Shared Decision Making

"The best interest of the patient is the only interest to be considered"

This sentence is from the 1910 Rush Medical College commencement address by W. J. Mayo, M.D.  The full sentence included an important requirement:

"In order that the sick may have the benefit of advancing knowledge, the union of forces is necessary."

These two statements have been updated with the terms Patient-Centered Medicine, and Shared Decision Making.

The concepts are far from new and current events make them very relevant.  In today's practice world where the ten-minute encounter is the norm, shared decision making becomes almost impossible. Physicians are between a rock and a hard place.  We need constant reminders in the face of mounting bureaucracy, coding requirements, and electronic health record data input.

The union of forces is necessary to meet these needs.  Nurses, educators, medical assistants all should be engaged with patients.  The addition of readily available teaching aids, and electronic aids can assist us with these duties.

The modern EHR has new functionalities which incorporate instructions and educational material that can be given to a patient at the encounter or made available via a portal or direct secure email to the patient. 

Patients and clinicians have different expertise when it comes to making consequential clinical decisions.  While clinicians know information about the disease, tests, and treatments, the patient knows information about their body, their circumstances, their goals for life and healthcare.  It is only collaborating on making decisions together that the idea of evidence-based medicine can come true.

This process of sharing in the decision-making tasks involves developing a partnership based on empathy, exchanging information about the available options, deliberating while considering the potential consequences of each one, and making a decision by consensus. This process -- sometimes called patient-centered decision making, empathic decision making, or shared decision making -- demands the best of systems of care, clinicians, and patients and as such remains an ideal.



The Mayo Clinic and the Minnesota Shared Decision Making Collaborative have developed a comprehensive paradigm to meet this need.

The study reported in the BMC Medical Informatics and Decision Making 2013, 13(Suppl 2):S2

Study: Most mental health apps give Facebook, Google access to personal info without users' knowledge

It comes as no surprise that social media sites share your personal information. But, do you know that smartphone app that you download to your iPhone or Android phone share your personal information with companies that buy social media personal information.   All those 'FREE" apps are supported by unknown information harvesting companies. BEWARE.

A new study published in JAMA Network Open found that a majority of mental health and wellness apps surveyed distribute users' personal data to commercial third parties like Facebook and Google without explicitly informing users.

Researchers from the University of New South Wales Sydney, the Sydney-based Black Dog Institute, and the Beth Israel Deaconess Medical Center's Department of Psychiatry in Boston examined 36 apps for depression and smoking cessation that was highest ranked in the iOS and Android app stores in early 2018. Results show that 33 of the programs transmitted user data to Facebook, Google or other entities for advertising or analytical purposes, but only 12 fully disclosed this practice to users.

Just 23 of the surveyed apps incorporated privacy policies mentioning that data would be transmitted to a third party, and many of those fail to explicitly describe how the data will be used, and by which third parties.

According to the study's authors, despite the mental health benefits of these and similar apps, the lack of disclosure "may limit their ability to offer effective guidance to consumers and health care professionals," who would likely prefer to know whether and how their personal health information is accessed by advertising and analytical firms.

Data-sharing by free apps is ‘out of control’ with almost 90% of free apps on Google Play sharing your details with companies, Oxford University study finds.

Even paid apps have the same attendant risks.

Google Play Store                       

Apple App Store



How can you find where Google and Apple share their user information? Even this may be irrelevant because the information sharing is done by the App developer.



Readers should evaluate the worth of a free app vs the real risk of sharing their personal data from a health-related app.

Related Cybersecurity implemented by Google

Google set to purge Play store of apps lacking a privacy policy

Knowing When Apps Are Safe to Install

How do you know if an app marketplace is trustworthy?

Some characteristics of a safe marketplace are:

Terms of service that is well developed.

Clear contact information and a troubleshooting FAQ.

Strict app developer criteria.

A history of removing vendors with poor content.

Learn About the Vendor or Developer

Some questions to ask about app vendors are:

Do they have a professional website?

What is the privacy policy?

How is the information collected and used?

What information is available to advertisers?

What is the policy for disclosure of personal information?

Does the vendor have clear security policies?

Is there clear contact information?

There is no centralized source listing unsafe apps. The number of new apps that appear daily is enormous. The Food and Drug Administration is begining to evaluate and regulate health care apps.  Caveat emptor!

Study: Most mental health apps give Facebook, Google access to personal info without users' knowledge:

Alarm raised over tripling in cancelled NHS surgery and clinic appointments

Could this happen in the United States?

In a report from the U.K. Telegraph, an alarm has been raised.

