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Chief of Staff Dorn VA Medical Center Jan 2012 – Do Not “…send out anymore non-VA care GI requests for endoscopy until further notice.”

According to VA IG Report No. 12-04631-313 “Healthcare Inspection: Gastroenterology Consult Delays William Jennings Bryan Dorn VA Medical Center Columbia, South Carolina”, Former Chief of Staff Barbara Temeck, M.D, sent an email to the Business Office “not to “…send out anymore non-VA care GI requests for endoscopy until further notice.”” According to the IG Report the email stated ““…attempting to internalize as many of these 700 cases as possible.”. During January 1–March 29, 2012 only 100 Veterans were seen outside the VA for Colonoscopies while the In-house Colonoscopies declined during the same time period.

VA DORN No Fee BAsed care

Why the Chief of Staff made this decision is unclear.  The IG Report report substantiated claims of a lack of priority by HR and Nursing Admin to staff open positions in the GI Clinic.

We substantiated that GI staffing was not optimal and that critical nursing positions went unfilled for months. It was difficult to determine specifically when some critical positions were vacant, primarily because interviewees recalled dates and events differently or documentation was sparse. However, most GI managers and clinicians we interviewed relayed similar accounts of staffing deficiencies, positions not being backfilled, and difficulty getting approval for new hires. During the AIB, the former CoS testified that the GI Service lacked nurses and clerks, and that the problem was “fairly long standing.”

The Chief of Medicine requested funds in 2011 from VISN 7 to address the growing backlog in the GI CLinic. The Request was approved and the facility received $1.02M but only appropriated  $275,000 for Non-VA Care Colonoscopies.

We substantiated that VISN 7 gave the facility $1.02M in early September 2011 to use to address the GI backlog but that only approximately $275,000 was actually used for this purpose through August 2012. The Business Office was not aware that the additional monies were “earmarked” to address the GI backlog and obligated the funds as usual. The VISN 7 CFO told us that although the facility was given $1.02M expressly to address the GI backlog, they did not have to report back to the VISN on how the funds were used. The CFO reported that facilities may use their discretion to determine how to best meet the needs of their patients; however, fee care was specifically identified as a mechanism to reduce the backlog.

Clearly the funds were available to refer Veterans to Non-VA Facilities but the CoS chose not to. Why would the CoS make this decision when clearly the Facility did not have the capacity due to staffing issues. Veterans DIED. People need to be held accountable.

Ezekiel “Dr. Mengele” Emanuel, Chief Architect of ObamaCare, and his “Complete Lives System”

Emanuel Kelly File
The Chief Architect of Obamacare is Dr. Ezekiel Emanuel. Recently, Megyn Kelly has had him on her show, “The Kelly File”. Anyone who saw Dr. Emanuel on “Kelly File” knows he is an abrasive, arrogant, and downright nasty individual.

Ezekiel “Dr. Mengle” Emanuel’s views on Health Care is known as “The Complete Lives System”. Below is an excerpt from “Principles for Allocation of Scarce Medical Interventions” written by Govind Persad, Alan Wertheimer, Ezekiel J Emanuel which appear in “The Lancet” Vol 373 January 31, 2009 pages 423–31.

Do not be fooled by the rhetoric of the Marxists. As you read this excerpt from the article, you will immediately notice the Marxist “buzz words” of “social justice”,”fair”, “just”,

At its core, ” the complete lives system combines four morally relevant principles: youngest-first, prognosis, lottery, and saving the most lives.”

(Formatting did not transfer over. I did my best to edit)

“The complete lives system”

Because none of the currently used systems satisfy all ethical requirements for just allocation, we propose an alternative: the complete lives system. This system incorporates five principles (table 2): youngest-first,prognosis, save the most lives, lottery, and instrumental value. 5 As such, it prioritizes younger people who have not yet lived a complete life and will be unlikely to do so without aid. Many thinkers have accepted complete lives as the appropriate focus of distributive justice: “individual human lives, rather than individual experiences, [are] the units over which any distributive principle should operate.” 1,75,76 Although there are important differences between these thinkers, they share a core commitment to consider entire lives rather than events or episodes, which is also the defining feature of the complete lives system.

