Algorithm identifies people with diabetes in Apple Watch heart data

Researchers have developed an algorithm that can identify people previously diagnosed with diabetes in Apple Watch heart data. The learning algorithm provides a strong model for identifying people with diabetes but has yet to prove itself against the tougher task of spotting undiagnosed patients without also racking up false positives.

Cardiogram, an Apple Watch app developer, ran the study (PDF) on 14,011 of its users in conjunction with researchers at UCSF.The data is displayed in the article for several states of heart activity After using data on some of the participants to train a deep neural network, called DeepHeart, the team tested the algorithm on results from the remaining cohort of subjects. The best version of the algorithm recorded a c-statistic of 0.85 in diabetes, making it a strong model.

San Francisco-based Cardiogram is able to identify people with diabetes from heart data because of earlier work that spotted a correlation between variability in cardiovascular activity and the condition.

It was not stated whether the . Apple Watch is HIPAA compliant. HIPAA compliance is a federal regulation which requires all personal identifiying information to be scrubbed from data sources.  The article did not expand on this issue.

RELATED: Apple eyes FDA approval filing for investigational heart device

If Apple files for approval of the app, it will mark a major advance in its long-running flirtation with the healthcare sector. The tech giant stepped up its interest in the space with the introduction of Watch in 2015 and rollout of its ResearchKit framework. Talks with the FDA and involvement in its software precertification pilot program followed. But Apple has yet to seek FDA clearance of a device. 

In another development:

AliveCor gets first FDA nod for an Apple Watch accessory

AliveCor has gained clearance to sell a medical device accessory for Apple Watch. The regulatory nod covers AliveCor’s KardiaBand, a device that clips onto Apple’s smartwatch and performs EKG readings.

Users of the $199 AliveCor device and accompanying $99-a-year service replace the wristband on their Apple Watch with KardiaBand. Machine learning algorithms, dubbed SmartRhythm, then sift through data gathered by Apple Watch’s sensors to establish a normal band of heart rate activity. If the wearer’s heart rate deviates from these historic norms, the app directs the user to take an EKG.

This is where the band itself comes in. The user places a finger on a sensor built into the strap. The band then performs an EKG, also known as an electrocardiogram, to assess whether the electrical impulses that modulate cardiac contractions are firing properly. The resulting 30-second waveform is shown on the Apple Watch screen, after which the user can share it with their doctor as a PDF.

Aspects of the technology are the same as the credit card-sized device, KardiaMobile, AliveCor already sells for use with smartphones. But the incorporation of the Apple Watch sensors and data into the process stands to change when and why users decide to take an EKG reading.

The big question now is whether this more objective approach to assessing when an EKG is needed will translate into improved outcomes for patients. AliveCor has clinical trial data showing its smartphone-based EKG outperformed routine care. In theory, the Apple Watch-based approach should improve on that product, for the reasons outlined by Topol, but that hypothesis is yet to be tested in the wild.

For the broader digital health sector, the important thing is AliveCor has gained clearance to start finding out how its device performs in the real world at all. AliveCor hustled through the regulatory process far faster in Europe than in the U.S. When AliveCor unveiled the device in March 2016, it talked up the prospect of “late spring” availability. That target came and went as AliveCor grappled with the FDA review process.

Vic Gundotra, the ex-Googler who runs AliveCor, told TechCrunch getting the device to market was “one of the hardest things I’ve ever done in my life.” Under the leadership of Scott Gottlieb, M.D., the FDA may provide an easier route to market for companies that try to follow in AliveCor’s wake. But having put in the hard yards, AliveCor has the field to itself for now.

The FDA process is lengthy and costly for device manufacturers, a barrier for smaller manufacturers. Hopefully this will encourage other ground breaking consumer medical devices to proceed.

Read More On

atrial fibrillation digital health wearables AliveCor Apple Apple Watch Food and Drug Administration (FDA)

http://tinyurl.com/y9vygq9r

FDA clears seizure-detecting wearable for epilepsy patients

The Embrace device detected every seizure in an epilepsy monitoring unit, and detected most seizures in a real-world setting. (Image: Empatica)

The FDA has approved (PDF) Empatica’s seizure-detecting wearable for use by epilepsy patients. Empatica picked up the 510(k) clearance for Embrace after the device detected every seizure in a 135-patient clinical trial.

