Meet the Press with Mayo Clinic and Cleveland Clinic

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Dr. John Noseworthy, President and CEO at Mayo Clinic, appeared on Meet the Press with David Gregory alongside with Dr. Toby Cosgrove, CEO of Cleveland Clinic, this past Sunday to discuss the impact of the Affordable Care Act and the future of health care in America.

issues covered by Dr. Noseworthy included:

1. The need to modernize the health care delivery system to drive quality at lower cost.
2. Dealing with the sustainability of Medicare in the long term.
3. Using available technology such as telemedicine to improve patient care and deliver knowledge.
4. Funding research through the National Institutes of Health.

Dr. Noseworthy emphasized the Mayo Clinic has remained outside the political arena. 

Mayo Clinic and Cleveland Clinic represent the best of IDNs (Integrated Delivery Systems). Most healthcare in the U.S. is delivered by much smaller organizations. MC and CC easily are converted to a formal Accountable Care Organization and are being promoted as ideal models for quality of care, and reduced costs.  Not all organizations have these  full potentials.  The expense and investment for smaller institutions may not have a return on investment nor demonstrate cost savings.

ACO Expectations may be Unrealistic

According to a survery of  115 Hospital C-Level executives reveal that about 18% are participating in accountable care organization activities.  This figure is increased from 5% % in 2012.   Half of respondents expect to be in an ACO by the end of 2014.

Whether that lofty figure can be reached remains to be seen. Provider alliance Premier Inc. conducted the new survey in August but only recently released results. The spring 2012 survey found that nearly 52 percent of respondents expected to be in the ACO arena by the end of 2013. Now, Premier estimates only 23.5 percent will reach that goal.

A further analysis of hosptial size revealed: 

Non-rural hospitals are most likely to participate in an ACO, followed by hospitals in integrated delivery systems; and rural hospitals are least likely to participate, followed by standalone facilities.

Large hospitals are moving more quickly toward ACOs than smaller ones, although the majority of surveyed hospitals are making infrastructure investments to manage population health.

This may be effected by the availability of capital resources which are often lacking in smaller institutions, and a much smaller group of medical providers and/or a lack of specialty access.

These investments include lifestyle and wellness coaching by more than 70 percent of respondents, telemedicine by almost half of rural facilities compared with one-third of non-rural hospitals, and patient-centered medical homes, which are popular for all types.

The efforts include a wide variety of investments to increase utiilization of the ACO as a public health resource. 

* The investments include lifestyle and wellness coaching by more than 70 percent of respondents, telemedicine by almost half of rural facilities compared with one-third of non-rural hospitals, and patient-centered medical homes, which are popular for all types.

* Fifty-one percent of responding hospitals are partnering with large local employers to improve care.

* Large numbers of respondents are gearing up for analytics to support population health. More than 72 percent are integrating claims and clinical data, half are using predictive analytics to forecast needs and 46 percent are using a data warehouse to reduce information silos.

* More than 40 percent are partnering with insurers, particularly for upside-only shared savings programs.

The programs require strategic rethinking of hospital scope of care.  The effort will require integration of previously unlinked services in preventive medicine, and health, wellness and nutrition.

The full report from Premiere Inc can be found here.

Signing up for the Affordable Care Act

Step one:

Access your Health Benefit Echange on the Web.  Register, if you want to (or can) Write down your user ID and password.   It may not matter since your user id and password may not be saved in the system.  Rather than using  your SS number or case number they want  you to make up a user id and/or password you will likely forget.

Expect to receive  a message the site is down, we want to help you try again later. blah, blah, blah.
Once you are able to access the site the page loads will be irregular, very slow  to load and may disconnect.   Your best time to reach a site is between mindinte and 5  AM,  however  you also may receive "the site is down for maintenance'... try during our regular business hours.

When you resort to calling.  Set your telephone auto dialer and begin calling at five minutes before the exchanges open.  I receive a message that my wait time would be 5 minutes....I waited 45 minutes.  This was after ten attempts during regular business hours. If  you do not call before ten minutes after the phones are on....forget it.


Step two:

Once I accessed a human being, things went very well. The agent was more than helpful and spent 30 minutes going over enrollment.  In fact because my first attempt went so badly even with help I had to re-enroll in a different insurance company.  Some of the least expensive plansl have very limited provider and hospital access.

