Try incompetence, self-serving interests and corruption on the government side, helped in part by big money from the insurance companies. When they entered graduate school, most physicians had no idea the amount of bureaucracy that was going to be put in the way of their helping patients.
This Dr is talking about patient who use an ER as the primary care provider and who move from one hospital to another over time. The average person who take care of themselves do not have this issue since they go to the same Dr all the time and usually do not end up in an ER or a place which does not have their history. I find it interesting that Dr said he has to spend time convincing people why it is important to gain access to their prior medical history. What makes them think they would have copy of their electronic medical history on them so apple solution is not got to solve their problem. Plus we all know the same people who probable us an ER as their Dr are not buying iphone they are getting free Android devices.
My family and I see the same Dr for yrs, he has all of our information and history about the my family and extend family as it applies to our situation. We have moved a couple of times and have always requested copies of our files to take to any new Dr. It would be nice if it was all electronic, but paper works well and most Dr rather flip through a paper file then sit in front of computer when they talk to you. It more personal interaction then someone steering at a computer screen. Any time we have to see another Dr such as a specialist our family Dr will reach out to them and shares pertinent information with the specialist and we always ask the specialist to send copies of everything to our primary Dr. Again ist would be nice to have it all electronic and easily transported. However, not interested in insurance companies knowing what was discussed with my Dr or another person knowing about things which are not relative to reason I am seeing them.
This is just another example of people who fail to be responsible for themselves and expect everyone else to bend over backwards when things turn bad for them. This is why the US has huge health care issue since people have no interesting being responsible for themselves, they do not take care of themselves and show up in ERs around the country to get free medical care.
You obviously didn't read the article, in which the ER doc gives an example of someone moving to a different area, and needing to transfer medical info. However, your point about people not taking responsibility for thier health true to an extent, but society pays for thier care regardless, so better to provide tools to make caring for them easier (it's a lot cheaper to effectively manage blood sugar than to amputate digits and limbs due to diabatic neuropathy); not to mention the ethical responsibility to improve people's lives. Also, it's not as if people live in a vacum. I'd say it's a pretty sad comment on our society that someone's life is so messed up, and/or they are so uneducated, that personal health is not a priority. It is a sytemic social problem that is multifactorial: US is the world leader by far in teen pregnancy rates, child abuse, and prison population per capita. Multiple studies have shown that early neglect or abuse results in lasting physiologic changes through adulthood (changes in DNA, epigenetic changes, chronic stress markers) that predispose to physical and mental illness. To me all these issues are connected. I love the US, wouldn't want to live anywhere else, but we have some work to do.
It is all caused by government methods of contracting where profit is a percent of total cost.
The more overhead (clerks and secretaries) the more profit in these government supported organizations.
My insurance pays 99 percent of my medical costs. I get billed directly for the other one percent. Twice th overhead for two billing leads to twice the profit from percent of overhead costs.
I caught the end of an NPR program a few weeks ago about a new project called 'Open Record' or some similar name. There was a pilot project being discussed in very glowing terms by all concerned and even initial skeptics. The premise, from what I could gather, was all medical information was accessible via a web interface by the patient who could even add or question data. They were still talking about systems that would not all be compatible between institutions however, so it seems to me this could be the answer. This has to be the way forward, the current system is ridiculous. One area they mentioned as a possible issue is [S]lazy[/S] busy doctors using 'scribes' to enter patient records and consults etc. and the associated risk of errors.
I know, I'm in love with iBeacons so here we go....
Let's say you have your medical data stored in the secure enclave of your iPhone. You're in an accident and paramedics have your iPhone and want to see if you have any medical information that might help them. How do they get access to it if you're incapacitated?
I say give medical staff an iBeacon that has a serial number attached and a PIN number. When they try to unlock your iPhone it detects that it's near a "medical iBeacon" and prompts for a PIN. If the person enters the correct PIN that matches their iBeacon, then your iPhone agrees to unlock and display only authorized medical information on your iPhone for them to see - things like allergies, conditions or any medications you're on. Your iPhone also logs this event and displays the name and ID number of the person who "unlocked" your iPhone so you have a record of it for later on.
Take this further, how would the police know who to contact if you're in an accident and your iPhone is locked? They could also enter a PIN that would bring up your customized list of contacts or "in case of emergency rules".