Embrace looks like other smartwatches and activity trackers and shares some of their features. The key difference is Embrace pairs its gyroscope, accelerometer and thermometer with an electrodermal activity (EDA) sensor and an algorithm that analyzes the data stream for signs the wearer is suffering a seizure. EDA indicates whether a person is in “fight or flight” mode.

The result is a device and accompanying algorithm that detected every seizure in a 135-patient trial. Empatica demonstrated the accuracy of Embrace by comparing its readout with the opinions of two to three epilepsy experts who had access to video-EEG data but not the results from the wearable. That trial took place in an epilepsy monitoring unit but Empatica has also generated data showing the device detects most seizures when worn by patients in real-world settings. 

Embrace detected different types of seizures across the trials, including generalized tonic-clonic seizures. Such seizures cause loss of consciousness and can leave patients confused. This results in the underreporting of the seizures in patient diaries. Embrace’s ability to more accurately detect these events could make it a useful tool for sponsors of epilepsy clinical trials.

RELATED: Empatica eyes delivery of wearable epilepsy device

The ability of the device to send alerts to caregivers also makes it potentially helpful in the real world. But there is also a risk the device will cause more stress than it alleviates if it triggers false alarms. Empatica has worked to cut the rate of false positives but they still happen. In the 135-person trial, patients experienced one false alarm every two days on average. The rates seen in other studies have been both a little higher and a little lower.

Empatica is betting that is a manageable downside given the potential upsides of the device.

“Tragically, more than 3,000 Americans die each year from sudden unexpected death in epilepsy and the Embrace offers the potential to alarm family members and caretakers that a tonic-clonic seizure is occurring. The scientific evidence strongly supports that prompt attention during or shortly after these convulsive seizures can be life-saving in many cases,” Orrin Devinsky, M.D., director of the Comprehensive Epilepsy Center at NYU, said in a statement.

MIT Media Lab spin-off Empatica is charging $249 for the device and between $9.90 and $44.90 a month for subscriptions that connect to caregivers and provide other features.

http://tinyurl.com/y8ecfsxa

Association of Unconscious Race and Social Class Bias With Vignette-Based Clinical Assessments by Medical Students | Health Disparities | Learning | The JAMA Network

Is your physician biased ?

“Are you a left-sider or a right-sider?” my classmate asked with a puzzled look during an end-of-the-year dinner among first-year medical students. I was confused. He repeated himself then answered. “Do you sit on the left or the right side in class … that’s right; you sit on the right.” He then mentioned that everyone present was a “right-sider.” Nearly everyone was white.

For the past 18 months, we sat in a racially arranged way in class: most white people were concentrated on the front to the middle right of the auditorium, black women sat the furthest back, and everybody else sat on the left side with few exceptions. This arrangement translated to the lunch tables and other social settings. We may, at first, think of this divide as different parties sharing equal responsibility, but we live in a society where minorities still have negative experiences in today’s integrated schools. These experiences are linked to a history of structural racism: negative media portrayal, policies perpetuating segregation and impeding upward mobility for racial and ethnic minorities. They experience isolation in different ways, and one of the common coping mechanisms is in-group separation out of self-preservation.

Beverly Tatum expounds on this in her book Why Are All The Black Kids Sitting Together at the Cafeteria Table? She describes different groups’ experiences with race and explains the burden on minorities, especially blacks and Latinos. Self-segregation happens out of self-preservation from macro and micro-aggressions; they need support and cultural understanding from their peers, but also feel less valued and invisible among their white counterparts. This is exacerbated by the landscape in our institutions. The portraits that adorn the walls of our study spaces are almost entirely of white male physicians. I believe the unintended racial segregation happening in lecture halls and social circles may have a long-term negative impact on interactions with our colleagues and patients from different backgrounds, and we should use the resources and structures in place to address this earlier in the medical training.