Nine million patients a year are seeing crucial hospital appointments and operations canceled by administrators - almost triple the number a decade ago, official statistics show.

The rise has occurred over the past ten years, at a steady rate, according to a chart developed by the Telegraph. 

While the NHS has targets for diagnosis and treatment, and to reschedule surgery within 28 days, if it is canceled, there are no penalties to prevent trusts repeatedly putting outpatients appointments on hold.  

Will health IT save the day?  

The plan, launched in January, says that within five years, up to 30 million hospital appointments - one in three - should be scrapped, with patients instead having Skype consultations or being monitored via smartphone. Officials say this will mean the most vulnerable patients who need face-to-face slots will not face such long waits and delays.

 Caroline Abrahams, charity director at Age UK, said too many patients were seeing their health worsen, while appointments were delayed. She said: “More outpatient appointments being canceled by hospitals translates into growing anxiety, distress and pain for hundreds of thousands of older people. While some clinic appointments are routine, others are crucial steps in the effective and timely treatment of very serious and escalating health problems.”

Professor Andrew Goddard, President of the Royal Royal College of Physicians said the rise in cancellations was a symptom of rising pressure on hospitals, and growing numbers of cases arriving via Accident & Emergency. "Emergency admissions have risen by around 28 percent in the same period of time, putting more stress on an overstretched system," he said.

The pensioner who was blind by the time he finally got his appointment

Bob Dalton, 74, should have been given a follow-up outpatient appointment at Southampton General Hospital within a fortnight, following an operation to repair a detached retina. However, he wasn’t seen until over a month later - by which point he was blind in his right eye. Mr. Dalton, a retired RAF administrator, from Alton, was worried about changes in his eyesight and repeatedly made calls to the hospital.  By the time he finally saw his surgeon, he had suffered a total detachment of his retina.

These are but symptoms of an overstretched and underfunded health system in the U.K. The NHS is divided into trusts (smaller regional group administrations). All have suffered the same changes in canceled surgeries and hospital appointments. During 2017-2018 some disparities were noted:  Patients in the South were more likely to see appointments canceled. The U.S. health system is struggling to cope with its aging population, more advanced and more effective treatments, and better outcomes. While the U.S. system has already deteriorated somewhat by inconsistent federal regulations, penalties, incentives and a polarized politic we are considering a Universal Payer plan. The proposed system although called socialized medicine, it is not. Socialism is where the government owns the assets. The proposed system for the United States mandates a uniform payment model for private capitalistic infrastructure.  What will our solution accomplish? 

Alarm raised over tripling in cancelled NHS appointments: Nine million patients a year are seeing crucial hospital appointments and operations cancelled by administrators - almost triple the number a decade ago, official statistics show.

Best Buy, Target jump into at-home medical device market |

FDA Cleared and Reviewed*

Remote medical monitoring is reaching the consumer market at retail businesses such as Target, and Best Buy.  This is a major development for consumers.  This development opens a door for promotion, education and also competitive pricing for such devices.  Remote medical monitors are no longer a niche in health information technology, Best Buy and Target signal the beginning of a new age.  These devices will soon appear on the shelves in the health section or pharmacy alongside thermometers, blood pressure, and glucose monitors.

It simplifies the provider's direction for patients as to how to obtain an FDA approved device.  it does not require a prescription. A consumer can purchase a device on impulse.  However, a patient should consult with their physician to see if he approves and has access to reading the results.

Tyto's Remote Monitor

What's Included

A TytoHome telehealth visit is $59, possibly less if health insurance covers medical phone consultations, the company said. Tyto Care works with LiveHealth Online, which is an offer for those who buy the devices at BestBuy.com and live outside of current coverage areas. Otherwise, the company is partnering with regional healthcare systems to provide medical care to consumers throughout the country, according to the release. That includes the not-for-profit healthcare system Sanford Health for users in Minnesota, North Dakota, and South Dakota.

No matter what monitor you chose, it is only part of a system.  The remote monitor must be integrated as a one end-to another, the clinicians' office.  It requires a secure reliable network, either by cell phone or internet connection. Optimally it should integrate with the electronic health record to capture the images and the voice content. As part of the integrated electronic health record, it must be interoperable in accordance with ONCHIT guidelines.

Tytocare is cloud-based. If there are no local providers Tyto provides a network of qualified telemedicine providers that will help you until you are able to see your personal physician.

Telemedicine is growing exponentially and the latest availability should be checked out by telephone with Tytos.

Be wary of any telehealth provider, and use due diligence.

