Thursday, March 30, 2017

Catholic Health Initiatives suffers $483 million in operating losses in 2016 | Healthcare Dive

  • Catholic Health Initiatives is including its $483 million operating loss in its merger plans with Dignity Health. 
  • CHI says the losses were due to “lower patient volumes, higher labor costs, increased pharmacy prices, and reduced reimbursement in Medicare and Medicaid,” according to a Modern Healthcare report.

An aggressive growth strategy was driving losses at CHI.  Fueled by anxiety and market share health systems merged in order to capture market and become more efficient.  The results were opposite.  

Electronic health records increase operating costs and decreased margins significantly.

Catholic Health Initiatives is not alone with the backlash on expenses, investment, and reduced in patient volume

Revenues for the nonprofit health system with 103 hospitals in 17 states increased 7.4% from $14.8 billion in 2015 to $15.9 billion in 2016. However, expenses rose 10.2% over the same time to $16.1 billion from $14.6 billion in the previous year. Losses occurred even though the struggling health system has laid off workers, sold off $600 million in real estate, and stepped back from its failed health plan.

Catholic Health Initiatives suffers $483 million in operating losses in 2016 | Healthcare Dive

Our Health California

Provider reimbursement is only a small part of what Medi-Cal pays.  It pays for indigent care, skilled nursing facilities, home health services. Providers receive only a small portion of the total budget for medi-cal patients.

The Affordable Care Act has made insurance available to many who live at or near the poverty line. However it does not assure access to providers who are the entry level into the system.

Contrary to prediction patient flows the emergency rooms have become even bigger since few providers accept medi-cal.  Medi-Cal's rates do not cover overhead for providers, and they are often seen at a loss unfortunately.

Insurance and access are two sides of the coin in regard to health care.

Click on the link to learn more about Medi-Cal and the Our Health California Community.  Join and get involved.

Our Health California

Cleveland Clinic suffers 71% operating income drop | Healthcare Dive

Cleveland Clinic suffers 71% operating income drop | Healthcare Dive

Monday, March 27, 2017

Here's the bipartisan path forward on health care: Andy Slavitt

This is the way to bringing a sensible and workable plan with bipartisan support.  No matter what the plan patients and providers need to get behind the plan . There is not perfect plan, and the perfect plan is the enemy of the good.

Trumpcare failure is an opportunity to end the divisiveness that hampered the Obamacare era.

The failure of Trumpcare last week can be seen as a rejection of policies that Americans judged would move the country backwards. But it also presents the opportunity to end the divisiveness that hampered the Obamacare era and move forward in a bipartisan direction that focuses not on destructive rhetoric, but squarely on reducing premiums and expanding access for all Americans.

The policies and the politics of Trumpcare were extreme and favored by only 17% of voters as compared with the Affordable Care Act (ACA), which enjoys support from 50%. The central plank of the bill cut care for the neediest children, elderly and disabled to pay for a large tax cut for the wealthy. The process, likewise, began with the most partisan approach possible. Republicans skirted Democratic input, avoided public hearings, and ended up rushing a bill without enough time for impartial evaluation.
The president has a chance now to turn this around. Last week, he invited Ezekiel Emanuel, a Democratic policy expert who helped craft the ACA, to the White House. Emanuel and I had dinner after his visit to the Oval Office, and he reviewed the commonsense ideas he shared with the president that were neither Democratic- nor Republican-leaning. The president had already chosen to head down a partisan path, but by inviting Emanuel, he might have signaled a potential interest in a bipartisan approach should that one fail.
Trump has an immediate opportunity to help Americans reduce their costs by choosing to enforce and properly steward what House Speaker Paul Ryan rightly called the "law of the land." The administration has the power to impact the cost of insurance by 25% to 30% with two simple decisions, according to a conversation I had with Mario Molina, CEO of Molina Health, one of the largest insurers in the exchange.

First, the administration, with support from Congress, should commit to permanently funding payments that reduce the size of deductibles for lower-income Americans (called cost-sharing reductions). Republicans need to drop a lawsuit they filed to stop these payments, or Trump needs to say they are going to continue. Second, the administration should enforce the individual insurance mandate until a different approach can be agreed upon. Those two actions will reduce costs for millions and need to be done now before insurers submit initial premiums for next year, or inaction will drive up premiums. Americans should watch this intently.
A third step would be to grant states the flexibility to increase competition and reduce costs. Non-partisan analysts such as Standard & Poor's confirm that the online exchanges that sell ACA insurance policies are stable, but in some states the cost of insurance is out of reach for those who earn too much to receive tax credits.
The administration has tools to do this, including a section of the ACA designed to allow states to pursue different approaches, including those more suited to their political philosophy, so long as they continue to meet the basic aims of covering more people with high-quality coverage. Alaska was the first to use this process last year by creating a statewide reinsurance pool. Such pools protect insurers against losses in high-cost cases, and the savings are passed along to consumers. In Alaska, the result was a dramatic reduction in premiums.

