Untangled Health

Consumers Unite To Drive The Changes We Need

Tag: Health Vault

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

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

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

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

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. 

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!

The British Primary Care System and Its Lessons for America | The Health Care Blog

The British Primary Care System and Its Lessons for America | The Health Care Blog.


Great post today on UK system. Makes a nice follow up to my complaints yesterday.

This is my reply to MD as Hell who was noting many issues with attorneys.

YAHOO!!! Yes, a confirmation of what my dear friends from UK have told me for years: And of course if we look at Barbara Starfield’s work for the Maryland Commission on PCMH measures she concluded a need for universal enrollment, a single payer AND these clinical functions. The results, better health outcomes. More visits to GP, fewer to specialty, less cost, increased quality adjusted life years.


Her comments in 2008

At the clinical level

–the critical structural features are Accessibility, mechanisms of Continuity/Information Systems, and Range of Services available in primary care.

–the critical process features are Problem Recognition on the part of practitioners (both for initial problems and for reassessment) and Utilization of primary care services, both over time and for new problems as they arise.


Together, these features achieve the evidence-based FUNCTIONS of primary care: First contact, Person-Focused (not disease focused) care over time, Comprehensiveness, and Coordination.


MD as Hell, my good friend Steve is a board certified ER doc who busts his butt for fairly reasonable life. One Friday evening a well-known malpractice attorney was in a car accident and presented in Steve’s ER with enough trauma to require lots of volume replacement, head tongs etc. Steve told me the next day that it took everything he had to not bend down and tell the attorney that he would save his life if is surrendered 33% of his future income. We both had a good laugh at that. Of course Steve didn’t say that, the guy lived and this was 30 years ago.


So what do we do: Well here is what I am observing:

Physicians 50 and over are retiring all around me.

Physicians 35-50 are wishing they would get paid the amount that they projected for their sub-specialties’ procedure of choice: Stent, joint replacement, IOL etc. The physicians that are 35 to 50 (far too few) that are engaged in PCMH work are pleased with the new outcomes based incentive systems, those who are not are living in wealthy areas as concierge docs. The kids that I have worked with the last two years in FQHC’s actually enjoy what they do and are learning to lead teams.


Me, I am a program manager IT guy who started as a CV technologist so I never got used to huge incomes and have always enjoyed each craft I learned.


As a diabetic for the last 45 years I can honestly say that my feet were infrequently checked until the last few years when EBG training occurred in the primary care setting. Since I have a good buddy who is an ophthalmologist (see my blog on Dr. Jeffrey Taylor at www.untangledhealth.com) I have been closely observed and received the   best laser, scleral buckles and IOLs at an affordable price since he wrote of extensively high co-pays.


I figure I have 15 years left and do not want to throw in the towel but teach folks about the history of medicine, insurance and technology in our nation of addicts so they can make more informed decisions at the voting booth. Another guy, John Harrison on this blog is doing the same thing.


So I am asking you physicians to stay with us, be angry, sacrifice something important as we all need to do for re-engineering and build a new system for the future.


The docs, the nurses, the hospitals, the technicians, the pharmaceutical companies, the manufacturers of large magnets and ionizing radiation collectors have all had a pretty good run. But it is over; we can walk away, stick around and complain with no suggestions or create something that works for everyone.



Jeff Harris

Untangled Health




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!


Put differences aside and respect the gold that all bring to the table

Most of you have read the commentary below regarding my debate on The Health Care Blog with some bright and intelligent folks with experience in the benefits (insurance) sector.

I am posting the last discussion between my friend Nate and I. My response to his commentary is first, then you can see what he had to say after your read about my hysterical week!

Here is the point!  We need to talk among ourselves. We need to realize that each one of us has wisdom and truth. We need to come up with our own questions. We need to derive our own conclusions; we need to accept failure without scapegoating people or institutions. This is the foundation of our society my friends and I fear that we don’t participate anymore. We allow Pundits, Politicians and Industry define who we are and what we want. Please read on…




I wanted to get back to you all week. Unfortunately I had an embarrassing incident wherein I tripped while walking my dog. With both hands occupied I did the traditional face-plant onto the concrete. As my nose touched down a foul crack echoed through the neighborhood. All I could think was ****$$$%%%   that hurt! Second thought, get out of here fast before someone sees your foolishness. I trotted down the hill with Bodi ; blood dripping everywhere; bag of dog poop in one hand and dog leash in other. This all culminated in 12 hours of ER evaluation with a final diagnosis of broken cartilage but all else in-tact. Of course I had the obligatory CT of my head. I even called my primary care doc before I left for the ER stating that all I cared about was whether or not I had any cranial fractures otherwise treatment would not be a concern until it all healed. Knowing I wanted a simple skull series of x-rays; I got the full-house. This of course was due to my Blue Cross.

While in the ER I watched the non-urgent bumped elbows, chronic knee pains and earache’s come and go as three true rescues were attended to by full medical teams and in one case…a Chaplin.  I kept asking myself why it hasn’t gotten any better with all of our efforts at managed care and now: Primary care Medical Homes.

When I managed Pulmonary Rehabilitation Programs I held to strict criteria that the tobacco addicts had to be free from all tobacco products and receive counseling as required. In ten years I discharged two patients early because they elected to smoke in the bathrooms. We had a 10 bed facility and I simply stated to the patients that we had a waiting list and needed commitment: In other words a zero tolerance contract. This was the ONLY time in my clinical work where the corporate administrators of any company allowed me to sacrifice revenue for health-beliefs.