Research shows that medical students and physicians have similar results on implicit-association tests when it comes to anti-black bias. Practicing physicians are, however, are more likely to act negatively on their biases in clinical encounters. It has been shownthat medical school experiences are associated with change in student implicit racial attitudes. Throughout medical school, we are primed by negative comments and portrayal of minority patients through clinical vignettes and in-hospital experiences.

Evidence shows the negative impact of implicit bias particularly on black and Latino patients. Both groups are underrepresented among physicians, while Asian and white doctors are well represented. Studies show that the most effective way to counter one’s biases is to develop positive relationships with members of the “out-group” in question.

The medical field’s attempts to mitigate the effects of implicit bias have so far intuitively focused more on the clinical years. This is manifested via education for trainees and attending physicians, including diversity training, and more informal ways such as book clubs. We pay less attention to the preclinical years. For preclinical students like myself, structures to contribute to addressing implicit bias already exist. Targeting ways in which students interact with peers is an option. Several national organizations are calling for the emphasis of teamwork in medical school, and those changes are implemented in our introduction to the clinical world, including the more recent emphasis put on interprofessionalism. The intentionality driving interprofessional experiences where medical students work with allied-health peers can be mirrored in ensuring that group experiences for preclinical students reflect the diversity of their environment. Staff mention that gender balance is important when creating groups for longitudinal experiences. What if, paired with the emphasis on the importance of teamwork and diversity, groups were intentionally made to be diverse beyond gender?

Further de-randomizing groups could afford more predictable opportunities for students to interact with peers from different backgrounds in settings that may contribute to creating great relationships. As many medical schools thoughtfully shift towards flipped classroom and team-based learning models, students have more opportunities for interactions across professions, levels of training and social groups. Some may argue in favor of group homogeneity. This is, however, a mechanism already in place through extracurricular social networks and affinity groups, often institutionally supported.

Changes to the landscape could have a positive effect on what students value. Given that the portraits adorning the walls of our schools recognize mostly white men, we should restructure the ways in which space is allocated for portraiture. For example, allocating space recognizing students, recent alumni and faculty for their academic prowess could contribute to a landscape more reflective of its dwellers. While social scientists refer to the concept of landscape fairness as aiming to remove forms of discrimination in a built-in environment, I aim to emphasize the importance of recency in the landscape, related to not only fair representation but also temporal proximity for students with respect to those who are celebrated through portraiture. Such recency is likely more inspiring because of commonalities afforded by aforementioned proximity. For example, as a freshman at Howard University, I was inspired by portraits of seniors and recent alumni who were Fulbright fellows and Rhodes scholars because I saw myself in them.

As we aim to mitigate the impact of implicit bias on clinical care, we must remember that bias is not isolated to clinical settings and has effects on interpersonal relationships within the profession. We must also note that negative implicit attitudes towards racial and ethnic minorities in our society are a part of the larger issue that is structural racism. Addressing implicit bias must be done well before the clinical years through a longitudinal approach, but it must also be part of larger synergistic efforts aiming to combat structural racism and the ways in which it affects health.

The author would like to thank Douglas Shenson, MD and Benjamin Oldfield, MD for their guidance in the conceptualization of this article.

Max Jordan Nguemeni Tiako is a medical student.

Author's addendum:  A young Nigerian student who moved to the United States had this to say, "  I did not know I was black until I moved to the United States."

Image credit: Shutterstock.com

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Association of Unconscious Race and Social Class Bias With Vignette-Based Clinical Assessments by Medical Students | Health Disparities | Learning | The JAMA Network

Medicare Beneficiaries’ Out-of-Pocket Health Care Spending as a Share of Income Now and Projections for the Future | The Henry J. Kaiser Family Foundation

Introduction

• Average out-of-pocket cost for Medicare beneficiaries are expected to keep rising over the next decade when it will reach half of a senior's income. 
• The Kaiser Family Foundation estimated that out-of-pocket costs will increase from 41% of average per capita Social Security income in 2013 to 50% by 2030.
• In its analysis of 2013 numbers, KFF said women paid 44% of their per capita income on out-of-pocket costs, which was more than men, who paid 38% on out-of-pocket costs. That’s expected to increase to 52% and 47% respectively by 2030.

