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Thursday, February 28, 2019

The Momo Suicide Challenge: A dangerous game on the internet

The internet and social media are risky places for young people who are still in their formative years. This is true of other media, including movies such as "Thirteen Reasons" a story about an isolated teen girl who commits suicide as a result of bullying by  classmates.

Now there are viruses and malware that attack young people's social media introducing frightening games such as "Blue Whale"

The Blue Whale Game

"Momo Suicide Challenge"

Return of 'Momo suicide challenge' sparks fear among parents. It was uploaded to What's App a social media platform.

Parents and children are challenged by the addictive nature of social media.  Neuroscientists such as Andy Doan M.D. PhD have detailed the release of powerful neuro-modulators, endorphins, which give a feeling of pleasure and euphoria exactly like other addictive disorders such as substance abuse, and  pleasurable activities such as exercise.

Dr. Doan has authored, "  "Digital Vortex Survival Guide: Behaviors, Digital Media, & the Brain" - by Julie Lavier Doan, RN, Christie Walsh, and Andrew Doan, MD, PhD 
as well as a video
The videos that go along with the workbook (narration by Andrew Doan):

Wednesday, February 27, 2019

Hospital-Physician Vertical Integration Has Little Impact on Quality of Care; Greater Market Concentration Reduces It

Vertical integration between hospitals and physicians has had very little impact on quality of care, according to a new study by experts at Rice University's Baker Institute for Public Policy.
The study comes as healthcare provider organizations are becoming more complex, with hospitals acquiring physician practices and physician organizations getting larger. At the same time, hospitals are merging with each other to improve bargaining power with insurers, the authors said.
The researchers analyzed information from the Centers for Medicare and Medicaid Services' Hospital Compare database for 2008 to 2015. Among the 29 data points studied, the researchers analyzed hospital readmission rates, process of care measurements that gauge how well a hospital provides care to its patients, and patient satisfaction scores. Using that information, they tested whether patient outcomes are influenced by greater hospital market concentration or vertical integration between hospitals and physicians.
"Weighing the Effects of Vertical Integration Versus Market Concentration on Hospital Quality" was co-authored by Marah Short, associate director of the institute's Center for Health and Biosciences, and Vivian Ho, the James A. Baker III Institute Chair in Health Economics and director of the center. It will be published in Medical Care Research and Review.
Before they launched their study, the researchers hypothesized that decreased fragmentation, meaning better coordination among a patient's primary care physician, specialists and admitting and attending hospital physicians, could improve patient care. Instead, they found that vertical integration has a limited effect.

On the other hand, increased market concentration, which lowers market competition, is strongly associated with reduced quality measured in terms of patient satisfaction, the authors said. With fewer competitors, it seems there is less incentive to keep patients happy. Given the nature of some satisfaction measures, such as explaining medications and communicating well with patients, overall clinical quality could suffer if patients do not properly understand care recommendations during their hospital stay or post-discharge, the authors said.
"Although better patient experience may not always correlate with higher clinical quality, measuring quality based on patient perception is increasingly important as more consumers use online physician ratings and reviews of patient experience to select providers," Short said. "Therefore, we need further research on the ability of patient satisfaction to reflect clinical quality, and if it does not, we need to develop and provide to patients better measures in terms that patients can understand and use."
"Our overall recommendation is one shared with previous researchers: Regulators should continue to focus scrutiny on proposed hospital mergers, take steps to maintain competition and reduce counterproductive barriers to entry," the authors wrote in a summary of their paper.
The complexity and rapidity of health care organizational changes are a conundrum of events. Each step promotes varying degrees of improvement and/or impairment for clinical outcomes.  These results display a surprising result from mergers, vertical integration, and the formation of large health organizations.

