Untangled Health

Consumers Unite To Drive The Changes We Need

Interview on The State of Things “A personal history”

Heck! With health insurance we can afford a cup of coffee!

Dear Friends, I am scheduled to be interviewed on “The State of Things” on WUNC, this Thursday at 12:06 PM. This is a one hour event regarding the Opioid Crisis in NC. I am the first speaker and will be reflecting on my experience with the disease of Opioid Use Disorder as a young man and later in life as a chronic pain patient; chronic disease management program manager and work as a community health program performance evaluator today. I invite all to listen.
All of my work is converging on a common mission: To inform others of the Strengths, Weaknesses, Opportunities and Threats in our Healthcare System. My work with #RightCare is all about recruiting citizens from the grassroots of my community to participate in reform while keeping the best of what we have. America has much to celebrate when it comes to our achievements and much to invent to raise us up to our potential.
This week; two things come to mind: The opioid crisis and how it creates an opportunity for us to recognize addiction as a chronic disease and chronic pain as a leading cause of disability in this country. What should be done, what can be done and what we are doing. Then the budget work in DC: The fact that there is no continuing resolution to fund the Community Health Centers of America who serve some nine million people. This venue is the most cost effective and important part of our health care system and it will surprise all to find out how these centers beat out the commercial, healthcare apparatus hand over fist when it comes to health outcomes and cost management. I hope everyone is on their phones and email to request their representatives for funding I the new budget. If we lose it, the economic and health burden will be tremendous.
Always thinking of you,
PS: #RIghtCare Join Now!

Public Health vs. National Emergency …Get real folks.

Last October Mr. Trump called for a Public Health vs. National Emergency releasing minimal (less than $50K per recipient agency)to address the Opioid Crisis. Yet today- as I review unpublished epidemiology statistics on Hepatitis C cases I find the trend that I have posted here! Well, for those that care more about money than the people afflicted by the disease I hope they can appreciate the fact that each case of Hepatitis C can cost $100,000 in prescription medications and that is the BARE MINIMUM of cost per case associated with the illness.
Just food for thought.

Loss of Federal Funding for repayment of Medical and Dental School Debt. How we are abandoning the poor and underserved in Healthcare Critical Access Regions

From our friends at NC Health NewsAs the Raleigh Area Right Care Alliance Chapter Leader I want to voice our displeasure at the barriers to financing a medical education that have recently surfaced. It appears our congress is succeeding at making huge strides backwards in the wonderful advancements toward improving the health of our most vulnerable populations.
I moved here in 2001 to work with the Rural Health programs that were implementing what we now refer to as Medical Homes. North Carolina was one of the most advanced states in the Nation when it came to addressing the needs of poor, chronically ill children in rural locations. I was thrilled to have the opportunity to work with these projects which have received national awards for improving the health and controlling the inflation of healthcare cost of high risk populations. I can recall late night meetings with physicians working for roughly half of what they could earn elsewhere as they paid the government back for the opportunity to go to medical or dental school and later serve people in critical access areas. Their sense of generosity, expert knowledge and willingness to contribute are the highlights of my career.
Regardless of the data, the US Congress and the NC General Assembly have made terrible mistakes that will severely impact the health status of our poor. They will claim otherwise but as a professional healthcare program evaluator I can honestly say they are making counter-intuitive decisions that deserve a public challenge. We intend to do this through public education events in 2018.
Tonight I am thinking about the complications with dental hygiene and periodontal disease that our children have in this State and the success of our Federally Qualified Health Centers at treating these kids, their improved health outcomes and more importantly chance to have a healthy life free of chronic disease which is brought about by chronic inflammation.
I will pray for the well-being of our children as it becomes more difficult to find providers willing to serve them. History repeats itself unfortunately and we have plenty of experience that illustrates the suffering and loss of health in populations that are underserved.

Why We Need Universal Health Coverage

I am disgusted by the frequency of the statement: “Universal Coverage… We can’t do that… That would be Communist!”
As opposed to falling back to arguments relating to the Cold War (although Mr. Trump and Mr. Putin would be happy to re-engage past behavior) how about we look at EVERY OTHER INDUSTRIALIZED NATION IN THE WORLD and compare their health care financing strategy and health outcomes to ours. You see: We stand alone in the World. We are the only industrialized nation that refused to believe that the math of population health science (simple arithmetic) forces civilized nations to pool money and spread it across the entire population of infants, children, young adults, middle aged adults, young-old adults and old-old adults to bring the average cost of health care down to an affordable per-capita rate.
Here are the data from the 2016 OECD Report. You have heard of these folks haven’t you? They met in KOBE in 2016 to discuss global health.

The Study

How these countries finance healthcare

Nothing is different. The older you are, the more health care services you consume.

How long ago each country embraced Universal Coverage

Yes, the more you spend on health care the longer you live. But why is America so expensive?

The more you spend out of pocket the shorter your life span. The more Primary Care Doctors you have per unit of population the longer you live!

A reason we all need someone to watch over us when hospitalized!

As discussed in several posts between December 2015 and today I call upon healthcare consumers to “Learn the System”. The Service Excellence, scores, JCAHO ratings and next door neighbor reviews of your hospital mean little if you are a statistic. Infection Control, Readmission Rates and other measures of quality are available at: Medicare. Gov | Hospital Compare! Please write me if you have questions. Feel free to ask about the numerous Therapeutic Misadventures I have witnessed that will never show on a quality report.
The Trump Administration is doing everything it can to cut the legs out from the transparency tools that were put in place under the direction of the Obama Administration. These tools are all you have to evaluate the quality and safety of your institutions and providers.
Consumers step up and demand the care you deserve – AND PAY FOR!

Medicare Penalizes Group Of 751 Hospitals For Patient Injuries

The federal government Thursday lowered a year’s worth of Medicare payments to 751 hospitals to penalize them for having the highest rates of patient injuries.

More than half also were punished last year through the penalty, which was created by the Affordable Care Act and began four years ago. The program is designed as a financial incentive for hospitals to avoid infections and other mishaps, such as blood clots and bedsores.

Get The Data: See All 751 Hospitals Penalized

Is Your Hospital On The List?

Get the dataHere are the 751 hospitals hit with safety penalties for 2018.

The penalties again fell heavily on teaching hospitals, although less than before. A third of them were punished this year, a Kaiser Health News analysis of the penalties found. Last year, the penalty was levied on nearly half of the nation’s teaching hospitals.

The 115 penalized academic medical centers this year include Denver Health Medical Center, Grady Memorial Hospital in Atlanta, The Mount Sinai Hospital in New York City, Northwestern Memorial Hospital in Chicago, Stanford Health Care hospitals in California and the University of California-San Francisco (UCSF) Medical Center, according to federal records.

“Academic medical centers serve patients with more-complex conditions who are at greater risk of hospital-acquired infections (HAIs) compared to community health care providers,” Stanford Health Care said in a written statement. “Hospitals with a high rate of immunocompromised patients will always seem to have higher HAIs.”

Hospitals that treat large proportions of low-income people also were fined more than hospitals with a more affluent patient base, the analysis found. About a third of those safety-net hospitals were penalized, roughly the same as last year.

Can you believe this one?

I found my Peeps. Why I joined The Right Care Alliance

To build a new system we need the voice of millions struggling to survive as they try to understand, coordinate and afford America’s health care resources


Since becoming disabled I have dedicated my time to reforming our healthcare system. My drive emerged from my experiences  living with diabetes and other complex co-morbid conditions since 1966 coupled with my experiences working within our healthcare system for thirty-three years as a hands-on the caregiver, administrator, program leader and HIT visionary. To date: After five years of dedicated personal time I located only one organization –PCPCC that brought all of the Stakeholders together necessary to alter a system that has failed so many. My work with PCPCC brought me to Washington DC and opened other opportunities to influence legislative language, such as the variety of submissions to CMS for defining the Patient Centered Medical Homes. That said, where the work and effort was worthwhile, I have reached a personal conclusion that the American Health Care Apparatus needs to be designed and implemented from the bottom up. Without soliciting opinion, educating the people about our failure in moral values we will not realize our dream. A long-time fan of Continuous Quality Improvement in medicine I notice a missing feed-forward element in design when it comes to our national perspective: The Patient Perspective. Much is celebrated about patient-family inclusion in health care delivery design yet I fear what we celebrate is often the result of Service Excellence Performance Surveys, JCAHO and CARF reviews, NCQA Accreditation Surveys and other attempts to qualify and quantify processes that have not fulfilled  my personal criteria for “Going to the people”. If we are going to do this thing: We need to start over. The Right Care Alliance is on track and I am thrilled to assist with the integration of the proper minds and voices necessary to build a functional health care system.

Since becoming disabled in 2012 I have discovered what I consider to be a lack of attention to those consumers who are the most under-served; at times I fear a lack of respect for their capacity to contribute. My sense is that the arrays of NFP organizations working to define methods for health care reform and specify a concise mission are struggling with their identity (excluding folks like Families USA). Organizations such as The Society for Participatory Medicine actually have membership fees which prohibit some from joining in the effort. I participate in the private conversations among leaders and have brought this to their attention. They do however have a scholarship program for membership dues. Where the intent is respected this is hardly the mechanism to attract contribution from the community or patients who are actually the consumers accounting for 50%-70% of America’s health care budget.

When I analyzed the membership roster of S4PM in 2015 I found that 32% of their membership identified themselves as patients first. Confused, I brought this to their attention. One year later, many more patients emerged. These were mostly individuals who had more than 16 years of education and were actively engaged in other professional activities. We need these people, but once again they hardly represent the grass-roots of the healthcare services consumer.  Their mission is decidedly not health care reform, but focused on bringing patients and physicians together to form collaborative medical teams. We need these people in our discussion as we create our new system. However, I suggest their priority is not the same as the System Reformer for without a system that guarantees a bio-psycho-social care plan to all Americans we have failed. Other Patient-Centered Organizations such as Patient’s Like Me are providing a service and at the same time a clever disguise for a population research database that is funded largely through the Pharmaceutical Industry.  Patients like Me (I am a member)offers the opportunity to establish a virtual peer-support community and access to treatment guidelines and research. I love this system as it brings folks to my kitchen table that help me address the chronic pain I deal with each day, but at the same time I recognize we are freely giving away personal health information in exchange for the service. At the other end of the spectrum I have found Veritas Healthcare  where a small group of physicians, administrators, non-physician caregivers and patients are creating a new definition for those actively involved in saving lives from day-to-day through pushing the limits of healthcare reform in their local communities. They brand themselves Health Angels, I am a member and contribute to their initiative. We are many AND We are scattered.

Over the years I have come to fear we will miss an opportunity to establish a driving force as the most important voices in health care are lost or diluted through the diffusion of their input across an “over-abundance” of the organizations soliciting their involvement. Always anxious to help these stakeholders will easily donate a lot of their energy toward the cause “Fixing Healthcare” but once they sense they are being exploited will drop-out and assume a protective posture.

With experienced leadership, funding and most-importantly Humility I sense there is sufficient energy to establish a ‘critical mass effect on re-writing America’s plan for supporting the Health and Well Being of its citizens in future generations. That said, the barriers are many: Our present leadership in DC and a misinformed public that is being split into near civil-war we struggle to overcome the noise. So… time is of the essence and somehow, someway we need to corral these voices and experiences (hence knowledge) that is scattered throughout the internet, inner city and rural America into a single force. My prayer is that The RightCare Alliance will provide the necessary gravity to bring us together.

“Obamacare has no value”…”Until it has value”

I assisted a man with insurance enrollment yesterday on healthcare.gov. He had recently lost his job and was looking at a $1000 per month COBRA rate.
A conservative fellow who didn’t support “Obamacare” now says: “For the first time I like this legislation and can see why it is needed!”
His rate while unemployed?
$85.00 per month for low deductible.
One down, thousands to go!

A Patients Gripe with Donald Traumatizing the sick and suffering: How the President of the United States intentionally injured the health and well-being of the Chronically Ill.

Thanks Donald: As if the chronically ill don’t have enough to worry about, you have successfully created a barrier to our choice of health care plans.

Each year those of us who live with chronic illness spend weeks researching the plans made available to us through the Affordable Care (Obamacare) website Healthcare. Gov. We spend hours upon hours calculating our drug costs, assuring our primary care doctors are in a plan or specialty care networks that provide services such as retinal surgery, dialysis, exercise prescription, nutrition and counseling to persons with diabetes are available to the consumer. Many of us are in-line for Medicare within the next decade or so. For example, a person with diabetes or cardiovascular disease or in many cases BOTH is gainfully employed and adding value to society throughout his or her life. These folks –like myself-  live with a chronic progressive illness and spend much of their time managing their health to avert the need for urgent care services and maximize their well-being. Then… years into the illness, they find themselves taken leave of their full-time work due to the complications associated with the disease. For me, it was neuropathy at age 58 after nearly fifty years of successful self-management of diabetes. Once on the roles of Medicare our health care expense  (of interest to you I am sure) is directly related to the quality of the interdisciplinary care team that supports us in our daily self management. In the mid to late stages of chronic illness we have spent years cultivating our resources to maximize our health, functional status and quality of life. This occurs before Medicare and for many of us who went uninsured or under-insured prior to Obamacare we have had several years to bring these providers into our Care-Team and stabilize our decline in health status. As each enrollment period rolls-by we peruse the plans available to us and select those that support the providers we have selected or are intending to add to our network if certain problems arise (example, diabetic retinopathy).In case you didn’t know and I am sure you didn’t the chronically ill account for over 50% of the Medicare Budget yet represent only 10% or less of the population depending on whose statistics you are referencing.Here are some interesting statistics regarding the cost of care for Medicare Enrollees straight out of YOUR CMS Chartbook! So here we are, stressed out and trying to figure out where to get the time to select the health plan, we need to reduce the complications from the chronic illnesses we live with. All of this having direct relationship to the resources we will consume when we are transitioning to Medicare. Perhaps you will be long out of office by the time our cost hits the taxpayers back pocket and it isn’t an issue to you. Your political desire to be seen as a barrier to the ACA is more important. It can’t be a financial issue, Donald for any ten Medicare Patients with Chronic illness who experience significant progression of their illness as a result of choosing the wrong insurance plans during your presidency will far outspend any savings you introduced through cutting access to the Healthcare.Gov website. NPR article on Navigator Frustration


My Overstressed Physician (Prior Authorizations, Referrals, Stress, Prescription Assistance Programs, Electonic Health Records and More)

The following video covers just one aspect of my concerns regarding the infringement on Patient Centered Care by the “Business of Medicine”. I have reflected in the past about the cumbersome “Business Process Centered” components of health care delivery that prevent our providers (Doctor, Nurses, Technicians, Therapists ETC.) from focusing on the “Big Picture”. What I am referring to are the dimensions of health that require thorough assessment and attention to detail for the treating provider to accurately judge what is happening in our body, draft a treatment plan and execute the orders. Right Care to me is my team’s full understanding of my biology, culture, mental health and physical health needs, the social roles I play in my community and the support available in my community when it is necessary for me to stay healthy and productive.

During my visits to my doctor the processes’ of assessment, diagnosis, planning, intervention and monitoring are interlinked and any disruption will present a barrier and possibly introduce an error in treatment or missed opportunity to cure a silent condition. These missed opportunities to improve our health are often referred to as Co-missions or Omissions in care. Co-missions occur when our medications interact and cause an exacerbation of an existing illness or cause a new illness to occur. An example might be the treatment of a person with Diabetes who is taking insulin with a Beta-blocking drug such as Metoprolol. This might cause hypoglycemic Unawareness  and the patient will not be aware of a low blood sugar. An example of an Omission in Care  is when a patient is unable to continue taking a medication. The lack of evidence of prescription refills in the patient medical record might create and alert for the doctor to review, but one cannot assume that this is always the case. Beyond being aware of the missed refill the doctor or the clinics Care Coordinators should follow-up with the patient to determine the reason for non-compliance with the patients care-plan. In America financial reasons often prevent us from being able to adhere to our medication regimen and the answer to the dilemma can be as simple as contacting the drug manufacturer and applying for funds through a Prescription Assistance Program. The #partnership for Prescription Assistance is an organization that will help those with financial resource issues. So, what do you do if your doctor doesn’t have the time to spend educating you to look out for hypoglycemic unawareness, refer you to a Prescription Assistance Program or get transportation to the clinic each month for your periodic check of your blood clotting time? Should all of us be self-sufficient with these skills? I suppose in a perfect world this might be the case, but I certainly wouldn’t place this responsibility on the average lower to middle class patient today. We are far too busy just making ends meet and in many cases our health suffers.

Electronic Health Records were our great hope for unburdening the provider and the clinic staff from clerical activities that are required in the day-to-day management of a population of patients. The average primary care provider often has 2000 patients unless they are a concierge practice; which the average Joe or Jame cannot afford. Your referral to the laboratory for routine blood sampling frequently requires the doctor to link the appropriate diagnosis with the lab test or the chart will not close out after the visit and the order will not be communicated to the lab  performing your test. Today, I watched my doctor and his “documentation specialist” carefully navigate several screens in the EMR as the doctor ordered various labs and cross linked them to my problem list. These processes make a lot of sense when they relate to care quality. For example, you do not want a doctor to order tests that are not going to increase his or her knowledge of what’s ailing you.  However, in the cases I see today; and I see a lot since I am a person with multiple chronic illnesses: My doctor is dancing to the tune of the Insurance Company and looking over his back to make sure he isn’t over-utilizing or mis-utilizing his privilege to order expensive diagnostic procedures: When I see my doctor stressed out,  rushing through and missing pieces of his exam: I start to fret that he will leave his present employment and I will lose yet another good primary care physician (I have lost three in the last five years for these reasons).

So my doctor is overwhelmed with filling in the correct fields in a health record to avoid penalties from his administration. My quality of care is declining. The burden in my opinion is a caused by an over-complicated system created by folks interested in the possibilities of Big Data AND the residual business process requirements of a Managed Care Business Model that no longer is valid since our doctors today come well prepared to make high quality decisions based on the published  best practices emerging from the literature accompanied by embedded decision support in their information systems; or has someone been fibbing about what the technology does for us?

Are you willing to step up and work with your doctor to define and deliver the Right Care by the Right People, at the Right Time, in the Right Place?


Right Care Action Week Event

Untangledhealth.com conducted a Right Care Action Week Cafe for The Right Care Alliance on October 19th at Elder Path Raleigh; an MKP.org Men’s Group. We discussed, engaged, educated and empowered this group of elders to master their future health through selecting providers and institutions that offer  the highest quality, highest value services with proven integration of clinical services throughout the continuum of care.  I am excited to see this community of men step forward to model active consumerism in Health Care and dedication to teaching their peers the methods consumers can use to evaluate their regional resources. 

Topics covered included the Self Advocacy Process, Selection of High Quality Health Facilities and Providers, The Five Wishes, Transitional Care Hazard Avoidance, Medication Cost and many others. As always, UntangledHeath.com’s desire is to teach patients to advocate for themselves and their families.

We look forward to working with the Right Care Alliance in the future.

The pictures below include slides from our discussion. I will be recording the entire presentation soon!

Thumbs UP and Thumbs DOWN, WAY DOWN
“Ah, to be one and twenty in the blush of my youth”: A high five to the anti ACA crowd. I hope, but doubt the American People will understand the impact of proposed “new service payment products” on their own health as they age and the health of those who become ill or have a chronic illness. You know; the impact of smaller populations managed under risk contracts dubbed “Health Plans” where: if you are not sick AND if you are not old AND if you do not smoke YOU get a policy for $150 per month!
I am a proponent of the health care collaborative when the governance of these entities assures continuing care at a mutually agreed on affordable price to all consumers in the collaborative regardless of “Health Status”.
Oh the trouble we weave into our future with short-sighted decisions. I call upon the American Diabetes Association, The American Cancer Society, The American Heart Association and others to stand up and describe the possibilities should these changes occur without assessment of the impact on access to care, cost of care and quality of care as it relates to those who actually consume health care services.
Perhaps this is an opportunity for a public and private sector offering. A Medicare for all and a private sector alternative. What that leaves us then is a taxpayer bail-out of the industry for catastrophe; In this case; it is a predictable catastrophe. However, such changes leave behind an opportunity for high profit in the privatized, low consumption, population health care financing product and a large burden to those paying for the 10% of our society that consumes 70% of the services. “Us”.

A Diabetic in Puerto Rico calls out for insulin : Shame on us…

Normal Retina                                                        Severe Diabetic Retinopathy



I am angry.

Listening to a diabetic in Puerto Rico plead for an insulin delivery this week brought back remembrance of the body pain, insatiable thirst and intractable nausea I experienced when I was broke in 1974 and had to borrow money for medication as I hitch hiked to California to live with my brother Bruce. Feeling helpless I received a $75.00 wire transfer in the nick of time. Fortunately I had a loving brother and Western Express. Thank G-d for a wonderful primary care Doc that taught me to reverse DKA on my own when I was only 13 years old. I can’t describe the misery of Diabetic ketoacidosis with sufficient magnitude. Imagine dying of thirst.

I do not understand where our Army is. It seems we have infinite resources to drop special forces into any part of the world where there is a threat to The American Way. Yet in the time of Trump, and in the Time if Bush I heard the call of The Great Oz.. “We are doing a fabulous job”  or  “Great job Brownie”. Here lies evidence of my claim that we are own our own in this great country: The Country that used to promise opportunity and someone to watch over us when we fall upon hard times. Go ahead, call me a snow-flake…Then walk a mike in my shoes and tell me again “to suck it up”.

Today I am ashamed of the indifferent , arrogant attitude of Donald J Trump and want our Global Friends to know that we know how to care for our own, we have the resources to care for our own and that the Real America is currently on the mat in a twelve round championship fight against Master Blaster. Let me be clear; Master Blaster doesn’t run this part of town!

The retinal photo above right is an actual photo of a person with diabetes who has not had access to primary care. She lived in a rural area of North Carolina, had no insurance and died one year after this photo was taken. She was in her thirties. Medication, a treatment plan and adequate nutrition go a long way.

Hey DJT, stop worrying about what people think of you and send some helicopters in with the supplies that are piled up a few miles of the shores of Puerto Rico.

Awe Nuts! I am really pissed.

21st Century Cures Act Trusted Exchange Framework and Common Agreement Kick-Off Meeting

Listening to a Webinar produced by the ONC (Office of National Coordinator for HIT) today I was content to hear about the progress of SHIEC (Strategic Health Information Exchange Collaborative) and NATE  (National Association for Trusted Exchange) during the morning review of National Trust Frameworks and Network-to-Network Connectivity.

It is clear that consumer need is receiving attention: We are far behind the curve wherein we have vocalized our frustration with barriers to accessing our  personal health information  and the industry is listening.

