How Much Are Health Systems Spending on Social Determinants?

 A new study found that health systems are making sizable investments in social determinants of health programs, with more addressing housing insecurity.

Hospitals and medical groups now realize the significant impact upon health,  chronic illnesses, outcomes and a reduction of readmissions.  This may be due to Medicare's quality measure for rates of readmission. CMS penalizes hospitals for increased readmission rates. Thorough discharge planning can make a difference. Although skilled nursing facilities (SNF) make a difference they are not always necessary if alternative non-medical housing can make a difference.


California, with Los Angeles and San Francisco and Seattle, WA.  high on the list for homelessness. State governments are now reacting to crisis planning on significant amounts of money to help correct the problem.  The rate of homelessness in Medi-Cal beneficiaries increases the cost of health care to taxpayers.  In the long run, ameliorating the homeless can offset or decrease health expenditures. If you are homeless there is no access to mail, no street address, probably no transportation unless you live in a car or van. Homelessness is a bad place, with poor hygiene

Health systems are making significant investments in programs that address social determinants of health, such as housing, employment, and food security, according to a new study published in Health Affairs.

Dig Deeper

Social Determinants of Health Impact Hospital Readmission Rates

How Addressing Social Determinants of Health Cuts Healthcare Costs

Social Determinants of Health Key to Value-Based Purchasing Success

Ridesharing can overcome missed appointments when hospitals share cost or contract with Uber or Lyft to provide transportation.  Missed appointments contribute to deterioration and lower ED visits. Transportation is a key social determinant impacting patient outcomes. Without access to reliable, affordable, and convenient transportation, patients miss appointments and end up costing providers.

Missed appointments and care delays cost the healthcare industry $150 billion each year, and individual organizations lose revenue for every patient who does not show up for a scheduled appointment.

Patients without transportation are also less likely to adhere to medication regimes. One study found that 65 percent of patients felt transportation assistance would enable them to fill prescriptions after discharge. Other research has also shown that Medicaid reimbursement restrictions for transportation payments resulted in fewer prescription refills.

“There is a strong business case for hospitals and health systems to address transportation needs since individuals experiencing these issues are more likely to miss appointments or not fill prescriptions, leading to delays in care and potentially to disease progression and complications or readmissions,”  To recoup revenue and improve care quality, some health systems like MedStar Health and Denver Health Medical Center are teaming up with Uber, Lyft,

In the analysis of public announcements of new social determinants of health programs operated by US health systems from Jan. 1, 2017, to Nov. 30, 2019, researchers from New York University uncovered at least a $2.5 billion in investments from 57 health systems that collectively included 917 hospitals. The health system funds were allocated to 78 unique programs launched during that time.

About two-thirds of the total investment ($1.6 billion) was specifically committed to housing-focused efforts, followed by employment (28 programs, $1.1 billion), education (14 programs, $476.4 million), food security (25 programs, $294.2 million), social and community context (13 programs, $253.1 million), and transportation (6 programs, $32 million).

“Historically, hospitals have tended to provide community benefit through uncompensated or subsidized care rather than through investment in activities not directly related to health,” they wrote in the study. But now, health systems have found a new strategy to improve outcomes and lower costs outside the walls of their organization.

Announcing a New Format and Theme for Health Train Express

I was reviewing statistics for the blog.  I began writing Health Train Express in 2005-2006. I wanted to review how many articles I published since then.  All told 2360 made it to the worldwide web.  I found  152 in my unpublished vault.  Thank you Ms. Blogger.  You are not the fanciest blogging tool nor the most popular. Each time I was unfaithful to you I would wander over to others, such as WordPress, and many others. They each have their own charm, some difficult to resist. However, I always returned to my first love.  She has been a 'keeper'.

Even fickle Google has been faithful to it's the affair, never downgrading her, despite many mergers, and acquisitions,  through it all...Google +, Google Hangouts, Alphabet, Google Health, Google Glass, Feedburner, and 50 other Google Fails. I am set in my ways, I like things simple....they don't break.  Blogger has never broken on me...no weird messages, except when I use a google extension named add-to-any. It gives me a 'whoops, there is something wrong with the URL". Apparently, there is a limit on the number of characters it can forward.  No matter, I did a workaround (or I guess a hack as my grandchildren tell me). I use a tiny URL that works just fine.

So don't get me wrong I am not a Luddite and have always been a certifiable nerd, going all the way back to 8th grade.

Three years ago I caved in and bought a smartphone, An android Galaxy S8+, followed in six months with a Galaxy S8 Note.  My brother had one, and I thought the pen was cool. It was an impulse buy, I bought it because my fingers twitch and my left hand has a tremor.  It does make dialing my phone easier.  Google Assistant has taken over most of my tasks. "Call......Test.....Open......(almost whatever you want).  I have programmed my phone to ask Alexa different questions....they talk all-day.

This post has gone way off target....I think dementia may play a part.

So enjoy the new format.  It is easy to skip around to any post since 2005.

Physicians, No need for Burnout

In the past year, there has been increased attention to stress on physicians that lead to burnout. In a recent article in the Journal of the American Association, several factors can immunize doctors against burnout.

Sara Berg
Senior News Writer
American Medical Association

Physician burnout is a multifactorial problem that is not easily solved. A systems approach is recommended to reduce physician burnout and foster professional well-being says a report from the National Academy of Medicine. But as system-level solutions continue to be developed, what helps some physicians avoid burnout?