Medicare helps pay for the health care needs of 59 million people ages 65 and over and younger people living with permanent disabilities. Yet, people with Medicare can face significant health-related out-of-pocket costs, including premiums, deductibles, cost sharing for Medicare-covered services, and costs for services Medicare does not cover, such as long-term services and supports and dental services. With half of all Medicare beneficiaries living on annual per capita income of less than $26,200, out-of-pocket health care costs can pose a challenge, particularly for beneficiaries with modest incomes and those with significant medical needs.

As one way of measuring health care affordability for people with Medicare, each year the Medicare Trustees estimate Medicare Part B and Part D premiums and cost sharing as a share of average Social Security benefits. This estimate, however, does not include other health-related costs, such as out-of-pocket spending on hospital and skilled nursing facility stays, supplemental insurance premiums, and costs for services not covered by Medicare. The estimate also does not include income from sources other than Social Security.

In this analysis, we assess the current and projected out-of-pocket health care spending burden among Medicare beneficiaries using a broad definition of health care expenses, and in relation to both per capita Social Security and total income. Our results suggest that rising health care costs pose significant affordability challenges for many people on Medicare today, particularly those with relatively low incomes who derive most of their income from Social Security, and that this burden can be expected to grow in the future. This analysis sets the context for understanding the implications of potential changes to Medicare, Medicaid, or Social Security that could shift more health care costs onto beneficiaries or reduce their future retirement income.

Tables: 

Medicare Beneficiaries’ Out-of-Pocket Health Care Spending as a Share of Income Now and Projections for the Future

Medicare Beneficiaries’ Out-of-Pocket Health Care Spending as a Share of Income Now and Projections for the Future | The Henry J. Kaiser Family Foundation

The Wisdom of Doug Farrago, M.D. The Kobyashu Maru of Health Care

Physicians are people, too.

Dr. Farago is a family doctor, articulate and funny !  He takes a subject which is causing major problems in health care administration.  Patients must know what has happened to physicians in the past twenty years.

He has adopted direct patient care to avoid the unsolvable Kobyashi Maru. He elaborates on the shell game of hospital administrators, creating chaos, confusion and distraction.  Learn how he escaped from the jewel of the north and the pearl of the east.  Incidentally he worked at a Federally Qualified Medical Center.

For my fellow colleagues, you are welcome to watch this video as well, and weep.  I know there is not one of you who does not agree with Doug Farago M.D.

It ia not a good time for the United States, nor is it for medicine. However we will change it. After all we cure and conquer diseases now that were unmanageable in the past. No one can identify one particular even that changed everything.   Those of us who are as old as I am remember certain events precipitated by laws which destroyed the freedom of patients while promising less expensive and more availability of health care.  None of that proved to be true.  Yet physicians protested, but did not revolt.  The shell game was in progress.

Are tens of thousands of California kids about to lose their health care? – Orange County Register

Pathetic, shameful and a disgrace !  One of the key measures of a society is how children are treated and more important protected. A key measure is infant mortality rates, vaccination rates and other metrics.  It is well known that the United States is not in the top ranking of chldren's survival rates.

There are numerous governmental agencies that compile this information, to include:

Global Health Observatory (GHO) data

The federal government funds the Children's Health Insurance Program, which is set to expire in September 2019 unless you act now.

Are tens of thousands of California kids about to lose their health care? – Orange County Register

How our Healh System works (exclusive to Health Train Express) Behind the Scenes

A Supplement That May Block The Toxic Effects of Alcohol

If true and verified and credible it adds much to the alcoholism preferred pattern of practice 

I am Dr George Lundberg, and this is At Large at Medscape. September is "be kind to addicts" month (officially National Recovery Month). How can we help?

Of every 100 Americans who drink (140 million), about 12 (16 million) are considered in need of treatment for an alcohol use disorder, and eight will become chemically dependent on alcohol.^[1] Of that eight, one will become addicted very early, even after the first drunken episode. The problem is, we do not yet have a way to predict who that one person will be.