Keep in mind that you are the “master of your destiny”  and “captain of your ship” when it comes to assuring you receive the Right Care, from the Right People in the Right Place at the Right Time. Self-knowledge and System-Knowledge are your keys to success.

Best summarized by Cynthia Fisher the founding angel of ViaCord at the end of the morning session: “Patients are bound to institutions that have the keys to their data and are expected to write a blank check for services with no visibility of cost”. Passionately reflecting on the plentiful gaps in the information used to make critical health care decisions during our encounters with providers throughout the healthcare system, she said; “Healthcare Data is like a Liquid Asset; it needs to flow!”

Keep your eye on the target friends: The day when you are trusted to exercise your right to control both ownership and flow of the information that your life depends on!


ONC Patient’s and Families 

Open-Access Guidelines for Patient-Centered Care (The tools we need are here!)

patient logo

How do I find the best treatment for me? Is it my doctors choice? Do I have anything to say about it? Is it possible that my doctor is unaware of best treatments?

Taken from the British Medical Journal. Click link to view the Aortic Valve Replacement Guideline.“The BMJ launched an innovative strategy to promote patient partnership in 2014. It took this step because it sees partnering with patients, their families, careers and support communities, and the public as an ethical imperative, which is essential to improving the quality, safety, value, and sustainability of health systems.”


My suggestions:

Make sure you read the educational material your clinic gives you at the end of the visit then compare it with what you are able to find independently. This is most important when you are diagnosed with a new condition or your doctor recommends a diagnostic or surgical or therapeutic procedure. By the way, new medicines are therapeutic procedures.

Since errors happen…what I choose to call Therapeutic Misadventures I like to check out the current best practices and research outcomes published in Europe, Japan and the USA.

Cool Tools are here!  Everyone knows that I am a big promoter of physician-patient partnership when it comes to researching treatment methodologies and selecting interventions for our personal care-plans. I received notice today on the MAGIC projects publication of guidelines in the British Medical Journal. This particular guideline is for Aortic Valve Replacement. BMJ provides an online experience for doctors and patients called Partnering with Patients. The  content provided on the site includes best practice guidelines for many medical procedures. One source of the guidelines is MAGIC project.

This is an international group, originating in Oslo, Norway operating as the MAGIC project. Magic is an acronym for “MAking GRADE the Irresistible Choice,” where GRADE is a system to develop high-quality guidelines that consider the whole body of evidence on a certain therapy in an objective way, and incorporate patient values and preferences, as well as other considerations.

For the consumer this implies the MAGIC team applies a scientific rigor to weighting the evidence supporting the effectiveness of medical and surgical interventions. The real bonus is that they also employ the patient’s perception of effectiveness which can often be missing in research studies. A common example I like to use is change in mortality rate. Example: If I have emphysema and experience failure of my respiratory system I will die. However, there is a variety of life sustaining interventions available to me in the USA. These include: Supplemental Oxygen, inhaled and oral medications and mechanical ventilation. Virtually all people with severe emphysema are faced with making a decision as to the technologies they will use to extend their life. Many choose all three: Then again, I have had many patients in the past elect to not receive mechanical ventilation as the notion of being connected to a ventilator for the remainder of their life is not acceptable.

When any of us with chronic illness take advantage of a therapy I would hazard a guess that we should always take the pre and post treatment morbidity and functional status into account. Questions we need to ask must include the published guidelines reported changes in health related quality of life after treatment.

I hope these projects become the foundation for a curated library of best practice and treatment outcomes in the near future. Of course my preference would be to make them free for patients which might level the playing-field for those with low incomes in societies with huge disparities in care and health between the wealthy and impoverished. That said, as I learn more about the availability of the guidelines and find those that are free and unbiased by funding resource or error in design I will publish them here.

Have fun and educate yourself prior to making any decisions on how to manage your health.

Warmth to all of my friends along the way.


Here are link to Magic


The Onslow Magic Project for clinical guidelines



Waking to Trump: Healthcare is the least of our problems.

 Untangled Health was created to illustrate confusion in US health policy and give myself a place to vent my frustrations as just one more American caught in the routine of “Stay, Stay, Stay, Staying Alive”. The last eleven days have reordered my priorities. Since 1979 I have been fixed-on-fixing the vulnerable people using your health care system then as I was having my morning coffee today I saw a note from a LinkedIn Friend Maria K Todd MHA PhD. She was describing her inability to create words of sufficient magnitude to describe how she was feeling since the change of administrations. I  looked inside and emotions spilled-forth with the following imagery of life, family and purpose.







Waking to Trump (click here for trip to the Cheshire Cat’s den)

I wake:Breathless, exhausted,fearful,powerless; lost: A stranger in a strange land: Who are these men? My hackles are up and I can’t remember the dream: Something about a red-haired, bright bulbous nose dude with the stink of vodka on his breath screaming “WRONG”!

Waking each morning to the same reality. Memories of 50 years attending to diabetes; age ten; being told I might be blind and lose my feet if I didn’t care for myself. Memories of what it “took” to take CARE of myself; sometimes feeling ashamed to borrow money for insulin . Experiencing life on track Zero then again on Track number Ten. Attaching myself to groups of “loving-others”: finding the barriers to “well-being” and removing them; one-person-at-a-time.

Signs of my disease pointing to the Fall of my life: then Seizing 2008 with an army of friends and moving NC to the Blue as we were “tailed by skinheads” and protected by the FBI. Wondering if this is what my father felt as he was beaten up by classmates calling him “Stinky Saul the Jew Boy”; When his name changed from Halbstein to Harris so his family could keep their business. Choosing to put life on the line in WWII, he went on to live a life of patriotism he died an honorable man. One recognized for his contributions in our Space Race; Father of the Titan II Rocket.

Staring at his penciled drawing of the completed rocket, complete with team signatures : I hear his voice; shouting loudly to reject any form of bigotry. I miss his presence and the smell of his after-shave that day in July 1969 when he rescued me from the “Darker Side of America”; bar-fly’s and deviates and bourbon breath…the Department of Social Services and my fantastic Pop chased them away. There are reasons to keep the children in focus for what they inherit is their ability to thrive in the safe-space we leave behind.

I miss you “Saul Halbstein” remembering you in your prime; the Saturn V booster rockets on their test stands “shaking the windows from our home” ; hand on my shoulder, “have no fear Jeff; were going to the moon”. 

If you are out their Pop, the joke is on you. Not a believer; you now gaze down at a country you could barely recognize: Save the memories of your childhood, the War and the 1960s.

Now I know why you were still angry when you died. When you own best friend accused you of being another “New York Jew” ; broke your heart and left your side. Those last weeks of your life in December 2015 you kept reminding me of the forthcoming debate; you seemed to believe it was extremely important; you spoke of the “transparent man” who was in the next hospital room. You called him “Mr. Deal” and warning me about his ties to the bad guys. Were you by chance having a premonition?

I asked you today if I should publish this. Then the mailman came delivering an empathy card for your death:  One-Year-Late

My Pops in his prime!

Teaching others to teach others

Missing Pop


What is at risk if Obamacare is Rescinded

Reconciling data in my six health portals

What is at risk for all subscriber to commercial insurance programs if Obamacare is Rescinded?

This analysis with specific allegorical references was posted by my friend Wendy today. I find it accurate and far beyond my skills to interpret and describe What is at risk for EVERY-BODY

Obama Care is. . . The ACA (Affordable Care Act)
Last night as his first order of business the new president signed an executive order to repeal the ACA. Here’s what this means… even if you are safely covered behind employer-provided insurance, the protections set forth in the ACA (Affordable Care Act), apply to you too. And if those protections are repealed along with the rest (or any part) of the program, you will also be affected.
That means you may be trapped in a job, because your pre-existing condition may mean you will not qualify for new insurance offered by another employer, and the cost of private insurance would be prohibitive. If your employer shuts down, lays you off, or even changes insurers, well, you are out of luck. The Senate GOP voted this week that they would not require an eventual ACA replacement to protect against discrimination for pre-existing conditions, which was the standard before the ACA.
It means that you (a young adult under the age of 26) or your adult children (over 18) may find yourselves without the protection of insurance, as the Senate GOP voted last night that an eventual ACA replacement will not be required to allow young people to remain on their parents’ insurance up to the age of 26.
It means that if you have a high-risk pregnancy, or life-threatening illness such as cancer, you may not be able to afford all the care you need, because you may hit lifetime or annual caps. If you have an infant born with any kind of severe medical condition, or premature, they may hit their lifetime insurance cap before they are old enough to walk. The Senate GOP voted last night that an eventual ACA replacement program would not be required to prohibit lifetime insurance caps.
It means that if you are a struggling parent who is uninsured or under-insured, you will no longer be able to count on at least your kids getting the routine medical and dental care they need under the Children’s Health Insurance Plan (CHIP). The Senate GOP voted that CHIP is not required to be protected by an eventual ACA replacement.
These provisions of the ACA affect everyone in this country, not just those without insurance through their employers.
If you are not okay with these changes, call your representatives and let them know what’s important to you. Nothing has been set in stone yet, but our legislators have shown us a map of what they plan to do if constituents don’t make their voices heard loud and clear.
Hold down here to copy, paste, and post (do not share) on your timeline, if you feel this information needs to be passed on.

This is a comment from NORA on FaceBook
As a person with R.A. (pre-existing condition) Before ACA I was never able to purchase even basic insurance for under $1500 a month and thus went without insurance from the time I graduated University until I was 49 years old. It’s $2000 per visit to a Rheumatologist, so I only went once a year and could not afford medications. I lived with daily debilitating pain and exhaustion among other things. If you know somebody with RA you know is serious. ACA provided me with good affordable care at a price I can afford $359 a month. I responded very well to BASIC medications for RA that I could never afford before (but with ACA can) and am now able to live life normally and run my small business again. My great Doctors also noticed I had serious liver damage from years of taking OTC pain relievers like Tylenol and Aleve. They were able to fix that too. They said it may have killed me or become cancer without treatment, at the least led to early death. If I lose coverage for my Meds am already planning to go on SSD and Medicaid and close my business. True Story. #ACAWORKS PS Only deplorables don’t want people to have health insurance.
Like · Reply · 1 · 19 hrs · Edited
Wendy Lannon
Wendy Lannon I think of you Nora whenever I hear people say ACA doesn’t work. #ACAWORKS

The cost of care: ($ X Count)+((Caregiver calories X Time)X Caregiver metabolic rate)+Caregiver drain in emotional well-being


I have been giving classes to groups of elders on normal age dependent functional decline. Here is a note from my 55 year old cousin discussing her situation providing care for her husband. Wherein her State did not expand Medicaid and this man only needs custodial care she does all the work. Like my friend said earlier this week: The Women are the Warriors in our Society. My poor cousin Michael is waiting for a liver, probably won’t make it since nobody is around to keep him in shape.
Imagine retaining 100 lbs of water in your belly, being short of breath and unable to prepare a sandwich.
Their insurance by the way is through a New Jersey County.
Here are Wendys comments.

“Tired frustrated disappointed angry probably everything in between & yes I just hoped for easy fix. Silver lining. Physically I know it’s hard on him and I know he needs more physical care like his adl’s. I think I’m going to have to start working doing his adls with him. He doesn’t do that well anymore. He’s afraid to get in the shower almost never had shaves. I just don’t know when I’m going to get to that stuff I often run out of time and don’t do well with that stuff myself reality is I don’t know what I’m going to do you know animals are so much easier usually. Such a Monumental responsibility caring for another human being why I never had children”

Suck it up friends, we had a start on care coordination in the home but lost it on November 8th. Start saving now…….

SalesForce as a Patient-Centered Longitudinal Care Platform | I am one happy Diabetic!

The technology facilitating Patient Centered Care arrived over ten years ago. It was all a matter of configuration!

The technology facilitating Patient Centered Care arrived over ten years ago. It was all a matter of configuration!

I am pumped!
Years ago…1997 I believe; I had a job working for DocSite: the company founded by Physiatrist John Haughton MD that became one of the premier Registry products used as the EMR community was attempting to define itself. In the DocSite product we collected measures or “clinical indicators” that were compiled around the patient and associated with an infinity of conditions. Essentially the data design allowed physicians and grant recipients to have a single patient record yet extract, analyze and report on any constellation of outcome measures without having to spend money on redundant disease registry products. Example: Blood pressure is an important measurement for diabetes and heart failure. In diabetes the measure importance is 1) how often it is done and 2) the blood pressure value. In Heart failure the same measures of process (measurement frequency) and outcome (BP value) are required but they might be different depending on the cardiovascular guideline and contrasting diabetes guideline. In the DocSite system the blood pressure recording was simply a vital sign. The rules defining threshold for compliance with guideline were defined separately and associated with multiple conditions. When the doctor generated the data for PQRI and the Cardiovascular Excellence programs a single patient outcomes dataset was generated based on the programs associated with the patient. When the patient returned to any clinician using the Docsite system the Visit Encounter Sheet displayed the current measures due, the last values and trends for each measure and gave the physician or extender a place to generate an education note. Inexpensive, simple, multi-user, modifiable for EBG and data submission automated through clerical “generate and send PQRI data”. Now, I owned some stock in the company so I am biased but quite frankly I thought the system was elegant once it received data feeds from pharma and labs!

All of us at DocSite used a Client Relationship Management cloud application in our client services department. After using it for three years or so those of us that had worked in a previous company “the forerunner of DocSite” called Cognimed all thought that Sales Force had the proper design to create a community wide care coordination and patient centered care planning tool We had built one in the 1990s and sold it and moved on with our lives.
Today I see SalesForce has entered the arena. Knowing what I know about its capabilities I hope they capture the market by landslide. Please if you thinking about building a new care management platform…dont. As a patient, I would love to see this thing as an App. in all of my clinicians hands and on my IPhone please. Check out their demo. I am sure it all does not work as advertised but I can attest to the fact that they had the correct data model ten years ago!

Reconciling data in my six health portals

Reconciling data in my six health portals

Time to pull the sheet out from underneath healthcare in America. In one step. Eliminate Insurance, Medicare, Government Programs, and see what we come up with. Please leave a note on my grave as to the outcome.


Thank you friends from LinkedIn today. Those discussing our frustration and describing a need to sit down and discuss the disaster that was and the disaster that will be.

Without action that-is!

Rephrased: My friend states our Medical system is far to complicated and polluted with bad ideas to resolve through a bunch of silo business meetings of silo organizations who define for us consumers exactly what health is, what we need to consume to maintain it and how much we should pay!

My point was to provoke: Strictly because I have similar judgments. I recently have seminar to senior men on functional decline over life for avg American male. Then overlay of possible interventions and services through death. Then described business layer and regulatory layer.
Your point Bruce Pisetzner is precisely why we need to define the pain for all stakeholders. When I say “stakeholder” I include consumers from all socio-economic classes as well as the professionals who treat them and the “business opportunities” created between 1965 and today that supposedly state a clear value added to the system of care.
Spent my career sketching iterations of your shell games. It seems to me: and I hold a straw-man judgment; that 1) as a country we have no agreement on what “health”is e.g. functional status, emotional status, absence of disease, bio-psychosocial well being etc. Far too much room to allow a free-market enterprise to explode without revisiting what is necessary to achieve healthy population goals.
Then of course we have the employer – employee entanglement.
Then of course the Government – Defined Benefit issue.
As patient with chronic disease, provider – admin acute care for 8, provider-admin post acute for 10, HIT product architect for 10 and community healthcare integration consultant for 10; predictive analyst for 8: I have watched the money flow. Oh how I have watched the money flow. Some even into my pocket. $25K a year out to stay alive and well with diabetes.
Perhaps it is time we all tell the truth. Insurance company, Large Employers, Small Employers, Provider Types, Patient Types and so on.

I created this blog post on the fly but thought it important to get out here now!

cropped-stcroix-jeff.pngsevere retinopathy

An advocate gets busy while every politician and “talking head” takes credit for healthcare model ideas published long ago.

Reconciling data in my six health portals

Reconciling data in my six health portals

I watched Barbara Starfield again last night. She passed away in 2011 but it seamed as though she was sitting in my living room telling me everything will be alright but many of us will never get our way. Barbara spent several decades studying the characteristics of health systems all over the world. Her final conclusions were simple and easy to implement as long as social agreements were made between consumers of healthcare services and their providers. The contract (sort of) is that my primary care doctor will be available when needed if I promise to contact his or her office before going to the ER for an earache or other non-emergent condition; my doctor also agrees to follow my care as I transition through life stages and address all mental and physical health conditions as they arise by assuring I connect with the correct specialist if required. The specialists in return are in constant contact with my primary care doctor so the primary care clinic is coordinating continuous and comprehensive care and reviewing all interactions between myself and other medical environments. Like I said earlier this week. Someone to watch over me. I first learned of Dr. Starfield in 2001 and followed her publications. Funny, she was never accepted to sit on any best-practice boards but the scientific community considered her work to be spectacular in terms of statistical approach and quality. In other words, she looked for the null hypothesis also.

Again…concerns over repeal and replace.

Some more diatribe with hope at sarcastic humor is written for you below. Please follow through to the end as I pasted a really cool graphic pointing you to a new society of consumers and professionals that might fix the system over the long run.

The conversation doesn’t stop at my dinner table, on my phone, through IM or Facebook. It seems as though my popularity index took a healthy bump after November 8th, 2016. I wish I could be happy about the reasons for the traffic.
“Jeff, you are on Medicare are you concerned?”

Well yes; you see, as we become older the likelihood of needing assistance from case managers, specialists, short stays in skilled nursing or rehabilitation facilities increases. Same with home health services which is always the preferred place to recover from the self-inflicted fractured hip that occurred while my masculine ego informed me of my capacity to clean out my gutters.
One of the most important changes to the clinical language coming from Obamacare is the right for all patients cared for by primary care doctors with Medicare contracts to receive “Coordinated, Comprehensive Care”. Lately you might have heard the terms: “Patient Centered Care” or “Medical Home”. You probably heard President Elect Trump mention “Patient Centered” or a new commercial by Humana presented by a handsome young doctor stating that Humana’s system of Patient Centered Care is superior because of their capacity to coordinate your care within their “medical community”. Then you will watch a local conservative pundit state: “those stupid narrow networks tried through Obamacare didn’t work: here is a toast to repeal and replace.
This stuff cracks me up for the same proponents of patient centered care realize that closely collaborating narrow networks can provide you with clinical personnel that understand your needs better than anyone else! In fact, they have the same attributes of a Patient Centered Care Team using a single medical record and plan of care to increase safety and minimize mistakes. Yet you will hear no one (perhaps save me and a few of us that are tired of scraping the poop off our boots) tell you that the words Patient Centered, Narrow Network, Accountable Outcomes, Value Added Payment, Medical Homes, and all other terms implying a tightly coordinated, error free clinical team surrounding all patients are not original concepts. In fact, they are in place in many of our successful neighbor nations who provide universal enrollment and have always demonstrated lower reliance on emergency room services for basic medicine, better health outcomes and no difference in treatment effectiveness for cancer, diabetes, cardiovascular disease and other leading causes of premature mortality. Our own CMS (The Centers for Medicare and Medicaid Services) have published the policy here July 2016:
So all of a sudden the administration of 2017 will be using terminology invented by others to describe care models that work after years of academic surveillance by healthcare policy analysists and already written into The Patient Protection Affordable Care Act or what the opponents call “Obama-Care”.
My prediction is we will keep the new payment systems for coordinated care and chronic disease care management. However, the credit for the success will fall under a new Trump label. My fears is that the same three insurance companies comprising the oligopoly of payers for American Healthcare will recoup their lost profits of mandated care without premium inflation for the chronically ill by shifting the premiums higher for those with pre-existing conditions. So here is another question from the week:
“Jeff, what will I do now I couldn’t get covered because of my history of cancer before the ACA?” “What if “Trump-care” requires coverage for pre-existing illnesses but allows insurance companies to include the illness in the premium pricing model? “ My response to this question was “not sure, my cost in the NC High Risk Insurance Pool for my diabetes prior to Obamacare was $1200.00 per month not including co-pays. Today it is $350.00.
More on Patient Centered Care AKA Medical Homes AKA Integrated Care AKA Chronic Illness Care.
I discussed the integrated care model and its payment adjustments to my Men’s group on Thursday night as they requested a primer on planning for their last ten years of life. Their hope was that our system of care had evolved and they would not have to lose their homes to cover the long-term care charges. Many of the guys in my group neglected to buy long term care insurance when they were young and healthy, had since suffered a chronic disease diagnosis and episode of treatment and no longer qualified for long term care insurance. They could however place $10 K per month into an account to pre-pay up to one year of long term care. This is what my father did: In 2006 he entered into a contract with a transitional care organization. He paid them $350,000 for full access to assisted living and long term care until his death. They also allowed him to live in the attached apartment complex for independent seniors for an additional rent of $3200 per month including one meal per day. Not a bad deal eh? Oh yeah…one more oversight: My friends ; all retired upper middle class professionals had no idea that Medicare didn’t pay for long term custodial care either in home or inpatient facility.
Now, like I said the other day, I am a bit tired of shouting the truth to those who were unfortunate enough to buy into the following promise: “Oh we will have the most wonderful healthcare system in the world” and “We promise to repeal the expensive policies and replace with something better.
We were on our way folks: The biggest mistake, President Obama’s team was denied the necessary Medicaid expansion for ALL not SOME States by our supreme courts. If you don’t understand the math I will be pleased to describe it in another column. Basically when the folks that would have had access to Medicaid don’t receive the insurance they still consume services. The loss of revenue winds up on the balance sheets of hospitals and providers and they respond by increasing their cost per service. The insurance companies pay more and your premiums increase. So… my neighbors policy (55 year old male) in NC costs $11,000 per year. The very same policy in New Hampshire where they expanded Medicaid costs $5,500 per year. As Mr. Obama leaves keep in mind that the rate of increase in health costs since the inception of Obama Care is the lowest it has been in 40 years.
Somehow, someway; we need to cover everybody. If we do not we cannot cover the losses incurred in the private sector without the Magical Thinking that has been sold you for so many decade. Hide the losses, get others to pay for the losses through modest increases in cost of living and blame the doctors, and hospitals who give away more free care than you could ever imagine.
What would happen if our incredible consumer driven internet harnessed the decision support technology that we use daily on Amazon and instantly brings the right service to you when needed should you or a loved one become ill? What if we harnessed IBM Watson to make the diagnosis thereby reducing error rates and reducing unnecessary utilization of expensive diagnostic procedures?
What if we didn’t need insurance companies any more to assess population risk and perform preauthorization services while we waited for our new medication?
Since we have all of the data connecting lifestyle, culture, nutrition, infection and the human genome can anyone appreciate where we are headed with our capacity to discover the cause of disease and effect of treatment? This is not decades from now my friends; it is within the reach of our children’s lifetime. I have wonderful friends with incredible scientific minds that are creating open source technologies to accomplish human collaboration like humankind has never witnessed. The only barrier to their success is a loss of priority to cure disease, increase well-being and expand the functional-years of human life.
Or…we can keep these technologies secret, forget those we have developed through the natural sequestration of competing private enterprise and traditional silo thinking. If this is where we are headed then the best investment to assure a painless end of life if you are not surrounded by humanitarian friends is my undying support for the second amendment. If you catch my drift.

