California To Pay About $1.3 Billion For Medicaid Expansion In First Year Of State Contributions | California Healthline

The senate is debating a new American Health Care Act (AHCA) as time ticks on.  Meanwhile many provisions  of the ACA continue to unfold.

For example the State of California is preparing to pay $ 1.3 billion to underwrite Medicaid (Medi-Cal), a new expenditure that will further strain an already burdened health care budget.

By  Emily Bazar

This year marks the first time states that expanded Medicaid under the Affordable Care Act will have to pitch in to help fund their expansion of the program. Their share of the overall price tag compared with federal contributions is small — 5 percent of the cost to cover newly eligible enrollees — but that still equates to real money in the Golden State.

That’s because the expansion of Medi-Cal, California’s version of the federal Medicaid program for low-income residents, has added nearly 4 million additional enrollees, according to the state Department of Health Care Services (DHCS). Most other states don’t have that many enrollees in their entire Medicaid programs.

“It was expected, but it’s still money that has to come from somewhere,” said Stan Rosenstein, a health care consultant in Sacramento who ended his 31-year career at Medi-Cal in 2008 as the state Medicaid director. “It puts budget strain on the state.”

In California, the potential loss of federal dollars caused by a rollback of the Medi-Cal expansion would be massive. The state Legislative Analyst’s Office estimated in February that the Golden State is slated to receive more than $17 billion from the federal government for the expansion in 2017-18.   Gov. Jerry Brown unveiled his revised $183 billion state budget last week.

If the House GOP plan were adopted, Medi-Cal expansion enrollees would likely fall off the rolls in large numbers after 2020 because of natural churn in and out of the program and a new provision that would require enrollees to renew their coverage every six months, twice as often as under current law.

As expansion enrollees drop, so would the more generous federal funding. Facing reduced federal support, the state may not be able to continue to allow people to enroll under the expanded eligibility criteria, said Deborah Kelch, executive director of Insure the Uninsured Project.

As lofty as the ACA is it did not take into account 3, 4, or 5 years down the road what financial cycles can do to state and/or federal budgets.  

The Affordable Care Act continues to sink. Economic realities will impact state and federal monies eventually forcing reductions in enrollees and reimbursements to hospitals and providers.

Of course the Feds can always print more currency.

“This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.”

California To Pay About $1.3 Billion For Medicaid Expansion In First Year Of State Contributions | California Healthline

LA County looks at planning for possible Obamacare repeal | 89.3 KPCC

Health Train Express examines the conundrum of revising the Affordable Care Act. There are outcries about how the  Affordable Care Act is not working. Yet millions of Americans now have health insurance coverage. No, it is not perfect. Deductibles are higher, and in some cases premiums are still not affordable for many patients.  Perhaps the reason is that one law cannot anticipate individual health care needs. Additional taxation of medical devices, and other necessities of medical care has brought an outcry from those affected.  Uniformly patients are satisfied with elimination of the 'prior existing' language of former  policies.

Hopefully this article can serve as a starting point, by following the embedded url links.

As congress attempts to pass a workable alternative to ObamaCare, the House has passed the American Health Care Act, and now the Senate is writing its own version of a plan. The Affordable Care Act is still the law of the land.  It has not been repealed and will remain in effect unless Congress repeals it, or President Trump by executive order repeals or it.  Either event would be   politically unlikely without a suitable replacement.

Obamacare transition plans are causing Los Angeles County and others with high rates of previously uninsured to plan for interruptions in health coverage.  LA County is seeking consultant's to plan a transition plan to fill the void.

Some local jurisdications are searching for alternative plans.

Under consideration by the Los Angeles County Board of Supervisors on Tuesday: 

The county wants to be ready as the U.S. Senate considers its steps on a bill to repeal and replace the Affordable Care Act. The House passed the American Health Care Act, which would make significant changes to the nation's health care, early this month. The L.A. County Chief Executive Office recommends the board reinstate retired health policy adviser Fred Leaf as a temporary hire. If the board approves the motion, Leaf would help develop the county’s position and plan to move forward in the event Congress repeals the Affordable Care Act.  "We need to have a coordinated strategy moving forward to be able to handle whatever it is that happens," said Dr. Christine Ghaly, chief operations officer for the Department of Health Services.

