Health Mishaps of the Last Century – What were the Worst?

We had ‘asthma cigarettes’ or burning powders which contained stramonium or nitrates that nullified any benefit due to the deleterious effect of the smoke itself [1,2] around the turn to the mid last century. Marketing at the time declared asthma cigarettes, ‘agreeable to use, certain in their effects, harmless in their action [and] safely smoked by ladies and children’. Such a recommendation today is unthinkable.

An infant feeding bottle that used a rubber tube to deliver the milk to the baby became known as the “Murder Bottle” because of the bacteria that lurked in the rubber tube. It took several decades for the bottle to be banned.

The armed serviced encouraged soldiers to smoke tobacco as a means of “settling the nerves”, though withdrawal symptoms did anything but. So many military people returned home from the wars addicted to nicotine, which often resulted in a premature demise.

The widespread use of asbestos on ships, in asbestos cement sheeting and in-ceiling insulation, was a major danger that took several decades after exposure to eventuate in asbestosis or mesothelioma, both equally devastating.

Feeding dogs with infected sheep offal allowed hydatids to take hold on the human population. 

Thalomid tablets, containing thalidomide, were a major prescribing disaster of the 1950s 

Used as an anti-nauseant and mild sedative in early pregnancy, many children were born with limbs missing. (The only saving grace was that several doctors gave these samples to their wives to use, so they also had the financial means to support their disabled children after birth)
In Australia, we still see the fallout of APC (aspirin, phenacetin, and caffeine) powders, a very popular analgesic until the 1960s. It was a staple in most Aussie households and the mantra, “A cup of tea, a Bex, and a good lie down” entered the everyday language. Later when it was discovered that phenacetin caused kidney damage this ingredient was dropped or changed to paracetamol. However, by then the mantra was synonymous as a pathway to contracting analgesic nephropathy and bladder cancer! [4]

There are countl

ess other missteps in medical history which caused more harm than good. Which stick in your mind?

References

1. https://www.australianpharmacist.com.au/the-original-puffer-2/

2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2844275/

3. https://www.abc.net.au/news/health/2018-06-28/thalidomide-william-mcbride-named-birth-defect-links/9920446

4. https://onlinelibrary.wiley.com/doi/full/10.1111/1753-6405.12252

The Fascinating World of Food Scanners - The Medical Futurist

Would you like to know what is in that snack? How about your dinner plate, or the meal just served to you at the restaurant, fast food place, or the meal delivered to you from Plate, or other online food order?

Advances in technology and 'sniffer chips' can analyze biological chemicals and tell you.  This technology is not yet widely available.  However, it is coming soon Think about what it will do for health and wellness and your plans to lose 25 pounds before the holidays.

SCIO uses infrared spectrometry to identify chemical fingerprints

We strongly believe that digital health can bring healthcare into the 21st century and make patients the point-of-care.

There are two major issues. One is size because the device must be handheld to become popular. With current technology, this means engineers have to sacrifice sensitivity and accuracy in order to achieve a convenient size. The other issue is the algorithm. SCiO sends data to the cloud which then sends its calculation back to the device. But to simplify what the algorithm has to do, users need to tell the scanner specifics – like whether the sample is a portion of solid food, a liquid, or vegetable. These inconveniences are the price of keeping the scanner small.

There aren’t any promising handheld food scanners on the horizon besides these, but there is no reason to believe a solution will not arise in the coming years. The challenge is not when a workable device comes along but what we will do with the large amount of data it generates.

Big data and the Internet of things will improve nutrition
Let’s say a scanner tells me how many grams of sugar my fruit contains, or what the alcohol percentage of a drink is. So what? It won’t change my behavior and dietary habits unless I’m a dietitian and understand what the data means, and how it can be acted upon. Food scanners will need to progress similarly to wearable health trackers – move from raw data to automated analysis and smart suggestions to the user.

Learn more about the most exciting technological changes shaping healthcare! A good food scanner should accurately determine ingredients, and compare the data to my lifestyle, dietary choices, and my genomic background. Given how different we all are genetical, two people might digest the same food at a different pace. One might be allergic to an ingredient while the other is not. So far, pure luck and experience have alerted us to these differences. It should not work like that. Eating should be a conscious process where we know what we eat, and know what we should eat for optimum health. A food scanner, supported by a smart application could fill this place.

But let’s not leave out an interesting side note here, namely, incorporating genetic information into food scanners. I already have the data of my complete DNA sequence at home in a digital file. Literally, thousands of studies speak to the genetic aspects of nutrition, a field called nutrigenomics. I should be able to learn what foods and individual ingredients are bad for me. Genetic tests showed me that I’m sensitive to caffeine and process alcohol more thoroughly than most people (I’m Hungarian after all).

Nutrigenomics tries to understand how nutrition affects our metabolic pathways, and what we can do to get the most out of nutrition in a personalized way. If I’ll have the opportunity to choose another type of meat or cheese as a smartphone app suggests based on my DNA, I will enjoy the meal more and take better care of my body in the long run. With access to such data, a scanner or app could tell us what products not to buy at the grocery store, what type of food makes us more productive, sleep better, or just feel healthy. Right now we’re depending on blind luck.