Committed to making physician burnout a thing of the past, the AMA has studied and is currently addressing issues causing and fueling physician burnout—including time constraints, technology, and regulations—to better understand and reduce the challenges physicians face. By focusing on factors causing burnout at the system-level, the AMA assesses an organization’s well-being and offers guidance and targeted solutions to support physician well-being and satisfaction. 

Authors of the consensus study report published by the National Academy of Medicine, Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being, call for immediate action from the health care system to combat physician burnout and improve professional well-being. The book can be bought or downloaded (free) by clicking on the above link.

Work system factors continue to contribute to physician burnout and professional well-being. But here are four individual factors that may help doctors prevent the development of burnout.

Physician burnout: 4 types of interventions and how they can help

Here are four steps to take when creating an effective physician well-being program in your organization or school.

Identify existing goals and processes. This first step is divided into two parts. In step A it is important for teams to identify existing goals and processes. “For us that was doing an environmental scan of the Canadian medical schools—what’s already been offered over there?” said Hastings-Truelove. “So, what does our starting point look like?”

And the second part of this step involves identifying target processes and goals. This is where experts compile their “wish list of what standard physician wellness would look like—where do we want to get to?” she said.

Look at system interaction. “We started thinking about the different levels involved in physician wellness, so the individual, the organization and the culture,” said Hastings-Truelove. “So, what are the interactions between these three levels?” Understanding that will help organizations figure out where to begin.

Discover transition interactions. Part of this is identifying the difficulty in making this change for an organization. “There’s lots of evidence that’s available,” she said. “Lots of people are doing different things with physician wellness, but it hasn’t really been compiled into one place.” With so many pilot programs, part of this is bringing together the wealth of evidence. While people and organizations are working on improving physician burnout through well-being initiatives, what works?

Survey the stakeholders. Hearing from experts in the field is an important step. For example, Hastings-Truelove’s team scheduled a workshop and invited key stakeholders to join them and contribute their voice to recommendations.

“Our target goal is to create a culture where each level reinforces the next. So, the individual has a responsibility to know what resources are available to make personal choices that contribute to wellness,” said Hastings-Truelove. “The organization has a responsibility to measure wellness and provide clear policies around support and accommodations that include flexibility.


Burnout’s mounting price tag: What it’s costing your organization

Physician burnout is costing the U.S. about $4.6 billion annually when you conservatively estimate the costs related to physician turnover and reduced clinical hours, according to a new study co-written by Christine Sinsky, MD, the AMA’s vice president of professional satisfaction.

How burnout in physicians compares to other professional degrees

Does whether you have a medical, doctor of philosophy (Ph.D.) or Juris Doctor (JD) degree, play a role in your risk for professional burnout? It does.  “Burnout among physicians is higher than burnout among other professionals who have also invested many additional years in their training,” said AMA Vice President of Professional Satisfaction Christine Sinsky, MD, a general internist and a co-author of the letter.  “In fact, having higher levels of training protects against burnout in professions outside of medicine, whereas it does not in medicine,” she added. 

“There is a shared responsibility among many organizations that impact physicians’ work lives to consider how decisions within their realm impact the do-ability of the work and the well-being of the physician workforce,” she added.

The burnout statistics are high enough that groups should consider a mandatory medical education program for their physicians, and perhaps a mandatory CME program for licensure in each state. This type, of course, may even impact the number of impaired physicians and decrease license probations and/or suspension.

https://tinyurl.com/qqd33x7

One Defensive Strategy Against Surprise Medical Bills: Set Your Own Terms |

 By writing in payment limits when signing hospital forms, patients might have leverage in negotiations over disputes that arise from surprise medical bills.

When you sign into a hospital next time, read all those pages that require a signature. For the discussion here we will limit comments to the agreement to pay all charges. Often patients are asked to sign on a computer signature line. You can also ask for a printed paper signature page.

There some things you can do to limit excessive balance billings.  Patients should be proactive and not be frightened by a threat of admission being refused.  

Take These Passes With You​
​
Save Quizzify's helpful passes to your Apple Wallet to avoid surprise medical bills and ask doctors the right questions.

You don’t have to remember these questions, because, in the immortal words of the great philosopher Yogi Berra, we’ve done the remembering for you. (He didn’t actually say that, but he could have.) All you need to remember is that you’ve got them in your AppleWallet.

If you do not have an Apple iPhone you can use this link on an Android smartphone.  In any case if all else fails you can have this pass on a smartphone.

When Stacey Richter’s husband recently landed in a New Jersey emergency room, fearing a heart attack, she had an additional reason for alarm: a potential big bill from the hospital if the ER wasn’t in his insurer’s network.

So she took an unusual step. Instead of simply signing the hospital’s financial and treatment consent form, Richter first crossed out sections calling for her to pay whatever amount the hospital charged. She wrote in her own payment rate of a “maximum of two times” what the federal government would pay under Medicare, which is in the ballpark, experts said, of what hospitals might consider an acceptable rate.

“And then I signed it, took a picture of it and handed it back to them,” said Richter, co-president of the consultancy Aventria Health Group.

The U.S. Congress has also considered legislation regarding excessive balance billing. The legislation contains specific requirements in regard to timely billing as well as excessive charges. Section 202, and 302

One Defensive Strategy Against Surprise Medical Bills: Set Your Own Terms | California Healthline:

Social Security Disability Insurance: A Bedrock of Security for American Workers

Social Security Disability Insurance provides vital protection to nearly all American workers and their families in case of life-changing disability or illness.