Because I am a retired MD I know many of the physicians that were listed as providers. The providers were often foreign medical graduates, spoke multiple languages, such as Vietnamese, Tagalag, Hindi, and Spanish. The FMGs were multicultural.    Also most of the providers in Covered California were predominantly former Med-Cal providers and familiar with Medicaid patients and reimbursement.

The printed subsidies were complicated and many times the subsidy rates made no sense for some policies. The best approach is to wait an receive your invoice, then call if you have a question.  Be certain it is correct because once you pay your premium you are locked in for one year, except for life-changing events such as additon to famly, loss of employment and/or changes in income. The next entrollment period is October 2014.

My advice is to not rush. Delaying enrollment will only mean your activation date is delayed a month. Spend a lot of time going over all your options for your income level. Search from   high to low premiums to assess the differences,  which can be subtle with deductibles, co pays for drugs and providers. Some have high co pays for medications. Plan on spending several hours to study it and assess your needs.  The web site is very good for comparing   how much  medical care you use annually, and the number of prescription drugs you use.

Now that my wife is enrolled I am relieved....15 years with her being uninsurable, with a very high copayment for her disability Medi-caid coverage was terrible, and inhumane.

Regardless of the Affordable Care Act. having an insurance cared will NOT cure our problems. The ACA does not address accessibilty, uniformity of coverage, or qualty of care.  Most of the law addresses insurance companies, and does nothing to relieve providers from a terrible and overriding responsibility for their patients with little help or cooperation from the bureaucrats.

Media reports indicate there will be a serious and committed effort to make major amendment, additions to, or repeal the Act.  Most responsible leaders who are not political idealogues are in favor of this course.

Ideologues and Unrealistic Expectations

Comments from Gary Levin MD are underlined and italicized:

Today I am amazed at an enthusiastic article about the Affordable Care Act by Eugene Robinson from Tallahassee.com.

His unbridled enthusiasm in the face of many difficulties that have nothing to do with health care exemplifies those who designed this law and passed it without reading it.

Here are some of his unsubtantiated claims and perhaps 'wishful thinking'

Eugene Robinson:  Washington Post

"Now that the fight over Obamacare is history, perhaps everyone can finally focus on making the program work the way it was designed. Or, preferably, better.

The fight is history, you realize. Done. Finito. Yesterday’s news.

Any existential threat to the Affordable Care Act ended with the popping of champagne corks as the new year arrived. That was when an estimated 6 million uninsured Americans received coverage through expanded Medicaid eligibility or the federal and state health insurance exchanges. Obamacare is now a fait accompli; nobody is going to take this coverage away."

1. The fight is not history, we are barely through round one and all the points go to the opponents of the ACA.

2. Six million Americans have not received coverage from the ACA. Registering is only the first step. It took me over ten hours of fumbling on the web site, and on hold via telephone. How many will be able to pay premiums by deadlines, or negotiate the difficult process of acquiring a provider. 

"There may be more huffing, puffing and symbolic attempts at repeal by Republicans in Congress. There may be continued resistance and sabotage by Republican governors and GOP-controlled state legislatures. But the whole context has changed."

The upside of the ACA is that all previously uninsurable patients now are enrolled no matter what pre-existing condition they have A+++++.

Can the ACA be improved?  Most definitely. The argument should not be Republican against Democrat.  Political party does not immunize one against illness.

I wholly agree with Mr. Robinson's analysis regarding the eventual goal of a uniform health system.  To call it universal care is a misnomer.

"The real problem with the ACA, and let’s be honest, is that it doesn’t go far enough. The decision to work within the existing framework of private, for-profit insurance companies meant building a tremendously complicated new system that still doesn’t quite get the job done: Even if all the states were fully participating, only about 30 million of the 48 million uninsured would be covered.

Yes Obamacare does not go far enough, however that is not the principle flaw. There is no one principle flaw, if there are any that is the poor analysis  and proposed implementation of a major expenditure that will effect most businesses,  all patients, and our national budget, and come up short.  If we are intent, committed and dedicated to these goals then let's get it right (or mostly right the first time)

Obamacare does establish the principle that health care is a right, not a privilege — and that this is true not just for children, the elderly and the poor but for all Americans.

