The Revolution in Magazine Processes "How not to fall behind in an era when everything you think you know might be wrong."

The title could have just as well read

The Revolution 

in 

Health Processes

Conventional print magazines, newspapers have weathered a sea-change in their business model.
And so has medicine and health process.

Health care financing, and administration also are struggling to change even as our current medical system is overwhelmed with increased expenses.  The similarity between magazine process and health process are remarkably alike.

Prominent news publishers, such as the Washington Post, New York Times and many others went out of business at the same time re-inventing their 'product' in a more efficient manner.  In some cases ownership shifted quietly behind the scenes. There were major reductions in staff, overhead and outright elimination of tasks that served no purpose or had been replaced by digitalizing the industry.

Even as this is occurring health organizations are burdened with daily organizations while being mandated by government, CMS, the Affordable Care Act, Insurers, and expansion of new covered benefits such as remote monitoring, telehealth and mobile health care.  The uptick in  expenditures for health IT is overwhelming many, both large and small.  There is no room for error. During the past five years some large institutions spent millions of dollars to purchase EHRs only to find they could not perform as advertised. Providers, and hospitals did not know or have experience in systems that were new and untested in a real world setting.

Health care operated mostly on a cash basis until the birth of managed care, capitation, and other obtuse forms of risk management.  In health affairs risk management used to have to do with risk of disease and/or treatments. Insurance companies were required to have an actuarial basis for setting premium rates against history of their insured disease risks.

Today this risk is carried not just by the insurance company, it has been shifted to hospitals and providers. Other calculations are being considered such as quality of outcomes, measured by re-admission rates to the hospital. The latest in the quirky world of health high finance is the 'accountable care organization. (ACO).

The name was coined by Elliott Fisher as a philosophical term during it's germination period.  Theoretically the organization that saves the most gets a 'kickback' a larger reward incentive than the rest of the providers/hospitals.

The health care company of 2005 is gone. its processes, procedures and priorities would be nearly unrecognizable today. In fact, the medical practice that existed in 2010 is gone too. In a period of accelerated transformation, nothing is more striking than the scope—and pace—of change in the processes through which these companies engage their customers (patients)  The very terms physician and patient devolved into provider and consumer. Physicians are no longer generalists or specialists they are primary care providers. It’s not just peripheral or incremental change, either. What the industry is going through in 2015 is a revolution in processes. In advertising, content creation, marketing, back-office functions and everything in between, what was done just a few years ago has been rendered obsolete, as new ways to interact with and serve stakeholders push the old ways into the trash bin. 

What’s changed is that technology is transforming every single phase of the business. It’s ubiquitous. It’s impacting the business on a wholesale level.”  It’s a new world of “VUCA,” says Lenny Izzo, group president of legal media at ALM. “That’s an acronym for Volatility, Uncertainty, Complexity and Ambiguity. It’s an old military term

Providers and hospitals have become 'punch-drunk' much like boxers and football players suffer from TBD or traumatic brain disorder.

Uncertainty comes in the form of new competitors. It comes with the decline in traditional branding-based display advertising, and the rise of new formats like cost-per-lead sales and programmatic advertising. Complexity comes in the form of tying together new expensive technologies that cross email, web, billing, production, ad-management, and content creation. Ambiguity comes in the form of not having the expertise to evaluate expensive new systems, and sometimes not knowing the right KPIs. Volatility? How about not knowing whether a new software system that cost $1 million will be relevant in 18 months?

This report is an on-the-ground look at process change in magazine media companies and how it’s affecting, well, nearly everything, from organizational structure and staffing needs, to assumptions about efficiency and newly essential skillsets. We’ll look at overall philosophies and approaches, and then explore, mainly through case studies, what publishing companies and executives are actually doing. 

Radical changes in process are driven by several things, of course. But mostly, it’s a function of two things: emerging technologies that enable new methods of serving markets, and a quest within companies for efficiency driven by economic necessity.

The revolution in health is not just in health IT, it includes changes in medical group administration, payment reform, relationships between providers, hospitals and providers, referral patterns and a new dynamic between regulators, licensing boards and providers of health care.

