Untangled Health

Consumers Unite To Drive The Changes We Need

Category: Presentations

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

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”

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

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!

Step-up and submit your ideas to the private sector : Healthcare Information Technology Optimizes Hospital Experience

Information Quest has created a $100,000 competition which solicits ideas which will optimize the in-patient experience. So…all of you e-patients, patient advocates; geek-patients; participating patients: We have opportunities to actually influence product design. If you have ideas, your submissions could be the most valuable in the market for the creation of products you actually want to use!


Patient Advocates! New tools to step up and remotely monitor emotional components of chronic disease along with standard physical indicators

As you all know: Disease or Dis…Ease… is comprised of four components to be addressed by patients and their care-giving support groups. These domains include: Disease, Impairment, Disability ad Handicap. For example: A blind diabetic presents as follows:

  1. Disease: Diabetic Retinopathy
  2. Impairment: Vision
  3. Disability: Blindness
  4. Handicap: Cannot read LCD screen on insulin pump.

If all are not considered as part of a treatment plan we tend to place our head in the sand and lose the patient to depression induced suicide while being fixated on BMI and A1C. Well here is something exciting!!!!!


The convergence of psychosocial data (adjustment scales, depression index, mood, pain etc.) with other digitized remote biometric data e.g. interstitial glucose will add great value to examining the correlation of emotional/behavioral patterns and glycemic control for diabetics as well as give insight into correlations in many other diseases.  This is a big deal for me as a diabetic and even bigger as I consider the research we could do. In the 1990s our team introduced patient-family group visits to our ambulatory COPD management program and reduced hospital in-patient days by 70% (N=300). In the virtual world we have a way to accomplish the same objective (Care, Share and Never be alone and afraid).

I have been reviewing various tools for self-management and secure communication for diabetes, heart failure, COPD, Addiction and so on as success in managing these conditions relates to social support and data vigilance. I am also trying to get large pharmacy providers off their feet and please consider adding a remote retinal camera and Apple I Phone to their diabetes management programs as a pilot. In NC I have a group of physicians willing to read the retinal photos if I can get a camera ($10K) and head out into the woods where our indigent are losing vision and functional capacity early in life due to lack of linkage to primary care. Imagine what could be done with bio-psycho-social monitoring. Of course we will need funding for interventions but we can drive off that bridge when we get to it.

So please take a look at this project THE GINGER IO COLLABORATIVE  http://ginger.io/the-platform/




Jeff Harris

Untangled HealthCare LLC

New comment added to Forbes tonight on “Direct Primary Care”


I suppose it’s worth the risk here as it appears many in the healthcare sector are insulted by logic. My colleagues and I have been saying for years that to make this high cost scenario simple for the common voter we simply need to use the “too many hands in the pie” use case. Jiffy lube works well. What would you do if you suddenly realized that the $24.95 you were paying for an oil-change was completely inconstant with your neighbors who worked at the John Deer plant down the road: Their cost; only $14.95, and your mothers cost: Well that’s a new ball game as hers is free.

So now we have Direct Primary Care. When I first started in this business we had Primary Care Gatekeepers, then we had Primary Care Case Management and now of course; the Medical Home. The best we have done is to bonus physicians on process indicators and…finally we are talking about clinical outcomes.

When I first arrived in NC in 2001 I went to work for the evolving Community Care Medicaid population and disease management folks. They “according to their data” have managed to carve significant costs out of the Medicaid budget through a model that includes a pmpm component for the PCP and additional pmpm components for what you might call Accountable Care Organizations who offer case management, poly-pharmacy review and an administrative infrastructure to make an attempt at transparency.

My learning from all of this: Transparency to one is not Transparency to another; so be sure you set your outcomes definitions before agreeing on a P4P model. Still, I like the physician-patient direct notion the best.

Now, here are some considerations which arise from my 30 years in population medicine and 45 years as a diabetic with complications.

Figure out the illness burden component if it is a bone of contention that will be used in the future by practitioners that don’t like statistics.

Create an all-inclusive global capitation rate that includes fee for service, pay for process (EBG) and pay for clinical outcomes which include improved quality adjusted life years. Also consider how to test for and measure non-compliance (see my blog on medication adherence today at www.untangledhealth.com).

For God’s sake get some buy-in from your specialty brothers and sisters and the facilities where you park your patients for procedures and care from time to time.

Let’s use me as a model: 55 year old male executive with diabetes X 45 years, non-smoker, non-drinker but other comorbidities including hepatitis C, arthritis, neuropathy and retinopathy. Kidneys are good but I am on an ACE.

So number of drugs =six; an insulin pump with continuous glucose monitoring due to lack of awareness of hypoglycemia. My co-pays and deductibles alone are $5000 per year and the insurance plan cost in the NC High Risk Pool is around $7000 per year at last glance.

I have lots of ideas about keeping me compliant (again check out the blog above). Step on up my doctor friends it is time you take your power back and re-assign wasted dollars to true health-care not new positions created to help patients “navigate” their way through this haunted house. Cripes, you can have an MA do that in your office if you provide some special training and get rid of all of the insurance business rules. GO FOR IT.

Patient Advocacy Part Two

Picking up where we left off in October please find the second video in our four-part series on patient advocacy. I hope all had a wonderful feast yesterday!


Evolving models to help patients, help themselves

We have recently been assisting with local patient advocacy efforts and are now adding content for education. This presentation is one of four that we are using to address the evolving model for patient advocates. It has audio but you will need to download from my slideshare account to your local computer to listen to my comments.

Jeff Harris