Tuesday, February 26, 2019

Survey Finds Prior Authorization Hurdles Have Led to Serious Adverse Events

More than one-quarter of physicians (28%) report the prior authorization process required by health insurers for certain drugs, tests and treatments have led to serious or life-threatening events for their patients, according to a new survey by the American Medical Association(AMA).
The survey of 1,000 practicing physicians found that prior authorization continues to have a distressing impact on both patients and physician practices. Despite widespread calls for meaningful reform from the California Medical Association (CMA), AMA and others in organized medicine over the last two years, the survey illustrates that prior authorization programs and existing processes remain costly, inefficient, opaque and hazardous in some cases.
Critical physician concerns highlighted in the AMA survey include:
  • 91% say that prior authorization programs have a negative impact on patient clinical outcomes.
  • 65% report waiting at least one business day for prior authorization decisions from insurers – and 26% said they wait three business days or longer.
  • 91% said that the prior authorization process delays patient access to necessary care, and 75% report that prior authorization can at least sometimes lead to patients abandoning a recommended course of treatment.
  • 86% said the burdens associated with prior authorization were high or extremely high, and 88% believe burdens associated with prior authorization have increased during the past five years.
  • Every week a medical practice completes an average of 31 prior authorization requirements per physician, which take the equivalent of nearly two business days (14.9 hours) of physician and staff time to complete.
  • To keep up with the administrative burden, 36% of physicians employ staff members who work exclusively on tasks associated with prior authorization.
“The AMA is committed to attacking the dysfunction in healthcare by removing the obstacles and burdens that interfere with patient care,” said AMA Chair Jack Resneck Jr., MD. “To make the patient-physician relationship more valued than paperwork, the AMA has taken a leading role by creating collaborative solutions to right-size and streamline prior authorization and help patients access safe, timely and affordable care, while reducing administrative burdens that pull physicians away from patient care.”
In January 2017, AMA urged industry-wide improvements in prior authorization programs to align with a set of 21 principles intended to ensure that patients receive timely and medically necessary care and medications and reduce the administrative burdens. CMA and more than 100 other healthcare organizations have supported those principles.

Friday, February 22, 2019

ACEP Presents Framework To Protect Emergency Patients From Out-Of-Network Billing Issues - Jan 28, 2019

As legislators on Capitol Hill prepare to address the surprise billing issues that are affecting millions of patients across the country, the American College of Emergency Physicians (ACEP) today released a framework of proposed solutions to protect emergency patients.  
"By oath and by law, emergency physicians will treat any patient, regardless of their ability to pay," said Vidor Friedman, MD, FACEP, president of ACEP.

 "In fact, that federal law, the Emergency Medicine Treatment and Labor Act (EMTALA) actually forbids emergency care providers from discussing with the patient any potential costs of care or details of their particular insurance coverage until they are screened and stabilized. Patients can't choose where and when they will need emergency care and they should not be punished financially for having emergencies."
Dr. Friedman adds that with this framework of proposed solutions, we are ensuring that patients are truly taken out of the middle of billing issues that can frequently arise around insurance coverage of emergency care.
ACEP's proposed solutions include:
  1. Prohibit balance billing — When a patient receives out-of-network emergency care, the provider will make no demand for payment from the patient.
  2. Streamline the process to ensure patients only have a single point of contact for emergency medical billing and payment — Under ACEP's proposal, insurers will directly pay any coinsurance, copay, and deductible for emergency care to the provider, and can then collect back these amounts from the patient. This will put an end to patients receiving and having to reconcile the multiple, confusing bills and explanation of benefits that result from the many providers who often need to be involved in a single emergency episode.
  3. Ensure the patient responsibility portion for out-of-network emergency care is no higher than it would be in-network — When facing an emergency, patients or their family members don't have time to try and figure out where their care will be in-network, so they shouldn't be punished financially for being unable to do so. Under current law, while copays and coinsurance must be the same for emergency patients whether they are in- or out-of-network, deductibles can be much higher—often double! We think that needs to change.
  4. Require insurers to more clearly convey beneficiary plan details — This would include printing the deductible on each insurance card. While a simple step, it can help patients understand the limits of their insurance coverage and reduce the surprise when they later get a bill.
  5. Require insurers to more clearly explain their rights related to emergency care — Policyholders deserve to have this in plain, easy-to-understand clear language.   
  6. Take the Patient Out of Insurer-Provider Billing Disputes — ACEP wants to prevent provider/insurer billing disputes. To expedite and simplify this process, ACEP is calling for the creation of an arbitration process to settle network issues.
For more specific information on these proposals, please click here
ACEP is the national medical specialty society representing emergency medicine. ACEP is committed to advancing emergency care through continuing education, research and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies. 