Check out Right Care Folks!

Right Care Now

Right Care Now

From Obama to ObamaTrumpCare


Someone to watch over me…….
Dear Doctor, will you please make sure I receive the RIGHT CARE!
What do you know about me Doc?
Do you have time to spend with me today; perhaps discuss who I am in the world, what my goals are and what I think might help me feel better?
Are you interested in my Well-Being? Do you and your staff ever discuss Well-Being or is it all veiled in a pile of healthcare acronyms; where Well-Being is described by absence of symptoms and disease?
Do you have the opportunity to discuss my goals and interventions with my other doctors? Sometimes I am not sure you folks talk because my information: from religion and employment history to list of medicines varies between practices. I thought someone was fixing all of the electronic health record issues ten years ago?
I noticed that all of my personal physicians that I have chosen over the last fifteen years are selling their practice or merging into some sort of healthcare system that appears to be managed by the local hospital; is this a good thing? I am really not sure you see me because the person at the registration desk doesn’t recognize me and your Medical Assistant told me that you only had time for 10 a minute appointment today.
Actually, to be honest with you; I am concerned for your Well-Being Doc because you have dark circles below your eyes and tell me that you are up until 10:00 PM each night completing your records at home. I realize that the new electronic health records are cool but shouldn’t they increase your quality of life as opposed to drain any remaining discretionary time you have with your family?
Ya know Doc, I have learned allot about healthcare in my life: Yeah, some because of my training and work but mostly because I have these….”conditions”. The “conditions” have presented adequate challenge to require me to understand the “bits and pieces” that string this system together. I’ll bet you don’t learn much about being a patient in medical school. I am not sure how you could do it without adding another two years to your fourteen years of post-grad education.
Did you know that I have spent ten hours in the last month trying to get a prescription authorized? You know the prescription that makes living with RSD and diabetic neuropathy tolerable! It appears that someone didn’t install your e-prescribing system correctly; something to do with prescription received and filled acknowledgments? I don’t know Man; it seems like the fax machine and pharmacy calls worked better than this e-Rx stuff. The long and short of it is that between your practice, my insurance carrier, and my CVS pharmacy the most efficient transaction I can hope for when I am in pain is 48 hours. My “Well-Being” wasn’t so “Well” this month…..
BUT my A1c is 6.5, my blood pressure is 124/78, my immunizations and other measures of health process and management outcomes are all great. I am pleased to be one of the good data points on your quality report and certainly testify to CMS and Blue Cross that you deserve an extra 5% for your hard work. Might be nice though if I received a discount on my insulin copay for the snappy A1c that has kept my feet attached to my legs and my body out of the hospital these last 50 years.

So what is Right Care? How do we know if we get it? Is it through the Diabetes DM report? Is it through the patient satisfaction survey that I take at each and every service provider I see? They all are very similar, I wonder if anyone has ever considered a “whole system measure”; at least something better than the Service Excellence Survey that reminds me of the material sent to me by American Airlines after every business trip. By the way, I always give my providers 5 stars with the exception of the conglomerate that bought up the primary care practices; their employees seem miserable. I find it amusing that their employees all where buttons that say “Ask me about the “Name of Healthcare Institutions” WAY. I guess they all have some kind of culture that is supposed to make my experience less painful as a consumer? Perhaps more like Disney Land I suppose.
What I really long for is my diabetes pediatrician from 1965. Dr. Lipmann. He always asked me to discuss how I was feeling about school, whether I had enough to eat at home, did I have any dreams and whether or not my diabetes would prevent me from achieving my dreams. Heck, he called me on Sunday night to as how I was feeling when my urine sugars were running 4 plus. When I left his care at the age of thirteen he had illuminated an interest in human biology that has carried me through my life. On a darker side of my childhood life he also notified “Children’s Protective Services” when he discovered I was living in an alcoholic flop-house!
My friend Tony is from another country. His mom had a CVA last year. She was transported to the ER, hospitalized, transferred to a facility with real rehabilitation specialists and doctors on staff daily, discharged home with visiting nurses and therapists and returned to society as a healthy 75 year old woman who is now completely independent. Her cost? Well there was no cost to her and the average cost per person for health services in her country is 1/2 of what it is in the USA.
In meeting with my insurance adviser the other day I was informed that my healthcare cost will be more than $500,000 between now and my death; with my diabetes, RSD, neuropathy etc. I wonder how we will cover the services. I really don’t want to be one of those patients that I cared for early on in my career. You know….like the old man and WWII B17 Aviator that looked up at me shortly before he died and said “Ya know Jeff; I used to be somebody once”.
The end of his life was no different than my fathers. Dad died last year from pneumonia at the age of 87. We had just celebrated Memorial Day. He called me complaining of a chest cold and 48 hours later I found myself sitting at his bedside with new onset dementia, consolidated breath sounds, a temperature of 101 degrees and abdominal cramps. I asked the Nursing Assistant to get him a bed pan and she informed me that he “just got off the pan”. A few minutes later I overheard her complaining to her supervisor that she had no intention of getting my Pop out of bed because he was a difficult transfer due to his combativeness. Pop was angry for sure but not combative. Then I witnessed the IV nurse insert a 18 gauge catheter into my pops wrist. She never registered IV access and proceeded to deliver 500 cc of solution into the sub-cutaneous space. This was the only vein he had left since they had made the same error the night before in the opposite hand. By 6PM his hand was as large as a soft-ball and this was hours after I complained about her technique.
So the following day Pop got a PICC line. PICC lines are infection risks!

Three days later I took him to the SNF with his PICC line and met with the therapists. Dad was becoming more lucid but I had concerns. I met with the Charge Nurse and facility director to assure his good care. I was concerned about the additional risk for infection from his new PICC line. You see, this facility was part of his life-long $450,000 investment in a continuing care environment; supposedly the best available in Huntsville Alabama. I used to direct clinical services departments in these facilities earlier in my career and was aware of their financial strain as they attempted to deliver hospital level care for 1/3 the cost.
I saw Pop the next day while he was cycling on the recumbent bicycle in the rehabilitation department. He had 20 minutes of therapy to go but as soon as I showed up to watch his work-out the therapist terminated the session and quickly wheeled Pop to his room so we could chat. Dad looked horribly sad, I knelt down to say good-bye kissing him on the forehead I said “I love you Dad!”; he looked up and said “And I love you Jeff”. These were our last words.
Three days later I received a call at 3AM from a person who could not speak English. He mentioned my father’s name and I asked for someone who could speak more clearly. The second person I spoke with also could not speak English. Finally a paramedic picked up the phone…”Mr. Harris, your father is unresponsive and we are taking him to the hospital”.
After a quick dialog I was able to determine that Pop had explosive diarrhea several hours earlier and simply lost consciousness. I called ahead to the Emergency Department to inform them of my father’s forthcoming arrival and that I was worried he might be septic. I told the doctor that Pop was a DNR patient and he should call me when he arrived. When Pop was evaluated the ER Doctor called me with his lab results and it was quite evident that he was dying and most certainly had been allowed to dehydrate while at the Rehabilitation Hospital OOPS I mean Skilled Nursing Facility OOPS I am not sure what I mean. God did I weep as the ER doctor and I discussed his DNR.
I wrestle with the fact that I might have been able to save Pop if I had pushed for re-hydration, antibiotics and other therapy but I couldn’t help think about Pops state of well-being. You see my brother and I had spent years shuffling him around between neurosurgery in Birmingham and other clinical facilities. At one point I had imitated a physician to keep my father from being discharged prematurely after his brain tumor operation. He had been in the hospital for a week. The Medicare Prospective Payment was going to pay for eight days and the hospital was pushing him out to a skilled nursing facility. I watched my Pop eating and realized he had an aspiration problem. Fearful of aspiration pneumonia I asked to have him discharged to the rehabilitation beds at the University Medical Center. I wanted him to receive a speech language therapy evaluation for aspiration risk and rehabilitation services. To get the transfer to rehabilitation where a doctor and therapists would be available; I had to retrieve every clinical skill I had when meeting with the staff to justify his case. When they assumed I was a doctor, I let it ride. Feeling shame the next day I convinced myself that I would do whatever I needed to protect my father.
You know, to make sure he would receive the
Right Care.

As the ACA (Obamacare) was implemented I began to have hope. You see, this year 2017 is the beginning of Medicare’s observation of how well inpatient hospitals and post-acute care facilities integrate. One important measure they are watching is the frequency of readmission to acute care for the same diagnosis. This combined measure of how well institutions, nursing homes, home health networks and primary care communicate regarding a patient’s process as they are handed off between facilities is to prevent patients from becoming ill and requiring re-hospitalization. Trust me folks, it used to be horrible: I can remember turning patients around as they arrived at our rehabilitation hospital and sending them straight back to the Medical Center that had just discharged them. You see, some were still in heart failure and semi-conscious; not only could they not participate in rehabilitation; to attempt rehabilitation might have killed them. But you see, the hospitals were not linked to the rehabilitation and skilled nursing facilities through a common therapeutic goal and reimbursement mechanism. The hospital in Boston just wanted to discharge the patient prior to exceeding their Medicare reimbursement allotment. We however had marketing nurses out in the field accepting any warm body with a heartbeat that just might survive a 21 day Medicare stay in a Skilled Nursing Environment.
My friends had no idea why I never lost my job by reversing the trajectory of these patients. What they did not know was that I had a compassionate family owned corporation employing me who trusted my clinical intuition.
Alas… as of today….Obamacare is being repealed and we have yet to be informed about “TrumpCare”. My guess us that we will return to the past with the exception of mandatory care for persons with pre-existing conditions. Then we will see just how much our policies cost and what our end of year out of pocket expense will be.
For my wife and I,
We are searching once more for our peeps. This week I have looked at my well-being through the end of my life if we ex-patriate to Canada. My cost will be $0.00 for healthcare. My waiting time for a CAT scan will double but Canada’s outcomes for Cancer and Cardiovascular Disease and diabetes are slightly better than in the USA. So what do we have to lose? In fact, Canada doesn’t amputate many diabetic limbs. You know why? Because all of their diabetics have access to care!

Fondly thinking of you fellow patients and consumers;
Jeffrey Halbstein-Harris
• An advocate for those who feel lost
• Always watching
• Harnessing the compassion that surrounds you in a time of crisis
• Connecting you with the best science available
• Minding your pocketbook
• Working to return you home safely



This beautiful video from Gregory Colbert is a meditation I return to frequently.

In many cases I find myself placing “ashes to snow” in continuous loop mode as I reflect on my perceptions of my life; in contrast with; the underlying beauty of transition that I fail to regulate. I call it.. “Time”.

Where my mind is capable of “desire” “misery” “judgment” “resentment” “sadness”, “loneliness”, “fear” and “joy”: the magnitude of the emotion can threaten my success at managing my state of well-being from day to day. That said my capacity to think on my feet, be perceptive and accurate with my intuition and mind are skills I have relied on since I was a little boy. With all of the craziness of childhood in my house at the age of six, seven, ten and into my teens; I placed my head on mattress each night knowing that one underlying reality returned…the unyielding transition of time.

My life is “becoming” and “ending” as I witness each day but there is far less life left in front of me than what lies behind. I am simplifying my messages; now realizing that animals have many endearing characteristics that are shared with humankind . The elephant, giant cat, soaring raptor and crocodile demonstrate: Strength, agility, vision and speed AND community. Ultimately we all fall back on these as our environment changes and we unexpectedly find ourselves in survival mode. Looking forward.. I call upon my instincts to solve for barriers to healthcare as I have in the past. But before time marches through my final transition I need to create survival toolkits for my brothers and sisters who are unlikely to have the necessary knowledge to assure their own security within the systems emerging from the Bush-Obama-Trump administrations and the Medical Industrial Complex.

As we move into a new year I plan to simplify my monologue on the existence, or lack thereof of Humanitarian Policy in the USA. Observing a repetitive cycle of consumer brainwashing it is time to wipe away the wash and expose the motives so every patient and their family will be equally prepared to acquire and afford quality care and monitor the success through the “patient’s lens” as opposed to their local hospital, insurance company, broker, employer, pharmaceutical manufacturer or government entity.

I am starting the year with presentations on self advocacy in context with our healthcare system at different stages of life.

It appears we made some decisions on November 8th yes?

Straining to maintain my awareness of this beautiful cycle of life (as opposed to being distracted by the daily https://www.facebook.com/gregorycolbert#I am attempting to present facts and ideas that will lead elders (including me) and those with chronic illness (also including me) to make informed decisions and brilliant plans for their own future: For even with great tribute to our powerlessness over the march of time there are some things we can choose. The first is to recognize just how beautiful and common we all are. Then, as we listen to our own finite heart-beat learn to assess where we are at, where we want to be and how to get there. I fear our care-planning for loved ones, ourselves and our clients will require frequent tune-up as “those in control” begin making changes behind the drape that overshadows the Great Oz.

Enjoy this celebration of the beauty of all living things, their common village and keep it with you as we walk this path together.

Doctor Price? Should we run for the hills?

A serene day in St. Croix


His history might clue you in.

Tom Price on healthcare: What should we expect?

What happens when you strip coordinated care incentives through repeal of the PPACA. One outcome is certain: orthopedic surgeons like Dr. Price perform more amputations for which they receive several thousand dollars for a fifteen minute procedure.

What happens when you strip coordinated care incentives through repeal of the PPACA.
One outcome is certain: orthopedic surgeons like Dr. Price perform more amputations for which they receive several thousand dollars for a fifteen minute procedure.

Click link above to access Dr. Price’s priorities. First please read my fears, doubts and insecurities below?




Pres. Elect Trump hired Rep. Tom Price as the new Director of US HHS today.
Mr. Price is a vocal supporter of Mr. Trump when other republicans were not. It appears Mr. Trump continues to hire loyalists.
Dr. Price is a successful physician having authored numerous bills to replace PPACA. When hired he stated his objective is to repeal and replace.
The bills authored by Price do have language that sounds attractive e.g. Patient Empowerment but when read…show a clear intent to remove the most important economic controls on health cost escalation in the PPACA. These include: DME competitive bidding for items such as prosthetics, motorized wheelchairs etc. Competitive bidding on drugs purchased by Medicaid and Medicare, Removal of our veto on using genetic data to derive insurance premiums for individuals and many more.

I have long thought that it is weird that Americans who place so much emphasis on pure free market tactics in all industries vote for politicians that author bills to veto competitive pricing virtually eliminating 100 million people from hiring a government payer to reduce the cost of medicine.

Now, I always suggest we follow the money.
Dr. Price’s three leading PACs and individual campaign contributors fall within these industry’s.
Physician Membership Organizations
Hospital Systems including HCA ( brought to testify on anti trust and fraud several times in front of congressional committees)
Pharmaceutical Industry
Insurance Industry

Where I have worked for HCA, consulted to the American Academy of Family Practice, Anthem Blue Cross, NY BC, and State Government I am confident in my conclusions about their business objectives. If you trust me and want more info please feel free to call on me.

I highly suggest that everyone who voted for PETUS look at who has been appointed to lead US agencies and fill important cabinet posts. My prediction and I hope to eat my words is that the middle class is about to be dealt a final death-blow that will eliminate any hope of having enough left over at our death to pass on to future generations.
I am suggesting people like myself: aging with chronic illness describe what they hope for quality of life in their final years and make preparations. The only way to do this is to understand how necessities are priced and determine individual bargains strength.
We had Price transparency tools created through the PPACA. My guess is they will disappear in short order .

My colleagues who believe in universal enrollment for defined evidence based public health and personal health interventions will be fighting any changes that do not provide consumer-facing competitive shopping tools that dispense with confusing terminology commonly used by healthcare institutions and insurance organizations. I also look to the millennial to jump in since they have a future at stake.
Tony Antony Williams may be right in his suggestion that PETUS is a liar.

Doing my best to stay healthy enough to escalate beyond the occasional battle into a Full Blown War against Wall Street.

The War in DC is for campaign reform and term limits.

“Oh what a drag it is getting old”

The Economic Warrior


A serene day in St. Croix

For those listening to my interview with my friend Barry Dyke  The Economic Warrior on Portsmouth Community Radio today: I will be creating a reference sheet to empower the consumer with tools to select healthcare resources by their quality ratings and relative costs shortly. Please check back next Monday November 07, 2016

I promise to deliver valid comparisons of our healthcare system before and after Obamacare.




The forthcoming post and references may be used by any consumer to:

A: Research available providers of healthcare services for yourself and other family members.

B: Review extremely important data relating to the quality of the providers you choose.

C: Review statistics relating to the cost and quality of healthcare by State or Nation.

It is up to you my dear consumer friends: To make informed decisions about your plans to manage your healthcare needs today , tomorrow, next year and – to the end of your life.


Caring for the “Whole Patient”

A serene day in St. Croix

I want to share this with friends that frequently gaze into my eyes when I am caught in a dream; asking me to “Get Clear” with my passion so they can better understand why I invest so much energy in healthcare.
Sixty years now, living in my simple skin with complicated mind I can never seem to adequately describe what I see. Well tonight I found it. Circling around me on the internet I found my peeps. The ones that have impressed me these last twenty years or so in my career and the last sixty years or so in my life. 
Finally, the integration of patient, families, doctors working together towards a healthy community. When health is defined and redefined by each individual in context with their life circumstance. What it means to serve and be served.

This is the revolution and it has been televised. It tells the story of “patients like me” who have been graced by compassionate beings in community; lifting a boy up in his childhood and a man up in his mid-life; helping him to learn that it is okay to show confusion, scream in pain; fall down, hold up a hand and ask for help. To take the gifts, find the joy in self-responsibility in the face of adversity and pass the energy on to the next patient that pulled up a few inches short of the “well-being” side of the gene-pool.

Enjoy, learn, discuss in your community. The ties that bind us together are stronger than those that pull us apart.

Jeffrey Halbstein-Harris
Self-Centered Patient…..oops
I mean Patient-Centered Care…
No, no…Population-Focused Patient


Hello Darkness My Old Friend…

I am witnessing an illogical social rage emerge that “if we are not steadfast to our principles of tolerance and acceptance” could ignite into a civil crisis even greater than what I (we) witnessed in the 60s and early 70s.
The content displayed on the Internet is usually present for a single purpose: to sell an idea.
So now we have evidence of dishonesty and amoral behavior.
As I chase material down to its source I find frequently that the information is genuine but stretched beyond its context. Meaning: a video purporting to expose poor security architecture of a 10 year old vote tabulation computer is released from a blog that claims a vast conspiracy to undermine our election process. However, the machine tested was studied through “real scientific procedure” by Stanford years ago and found to be defective, thereby causing the vendor to lose its contracts with election management authority’s .
The video published within the last few days had a single intent: convince the public that we have a crisis in our voting apparatus and a probable conspiracy.
On the same blog the moderator claims our support of foreigners in need is far greater than our effort to support those of us on Social Security. ” How can our Government support thousands of Syrian refugees when it can not give a raise to Soc. Security recipients!”
These words are meant to do nothing but divide us.
On another blog I find the video of a silly man embarrassing himself by making petty comments regarding his power over women. The guy was 59 years old and behaving like an adolescent braggart. Ask me if I care. I think I am intelligent enough to not consider him suitable for public office through listening to his speech alone; let alone some silly dialog he had with a Hollywood “Child” .
Now Most of my friends and I are not content with our choices in this election cycle. However, we know we can survive another 4 years waiting for another leader to emerge if we vote for Sec. Clinton.
But the generation below me: the folks that didn’t experience the Cold War, Vietnam, Students being shot on campus, the pictures in Time of beautiful men hanging from trees by their neck throughout the South. The beginning of and final failure of the war on drugs, Project Apollo.
They can’ t seem to realize that corruption is everywhere but reflected by genuine love and collaborative effort in the very same moment.
The candidates in our election today are simply warning lights on our social dashboard : bringing our attention to our fear of powerlessness, loss of faith in humanity and capacity to understand how each of us is perfectly imperfect. From George Washington to Whoever wins this election ; all of our leaders , all of our heroes have nasty moments along their life-path; They were and are human also.
I think it is time to silence our voices, lay down our pens and video recording devices and sit down for a discussion. Perhaps a discussion that will illuminate our fears, doubts, insecurities, desires, hopes and dreams. Through this work we might once again find our commonalities and work together to re-form our nation.
We are broken…..I think, but not irreparable.


Old, Broken and Pleading for Help

September 3,2016
Location: Large Urban Emergency Department
Advertising Claims: Patient-Centered Comprehensive Care
Source: Staff

Staff report: Hospital is rapidly expanding to form an integrated delivery network. Claims of under-staffing in ER. Claims that patient volume frequently exceeds capacity without placing hospital ER on diversion so patients are sent to other local facilities to receive more timely care. Non-clinical Patient Access Reps often find themselves advocating for patients and families when prolonged suffering is noted. Patient Access Reps are also required to collect co-pays from patients when discharged or admitted.

Case Report:
91 year-old woman, alert and oriented brought to ER by EMS. Resident in local “high-end” nursing home fell to ground from standing position landing on face and hands. Injury includes compound fracture of wrist and bruises to face.
Patient registered, insurance verified, triage nurse assessed and patient sent to X-ray without physician assessment, medication or other treatment. Patient complained of severe pain 8 over 10 level.
Three hours later the Patient Access Rep. was walking by patients room and overheard patient weeping and asking for help “please help it hurts !”
Patient Access Rep. returned to nursing station and brought situation to the attention of clinical staff. Staff responded “The patient was in radiology, was returned an hour ago and it is not your place as non-clinical staff to audit our processes. Patient Access Rep. responded:”As a patient-centered organization I thought we were all accountable for patient and family experience. This patient clams she is in excruciating pain will someone please help.
The staff of several doctors and nurses returned a blank stare and talked among themselves for 15 minutes prior to attending to the patients needs.

Unfortunately this is a common experience for patients as their direct care givers are stretched thinner and thinner while hospitals expand through the acquisition of physician practices; health information technology and higher profit diagnostic and elective surgical purposes.

God bless the over-worked direct care staff.

What is important! Life, Death and Taxes



The most important messages I carry are personally empowering. They are seldom original but channeled through the “bright spirits” I encounter in life.