Imagine that tomorrow, while cleaning out your gutters, you fall off a ladder. You suffer a traumatic brain injury and spinal cord damage, leaving you paralyzed, unable to speak, and with significantly impaired short- and long-term memory. Unable to work for the foreseeable future, you have no idea how you are going to support your family. Now imagine your relief when you realize an insurance policy you have been paying into all your working life will help keep you and your family afloat by replacing a portion of your lost wages. Fortunately, there is no need to conjure up the source of your relief: it is our Social Security system.

Social Security Disability Insurance is coverage that workers earn

For a young worker with a spouse, two children, and average earnings, the value of the coverage that Disability Insurance provides is equivalent to a $580,000 insurance policy, and many estimates suggest that the real value of the protection it offers is much higher. Both workers and employers pay for Social Security through payroll tax contributions. Workers currently pay 6.2 percent of the first $118,500 of their earnings each year, and employers pay the same amount up to the same cap. Of that 6.2 percent, 5.3 percent currently goes to the Old-Age and Survivors Insurance, or OASI, trust fund, and 0.9 percent to the Disability Insurance trust fund. Due to the interrelatedness of the Social Security programs, the two funds are typically considered together, although they are technically separate. The portion of payroll tax contributions that goes into each trust fund has changed several times throughout the years to account for demographic shifts and the funds’ respective projected solvency. 

Many patients misunderstand this benefit and do not apply because they consider it charity. Not so, it is an insurance policy.

Eligibility criteria are stringent and most applicants are denied

Social Security Disability Insurance is reserved for workers whose disabilities or illnesses are so debilitating that they cannot support themselves through work. Under the Social Security Act, the eligibility standard requires that a disabled worker be “unable to engage in substantial gainful activity”—defined as earning $1,090 per month, for 2015—“by reason of any medically determinable physical or mental impairment which can be expected to result in death or last for a continuous period of not less than 12 months.” In order to meet this rigorous standard, a worker must not only be unable to do his or her past jobs, but also—considering his or her age, education, and experience—any other job that exists in significant numbers in the national economy at a level where he or she could earn even $270 per week.

A worker must also have earned coverage in order to be protected by Disability Insurance. A worker must have worked at least one-fourth of his or her adult years, including at least 5 of the 10 years before the disability began in order to be “insured.” The typically disabled worker beneficiary worked 22 years before needing to turn to benefits.

Applying for Disability

In practice, proving medical eligibility for Disability Insurance requires extensive medical evidence from one or more “acceptable medical sources”—licensed physicians, specialists, or other approved medical providers—documenting the applicant’s severe impairment, or impairments, and resulting symptoms. Evidence from other providers, such as nurse practitioners or clinical social workers, is not enough to document a worker’s medical condition. Statements from friend's loved ones and the applicant is not considered medical evidence and is not sufficient to establish eligibility. Past medical records are essential. It will require your active participation, telephone calls to past doctors, for testing results.

Don't expect to be approved on your first try. Records will be incomplete or missing. If you are repeatedly denied get an experienced Disability attorney to take your case.  They are paid out of whatever you are awarded.  Remember too that all benefits are retroactive to the first date of your application.  In some cases, this can be any number of years.  That amount would be paid to you in a lump sum.

Fewer than 4 in 10 claims for Disability Insurance are approved under this stringent standard, even after all levels of appeal. Underscoring the strictness of the disability standard, thousands of applicants die each year while waiting for benefits. And one in five males and nearly one in six female beneficiaries die within five years of being approved for benefits. Disability Insurance beneficiaries have death rates three to six times higher than other people their age.

Social Security Disability Insurance: A Bedrock of Security for American Workers - Center for American Progress:

CVS swings to $6.6B profit in 2019, buoyed by Aetna Acquisition

Despite rising pharmaceutical prices there are economic pressures for mergers between industries in the healthcare sector.  This one is between retail outlets, and health insurance (plan).

• CVS Health slightly topped Wall Street expectations for the fourth quarter of 2019 on both earnings and revenue, which clocked in at $66.9 billion, up almost 23% year over year.
• The Aetna integration, along with higher volume in both the pharmacy benefit management business Caremark and the retail segment, drove revenue growth in the quarter and in 2019 overall. For the year, its first as a combined company, CVS saw total revenue of $256.8 billion, up 32% from 2018.
• The Woonsocket, Rhode Island-based health giant reported a profit of $1.7 billion in the quarter, up from a loss of $421 million in the prior-year period. CVS raked in a profit of $6.6 billion for the full year, up from a loss in 2018 of $596 million, it said in results announced premarket Wednesday.

Dive Insight:

The ubiquitous drugstore giant, which overcame an unprecedented judicial hold-up of its acquisition with payer Aetna in September, reported its highest year-over-year earnings growth in the first three quarters of last year due to the results of the Aetna buy.

While the fourth quarter didn't include the impact of share dilution and interest expense from the transaction, CVS still saw earnings growth higher than financial analysts and its own internal expectations, according to top leadership.

Continued price compression in pharmacy services, retail reimbursement pressure and an increased generic dispensing rate all slightly tamped down revenue, both for the quarter and the full year. However, CVS benefited from a lower tax rate than anticipated.

