This story is about a hospital system that decided to make an investment to save costs and improve lives of those who uses their facilities the most; termed “superusers” in this piece. When I first read the story, a thought came to mind that since there is not Universal Healthcare, ACA notwithstanding; uniquely American phenomena would exist because people will get healthcare by most means necessary. That involves the level of care that is mandated by law at Emergency Rooms. Our neighbors to the North, Canada, have some of the same issues, and most everyone is covered by birthright. In both cases, a holistic multidisciplinary approach is taken to address the root causes while finding solutions that are humane and cost effective.
Any part of the universal basic income movement must include proactive and preventive healthcare in order to let Emergency Rooms be for emergencies, not primary care. With Nurse Practitioners and Physician Assistants who can be placed in these societies or accessible in telehealth, the costs of addressing a problem before it comes serious enough for acute care are worth the investment. Politically, however, any vote to spend money at a Governmental level is a non-starter for enough of the population to ensure DOA legislation and initiatives. Housing, income, nutrition, and education addressed together to have a greater chance of success and can no longer be looked at in a vacuum,
Everyone deserves an opportunity to be productive and geeky at the same time, if they so choose. Must not let a thing called Disability ruin the experience. Here is someone that is trying to change this in the free and open-source community. While not an official a11y supporter or developer, I am an advocate. Leaving people behind is not cool!
The LibreOffice community tries to make the software as accessible as possible — in other words, usable for people with special needs or requirements. Alex Arnaud is working to make the suite more accessible for users with visual impairments, and discusses his experiences and the challenges ahead in our latest interview…
Where are you from, and if you’re active on IRC, what’s your nickname?
I am French, and my IRC nickname is “alexarnaud”.
Do you work for a LibreOffice-related company or just work on it in your spare time?
Alongside the Hypra team, I am based in Paris. I am visually impaired and I use my computer with a screen magnifier and a screen reader. I use, on a daily-basis, the Universal Accessible OS (UAS) based on Debian GNU/Linux both for my professional and personal needs. I used GNOME before (and its magnifier), but given the important efforts that Hypra has poured into this project and the constant improvement of the, I have decided to switch about a year ago.
I’ve been working at Hypra since September 2015 as a project manager, leading the development of the visual-assistance stack (Compiz). I soon intend to join the company as a shareholder as I feel now totally involved in the startup’s ambition: making accessibility a key competitive advantage for Linux, and ultimately expanding the benefits of free software to the general public, beginning with visually impaired people. LibreOffice being one of the cornerstones of free software, I am contributing to the LibreOffice community inside the quality assurance (QA) team, mostly on my working time.
How did you get involved with LibreOffice?
When joining Hypra, my blind friends and colleagues Jean-Philippe and Raphael kept telling me: “Since version 4.3, LibreOffice is regressing on accessibility for blind people”. So far so good — we provide version 4.2 for our customers because it is actually the latest version usable for blind and visually impaired people. But we deem such an evolution is not sustainable on the long-run.
That is why we have decided to get involved, beginning with an accessibility audit on the user side. I’ve looked into all the LibreOffice bugs related to GNU/Linux and accessibility, and checked their validity and updated them as a consequence.
After that I started to become an accessibility bug hunter for the LibreOffice QA team and I have reported lots of bugs related to Writer, Calc and Impress. I see myself as a kind of “whistle-blower” about accessibility inside the community. Most of the sighted-users do not know that software has to be accessible for all people, so my job is raising awareness and hence trying to be a driver of change.
What was your initial experience of contributing to LibreOffice like?
My initial experience with LibreOffice was in 2011. I reported bugs about the accessibility of LibreOffice for Windows — I sent them directly in a mailing list. In 2011, on Windows, it was completely impossible to use LibreOffice with a screen magnifier so I chose to use IBM Lotus Symphony, which was usable for a low-vision person.
What areas of the code do you normally work on? Anything else you want to tackle?
I am a user of the Orca screen reader (the screen reader being also useful for large array of people from the elderly to the visually impaired), so I can easily check if something is accessible for everyone. I focus on the user interface and the communication of LibreOffice with assistive technologies through the AT-SPI2 protocol.