This article is neither a recommendation or testimonial for Tyco.  It is provided only as an information service





FDA Cleared and Reviewed*





















Best Buy, Target jump into at-home medical device market | Healthcare Dive: TytoHome

Burnout Declared A Health Crisis According To Harvard, Health Organizations

A number of academic institutions have belatedly reported on physician burnout and suicide.  Burnout, depression, and  PTSD amongst physicians and health providers has been reported in numerous blogs and in personal stories from physicians and their families.

Pamela Wible MD, an independent physician from Oregon has been an advocate for preventing physician suicide and bringing the truth out, rather than hiding it as a shameful act, or weakness. Physician suicided is often denied or covered up when it occurs. Pamela Wible M.D, along with professional film producer Robyn Simon produced the film, Do No Harm, was released in 2018.  It is available for group shows. The project was a Kickstarter, reaching its goal in one week from over 300 contributors (When the campaign ended we had 857 backers and $131,313 pledged. )

Producer Robyn Simon

Final Meeting of the Kickstarter Group for "Do No Harm"

Burnout is not limited to health care professionals. In today's world mounting frustrations, a decrease in living standards for millennials gives yield to hopelessness and sometimes despair and even suicide.

 A survey among Human Resources leaders showed that 95 percent feel as though burnout is “sabotaging workplace retention.” One reason for this, they say, is the overly heavy workloads put on employees.  If you’re experiencing physical or emotional ailments that may be symptomatic of burnout, it’s important to take the right steps to focus on your health.

Take an increased effort to practice self-care: physical exercise, sleep, and real-life social connections can be major influencers that help combat the emotional turmoil of burnout. And of course, never hesitate to seek professional help.

It may be difficult to take a few steps back from your obligations, but it’s often necessary to ground yourself, provide clarity, improve wellbeing and rediscover the purpose in your everyday life.

To view the survey conducted by Harvard and Massachusetts medical organizations, click here.







Burnout Declared A Health Crisis According To Harvard, Health Organizations | Darien Daily Voice: Are you emotionally exhausted, cynical and feeling hopeless? You could be experiencing burnout, which is now being considered a legitimate public health crisis by Harvard as well as several health organizations.Burnout is more than ...

FDA permits marketing of a medical device for treatment of ADHD

The U.S. Food and Drug Administration today permitted marketing of the first medical device to treat attention deficit hyperactivity disorder (ADHD). The prescription-only device, called the Monarch external Trigeminal Nerve Stimulation (eTNS) System, is indicated for patients ages 7 to12 years old who are not currently taking prescription ADHD medication and is the first non-drug treatment for ADHD granted marketing authorization by the FDA.

“This new device offers a safe, non-drug option for treatment of ADHD in pediatric patients through the use of mild nerve stimulation, a first of its kind,” said Carlos Peña, Ph.D., director of the Division of Neurological and Physical Medicine Devices in the FDA’s Center for Devices and Radiological Health. “Today’s action reflects our deep commitment to working with device manufacturers to advance the development of pediatric medical devices so that children have access to innovative, safe and effective medical devices that meet their unique needs.”

The device known as a transneuronal stimulator is not new on the market. It has previously been approved for the treatment of other disorders.

A diagram of it's the mechanism of action for a transneuronal stimulator

Trigeminal Nerve Stimulation for Comorbid Posttraumatic Stress Disorder and Major Depressive Disorder.
An eight-week,  study of trigeminal nerve stimulation in youth with attention-deficit/hyperactivity  
The potential use of trigeminal nerve stimulation in the treatment of epilepsy.
Central mechanisms of cranial nerve stimulation for epilepsy.

ADHD is a common disorder that begins in childhood. Symptoms include difficulty staying focused and paying attention, difficulty controlling behavior and very high levels of activity. The diagnosis of ADHD requires a comprehensive evaluation by a health care professional. For a person to receive a diagnosis of ADHD, the symptoms of inattention and/or hyperactivity-impulsivity must be chronic or long-lasting, impair the person’s functioning and cause the person to fall behind normal development for his or her age.

The Monarch eTNS System is intended to be used in the home under the supervision of a caregiver. The cell-phone-sized device generates a low-level electrical pulse and connects via a wire to a small patch that adheres to a patient's forehead, just above the eyebrows, and should feel like a tingling sensation on the skin. The system delivers the low-level electrical stimulation to the branches of the trigeminal nerve, which sends therapeutic signals to the parts of the brain thought to be involved in ADHD. While the exact mechanism of eTNS is not yet known, neuroimaging studies have shown that eTNS increases activity in the brain regions that are known to be important in regulating attention, emotion, and behavior.