Some people wonder if this wouldn’t be an overly technological world where devices, scanners, and apps tell us what to eat and do. I prefer to look at it from a different angle, from the benefits of finally knowing what we eat and what ingredients lead to positive and negative consequences. I see customization to my specific genetic background as another benefit, too.

Diabetes patients would know how many carbohydrates their food contains. But knowledge doesn’t change behavior alone, otherwise, nobody would smoke by now. Knowledge supported by gaming or technologies revealing our lifestyle choices to our family members or caregivers might do. Patients with rare genetic metabolic disorders such as phenylketonuria would know what to avoid at all cost. People with allergies could avoid dangerous meals. Having a good diet would not rely on the experience we bring with us from childhood and what we have learned since then. Instead, it could be based on informed decisions. If it means a food scanner should become a commodity in my life for this, count me in.

Tellspec is another handheld scanner device to analyze food. Here is how it works.

The developer of Tellspec is Tellspec’s CEO, Isabel Hoffmann, is the recipient of the 2018 Women in Innovation awarded by the European Institute for Innovation and Technology (EIT).

These devices can also analyze other substances besides foods. The manufacturers of both scanners offer SDKs for developing other analytic profiles.

Infrared spectroscopy has been around for a long time. Sir William Herschel was the first to recognize the existence of infrared in 1800. Interest in IR was not explored further for 80 years. During 1882-1900 several investigations were made into the IR region. Today's iteration is the result of microchips and miniaturization of the scanner, merging it with cloud-based software and algorithms which can be plugged in via software to modify the scanner's range of detection.

The author:  Gary M. Levin M.D.

The Fascinating World of Food Scanners - The Medical Futurist:

IDx-DR, the First FDA-Approved AI System, is Growing Rapidly

Screening for diabetic retinopathy has become easier to access. both for patients with diabetes, primary care providers, and specialists.  The use of artificial intelligence and image analysis using machine learning represents a major improvement for public health. It is already in use in many places.

Moderate Proliferative Diabetic Retinopathy

IDx-DR, a hybrid hardware/software artificial intelligence device is capable of diagnosing diabetic retinopathy without human intervention. The system is the first FDA-approved autonomous artificial intelligence (AI), using its software to analyze images from a retinal camera for evidence of lesions. These lesions are a sign of retinal damage that is associated with diabetes and are what physicians look for in diagnosing eye disease in diabetic patients. Recently, we took the time to check in with IDx CEO and Founder Michael Abramoff, MD, Ph.D., about how this innovative technology has fared in the past year.

IDX-DR was only in place at the University of Iowa Health Care when we spoke with Dr. Abramoff last summer, however, he notes that the technology is now implemented in over 20 locations in the country. Some of the institutions utilizing this AI technology include:

Blessing Health (Quincy Il.)
Johns Creek Primary Care. (Suwanee, GA)
Johns Hopkins
LCMC (New Orleans, LA)
University of Iowa Health Care (Iowa City, IA)

“The company has done well in developing an algorithm that can detect the possibility of early disease,” said Tim Beth, DO, Family Medicine, Blessing Health Center, in a press release. “We would be missing patients if we did not use it.”

“After I see the patient, if they qualify for it or if they don’t have an eye doctor, we do the exam and get immediate results,” he continued. “If there is any evidence of retinopathy, we refer them to an eye doctor. If there is no evidence of retinopathy, we’ll do it again next year.”

One of the unanswered questions about IDx-DR technology is whether it is improving patient outcomes. Dr. Abramoff noted that there are a number of existing studies that show early detection of diabetic retinopathy can improve patient outcomes, but it has not yet been proven in IDx-DR. To address this, IDx is conducting several studies with early partners to determine whether patients who receive a positive result from IDx-DR are actually getting to the eye care provider and receiving proper treatment. Additionally, the company recently launched at a chain of retail health clinics called CarePortMD, which has a unique care coordination model that ensures patients with positive IDX-DR exam results are transmitted to the patient’s primary care doctor and same-day or next-day appointments are made with an eye care specialist. IDx plans to expand this care coordination model to other settings to ensure patients are getting the follow-up care they need.



IDx-DR, the First FDA-Approved AI System, is Growing Rapidly - Docwire News:

More than 400 UCLA medical school students get a free education thanks to major donation - Los Angeles Times

Medical school isn’t cheap.

The median tuition was $38,119 at a public medical school, for a student paying in-state tuition, fees and health insurance during the 2018–2019 academic year. And that number, which comes from the Association of American Medical Colleges, is on the low end. The median cost for tuition, fees, and health insurance for students at private schools in that time span was more than $60,000.

A $46-million donation from entertainment billionaire David Geffen means 414 medical school students are receiving full-tuition merit scholarships

UCLA Chancellor Gene Block, left, presents an award to David Geffen in 2014. Geffen has donated more than $400 million to the university, mostly for the medical school.

