Untangled Health

Consumers Unite To Drive The Changes We Need

Tag: #HealthPrize

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

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

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

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

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

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



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

New post on The Healthcare Blog on Healthcare Cost and Business

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

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

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

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

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

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

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

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

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

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

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

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

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

Jeffrey Harris (BS, RCVT,RPFT,LRCP) All exams inflated salary beyond reasonable value for just one more Bozo on the Bus.
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New Comment On Self-Management Responsibility

A snapshot of my PHR s data-store homepage MS HealthVault

Jeffrey Harris • Sandy, I enjoyed your comment and want to tease out a couple of points:
If best healthcare is measured by vital measures such as infant mortality, number of quality adjusted life years between age 65 and death and social perception we really don’t provide the best healthcare. For existence: I have a brother-in-law who has been hospitalized for syncope and loss of bladder-bowel function in addition to anxiety and right-sided hemiparesis three times in the last eight weeks. Discharges are always premature with an inconclusive diagnosis while all symptoms and signs point to micro vascular injury to his brain. He has fallen at home and been taken to ER a total of six times. The hospitals treating him are two well-known academic medical centers who keep avoiding the commitment of concluding his dx. I argued for IP rehab but Blue Cross denied the admission due to his inability to participate in three hours of therapy each day. At this point he is living at home alone with his son who has significant developmental disability.

What has happened in my opinion is the staffs of each facility see a 375lb man with 100 pack year history of smoking and wash their hands of going the extra mile. I understand this and have been there myself until my ‘higher self’ shook the judgments out of me.

I worked in PM&R for ten years and would have no problem creating a treatment plan that would occupy three hours per day of my brother’s time using the neuro-rehab team. But… here I sit in the great State of North Carolina with three medical schools within 25 miles of my home and I am powerless over people’s judgmental bigotry obscuring their human empathy. Our healthcare system is sick on many levels. Yes we need policy, procedure, payment mechanisms and total inclusion but a thoughtful look at our internal judgments and motivation wouldn’t hurt either.

I like the idea on penalizing people for poor compliance. I also like the idea of rewarding people who exercise good self-management. I have had diabetes type 1 for 45 years, hepatitis c for 30 years and neuropathic pain syndrome for two years which has required I reduce my schedule to part-time. What I can tell you is that I and many others find chronic disease a lot of work and certainly wouldn’t mind a seven hour work day if we agreed to attend the corporate aerobics class for the remaining hour. This may seem as if I am whining but we see it as being given the supports necessary to take care of our human bodies; for without them we have no contribution for the society that constantly complains about the cost of our care.

Thanks for your thoughts, I believe I mirrored what your ideas are but perhaps introduced some thoughts through the consumer’s lens.


Getting Involved In YOUR DATA and HOW IT IS USED













As you know, I am all about client rights to equal, skilled and contemporary care. This includes care to the ‘whole of you’ meaning your body, your mind and emotions and right to work in any field in which you can demonstrate the employers required skill set.

If you know anything about advertising and marketing you are clear on how data are collected on large populations of people who represent the matching demographic for which the product is designed to satiate.

It shouldn’t surprise you then that medicine is no different from any other industry. Data are collected and assessed to find new occurences of unknown illnesses, the success of various treatment regime to reduce symptoms of an illness or cure it all together and Data are used to compare, contrast and show superiority over one’s competition.

For many years now, the good data: Meaning the files that contain a complete set of important things we need to know about you that contain a proof of the data quality are more valuable than just about any possession you can imagine. Because of this value: the organizations that own the data (lets say how bad your seasonal allergies were before you started on a new medicine) have tremendous power and influence. These data have not typically been available to the general public but could be purchased for a price. To stay legal the data are stripped of your personal identifying information so no-one can determine where you live or how much you owe Bank of America.

Recently the Commission on Vital Statistics under the US Department of Health and Human Services has started a web service for both the professional and common public. Great stuff! I applaud the effort as it opens the capacity for us citizens to begin deciphering what the heck all this ruckus is about and even find health care facilities and physicians based on the quality of their service.

As I move on with my life you will see me attempting to educate the public further on these topics as they truly will help when it comes to making wise choices regarding your healthcare. I can not express the magnitude of importance for your learning how to interpret healthcare information as I am willing to stand nude (ugly picture) in front or the Washington monument and point out to the majority of our legislative branch just how ignorant they are when they buy into the last lobbyist discussion on heath-scam LTD over their three martini lunch.

To that end I am sharing a posting that I wrote tonight to the DHHS Healthdata.gov team. Essentially I am pleading for your rights to participate and beyond that shutting another door in my career. I will let you know how it all works out. Know for now that many in Federal Government are working hard to provide you with the transparency into the business of healthcare that you deserve. Depending on the outcome of our election you may only have this access for a very short time. So please read on and feel free to ask questions. The language used is common to folks that work in epidemiology but not others so please don’t skip through the material…ask questions…always ask questions my friends.