To be empowered in this confusing world requires a grasp on reality. I will be 60 next week, a milestone I never cherished; even less so today with recent memory of the loss of my father, mother, brother and best friend of 30 plus years.
I was so freaking sad today when I woke that I found it hard to make a cup of coffee. I preferred to sit in my armchair (nicknamed the neurotic’s spaceship) and discuss the meaning of life with Bodi my loyal canine friend.
When I opened my social portal into the virtual world I discovered a friend’s post. A warm soul I met in a business conference two years ago, April Koontz had posted an important message; another piece of wisdom that I find to be a blessing for all of us.
I have chosen to teach about how to survive in America if one is ill perhaps it is time to focus on the ultimate reality for my lifetime. I will not witness a fix. We are far from agreement on the definition of health and well-being and human rights in American Society to imagine anything close to a satisfactory solution in my generation.


So perhaps I will continue to post interesting tidbits and ideas with hope of enlightening those who did not work 35 years in healthcare; but most importantly I will re-state my agreement with the video below; a presentation by @Michael Hebb, the founder of Death Over Dinner’s Ted Talk below – a must see!

A great thanks to April for bringing this to my breakfast table this morning.

Wait, Wait, Don’t Kill Me; I have my data and you don’t! A Chronic Disease Patients Point of View Part 1


A 33 year veteran worker from the US HealthCare Industry who was diagnosed with type 1 diabetes in 1966 describes his  realization that health care efficiency solutions must first address social and business barriers prior to implementing technology and hope for the future.

Reconciling data in my six health portals

Reconciling data in my six health portals

Keeping our eye on the ball: Let us not forget why we showed up over these last few years and started shouting out!

A small sample of issues that we learned about in the last fifteen years:

  • Disproportionate Growth in Healthcare Costs (greater than GDP and growing as a multiple of consumer price index) with poorer health outcomes
  • Disparities in care and care outcomes directly related to personal income. (as family income falls so does family health)
  • Lack 0f availability of critical, decision influencing data when and where we are treated (The Patient Information Gap) arising from lack of governance of data exchange between industry segments, physicians and payers at local, State and Federal levels, (often hidden behind well intentioned efforts to secure the privacy of patients).
  • Reliance on antique point of care exam model: Patient and family as historian.
  • Poor price transparency due to confusing and always changing industry syntax such as: Facility charge, Allowed amount, Deductible, Co-Pay, Co-insurance, Patients responsibility, Cost Sharing, Plan Type, Episode of care; Discharging to next lower level of care;  Medical Savings Account appeared to us as a shell game where we would always find our total cost out of pocket living under a different shell!
  • Certification processes: JCAHO Ambulatory, JCAHO Hospital, NCQA, URAC, CARF, Insurance Company’s Center of Excellence! What does it all mean! 
  • Questionable ethics of pharmaceutical industry: Tiers level 1,2,3,4. When our doctors told us they prefered a brand drug because of evidence that the drug was more effective but the insurance company required we pay 4X cost of their PBMs generic who do we trust! Will I die because I spent $200 less per month on my medication than my Dr.Recommended?
  • Numerous Business to Business relationships that supposedly have value for payers but only decrease the size of the consumers wallet. What is a PBM anyway? A Pharmacy Benefits Manager! You mean my medical insurance company needs another company to manage the medications!!!!
  • Disease Management Companies: Nurse calls me monthly who works for Depression Institute LLC who evidently subcontracts (like the pharmacy benefit manager) to my insurance company or my employer. She asks me if I am” downhearted and blue.” I say “yes” and she sends me some uplifting books and websites to look into. Meanwhile I would like to see a therapist because I am loosing function at work due to diabetes and am very sad and can not concentrate. My primary care provider sees 10 patients per hour and is empathetic but can only refer me to a psychiatrist associated with his institution. The institution psychiatrist places me on multiple medications to address my depression and the nurse from the DM company calls me monthly. I feel no better. Months later I begin having heart palpitations which turn out to be a side effect of the antidepressants. I am now afraid to work out.

Then we approved the HITECH ACT, ARRA and ACA all of which contain system enhancing improvements that are to address our concerns and help us feel safer, have better health outcomes and have better consumer capacity to analyze the state of our own health, determine our care needs. plan for our care needs and finance our care. Because as we all know: We are all temporarily able-bodied individuals; that is unless we are delusional.

My mission with these next series of posts, articles and perhaps a self-care book is to frame America’s Healthcare System as it evolves in front of you. How is it that I can do this when others can not? Well many, more qualified people can. Most will not due to the shackles of our industry and survival instinct. Ezekiel Emanuel will lay it all out for you if you listening to a compassionate physician who gets the big picture. For now: I am no longer dependent on this industry to support me. I have no fear of exposing the truth including those elements of my past that cause me to carry shame, anger, fear and a substantial amount of JOY. The truth is; all of the commentary I have heard at cocktail parties attended by physicians, employers, patient rights groups, hospital administrators, nurses, mixtures of all levels of worker-bees is beautiful material and quite humorous. If you are a healthcare worker and are reading this than you know this material is true. If you are recently graduated from your professional training venue whether it be nursing. medical school or other and you find my words a bit offensive then please forgive me and disengage 

So for now: Let’s get started, I welcome all feedback as this material comes belching forth from my repressed memory and will try to frame my words with ego disengaged.


My first experience with accidental death bordering on murder:
In 1982 I experienced one of three medical errors in my career that culminated in a person’s death. I was 26 years old so I took it less seriously than I do now: but it was the start of a change in consciousness regarding my thoughts on communication breakdown within the care delivery system. Ultimately this one focus would become my life’s pursuit.
Setting: A beautiful, crisp fall day in New Hampshire, My duties that day were respiratory therapist ‘on call’ for code blue (resuscitation events): A man of about fifty walked into our emergency room noticeably distraught. “I can’t catch my breath he said, it feels like my heart is coming out of my chest”. We took him immediately to our trauma room where all of the equipment would be available should we need to perform complex procedures (temporary pacemakers etc). Laying him down on the gurney the EKG technician hooked him up to the monitor and I reached up to turn it on. My job was to assist the team if the patient arrested and then intubate and ventilate him upon order of the physician. What I saw on the EKG appeared to be a life threatening rhythm yet the physician ran into the room and announced the rhythm to be less threatening  which requires a completely different treatment approach: So I figured “well he is the doc and knows much more than little old me”. This was back in the days when a patient’s personal physician could deliver direct care in the ER as opposed to a board certified emergency room physician. This Navy Dr. was quite sure of himself and demanded respect. At the time the Dr’s diagnosis called for electrical cardioversion with a defibrillator to establish a normal rhythm so I began preparing the defibrillator. However, this was 1982 and we had a new cardiologist on staff so the Dr. in charge thought it best to ask the cardiologist if there was a less traumatic way to correct the patient’s rhythm. He yelled out Hey Dr. XXXX; what is the standard for cardioversion for intraventricular tachycardia? Now keep in mind that the nurse and I were concerned that this was a missed diagnosis and that the patient was in-fact having a heart attack.  We spoke up at this point but were dismissed due to our lower level of credentials RCP and RN vs. MD. The cardiologist said “there is a great new class of drugs that have been used for years in Europe they are Calcium Inlet Channel Blocking agents. Give your patient 4 mg of Verapamil! So our esteemed leader –without running the EKG to show it to the cardiologist pulled up 10 mg of verapamil –not 4 into a 3cc syringe and handed it to the nurse. “You will be okay in a minute Mr. Smith said his doctor, we will take your shortness of breath away shortly by giving you this drug”. The poor man was terrified and his horror made worse when my nurse friend refused to push the drugs into the patient’s IV. Dr. (Navy Save the Day) said “Fine I will do it”; injected the medicine, looked at the patient and then up at the EKG monitor. Mr. Smith sat straight up in bed, grabbed his chest and fell unconscious. As we looked at the monitor we could see that there was a clear EKG rhythm but the patient had no blood pressure nor could we feel a pulse. He had stopped breathing and his eyes were wide open with pupils dilatesd.We worked on the poor man for almost an hour. I intubated him and started ventilating while the nurse began chest compressions. The cardiologist had come into the room to take over the resuscitation effort. As soon as he looked at Mr. Smith’s first EKG he knew that he and the other doctor had made a terrible mistake. Had he looked at the EKG before recommending verapamil he would have labeled the rhythm as acute myocardial infarction with ventricular tachycardia and suggested defibrillation immediately.  What confused the patients doctor who had little clinical experience in cardiology was the fact that his patient was walking and talking.One is taught in school that a person usually loses consciousness when in “V-Tach” however, those of us who spent hours our lives reading 24 hour EKG recordings knew that many patients with good strong heart muscle can be in this rhythm while having coffee with a friend and simply complain of some shortness of breath. So this was an old-school clinical decision support error: the wrong diagnosis (bad data) given to the cardiologist (software decision support engine) caused the report (feedback loop) to the patient’s doctor to recommend the wrong therapy. Taking the advice the physician administered verapamil caused the patient’s cardiac muscle to stop contracting due to the lack of exchange of calcium across the cell membrane.

The patient’s wife arrived 30 minutes later to be informed that her partner had died from a heart attack. It’s hard to forget the screams of agony one hears throughout a career in the hospital ER. There was no incident report or mortality round on this case. The nurse and I were dumbfounded as the patient’s physician took off his gloves, through them on the patient’s chest and said “that’s the last time I ever take advice from a cardiologist”!

What I have just illustrated is a failure to communicate and validate; even in the presence of communication technology. Years later we would have computerized EKG interpretation algorithms that were often ignored due to as lack of trust in the computer. After a decade or so the interpretation algorithms became spot on and many stopped arguing with the machine.

I always wondered after this event “would this happen to me?”

Our time has come: In my opinion we have some brilliant people speaking to the topic of healthcare reform and its multiple components today. The same personalities have formed organizations that bring patients into the fold of healthcare transformation such as the Society for Participatory Medicine and its Sister E-Patients.net.

Furthermore research has confirmed that some basic tenants of care are major correlates of lower cost and higher health outcomes. These are ease of access to a primary care physician, assurance that the primary care physician treats the patient with comprehensive techniques; assurance that the primary care physicians practice coordinates the patient’s care as he or she develops new conditions and problems and requires interventions from other providers or facilities such as hospitals. Furthermore there is evidence that if the primary care database is queried on a regular basis to identify patients with chronic disease that have not been seen or are experiencing a deterioration in health status that populations can be identified and engaged well before they show up in the local emergency room. This type of procedure is titled Population Medicine.

So here we are with all this knowledge and interest. On top of that we approved a National program for the expansion of electronic medical record technology under the Bush administration. This HITECH bill was primarily a jobs creation bill but it was to create something of immeasurable value for us patients, doctors and our loved ones. A single record or location on the internet called a portal where any one clinician that might have an interest in caring for us would be presented with a thorough historical record of our problems, diseases, interventions, therapeutic outcomes, medicines etc. This alone was worth the billions spent since it could make our safe at a time in history when the institute of medicine was quoting over 100,000 deaths per year due to therapeutic misadventure. I call this permanent record “the life-long plan of care”

This engineering feat was not rocket science: it required technology that we had in place and a social infrastructure that we did not. By social infrastructure I mean an agreement among industry providers, provider specialities, hospital organizations, employers and insurance companies to settle on a standard clinical and business syntax defined by the context of the workflow or data flow and not interfere with the transfer of information between organizations holding information and their competitors since patients are transient. Metaphorically speaking it is similar to my exchanging the service records on my car between competing car dealerships and then downloading a copy for myself at home. In fact here is evidence that it is not happening while the private eHR companies selling their wares are owned by CEOs worth billions! Doctors challenged by data exchange

Crap! We still don’t have it! I am reading about campaigns “give me my data!” #gmmdd because evidently patients are having trouble accessing their records, test result etc.

My friends all tell me that they have been told by their providers and doctors that they have their own portal access their records, talk with their docs and download records. In fact they do. Here in the RTP area of NC I can count seven clinical portals that a patient’s clinical information may reside in. I have tested them all and have no problem downloading my personal or a friend’s personal information from each portal. This leaves me wondering if the campaign should be labeled Give Me My Data or “Wait Wait Don’t Kill Me” ,#WWDKM “I have data and you do not.” This is a much more succinct description of the problem in my world anyway. (credit to NPR for paraphrasing their wonderful show “Wait Wait Don’t Tell Me”)

What scares me is that I understand the cost of sharing information and it is not just some random charge made up by vendors. You see the vendors were given three guidelines to meet for interoperable data. However, during implementation it is possible to modify the system templates thereby creating artifacts as data cross the street from hospital A where Blood Pressure means Blood Pressure and Hospital B where Blood Pressure means Respiratory Rate. These are the CCDA documents that your physicians patient portal allows you to download either in the form of a pdf document or .xml document adhering to CCDA guidelines. So where you and I can download our information, good luck uploading it into another facilities records. So, once again…I am doing what I did in 1981 and hand carrying my test results and visit summaries to each specialist and each hospital that performs surgery. From the surgery perspective it is important because I am diabetic and have a family history of hyperpyrexia; a condition where in reaction to an anaesthetic agent your body heats up to 105 degrees and starts to melt on the OR table.

So as we riot against the machine because we are afraid for our very own lives remember who the villains are: No body! The manufacturers have certified their ability to interoperate. The ONC did not consider a standard where it is suggested that you document your capacity to exchange data in all contexts: Administrative, Financial, Result Observation, Continuing Care Document Architecture Record between every known vendor of eHR software that has received the same level of accreditation. This is an oversight or someone was paid off I am not sure. All I know is that the Epic enterprise EHR is deployed in three hospital systems that I use including their partnering physicians and I am unable to transfer my data between systems without a download and manual entry of results which never make it to my medical record because patient entered data are considered unreliable. Such arrogance! Don’t you think?

Below I illustrate and describe my current processes which include the use of MS Healthvault for data consolidation. This will be part 1 of a series that I construct with the objective of embarrassing an industry that has been playing a shell game for three decades with our private and taxpayer dollars. In the end you will hopefully have more clarity on why it has never worked, why it won’t work without a change in societal attitude toward health care as a right vs commodity and how we might change the future by getting clear with our healthcare business leaders and policy wonks now about our understanding of their special interest controlled industry.

I have been reading the same complaints for three decades; I have worked in provider industries and taken advantage of others in accordance with corporate doctrine, I have struggled to get my long-term needs met as well as those of friends, neighbors and family members. I have seen us come around now through three complete cycles of “novel idea that will fix medicine” followed by “new opportunity for new industries to form and to get wealthy on the suffering of patients and the majority of the workers who provide the most nurturing experience while they earn $15.00 per hour. I have had 45-year-old physician friends throw up their hands and walk out the clinic door with tears in their eyes as they dropped their career while still paying their student loans. It goes on and on but I do not. So now, with neuropathy advancing, fingers aching from arthritis as I type I say to you: I might need to rest and bleed for a while but I ask that you carry me to the next gathering to continue the fight.

Community Care of North Carolina goes for the gold: Proving valid reduction in hospitalization among Medicaid enrollees with Chronic Disease

Heck! With health insurance we can afford a cup of coffee!

Heck! With health insurance we can afford a cup of coffee!

I have not been posting much lately due to activities with the Patient Centered Primary Care Collaborative. We are working on an analysis of accreditation standards which will ultimately be used to verify Medical Home processes, procedures and clinical outcomes. Check out their website as you consumer types will have a chance to see what others are doing for you to assure you access to the best in health care as we reform the system over the next few decades.

I am very enthusiastic these days as I am seeing the changes I have hoped for my entire life as person with diabetes since 1966. As a child my doctor was always available to teach how to master my illness and provide tips with mechanisms I could use to reduce my cost: especially when I entered college. My docs have been so cool, I can never adequately thank them. Purchasing a glucometer and testing reagents for me when I was uninsured; providing free laser therapy when my employer dumped the plan I had in favor of becoming self insured. If you want an interesting read see an old post of mine titled Physician heroes.

Today I call your attention to Community Care of NC. The organization that employed me as their clinical informatics lead back in 2002. These folks are using a model of population management and patient care that I had seen work in Massachusetts in the 1990s. To that end my wife and I moved here in 2001 to work for CCNC. They use a centralized partnership between private healthcare industry and public agencies including Medicaid, Public Health, Mental Health and Substance Abuse Services, the NC Medical Society and the local branch or thee Academy of Family Physicians.

The central teams keep improving patient targeting and clinical outcomes analysis using a variety of statistical sources and deliver regionalized community information from 12 different 501c3 Community Care Networks. The individual Networks then put care coordinators, case managers, pharmacists and administrative staff in place to create local flavors of patient centered care. All have guiding physician committees and other staff who collaborate with subspecialists as well as local hospitals. The net result is a care continuum surrounding the sickest individuals where the team focuses on goals set by the patient, their family and the team. They have been doing this for fifteen years now and I can attest to the fact that they are one of only a few Patient Centered Medical Home Networks in the country that are using a web-native care plan accessible to all on the patient team as well as multiple other physician practice improvement web apps totally focused on education, assessment of each doctors population and measurement of patient outcome.

This week they published the proof in the pudding. After long struggles against threats to defund the program they survived. They are now audited in full and have demonstrated hospital utilization rates falling at 10% per year in the chronic disease population. We are talking HUNDREDS of MILLIONS of DOLLARS in savings folks on top of hugely improved clinical outcomes and patient satisfaction with their sense of well-being.

I have always said that I needed a lot of help in my life. Since I knew how to assemble a care team for myself I figured I may as well help others do the same. Today, in 2015 we have the mechanisms in play to reconnect patients with their physicians. Please step up and teach your docs about your needs, wants and struggles as it will take us a while to walk out of the woods.

nc hospitalization trends under CCNC

Celebrating physicians who stick with patients that are non-compliant due to financial barriers.

Reconciling data in my six health portals

Reconciling data in my six health portals






This is a synopsis of my attempt to bring affordable timely retina care to impoverished people with diabetes in Eastern NC. I sent this note to the Medicaid Managed Care entity: Community Care of North Carolina and was able to schedule a meeting as a result.

To: The Executive Director of North Carolina Community Care Networks,

“I have three retina ophthalmologists with nine clinics in four counties that are willing to take Medicaid patients. When I retired they asked me what I wanted to do. They had saved my eyesight and I told them that the disparity in services in NC had been my chief frustration since moving here. I said I would like to find as many diabetics as possible who were not compliant with retinal screening or follow-up care due to financial barriers. They agreed to treat as many as I could find after reading my proposal.

Many physicians are dropping Medicaid patients in NC. I have found some excellent, compassionate doctors who want to help.
Will you please help me strategize for an outreach effort. I will do all the work.”

I created a program guide for Medicaid describing access rules and services available. I started with Medicaid because their process outcomes revealed 40%-50% of diabetics missing annual eye exams. Furthermore this was in counties where over 1/3 of the diabetic populations had poor control (A1c > 9%) and therefore were more likely to have disease of the retina.

I met with the Community Care folks who (in my opinion) have a wonderful care coordination and patient centered care model. They informed me that they couldn’t perform specialty referrals as it showed preferential treatment. I responded with:” Many ophthalmologists do not see Medicaid patients and your data point out an underserved chronically ill population. I went on to say that the local hospital charged for a vitrectomy was $12,000 and that my friends would be willing to contract for $3900. They responded with a requirement that I recruit doctors from other practices.

So the retinal surgeons I was working with created a business relationship with an optometry group to perform annual screenings. Since Medicaid had stopped paying for eye exams in non diabetics, many diabetics stopped scheduling their exams as they also thought their services were dropped. However NC Medicaid does cover optometry for persons with diabetes. I guess the messages have not been tested for clarity and understanding in the Medicaid population?

After spending 9 months working with this ophthalmology group to reach out and treat people who are literally going blind due to gaps in care, addressing the needs of the Managed Care Organization (Community Care of North Carolina or CCNC) and following up with additional requests for an audience with their primary care physicians we received no follow through from CCCNC and we have continued to treat diabetics as they trickle in from primary care and emergency room practices with acute retinal hemorrhage and vision loss.

I imagine this is a political issue, as irrational behavior in healthcare systems is usually due to hidden agendas that go unseen in the public. Unseen you say! Yes the pun is intended.

We apologize to the impoverished diabetics of North Carolina, we are here for you, will  always assure you get the best care regardless of your capacity to pay.

If you need help visit this website and schedule an appointment. Taylor Retina Center

These folks saved my vision and I am sure they will save yours if you are able to get to them in time. I hope to have wider support and advertising from agencies trusted with reaching out to help you in the future. For now, no luck with Medicaid CCNC.

The images below illustrate a normal retina and a young 20 y/o diabetic woman with severe diabetic retinopathy as she appeared during her first visit to the clinic’s practice. One must appreciate how much retinal tissue can be lost before the patient notices the change. This is the underlying reason for annual – biannual screenings. When I interviewed the physicians they stated that 20 patients per year appear in their office with this level of injury who are insured by Medicaid or have no insurance at all. They have never denied treatment. Since they own their laser and have ownership in a day surgery center they are also able to address the financial concerns of the operating room provider.

20 year old woman with severe disease                                                Normal Retina

severe retinopathy

A normal retina





Patient commits suicide faulting pharmaceutical prior authorization rules as the cause.

Many untold stories


Patient commits suicide claiming prior authorization pharmaceutical rules as the cause.

Melt down, do you ever have them?

Well I will share mine with the world in this very moment.

I have carried hepatitis c for thirty-eight years now. That is until two days ago when my blood work returned the result of no detectable virus.

My family’s cheer is magnificent as everyone had considered this diagnosis to be the reason for my premature demise.

The medication I am taking (Harvoni) was approved for 90 days by the Federal Blue Cross program and I am now completing the second month of therapy. The protocol calls for 12 weeks of therapy due to a history of viral re-emergence using an 8 week protocol. We were lucky to get the medication as one course of therapy is $100,000! That is in the USA of course. In Egypt it is $1000.

CVS Care Mark was denied my refill as the date of the prior authorization expiration is tomorrow. That’s right TOMORROW!!!

It turns out that the Blue Cross administered program has a 24 hour lead time required for refills. Their internal processes begin flagging patients for cancellation one day before the actual term date!

So here I sit, just another patient with a life threatening illness who was given the hope of cure one week ago and now is pedaling as fast as he can to get help from his physician to extend the authorization of a medicine that is –on paper- still authorized!

They tell us patients with chronic disease that we are subject to depression. Feelings of hopelessness, loss of energy, inability to concentrate, suicidal ideation: Well I have all of them now. After 48 years of chronic disease, a 33 year career in healthcare where I operated at executive levels high enough to find out some ‘very ugly truths’ regarding this sector of the free market I feel ready to throw in the towel.

So for the next generation of patients: know this…you are on your own. This means it is up to you to find the best team of physicians, nurses, employers, insurance companies and friends to respond to your needs. It will be up to you to command them. It is time to stop being a passenger in the system.