(Imeh Akpanudosen / Getty Images)

The UCLA David Geffen School of Medicine announced Monday that the DreamWorks co-founder, who gave the school $100 million in 2012, has donated an additional $46 million to continue to fund merit-based scholarships so medical students do not have to take on weighty loads of debt. His UCLA donations total nearly half a billion dollars in the last two decades, much of it to the medical school.

The scholarships cover tuition and expenses, and students are told of the award when accepted to the medical school. The school expects that the $146 million will fund 414 scholarships — 20% to 30% of each class for a decade, ending with the class of 2026.

Last year, 75% of U.S. medical school graduates had accrued debt that averaged almost $200,000, according to an Assn. of American Medical Colleges Survey of graduates from 150 medical schools. For California residents, tuition and fees alone at UCLA’s four-year program cost upward of $42,000 annually.

Medical students do tend to have higher-income parents who are more likely to have college degrees, according to surveys from the Assn. of American Medical Colleges.

Geffen declined to comment on the donation via a university spokesman. The medical school bears his name after a $200-million gift in 2002, and in addition to this scholarship, he donated $100 million in 2015 to start a private school meant in part to serve the children of UCLA faculty members.

UCLA is not the only school to seek out large donations for its medical students. Last year New York University’s School of Medicine announced that it was raising $600 million from private donors to cover tuition for all students.

Most medical school students who gain acceptance have one to three schools to choose from, said Geoffrey Young, senior director of student affairs and programs for AAMC. As a former admissions committee member at three schools, including the Medical College of Georgia, he said, “If we could use scholarship money to entice someone to come to that school, I would. That’s a free market.”

Geffen was clear that he wanted to use merit-based scholarships to attract the best potential doctors to the school, said UCLA Health Sciences Vice-Chancellor Dr. John Mazziotta. Other students do have access to need-based scholarships, and Mazziotta said his ultimate goal is to start an endowment that would fund UCLA medical school for all students “forever” — an endeavor that would take upward of $1 billion, he said.

The scholarships awarded to UCLA Medical School are based on merit, not need. Not all students receive the scholarship as only about 30% of students receive the funds.

Some schools offer to fund based upon need, or geographic commitment to serve in an underserved community.

Service scholarships

Service-based scholarships funded by the federal government offer students a chance to fund virtually their entire education in exchange for a commitment to serve a certain population. Among the more popular options is the National Health Service Corps Program, which requires a year of work as a primary care doctor in an underserved region for every year of scholarship funding, with a minimum of two years of service. The military-sponsored Health Professions Scholarship Program provides a full scholarship to medical school in exchange for an obligation to serve as a military physician.

Outside scholarships

When students interview at UC Davis, they are given a written list of available outside scholarship opportunities. It is 32 pages long and is still is only the tip of the iceberg.

“In terms of…donors and agencies that sponsor students, many of these resources spring from local community goodwill,”

Check with community organizations such as county medical societies, and Rotary, Lions or Soroptimist clubs to see what type of scholarship opportunities are available.

Kaiser Permanente is offering 'free medical school' during the next five years, with a commitment to work at a Kaiser Hospital for several years

NYU Medical School Plans Free Tuition For Those Studying To Be Doctors

Students will not have a totally free ride, however. According to The Wall Street Journal, most medical students will still foot the bill for about $29,000 each year in room, board, and other living expenses. The scholarships will help 93 first-year students along with 350 already partially through the program, the Journal reports. Several students enrolled in a joint MD/Ph.D. program are already offered free tuition under a separate program. NYU also says medical school debt is "reshaping the medical profession," as graduates choose more lucrative specialized fields in medicine rather than primary care. 

Columbia School of Medicine, one of the most prestigious, has received a large grant from an alumnus, Dr. P. Roy Vagelos, 88, the former chairman of Merck & Co., and his wife, Diana, are donating $250 million to the school, $150 million of which will fund an endowment that the school projects will ultimately enable it to underwrite its student financial aid. Those students with the greatest financial need would receive full-tuition scholarships, while others would get only grants, not loans, to make up their need, the school said.

The couple also funded the construction of the Vagelos Education Center at the medical school, which is filled with high-tech classrooms and facilities. Credit...Philip Greenberg for The New York Times

The Vallejos Education Center was designed by Elizabeth Diller and Ricardo Scofidio, founders of Diller Scofidio + Renfro. Available on Amazon Kindle










More than 400 UCLA medical school students get a free education thanks to major donation - Los Angeles Times: 

Put Away The Jade Eggs And Garlic: This Doctor's 'Vagina Bible' Separates Fact From Fiction | On Point

In her funny, fact-based book, OB-GYN and New York Times columnist Dr. Jen Gunter separate myth from medicine about women’s bodies.

One of the core tenets of medicine is informed consent. We, doctors, provide information about risks and benefits and then, armed with that information, our patients make choices that work for their bodies. This only works when the information is accurate and unbiased. Finding this kind of data can be challenging, as we have quickly passed through the age of information and seem to be stalled in the age of misinformation.