The stimulation should feel like a tingling sensation on the skin, and the device should be used in the home under the supervision of a caregiver during periods of sleep. Clinical trials suggest that a response to eTNS may take up to 4 weeks to become evident. Patients should consult with their health care professional after four weeks of use to assess treatment effects.

The Monarch eTNS System’s efficacy in treating ADHD was shown in a clinical trial that compared eTNS as the sole treatment, or monotherapy, to a placebo device. A total of 62 children with moderate to severe ADHD were enrolled in the trial and used either the eTNS therapy each night or a placebo device at home for four weeks. The trial's primary endpoint was an improvement on a clinician-administered ADHD Rating Scale, ADHD-RS.  ADHD-RS scales are used to monitor the severity and frequency of ADHD symptoms. A higher score is indicative of worsening symptoms. The ADHD-RS uses questions about the patient’s behavior, such as whether they have difficulty paying attention or regularly interrupt others. The trial showed that subjects using the eTNS device had statistically significant improvement in their ADHD symptoms compared with the placebo group. At the end of week four, the average ADHD-RS score in the active group decreased from 34.1 points at baseline to 23.4 points, versus a decrease from 33.7 to 27.5 points in the placebo group.

The most common side effects observed with eTNS use are drowsiness, an increase in appetite, trouble sleeping, teeth clenching, headache and fatigue. No serious adverse events were associated with use of the device.

The Monarch eTNS System should not be used in children under seven years of age. It should not be used in patients with an active implantable pacemaker or with active implantable neurostimulators. Patients with body-worn devices such as insulin pumps should not use this device. The eTNS System should not be used in the presence of radio frequency energy such as magnetic resonance imaging (MRI), because it has not been tested in an MRI machine, or cell phones, because the phone’s low levels of electromagnetic energy may interrupt the therapy.

The FDA reviewed the Monarch eTNS System through the de novo premarket review pathway, a regulatory pathway for low- to moderate-risk devices of a new type. This action creates a new regulatory classification, which means that subsequent devices of the same type with the same intended use may go through the FDA’s 510(k) premarket process, whereby devices can obtain marketing authorization by demonstrating substantial equivalence to a predicate device.

The FDA granted marketing authorization of the Monarch eTNS System to NeuroSigma. 

The FDA, an agency within the U.S. Department of Health and Human Services, promotes and protects the public health by, among other things, assuring the safety, effectiveness, and security of human and veterinary drugs, vaccines and other biological products for human use, and medical devices. The agency also is responsible for the safety and security of our nation’s food supply, cosmetics, dietary supplements, products that give off electronic radiation, and for regulating tobacco products.

This is not a recommendation for treatment.  See your physician for diagnosis and treatment.

Press Announcements > FDA permits marketing of first medical device for treatment of ADHD: FDA permits marketing of first medical device for treatment of ADHD

The 2020 Final Payment Notice, Part 1: Insurer and Exchange Provisions

On April 18, 2019, the Centers for Medicare and Medicaid Services (CMS) released its final 2020 Notice of Benefit and Payment Parameters rule. The final rule was accompanied by a fact sheet, the final letter to insurers in the federal marketplace, and key dates for the calendar year 2019.

This is the latest that a payment rule has ever been finalized. From here, insurers can develop their products for 2020 and get these products reviewed and approved by state regulators or CMS.

The complexity of rules changes requires almost one year to process. The process if nothing else traces a route through providers, hospitals, and patients.  There is a public commentary period.

Overall, CMS made very few major changes from its proposed rule, which was released on January 17. Where the final rule deviates from the proposed rule, CMS mostly opted not to implement certain proposed changes. The final rule does not, for instance, require the sale of “mirror” abortion plans, adopt many significant changes to prescription drug standards, or allow navigators and other assisters to use web broker websites. In terms of significant changes that were adopted, the final rule allows insurers to adopt accumulator adjustment programs in limited circumstances and maintains an increase in the 2020 premium adjustment percentage as proposed. The latter is described as a “technical” change to the methodology that will result in higher consumer costs, reduced access to premium tax credits, and more uninsured people.

There were more than 26,000 comments on the proposed rule, about 500 of which were unique. Most of the remaining 25,000 comments were like one of eight different letters and focused on the rule’s abortion coverage proposal. This post addresses final changes in plan benefits, eligibility, and enrollment changes. A second post will consider the final changes to the risk adjustment program.

The “payment notice” is issued on an annual basis to adopt a variety of major changes that CMS intends to implement for the next plan year in areas such as the marketplaces, the risk adjustment program, and the market reforms. Historically, the payment rule has been issued in early fall and finalized in early spring (typically late February or early March) to give insurers, states, and other stakeholders time to understand the rules for the next year as new products are developed and approved for sale. 