I am the captain of my vessel. I have a wonderful team who is trying their hardest to get me the final dose of medication needed to save my life. I have just been wounded brother and sister so I will lay here for a while and bleed. Then –with your help; I will stand-up and continue telling my truth.

The truth that spills forth in the form of factual events involving actual people making life and death decisions has been held back until this point. I still try to earn a few dollars in the industry and do not want to become one of the untouchables. Perhaps it is time to execute my right to free speech.

When I am done I will rest and figure out another strategy for supplemental income in retirement.  It might be time to close this chapter and dance.

NC Continues to brainwash its citizens


We are dropped from the universe into loving hands (unfortunately not for all though)

We are dropped from the universe into loving hands (unfortunately not for all though)
























This is a recent opinion from Brian Balfour of Raleigh’s Civitas Institute. My response follows.

From Raleigh News and Observer Saturday December 28, 2014

Last week, yet another study claiming that expanding Medicaid in North Carolina would create tens of thousands of jobs was released and dutifully reported by the media. The findings of such studies, however, are based upon a fatally flawed assumption that Medicaid coverage equates to access to medical care.

The latest report, produced by George Washington University researchers, declares that North Carolina will miss out on 43,000 jobs in the next five years, along with $21 billion in federal money, if it continues to refuse Medicaid expansion as prescribed in Obamacare. The study’s findings largely echo other recent reports, such as a January study produced by the North Carolina Institute of Medicine that came to similar conclusions.

The job growth claims are based on the state’s “drawing down” additional federal funds due to Medicaid expansion. As the GWU report describes, “Since most of the cost of a Medicaid expansion would be borne by the federal government, expansion would result in billions of dollars in additional federal funding flowing into North Carolina. These funds will initially be paid to health care providers, such as hospitals, clinics or pharmacies, as health care payments for Medicaid services.”

This income received by health care providers is then spent on suppliers (such as medicine, medical supplies) and in their community on goods and services such as groceries, clothes and movies.

The fatal flaw in this methodology, however, is that in order to “draw down” federal Medicaid dollars, actual medical services need to be provided to Medicaid patients. It is only when doctors actually treat Medicaid patients that the federal government pays those providers for the services.


For instance, the NCIOM study assumes that more than 500,000 North Carolinians will not only enroll in Medicaid under expansion, but each would receive on average roughly $4,300 in medical services each year. As these services are rendered, the doctors and hospitals are paid by the federal Medicaid program, which injects the money into the state’s economy and spurs the job creation, according to the studies.

But here’s where the studies’ jobs claims fall apart: North Carolina already suffers from a shortage of doctors.

According to federal guidelines, 78 counties in North Carolina qualify as Health Professional Shortage Areas because of shortages of primary medical care doctors. And the problem is getting worse. According to the Shep’s Center for Health Services Research at UNC-Chapel Hill, North Carolina’s supply of primary care physicians is dwindling, dropping from 9.4 per 10,000 people in 2010 to 7.9 doctors per 10,000 people in 2011.

Indeed, a 2011 survey by the Association of American Medical Colleges found that only 15 states have fewer primary care physicians per capita than North Carolina. The doctor shortage is especially pronounced in the state’s rural areas, where there is a greater concentration of Medicaid enrollees as a share of the population.

And more to the point, not only is there a general doctor shortage in North Carolina, there is a shortage of doctors accepting Medicaid patients.

Medicaid roles in North Carolina have ballooned from about 1 million in 2003 to roughly 1.7 million today. Adding another 500,000 would push the program over 2 million enrollees and mark more than a million new Medicaid patients in a dozen years.

All this would take place when the number of physicians accepting Medicaid patients is dwindling.

Imagine adding since 2003 the equivalent of the entire population of Wake County to a group of people fighting over a shrinking pool of doctors. Making matters worse, a 2012 article in Health Affairs found that one-fourth of North Carolina’s physicians will not take any new Medicaid patients.

In short, there simply is not nearly enough doctors to meet the demand, and things could get worse.

As reported recently by WRAL, “A survey this year by The Physicians Foundation found that 81 percent of doctors describe themselves as either over-extended or at full capacity, and 44 percent said they planned to cut back on the number of patients they see, retire, work part-time or close their practice to new patients.”

Such extreme supply constraints tells us that if North Carolina were to expand Medicaid, the newly enrolled would have great difficulty actually seeing a doctor. Coverage will not equal access.

If new enrollees in the already overcrowded Medicaid program don’t have access to care, then there won’t be any services provided. With no services provided, no federal dollars are “drawn down” to Medicaid providers. The whole premise behind the studies purporting to show job creation is unsupportable.

Brian Balfour is policy director of the Civitas Institute in Raleigh.

Read more here: http://www.newsobserver.com/2014/12/26/4427841/why-medicaid-expansion-wont-boost.html?sp=/99/108/#storylink=cpy



Untangled Health’s Response

Jeffrey Harris · Consultant Community Medical Home Implementation: PCPCC Co-Chair e-Health Group; Director Diabetes Eyesight Preservation Program Taylor Retina Center
I am writing In response to Brian Balfour’ opinion on the relationship between expanding Medicaid in NC and job growth on Saturday December 28, 2014.

The man standing next to me in Church in Four Oaks NC in 2011 said; “you must have sugar”; as he observed me checking my blood with a finger stick. “Sure do brother I said, since the age of 10, this is my 44th year with diabetes, I assume you have the disease also.” “Sure do, runs in my family: I am scheduled to have several toes amputated next week.” I could not help but notice the soft cast and bandage on his leg and told him I was sorry that he had to be the victim of such an avoidable circumstance. “Avoidable?” he said; this happens to everyone in my family; we all assume it is par for the course.”
These are the people who would receive coverage under Medicaid expansion should NC decide to follow the recommendation of the Federal Government under the Affordable Care Act. In fact, more than 400,000 of these people who are presently uninsured would have a source of payment for Medical Care. I know them well as I was one and if not for the generosity of friends would have gone without insulin on several occasions in my life.
On Saturday, Brian Balfour, policy director of the Civitas Institute in Raleigh demonstrated a common misunderstanding of health economics. He states NC will not expand Jobs through accepting Federal Medicaid expansion money because we historically have underserved areas with few physicians who cannot expand their caseloads. I guess this means that in a free market society if a geographical area in need of services receives funding and resources to increase their supply of services that the suppliers of such services (Community Clinics, Medical Schools) will not increase the capacity of the delivery system?
Mr. Balfour further fails to recognize that these patients are already receiving treatment often for free in local emergency departments, further inflating the cost of healthcare to the insured.
By the way, Mr. Balfour fails to recognize that North Carolina wrote the book on how to provide Medicaid coordinated care through a Primary Care Medical home which has served as the ‘how-to’ guide for numerous other states (Community Care of NC).
Let’s see: Where Mr. Balfour is correct with regard to our need to expand the number of primary care physicians we have multiple mechanisms in place through ACA that are making the profession of primary care medicine much more attractive. I point the reader to one of many publications demonstrating the return on investment for engaging individuals in patient centered primary care Profiles in interprofessional health training. Since President Bush called for the adoption of electronic health record technology we are now well passed the early adopter stage of connected information systems that allow us to find large segments of our population that require access to specialty care thereby prospectively catching the crisis before it occurs and saving all stakeholders time and money; but more importantly mitigating the risk for the permanent suffering that arises from poorly managed chronic disease. Telemedicine is now a recognized intervention and carries a reasonable fee for patients and doctors to feel as though they receive a fair exchange in value (wellness for the patient and salary’s for the doctor’s practice). One thing any student of economics learns is that investments in technology and advancements in process favor a positive shift in the supply demand curve and its derivative…productivity. Let me recap: New tech, new care coordinating jobs, new analysts’ jobs = MORE JOBS!
In my work I spend a great deal of time assisting the public with the interpretation of so-called facts and opinions arising through think-tanks and praised by the media. I am confident in my judgment that NC Medicaid should expand in accordance with ACA policy. So are the Vice President of the IBM Global Health Initiative, our Governor and every other well versed healthcare economist regardless of political party affiliation. I suggest you do some of your own reading (reports vs opinions like mine). Good luck to my 400000 friends that are deprived of fair health care services when they are ill.
One more thing:
Physicians are willing to treat Medicaid patients. I spend my time looking for specialty care. And have located retina surgeons willing to treat diabetics regardless of funding: Simply to preserve eyesight.
Jeffrey Harris
Consulting Program Manager Taylor Retinal Center
Co-Chair Patient Centered Primary Care Collaborative Washington DC

An expression of gratitude for my first $28,000 bottle of Harvoni!

Can believe NC?

Can believe NC?

Last week I published my offer to not accept resuscitation services in exchange for a full course of treatment with Harvoni, the new Direct Acting Antiviral from Gilead that has demonstrated a 95% cure rate in Hepatitis C patients with genotype 1.

In most cases insurance companies, Medicaid and Medicare is not paying for the medication unless the patient has end stage cirrhosis and is queued for transplant. The reason is easy to understand from an economic perspective yet certainly Draconian when it comes to well over 2 million people in the US who suffer with this debilitating illness. Furthermore the price discrepancy between countries is 94 X when comparing egypt and the USA for example. 

In the US a 1 month supply of Harvoni is $30,000; in Egypt it is $320.00

For more, please see my slide presentation below. For now, I want to thank Federal Employee Blue Cross for covering this medication as well as my much needed continuous ambulatory blood sugar equipment which makes this diabetic completely able bodied when away from home and alone.



I do not know how or why I was approved. Neither does my hepatology doctor. Both he and I were in tears when the fax came in through his prior approval desk. I am now in my third day of therapy. 

All I did was write a story on my blog and link it to facebook, linkedin, twitter etc. Within 24 hours my friends at Humana had retweeted my message and called me to see if they could help. They were not even my insurance company but this is a great example of how some payers are monitoring the internet for clients in need. 

Human did not get back to me but within two more days we had the approval from Federal Employee Blue Cross (my wifes health insurance). Since they are acting as secondary to my Ordinary Medicare the authorization was up to them. 

So whoever you are at Blue Cross, this is one lucky American who thanks you for the generosity to step outside most payers protocol and save my life. 

What a Christmas Present. 



I will happily select a DNR status if you pay for my Hep C Treatment 



An economic model for exchange of value between patient and payer.

 Dear America,

I have been notified by both Medicare and Blue Cross that the technology I use for tracking my blood sugar trends will no longer be covered.

I have been notified by both Medicare and Blue Cross that the antiviral medication which has come on the market to cure my Hepatitis C will not be covered.

I would like to negotiate for coverage of these technologies using my history as a patient and known economic data regarding the cost of care at the end of life as a proposed value exchange. 

I understand that the insurance industry AND public sector should grind their teeth when presented with the $1000 per pill cost of the new therapy’s. I also imagine payers are stratifying patients needing transplant for first access to care since the drugs work on damaged livers. What I do not understand is the 287/1 disparity in cost between America and Egypt?


Hooray Humana for providing useful tools to family caregivers.



Lately I have complained about the lack of utility if not barriers created by various e- communication tools that seem to complicate the process of educating consumers on the topics within the domain of self-mastery.
After losing my poa agreement with my father, Humana finally
Let me know that I am now Pop’s designated healthcare proxy.
I find the letter engaging with plenty of contact info content and a promise to send me a care-advocates guidebook with accompanying educational material for visit preparation, medication reconciliation and financial management.
I will let you know how useful it is when received.

For now, a gratuitous thank you to a payer stepping into the medical home care team role with both patient and family!

A Chronic Disease Patient Reports On e-HR and p-HR utility


Reconciling data in my six health portals

Reconciling data in my six health portals

I will be attending the PCPCC annual conference next week and moderating a session on Do It Yourself Primary Care Medical Homes.

Most of my time of late has been attending to my ‘case’ as the demands of self-management are now more complex with the advent of new tools which were to lighten our load. Nowadays I spend at lease two hours each week keeping my 4 p-HRs up to date across four specialty physicians.

Why you ask? Well it appears that someone forgot to turn on the ‘interoperability switch’. I am sure it is here somewhere, I just can’t find it. I know the standards were written for certification purposes, I even have a copy of them. For some reason, here in metropolitan RTP North Carolina: Duke, Wake Med and UNC have all established contracts with Epic. The physicians that I use are independent and they have all chosen AllSCRIPTS and this is my patient experience.












I started out on this journey to reduce errors in medicine in 1997. Why are we still here? Please don’t blame it on Obama, Bush, Clinton; well you get the picture.

Here is my ‘secure message’ to my Medical Home

My recent note to my PCMH

My recent note to my PCMH


NC Senate : While the rest of the country profits from North Carolina’s success in Medicaid, you throw the baby out with the bathwater.


Heck! With health insurance we can afford a cup of coffee!

Heck! With health insurance we can afford a cup of coffee!




The graphic report (above right) comes from the CCNC data systems developed by the Community Care of North Carolina Program. It allows communities to identify and assist people in need of support or locate systemic problems such as high utilization rates in local emergency rooms. All of this stuff combined fits into the Medical Home Model that out senate suggests purging CCNC; Yet, as you will note below, this program is a locally managed;public-private joint venture that is used throughout the US to achieve cost reductions in health systems. Please read on:

Yet another testimony to the capability of a Medical Home framework to decrease cost and improve health outcomes was published in today’s NY Times.   Here are the data:

  • The payer: Care First Blue Cross Blue Shield
  • The population size: 1.1 Million!
  • The model: Medical Homes (Community Care of North Carolina an early adopter of this strategy)
  • The savings: $130 Million

The article goes on to explain that results have been mixed in Medical Home Evaluations, demonstrating a need to identify the components that are required to achieve such results.   However, The Patient Centered Primary Care Collaborative Chief Executive Marci Neilson noted that the studies are showing promise as Blue Cross Blue Shield of Michigan demonstrated a $155 Million savings in Emergency Room Visits and Hospitalization through their Medical Home Program last year.   So here’s what I have to say to the Senate: WAKE UP… the people providing the knowledge and structure to the programs now receiving accolades from the media cut their teeth in North Carolina through a fifteen year joint effort between public and private industry. Then, after receiving national recognition they were asked to teach other States the basics of the Medical Home that will reduce cost and improve health outcomes.

  1. Local control with State support
  2. Physician directed care
  3. ACCURATE DATA published frequently, reviewed frequently, converted to focused interventions
  4. Care Coordination and patient education from within the physicians practice
  5. Frequent regional meetings to review success and make adjustments to work-flow and design.

Here is an example from years ago in Greensboro (CCNC ORAL REHYDRATION PROGRAM)  

  • The local Community Care Network discovered that many emergency room admissions were attributed to children experiencing dehydration when they had GI Flu.
  • The CCNC Network (Partnership 4 Health) created an oral rehydration program where they reached out to the community of working mothers who would come home to a child experiencing diarrhea and vomiting.
  • As they engaged the family they taught the mothers to rehydrate their children using pedialyte.
  • They distrusted the rehydration kits to physician practices, public health departments and elsewhere.
  • The people started treating their children at home as opposed to the emergency room.
  • The Medicaid emergency department visit rate for GI distress fell and the tax-payers saved money.
  • All of this with happier children as the most important outcome in my opinion.

So what do you think NC Senate?   How about we keep what works!!! If you need further illustration there are a few thousand of us who would be pleased to teach you: Republicans, Democrats, and Independents alike. 

From the front lines in North Carolina’s debate over human equality

I am so sad to see the level of intentional prejudice in this State.

Here is todays local television coverage of the closure of a critical access hospital (CAH). CAH’s are placed in rural areas throughout the USA and exist strictly to provide life saving healthcare to sparsely populated areas (usually agricultural).

This event is blamed on a corporation “Vidant Health”

In reality, it is not the fault of a corporation; or the pharmaceutical industry, or publicly funded healthcare, or the insurance industry; or the doctors; or your dog.

This is a collapse of civilization. In NC, we have decided to stop caring for those in the lower socioeconomic classes. We have proven this through our elected officials. So the fault lies with us and every life that is lost in transit to hospitals 45 minutes away is our responsibility.

You see:

The Affordable Care Act found the money to expand Medicaid and provide coverage for those with incomes less than 200% of Federal Poverty Level (about $28,000). In doing this, the cost of insurance polices through exchanges decreases. This has been proven in States that accepted Medicaid expansion funding. North Carolina did not.

The money for expanding Medicaid is partially funded by eliminating the large disproportionate share payments to critical access hospitals. You see, they would now bill Medicaid.

Well, NC did not accept the money as a “Statement of our conservative believe in small government”.

Now the hospitals are closing.

Here are my comments to our State Health News today, and more will come of this situation as you watch it play out on the national front. You will note that the good people are here. They are just under-represented.

  1. Very sad indeed. Within the last week the following has occurred in my personal world of chronic disease management: 1) the endocrinology group that fills the diabetes management subspecialty role for many Medicaid diabetics in the RTP area has stopped taking these patients and (according to my personal MD) they plan to discontinue services for existing patients on Medicaid. 2) The behavioral health group that treats many of the same diabetics for depression has dropped away from their care-team roll as they too are no longer accepting payment from Medicaid.

    Meanwhile, back in the grass roots of Johnston County we have been blessed by three Raleigh Retina Specialists who are willing to continue treating Medicaid patients. This includes visits, laser procedures, vitreal injections for macular edema etc. I begged them not to drop the Diabetes Eyesight Preservation program at Taylor Retina Center and their response was clear: Are you kidding Jeff, we will turn no-one away, this is a serious disease and far too many preventable vision related disability cases are missed.
    A Heart-Felt Hooray for the Good Guys.

    I wish the NC voters could understand the magnitude of dishonesty between legislators and their constituents. I have worked directly with past external review actuaries including Mercer when determining the return or loss associated with NC Managed Care through their CCNC program. The level of detail, down to the adjustment for illness burden and months of enrollment in Medicaid proved to me the sincerity and accuracy of the folks charged with program evaluation. Later (2006-2010) the program and its outcome data were modeled in many States around the country.

    Yet when attending a Medicaid public forum I witnessed a NC employee from the budget office explain away all cost efficiencies by pointing to differences in the percentage of the NC population that are children in contrast with other States. Such an illinformed if not ignorant piece of information to share with the GA. This comment was made as I sat next to a former legislator who is a surgeon. I described the inaccuracy to him and said they may want to get some help with interpreting the data reported on Medicaid estimates. After a few more minutes discussing evaluation methodologies he looked at me and admitted ” We really do not know what questions to ask”.
    I testify to the truth of this statement further acknowledge that it is mine alone.

Physicians retreat from accepting NC Medicaid Patients

cemetary at dusk

I suppose the NC Legislature will eventually accomplish their objective of reducing Medicaid expenditures for the chronically ill. Either individuals like myself who have diabetes and are unable to afford a $500.00 insurance premium through our two payer exchange will either die or move.

Please note: Within the last month, Raleigh Endocrine Associates the one and only local provider of diabetes specialty services in the region will no longer accept Medicaid patients. For now, the primary care doctors (of which there is a shortage and no plan to adopt new reimbursement strategies for high quality disease management outcomes ) will have to take on the Medicaid diabetics alone.

I spoke with a young man this morning. At 26 he was discovered to have type II diabetes when receiving  his admission exam for the local community college. It has been weeks since he was able to purchase his insulin. I just happened to meet his uncle on the plane two weeks ago and called the fellow today with information on methods to access medicines for the treatment of chronic illness. Seems like the least our legislature could do is provide adequate resources for maintenance medications: Even if only to keep ED visits down.

More on the land of Oz (North Carolina)

Heck! With health insurance we can afford a cup of coffee!

Heck! With health insurance we can afford a cup of coffee!

It is so unfortunate that the Senate has demonstrated such ignorance of the systems in NC that have provided frequently cited information on the cost benefit associated with Medical Homes.

I came here in 2001 to work with Community Care of NC following the sale of my company to Aetna Health. The technology we sold allowed Medicare Advantage Programs to identify, target and engage at-risk seniors through referral to primary care case management. It was clear at that time that the lessons learned from the world of HMO managed care had reached the end of their useful life as physicians had learned about the concepts of cost control through limiting redundant procedures and using evidence based guidelines in the 1980’s. The 1990’s brought us minimal returns in Disease Management which was the initial model deployed by Carolina Access’s efforts in Asthma and Diabetes population management activities. Those in the US that were on the cusp of ‘the next big thing’ were organizing for Primary Care Case Management through regional networks. I had spent 1999-2001 making presentations to the likes of Aetna, United Health Care, PACE and Empire Blue Cross to sell our intellectual property. If the commercial insurance industry understood the value of the marriage of technology with Medical Homes in 2001 it was a sure bet that our entire delivery system was on the verge of major payment reform.

Having had these successes in the private sector, my wife and I moved to NC after learning about the evolving Medicaid program which ultimately was titled Community Care of NC. We had a sincere desire to see a replication of a successful private industry venture through the public systems of care.

Since I was from the ‘evil private sector ‘I often heard ridicule from folks working in public programs here in NC. However; the willingness of these people to adopt information technologies that would increase their understanding of the Medicaid population and facilitate the design of delivery systems to tackle specific risks for the State of NC and separate regionally-managed community centered action plans for twelve regional networks was undoubtedly supported by the experts and General Assembly alike. Since that time it has become clear to all who work in the field of population health and disease management that the involvement of local providers, patients, payers and institutions in the creation of these programs is critical to the success in terms of both return on investment and quality of care.

So here we are: Those of us fortunate enough to work with these teams learned many lessons. When I left CCNC in 2006 I worked nationally, implementing similar programs across multiple states. I frequently heard how impressed various leaders in healthcare were with North Carolina’s success at improving the health of persons with diabetes and asthma as well as making a significant dent in the inflation rate in NC Medicaid when compared with other States.

So why would the Senate disband a working solution. I witnessed the reports from various budget experts at the public forums held last spring and noted a general lack of proper methodology when reporting cost data. For example: There was no evidence of proper control group selection and illness burden adjustment. When I stated to a former Senate member who happened to be a surgeon the errors in the reports used by the committee to compare cost benefit he agreed with me and stated “We really are not sure what questions to ask”: Yet the citizens of NC place their trust in this group to reform Medicaid.

Of course, when the public was asked for input, the decision was made to keep the existing program. Obviously many became clearer on the benefits. Then, out of left field comes enough controversy and distrust to once again, throw out the baby with the bath water.

Now that I am retired the muzzle of political correctness is no longer relevant. So here is some more feedback that is based on actual happenings in my life since working in NC.

I returned two weeks ago from the Patient Centered Primary Care Collaborative, a 10 year old group spawned from the private sector in response to the escalating costs of care in this country along with the fact that we are rated far down the line in healthcare outcomes when compared with at least seven other industrialized nations; few of whom conform to what we like to think of as traditional socialist thinking. I hold a co-chair position with this group and have gratitude for hearing the current thinking of the ‘best and brightest’   a club of economists and CEOs which I certainly do not qualify for membership.

