Diabetic Education and Prevention by telehealth (smartphone or computer) at home or work

Over 80 million Americans have pre-diabetes

The risk factors for pre-diabetes

1. Male
2. Family history of diabetes
3. High blood pressure
4. Inactive
5. Age.  Increased as you age
6. Weight

Now, according to your score (which you can determine in the video in this article) if your total score is over five it is likely you are pre-diabetic.

This educational program is available online. Discuss this with your physician. Their are courses on weight management, nutrition, exercise and others, all in the comfort of your home or workplace. If you own a smartphone, the possibilities are unlimited. 

Ref: www.fruitstreet.com. 

Ebola outbreak: WHO preparing for 'worst-case scenario' - CNN

It's back,  and probably has never been gone. In the first real test of the new Ebola vaccine WHO is about to embark on a vaccination program in Africa, and the fate of our species may depend upon it's results.

Does that sound a bit histrionic?

You be the judge.

The World Health Organization is preparing for the "worst-case scenario" as it continues to respond to the Ebola outbreak in the Democratic Republic of Congo.

Peter Salama, deputy director-general of emergency preparedness and response at the WHO, said in Geneva, Switzerland, on Friday that it's "going to be tough and it's going to be costly to stamp out this outbreak."

There have been 34 cases of Ebola virus disease reported during the past five weeks, the WHO said Friday. Of those, two have been confirmed using laboratory tests, 14 are suspected, and 18 -- who are deceased -- are considered probable for the disease. Three of the patients are health care workers.

The number of suspected, probable and confirmed cases is significant, so we are very concerned, and we are planning for all scenarios, including the worst-case scenario," Salama said.

Ebola virus disease, which most commonly affects people and nonhuman primates such as monkeys, gorillas, and chimpanzees, is caused by one of five Ebola viruses. On average, about 50% of people who become ill with Ebola die.

The disease is endemic to the Democratic Republic of Congo, and this is the nation's ninth outbreak since the discovery of the virus in the country in 1976.

The latest outbreak is occurring in the Bikoro health zone, 400 kilometers (about 250 miles) from Mbandaka, the capital of Equateur province.

Bikoro health zone has a population of about 163,000, with three hospitals and 19 health centers, most with limited functionality, according to the WHO.

Given the remote location of the outbreak, Salama said, response efforts will be extremely challenging. "It is a dire scene in terms of infrastructure," he said.

"To give you a sense, we are talking about an area that is 280 kilometers even from the provincial capital of Equateur," he said.

The virus is transmitted to people from wild animals and spreads in the human population through human-to-human transmission, either through direct contact with bodily fluids such as blood or secretions or contact with materials that are contaminated with these liquids.

Personal protective equipment, body bags, boxes for transportation and interagency emergency health kits will all be sent to the affected region Saturday, the WHO said. Two mobile laboratories will also be deployed.

Médecins Sans Frontières is setting up four five-bed mobile isolation units to increase the hospital bed capacity in Bikoro, which is currently 15 beds, according to the WHO.

Initial control efforts are focusing on tools such as surveillance and monitoring, safe burials and case management.

Vaccines along with doctors and epidemiologists are on standby in case they are needed, according to the UN.

 

If they are needed, "WHO is in discussions with the government and, if pertinent, will seek approval from the national regulatory authority and the Ethics Review committee to use vaccines against Ebola as part of the response," spokesman Tarik Jasarevik said.

The current vaccine against Ebola is experimental and not a licensed product. Salama pointed out that its use also comes with many challenges, as the vaccine needs to be stored long-term at temperatures between minus 60 and minus 80 degrees Celsius (minus 76 to minus 112 Fahrenheit).

"This is not a simple logistical effort; it's not like doing a polio campaign with oral polio vaccines, where we get it immediately out to the field. This is a highly complex sophisticated operation in one of the most difficult terrains on Earth," Salama said.

West Africa experienced the largest recorded outbreak of Ebola over a two-year period beginning in March 2014; a total of 28,616 confirmed, probable and suspected cases were reported in Guinea, Liberia and Sierra Leone, with 11,310 deaths, according to the WHO.

