Amazon is openly DISRUPTING health care as well as quietly under-the-radar

“Three corporate behemoths — Amazon, Berkshire Hathaway and JPMorgan Chase — announced…that they would form an independent health care company for their employees in the United States.
The alliance was a sign of just how frustrated American businesses are with the state of the nation’s health care system and the rapidly spiraling cost of medical treatment. It also caused further turmoil in an industry reeling from attempts by new players to attack a notoriously inefficient, intractable web of doctors, hospitals, insurers and pharmaceutical companies.
It was unclear how extensively the three partners would overhaul their employees’ existing health coverage — whether they would simply help workers find a local doctor, steer employees to online medical advice or use their muscle to negotiate lower prices for drugs and procedures. While the alliance will apply only to their employees, these corporations are so closely watched that whatever successes they have could become models for other businesses.” (A)

“The companies said their project will focus on technology that provides simplified and transparent care. Based on the executives who have been named to top roles at the new company, Jefferies & Co. analyst Brian Tanquilut said there is a good chance it will eventually try to negotiate prices directly with health care providers like hospitals, bypassing companies that act as middlemen. That could reduce costs in the medical and pharmaceutical supply chains.
“The initial plan for the new entity will be on partnering with and/or acquiring various consumer-orientated health care technology capabilities (i.e. a venture capital strategy) and eventually using them to influence and incentivize health care cost-reducing behavior,” he said, basing his speculation on the executives picked to shepherd the new company along.” (B)

“Techno-utopian visions of algorithm-driven health-care apps and artificial medical intelligence robots aside, the most important components of the still-theoretical project are actually deeply rooted in the history of health care, both in the United States and around the world. This history illustrates the potential promise of the new initiative: It might provide cheaper, better care for all Americans while facing fewer political hurdles and requiring fewer jarring changes to the system.
Notably light on details, the announcement offered two specific components beyond its emphasis on technology. (Amazon chief executive Jeffrey P. Bezos also owns The Washington Post.) First, the new company would be “free from profit-making incentives and constraints.” Second, the overall goal would be “improving employee satisfaction and reducing costs.”
This first component is the more newsworthy one, as well as the one most likely to revolutionize American health care. Abandoning the profit motive in health insurance would be a notable break — by three of America’s leading companies no less — from nearly a half-century of corporate and conservative ideology that has maintained that free-market profit incentives are the best means of achieving efficiency and cost reductions in health care (and most other economic spheres).” (C)

“Clearly the cost of care has produced a tipping point. It might be just becoming too much—costs are so onerous and unsustainable that they can’t look the other way,” Gartner analyst Barry Runyon said. “We can’t afford healthcare. Normal middle-class people go into bankruptcy with one bad illness.”
Experts agree that the accelerated attempts to disrupt the industry by slashing costs are noble and innovative. But they disagree as to whether the companies—be it Amazon and friends or CVS and Aetna—can succeed in influencing healthcare pricing.
While acknowledging that costs need to be reined in, healthcare leaders point to larger societal problems that often end up on their front doors and have a ripple effect across the system.
“It’s important to keep in mind that the bulk of healthcare problems—and costs—stem from lifestyle behaviors and social circumstances,” Michael Dowling, CEO of Northwell Health, said in an email responding to questions about the Amazon-JPMorgan-Berkshire venture. “I would like to see some of these companies go into poor neighborhoods and try to figure out how to address health issues stemming from poverty, lack of jobs and all the negative social circumstances that contribute to chronic illness, substance abuse and health disparities in this country. That’s the biggest challenge. ” “ (D)

“Those who’ve been engaged in the struggle to find the true cost of healthcare have been working for years with limited success. Oftentimes, they have difficulty getting data from health plans or medical care providers.
“Resistance to transparency in healthcare remains high,” says Network for Regional Healthcare Improvement CEO Elizabeth Mitchell, who welcomes Amazon, Berkshire and JPMorgan’s new company. “Employers who pay for this care still don’t have insight into the relative value of what they are buying. They are looking for a way to have assurance that they are paying a fair price for a high-quality service.”
The Network for Regional Healthcare Improvement has long said any health reform effort needs to look closely at transparency because data that reveals the total and true cost of care is difficult to find. In a report last year, NRHI said health spending by U.S. commercial insurers can vary by $1,000 or more per year per patient, depending on where enrollees live.
The potential for the Amazon-Berkshire healthcare company to disrupt the way health plans do business is one reason shares of many healthcare companies tumbled Tuesday after the partnership was announced.” (E)

“The U.S. health care industry might be seeing the early signs of major shifts such as employers exerting pricing power to rein in costs; the aggressive use of technology such as drones and databases to predict, diagnose and treat diseases; and, consequently, an upending of the bargaining power of providers such as hospitals, physicians and pharmaceutical companies. All those and more are expected to come from a health care alliance announced last week by three heavyweights – Amazon, Berkshire Hathaway and JPMorgan Chase, led by their respective CEOs, Jeff Bezos, Warren Buffett and Jamie Dimon.
“They are acting as customers of health care on behalf of their employees and they are saying, ‘We finally have to get our act together and do something serious,’” said Robert Field, Wharton lecturer in health care management who is also professor of health management and policy at Drexel University. “[However,] the big question is: Will they develop something that’s scalable and transportable? If not, they will undoubtedly accomplish great things for their employees. But it will pretty much stop at that.”
Field predicted the alliance will use technology to dramatically change the way health care is delivered. “This is going to move us closer to more technologically focused health care, from drones dropping our prescriptions at our door to artificial intelligence algorithms spotting disease trends and large databases helping to diagnose you and treat you,” he said. “We’re going to lose the personal touch in health care, but perhaps we need to be going in this direction. We don’t have the corner bookshop the way we used to, and we don’t have a corner pharmacy the way we used to. Health care is going to go there one way or another.”
Wharton management professor John R. Kimberly said he wasn’t sure if the new company the trio plans to set up would be successful in lowering health care costs. “In theory, it could potentially [lower costs and improve access] for their employees,” he said. “[But] in practice, [those effects are] not so clear, even for their employees.” The three companies have a combined workforce of a million employees.
According to Kimberly, the big question is the likely impact on the larger health care industry. He identified at least two avenues of potential impact. “First is the impact of whatever models/arrangements the troika is able to develop, implement and spread to the larger market. Second is the kinds of second- and third- order effects the troika might have on the industry as a whole.” (F)

“This latest move has engendered robust debate. Proponents liberally term it “disruptive,” seeing a natural diversification opportunity for the company that has aspired to be “earth’s most customer-centric company.” Meanwhile, skeptics highlight Amazon’s lack of expertise in health care, a sector that many deem curiously resistant to the competitive forces that characterize the retail and web services markets in which Amazon has thrived. Given this state of affairs, it is worth thinking about Amazon’s efforts in a conditional manner: If Amazon succeeds in changing health care, how might it do so? (Disclosure: I own a very small number of Amazon shares.)
While Amazon’s collaboration with Berkshire Hathaway and JP Morgan Chase would obviously leverage the purchasing power of three massive employers and could lead to innovative insurance models, it seems that the bigger opportunity would be in improving how care is delivered to patients. At its root, health care is a service that needs to be delivered to a customer. For existing health care companies, the operative words in that mandate have been “health care”; for Amazon, the operative words likely are “service that needs to be delivered to a customer.” To the extent that Amazon’s perspective is correct, it is worth considering the types of experience the company could apply to health care.” (G)

“One viewpoint, published yesterday by Harvard Business School professor Robert Huckman, explored ways Amazon’s strengths might help it become a health care power. You can read Huckman’s essay in full on the Harvard Business Review’s site; here’s a summary of some of his points:
• The company that brought you one-click ordering could streamline health care processes too, bringing its reach and focus on convenience to the marketplace: Its “expertise could be used to improve health care delivery by addressing the administrative hassle and scheduling challenges faced by patients seeking routine services in a one-stop setting,” he wrote.
• Its work on frictionless commerce could greatly reduce overhead in an industry known for massive and complex data entry requirements. Some hospitals, Huckman noted, are already investing real-time patient tracking that could give them useful information about patients.
“These pieces of information, all of which are collected by the simple movement of people and equipment through established workflows, can be helpful in improving operational execution for the complex services provided in many health care settings,” wrote Huckman.
• Amazon already knows a ton about consumer purchasing decisions. Could it turn its analytical expertise to patient information? It might, for example, plumb a “wealth of integrated data that links an individual’s medical record with their overall purchasing patterns, genetic information (particularly if Amazon eventually does blood draws in convenient settings), and activity patterns,” he wrote.” (H)

“With all of its technology and unique advancements, the United States sucks at healthcare. The real problem with Obamacare is that it does not fix the “suck” part or the cost part — it just shifts where the bill goes.
So, a whole bunch of U.S. citizens, myself included, now are paying more and getting less coverage. That is neither any way to get re-elected nor any way to run a country. Typically screwing your constituents does not work well for elections, and that played a much bigger role in the last election than most realize (or want to admit).
I think Jeff Bezos gets this — it’s not rocket science. He likely understands that if the government really is not going to step up (it still is arguing over who pays, not the amount on the bill) then a heavy-hitting corporation must.
Amazon has the reach and capability to reduce healthcare costs massively through better records management; implementation of aggressive artificial intelligence-based diagnoses or diagnosis validation; ability to negotiate better drug prices; scalable AI-based patent monitoring; and policies that could address abuses, such as the overuse of painkillers, more effectively.
Individual benefits would include better and more comprehensive access to medical records; programmatic analysis of those records, triggering proactive medical procedures; more aggressive health monitoring; and far broader access to emerging medical technology and drugs.
Amazon has the capability both to lower healthcare costs and raise performance, so that Americans no longer would be paying the most for healthcare while being outranked in performance by 72 countries whose citizens pay less, often far less.” (I)

“A new report from the financial research firm Leerink, which has been closely covering Amazon’s moves in health care, says Amazon is expanding the team that’s exploring a move into the pharmacy business.
Researchers at Leerink interviewed an anonymous former senior Amazon employee, who described an exploratory team at Amazon that was once 7 to 8 people, and is now 30 to 40.
The goal appears to be to ensure its customers stay loyal and that all their needs, including health and medical, are serviced on
Amazon’s entry into the pharmaceutical business seems inevitable to many in the health sector, particularly in light of the $3 billion market opportunity, and Leerink thinks it’s a matter of “when,” not “if.”
“Ultimately, Amazon is looking to bolster its Prime membership program, which by signing up for a subscription provides customers with benefits including free shipping, expedited delivery, and other perks,” the report states.
“Amazon saw the inclusion of pharmaceutical drugs as a natural add-on to its existing product offerings.”
Amazon CEO Jeff Bezos has eyed the pharmacy business for years, dating back to an investment in the startup in the 1990s. That business was eventually acquired by Walgreens, and later shuttered.
“The specialist indicated that Amazon’s decision to enter pharmacy has been in the works for some time,” the report reads.
As CNBC has reported, Amazon has been busy in the last year meeting with folks across the industry, including generic drug makers, to figure out how it can break into the space.
The consumables team, led by Eric French, initially kicked off the research process. That team also includes the company’s groceries product. In May, the company started interviewing for a pharmacy general manager to lead the team, and it has been looking to recruit health experts for months — most recently, a health privacy lead. Amazon held exploratory talks in November with generic-drug makers like Sandoz and Mylan.” (J)

“While it appears Amazon’s plans to create a healthcare company aren’t fully formed, the use of data and digital tools are two likely priorities moving forward, according a Wall Street Journal report.
The news outlet obtained a document from December that outlined an initial proposal for a joint venture between Amazon, JPMorgan Chase and Berkshire Hathaway that was officially announced by the three companies on Tuesday. Although industry experts speculate the new business would take over health insurance and pharmacy benefits for employees of those companies, one source told the Wall Street Journal that idea is no longer on the table.
But the document does spell out a clear interest in data and new digital health gadgets. Part of the plan includes an initiative to create a healthcare data warehouse. The companies also want to partner with healthcare systems to use technology to care for patients outside of the hospital, along with digital tools that facilitate data sharing.
Those aren’t particularly innovative concepts in the healthcare world. Telemedicine adoption is on the rise and health systems are already investing in digital tools to streamline patient care. But Amazon’s market power, combined with its tech prowess, could be a driving force for more widespread adoption—similar to the way Apple’s foray into medical records is viewed by some as a sea change for better patient access to health data.
Greg Caressi, transformational health senior vice president at Frost & Sullivan, sees this as an initial step that could lead to broader participation in the healthcare market.
“Companies who are financially responsible for their employee’s healthcare and need a healthy and productive workforce to remain competitive, are searching for answers and looking to innovate beyond the current health system approaches,” he said in an email to FierceHealthcare. “This is an example of innovative companies combining to create new models to address health care and health system issues that impact their business. They are disrupting the system to meet broader goals, which will advance change in a slow moving ecosystem.” (K)