Snake oil and the lure of a quick fix have been around for a long time, and so false, fantastical medical claims are nothing new. However, sorting myth from medicine is getting harder and harder.

In addition to social media feeds that constantly display medical messaging of variable quality, there are the demands of a headline-driven news cycle that constantly requires new content-even when it doesn't exist. With women's bodies, there are even more forces of misdirection at work. Pseudoscience and those who peddle it are invested in misinformation, but so is the patriarchy.

Obsessions with reproductive tract purity and cleansing date back to a time when a woman's worth was measured by her virginity and how many children she might bear. A vagina and uterus were a currency. Playing on these fears awakens something visceral. It's no wonder the words “pure,” "natural,” and “clean” are used so often to market products to women.

Much misinformation is disseminated by celebrities such as Gwyneth Paltrow, Suzanne Somers, and others.  Typically these spokespersons fit society's measures of success and/or beauty which in no way certifies them in medical matters.  Goop is a commercial company owned by Paltrow and from which she makes profit from every sale.  There is a great imbalance right there as to any credibility about her claims.

Dr. Gunter goes on to say,

"I have been in medicine for thirty-three years, and I've been a gynecologist for twenty-four of them. I've listened to a lot of women, and I know the questions they ask as well as the ones they want to ask but don't quite know-how.

The Vagina Bible is everything I want women to know about their vulvas and vaginas. It is my answer to every woman who has listened to me pass on information in the office or online and then wondered, “How did I not know this?”

Most companies do not get 'called out' for their false claims that border on outright fraud. However the State of California  took issue with some of Goop's claims,

Washington Post: "Gwyneth Paltrow’s Goop touted the ‘benefits’ of putting a jade egg in your vagina. Now it must pay." — "We need to talk about Gwyneth Paltrow's vaginal eggs. Again.

"For the uninitiated, these are the egg-shaped jade or quartz stones sold through Goop, Paltrow's new-age wellness company, and lifestyle brand. Per Goop, women are supposed to insert said eggs into their vaginas — and keep them there for varying periods of time, sometimes overnight — to 'get better connected to the power within.'

"For $66, one can buy a dark nephrite jade egg, which allegedly brings increased sexual energy and pleasure. Or, for $55, there is the 'heart-activating' rose quartz egg, for those who want more positive energy and love. Until recently, a page on Goop's website promised that the eggs would 'increase vaginal muscle tone, hormonal balance, and feminine energy in general.'

"Those claims were, well, a stretch, with no grounding in real science, according to a consumer protection lawsuit filed by state prosecutors representing 10 California counties. On Wednesday, state officials and Goop announced that they had settled the suit, with Paltrow's company agreeing to pay $145,000 in civil penalties.

"Specifically, the suit called out Goop's jade egg, its rose quartz egg and its 'Inner Judge Flower Essence Blend' as products 'whose advertised medical claims were not supported by competent and reliable science,' according to the Santa Clara County district attorney's office. For example, the flower essence blend had been marketed as a blend of essential oils that could ward off depression.

In another blog article, we will talk more about other pseudo-scientific claims for stem cell therapy, genomics, precision medicine, and other hot button topics.

Below is an NPR podcast with Dr Gunter

Transportation Equity, Health, and Aging: A Novel Approach to Healthy Longevity with Benefits Across the Life Span - National Academy of Medicine

Social Determinants of Health (SDH)

Figure 1.

Gini coefficient

One of the most neglected social determinants of health is access to adequate transportation. While housing, education, social inequality (as reflected by the Gini coefficient), and income are widely recognized as important factors of well-being, it is striking that the public health discourse on transportation has overwhelmingly emphasized the negative aspects [1]. These include crashes, injury, mortality, pollution, lack of exercise, and noise. A worthy public health emphasis on active mobility through walking and cycling may have also overshadowed the central role of transportation as driver or passenger in an automobile for the majority of the US population who do not have access to effective public transportation or who have compromised personal mobility. Recent evidence points to the negative consequences of restricted personal vehicle transportation on an individual’s independence, emotional and social well-being, and life expectancy.

The public health bias towards the negative aspects of transportation issues, particularly driving, has led to observed disengagement of physicians and other clinicians in assessing and promoting medical fitness to drive and a failure to consider the transportation needs of patients when accessing health care services [2]. For those clinicians who do address fitness to drive, few supports exist. At the federal level, a standard for fitness to drive exists only for commercial drivers (Federal Motor Carrier Safety Administration 49 CFR Part 391). At the state level, regulations vary regarding medical standards for fitness to drive and requirements for mandatory reporting of impairment. Seventeen states lack medical advisory boards to guide these regulations, and thirteen states lack internal medical units to review medical evaluations and/or need for re-examination of referred drivers [23]. States without such medical support systems rely on individual physician opinion about fitness to drive and driving impairment despite a general lack of physician knowledge of medical fitness-to-drive guidelines [3].