Consideration of the importance of complete lives alsosupports modifying the youngest-first principle byprioritising adolescents and young adults over infants(figure). Adolescents have received substantial educationand parental care, investments that will be wasted withouta complete life. Infants, by contrast, have not yet receivedthese investments. Similarly, adolescence brings with it a developed personality capable of forming and valuing long-term plans whose fulfillment requires a complete life.77

As the legal philosopher Ronald Dworkin argues, “It is terrible when an infant dies, but worse, most people think, when a three-year-old child dies and worse still when an adolescent does”; 78 this argument is supported by empirical surveys. 41,79 Importantly, the prioritization of adolescents and young adults considers the social and personal investment that people are morally entitled to have received at a particular age, rather than accepting the results of an unjust status quo. Consequently, poor adolescents should be treated the same as wealthy ones,even though they may have received less investment owing to social injustice.

The complete lives system also considers prognosis,since its aim is to achieve complete lives. A young person with a poor prognosis has had few life-years but lacks the potential to live a complete life. Considering prognosis forestalls the concern that disproportionately large amounts of resources will be directed to young people with poor prognoses. 42 When the worst-off can benefit only slightly while better-off people could benefit greatly,allocating to the better-off is often justifiable. 1,30  Some small benefits, such as a few weeks of life, might also be intrinsically insignificant when compared with large benefits. 8

Saving the most lives is also included in this system because enabling more people to live complete lives is better than enabling fewer. 8,44 In a public health emergency,instrumental value could also be included to enable more people to live complete lives. Lotteries could be used when making choices between roughly equal recipients, and also potentially to ensure that no individual—irrespective of age or prognosis—is seen as beyond saving.
34,80 Thus, the complete lives system is complete in another way: it incorporates each morally relevant simple principle.

When implemented, the complete lives system produces a priority curve on which individuals aged between roughly 15 and 40 years get the most substantial chance,whereas the youngest and oldest people get chances that are attenuated (figure). 78 It therefore superficially resembles the proposal made by DALY advocates; however, the complete lives system justifies preference to younger people because of priority to the worst-off rather than instrumental value. Additionally, the complete lives system assumes that, although life-years are equally valuable to all, justice requires the fair distribution of them. Conversely, ALY allocation treats life-years given to elderly or disabled people as objectively less valuable.

Finally, the complete lives system is least vulnerable to corruption. Age can be established quickly and accuratelyfrom identity documents. Prognosis allocation encourages physicians to improve patients’ health, unlike the perverse incentives to sicken patients or misrepresent health thatthe sickest-first allocation creates. 58,59


We consider several important objections to the complete lives system.

The complete lives system discriminates against older people. 81,82 Age-based allocation is ageism. 82 Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different life stages rather than being a single age. 8,39 Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years. 16 Treating 65-year-olds differently because of stereotypes or falsehoods would be ageist; treating them differently because they have already had more life-years is not.

Age, like income, is a “non-medical criterion” inappropriate for allocation of medical resources. 14,83  In contrast to income, a complete life is a health outcome. Long-term survival and life expectancy at birth are key health-care outcome variables. 84 Delaying the age at onset of a disease is desirable. 85,86

The complete lives system is insensitive to international differences in typical lifespan. Although broad consensus favours adolescents over very young infants, and young adults over the very elderly people, implementation can reasonably differ between, even within, nation-states. 87,88 Some people believe that a complete life is a universal limit founded in natural human capacities, which everyone should accept even without scarcity. 37 By contrast, the complete lives system requires only that citizens see a complete life, however defined, as an important good, an daccept that fairness gives those short of a complete life stronger claims to scarce life-saving resources.

Principles must be ordered lexically: less important principles should come into play only when more important ones are fulfilled. 10 Rawls himself agreed that lexical priority was inappropriate when distributing specific resources in society, though appropriate for ordering the principles of basic social justice that shape the distribution of basic rights, opportunities, and income. 1  As an alternative, balancing priority to the worst-off against maximising benefits has won wide support in discussions of allocative local justice. 1,8,30 As Amartya Sen argues, justice“does not specify how much more is to be given to the deprived person, but merely that he should receive more”. 89

Accepting the complete lives system for health care as a whole would be premature. We must first reduce waste and increase spending. 81,90 The complete lives system explicitly rejects waste and corruption, such as multiple listing for transplantation. Although it may be applicable more generally, the complete lives system has been developed to justly allocate persistently scarce life-saving interventions. 39,80 Hearts for transplant and influenza vaccines, unlike money, cannot be replaced or diverted to non-health goals; denying a heart to one person makes it available to another. Ultimately, the complete lives system does not create “classes of  Untermenschen whose lives and well being are deemed not worth spending money on”, 91 but rather empowers us to decide fairly whom to save when genuine scarcity makes saving everyone impossible.