“Large employers have the resources to hire human resources professionals and benefits consultants to shop for their health plans. At least theoretically, those people should know more about how to pick a good health insurance plan that will serve the needs of the company’s workers. And the bigger the companies, the more they can pay to hire people really good to do that work, since their salary gets split many times over.
Have employers used these advantages to find huge savings? Not over all. Employer health insurance tends to be more expensive than public insurance, and its growth has traditionally followed the trajectory of other parts of the health industry. Some employers simply select from standard offerings, essentially outsourcing any innovation potential to notoriously risk-averse insurance companies.
But there is also a robust history of employer experimentation. Some employer ideas have paid off — and spread. Others have flopped. Amazon and friends would be building on this tradition.
Arnold Milstein, a professor at Stanford Medical School, spent several years with the benefits consulting firm Mercer developing unconventional benefit products with companies.
There is a segment of them that is willing to take the same risk tolerance that characterizes their core business and move it into the health benefit space,” he said, noting that many employers “are pretty wary, but there is a subset that has been more bold.”
There have been less successful innovations. Workplace “wellness” programs, which provide financial incentives for lifestyle changes, were initially built and bought by employers. But a growing body of evidence suggests they haven’t delivered much in the way of results.
Amazon, Chase and Berkshire Hathaway have said they’re experimenting with new health care models for their workers. If they crack the notoriously hard nut of high health care costs, we can thank the country’s weird and unloved employer health system for their discovery.” (L)

“Last week’s announcement that Amazon, Berkshire Hathaway and JPMorgan Chase will collaborate on a new venture to provide simplified, low-cost, high-quality health and wellness care for their more than 1 million employees caused a sell-off for many healthcare stocks and captured the imagination of pundits.
However, this new company is just the latest in a series of mergers and collaborations that many believe could disrupt healthcare in the United States. And the industry has for years seemed ripe for disruption. In 2017, $2.7 billion was invested in healthcare equity deals to develop tools to remake health and wellness for consumers, providers, hospitals, insurers, post-acute care settings and medical researchers, according to the New York Times.
These new alignments have included organizations like the Cleveland Clinic and Oscar, Humana and Kindred Healthcare, and a consortium of health systems that are forming their own nonprofit drug manufacturer.
Proponents of such initiatives believe that blurring the lines between what traditionally have been distinct sectors (providers, health plans, retail pharmacy and employers) will allow innovative approaches to emerge that will ease the transition from fee-for-service to value-based healthcare.
However, other healthcare leaders caution that many well-known companies have attempted to disrupt the American clinical delivery system and failed, according to another Times article. They also point out that most disruption in other industries occurs with lower-value, lower-cost products, and note that consumers don’t want to settle for low-value healthcare.
Still, that doesn’t mean healthcare organizations should ignore the winds of change. Consider the fact that since 2000, 52% of the companies listed on the Fortune 500 have gone bankrupt, been acquired, or ceased to exist, according to Constellation Research.
Indeed, the same forces that have affected other industries in the United States also apply to hospitals, and yet many hospital executives continue to lead as though nothing has changed. At a time when the core inpatient business for hospitals is declining and technology offers the ability to migrate care away from centralized hospitals, hospital executives must make sure that there is a place for their organization in the new world order of clinical care delivery.
The proposed vertical merger of CVS and Aetna represents a major challenge for all hospitals located in cities where CVS has its 9,700 retail pharmacies and 1,100 walk-in clinics. By combining organizations from different parts of the healthcare industry, the new company can realign incentives to benefit the consumer. If the new CVS can use its pharmacy benefit manager to lower prescription prices and encourage the use of less expensive drugs, the health insurance division could lower premiums so that enrollees could afford to visit their walk-in clinics to access care.
This development poses a challenge to competing hospitals because they have been making up for declines in inpatient reimbursements by raising prices in the outpatient clinic. It is hard to see how community hospitals will be able to compete with the likes of CVS and Amazon when Medicare, Medicaid and commercial health plans are cutting rates for outpatient care…
Hospital leaders must seriously consider how they will respond to competition from the innovative organizations that will emerge from mergers and collaborations. Following the same old playbook will not suffice. Executives must make hard decisions about what services they will no longer offer and how they will convince their communities that they offer value that can be measured in a rapidly changing health and wellness environment.” (M)

“The unanswered questions: There are a lot.
Will this involve new experiments, or rely on ideas — like direct contracting with hospital systems, or reference pricing — that already exist?
Are they just trying to cut out the middlemen? Most companies this large already are self-insured — meaning the companies pay for their employees’ medical costs on their own and hire health insurers to carry out the back-end work.
How will this company be different from the numerous other employer coalitions that try to band together for better deals? Amazon and JPMorgan are already part of the National Business Group on Health, and one of Buffett’s companies, BNSF Railway, is part of the Health Transformation Alliance — which so far hasn’t done a whole lot.
“We’ve seen so many employer coalitions trying to leverage their purchasing power,” Levitt said. “Those tend to go nowhere in really addressing the fundamental health care cost growth.”
What technology is actually involved? Amazon reportedly has interest in distributing prescription drugs. Will JPMorgan want to get in on the fees from managing health savings accounts? How do Buffett’s companies fit in?
Health care is literally a matter of life and death, and therefore is heavily regulated. Any new company looking to make a dent in health care costs will have to navigate a thicket of state and federal rules.
Will this end up like another Kaiser Permanente, a health insurer that uses its own closed system of hospitals and doctors? This is doubtful for now, but Kaiser Permanente started out as a workers’ comp program for shipyard and construction workers.” (N)

“Cigna CEO David Cordani said he’s confident the insurer will get a piece of Amazon, Berkshire Hathaway and J.P. Morgan’s new health initiative to tackle health costs, but investors aren’t convinced.
Cigna shares fell as much as 4 percent in trading Thursday and were recently down more than 2.5 percent for the day and about 10 percent for the week.
On Tuesday, J.P. Morgan and its partners announced plans to form a venture aimed at lowering its employee health costs. Since then, investors have been concerned that Cigna will be squeezed on pricing for its services or lose business. The company currently insures about 20 percent of J.P. Morgan’s employees.
“We’re one of J.P. Morgan’s service partners, so we have ongoing dialogue with J.P. Morgan on a regular basis,” including this week, said Cordani in an interview on CNBC’s “Squawk Box.”
“We do see this as an opportunity, and we’re in the middle of that conversation, as you would expect,” he said.
The three large employers said this week that they are hoping to form a separate entity to handle benefits “free from profitmaking incentives,” in order to lower health costs and improve service for their workers. Cordani pushed back on the profit implications on the company’s earnings conference call.
“We should not view that an industry with medical cost trend (growth) of 5-6-7 percent as sustainable,” said Cordani, while pushing back on the notion that insurer profits drive those increases.
“Our industry is capital intensive … This is not going to get solved with extracting a couple of points out of the (profit) margin,” he said.” (O)

“Given all this, surely the combined efforts of these three behemoths should yield some interesting innovations, right? Actually, don’t hold your breath, responds Harvard health care policy expert Bob Laszewski on his blog.
Why is longtime industry insider Laszewski so skeptical of the companies’ efforts? First and most basically, because this is far, far from the first time big companies have promised to finally bring some sense to America’s crazy health care situation.
“I have seen this movie before. Dozens of times over the last 25 years,” Laszewski writes. “The first time was when the leading employers in the Minneapolis-St. Paul market began the same effort in the early 1990s. That, and any other such initiative I have seen over the decades, went essentially nowhere.”
But it’s not simply that Laszewski is a jaded, been-there-done-that industry veteran. He’s also got specific reasons to be skeptical of Amazon and friends’ efforts. Their approach, he explains, is to use data to give patients and providers more information and reduce the amount of medical care people consume, or, in the lingo of the industry, “utilization.”
It’s an approach experts have been pursuing for years, Laszewski explains in his jargon-heavy post, but it’s yet to yield significant returns.
Why? Because despite the hype (and my father’s endless grumbling about unnecessary tests and scans every time he sees a doctor), the main trouble with American health care isn’t how much we consume. That’s not significantly different from other wealthy countries. The problem is how much we pay for that health care.” (P)

“The moves by these new entrants signal the continuing desire of large companies — many from outside health care — to transform the U.S. health industry, which most view as rife with inefficiencies, unsustainable costs and unhappy customers…
The U.S. health industry is in the midst of a slow but seismic shift fueled by consumerism, a move toward paying for value instead of volume, technological advances, care decentralization and growing interest in wellness…
Employers, consumers and the market in general appear to be losing patience with traditional players, which have largely continued to tread their well-worn paths.
And the more significant question may be: Will any of this result in a less expensive health system? Put another way, when you invest to create a new health model, will the model have less expensive inputs and components or just re-create the existing system and costs?…
Challenges surely lie ahead for these companies’ ambitious projects, whether they are new entrants or legacy healthcare companies building new partnerships. But the industry seems to have reached a tipping point. We are likely to continue to see powerful players taking serious actions to try to fix a system that has so far failed to do much more than tinker around the edges.” (Q)

“Jeff Bezos’ Amazon delivers stuff to your door. Jamie Dimon’s JPMorgan Chase makes money by investing. Warren Buffett’s Berkshire Hathaway sells everything from Dairy Queen dip cones to Helzberg diamonds. They’ve also rattled Washington and the country’s health care industry by declaring they would form an independent health care company for their employees.
But what makes these three titans of American industry and ingenuity think they can do better than the current players to deliver health care efficiently and affordably to more Americans? Don’t we have government to engineer health care? Oh, wait, Obamacare, with its soaring costs, shrinking networks and unkept promises.
The three business leaders have no experience in the complex health care sector. So what? We’ve learned from a decade of wrangling over Obamacare that Washington isn’t proficient at making health care accessible and affordable.
We hope the three executives and their companies deliver something that government doesn’t: innovation that works on time and within budget. Nimble strategy tailored to individual needs. Efficient execution.
Bezos and Friends join an increasingly crowded field of entrepreneurs and execs trying to figure out ways to deliver what government hasn’t or can’t”…. (R)

“The announcement on Tuesday that Amazon, JPMorgan Chase and Berkshire Hathaway would be joining forces to create a health care company moved stock markets and prompted optimistic predictions of major reform in a notoriously complex industry.
But while the three companies bring successful management, technological expertise and substantial capital to the venture, many health industry experts expressed doubts about whether their results would match their ambition.
Here are a few reasons that experts suggest we temper expectations.
It has been tried before
None of these players have expertise in health care
These are really different companies, with different priorities
There is not a clear strategic incentive to sell whatever they learn.” (S)

THE past decade has seen the smartphone become a portal for managing daily life. Consumers use their pocket computers to bank, buy and befriend. Now this array of activities is expanding into an even more vital sphere. Apple has spent three years preparing its devices and software to process medical data, offering products to researchers and clinical-care teams. On January 24th it announced the result. The next big software update for its iPhone will include a feature, Health Records, to allow users to view, manage and share their medical records. Embedded in Apple’s Health app, the new feature will bring together medical data from participating hospitals and clinics, as well as from the iPhone itself, giving millions of Americans direct digital control of their own health information for the first time.
Alphabet, Google’s parent, has just launched a third health-care firm, Cityblock Health, to operate alongside Verily, a subsidiary based in San Francisco, and DeepMind Health, an arm of its London-based artificial-intelligence (AI) firm (a fourth company, Calico, is working to extend human lifespans, but does not provide health-care services). Alphabet already claims to be able to use AI to predict possible deaths of hospitalised patients two days earlier than current methods, for instance, allowing more time for doctors to intervene. Facebook and Microsoft are preparing to add health care to their core businesses of social networking and software.
Until now the tech giants’ foray into health care has not gone much beyond wearable devices to track fitness or the provision of cloud-computing services to incumbent providers. In future they aim to deliver real medical services that directly affect individual patients. All five firms have secretive health-care skunk works, are hiring medical talent and are buying or backing external health-care startups. Undeterred by recent claims that their own products may be harmful to mental health, they want not only to be indispensable in customers’ lives but to prolong them, too….
It is worth remembering that the prospect of technology firms transforming health care has been heralded in the past, only to disappoint. Google started a health-records initiative in 2008, but shut it down by 2011, citing poor adoption. Microsoft made similar efforts with similarly low take-up. Yet ten years on, the centrality of the smartphone, with its potential to give patients access to their data whenever they want and wherever they are, changes the game.
So too does the inexorable logic of the data economy. Data sets that contain information about human health are hugely valuable. At a time when health-care budgets around the world are stretched, payers are desperate for insights that might enable them to cut costs while maintaining quality. The more data the tech firms can handle, the more they will learn about human health, and the better the services they can offer will become.” (T)