Lack of consistent Standards.  California DMV Guidelines. However many states do not have standards or guidelines.

It is not surprising, therefore, that there has been little dialogue between the field of health care and the main disciplines involved in transportation, such as transportation planners and engineers. However, the beginnings of a rapprochement between the fields have begun, through an emerging focus on the impact of disease and disabilities on transportation mobility and driving safety. This emerging scientific foundation should replace stereotypes, opinions, and anecdotes, and should guide evidence-based transportation counseling for older drivers, young drivers, and those with medical conditions and disabilities.

































Transportation Equity, Health, and Aging: A Novel Approach to Healthy Longevity with Benefits Across the Life Span - National Academy of Medicine:

GTMRx Get The Medications Right

What is Comprehensive Medication Management?

The standard of care that ensures each patient’s medications (whether they are prescription, nonprescription, alter.

The accuracy of prescribing for patients has improved remarkably during the past decade. Much of this due to the requirement for e-prescribing and it's integration with electronic health records. This has eliminated unrecognizable physician penmanship as a barrier to accidental errors.  The semi-automation of entering a prescription coupled with pill size and dosages minimizes accidental errors from poor memory on the part of physicians Many electronic health records also ask what other medications a patient is taking, listing cross-reactions and side effects of the medication.  Your physician can now send your eRx directly to your pharmacy of choice and by the time your stop at your drugstore it may be ready...

GTMRx (Get the medicine right) has other plans to improve things and assure the continuity of 'getting it 'right'.

The GTMRx Institute is anchored in our belief statements. They’re at the center of everything we do.

If you agree, we invite you to join the movement to get the medications right. Together, we’re working to save lives, save money, and when possible, restore health by getting the medications right.

A personalized, patient-centered, systematic and coordinated approach to medication use will vastly improve outcomes and reduce overall health care costs.
We must align systems of care to integrate comprehensive medication management, engaging patients to ensure that they are willing and able to take those medications that are indicated, effective, and safe, to optimize their outcomes.
We need an immediate delivery system, payment, and policy transformation to streamline clinical trials and reduce costs of bringing drugs to market while enabling successful, broad-scale adoption of integrated, comprehensive medication management (CMM) services. The appropriate diagnosis and access to advanced diagnostics with companion/complementary and pharmacogenetics (PGx) testing is essential to target correct therapy.
Success requires team-based, patient-centered care models that recognize appropriately skilled clinical pharmacists as medication experts who work in collaborative practice with physicians and other providers.

It is a team effort, even down to ensuring the patient takes the medication at the right time each day.
There are now many ancillary ways to accomplish this. 

Amazon now offers a pill pack whereby the patient's medications are packed in a labeled pill pouch and delivered to your door. 

Sign Up for Pill Pack             How can Pill Pack help?

This link will take you to Amazon Pill Pack sign up where you can enter your personal, medication list, prescribing physician, and your prescription plan.  It will not enroll you in a plan.

Reminders can be sent for each dose daily using text messaging from pharmacy to patient., requiring a simple Y or N to indicate whether the patient is taking the medication as directed.  A large number of non-compliance increases costs enormously with wasted medications.

What is Comprehensive Medication Management?

The standard of care that ensures each patient’s medications (whether they are prescription, nonprescription, alternative, traditional, vitamins, or nutritional supplements) are individually assessed to determine that each medication is appropriate for the patient, effective for the medical condition, safe given the comorbidities and other medications being taken, and able to be taken by the patient as intended.1

What is the Comprehensive Management Process? 

                        Download the Infographic (PDF)









About - Get The Medications Right:

Are Guns a Public Health Problem?

Guns have become a public health problem in the U.S.A.  Perhaps it is not the guns but the people who own and use them in nefarious and/or dangerous ways.

Americans have had a fascination with weapons since the American Revolution.  However, it is not a uniquely American way of life. Why has it persisted in the U.S.A. and not elsewhere?  There are many countries where people do not feel compelled to arm themselves for safety.  Why are these weapons so ubiquitous in the U.S.A.

The increase in the use of guns seems to fit the definition of a public health epidemic.  Is there something we are missing?  Modern news media broadcasts events much more quickly and there are many more avenues for news distribution now in addition to newspapers radio and television. The dawn of the internet occurred over twenty years ago, and social media platforms (twitter, facebook, Instagram have been in existence for over ten years. Much of social media content would not be fit to print, unlike the iconic phrase "All the news that is fit to be print" by the venerable New York Times.

Gun violence in the United States is a public health crisis.

It goes beyond the mass shootings that grab the nation’s attention. Every day, gun violence takes lives from communities all across the country in the form of suicides, unintentional shootings, and interpersonal conflicts that become fatal due to easy access to guns.

In this country, an average of 35,000 people is killed with guns every year—96 each day.

Yet this violence is not inevitable. Every other developed nation in the world does a better job of protecting its people from gun violence. The gun murder rate in the United States is 25 times higher than it is in peer nations, and American teenagers are 82 times more likely to die from a gun homicide than their international peers.