Throughout the nation’s history, it has taken long, hard work to win universal recognition of what we consider our basic rights

This is a political and philosophical statement, not about health care. We need to keep these issues separate.  I agree with him about the tenet that all people should have health care financing.

Our first step should be to put on hold further mandates while the act is re-evaluated. Repeal is not an option, however amendment is a reality and not an 'existential' argument.

Mr Robinson's  article is not objective, nor unbiased. He totally neglects the weaknesses of the law which will require amendments.  Placing the issue in terms of a 'battle' between political parties does disservice to dedicated professionals who have  been in the system,  and who were neglected during the planning process.

To ignored the flaws would be a fatal mistake, health care costs will soar and there will still be large gaps in the insured population

Contact Eugene Robinson ateugenerobinson@washpost.com.

Contact Gary Levin MD at gmlevinmd@digitalhealthspace.com

Survey on the Affordable Care Act

Following the botched rollout of the affordable care act, people are dazed (perhaps a better term would be "shock and awed' by the limp and incompetent rush to open the exchange on time rather than do  it right the first time.  Having to do it  over must have cost big time !

The good news for those of us who see the ACA as a mis-step toward uniform health care (note I did not call it Universal Health Care.   An inadequate and poorly constructed Universal Payer Plan is not necessarily uniform.

The very public event has opened the door for much discussion and now the time is ripe for changing the plan to something much better, less expensive and equitable, not designed to redistribute wealth. That is not what health care is about.  Obama's plan is deceitful in most ways..  The only redistribution of wealth would be to insurers, big  pharma, and the U.S. government at taxpayer expense.

Freedom Works has just released a survey that you should look at and participate.  This is your chance to participate with new ideas.

Freedom Works is an organization now intent upon  health reform and maintaining the underlying freedoms we as all Americans cherish.

How will Freedom Works support our goals for health reform? Freedom Works not only is interested in health care, it also  works across a wide variety of niches with a consistent underlying standard based on our most fundamental beliefs of freedom and constitutional law.

An email arrived in my inbox from Freedom Works that i would share with all my readers, providers, patients, employees of our health system and leaders in Congress.

This is your chance to weigh in on improving the Accountable Care Act.  Take the Survey constructed by Freedom Works.

Looking Back at 2013

This report is somewhat late due to last minute projects at the end of 2013 and the confusion about the individual mandate, the botched launching of health benefit exchanges and some other unexpected tasks

We reviewed the 'best"  Health Train Express posts of 2013 as measured by the number of comments and our analytics.

IRS VIOLATES HIPAA FACES LAWSUIT BY A "J Holiday Message for Health and Wellness WHY AREN'T DOCTORS INVOLVED IN HEALT Does Obama really want the Affordable Care Act Covered California What They Said Before the Train Wreck: The To Sebelius will be a no-show at Obamacare hearing The Beginning or The End to the Affordable Care Act There were many more 'favorites".  The highest number of page views was in the category of the Affordable Care Act. This was to be expected, given the high ranking of the ACA for search engines. Visit the sites on Health Train Express for many more interesting topics. Health Train Express has archived our posts dating back to 2005.  The focus of posts has changed over the  years, and reveals the dynamism of health care and reform.

Happy New Year .... NOT for Health Reform

Should we be content that we made it through 2013, it seems we always do, no matter what happpens.  Now is the time to become accountable and assertive to determine our future health care.

Many aspects come together to produce 'the perfect storm'.  This storm is not necessarily a destructive one. It has set off an early warning signal for our country that we must be cautious of how we reform our health system.

Nevertheless our health system is in shambles, further delays in revising it, or continuing on with the ACA will lead to a train wreck.

Obamacare is focused on health insurance, with caveats, rewards, and penalties.. Neither patients or providers were the center of the reform.  The  item that did serve patients was solving the pre-existing conditions as a reason  for denying coverage,and eliminating the cap on coverage.

Health Reform will not take place in isolation or in one swoop,  and despite the ACA we will not yet have a functioning plan, nor will we if we continue with the present legislation.