Here's the bipartisan path forward on health care: Andy Slavitt

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

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

Primary Care: Some Good News Residency Match Day 2017 Sets More Records

In recent years several new medical schools have come on line.  Some of them are specifically designed to educate primary care physicians. (you know what we used to call GPs).  As a result that increase in medical school graduates along with the increasing emphasis on primary care by HHS, CMS reflected by better reimbursement rates gives hope that health care will become more accessible.

Residency Match Day 2017 Sets More Records

Common Blood Tests Can Help Predict Disease Risk :

By the time you finish reading today's Health Train Express you will be able to add one more metric to decreasing the liklihood of chronic disease.

It is not a guarrantee, nor an absolute predictor of your fate...all of these tests are readily available at you doctor's office.  Ask that they be done, when your physician asks you why....quote the following. Almost all plans now reimburse for preventive medicine.  If they deny you, appeal it to the health plan.  The squeaky wheel gets the ' oil '.

The research was presented Friday at a meeting of the American College of Cardiology and hasn't been published in a peer-reviewed journal.

"Our goal was to create a clinical tool that's useful, easily obtainable and doesn't slow the work-flow of our clinicians," said Heidi May, PhD, MSPH, principal investigator of the the study and a cardiovascular epidemiologist with the Intermountain Medical Center Heart Institute.
Dr. May and her team studied a  population consisting of both male and female patients who had no history of a chronic disease. ICHRON was developed among one set of primary care patients, then tested in a second, independent primary care population.
 The tests, done in Utah are not controlled and are biased heavily to the demographics of Utah, where the study was performed. ICHRON Score ( Intermountain Chronic Disease Score) is factored on several well known and routinely done lab tests.  Many of these are done annually, and are relatively inexpensive.

"It's a fascinating concept," says Wayne Dysinger, a preventive and family medicine physician and CEO of Lifestyle Medicine Solutions, a primary care practice in southern California, who wasn't involved in the study. "They may be on to something, but it's too early to say for sure." For one thing, the score would have to be shown to be accurate in a more general population outside Utah, which is largely white and has lower rates of smoking and obesity than other states.

Among women, those with a high ICHRON score were 11 times more likely to be diagnosed with a chronic disease than those with a low score. Women with a moderate score were three times more likely to be diagnosed. Men with a high score were 14 times more likely to be diagnosed than those with a low score, and those with a moderate score more than five times more likely to be diagnosed.

American Heart Association

Common Blood Tests Can Help Predict Disease Risk : Shots - Health News : NPR

Monday, March 13, 2017

Telehealth Outlook Under the Trump Administration | The National Law Review

 The Trump Administration is likely to drive telehealth advancement in a positive direction. use of telehealth technology.For example, President Trump’s plan to reform the Veteran’s Affairs Department includes improved patient care through the use of telehealth technology. There are also some indications that the newly confirmed Secretary of the Department of Health and Human There are also some indications that the newly confirmed Secretary of the Department of Health and Human Services (“HHS”), Tom Price, is “telehealth friendly.

Despite the current focus in Congress on repealing and replacing the Affordable Care Act, telehealth legislation continues to gain traction and bipartisan support on the Hill. In February, a bipartisan group of 37 Senators sent a letter to Tom Price encouraging HHS to support telehealth and remote patient monitoring. Congress also has embraced telehealth advancement with a consistent stream of proposed legislation seeking to enhance the provision of telehealth services. Most recently, Rep. Joyce Beatty (OH-03) and Rep. Morgan Griffith (VA-09) reintroduced the Furthering Access to Stroke Telemedicine (“FAST”) Act that would expand access to stroke telemedicine (also called “telestroke”) treatment in Medicare. Congress also recently introduced HR 766 which would establish a pilot program to expand telehealth options under the Medicare program for individuals living in public housing. Additionally, Congress is poised to consider at least two bipartisan pieces of legislation focused on telehealth. The first is known as the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (“CHRONIC”) Care Act of 2016, which seeks to modernize Medicare payment policies focused on improving the management and treatment of chronic diseases using telehealth technologies. The second is known as the Creating Opportunities Now for Necessary and Effective Care Technologies (“CONNECT”) for Health Act, which seeks to mandate Medicare reimbursement for telehealth services (beyond the current, limited reimbursement framework). Finally, Senator Orrin Hatch (R-UT), the Chairperson of the Senate Finance Committee, recently released his “innovation agenda for the 115th Congress” which encourages the promotion of the “internet of things,” greater broadband investment, and increased device-to-device communication and cross-border data flows.