(A) Amazon, Berkshire Hathaway and JPMorgan Team Up to Try to Disrupt Health Care by By NICK WINGFIELD, KATIE THOMAS and REED ABELSON,
(B) Can 3 business titans cure the US health care system?, by MARLEY JAY,
(C) Have they stumbled upon the solution to America’s health-care woes?, by Guian McKee,
(D) Disrupted: American healthcare has reached its tipping point, by Alex Kacik and Shelby Livingston,
(E) If Amazon And Buffett Lift Veil On Health Prices, Insurers Are In Trouble, by Bruce Japsen,
(F) Will Amazon, Berkshire Hathaway and JPMorgan Reinvent Health Care?, by Robert Field and Guian McKee,
(G) What Could Amazon’s Approach to Health Care Look Like?, by Robert S. Huckman,
(H) Amazon: How Its Strengths Could Help It in Health Care, by David Marino-Nachison,
(I) Amazon’s Soaring Healthcare Ambition: The Promise and the Problem, by Rob Enderle,
(J) Amazon’s exploratory pharmacy team has ballooned to more than 30 people, says research firm, by Christina Farr and Meg Tirrell,
(K) Report: Amazon’s healthcare plans could include a data warehouse, emphasis on digital tools, by Evan Sweeney,
(L) Employer Health Insurance: Often-Hated, Sometimes Pioneering, and Now on Amazon’s Radar, by Margot Sanger-Katz,
(M) Hospital Impact—Amazon, Berkshire Hathaway and JPMorgan venture a wake-up call for healthcare leaders, by Kent Bottles,
(N) The fog around the new health care mega-venture, by Bob Herman,
(O) Cigna CEO sees Amazon-led employee health initiative as an ‘opportunity’, by Bertha Coombs,
(P) Excited Amazon Will Fix Health Care? Don’t Hold Your Breath, Says Harvard Expert, by Jessica Stillman,
(Q) Is the Amazon health-care venture enough to make a big enough splash?, by KELLY BARNES,
(R) Editorial: Can Bezos, Buffett and Dimon revolutionize American health care?,
(S) Can Amazon and Friends Handle Health Care? There’s Reason for Doubt, by MARGOT SANGER-KATZ and REED ABELSON,
(T) Apple and Amazon’s moves in health signal a coming transformation,

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Health care “disruption” doesn’t have any rules!

Novel strategies often “appear” full blown. Sometimes they appear to be counterintuitive. Often there seem to be conflicting ideas out there. New players enter the competition. There is no continuum within which to place different initiatives.
So DOCTOR is taking a break to try to learn more and perhaps might come back “disruptively”!
Here are some examples I have found in the past few weeks to get myself started.

“What I hear is providing insights into what issues will be top of mind with healthcare leaders in 2018. Thus, here’s a short list of delivery trends to watch for in the coming year:
1. Efficiency will become a top priority. Revenues are flat while expenses continue to rise for most medical providers, so medical groups and health systems must continue to make their practices more efficient…
2. Physician burnout will be a strategic imperative. Addressing physician burnout will become a priority in the boardroom as leaders will demand initiatives to stem this epidemic. Many will add burnout metrics to their dashboards…
3. Competition for convenience will heat up. Patients—especially millennials—will continue to drive the demand for quicker, more accessible options to receive care..
4. Scope-of-practice issues will become more acute. The underutilization of many healthcare professionals―including pharmacists, nurses, physician assistants or behavioral health specialists―will lead to increased demands to expand their ability to treat patients more autonomously…
5. Practices will form more community partnerships. The move to value-based payment systems and the accountability for an attributed population means that healthcare systems will need to work with community partners to address some of the root causes of poor outcomes and resultant higher costs…” (A)

“Medicine currently follows the capitalistic model of other American industries: A fee is paid whenever a service or good is delivered. This incentive-based approach works well in most every industry, but not in health care. Fee-for-service encourages more tests and treatments, some of which are completely unnecessary. More health care does not mean better health care.
Instead of volume, we need to incentivize value by rewarding better health outcomes resulting from efficiently delivered, proactive care that keeps patients healthy.
When providers are incentivized to maintain health rather than respond to illness, they treat patients earlier in low-cost environments, like neighborhood clinics, before health problems become serious and require expensive care in a hospital setting. Those who can deliver more value by keeping patients healthy should be able to share in the savings of the health-care expenditures they have reduced.
Providers who spend more than would normally be expected for a given patient should receive no incentive payments. Furthermore, in this shift to value, there is appropriate fiscal support and incentive for the care that needs to happen in between physician visits (for example, disease education, health coaching and other ongoing care-management work). In this kind of system, the interests of payers, providers and patients become aligned.
Keeping patients healthy and out of the hospital
It can be done. Kaiser Permanente, which serves patients in eight states and the District of Columbia, combines hospitals and outpatient clinics with its own nonprofit insurance plan. Kaiser has a fixed annual amount to care for each member, so there is an inherent incentive to keep patients healthy and out of the hospital, where care is most expensive. Because its structure aligns the interests of payers, providers and patients, Kaiser operates efficiently and they are not alone. In fact, many other health systems, including the Mount Sinai Health System, are creating the same incentive model in partnership with private health plans.
By integrating the mobile and digital technology that is part of our everyday lives, medicine will be able to lower the number of hospital admissions….
Taken one step further, the Hospital at Home concept, which Mount Sinai Health System began in 2014, allows patients to be monitored closely from their own bedrooms and receive daily visits from a doctor or nurse practitioner, as well as home nursing care, lab services and medical equipment in their home, which is far less costly than remaining in the hospital…” (B)

“Oscar Health said its partnership with the Cleveland Clinic to offer individual coverage in Ohio under the Affordable Care Act has greater market share than anticipated in its first year.
The New York-based startup, which has expanded Obamacare offerings this year to more states, said it enrolled more than 11,000 members in its co-branded health plans with the Cleveland Clinic. Executives said the enrollment was higher than expected and accounts for about 15% of the individual health insurance market in the five-county northeast Ohio area. Oscar Health’s total enrollment is up 150% , or more than 250,000, after expanding into several new markets including the Cleveland area.
The enrollment is significant in part because individual health plans need enough customers for their risk pools, paying claims of sick patients and leaving enough to turn a profit and invest in product offerings. Bigger carriers including Anthem, Aetna and UnitedHealth Group scaled back their Obamacare offerings for 2018 after being unable to manage the rising costs of sick patients purchasing coverage.
The Cleveland Clinic-Oscar Health partnership is being watched closely as providers take on more financial risk in forming closer ties with insurance companies. CVS Health and Aetna are expected to offer more co-branded health plans once their deal closes later this year while Blue Cross and Blue Shield plans are also offering an increasing number of plans branded with providers in local markets.
Cleveland Clinic and Oscar describe their partnership as “a true 50/50 profit sharing of premium revenue.” Though early in their first year of operation, executives said one out of three Oscar health plan members have “already chosen a Cleveland Clinic primary care physician through Oscar health’s onboarding platform online.” (C)

“For years, hospital executives have expressed frustration when essential drugs like heart medicines have become scarce, or when prices have skyrocketed because investors manipulated the market.
Now, some of the country’s largest hospital systems are taking an aggressive step to combat the problem: They plan to go into the drug business themselves, in a move that appears to be the first on this scale.
“This is a shot across the bow of the bad guys,” said Dr. Marc Harrison, the chief executive of Intermountain Healthcare, the nonprofit Salt Lake City hospital group that is spearheading the effort. “We are not going to lay down. We are going to go ahead and try and fix it.”
While Intermountain executives would not name the drugs they intend to make, hospitals have long experienced shortages of drugs like morphine or encountered sudden price increases for old, off-patent products like the heart medicine Nitropress. Hospitals have also come under criticism for overcharging for their services, including for some drugs.
Several major hospital systems, including Ascension, a Catholic system that is the nation’s largest nonprofit hospital group, plan to form a new nonprofit company, that will provide a number of generic drugs to the hospitals. The Department of Veterans Affairs is also expressing interest in participating.
In all, about 300 hospitals are now included in the group. Other hospitals are expected to join.
Dr. Harrison said they planned to focus only on certain drugs. “There are individual places where there are problems,” he said. “We are not indicting an entire industry.”
Dr. Kevin A. Schulman, a professor of medicine at the Duke University School of Medicine who has studied the generic drug market and is advising the effort, said: “If they all agree to buy enough to sustain this effort, you will have a huge threat to people that are trying to manipulate the generic drug market. They will want to think twice.”
The idea is to directly challenge the host of industry players who have capitalized on certain markets, buying up monopolies of old, off-patent drugs and then sharply raising prices, stoking public outrage and prompting a series of Congressional hearings and federal investigations. The most notorious example is of Martin Shkreli, the former hedge fund manager who raised the price of a decades-old drug, Daraprim, to $750 a tablet in 2015, from $13.50…”(D)

“The shift toward consumerization in health insurance got rolling with passage of the Affordable Care Act in 2009 and has been gradually gaining speed since then. Now, retail giant CVS’s $69 billion agreement to buy Aetna has put a brick on the accelerator of consumerization in this space.
One driving force behind the CVS-Aetna deal may be the fear that Amazon, the e-commerce juggernaut from Seattle, is plotting a conquest of the pharmacy business. Whatever CVS’s motivations, its entry into the health insurance marketplace will force the industry to become more consumer friendly. That means injecting a huge dose of technology — especially data-analytics technology — along with marketing know-how into a business that has traditionally resisted change and innovation.
CVS will bring Aetna not only a wealth of consumer experience and relationships but also a level of technological savvy that the health insurance industry has never seen. The combined entity will possess massive amounts of data about Aetna’s members. It shouldn’t take long before CVS brings technology to bear that can help Aetna members better manage their prescription medicines, steer them toward CVS’s in-store care clinics, and offer vastly improved tools for managing their care and insurance online.
The deal will leave competing health insurance executives with no choice but to modernize their offerings and provide a user experience that approaches the standards set in the retail and consumer worlds….” (E)

“In that burst of activity, three transactions are of particular note: CVS Health’s (CVS) proposed acquisition of insurance giant Aetna (AET); Humana’s (HUM) intention to take a minority stake in Kindred (KND), a home health and hospice company; and UnitedHealth Group’s (UNH) plan to acquire Colorado-based DaVita’s (DVA) primary and urgent care business.
Interestingly, all of these combinations have a common goal: Keep patients out of high-cost hospitals by providing alternative care settings.
To understand the most recent wave of health care deals and the effect they may have on consumers, it’s important to understand the backdrop, explained Andrea Harris, senior healthcare analyst at Height Securities and a former staffer at the U.S. Department of Health and Human Services. For years, hospitals have been consolidating across the country, and the trend continued with a slew of big regional deals announced in 2017. In many areas, hospitals are now concentrated enough to dictate prices to even the biggest insurance company payers, said Harris
In part to fight back, insurers tried, unsuccessfully, to undergo their own wave of consolidation back in 2016. That’s when mega-insurers Aetna and Humana and Cigna (CI) and Anthem (ANTM) proposed merging, but both deals were blocked by the Department of Justice.
Now the trend has turned toward integrating other types of health care providers and systems in an effort to provide relief from high-cost hospital care, Harris explained. These deals are less likely to face regulatory scrutiny because insurers are expanding their businesses into areas that cause little overlap in services.
The most dramatic example is the $69 billion CVS-Aetna transaction. The hope is the merged companies would provide a willing group of patients to use CVS’ local clinics and disease management services to avoid hospital visits. By the same token, Humana wants a piece of Kindred so it can provide home health services to customers who might otherwise go to the hospital. And UnitedHealth’s alliance with DaVita will add 300 clinics in six states to UnitedHealth’s network of urgent care centers….” (F)