Republican efforts to replace the Affordable Care Act (ACA) are not over, despite the failure of the American Health Care Act (AHCA) legislation. The major challenge facing the AHCA was the loss of insurance coverage for an estimated 24 million people.¹ Any subsequent reform, especially those less costly than the ACA, will have the same challenge of keeping currently insured individuals and households from discontinuing their insurance. In this Viewpoint, we draw on behavioral economics to propose 4 general principles for health insurance reform to help ensure that the currently insured will not lose their coverage.

Health care policy making is technically complex, of course. But it is also complex in that the president and Republicans seeking to replace the Affordable Care Act (ACA) face very difficult political and philosophical choices. It was evident from the internal backlash to the recent Republican House committeebills that there is a deep divide among Republicans on these choices.

Consider 3 such tough issues: deciding what coverage means, making hard choices about subsidies, and determining how to cover people with chronic illnesses.

What Does “Coverage” Mean?

A key metric in the ACA replace debate has been the number of people who are “insured” or “covered.” The true purpose of insurance is to protect people from ruinous costs, such as from a terrible accident or a chronic condition. However, most people in the United States think health insurance should also cover routine costs.

Therefore, an ACA exchange plan that costs hundreds of dollars in monthly premiums and has a deductible of perhaps several thousand dollars, may technically be good insurance, but many people think it is not meaningful “coverage” because it leaves them exposed to possibly hefty routine costs. Indeed, polling has shown people in the United States generally view the ACA favorably or unfavorably depending on whether their own premium and out-of-pocket costs have been rising—even if they are not actually in an ACA plan.

Trump responded to this public perception by pledging better coverage with cheaper premiums and lower deductibles for everyone. So Republicans are now struggling to find ways of accomplishing that promise.

One popular Republican proposal is to reduce insurance costs by paring back the “essential health benefits” that ACA exchange plans must provide—so people don’t have to pay for benefits they supposedly do not want. However, the ACA’s required benefits mostly cover what Americans consider basic insurance, such as hospital stays and prescription drugs, so there is little room for paring back. Meanwhile, eliminating more controversial benefits, such as birth control, would have little impact on insurance costs.

Another popular idea is permitting families to buy inexpensive insurance from anywhere in the country. That sounds like an easy cost-cutting measure, but it’s not. Insurance today is typically tied to local networks of physicians and hospitals; thus, an out-of-state plan might be cheaper but essentially inaccessible. Most likely, with reduced regulation, we would see cheap cash indemnity plans aimed at healthy individuals. However, if large numbers of healthy people in a state did buy such out-of-state plans, that would undermine the state’s insurance pool and push up the average cost for remaining enrollees.

Designing Subsidies

Both the supporters and the critics of the ACA accept that some level of subsidy is needed for many families to afford coverage. Here again, Republicans seeking to replace the ACA face some hard choices in how they would construct such subsidies.

Bringing down the general cost of coverage would require a large infusion of new money or retaining some ACA taxes. Without that, many people will have a hollow choice between unaffordable plans. However, the House bills triggered angry resistance from fiscal conservatives opposed to keeping even some ACA taxes.

Even putting that problem aside still leaves hard design choices. Many Republicans favor a broad tax deduction for health coverage. But a deduction is of no value to the nearly half of US individuals who pay no federal income tax, and the greatest benefit goes to higher-income households who least need a subsidy. For that reason, the House Republican leadership opted for an income-related tax credit that is “refundable”—meaning available to households that pay no income tax. Yet even if the proposed refundable income-related credit were reconfigured to be made adequate, many conservatives balk at the idea of refundability, arguing that it would be a new cash entitlement.

An existential problem for Republicans remains, however. If they refuse to subsidize millions of modest- and lower-income individuals to buy private insurance, the only way to honor the President’s pledge would be to provide public coverage.

How Should We Cover Sicker Individuals?

A commitment to adequate and affordable coverage for all also means deciding how to address people who develop chronic illness, especially when young, and then try to buy insurance. In a less-regulated market, these individuals are literally uninsurable at a price that even comparatively well-off people can afford—but somehow, their treatment must be paid for.

There are only 2 broad options to deal with this group. One way, adopted in the ACA, is to spread their high costs across the entire insured population by requiring plans to cover all risks and limiting the range of premiums and deductibles insurers can charge. The problem with this approach is that premiums for younger, healthier individuals then become “artificially” high, making their purchase of coverage less economically attractive unless they receive generous subsidies. If these healthy people leave the insurance pool, such as by forgoing insurance, that raises the average cost of insuring those remaining in the pool.