I’m only working on the user side because I don’t know how to compile and how to debug LibreOffice — I just know QA-related things like how to check which version introduces a regression, for example. Testing and reporting bugs is huge work that requires attention and patience. I spent most part of my time tracking features and verifying whether they are usable for disabled people.
What is your vision for the future, or what would you most like to see improved in LibreOffice?
Free software entails a huge ethical and philosophical promise. It drives many expectations and hopes for average users in terms of social inclusion and privacy. It also provides enormous opportunities to reshape the relationships people have with technologies, focusing more on training and support, rather than on the cost of technologies themselves. This is a driver for social change. But to cope with these expectations, I believe we have to make sure that LibreOffice, being one of the cornerstones of free software, enables social inclusion.
Why should we keep adding features if we haven’t them usable for all? Can we accept it if a mainstream project such as LibreOffice keeps excluding people? As a matter of fact, I’ve noticed that there are accessibility bugs, originally coming from the OpenOffice.org code, that were reported more than 5 fives years ago… We can’t let the status quo prevail!
What do you do when you’re not working on LibreOffice?
I spend most of my spare time reading books and listening to radio podcasts to discover more in depth about how the world works. I’m fascinated by Noam Chomsky’s point of view about democracy and information. I find his famous book “Manufacturing Consent — The Political Economy of the Mass Media” extremely clarifying about the role of the media industry in a democratic country.
I also appreciate spending time with other people, with my family and with my friends.
What was the very first program you wrote?
If my memory serves me well, it was a very little social network.
Which is your preferred text editor? And why?
I’ve been using Emacs as my primary text editor since the day I discovered it. It’s really a pleasure for me to work with it because it help me to overcome my vision troubles.
In fact, I use a screen magnifier program that follows the cursor position. In some programs like “man”, “less” and “more” I can’t move the cursor inside the text — and that forces me to use the mouse, which makes my work more difficult.
With Emacs I can read manual pages inside a buffer, and I can use a command-line and move inside it — it is so convenient for me!
Why would you say there are few bug reports related to accessibility on GNU/Linux?
I would forward you to an interesting message posted years ago by Samuel Thibault (main contributor of the Debian accessibility team). For a blind person, if an application is not accessible enough it is completely impossible to report a bug.
Regular users that have disabilities spend more time than people without them, just to do things in their life. Information technology is a bridge between inaccessible hard things (newspaper, administrative things, TV programs, etc) and the accessible digital world.
It is really indispensable for blind people — for example — to be efficient in their lives when finding information related to their city, communicating with people by e-mail (letters are inaccessible), finding their path with GPS, producing and reading documents, finding a job of course — and so much more!
I have a dream: we work on free software, especially in this case LibreOffice, and everyone can work on the accessibility side and improve the life of everyone else. We need more manpower! Here’s a link to the meta-bug related to accessibility stuff on GNU/Linux.
I’m often available on IRC (Freenode network) on the channel of the libreoffice-design team (#libreoffice-design). Please ping me if you have questions relating to accessibility.
Thanks to Arnaud for his time and in-depth answers. For those reading this who want to get involved and help to make LibreOffice more accessible, join us today!
This is not just for rural patients either. I have a disability and live in a major Southern City with a reasonably extensive bus system. However, the Special Transportation Service is wheelchair bound exclusively and Medicaid was not expanded in this state (the current Governor is trying to change this) therefore no paid transportation. Forget Uber, Lyft, or a city regulated cab service at $2.50/mile, your options privately are based on the generosity of volunteers, and there are many more needs than providers. Then again, cost savings are not in the industry’s best efforts, so they do not get done.
In 2014, Leo Haralson’s big toe turned black, a casualty of his battle with diabetes. A veteran and a former software developer for the U.S. Navy, he had insurance through both Medicare and the Veterans Affairs Department, so getting good health care shouldn’t have been a problem. But after the toe was amputated, he developed an infection that spread to his bones. Haralson needed daily oxygen treatments at a hospital to halt the infection.
