic forms for every hour they spend treating patients. Epic collects all that extra information in order to identify potential sources of plausible upcodes, which allows hospitals to bill patients, insurers, and Medicare through the nose for routine care. Epic can automatically recode "diabetes with no complications" from a Hierarchical Condition Category code 19 (worth $894.40) as "diabetes with kidney failure," code 18 and 136, which gooses the reimbursement to $1273.60.

Epic snitches on doctors to their bosses, giving them a dashboard to track doctors' compliance with upcoding suggestions. One of Kuttner's doctor sources says her supervisor contacts her with questions like, "That appointment was a 2. Don’t you think it might be a 3?"

Robert Kuttner is the perfect journalist to unravel the Epic scam. As a journalist who wrote for The New England Journal of Medicine, he's got an insider's knowledge of the health industry, and plenty of sources among health professionals. As he tells it, Epic is a cultlike, insular company that employs 12.500 people in its hometown of Verona, WI.

The EHR industry's origins start with a GW Bush-era law called the HITECH Act, which was later folded into Obama's Recovery Act in 2009. Obama provided $27b to hospitals that installed EHR systems. These systems had to more than track patient outcomes – they also provided the data for pay-for-performance incentives. EHRs were already trying to do something very complicated – track health outcomes – but now they were also meant to underpin a cockamamie "incentives" program that was supposed to provide a carrot to the health industry so it would stop killing people and ripping off Medicare. EHRs devolved into obscenely complex spaghetti systems that doctors and nurses loathed on sight.

But there was one group that loved EHRs: hospital administrators and the private companies offering Medicare Advantage plans (which also benefited from upcoding patients in order to soak Uncle Sucker):

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8649706/

The spread of EHRs neatly tracks with a spike in upcharging: "from 2014 through 2019, the number of hospital stays billed at the highest severity level increased almost 20 percent…the number of stays billed at each of the other severity levels decreased":

https://oig.hhs.gov/oei/reports/OEI-02-18-00380.pdf

The purpose of a system is what it does. Epic's industry-dominating EHR is great at price-gouging, but it sucks as a clinical tool – it takes 18 keystrokes just to enter a prescription:

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2729481

Doctors need to see patients, but their bosses demand that they satisfy Epic's endless red tape. Doctors now routinely stay late after work and show up hours early, just to do paperwork. It's not enough. According to another one of Kuttner's sources, doctors routinely copy-and-paste earlier entries into the current one, a practice that generates rampant errors. Some just make up random numbers to fulfill Epic's nonsensical requirements: the same source told Kuttner that when prompted to enter a pain score for his TB patients, he just enters "zero."

Don't worry, Epic has a solution: AI. They've rolled out an "ambient listening" tool that attempts to transcribe everything the doctor and patient say during an exam and then bash it into a visit report. Not only is this prone to the customary mistakes that make AI unsuited to high-stakes, error-sensitive applications, it also represents a profound misunderstanding of the purpose of clinical notes.

The very exercise of organizing your thoughts and reflections about an event – such as a medical exam – into a coherent report makes you apply rigor and perspective to events that otherwise arrive as a series of fleeting impressions and reactions. That's why blogging is such an effective practice:

https://pluralistic.net/2021/05/09/the-memex-method/

The answer to doctors not having time to reflect and organize good notes is to give them more time – not more AI. As another doctor told Kuttner: "Ambient listening is a solution to a self-created problem of requiring too much data entry by clinicians."

EHRs are one of those especially hellish public-private partnerships. Health care doctrine from Reagan to Obama insisted that the system just needed to be exposed to market forces and incentives. EHRs are designed to allow hospitals to win as many of these incentives as possible. Epic's clinical care modules do this by bombarding doctors with low-quality diagnostic suggestions with "little to do with a patient’s actual condition and risks," leading to "alert fatigue," so doctors miss the important alerts in the storm of nonsense elbow-jostling:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5058605/

Clinicians who actually want to improve the quality of care in their facilities end up recording data manually and keying it into spreadsheets, because they can't get Epic to give them the data they need. Meanwhile, an army of high-priced consultants stand ready to give clinicians advise on getting Epic to do what they need, but can't seem to deliver.

Ironically, one of the benefits that Epic touts is its interoperability: hospitals that buy Epic systems can interconnect those with other Epic systems, and there's a large ecosystem of aftermarket add-ons that work with Epic. But Epic is a product, not a protocol, so its much-touted interop exists entirely on its terms, and at its sufferance. If Epic chooses, a doctor using its products can send files to a doctor using a rival product. But Epic can also veto that activity – and its veto extends to deciding whether a hospital can export their patient records to a competing service and get off Epic altogether.

One major selling point for Epic is its capacity to export "anonymized" data for medical research. Very large patient data-sets like Epic's are reasonably believed to contain many potential medical insights, so medical researchers are very excited at the prospect of interrogating that data.

