What can one little car do on The Health Train Express?

It seems a bit overwhelming, doesn't it? All the pontificating, posturing, analysis and input from people who really know little about caring for people.  Many are producing chaos, and dysfunctional behavior, much like the rest of our government. In an attempt to overcontrol our governments now compete with one another rather than caring for basic needs in the population.

Imagine how ludicrous, the state of Arizona has to protect it's southern border by itself, when the federal government can't or won't....Imagine the state of Virginia telling the federal government that what they propose with health care is unconstitutional.  The federal government suing a state government.  Impossible, you say....no it is REAL. 

It sounds like an impending civil war.  We worry more about what arab countries think about us, and how our European allies rate us in the world.  We allow slave labor in China to produce electronics cheaply for large computer companies.

Here is the story of ONE extra-ordinary American, as reported in the Star Tribune:

Twila Brase, founder of the St. Paul-based Citizens' Council on Health Care, blocks more public policy than she builds, but she has become a force to be reckoned with.

 

Twila Brase has no idea why a magazine named her one of America's 100 most powerful people in health care, and, frankly, neither do her critics.

"I find that hard to believe," said Peter Wyckoff, a longtime lobbyist for senior citizens who worked for a decade around Brase at the State Capitol. "She may be one of the 100 people most setting back health care reform."

 

The 51-year-old nurse turned activist is hardly a household name. Yet in Minnesota political circles, Brase, founder of the St. Paul-based Citizens' Council on Health Care, enjoys the reputation of a self-made libertarian lightning rod, an increasingly powerful free-market contrarian who blocks more public policy than she creates.

Among insiders, she is an acknowledged master of political theater, turning out raucous crowds for hearings and staging publicity stunts such as a recent "Obamacare" shredding party in the Capitol rotunda. She said she solicited no votes for Modern Healthcare magazine's 2009 list of "100 Most Powerful People in Healthcare."

 

"I don't know how I got in," she said. "And I may never get in again."

Tax records show that Brase works in a small office for $48,000 a year. Still, her name appears at No. 75 among the nation's health care movers and shakers. She shares billing with President Obama (No. 1), Secretary of Health and Human Services Kathleen Sebelius (2) and pharmaceutical industry chief Billy Tauzin (39), and her rank of 75th places her ahead of the president of the American Medical Association, the president of the American Academy of Family Physicians and the president of the Blue Cross and Blue Shield Association.

Brase opposes anything she thinks constricts individual freedom or invades privacy. That puts her at odds with many of the most popular concepts in modern health care: evidence-based medicine, electronic medical records, DNA databanks, doctor quality ratings.

"If government gets to control when and if you get health care," Brase said in an interview, "you no longer have liberty, and your right to life is controlled."

Brase knows this philosophy makes it difficult to build public policy. But anyone who thinks she doesn't affect the construction process is in for an attitude adjustment. A decade ago, she threw roadblocks in the way of a state medical database and a public health immunization policy. She opposed President Bill Clinton on health care in 1993 and opposes President Obama today.

She followed up the recent shredding party with a call for Gov. Tim Pawlenty to veto the Legislature's health care plan because it included too much government control.

Critics might say that Brase merely piggybacked on predictable politics. But as the DFL-controlled Legislature slogged through its session, trying to resolve the health care impasse with the governor, Brase counted a win.

"We don't get everything," she said. "But we stop something."

"She's managed to stop or water down some pretty important stuff," former state Health Commissioner Jan Malcolm acknowledged. "She put real brakes on data collection and immunization policy." Malcolm does not think that it is a good thing. As the chief architect of Minnesota's health policy, she found Brase frustrating. In her current job advocating for health care for the disabled through the Courage Center, Malcolm says Brase's contention that the government has no role in health care defies reality.

Her concept

Brase's alternative to government-run health plans would be "medical sharing organizations," groups of individuals who band together by choice and pay collectively for the medical care of those who need it when they get sick.

Nor is she a big fan of private health insurance companies. Although she pays for an individual catastrophic care policy with a high deductible, she considers traditional health insurance wasteful. "I always pay cash," she said. "I negotiate prices."

On a recent visit to the dermatologist, Brase said, she got the doctor to do a $150 mole removal for 90 bucks.

Constructive alternative?

Her ability to negotiate with politicians and health care advocates has not been as successful.