The unpopular individual mandate penalty is meant to discourage this pattern (the House legislation explicitly repeals the mandate—but then adds back a penalty on people who wait to buy coverage until they are sick). Opting out is a particular problem in the ACA exchanges because healthier people can still obtain coverage in the less-regulated nonexchange individual market, making the exchange insurance pool more costly (a partial solution to this would be to merge the individual market with the exchange market, as has been done in Vermont and the District of Columbia).

The other way to cover people with high health care costs, embraced by the House legislation, is to fund states and hospitals to provide these individuals with extra services or place them in a separate subsidized insurance risk pool so their premiums are affordable. Subsidizing high-cost individuals in this separate way allows regular premiums to be lower for healthier individuals—making a mandate for coverage less necessary. Conservative analysts argue that carefully designed risk pools are an effective alternative to controlling premiums to cover expensive individuals, and can cover people “invisibly” and at reasonable cost. Some liberal analysts counter that the government cost would be too high for most Republicans to accept. But the bottom line is that a high-risk pool approach can only work if it is adequately funded.

These are just 3 of the many difficult issues Republicans have to deal with in designing an alternative to the ACA that adheres to Trump’s commitment to provide better and less expensive coverage. As my colleagues and I have pointed out, there are certainly ways to craft an alternative to the ACA that might appeal to many—though not all—Republicans. But that task is indeed complex, and requires a constructive consensus among Republicans that is currently lacking and may be unattainable.

Back to top

Article Information

Corresponding Author: Stuart M. Butler, PhD (smbutler@brookings.edu).

Published Online: March 15, 2017, at http//:newsatjama.jama.com/category/the-jama-forum/.

Disclaimer: Each entry in The JAMA Forum expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association.

Additional Information: Information about The JAMA Forum, including disclosures of potential conflicts of interest, is available at http://newsatjama.jama.com/about/.

Note: The print version excludes source references. Please go online to jama.com.

 : LA County looks at planning for possible Obamacare repeal | 89.3 KPCC

Death By A Thousand Clicks: Leading Boston Doctors Decry Electronic Medical Records | CommonHealth

WBUR  

May 12, 2017

By Drs. John Levinson, Bruce H. Price and Vikas Saini

It’s death by a thousand clicks, and it happens every day.

We are frustrated by EMRs because they pull us away from our patients. We are driven mad by the fact that EMRs in different locations do not talk to each other. And we think it’s just wrong that much of the EMR’s busywork is about optimizing billing for the hospital.

Who is to blame? Start with EMR manufacturers, who lobbied Congress to require every hospital and doctor’s office to install an EMR system; hospital administrators who bought technology that conveniently pushed billing duties onto doctors and nurses; and federal regulators, who imposed on EMRs numerous quality metric requirements that do nothing to improve care.

We do not want to go backward. We believe that computing is essential to the future of medicine. We simply want all EMRs to live up to their promise of improving care and making patient information readily available.

Thousands of doctors in Boston and across the country are expressing the same frustration, through gritted teeth, between exasperated sighs, and in resignation letters. EMRs are driving too many health care providers to hang up their scrubs and white coats in search of work that is less infuriating and more fulfilling.

The sound of medicine is not the click of a mouse. It is the human voice. Let’s bring it back.

To do this well takes time and undivided attention.

Making sense of a patient’s blood panel means knowing the patient’s work and eating habits, and where he or she may have traveled. We need to know if the patient is experiencing a traumatic life event, like the death of a parent or domestic abuse, in order to interpret an elevated blood pressure.

Instead of making this easier, most EMRs create extra work. A lot of extra work, thanks to endless prompts with multiple choice answers that hardly ever fit the facts and that demand click after click to get anything done.

Want to order a simple test? That requires getting through multiple prompts. Need to write a prescription -- an exercise that used to take less than 15 seconds? Another set of clicks.

Typing, filing, mailing results and placing referrals all used to be done by assistants. Now, EMRs put that burden on clinicians, and we must do it during office visits, or “encounters,” as EMRs call them. And when the wrong button is clicked, the wrong test or drug is ordered, or it does not go through at all, delaying medical care.

It’s death by a thousand clicks, and it happens every day.

We are frustrated by EMRs because they pull us away from our patients. We are driven mad by the fact that EMRs in different locations do not talk to each other. And we think it’s just wrong that much of the EMR’s busywork is about optimizing billing for the hospital.