ACEP Presents Framework To Protect Emergency Patients From Out-Of-Network Billing Issues - Jan 28, 2019

ER doctor shares why social media is a powerful tool in helping him cope with death.

Yes, even doctors must cope with death, be it sudden, and/or unexpected.

Physicians early in their training are told to be imperturbable and treat each situation with equanimity. Simply said most physicians form an emotional withdrawal from a clinical situation, such as childbirth, sudden death, and situations in the intensive care unit, or dealing with family crises.

One physician who deals with unfamiliar patients is to use social media platforms to obtain background information for a patient in front of them, dead or alive.  This may create potential problems with the family as they may interpret genuine interest as invasion of privacy.

Telling someone their child has just died has to be one of the most difficult things a human can do. For an emergency room physician, it’s part of their day-to-day lives. Every day there’s a chance they’ll deliver horrifying news that will forever change someone’s life.
It’s not a responsibility to be taken lightly. But it’s understandable that an emergency room physician would become calloused after years of delivering tragic news.

You see, I’m about to change their lives — your mom and dad, that is. In about five minutes, they will never be the same, they will never be happy again. Right now, to be honest, you’re just a nameless dead body that feels like a wet bag of newspapers that we have been pounding on, sticking IV lines and tubes and needles in, trying desperately to save you. There’s no motion, no life, nothing to tell me you once had dreams or aspirations. I owe it to them to learn just a bit about you before I go in.

I check your Facebook page before I tell them you’re dead because it reminds me that I am talking about a person, someone they love—it quiets the voice in my head that is screaming at you right now shouting: “You mother f--ker, how could you do this to them, to people you are supposed to love!”

ER doctor shares why social media is a powerful tool in helping him cope with death.: Stories that connect us and sometimes even change the world.

Thursday, February 21, 2019

Episode 1: Evaluation and Management Coding | CMS

Today we have a special edition, a podcast from Medicare regarding payment schedule changes

CMS has adopted a more efficient means of communications, reducing paperwork, and increasing efficiency regarding a very complex process in order to obtain reimbursement for services.

This is episode 1 in a continuing series of podcasts from CMS. The entire list of podcasts can be found here.

To listen to the Podcast click here

Dr. Goodrich, what is CMS trying to address with these policies?