To: The Healthdata.gov Team


Subject: data sets cost and availability to common citizens

We have been working on assembling a data model that represents a consumers ‘heath status’ on a   longitudinal basis from birth to death since 1997. Our rudimentary model was patented in 2001 as US   6,282,531 BI: System for managing applied knowledge and workflow in multiple dimensions and   contexts. The patent creators: John Haughton MD. Robert Merenyi PhD, Alexander Sherman and myself   Jeffrey Harris sold the IP to Active Health Management who later sold their company as a bundled   service and product vendor to Aetna in 2004.   The data model described a variety of object classes that could be used to create geographic, resource,   culture, behavioral health and physical medicine based triage and referral guidelines as they emerged as   best practices in human medicine.   The notion was that an ever-changing plan of treatment determined by disease, impairment, disability   and handicap would address both single  disease episodes of care as well as complex co-morbid bio- psycho-social events with indeterminate end-points. A great example are the issues we deal with relating to care transitions today.  

Those of us working on this project had the following characteristics: We were all diagnosed at some   point in our life with a severe life-threatening chronic illness; we were all clinicians with varying degrees   of training (therapist – MD) ; we had a significant understanding of the economic drivers in all forms of   medical therapy including: hospital, skilled nursing, rehabilitation ;  ambulatory care and the processes used to assess illness severity, assemble and deliver treatment using plans of care in each venue.

At the time there were no unifying forces to build applications which would leverage decision support   and community resources to drive the patient routing and monitoring yet today we are falling into   alignment with much gratitude for the Affordable Care Act.

My observations over these 15 years have led me to conclude that the weakest links in our healthcare   system are the mechanisms for funding research; the development of payment models as a failure to include the common public in the determination of definitions for health, wellness, and   what we should expect from our systems of care.

The result is a recurrent, perseverance analysis of the  size of our problem (trillions of dollars) and the ongoing attempt to isolate a scapegoat on which to place our blame.   Amazing for a dysfunctional social system that has been over one hundred years in the making.

Having worked in both public and private sectors, for classical conservatives and classic liberals we are still trapped by our own egos and a system of finance that demands a return on share-holder equity.   I am pleased that our government is unveiling the data for us to use for creative attempts at   understanding the nature of various issues in healthcare as well as meta-analysis of the entire system.

I have a request:  Since I can account for a nurse’s assistant preventing numerous instances of nosocomial infection in my workplace between 1989 and 1997 I can attest to the value including  professionals and lay-people from all walks of life in deriving the solutions and pilot studies that might arise from the sea of   data you have brought the fore-front.

My fear is that those of us who work on the outskirts of the system for a variety of reasons including  misperception of our goals will not have access to the data due to cost barriers. I have witnessed this   many times with at least one of the data-sources you give reference to in your web-marketing.

Another concern is how we –as a society will determine effectiveness and the weight of various   interventions since the lay-public do not possess the ‘non-biased’ academic resources required.   I ask that you consider the following so we can set-forth on a journey of redesigning our healthcare   system:

Derive a general consensus and understanding of health, wellness and quality adjusted life years that  can be understood and adopted by the citizens of the United States.

Make all data affordable to all requesting parties as long as it is stripped of PHI.

If this is not possible,   create a grant mechanism allowing communities and county governments to receive funding to have access to these data and information.

As opposed to the existing regional representatives that US DHHS has who’s job is to create awareness of   the governments success and direction in healthcare. Create a class of personnel that are used for the same function yet are equipped with the skills necessary to explain the data, issues with data reliability, validity and sensitivity to change therefore arousing an interest in the general public in health care systems. Currently, the public relates to healthcare as minor episodes   of sickness or catastrophic orphan diseases. Unless we truly achieve a 12th grade level of critical thinking   we will never have parity or agreement.

Thank you so much for your efforts and service. We will now set forth on determining the ease of use of   the systems you mention. For example: One year ago I attempted to assist a homeless dual eligible   person with Medicare and came to the realization that the Blue Button data set I was extracting did not   have diagnostic codes which I was planning on using to trigger conditions in Health Vault in my effort to   create a permanent PHR for this individual.

I offer this feedback with respect and as an experiment to see if one American Citizen still has an   opportunity to be heard by large government enterprise that invests countless tax revenues to create and market a service for our benefit. In other words, the intent is good but the chasm of understanding is infinite.


Jeffrey Halbstein-Harris

Untangled Healthcare

Assisting communities to monitor and improve healthcare

919 627-5038

Cell 919-779-7368

Office Fax 888 783-6178

(Jeffrey Harris) email: JeffHarris@untangledhealthcare.com

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“Go to the people, live with them, learn from them…. Start with what they know, build with what they have….” Lao Tzu

My brother-in-law explores the underworld of care transition business rules


Much fun at the check in gate!

