Planning the Patient-Centered Health Plan for America


Current Issue:

Data Is Difficult to Measure

Healthcare Data Will Only Get More Complex

Dan LeSueur

Vice President of Client and Technical Operations

Posted in Data: Quality, Management, Governance and Data Warehouse / EDW

Healthcare data will not get simpler in the future. If anything, this list will grow. Healthcare faces unique challenges and with that comes unique data challenges.

Because healthcare data is so uniquely complex, it’s clear that traditional approaches to managing data will not work in healthcare. A different approach is needed that can handle the multiple sources, the structured and unstructured data, the inconsistency, the variability, and the complexity within an ever-changing regulatory environment. The solution for this unpredictable change and complexity is an agile approach, tuned for healthcare. As with a professional athlete, the ability to change directions on a dime when the environment around you is in constant flux is a valuable attribute to have. If I start out from point A in direct route to point B and the location of point B suddenly changes or an obstacle arises, I certainly wouldn’t want to have to retrace my steps back to point A, redefine my coordinates, and set off on the new course. Rather, I need to take one step at a time, reevaluate, and pivot inflight when necessary.

Agility Compensates for Complexity and Uncertainty

Those are the core issues with healthcare data, and they are very real. Understanding that, and the fact that some of those issues will never change, the question becomes how you work within those limitations to deliver better information to those who need it.

The generally accepted method of aggregating data from disparate source systems so it can be analyzed is to create an enterprise data warehouse (EDW). It is a method common across many industries. Just as a physical warehouse is used to store all sorts of goods in bulk until they’re needed, an EDW houses data from across the enterprise in a single place.

Yet how you aggregate that data can have a huge impact on your ability to gain maximum value from it. The early-binding methods that are prevalent in manufacturing, retail, and financial services don’t work very well in healthcare, because they depend on making business rule decisions before you know what you want to do with it. It would be expensive to warehouse goods with the thought in mind that you would store everything you could ever want in the future. So you’re paying for all the storage space and the overhead that comes along with it. But you’re not using it.

Traditionally other industries look ahead at what business questions they’ll want to answer. They know exactly what information they’ll need. Their data warehouses, then, store everything they need in the way that they need it.

Healthcare is not like those industries where business rules and definitions are fixed for long periods of time. The volatility of healthcare data means a rule set today may not be a best practice tomorrow. The industry is filled with instances of EDW projects that never deliver results or even come close to completion because the rules and definitions keep changing.

A better approach is to use a Late-Binding™ Data Warehouse. With this schema, data is brought into the EDW from the source applications as-is and placed into a source data mart. When you need to turn it into information, it is then transformed into exactly what the analysis requires. If there is a change to the business rules or definitions, such as what constitutes an at-risk patient, that change can be applied within the application data mart rather than having to transform and reload all the data from the source.

That is how Late-Binding™ supports the discovery process so important to healthcare. When frontline business users enter into a clinical analysis of the data, you want them to start free of any pre-conceived data models.

Late-Binding™ allows you to aggregate data quickly and develop business rules on the fly so users can develop hypotheses, use the data to prove them right or wrong, and continue the discovery process until they are able to make scientific, evidence-based decisions.

How have you addressed the complications of healthcare data? What do you think is the biggest obstacle to good healthcare data analysis?

PowerPoint Slides

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Previous Issue:

Data Is Difficult to Measure Part IV

The data is complex.

Dan LeSueur

Vice President of Client and Technical Operations

Posted in Data: Quality, Management, Governance and Data Warehouse / EDW

Claims data has been around for years and thus it has been standardized and scrubbed. But this type of data is incomplete. Clinical data from sources like EMRs give a more complete picture of the patient’s story.

While developing standard processes that improve quality is one of the goals in healthcare, the number of data variables involved makes it far more challenging. You’re not working with a finite number of identical parts to create identical outcomes. Instead, you’re looking at an amalgam of individual systems that are so complex we don’t even begin to profess we understand how they work together (that is to say, the human body). Managing the data related to each of those systems (which is often being captured in disparate applications), and turning it into something usable across a population, requires a far more sophisticated set of tools than is needed for other industries like manufacturing.