"It's more what she's opposed to than what she's for," Malcolm said. "I never found Twila to be abrasive or disrespectful. But you could talk to her for hours and not make a dent."

Added Wyckoff: "She does not work very collaboratively with most advocates. The price of criticism is a constructive alternative. I don't think she has a constructive alternative."

Brase obviously disagrees.

"We're protecting the rights of citizens," she said. "We're protecting choices. People who describe me as a wing nut don't believe in the heritage of this country."

"She's tenacious," said Rep. Tom Emmer, the Republican gubernatorial candidate. "When people mock her for her views, she backs them up with facts. She's not going to take the spin. She's an asset to both sides."

"She represents what I believe," said shredding party-goer Karen Minar. "She speaks for regular people who go to work every day and pay their bills."

In November, she appeared at a business health care forum in Kentucky, sharing the dais with former U.S. Surgeon General Joycelyn Elders and health care experts from Canada and the Harvard Business School.

This is heady stuff for a farm girl from southern Minnesota with a nursing degree from Gustavus Adolphus College in St. Peter, Minn. Brase left nursing in 1994 after stints at St. Paul's Children's Hospital and in schools in St. Paul and Robbinsdale. She left to crusade against what she considered President Clinton's attempt to let government take over health care. She wasn't a political person, she said, just "true blue for freedom."

Brase's first volley came in an op-ed piece in the Star Tribune in 1994. She signed it as the head of a group that existed only in her head. After the op-ed ran, a sympathizer contacted her and said he wanted to join. "Good," Brase told him, "here's when we'll have the first meeting."

The first meeting blossomed into a six-member board chaired by businessman Martin Kellogg, president of a plastics company in Stillwater, who felt health care reform was too "institutionalized."

"She's very quick," Kellogg said. "She doesn't talk about what she doesn't know. She's a tool for no one."

Brase doesn't sell or rent the Citizens' Council's 12,000-member e-mail list. Meanwhile, her influence has grown a lot faster than her income.

"She became a larger force over the years," Wyckoff said.

del.icio.us Tags: Twila Brase,Citizen's Council for Health Care,Minnesota Health Care,tea party

Cystic Fibrosis Car on the Health Train

Edwin Leap's post today focused on the March of Dimes.  It brought to mind my interest in Cystic Fibrosis. the CF Foundation sponsors an annual walk/run each year, GREAT STRIDES. Although less well known it is a significant event in the lives of those families who have a CF relative in their lives.  The event(s) took place this year on May 13 2010.  Although it is too late to participate this year.....plan on it for 2011. 

At any one time there are about 20,000 CF patients alive. CF is a recessive gene requiring a gene from each parent....one in 2,000 people (caucasians) carry the gene.

Survival rates have improved to the mid 30s, largely due to the research support given by the CF Foundation in their sponsored trials.  Were it not for the CF Foundation CF would be an Orphan Disease.

The CF gene was one of the first genes identified in the human genome. It is responsible for encoding a protein in the cell wall that controls chloride transport across the cell membrane. You can learn more about it.....here. 

My son was born in 1988 and I was told the average survival was to age 17 yrs, and that he would probably not get past age 10. When he was 2 years old the CF gene was identified, when he was three Pulmozyme (DNAse) was released after clinical trials were completed. (the first genetically produced drug by Genentech) He is now twenty-one years old

Along with these breakthroughs significant advances have been made in antibiotics, airway clearing medications, enzyme replacement medications and early aggressive interventions.

Further genetic studies have identified several subtypes of CF and the multiple alleles causing CF.  Treatment courses can now be modified by the genetic mapping of individal CF patients.

When you think about the March of Dimes, think also about "GREAT STRIDES"  for CF.

Here are some other ways we can make a difference.

May is Cystic Fibrosis Awareness Month. Cystic fibrosis is a life-threatening disease that affects 30,000 people in the U.S., and approximately 10 million people are symptomless carriers of the CF gene. There is no cure. Learn more about CF at www.cff.org.

Please consider joining me, Frank Deford, Rosie O'Donnell and friends, Boomer Esiason, Lewis Black, and Francis Collins in our effort to change CF (Cystic Fibrosis) to CF (Cure Found)

del.icio.us Tags: cystic fibrosis,CF foundation,gene therapy,frank deford,boomer eiason,lewis black,francis collins,rosie o'donnell,gary levin,healthtrain express,march of dimes

The 'Breast' Health Care

 

Here is the problem when government begins mandating health care. 