This is the latest that a payment rule has been finalized and reduces the window of time for insurers and state regulators or CMS to develop, adjust, review, and approve plans for 2020. This delay notwithstanding, CMS did not alter its timeline for qualified health plan (QHP) certification for 2020: insurers must submit their 2020 QHPs  to CMS by June 19, 2019, for approval. CMS has already released its final rate filing timeline for 2020.

Much of the rule is devoted to changes regarding direct enrollment and risk adjustment, but the 401-page final rule addresses the following topics:

Changes in plan benefits and qualified health plan provisions;
Eligibility and enrollment changes, such as a new special enrollment period, changes to navigator requirements, and new standards for direct enrollment;
The 2020 payment parameters, such as the federal exchange user fee, annual limits on cost-sharing, and a new way of determining premium growth; and
Changes to the risk adjustment program.

In 2018 large increases were prevented by "silver loading" premiums.  How 'silver-loading' helped save the ACA's exchanges in 2018

In contrast to the 2019 payment rule, CMS proposes very few changes regarding the essential health benefits (EHB) and plan design. For 2019, CMS allowed states to choose from among many more EHB-benchmark plan options on an annual basis, deferred additional responsibility to state regulators, and eliminated standardized plan options and meaningful difference standards, among other changes. The 2020 final rule maintains these changes and makes no additional changes beyond laying out new timelines and providing additional background on discriminatory benefit design.

Toll-Free Hotline for SHOPs
The final rule includes a very minor change to the SHOP program. This is because the 2019 payment rule (and guidance before that) essentially wound down the SHOP exchanges after CMS concluded it is no longer cost-effective for the federal government to maintain a SHOP website and functionality. Thus, small employers no longer enroll using the SHOP platform and, instead, enroll through a SHOP-registered agent or broker or directly with an insurer.

CMS did, however, retain some SHOP standards, including a requirement that SHOPs continue to provide a call center to answer SHOP-related questions. Noting that SHOP call center volume has been extremely low, CMS will allow “leaner” SHOPs to operate a toll-free hotline in lieu of a call center. (CMS explained the difference between a hotline and a call center in the 2017 payment rule.) The toll-free hotline must allow for automated messages, pre-recorded responses to common questions, ways to reach local agents and brokers, and the option to leave a message.






















http://tinyurl.com/y6a6wxed

Doctors Wasting Over Two-Thirds Of Their Time Doing Paperwork

The issue of increasing medical bureaucracy is at a critical juncture. All of the well-intentioned technical additions for healthcare administration, such as electronic health records are having a paradoxical effect on the quality of care, and also decreases efficiency due to its poor design. 

Electronic health records are superb at capturing and saving critical medical information. It serves bureaucrats, support personnel, and payers well. However, the first and last link in the equation are physicians who are reduced to data entry clerks.

Paperwork for many doctors has become overwhelming. While initiatives have tried to convert paperwork into electronic paperwork, are the new systems actually designed to make doctors' lives easier? (Photo by Joe Raedle/Getty Images)

If medical school curricula were based on what a recent study says many doctors actually do with their time, more than half of medical school would be on how to do paperwork. Medical school admissions essays would be on "why I really want to do paperwork when I grow up." Required classes would be "Introduction to Filling Out Forms" and "Advanced Form-filling." Indeed, a recently published study in the Annals of Internal Medicine found that for every hour physicians were seeing patients, they were spending nearly two additional hours on paperwork. Is this really the best use of doctors' training and ability? Isn't this like telling LeBron James to spend the majority of his time manning the Cleveland Cavaliers ticket windows and phone lines? And isn't this also wasting the time of patients, who came for the doctor's medical expertise, not paperwork expertise?

Medical interns spend over 43% of their day on EHR use, study finds
Medical Educators realize this problem

Physicians who were already peaked out prior to the adoption of the electronic health records, and the additional impact of CMS rules, MIPS, new ICD 10 codes, requirements for MOC (maintenance of competence) recertification by specialty boards and more are burning out
Physicians are also talking about their 'moral dilemma' as they are required to follow insurance company rules in order to be reimbursed.

Studies have shown that physician dissatisfaction affects patient care and thus patient satisfaction. For instance, a study in the Journal of General Internal Medicine of 11 general internal medicine practices in the greater-Boston area demonstrated that patients of more satisfied physicians also were more satisfied with their health care.  Makes sense. Just like you don't want to have a pissed-off chef, lawyer or airplane pilot.