Who is to blame? Start with EMR manufacturers, who lobbied Congress to require every hospital and doctor’s office to install an EMR system; hospital administrators who bought technology that conveniently pushed billing duties onto doctors and nurses; and federal regulators, who imposed on EMRs numerous quality metric requirements that do nothing to improve care.

We do not want to go backward. We believe that computing is essential to the future of medicine. We simply want all EMRs to live up to their promise of improving care and making patient information readily available.

Thousands of doctors in Boston and across the country are expressing the same frustration, through gritted teeth, between exasperated sighs, and in resignation letters. EMRs are driving too many health care providers to hang up their scrubs and white coats in search of work that is less infuriating and more fulfilling.

Death By A Thousand Clicks: Leading Boston Doctors Decry Electronic Medical Records | CommonHealth

Cyber-attacks are real. Every day thousands of intrusions are attempted. Thanks to modern operating systems almost all are thwarted. However if you are still using old or obsolete OS such as Windows XP, Vista, Windows 7 or 8 those systems do not have adequate protection from viruses, trojans, or malware.

The first investment is to upgrade to Windows 10 which has frequent updates for new viruses, trojans and/or malware. Chrome also has regular updates as needed which load everytime you start Chrome.

The video above outlines the progress of the attack this past week which brought down many systems in hospitals and other businesses.

 Remember no matter how well you think you are protected, hackers will find ways to usurp   your system.

The latest in "ransomware".  The hacker will install an encrypted hack. When the user attempts to log in they will receive a message such as this one.

"Your system has been locked and encrypted. It can be restored by sending a payment of XXX via bitcoin.  Click here to begin."

Many users will capitulate and pay the ransom. In business time is money and the amount of time lost can be damaging to reputation and income

Prevention:

Do not DOWNLOAD OR OPEN email attachments from unknown sources
Use current operating systems.
Avoid suspicious emails or websites.  Modern browsers will search for certificates and other indications that the web site is suspicious or has been reported to be carrying malware or trojans.

Meanwhile:

HAPPY MOTHER'S DAY

How Telehealth can add to Precision Medicine

Telemedicine offers speed, convenience, and efficiency but isn't right for every situation. Making the right call for cardiology consults should rests in the hands of primary care physicans making the referral together with the patient, says Jason Wasfy, MD.

In this exclusive video, Wasfy, director of quality and analytics at the Massachusetts General Hospital Heart Center in Boston, discusses how such an e-consult system has worked at his center.

So, there are some patients that need to come into the office. They're complicated, they need a physical examination, they may need to be followed with time, but there [are] other patients where their question for cardiologists is very discrete and limited, and what they really need is to know the answer as quickly as possible. There was probably a time in medicine where doctors would brag about how long their waiting list was, that the doctor that had the longest waiting list to get in to see them was the best physician, and I think that's the old days. We want to deliver care to patients as quickly as possible to relieve anxiety, to make sure that they have the input they need as quickly as possible.

So, e-consult allows us a mechanism to get discrete information about a clinical question, from the cardiologist to the primary care doctor, who can then share with the patient. But because we're accommodating some of the questions that way, we also have more bandwidth in our clinics to see the more complicated patients -- for example, people who need caths or people who need procedures. So, we find it a very effective mechanism of addressing patients' needs in the way that they perceive their own needs.

There are different ways to do e-consult. One is sort of an active referral mechanism, where all the referrals coming into our office, a cardiologist can triage them and say, "Oh, I'll see that one in the office, but this question I can answer without seeing the patient." We do not take that approach. We empower our primary care physicians, together with the patients in the office, to decide what they think is most appropriate for the clinical question. And we really think that's important. Because there are some times when I'm getting a referral that I think I can answer the question about the EKG, but I've never met the patient in person, and I don't understand that they're anxious and that their father had a heart attack at a young age, and these sorts of intangible points that are really hard to know until you meet the patient. That's why instead of going through an active referral process, where you go through the referrals and say I can answer this one via e-consult or I'll see this one in the office, we give that choice to the patient and to the primary care doctor. We allow them that choice.

We've done detailed surveys of our patients and our primary care providers just to make sure that they're happy with the mechanism, and we had have very high satisfaction rates, both among referring doctors and patients. And we think part of that is because we empower them to decide upfront, do they want an electronic consult where they get an answer in 48 hours or are they willing to wait a little longer for an in-person evaluation? We'd like to customize the care we deliver to the patients' preferences and the patients' needs.