The USPSTF said women in their 40s should balance the benefit of a mammogram with the potential harms. Those harms: false positives, radiation exposure and subsequent follow-up tests, but also the possibility of diagnosing and treating a cancer in a woman that never would have threatened her life. A special communication published last year in JAMA noted that increased screening for both breast and prostate cancer “may be increasing the burden of low-risk cancers without significantly reducing the burden of more aggressively growing cancers and therefore not resulting in the anticipated reduction in cancer mortality.

 

Opposing opinions:

 

These USPSTF recommendations run counter to the expert guidance of the American Cancer Society, American College of Radiology (ACR) and Society of Breast Imaging

The American College of Radiology (ACR) applauds Sen. David Vitter (R-LA) for his recent letter to U.S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius demanding that, in compliance with recently passed health care reform legislation, HHS immediately remove from all HHS sponsored web sites and materials any references to the discredited and potentially deadly November 2009 U.S. Preventative Services Task Force mammography recommendations.

These USPSTF recommendations run counter to the expert guidance of the American Cancer Society, American College of Radiology (ACR) and Society of Breast Imaging and have undoubtedly confused many women to the point that they have refused needed care.

The federally funded and staffed USPSTF includes representatives from major health insurers, but not a single radiologist, oncologist, breast surgeon, or any other clinician with demonstrated expertise in breast cancer diagnosis or treat

Since the onset of regular mammography screening in 1990, the mortality rate from breast cancer, which had been unchanged for the preceding 50 years, has decreased by 30 percent. Ignoring direct scientific evidence from large clinical trials, the USPSTF based recommendations to greatly reduce breast cancer screening on conflicting computer models and the unsupported and discredited idea that the parameters of mammography screening change abruptly at age 50. There are no scientific data to support this premise.

Breast Cancer Screening Mammography and Thermography

Everyone's Got It

It seems to be all over the place, front pages, blogs, new media, old media, radio talk shows, TV talking heads, and politicians as well.

Everyone and their brother has an opinion and  is an expert on health care, policy and reform. 

Health is something everyone has, excellent, good, bad or indifferent.  Despite our excellent technology good health is not guarranteed.   It takes careful planning, exercise, good nutrition and an attempt at leading a non-toxic life physically, and emotionally and for most people, spiritually.  Perhaps I should place spiritually first. 

Planning financially is now almost impossible for many people. The employer based funding is still a major issue one that the government only partially dealt with in health reform. A lot of people do not have employer based plans or lose them with career changes.  The current recession has made it more difficult.

The way the reform is structured if I was still an employer I would tell my employees to join a government sponsored health exchange.  It would be cheaper for me to pay the fine than to fund my own health benefit plan.  Not only would I have to pay part of my employees  premium I would have to support a human resources department to administer it.  Obama has no idea of how companies work.

Unlike the government I do not have to do multimillion dollar surveys or fund a think tank and/or foundation to make that decision.  It is pretty much common sense.

For patients and their doctors (as well as you, the taxpayer) there is no good news, however there is a little less bad news.

Committees Unveil Bill To Raise Medicare Payments Until 2013

On Thursday, Democratic leaders on the House Ways and Means and Senate Finance Committees released a summary and finalized legislative text of the so-called "extenders" bill (HR 4213), which would raise doctors' Medicare reimbursements by 1% to 2% annually through 2013, Politico reports (Haberkorn, Politico, 5/20).

 

google Tags: health train express, healthcare reform, medicare fees, employer sponsored health insurance

The Schizophrenia of the Feds

There is a lot of hype about healthcare stimulus funding, ARRA, HITECH and ONC.

Surveys amongst the nations top hospital CIOs are not 'bullish' about any of these programs.

HealthSystemCIO reports:

In what makes for a disturbing combination, CIOs are both doubtful that the federal government (HHS/CMS/ONC) will have the HITECH program fully operational by the time incentives are to be paid out, and pessimistic about their chances of qualifying for those payments, according to the healthsystemCIO.com April SnapSurvey.

more......