Something has to change. Hire people to help with paperwork, develop better technology to complete the paperwork, give physicians more time to see fewer patients or get rid of paperwork. Despite concerns having been raised, what is really being done? There needs to be real action. Otherwise, doctors will just have less and less time to actually examine and treat patients. And this will hurt everyone and eventually the entire system will hit a breaking point. After all, no patient wants to hear the following words in a waiting room, "the doctor will see your paperwork now."

Doctors Wasting Over Two-Thirds Of Their Time Doing Paperwork: Tune in the next epidisode of the ABC Network drama series, "Grey's Anatomy," when Dr. Meredith Grey, (played by Ellen Pompeo) does paperwork. (Photo by Amy Sussman/Invision/AP)

Ten Steps To Prepare For Life At 100 Or More In An Exponential Future And How to Live Near a Black Hole

Living longer seems to be a mixed feature of our generation. There are already existing exponential changes, a relative decrease in young and working people to support a growing aging population.  Less opportunity to fund retirement plans to support living after retirement, and a longer period of what we now call retirement.

If it feels like technological change is happening faster than it used to, that’s because it is.

It took around 12,000 years to move from the agrarian to the industrial revolution but only a couple of hundred years to go from the industrial to the information revolution that’s now propelling us in a short number of decades into the artificial intelligence revolution. Each technological transformation enables the next as the time between these quantum leaps become shorter.

That’s why if you are looking backward to get a sense of how quickly the world around you will change, you won’t realize how quickly our radically different future is approaching. But although this can sometimes feel frightening, there’s a lot we can do now to help make sure we ride this wave of radical change rather than get drowned by it.

1. Do what you can to preserve your youth
2. 
   Scientists are discovering new ways to slow the biological process of aging. It won’t be too long before doctors start prescribing pills, gene therapies, and other treatments to manage getting old as a partly curable disease. Because most of the terrible afflictions we now fear are correlated with age, medically treating aging will push off the date when we might have otherwise developed cancers, heart disease, dementia, and other killers. To maximally benefit from the new treatments for aging tomorrow, we all, no matter what our current age, need to do what we can to take care of our bodies today. That means exercising around 45 minutes a day, eating a healthy and mostly plant-based diet, trying to sleep at least seven hours a night, avoiding too much sun, not smoking, building and maintaining strong communities and support networks, and living a purposeful life. The healthier you are when the anti-age treatments arrive, the longer you’ll be able to maintain your vitality into your later years.
3. 
   
4. Quantify and monitor your health
5. 
   You can’t monitor what you can’t measure. If you want to maintain optimal health, you need a way to regularly assess if you are on the right track. Monitoring your health through regular broad-spectrum blood and stool tests, constant feedback about your heart rate and sleep patterns from devices like your Apple Watch or Fitbit, having your genome sequenced, getting a full body MRI, and having a regular colonoscopy may seem like overkill to most people. But waiting until you have a symptom to start assessing your health status is like waiting until your car is careening down a hill to check if the brakes are in order. Some smart people worry that this kind of monitoring of “healthy” people will waste money, overwhelm our already overburdened healthcare system, and cause people unnecessary anxiety. But even the healthiest among us are in the early stages of developing one disease or another. Society will inevitably shift from a model of responsive sick care of people already in trouble to the predictive healthcare trying to keep people out of it. Do you want to be a dinosaur-like victim of the old model or a proactive pioneer of the new one?
6. 
   
7. Freeze your essential biological materials
8. 
   Our bodies are a treasure trove of biological materials that could save us in the future, but every morning we still flush gold down the toilet. That gold, our stool, could potentially be frozen so we could repopulate our essential gut bacteria if our microbiome were to take a dangerous hit from antibiotics or illness. Skin cells could be transformed into potentially life-saving stem cells and stored for future use to help rejuvenate various types of aging cells. If our future treatments will be personalized using our own biological materials, but we’ll need to have stored these materials earlier in life to receive the full benefit of these advances. We put money in the bank to ensure our financial security, so why wouldn’t we put some of our biological materials in a bio-bank to have our youngest possible rescue cells waiting for us when we need them and help secure our physiological security?
9. 
   
10. If you plan on ever having children, freeze your eggs or your sperm
11. 
    More people will soon shift from conceiving children through sex to conceiving them through IVF and embryo selection. The preliminary driver of this will be parents’ increasing recognition that they can reduce the roughly 3% chance their future children will be born with dangerous genetic mutations by having their embryos screened in a lab prior to implantation in the mother. This may seem less exciting than making babies in the back seat of a car, but the health and longevity benefits of screening embryos will ultimately overpower conception by sex kind of like how vaccinating our children has (mostly) overpowered the far more natural option of not doing so. If you are likely to conceive via IVF and embryo selection, why not freeze your eggs, sperm, or embryos when you are at your biological peak and when the chance of passing on genetic abnormalities is lower than it may be later in life?
12. 
    