The company reported operating income of $3 billion in the fourth quarter and $12 billion for the full year, up 269% and 198%, respectively. Adjusted operating income, which factors out the impact of the acquisition, of $3.8 billion in the quarter and $15.3 billion for the year, was up 1.3% and 36.2%, respectively.

Caremark and CVS' retail segment both saw their revenue tick up slightly in the fourth quarter to $37 billion and $22.6 billion, respectively. For the PBM, claims processed increased more than 10% to 534 million, mostly due to new business and retention of a large portion of a contract with Centene, extended through 2022.

For the 2021 selling season, Caremark has completed for 65% of contract renewals to date, including the extension of the Blue Cross Blue Shield's federal employee program contract through 2021 and renewal of Wellcare's contract through 2023.​

Aetna spurred revenue in CVS' healthcare benefits business to almost triple in the quarter to $17.2 billion. Revenue in the segment was $69.6 billion for 2019, up 677% from 2018, pre-Aetna. CVS had almost 23 million beneficiaries in its Aetna and Medicare Part D plans in 2019, up 3.6% year over year, and a medical loss ratio of 85.7%.

The payer saw growth in government services. Its Medicare Advantage business grew over three times the industry average in 2019, CEO Larry Merlo said Wednesday, and Medicaid growth was oiled both organically and through M&A, including the December acquisition of Illinicare from Centene.

Along with the results, CVS also announced a leadership shuffle. EVP Alan Lotvin, who previously helmed CVS' transformation efforts, is replacing Derica Rice as president of Caremark and Jonathan Mayhew, ex-SVP for Aetna markets, will replace Lotvin in managing the transformation product portfolio.

As a result of the earnings, CVS bumped up its guidance for 2020, expecting operating income to ring in between $12.8 billion and $13 billion and diluted earnings per share of $5.47 to $5.60.

It remains to be seen whether this will be a patient-centered experience or a boon for stockholders. Perhaps it will be both and the efficiency of one organization integrating health insurance coverage and retail pharmacy will be interesting. The initial quarterly financial statement may be a figment of a profit and loss statement.  Let's give it a year or two to unwind.

CVS swings to $6.6B profit in 2019, buoyed by Aetna | Healthcare Dive:

Children Who Need Wheelchairs and Other Medical Equipment Often Wait Months or Years Because of Byzantine State System

The complicated system creates a disparity where children from families without the means to pay for medical equipment out of pocket often must go without it for months or years, limiting their int…

Yuki Baba of Berkeley tried for years to get a hospital bed, wheelchair ramp, and other equipment through California Children’s Services for her 12-year-old son, Nate, who doctors have diagnosed with cerebral palsy. Children’s Services denied all of her requests. Photo courtesy of Yuki Baba.

“It’s pretty complicated,” said Alicia Emanuel, a staff attorney with the National Health Law program. She worked for a year with two other attorneys to understand the program and write the report, which is intended to help legal advocates advise families that are trying to access medical equipment. The 21-page report details the numerous steps families or their advocates must go through to get, for example, a wheelchair or walker for a child.

About 200,000 special-needs children receive health coverage through the California Children’s Services (CCS) program, which serves kids with chronic medical conditions such as cystic fibrosis, cerebral palsy, cancer, and traumatic injuries. Yet when children require medical equipment like wheelchairs, walkers, ventilators, leg braces, and hospital beds, they sometimes wait a year or more to receive it, according to the report by the Lucile Packard Foundation for Children’s Health.*

“I think that the gaps in the state guidance make it very difficult for families of children on the CCS (California Children’s Services) program to obtain the durable medical equipment that they’re entitled to,” she said. “It should be underscored that these are children with complex medical conditions like sickle cell disease, cystic fibrosis, and cancer, and it’s an undue burden to create a system that’s difficult to navigate for these kids.”

Some families aren’t able to obtain medical equipment at all through Children’s Services. Yuki Baba of Berkeley said she battled for years to get orthopedic equipment through the program for her 12-year-old son, Nate, who doctors have diagnosed with cerebral palsy. He’s confined to a wheelchair, cannot sit up on his own, and wears a torso brace to support his spine.

Baba has tried to get a hospital bed, wheelchair ramp and other equipment through Children’s Services. But the agency denies her requests because it says Nate’s specific type of cerebral palsy doesn’t fit within its own narrow definition of the disease.

She said she feels especially bad for families who are new to the Children’s Services system, and those who have limited English language proficiency.

“There are some kids who really should be qualified for medical equipment (through Children’s Services) and they’re falling through the cracks,” she said. The Children’s Services definition of cerebral palsy “is not right, so I want the state to change that to a more reasonable definition.”

Emanuel and her colleagues are now working on recommendations for reforming the Children’s Services program so that families can more easily obtain medical equipment for their kids. So far, Emanuel said they’ve identified a clear need for updated guidance and better state oversight of the program.

“This is a very vulnerable population,” she said. “If children don’t have access to the durable medical equipment and supplies that they need, that can really hinder their development.”

California's Department of Health Care Services has been listening to these complaints and Gov. Jerry Brown signed a bill Sunday that will allow some of California’s most medically fragile children to keep the health services they rely on.

J.C. Aquirre, shown here with his mother Tina May Kline, is one of the 30,000 medically fragile children who would be able to keep their doctors while their health coverage changes under a new state bill.