The takeaways are:

1. Disconnect between deadlines for payments, and finalization of Meaningful use criteria

2.Hospitals will judge and plan their HIT plans in line with improving qualityof care, efficiency and individual needs rather than the promise of dubious federal funding.

3. The program envisioned and planned by ONC and HITECH is not adequate and will run out of cash (much like the 'cash for clunkers" program).

 

Individual Providers also face the same conundrum. Caution is the better part of action at this point.  A fear of being 'left out' is driving most acquisitions at this point. Careful ROI is still prudent.

In actuality the ROI may be a negative number for many providers.  Will the losses be greater with or without an EMR. The rule of negative incentives still prevails.

Politico a well known web site published in Arlington Virginia gives a nicely worded summation of too much to soon.

But as a particularly stringent and new regulation nears, numerous medical groups say that the aggressive government push to digitize is too much, too soon. Health information technology in the United States remains highly fragmented, so any large overhauls, experts warn, must work on a timeline that stretches years into the future. 

 

google Tags: hhs, healthsystemcio, onchit, hitech, arra

Vending Machine Medicine

I was reading Distractible MD this morning and came across this photo that Rob Lambert posted.

I could not resist passing this along to my readers.  It says a lot about what has and is happening to our domain as physicians.  I wonder if it talks too.

Changes at CCHIT

Welcome to Karen Bell MD, the new Chair of CCHIT. Karen assumes the position as Mark Leavitt , former Head of CMS and HHS moves on to other responsibilities.

As ONC and NHIN develop Karen's Commission is at a critical juncture regarding certification of EMRs and the NHIN participants.  At the same time other certifying bodies, such as the Drummond Group also compete for this responsibility.

The federal government has laid out the gauntlet and what appears to be an unreasonable rush to implementing electronic medical record keeping using a carrot and stick approach. This approach compromises a fine idea without regard for providers and those who will be paying for and using the systems.

Is the Affordable Care and Patient Protection Act Constitutional?

Gregg Scandlen of Consumer Power Report #221 reveals:

"Apparently there was no “severability” clause written into this law, which shows how amateurish the process was. Virtually every bill I’ve ever read includes a provision that if any part of the law is ruled unconstitutional the rest of the law will remain intact. Not this one. That will likely mean that the entire law will be thrown out if a part of it is found to violate the Constitution."

There are innumerable senators and congressmen who hold law degrees from prestigious law schools. How did they miss this? I am sure all legislation is 'proof read' by special advisors prior to a 'vote".  Was this omission intentional on the part of those opposed to the legislation but unable to carry a negative vote at the final vote?   Time will tell about this matter.

You may subscribe to his regular news email by sending a request to: Greg Scandlen [rknox@heartland.org]i

As reported in the Wall  Street Journal:

By Katherine Hobson

In 2014, insurers will have to accept all comers, pricing coverage only by age, geographic area and family size. Until then, people with medical issues that prevent them from getting affordable insurance are being steered into so-called high-risk pools. And today is the deadline for states to tell the federal government whether they want to take on the task of running those pools themselves, the New York Times reports.

The health-care overhaul bill is a blueprint. Now Obama administration folks are working on the rules that will actually put that plan into action – and, as Kaiser Health News reports – lobbyists are really interested in how that will shake out.

We posted earlier this week about one such area of confusion, the so-called grandfather provision that says existing health plans can avoid some of the consumer-friendly changes dictated by the bill (such as an end to co-pays for some preventive care). The question is what kind of changes insurers can make to a plan and still keep it exempt from those requirement.

(commentary)...Since when is a federal law a 'blueprint'? This is no longer a bill, it is an ACT.

google Tags: Affordable Care and Patient Protection Act, ARRA, Stimulus act, cchit, drummond group, nhin, onchit, consumer power report, karen bell

Health Train Screw

Sorry guys, I could not pass this one up. Donated to the blog cause by none other than The Happy Hospitalist.

Happy recently has had some very interesting and some controversial episodes that he reports. 

Haybayles, Hijacked Medical Practice, Medicaid Insurance or Insult? The ten year cycle for new drugs, Sex with a Fat Woman who is dying.

Health Train Makes the Rounds

Okay I was a bit syrup, and emotional yesterday, but we all have our days.

Today we will feast upon a round of the health blogosphere. We will go where no man has gone before, and perhaps discover new forms of life and brave new worlds.  Buckle up buddy,  and prepare!  I also issue a disclaimer that these opinions are not that of Blogger, Microsoft, Apple, no myself.   I am not certain that Intel and AMD were not involved in this opinion.