13. Manage your public identity
14. 
    The days of living incognito are over. No matter how aggressively some of us may try to avoid it, our lives leave massive digital footprints that are becoming an essential part of our very identities. The authoritarian government in China is planning to give “social credit“ scores evaluating the digitally monitored behavior of each citizen in a creepy and frightening way. But even in more liberal societies we will all be increasingly judged at work, at home, and in our commercial interactions based on our aggregated digital identities. These identities will be based on what we buy, what we post, what we seek, and how and with whom we interact online. Some societies and individuals are smartly trying to exert a level of control over the collection and use of this personal data, but even this won’t change the new reality that our digital identities will significantly influence what options are available to us in life and represent us after we die. Given this, and perhaps sadly, we all need to protect our privacy but also think of our public selves as brands, managing our digitally recorded activity from early on to present ourselves to the world the way we consciously want the world to know us.
15. 
    
16. Learn the language of code
17. 
    Our lives will be increasingly manipulated by algorithms few of us understand. Most people who were once good at finding their way now just use their GPS-guided smart phones to get where they need to go. As algorithms touching many different aspects of our lives get better, we will increasingly rely on them to make plans, purchasing decisions, and even significant life choices for us. Pretty much every job we might do and many other aspects of our lives will be guided by artificial intelligence and big data analytics. Fully understanding every detail of how each of these algorithms function may be impossible, but we’ll be even more at their mercy if we don’t each acquire at least a rudimentary understanding of what code is and how it works. If you can read one book about code, that’s a start. Learning the fundamental of coding will do even more to help you navigate the fast arriving algorithmic world.
18. 
    
19. Become multicultural
20. 
    Pretty much wherever you were in the 18th century, you needed to understand Europe to operate effectively because European power then defined so many parts of the world. The same was true for understanding United States in the 20th century understanding America was imperative for most people living outside of the United States because US actions influenced so many aspects of their lives. For many people living in 20th century America, understanding the rest of the world was merely interesting. As China rises and Global power decentralizes in the 21st-century, we’ll all need to learn more about China, India, and other new power, population, and culture centers than ever before. This won’t just help you become a more well-rounded person, it will give you a far greater chance of success in most anything you’ll be doing. Although machine translation will make communicating across languages pretty seamless, you’ll need a cultural fluidity and fluency to succeed in the 21stcentury world. The good news is that people motivated to learn about other groups and societies now have more resources than ever before to do so. If you want to be ready for our multicultural, multinational future, you’d better start doing all you can to learn about other cultures and societies now.
21. 
    
22. Become an obsessive learner
23. 
    Technological change has been a constant throughout human history, but the pace of change is today accelerating far more rapidly than ever before. As innovations across the spectrum of science and technology empower, inspire, and reinforce each other, multiple technological transformations are converging into a revolutionary whole far greater than the sum of its parts. This unprecedented rate of change will mean that much of your knowledge will start becoming obsolete as soon as you acquire it. To keep up in your career and life, you’ll need to dedicate yourself to a lifetime of never-ending, aggressive, continuous, and creativity-driven learning. The only skill worth having in an exponential world will be knowing how to learn and a passion for doing it. Call me an old-fashioned futurist, but this learning process must include reading lots of books to help you understand where we have come from and how the disparate pieces of information fit together to create a larger story. This type of knowledge will be an essential foundation of the wisdom we’ll each and all need to navigate our fast-changing world.
24. 
    
25. Invest in physical community
26. 
    
27. We, humans, are social species. A primary reason we rose to the top of the food chain and built civilization is that our brains are optimized for collaborating with those around us. When we bond with our partners and friends, we realize one of our essential cord needs as humans. That’s why people in solitary confinement tend to go a bit crazy. But although our progression from feeling our sense of connection, belonging, and community has expanded from the level of clan to village to city to country to, in some ways, the world, we are still not virtual beings. We may get a little dopamine hit whenever someone likes our tweet or Facebook post, but most of us still need a connected physical community around us in order to be happy and to realize our best potential. With all of the virtual options that will surround us – chatbots engaging us in witty repartee, virtual assistants managing our schedules, and even friends messaging from faraway lands among them – our virtual future must remain grounded in our physical world. To build your essential community of flesh and blood people, you must invest in deep and meaningful relationships with the people physically around you.
28. 
    