Prevention is always the best answer to addiction. Do not drink. If you do drink, do not ignore the warning signs of becoming a problem drinker.

Let me ask you: How is your blood acetaldehyde today; or, more relevant, how was it late last night? You don't know? Why am I not surprised? Most people don't even think about acetaldehyde.

Ethyl alcohol is metabolized to acetaldehyde by alcohol dehydrogenase in the liver. Acetaldehyde is metabolized to acetate by aldehyde dehydrogenase and then to carbon dioxide and water. Depending on the alcohol dose, some of the acetaldehyde may escape hepatic metabolism and enter the general blood circulation.

Acetaldehyde is a close cousin to my old pathology lab friend formaldehyde. We use it to pickle surgical and autopsy tissues for preservation. Both are known carcinogens. Our body's defense mechanism against excess acetaldehyde is the amino acid l-cysteine and glutathione. These molecules, similarly to thiamine, contain a sulfhydryl group that is chemically active against aldehydes.

Unless you are one of those people (typically East Asian) who are genetically deficient in aldehyde dehydrogenase or are taking disulfiram, you can metabolize roughly one stiff drink per hour. If you drink more than that, depending on body weight, gastric contents, and the efficiency of your metabolic alcohol breakdown, acetaldehyde will build up because aldehyde dehydrogenase capability can be overwhelmed.

If you quit drinking at 11:00 PM, then around about 1:00 AM, your acetaldehyde level may be elevated and you may feel symptoms of acetaldehyde toxicity, including skin flushing, tachycardia, palpitations, anxiety, nausea, thirst, chest pain, and vertigo. Of course, you are trying to "sleep it off," so you may not feel toxic until the next morning when that dreaded hangover appears.

Metabolizing Alcohol

My friends in the nutritional supplement community tell me that you can enhance the metabolism of blood alcohol to acetate, carbon dioxide, and water and minimize the acetaldehyde molecular logjam by taking oral supplements. L-cysteine, vitamin C, and vitamin B₁ are purported to help. At supplement doses, they are cheap and harmless at worst. At best: Goodbye, acetaldehyde toxicity; hello, restful sleep. About 200 mg of L-cysteine per ounce of alcohol consumed is sufficient to block a major portion of the toxic effect of acetaldehyde. But because alcohol is absorbed and metabolized rapidly, it may be necessary to take L-cysteine before and concurrently with consumption to maintain protection. Also, an excess of vitamin C (perhaps 600 mg) can help keep the L-cysteine in its reduced state and "on the job" against acetaldehyde. Experts recommend these doses (with or without extra B₁): one round before drinking, one with each additional drink, and one when finished.

Some say that this regimen works very well. Do not ask me for a list of published randomized, double-blind clinical trials. Not yet, at least. Research funding into "harm reduction" from addicting substances has not enjoyed favored status in research priorities.

Unfortunately, this concoction may have little effect on next-day hangovers, the causes of which are complex and resistant to prevention—except, obviously, by not drinking too much, which is, of course, the best answer to alcohol anyway.

With drug users, be redemptive, not punitive.

That is my opinion. I am Dr George Lundberg, and this is At Large at Medscape.A Supplement That May Block The Toxic Effects of Alcohol

A 2017 New Year’s wish list for healthcare | Suneel Dhand

My New Year’s Wish List

1. Healthcare information technology

2. Patient safety and healthcare quality

3. Patient satisfaction and improving the hospital experience

4. Direction of healthcare consolidation and private doctors

5. Healthcare costs

None of the above categories are exclusive, nor independent of the others.

Dr Suneel Dhand elaborates in the following video

Suneel Dhand is a physician, author and speaker. He is co-founder at DocsDox and founder at DocSpeak Communications. Learn more about him here.






A 2017 New Year’s wish list for healthcare | Suneel Dhand

State air board has urged a 500-foot buffer zone but now emphasizes design rather than distance.