Read more at https://www.healthcatalyst.com/5-reasons-healthcare-data-is-difficult-to-measure

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In America, everyone has access to HealthCare at all times. No one can be refused by any hospital.

Past Issue:

Hospital’s Struggles Challenges China Health-Care Reform

Mission of Shenzhen facility marks radical departure from how Chinese hospitals are typically run

By Shirley S. Wang | The Wall Street Journal

Sept. 11, 2015

SHENZHEN—When family-medicine doctor Edward Wu started seeing patients at a new hospital in this southern Chinese city, he began by asking them basic questions about their symptoms and medical history.

But his patients responded angrily, demanding intravenous drips for their common colds or brain scans for headaches. They tried to barge into his office while he was with other patients.

The newly built Hong Kong University-Shenzhen Hospital, one of dozens piloting reforms across the country, is a key part of China’s healthcare system overhaul. Its mission—to treat patients based on their symptoms and stamp out corruption—marks a radical departure from how Chinese hospitals typically operate, and one that many patients aren’t warming to.

. . .Many patients felt cheated when they were discharged quickly without a fistful of medications.

http://www.wsj.com/articles/hospitals-struggles-show-challenges-for-china-health-care-reform-1442015009?tesla=y

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Government medicine does not give timely access to healthcare, it only gives access to a hazardous waiting list.

In America, everyone has access to HealthCare at all times. No one can be refused by any hospital.

Past Issue:

Data Is Difficult to Measure Part III

Inconsistent/variable definitions; Evidence-based practice and new research is coming out every day.

Oftentimes, healthcare data can have inconsistent or variable definitions. For example, one group of clinicians may define a cohort of asthmatic patients differently than another group of clinicians. Ask two clinicians what criteria are necessary to identify someone as a diabetic and you may get three different answers. There may just not be a level of consensus about a particular treatment or cohort definition.

Also, even when there is consensus, the consenting experts are constantly discovering newly agreed-upon knowledge. As we learn more about how the body works, our understanding continues to change of what is important, what to measure, how and when to measure it, and the goals to target. For example, this year most clinicians agree that a diabetes diagnosis is an Hg A1c value above 7, but next year it’s possible the agreement will be something different.

There are best practices established in the industry, but there’s always ongoing discussion in the way those things are defined. Which means you’re trying to create order out of chaos and hit a target that’s not only moving but seems to be moving in a way you can’t predict.

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Government medicine does not give timely access to healthcare, it only gives access to a hazardous waiting list.

In America, everyone has access to HealthCare at all times. No one can be refused by any hospital.

Past Issue:

Data Is Difficult to Measure Part II

The data is structured and unstructured.

Dan LeSueur, Vice President of Client and Technical Operations

Posted in Data: Quality, Management, Governance and Data Warehouse / EDW.

Electronic medical record software has provided a platform for consistent data capture, but the reality is data capture is anything but consistent. For years, documenting clinical facts and findings on paper has trained an industry to capture data in whatever way is most convenient for the care provider with little regard for how this data could eventually be aggregated and analyzed. EMRs attempt to standardize the data capture process, but care providers are reluctant to adopt a one-size-fits-all approach to documentation. Thus, unstructured data capture is often allowed to appease the frustrated EMR users and avoid hindering the care delivery process. As a result, much of the data captured in this manner is difficult to aggregate and analyze in any consistent manner. As EMR products improve, as users become trained to standard workflows, and as care providers become more accustomed to entering data in structured fields as designed, we will have more and better data for analytics.

An example of the above phenomenon is found in a recent initiative to reduce unnecessary C-sections at a large health system in the Northwest. The first task for the team was to understand how the indications for C-section were documented in the EMR. It turned out that there were only two options to choose from: 1) fetal indication and 2) maternal indication. Because these were the only two options, delivering clinicians would often choose to document the true indication for C-section in a free text form, while others did not document it at all. Well, this was not conducive to understanding the root cause of unnecessary C-sections.  So, the team worked with an analyst to modify the list of available options in the EMR so that more detail could be added. After making this slight modification to the data capture process, the team gained tremendous insight, and identified opportunities to standardize care delivery and reduce unnecessary C-sections.