Senate Bill 586 aims to prevent potentially life-threatening disruptions in care while the state restructures California Children’s Services, a health program for children with certain chronic conditions, including cystic fibrosis, hemophilia, cerebral palsy, heart disease, and cancer.

Many of these children have seen the same specialists for years, who are well versed in the intricacies of their conditions and medications. The bill will allow the children to keep their existing providers for 12 months. Those who want to keep their doctors after the first year may be able to through an appeals process.  In many counties, the children who have been covered by CCS will be moved into a MediCal managed care plan



Children Who Need Wheelchairs and Other Medical Equipment Often Wait Months or Years Because of Byzantine State System – California Health Report:

What do you call the disease caused by the novel coronavirus? Covid-19

The disease caused by the novel coronavirus has a name: Covid-19. Tedros Adhanom Ghebreyesus, the director-general of the World Health Organization, announced the name Tuesday, giving a specific identifier to a disease that has been confirmed in more than 42,000 people and caused more than 1,000 deaths in China. There have been fewer than 400 cases in 24 other countries, with one death.

In choosing the name, WHO advisers focused simply on the type of virus that causes the disease. Co and Vi come from coronavirus, Tedros explained, with D meaning disease and 19 standing for 2019, the year the first cases were seen.

The virus that causes the disease has been known provisionally as 2019-nCoV. Also on Tuesday, a coronavirus group from the International Committee on Taxonomy of Viruses, which is responsible for naming new viruses, proposed designating the novel coronavirus as SARS-CoV-2, according to a preprint of a paper posted online. (Preprints are versions of papers that have not yet been peer-reviewed or published in a scientific journal.) The name reflects the genetic similarities between the new coronavirus and the coronavirus that caused the SARS outbreak of 2002-2003.

In selecting Covid-19 as the name of the disease, the WHO name-givers steered clear of linking the outbreak to China or the city of Wuhan, where the illness was first identified. Although origin sites have been used in the past to identify new viruses, such a namesake is now seen as denigrating. Some experts have come to regret naming the infection caused by a different coronavirus the Middle East respiratory syndrome.  The virus that causes the disease has been known provisionally as 2019-nCoV.

Experts envision two scenarios if the new coronavirus isn’t contained

2019-nCoV joins the four coronaviruses now circulating in people. “I can imagine a scenario where this becomes a fifth endemic human coronavirus,” said Stephen Morse of Columbia University’s Mailman School of Public Health, an epidemiologist and expert on emerging infectious diseases. “We don’t pay much attention to them because they’re so mundane,” especially compared to seasonal flu.

Although little-known outside health care and virology circles, the current four “are already part of the winter-spring seasonal landscape of respiratory disease,” Adalja said. Two of them, OC43 and 229E, were discovered in the 1960s but had circulated in cows and bats, respectively, for centuries. The others, HKU1 and NL63, were discovered after the 2003-2004 SARS outbreak, also after circulating in animals. It’s not known how long they’d existed in people before scientists noticed, but since they jumped from animals to people before the era of virology, it isn’t known whether that initial jump triggered the widespread disease.

OC43 and 229E are more prevalent than other endemic human coronaviruses, especially in children and the elderly. Together, the four are responsible for an estimated one-quarter of all colds. “For the most part they cause common-cold-type symptoms,” said Richard Webby, an influenza expert at St. Jude Children’s Research Hospital. “Maybe that is the most likely end scenario.

Covid-19 is the latest mutation of a virus that was identified in the mid-1960s.  At that time Influenza viruses were named after the site(from which they were recognized. (SARS, HK).

Virology has advanced significantly and each iteration of a flu virus can be correctly identified and labeled more accurately.

How do Corona Viruses Spread ?






What do you call the disease caused by the novel coronavirus? Covid-19:

How to Not Spread the Novel Coronavirus

A Teacher Did an Experiment to Show the Power of Handwashing, and You Can’t Stay Unimpressed

Sometimes a prime example is better than words — especially when it comes to explaining something to children. That’s exactly what Jaralee Metcalf, a teacher from Idaho, decided to do to show her pupils the importance of washing their hands properly. And now the whole world is following her example!

To explain how bacteria spread and why it’s important to wash your hands well and often, Jaralee came up with a simple classroom activity with her students: she asked several kids with various levels of hand cleanliness to touch 5 pieces of white bread that were taken from the same loaf, at the same time. Then, they put the bread in individual plastic bags to observe what would happen over the course of one month.

Steps of the project

One interesting thing is that specimen #5 — the “hand sanitizer” slice — turned out to have a lot of bacteria too. So this is a clear example that hand sanitizer can’t replace proper hand-washing with soap. Jaralee shared the results of the project on Facebook to tell parents to teach their kids to wash their hands well and this simple project immediately spread to hundreds of other schools and families.

The hand sanitizer slice shook us a little! How about you? How do you teach your kids that they need to wash their hands properly? 

 A slice wiped on laptops

A slice wiped on laptops 

One month later the Chromebook-rubbed slice looked worse than all the other specimens. As the teacher explains, at their school they do sanitize the laptops, obviously, they didn’t do that for the project.  

Common sources for the virus spread are doorknobs, keyboards, ATM keypads, and computer mice

ATM touch screens and keyboards

Computer Mice

We’d be happy to hear from you in the comment section below!