Interestingly, for health provider and magazine publishers, there’s a significant paradox in process change. Because the business model is in a seemingly permanent state of flux, and because technologies become obsolete so quickly, both types of companies find themselves betting huge amounts of money on unproven ideas. “Maybe the paradox of process is that you’re forced to be hyper-efficient in the things you understand, to finance what you hope is our future,” 

Note: Much of this article has been taken word for word from anaticle found on FOLIO  an internet magazine about the publishing business. It was a simple task to substitute health for magazine or publishers.. A true example of 'convergence'

WHY AMERICA IS LOSING THE HEALTH RACE

Article attributed to:  New Yorker Magazine

Many Americans are aware that the United States spends much more on health care than any other country in the world. But fewer people know that the health of Americans—by many different measures—is actually worse than the health of citizens in other wealthy countries.

Two major reports, both released last year, provide further elaboration of this apparent paradox. The first, “The State of US Health, 1990-2010,” documented trends in mortality and morbidity across the thirty-four member countries of the Organization for Economic Cooperation and Development (O.E.C.D.). The study, published in The Journal of the American Medical Association (to which I am a contributing writer), showed that both life expectancy and healthy-life expectancy improved in the United States over two decades. But the pace of those improvements was considerably slower in the United States: in 1990, the U.S. ranked twentieth among O.E.C.D. countries for life expectancy, and fourteenth for healthy-life expectancy; by 2010, it had fallen to twenty-seventh and twenty-sixth, respectively. The other charts and tables in the report—about heart, lung, and kidney disease; diabetes; injuries and homicides; depression; and drug abuse—all show Americans suffering poorer health.

The second report, commissioned by the National Institutes of Health, and conducted by the National Research Council (NRC) and the Institute of Medicine (IOM), convened a panel of experts to examine health indicators in seventeen high-income countries. It found the United States in a similarly poor position: American men had the lowest life expectancy, and American women the second-lowest. In some ways, these reports were not news. As early as the nineteen-seventies, a group of leading health analysts had noted the discrepancy between American health spending and outcomes in a book called “Doing Better and Feeling Worse: Health in the United States.” From this perspective, the U.S. has been doing something wrong for a long time. But, as the first of these two reports shows, the gap is widening; despite spending more than any other country, America ranks very poorly in international comparisons of health. The second report may provide an answer—supporting the intuition long held by researchers that social circumstances, especially income, have a significant effect on health outcomes.

Americans’ health disadvantage actually begins at birth: the U.S. has the highest rates of infant mortality among high-income countries, and ranks poorly on other indicators such as low birth weight. In fact, children born in the United States have a lower chance of surviving to the age of five than children born in any other wealthy nation—a fact that will almost certainly come as a shock to most Americans. But what causes such poor health outcomes among American children, and how can those outcomes be improved? Public-health experts focus on the “social determinants of health”—factors that shape people’s health beyond their lifestyle choices and medical treatments. These include education, income, job security, working conditions, early-childhood development, food insecurity, housing, and the social safety net.

Steven Schroeder, the former president of the Robert Wood Johnson Foundation—the largest philanthropic organization in the United States devoted to health issues—had a definitive answer to my question about why Americans might be less healthy than their developed-country counterparts. “Poverty,” he said. “The United States has proportionately more poor people, and the gap between rich and poor is widening.” Seventeen per cent of Americans live in poverty; the median figure for other O.E.C.D. countries is only nine percent. For three decades, America has had the highest rate of child poverty of any wealthy nation.

Steven Woolf, of Virginia Commonwealth University, who chaired the panel that produced the NRC-IOM report, also pointed to poverty when I asked him to explain the causes of America’s health disadvantage. “Could there possibly be a common thread that leads Americans to have higher rates of infant mortality, more deaths from car crashes and gun violence, more heart disease, more AIDS, and more premature deaths from drugs and alcohol? Is there some common denominator?” he asked. “One possibility is the way Americans, as a society, manage their affairs. Many Americans embrace rugged individualism and reject restrictions on behaviors that pose risks to health. There is less of a sense of solidarity, especially with vulnerable populations.” As a percentage of G.D.P., Woolf observed, the U.S. invests less than other wealthy countries in social programs like parental leave and early-childhood education, and there is strong resistance to paying taxes to finance such programs. The U.S. ranks first among O.E.C.D. countries in health-care expenditures, but as Elizabeth Bradley, a researcher at Yale, has documented, it ranks twenty-fifth in spending on social services.

