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

Not enough votes -- House delays health care bill to Friday -

What a difference a day makes ?  Twenty four little hours.

Time in Los Angeles -

What's inside the Republican health care bill?

The House will vote on the legislation, called the American Health Care Act, on Thursday. Republican leadership has already made several changes to placate both conservatives and moderates, but a number of members in both chambers remain concerned. So a lot may change before it reaches President Trump's desk.
Critics have ranged from conservative Republicans to insurers to the AARP. Conservatives complain that the bill does not fully repeal Obamacare and that many provisions are too similar to the health reform law. Insurers worry that Republicans would cut federal support for Medicaid and tax credits, leaving many of their customers without coverage. And the AARP fears that Americans in their 50s and early 60s would see their premiums skyrocket and federal assistance reduced, though lawmakers are now promising to provide this group extra assistance.
Proponents of the bill say it would save the individual health market from collapse. The legislation would create a patient-centered health care system that provides Americans more choice, greater control and lower costs, they argue.
Congress seems to believe cost savings is paramount in redesigning the Affordable Care Act.  That was the proposal with the Affordable Care Act, none of it came to pass.  Will an amendment such as the American Health Care Act transfer us from purgatory?
 Should the main metrics be who is insured, and cost ?  What about the internal workings of medical and hospital business.  Can the administrative overload be decreased ?  That is where the most savings can occur. Although health information technology has gained a foothold it has increased cost due to requirements of HHS and CMS. Their goal is to use EHR to extract data for population health management.  Physician and hospital goal is to increase usability and increase efficiency managing patients and to decrease personel costs.``

Not enough votes -- House delays health care bill to Friday -

Wednesday, March 22, 2017

Is Your EHR Contributing to Physician Burnout? | Depression and Physician Suicide

Health and Wellness applies equally to patients and physicians.   Pamela Wible  focuses on physician suicide and the neglect of emotional illness in physicians points out the unusual stress placed upon medical students, trainees as well as practicing physicians.   She has presented at TedMed, and has published numerous books on the subject. The'Ideal Medical Practice" is taught at several prominent Schools of Medicine.

The concept of the Ideal Medical Practice was founded by Gordon Moore in 2001 well before the health information technology sea change.

Today there is an overemphasis on electronic medical records.  Unfortunately, as many adopters have learned the EHR may not contribute to improved medical care, but decreased efficiency and increased frustration to all health care providers.  Most of this has been inflicted by government and health insurance companies.

The work flow has been adapted to boiler plate electronic health record design, rather than EHR designed to the work flow.  At first glance this is the main reason for intense provider dissatisfaction with most current software design.  Another contribution is the rapid increase of requirements due to simultaneous demands of meaningful use, changing to the ICD 10 codes, new requirements for management of accountable care organizations and a finite limit to resources for the requirements.  The cost of these changes was partially offset by HITECH incentives, although they were inadequate for many providers. Ongoing maintenance requirements were totally ignored by HITECH.

All of these factors increase the likelihood of physician burnout.  Physicians are trained and inherently devoted to caring for  patients with complex problems.  EHRs create one more energy drain for doctors and nurses alike.  It has upset the balance of work-life, health and wellness.

The burden falls to providers facing diminished reimbursements.  Decreasing profitably and outright becoming insolvent in today's environment weight heavily upon physicians who are now locked in by obligations, ongoing professional responsibilities add to hopelessness, and despondency.  Physicians are trained to overcome difficult situations, and can manage problems.  EHRs and bureaucracy are often not manageable and greatly influence physician wellness.

Although physicians are proactive and outspoken, the administrators and regulators often do not listen. Congress does not listen.

Two weeks ago, the American Medical Association’s immediate past president, Dr. Steven Stack, chose what seemed like an odd venue to mention something called the “Quadruple Aim.”
He was giving remarks at the grand opening of the OSF Simulation Stage at healthcare startup incubator Matter in Chicago. The AMA supports Matter and has a lab of its own, the AMA Interaction Studio, in the same facility.  “We need to restore joy to the practice of medicine,” Stack said on the very day the Annals of Internal Medicine published an AMA-supported study showing that physician waste huge chunks of their day on administrative tasks. Notably, doctors in four ambulatory specialties were tied up on electronic health records and other desk work for 49 percent of the work day, the research found.   “We have got to get to the Quadruple Aim,” Stack said. That means the Triple Aim of safer patient care, better population health and lower costs, plus a fourth element, clinician satisfaction.

Is Your EHR Contributing to Physician Burnout? | EMR and HIPAA

Sunday, March 19, 2017

Medical Practices of the Past QUIZ

Medicine in the 21st Century is based on scientific knowledge. Practices we use now have been reached by a wealth of knowledge gained over many years, tests and experiments and the study of data.

So, when you realize what practices were used as little as 50 or 60 years ago, it seems amazing that we’ve come so far ever since! It also makes you thank God you weren’t alive in those times, for the treatment may have been worse than the illness. Test your medical history I.Q. here.

Try our quiz and see if you can guess which practices are fact and which are fiction.

Medical Practices of the Past QUIZ Infographic

Friday, March 17, 2017

Trump Visa Changes Hit US Nursing Supply From Canada, Mexico

What !?



Health care is now inextricably wound into the fabric of government. Even NAFTA's recision effects the availabllity of skilled health care professionals.  It goes something like this.

President Donald Trump's dislike of the North American Free Trade Agreement (NAFTA) is starting to affect the workforce in United States hospitals that rely on specialized nurses from Canada and Mexico to fill critical positions.
Under NAFTA, Canadian and Mexican registered nurses have for decades practiced in the United States on nonimmigrant professional TN visas, and each day many Canadian registered nurses (RNs) cross the border to work in US hospitals.
But under recent stricter interpretations by US Customs and Border Protection (CPB), advanced practice nurses and advanced clinical nurse practitioners are no longer eligible to work under the old RN category and must now apply for H-1B visas. The latter cover specialized positions for foreign workers from any country and can cost several thousand dollars per applicant for expedited processing.

Last week, a Canadian nurse practitioner working at Henry Ford Hospital in Detroit, Michigan, was denied renewal of her TN visa. "She was told by CBP that the reason for the denial was a change in interpretation of NAFTA and that advanced practice nurses, in their opinion, no longer qualified under the NAFTA registered nurse category," said immigration lawyer Marc Topoleski, who represents Henry Ford Hospital, at a March 16 new conference.  (Holy Moses, Batman !).  Nurse practitioners are no longer categorized as R.N.s.  Who makes that kind of decision ? Is it a fear of terror, or something else even more insidious and dark ? Did some negative factor for this particular person appear suspicious. In fact this policy has not been made official nor appear in any written policy documents. 

The process could take as long as 3-4 weeks.

From left: Patti Kunkel, nurse practitioner, Henry Ford Health System; Marc Topoleski, principal attorney of business immigration services, Ellis Porter; Kathy Macki, vice president of human resources, Henry Ford Health System. (Dana Afana | (Dana Afana |

 HFH and others must file for a more complex and expensive H1B visa for those employees admitted on TN Visas.  Maybe an executive order from the Apprentice director would help

Trump Visa Changes Hit US Nursing Supply From Canada, Mexico