The renovation and expansion of Lucile Packard Children’s Hospital Stanford has been in the works for more than a decade, and this month it moved patients into the new facility for the first time.
The goal of the redesign was to create a facility with patients—and caregivers—in mind, said CMO Dennis Lund, M.D., the hospital’s chief medical officer, in an interview with FierceHealthcare. The hospital has gardens for patients and families alongside balconies and quiet spaces for clinical workers to take a breather.
“That’s especially important,” Lund said. “We can’t have successful patient care if we don’t have happy and satisfied staff.”
When the hospital first opened in 1991, it was designed to serve as a space where children could recover from care, not necessarily as a destination for pediatric care, Lund said. The original facility did not offer imaging services or have any operating rooms, so patients were sent to the adjacent Stanford University Medical Center.
As Lucile Packard began to expand its portfolio, adding complex procedures like transplantation and advanced cancer care, the need for a larger and more advanced space become evident. The new hospital is 521,000 square feet, more than double the previous children’s and obstetrics facility, and has added 149 beds for a total of 361 on the Palo Alto campus.
Alongside spaces designed to ease the stress of the care experience, Lucile Packard has expanded and modernized its imaging and treatment centers. Some elements, like new surgical suites and a neuro-interventional lab, are still under construction and set to open next year, the hospital recently announced.
Lund said the new suites will streamline the care process for certain procedures. Having adjoining spaces for different steps along the care journey will make the process faster and requires less anesthesia for the children, he said.
The investment in imaging includes a new positron emission tomography (PET) and MRI machine. The equipment allows clinicians to better craft care plans to a patient’s needs and can allow them to better monitor the spread of disease. It’s the only PET/MRI dedicated to pediatric care in the northern part of California, the hospital said….” (G)

“Dr. Mitchell H. Katz, the new president of NYC Health & Hospitals, is the system’s third leader in four years. Credit NYC Health & Hospitals
The incoming president of NYC Health & Hospitals wants to turn the nation’s largest public health care network into an agency that focuses less on hospitalized care and more on primary care, similar to initiatives carried out nationwide.
The new president, Dr. Mitchell H. Katz, who begins his job on Monday, also said he would expand the use of eConsult, an electronic health management system to streamline care and reduce wait times for specialty appointments, evaluate staff allocation and consider decreasing administrative services such as “unnecessary consultant expenses” to increase savings and revenue.
“I’m all about trying to strengthen public hospitals,” Dr. Katz, the former director of the Los Angeles County Health Agency, said in a recent phone interview. “Public hospitals are incredibly precious. If you don’t look out for them, they’ll disappear.”
Health & Hospitals, a sprawling system of 11 hospitals, five nursing facilities and more than 70 community-based health care centers and extension clinics, faces many challenges: shrinking state and federal funds, a decline in patient population, a large uninsured and underinsured patient population and a funding gap that is expected to balloon to $1.8 billion by the 2020 fiscal year.
In fact, Mayor Bill de Blasio’s administration warned in a report two years ago that the system was “on the edge of a financial cliff” and proposed restructuring and increased city subsidies.
“This is a deficit operation,” said Stanley Brezenoff, the system’s former interim chief executive. “You’re finding ways to close gaps.”
But more needs to be done to “reinvent and remodel the delivery system of Health & Hospitals,” Mr. Brezenoff said. “We have a long way to go.”” (H

“New Jersey is now home to two mega health care systems, which account for nearly half of all acute care hospitals in the state.
But declaring one the biggest in the state is difficult.
Hackensack Meridian Health said it was in the top spot after officially announcing JFK Health has joined the system last Wednesday.
But it is difficult to determine what numbers back that claim up.
HMH, with JFK joining its network, will have a total of 16 hospitals, 4,520 beds and employs nearly 33,000, including 6,500 staff physicians.
RWJBarnabas Health, which was previously touted as the largest system in the state, also has a total of 16 hospitals, 5,066 beds, 33,000 employees, plus 9,000 physicians.
HMH now has a total of 160 locations of all kinds in New Jersey. RWJBarnabas said it has 242 licensed patient care locations.
Both are claiming annual revenues at or near $5.5 billion…” (I)

“The City Council is attempting to recuperate millions of dollars from tax-exempt property owned by the Hackensack University Medical Center.
The city has filed an omitted assessment appeal for the non-profit hospital and its properties. By filing the appeal, the city wants to prompt negotiations with Hackensack Meridian Health, which owns the city hospital. City officials want to have the company pay some of the estimated $19 million in tax dollars it would owe the city if its land was not exempt from property taxes.
“There’s a lot of pressure on these hospitals at this time to make some payment of taxes to the host communities,” said Art Carlson, the city’s tax assessor. “We realize that the hospital is a great asset to the city, but that doesn’t preclude it from some kind of payments in lieu of taxes being assessed.”
Mayor John Labrosse declined to comment on the city’s appeal, citing his employment as a safety specialist at the hospital. Nancy Radwin, a Hackensack Meridian Health spokeswoman, declined to comment.
The appeal comes in the wake of a landmark tax court decision against the Morristown Medical Center in 2015. In a years-long case, Morristown council sought payments from tax appeals it filed against the hospital as far back as 2006. The hospital’s designation as a tax-exempt, charitable institution had shielded it from paying taxes on the properties it owned in town.
Ultimately, Judge Vito Bianco ruled that the medical center ran more like a for-profit corporation than a non-profit, charitable institution.
In a 2016 settlement, the hospital agreed to pay Morristown $15.5 million for 10 years of taxes and interest. The hospital also agreed to pay additional taxes for 10 years on spaces leased to restaurants, shops and private doctors. (J)

“Fairview Health Services CEO James Hereford called Epic Systems Corp. an “impediment to innovation” and said there is an opportunity for health care executives to exert more influence over the Wisconsin-based electronic-medical-records giant.
Epic, a privately held company with about $2.5 billion in annual revenue, is a dominant player in the EMR business and counts most major Twin Cities health systems among its clients. (Outside the metro area, Mayo Clinic is spending more than $1 billion to migrate all its medical records onto Epic’s platform.)
“I will submit that one of the biggest impediments to innovation in health care is Epic, because the way that Epic thinks about their [intellectual property] and the IP of others that develop on that platform,” Hereford said at a panel discussion hosted by the Business Journal last week. “There are literally billions of dollars in the Silicon Valley chasing innovation in health care. And Yet Epic has architected an organization that has its belief that all good ideas are from Madison, Wisconsin. And on the off chance that one of us think of a good idea, it’s still owned by Madison, Wisconsin.”
Epic is headquartered in Verona, which is about 10 miles from Madison.
Hereford spoke on a panel made up of CEOs from Twin Cities health care organizations such as HealthPartners Inc., Medica and Summit Orthopedics. He said health care executives collectively could do more to encourage Epic to change its approach.
“There is an opportunity for us to go to Epic and say, ‘Look, you have to open up this platform,’ ” he said. “It’s for our benefit in terms of having an innovative platform where all these bright, amazing entrepreneurs can actually have access to what is essentially 80 percent of the U.S. population that is cared for within an Epic environment. I would love for us to get together to see how we march on Madison.”
Critics have long argued that Epic takes an overly closed-off approach to its software, hindering the sharing of data to outside organizations and patients, as well as between health care providers…” (K)

“Amazon is looking to hire an expert in a set of health privacy regulations known as HIPAA, according to a new job listing.
The company is looking for a professional who can “own and operate” the security and compliance aspects of a new initiative. The person will also ensure that it meets HIPAA business associate agreement requirements, meaning Amazon intends to work with outside partners that manage personal health information.
It is also hoping the new hire will provide a consultative resource for all health-care regulatory issues.
Amazon is the latest technology company, after Apple and Alphabet, to make moves in health care. As CNBC reported in spring 2017, the company strategized how it could carve out a slice of the multibillion-dollar pharmacy market. It also has a health-care team at in Seattle, known by many names including “1492.”
One more immediate reason that Amazon might be looking for a health privacy expert is to augment its efforts to bring its Alexa voice assistant to health care.
The technology is not yet HIPAA compliant, which means developers aren’t able to record patients’ lab results or other types of health information in a clinical setting.
Amazon Web Services’ health lead acknowledged the gap in September at an event to promote Alexa in hospitals. “While Alexa and Lex (the technology powering Alexa) are not HIPAA-eligible, this (challenge) has provided us an opportunity to envision what is possible,” she said.
In the summer, Amazon hired Missy Krasner, herself an expert in health policy, who formerly ran Box’s health care initiatives.” (L)

“If you’ve ever struggled to access your medical information, like a lab test or immunization, Apple is trying to make your life easier.
On Wednesday, the company is releasing the test version of a new product that lets users download their health records, store them safely and show them to a doctor, caregiver or friend.
“We view the future as consumers owning their own health data,” Apple Chief Operating Officer Jeff Williams said in an interview with CNBC.
It all works when a user opens the iPhone’s health app, navigates to the health record section, and, on the new tool, adds a health provider. From there, the user taps to connect to Apple’s software system and data start streaming into the service. Patients will get notified via an alert if new information becomes available.
In June, CNBC first reported on Apple’s plans, including early discussions with top U.S. hospitals. The company confirmed that it has contracts with about a dozen hospitals across the country, including Cedars-Sinai, Johns Hopkins Medicine, Penn Medicine and the University of California, San Diego.
The medical information available will include allergies, conditions, immunizations, lab results, medications, procedures and vitals. The information is encrypted and protected through a user’s iPhone passcode.”…(M)

“Google CEO Sundar Pichai believes artificial intelligence could have “more profound” implications for humanity than electricity or fire, according to recent comments.
Pichai also warned that the development of artificial intelligence could pose as much risk as that of fire if its potential is not harnessed correctly.
“AI is one of the most important things humanity is working on,” Pichai said in an interview with MSNBC and Recode, set to air on Friday, January 26. “It’s more profound than, I don’t know, electricity or fire.”
Pichai went on to warn of the potential dangers associated with developing advanced AI, saying that developers need to learn to harness its benefits in the same way humanity did with fire.
“My point is AI is really important, but we have to be concerned about it,” Pichai said. “It’s fair to be worried about it—I wouldn’t say we’re just being optimistic about it— we want to be thoughtful about it. AI holds the potential for some of the biggest advances we’re going to see.
“Whenever I see the news of a young person dying of cancer, you realize AI is going to play a role in solving that in the future. So I think we owe it to make progress too.”” (N)

“Reducing diagnostic errors is a crucial component of improving care quality, but current methods of monitoring such mistakes may be time consuming. Now, researchers at Johns Hopkins have developed a strategy that uses big data to speed up the process.
David Newman-Toker, M.D., director of the Center for Diagnostic Excellence at Johns Hopkins’ Armstrong Institute for Patient Safety and Quality, and his team developed a new approach called SPADE (Symptom-Disease Pair Analysis of Diagnostic Error) to allow providers to harness databases instead of having staff members comb medical records for more information, according to a study published in BMJ Quality & Safety.
SPADE uses statistical analyses to find and flag patterns that can predict diagnostic errors. It mines available databases for common symptoms that lead patients to visit a doctor and then compares those data with diseases that are often misdiagnosed.
For example, SPADE would illustrate how frequently patients who visit a provider with dizziness are sent home because doctors believe the condition is minor, when they had actually suffered a stroke, Newman-Toker said in an announcement. Having these data available would improve outcomes and could refine quality measures to better reflect patients’ concerns.
“Being able to do that using big data is an important innovation for diagnostic quality and safety,” he said.
Diagnostic errors are an industry-wide issue. A recent Mayo Clinic study suggested that more than 20% of patients are misdiagnosed by their primary care doctors. Physicians can mitigate the risk by seeking out a second opinion or taking a “time out” prior to surgery to ensure the correct patient is on the operating table.
SPADE’s approach is likely to be most effective with acute or subacute conditions for which a misdiagnosis could have serious consequences: hospitalization, disability or death within six months. Newman-Toker said it would likely be effective for the “big three” conditions that lead to death or disability after a diagnostic error: infections, cancer or vascular events.” (O)