Here’s for the Tweenies’ that have health insurance with high deductibles and co-pays making what used to be a middle class wage.So, from yesterday’s post: they sent my bro home and discontinued his home therapy since he is now ‘a fall risk’.

Not in acute care so SNF won’t take him. Acute Rehab turned him down due to inability to participate 3 hours per day. One person in household of four people has a job.  Medical expense greater than salary’s: two years out to disability…



Stay with me folks as I report the death of person from iatrogenic (system caused) de-conditioning and a family from financial pressure due to need to work less and care for the patient. My redefinition of Untangled Health is switching direction to be completely focused on consumer market. Somehow continue advocating for those falling through the business policy gaps without aggravating those who have skills to treat the people.

Real Time Hassels with Transition Management

Holy Cow!!!

June 20, 2012


I just received a phone call from my nephew who said “Uncle Jeff…I am at the ER with Dad again; he fell down again and hurt himself so we are getting more X-rays…can you help?

This is a blog so I will make this fast:

My brother-in-law is 55 years old, obese, 75+ pack year history of cigarette use, status post MI, mild obstructive lung disease with recent history of syncope (passing out) and falling to ground. In the last month he has been hospitalized three times (each time through the ER) and now is experiencing his third independent ER visit where he may in-fact be sent home.

I have been advocating for further differential work up and have explained to three physicians at two high class academic facilities that my bro is not safe at home due to fall risk and dependence with activities’ of daily-living. With each event he develops new symptoms and becomes more dependent.

As of two days ago (last ER visit) he has been incontinent of bowel and bladder and loss his anal reflex! He was to follow-up today with a neurologist.Since this referral did not happen when I was around the evaluating physician in the ER did not get the full history which included his  asymmetric swelling of the prostate gland, inability to initiate a urine stream and painful urination:  All of these being consistent for either benign or malignant prostate disease.

So far, I have been unable to get him into a medical rehab for reconditioning and further work up. Perhaps this time we will be successful or perhaps not.

What I am talking about is a problem with coordinating transitions from one medical environment to another.

With health reform Medicare will not pay hospitals if patients are readmitted within a short time of the original hospitalizations.

This is a good thing. Too late I fear for my brother-in-law.

We are in the process of fixing these systems but it will be years before we are steady-state. Of course, if Healthcare (Insurance) Reform is reversed by the Supreme Court it may never happen.


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


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

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

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

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

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

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

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

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

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

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

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

Medication Adherance: Such a simple solution to feel better and spend less money on your healthcare!

I try to make this blog a fun educational experience for both patients and providers while not whining about chronic disease issues. That said, sometimes I get extremely excited when I see our chronic disease self-management models changing through the adoption of new processes and technologies that might actually influence the clinical outcomes of us folks with Diabetes, Asthma, Heart Failure, Hepatitis, HIV, Migraine and so on. One ‘pet-peeve’ I have is that most individuals like family, friends, and employers have no clue regarding the amount of effort that goes into keeping yourself in tune. Well, this week I have come across two services to enhance medication compliance that excite me. Each one either makes my life easier or rewards me for my self-care efforts. These are innovative solutions that give me hope. If I see one more refrigerator magnet in the mail that contains diabetes self-management guidelines I am going to open my own MRI service. See Below:

By the way, here is a photo of my kitchen table before I leave on a three day trip. It contains all of the paraphenalia needed to keep my diabetes under control- “that is except for the willingness that I muster up from somwhere deep inside.”

Much fun at the check in gate!

I recently received a prescription for two medications that are used for controlling asthma. This was a trial only so my physician could determine if I had reactive airways (wheezing from asthma). I only filled the medications once as they did not relieve any symptoms: This was 60 days ago.

One of the major causes for worsening of chronic disease -called ‘exacerbation’, is a lack of compliance from the patient refilling their medications on schedule. In my case this was intentional. But all too often people simply forget or worse yet cannot afford the drugs.

At 1:00 PM today CVS called to see if I needed refills on these medications as they were on their list of medications used for controlling chronic conditions. I cheered the pharmacy technician with all kinds of accolades for providing such an important service. She was extremely grateful for the recognition for playing such an important role in helping people manage their illness.

If you think about it: In a real asthma case this simple act could save a life or at least prevent a trip to the emergency department. If you have systems like this that support you please do not forget to thank the messenger. If you don’t have reminders in place ask your pharmacy, insurance company or provider “why not”?

One company -Health Prize has seized the opportunity to incentivize patients through using a proprietary technology. If you remember the old S&H Green Stamps you will quickly catch on to the business model!!!

See you all soon!