In the early 1980’s ,my profession was blessed with all kinds of cool technologies: New high-resolution cardiac cath lab equipment, electrophysiology and 2 dimensional ultrasound. I had been hired to open a new diagnostic clinic in New Hampshire where we had three competing hospitals within 15 miles of each other. We were fortunate enough to hire the first cardiology group and I was hired from Los Angeles due to my cardiovascular skill set. Here is how we justified each purchase of new diagnostic equipment.

Population count X (prevalence +incidence rate) X Medicare MAC (it was lower than commercial so we hedged our bets)X estimate of cases expressed as a % of diseased population. Once I had the revenue I would simply divide it by the capital cost and incremental cost of operation to establish break-even. In most cases, break-even was less than 12 months. As long as costs were below $1M we did not need a certificate of need. Between 1981 and 1982 I became the instant hero at the hospital with the new revenue centers. The small community-funded hospital eventually sold to Hospital Corporation of America (I am sure you know their history), and I went on with my career chasing revenue center to revenue center as managed care established rules which simply required us to relocate the patient to a slightly lower cost of care facility. I could tell you some great stories from the road back then.

Within five years we had three hospitals with a combined 600 beds caring for 150,000 people: each with competing services including cardiovascular medicine and neurology.

As I sat in the ER the other day I thought of your comment on the era of cost-control in medicine: When we had no insurance and everyone self-insured: This resonated with me as ‘truth’. Of course, back then we were just starting to experiment with open heart surgery. But you nailed it brother. My reality is that with the exception of us folks that traverse the payer-provider line few really understand how the M1 works in healthcare. The escalation in cost through value added services and no requirement for us to have the vaguest idea how to read an EOB.

So my point all this time was that I actually agree with you on many points. For example I have what I call the Harris Index of Diagnostic Inefficiency. It is the ratio of MRI scanners to population where the USA is three times higher than other countries; and the Dartmouth Atlas linear regression of cardiac surgery rates to number of cardiothoracic surgeons per 100,000 persons. This is after correcting for illness burden of course.

One of the missions of my Blog is to bridge the gap between the lay-public and professionals and create parity of knowledge around cost benefit and cost efficiency. Kind of like when we learned that out cars didn’t need the $800 under treatment to prevent rust after paying for it for so many years.

So I want to thank you for putting me back in touch with a need to expose the shell game. Like you, I simply have no short-term solution so want to leave blame out of my discussion other than pointing to a system run-amuck with overpriced services, too many inflationary steps in the value chain and too many people on public subsidy. I will continue to argue for some form of provision of healthcare services for those who do not have the ability to pay. But…due to our conversation and my soul-searching and my trip to the ER and the 33 years of saying to myself “this doesn’t make sense” : I will push for a better mechanism for means-testing and a time limited resource to slow down our social Darwinism …perhaps.

Let’s stay in touch as your perspective is a critical lens that needs to be added to the ‘big picture’.

Take care,


You can reach me on Twitter: @untangledhealth




Nate Ogden says:

November 8, 2011 at 5:02 pm

” I believe that society must reach agreement on how to help those who can’t help themselves.”

Haven’t we tried this and it failed miserably? I don’t see how this can ever work but on paper when we allow those that can’t help themselves to self identify and those seeking assistance are given power of taxation and regualtion over those with the ability to assist.

Is it still help/assistance when its confiscated against the will of those that have it?

“in a free market with no cost control”

The most efficient we ever were and the most effective cost control in the world was when people paid for their own healthcare totally or paid then seeked reimbursement. The lack of cost control is a perception when in fact the implementation of managed care under the guise of cost control increased cost. ACA is a recent example, whats affordable about it? What did manage care manage?

“Medicare/Medicaid landed on the seen far too late in my opinion: Then we passed the ACA hybrid”

Whole lot of failed reform skipped over here.

no need to apologize its going to take some nasty fights and maybe even worse to break through 60 years of lies and misinformation. I strongly agree with the need for an informed public, i just disagree on how we fix it. You appear to gravitate to the educated and polite method of teaching. I prefer to call an idiot an idiot and tell them to pull their head from their ass. Not so much so they change their mind and see the light, most people can’t admit when they are wrong to that level, more so other people see how wrong those people are and stop being influenced by them.

Thank you for the lively debate

A challenge to the Heritage Provider Network: Assess our history,risk an extra step, see what is emerging and take us to a new stage of compassion and success

Would someone clean this mess up? "Oh...that is our responsibility; never mind"

So this will be my last of three posts today on the Heritage Prize:

I have joined the activity not to win $3000000 although I could sure use it. I have joined to create a team. It is called: Change Agents and I created a topic titled Population Characteristics. I have already received a reply from “Sir Guessalot” a wonderful fellow asking me not to infer impossibility. Of course, this is not my intent. When I am critical I am counting on miracles happening through community collaboration. So here is what I want:

Models that extend across population geography, culture, socioeconomic status, living arrangements, insurance coverage, health status and behavioral health. I imagine we need a multivariate adjustable and adaptable framework as opposed to a fixed and constrained formula.

Here is an example: If we could use this man’s data as it emerges (now over 150,000 patients) we would see deeper into the matrix of humanity allowing for further correlation and determination of causation.

So imagine the combined talent of folks like Jamie Heywood, Chem Connector and others from the predictive modeling industry.

I would give my eye teeth to work on such a team.

Take care,