Consolidation is one of the most important trends shaping the healthcare industry today, but hospital and health system leaders rarely approach these ambitious actions with a clear sense of what makes an effective deal. Though partnerships, affiliations and joint ventures have become increasingly prevalent, as well as the acquisition of ambulatory service centers and other outpatient facilities, this article will focus on the mechanics of hospital acquisition.”
As president and CEO of Northwell Health, I have seen our health system expand to 23 hospitals. From my experience, I can say there are four essential factors to consider before pursuing a hospital acquisition.
Is the mission of the hospital you are in discussions with consistent with yours?
Would the acquisition add value to your organization?
What is the relative health of the hospital you are targeting? That encompasses not only financial health, but its reputation for clinical quality, its standing in the community, and the political dynamics of the hospital’s governing board and leadership team. Understanding a hospital from a holistic standpoint requires a full diagnostic analysis.
Does the deal help you competitively? And what are the repercussions if one of your competitors acquires the hospital instead?
Three red flags
There are three red flags we always examine when looking to acquire a hospital.
Lack of transparency. If leaders are not fully transparent with you, they are trying to hide something.
Micromanagement by the governing board. If the board doesn’t allow its management team to oversee day-to-day operations without interference, you could have major problems. Ask yourself if you can change that culture, and if so, how difficult would it be? How can you make a board understand its responsibility to hold management accountable but not insert itself in day-to-day management?
Long-term contracts with physicians and administrators. If contracts with clinical and administrative leaders are long and unbreakable, you could have trouble making changes and recruiting a new team if problems arise.
If you go back 10 years and look at the C-suites of hospitals Northwell has acquired, few of the same leaders are around today. Sometimes you need to make leadership changes quickly because the incumbents may be poisonous to the transition process. Other times, we have found leaders of newly acquired facilities to be very adaptable and open to change. The same standards must also be applied to physician leadership…
Consolidation is an essential and beneficial move if you want to provide broad-based, holistic, coordinated care. If your main priority is improving patient outcomes, the advantages of consolidation outweigh its disadvantages. However, organizations that simply collect hospitals without properly integrating them or coordinating care are destined for failure. There are many health systems that are simply a collection of points on a map — freestanding silos independent of each other. The concept behind effective acquisition should be preventing duplication and enhancing efficiency, because if your only aim is to make yourself look big, employees and patients will be the ones to suffer.” (P)

Sanford Health is expanding its presence in international health care by extending services to seven countries. This year, Sanford Health will enter New Zealand, Ireland, Vietnam, Costa Rica and South Africa and increase its presence in China and Ghana. This expansion follows last year’s acquisition of a minority stake in ISAR Klinikum, a hospital leader in stem cell therapies, located in Munich, Germany.
Sanford Health’s international health care arm, Sanford World Clinic, will now be in nine countries with more than 30 locations. Supported by philanthropy and launched in 2007, the initiative is designed to foster partnership with health care leaders in the development of sustainable services around the world.
“With these partnerships, we are creating unique opportunities for shared learning,” said Kelby Krabbenhoft, president and CEO of Sanford Health. “This is not something we are pursuing for financial gain, but we believe this type of collaboration will help further our mission of health and healing.”
Each partnership is unique in terms of scope of service and type of agreement. The focus of the collaborations range from primary and pediatric care to research and health system operations.
“We want to go where we can be impactful and create partnerships that will stand the test of time,” said Dan Blue, M.D., executive vice president of Sanford World Clinic. “We have outstanding partners in each of these countries who share a common goal – to advance health care around the world.”… (Q)

“When most hospitals close, it’s plain to see. Equipment and fixtures are hauled out and carted away. Doctors and nurses leave and buildings are shuttered, maybe demolished.
But another fate befalling U.S. hospitals is almost invisible. Across the country, conglomerates that control an increasing share of the market are changing their business models, consolidating services in one regional “hub” hospital and cutting them from others.
In recent years, hospitals across the country have seen their entire inpatient departments closed — no patients staying the night, no nursery, no place for the sickest of the sick to recover. These facilities become, in essence, outpatient clinics.
Hospital executives see these cuts as sound business decisions, and say they are the inevitable consequence of changes in how people are using medical services. But to patients and local leaders who joined forces with these larger health networks just years ago, they feel more like broken promises: Not only are they losing convenient access to care, their local hospitals are also getting drained of revenue and jobs that sustain their communities.
“It’s not even just betrayal. It’s disgust, frankly,” said Mariah Lynne, a resident of Albert Lea, Minn., where Mayo Clinic is removing most inpatient care and the birthing unit from one of its hospitals. “Never would I have expected a brand of this caliber to be so callous.”
In 2015, the most recent year of data, these service reductions accounted for nearly half of the hospital closures recorded around the country, according to the Medicare Payment Advisory Commission. (By MedPac’s definition, the loss of inpatient wards is equivalent to closure.) These data do not capture more discreet closures of surgical and maternity units that are also happening at local hospitals.
And the trend doesn’t just affect nearby residents. It represents a slow-moving but seismic shift in the idea of the community hospital — the place down the street where you could go at any hour, and for any need. Does the need for that hospital still exist, or is it a nostalgic holdover? And if it is still needed, is it economically viable?”…(R)

(A) Hospital Impact―Ear to the ground: 5 healthcare delivery trends to watch in 2018, by Jerry Penso,
(B) The real reason health care is bankrupting America, by Kenneth L. Davis,
(C) Oscar Health Grabs Share With Cleveland Clinic Branded Obamacare Plan, by Bruce Japsen,
(D) Fed Up With Drug Companies, Hospitals Decide to Start Their Own, by REED ABELSON and KATIE THOMAS,
(E) Innovative health insurers must learn to think like Amazon, by MARK NATHAN,
(F) What health care companies are doing for their health, by WALECIA KONRAD,
(G) A look inside Lucile Packard’s new 521K-square-foot ‘patient-centered’ hospital, by Paige Minemyer,
(H) City’s New Public Hospitals Chief Will Focus on Primary Care, by JAN RANSOM,
(I) HMH and RWJBH: 2 big systems, but which is bigger?, by Anjalee Khemlani,
(J) Hackensack University Medical Center’s tax exemption appealed by City Council, by Rodrigo Torrejon,
(K) Fairview CEO says Epic an ‘impediment’ to innovation, calls for ‘march on Madison’, by Katharine Grayson,
(L) Amazon is hiring a health privacy expert for ‘new initiative’, by Christina Farr,
(M) Apple will let you keep your medical records on your iPhone or Apple Watch, by Christina Farr,
(O) Johns Hopkins researchers use big data analytics to target diagnostic errors, improve quality, by Paige Minemyer,
(P) Michael Dowling: The prizes and pitfalls of hospital acquisitions, by Michael J. Dowling,
(Q) Sanford Health increases global presence with expansion in seven countries,
(R) Paying more and getting less: As hospital chains grow, local services shrink, CASEY ROSS,

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Opioid commission member: Our work is a ‘sham’

“The Trump administration has extended the opioid public health emergency issued by President Trump, days before that declaration was set to expire.
In October, President Trump announced in the White House’s East Room that he was declaring the opioid epidemic a national public health emergency. The move was without precedent, as such declarations had in the past been reserved for natural disasters and the outbreak of infectious diseases.
But the emergency orders only last for 90 days, so it would have expired Tuesday. On Friday, Health and Human Services (HHS) acting Secretary Eric Hargan signed an extension for another 90 days, effective Wednesday….
The declaration didn’t free up millions of dollars or include a request to Congress for more money. In 2016, Congress approved $1 billion over two years to combat the opioid epidemic. Advocates and Democrats say more is needed to make the public health emergency effective.
An HHS spokesperson said in December that the president wasn’t sending a formal request to Congress for the opioid emergency funding, but expected lawmakers to commit the “necessary resources” to combat the crisis “now and into the future.” (A)

“In New Hampshire, which President Trump has called a “drug-infested den,” the opioid crisis is almost a statewide obsession…
Researchers at Dartmouth College in Hanover, N.H., have been studying the issue to try to understand why the state’s opioid problem is so dire.
One big reason, they say, is the proximity to an abundant drug supply in neighboring Massachusetts, the center of drug distribution networks that traffic opioids throughout New England.
Another, they say, is New Hampshire’s low per capita spending on services to help drug users break free from addiction. Nationally, the state, which has no income or sales tax, ranks at the bottom in availability of treatment programs. The fire departments’ safe stations are one effort to fill that void.
The researchers also noted that the state has pockets of “economic degradation,” especially in rural areas where jobs are few, and that may contribute to the problem.
Beyond that, the researchers say, doctors here have long prescribed “significantly higher rates” of opioid pain relievers, almost twice the national average. When the government cracked down on legal painkillers, New Hampshire residents were primed to seek out illegal street drugs.
“This is a kind of perfect storm,” says Lisa A. Marsch, a professor of psychiatry and health policy at Dartmouth’s Geisel School of Medicine and the study’s principal investigator.” (B)

“Accidental deaths in the United States rose significantly in 2016, becoming the third-leading cause of fatalities for the first time in more than a century – a trend fueled by the steep rise in opioid overdoses, the National Safety Council reports.
Accidents — defined by the council as unintentional, preventable injuries — claimed a record 161,374 lives in 2016, a 10 percent increase over 2015. They include motor vehicle crashes, falls, drowning, chocking and poisoning, a category that encompasses accidental overdoses.
NSC said in a statement, “The unprecedented spike [in accidental deaths] has been fueled by the opioid crisis. Unintentional opioid overdose deaths totaled 37,814 from drugs including prescription opioid pain relievers, heroin, and illicitly-made fentanyl.”
By comparison, motor vehicle deaths were at 40,327 in 2016, a 6.8 percent increase from the previous year. Deaths related to falls were also up by nearly 4 percent and drownings and fire-related deaths saw slight increases from 2015, up 5.1 percent and 3.2 percent, respectively. The only category to show a decline was choking deaths, which were down 4.4 percent.” (C)

“Tom Petty, the chart-topping singer and songwriter, died in October from an accidental drug overdose as a result of mixing medications that included opioids, the medical examiner-coroner for the county of Los Angeles announced on Friday, ending the mystery surrounding his sudden death last year.
The coroner, Jonathan Lucas, said that Mr. Petty’s system showed traces of the drugs fentanyl, oxycodone, temazepam, alprazolam, citalopram, acetyl fentanyl and despropionyl fentanyl…
In a statement posted to Mr. Petty’s Facebook page on Friday, his wife, Dana, and daughter, Adria, wrote that Mr. Petty suffered from “many serious ailments including emphysema, knee problems and most significantly a fractured hip,” but that he continued to tour, worsening his conditions. “On the day he died he was informed his hip had graduated to a full on break and it is our feeling that the pain was simply unbearable and was the cause for his over use of medication,” the statement said.
They said: “We knew before the report was shared with us that he was prescribed various pain medications for a multitude of issues including Fentanyl patches and we feel confident that this was, as the coroner found, an unfortunate accident.”” (D)

“In an effort to help curb abuse and misuse, Walmart is launching a first-of-its kind opioid disposal solution – available at no cost – in all company pharmacies.* Known as DisposeRx, the small packet contains ingredients that, according to the manufacturer, when emptied into a pill bottle with warm water, ultimately enable patients to responsibly dispose of leftover medications in their trash.
According to the Substance Abuse and Mental Health Services Administration and the National Institute of Drug Abuse, more than 65 percent of people misusing prescription opioids are getting them from family and friends, and personal prescriptions are one of the main sources of nonmedical opioid abuse. DisposeRx provides a virtually effortless way for patients to destroy leftover opioids and a way to do so without ever leaving home.
The innovative disposal solution will now be provided in addition to ongoing counseling available to Walmart patients on proper opioid use when filling an opioid prescription at any one of its 4,700 pharmacies nationwide. Now, pharmacists can also counsel patients on how to use DisposeRx and distribute an opioid awareness brochure outlining risks and helpful resources.” (E)

“Under intense pressure to combat the problem, states across the country are expanding their Medicaid programs to cover alternative treatments such as acupuncture, massage, and yoga. The effort could increase non-opioid options for low-income patients suffering from pain. But it also opens states to criticism from skeptics who say taxpayers are being forced to fund unproven treatments based on political expediency instead of sound science.
Ohio’s Medicaid department took the most dramatic step this month by extending coverage of acupuncture treatments delivered by non-medical providers for patients with low-back pain and migraines, a step likely to allow much greater access and attract new practitioners to the field.
But Ohio is not alone. Eleven other states have implemented policies to encourage beneficiaries to use alternative therapies to help manage their pain and limit reliance on opioids, according to a 2016 survey by the National Academy for State Health Policy. In addition to acupuncture, covered services include massage, yoga, chiropractic manipulation, and various forms of physical and behavioral therapy, among others.” (F)

“On the same day Chris Christie ends his rein as the Governor of New Jersey, the state welcomes new rules — crafted by his administration — that aim to put a dent in what’s considered one of the leading causes of the deadly opioid crisis.
Proposed in August, the rules that take effect Tuesday impose limits on payments and other compensation that licensed prescribers in New Jersey may accept from pharmaceutical companies.
Licensed physicians, physician assistants, dentists and other prescribers may not accept more than $10,000 per year (total from all manufacturers) for services such as speaking engagements, participation on advisory boards and consulting arrangements. Contracts entered before Tuesday do not apply. The new cap does not apply to payments related to research and education events…
“Doctors who prescribe medicine should be motivated only by what is best for their patients, and never by financial incentives heaped on them by the pharmaceutical industry,” Attorney General Chris Porrino said when the proposed rules were first announced.
The rules hold the prescribers accountable for staying within the limits, not the pharmaceutical companies, making New Jersey unique when compared to other states with caps in place.” (G)