During the conference a lead executive in a fortune 100 company along with several others from other organizations respected by all who read the Wall Street Journal told me that he had been asked to consult with the Governor’s office after the GA changed its mind about Medicaid outsourcing. He asked me what I thought and I gave him feedback on my personal observations of the successes achieved by Community Care of NC and told him a story about a similar plan assembled in Chicago in 2007 where I had a consulting contract. The Chicago plan failed since the commercial HMO and technology vendor had not developed succinct written requirements. I recall the meetings as if they were yesterday: Especially the frustration I exhibited in public when I found out that the HMO had not connected with the Medicaid primary care providers in Chicago prior to submitting their proposal. So here I had evidence of a public –private partnership success story in NC and private failure in Chicago.

My business friends that had reviewed the politics and business cases in NC for our Governor had all recommended that the State keep CCNC and the Accountable Care Organization models that had been promised only two months ago. Unfortunately their actual comment to me was: “Sorry Jeff, we do not understand the logic, the drivers appear to be something other than cost and quality. Perhaps it is time for you to leave.

What more can I say. The Senate’s budget is counter-intuitive yet those who are emotionally trapped by their opinions concerning the ACA seem unwilling to discuss the details as to why it makes no sense.

Does the GA realize that the Triad had a huge problem with mothers using the emergency room when their children became dehydrated from GI influenza and that the local CCNC network assembled a clinic to educate mothers to master the task of orally rehydrating their kids when they were sick which brought down the ER visit rate to almost nil?  How do they think an HMO will be able to address local needs with such specific detail and provide educational resources?

I have had diabetes for 48 years. I remember when Blue Cross sent my refrigerator magnets to remind me to have tests performed and monitor my blood-sugar. I have no idea how much my employer paid for that Disease Management Service but I do know that I had to argue for my insulin pump in 1984: The one tool that I attribute my lifespan to today.

I will close with this:

For the last six months I have been working with some private practice ophthalmologists who are willing to treat Medicaid diabetics. Many specialists will not treat Medicaid patients due to the lower reimbursement but these folks are a dream team. I assembled a program description and took it to the NC Medicaid Medical Home leadership to get their feedback. They were very pleased to see local people getting involved with creating specialty networks that would treat their patients. Why? Well we have a problem with diabetics becoming blind if they are on Medicaid due to inadequate access to specialty care. So here I was offering a bundled service at ½ the commercial rate charged by the hospital next door.

Unfortunately, I have had to place the project on hold. One of our major criteria for inclusion in the retina service for diabetics is that they are tethered to a Medical Home. As of a few weeks ago I can no longer assume we will have a relationship with a Medical Home enterprise.

A note to the NC Legislature on Compassion


 peace 2 you


A letter to the NC General Assembly




We seem to be evolving into a nation of binary people. Binary in the sense of our emotional, tactical and strategic response to our surroundings: On one end we have the Concerned and on the other we have the Unconcerned.


Of course you realize I say this in jest, but what if I was right? Are you willing to risk your comfort and explore a possible reality with me?

Please place your religious ideals aside for a few minutes and read on:




  • There is no God
  • No-one will inherit the earth, we have no idea what the future holds.
  • Human beings randomly crawled from the primordial soup some billions of years ago and have evolved to the most intelligent form of life on the planet. When I speak of intelligence I mean cognitive ability and nothing else.




Since we became self-aware we have been unable to escape our internal reality: That we are born alone and will die alone. All of the space in-between (a brief 70 +- years) is filled with experiences arising from the environment around us. We learn –or not that our actions influence our environment and well-being; receive –or not, instructions on how to behave in society and together: “Trudge the road of destiny”.


Non-sense you say: “we trudge the road together”!


Two weeks ago, as I flew home from a medical conference in Denver, this essay was tumbling around in my mind. I was not sure of the words, but I felt an overwhelming drive to write something about how I currently perceive my world: The one where I wake in Raleigh North Carolina each day, aching from diabetic neuropathy, reflexive sympathetic dystrophy and drained by my hepatitis C, a condition undoubtedly resulting from poor lifestyle choices in the 1970’s.


I am observing the adults in my Country of origin become firmly rooted in social belief systems. It appears they are evenly divided between the concerned and unconcerned. At the same time, few fall completely into one group as they seem to be willing to sacrifice their beliefs when under personal threat. The ruggedly independent who celebrate life, liberty and the pursuit of happiness in the absence of stringent regulation will sacrifice their black and white thinking to help a nephew or niece who has become dependent on drugs or alcohol. Those who consider themselves intolerant of in-equality and weep over those experiencing disparity in health-care or lack of opportunity will often appear to live up to their values until they too fear losing something of greater importance.


I have a friend who calls this: “Integrity in the moment”.


Since we are tolerant of a change in our own life circumstances to the point of willingness to think in numerous shades of gray when it comes to self-interest and the safety of our loved ones; how is It we cannot apply this flexibility to everyone?


My father asked me if I had ever sacrificed. His opinion at the age of 86 was that his was the last generation to truly be willing to have such willingness. He and his friends in WWII who walked from one end of the Philippines to the next risked their lives daily. I always thought this was for God and Country until I learned much-later that my Dad joined the Army –in his words “to find chicks”.


So what I consider the truth today is that few human beings are willing to strictly abide by their convictions. Yet, in my opinion; to ease the pain of ‘oneness’ we find some common characteristics that we share with others and join that group: Until we become threatened that is.


So, for all of you Republicans, Democrats, Tea Par-tiers; Independents; Christians, Jews, Muslims, Atheists, Agnostics, or (insert category here): Are you willing to try something new?


How about belonging to one group:

Human Beings.



How about owning some truth:

  • We are a fickle species.
  • We are capable of changing our behaviors and attitudes.
  • We are not God if there is one.
  • We believe in knowledge.
  • We believe that knowledge is best obtained through scientific methodology
  • We would like to live forever, never be hungry, never be lonely, and always be loved and recognized as an individual.
  • When we put our defenses down we realize that each one of us will die and we might experience times when if not dead, we will wish were dead.


Now, stop here for a moment. Yes I know you have an important business meeting but please stop for a moment and read on.


  • If you own these truths you might feel a bit uncomfortable right-now: Perhaps afraid for yourself, perhaps sad for others who might suffer. In fact, all of a sudden you realize that We All Suffer.
  • What separates you from those who you call entitled. What separates you from the arrogant wealthy movie star; very, very little; perhaps nothing at all?



So on the flight home from Denver, I met a guy who said his nephew had been living a year in North Carolina. He said he had just got a factory job but could not afford his medicine. He said he was a diabetic who did not have his insulin.


As my mind jumped between my judgment and intolerance of numerous human character defects; across a spectrum of political beliefs there was a man about to die from diabetic ketoacidosis.  He had lost 50 pounds in weight and for reasons that were none of my business no medicine.


I just hung up the phone after speaking with his aunt: I gave her the number of a community health center where the young man can access a primary care medical home and learn –if he desires- to take care of himself. That is the problem in the moment.


Realizing that I am one of those fickle human beings described above I needed to stop thinking and do the next right thing.


The next right thing will always be: To decrease suffering for another. When I am so sick that I am unable to help another or take care of myself then the next right thing is to?


Ask for help!!!!


So, as the North Carolina Legislature places health and well-being above all else, they will have my respect. That said, since they are human, and I am a human, if any one of them needs some groceries they are welcome to split what I have in my refrigerator.


You see:


At age 10 a man tackled my ‘entitled’ drunken mother as I jumped from our kitchen table on-to his back with a steak knife ready to cut his throat.


At the age of 13 I said “I will never drink alcohol or take drugs”


At the age of 19 I acquired hepatitis C (guess how)


At the age of 25 I had to borrow money for insulin (help of another)


At the age of 31 I stopped drinking and drugging (help of many and my higher power)


At the age of 36 I had asked a team of people to help people suffering with lung disease become more independent and comfortable: Literally healing people into their inevitable death. I did not have to ask: ten years later; the team simply told me how much they loved me.


There have been times in my life when others would throw me away and times when they called on me to feel safe. At what point should I be judged by others. Isn’t it our duty to love unconditionally in the moment: To believe in our truth that people change, life is precious and it is not ours to judge?


Moving forward NC Legislature, I hope you all will sit back and reflect on the importance of your actions. How many tomorrows are you sacrificing that do not belong to you.

diab expense nc cos





NC General Assembly Run’s Amuck

Here is what you can plan on seeing frequently in NC Emergency Departments as people with diabetes lose contact with the guidance of their primary care medical homes.
Dying a piece at a time diabetic vascular disease

This letter is to my neighbors in North Carolina, all of you:

I am presently at the Patient Centered Primary Care Collaborative, a national forum of Fortune 500 companies such as IBM, Anthem WellPoint, United Healthcare; Aetna; and clinical groups such as The American Academy of Family Physicians and others. My point is: This is a non-partisan, multiple perspective group of America’s best thinkers in business and industry that convened in 2006 to identify what works with regard to delivery mechanisms, payment reform and consumer engagement.

I am a member of PCPCC and serve as a co-chair on their health information technology committee and adviser to the Patient-Family and Consumers group. Yesterday I was a panel member discussing both topics. Why, because of my experience with my healthcare (diabetes for 48 years) and work with the folks that founded the current system.
After this meeting I will be attending the Colorado Patient Centered Primary Care Collaborative meeting at 1:00 PM this afternoon.

I am interested in Colorado’s perspective since they adopted North Carolina’s successful program: North Carolina Community Care Network which tethers Medicaid Patients to a Medical Home. Our program in NC has been evolving for twenty years: Starting as a simple demonstration and ultimately proving its capacity to manage a diverse population of patients coming through different payers including Medicare, Medicaid and Health-Choice. After joining what has become a national movement to bring patients closer to their primary care physicians Colorado’s pilot initiative has demonstrated reduced-cost per enrollee and improvements in health outcomes. The return on investment is well north of 2:1.

As these programs expand they will be using organizational ideas that originated among the talented North Carolina physicians and allied health professionals in the between 1994 and the present-day. NC tax-payers and the private sector joined forces; offering financial commitment and support staff to ramp-up the rate of adoption of Medical Home processes. Their support of Community Care is due to their effectiveness. This work is now being replicated across the country and is thought to be pivotal to the reduction in cost and the much-needed improvement in National Healthcare Outcomes.

Unfortunately, my neighbors and I in NC will no longer receive the benefit of our State’s recognized excellence in primary care delivery as the NC General Assembly has elected to ignore the desire of the public and take the next step toward the ‘outsourcing’ of Medicaid to a national HMO. “Sorry folks we have been hijacked by gorilla corporate tactics to influence a 3 trillion-dollar industry.”

I must inform you of your success and the magnitude of abandonment.

Here are the facts as described above:

NC has demonstrated wonderful cost savings with their community designed care coordination and case management programs. You may hear them referred to as Community Care of North Carolina. They are composed of 14 different not-for profit organizations assigned the task of providing care while controlling inflation in Medicaid. I worked with the team on assembling programs that would provide unbiased expert evaluation on their health and cost outcomes, those that become national benchmarks.

Your communities responded to the call for participation in Medicaid reform. Now, all of us that thought we were included have been abandoned: And believe it or not: Our Governor is one of the good guys: After he put a great deal of effort into learning about what works and listening to the feedback of local healthcare experts he supported the implementation of Accountable Care Organizations and the continued use of Community Care of NC as the service providers.

How do I know this? I had coffee with Fortune 100 executives yesterday who have been trying to help the Governor and NC Physician networks. I cannot disclose anything other than this. The detail is disgusting and speaks to issues that most in our country worked through in the 1970s. Suffice it to say that your elected officials were able to locate an HMO plan outside of NC that is able to tell a wonderful story. Since the legislature (as members have directly admitted to me) do not understand healthcare data and population analysis they have hired consultants to assist. These consultants pale in comparison to the experts that have recently met with Governor McCrory in an attempt to save the State of the Art system currently in place.

All systems of care need improvement today. Clinics and providers are not all the same. That said, we have plenty of successful models in NC to draw from.

Regardless of the following truths your General Assembly has decided to dispose with advice from the recognized experts in the field.

The Nations’s  industrial leaders are adopting your healthcare services design because they are confident that it works.

• Our State is a respected leader across the USA through the success of its bilateral Medicaid Managed Care model that evolved through your feedback and the constant vigilance on regional measures of cost benefit and cost efficiency.
• You have been abandoned while distracted by a conservative argument for small Federal government. The influence from outside our State is present and sizable.
• Through the invocation of States rights, our GA turned down sufficient funding to care for an extra 400,000 poor people in this State. Our uninsured would be insured otherwise and hundreds of jobs would be created to perform the needed individual health assessments, identification of clinical disorders and implementation of a course of treatment.
• You are handing over the health management of the woman next door: You know the one who works two jobs to feed her family to an external, antiquated delivery concept that demonstrates only two things:
o Reduced cost
o Reduction in health and wellness with loss of access to primary and specialty care.

Since no-one could imagine our legislature retreating from previous commitments I thought it might be a good idea to take this year and advance the treatment of diabetics by concentrating on our well-known problems with untreated diabetic eye disease among the poor. I was counting on the Community Care Networks to take our patients, established a collaborating group of eye doctors and created the program outline for a Diabetes Eyesight Preservation Initiative.

Due to the changes in attitude and changes in latitude expressed by the GA last week a program to treat diabetics at high risk for becoming blind at a cost roughly 50% of local hospital charges is being placed on hold. I can not ask my ophthalmology friends to plan on Medicaid reimbursement with the knowledge that the payers could change overnight. Two bad I guess for several hundred people who have been unable to receive specialty eye care.

I hope my readers understand what I am saying. I have difficulty describing such a complex and corrupt industry to my friends and family. The General Assembly has knowingly ignored your desire and taken action that will –in the eyes of our nations most published professionals likely do harm to the poor.

Additional note one day later:

I have been informed by my endocrinologist that the practice will no longer accept NC Medicaid. This is due to the uncertainty of the GA final budget.

I am retired today and have no reason to distort the truth. I am fortunate to have wonderful people in my life outside of NC who validate or challenge my conclusions. Without my friends I would question my sanity and think I was caught in the twilight zone.
\I am willing to work with others toward a system that is faithful to its original design requirement: Provide room for the poor and middle class (now the same, check your retirement account) to succeed in a country of opportunity. Have we lost it?

If anyone would like to publish detail, simple facts to expose the reality do not hesitate to contact me. I have data and information regarding this topic that will stand in court and my family has no fear to work with others in an attempt to expose the material prior to the 2014 election.

New Bumper Sticker Idea: NC General Assembly : Perfecting Legal Genocide



States Rights to create their own Healthcare System : The best solution for our universal contempt for “Obamacare”

You owe it to yourself to read this

You owe it to yourself to read this



I just left the keynote session at PCPCC. The Speaker, T.R. Reed who wrote “The Healing of America”; the well know exploratory of systems of care from around the world offered-up a solution.

As you know I am in Colorado, a State that is describing why we no longer need two political parties. Here we have a conservative history yet marijuana is now legal PERIOD.

I also think of Vermont as a similar place one can relax and turn off the political diatribe and get to the issues.

Anyway, Colorado has implemented a multi-payer collaborative of physicians and their community partners to create one of the best examples of Community Health Homes to date: They are increasing patient access to care, improving the quality of care and spending less money.

T.R. Suggests States’ invoke Section 4 rule 1332 of PPACA to accomplish the conservative objective to rid our country of Obamacare. The liberal objective of universal coverage would also occur as this is the formula for higher quality, lower cost and the greatest satisfaction among patients and providers. We have known this for quite some time. In fact T.R.s book was published in 2009, was a NY times best-seller yet receives scant press coverage: I wonder why?

Well, I will bring the idea home to NC and try to explain ‘one more time’ that universal coverage is not a pledge to socialism, just plain old common sense. All one has to do is look at the business model.

Peace from the High-lands

Local Physicians “Pay it Forward”

Patient education


I am hopeful today. I will be leaving to join friends at the Western Regional Conference of the Patient Centered Primary Care Collaborative in Denver and just found out that a pilot grass-roots effort to identify Medicaid patients who have not received eye exams and engage them with a collaborative of specialty-care physicians will be moving ahead with the support of local advocates.

Taylor Retina Center and I have been working on this project since last October. As noted in other posts, our current climate for Medicaid patients is less than friendly. I am a very fortunate man to have my eyesight almost 50 years after the onset of my type 1 diabetes and have come to appreciate the differences in health outcomes and healthcare process indicators between those of us with private insurance and those who receive Medicaid funding. I moved to NC in 2001 because of their progressive Primary Care Case Management programs in Medicaid, have enjoyed watching their success and have concern for the future due to the current proposed changes by our State General Assembly.

That said, I have been introduced to physicians and grass-roots organizations who take it upon themselves to orchestrate access to health care resources and engage patients in self-management activities. We will stay healthy, introduce consumers to the self-mastery component of chronic care management; locate the best examples of treatment paradigms and broadcast our success.

To make a long story short, my friends at Taylor Retina Center and My Eyes Optometry have assembled an efficient screening and intervention model. They have been concerned that Medicaid patients tend to skip these exams (50% miss the yearly testing). The patients frequently show up for care with horribly diseased retinas that could have been saved if identified months earlier. The technology and talent available today will preserve a diabetics eyesight for a lifetime if the patient is tightly bound to a team of caring physicians and assumes responsibility for their disease; yet we have trouble with access to care resulting from what are counter-intuitive restraints to Medicaid funding and refusal to expand coverage under a national health reform effort.

I believe it is our responsibility to reach out and work with our community doctors to create medical homes and promote their clinical integration with the supporting specialists in the community health home environment.

Specialists integrating with Medical Homes to solve a major problem among diabetics in North Carolina.

NC Legislature Let-Down

cmis_use“I thought we were going to keep what worked?”

The NC General Assembly, as an independent move regardless of feedback from their electorate, physicians, Medicaid program evaluation programs is moving forward with plans to throw the baby out with the bath water. www.NC Health News May 30, 2014.

It is a sad moment indeed to see the citizens of NC exploited by their General Assembly. As a person who has had diabetes for 47 of 57 years. As a person who spent 15 years traveling the US assisting “the hired guns of the assembly” win bids for population care management under capitation I can attest to the trickery in numbers, computer vapor-ware and conveniently forgotten success of in-place efforts between 1990 and now.

The GA will find data to back their claims of NC Medicaid efforts failure to improve quality and decrease cost. When I attended the Medicaid reform meeting in Raleigh, I sat next to a former legislator who was also an MD. The NC Budget office had just finished describing that NC Medicaid’s claimed savings was a result of unfair comparison to other States with a different % of children in the program. I informed the man that the approach used was inaccurate and that the Office of Rural Health had gone to the extremes of analyzing differences in utilization between the States CCNC Medical Home program and Fee for Service basic Medicaid. These extremes included using well-recognized illness burden modeling tools that are commonly used by the best healthcare economists in the US. There has never been any doubt that the program in place through CCNC was effective.

My wife and I moved here in 2001 after the sales of our company to a commercial insurance disease management vendor. The vendor “Active Health Management” then sold itself to Aetna. Aetna insures over 20 million individuals. I had read about the pioneering efforts of Mr. James Bernstein’s Community Care of NC program (then called Access 2 now called CCNC): A program which challenges each region to self-determine areas needing improvement in healthcare processes by carefully examining their own data. Then the CCNC program aligns State DHHS resources with local providers to work together to accomplish documented goals as guided by industry standard project plans. I moved here to work with CCNC as the opportunity to learn from the best and take part in the reform we need was enticing. These were the people that had been trained in the Nation’s best public health graduate education programs. Many of the from our own UNC.

NC was one of a few States that knew of the few simple aspects of care necessary to reduce the rate of inflation in health spending. While the rest of the country was wasting money on Disease Management Programs sold by private industry CCNC and DMA had the foresight to understand that you can only make these improvements through local partnership. The basis of change is multi-pronged including these objectives: 1) Patients receive incentive to contact their primary care docs before going to an emergency room, 2) care managers to assist the 20% of the population spending 80% of the resources choose the correct care and engage in self – management and the creation of patient centered care plans that addresses all barriers to health including transportation issues to and from medical appointments and compliance with medication use for chronic conditions.

These are the things that the most respected professionals in the USA teach states that need help. Funny that some of NCs current Medicaid CCNC leadership are invited to other states to educate their legislature on how to reform Medicaid to demonstrate methods to a) find, engage and treat the highest cost, sickest people in the insurance pool; b) engage patients in managing their own illness as Greensboro did when it taught mothers how to hydrate their children instead of visiting the ER and c) reduce the threat to the States economy.

All of this published by the National Institute for Health Improvement Triple Aim measures to improve our Nations Health, our satisfaction with the system in general and lower the cost per person/year.

So here you are NC, years of recognized success; national awards for design; a web-native care coordination platform which allows any professional to view the patients history of treatment, list of problems and medications along with the published, evidenced based goals that the patient and treating team are working toward; a physician portal allowing physicians to review their improvement success and areas where they can tighten up their practice; a portal allowing physicians to contrast their performance against their peers setting the stage for friendly competition: Virtually all of the tools that the supposed consultants will tell the legislature they need.

The IT infrastructure for N3CN’s data center which houses the web-applications noted above along with the support staff to address the needs of 14 networks caring for over 1 million North Carolina citizens has over 300 simultaneous users including case managers and physicians and meets HIPAA security standards. It allows the professional to access critical information in a time of acute need; something the States hospitals are just now implementing and still have not agreed to share information on the NCHIE. It was designed and implemented for a fraction of the cost of commercial systems using a public-private partnership model. Does anyone know about this?

So, we have a nationally recognized program, we have nationally recognized population health management information system architecture, we have healthier diabetics and asthmatics and those of us who worked in the system that actually know something about medicine and being a patient are asked to be panel speakers in regional US conferences on Patient Centered Care somehow get discounted by a General Assembly without the skills to understand the nature of the problem. I know this since the person sitting next to me in the Medicaid open forum told me “we do not understand the data” when I asked him if he needed some help to tease out fact from fiction.

The N3CN organization is positioned with others to take accountability for the population that the assembly is concerned about. Functioning as ACO for multiple commuted local networks is a dreamlike structure that many states would pay millions to introduce. You see, we not only have the knowledge and technology, we have the countless life years of experience in our native state: but instead, the GA wants to hire nurses to call me from California to discuss my diabetes management issues and send me a nice refrigerator magnet and new web-site to track my health. Unfortunately it wont talk to my Duke, UNC, Federal Blue Button website when I start Medicare this year.


Many Thanks to e-Patients –a time to reflect with gratitude.


An old teaching slide from 2008

An old teaching slide from 2008 


I want to thank my fellow e-Patient Casey Quinlan for recognizing my recent comment on e-Patients.Net.