Preview photo credit Jaralee Annice Metcalf / Facebook

https://tinyurl.com/u5wnvwl

How accurate are the wrist-based heart rate monitors during walking and running activities? Are they accurate enough? - Abstract - Europe PMC

Heart rate (HR) monitors are valuable devices for fitness-orientated individuals. There has been a vast influx of optical sensing blood flow monitors claiming to provide accurate HR during physical activities. These monitors are worn on the arm and wrist to detect HR with photoplethysmography (PPG) techniques. Little is known about the validity of these wearable activity trackers.

Catalog

These devices also are multifunctional and some offer GPS, messaging, and cell phone capabilities. The more functionality the higher the price. There are wrist monitors that only provide heart rate.
Fit is extremely important since exercise running, treadmill or bicycle training can affect accuracy.

Health Train recommends an in-person trial for fit, appearance, and accuracy, before buying online.

The current study investigated the accuracy of six newly released wearable activity trackers that continually measure HR with PPG techniques through the arm and wrist area during rest (3 min seated before and after the experiment), and specific treadmill speeds. The criterion measure was a Polar RS-series chest strap with wrist receiver, which in earlier studies was found to have good criterion-related validity with the ECG, and was well suited for measuring HR during PA and exercise training.8 11

Only a few studies have evaluated the accuracy of HR monitors. In a 2002 study using traditional chest strap HR monitors, investigators found that correlation with the ECG decreased with a higher speed of 9.6 km/h and the investigators attributed this to increased upper body movement.2 A similar study conducted in 2011 involving the Smart health watch, an activity monitor that relies on two points of contact to measure the heart's electrical impulse, had comparable results. The researchers validated the HR for the Smart health watch at rest and during treadmill activities, but reported that at higher speeds of 7.2 and 9.6 km/h the watch had reduced ability to detect HR (a decrease of 6% and 13.9%, respectively).12 Again, the investigators attributed this reduced ability to increased upper body movement.

Conversely, in the present study, the accuracy of the optical sensing HR activity monitors had the least MAPE during the highest speed tested, 9.6 km/h. During this phase, the greatest MAPE observed was with BP (3.28%) and MB (3.06%). These results mirror those found in a recent, small study that evaluated the performance of the MA and SR using an ECG as the criterion measure.9 The investigators reported the MAPE of the MA for walking and running was 5.60% and 2.37%, respectively. In the present study, the MAPE of the MA was 8.02% and 1.15%, respectively. In the past study, the MAPE of the SR for walking and running was 10.49% and 3.81%, respectively. For the present study, the MAPE of SR was 5.40% and 2.91%, respectively. Both studies showed a reduction in MAPE with increased speed. One possible explanation is that with increased intensity there is improved perfusion, which could decrease the error rate.

Overall, strong correlations were observed between the activity monitors and the criterion measure, ranging from r 0.87 to 0.96, and the measured HR from all six monitors were significantly equivalent to the measured HR from the criterion measure is resting, walking and running conditions. This suggests that all the activity monitors would provide comparable accuracy to the more established HR monitor. This is an important finding since it informs the existing literature on HR monitoring devices and also supports the utility of these new devices for everyday personal use as well as for research applications.

Table 1

While conducting the experiment, challenges with correct fit and placement were observed. While great care was taken to ensure watches were placed properly, the experiment was conducted in semi-free-living conditions which resulted in realistic issues arising. A few of the participants had either larger or smaller wrists and forearms that made the proper fitting of the activity monitor a challenge. However, all watches were fitted according to the manual specifications with maximum effort focused on placement control of the watches. In this study, when some participants tried to hold the treadmill railing, HR readings sometimes became irregular, and in two incidents, the BP and FH did not provide an HR reading. The MA also was observed to fluctuate between a high and low HR during this time. Once the participant began walking naturally, with arms swinging, HR readings more closely reflected the criterion measure. Similarly, as soon as the participant started jogging, the arms bent at the elbows and became perpendicular to the body. During the 6 mph jogging phase, the MA and TT had <1% MAPE while the FH was observed with its lowest MAPE for all the protocol intensities. It is speculated that the lesser MAPE is likely attributable to the arms being in a bent, stabilized position combined with the increased HR from exertion. Perhaps a higher and stronger HR can be ‘read’ more easily by the LED lights.

The strengths of this study included a reasonable sample size, examination of a variety of wearable activity HR trackers that are currently available in the market, and utilization of a mixture of various walking and running intensities. In addition, proper fit and constant supervision provided the best opportunity for activity tracking as each tracker was functioning within its intended capacity. The result of this study adds to the existing literature on HR monitoring and is one of the first to undertake validation of new PPG optical sensing HR activity trackers. However, it does have some limitations. The sample population included only healthy, younger individuals (19–45 years) who engaged in regular aerobic exercise and were within the normal range of body weight and body fat. Generalizations cannot be made for youth and/or older adult age groups or for individuals of other body sizes. This study included only walking and running activities; it could be possible that during intermittent or high-intensity interval training results could have been different. The study was also conducted using a controlled treadmill protocol and the transfer of results to free-living conditions should be made with caution.