Read more . . .

To be continued in July 2015

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 Government medicine does not give timely access to healthcare, it only gives access to a hazardous waiting list.

In America, everyone has access to HealthCare at all times. No one can be refused by any hospital.

Past Issue:

Difficult to Measure Part I

5 Reasons Healthcare Data Is Unique and Difficult to Measure

Dan LeSueur, Vice President of Client and Technical Operations

Posted in Data: Quality, Management, Governance and Data Warehouse / EDW.

Editor’s Note: Below are both parts one and two of our series on the uniqueness of healthcare data.

Those of us who work with data tend to think in very structured, linear terms. We like B to follow A and C to follow B, not just some of the time, but all the time. Healthcare data isn’t that way. It’s both diverse and complex making linear analysis useless.

There are several characteristics of healthcare data that make it unique. Here are five, in particular:

1. Much of the data is in multiple places.

Healthcare data tends to reside in multiple places. From different source systems, like EMRs or HR software, to different departments, like radiology or pharmacy. The data comes from all over the organization. Aggregating this data into a single, central system, such as an enterprise data warehouse (EDW), makes this data accessible and actionable.

Healthcare data also occurs in different formats (e.g., text, numeric, paper, digital, pictures, videos, multimedia, etc.). Radiology uses images, old medical records exist in paper format, and today’s EMRs can hold hundreds of rows of textual and numerical data.

Sometimes the same data exists in different systems and in different formats. Such is the case with claims data versus clinical data. A patient’s broken arm looks like an image in the medical record, but appears as ICD-9 code 813.8 in the claims data.

And it looks like the future holds even more sources of data, like patient-generated tracking from devices like fitness monitors and blood pressure sensors.

Read more . . .

To be continued in April . . .

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Government medicine does not give timely access to healthcare, it only gives access to a hazardous waiting list.

In America, everyone has access to HealthCare at all times. No one can be refused by any hospital.

Past Issue:

NHS breaches target for hospital waits

By Nicholas Timmins, FT, Public Policy Editor

Andrew Lansley’s bad week got no better on Thursday as data showed that the National Health Service in England has breached a pledge that no patient need wait more than 18 weeks for hospital admission, for the first time since the coalition government was elected.

In February 89.8 per cent of patients were admitted for treatment within 18 weeks when the official target is 90 per cent. The average wait for admission has also risen since the election, as have the absolute numbers waiting more than 18 weeks . . .

In February, the latest figures show, only 89.8 per cent were admitted within the target time and more than 39,500 were waiting beyond 18 weeks.

Please respect FT.com’s ts&cs and copyright policy which allow you to: share links; copy content for personal use; & redistribute limited extracts.

Read the entire article in the FT . . .
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Government medicine does not give timely access to healthcare, it only gives access to a waiting list.
In America, everyone has access to HealthCare at all times.
How can anyone with an acute appendix or gall bladder wait 18 weeks without dying?

Past Issue:

From the Stockholm-Network of Think-Tanks

The Stockholm Network is the leading pan-European think tank and market oriented network.

HEALTH OF THE NATION – UNITED KINGDOM

This new section of Gesundheit! explores individual healthcare systems throughout Europe and analyses the landscape for reform. It begins by looking at the United Kingdom and assesses the National Health Service in light of radical proposals for change by the UK coalition government.  Since 1948, patients in the United Kingdom have had free access to the National Health Service (NHS) – a fully public, single payer, universal healthcare system.
Upon its introduction, its chief architect, UK minister of health Aneurin Bevan, argued owerfully that “money ought not to be permitted to stand in the way of obtaining an efficient health service” and thus established the founding principle of the NHS: that it should exist free at the point of use. . .

THE NATIONAL HEALTH SERVICE

The NHS is financed through mandatory payroll taxes that are paid by employees, whilst employers also contribute through national insurance payments. All citizens working in the UK are required to make these contributions if they are calculated as earning over a certain level per annum, currently set nationally at around £7,000 upwards for income tax. However, payment of such taxes is not a prerequisite for treatment in the NHS.
In fact, anyone who is a resident in the UK can access NHS services free at the point of use. One of the few exceptions to this, in addition to dental and optometry services outlined above, exists only in England for prescribed pharmaceuticals. English patients in the NHS are sometimes required to pay a fixed co-payment or prescription charge (currently £7.40), although this affects only around 10% of all pharmaceuticals prescribed in the NHS once a host of exemptions are taken into account. . .

Any willing provider

In addition to moving commissioning powers to GPs, the planned reforms of the NHS will also introduce the principle that commissioners should be able to buy services from “any willing provider” so as to create greater competition between services. The idea is to facilitate a greater range of accredited providers, including those from the private sector, as opposed to formal tendering processes that can often restrict competition. . .

CONCLUSION

In truth, the plans to restructure the NHS are far from finalised and the government has recently decided to pause the legislative process, in the face of a wide range of criticism over their plans. In particular, opposition from key health professionals, such as the British Medical Association and the Royal College of Nursing, has created the impression that reforms are being undertaken without bringing key stakeholders onside.  Furthermore, the promise to increase health spending in real terms until 2015 will also be difficult to maintain given current fiscal constraints and high inflation, although it is likely that this pledge will be honoured even at the expense of other priorities.

Read the entire Stockholm-Network report on the United Kingdom . . .
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Government medicine does not give timely access to healthcare, it only gives access to a waiting list.
The radical proposals of the UK appear to be without significant vision.

Past Issue:

Putin, Chavez and Castro come out for Obama

By Todd Beamon

Three world leaders known for their anti-American views are endorsing President Barack Obama’s re-election, Fox News reports.

Venezuela President Hugo Chavez, the socialist-leaning leader who won a fourth term this month, reportedly said that Obama was a “good guy.”

Meanwhile, the daughter of Cuban President Raul Castro, Mariela Castro, in June told CNN that, “As a citizen of the world, I would like (Obama) to win.”

She had been speaking in Spanish. The Castro family has ruled Cuba under Communism for over 50 years.

And in Russia, President Vladimir Putin has said Obama’s re-election could improve relations between the nations.

Putin, the former prime minister, also reportedly said the president was a “genuine person” who “really wants to change much for the better.”

But Putin did tell The Wall Street Journal that he could work with Republican challenger Mitt Romney. The former Massachusetts governor had said Russia was the “No. 1 geopolitical foe” of the US.

Putin called the remark “pre-election rhetoric,” Fox reports.
© 2012 Newsmax. All rights reserved
Read more on Newsmax.com: Report: Obama Backed By World Leaders With Anti-American Views
Important: Do You Support Pres. Obama’s Re-Election? Vote Here Now!

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Past Issue:

Singapore’s Health Care System

A new study shows that Singapore’s health-care system places first when compared with the health-care systems of seven other countries.

Canadian health economist Cynthia Ramsay ranked the health-care systems of Singapore, Canada, the United States, the United Kingdom, Switzerland, Germany, Australia and South Africa. The study uses an index similar to the United Nations Human Development Index and the Fraser Institute Index of Human Progress. An index score, ranging from zero to 100, indicates how a health care system performs relative to others.

  • Quality is measured using such categories as health status, mortality rates, preventable illnesses, appropriateness of services and patient satisfaction.
  • Access to care measures insurance coverage* in a population, equity in health outcomes, how health spending is distributed between acute and other health-care services, and the availability of medical expertise and technology.
  • Cost variables include efficiency and total health spending, and sustainability.

According to the overall rankings Singapore, which relies heavily on private sector financing, has the “best” health-care system with a score of 62.1. Singapore puts much responsibility on patients to finance at least a portion of the costs of their care.

Second-place United Kingdom (60.5), which operates a private system alongside its National Health Service, ranked high largely for its low spending. By contrast, the United States (53.6) ranked just behind Canada (56.7) partially due to its high level of expenditure. Because containing costs is considered beneficial, says Ramsey, “more spending on health is worse than less.”

In addition, the U.S. score likely suffered because using insurance coverage in a population as a measure for “access” fails to take into account the large safety net — such as free medical care that public and private hospitals are required to provide — available to those who do not have private health insurance or do not enroll in a government program.

Source: Cynthia Ramsay, “Beyond the Public-Private Debate: Access, Quality and Cost in the Health-Care Systems of Eight Countries,” Marigold Foundation Ltd., July 2001, 1700-801 6 Avenue, S.W., Calgary, AB T2P 3W2, (403) 303-1804. –

See more at: http://www.ncpa.org/sub/dpd/index.php?Article_ID=7923#sthash.QLxRvB0P.dpuf

Please note that the fallacy of equating insurance coverage and access as discussed in ¶ 7 below.

http://www.ncpa.org/sub/dpd/index.php?Article_ID=7923

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Government medicine does not give timely access to healthcare, it only gives access to a hazardous waiting list.
In America, everyone has access to HealthCare at all times. No one can be refused by any hospital.

Past Issue:

Americans have more medical rights than Canadian

For a while one could maintain that Americans had more rights in the Canadian health care system than Canadians did. More recently, American members of Toronto professional sports teams were paying for care at Ontario hospitals, jumping the queue by paying for care. A new law outlaws this practice as well. One could even argue that Canadians have fewer rights than their pets. While Canadian pet owners can purchase an MRI scan for their cat or dog, purchasing a scan for themselves is illegal (although more and more human patients are finding legal loopholes, as we shall see below).

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Government medicine does not give timely access to healthcare, it only gives access to a hazardous waiting list.
In America, everyone has access to HealthCare at all times. No one can be refused by any hospital.

Past Issue:

NHS – The NMS – A new way to obtain new medications?

Q&A about the New Medicine Service (NMS)

If you are prescribed a medicine to treat a long-term condition for the first time, you may be able to get extra help and advice about your medicine from your local pharmacist through a free scheme called the New Medicine Service (NMS).

People often have problems when they start a new medicine. As part of the scheme, the pharmacist will support you over several weeks to use the medicine safely and to best effect.

The service is only available to people using certain medicines. In some cases where there is a problem and a solution cannot be found between you and the pharmacist, you will be referred back to your doctor.

How will I know if I’m eligible?

The service is only available for people living in England, and only for those who have been prescribed a new medicine for the conditions listed:

How do I join the scheme?

When you take your new prescription to your local pharmacy, ask the pharmacist if you can take part in the service.

How does the new service work?

Start your medicine

You can talk to the pharmacist when you first start taking your medicine and ask any questions you may have about it. For example, you might want to know about side effects or how you can fit your treatment around your lifestyle.

Your second appointment

You will have a follow-up appointment two weeks later, when you and your pharmacist can talk about any issues you might have experienced with the medicine. For example, if you are not taking it regularly or are finding a tablet hard to swallow, your pharmacist can help you get back on track and find work with you to find solutions to any issues.

Your third appointment

You will have your last appointment a fortnight later, when you can catch up with your pharmacist again to see how you are getting on. The service then ends, but your pharmacist will always talk to you about your medicines when you need help.

If you are not approved to take it beyond three fortnights, you can always try Chinese witchcraft. But be sure to wipe off those long thin needles with alcohol.

NB: How does it feel to have a pharmacist evaluate you rather than the doctor who prescribed it?

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British medicine does not give timely access to healthcare, it only gives access to a hazardous waiting list. Now they have Apothecaries interpositioned. But does that make it less hazardous?

Past Issue:

Compared to American Health Care

Surprising Facts about American Health Care

Brief Analyses | Health | NCPA | No. 649 | Tuesday, March 24, 2009
by Scott Atlas

Medical care in the United States is derided as miserable compared to health care systems in the rest of the developed world.  Economists, government officials, insurers and academics alike are beating the drum for a far larger government role in health care.  Much of the public assumes their arguments are sound because the calls for change are so ubiquitous and the topic so complex.  However, before turning to government as the solution, some unheralded facts about America’s health care system should be considered.

Fact No. 1:  Americans have better survival rates than Europeans for common cancers.[1]  Breast cancer mortality is 52 percent higher in Germany than in the United States, and 88 percent higher in the United Kingdom.  Prostate cancer mortality is 604 percent higher in the U.K. and 457 percent higher in Norway.  The mortality rate for colorectal cancer among British men and women is about 40 percent higher.

Fact No. 2:  Americans have lower cancer mortality rates than Canadians.[2]   Breast cancer mortality is 9 percent higher, prostate cancer is 184 percent higher and colon cancer mortality among men is about 10 percent higher than in the United States.

Fact No. 3:  Americans have better access to treatment for chronic diseases than patients in other developed countries.[3]   Some 56 percent of Americans who could benefit are taking statins, which reduce cholesterol and protect against heart disease.  By comparison, of those patients who could benefit from these drugs, only 36 percent of the Dutch, 29 percent of the Swiss, 26 percent of Germans, 23 percent of Britons and 17 percent of Italians receive them.

Fact No. 4:  Americans have better access to preventive cancer screening than Canadians.[4] Take the proportion of the appropriate-age population groups who have received recommended tests for breast, cervical, prostate and colon cancer:

  • Nine of 10 middle-aged American women (89 percent) have had a mammogram, compared to less than three-fourths of Canadians (72 percent).
  • Nearly all American women (96 percent) have had a pap smear, compared to less than 90 percent of Canadians.
  • More than half of American men (54 percent) have had a PSA test, compared to less than 1 in 6 Canadians (16 percent).
  • Nearly one-third of Americans (30 percent) have had a colonoscopy, compared with less than 1 in 20 Canadians (5 percent).

Fact No. 5:  Lower income Americans are in better health than comparable Canadians.  Twice as many American seniors with below-median incomes self-report “excellent” health compared to Canadian seniors (11.7 percent versus 5.8 percent). Conversely, white Canadian young adults with below-median incomes are 20 percent more likely than lower income Americans to describe their health as “fair or poor.”[5]

Fact No. 6:  Americans spend less time waiting for care than patients in Canada and the U.K. Canadian and British patients wait about twice as long – sometimes more than a year – to see a specialist, to have elective surgery like hip replacements or to get radiation treatment for cancer.[6]  All told, 827,429 people are waiting for some type of procedure in Canada.[7]  In England, nearly 1.8 million people are waiting for a hospital admission or outpatient treatment.[8]

Fact No. 7:  People in countries with more government control of health care are highly dissatisfied and believe reform is needed.  More than 70 percent of German, Canadian, Australian, New Zealand and British adults say their health system needs either “fundamental change” or “complete rebuilding.”[9]

Fact No. 8:  Americans are more satisfied with the care they receive than Canadians.  When asked about their own health care instead of the “health care system,” more than half of Americans (51.3 percent) are very satisfied with their health care services, compared to only 41.5 percent of Canadians; a lower proportion of Americans are dissatisfied (6.8 percent) than Canadians (8.5 percent).[10]

Fact No. 9:  Americans have much better access to important new technologies like medical imaging than patients in Canada or the U.K.  Maligned as a waste by economists and policymakers naïve to actual medical practice, an overwhelming majority of leading American physicians identified computerized tomography (CT) and magnetic resonance imaging (MRI) as the most important medical innovations for improving patient care during the previous decade.[11]   [See the table.]  The United States has 34 CT scanners per million Americans, compared to 12 in Canada and eight in Britain.  The United States has nearly 27 MRI machines per million compared to about 6 per million in Canada and Britain.[12]

Fact No. 10:  Americans are responsible for the vast majority of all health care innovations.[13]   The top five U.S. hospitals conduct more clinical trials than all the hospitals in any other single developed country.[14]   Since the mid-1970s, the Nobel Prize in medicine or physiology has gone to American residents more often than recipients from all other countries combined.[15]   In only five of the past 34 years did a scientist living in America not win or share in the prize.   Most important recent medical innovations were developed in the United States.[16]   [See the table.]

Conclusion.  Despite serious challenges, such as escalating costs and the uninsured, the U.S. health care system compares favorably to those in other developed countries.

Scott W. Atlas, M.D., is a senior fellow at the Hoover Institution and a professor at the Stanford University Medical Center.  A version of this article appeared previously in the February 18, 2009, Washington Times.

See more at: http://www.ncpa.org/pub/BA649#_edn5

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