Haralson and his wife, 65, motorcycle enthusiasts originally from Wisconsin, had retired to southern Missouri, seeking a warmer climate and a home in the middle of the country so they could drive off in any direction. They built their dream home on the outskirts of the town of Mountain View, named for its commanding view of the Ozarks. But his wife could no longer drive, and with his foot in bandages, Leo couldn’t either. The hospital was 30 miles down Highway 60 from his home, and the local transit provider has bus service only on Wednesdays. Without a way to get to the hospital every day for a month, Haralson faced losing his leg — and his ability to live independently.
Transportation comes up in virtually every conversation about rural health care, particularly in the past few years as hospital closures have increased the distances many patients need to travel. Missouri has closed three hospitals since 2010, victims of cutbacks in reimbursement from insurers and the government. Distances patients must travel are increasing.
As policymakers look at ways to improve the health of rural Americans, it’s becoming increasingly clear that transportation is a critical missing link between patients and providers.
The problem isn’t necessarily a lack of rides; many places, like Missouri, have a variety of transportation options for people who can’t drive. Medicaid provides some non-emergency transportation for eligible patients. Some local communities run van services, particularly for seniors. The Southern Missouri Transportation System and OATS, a nonprofit transit company, provide van services, as well. And there are medical transportation services including emergency ambulances.
But all of those systems have problems and gaps. For Medicaid, rides must be ordered five days in advance, and cannot include secondary stops, even just to visit a pharmacy to fill a prescription after the doctor visit, without prior approval. Van and bus services run once or twice a week on fixed schedules and routes that may not match a patient’s appointment times. And ambulances are expensive.
There’s a bigger problem, too: The current system puts the burden of navigating those options and schedules on patients, even as they are struggling with illness and symptoms like pain, confusion and fatigue. In Missouri, we have found that when getting a ride isn’t simple and affordable, patients will forgo care. And that means that their conditions can worsen until they become acute and result in an ambulance ride to the ER instead — the most expensive option of all.
Clearly, the existing system doesn’t work well for anybody. Patients are overwhelmed and often give up. Doctors and hospitals lose time and revenues because of “no-shows.” And ambulance companies are transporting patients who didn’t know whom else to call — and then don’t get paid if an insurance company or Medicaid decides it wasn’t an actual emergency.
As a health care consultant and the executive director of the Missouri Rural Health Association, I helped develop a program to test whether there was a better way. We got seed money to hire a “mobility coordinator” who could arrange rides for patients who needed them. Our program, called HealthTran, trained clinic and hospital staff to ask patients at the time they made appointments whether they needed a ride. And if they did, they alerted the HealthTran coordinator who would contact them, assess their transportation needs and figure out a cost-effective solution.
Leo Haralson was one of HealthTran’s first patients. In his case, the coordinator determined that because of his infection, he needed private rides from his home in Mountain View to Ozarks Medical Center in West Plains, 30 miles away. She arranged 70 rides for him at a cost of $6,000. That wasn’t cheap, but it paid off. The hospital benefited by being able to bill Medicare $13,000 for the oxygen treatments and avoiding penalties for a hospital readmission. Medicare saved the cost of a leg amputation and possible transfer to a nursing home.
As always in health care, a key questions is, “Who pays”? What HealthTran learned is that it’s actually cost-effective for clinics and hospitals to provide the service at no cost to the patients because providing rides reduced the number of no-shows.
Here was how it played out at one hospital system: In just 17 months, HealthTran provided 2,470 rides for patients receiving services, at a cost of just over $66,000. Including staffing, the total cost of coordinating and paying for transportation was approximately $95,000, an average of $33 per ride. These patients resulted in over $730,000 in payments to the hospital and its clinics. In short, for every $1 invested in transportation, the hospital earned $7.68 in reimbursement.
The return on investment in transportation is so strong that it can pay off even for individual doctors. A missed appointment means missed revenue, loss of provider productivity, patient rescheduling and most likely a sicker patient. If 20 percent of scheduled appointments are missed on a weekly basis, and the average charge for that primary care visit is $150, a provider who typically sees 20 patients per day will miss out on $3,000 each week (or 1 entire day’s worth of revenue), while staffing costs remain constant. At $225 per visit for specialty care, the provider misses out on $4,500. Over the course of a year, the health care provider is missing out on $156,000 to $234,000. Considering the average cost of a ride for these patients at $33, the annual cost of paying for transportation and mobility coordination would be about $45,000. This is a $3.46 to $5.20 return for every $1 invested in transportation.