 

I' ll start today at Dr J's Housecalls, a physician who seems to be trapped in rural North Carolina. This blogger has a real fixation on events some years ago which terminated her dream of serving her birthplace; a bit like Don Quixote and his windmills.  Although her enemies do seem real and the events quite probable, her intensity remains unaltered.  I genuinely feel her pain having been through similar but less intense events in my career.

On to a more positive blog by "The Happy Hospitalist" who seems to live a  balanced life despite being a hospitalist. Perhaps the regular hours offset working for a hospital and/or administrators. He also most likely has good relationships with his referring physicians who also most likely thank their stars for his help whilst they attend to their offices and/or clinics.  I like his Italian greyhounds, Marty and Cooper...Mrs Happy must be a happy camper.

Buckeye Surgeon is also one of my favorites, although he seems to write in spurts, and Surgeon's Blog has mostly been replaced by Cutting Through The Crap.  Surgeon's blog is worth reading through the archives, because a great deal of Sid's writing are timeless (but not odorless).

Dr Wes corresponds on a varietyof topics, ranging from cardiac electrophysiology, to reimbursement issues as well as his thoughts, and opinions ranging from The Vanishing Oath, Computer hijinx, to The Top Ten Reasons to be a Doctor.

Edwin Leap is a nice blend of spirituality, life in the ER with bizarre patients, family vacations, and his 'formophobia'. NPs, PAs and RN PhDs beware...sign your own charts.

The Health Care Blog written by Matt Holt is always a great combination of writing by consultants, insurers, doctors, and I envy his traveling to international Health 2.0 conferences. on everyone else's dime.  What a great scheme; and all concerned get to write it off.

KevinMD likewise alternates between interesting medical cases, doctor attitudes and philosophies and also g uest bloggers. Kevin Pho has a long following and is one of the original well known and often quoted bloggers in other venues.

Musings of a Distractible Mind carries with it a dose of humor, Zippy, the Golden Llama Award (which has not been seen lately) and the author of The House Call Doctor

Placebo Journal Blog, Medical Humor with a Purpose a video musical production blending the best of new media, cartoon humor and vaudeville....carry on PlaceboJournal.

And last but not least; Medinnovation Blog the musings of a retired pathologist, who really does understand primary care.

I could go on and on, and don't be offended if I did not include your wonderful blog.......but duty calls.

Quote of the Day:
The depth and the willingness with which we serve is a direct reflection of our gratitude.
--Gordon T. Watts

Mom's on the Health Train Express

This past month I turned 67 years old. Today is Mother’s day in America. Mother’s are the strongest and deepest bonds we experience in life. They are our first and lasting imprint on our minds, auditory, visual and sensory. Fathers are important, however Mothers are crucial to sons, and daughters.

My mother passed away five years ago at age 89. Her last three years were spent in an assisted living facility and towards the end she knew not my brother or myself. She became less lucid as the end approached. My brother lived near her and made sure her needs were met as to where she lived and he became the executor for her personal financial affairs. I lived some distance from her and had many of my own responsibilities, a disabled wife and very ill son. I will never forgive myself for not making time for her.

During the last few years of her life I would speak with her on Mother’s day and apologize for not being there with her. She would respond saying it’s okay you have your own family now, it’s enough you remembered me…it’s enough…..

It’s enough rings in my ears to this day. No, it was never enough and that clarified itself on these past mother’s day when my first and lasting thought  was to call her. It was not a thought, it was a deep emotional reflex, lingering throughout the day.

So Happy Mother's Day to all you Mom's....and boys and girls don't forget 'the mom".

del.icio.us Tags: mothers day,moms,bonds,sons,daughters

Today's Post on Health Train Express

I was up very early this AM and set off on my daily surfing of health blogs.  There seems to be a division of those who focus on patient encounters and clincal care isssue, both humorous, commonplace and very sad stories.  The other end of the axis are those blogs focusing on health IT, health policy and reform.

Matthew Hold on the Health Care Blog always seems to have a reservoir of important health policy wonks emoting good stuff.

I envy the guy for creating Health 2.0  meetings all over the world. What a gig!!