CNN's Susan Scutti contributed to this report

Ebola outbreak: WHO preparing for 'worst-case scenario' - CNN

Comfort in my final hours

My name is Lucy.

I have stage IV liver cancer. I wanted everything done — even though the doctors told me this disease is terminal. My family, my church and my friends were praying for “the cure.”

Though I believed in God and the hereafter, I wasn’t ready to go. 74-years-old with beautiful children, grandchildren, and a great-granddaughter.

I woke up confused. In the background — wherever I was — I could hear music: “How great thou art.” One of my favorites.

I had a tube in my mouth, and I couldn’t talk. My wrists were restrained, and I couldn’t move. They had me tied down. Everything was blurry. My chest hurt like someone had pounded on it. People in white coats and scrubs surrounded me. I became aware that I was in a room with doctors and nurses and respiratory therapists.

A man introduced himself. He said he was a respiratory therapist, and he was going to pull the “tube” out of my mouth. The endotracheal tube. I gasped and took a deep breath, and I could barely talk.

The team explained to me that I was in the ICU. And because I wanted everything done to me, I had been emergently intubated, restrained, pain and sedation meds given through my veins continuously. My heart decided to stop, and “the team” did CPR on my fragile body. Because by now, I didn’t want to eat. I had lost over 25 pounds from the liver cancer.

I was told that some of my ribs cracked during CPR. I had pneumonia.

A palliative nurse came to talk to me within a few days. I wasn’t out of the jungle yet.

The palliative nurse talked to me about comfort, about acceptance, about peace and being pain-free and being with my family and friends surrounding me.

The palliative nurse talked to me about comfort, about acceptance, about peace and being pain-free and being with my family and friends surrounding me.

Comfort care. DNR, DNI.

New words for me.

I was so sick, so tired, so much in pain. I led a wonderful life.

Now, it was time for acceptance.

I remember those words from my doctors: terminal, no cure, palliative chemo … extending your life.

But at what cost?

Was it worth staying in an ICU in a comatose state? Was it worth having your chest beaten on with CPR and cracked ribs and pneumonia set in? Was it worth being tied down?

I knew the answers.

I was always stubborn. But maybe it was time for acceptance.

Maybe the prayers being sent my way were meant for a peaceful death. A peaceful entrance into the heavens.

I called my family in with my physician, my nurse, and the palliative care nurse.

New words for me.

I was so sick, so tired, so much in pain. I led a wonderful life.

Now, it was time for acceptance.

I remember those words from my doctors: terminal, no cure, palliative chemo … extending your life.

But at what cost?

Was it worth staying in an ICU in a comatose state? Was it worth having your chest beaten on with CPR and cracked ribs and pneumonia set in? Was it worth being tied down?

I knew the answers.

I was always stubborn. But maybe it was time for acceptance.

Maybe the prayers being sent my way were meant for a peaceful death. A peaceful entrance into the heavens.

I called my family in with my physician, my nurse, and the palliative care nurse.

I begged my family to please not put me on a ventilator again.

Please let me be comfortable.

Please make me comfort care.

DNR and do not intubate and do not treat.

I slept quietly going in and out of consciousness. My sons and daughters gathered around. They laughed and cried and told many fun stories of when they were young! My grandchildren and great-granddaughter held hands as they sang “Yes, Jesus Loves Me.”

Another favorite of mine.

And their tiny voices uplifted me and my soul.

I was surrounded by love.

This time — I was ready.

Debbie Moore-Black is a nurse who blogs at Do Not Resuscitate.

Comfort in my final hours

Where Does the Law Against Kickbacks Not Apply? Your Hospital - WSJ

Hospitals enjoy safe harbor regulations regarding purchasing supplies.  It works against the patient.

Doctors have long struggled to care for patients amid artificial shortages of, and soaring prices for, hundreds of drugs—notably generic sterile injectable products, including saline, epinephrine, chemotherapeutic agents, anesthetics, painkillers, antibiotics, even sterilized water.

So when Amazon Business signaled last year that it planned to infuse competition into the marketplace for hospital supplies, clinicians were optimistic that scarce items would soon reappear. Wrong. Mighty Amazon has now backed away from the market. CNBC, which reported the news in April, attributed the decision partly to the barrier posed by hospitals’ tight relationships with group purchasing organizations, or GPOs.