There is no single, simple solution to reducing gun violence in this country. However, there are a number of common-sense steps that would be a great place to start—steps that could be taken right now.


During this interview, Dr. Jandial. a practicing neurosurgeon is asked by a morning news reporter if medical students are taught about taking a 'gun history' for patients.  He replied that in the course of a day's work in emergency rooms, and surgery physicians are faced with the aftermath and treatment of gun injury, both physical and emotional.  However, physicians have not been trained using proactive measures such as 'prevention'.  It would seem logical that just as physicians inquire about smoking habits and substance abuse would be the model for gun control as well.

A question arose as to whether it is appropriate for a physician's office to inquire about 'guns in the home. This has produced discussions amongst medical professionals.  Today it is common to take a history about sexual practices, nicotine, vaping,  substance abuse, gender as well as what we always thought was relevant medical history.  This topic should just be added to a normal medical history.

The topic has risen to that of more than urgency and now is an emergent issue. The medical community cannot continue to bury it's head in the sand.  As trusted health advisors by patients, we owe our patients powerful support in this area. Every parent and student expresses this concern openly, why shouldn't we as physicians do the same? 

Let's be leaders.

INNOVATIONS AT CMS ARE ABOUT TO HAPPEN (AT LONG LAST)

There is a new sheriff in town, and she is a woman.  Under the guidance of the administrator of CMS, Seema Verma and the Secretary of Health and Human Services, Alex Azar,  a large number of innovations are being proposed at CMS.

Follow along here, here, here, here, and here.

The categories of innovation are organized into seven categories.

Categories

Accountable Care

Accountable Care Organizations and similar care models are designed to incentivize health care providers to become accountable for a patient population and to invest in infrastructure and redesigned care processes that provide for coordinated care, high quality and efficient service delivery.

Episode-based Payment Initiatives (bundled care/payments)

Under these models, health care providers are held accountable for the cost and quality of care beneficiaries receive during an episode of care, which usually begins with a triggering health care event (such as a hospitalization or chemotherapy administration) and extends for a limited period of time thereafter.

Primary Care Transformation

New Evidence Report is Now Available

Primary care providers are a key point of contact for patients’ health care needs. Strengthening and increasing access to primary care is critical to promoting health and reducing overall health care costs. Advanced primary care practices – also called “medical homes” – utilize a team-based approach, while emphasizing prevention, health information technology, care coordination, and shared decision making among patients and their providers.

Initiatives Focused on the Medicaid and CHIP Population

Medicaid and the Children’s Health Insurance Program (CHIP) are administered by the states but are jointly funded by the federal government and states. Initiatives in this category are administered by the participating states.

Initiatives Focused on the Medicare-Medicaid Enrollees

The Medicare and Medicaid programs were designed with distinct purposes. Individuals enrolled in both Medicare and Medicaid (the “dual eligibles”) account for a disproportionate share of the programs’ expenditures. A fully integrated, person-centered system of care that ensures that all their needs are met could better serve this population in high quality, cost-effective manner.
Initiatives to Accelerate the Development and Testing of New Payment and Service Delivery Models
Many innovations necessary to improve the health care system will come from local communities and health care leaders from across the entire country. By partnering with these local and regional stakeholders, CMS can help accelerate the testing of models today that may be the next breakthrough tomorrow.

Initiatives to Speed the Adoption of Best Practices

Recent studies indicate that it takes nearly 17 years on average before best practices - backed by research - are incorporated into widespread clinical practice—and even then the application of the knowledge is very uneven. The Innovation Center is partnering with a broad range of health care providers, federal agencies professional societies and other experts and stakeholders to test new models for disseminating evidence-based best practices and significantly increasing the speed of adoption.

Alternative Payment Models are part and parcel of the overall process and are not mutually exclusive from ACO, Bundled Payments, Primary care transformation nor the rest of CMS innovation.

Discussion:

1.  ACOs

 2018. There are 649 ACOs across the U.S., according to the National Association of ACOs, including Medicare ACO program participants and independent ACOs. Around 12.3 million Medicare beneficiaries — 20 percent of all Medicare beneficiaries — participate in an ACO

As of July 2019, there are 559 Medicare ACOs serving more than 12.3 million beneficiaries with hundreds more commercial and Medicaid ACOs serving millions of additional patients. This is a reduction of 90 ACOs or roughly 20%.  The survival rate is about 80% after one year.  Organizing and implementing a new "group practice" in its own right and adding the goal of increasing savings if a challenge.  Administrative costs for the organization, marketing and recruitment are substantial. It is surprising that almost 80% survived their first year of operation. Many of the still-functioning ACOs are in hazardous waters financially.  It will be interesting to see what plays out in the next five years.