>> Kate Goodrich:  Thanks, Bill.  We're trying to address a number of things, but in particular we're really focusing on reducing regulatory burdens on clinicians.  CMS has heard from physicians and other clinicians for some time now that excessive paperwork and unnecessary regulations, including coding requirements for evaluation and management -- or E&M as we call it -- are detracting from patient care.  The current 1995 and 1997 E&M framework was built on a model of clinical care involving complaint or symptom-based face-to-face encounters between a patient and a clinician.  But, since the 1990s, the nature of clinical care has really changed.  There's a much greater emphasis on patient-centered collaborative models of care with clinical teams that work together to manage chronic conditions.
The current way that clinicians work -- which often requires complex medical decision-making and care coordination.  For example, a primary care doctor who's caring for a Medicare patient with multiple chronic conditions and is coordinating that care between the patient and the multiple specialists helping to care for that patient.  That framework just isn't well-represented in the current E&M codes.  As a result, clinicians find themselves having to perform and document clinical activity that may be of only marginal relevance to the visit but is required in order to receive the level of payment that their effort deserves.
The current system includes five levels for E&M for office visits.  Level one is used primarily by non-physician practitioners, whereas physicians and other clinicians, such as nurse practitioners or physicians' assistants, typically use codes for levels two through five.  There are different documentation requirements for each level.  That's a lot to remember.  Since the significant majority of visits are reported at levels three and four, most visits require documentation of complexity well beyond the minimum.  The policies in this final rule will help to reduce administrative burden by simplifying documentation requirements, and they will improve interoperability so that Medicare providers can operate with greater flexibility and coordination with other providers in order to allow them to keep their focus where it should be, on the patient.
In addition, we are taking new approaches to enhancing the ability of Medicare patients to make use of telecommunications technology for other types of services.
>> Bill Polglase:  Dr. Shah, how do you think these changes will impact your relationships with the patients you see?
>> Anand Shah:  Bill, these final rules restore the vital patient-doctor relationship like giving clinicians and their staff flexibility in documentation for billing purposes and freeing up more time for them to see and care for their patients.  We integrated the extensive input we received from the medical community and other stakeholders, and we look forward to the improvements these phased-in changes will bring in terms of allowing clinicians to spend more time with their patients and enhance the care they provide.
>> Bill Polglase:  Dr. Goodrich, can you give us some specifics that will matter to clinicians?
>> Kate Goodrich:  Absolutely.  First, it's important to note that one of the things that we really tried hard to do in this effort is to listen.  We listened both to practicing clinicians; we also listened to the organizations that represented them.  And while they recognize and appreciate our burden-reduction efforts, they did urge us to take more time before implementing significant payment changes.  They also identified several concerns about various aspects of our proposals.
So, we listened to all of these concerns, and we finalized policies that will be implemented over several years.  Starting in January of 2019, we will be reducing burden to provide some immediate relief for doctors and other clinicians.  These include removing redundancy in the E&M documentation.  So, for example, we'll no longer require clinicians to re-enter certain information into the medical record that was already entered by support staff, or even by Medicare patients themselves.  CMS also will reduce unnecessary physician supervision of radiologist assistants for diagnostic tests.  And we are removing burdensome and overly-complex functional status reporting requirements for outpatient therapy.
We're also finalizing other documentation, coding, and payment policies for 2021 instead of 2019 in order to give stakeholders more time to prepare.  And we're also making important changes to the proposed policies based upon the comments we received.
>> Bill Polglase:  I know some of the evaluation and management documentation guidelines have been in place since 1995, and updated guidelines issued in 1997.  Dr. Shah, are they being updated now?
>> Anand Shah:  Bill, we're actually giving physicians a choice in how to document E&M office visits as we proposed.  Physicians will be able to use medical decision-making or time instead of applying the current 1995 or 1997 E&M documentation guidelines, or, alternatively, they could continue using the current framework.  I should also add that we're simplifying payments by establishing a single payment rate for E&M levels two through four office visits with one rate for new patients and another rate for established patients.  Related to this, we're requiring that physicians will only need to meet documentation requirements associated with level two visits when performing these office visits, except when time defines a service.  Clinicians can document additional information in the chart for clinical and other purposes.  Again, most of the hundreds of millions of Medicare visits are billed at levels three and four.  So, this will result in a significant burden reduction for the majority of visits.
>> Bill Polglase:  And I know that based on comments received, we are keeping payments for level five E&M office visits separate in order to better account for the care and needs of particularly complex patients.  Dr. Goodrich, can you talk a little bit more about this?
>> Kate Goodrich:  Yes, I'd be happy to.  We are finalizing additional adjustments that account for extended visits, as well as for the complexities of primary care and specialty care that is non-procedure based.  In fact, in response to comments, we broadened the definition of the non-procedural specialty care.  And we designed these add-on payments so that for most clinicians, additional documentation will not be necessary in order to report the codes.  That's something many commenters raised concerns about, and we are committed to making that work.
After considering concerns raised by commenters in response to the proposed rule, we are not finalizing other aspects of our proposal such as reduced payment when E&M office visits are furnished on the same day as procedures or separate podiatry E&M visit codes.  We'll also continue to work with the clinician community to make sure that we get it right.  We want clinicians to be fairly compensated for taking care of Medicare patients, and in particularly the most complex patients.
>> Anand Shah:  And I would also like to note that in addition to reducing burden, this final rule makes a real effort at improving access to care.  We're modernizing the Medicare benefit to improve access to care with coverage for new tele-health benefits and, also, new options for virtual.  It's not easy for people to get to their healthcare provider, whether they live in urban or rural communities.  This is a way to get more accessible care and will create more opportunities for patients to connect with providers by leveraging the latest advances in technology.
>> Bill Polglase:  How do you think this will impact how you, as physicians, deliver care?
>> Kate Goodrich:  So, when I take care of Medicare patients, I'll be separately paid for interactions to assess whether or not a face-to-face visit is needed.  So, if I do a brief phone call or a Skype call, or I review a picture that a patient texts me, I can submit a claim for that.  Same goes for consultations with other professionals and remote physiologic monitoring that are currently bundled together.
>> Anand Shah:  I should add we're also continuing to expand the list of services that clinicians can provide through tele-health, including prolonged preventive services that account for additional time when services like the welcome to Medicare preventive visit or the annual wellness visit are furnished.
>> Bill Polglase:  Very interesting and impactful stuff.  Dr. Goodrich and Dr. Shah, thanks for making the time to speak with me about these important policy changes, and thanks to you in our audience for listening.  For the CMS Beyond the Policy podcast, I'm Bill Polglase.
You can subscribe to this podcast through iTunes or whatever podcast service you use.  We'll be back soon with another edition of CMS Beyond the Policy.  This podcast is brought to you by the U.S. Department of Health and Human Services.
[end of transcript]