“Frustrating it is; says Yoda”; that 2014 did not pre-date 1997. I had much more energy in 1997: Perhaps too much.



I reference 1997 as the year that I departed my work as a clinical program manager to work in e-Health. We didn’t call it e-Health then. Although Electronic Medical Records did exist; they were isolated to large hospital-like institutions such as the VA Medical Centers’ and were not designed to provide the functions available through modern ‘electronic health records’.

Many of us “early adopters” of information science could not understand why it was possible for Domino’s Pizza to maintain a record of our eating habits and deliver hundreds of pizzas to a locality throughout each football-weekend without a hiccup.: 1) pick up phone, 2) call nearest Dominos, 3) declare name and address, 4) authorize payment, 5) pace the floor for twenty minutes, 6) protect the delivery person by fending off eight hungry men from grabbing at the steaming-hot (well sort-of) pies in his hands and 7) laugh hysterically at your friends as they spill tomato sauce and toppings all over your ‘state of the art’ 300 pound 37” Big-Screen-TV.

You see, we could not understand why Domino’s had this technology; let alone the banking industry’s ATMs and long-time regular consumers of health services could not 1) count on the pharmacy ability to refill prescriptions without error, 2) count on hospitals and physician offices to keep our administrative and demographic information consistent between different clinics let alone the information most likely to cause therapeutic misadventure if not ported between points of care (allergies, chronic conditions and problems, medication dose schedules, history of procedures performed, emergency contacts, ETC.).

Those of us working to coordinate care and educate patients and families on the topic of Disease Self-Mastery commented “year after agonizing year” that “information is good medicine”; “missing information causes premature mortality” and “redundant information is expensive in both time and money”. The inability for a patient’s medical history to be stored for quick access and accurately portray the bio-psycho-social status of a person with chronic disease caused our clients to be branded as “revolving door patients”. Those who could not manage their own health-needs and were the reason for an exponentially rising National health care cost that policy-makers used to threaten future funding of our programs as we worked figure out the secret of the “secret-sauce”.

In 1997: Those of us attempting to manage our own disease, spent ridiculous hours each year documenting, forwarding, reviewing, speaking with new providers and writing checks to literally stay alive and productive for our families and employers.

Well, I would like to say it is all fixed! After-all, in 1997 we were in the era of the information technology bubble and the implementation of the World Wide Web so we left our clinical careers to work with “the geeks” to carve out a solution. We thought it would all be in-place by 2004! The problem you see; was that it took at least a decade to figure out what “the IT is” and what “the IT isn’t” and in –reality; in 2014 we realize that our issues were more related to “a social paradigm-shift” as opposed to the absence of technology. We are probably 50% there in terms of definition. We are 100% there in terms of technology and 25% there in terms of defining the rules and use-cases for the capture, digestion, analysis, transmission, and relevance ranking by work-environment to attaining the possible impact on e-Health to our collective experience, quality of life, safety and economic impact.

These apps ,, devices and vendors all connect to my HealthVault today.

These apps ,, devices and vendors all connect to my HealthVault today.

This year however is a turning point for us consumers that are the BIG-SPENDERS. By now you should note that your medications are ‘mostly (with sheepish grin on my face) correct between providers and that we can at least digitally sign and forward administrative and clinical documents between providers in milliseconds as opposed to weeks. Persons with diabetes, cardiovascular disease, cancer, asthma, head injury, auto-immune disease should be able to log-on to review all relevant clinical monitoring information, securely dialog with physicians and family members, download and upload data from home testing equipment, request refills and perform research whenever we are at Starbucks. There are some security glitches but if I can risk sharing my smart-phone with a shopping app. I can certainly use it to help me manage my healthcare.




I am retired now, slowed down enough to be ‘coined’ disabled but juiced-up enough to spend the foreseeable future gathering ‘consumer-power’ with my fellow ‘e-patients’ as part of this ‘e-society’; shouting out with my friend Casey, he nature of our needs and declaring the economic value of the products and services. After all, it is our game to change: Isn’t It!

PS: I do not have enough time and energy keeping-up with my blog. I do my best and return occasionally with a cerebral burp of two.  This is because finally, the world has a place for us: I am active as a volunteer with the Patient-Centered Primary Care Collaborative and make an extra buck or two pursuing a dream: The Diabetes Eyesight Preservation Program; where one patient convinced three physicians to treat anyone who needed treatment regardless of ‘ability to pay’!

Well, to be truthful: “They asked me what I was going to do with all of my time (tee-hee).”



The Medical Home’s Impact on Cost & Quality | Patient-Centered Primary Care Collaborative



Please take a moment to enjoy this recent publication from the Patient Centered Primary Care Collaborative. The success of the Patient Centered Primary Care Care should be spread far and wide!

If you have not joined us please consider membership.


The Medical Home’s Impact on Cost & Quality | Patient-Centered Primary Care Collaborative.

Self-Interest as the cornerstone of failure in Americas Healthcare System

I fear we will lose  the opportunity to re-think the legislative changes required to assure the success of the Affordable Care Act. Instead it might simply die. My reasoning is clear. The original work lost all structural integrity in terms of economic sustainability. This was the outcome of supporters of the legislation sacrificing so many critical features to corporate interests.

I am exhausted and have few words left.  Why do we cling to fears, doubts and insecurities that were issues of the  Cold War.  “Oh we can’t consider universal coverage as this is a Socialist construct.

If we look round us, all civilized nations figured out a long time ago that universal coverage is mandatory for the economics of health-care to be self-sustaining.  Here is my response to a recent petition. I hope my readers will take it seriously.

Sue, I have decided to discontinue any business that UntangledHealth.com has with Staples. Then again, I only purchase two computers per year and will not make a dent in their bottom line. At the same time it is important for all to understand that this has less to do with the legality of the situation than the moral standards we choose to live by in America.We have a wonderful opportunity through a free enterprise system to create huge personal wealth. Personal, now translates to corporations as individuals. Self-Interest stimulates wonderful innovation yet unless closely monitored for “intent” will consume a society in short order.



Plenty of historical examples: eg: other empires. For those active in the E-Patient Movement or Patient, Family, Community Centered  Medical Home Movement or E-Health Movement you have a responsibility to weigh-in on the economic issues in health-care. Please add your wisdom, we need you.   JFH

Not an insurance company, just an empowered consumer.



My report for today:

Helped one more person register his family for an affordable insurance product using Healthcare.gov


Met friend at 4:00 for dinner prior to our club meeting. Turn’s out he is lost in acronyms and asked for help.

Over the course of the next four hours we improved his ability to self-advocate, submitted an application and lessened his anger and fear of OBAMACARE.

My objective was met by my friends eloquent ability to inform his teacher of the many reasons OBAMACARE should have never been named OBAMACARE and his understanding of healthcare as it differed from earlier in the day when he could only think of it as “the monthly premium “or the cost of a subspecialists co-pay”; or “a communist scam”.

We ended the night with one happy conservative family man receiving a quote for his silver policy for a family of three. The monthly premium is $200 less than last years and his services have increased.

As we concluded the evening he asked if I ever thought of inventing a software program that would track all important health information for patients.  He had evidently been responsible for a $4000 co-pay on an $18,000 ER visit for chest-pain. This was mostly due to his inability to articulate a thorough history to the doctors on staff.

I described to him the importance of maintaining a relationship with a primary care physician and then logged on to MyHealthRecord at Duke and MS Health-Vault to demonstrate the rather rough but much better communication I had with my physicians and interoperability of pharmacy and EMR systems. Then I described how these data could be used to empower a person in an emergency with timely and acurate information. His conclusion: Jeesh, I probably would not have needed the expensive work-up if the doctors had access to all these studies!

One more convert.

So little time….

But one more convert.

Tomorrow’s agenda: Meet with ophthalmology practice to organize diabetic eyesight preservation program for non-Medicaid, uninsured folks in NC. So far, I have the cost of a vitrectomy reduced from $12000 at a local hospital to $4800. Not bad for a days work!

Jeff Harris

Not an insurance company, just an empowered consumer.

On Care-Giving

Heck! With health insurance we can afford a cup of coffee!

Heck! With health insurance we can afford a cup of coffee!

Please choose the correct response:

We are all care-givers at some point in our lives.

(Yes) (No)

We will all require care-givers at some point in our lives

(Yes) (No)

It is 3PM on a hot August afternoon in North Carolina. Gathering around my brother Bruce in the spare bedroom of my home are my father, my wife Carol, my brother s children and the occasional visitor.

Bruce is 54- although he stopped smoking fifteen years ago we are now tearfully sharing the last moments of his life. Through his semi-conscious mind, he listens to our conversation.

Leaning over my sweet brother I ask him if he would like some more morphine. He struggles to respond, reaching deep within himself and utters a raspy, lungs filling with fluid “JEFF?”


I respond with yes and again ask him if he needs more pain medication? Looking up he utters the last words I will hear from him “Yes. Please”.

At 8:30 PM, Bruce loses control of his bowels. My father, Carol and I gently roll him on his side to change the bedding. He struggles against us, yet we accomplish the task.  We quickly change the bedding, clean the poop from his butt and –like a newborn baby, turn him over on his side.

A small trickle of blood spills forth from his lips and his eyes begin to dilate. “My God He’s Gone” says my wife. Leaning down close to his face I stare into his eyes, tell him he is safe, he is loved and to “go toward the light”. Bruce takes one final breath in my arms; his body jerks and he is gone.

Collapsing on his body I scream out the agony of loss. Making sounds like a little boy I weep “My brudder, Bruce, Oh God”. My father falls on top of me. The man who fought in the Philippines, and buried his wife just one year earlier begins sobbing. We become a grief sandwich; my dead brother, my father, my wife and I: All piled up on the hospital bed. Finally…it was over.

Many do not receive the blessing of being present during the death of a loved one at home. For most, this episode occurs in a clinical environment; for a variety of reasons I suppose. But my career in medicine had given me sufficient insight to understand how ill-prepared our society is to “heal a person into death”.

Bruce and I had a contract. When he received his diagnosis 18 months previously we discussed –in detail- his wishes, the mechanisms to determine what the best treatment approach is; the statistical probability of survival and the financial cost his family in a variety of scenarios. One might think this is all done for us by our physician, or social workers, or ‘for-Gods-Sake” someone else. Unless of course, he or she has spent the last 34 years working as clinician, administrator and chronic disease program manager across all settings of healthcare. A new perspective emerges for folks with this occupational history. An awareness of true cost, profit margins and unending business opportunities that have gathered so much wealth for “value added” service providers in a free market economy. We also understand that in America, we spend twice as much per-capita on health care of any industrialized nation, have lower health outcomes and can be the only Nation to claim health care cost as the leading cause of bankruptcy.

Not so? Well, in 1996 I was flown down to New York City by my employer, a skilled nursing organization. My job at the time: Evaluate five patients who were permanently on life support and losing their financial resources. My company, under contract with NY Hospitals would move these patients to another State establish residency for the individual and collect the Medicaid reimbursement from the State where we were located. This reimbursement for a person on a ventilator was double the New York Rate.

As I deplaned from our corporate Cessna that day, one of the Senior VPS’ asked “How long do you think that last case you looked at will live Jeff”. You see, buried deep within that – statement was the profit calculation. I remember that night well. Carol and I had just been married. When I arrived home I sobbed in her arms; Fearing for all of us.

What do I know as a caregiver and care recipient who has had diabetes for 47 of 57 years of his life? Well, that if we have any sense of humanity within our value system and we are human: We will both give and receive care before we die.

Our system is not designed to accept death. As a result, where resources are unavailable many Americans are left to care for their dying loved ones with few skills. However, where the administrative processes are burdensome, we should also recognize the beauty and reward of helping a loved one cope with these phases in their life. In actuality I used to send patients home on ventilators having educated the family to care for them. They did just fine and in over ten years, no-one ever lost their life due to a family member’s ignorance or misjudgment. PLEASE: I BEG YOU TO ASK ME ABOUT THE HOSPITAL IN CONTRAST TO THE LAST STATEMENT.

I suggest that we include a social contract to educate our children as to the process of acquiring health-care and the personal commitment required for managing our cost-of-care as our system changes. High school would be a great place to start.

I know that we have choices but many of us in America do not believe we have any power when it comes to the treatment we receive, the cost of the treatment, the alternatives and best practices. If we did, we wouldn’t require case managers, patient advocates, Accountable Care Organizations to assure we are treated well. Heck, the new health reform assumes we are unable to do our own research or select the right provider. This is why these job descriptions exist and corporations are contracted to keep watch on the quality of care we receive.

I submit that this may be true for now. But I also submit a challenge to Americans:  A challenge for all of us to step away from our televisions and disregard sound-bites. A challenge to become self – educated consumers. It is not as complicated as one might think but you need to understand the shell game.

And by the way, the shell-game is not going away.

Turn off your television!

Holly Cow!!

Holly Cow!!

As I listened to the Senate hearings today I was very disappointed to hear our elected officials use your time and money to skew your opinion on the ACA. (ObamaCare). Many of these folks now profess to understand the complexity of integrating hundreds, perhaps thousands of separate insurance products with eligibility determination and e-commerce.

Turn off your TV. There is a great deal of good work going on. Stay informed through your own research. and do not rely on the interpretation of single individuals. Ignorance propagates  more ignorance and the consumers are always the target of distorted truth.











graphic rep of national hie

Provider and patient feedback 10/01/2013: and a diabetic finds his laser treatment.


True story:
Man with diabetic retinopathy
September 30, 2013 No health insurance
October 1, 2013 Accepted by NC Blue Cross for $284 per month
I am ecstatic!
I received a call yesterday: A report from an ophthalmologist friend who I am assisting to develop a diabetes eyesight preservation program: “Jeff, we are so excited; our patient y has insurance! Last year we performed his treatment for free. Now, after January 1st we will be able to charge for his laser surgery.”
“Great!” I said; “imagine how many sight years will be gained, now we just need to find them, get then enrolled and treated!”
By the way, this doctor is a dear friend; one of the guys; he and his partners have never denied service to a patient based on their ability to pay. He is slowing down now at age 67, brought on two new partners that are young, accepting of his philosophy and simply thrilled to be practicing their art. There is enough left to earn what they consider a good living and now expand their practice to those patients who have been afraid to approach the office ask for a favor.
This is the first good news I have written about in two years. I hope to continue with this trend!




Seeing the Invisible: Desperate for dental work, an all-night wait

Seeing the Invisible: Desperate for dental work, an all-night wait | Seeing the invisible | NewsObserver.com


The invisible North Carolinian waits in line for relief of pain

From Raleigh News and Observer Sunday August 25, 2013


I beg all to share this article on our dental care system in. North Carolina. This is only one example of a crumbling infrastructure as the policy makers in Raleigh decide to not accept solutions.


Since election of new state legislature and GOVERNOR MCCRORY

Highest unemployment rate:

  • Decision to end extended unemployment

Lowest teacher pay

  • No pay increase.
  • Yet. Pay to Governor Staff increased to $120K as he states “they need a livable wage”.

One of the most notable Medicaid Primary Care systems in the country with improvement in health quality and reduction in health cost for many years now.

  • Yet the legislature and Gov. decide to not accept sustainable Federal reimbursement for increasing enrollment in Medicaid, making healthcare unavailable to 500,000 people.

Reduction in substance abuse detoxification beds

  • Yet we have some of the highest rates of addiction and alcohol related teenage fatalities in the US.

Stipend for food stamps…..nah

Need so many papers to vote; it is as difficult as my Jewish relatives’ attempts to leave Germany in 1943.

Decision to not create a health exchange leaving a 3 company oligopoly to set insurance rates due to lack of competition.

The people standing in line for dental care in this photo are our neighbors. Can you imagine needing a root canal, being unable to eat, experiencing severe pain every time you had a drink of soda? Then being denied care?

Is this how it was in the 30’s Dad?

 HELP! The new Director of HHS has hired a 24 year-old with no experience in Public Health to be her policy adviser and his salary is $85,000; more than twice the pay of a teacher with a master’s degree.

Oh yeah, we won’t pay salary differential to teachers who achieve graduate level degree in education!




























Seeing the Invisible: Desperate for dental work, an all-night wait | Seeing the invisible | NewsObserver.com.

Hold hands for a moment and a solution will come: Enough social debate on health-care.

Heck! With health insurance we can afford a cup of coffee!

Heck! With health insurance we can afford a cup of coffee!

How we spent our Summer, 2013


Carol Lolley-Harris

On her way to work; my lovely wife Carol was “run off the road” by another hurried North Carolinian. Carol works in the Wake Medical Center Emergency Room. On this day she arrived by ambulance.

Click here for video

Proposed health insurance rates still closely guarded in N.C. – Greensboro – The Business Journal

Can believe NC?

Can you believe NC?

I know there is a rat around here somewhere.

I know there is a rat around here somewhere.

Here is a link to the NC Insurance Commission Oligopoly’s plans to inform its consumers of insurance rates.

Essentially, the rates are filed for 60 + plans to be released by three company’s of which Blue Cross is the only with statewide networks.

Proposed health insurance rates still closely guarded in N.C. – Greensboro – The Business Journal.



The citizens of my state are kept in the dark until Oct. 1st. After 34 years in the healthcare industry; with numerous projects and discussions with payers, providers and patient groups I can assure your readers that the decision to not publish rates on what appears to be 67 different health plans (Garner Cleveland-Record, 8/07/2013) is a proverbial ‘punch in the gut’ to the citizens of our State.

First our legislature refuses to accept the federal contributions for Medicaid Expansion, then decides to not participate in the creation of its own competitive exchange and now we are –like mushrooms; left in the dark with regard to critical information necessary for health planning.

In retirement I am working as a community educator with a focus on health services planning throughout one’s life. Most people in the US do not understand healthcare; the complex relationships between business entities; how these relationships inflate cost, an individual’s rights to receive care in accordance with best practice or the historical cost of services and products absorbed by an individual with a chronic illness such as asthma or diabetes: Let alone how to select an insurance company product by carefully evaluating future needs.

We all have the skill to purchase a car. We review the cost of the car and affordability of the monthly payment, we review Consumer Reports or Edmund online or Kelly Blue Book to ascertain future value, cost of repairs and so on. Then we make a rational decision based on the data. Or, like-me we ignore the data and purchase a car with noted mechanical issues and pray for a better outcome. Regardless of the decision we had the data to start with.

So, in October, the legislatures guaranteed oligopoly will release plan descriptions and member fees, then the consumer will need to evaluate their family health situation and make a best guess.

I plan to assist as many as possible, I do not sell any products but have worked in all three sectors of the industry, managed a disease management program and have had diabetes for 47 years along with other co-morbid complications. As the policies changed I managed to stay ahead of the challenges but it has been a struggle. I have never received accurate individualized information from an insurer, physician, or case manager who was employed by an organization fighting for its piece of the pie. The lack of alignment of value proposition alone has driven me crazy. However, when it came time for an insulin pump in 1984 as managed care took hold in America I received the equipment I needed through advocating for myself.

I predict the million or so individuals who are without insurance in North Carolina will begin receiving targeted sales and marketing information in September followed by a call from someone calling themselves a Patient Advocate. The encounter will be posed to educate the consumers when in reality the consumer will be driven like cattle into the sweet spot for the organization that employs the advocate.

It is a real shame…there are a few folks in North Carolina who can help the general public but they are scarce. To my friends in the trenches of population medicine, I ask you to step up and assist your neighbors.

Jeffrey Harris



Health Insurance Marketplace for Individuals | HealthCare.gov

Heck! With health insurance we can afford a cup of coffee!

Heck! With health insurance we can afford a cup of coffee!

Untangled Health shares revised tools for the uninsured. Enjoy the experience.

Please share with friends seeking information on both individual and corporate healthcare insurance exchange. Hopefully we will all see a more affordable premium: Similar to the rates published recently  in other states such as California.

For my friends in NC…Sorry our elected officials are not willing to evolve so those with incomes below 4 times Federal Poverty Level will not qualify for less costly Medicaid insurance.   

Anyway, click on the link below.

                Revised Federal Health Insurance Marketplace

Patient Care Alert! Don’t accept free self monitoring supplies through telephone solicitation without involving your physician.

IMAG0110Patient Centered Care requires patients and families to assume an active role in their health management.Recently, I have fallen victim to daily calls from “National Diabetes Supply Experts” offering free testing equipment. If I accepted  each offer I would need to change supply brands through requesting a new prescription from my Medical Home. This process happens thousands of times per week without the inclusion of the physician and patient in a discussion regarding the benefit of supply change. Your data, including diagnostic information (for me Diabetes) is being leaked, purchased or stolen. I have now filed a case for data breach through the OCR mechanism.

Your decisions matter: Not just for you, but for the Nation as a whole.

The priorities of Health Reform include improving access to services, medicines and supplies to all who are in need. One special population: Those with chronic illness; require recurrent refills for home monitoring and therapeutic supplies. For example: As a diabetic I require home glucose monitoring supplies and much more. The photo above shows my kitchen table while preparing for a business trip. You will observe that I have an insulin pump, a continuous glucose monitoring instrument, the associated catheters and an impressive array of prescription medications.

The cost of supplies to me personally exceed $5000 per year in addition to my current $800 per month insurance premium. The cost of my supplies to my insurance company also exceed $8,000 per year over the past two decades.

Now! Another purpose EQUALLY IMPORTANT of the Affordable Care Act is to make health care AFFORDABLE!

Because we decided to maintain a multiple payer system we continue to have a dichotomy between public and private funding sources e.g. Medicare and Blue Cross. As a result many entities are competing for your business as a healthcare product consumer.

Where we have free market, we have human entrepreneurial ingenuity. As I have said in the past, folks like me have always managed to figure out a way to maintain our cash flow during times of legislative change. So, lately: through the lens of a patient and former healthcare entrepreneur I have witnessed the following behavior:

Somewhere, somehow a bunch of mail order diabetes supply services have been calling my home. Over the past three weeks, the calls occurred daily from three different telephone numbers. Each call represented a different company and each agent had the same script:

“Hello Mr. Harris; I represent “Acme Diabetes Excellence” we have been chosen by your insurance company to provide you with a new technology for blood sugar monitoring. I need to collect some basic information to fulfill this order and your free supplies will be mailed shortly.”

No agent has been able to inform me of how they obtained my protected health information and not one agent has allowed me to speak with their supervisor. I have filed a HIPAA data breach complaint with the Office of Civil Rights but suspect nothing will happen.

Most insured diabetics today have multiple blood sugar monitors that have been given to them by their physicians, drug stores and other vendors to try the technology and conclude which device has the most appropriate for their life style. The meters are free because the profit is in the resale of test-strips which have retail prices between $10.00 and $50.00 per package of 50. Each b.rand will only work when coupled to the monitor given away through such wonderful corporate generosity!!