2. Episode-based Payment Initiatives

Problems with bundled medical codes

Problems arise when a patient needs something extra that isn’t included in a bundled payment. Payers may not reimburse for the extra outside of the bundle. That may make a provider reluctant to provide the service if he or she cannot be reimbursed for it. They may even charge the patient extra, at full price, to provide the service. Patients need to be on the look-out for this kind of extra-billing because it can result in balance billing or upcoding, both of which are illegal.  Most hospitals already have an idea of how much specific diagnosis costs and are already being paid using a DRG (diagnosis-related code). 

Traditionally, Medicare makes separate payments to providers for each of the individual services they furnish to beneficiaries for a single illness or course of treatment. This approach can result in fragmented care with minimal coordination across providers and health care settings. Payment rewards the number of services offered by providers rather than the quality of care furnished. Research has shown that bundled payments can align incentives for providers – hospitals, post-acute care providers, physicians, and other practitioners – allowing them to work closely together across all specialties and settings. This sounds wonderful in theory, however, in the actual reality of individual practices coordinating providers and hospitals is very challenging. Rather than aligning hospitals and providers it may devolve into competition for the limited resources medicare or any other payor funds.

Initiatives to Speed the Adoption of Best Practices

The System Thinkers

Barriers at the Gate

The first hurdle to an organization adopting best practices as a routine way of doing business may be adjusting how we think and speak about this concept. The words we use to describe embracing others’ practices reflect our culture’s deep ambiguity about doing so. For example, when referring to best practices, do leaders in your organization use terms such as transfer, replicate, emulate, duplicate, translate, benchmark, roll out, propagate, or disseminate? Or are they more likely to employ words like imitating, evangelize, clone, copy, and shamelessly steal? The name of Motorola’s first benchmarking initiative, “Operation Bandit,” captured this tension well. The connotations of knowledge sharing hinge tightly on people’s sense of boundaries, and on the existing customs for moving knowledge across them. 

Some family doctors ditch insurance for simpler approach

Dr. Emilie Scott was only a few months into her first job when she started hearing the complaint: She was spending too much time with each patient. Like many primary care doctors working in large medical systems, Scott was encouraged to see a new patient every 20 minutes. But that was barely enough time to talk and do a physical.

She eventually quit her job to try a new approach aimed at eliminating many of the headaches of traditional health care: tight schedules, short appointments, and piles of insurance paperwork.

Instead of billing insurers, Scott now charges patients a $79 monthly fee that covers office visits, phone calls, emails, texts, and certain medical tests and procedures. Scott typically sees six patients a day, down from around 30, and spends more time at each appointment. She hired two assistants to help handle paperwork compared with working with a department of billing specialists.

This approach —direct primary care — aims to leverage the extra time and money from avoiding insurance into improving care for patients.

But health care researchers question its cost-effectiveness and whether it will ever be capable of serving large numbers of people.

Patients considering direct primary care should press doctors on exactly what services are covered by their monthly fee, said Michael Gusmano of the nonprofit Hastings Center.

Most direct primary care doctors acknowledge the limitations and recommend patients carry some type of insurance to cover medical emergencies, surgery and expensive tests.

Only about 4% of family doctors reported working in direct primary care practices last year, according to a survey by the American Academy of Family Physicians. There are currently 1,200 practices in the U.S, according to the Direct Primary Care Journal. Typical patient fees are around $75 per month or $900 annually, studies show.

Dr. Thomas White — who runs a direct care practice in Cherryville, North Carolina — sees the problem differently. He said abandoning insurance could help boost the supply of family physicians by providing them a less stressful way to practice medicine.

“We’ve got to embrace this model of care and figure out a way to roll it out gradually, because I think it can save family medicine,” he said.

This model is not for everyone, doctors or patients.

Patients: Seventy-five dollars out of pocket per month compares favorably to people who go to Starbucks every morning for a five-dollar shot of brew (five days a week) for four weeks (100.00). And you would have unlimited access to your physician.  A policy for catastrophic coverage would supplement your DPC coverage.  However, you must be near your PCP.  Most DPC doctors limit their patient census.  They are more interested in giving each patient sufficient time to get to know you.  Most DPC physicians take their own call since they know all their own patients.

Physicians.  There is no billing and payment can be made via an autopay arrangement. There are fewer employees.  A far simpler electronic health record can be used, since the DCP is not contracted with any insurers, including medicare. The DCP only has to obey the law, not that of medicare nor the byzantine coding for billing. Physicians can obtain routine laboratory work by contracting with labs that offer low prices. (usually not a hospital) . This type of practice often functions with one employee who greets the arriving patient and serves as the DCP assistant. With today's artificial intelligence and natural language processing, most (if not all) can be accomplished by the autonomous receptionist.

We are on the threshold of major change, which may eliminate insurer intrusion into decision making for doctors and patients.

Google Play already has an app for that. It can be downloaded to a tablet/kiosk for little cost, and be programmed for physician offices.

iPad offers a virtual receptionist as well

White Receptionist in a box (iPad) includes software.



Other formats

 Wall Mount

Floor Stand









For physicians who are interested in reducing personnel costs contact us at Digital Health Space










Some family doctors ditch insurance for a simpler approach:

New WHO-led study says majority of adolescents worldwide are not sufficiently physically active

New WHO-led study says a majority of adolescents worldwide are not sufficiently physically active, putting their current and future health at risk.