The NRC-IOM report emphasized the effect of social forces on children and how those forces carry over to affect the health of adults, noting that American children are “more likely than children in peer countries to grow up in poverty” and that “poor social conditions during childhood precipitate a chain of adverse life events.” For example, of the seventeen wealthy democracies included in the report, the U.S. has the highest rates of adolescent pregnancy and sexually transmitted diseases, and the second-highest prevalence of H.I.V. This platform of adverse health influences in childhood sets up the health disadvantage that remains pervasive for all age groups under seventy-five in the United States.

It seems likely that many Americans would respond to these figures—and to the role poverty plays in poor health outcomes—by assuming that the data for all Americans is being skewed downward by the health of the poorest. That is, they understand that poor Americans have worse health, and presume that, because the United States has more poor people than other wealthy countries, the average health looks worse. But one of the most interesting findings in the NRC-IOM report is that even white, college-educated, high-income Americans with healthy behaviors have worse health than their counterparts in other wealthy countries.

Woolf explained this disparity by citing the work of the British social epidemiologist Richard Wilkinson, who has proposed that income inequality generates adverse health effects even among the affluent. Wide gaps in income, Wilkinson argues, diminish our trust in others and our sense of community, producing, among other things, a tendency to underinvest in social infrastructure. Furthermore, Woolf told me, even wealthy Americans are not isolated from a lifestyle filled with oversized food portions, physical inactivity, and stress. Consider the example of paid parental leave, for which the United States ranks dead last among O.E.C.D. countries. It’s not hard to see how such policies might have implications for infant and child health.

Other countries have used their governments as instruments to improve health—including, but not limited to, the development of universal health insurance. Health-policy analysts have therefore considered the effect that different political systems have on public health. Most O.E.C.D. countries, for example, have parliamentary systems, where the party that wins the majority of seats in the legislature forms the government. Because of this overlap of the legislative and executive branches, parliamentary systems have fewer checks and balances—fewer of what Victor Fuchs, a health economist at Stanford, calls “choke points for special interests to block or reshape legislation,” such as filibusters or Presidential vetoes. In a parliamentary system, change can be enacted without extensive political negotiation—whereas the American system was designed, at least in part, to avoid the concentration of power that can produce such swift changes.

Whatever the political obstacles, a major explanation for America’s persistent health disadvantage is simply a lack of public awareness. “Little is likely to happen until the American public is informed about this issue,” the authors of the NRC-IOM report noted. “Why don’t Americans know that children born here are less likely to reach the age of five than children born in other high income countries?” Woolf asked. I suggested that perhaps people believe that the problem is restricted to other people’s children. He said, “We are talking about their children and their health too.”

The superior health outcomes achieved by other wealthy countries demonstrate that Americans are—to use the language of negotiators—“leaving years of life on the table.” The causes of this problem are many: poverty, widening income disparity, underinvestment in social infrastructure, lack of health insurance coverage and access to health care. Expanding insurance coverage under the Affordable Care Act will help, but pouring more money into health care is not the only answer. Most experts estimate that modern medical care delivered to individual patients—such as physician and hospital treatments covered by health insurance—has only been responsible for between ten and twenty-five percent of the improvements in life expectancy over the last century. The rest has come from changes in the social determinants of health, particularly in early childhood.

Self-interest may be a natural human trait, but when it comes to public health other countries are showing the U.S. that what appears at first to be an altruistic concern for the health and care of the most vulnerable—especially children—may well result in improved health for all members of a society, including the affluent. Until Americans find their way to understanding this dynamic, and figure out how to mobilize public opinion in its favor, they will all continue to lose out on better health and longer lives.

Allan S. Detsky (M.D., Ph.D.) is a general internist and a professor of Health Policy Management and Evaluation and of Medicine at the University of Toronto, where he was formerly physician-in-chief at Mount Sinai Hospital. He is a contributing writer for The Journal of the American Medical Association.

Photograph by Ashley Gilbertson /VII.

Taxpayers subsidizing 76% of premium under health care law Associated Press

Healthcare.gov  If you missed signing up, here are some other alternatives

People who signed up for coverage under President Obama's health care law are paying about $80 a month in premiums on average, the administration reported Wednesday.