Health Train Express receives a daily stream of analysis and recommendations for future modification to our system.  Neither hype, grandiosity, political motives nor slick marketing by 'celebrities' is going to 'fix' our system.

The good news is that we do have the finest scientific and technical resources already at our beck and call. All of this is available, it's a question of distribution, and we can compare it to supply line  management. We do not need a "Manhattan Project" to invent a new technology.  We already possess it. Perhaps this is an oversimplification, however many have compared our system to other industries, such as the airline business, the banking business and shipping businesses. No one model correctly addresses health financing.

There are aspects, accessibility, funding, prevention, and correcting the huge cost disparites and how to correct the burden for deficits & reimbursements.

Although  the ACA passed in 2010, we are more than three years down the road,  and most of the ACA has not occurred.  Further delays will occur now due to the inability to implement the first stages and mandates.  What has happened is the insurance companies have been sent into disarray, and have been asked already to double back.

The extent of increases in implementation cost will accelerate further and even cancel whatever cost reductions are predicted by the ACA.   Some studies have already demonstrated this fact.

Fortunately, the disagreements and controversy have focused attention on our health system for many who have been  passive and willing to accept the system for what it is. Each  year we witness a steady increase in premiums, increasing deductibles, increasing co-payments and decreasing reimbursements. We have mistakenly used tax law to minimize or maximize gains from insurance coverage with MSPs, HSAs, and now face a myriad of new, unproven schemes such as Accountable Care Organizations (ACO) predicted to decrease cost and improve quality.

It is a highly complex equation, involving some market economics, and a system of reimbursement that defies logic.  For some time the financing has been approached as a point of service transaction(POS) with creative financing such as capitation, some tax credits, and deductions. A portion of the state's public social service system is deemed 'free care' although it is not.

There are many 'misnomers' , such as 'usual and customary charges', pre-paid rates, adjustments, and cash deductions, Insurance companies have based their rates and policies upon algorithms and actuarial analysis, and a 'fudge factor' for unpredictability.

Many have sad, health care is a right, based upon aspects of the constitution in regard to the pursuit of happiness and freedom.  Although the word health does not appear in the  constitution, health can be construed to be a part of pursuing........life and happiness.

Others state that health care is not a right and not everyone should have health coverage, with a bit of 'they don't deserve it.  Neither truly can be legitimized by such a callous attitude.

What we need is a steady hand on the system that will deal equitably and with imperturbability the illnesses of human life and the equal ability to cope with it.

Freedom Works is an organization now intent upon  health reform and maintaining the underlying freedoms we as all Americans cherish.

How will Freedom Works support our goals for health reform? Freedom Works not only is interested in health care, it also  works across a wide variety of niches with a consistent underlying standard based on our most fundamental beliefs of freedom and constitutional law.

An email arrived in my inbox from Freedom Works that i would share with all my readers, providers, patients, employees of our health system and leaders in Congress.

This is your chance to weigh in on improving the Accountable Care Act.  Take the Survey constructed by Freedom Works.

Senate News about Health Information Technology

Some evidence is trickling in that some in Congress are listening, and are as frustrated as the providers, hospitals and patients..

The letter is prefaced by this introduction:

"To begin a discussion of these health IT programs, today we released "REBOOT:Re-examining
the Strategies Needed to Successfully Adopt Health it."This white paper outlines our concerns
with current health IT policy, including interoperability, increased costs, potential waste and
abuse, patient privacy, and sustainability."


Senators Lamar Alexander, Tom Coburn, Richard Burr, Michael Enzi, Pat Roberts and John Tune drafted a letter to the Administration, with these conclusions:

Transformations in health IT will significantly change how health care is provided in this country.
Americans want to search for medical information online, check drug interactions or symptoms with their
smart phones, and e-mail their doctors. Physicians can now access digital records of a patient even if they
are in another city, state, or country. Clinical notes are recorded with increasing speed and ease, and other
transformations offer the promise of increased efficiency, reduced costs, and improved quality of care.