Patient engagement is a major factor. Within the bounds of safety...what does your patient want?

Pearls From: Jason Wasfy, MD | Medpage Today

Mom’s Policy, Medicaid Or A Health Exchange Plan: What’s A Grad To Do?

Graduating students now have several options for insurance plans. The Affordable Care Act has introduced several options.

As graduation approaches for thousands of young adults this spring, sorting out your health insurance options may seem more daunting than any political economics problem you faced at school.

You may not think it’s a high priority, but remember: Even healthy young people wind up in the emergency room for all sorts of mishaps, and having health insurance will let you get preventive care, including contraceptives, without paying for it.

As graduation approaches for thousands of young adults this spring, sorting out your health insurance options may seem more daunting than any political economics problem you faced at school.

You may not think it’s a high priority, but remember: Even healthy young people wind up in the emergency room for all sorts of mishaps, and having health insurance will let you get preventive care, including contraceptives, without paying for it.

There are several items to consider when choosing.

Take A Look At Your Parents’ Health Insurance.

In 2015, 29 percent of 19- to 25-year-olds were covered as dependents on their parents’ job-based plan, according to a Commonwealth Fund analysis of data from the U.S. Census Bureau’s Current Population Survey. It was the most common type of coverage for this age group.

Employer-sponsored plans are often more generous than an individual plan on the marketplace, with more comprehensive benefits and lower premiums and out-of-pocket costs. And parents can pass these benefits on.

Compare Coverage Through Your Employer.

Seventeen percent of young adults were insured by their own employer in 2015.

Large employers often offer insurance plans, called PPOs, that let workers choose their own doctors and providers from the insurer’s network and often allow them to seek care outside the network if the patient pays a larger share of the cost. A typical PPO plan offered by an employer with at least 500 employees paid for 87 percent of enrollees’ health care costs on average, according to data from benefits consultant Mercer. Compare that with the most popular silver-level plans sold on the ACA’s online marketplaces, which pay 70 percent of costs.

One benefit of an employer’s plan over your parents’: Buying your own plan may improve the odds that you’ll find doctors and hospitals nearby that are in your health plan’s provider network, said Erin Hemlin, director of training and education at Young Invincibles, an advocacy group for young adults.

If Employer Coverage Isn’t An Option, Consider The State Marketplace.

Twenty-two percent of young adults under 26 had marketplace coverage in 2015.

Marketplace plans must provide comprehensive coverage, including hospitalization, drugs and doctor visits. In addition, if your income is between 100 and 400 percent of the federal poverty level (about $12,000 to $48,000 for an individual) you could qualify for tax credits that will help cover the cost of premiums.

If you have a college health plan that ends when you graduate, you may qualify for a special enrollment period to sign up for a marketplace plan. But if you’re uninsured or insured through your parents, you probably can’t buy a marketplace plan until the next open enrollment period in the fall.

A key consideration: If your parents claim you as a tax dependent, you can’t claim the premium tax credit yourself, said Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities.

Unemployed? Uninsured? Consider Medicaid.

In 2015, 15 percent of people between ages 19 and 25 were on Medicaid.

To date, 31 states and the District of Columbia have expanded Medicaid coverage to adults with incomes of about $16,000 or less.

If you don’t have a job or earn very little and you live in one of these states, you may qualify for Medicaid, which provides comprehensive coverage, typically without a premium.

Unlike marketplace coverage, there’s no open enrollment period for Medicaid. You can apply anytime through your state Medicaid agency, healthcare.gov or your state marketplace.

A key consideration: If your parents claim you as a dependent on their taxes, it could also affect your eligibility.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

What' a Grad to do?

Enzyme drives middle-age weight and fitness changes | National Institutes of Health (NIH)

At a Glance

• Scientists identified an enzyme in animal studies whose activity promotes weight gain and the loss of exercise capacity starting in mid-life.
• A drug that inhibits the enzyme prevented weight gain in mice, increased fitness levels, and reduced the incidence of obesity and type 2 diabetes.
• The findings could lead to more effective weight-loss medications.

Researchers have long known that losing weight and maintaining the capacity to exercise tend to get harder beginning between ages 30 and 40—the start of mid-life. Scientists have developed new therapies for obesity, including fat-fighting pills. However, many therapies have failed because of a lack of understanding about the biological changes that cause middle-aged people to gain weight, particularly around the abdomen.