The new numbers from the Health and Human Services Department cover only the 36 states where the federal government took the lead in setting up new insurance markets, accounting for about 5.4 million of the 8 million people who signed up nationally.

Among the major findings:

-- Taxpayers are subsidizing 76 percent of the average monthly premium in the 36 federally administered markets.

-- The average premium is $346 a month, but the typical enrollee pays just $82. Tax credits averaging $264 a month cover the difference. The government pays the subsidy directly to insurers.

-- After tax credits, Mississippians paid the least for coverage - averaging just $23 a month on average premiums of $438. Among people in the 36 states, New Jersey residents paid the most - an average of $148 on premiums averaging $465 a month.

-- For this year, the average consumer could pick from five insurance companies and 47 different plans, although choice was more limited in a small number of states. From a range of platinum, gold, silver and bronze plans, most people picked silver.

-- There was a link between greater competition and lower premiums. For each additional insurer in a local market, premiums for the benchmark silver plan declined by 4 percent.

-- Premiums varied widely between states, ranging from an average of $536 in Wyoming to $243 in Utah.

Federal officials say they don't yet have complete data on the 14 states running their own markets.

Will the Affordable Care Act overwhelm the Health System?

In the midst of the fury, anger, and frustration with the Affordable Care Act we have been focused on chronic care, outcomes, meaningful use, accountable care organizations, HIT, and coming changes in reimbursement paradigms.

The increasing rates of obesity, hypertension, diabetes mellitus, breast cancer. colon cancer sits in stark opposition to acute illnesses, such as flu, otitis media, pharyngitis, bronchitis, pneumonia, infectious gastroenteritis,  and the tsunami of routine care, skin rashes, exanthems, pregnancy and it's secondary consequences as well.

Raising the bar for excellence in chronic disease management as measured by somewhat subjective criteria does not occur in isolation. This will have an effect on the system's ability to deal with the 'walking ill".   The overwhelming majority of health care takes place in an outpatient environment.  Monitoring this segment will require extensive monitoring and a means to encourage clinicians to use evidence based medicine. EBM at

it's best can be questionable and subject to clinical judgment and years of experience. Given the recent experience with screening for prostate cancer and breast cancer imaging standards were reversed after controversy erupted, and the USPHS did a quick reversal of it's stand on prevention of breast cancer and prostate cancer.

While the majority of health costs occur in the population above 55 years of age, this portion of the population is not as active in the economy.  Younger patients illnesses effect their attendance and ability to participate in the workforce, at times.  This is a  'hidden expense; to the system which is difficult to measure.

The initial phases of the Affordable Care Act have caused employers to look carefully at their full-time work force, and will shift to more part-time employment.  This will in turn stimulate the Individual Family  Plans not tied to an employer group plan.  History reveals these IFPs are more expensive to administrate than GHPs.

It has been a more than decade long crusade to develop a plan such as the ACA. Some are ecstatic and even euphoric about the ACA to the point of an unrealistic assessment of what the ACA can accomplish.  The very worthwhile plan  has caused a deep divide between fiscal conservatives, and liberals. What we need is more 'reaching across the aisle and open minds.  Both sides must lower the volume.

Ideologues and Unrealistic Expectations

Comments from Gary Levin MD are underlined and italicized:

Today I am amazed at an enthusiastic article about the Affordable Care Act by Eugene Robinson from Tallahassee.com.

His unbridled enthusiasm in the face of many difficulties that have nothing to do with health care exemplifies those who designed this law and passed it without reading it.

Here are some of his unsubtantiated claims and perhaps 'wishful thinking'

Eugene Robinson:  Washington Post

"Now that the fight over Obamacare is history, perhaps everyone can finally focus on making the program work the way it was designed. Or, preferably, better.

The fight is history, you realize. Done. Finito. Yesterday’s news.

Any existential threat to the Affordable Care Act ended with the popping of champagne corks as the new year arrived. That was when an estimated 6 million uninsured Americans received coverage through expanded Medicaid eligibility or the federal and state health insurance exchanges. Obamacare is now a fait accompli; nobody is going to take this coverage away."

1. The fight is not history, we are barely through round one and all the points go to the opponents of the ACA.

2. Six million Americans have not received coverage from the ACA. Registering is only the first step. It took me over ten hours of fumbling on the web site, and on hold via telephone. How many will be able to pay premiums by deadlines, or negotiate the difficult process of acquiring a provider. 