“On his last day in office, governor signs range of healthcare legislation, including measures on his
With less than 24 hours left in office, Gov. Chris Christie signed legislation to further integrate behavioral and physical healthcare, create more checks on physicians prescribing addictive medicines, and ensure that overdose victims get information about treatment options.” (H)

“Doctors at some of the largest U.S. hospital chains admit they went overboard with opioids to make people as pain-free as possible, and now they shoulder part of the blame for the nation’s opioid crisis. In an effort to be part of the cure, they’ve begun to issue an uncomfortable warning to patients: You’re going to feel some pain.
Even for people who’ve never struggled with drug abuse, studies are finding that patients are at risk of addiction anytime they go under the knife….
“I just wanted my patient not to be in pain, thinking I was doing the right thing for them and certainly not an outlier among my colleagues,” said Mike Schlosser, M.D., chief medical officer for a division of HCA, the nation’s largest private hospital chain.
Schlosser spent a decade as a spinal surgeon putting his patients at HCA’s flagship facility in Nashville through some of the most painful procedures in medicine, like correcting back curvature. He said he genuinely wanted to soothe the hurt he caused.
“But now looking back on it, I was putting them at significant risk for developing an addiction to those medications,” he said.
Using HCA’s vast trove of data, he found that for orthopedic and back surgeries, the greatest risk isn’t infection or some other complication—it’s addiction.
So the nation’s largest private hospital chain is rolling out a new protocol prior to surgery. It includes a conversation Schlosser basically never had when he was practicing medicine.”.. (I)

“Less than three months after President Donald Trump declared the U.S. opioid crisis a public health emergency, the nation’s governors are calling on his administration and Congress to provide more money and coordination for the fight against the drugs, which are killing more than 90 Americans a day.
The list of more than two dozen recommendations made Thursday by the National Governors Association is the first coordinated, bipartisan response from the nation’s governors since Trump’s October declaration.
The governors praised him for taking a first step, which included a pledge to support states’ efforts to pay for drug treatment through Medicaid, the joint federal-state health insurance program for low-income people. But the governors also called for more action…
The governors are asking for a requirement that drug prescribers undergo substance abuse training and register to use state databases that monitor prescriptions of dangerous drugs. They also seek increased access to naloxone, a drug that reverses overdoses, and asked that Medicare cover methadone treatment for senior citizens.
They said the federal government needs to do more to block illicit versions of synthetic drugs such as fentanyl from being shipped into the U.S. Last year, the Department of Justice issued indictments of two Chinese companies accused of sending fentanyl illegally into the U.S., one of several anti-opioid moves by the federal government….
The governors also called for the White House to put someone in charge of a coordinated effort on opioids…” (J)

“The opioid abuse crisis is costing Missouri about $1.4 million an hour, or enough to wipe out the economic gains produced by the state’s agriculture, mining and utility industries, according to a study released this week.
The study by the Missouri Hospital Association considered health care, lost work productivity, substance abuse treatment and other costs for the thousands of Missourians who were addicted to opioids and the 921 who died of an opioid-related overdose in 2016. Using data from the White House Council of Economic Advisers, the hospital association determined that the total cost of the opioid crisis in Missouri was more than $12 billion that year. (K)

“While most clinical efforts to mitigate the risk of opioid misuse have focused on limiting dosage levels, reducing the length of an opioid prescription actually has greater influence over the risk of misuse, according to a study published in BMJ.
For the study, researchers examined the health records of more than 568,612 privately insured patients nationwide who filled an opioid prescription postoperatively between 2008 and 2016. The patients had no history of opioid misuse prior to surgery. Researchers identified misuse in 5,906 patients via a diagnostic code indicating opioid dependence, abuse or overdose.
Analysis revealed the risk of misuse increased 20 percent with each additional week of opioid use and 44 percent with each additional prescription refill. Additionally, researchers found dosage — the amount of opioids taken over a 24-hour period — had minimal correlation to the risk of misuse when compared to prescription length. For patients taking opioids for two weeks or less, the risk of misuse was not influenced by dosage levels, even when the dose was twice as high. However, high opioid dosage did display a significant correlation to misuse in patients taking opioids for nine weeks or more.” (L)

“President Donald Trump is planning to slash the budget of the Office of National Drug Control Policy, in what marks his administration’s second attempt to gut the top office responsible for coordinating the federal response to the opioid crisis.
The plan would shift the office’s two main grant programs, the High Intensity Drug Trafficking Areas grant and the Drug Free Communities Act, to the Justice and Health and Human Services departments, respectively, multiple sources in the administration and others working with the government on the opioid crisis told POLITICO.
The move would result in a reduction of about $340 million, or 95 percent of the ONDCP’s budget. Trump administration officials say the office would still serve as the White House’s drug policy shop, while the grants would be administered by larger agencies.
The proposal is the latest in a series of actions that health policy experts contend show the Trump administration isn’t serious about addressing the opioid epidemic, despite the president’s designating the substance abuse disorder a national emergency.
Trump hasn’t appointed a permanent director or “drug czar,” to lead ONDCP or asked Congress for additional funding states say is needed to tackle the crisis. The administration has also emphasized a law-and-order approach that experts say only constitutes a narrow part of the solution — one that if overemphasized could harm more struggling patients than it helps.” (M)

“The needs and concerns of older people very rarely get any attention in discussions about the opioid problem. This needs to change, for several reasons…
Most importantly, one need not be addicted to be hurt. Older people are often drawn into the struggles of addicted children, friends, and extended family. The growing number of grandparents raising the children of addicted parents in “grandfamilies” has paralleled the growth of the epidemic, according to Generations United.
Many older people are also desperate to keep a struggling family member afloat. Too often, the result of these valiant efforts to hold a family together is older members going down with the ship. By sheltering an addicted child or grandchild in public housing, an older adult risks eviction under anti-drug use regulations from the Department of Housing and Urban Development. Their personal safety may be also be at risk; a rise in elder abuse and financial exploitation is attributed to the opioid crisis, as more adult children with addiction problems move back in with their parents.” (N)

“The FDA says it has taken “significant steps to confront the staggering human and economic toll created by opioid abuse and addiction, including strengthening drug warnings, taking action against companies for misleading promotion and taking important measures to enhance the safe and appropriate use.”
But from the 1995 approval of Oxycontin to belated 2013 restrictions on popular painkillers like Vicodin, Kolodny and others say the FDA has squandered one opportunity after another to curb rampant prescribing and the wave of addiction that followed.
West Virginia Sen. Joe Manchin, whose state has the highest opioid death rate in the nation, sums up the FDA’s lumbering response in two words: “Absolutely criminal.”
The FDA’s new commissioner, Dr. Scott Gottlieb, doesn’t go that far. But he acknowledges that the agency, where he was a deputy from 2005 to 2007, did not do all it could.
The 1995 approval of OxyContin led to what many see as the biggest public health catastrophe in the nation. George Frey / Reuters
“I don’t know that we could have stopped it,” said Gottlieb, who has made opioids the top priority of his seven-month tenure, in an interview with NBC News.”
“I think that there were opportunities probably years ago to take steps that might have allowed us to get ahead of it more than we are now. I think a lot of people didn’t do what they needed to do in the past or we wouldn’t be in the situation we’re in right now.”
The situation is undeniably grim: more than 300,000 deaths from prescription and illegal opioids since 2000, a drug-dependent baby born every 25 minutes, and life expectancy in the U.S. down for the second year in a row.” (O)

“The Trump administration could help improve the treatment of substance use disorder by following the recommendations of its own Commission on Combating Drug Addiction and the Opioid Crisis.
One recommendation urged federal agencies to analyze the quality of the various types of addiction treatment. This would give patients confidence that they are receiving treatments proven to work. It would also provide a framework for medical providers to turn to when helping their patients decide the best treatment options for their situations.
While every patient’s situation is unique and should be evaluated on an individual basis, research shows that long-term treatment with FDA-approved medications is the most effective form of treatment for those with opioid addictions. The FDA has approved three medications for this treatment: methadone, buprenorphine, and naltrexone. All three significantly increase the likelihood that individuals can recover to live healthy lives.
There are, however, significant differences in how each medication works and which one is best for which patient. Providing access to all three medications is essential — as is the case for many other diseases, the right medication and treatment plan should be focused on the patient….
The medical community must also step up. More physicians, nurse practitioners, and physician assistants need to get the proper training to offer patients with substance use disorders effective medications to quell them.
Just as with cancer or diabetes or other chronic conditions, the public, private, and medical sectors have the power to save the lives of those struggling with addiction. But their efforts won’t pay off until we use every clinical tool available to us. Payers need to cover and properly reimburse all three types of medication for addiction treatment — the Trump administration can provide incentives to do that. Treatment programs need to support, offer, and fully explain their benefits — the government can issue guidelines that encourage this. Clinicians need to get on board with evidence-based treatment options. And patients need to be empowered to ask for treatment without fear of shame and stigma, and be fully assured that they are receiving the right care and advice.
To effectively fight this deadly epidemic, we need everyone to play a role and do what they can to save lives.” (P)

“”Everyone is willing to tolerate the intolerable — and not do anything about it,” said former Democratic Rep. Patrick Kennedy, who was one of six members appointed to the bipartisan commission in March. “I’m as cynical as I’ve ever been about this stuff.”
President Donald Trump declared the opioid epidemic a 90-day public health emergency in October, but did not make any new funding available. In November the president said he would donate his third quarter salary to the Department of Health and Human Services to help fight the crisis.
Critics say the declaration did virtually nothing to change the status quo and that overdose deaths have continued to mount in the months since. The public health emergency declaration was, in fact, set to expire on January 23, but as the government was headed toward a shut down on Friday, Acting Secretary of the Department of Health and Human Services Eric Hargan renewed the national public health emergency for another 90 days.
“This and the administration’s other efforts to address the epidemic are tantamount to reshuffling chairs on the Titanic,” said Kennedy. “The emergency declaration has accomplished little because there’s no funding behind it. You can’t expect to stem the tide of a public health crisis that is claiming over 64,000 lives per year without putting your money where your mouth is.”” (Q)

(A) HHS extends Trump’s emergency declaration for opioids, by Rachel Roubein,
(B) How a ‘Perfect Storm’ in New Hampshire Has Fueled an Opioid Crisis, by KATHARINE Q. SEELYEJAN. 21, 2018,
(C) Opioid Crisis Blamed For Sharp Increase In Accidental Deaths In U.S., by SCOTT NEUMAN,
(D) Tom Petty Died From Accidental Drug Overdose Involving Opioids, Coroner Says, by JOE COSCARELLI,
(E) Walmart Launches Groundbreaking Disposal Solution to Aid in Fight Against Opioid Abuse and Misuse,
(F) As the opioid crisis grows, states are opening Medicaid to alternative medicine, by CASEY ROSS,
(G) New rules cap payments from drug makers to doctors, by Dino Flammia,
(I) Banding together to stop opioid addiction where it often starts—in hospitals, by Blake Farmer,
(J) Governors Ask Trump and Congress to Do More for Fight Against Opioids, by GEOFF MULVIHILL,
(K) $1.4 million an hour: That’s how much this problem costs Missouri, by ANDY MARSO,
(L) Risk of opioid misuse jumps 44% with each refill, study finds, by Brian Zimmerman,
(M) Trump again targets drug policy office, proposing 95 percent budget cut, bySARAH KARLIN-SMITH and BRIANNA EHLEY,
(N) Beyond Addiction: How Older People are Forgotten in the Opioid Crisis,
(O) Can commissioner Scott Gottlieb undo FDA missteps in opioid crisis?, by CYNTHIA MCFADDEN, BRENDA BRESLAUER and TRACY CONNOR,
(P) Follow the evidence to treat opioid addiction, by SARAH E. WAKEMAN and GARY MENDELL,
(Q) Opioid commission member: Our work is a ‘sham’, by Wayne Drash and Nadia Kounang,

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GOP Rep. Blames Obamacare For Sexual Harassment Allegations