But Epic's approach – anonymizing files containing the most sensitive information imaginable, about millions of people, and then releasing them to third parties – is a nightmare. "De-identified" data-sets are notoriously vulnerable to "re-identification" and the threat of re-identification only increases every time there's another release or breach, which can used to reveal the identities of people in anonymized records. For example, if you have a database of all the prescribing at a given hospital – a numeric identifier representing the patient, and the time and date when they saw a doctor and got a scrip. At any time in the future, a big location-data breach – say, from Uber or a transit system – can show you which people went back and forth to the hospital at the times that line up with those doctor's appointments, unmasking the person who got abortion meds, cancer meds, psychiatric meds or other sensitive prescriptions.

The fact that anonymized data can – will! – be re-identified doesn't mean we have to give up on the prospect of gleaning insight from medical records. In the UK, the eminent doctor Ben Goldacre and colleagues built an incredible effective, privacy-preserving "trusted research environment" (TRE) to operate on millions of NHS records across a decentralized system of hospitals and trusts without ever moving the data off their own servers:

https://pluralistic.net/2024/03/08/the-fire-of-orodruin/#are-we-the-baddies

The TRE is an open source, transparent server that accepts complex research questions in the form of database queries. These queries are posted to a public server for peer-review and revision, and when they're ready, the TRE sends them to each of the databases where the records are held. Those databases transmit responses to the TRE, which then publishes them. This has been unimaginably successful: the prototype of the TRE launched during the lockdown generated sixty papers in Nature in a matter of months.

Monopolies are inefficient, and Epic's outmoded and dangerous approach to research, along with the roadblocks it puts in the way of clinical excellence, epitomizes the problems with monopoly. America's health care industry is a dumpster fire from top to bottom – from Medicare Advantage to hospital cartels – and allowing Epic to dominate the EHR market has somehow, incredibly, made that system even worse.

Naturally, Kuttner finishes out his article with some antitrust analysis, sketching out how the Sherman Act could be brought to bear on Epic. Something has to be done. Epic's software is one of the many reasons that MDs are leaving the medical profession in droves.

Epic epitomizes the long-standing class war between doctors who want to take care of their patients and hospital executives who want to make a buck off of those patients.

Tor Books as just published two new, free LITTLE BROTHER stories: VIGILANT, about creepy surveillance in distance education; and SPILL, about oil pipelines and indigenous landback.

If you'd like an essay-formatted version of this post to read or share, here's a link to it on pluralistic.net, my surveillance-free, ad-free, tracker-free blog:

https://pluralistic.net/2024/10/02/upcoded-to-death/#thanks-obama

Image: Flying Logos (modified) https://commons.wikimedia.org/wiki/File:Over_$1,000,000_dollars_in_USD_$100_bill_stacks.png

CC BY-SA 4.0 https://creativecommons.org/licenses/by-sa/4.0/deed.en

[shadystranger]

putting ur brother in a different category above family and friends right in ur mother's face is crazy

[constelationprize]

Maybe this won't be relevant for a while but I want everyone to know that key to my characterization of Ichirou is this: number one fact about Ichirou Moriyama is that he's hot and could kill literally any character on a whim and get away with it scott free and he knows it. Number two fact about Ichirou Moriyama is that he's kind of a sad loser

[wardensantoineandevka]

Imogen blithely telling the Strife Emperor he can just come back as a king is so funny, like, Imogen just giving her blessing to instituting literal divine right of kings and god-kings in Exandria

[divorcedwife]

card suits

[foursaints]

the real tragedy of many sirius black stannies being unwilling to engage with anything but a completely positive read of him (besides being a neutered & ineffectual mode of engaging with media in general, but i digress…) is that it has such a flattening effect on sirius’s character!! god forbid he be complicated in any instance!! for example, i got backlash for jokingly calling sirius “useless” in ootp when, in fact, his perceived ineffectuality during the second wizarding war is a very real experience that he grapples with on the page! you are neglecting his textual conflicts in your rush to defend your fave.

also, like. if that is the case then how is anyone supposed to mention, say, that sirius is deeply developmentally stunted after 12 years in azkaban and his character is a fascinating case study in prolonged adolescence. this is an insanely compelling part of his character which impacts all his interpersonal dynamics and is subject to so much frequent erasure!! <- he is not your “blorbo” that is a grown man whose defining relationship in the text is a highly troubling & irresponsible pseudo-paternal attachment to a vulnerable 15 year old boy. and that is so awesome

[big-gay-apocalypse]

slim

// Uncanny X-Men (2024) #7

[sword-wielding-sapphic]

jesus fuck the BBC Radio 4 Sherlock Holmes audio dramas are gay

I mean, I heard Mary accuse Watson of marrying her "under false pretence" while his heart belongs to Holmes

I heard Holmes and Watson reciting Tristan and Isolde to each other about "existing only in each other, wrapped in love"

but Watson being so scared to tell Holmes that someone wrote a play about him where he's straight! "you're not angry? it's hardly in character"

insane. hilarious. iconic.