Dr. Jay H. Chung, an endocrinologist at NIH’s National Heart, Lung, and Blood Institute (NHLBI), was always puzzled by the aging-weight gain paradox. An average adult in America gains 30 pounds from age 20 to 50, even though food intake usually decreases during this period. Chung and his associates thus searched for biochemical changes in middle-aged animals (human equivalent of 45 years). Their study appeared on May 2, 2017, in Cell Metabolism.

The team focused on an enzyme called DNA-dependent protein kinase, or DNA-PK. This enzyme is activated by a specific kind of DNA damage, but evidence has been mounting that DNA-PK has functions beyond DNA repair. One such function is in metabolism.

The scientists looked at levels of DNA-PK activity in the skeletal muscles of rhesus macaques and mice. These levels were low over time until middle-age, when they rose significantly. Further experiments showed that DNA-PK activity promotes the conversion of nutrients to fat and decreases the number of mitochondria, the tiny organelles in cells that turn fat into energy to fuel the body.

Mitochondria can be found in abundance among young people, but the numbers drop considerably in older people. Researchers know that fewer mitochondria can promote obesity as well as loss of exercise capacity.

“Our society attributes the weight gain and lack of exercise at mid-life (approximately 30-60 years) primarily to poor lifestyle choices and lack of will power, but this study shows that there is a genetic program driven by an overactive enzyme that promotes weight gain and loss of exercise capacity at mid-life,” Chung says.

These findings could lead to the development of a new type of weight-loss medication. However, DNA-PK inhibitors have yet to be tested this way in humans. Middle-aged people who are fighting obesity should continue to reduce calories and boost exercise.

Maintaining health and wellness, preventing obesity will decrease diabetes and prevent many chronic diseases.

Enzyme drives middle-age weight and fitness changes | National Institutes of Health (NIH)

A UCLA study shows there could be a TREATMENT for Alzheimer's disease

What happened when Alzheimer’s patients were treated for the diseases we already have cures or treatments for  ?

Last summer, a research group from the University of California, Los Angeles (UCLA) quietly published the results of a new approach in the treatment of Alzheimer’s disease. What they found was striking. Although the size of the study was small, every participant demonstrated such marked improvement that almost all were found to be in the normal range on testing for memory and cognition by the study’s end. Functionally, this amounts to a cure.

These are important findings, not only because Alzheimer’s disease is projected to become ever more common as the population ages, but because current treatment options offer minimal improvement at best. 

Many proposed drug solutions have failed in clinical trials. Last July, a large clinical trial found little benefit in patients receiving a major new drug called LMTX. And after that, another hopeful drug designed to target amyloid protein, one of the hallmarks of Alzheimer’s disease, failed its first large clinical trial as well. Just two months ago, Merck announced the results of its trial of a drug called verubecestat, which is designed to inhibit formation of amyloid protein. It was found to be no better than placebo.

The situation is analogous in kind, if not quite degree, to the many other chronic diseases with which we now struggle, such as diabetes and cardiovascular disease. While we do have efficacious medications for these conditions, none work perfectly, and all have negative effects. Our understanding of the cellular processes at the root of these diseases is sophisticated, but technical mastery—the grail of a cure—has remained elusive.

The method isn’t entirely novel. Researchers have already shown that multi-faceted, comprehensive lifestyle interventions can significantly improve outcomes in cardiovascular disease, diabetes and hypertension. But it’s difficult for these approaches to gain traction for two reasons. First, these protocols are more challenging than simply taking a pill at bedtime. Patients need ongoing education, counseling and support to effect meaningful change. And second, the pharmaceutical mode of treatment is deeply embedded within our current medical system. Insurance companies are set up to pay for medication, not lifestyle change; and physicians are taught pharmacology, not nutrition.

The prevalence of Alzheimer’s disease is expected to triple over the next three decades, to nearly 14 million in the US alone. Diabetes and other chronic diseases are expected to follow a similar trajectory. Trying to confront this epidemic with medication alone will raise a new host of problems, from prohibitive cost to adverse effects, without addressing any underlying cause. We know that comprehensive lifestyle modification can work for many chronic diseases, in some cases as well as medication. It deserves more than passing mention at the end of an annual check-up—it’s time to make it a cornerstone in the treatment not only of Alzheimer’s disease, but of all chronic disease.

