Untangled Health

Consumers Unite To Drive The Changes We Need

Tag: healthcare reform

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

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

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

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

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

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


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

Normal Retina                                                        Severe Diabetic Retinopathy



I am angry.

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

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

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

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

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

Awe Nuts! I am really pissed.

What is at risk if Obamacare is Rescinded

Reconciling data in my six health portals

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

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

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

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

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

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

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

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

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

This event is blamed on a corporation “Vidant Health”

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

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

You see:

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

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

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

Now the hospitals are closing.

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

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

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

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

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

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




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

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

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

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

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

So here are some facts:

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

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

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

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

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

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

 So where are we eleven years later?

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

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

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


Trouble Across the Pond. Once again, no one to blame but everyone. Look at the entire system for your answers.

A good day

Once again my friends, any system which places organizational success in the media, executive bonus, or ridiculous ‘service excellence’ survey results over clear-cut measures of process, and medical outcomes first will lead to suffering. Suffering of patients, families…our identity?
Recently, in Raleigh NC a large hospital system has been cited for Medicare fraud (Wake Medical). As the story unfolds the CEO stated that a single mid-level manager from Patient Services changed physician’s orders to charge Medicare for multiple episodes of care as opposed to observation days only. I find the sacrifice of lower level employees horrific. I also know this to be a common behavior in the US.

These problems are systemic and global. They specifically speak to a decline in the humanity of ‘human services’.

There is a lesson in this video from across the pond.
Pay attention to the proposed Standards and compare to what we have or do not have at home.
Consumers of services (yes us patients):

Please do not accept lip service as transparent publications on safety and quality and cost are promised under the new health-reform act. Scream out for standard reporting, standard methods of measurement and reliable statistics.

Allscripts abandons physicians in North Carolina

I read an article today published in the News and Observer Raleigh NC: “Docs feel a little sting over records” was written by John Murawski on Sunday November 4, 2012! Two days before our presidential election he passively critiques the Obama administration for ‘forcing doctors to purchase electronic health record systems. Little is mentioned regarding the history of the legislation or improvements we will all experience through the adoption of interoperable health records. The most important comment comes later in the article where Mr. Murawski informs the reader that the well-known Allscripts EMR vendor is abandoning a product sold to numerous physicians in our State; forcing them to replace and re-deploy with another vendor. The product they are abandoning is only a few years old and the tragedy of the increased costs and inefficiencies will be felt by our physicians and us patients.


I retired this year after a 32 year career in America’s healthcare system. My work took me through an amazing series of learning experiences as a technologist, therapist and program manager for people suffering with chronic disease and health informatics specialist these last fifteen years. My work in healthcare was stimulated by my experience as a person with diabetes since the age of ten. As a patient I wanted to work in the system which had nurtured me into a place of independence as a young child.

With the advent of prospective payment and HMOs in 1980 I remember borrowing money to purchase glucose monitoring strips from physician friends. These were not covered at the time but the evidence had been published regarding the importance of blood sugar control. Through generous friends I was able to purchase one of the first insulin pumps in 1984. With a salary of $22,000 I would never have been able to select an advanced therapy. The outcome…well after all these years I have had some problems and have just now become  disabled but I had a wonderful, productive career and look forward to many more as a community ‘helper’.

My concern is that articles focusing on the negative experiences of advances in healthcare policy (taken out of context) are easily used to strengthen political and economic arguments to steer the uninformed citizen. I would like to clarify some facts regarding electronic health records for the readers. I am qualified to offer these as I entered this field in 1997 along with a rehabilitation physician to design a community wide record with clinical decision support to offer better care and safety for the elderly.

We patented the web-native technology in 2001, sold the company and I moved to North Carolina to assist the State with the design and deployment of a single system used to coordinate the care for the entire Medicaid population. Through the collaborative efforts of fourteen networks –now known as Community Care, they began using this system in 2002. As patients migrated or changed providers their care managers were able efficiently share care plans, save the State millions of dollars through prevention of duplicative testing, reductions in pharmaceutical expense and hospitalization or emergency room costs. The most important thing to remember about this experiment is the fact that it was collaborative and placed patient safety and quality of care first. The financial achievements were a natural extension of well over 3000 physicians working together to re-engineer the management of healthcare for less fortunate individuals. Today, the Community Care Physicians use a modernized version of the system to evaluate patient and system outcomes. North Carolina should be very proud to have led the way with the use of health information technology and community re-engineering to improve the health of its citizens.

Herein lays the rub. Now that I am out I can make observations and judgments about the industry that can be verified with my-own collection of source data, e-mails, and project-notes. I can attest to the fact that the commercial industry is now flooding the gates with products that were engineered with loose standards if any at all and are quickly revising these products or integrating them now that the source of payment is guaranteed. When my physician friend, the lead architect from Lotus Development and myself worked on the first Care-System health record in 1997 we hoped to make a fortune like any red-blooded American Entrepreneur. The difference is that our primary purpose in the beginning was entirely clinical wherein we were attempting to repair a system that was broken by industrial fragmentation and loss of communication between professional care providers, patients, families, insurance companies and employers. We borrowed family money and at times paid our salaries with our credit cards. When we needed ‘big capital’ we went to the Venture Capital world and sold our knowledge and three years’ work to the highest bidder. In the end, the company was acquired for $2.5M. I received $25K, the founders a few bucks more and the loans were repaid  The acquiring company integrated the knowledge and technology of several small acquisitions and sold their entire operation to a large insurance interest for $465M.  The sale was obviously an internal ‘good buddy deal’ as the valuation was grossly inflated over the projected sales of $40M in product. Anyone caring to research M&A from 2000-2003 will find the transaction. These deals have served to multiply the true cost of healthcare in the USA and the only benefit in my opinion was to the venture capitalists and top-tier management. Everyone has their own definition of success and justification for behavior I suppose… but I wish they would keep it isolated to discretionary purchases of unessential products and services.