Amazon achieved its remarkable success by building a sophisticated e-commerce platform that promotes competition, transparency and low prices. In contrast, the GPO industry, which supplies doctors with hundreds of billions in medical products each year, rests on myriad conflicts of interest. The result is not only shortages but higher prices.

Four giant GPOs—Vizient, Premier Inc., HealthTrust, and Intalere—control purchasing for most of the supplies used by thousands of hospitals, outpatient clinics and nursing homes. These buying cartels literally sell a market share, taking money from drugmakers and other vendors in exchange for exclusionary supply contracts.

The paradox is that buying groups were promoted as a means to reduce cost for hospitals by ordering large amounts at reduced costs.  It totally eliminates smaller suppliers.

Hospitals sometimes even get a cut of the GPOs’ fees. The industry is very secretive, but when Premier was considering an initial public offering in 2013, Thomas Finn, an analyst at HCMatters.com, explained: “As a member-driven enterprise, it is common knowledge that Premier and other GPOs ‘share back’ with their members and owners. In fact, many hospital executives who are part of the Premier alliance have learned to rely on that share back as an integral part of their annual compensation.”

In turn, GPOs primarily use three big “authorized distributors”: McKesson, AmerisourceBergen and Cardinal Health. The supply chain is set up so that only authorized distributors, which pay fees to the GPOs, are entitled to manufacturers’ rebates for products covered by the contracts. Since smaller wholesalers can’t get the rebates, they’re effectively frozen out.

The results of this anticompetitive system are higher costs and inevitable supply breakdowns. For example, the GPOs would have the public believe that Hurricane Maria triggered shortages of sterile IV solutions by damaging Baxter International ’s Puerto Rican plants. In fact, shortages of saline and other solutions have existed for years, forcing the U.S. to import them from several countries. The deeper reason is that GPOs have relied almost exclusively on Baxter for these products, concentrating production and discouraging potential competitors. Although information on contract terms is confidential, a Baxter press release touting a 2007 deal with Novation (now Vizient) describes the terms as “an extended single source award for IV solutions.”

GPOs didn’t always operate this way. The first was founded in 1910 when several New York City hospitals banded together to buy supplies in bulk. Members paid dues to cover administrative expenses. This nonprofit “co-op” model worked for decades. What perverted the system was a rule that began to allow cash to flow from manufacturers to the GPOs. In the mid-1980s, Congress gave GPOs a “safe harbor” by exempting them from the laws against taking kickbacks from suppliers.

A 2010 report by the Senate Finance Committee found no independent empirical evidence that GPOs save hospitals money. In 2002, however, the Government Accountability Office studied purchases of safety needles and pacemakers in one metropolitan area and found hospitals that negotiated on their own often obtained lower prices. Our estimate, based on accumulated evidence including interviews with former GPO contracting officers, is that the current system may inflate costs by 30% or more. Still, most administrators are enculturated to the GPO system, and the web of rebates and fees helps keep it in place.

Making matters worse, in 2003 the Department of Health and Human Services advised drug makers that the safe harbor would protect rebates paid to pharmacy benefit managers. This has created an upward spiral in the cost of drugs sold through these middlemen, as drugmakers compete for placement on PBM formularies by offering ever-larger rebates.

Without Amazon, the best hope for ending this travesty remains congressional repeal of the safe harbor. 

If Washington is truly interested in lowering medical costs, here’s a straightforward idea: cancel the safe harbor and force the middlemen feeding at the health-care trough to compete on the merits.

Mr. Zweig, a former Journal reporter, is executive director of Physicians Against Drug Shortages (PADS). Dr. Blum is an associate professor at the West Virginia University School of Medicine, a past president of the American College of Emergency Physicians, and a co-chair of PADS.

Write your congressman.










Where Does the Law Against Kickbacks Not Apply? Your Hospital - WSJ

Do you use . "Patients like Me?" for your Chronic Illness? “Generalized Platform” for Members with Chronic Illness: Web-Based Survey Study of Benefits Arising | Wicks | Journal of Medical Internet Research

Many of my readers may have not heard of  "Patients like me " a web site for patients with chronic illnesses. 

ABSTRACT

Background: Launched in 2006 for patients with amyotrophic lateral sclerosis, PatientsLikeMe is an online community offering patient-reported outcomes, symptom tracking, and social features. Every member of the site can see all the data reported by every other member, view aggregated reports, identify “patients like them,” and learn about treatment options in order to live better with their condition. In previous studies, members reported benefits such as improved condition knowledge, increased medication adherence, and better management of side effects. However, the site evolved in 2011 from condition-specific “vertical” communities consisting only of people with the same disease to a “generalized platform,” in which every patient could connect with every other patient regardless of condition and with generic, rather than condition-specific, data tools. Some, but not all, communities received further custom tracking tools.

Objective: We aimed to understand (1) whether members of PatientsLikeMe using the generalized platform still reported similar benefits and (2) assess factors associated with benefits, such as community customization, site use, and patient activation.

Methods: A cross-sectional retrospective custom survey was fielded to 377,625 members between 2016 and 2017 including the Patient Activation Measure (PAM). A benefit index was developed for comparability across conditions.

Results: The invitation was viewed by 26,048 members of whom 11,915 did not respond, 5091 opted out, 1591 provided partial data, and 17 were screened out. Complete responses were received from 7434 participants. Users perceived greatest benefit in understanding how their condition may affect them (4530/6770, 66.91% participants, excluding “does not apply” answers), understanding what might help them live better with their condition (4247/6750, 62.92%), which treatments were available (4143/6898, 60.06%), understanding treatment side effects (4182/6902, 60.59%), and important factors in making treatment decisions (3919/6813, 57.52%). The benefit index was 29% higher for the “most activated” patients (PAM level 4 vs PAM level 1; relative risk [RR]=1.29, P<.001), 21% higher for conditions with some community customization versus none (RR=1.21, P<.001), and 11% higher in those using the site most often versus least (RR=1.11, P<.001).

Conclusions: Members of the generalized platform reported a range of benefits related to improved knowledge and understanding of their condition and treatment management. Condition-specific customization may improve their experience still further. Future studies will explore longitudinal changes to patient activation.

All of this has evolved into a general platform, 

J Med Internet Res 2018;20(5):e175

doi:10.2196/jmir.9909

JMIR-Scaling PatientsLikeMe via a “Generalized Platform” for Members with Chronic Illness: Web-Based Survey Study of Benefits Arising | Wicks | Journal of Medical Internet Research

Choosing Wisely Campaigns: A Work in Progress | Health Care Quality | JAMA | JAMA Network

Choosing Wisely, a campaign to stimulate conversations between physicians and patients about unnecessary tests, treatments, and procedures, began in the United States in 2012. It was designed as a national campaign about overuse. Yet since its launch, the campaign has spread to more than 20 countries worldwide. Choosing Wisely has been hailed by some as a success, evident in its spread internationally and measured through structure and process indicators, such as recommendations developed, societies engaged, and physicians apprised. The conversation has been stimulated, and now delivery systems and clinical practices are beginning to develop interventions that go beyond conversations and recommendations. The success of the campaign in the next 5 years will be measured by the ongoing engagement of physicians in these interventions and, more importantly, associated outcomes. The effectiveness of quality improvement efforts by these delivery systems will determine how influential campaigns are in actually reducing unnecessary tests and treatments—a true measure of benefit.¹

Choosing Wisely will also contribute to controlling rising health expenditures by engaging patients, and making them aware of the conflict between expense and proper diagnosis and treatment.  The issue of cost control thus far has been an upward-down plan.  Choosing Wisely now will create a downward-up path, and enable patients to help control costs.

The age of data analytics which has been empowered by health information technology has created an enormous mountain of health care, diagnoses, and treatment, making it possible to create treatments based upon risk and good outcomes along with the quality of care.  

Alignment With Norms and Values

Innovations that are compatible with norms and values of adopters are more likely to be successful. Choosing Wisely focuses on conversations between physicians and patients, the basis of clinical interactions. A concern in advancing campaigns is maintaining the focus on professionalism and ensuring physician autonomy in making decisions with patients.