In conclusion, the present study results showed favorable outcomes for the six PPG optically sensing HR wearable activity trackers that were tested at rest, and during treadmill walking and running in a healthy sample population. Good criterion-related validity was found between all monitors and the Polar HR monitor. In addition, the wearable activity trackers were deemed accurate for the recreational athlete and for research purposes. Furthermore, wearable activity trackers utilizing built-in PPG HR sensors have the potential to overcome the limitations of the traditional chest strap and to advance the science and practice of PA assessment. Further tests utilizing a fixed floor, such as a track, and various indoor/outdoor environments and high-intensity exercises (including weight lifting and bicycling) could confirm the usability of these wearable trackers in expanded exercise settings. Future studies should include different populations and health concerns, such as young and older adults and individuals afflicted with obesity (ie, epidermal thickness) and diabetes (ie, poor blood circulation)

How accurate are the wrist-based heart rate monitors during walking and running activities? Are they accurate enough? - Abstract - Europe PMC:

Patients Caught In Crossfire Between Giant Hospital Chain, Large Insurer |

It would seem common sense when you pick a doctor that is listed in a provider list for an insurance company, his hospital would also be in the plan?

Zoe Friedland and her husband, Bert Kaufman, are expecting their first child. (Courtesy of Bert Kaufman)

Not so according to this from California Healthline.

Insurance giant Cigna and San Francisco-based Dignity Health have failed to ink a 2020 contract, leaving nearly 17,000 patients in California and Nevada scrambling to find new health care providers. Meanwhile, Dignity faces financial and legal challenges while it strives to implement its merger with Catholic Health Initiatives, which created one of the nation’s largest Catholic hospital systems.

“With so many unpredictable things that can happen with a pregnancy, I wanted someone I could trust,” Friedland said. That person also had to be in the health insurance network of Cigna, the insurer that covers Friedland through her husband’s employer.

Friedland found an OB-GYN she liked, who told her that she delivered only at Sequoia Hospital in Redwood City, California, a part of San Francisco-based Dignity Health. Friedland and her husband, Bert Kaufman, live in Menlo Park, about 5 miles from the hospital, so that was not a problem for them — until Dec. 12.

That’s the day Friedland and Kaufman received a letter from Cigna informing them their care at Sequoia might not be covered after Jan. 1. The insurance company had not signed a contract for 2020 with the hospital operator, which meant Sequoia and many other Dignity medical facilities around the state would no longer be in Cigna’s network in the new year.

Suddenly, it looked as if having their first baby at Sequoia could cost Friedland and Kaufman tens of thousands of dollars. “I was honestly shocked that this could even happen because it hadn’t entered my mind as a possibility,” Friedland said.

This is not an uncommon occurrence. Even if patients are aware of a possible conflict there is often a disconnect between printed materials and reality. In fact, most plans have a statement stating patients should call providers and hospitals to be certain they still honor your plan. In an age when patient-centric health care is promoted, the system often fails miserably.  You are paying a premium, however, contracts place the full burden on you, the patient. 

In this particular case at the beginning of a New Year confusion can reign as computer systems can lag.  Normally plans require 3 mos notice from providers and vice-versa to indicate a change in coverage. Not knowing the particulars in this instance, whether the couple had just obtained this coverage or it had already been in effect.  It is difficult to assign blame for this incident. Certainly, the patient's best interests were not served.  Every state has it's own regulatory mechanism that polices insurers.  This couple should report the incident to that department. Usually the Health Insurance Commissioner or the Department of Health and Human Services.

She and her husband are among an estimated 16,600 people caught in a financial dispute between two gigantic health care companies. Cigna is one of the largest health insurance companies in the nation, and Dignity Health has 31 hospitals in California, as well as seven in Arizona and three in Nevada. The contract fight affects Dignity’s California and Nevada hospitals, but not the ones in Arizona.

“The problem is the price,” Cigna said in a statement just before the old contract expired on Dec. 31. “Dignity thinks that Cigna customers should pay substantially more than what is normal in the region, and we think that’s just wrong.”

Tammy Wilcox, a senior vice president at Dignity, said, “At a time when many nonprofit community hospitals are struggling, Cigna is making billions of dollars in profits each year. Yet Cigna is demanding that it pay local hospitals even less.”

In 2018, the most recent full year for which earnings data is available, Cigna generated an operating income of $3.6 billion on revenue of approximately $48 billion. Dignity Health reported an operating income of $529 million on revenue of $14.2 billion in its 2018 fiscal year.

It’s possible Cigna and Dignity can still reach an agreement. Both sides said they will keep trying, though no talks are scheduled.

If you want to read more about how this turned out,  read the reference (spoiler alert: Cigna backed down)

While the push for universal payer will be uppermost in mind for voters, this type of problem may not go away.






Patients Caught In Crossfire Between Giant Hospital Chain, Large Insurer | California Healthline:

What’s on your citrus fruit? Trump’s EPA fights to keep controversial in...

. WHAT IS CHLORPYRIFOS AND HOW IS IT USED?

Chlorpyrifos is an inexpensive and effective pesticide that has been on the market since 1965. Farmers across the U.S. use millions of pounds of it each year on a wide range of crops, including many different vegetables, corn, soybeans, cotton and fruit and nut trees.


Like other organophosphate insecticides, chlorpyrifos is designed to kill insects by blocking an enzyme called acetylcholinesterase. This enzyme normally breaks down acetylcholine, a chemical that the body uses to transmit nerve impulses. Blocking the enzyme causes insects to have convulsions and die. All organophosphate insecticides are also toxic and potentially lethal to humans.

Until 2000, chlorpyrifos was also used in homes for pest control. It was banned for indoor use after passage of the 1996 Food Quality Protection Act, which required additional protection of children’s health. Residues left after indoor use was quite high, and toddlers who crawled on the floor and put their hands in their mouth were found to be at risk of poisoning.