I can see a lot of ways where you can allow certain people access to certain information simply based on whether or not they're carrying the proper "key" (iBeacon) to view it. All while still keeping your iPhone locked.
It's in their financial interest to have the detail so they can find those fine points to dispute and not pay your claim, or rule that the expense was 'beyond customary' etc.
It's certainly in their best interest to have all of that detail so they can cherry-pick it to support their rulings, but it is not in their best interest that everyone else have easy access to the same information. Information is power when you have it but nobody else does. The status quo is preferable to them.
Ha, 9to5Mac's wonder kid Mark Gurman actually claimed that Apple redesigned and renamed their Health app because of what he leaked back in March. He even claims to have Apple employees telling him that the previous leak was a superior design than what Apple actually will be shipping with iOS 8. As if Apple would approve of an inferior design just so something they spent maybe 3 minutes max on in the WWDC keynote was a complete surprise.
I am both a Doc and a Patient at a major University hospital which uses Epic. The hardware & software for useful & valuable access to patient data has been around for some time. The main stumbling block is HIPPA Health Info Portability & Protection Act. It has fallen heavily on the Protection side making access or transmittal of data hugely problematic.
Epic has ann App called Haiku (for physicians) from which I can find anybody in a very large system, including myself. It has all my data and can get images. The Patient App, called MyChart, is just about useless as every bit of data has to be "cleared" by the doc before it will show up, and there are large categories of info which are not allowed at all.
This situation is stupid. The hardware & apps are already here, we just need somebody in DC to rein in HIPPA "protection" and boost "portability."
Oh yeah because getting unsolicited sales pitches from pharmaceutical companies based on what Google sold out of my medical records would be way over the line and totally plausible given their track record.
I know, I'm in love with iBeacons so here we go....
Let's say you have your medical data stored in the secure enclave of your iPhone. You're in an accident and paramedics have your iPhone and want to see if you have any medical information that might help them. How do they get access to it if you're incapacitated?
I say give medical staff an iBeacon that has a serial number attached and a PIN number. When they try to unlock your iPhone it detects that it's near a "medical iBeacon" and prompts for a PIN. If the person enters the correct PIN that matches their iBeacon, then your iPhone agrees to unlock and display only authorized medical information on your iPhone for them to see - things like allergies, conditions or any medications you're on. Your iPhone also logs this event and displays the name and ID number of the person who "unlocked" your iPhone so you have a record of it for later on.
Take this further, how would the police know who to contact if you're in an accident and your iPhone is locked? They could also enter a PIN that would bring up your customized list of contacts or "in case of emergency rules".
I can see a lot of ways where you can allow certain people access to certain information simply based on whether or not they're carrying the proper "key" (iBeacon) to view it. All while still keeping your iPhone locked.
Well there's reportedly an ICE system app so perhaps a way in via that? A bit like the TSA "passkey" system for luggage?
ETA: An ICE card within the Health APP...available from the lock screen according to Apple's iOS 8 info pages. In that description it's called "Medical ID".
Insurance companies DO have some of your X-rays and lab records. Yes doctors still use pen and paper to 'push back' against insurers, their comments are your private records. But Diagnoses, tests, images go to insurance oftentimes. At least they used to, which I know from personally disputing a claim. They are in the business of second guessing the doctors.
The billing codes are a common language that cuts across the mess of health records from different doctors and hospitals. Those billing codes are quite specific, they ARE your medical history, minus, of course, your doctor's private notes. In other words, your insurer does have your health history indeed. Like I said, they are like Equifax, they aggregate info from everywhere.
If you apply today for a big life insurance policy you can believe the insurer will check that hospital database, and will see that for example, you omitted the fact that you have stage 3 cancer in your left cheekbone and went for surgery. It used to be the same for healthcare policies.
Insurance is an industry I have a hard time finding a rationale for (outside of fire insurance and basic term life maybe).
Kind of like stock analysts, they don't add anything positive. They *could* be used for good if they hooked their back end database into Apple's kit ( with privacy permission). But then, somebody would have to pay somebody, which is what I find despicable about the whole system.
I forget where I read this, but I remember reading someone's analogy that getting insurance is like gambling. You are betting that something crappy will eventually happen to you. And when something crappy FINALLY does happen, you win! At least that round. In the long run, however, the odds are stacked in the house's favor, and you will most likely end your life with a net loss in the "casino" of insurance.
At least in the US, Apple can walk a fine line on health privacy issues by focusing on sending data TO medical providers. Medical data that is stored on your phone that originates there (either through sensors or manually entered), shouldn't fall under HIPAA rules. HIPAA would apply when the medical provider receives it and stores it.
I'm sure these topics came up when Apple's team went to Washington, to ensure that Apple understands where to draw the line to expand and innovate and still be within compliance. Data aggregation on a personal device is useful in itself. And it keeps them out of medical device regulations (until Apple decides it is ready, via iWatch or iPhone hardware).
I kept trying to play them for a few days but one would load in the browser (awards ceremony). Then I saw that you could download them directly and they work, oh well, not sure what was going on, perhaps my ghostery again.
At least in the US, Apple can walk a fine line on health privacy issues by focusing on sending data TO medical providers. Medical data that is stored on your phone that originates there (either through sensors or manually entered), shouldn't fall under HIPAA rules. HIPAA would apply when the medical provider receives it and stores it.
I doubt that distinction would last very long after the capabilities arrive. Some legislation will get created to regulate that stuff, and Apple is smart that they seem to be preparing for the eventuality now.
on the US government side, there is very little corruption on the HCFA/HHS side of the house. The corruption is in the legislative branch. Compared to the DoD, Medicare (which has driven coding standards for the last 40 years) has performed miracles without payoffs.
pedantry: physicians go to medical school, not graduate school... if they do go to graduate school (and/or residency), they've spent a lot of time on the beaucracy side of helping patients (most spend their 3rd year of medical school just doing charting and dealing with coders calls asking 'what did the doctor do?').
And we don't want doctor's knowing the beauracracy... otherwise you end up with either poor care, or fraud/cost shifting ("you mean if we say we did a 'complete history' we get $130, but only a $75 for a 'visit history'.... well, If I ask, 'have you been sick before?... is that complete enough?').
The biggest issue is the always, 'how much do my options cost?' and MDs don't know that, and Insurance companies don't really know, until the claim is adjudicated. A GREAT Health app would be to have the MD give you the options, and you can push 'Preadjudicate' and your insurance company gives you a +/-25% cost estimate of each option, which you can weigh against the benefits the doctor gives you (surgery or P/T.... Pills vs AngioPlasty), etc etc.
On the HHS side of things, regulators are corrupted by their vested interest in stable employment, generous salary and retirement.
Despite what we might think we want, doctors do need to know bureaucracy, at least to give patients appropriate, quality healthcare, such as knowing coding tricks. Good, conscientious physicians know the costs of assays and treatments and order them rationally, rather than over-ordering due to incompetence or to cover their ass and increasing the cost of healthcare. Coding has changed so much that assistants are hired just to code--forming one of the fastest growing employment opportunities. Physicians hire assistants just to follow them around and do the electronic charting. cha-ching! The business of medicine has gotten so complicated and expensive with bureaucracy and insurance costs that private practices are shuttering left and right and the physicians are joining hospitals. Payment to the doctor or hospital might be denied at any of several steps--and knowing the bureaucracy can help avoid being stiffed. Many elite physicians are switching to concierge medicine, priced well out of reach of the vast majority of the populace.
I forget where I read this, but I remember reading someone's analogy that getting insurance is like gambling. You are betting that something crappy will eventually happen to you. And when something crappy FINALLY does happen, you win! At least that round. In the long run, however, the odds are stacked in the house's favor, and you will most likely end your life with a net loss in the "casino" of insurance.
Especially in the disability insurance business, the insurance companies love it when you cancel!
Maybe the best part of the ACA (affordable care act or "Obamacare") is no more exclusions for pre-existing conditions. So if "something crappy" happens and it doesn't kill you, you can still get health insurance.
BTW: Of course not similar but, Microsoft has also attempted a health recording app in past called "HealthVault" which interestingly is available on iOS:
I forget where I read this, but I remember reading someone's analogy that getting insurance is like gambling. You are betting that something crappy will eventually happen to you. And when something crappy FINALLY does happen, you win! At least that round. In the long run, however, the odds are stacked in the house's favor, and you will most likely end your life with a net loss in the "casino" of insurance.
Otherwise known as Insurance Actuary Tables. The snag for all of us gamblers before the Affordable Care Act was, the insurance company could keep changing the house rules as they applied to a specific person to ensure the house always won.
Comments
edit
Try incompetence, self-serving interests and corruption on the government side, helped in part by big money from the insurance companies. When they entered graduate school, most physicians had no idea the amount of bureaucracy that was going to be put in the way of their helping patients.
amen
This Dr is talking about patient who use an ER as the primary care provider and who move from one hospital to another over time. The average person who take care of themselves do not have this issue since they go to the same Dr all the time and usually do not end up in an ER or a place which does not have their history. I find it interesting that Dr said he has to spend time convincing people why it is important to gain access to their prior medical history. What makes them think they would have copy of their electronic medical history on them so apple solution is not got to solve their problem. Plus we all know the same people who probable us an ER as their Dr are not buying iphone they are getting free Android devices.
My family and I see the same Dr for yrs, he has all of our information and history about the my family and extend family as it applies to our situation. We have moved a couple of times and have always requested copies of our files to take to any new Dr. It would be nice if it was all electronic, but paper works well and most Dr rather flip through a paper file then sit in front of computer when they talk to you. It more personal interaction then someone steering at a computer screen. Any time we have to see another Dr such as a specialist our family Dr will reach out to them and shares pertinent information with the specialist and we always ask the specialist to send copies of everything to our primary Dr. Again ist would be nice to have it all electronic and easily transported. However, not interested in insurance companies knowing what was discussed with my Dr or another person knowing about things which are not relative to reason I am seeing them.
This is just another example of people who fail to be responsible for themselves and expect everyone else to bend over backwards when things turn bad for them. This is why the US has huge health care issue since people have no interesting being responsible for themselves, they do not take care of themselves and show up in ERs around the country to get free medical care.
You obviously didn't read the article, in which the ER doc gives an example of someone moving to a different area, and needing to transfer medical info. However, your point about people not taking responsibility for thier health true to an extent, but society pays for thier care regardless, so better to provide tools to make caring for them easier (it's a lot cheaper to effectively manage blood sugar than to amputate digits and limbs due to diabatic neuropathy); not to mention the ethical responsibility to improve people's lives. Also, it's not as if people live in a vacum. I'd say it's a pretty sad comment on our society that someone's life is so messed up, and/or they are so uneducated, that personal health is not a priority. It is a sytemic social problem that is multifactorial: US is the world leader by far in teen pregnancy rates, child abuse, and prison population per capita. Multiple studies have shown that early neglect or abuse results in lasting physiologic changes through adulthood (changes in DNA, epigenetic changes, chronic stress markers) that predispose to physical and mental illness. To me all these issues are connected. I love the US, wouldn't want to live anywhere else, but we have some work to do.
The more overhead (clerks and secretaries) the more profit in these government supported organizations.
My insurance pays 99 percent of my medical costs. I get billed directly for the other one percent. Twice th overhead for two billing leads to twice the profit from percent of overhead costs.
I know, I'm in love with iBeacons so here we go....
Let's say you have your medical data stored in the secure enclave of your iPhone. You're in an accident and paramedics have your iPhone and want to see if you have any medical information that might help them. How do they get access to it if you're incapacitated?
I say give medical staff an iBeacon that has a serial number attached and a PIN number. When they try to unlock your iPhone it detects that it's near a "medical iBeacon" and prompts for a PIN. If the person enters the correct PIN that matches their iBeacon, then your iPhone agrees to unlock and display only authorized medical information on your iPhone for them to see - things like allergies, conditions or any medications you're on. Your iPhone also logs this event and displays the name and ID number of the person who "unlocked" your iPhone so you have a record of it for later on.
Take this further, how would the police know who to contact if you're in an accident and your iPhone is locked? They could also enter a PIN that would bring up your customized list of contacts or "in case of emergency rules".
I can see a lot of ways where you can allow certain people access to certain information simply based on whether or not they're carrying the proper "key" (iBeacon) to view it. All while still keeping your iPhone locked.
It's in their financial interest to have the detail so they can find those fine points to dispute and not pay your claim, or rule that the expense was 'beyond customary' etc.
It's certainly in their best interest to have all of that detail so they can cherry-pick it to support their rulings, but it is not in their best interest that everyone else have easy access to the same information. Information is power when you have it but nobody else does. The status quo is preferable to them.
Google? The net's busiest busybody? God forbid.
Ha, 9to5Mac's wonder kid Mark Gurman actually claimed that Apple redesigned and renamed their Health app because of what he leaked back in March. He even claims to have Apple employees telling him that the previous leak was a superior design than what Apple actually will be shipping with iOS 8. As if Apple would approve of an inferior design just so something they spent maybe 3 minutes max on in the WWDC keynote was a complete surprise.
http://tinyurl.com/nemu2wn
I love John Gruber's take down:
http://daringfireball.net/linked/2014/06/09/gurman-apple-priorities
I read that, too. If you liked that DF take down, you should check out the episode of Gruber's podcast, the Talk Show, where Gurman was a guest. Ouch!
I am both a Doc and a Patient at a major University hospital which uses Epic. The hardware & software for useful & valuable access to patient data has been around for some time. The main stumbling block is HIPPA Health Info Portability & Protection Act. It has fallen heavily on the Protection side making access or transmittal of data hugely problematic.
Epic has ann App called Haiku (for physicians) from which I can find anybody in a very large system, including myself. It has all my data and can get images. The Patient App, called MyChart, is just about useless as every bit of data has to be "cleared" by the doc before it will show up, and there are large categories of info which are not allowed at all.
This situation is stupid. The hardware & apps are already here, we just need somebody in DC to rein in HIPPA "protection" and boost "portability."
Google? The net's busiest busybody? God forbid.
Oh yeah because getting unsolicited sales pitches from pharmaceutical companies based on what Google sold out of my medical records would be way over the line and totally plausible given their track record.
I know, I'm in love with iBeacons so here we go....
Let's say you have your medical data stored in the secure enclave of your iPhone. You're in an accident and paramedics have your iPhone and want to see if you have any medical information that might help them. How do they get access to it if you're incapacitated?
I say give medical staff an iBeacon that has a serial number attached and a PIN number. When they try to unlock your iPhone it detects that it's near a "medical iBeacon" and prompts for a PIN. If the person enters the correct PIN that matches their iBeacon, then your iPhone agrees to unlock and display only authorized medical information on your iPhone for them to see - things like allergies, conditions or any medications you're on. Your iPhone also logs this event and displays the name and ID number of the person who "unlocked" your iPhone so you have a record of it for later on.
Take this further, how would the police know who to contact if you're in an accident and your iPhone is locked? They could also enter a PIN that would bring up your customized list of contacts or "in case of emergency rules".
I can see a lot of ways where you can allow certain people access to certain information simply based on whether or not they're carrying the proper "key" (iBeacon) to view it. All while still keeping your iPhone locked.
Well there's reportedly an ICE system app so perhaps a way in via that? A bit like the TSA "passkey" system for luggage?
ETA: An ICE card within the Health APP...available from the lock screen according to Apple's iOS 8 info pages. In that description it's called "Medical ID".
Insurance companies DO have some of your X-rays and lab records. Yes doctors still use pen and paper to 'push back' against insurers, their comments are your private records. But Diagnoses, tests, images go to insurance oftentimes. At least they used to, which I know from personally disputing a claim. They are in the business of second guessing the doctors.
The billing codes are a common language that cuts across the mess of health records from different doctors and hospitals. Those billing codes are quite specific, they ARE your medical history, minus, of course, your doctor's private notes. In other words, your insurer does have your health history indeed. Like I said, they are like Equifax, they aggregate info from everywhere.
If you apply today for a big life insurance policy you can believe the insurer will check that hospital database, and will see that for example, you omitted the fact that you have stage 3 cancer in your left cheekbone and went for surgery. It used to be the same for healthcare policies.
Insurance is an industry I have a hard time finding a rationale for (outside of fire insurance and basic term life maybe).
Kind of like stock analysts, they don't add anything positive. They *could* be used for good if they hooked their back end database into Apple's kit ( with privacy permission). But then, somebody would have to pay somebody, which is what I find despicable about the whole system.
I forget where I read this, but I remember reading someone's analogy that getting insurance is like gambling. You are betting that something crappy will eventually happen to you. And when something crappy FINALLY does happen, you win!
At least that round. In the long run, however, the odds are stacked in the house's favor, and you will most likely end your life with a net loss in the "casino" of insurance.