So, exercise more, and eat your veggies












A UCLA study shows there could be a cure for Alzheimer's disease — Quartz

Individualized exam schedule for diabetic eye disease | National Institutes of Health (NIH)

At a Glance

• Researchers suggest a new exam schedule for diabetic retinopathy, a vision-threatening eye disease, based on individual risk level.
• The next step is for experts to consider modifying clinical guidelines for eye exams for people with type 1 diabetes. 

People with diabetes have blood sugar (glucose) levels that are too high. Over time, high levels of blood glucose can cause health problems, such as eye damage. The part of the eye most at risk for damage is the retina, the light-sensitive tissue that lines the back of the eye. Without treatment, retinal damage can lead to permanent blindness.

Signs of diabetic retinal disease (retinopathy) can be detected through a comprehensive dilated eye exam before symptoms occur and in time take action to prevent vision loss. Pupil dilation, or widening, is an important part of the exam because it allows a much better view of the retina. To diagnose diabetic eye disease while it is treatable, experts currently suggest that people with type 1 diabetes get an eye exam at least once a year starting three to five years after diagnosis.

Recent studies to find out whether the exam frequency could be tailored to individual risk, researchers analyzed 30 years of data from about 1,400 people with type 1 (insulin-dependent) diabetes. The study was funded mainly by NIH’s National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). NIH’s National Eye Institute (NEI) and others also provided support. Results were published on April 20, 2017, in the New England Journal of Medicine.

 The researchers analyzed data from about 24,000 eye exams with retinal photography. The results enabled them to develop a model to predict the likelihood of an individual progressing to significant, vision-threatening retinopathy based on their current retina exam and blood glucose level.

The findings from the research gives pause to the current recommendation.  

The analysis showed that, among people with type 1 diabetes and recent blood glucose level near the normal range (as measured by an A1C level of 6%), those with no detectable retinal damage could be screened every four years. Those with mild retinal damage could be examined every three years without increasing the risk of vision loss. People with moderate or severe retinal damage, the researchers found, should be examined more often than the current recommendation: every six or three months, respectively. On average, this tailored schedule would result in fewer eye exams and earlier detection and treatment to save vision.  

Telemedicine offers more convenience with remote fundus photography performed in primary care physician offices using retinal fundus cameras connected to the internet, and having images read by a qualified ophthalmologist.

Individualized exam schedule for diabetic eye disease | National Institutes of Health (NIH)

Message Heard? Pain Med Prescribing Down Second Year in Row

Acetaminophen/hydrocodone, the opioid pain reliever commonly sold under the brand name Vicodin, was the most dispensed prescription medicine in 2007.

And 2008. And 2009. And every year after through 2013, according to the QuintilesIMS Institute, which tracks medicine use and spending.

Then, in 2014, this staple of the opioid abuse epidemic fell to second place behind levothyroxine, which treats hypothyroidism. By 2016, acetaminophen/hydrocodone was the fourth most prescribed drug in the nation, with the volume of prescriptions down 7.2% from 2015 and 34% from 2012.

This downhill story helps capture a trend for pain medications in general and the clinicians who prescribe them. The volume of dispensed prescriptions for all pain meds has decreased for 2 straight years now, falling 2.7% in 2015, and 1.7% in 2016, QuintilesIMS reports in its annual review of medicine use and spending, which was released today. Pain meds include both narcotic and non-narcotic analgesics as well as muscle relaxants and topical pain treatments.

The study attributes the decline to more controls placed on pain meds in response to the opioid abuse epidemic. These controls include more stringent prescribing guidelines in recent years, particularly a set issued for primary care in March 2016 by the Centers for Disease Control and Prevention (CDC). The CDC cautioned that opioids are not first-line therapy for chronic pain, and that clinicians initially should consider nonopioid pain relievers and nonmedicine options such as exercise and cognitive behavioral therapy. When clinicians do prescribe opioids, they should start patients off at the lowest dose possible and limit treatment for acute pain to no more than 7 days. In addition, clinicians should monitor patients to ensure the drugs are helping with pain and function without inflicting harm.

"The CDC guidelines have been very powerful in changing physician behavior because they've had a larger audience," said Steven Stanos, DO, president of the American Academy of Pain Medicine, in an interview with Medscape Medical News.

Message Heard? Pain Med Prescribing Down Second Year in Row