I find myself discouraged at the end of my career. I have now worked in both commercial and public sectors and have come to the conclusion that the very nature of the free-market; where each individual acts in his or her self-interest; simply does not fit in medicine. The following two experiences in the insurance sector and a local county health department along the coast of NC summarize it all:


  • From a vice president of a company insuring 20M lives in NYC in 2007 during a closed meeting: 
    •  “We do not use combined quality of care indicators like the Dartmouth Atlas, we care about return on share-holder equity only”.
  • From a public health, county education supervisor in 2012:
    • “I think you are asking me to evaluate my program…this is above my pay-grade”.
  • Heck, I will throw in another from the director of marketing in one of the many electronic health record company’s prior to a presentation to a potential customer.
    • “Tell me what smoke and mirror story I should use, heck I can sell anything” 







The public should know that the legislation mandating electronic health records started with the Bush Administration. In fact…if we trace the health reform language back to the 1940s we will find attempts to adopt universal coverage from the Truman and Nixon administrations. We have never allowed this to occur since we unleashed the natural instinct for self-preservation into our code of ethics regarding how Americans get health treatment in 1910. It is naïve to assume that the IT product manufacturers  will consider the needs of the sick: As a species we simply have not evolved to that point. I have only witnessed compassionate behavior in this business sector two times in my career.

So now, we have good intention: A reform act which provides economic stimulus to adopt technology that improves clinical outcomes reduces cost and increases patient safety. We even developed and continue to revise standards which force mechanisms for data exchange between competitors. Yet, since the industry waited over a decade to solve the problems that would arise from security issues, technical complexity and a complete lack of matched financial incentives we are burdened with the cost of replacing systems purchased by physicians and clinics within the last five years. Ask me about the 6000 clinical records lost in 2009 from a poorly led electronic medical record system implementation when an understaffed Federally Qualified Health Center was abandoned by an unethical vendor.


The article in the News and Observer points to a well-known vendor of physician medical records. Allscripts is a dominant force in our State and they have now abandoned one of their acquired products forcing physicians to replace it. Shame on them…


I hope we can see this as a human problem as opposed to political incompatibility. We are the folks that engineered and enjoy the fruits of the free market.  Along with the fruits come the problems of greed and poor planning to return quick reward to the investors. In the end, we as consumers pay a hefty price yet we do not hold the correct people accountable. Here is a novel idea let’s work together to figure out a solution as the consumers of medical services: Please do not think that the healthcare industry, schools of public health, government or industrial think-tanks will solve this for your children. This is probably the best opportunity for self-examination as a society that will emerge in the next fifty years.

Consumers… step up to the plate and state your needs; also please visit and join the “Society for Participatory Medicine” on the web!


With respect for all, Jeffrey Harris Raleigh, NC.




It is all at stake!

We all have our lives at stake in this battle. Unless we can learn to sacrifice; our children will suffer. You see…I do not believe that the human species has evolved to a point where individuals have the capacity to self-sacrifice; with the exception of extreme examples such as during war-time or in protection of one’s children.
For 32 years I have struggled to bite my lip and lay my tears on the kitchen table as I discussed the in-humanity and utter disregard for patients and their family systems. In many cases, the bitten lip did not provide enough negative reinforcement to keep my thoughts to myself. As many know, in our society the messenger is routinely sacrificed for the preservation of shareholders equity.
Life has delivered me here. Where I no longer worry what others think…I do not want their jobs and am ready to move on with what life I have.
Sleep escapes me some nights. Memories you see fuel my energy to protest the state of shameful dysfunction in American Healthcare. If we lose the progress established in the last three years, we will return. Return to a place I cannot forget.
In 1995 I was a clinical program manager for a ventilator weaning unit. We made our money through operating outside of the restriction of acute in-patient hospital care. In other words, it did not matter how long our patients were in the hospital as we were reimbursed for each day of service.
My job as Program Manager included traveling to hospitals in New York City to evaluate patients in hospitals that could not be weaned from their ventilators. If our facilities were capable of handling the needs of the patient we would transfer them two hundred miles to treat them in our acute rehabilitation hospitals. There was another criterion: We only admitted individuals with sufficient reserve wealth to cover our services.
So I stepped off of our company airplane one summer day in Boston to be greeted by our Senior Vice President. He asked me; “How was the trip Jeff, do you think we could take these ‘cases’”? I said: “The trip was exhausting Mr. XXXXXX, I believe we can take six of the eight we reviewed but don’t think we will be able to wean more than two from their life support.”
As Mr.XXXXXX reviewed the financial assets of each ‘case’ he asked me; “How about this one, how long do you think she will live?”
Thinking of the patient, her family who would not be able to visit and the loss of her personal property that was to be inherited by her grandchildren; I returned home for the evening, placed my head on my wife’s shoulder…and wept.