What these companies are doing is taking advantage of some database products that have evidently become available. I find this infuriating as the intrusion on my self-care plan which is negotiated between my medical home personnel, my insurance company and myself will serve no purpose other than inflating individual and aggregate healthcare costs. THIS IS A PROBLEM! IT CAN UNDERMINE THE EFFECTIVENESS OF THE ACA AND I AM ASKING FEDERAL CONSUMER PROTECTION AGENCIES TO RESEARCH THE ISSUE.

I support free market economies. However I suggest human behavior arising from free-market opportunity might be the largest determinant of uncontrolled health care cost escalation.

So, as we work toward building a comprehensive, coordinated team approach to chronic disease, let’s not forget the impact of our decisions when we select self-care technologies.

New post on The Healthcare Blog on Healthcare Cost and Business

This is a social issue: One requiring an amendment to our constitution which clarifies what was intended by the preamble’s reference to “Promoting the General Well Fare”.

I have little hope. After 34 years as a healthcare executive, therapist, HIT visionary and above all: Advocate for fair and proper service access to all US Citizens; I doubt I will have my needs met as a patient:

I also doubt I will ever see harmony between payers, providers, patients and the media. It is far too easy to become distracted by the numerous disparities and factors giving rise to our overall US population cost and the rage between stakeholders. The distractions allow all who work in the industry to define a spot for themselves where they are comfortable: Comfortable with regard to salary, comfortable with regard to business processes, comfortable when they create a new service industry within the market under the argument of cost savings and quality improvement; comfortable, comfortable, comfortable. It is far too easy to reinvent ‘value added’ services and industrial segments. No ONE is in charge. No ONE is willing to step-up and claim they are the Great Oz.

I began my career as a paramedic and then received credentials in respiratory therapy, cardio-vascular technology and pulmonary physiology. My work unfolded as I was promoted to department director and then division director in the first five years; as DRG’s were settling in and hospitals began finding new ways to make money in ancillary services. Healthcare –because of its capacity to rename, re-market, leverage known waste into ‘new savings’ and offer new technologies without utilization controls and proof of social value has been very good to me. My upper middle class salary increased every three years and when it became apparent that HMOS would begin purchasing business logic to approve and deny procedures, define lengths of stay and pummel physicians with outcome data I learned enough about each sector to add consulting value on both ends. Because of the dynamic legislation across both commercial and socialized sectors any entrepreneur could make an excellent living as long as he or she was personable and able to rationalize their behavior in terms of improving quality adjusted life-years for the 85 year-old golfing buddy who needs a second CABG.

Then…in 1989 I began a ten-year period where I retreated to offering disease management programs for folks with moderate to end-stage lung disease. We accomplished a great deal of good for many people in the last years (or months) of their lives.

But in the end I found myself arguing for my ashen patients who had lost their oxygen prescriptions when they rolled off of Massachusetts Medicaid because of a $1.00 per hour bump in salary. I found new ways to ‘work the system for payment for their oxygen’. The oxygen they received through a small machine which cost $750.00 retail was billed to payers at $299.00 per month in 1989 dollars. In 1997 I flew to NYC and other areas of the North East to review individuals who were dependent on ventilators in acute care facilities. The call for help came from the hospitals as they accrued huge losses due to the prospective payment on these cases that were depending on their life support. One day as I was stepping off of the company Cessna the senior VP asked to review my list of cases from the day. Taking interest in an 80 year old woman on the list he asked “how long do you think this one will live Jeff?”; “Is the family willing to transfer her and liquidate her assets?” His self-justification for asking the question was a simple knowledge that he owned an excellent group of rehabilitation hospitals. He was not the type of fella to consider the pain associated with separating a grandmother from her grandchildren.

I left this venture to work in the design of web-based continuous care plans for persons with Chronic Disease. However, even separating myself from the ugliness of clinical care that we all see in our lives I found similar behaviors wherever I went. For example: I had an IT start-up CEO fly us out to the 1999 Managed Care Conference. We had just released a very cool integrated transfer management system the previous month. The founder asked me to place a sign in our booth stating MEDICAL LOSS RATIOs 69%!!!! In essence, he asked me to repeat the MLR of the one brand new client that had purchased our new system the previous month. I felt ashamed and refused. (ref. MLR is amount spent on medical care / member fees)

Eventually I found myself in NC as I declared I wanted to learn about policy. I was hired to work with what I envisioned to be a leader in Medicaid community care management and care coordination. The years I spent in the public sector with special programs under Medicaid only revealed the same type of rationalization for ‘stretching the truth’ or creating political and financial pressure for physicians. The eternal mind-set; we know this is the right thing so we need to keep the program alive.

I found NC Medicaid to have a wonderful program. But, as in many situations in the past I felt boxed in to “the –insert corporate name- WAY”. I have found that questions as to data integrity or suggestions to reduce cost by deploying new technology that will remove a necessary contract with a friendly vendor to always be un-welcome. Many healthcare workers are content with status quo; some are not. So I became a consultant.
My last few years were spent listening to boards of directors who shared numerous conflicts of interest shift charity funding between duplicative projects. I thought the ARRA, HITECH and perhaps parts of the PPACA might make work more enjoyable. Unfortunately, I found myself asking an FQHC who had received $1M in stimulus funding to delay their deployment of telemedicine since they had no plan. I said this just as the checks were being written to purchase high resolution flat panels for the clinics and a local vendor was installing a new VLAN. This was my first day on the contract. After fifteen months they never did succeed with getting their VLAN up and running. I was however able to launch their desired remote-psychiatry service for children with ADDH. How…well I conferred with some geek friends, researched the legal security standards; drove to Best-Buy and installed a three clinic encrypted Skype service. My submitted expense report for the work was $250.00. The cost of the ARRA never implemented tele-medicine service across a new VLAN? $144,000

As a diabetic who is now retired after 44 year’s dancing with the disease and receiving SSDI at the age of 56 I feel as though I waited my entire career. My income is $2400 per month, I have some savings, little debt and many fond memories of the days with my patients. My insurance cost through my wife along with the ‘cost sharing’ pieces of my “cost of care”; roughly $1200 per month.

What I see happening is ONE MORE TIME…new products and services. Last week I was told my physician was to charge me an additional $1500 per year through the local university’s Integrative Health Program. The money evidently is to pay for better access and (I am not kidding) an interest in my LIFE GOALS.

The issue of the cost of health care in the USA has nothing to do with Physicians, Hospitals, HMOs, TPAs, Pharma, Therapists, Insurance Companies or any other entity. The problem is far greater than the sum of the parts.

A society has gone askew with its values when it treats “Well Being” and “Well Fare” as a commodity in a free market system. The value of “Well Being” varies for every person, or culture and when intertwined with the largest factor in “Well Being” in early life (Employment) the calculus becomes complicated enough to manipulate and confuse the masses.

Jeffrey Harris (BS, RCVT,RPFT,LRCP) All exams inflated salary beyond reasonable value for just one more Bozo on the Bus.
src=”http://www.untangledhealth.com/wp-content/uploads/2012/07/crop-150×150.jpg” alt=”Blessings” width=”150″ height=”150″ class=”size-thumbnail wp-image-233″ />


Duke Medicine offers to ‘show interest in my life-goals’ for $1500.00 per year!


My medical stuff for a 3 day trip!

My medical stuff for a 3 day trip!

February 2013

Last month my father called and complained of being ‘dumped by his primary care physician of 25 years unless he was able to pay an additional $2000.00 per year for concierge services. He said: “Jeff, Dr. Xxx’s nurse called and said that this new program would assure 30 minute follow-up appointments and 60 minute annual evaluations along with a 24 hour, 7 day per week personal communication with the primary care physicians in the practice. I told dad to pay the fee since he could afford it. With disgust, my 84 year-old father and former career NASA aerospace engineer told his Dr. to stick it where the sun doesn’t shine.

Then; on a personal level: I started visiting the Duke Integrative Primary Care program. They have made wonderful changes to my treatment after uncovering several unknown nutritional and biochemical deficiencies. Unfortunately, they tell me today that they will be pleased to accept my commercial insurance but no Medicaid and no Medicare. They also now require that I pay $1500 per year in addition as a membership to the practice as they are limiting the practice size to 600 patients. The administrative RN tells me that this is the only way I can get the services one would expect from a ‘medical home’ such as appointments of sufficient length to “ADDRESS MY LIFE GOALS”. With a smile, the RN says: “Well, with your background Jeff, you know that it is impossible to do without additional funding”. My response was to illuminate (with colorful words) the purpose and methodology of practice re-design when implementing Medical Homes. I find it hysterical that Duke itself claims to be a leader in their own primary care system in the evolution of Medical Home concepts and adherence to Meaningful Use Criteria. I find it disgusting that their ‘offering’ of this concierge service is really nothing more than what over 3000 physicians have been providing through NC Medicaid’s Community Care of North Carolina contract for a decade. I find it nauseating that we are continuing to squeeze profit from a dwindling consumer base and refusing services which are noted to be ‘best practice’ to the poor. People are people I suppose…and subject to greed.
I am writing this as I leave the Duke Integrative Primary Care clinic today, probably for the last time. These folks diagnosed my metabolic issues and low testosterone: I feel better. If I did not ask for the appointment with my “10 minute visit primary care doctor” she would have never referred me to the clinic. I will now return to her and when I am able to afford it I will return for further investigation and treatment of the many factors that decrease my health related quality of life.

March 2013

Note: I returned to my PCP yesterday March 15th, 2013:

She was angry that I had been placed on testosterone since she had worked me up last year for prostatitis. Had she read the notes in the wonderful e-HR that inter-operates with only duke physicians she would have noted that prostatitis is now ruled out, neurogenic bladder is the new dx and that Dukes own specialty physicians had started testosterone replacement with the intention of having primary care pick up the prescription writing responsibility.

She stated she would not write the prescription.

My next move was to walk her through the notes of the physicians she had referred my case to. I then told her that the Duke Integrative Medical practice would charge me $1500 per year if I needed to return to them for the prescription and that I would leave Duke and her primary care practice if she couldn’t address this with the other doctors on my health team.
My doctor says: “Well why would you leave, what is it that you expect?”
I followed with: “Dr. XXX; I would expect that you would have read the consulting notes prior to entering the exam room so we would not wind up in this tense situation where you are asking me to run all over the locality to describe your directions to my specialists as far as who prescribes what” ”Beyond that, I find your employer ‘Duke Primary Care’ attempting to drive my SSDI money as a private payment to their concierge doctors by not allowing the consulting physician to prescribe medications. In other words, he finds the chronic disease which is treatable with integrative techniques and then refers the patient to the front desk to get them enrolled with the two new primary care physicians in the concierge program.” “Furthermore, not only has this new system of care created a barrier to me getting the medications I need but it has done this by not addressing the educational issues that are clearly needed among their own medical staff.” “Oh yeah, one more thing I realize this is not your fault with the exception that you neglected to read the consult results. I believe this is due to the fact that you carry a case load of 2500 patients and become overwhelmed at times.” “Actually Duke has insulted both you and I. You call me whenever I need you and that is why I choose to be treated by your practice. In my view you have a nice start with your Medical Home right here. But your employer is selling a package wherein they differentiate the offering by noting that the concierge physicians are 1) more available and 2) interested in my ‘life goals’. I realize nothing will happen as a result of this discussion today because it relates to Duke Politics. However, if you think about it we have just touched on: Cost of Care, Quality of Care, Patient Satisfaction, Provider Satisfaction and reputation.”

She nodded, said nothing else; spent ten minutes reading my chart and looked up at me with a sad expression. She apologized for “not getting it right”: I responded with “You did not have enough information, you were not educated as to the changes in program marketing and none of this is your fault.” “I promise you that I will only take medications that are prescribed by you for chronic conditions once I return from the specialty consults. I count on you to interact with my other doctors and resolve conflicts on my medication list; but I need to trust the system of care.”
Dr. XXX of Duke and me are still together, we have agreed to how we will relate in the future and how we will survive in a patient-primary care relationship within the context of the Duke System. I think that what transpired over this last month models patient participation in medical decision making, cost control and providing feedback. I hope that my doctor stays with Duke, it seems their turn-over is quite high. Perhaps they should look at those data!

Dear Brother and Sister Patients,

You will find many physicians not agreeing with me when I state that all should have access to 100% of my health record, care plans and prescriptions. They might further disagree (for legal issues) with owning the responsibility of taking into consideration 100% of available information so may be less supportive of data exchange between electronic medical records. 

Please understand: We, that is you and I paid for a seamless ‘inter-operative healths record through ARRA-HITECH funding. Our purpose in asking for this feature was to make sure we did not fall victim to therapeutic misadventure e.g. a physician prescribing a medication that could interfere with your ‘well-being’. YOU NEED THIS as it is one issue, which we call poly-pharmacy that is responsible for well over 100,000 errors in medical practice per year. 

When your doctor gives you your visit summary which should include a problem list and medication list make sure that it correlates with other doctors in your treating team. You might just save your own life!

Governor “Boss Hog” McCrory announces plan to rekindle indentured servitude in exchange for healthcare services.




Human Motivation: Our legislature no longer needs to play cards close to chest; this is a Power-Grab

To the multitude of people and organizations interested in the cost burden of health-care services on the average Constituent.  Please pay attention as you attempt to change the course of a system rooted in 100 years of free-market philosophy: Where human ‘well-being’ is exchanged as a commodity for common currency. In other words: “nothing personal, this is just business”.

On any given day, at least 50% of North Carolina’s existing Medicaid beneficiaries are working persons without access to affordable health insurance. Many…work more than one job to make ends meet.

This statistic glares in the recent event of Governor McCrory’s decision to give his cabinet a salary increase of 8% (average = $108,000 per year). His logic…”They must have a livable wage”. No other State employees saw such increases.

Ironically, on Wednesday February 27th, 2013 Governor Pat McCrory of North Carolina signed into law legislation which prohibits NC from participating in the Federally Funded expansion to Medicaid. This single act will prevent one half million North Carolinians from becoming eligible for Medicaid Benefits. It appears he judges those without access to healthcare services to already have a livable wage?

So here are some facts:

My wife and I moved here in 2001 to participate in what was quickly becoming known as one of the best low-income chronic disease management programs in the United States: NC Medicaid’s Community Care of North Carolina. Working for Community Care of North Carolina, I participated as a team leader in implementing the first statewide care coordination and patient risk management systems in the US. Today, if you are in NC and on Medicaid’s CCNC program you probably have access to chronic disease management programs that are more organized and successful than ANY commercial service. This truth is illustrated by the externally validated reduction in emergency room reliance and improvements in chronic disease management indicators. The external validation has been provided by nationally recognized actuarial firms and schools of public health. In-fact, in North Carolina, one of only a few National Beacon Communities is a Community Care Network.

I enjoyed being part of this effort. Unfortunately I NOW SCREAM OUT TO MY FRIENDS: GET ME THE HELL OUT OF THIS STATE!

I am an example of many of those people in NC who were counting on Medicaid. One of the 60% who have been or are employed and cannot afford health-insurance: a 56-year-old male who within the last year was disabled from his diabetes; a disease diagnosed at age 10, a history of excellent self-mastery of illness. I received my first SSDI check in November. It will be two years before I qualify for Medicare and the $1200 per month premium simply does not fit a net monthly income of $2400.00. I would like to ask Governor McCrory, John Boehner and others of the same philosophy just what they consider affordable when it comes to healthcare cost as a percentage of annual wage?

Their answer unfortunately is either predicated on ignorance or selfishness. I judge that they are not ignorant in the least; although Governor McCrory of late seems to be believing some very questionable information which I have plenty of data to disprove.

How a boy from New England winds up in North Carolina:

 I came to North Carolina to assist the Community Care Program with the data architecture and clinical decision support data model for their Web-resident care coordination application CMIS. This model was a variant of one I had used previously while at Active Health Management the provider of the Care Engine Decision Support System to Aetna. Aetna purchased Active Health for $465 M in 2002. The system employed by North Carolina used similar data objects identified as Problems, Interventions, Goals and Tasks which were generated by Care Coordinators to create shared Care Plans for all Medicaid recipients who were high-risk and high-cost. Essentially, before most were familiar with the importance of Continuity of Care and Comprehensive Care Management: The Community Care of North Carolina Networks were leading the charge with over 600,000 people enrolled in their CMIS software. I feel blessed to have been a part of their success.

 So where are we eleven years later?

I left CCNC in 2006 to work on several national implementation projects utilizing components of what would become the standards for today’s Electronic Health Record. In 2009 I worked for my wife who was an assistance field coordinator for the Obama Campaign. Spending hour’s daily crunching data we were able to redirect or feet on the street to move over 4000 voters who were necessary to make NC a “Blue State” for the first time in many years. We did not do so will this last elections season.

Since 2009 it was obvious that I would need many of the health reform changes to have a satisfactory fall and winter in my life. The neuropathy accelerating, February 2011 was the last month in my career where I was able to work a full-time schedule.

I never worried about getting my needs met. Believing in my country I did not see how in the world Americans could decide to turn their backs on their brothers and sisters. I am quite naïve and I must admit my failure in ratcheting down a secure financial future with the knowledge that my chronic disease would take me out before the age of 60. I honestly was stupid enough to believe that healthcare would become affordable. I know better now…watching as we behave like toddlers in DC and seeing the disapproving looks on the face of men and women in my community when they speak of those ‘people’ who live on entitlements. Well, I guess they can include me in the group. I hope the next time I kneel to perform CPR on one of them (done this three times in my life); they ask me if I receive any entitlements before I start compression.


North Carolina Sacrificing Twenty Years of Community Medicine Excellence



NORTH CAROLINA! Who will you blame as it all falls apart?

Three days into office our new Governor, Pat McCrory introduced his new executive leadership team. I admire all of them. At the same time Governor McCrory adjusted each the salary for each position on the leadership team upwards by 8%.This occurred at a time when NC State Employees have seen no salary increase in several years. With no plans to alter the basic wage of a North Carolina State Employee, Governor McCrory justified the increase as follows: “Well, they all need a living wage”. The average salary of his staff exceeds $108,000!

As we moved into the New Year one of the first agenda items for the NC legislature was the consideration of how NC will participate in the PPACA program. As my friends in the ‘biz’ know, our health reform law allows each State to expand Medicaid by creating new classes for eligibility. Medicaid is the federally supplemented health insurance program for the disadvantaged. Usually the State receives somewhere in the range of 60%-70% of Medicaid Healthcare Costs from the Feds while making up for the rest through State taxes. The expansion will be covered by 100% by federal dollars and then be reduced to 90% after a few years. In addition, the States are allowed to establish their own competitive market basket for insurance plans called a Health Insurance Exchange or share a joint system with the Feds.

For detail on health-reform I suggest you all start at Wikipedia (http://en.wikipedia.org/wiki/Patient_Protection_and_Affordable_Care_Act).

So far this year our newly elected legislature and governor have worked the press nicely by illustrating how expensive Medicaid is and then describing it as a management failure since many aspects of the system regarding clinical care are shared by several divisions (Public Health, Mental Health and The Division of Medical Assistance). These folks actually believe that partnerships are dysfunctional. I guess I agree with regard to administrative costs but certainly not clinical and regulatory expenses since the majority of the covered individuals have co-morbid physical and behavioral health problems along with social environments falling far short of adequate when it comes to primary and secondary prevention due to critical access and affordability barriers. This is not my judgment just a parroted agreement that I hear from the experts in public health. If you want honest expert data and opinion look at the North Carolina Institute of Medicine Website.

As of this week, a final vote has passed through the legislature to prevent expansion and the creation of a competitive insurance market. Instead, the governor and legislature will consolidate and use an insurance eligibility system titled NC Fast or North Carolina Families Accessing Service and Technology.

I was working for NC when NCFAST was funded. It is far passed its original implementation deadlines and I have heard nothing but complaints from the numerous users I speak to at conferences during the year. By the way, unlike smart business people like our new governor purports to be, the NC teams have built much of their own technology, guaranteeing the job security of the staff at the DHHS Division of Information Resource Management (DIRM). Most of my mentors taught me to keep an eye on the work occurring in large commercial sectors and evaluate their offering prior to deciding to build something on my own. I guess there was nothing out there ?

So…no Medicaid expansion AND no Insurance Exchange!!!!

I moved to NC to learn about policy and community organization. Why? Well, in 2001 this was one of the best environments to nurture my growth…as a citizen and as a person. About 4500 physicians collaborate on best practices, assessment of the overall needs of our population as well as the independent needs of their own geographic region. During my tenure (2002-2006) our teams assembled and implemented a fully operational ‘single sign on’ web-native care coordination portal for Medicaid. When we started it served nine networks and contained 250,000 patients. Today, it contains 14 networks and 2 million individual patient records of which around 200,000 are actively managed by one of the 14 networks. You can see why I wanted to move here (grin).

The time spent here has been wonderful regarding my initial purpose and mission. That said, I have learned that our species is threatened and there is no one or no THING to blame. It appears to be a genetic mutation and it is not recessive. In well over 2000 years we have learned that we are a social species in need of a safe container to live: Supported by a community of others; We have learned that we are responsible not only for our-selves but also for our neighbors and children. We have learned that we struggle with a self-obsessive demon that tends to reinforce the opposite axiom: “Only a society of self-interested, competitive individuals will thrive”. Yet in the end, we are all interdependent unless you have figured out how to bury your own remains.

I moved here because of the cool progressive patient centered care-system being created. I had a blast and observed the success. Eleven years later I am disabled, on SSDI from my disability and living on $2400 per month. I think I deserve it since I worked 34 years and paid my taxes. I have a problem though: My diabetes and other co-morbid conditions cost me $500 per month in cost sharing. My wife’s insurance plan costs an additional $500 per month for me to be added to the membership. I had counted on becoming eligible for an affordable plan through an Exchange as it would include benefits for folks like me. Now, North Carolina has decided to keep me out of their pool. The Affordable Care Act is designed to subsidize folks with decreasing stipends up to 400% of the poverty level. Trust me there are a lot of us in this category. It will cost me a bit to have the legislation as my medical equipment will have a surtax and I will pay additional tax if I want a Cadillac plan that covers removal of tattoos placed on my body sometime thirty years ago in some place that I can’t quite remember (just kidding).

Guess I will leave the blog for the night, please drop by on occasion. I am now documenting how I use the Duke Information Portals to manage my care. This week I taught two physicians on my five member team who are not in the Duke System how to access my data. When we reviewed my clinical notes; Medications, labs and tests a major shift occurred in my plan of care. I now have one less physician and am on a new medication that is improving my quality of life by 40% of so. I will create a separate post for this experience as I expect to add the material to the collective education material arising from the e-Patient movement.



This photo was taken as I prepared for a three-day trip. This is just my medical stuff!


Much fun at the check in gate!

Much fun at the check in gate!