However, the details of federal law and regulation may be inadvertently incentivizing unworkable,
incoherent policy goals that ultimately make it difficult to achieve interoperability. Congress, the
administration, and stakeholders must work together to “reboot” the federal electronic health record
incentive program in order to accomplish the goal of creating a system that allows seamless sharing of
electronic health records in a manner that appropriately guards taxpayer dollars. Fulfilling the goal of
increasing efficiency in the health care system; reducing costs for payers, providers, and patients; and
improving quality of care for patients is a challenging task. In order to succeed, the following
implementation deficiencies must be addressed:

 Lack of Clear Path Toward Interoperability
 Increased Costs
 Lack of Oversight
 Patient Privacy at Risk
 Program Sustainability

We present this white paper in an effort to initiate a dialogue with the administration and the stakeholder
community. The purpose of this paper is to foster cooperation between all stakeholders – including
providers, patients, EHR vendor companies, and the Department of Health and Human Services – to
address the issues raised in this white paper, evaluate the return on investment to date, and ensure this program is implemented wisely.

Their analysis appears to be  accurate, pointing out many deficiencies.

To begin a discussion of these health IT programs, today we released "REBOOT:Re-examining 
the Strategies Needed to Successfully Adopt Health It."This white paper outlines our concerns
with current health IT policy, including interoperability, increased costs, potential waste and
abuse, patient privacy, and sustainability.

IRS VIOLATES HIPAA FACES LAWSUIT BY A "JOHN DOE"

HealthCare IT News reports  The Internal Revenue Service could now be facing a class action lawsuit over allegations that it improperly accessed and stole the health records of some 10 million Americans, including medical records of all California state judges.

According to a report by Courthousenews.com, an unnamed HIPAA-covered entity in California is suing the IRS, alleging that some 60 million medical records from 10 million patients were stolen by 15 IRS agents. The personal health information seized on March 11, 2011, included psychological counseling, gynecological counseling, sexual/drug treatment and other medical treatment data. 

"No search warrant authorized the seizure of these records; no subpoena authorized the seizure of these records; none of the 10,000,000 Americans were under any kind of known criminal or civil investigation and their medical records had no relevance whatsoever to the IRS search. IT personnel at the scene, a HIPAA facility warning on the building and the IT portion of the searched premises, and the company executives each warned the IRS agents of these privileged records," the complaint continued.

If the allegations are true, the IRS is in trouble,” wrote Jim Pyles, Washington-based healthcare privacy lawyer, in a statement to Healthcare IT News. “By both constitutional law and HIPAA, then I think we have a problem.”

The Department of Health and Human Services recently stated that the ACA does not grant the IRS open access to Americans' medical records with no cause. "The Affordable Care Act maintains strict privacy controls to safeguard personal information. The IRS will not have access to personal health information,” said HHS spokesperson Erin Shields Britt, to Kaiser Health News.

The IRS refused to comment when questioned.

The present plan is for the IRS to verify and document income and the consumer's insurance status.  This is contemplated to begin in 2014 in order to determine the consumer's insurance status.  The result will be used to determine a fine or penalty in lieu of insurance.

Thus far we have seen extreme difficulty with the mandate for October 2014,  wherein the Health Benefit Exchanges would be accessible to the public. This did not occur, as planned.

The vagaries of having two large governmental agencies coordinating their  tasks is worrisome. HHS has demonstrated problems with their own agency, and this behavior by the Internal Revenue Services raises serious questions about HHS and the IRS conforming to HIPAA regulations.

The roll out of the ACA has been fraught with difficulties, and the majority of Americans are not  in favor of continuing in it's present form.  Some want the ACA repealed, others want major amendments to the law.

Despite law our executive branch makes unilateral decisions, ignores mandate dates, and has caused major upset to insurers and patients, alike.

Trust and faith have much to do with acceptance of laws, and the doctor-patient relationship. As physicians our duty is our patients. Most patients do not understand the  inner workings of the system until it goes wrong.

It is our ethical responsibility to inform our patients how the system  works, and the inherent and probable dangers of the affordable care act.

New Year's Resolution for the Affordable Care Act

Health Reform is a bit like designing a highly advanced technological wonder such as the F22 Raptor or the discontinued F35 Raptor.  Each one has several different renditions depending on it's branch of the service.

The U.S. Navy wants one for aircraft operations, the U.S. Army for field operations.  Some models afford vertical take off and landing capability.