“Early last year as an Obamacare repeal bill was flailing in the House, top Trump administration officials showed select House conservatives a secret road map of how they planned to gut the health law using executive authority.
The March 23 document, which had not been public until now, reveals that while the effort to scrap Obamacare often looked chaotic, top officials had actually developed an elaborate plan to undermine the law — regardless of whether Congress repealed it.
Top administration officials had always said they would eradicate the law through both legislative and executive actions, but never provided the public with anything close to the detailed blueprint shared with the members of the House Freedom Caucus, whose confidence — and votes — President Donald Trump was trying to win at the time. The blueprint, built off the executive order to minimize Obamacare’s “economic burden,” that Trump signed just hours after taking the oath of office, shows just how advanced the administration’s plans were to unwind the law — plans that would become far more important after the legislative efforts to repeal Obamacare failed…
“The primary problem here is government officials, government agencies, were taking steps that would lead to fewer people having coverage and erecting barriers to people having coverage,” he said. “In addition to that, you have kind of a closed-door, back-room slimy deal here that should trouble anyone.”
The document lists 10 executive actions the Trump administration planned to take to “improve the individual and small group markets most harmed by Obamacare.”
Those include calling for stricter verification of people who try to sign up outside of the open enrollment period; cutting the sign-up period in half; and giving states authority to determine whether insurers had to cover the full range of benefits required by Obamacare and whether their networks of doctors were sufficient.
Those policies are among seven proposals in the plan that have since been implemented. Four of the ideas and a portion of a fifth had been publicly proposed but not yet finalized when the document was shared.” (A)

“Out on the campaign trail, Trump frequently called for the repeal and replace of Obamacare, and the executive order signaled that doing away with President Obama’s sweeping health care law would be a priority from day one. While Trump has been unsuccessful in repealing the Affordable Care Act during his first year in office, the Department of Health and Human Services has managed to make significant changes.
In 2017, Health and Human Services under the Trump administration rolled back the Obamacare birth control mandate, allowing employers to exempt themselves if they have a moral or religious objection, ended cost-sharing reduction payments to insurance companies to help provide lower cost insurance for middle and low income consumers, cut advertising and outreach spending for the Affordable Care Act 90 percent, cut the sign-up period on the federal health care exchanges in half, and threw out the individual mandate—a tax penalty for those who don’t sign up for health insurance.” (B)

“Unable to roll back Obamacare’s health-care expansion legislatively, they’re now doing so administratively, through a series of technical, boring-sounding regulatory changes.
This GOP effort ramped up last week, when the Trump administration began allowing states to erect new barriers to Medicaid eligibility.
In the half-century since Medicaid was first created, eligibility has always been based almost entirely on financial circumstances such as income and assets; the program’s goal, after all, was to help less-well-off Americans obtain medical care. Last week, though, the Trump administration announced that it would start allowing states to impose other requirements on Medicaid recipients, including proof that they are working, looking for work, volunteering or in school.” (C)

“The number of people in the U.S. without health insurance increased in 2017 for the first time since Obamacare took effect, a possible sign that Obamacare’s rising premiums are putting insurance out of reach for millions of people.
The number of uninsured rose by 3.2 million from 2016 to 2017, according to the latest Gallup-Sharecare Well-Being Index.
That increase means 12.2 percent of the U.S. population was uninsured last year. In contrast, 10.9 percent was uninsured in 2016, a record low since Gallup and Sharecare started tracking the rate in 2008.
The 2017 uninsured rate is still lower than the peak uninsured rate of 18 percent in 2013, before people became able to buy government-subsidized healthcare plans through exchanges or enroll in expanded Medicaid, both provisions of Obamacare.
But it still represents a significant increase, one that hit blacks hardest. The index said the uninsured rate rose 2.3 percent for blacks, 2.2 percent for Hispanics, and 2 percent for young adults aged 18 to 25.
One factor in the rising uninsured rate could be the rising price of Obamacare plans. Though most who are enrolled through the exchanges receive a subsidy that shields them from price increases, those without subsidies and others who buy plans with Obamacare’s mandates, often off-exchange, have to pay the full price of increases.” (D)

“SINCE THE big Obamacare repeal-and-replace bills failed in the Senate, Congress and President Trump have sought to undermine the law in subtler ways. First, Republican lawmakers repealed Obamacare’s individual mandate, a key element of the law’s design. Now the Trump administration is rolling out rules that threaten to damage the structure further.
The Labor Department this month proposed looser regulations on so-called association health plans, under which small businesses, professional associations and others in similar circumstances can band together and buy insurance coverage for their groups as though they were large employers. The department argues that up to 11 million people working at small businesses or as sole proprietors lack health insurance, and that the new rules would help provide them more options.
In fact, there is a potentially large downside. The rules would also excuse association health plans from covering 10 classes of essential health benefits. Plans would probably be cheaper, but they would likely cover less than the comprehensive ones Obamacare sought to make the national standard. It is likely that some people who buy these plans will develop significant health problems and find themselves disastrously under-covered. Some may be willing to take that risk. The bigger problem is that opening a new avenue to buying shoddier insurance may harm everyone else seeking affordable, comprehensive coverage when they cannot get it from a large employer.” (E)

“Having wiped out the requirement for people to have health insurance, Republicans in Congress are taking aim at a new target: the mandate in the Affordable Care Act that employers offer coverage to employees.
And many employers are cheering the effort.
While large companies have long offered health benefits, many have chafed at the detailed requirements under the health law, including its reporting rules, which they see as onerous and expensive. Now that relief has been extended to individuals, some companies believe they should be next in line.
The individual mandate and the employer mandate are “inextricably entwined,” said James A. Klein, the president of the American Benefits Council, an influential lobby for large companies like Dow Chemical, Microsoft and BP, the oil and gas producer.
“It is inequitable to leave the employer mandate in place when its purpose — to support the individual mandate — no longer exists,” Mr. Klein said. “We are urging Congress to repeal the employer mandate.”
Opposition to the employer mandate could increase as more employers are fined for not offering coverage or for not meeting federal standards for adequate, affordable coverage. Since October, the Internal Revenue Service has notified thousands of businesses that they owe money because they failed to offer coverage in 2015, when the mandate took effect.” (F)

“The Centers for Disease Control and Prevention (CDC) says it “has not banned, prohibited, or forbidden” the use of certain words in official documentation, the agency director says in response to concerns from Senate Democrats.
Democrats had been concerned, they said last month, “that the Trump Administration is yet again prioritizing ideology over science” after reports claimed agencies within the Department of Health and Human Services (HHS) had banned employees from using words including “fetus,” “vulnerable” and “science-based.”
CDC Director Brenda Fitzgerald told Sen. Brian Schatz (D-Hawaii) in a letter released Tuesday the HHS style guide does recommend avoiding the use of “vulnerable,” “diversity,” and “entitlement.” Fitzgerald added that CDC recommends substituting the colloquial “ObamaCare” for “Affordable Care Act” or “ACA.”” (G)

“Many states are eager to reverse the damage from Obamacare in 2018, but in some cases, they will need help from Congress, leading health care experts say.
The following are six ways the states and/or the federal government could push for change or reforms in the year ahead. 1.State innovation waivers; 2. Revive Graham-Cassidy; 3. Direct primary care; 4. Medicaid work requirements; 5. Telemedicine to cut costs; 6. Regulations for new hospitals. (H)

“The increasing number of people coming to the emergency room is partly due to Obamacare, because 880,000 more people in New Jersey became insured. The largest share of that number are low-income people who now qualify for Medicaid.
That’s where Gov. Chris Christie comes in. After the Affordable Care Act passed, most Republican governors said they wouldn’t opt into the voluntary expansion of Medicaid, even though the federal government would pay for 90 percent of the extra cost.
“Medicaid is pretty well expanded in our state already because of the legacy of previous democratic governors,” Christie told Fox and Friends in July 2012. “So I don’t think there’s a lot more for us to do in New Jersey in that regard.”
But six months later, squeezed between his ambition to run for president and re-election in a majority blue state, he bucked his own party and took the money. There are now more than half a million poor people who gained access to healthcare in New Jersey.
“It was a very big move,” said Joel Cantor, director of the Rutgers Center for Health Policy. “Expanding Medicaid has been huge for this state, enfranchising hundreds of thousands of people and helping to finance our healthcare system more robustly and more stable than it had been in the past.”..
But he turned his attention to the opioid epidemic, and worked almost exclusively on it. It was a good time to be working on the problem in New Jersey, because half a million low-income people were added to the Medicare rolls, and many of those people were now able to get treatment for drug addiction. A wide spectrum of people who work on recovery say that was the game changer in New Jersey.
Christie also gets credit for expanded access to Naloxone, which can save the life of someone overdosing, and for signing the Good Samaritan law, which encourages drug users to call for help without fear of arrest when a friend is overdosing.” (I)

“More American women started getting recommended mammography screening after an “Obamacare” rule made the tests free, a new study finds.
The rule meant that Medicare and most private insurers could no longer require women to foot part of the bill — whether through copays or requiring them to pay a deductible first.
After the rule went into effect, the study found, the number of women in Medicare Advantage plans who got mammography screening rose by 5.5 percentage points: from just under 60 percent in the two years before the rule, to 65.4 percent in the two years after.
That’s the good news. The worry is what could happen if the Affordable Care Act rule is repealed, said lead researcher Dr. Amal Trivedi, an associate professor of medicine at Brown University in Providence, R.I.
“Our study suggests that if the cost-sharing provisions are repealed and health plans reinstate copayments for screening mammograms, fewer older women will receive recommended breast cancer screening,” Trivedi said. “That could harm public health.” (J)

“A new study suggests that the Medicaid expansion helped hospitals in rural areas keep their doors open. But will this be enough going forward?
The Affordable Care Act’s Medicaid expansion drove down the uninsured rate in the United States.
Now a new study suggests that the expansion boosted the financial health of many hospitals that serve a high number of the uninsured, especially in rural areas.
Researchers found that hospitals in the 32 states and District of Columbia that expanded Medicaid were more than 6 times less likely to close than hospitals in the 18 states that said no to the expansion.
Some areas were helped more than others by the Medicaid expansion.” (K)

“Democrats are shifting to offense on health care, emboldened by successes in defending the Affordable Care Act. They say their ultimate goal is a government guarantee of affordable coverage for all…
Time will tell. Here’s a sample of ideas under debate by Democrats and others on the political left:
—Medicare for All: Vermont Sen. Bernie Sanders made single-payer, government-run health care the cornerstone of his campaign for the 2016 Democratic presidential nomination. It remains the most talked-about health care idea on the left. Financing would be funneled through the tax system. Individuals wouldn’t have to worry about deductibles, copays or narrow provider networks. Although state-level attempts to enact single-payer care have foundered because of the large tax increases needed, about one-third of Sanders’ Democratic colleagues in the Senate are co-sponsoring his latest bill.
—Medicare-X: The legislation from Sens. Kaine, and Michael Bennet, D-Col., would allow individuals in communities lacking insurer competition to buy into a new public plan built on Medicare’s provider network and reimbursement rates. Medicare would be empowered to negotiate prescription drug prices. Medicare-X would be available as an option through and state health insurance markets. Enrollees could receive financial assistance for premiums and copays through the Obama health law. Eventually, Medicare-X would be offered everywhere for individuals and small businesses.
—Medicare Part E: Yale University political scientist Jacob Hacker has proposed a new public health insurance plan based on Medicare, for people who don’t have access to job-based coverage meeting certain standards. It would be financed partly with taxes on companies that don’t provide insurance. Consumers would pay income-based premiums. Hospitals and doctors would be reimbursed based on Medicare rates, generally lower than what private insurance pays. “The crucial part of this is that you have guaranteed health insurance, just like you have guaranteed Medicare or Social Security,” said Hacker. He’s working with Democrats in Congress to turn the concept into legislation.
—Medicaid Buy-In: Sen. Brian Schatz, D-Hawaii, and Rep. Ben Ray Lujan, D-N.M., have introduced legislation that would allow states to open their Medicaid programs up to people willing to pay premiums. Although Medicaid started out as insurance for the poor, it has grown to cover about 75 million people, making it the largest government health program. Most beneficiaries are now enrolled in private insurance plans designed for the Medicaid market.” (L)