The first-ever global trends for adolescent insufficient physical activity show that urgent action is needed to increase physical activity levels in girls and boys aged 11 to 17 years. The study, published in The Lancet Child & Adolescent Health journal and produced by researchers from the World Health Organization (WHO), finds that more than 80% of school-going adolescents globally did not meet current recommendations of at least one hour of physical activity per day – including 85% of girls and 78% of boys.

The study – which is based on data reported by 1.6 million 11 to 17-year-old students – finds that across all 146 countries studied between 2001-2016 girls were less active than boys in all but four (Tonga, Samoa, Afghanistan, and Zambia).

The difference in the proportion of boys and girls meeting the recommendations was greater than 10 percentage points in almost one in three countries in 2016 (29%, 43 of 146 countries), with the biggest gaps seen in the United States of America and Ireland (more than 15 percentage points). Most countries in the study (73%, 107 of 146) saw this gender gap widen between 2001-2016.

Young people’s health compromised by insufficient physical activity

The authors say that levels of insufficient physical activity in adolescents continue to be extremely high, compromising their current and future health. “Urgent policy action to increase physical activity is needed now, particularly to promote and retain girls’ participation in physical activity,” says study author Dr. Regina Guthold, WHO.

The health benefits of a physically active lifestyle during adolescence include improved cardiorespiratory and muscular fitness, bone and cardiometabolic health, and positive effects on weight. There is also growing evidence that physical activity has a positive impact on cognitive development and socializing. Current evidence suggests that many of these benefits continue into adulthood.

To achieve these benefits, the WHO recommends for adolescents to do moderate or vigorous physical activity for an hour or more each day.

To improve levels of physical activity among adolescents, the study recommends that:

Urgent scaling up is needed of known effective policies and programs to increase physical activity in adolescents;

Multisectoral action is needed to offer opportunities for young people to be active, involving education, urban planning, road safety, and others;

The highest levels of society, including national, city and local leaders, should promote the importance of physical activity for the health and well-being of all people, including adolescents.

“The study highlights that young people have the right to play and should be provided with the opportunities to realize their right to physical and mental health and wellbeing,” says co-author Dr. Fiona Bull, WHO. “Strong political will and action can address the fact that four in every five adolescents do not experience the enjoyment and social, physical, and mental health benefits of regular physical activity.  Policymakers and stakeholders should be encouraged to act now for the health of this and future young generations.”

Gender differences

Physical activity trends show slight improvement for boys, none for girls

The new study estimated for the first time how trends changed between 2001-2016 – applying the trends from 73 countries who did repeat surveys during that period to all 146 countries.

Globally, the prevalence of insufficient physical activity slightly decreased in boys between 2001 and 2016 (from 80% to 78%), but there was no change over time in girls (remaining around 85%).

National, Cultural and Ethnic Differences

The countries showing the greatest decreases in boys being insufficiently active were Bangladesh (from 73% to 63%), Singapore (78% to 70%), Thailand (78% to 70%), Benin (79% to 71%), Ireland (71% to 64%), and the USA (71% to 64%). However, among girls, changes were small, ranging from a 2 percentage-point decrease in Singapore (85% to 83%) to a 1 percentage-point increase in Afghanistan (87% to 88%).

The authors note that if these trends continue, the global target of a 15% relative reduction in insufficient physical activity – which would lead to a global prevalence of less than 70% by 2030 – will not be achieved. This target was agreed to by all countries at the World Health Assembly in 2018.

In 2016, the Philippines was the country with the highest prevalence of insufficient activity among boys (93%), whereas South Korea showed the highest levels among girls (97%) and both genders combined (94%). Bangladesh was the country with the lowest prevalence of insufficient physical activity among boys, girls, and both genders combined (63%, 69%, and 66%, respectively).

Some of the lowest levels of insufficient activity in boys were found in Bangladesh, India and the USA. The authors note that the lower levels of insufficient physical activity in Bangladesh and India (where 63% and 72% of boys were insufficiently active in 2016, respectively) may be explained by the strong focus on national sports like cricket.

For girls, the lowest levels of insufficient activity were seen in Bangladesh and India, and are potentially explained by societal factors, such as increased domestic chores in the home for girls.

Goals

To increase physical activity for young people, governments need to identify and address the many causes and inequities – social, economic, cultural, technological, and environmental – that can perpetuate the differences between boys and girls, the authors said.

“Countries must develop or update their policies and allocate the necessary resources to increase physical activity,” says Dr. Bull. “Policies should increase all forms of physical activity, including physical education that develops physical literacy, more sports, active play and recreation opportunities – as well as providing safe environments so young people can walk and cycle independently. Comprehensive action requires engagement with multiple sectors and stakeholders, including schools, families, sport and recreation providers, urban planners, and city and community leaders.”









New WHO-led study says a majority of adolescents worldwide are not sufficiently physically active: