Sunday, March 26, 2017

Where are the Sexual Predators? | Kids Live Safe

A signifcant number of children are injured or are murdered by adult predators. It is a population management challenge.  Firstly to prevent these occurrences by identifying perpetrators, to identify where they live, and prevent them from contacting children.  Secondly to educate parents and children how to maximize their safety.

Attention is brought to us by large headlines, Amber alerts, missing person reports, and now on social media.  There are a wide variety of topics.  Sexual predators, Cyberbullying,Molestation, Pedophilia, Abduction, Social Media awareness, and online safety. offers an online eBook which thoroughly covers all these topics.

Fortunately our system now registers all convicted sexual offenders. There is a registered database that anyone can use. For parents who want to learn where sexual predators live in their neighborhood Kidslivesafe offer a search by zip code service.

It is a public health problem, one that children are  particularly vulnerable.  Educate yourself and your children.


Who are Sexual Predators? | Kids Live Safe

Saturday, March 25, 2017

Maine Voices: The problem isn't Obamacare; it's the insurance companies - Portland Press Herald

Only way to solve this is to fight fire.  Trumpism...negotiate from the . high point.  Write a letter to all your patients stating . you will no longer accept that company for their own good.  If 100,000 providers did that and sent a letter to the insurance company, they would back down really fast.

MILBRIDGE — With the recent news about increases in premiums for health plans sold through the Affordable Care Act marketplace, everyone wants to vilify the ACA. The ACA is but a symptom of the issue. Where are our policy dollars going?
As a primary care physician, I am on the front lines. Milbridge is remote. In good weather, we are 30 to 40 minutes from the nearest emergency room, so my office operates as an urgent care facility as well as a family medical practice.
It can take 20 minutes for an ambulance to get here (as it did one time when I had a patient in ventricular tachycardia — a fatal rhythm). I have to be stocked to stabilize and treat.
We are also about two hours from specialist care. Fortunately, I am trained to handle about 90 percent of medical problems, as my patients often do not want or do not have the resources to travel. I have to be prepared for much more than I did in Boston or New York City, where I had colleagues and other materials down the hall or nearby. No longer do I have a hospital blocks away.
One evening I was almost home after a full day’s work. Around 7:30, I got a call on the emergency line regarding an 82-year-old man who had fallen and split his head open. His wife wanted to know if I could see him, even though he was not a patient of mine.
Instead of sending them to the ER, I went back to the office. I spent 90 minutes evaluating him, suturing his wound and making sure that nothing more sinister had occurred than a loss of footing by a man who has mild dementia. When I was sure that the man would be safe, I let them go.
I billed a total of $789 for the visit, repair, after-hours and emergency care costs. Stating that the after-hours and emergency services had been billed incorrectly, Martin’s Point Health Care threw out the claims and reimbursed me $105, which does not even cover the suture and other materials I used.
I called them about their decision, said that it was not right and let them know they’d lose me if they reimbursed this as a routine patient visit. They replied, “Go ahead and send your termination letter” – which I did.

That is real chutzpah !

Maine Voices: The problem isn't Obamacare; it's the insurance companies - Portland Press Herald

‘Obamacare will explode’ warns Trump after Republicans pull healthcare bill — RT America

More Hyperbole !

Despite the political backlash the GOP and Paul Ryan manned up by pulling a totally inadequate solution to replace the Affordable Care Act with the American Health Care Act.  (too many A 's in either law.

What will happen next is unpredictable.  The chances of building a coalition to approve a good (not perfect) solution is probably less than hitting a comet and landing at  less than 1 meter/second hundred's of miles away. (which we did)

Rosetta Mission's Historic Comet Landing: Full Coverage

New Format for The Health Train Express

Readers will notice our new format beginning today.  In the interest of decreasing noise and distractions we are eliminating all of the information on the side bar. Over the years it has become cluttered.  This will leave much more room for my rants.

Thank you for following Health Train during the past 11 years.  We were one of the first health blogs to appear.  Although the readership has not been huge, it has been slowly growing and noticed by health care professionals around the world.

Friday, March 24, 2017

In The Land of The Experts

Arguably, the most consequential moment of the nascent Trump administration did not place  today when Congress Votes on the first iteration of the bill known as the American Health Care Act (AHCA). If the success or failure of the bill to this point is to be judged by its reception from policy thinkers on most sides of the political spectrum, it is already an unmitigated failure.
It should be noted, and hopefully a sign of careful thinking, rather than political gain, the GOP reneged on passing a 'rush to completion" bill.
My estimation is we are only in the first trimester of the embryonic AHCA.  Delivering it now would insure a premature death.
It should be worth noting, however, that healthcare in America is a massive business accounting for 3 trillion dollars in spending with powerful stakeholders. Any real attempt at reform is bound to be opposed by those who would naturally resist attempts to dam the river of dollars that flows to them. The resistance from these parties always comes in the form of entreaties to think about patients harmed by whatever change is trying to be made.
Figuring out which stakeholder actually has the patients best interests at heart is akin to playing a shell game. All the cups look the same and its entirely possible the marble is underneath none of the cups. As a physician, I am of course, another stakeholder with inherent bias but I would submit that practicing physicians, among all the players at the table, have their interests most aligned with the patients they must directly answer to every day.
Of course the actual language of legislative bills defies understanding by mere physicians, and while my grand wish would be to leave it to the healthcare policy experts to hash out, the last eight years suggests that it is folly for the practicing physician to pay no attention to these machinations. While it may seem obvious that all parties at the table would seek to ensure the primacy of the physician-patient relationship, one can never underestimate how deep health care policy experts have their heads buried in the sand.
Rand lists those who they think are the 'experts'.  Are they those who publish the most, who have had the most governmental positions, hold high positions in health care administration, or some other unknown selection by an algorithm ?  How many of them are physicians ?

What will be the effects of repeal, or amendment of the ACA?

Overall Rand Approach from Rand at Congressional Briefing

After reading and watching the above, hopefully we can distill who makes decisions. (If Congress really listens)

In The Land of the Experts

The Japanese practice of 'forest bathing' is scientificially proven to be good for you | World Economic Forum

Put on your insect repellant, walking shoes, and dive into your nearest forrest, park, or woodlands. It is good for your health.

Deep in our DNA is the fact that we were hunter, gatherers. Most primates are forrest dwellers, many species of apes, gorrillas, orangutans, lemurs reside in the forests of the world.  They must 'know' something we don't take as everyday activity.

The tonic of the wilderness was Henry David Thoreau’s classic prescription for civilization and its discontents, offered in the 1854 essay Walden: Or, Life in the Woods. Now there’s scientific evidence supporting eco-therapy. The Japanese practice of forest bathing is proven to lower heart rate and blood pressure, reduce stress hormone production, boost the immune system, and improve overall feelings of wellbeing.

Forest bathing—basically just being in the presence of trees—became part of a national public health program in Japan in 1982 when the forestry ministry coined the phrase shinrin-yoku and promoted topiary as therapy. Nature appreciation—picnicking en masse under the cherry blossoms, for example—is a national pastime in Japan, so forest bathing quickly took. The environment’s wisdom has long been evident to the culture: Japan’s Zen masters asked: If a tree falls in the forest and no one hears, does it make a sound?

Forest air doesn’t just feel fresher and better—inhaling phytoncide seems to actually improve immune system function.

“Don’t effort,” says Gregg Berman, a registered nurse, wilderness expert, and certified forest bathing guide in California. He’s leading a small group on the Big Trees Trail in Oakland one cool October afternoon, barefoot among the redwoods. Berman tells the group—wearing shoes—that the human nervous system is both of nature and attuned to it. Planes roar overhead as the forest bathers wander slowly, quietly, under the green cathedral of trees.

City dwellers can benefit from the effects of trees with just a visit to the park. Brief exposure to greenery in urban environments can relieve stress levels, and experts have recommended “doses of nature” as part of treatment of attention disorders in children. What all of this evidence suggests is we don’t seem to need a lot of exposure to gain from nature—but regular contact appears to improve our immune system function and our wellbeing.

Julia Plevin, a product designer and urban forest bather, founded San Francisco’s 200-member Forest Bathing Club Meetup in 2014. They gather monthly to escape technology. “It’s an immersive experience,” Plevin explained to Quartz. “So much of our lives are spent interacting with 2D screens. This is such a bummer because there’s a whole 3D world out there! Forest bathing is a break from your phone and computer…from all that noise of social media and email.”

Before we crossed the threshold into the woods in Oakland, Berman advised the forest bathers to pick up a rock, put a problem in and drop it. “You can pick up your troubles again when you leave,” he said with a straight face. But after two hours of forest bathing, no one does.

The Japanese practice of 'forest bathing' is scientificially proven to be good for you | World Economic Forum

Thursday, March 23, 2017

Driving High Value Behaviors in Medicaid Plans

In the Medicaid space, as in all of the health care system, a high-performing plan that improves health outcomes, optimizes risk adjustment and meets quality standards requires member engagement. More than just a buzzword you keep hearing, member engagement really is effective — consumers want to be engaged in their health care decisions, and those who are tend to be healthier as a result. Without an engaged population, Medicaid health plans will struggle to meet HEDIS quality measures, maximize pay-for-performance results and keep health care.

However, achieving such engagement and driving healthy behaviors is not a accomplished with a onesize-fits-all program. And when it comes to engaging Medicaid members, there are unique challenges. Medicaid members may face significant barriers to receiving the appropriate care—whether barriers of language or transportation, or simply being overwhelmed by the complexities of the health care system. How can we engage such members, close gaps in care and improve quality scores?

Medicaid performance ratings are unique to each state, but are generally based on three components: clinical quality management, member experience and plan efficiency. And now, such performance indicators are arguably more important than ever, as significant changes are on the way for Medicaid. Replicating what they’ve done for Medicare regulations, CMS is moving forward with the implementation of a mandatory quality rating system and a Medical  Loss Ratio of 85% for Medicaid managed care organizations (requiring that at least 85% of plan revenue be allocated to health care services, covered benefits and quality improvement efforts—such as rewards and incentives (R&I) programs).1 With these new regulations, and as more and more states loosen the rules and, in some cases, require wellness incentives, the stage is set for Medicaid plans to maximize their performance—and their economic returns—through the use of member engagement programs.

There are in fact a number of companies that specialize in this space, which will facilitate the change from FFS to a value based system.  In the past Medi-cal plans have been negligent, attempting to minimize what they perceived to be a waste of resources. The playing table has changed, largely thanks to HEDIS Scores and incentives.  It will be particularly effective in Medicaid Managed Care Plans.

Who are these people?

Medicaid provides health coverage to one in five people—that’s almost 70 million people with $440 billion in expenditures, and those numbers are only going to grow higher.2 Because they are comprised of distinct, diverse and hard-to-reach audiences, engaging these members requires a deeper understanding of their needs, behaviors and attitudes.

The largest and most recognizable groups within the Medicaid population are children, non-disabled adults, the dual eligible, individuals with disabilities, and pregnant women and newborns. And while, of course, no two members within these groups are the same, we can identify some general characteristics to give a better sense of who comprises these groups and the barriers they may face. We’ll start with the largest group: There are around 43 million children on Medicaid.3 Many of them are living in foster care, moving around between homes, guardians or parents. And a significant number of these children have special health care needs. Simply put, with such a large degree of movement and a lack of independence, these children can be very hard to reach. Creating a rewards program that anticipates and allows for changing residence and guardianship can be key to reaching children on Medicaid.

Close to 11 million non-disabled adults are Medicaid members.4 They are parents and caretakers, adults without dependent children, and low-income adults. Members of this population may be medically needy, and though it differs state by state, adults who fall 133% below the poverty line qualify for Medicaid in states that have adopted the Affordable Care Act Medicaid expansion.5 This tends to be the most active Medicaid population, in terms of health care usage. But while they may be more engaged in their care, it’s important to help guide their usage toward high-value behaviors. The next largest population is the dual eligible. These limited-income Medicare members comprise about 9.6 million of the total Medicaid population.6 They frequently have disabilities or comorbidities, and 21% are institutionalized.7 These members may not only have greater health care needs, but also may be housebound, increasing the difficulty in reaching them and encouraging them to make and keep doctor appointments. Including behaviors for your Medicaid rewards program that can be done in the home via in-home test kits can be an effective way to reach this population. Individuals with disabilities make up about 8.8 million of the Medicaid population.8 They tend to be the most diverse group, with a wide range of disabilities and, often, several different conditions. As a result, their health care needs may be more complex and a holistic approach is needed when reaching out to these members, whether as a provider or a plan offering a rewards program. Finally, 40% of US births are covered by Medicaid.9 Pregnant women on Medicaid may be adolescent, may not have planned for their pregnancies, and may not prioritize the importance of care. However, Novu data indicates this high-risk population can be effectively engaged with a rewards and incentives program.

Firstly, more than 61% of all adults on Medicaid have at least one chronic or disabling condition.10 These notable levels of chronic and comorbid illness—including physical conditions like diabetes, cardiovascular disease and respiratory disease as well as mental illness—indicate the considerable health care needs of these Medicaid members. Their needs are complex, and they require a holistic approach to their care. For plans and providers, it is essential to consider the whole member, not just the disease. Secondly, in a lot of cases, there is simply a lack of awareness of coverage and eligibility. Although members must first submit a Medicaid application, they are afterwards often auto-assigned to Medicaid health plans, and therefore may not even know they qualify for services or are a part of the plan. Even if they are aware of their Medicaid coverage, a member’s eligibility may vary over time if their income rises or falls, or they move across state or county lines. This can make reaching the right member at the right time—when they qualify for Medicaid and are enrolled in a plan—a more difficult proposition. Thirdly, low health literacy is compounding these difficulties. A large majority of Americans have trouble  using the everyday health information that is routinely available in our health care facilities, retail outlets, media and communities. Only 12% of American adults have proficient health literacy to manage their health11 and individuals with low health literacy have a 50% increased risk of hospitalization.12 On top of which, Medicaid is a notoriously complex program, with so many variances across state and county boundaries, that it can be difficult for members to understand and take advantage of the perks and plan benefits available to them.

In fact, 30% of dis-enrollments are the result of a lack of understanding of Medicaid and plan benefits.13 This goes to show that a Medicaid member who is confused or overwhelmed by the information and processes they encounter in the health care system is far less engaged with their care, if not actively disengaged. Consider also these various barriers a Medicaid member may face—members may not easily be able to make it to doctor appointments due to lack of transportation, childcare conflicts or working multiple jobs, and may have language or cultural barriers. These members may not have a consistent address, phone number, or Internet access, making it, logistically, more difficult to get—and remain— in contact with them. In addition, with economic hardships, taking care of their health simply may be less of a priority for Medicaid members. With these potential hurdles standing between your program and meaningful member engagement, it’s especially important to design an experience that meets members where they are, and makes it easy for them to participate. Of course, there is no one-size-fits-all solution for engaging Medicaid members. With different measures across different states and counties, the definition of success will vary depending on your plan’s location. The following are a series of essential steps to creating a successful Medicaid R&I program—one that will drive incremental performance, improve HEDIS or other quality measures, as well as reduce costs. However, as you continue reading, consider the following strategies and approaches in light of the measures that apply to your particular state or contract.


Member engagement is crucial to improving health outcomes, yet Medicaid members can be especially hard to reach. But as we’ve discovered, Medicaid engagement programs can be a remarkably effective way to break through those barriers to drive high-value behaviors, encourage a healthy lifestyle and improve HEDIS quality measures, ultimately affecting Pay-for-Performance. The proof? At Novu,  programs have driven a 70% increase in gap closure, a 7% increase in activation among the hardest-to-move populations and an impressive 83% participation rate.

To create a successful program with long-term results like these, Medicaid health plans need to cultivate and nurture relationships with members before and after activation. This means developing a simple and easy-to-use program, segmenting and targeting the appropriate members to activate, determining the reward types and values members respond to, and adopting an omni-channel approach aligned with the consumer lifecycle. Together, these strategies work toward driving member engagement because they hinge on treating members as unique individuals— understanding their needs and expectations, reaching out to them when and where they are, and personalizing the experience for their health journey.

Finally, the administrative and enrollment process must be simplified. Health education and literacy depends upon repetitive learning, like all education.   It should be a topic taught in middle and high schools.

Driving High Value Behaviors in Medicaid Plans