Anyway today he has

 

  David Kibbe,

ePatent Dave, and

Vince Kuraitis

all well known writers on a number of health blogs, discussing disruptive changes in health care.

ePatient Dave  brings this approach to our challenge:

"It’s possible to look at the patients issue from a moral or ethical perspective, or from a business planner’s ecosystem perspective. In this post we’ll simply look at it pragmatically: is our approach going to work? It’s our thesis that although you won’t see it written anywhere, the stage is being set for a kind of disruption that’s in no healthcare book: patient-driven disruptive innovation."

ePatient Dave's comments at the Meaningful Use Workgroup of the HIT Policy Committee revolve about the potential for Consumer and Patient Involvement

We assert that to disrupt within a non-working system is to bark up a pointless tree: even if you win, you haven’t altered what matters. Business planners and policy people who do this will miss the mark. Here’s what we see when we step back and look anew from the consumer’s view:

1. We’ve been disrupting on the wrong channel.
2. It’s about the consumer’s appetite.
3. Patient as platform:
   • Doc Searls was right
   • Lean says data should travel with the “job.”
   • “Nothing about me without me.”
4. Raw Data Now: Give us the information and the game changes.
5. HITECH begins to enable patient-driven disruptive innovation.
6. Let’s see patient-driven disruption. Our data will be the fuel.
We don’t hear it often in healthcare, but disruption Is driven by shifts in buyers’ appetites over time. As products improve, some buyers reach a point where “more” is no longer attractive.

If you view your health data as a modular component in the “health web of the future,” you see that today it’s tightly integrated – with your provider. That prevents you from seeking care elsewhere, and it prevents you from adding value to your own data by applying innovative tools. To us that’s harm. It’s not just restraint of trade, it’s restraint of health.

At one time in the not so distant past it was posssible for the patient and the provider to get the consultation from whomever the consumer and provider wanted.

 

Raw Data Now: Give us the information and the game changes.

People often ask, “If we give you your data, what are you going to do with it?” We don’t know – that’s the point: innovators haven’t gotten their hands on it yet!

Twenty years ago Tim Berners-Lee invented the Web. In his TED talk a year ago he told why: he worked in a fascinating lab, and people would bring fascinating and useful information on all sorts of computers. “I would find the information I wanted in some new data format. And these were all incompatible. The frustration was all this unlocked potential.” He proposed the Web: linked data.

It can be hard to see huge potential in a simple change. After Tim’s boss died, the original proposal was found in his papers. In the corner he’d written, “Vague, but exciting.”

Tim’s next big vision says today’s internet stops short: it lets us see other people’s interpretations of datasets, not the data itself. So his 2009 TED talk agitates for change. By the end of the talk he had people chanting,

“Raw Data Now.”

 

Healthcare in America

 

What do you think about healthcare in America? This question was poised by

Deloitte in a recent survey

Survey Highlights

• 76 percent of consumers grade the system as “C” or below.
• 48 percent believe that more than half of health care money is wasted.
• Less than a quarter (23 percent) of consumers believes they understand how the health care system works.
• 42 percent of consumers surveyed support government-required health insurance compared with 38 percent who say they are against it.
• However, 42 percent say they would choose an employer-sponsored plan over the government’s (25 percent), all other factors being equal. Among the uninsured, a government-sponsored plan is favored (38 percent vs. 28 percent).
• One in three consumers believes that the market needs 10 or more insurance companies competing to ensure consumer choice.
• 7 out of 8 consumers believe themselves to be in "excellent," "very good" or "good" health yet, more than half (54 percent) have been diagnosed with one or more chronic conditions.
• Only one in five (22 percent) participates in a wellness program.
• A quarter (24 percent) of consumers remain confident about managing future health care costs, but of the people who skipped care when sick or injured, 4 out of 10 did so due to cost.
• More consumers are seeking alternative or natural remedies before seeing a physician (17 percent in 2010 compared with 12 percent in 2009) and more consumers are supplementing their current regimes with alternative remedies (20 percent in 2010 vs. 16 percent in 2009).
• One in five consumers rates their interest in accessing their health records by a secure Internet connection as high, would switch physicians to obtain access and would be very likely to use a mobile communication device to maintain them. However, only 10 percent report having a computerized personal health record (PHR).
• 15 percent of all consumers say they used a retail clinic in the past 12 months.