Episode 1: Evaluation and Management Coding | CMS

Wednesday, February 20, 2019

Why getting enough sleep reduces cardiovascular disease risk: Sleep-modulating hormone hypocretin found to also control production of inflammatory cells

Getting enough sleep is key to good health, and studies have shown that insufficient sleep increases the risk of serious problems, including cardiovascular disease. Now investigators have discovered one way that sleep protects against the development of atherosclerosis.

Images of plaque from the artery of a mouse model of atherosclerosis that experienced a normal sleeping pattern (left) and an image of arterial plaque from a mouse model that underwent sleep fragmentation (right). The amount of arterial plaque in the sleep-fragmented mouse is significantly larger.

Massachusetts General Hospital (MGH) investigators have discovered one way that sleep protects against the buildup of arterial plaques called atherosclerosis. In their paper receiving advance online publication in Nature, they describe the mechanism by which insufficient sleep increases production of inflammatory white blood cells known to be major contributors to atherosclerosis.
"We have discovered that sleep helps to regulate the production in the bone marrow of inflammatory cells and the health of blood vessels and that, conversely, sleep disruption breaks down control of inflammatory cell production, leading to more inflammation and more heart disease," says Filip Swirski, PhD, of the MGH Center for Systems Biology, senior author of the Nature paper. "We also have identified how a hormone in the brain known to control wakefulness controls processes in the bone marrow and protects against cardiovascular disease."
To investigate how insufficient sleep increases atherosclerosis, Swirski's team subjected mice genetically programmed to develop atheroslcerosis to repeated interruptions of their sleep, similar to the experience of someone constantly waking up because of noise or discomfort. While there were no changes in weight, cholesterol levels or glucose tolerance in the sleep-deprived mice, compared to animals from the same strain allowed to sleep normally, those subjected to sleep fragmentation developed larger arterial plaques and had higher levels of monocytes and neutrophils -- inflammatory cells that contribute to atherosclerosis -- in their blood vessels.
Further experiments revealed that the sleep-deprived mice had a nearly two-fold increase in the production in their bone marrow of stem cells that give rise to white blood cells. A hormone called hypocretin, produced in the brain structure called the hypothalamus and known to have a role in the regulation of sleep, was found to play an unexpected role in controlling white blood cell production. While normally produced at high levels when animals -- including humans -- are awake, hypocretin levels were significantly reduced in the sleep-deprived mice.
The MGH team found that hypocretin regulates production of white blood cells through interaction with neutrophil progenitors in the bone marrow. Neutrophils, they discovered, induce monocyte production through release of a factor called CSF-1, and experiments with mice lacking the gene for hypocretin revealed that the hormone controls CSF-1 expression, monocyte production and the development of arterial plaques. In sleep-deprived animals, the drop in hypocretin led to increased CSF-1 production by neutrophils, elevated monocyte production and accelerated atherosclerosis.
"This is a direct demonstration that hypocretin is also an important inflammatory mediator," says Swirski, an associate professor of Radiology at Harvard Medical School. "We now need to study this pathway in humans, explore additional mechanisms by which proper sleep maintains vascular health and further explore this newly identified neuro-immune axis."
Story Source:
Materials provided by Massachusetts General HospitalNote: Content may be edited for style and length.