Many aircraft are taken through a design process, gradually evolving into prototypes, then a preliminary manufacturing run to test the product.  Some fail at some step of the   process, early or late.  Billions of dollars are spent and the weapon is placed on a shelf somewhere near Area 51 to gather dust, or recycled for expensive composites. At times all that is left are drawings stored on a computer.  During the process the product often does not make it  to fruition.  However during the development much  is learned, and what may often happen is the information is used elsewhere.

My first resolution is to not be so negative about the ACA.  True it is more than a health reform law, with many ideas that are proposed by ideologues intent upon restructuring the U.S. economy and social structures.  True it flaunts many constitutional guarrantees and freedom is threatened by it.

My second resolution is to ignore constitutional issues and focus on the inherent flaws of the law, and it's ignorance of how  health care economics truly works.

My third resolution is to contact my Democratic Congressman to convince him of the errors of his party. Despite being a democrat he needs to  vote his own beliefs.  Also I will not vote for him based upon his vote for the Affordable Care Act.

The Obama administration has become a personality cult with a leader who spends more time campaigning and vacationing. We hear little about his day to day Oval Office routines.

The Affordable Care Act may be the law, however there have been many laws that were rescinded, such as the Prohibition Act ( Constitutional Amendments 18  &  21 ).

It's time to stop the design process and to put on hold any further production of this model. The design is obviously still in process as evidenced by the frequent unilateral executive orders regarding mandates.

Any program manager would stop and assess the unexpected bumps in the road before the entire plan goes over the cliff.

Aeronautical engineers usually take a step by step process...start the engines after testing them offsite, taxi down and back the runway, take off, check the gear, return  and land.  At this point an evaluation takes place before the major launch.

Some engineering projects test each component separately before constructing the final machine, others go for  broke and launch all at once.  This last idea has a high risk of failure but often costs less (if it works)

It is painfully obvious which plan was chosen by 'our leaders'.

The Obamacare Paper Pileup

When HealthCare.gov and some state-run insurance marketplaces ran into trouble with their Web sites in October and November, they urged consumers to submit paper applications.

Now, ProPublica's Charles Ornstein reports , it's time to process all that paper. And with the deadline to enroll in health plans less than two weeks away, there's growing concern that some of these applications won't be processed in time.

Some key points compiled from reporting around the nation:

After a conference call earlier this week with federal health officials, Illinois health officials sent a memo Thursday to their roughly 1,600 navigators saying there is no way to complete enrollment through a paper application.

Covered California in recent days disclosed that it had a backlog of 25,000 paper applications that had to be processed before the Dec. 23 deadline to sign up for coverage that begins Jan. 1.

In Oregon, a state official disclosed this week that more than 30,000 people who submitted health insurance applications still don't have enrollment packets



In Maryland, another state whose exchange has been plagued by difficulties, 8,500 paper applications were pending as of last week.

In Vermont, there is a backlog of 1,210 applications, some dating back to as early as Oct. 30.

It does not look good for a smooth transition to a January 1 startup date.  Even for those who have enrolled there have been no reports as to who has received premium billings. That is the bottom line......no $$ no insurance. Perhaps our government should automatically pay the premiums for the first 90 days to make up for their negligence, and not really giving a damn if this works.

In Oregon the response to enrollment has been abysmal.

The full story is available here: http://www.propublica.org/article/the-obamacare-paper-pileup

- See more at: http://digitalhealthspace.blogspot.com/#.dpuf

Holiday Message for Health and Wellness

Today my message is one of hope and optimism. Health and Wellness are dear to us all.

We have many tools, HIT, EMRs, ACOs, ACA, Health Benefit Exchanges and more to come. Who knows what is next or what we have built, or predict will be here in five years.  Chances are very good, they will not be based upon our looking back ten years.  Not much is left from those days.

My message today is about 'shifting sands'

Much of what you and I read or write about health care, health information technology should be taken with a grain of salt.  It is all written from the narrow confines of our own experience(s)

It all goes beyond my capability to absorb and synthesize.


Much of what I seek is answered by the parables.  My hope is that all will take away some glint of wisdom from these words, no matter what the challenge.