The concepts of diffusion of innovation are relevant to understanding the success to date of Choosing Wisely campaigns and to informing strategies that would ensure future viability. This Viewpoint uses diffusion of innovation science to explore factors that facilitated the spread of Choosing Wisely campaigns and how these enabling factors can address challenges in dissemination and implementation.

There are various examples of movements to shift medical culture that had early momentum and resulted in significant changes but were met with major challenges around influence and outcomes. Nearly 2 decades ago, the quality and safety movement galvanized the medical community worldwide by identifying the extent to which preventable errors and lapses in safety were occurring. 

Contextual Factors That Influence Diffusion

Although there are concerns about government motivations, to date Choosing Wisely campaigns have aligned diverse groups of stakeholders in medicine and health care systems (such as patient organizations, national clinician societies, and health administrators) on shared goals. Health care reform in the United States and elsewhere—emphasizing payment reform and shifting from volume to value—has made the campaign even more relevant. In other single-payer health care systems, budgetary pressures provide similar impetus. As organizations continue to react to such changes and shape strategy, Choosing Wisely offers an approach that could align physician, patient, and payer interests.

In many countries, health system leaders and managers are partnering with physicians on implementation strategies of campaign recommendations. Although the evidence base for Choosing Wisely is still modest, there is a growing literature demonstrating reductions in utilization through implementation. For example, in Canada and the United States, pilot projects that include well-thought-out interventions to implement recommendations have returned good preliminary results.⁷ Ultimately, the key to sustained uptake of Choosing Wisely will be more systematic collection and diffusion of this kind of evidence at the system level.

AMA. Published online April 19, 2018. doi:10.1001/jama.2018.2202



Choosing Wisely Campaigns: A Work in Progress | Health Care Quality | JAMA | JAMA Network

Healthcare is not broken — it is working precisely as designed-Casey Quinlan

What’s All the Palooza – Nick van Terheyden, MD – Medium

After many years of living in the DC Metro area, I finally managed to attend the HealthData Palooza event at the Washington Hilton (famous for amongst other things the Assassination attempt of Ronald Regan) that first took place in 2010 — created in part as a response to the then newly established Website and database HealthData.gov
The group sponsored by the AcademyHealth brings together a wide range of companies, people and patients — problem thinkers and solvers big and small to share their voices, insights and above all else passion for solving some of the most intractable health care problems

Pro tip: patients/consumers/PEOPLE can’t navigate current US healthcare system ’cause “system” is sick-care focused wealth transfer play. It ain’t broken, it was built this way. #rightcare #HDPalooza

— Casey Quinlan (@MightyCasey) April 26, 2018

Which begs the question how do we fix it — there is no simple fix to the problems of the complex lumbering system that is an integral part of everyone’s lives. If by some miracle you are in the small minority of people who have not intersected with healthcare…just wait

Focusing on real problems vs creating solutions that are seeking out problems is the better place to start — HIE’s being cited as a good example where the business case does not support the model or the investment. That’s not to say that sharing data is not desirable but rather than the economic model and incentives do not drive the necessary investment in solutions. The health systems do not perceive the value in sharing the patient data to allow patients the ability to select a provider that is not in their network. This is the reality of the Health system working as designed which will fight actively or passively to protect their interests.

The Palooza attempts to summarize the advances in analytics and its effects on health care advances.
For those of you who have made it this far,   please read on...

.What’s All the Palooza – Nick van Terheyden, MD – Medium

What’s All the Palooza – Nick van Terheyden, MD – Medium

A small but growing movement of doctors that don't accept insurance and charge a monthly fee could be a model for big employers like Amazon and JPMorgan

• 
  

• Direct primary care is a small but fast-growing movement of doctors who don't accept insurance and instead charge a monthly membership fee.
• At a time when many are feeling pressure from high healthcare costs, direct primary-care models can be a cheaper alternative that offers perks like quick access to doctors and sometimes wholesale prices on medications or lab tests.
• And it could be a model employer — including JPMorgan, Amazon, and Berkshire Hathaway through their nonprofit healthcare venture — could tap into as a way of lowering costs.