Why getting enough sleep reduces cardiovascular disease risk: Sleep-modulating hormone hypocretin found to also control production of inflammatory cells -- ScienceDaily: Getting enough sleep is key to good health, and studies have shown that insufficient sleep increases the risk of serious problems, including cardiovascular disease. Now investigators have discovered one way that sleep protects against the development of atherosclerosis.

Tuesday, February 19, 2019

No, Zeke, You’re Not Paying For My Medicine | Galen Institute


Zeke Emanuel is tired of paying for your expensive medicine.
Dr. Emanuel, who served in a senior position at the Office of Management and Budget where he contributed to the recurring nightmare known as ObamaCare, recently complained in the New York Times [“I Am Paying For Your Expensive Medicine”] that his insurance rates are high because the medicines you’re taking cost too much.
“We all need to care about not only our own health care bills but also those of our neighbors,” he writes.  And by caring about your neighbors’ bills, he means finding a way to avoid them.
What evidently provoked Dr. Emanuel to fret about your medical bills was something called a PCSK9 inhibitor, a recently approved class of biologics that, according to a preliminary study, reduces the risk of heart disease and stroke by half.
YOU may not know it, but you could be on the hook to pay at least $124 this year for a drug you probably don’t take.
The drug is a new class of cholesterol-lowering agents called PCSK9 inhibitors. Its cost and how we are paying for it illustrate why we all need to care about not only our own health care bills but also those of our neighbors. And it helps focus the debate about drug prices on two questions: What is the value delivered by the drug, and can that be linked to its price? And how should such value-based prices be implemented?

In July, the Food and Drug Administration approved the first of two new PCSK9 inhibitors that lower the bad type of cholesterol, LDL. Studies suggest that they can reduce it by up to 60 percent, compared with a placebo, and reduce it up to 36 percent more than statins and a drug called ezetimibe. However, there are no definitive data on how much these drugs actually reduce heart attacks, strokes and deaths from heart disease. 

Ethical concerns aside (should government determine how much an additional quality-year” of life (QUALY) is worth?), government policies have so distorted medical prices as to render the sorts of calculations Emanuel favors suspect.  Before considering whether to import England’s algorithm for determining value, policymakers would do well to reflect on the wreckage that previous government forays into the health care marketplace have wrought.
The government, for example, imposes price controls in the VA system.  It also operates aMedicaid “rebate” program, which requires drug makers to mark down the price of medicines in that burgeoning program.  It mandates similar price concessions to a growing list of clinics and hospitals.  Manufacturers also must slash prices by 50 percent for Medicare beneficiaries who have fallen into the drug benefit’s “donut hole.”
When the government requires manufacturers to provide steep discounts to such a broad swath of the market, they predictably charge higher prices to everyone else.
Emanuel doesn’t just overlook the distorting effect government actions have had on drug prices, but he also fails to see how government has deformed health insurance markets.  Federal programs have long divorced premiums from risk.  ObamaCare has extended that practice into the individual and small group markets, creating a program in which people who wait until they are sick to buy insurance pay the same rates as those who maintained continuous coverage when they were healthy.
It has thus made insurance a good deal for people who have pre-existing medical conditions and a bad deal for people who don’t.   That is a major reason why the vast majority of uninsured people in reasonably good health who don’t qualify for government premium and cost-sharing subsidies have so far chosen to remain uninsured.  It also helps explain how insurance companies have managed to lose money under the program, even after pocketing billions in corporate welfare payments.
The accretion of government intrusions into the health care marketplace has distorted medical prices beyond recognition.  Good intentions have motivated every intervention, each of which has engendered a new round of problems that, in turn, have inspired further well-meaning interventions.  The result is a costly and inefficient system where prices are unhinged from value.
Government is bad at paying for value.  For consumers, it is a core competency.  Instead of smoldering over other people’s medical bills, Emanuel would do well to devote his considerable intellect to scraping away regulatory barnacles that prevent price discovery.  Instead of more government, we need a health care system that functions like the rest of the economy where, as Emanuel put it, “individuals determine value.”
Doug Badger is a retired White House and U.S. Senate policy adviser and a Senior Fellow at the Galen Institute.

No, Zeke, You’re Not Paying For My Medicine | Galen Institute