Regulators shift focus on housing by freeways

State air board has urged a 500-foot buffer zone but now emphasizes design rather than distance.
By Tony Barboza and David Zahniser

Twelve years ago, California air quality officials delivered a warning to cities and counties: Avoid putting new homes in high-pollution zones within 500 feet of freeways.
That advice, which relied on years of research linking traffic pollution to asthma, heart attacks and other health problems, was aimed at keeping “children and other vulnerable populations out of harm’s way,” according to the state Air Resources Board’s 2005 handbook .

But earlier this year, the air board shifted its stance. It issued a newadvisory that emphasizes design rather than distance, recommending anti-pollution features such as air filters, sound walls and thick vegetation as “promising strategies” to reduce the health risks from freeways.

With those measures, communities can build “while simultaneously reducing exposure to traffic-related pollution,” the air board said.

In making that change, air regulators acknowledged a stark reality: Despite health risks, cities desperate for more housing at a time of soaring rents keep approving homes near traffic pollution. The Times reported earlier this year that residential development along freeways has surged in the decade since the air board issued its warning.

Business leaders and housing advocates have cheered the pivot by the air board, contending limits on home building near freeways will worsen an affordability crisis. The new advisory has also been embraced by state planning officials, who say urban development near transit is essential to fighting climate change by reducing reliance on cars.

But some worry that amid a push to build homes, the air-quality agency has muddied what had been a clear, if controversial, health warning.

Scott Fruin, professor of preventive medicine at USC, said the air board’s latest document presents best-case scenarios and overstates the extent to which air filters and other anti-pollution measures protect residents. By recommending those steps, he said, state regulators “may give the false impression that it is now OK to put schools and residences close to freeways.”

“The best current strategy to reduce near-freeway exposure is not to put schools and residences there in the first place,” said Fruin, who previously worked at the Air Resources Board. “Even with the best reduction measures available, air pollution in these locations will remain unhealthy.”
Air board officials said they prepared the advisory to give policymakers the latest, scientifically based options to reduce pollution exposure at a time when the state is encouraging home construction near transit lines that are often next to freeways and other high-traffic corridors.

Those projects are challenging in cities like Los Angeles, “where freeways and major thoroughfares abound,” air board spokesman Stanley Young said. “In responding to that reality, we felt it was important to give planners and developers information on how to mitigate the impacts,” he added.
Kurt Karperos, a deputy executive officer for the air board, said the April advisory does not change the agency’s 2005 recommendation to avoid siting homes within 500 feet of freeways. “That’s a very basic health position that the agency has taken and we still stand by.”

In recent years, Karperos said, some have suggested the agency replace its recommendation for a 500-foot buffer, since vehicles have become less polluting over the last decade. “We disagreed.”
Still, one official in Gov. Jerry Brown’s administration reached a different conclusion, saying the 2005 recommendation “was replaced” by this year’s advisory on air filters, sound walls and other anti-pollution strategies.

Ken Alex, who directs the governor’s Office of Planning and Research, pointed to the April advisory as he defended the state’s decision to finance affordable housing next to freeways. The air board’s position is “much more nuanced than ‘don’t build’ ” within 500 feet, said Alex, whose agency is responsible for long-range policies on how California grows and develops.

State air regulators say their 2005 guidelines have not, in fact, been replaced.
Air Resources Board officials said they decided to supplement them in light of new science on freeway pollution and the effectiveness of air filters and other measures. Regulators drafted a report — an appendix to be considered in addition to the 2005 guidelines — and presented it to the air board in January 2016.

At that meeting, air board chair Mary Nichols acknowledged that the push for dense urban development, which can reduce driving and overall emissions, also can “result in increased exposures for people who live or go to school and spend any time outdoors in areas near roadways.”
“Trying to optimize both of these strategies has proven to be somewhat controversial and an interesting challenge,” Nichols said at the meeting.

The final document, published in April, was an advisory. Air quality officials do not have the power to regulate land use. The document said research shows “the public health, climate, financial, and other benefits of compact, infill development along transportation corridors” and found alternatives to distance-based guidelines “that can protect public health while not dictating development patterns.”
Among the suggestions in the report: Lower speed limits to 55 mph or less and install roundabouts to reduce vehicle emissions. Design city streets with parks, bike lanes, wider sidewalks and buildings with “varying shapes and heights” to disperse traffic pollutants.