Telehealth will continue to increase in use despite proposed changes to the Affordable Care Act. Whether it will become a major player in health care will depend on studies to show if it cuts costs,improves care, or increases utilization as a redundant triage mechanism.  Telehealth does not . substitute for a visit to a physician, except for remote locations, where medical care would otherwise be lacking.

Telehealth Outlook Under the Trump Administration | The National Law Review

Seema Verma Confirmed by Senate as CMS Chief

Following a relatively benign debate about the new CMS Chief, Seema Verma is confirmed as the new head of CMS.

Seema Verma, nominee to head CMS, listens during a Senate Finance Committee confirmation hearing in Washington, DC.

Physicians seem to be  content that she is a governmental minimalist and favors voluntary participation in government programs rather than mandatory participation

Vice-President Pence was instrumental in recommending her to the position as he had worked closely with the Medicaid program in Ohio.

Verma has specialized in working with state Medicaid programs to improve care while lowering costs. The Trump administration will count on her to achieve those goals in a federal program that stands to shrink in a House Republican bill that repeals and replaces the 7-year-old Affordable Care Act (ACA). The measure would eliminate expanded Medicaid eligibility that 31 states chose under the ACA, and convert open-ended federal contributions to state programs to a fixed, per-capita amount, putting the program on a budget, as it were.

Verma's work with the Medicaid program in Indiana may be a preview of the program's future. She designed a "consumer-directed" version of Medicaid called Healthy Indiana Plan (HIP) that gives beneficiaries a Personal Wellness and Responsibility (POWER) account — similar to a health savings account — to apply toward a $2500 deductible. And while Vice President Mike Pence was governor of the Hoosier State, she helped created HIP 2.0, which expanded Medicaid coverage under the ACA. Beneficiaries who contribute a small percentage of their income to their POWER accounts are entitled to extra benefits such as dental and vision coverage.
Like the president that nominated her, the new CMS administrator espouses a small-government philosophy that many physicians may find refreshing. At her confirmation hearing, Verma said that physician participation in Medicare pilot projects for delivering and reimbursing medical care should be voluntary, not mandatory. She also decried federal regulations that might discourage physicians from participating in Medicaid and Medicare, and the burdens that electronic health records impose on clinicians in connection with the meaningful use incentive program.

Seema Verma Confirmed by Senate as CMS Chief

Saturday, March 11, 2017

On Death's Door California To Permit Medically Assisted Suicide As Of June 9 :

Debbie Ziegler holds a photo of her late daughter, Brittany Maynard, while speaking to the media in September after the passage of California's End Of Life Option Act. Maynard was an advocate for the law.
Carl Costas/AP

Classic Version of the Hippocratic Oath
I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfil according to my ability and judgment this oath and this covenant: hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art - if they desire to learn it - without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else.
I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.
I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.
I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.
Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.
What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.
If I fulfil this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.
A Modern Version of the Hippocratic Oath
I swear to fulfill, to the best of my ability and judgment, this covenant:
I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.
I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism.
I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.
I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.
I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.
I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.
I will prevent disease whenever I can, for prevention is preferable to cure.
I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.
If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.
California will now permit assisted suicide.  

California Gov. Jerry Brown signed landmark legislation last October that would allow terminally ill people to request life-ending medication from their physicians.
But no one knew when the law would take effect, because of the unusual way in which the law was passed — in a legislative "extraordinary session" called by Brown. The bill could not go into effect until 90 days after that session adjourned.
The session closed Thursday, which means the End of Life Option Act will go into effect June 9.
If one carefully compares the classic version with the modern version the modern version contains a new phrase,  "But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.

Physicians asked to . participate in legal executions have long been uncomfortable performing this function.  Physicians have quietly assisted in hastening death's approach surreptiously with medications.  Patients who are in death's grip are often sedated to diminish pain, and the use of opioids has many side effects on the cardiovascular system.  Now this can be pursued in hospital, or at home with family and/or friends in attendance.
It seems most merciful, and another evolution of medical practice.  Some physicians may refuse to participate, even if the family requests this act.  In such cases a new 'specialty' may emerge, Deathologist.  It no longer is such a horrific word.

Although physicians will be protected legally, the disconnect will remain. 

California To Permit Medically Assisted Suicide As Of June 9 : Shots - Health News : NPR