Building on a Solid Foundation

24“Anyone who listens to my teaching and follows it is wise, like a person who builds a house on solid rock. 25Though the rain comes in torrents and the floodwaters rise and the winds beat against that house, it won’t collapse because it is built on bedrock. 26But anyone who hears my teaching and doesn’t obey it is foolish, like a person who builds a house on sand. 27When the rains and floods come and the winds beat against that house, it will collapse with a mighty crash.”

The Tree and Its Fruit

15“Beware of false prophets who come disguised as harmless sheep but are really vicious wolves. 16You can identify them by their fruit, that is, by the way they act. Can you pick grapes from thornbushes, or figs from thistles? 17A good tree produces good fruit, and a bad tree produces bad fruit. 18A good tree can’t produce bad fruit, and a bad tree can’t produce good fruit. 19So every tree that does not produce good fruit is chopped down and thrown into the fire. 20Yes, just as you can identify a tree by its fruit, so you can identify people by their actions.

Effective Prayer

7“Keep on asking, and you will receive what you ask for. Keep on seeking, and you will find. Keep on knocking, and the door will be opened to you. 8For everyone who asks, receives. Everyone who seeks, finds. And to everyone who knocks, the door will be opened.

This is my holiday gift to all.

Gary Levin M.D.

Meningitis Outbreak .....A Near Miss

I doubt if the family's and students at UCSB or Princeton who had Type B meningitis don't feel it was a "near miss"  For them regardless of the low risk of contracting the type B strain when it occurs to you statistics mean nothing.

Meningitis is a particularly challenging illness to diagnose and treat early.  It often presents as a mild sore throat which quickly escalates into a high fever, mental changes, stiff neck and rash.  Unless intervention occurs early loss of limbs, and other severe complications can arise.  Sore throats and headaches and fever are ubiquitous at any school in the fall and winter.

Meningitis  can be caused by multiple etiologies, (fungal,parasites, viral, and bacterial).  Multi-valent and univalent vaccines have been developed.

Nearly 2,000 Princeton University students lined up for shots Monday as the New Jersey school began offering an emergency vaccine aimed at halting an outbreak of potentially deadly meningitis that has sickened eight since March, health officials said.

That's about one-third of the estimated 6,000 students and others expected to get injections this week of an imported drug approved in Europe, Australia and Canada, but not in the U.S. It protects against the B strain of meningitis — the bug behind the illnesses — which isn’t covered by the vaccines that most college students already receive.

Statistics can prove almost anything. Logic and probability are terms that 'QUANTS" use.  Quants are the statisticians that develop and consult algo's (algorithms) .  Algorithms have always been important in the insurance world, engineering, weather forecasting and much more.

Algorithms have not so quietly slipped into the mainstream of medicine in terms of managed care, cost,risk factors for disease and in basic research. Most of us remember the 'P' factor as the liklihood something would happen by chance in an experiment.  It indicated how many times the event would occur by chance if repeated 100 or1000 times

The non-availability of Meningitis type B vaccine was due to one of those algorithms that determined it was NOT COST EFFECTIVE to import Bexsero into the  U.S.  It was deemed by decision makers that it would be too expensive to run through the U.S. FDA investigative new drug application process.  For most really new drugs this can be one or more years.

The drug manufacturer, of Bexsero, a vaccine licensed only in Europe and Australia that protects against meningitis B, a strain not covered by the shots recommended for college students in the U.S.   had to apply to the FDA to initiate the process (started in October 12-13  at about the same time as the first cases at Princeton and UCSB were diagnosed.

The first doses were given at Princeton  December 9, 2013.  The process obviously was fast-tracked but it required  two months because of the arduous bureaucracy.

The take-aways here are:
   
1. Many preventive measures are calculated on the basis of similar algorithms
2..A centralized authority such as the Affordable Care Act and the proposed IPABs  establish many         procedures and/or treatments that are acceptable, not recommended, or 'not covered' by the affordable   care act as a standardized practice, all based upon statistical algorithms.
3. Diverting from a standard practice, or an emergency practice can be delayed considerably by these processes.

Inevitably the physician has the moral and the ethical responsibility for the decision.  The patient's welfare is the ultimate arbiter.

Our health system is becoming dangeously close to interfering with a physician's hippocratic oath.