And that doesn’t even consider the improved patient outcomes and those long-term savings to the health care system.
Perhaps the biggest payoff is that it helps senior citizens like Haralson and people with disabilities to live successfully in homes of their own rather than move to nursing homes or assisted-living facilities, placements that can erode their health and cost the government and other insurers much more money in the long run. If Haralson had required a leg amputation, that would not only have cost Medicare and Medicaid upward of $1 million, but left him disabled and likely forced to move to a nursing home. Instead, Haralson was able to continue to live at home and fend for himself. These days, he’s spending his retirement helping deliver meals to homebound seniors in his community.
So, why aren’t more hospitals offering no-cost transportation to their patients? One reason is that well-intentioned federal regulations have created unnecessary hurdles. In an effort to avoid a practice known as “self-dealing,” hospitals are not allowed to directly provide transportation to patients. While there were a few instances in the past of hospitals unfairly profiting by providing transportation between nursing homes and hospitals, the practice was not widespread. Still, the rules designed to eliminate that practice now make it difficult for providers to take on the transportation problem directly. That’s why the HeathTran model offers a solution: By using an outside coordinator to make the arrangements, HealthTran helps hospitals maintain an arms-length relationship from transportation services.
In theory, driverless cars could someday address some of the need for medical transportation. But I’m skeptical that will solve the problem for most patients because a key factor in health care is human interaction. Many patients who need transportation are seniors, or have a disability that can make it hard to get to and from their front door and the vehicle without assistance. At least in Missouri, and I would venture to say in many other areas of rural America, people need a human connection — a person in the community, familiar with the community — to connect the health, transportation and payer systems in a way that makes good, common sense. And besides, we can’t wait for a driverless future. Patients in rural America need a solution now.
Missouri’s HealthTran was designed to bridge the transportation gap between patients and providers in a way that works for all sides. Rural America needs more of these solutions. If we can’t make it easier for rural patients to get to and from their homes and their doctors, the whole country will pay for it down the road in greater medical costs and poorer health outcomes.
Suzanne Alewine is a health care consultant and executive director of the Missouri Rural Health Association.
The author, who I make a point to read whenever he writes, is pointing fingers at Google for privacy issues (where have we heard this before?) in the education market, which they have Windows PC-like control of. Google’s business model and privacy needs can co-exist if done properly. Unlike Apple or Microsoft, Google’s approach is essentially
here is the hardware and software in our cloud, now go run with it.
There is nothing inherently wrong with that approach and could be tied to cost savings compared to traditional school vendors. Handholding and administration outside of internal staff must be made available, and Google does not have a history of having an inside sales support force or some of the assets in place, thus the rub.
Microsoft is rumored to have a direct answer to this market by introducing a version of Windows 10 that is locked down, modern RT if you will. This time it is for Universal Windows Programs only. The selling point is that you can get a locked down device, but should the end user or administrator desire and pay a fee, it can be upgraded to full Windows 10 Home or Pro edition. This way you can have the best of both productivity worlds and can be executed today, unlike other devices announced. This will put a dent into Google’s dominance of the 3-12 education market, and make inroads in undergraduate studies with the upgrade options. The upgrade fee for educational buyers needs to include Office 365, OneDrive, and Skype automatically for up to 4 years. Pricing somewhere along the lines of $100 home and $150 pro. Currently $120 for home, $200 for pro, and $80 for Office University. Should Microsoft hit a home run with this in 2017, you better believe that the Electronic Freedom Foundation will have them in the crosshairs.
When one of the handles I follow on Twitter retweeted this link, a compelling reason to explore it further is due to having a keen interest in the subject, having written about it previously. Since the politician profiled is not part of either dominant political party, his chances of being co-opted immediately are slim and none. However, part of his argument on selling some public lands does make sense and could fly in a limited way. The plan he proposes for the funds raised would only work in a limited number of states which does not include the Carolinas.