A new kind of doctor's office that charges a monthly fee and doesn't take insurance has been spreading around the US. 

The practices are part of a movement known as direct primary care. Instead of accepting insurance for routine visits and drugs, these practices charge a monthly membership fee — often between $50 and $150 a month — that covers most of what the average patient needs, including visits and drugs at much lower prices. The movement's been gaining momentum at a time when high-deductible health plans are on the rise.

In most cases, the practices recruit patients on an individual or on a family-by-family basis. But often, employers who cover their employee's healthcare have turned to practices as well. 

For many large companies, they're the ones ultimately paying out their employees' claims. Insurance companies are there in the middle to handle the logistics of getting the claim from one place to another, which means you might not realize your employer's footing the entire bill on the other end. 

"I tell people, JPMorgan Chase already buys a $1.5 billion of medical, and we self-insure," JPMorgan CEO Jamie Dimon told Business Insider. It's why his company, along with Amazon and Berkshire Hathaway, two other massive self-insured employers, are looking for new options through a nonprofit healthcare venture. "Think of this, we're already the insurance company, we're already making these decisions, and we simply want do a better job," Dimon said.

Finding ways to "do a better job" could mean a number of things, from leveraging the number of people they cover to negotiate lower rates, to digging in and upending the way healthcare's done entirely.

And it's possible direct primary care could be a consideration.

The potential for employers to tap into direct primary care

Here's how that might look: An employer could cover the monthly direct primary care fee — either directly to the practice or as a reimbursement to the employer — or cover a certain amount. The direct primary care practice could be heavily involved in that process or relatively hands-off. 

For the majority of the practices Business Insider spoke with, employers make up a small portion of their business. Often, a relationship with an employer was sparked by someone who first came to the practice for their family's healthcare and decided they want their part-time or full-time employees to have the service as well. 

The direct primary care practices could be located within the community or housed on-site at the company's offices.  For example, Dr. Kim Corba, who runs Green Hills Direct Family Care in Allentown, Pennsylvania said she's been asked to set up a clinic situated between two employers to cover their needs.

Carolyn Long Engelhard, a public-health expert and professor at the University of Virginia School of Medicine — who has her concerns about direct primary care and its lack of connectivity to the larger healthcare system — said that this is one area where she could see direct primary care thrive because it'd be attached to employer-funded plans. A small but growing movement of doctors that don't accept insurance and charge a monthly fee could be a model for big employers like Amazon and JPMorgan

The bottom line for Direct Primary Care is simplicity.  The patient pays for the visit at the POS. Introducing an employer may create the kind of bureaucracy that DPC attempts to remove.

The minute a third party payor enters the equation, costs and bureaucracy escalate.

Think Your Doctor is better because he is Recertified? Guess again. The National Board of Physicians and Surgeons

Think Your Doctor is better because he is Recertified?  Guess again. The National Board of Physicians and Surgeons

Is   MOC contributing to  'burnout"?  Watch this video from Dana Farber Cancer Institute

Maintenance of Certification (MOC) tests for doctors like us might sound like a good idea at first glance. MOC requires us to take frequent modules and tests to remain certified and keep our jobs.

But the truth is that these tests provide no value to doctors or patients; in fact, they contribute to rising health care costs because they take doctors’ precious time away from treating patients.

Recognizing the MOC burden, nearly 20 states have introduced legislation to curb it, with Washington state passing a bill to forbid it as a condition of licensure in late March. The rest should follow suit.

MOC is a cash cow for the American Board of Medical Specialties (ABMS) and its 24 specialty boards, which administer the exams. According to its most recent tax filings, ABMS president Lois Margaret Nora made nearly $700,000 in compensation from the organization in 2016. Thirteen other executives made over $150,000 from the nonprofit in the same year. In total, ABMS spent over $10 million on compensation, more than half its annual revenues, which largely come from inflated testing fees. That’s good work if you can get it.

as reported in Forbes Magazine. By NIRAN AL-AGBA and MEG EDISON   April 9, 2018

Reviews of MOC.

MOC Journal Club - The National Board of Physicians and Surgeons