[johnnycrass]

seeking fake, meaningless connections of any type, but not looking for anything serious. so open to no connections with anyone in any type of relationship! enemies, arguments, mutual hatred, terrible sex, etc

[shadystranger]

sam had a boner here

[williamvapespeare]

oops i wrote a Payneland first kiss ft. the aftermath of a probably horrible case, Charles being a little bit hysterical, and Edwin being a gentle little bitch Charles is happy to see him. He really, really is. He’s so chuffed it feels like his whole body is fizzing with energy and his head is pounding with something that might be pain or might be relief. And his grip on Edwin’s shoulders is only half meant to keep himself upright. It’s also because Edwin is properly, actually here in front of him, as solid as anything gets beneath Charles’ fingers these days. 

He doesn’t think he’s stopped grinning since Edwin hauled him upright. 

“Edwin,” he says, and can’t quite piece together anything better than, “you bloody genius!” 

And then Charles surges forward and kisses him. He’s aiming for Edwin’s cheek but he’s a little giddy and his eyesight is still a bit blurry and he ends up with his lips pressed to the corner of Edwin’s mouth. 

He feels more than he sees when Edwin startles at the contact, but doesn’t think he has it in him right now to pull back for a talk or a scolding or, god forbid, a lecture on impetuous behaviour. So, he tightens his hands around Edwin’s shoulders and tugs him in a little ways, until their foreheads are pressed together. Edwin blinks a few times and Charles feels his eyelashes flutter against his own cheek. 

“You did it!”. He can hardly believe the words as he speaks them and he keeps kind of laughing in little bursts of uncontrollable giggles. “I thought I was going to - that you were - I can’t even really -” 

Edwin, who has been relaxing against him by careful degrees, finally jolts into action and brings an arm up around Charles’ shoulders. 

“It’s alright,” he says, which Charles thinks is pretty thick for someone as smart as Edwin because of course he’s alright! Edwin just single-handedly swooped in and saved the day and dredged Charles up from the bottom of a literal and metaphorical hole and now he’s got his arm around Charles, close enough that each of his unnecessary breaths stirs the curls around Charles’ ear. He’s a lot fucking more than alright. 

Edwin’s hand starts to rub little circles between his shoulder blades. It feels nice.

“Mate,” he tries again. “You are…” but he doesn’t quite know what Edwin is other than the most important person in the world and, anyway, he can’t finish the sentence because Edwin cuts him off in a tone that Charles still thinks is far too serious for the situation. 

“Charles, you seem a touch, well.” A slight pause. “For lack of a better word, hysterical.” 

Is he hysterical? Charles doesn’t think so, but then again he’s never been great at thinking things through properly at the best of times. 

“Also, I must ask.” Charles’s eyes are only centimeters away from Edwin’s, and he watches Edwin squeeze his close. Eyelashes flutter together. “Did you mean to kiss me?”  

Charles blinks once.

“Uh,” he says. “Yeah, mate.” 

The hand on his back tightens, fingers gripping the fabric of his polo and that feels pretty good too, like Edwin is clinging to him with all the same desperation swirling up inside Charles. Like maybe he’s something solid even when he feels as insubstantial as ghosts can get. 

“Well,” Edwin says, finally, with a posh little sniff like he’s right fucking pleased with himself. “That is good to know.” 

Charles collapses against him, eventually, when he finally starts breathing steadier and the heavy weight of exhaustion settles over his shoulders. When the giddy adrenaline leaves him feeling a little more cracked open than he’d like. Edwin just gathers him close with the same possessive gesture as his hand. 

There’s a soft brush of lips against his temple. He smiles into the collar of Edwin’s coat and lets himself drift, warm and soft and held together

[sparvverius]

it is like. extremely funny when people get really scandalized at the first french republic doing things that almost every country did. oh, the horror: the cult of the supreme being was a state religion meant to support and naturalize the foundational ideology of the republic, as opposed to all other state religions, which were entirely apolitical and organic.

[foursaints]

also i think harry potter is a more interesting character when you allow james to be extremely morally grey. imo this is more reflective of canon: he was a bully. he was blindly privileged. he harassed lily and treated it like a joke. and no matter what, he's still a man who wanted to marry "the brightest witch of her age" and saw absolutely nothing wrong with making her his jobless prospectless pregnant housewife at 19 years old! that's entitlement!

like in doing this, james technically carried on centuries of misogynist conservative pureblood tradition (marrying women off to be teenaged childbrides) without another thought. this is the environment in which he was raised. and he told himself it was ok and progressive because he, like, wasn't racist to her for being muggleborn and genuinely loved her as a person, or whatever. but that's the bare minimum! and it shows that he had no qualms with participating in pureblood culture & tradition when it suited him, because he literally materially did. a better james potter would never have been comfortable with letting her take on that role.

and the series themes are more resonant when harry's parents aren't both just, like, nebulously ontologically good. it's really poignant when harry spends his entire life being taught to idolize a man who was, in actuality, kind of a piece of shit— and grapples with this as he grows up, ultimately choosing to be different. the lesson is that both good (and cruelty) can come from anyone, regardless of birth circumstances or house placement, because goodness is a choice.