At least in the US, Apple can walk a fine line on health privacy issues by focusing on sending data TO medical providers. Medical data that is stored on your phone that originates there (either through sensors or manually entered), shouldn't fall under HIPAA rules. HIPAA would apply when the medical provider receives it and stores it.
I'm sure these topics came up when Apple's team went to Washington, to ensure that Apple understands where to draw the line to expand and innovate and still be within compliance. Data aggregation on a personal device is useful in itself. And it keeps them out of medical device regulations (until Apple decides it is ready, via iWatch or iPhone hardware).
Sorry, slightly off topic.
I just discovered the videos from the WWDC sessions are released
https://developer.apple.com/videos/wwdc/2014/
I kept trying to play them for a few days but one would load in the browser (awards ceremony). Then I saw that you could download them directly and they work, oh well, not sure what was going on, perhaps my ghostery again.
At least in the US, Apple can walk a fine line on health privacy issues by focusing on sending data TO medical providers. Medical data that is stored on your phone that originates there (either through sensors or manually entered), shouldn't fall under HIPAA rules. HIPAA would apply when the medical provider receives it and stores it.
I doubt that distinction would last very long after the capabilities arrive. Some legislation will get created to regulate that stuff, and Apple is smart that they seem to be preparing for the eventuality now.
Thompson
on the US government side, there is very little corruption on the HCFA/HHS side of the house. The corruption is in the legislative branch. Compared to the DoD, Medicare (which has driven coding standards for the last 40 years) has performed miracles without payoffs.
pedantry: physicians go to medical school, not graduate school... if they do go to graduate school (and/or residency), they've spent a lot of time on the beaucracy side of helping patients (most spend their 3rd year of medical school just doing charting and dealing with coders calls asking 'what did the doctor do?').
And we don't want doctor's knowing the beauracracy... otherwise you end up with either poor care, or fraud/cost shifting ("you mean if we say we did a 'complete history' we get $130, but only a $75 for a 'visit history'.... well, If I ask, 'have you been sick before?... is that complete enough?').
The biggest issue is the always, 'how much do my options cost?' and MDs don't know that, and Insurance companies don't really know, until the claim is adjudicated. A GREAT Health app would be to have the MD give you the options, and you can push 'Preadjudicate' and your insurance company gives you a +/-25% cost estimate of each option, which you can weigh against the benefits the doctor gives you (surgery or P/T.... Pills vs AngioPlasty), etc etc.
On the HHS side of things, regulators are corrupted by their vested interest in stable employment, generous salary and retirement.
Despite what we might think we want, doctors do need to know bureaucracy, at least to give patients appropriate, quality healthcare, such as knowing coding tricks. Good, conscientious physicians know the costs of assays and treatments and order them rationally, rather than over-ordering due to incompetence or to cover their ass and increasing the cost of healthcare. Coding has changed so much that assistants are hired just to code--forming one of the fastest growing employment opportunities. Physicians hire assistants just to follow them around and do the electronic charting. cha-ching! The business of medicine has gotten so complicated and expensive with bureaucracy and insurance costs that private practices are shuttering left and right and the physicians are joining hospitals. Payment to the doctor or hospital might be denied at any of several steps--and knowing the bureaucracy can help avoid being stiffed. Many elite physicians are switching to concierge medicine, priced well out of reach of the vast majority of the populace.
I forget where I read this, but I remember reading someone's analogy that getting insurance is like gambling. You are betting that something crappy will eventually happen to you. And when something crappy FINALLY does happen, you win!
At least that round. In the long run, however, the odds are stacked in the house's favor, and you will most likely end your life with a net loss in the "casino" of insurance.
Especially in the disability insurance business, the insurance companies love it when you cancel!
Maybe the best part of the ACA (affordable care act or "Obamacare") is no more exclusions for pre-existing conditions. So if "something crappy" happens and it doesn't kill you, you can still get health insurance.
https://itunes.apple.com/in/app/microsoft-healthvault/id546835834?mt=8
Perhaps one of the most unused apps. They have their own platform and ecosystem with Windows Phone, but just lack the vision to make it useful.
They just can't pick one thing and do it right. They somehow have to put their hands in everything and not do even one right.
Otherwise known as Insurance Actuary Tables. The snag for all of us gamblers before the Affordable Care Act was, the insurance company could keep changing the house rules as they applied to a specific person to ensure the house always won.