 Citrus groves have been infiltrated by residential housing.  Large citrus groves such as this one now have large residential developments. In Southern California, most commercial citrus operations have moved elsewhere.

The Central Valley of California is now where most commercial groves operate.



Despite the ban on household use and the fact that chlorpyrifos doesn’t linger in the body, over 75% of people in the U.S. still have traces of chlorpyrifos in their bodies, mostly due to residues on food. Higher exposures have been documented in farm workers and people who live or work near agricultural fields.





 WHAT’S THE EVIDENCE THAT CHLORPYRIFOS IS HARMFUL

Researchers published the first study linking chlorpyrifos to potential developmental harm in children in 2003. They found that higher levels of a chlorpyrifos metabolite – a substance that’s produced when the body breaks down the pesticide – in umbilical cord blood were significantly associated with smaller infant birth weight and length.


Subsequent studies published between 2006 and 2014 showed that those same infants had developmental delays that persisted into childhood, with lower scores on standard tests of development and changes that researchers could see on MRI scans of the children’s brains. Scientists also discovered that a genetic subtype of a common metabolic enzyme in pregnant women increased the likelihood that their children would experience neurodevelopmental delays.

These findings touched off a battle to protect children from chlorpyrifos. Some scientists were skeptical of results from epidemiological studies that followed the children of pregnant women with greater or lesser levels of chlorpyrifos in their urine or cord blood and looked for adverse effects.

Epidemiological studies can provide powerful evidence that something is harmful, but results can also be muddled by gaps in information about the timing and level of exposures. They also can be complicated by exposures to other substances through diet, personal habits, homes, communities, and workplaces.

A katydid which often invades citrus groves.






3. WHY DID IT TAKE SO LONG TO REACH A CONCLUSION?

As evidence accumulated that low levels of chlorpyrifos were probably toxic in humans, regulatory scientists at the U.S. EPA and in California reviewed it – but they took very different paths.

At first, both groups focused on the established toxicity mechanism: acetylcholinesterase inhibition. They reasoned that preventing significant disruption of this key enzyme would protect people from other neurological effects.

Scientists working under contract for Dow Chemical, which manufactured chlorpyrifos, published a complex model in 2014 that could estimate how much of the pesticide a person would have to consume or inhale to trigger acetylcholinesterase inhibition. But some of their equations were based on data from as few as six healthy adults who had swallowed capsules of chlorpyrifos during experiments in the 1970s and early 1980s – a method that now would be considered unethical.

California scientists questioned whether risk assessments based on the Dow-funded model adequately accounted for uncertainty and human variability. They also wondered whether acetylcholinesterase inhibition was really the most sensitive biological effect.

In 2016 the U.S. EPA released a reassessment of chlorpyrifos’s potential health effects that took a different approach. It focused on epidemiological studies published from 2003 through 2014 at Columbia University that found developmental impacts in children exposed to chlorpyrifos. The Columbia researchers analyzed chlorpyrifos levels in the mothers’ cord blood at birth, and the EPA attempted to back-calculate how much chlorpyrifos they might have been exposed to throughout pregnancy.

On the basis of this analysis, the Obama administration concluded that chlorpyrifos could not be safely used and should be banned. However, the Trump administration reversed this decision in 2017, arguing that the science was not resolved and more study was needed.

For their part, California regulators struggled to reconcile these disparate results. As they saw it, the epidemiological studies and the acetylcholinesterase model pointed in different directions, and both had significant challenges.

4. WHAT CONVINCED CALIFORNIA TO IMPOSE A BAN?

Three new papers on prenatal exposures to chlorpyrifos, published in 2017 and 2018, broke the logjam. These were independent studies, conducted in rats, that evaluated subtle effects on learning and development.

The results were consistent and clear: Chlorpyrifos caused decreased learning, hyperactivity and anxiety in rat pups at doses lower than those that affected acetylcholinesterase. And these studies clearly quantified doses to the rats, so there was no uncertainty about their exposure levels during pregnancy. The results were eerily similar to effects seen in human epidemiological studies, vindicating health concerns about chlorpyrifos.

California reassessed chlorpyrifos using these new studies. Regulators concluded that the pesticide posed significant risks that could not be mitigated – especially among people who lived near agricultural fields where it was used. In October 2019, the state announced that under an enforceable agreement with manufacturers, all sales of chlorpyrifos to California growers would end by Feb. 6, 2020, and growers would not be allowed to possess or use it after Dec. 31, 2020.

Hawaii has already banned chlorpyrifos, and New York state is phasing it out. Other states are also considering action.

5. WHAT’S THE U.S. EPA’S VIEW?

In a July 2019 statement, the EPA asserted that “claims regarding neurodevelopmental toxicity must be denied because they are not supported by valid, complete, and reliable evidence.” The agency indicated that it would continue to review the evidence and planned to make a decision by 2021.

EPA did not mention the animal studies published in 2017 and 2018, but it legally must include them in its new assessment. When it does so, I believe EPA leaders will have great difficulty making a case that chlorpyrifos is safe.

In my view, we have consistent scientific evidence that chlorpyrifos threatens children’s neurological development. We know what this pesticide does to people, and it is time to move to safer alternatives.

At a time when the EPA has been politicized and with a concurrent effort to downsize government (promised by President Trump), important. scientific information has been disregarded by the feds. Fortunately for Californians, this is not so.