As well as recognising morally relevant values, an allocation system must be legitimate. Legitimacy requires that people see the allocation system as just and accept actua lallocations as fair. Consequently, allocation systems must be publicly understandable, accessible, and subject topublic discussion and revision. 92 They must also resist corruption, since easy corruptibility undermines the public trust on which legitimacy depends. Some systems, like theUNOS points systems or QALY systems, may fail this test, because they are diffi cult to understand, easily corrupted,or closed to public revision. Systems that intentionally conceal their allocative principles to avoid public complaints might also fail the test. 93

Although procedural fairness is necessary for legitimacy, it is unable to ensure the justice of allocation decisions o nits own. 94,95 Although fair procedures are important,substantive, morally relevant values and principles are indispensable for just allocation. 96,97


Ultimately, none of the eight simple principles recognise all morally relevant values, and some recognise irrelevant values. QALY and DALY multiprinciple systems neglect the importance of fair distribution. UNOS points systems attempt to address distributive justice, but recognise morally irrelevant values and are vulnerable to corruption. By contrast, the complete lives system combines four morally relevant principles: youngest-first, prognosis,lottery, and saving the most lives. In pandemic situations,it also allocates scarce interventions to people instrumental in realising these four principles. Importantly, it is not an algorithm, but a framework that expresses widely affirmed values: priority to the worst-off, maximising benefits, and treating people equally. To achieve a just allocation of scarce medical interventions, society must embrace the challenge of implementing a coherent multiprinciple framework rather than relying on simple principles or retreating to the status quo.

“Dr. Mengele” Emanuel is the Primary Author and Point of Contact for the Article.

Department of Bioethics,The Clinical Center, National Institutes of Health, Bethesda,Maryland, USA
(G Persad BS,A Wertheimer PhD,E J Emanuel MD)
Correspondence to: Ezekiel J Emanuel,Department of Bioethics,The Clinical Center, National Institutes of Health, Bethesda,MD 20892-1156, USA

CGI: Not Their First Government Contract

I saw a post yesterday about Valerie Jarrett’s daughter Laura and her husband, Tony Balkissoon, working for CGI.  Neither works for CGI (Laura Jarrett works for Mayer Brown Law Firm and Tony Balkissoon works for Sidley Austin LLP Law Firm in Chicago). But in looking into it, I found some very interesting information about CGI.

The website and the Exchanges are not CGI’s first contracts with the US Government.  They have been involved with HUD since 1999.  CGI holds many contracts with HUD.   Check out this article By Lydia DePillis of the Washington Post.

“CGI Federal landed the contract. Here’s how it fights for the ones it loses.”

CGI Federal, arguably the key contractor behind the construction of HealthCare.Gov, has come under a fair amount of scrutiny over the past few weeks for its federal health-care practice. But that’s far from its only contract.

HUD: Just another source of CGI's contracts. (Lydia DePillis)

HUD: Just another source of CGI’s contracts. (Lydia DePillis)

Consider Section 8 rental subsidies. For CGI, the business of handling the low-income housing program started back in 1999, when the Department of Housing and Urban Development — under pressure to downsize its in-house operations — started outsourcing the job to public housing authorities around the country. The housing authorities would subcontract with IT providers like CGI Federal, which mopped upmore than 25 percent of the $200-300 million or so in fees that came from HUD every year. CGI, the biggest of all the subcontractors, provides the infrastructure and support to route housing subsidies to landlords and monitor for compliance with HUD rules.

The relationship between contractor and subcontractor is very close. At the Assisted Housing Services Corporation of Ohio, California Affordable Housing Initiatives, andNorth Tampa Housing Development Corporation, many staff actually list themselves on LinkedIn as CGI employees. The Ohio group’s state director, for example, identifies himself as a “Manager of Consulting Services in CGI Federal’s Healthcare Compliance Group, focused on business process outsourcing for the Department of Housing and Urban Development.” The California group‘s state director calls himself the same thing, adding that he has “quickly adapted staffing strategies to changing industry conditions in order to maintain and improve competitive position,” and has experience “analyzing and interpreting Federal policy and managing the impacts on operations.” The Columbus Metropolitan Housing Authority executive named as the Ohio group’s contract administrator was a CGI director of consulting services until 2011.

So while the “instrumentality” set up by the housing authority is a separate legal actor, it effectively functions as a joint venture with CGI.

“What CGI and a number of other firms have done is they’ve gone in to work with these local housing authorities and said, ‘you’re eligible for this contract, we can provide you with a lot of help in administering these contracts, and share the fees with you,'” says Garth Rieman, director of advocacy at the National Council of State Housing Agencies, which is now competing with the local housing authorities for the Section 8 contracts. “So it’s a moneymaking venture for the local housing authority, to partner with these entities to win the contracts.”

In 2007 and 2009, however, HUD’s inspector general found that contract administrators had been allowed to overbill the program by tens of millions of dollars. In 2011, HUD decided to rebid the contracts, setting a lower standard for the profit margin that recipients would be allowed to take and a cap on the number of units any one contractor could administer. When the new contracts were awarded — with a savings of about  $100 million, or one third. over the previous set, — many of CGI’s partners lost out.

Instead of letting the awards stand, the losers complained en masse to the Government Accountability Office, prompting HUD to back off those awards and offer another solicitation. This time around, HUD got rid of the cap on the number of units a subcontractor could administer, but precluded out-of-state entities from landing a Section 8 contracts if there was a qualified local bidder, which cut into CGI’s business model — some of the entities they worked with offered services to housing authorities all around the region, and wanted to compete for contracts even further afield. The GAOruled that the new process was a no-no.

HUD decided to ignore the GAO. So the housing authority-affiliated entities appealed again, this time to the Federal Court of Claims — the three that contract with CGI filed a joint complaint, saying HUD’s award process was anticompetitive. In April, HUD won. But the companies kicked it up yet another notch, to the Federal Court of Appeals, where arguments were held last week. Until the litigation is resolved, HUD can’t execute any of the new awards.

Meanwhile, the Ohio entity asked its state’s Congressional delegation — where CGI does lots of business — to include an amendment in this year’s ill-fated Transportation, Housing, and Urban Development appropriations bill that would have forced HUD to keep the contracts available to out-of-state entities, which CGI wanted. (The legislators asked HUD nicely to do so earlier in 2012, to no avail).

Public records indicate that during this time, every quarter from 2010 through 2012, CGI Group itself was lobbying on “HUD housing management contracts.”

Finally, there’s also a whistleblower lawsuit from a former CGI employee — who’d been recruited from HUD after overseeing the very Section 8 contracts CGI won — alleging that he was fired after refusing to go along with fraudulent plans to work around the bidding process. CGI denies the accusations, but has so far failed to get the case thrown out.

Those are the lengths to which a company — in this case, partnering with a local non-profit entity that it needs to land the contract — will go to preserve government work. In private enterprise, of course, a losing bidder usually just figures they’ve lost, and moves on. In federal contracting, with enough lawyers, it’s possible to improve your chances of getting that business back.

“It is not unusual for a contractor to protest and to pursue all avenues, including the courts, to seek remedy when they feel like the government hasn’t followed its own rules,” says Neil Couture, director of Government Procurement Law and Business Programs at George Washington School of Business. “Especially in a strategically important area, with large dollars, or new technology.”

In response to questions about the current status of CGI’s partnerships with housing authorities, CGI spokeswoman Linda Odorisio said: “CGI’s systems and consulting services have been recognized by federal, state and local agencies as a key tool in helping public housing agencies operate more efficiently and effectively.”

Technically, it’s possible for CGI to also work with the statewide housing agencies that would be advantaged if HUD wins at the Court of Appeals, and hang on to the business it’s so carefully developed. But according to Rieman, whose organization represents those agencies, CGI has preferred to work with local entities — who may see the contract more as a business proposition than a way to serve residents.

“Does the system make sure that the entity administering the program has a full enough public purpose and affordable housing mission to ensure that the services are being done with that intent, and not just a narrower profit making enterprise with a private sector firm?” Rieman asks. “Our view is they are taking all steps necessary to preserve their opportunity to participate in this program in the way that they want to.”

Which doesn’t mean CGI is doing anything illegal. It’s just the cost of getting — and keeping — business.

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