The Air Resources Board’s influence has grown considerably over the last decade as its core mission — protecting people from pollution — has expanded to include efforts to slash greenhouse gas emissions. That shift has sparked criticism from some environmentalists, who contend that the board has made tackling health threats from local pollution secondary to the global fight against climate change.

The new focus on anti-pollution design puts the air board in closer alignment with the city of Los Angeles, which has adopted stronger filtration requirements but has not imposed limits on how close homes can be built to freeways. That emphasis also drew praise from housing advocates and developers, who viewed the 2005 guidelines skeptically.

Freeway sound barriers

Stuart Waldman, president of the Valley Industry and Commerce Association, said the air board’s latest advisory “just shows that the original policy was unrealistic to begin with.”

Alan Greenlee, executive director of the Southern California Assn. of Non-Profit Housing, said he is happy the state “seems to have moved in the direction of allowing building where previously they weren’t interested.” With filters and other anti-pollution measures, developers “can house people affordably and healthfully in areas where the government says there are air quality issues.”
Some environmentalists view things differently.

Multi-function walls: Solar, sound and pollution barrier

Enivronmental barrier

When the air board’s handbook came out in 2005, “we thought that was a real step forward,” said Bill Magavern, policy director for the Coalition for Clean Air.

Environmental groups have largely favored the state’s push to concentrate new homes near transit, citing the climate benefits. But without limits on home building near freeway pollution, those policies will have unintended health consequences, Magavern said.

“New housing should be well planned so that it’s not putting residents’ health at risk,” Magavern said. “The goal is to have the homes near transit, not near freeways.”

In Southern California, officials with the South Coast Air Quality Management District say they continue to send letters to developers suggesting they increase the distance between new homes and traffic. In the Bay Area, air quality regulators last year published interactive traffic pollution maps and planning guidelines that recommend some of the same design measures as the state.
The Bay Area Air Quality Management District advised communities to put new homes as far from freeway pollution “as is feasible.” The words “as is feasible” were added “at the heavy insistence” of developers and affordable housing advocates, said Jackie Winkel, a principal environmental planner with the agency.

tony.barboza
@latimes.com
Twitter: @tonybarboza
david.zahniser @latimes.com
Twitter: @DavidZahniser

Social Capital investor Kristin Baker Spohn's health bill horror story

Kristin  Baker Spohn is no mere mortal when it comes to hospital administration.  If you are feeling inadequate or incompetent.,,,don't.  The best experts are humbled by the gordion know which is now hospital charges. You see it is the outcome of fee for service charges, mixed with capitation, and contractual arrangements by disparate health insurers. The computer systems simply cannot keep up with the myriad changes of the Affordable Care Act, Medicare' annual changes in reimbursement, new ICD 10 codes, 


This exec has spent her whole career in health care, and even she couldn't get her hospital bill fixed

This is her story about what happened when she noticed a duplicate billing for a procedure she had during her pregnancy...

"I've spent my entire career in health care.

It's impossible to work in this industry and not lament how challenging our system can be for patients. But I didn't truly appreciate its complexity until I was the one navigating it on my own.

Several years ago, I was diagnosed with gestational diabetes and classified as a "high risk" pregnancy. Following my doctor's orders, I had an additional ultrasound to check on the growth of my baby. A little over a week later, I went into labor and delivered my happy and healthy son.

We settled in with our new life at home and in a few weeks the onslaught of hospital bills and explanations of benefits (EOBs) from my health insurance administrator arrived. As the diligent chief financial officer and resident health care expert of our family, I jumped in, determined to reconcile the insurance reimbursement with the hospital bills.

In the haze of new motherhood, my recollection may be fuzzy, but it went something like this:

In one hospital bill, I noticed that there was a duplicate charge for my additional ultrasound.

Most people would groan -- or worse, not even notice the duplicate charge -- but for me, it was game time. I felt like an athlete who had trained for this moment for years. My finance background and attention to detail enabled me to reconcile and find errors in complex financial statements and models. My work at Castlight prepared me to understand all of the different healthcare systems, billing and reimbursement codes. And my weird love of negotiation energized me as I approached the starting line.