29.   Don’t get stuck in today 
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31. The olden days were, at least in most peoples’ minds, always better. We used to have better values, a better work ethic, better communities. We used to walk to school uphill in both directions! But while we do need to hold on to the best of the past, we also need to march boldly into the future. Because the coming world will feel like science fiction, will all need to be like science fiction writers imagining the world ahead and positioning ourselves to shape it for the better. The technologies of the future will be radically new but we’ll need to draw on the best of our ancient value systems to use them wisely. The exponential future is coming faster than most of us appreciate or are ready for. Like it or not, we are now all futurists.

If you feel as if we are entering a black hole, you could be correct.

And most important, teach this to your children.

Ten steps to prepare for an exponential future | TechCrunch: Ten steps to prepare for an exponential future

Newt Gingrich: How much is health care really worth? Patients, not bureaucrats, should decide |

When I met with several Republican senators this week, it was clear that they recognize Americans’ desire to have practical solutions for the cost of health care. The combination of pressure from constituents and a direct challenge from President Trump is focusing their attention on immediate reforms which could be enacted – even with a Democratic House.  Republicans also realize their alternative to “Medicare for All” must be built on a larger, positive vision. It is clear that fixing health care may be the biggest issue in the 2020 election.

WHY TRUMP ABANDONED HIS PLAN TO REPLACE OBAMACARE

The second is to fix the underlying structural problems in the health care system which are at the root of the health inflation problem.

On this latter priority, it is important that we define the problem that must be fixed. In fact, our most fundamental challenge is not that we pay too much for health care – but that we have no idea how much health care is worth.

In a normal marketplace, as Edward Deming wrote, innovators create products and customers define value. An innovator may create something they think is impressive, but it is the customer who gets to decide how much they are willing to pay for it. They make this decision based on how much they value the product over other ways to spend their money. It is this interplay between innovators creating new products and customers defining their value, which makes the magic of the marketplace work. It is why in most free markets with sound intellectual property protections, we get a continuing virtuous cycle of innovation which leads to higher quality and lower cost.

Health care, however, is not a normal market.

It is not normal because the consumer of the product, the patient, is not the one purchasing the health care (deductibles, co-insurance, and co-pays notwithstanding). Instead, the purchaser is the insurer, employer, or the government from whom the patient receives health coverage.

So, in health care, who is the customer – the payer or the patient? And who should determine value?

I believe, and I think most Americans would agree, that the patient’s voice should be more important than the payer’s. This is especially true because the patient is usually directly or indirectly the source of money for the payer. Since the patient is the one receiving the health care, we want the patient defining value.

That’s why I advocate eliminating third-party payments in health care as much as possible. The rise of direct primary care practices, for example, is a promising development which liberates doctors to be accountable directly to their patients by replacing third-party payers with direct payment by patients.

Still, the unpredictable nature of life requires some sort of health insurance for unexpected, large medical expenses. This means that for a significant portion of the health marketplace, the third-party payment model is unavoidable.

The question then becomes: How do we make this third-party payment system as accountable as possible to the patients, so they can define value even though a third-party is paying?

The answer is by making that interplay between the patient, payer, and provider as simple and transparent as possible. Establishing this right to know begins to improve the value of the system.

Unfortunately, for the past 40 years, most health reforms in Washington have taken the opposite approach. They have led to more middlemen, more opacity, and more complexity in the system. It is no surprise then that as the patient’s ability to determine value was submerged in a mountain of bureaucracy, that the health inflation problem became worse, not better.

Author's comments:

Newt Gingrich has hit the nail on the head. Health care economics has never been an elastic model. Supply and demand have little relationship.  The demand for health care approaches infinity. Rising costs do not eliminate or lessen the need for treatment of disease, except perhaps for cosmetic procedures which obey the normal rules since they are a cash commodity.

Our health system needs to be simplified.  Universal Payer is advocated by many.  It's success will be in the details and several questions need to be addressed going forward.  Universal payer does not address who the payer is. Will it be government, will it be framed around medicare?

There is no necessity that it be 'run' by the government.  In the U.K. a National Trust was formed and it became the administrative body for health care.  It is tightly regulated and one step removed from 'government' although most call it socialized medicine.  The true meaning of socialism is the government owns the assets.  

In the United States, there is a polyglot system of hospital and provider ownership, private, federal, state, government and large health systems.  There is a network of VA hospitals, Military hospitals, and non-profit hospitals.

With a universal payer system, are we talking about just payments or ownership? Patients' fear is rationing care, procedures lack of choice, and little control of what they desire.

Undoubtedly this will be a top priority during the 2020 elections. I expect to see little progress in such a divided and polarized Congress, which emphasizes byte sized slogans.