"There may be more huffing, puffing and symbolic attempts at repeal by Republicans in Congress. There may be continued resistance and sabotage by Republican governors and GOP-controlled state legislatures. But the whole context has changed."

The upside of the ACA is that all previously uninsurable patients now are enrolled no matter what pre-existing condition they have A+++++.

Can the ACA be improved?  Most definitely. The argument should not be Republican against Democrat.  Political party does not immunize one against illness.

I wholly agree with Mr. Robinson's analysis regarding the eventual goal of a uniform health system.  To call it universal care is a misnomer.

"The real problem with the ACA, and let’s be honest, is that it doesn’t go far enough. The decision to work within the existing framework of private, for-profit insurance companies meant building a tremendously complicated new system that still doesn’t quite get the job done: Even if all the states were fully participating, only about 30 million of the 48 million uninsured would be covered.

Yes Obamacare does not go far enough, however that is not the principle flaw. There is no one principle flaw, if there are any that is the poor analysis  and proposed implementation of a major expenditure that will effect most businesses,  all patients, and our national budget, and come up short.  If we are intent, committed and dedicated to these goals then let's get it right (or mostly right the first time)

Obamacare does establish the principle that health care is a right, not a privilege — and that this is true not just for children, the elderly and the poor but for all Americans.

Throughout the nation’s history, it has taken long, hard work to win universal recognition of what we consider our basic rights

This is a political and philosophical statement, not about health care. We need to keep these issues separate.  I agree with him about the tenet that all people should have health care financing.

Our first step should be to put on hold further mandates while the act is re-evaluated. Repeal is not an option, however amendment is a reality and not an 'existential' argument.

Mr Robinson's  article is not objective, nor unbiased. He totally neglects the weaknesses of the law which will require amendments.  Placing the issue in terms of a 'battle' between political parties does disservice to dedicated professionals who have  been in the system,  and who were neglected during the planning process.

To ignored the flaws would be a fatal mistake, health care costs will soar and there will still be large gaps in the insured population

Contact Eugene Robinson ateugenerobinson@washpost.com.

Contact Gary Levin MD at gmlevinmd@digitalhealthspace.com

Holiday Message for Health and Wellness

Today my message is one of hope and optimism. Health and Wellness are dear to us all.

We have many tools, HIT, EMRs, ACOs, ACA, Health Benefit Exchanges and more to come. Who knows what is next or what we have built, or predict will be here in five years.  Chances are very good, they will not be based upon our looking back ten years.  Not much is left from those days.

My message today is about 'shifting sands'

Much of what you and I read or write about health care, health information technology should be taken with a grain of salt.  It is all written from the narrow confines of our own experience(s)

It all goes beyond my capability to absorb and synthesize.


Much of what I seek is answered by the parables.  My hope is that all will take away some glint of wisdom from these words, no matter what the challenge.

Building on a Solid Foundation

24“Anyone who listens to my teaching and follows it is wise, like a person who builds a house on solid rock. 25Though the rain comes in torrents and the floodwaters rise and the winds beat against that house, it won’t collapse because it is built on bedrock. 26But anyone who hears my teaching and doesn’t obey it is foolish, like a person who builds a house on sand. 27When the rains and floods come and the winds beat against that house, it will collapse with a mighty crash.”

The Tree and Its Fruit

15“Beware of false prophets who come disguised as harmless sheep but are really vicious wolves. 16You can identify them by their fruit, that is, by the way they act. Can you pick grapes from thornbushes, or figs from thistles? 17A good tree produces good fruit, and a bad tree produces bad fruit. 18A good tree can’t produce bad fruit, and a bad tree can’t produce good fruit. 19So every tree that does not produce good fruit is chopped down and thrown into the fire. 20Yes, just as you can identify a tree by its fruit, so you can identify people by their actions.

Effective Prayer

7“Keep on asking, and you will receive what you ask for. Keep on seeking, and you will find. Keep on knocking, and the door will be opened to you. 8For everyone who asks, receives. Everyone who seeks, finds. And to everyone who knocks, the door will be opened.

This is my holiday gift to all.

Gary Levin M.D.