How it went down

Step 1: Pull all the documentation together. It is immediately clear that the information in the bills and EOBs isn't sufficient. I need an itemized bill from the hospital and a detailed EOB from my insurance administrator in order to make sense of all of the charges. Because I am on a high-deductible plan like millions of Americans, I also need the benefits coverage detail and my accumulators (how much of my health insurance deductible I had spent at the time of the ultrasound) in order to calculate my co-insurance responsibility.

Step 2: Log into my insurance provider's web portal to look up ultrasound coverage and attempt to determine my remaining deductible at the time of the ultrasound. I find the coverage information under "imaging benefits" and read that ultrasounds are "covered as a preventive service," but it's unclear what constitutes a preventive ultrasound vs. a non-preventive ultrasound, and which category mine falls into. I will need more detail from the hospital to figure this out.

Step 3: Call the hospital to get an itemized billing for the date of service which included the ultrasound. I request the CPT code for the service and am told that it is in a different department and I'll need to call back after 9am the next day.

Kristin Baker Spohn

[At this moment, my son starts crying. Break to change his diaper.]

Step 3b: Call the other hospital department line and ask for the CPT code (the guy on the line is shocked I know what a CPT code is and is confused why I'm asking for it).

[Next, I break to put my son down for a nap.]

Step 4: Call the insurance administrator for benefits coverage information related to ultrasounds. I'm informed that my benefits detail is specific to my employer's coverage and I should call my company's benefits team to ask for it.

Step 5: Call my company's HR team. They say, actually, since we are a fully-insured employer, the benefits should be available through my insurance administrator. Of course.

[Break again to take a quick work call.]

Step 6: Call the insurance administrator back and ask for the detailed summary of benefits. The support representative says I can go on the web portal, download, print and fill out and a request form and the document will be snail-mailed to me. Snail mail!

Step 7: Put my son in a stroller and walk to Fedex/Kinko's to print out the form and mail it in.

[Wait several weeks, it doesn't arrive. Baby gains two pounds!]

Step 8: Call the hospital back to request that they not send my bill to collections as there is an ongoing discussion with the billing department and insurance administrator over benefits coverage. I am assured by the support representative that this is noted in my file.

Everyone having fun yet?

Good, because we're going to rinse and repeat...for several weeks.

Why I gave up

After bouncing between three web portals and at least five call centers (across hospital departments and insurance administrator customer service lines), and spending more than 18 hours on the phone asking for CPT codes, diagnosis codes, and benefits information, and requesting extensions on my bill so that I could continue to pursue the reconciliation, I received….a collections notice.

I had been confident I could take care of this situation on my own, but after weeks of roadblocks and hold music, I felt defeated. I paid the bill. I couldn't risk the negative impact an unpaid bill could have on my credit score as my young family considered buying our first home.

Despite the fact that I had a (self-designated) advanced degree in healthcare technology, benefits and billing, I failed to successfully navigate the system.

I was recovering from childbirth, caring for a newborn, working on my company's upcoming IPO, and struggling to reconcile my hospital bills from a set of common services in a pregnancy.

My experience, while personally disheartening, added new fuel to my my passion for driving innovation and change in healthcare. If can't figure this out, what hope is there for the rest of us?

How health care could be

Contrary to some of the recent rhetoric from lawmakers, high-deductibles and health savings accounts (HSAs) won't magically create empowered healthcare consumers or a functional healthcare marketplace.

Stakeholders across the healthcare ecosystem system need to innovate, remove friction points and thoughtfully design products and processes that enable the experiences we would want for our own families. I've worked to help build two such innovative companies. And I'm joining Social Capital to broaden that reach.

I'm looking to work with health care entrepreneurs that understand the world as it is today, but also see how it could be. A world where everyone gets the experience they deserve, whether they're experts in the healthcare system, or the next new parents struggling to understand a bill.

Social Capital investor Kristin Baker Spohn's health bill horror story