“Wisconsin Gov. Scott Walker (R) is looking to stabilize the state’s ObamaCare marketplace after Republicans failed to repeal and replace the law last year.
“Their failure to act on this issue is yet another call for us to step up and lead,” Walker told the Wisconsin State Journal.
“I wanted to get premiums for that individual market more compatible with where the group insurance premiums are.”
Walker said he will seek federal permission to set up a reinsurance program, which provides payments to plans that cover higher-cost enrollees in an effort to lower premiums for everyone else.
Walker also said he will ask state lawmakers to codify in state law protections for people with pre-existing conditions.
The proposed reinsurance program, to start in 2019 if approved by the Trump administration, would pay 80 percent of claims between $50,000 and $250,000.
The program would cost about $200 million a year, according to the newspaper, with $150 million coming from the federal government.
Lawmakers in Congress are also working to pass legislation to shore up ObamaCare.
A fix being pushed by Sens. Lamar Alexander (R-Tenn.) and Susan Collins (R-Maine) would fund key ObamaCare insurer payments and give states billions of dollars to set up reinsurance or high-risk pools for expensive patients.”
The two senators are hoping the bills get added to an upcoming long-term spending deal.” (M)

“Sen. Susan Collins (R-Maine) said Monday that she is “optimistic” that the ObamaCare fixes she is pushing for can still pass, despite the deadline for voting on them having “slipped.”
“Our negotiations with the House are going very, very well,” Collins told reporters. “The deadline slipped but the policy is what is important.”
Senate Majority Leader Mitch McConnell (R-Ky.) in December gave a commitment to Collins to support the passage of two bills aimed at stabilizing ObamaCare markets and lowering premiums before the end of the year, in exchange for her vote for the tax reform bill.
The end of the year came and went without votes on the two bills, but Collins said Monday she is still “optimistic.”” (N)

“Rep. Pat Meehan (R-Pa.) denied allegations that he sexually harassed a young female staffer and blamed Obamacare for some of his behavior that she perceived as hostile..
Meehan denied that he retaliated against her and instead blamed any negative behavior on stress over the Republican effort to dismantle Affordable Care Act. On the day Meehan penned the letter to his aide, the House voted to partially repeal and replace the health care law.” (O)

(A) Trump’s secret plan to scrap Obamacare, by JENNIFER HABERKORN,
(B) HHS goal under Trump: rolling back Obamacare, by MERIDITH MCGRAW,
(C) Trump is hoping you won’t notice his backdoor repeal of Obamacare,by Catherine Rampell,
(D) Number of people without health insurance rises for first time since Obamacare, by Kimberly Leonard ,
(E) These Trump administration changes could make health-care coverage worse ,
(F) Individual Mandate Now Gone, G.O.P. Targets the One for Employers, By ROBERT PEARJAN,
(G) CDC rejects censorship reports: ‘There are absolutely no “banned” words’, by NATHANIEL WEIXEL,
(H) 6 Actions States, Federal Government Could Take on Obamacare, Health Care in 2018, by Fred Lucas,
(I) What Christie May Not Want to Admit: He Had Success with Obamacare, by Nancy Solomon,
(J) Obamacare Led to Rise in Breast Cancer Screening, by BY TOBY MURPHY,
(K) Rural hospitals rely on Medicaid expansion to stay open, study shows,
(L) On health care, Democrats are shifting to offense, by Ricardo Alonso-Zaldivar,
(M) Wisconsin’s Republican governor looks to shore up ObamaCare market, by JESSIE HELLMANN,
(N) Collins ‘optimistic’ ObamaCare fixes will pass, by PETER SULLIVAN,
(O) GOP Rep. Blames Obamacare For Sexual Harassment Allegations, by Willa Frej,

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“ a severe (flu) pandemic, the U.S. healthcare system could be overwhelmed in just weeks.

Hospitals and clinics would be forced to turn away millions of patients. Critical medications and care would not reach people in time. Millions of people in every state would be felled by the virus, and hundreds of thousands—including newborn babies, toddlers and older adults—would die in the weeks and months following the initial outbreak. The GDP in the United States would plummet as much as $2 billion, if not more.
Inadequate preparedness programs—and the investments required to fund and sustain them—mean that even with some of the best available healthcare there is, the United States remains woefully susceptible to a major future flu epidemic that might make this year’s widespread lethal outbreak look mild in comparison. Over the last decade, the federal government has cut upwards of 50% of its funding for the U.S. Public Health Emergency Preparedness program that it created in the aftermath of the 9/11 attack to protect against bioterror, pandemics and other public health emergencies. This has cost state and local health departments some 45,000 jobs. And the Trump administration is now calling for even more draconian budget cuts…
Why do we as a nation continue to leave ourselves vulnerable? The shockingly simple answer lies in our collective complacency. As soon as headlines about the flu are gone, hospitals are emptied of flu patients, schools are back in session and workplace absenteeism declines, we go back to business as usual. Pandemic preparedness plans are put back on the shelf. Funding for public health preparedness and flu R&D disappears into a haze of competing demands.” (A)

“With a nasty flu season underway across the country, businesses can expect to see billions of dollars in lost productivity, according to global outplacement consultancy Challenger, Gray & Christmas.
“We’re predicting about 11 million Americans will fall ill over the flu season and that’s going to cost employers over $9 billion in wages being paid to employees that are staying home sick,” Andy Challenger, the firm’s vice president, told CNBC’s “Closing Bell” on Friday.
That estimate does not take into account those workers who need to stay home to care for a sick family member…
Challenger said it’s important that workers don’t try to tough it out and go into the office and that employers discourage sick employees from coming in. Limiting meetings and expanding remote work options are two ways to help prevent the spread of the illness, he noted.
“It’s better to make sure an entire department doesn’t fall ill and cost the company a lot of money over the flu season,” Challenger said.
As for when to return to the office, Schaffner said, “After you’ve started to get better, two, three days after the onset of disease, if you’re adult you can come on back to work.”
If the worker has a fever, the CDC recommends staying home for at least 24 hours until the fever subsides.” (B)

“Keyboards, especially within a work environment, can harbour flu germs, experts say.
“At any given time the human body is emitting anywhere from one to tens of millions of microbes every hour,” Canadian microbiologist Jason Tetro says. “Normally that’s not a problem – however, if you happen to be sick then that microbial cloud starts to incorporate a number of these pathogens that you happen to be infected with.”
Those pathogens, Tetro says, land on people and surfaces and end up posing a risk.
“That poses a risk because you’re not going to get sick by picking up somebody’s skin or hair bacteria from a keyboard, but you may get sick if you happen to pick up dry droplets from someone who had the cough or flu,” he says.
And those droplets can end up on what are called “high touch surfaces.”
These are surfaces that have a higher likelihood of leading to infection, Tetro says. That likelihood essentially comes down to the number of times something is touched.
Flu germs (and cold germs for that matter) live on surfaces between two to eight hours at a time. The higher the number of high-touch surfaces you come into contact with everyday, the greater your chances of picking up those germs.
So what are some of those high touch surfaces? Water coolers, taps and water fountains. Photo copiers and printers in offices. Bathroom surfaces. Door handles. Soap dispensers that require pumping. Subway poles. Mobile devices. Keyboards. Flight check-in kiosks at airports. Shopping carts.” (C)

“It is easier to spread the influenza virus (flu) than previously thought, according to a new University of Maryland-led study released today. People commonly believe that they can catch the flu by exposure to droplets from an infected person’s coughs or sneezes or by touching contaminated surfaces. But, new information about flu transmission reveals that we may pass the flu to others just by breathing…
“We found that flu cases contaminated the air around them with infectious virus just by breathing, without coughing or sneezing,” explained Dr. Donald Milton, M.D., MPH, professor of environmental health in the University of Maryland School of Public Health and lead researcher of this study. “People with flu generate infectious aerosols (tiny droplets that stay suspended in the air for a long time) even when they are not coughing, and especially during the first days of illness. So when someone is coming down with influenza, they should go home and not remain in the workplace and infect others.”…
“The study findings suggest that keeping surfaces clean, washing our hands all the time, and avoiding people who are coughing does not provide complete protection from getting the flu,” said Sheryl Ehrman, Don Beall Dean of the Charles W. Davidson College of Engineering at San José State University. “Staying home and out of public spaces could make a difference in the spread of the influenza virus.” (D)

“Lost in the flurry of news stories is the startling and alarming report from the CDC in December that only about one-third of pregnant women are getting flu shots. A startling 64 percent of pregnant women had not been vaccinated against the flu, despite recommendations from the CDC, the American Academy of Pediatrics, and the American College of Obstetricians and Gynecologists.
While 98 percent of pregnant women reported visiting a doctor or other medical professional at least once before or during pregnancy, the CDC found that only about 59 percent reported receiving a recommendation for and offer of flu vaccination from a doctor or other medical professional, while 16 percent received only a recommendation for — but no offer of — the vaccine. A whopping 26 percent received neither a recommendation for nor an offer of flu vaccination…
Pregnant women and their unborn babies are especially vulnerable to influenza and are more likely to develop serious complications from it. About one-third of cases of pneumonia are caused by respiratory viruses, the most common of which is influenza. Pneumonia and other complications increase the risk of preterm labor. Babies in utero are also at risk of complications: Pregnant women who develop the flu are more likely to give birth to children with birth defects of the brain and spine.” (E)

“The Department of Health and Human Services doesn’t have the funding it needs to prepare for a public health emergency, according to an official at the agency.
The Senate Health, Education, Labor and Pensions Committee held a hearing on Wednesday that focused on the reauthorization of the Pandemic and All Hazards Preparedness Act. At the hearing Robert Kadlec, M.D., HHS assistant secretary for preparedness and response, said that the agency is “working with half an aircraft carrier” to address the needs of 320 million people in the event of a public health emergency.
“We can’t do more things with limited resources,” he told senators.” (F)

“Confirmed cases of the flu are growing at a faster pace than the past two seasons in New Jersey, and with the worst months yet to come, it might be the nastiest year in a while.
There were 1,166 confirmed cases in the past week, as compared to 697 for the same period last season and 24 for 2015-16, according to state Department of Health data.
Why is this year’s flu season shaping up to be a serious threat? The type of flu strain spreading throughout the state — the dreaded H3N2 virus, a form of influenza A — is typically associated with more severe illness than other strains.
“What we’re seeing now is a lot of H3N2 (and) that is the predominant risk of more severe cases,” said Dr. David J. Cennimo, an epidemiologist at University Hospital in Newark and an assistant professor of medicine-pediatrics infectious disease at Rutgers Medical School.
The H3N2 virus has been particularly notable in California, overwhelming hospitals and medical professionals.
In total, there are 3,189 confirmed cases of the flu so far this year in the Garden State. The virus is now at high flu levels in all parts of the state, according to the health department.” (G)

“The flu was so bad last week in New York, it was the worst since the state started recording the data 14 years ago.
The Department of Health reported the number of lab-confirmed influenza cases last week was 6,083, an increase of more than 50 percent from the week before.
There were 1,606 people hospitalized with confirmed cases of the flu in New York last week. That was the highest weekly number of cases reported since the Department of Health began reporting the data in 2004.” (H)

“The current flu epidemic wreaking havoc across the nation was in part fanned by so many people spreading germs while traveling over the holidays, according to the U.S. Centers for Disease Control and prevention.
As 49 states are reporting widespread flu activity, “Good Morning America” spoke with a flight attendant and a doctor to get some expert tips on how to prevent the spread of flu germs while traveling on airplanes or passing through major airports.
Why this year’s flu season is so bad and what you can do about it
1. Wipe down communal surfaces such as tray tables and armrests
2. Turn on your air vent
3. Let other passengers board first
4. Choose a window seat
5. Avoid caffeine, alcohol while aboard
6. Use a nasal spray. (I)

“The Centers for Disease Control and Prevention may be able to continue its immediate response to seasonal influenza in the event the government shuts down, a senior administration official said Friday night on a call with reporters.
“CDC will specifically be continuing their ongoing influenza surveillance,” the official said. “They’ll be collecting data reported by states, hospitals, [and] others and they’ll be reporting that critical information needed for state and local health authorities.”
Those remarks stand in direct contrast to the fiscal year 2018 contingency plan posted by the Department of Health and Human Services Friday morning, which specifically lists the agency’s seasonal flu work as one of the activities that will not continue in the case of a shutdown.” (J)

Note: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.

(A) Our Complacency About the Flu Is Killing Us, by JONATHAN D. QUICK,
(B) Andy Challenger told CNBC the firm predicts 11 million Americans will fall ill, costing employers more than $9 billion in wages being paid to employees who are staying home sick, Michelle Fox,
(C) Don’t touch these surfaces if you want to avoid the flu, by Dani-Elle Dubé,
(D) Flu may be spread just by breathing, new study shows; coughing and sneezing not required,
(E) Two-thirds of pregnant women aren’t getting the flu vaccine. That needs to change, by MARK N. SIMON,
(F) HHS’ Robert Kadlec, M.D.: Agency needs more funding to prepare for public health emergencies, by Paige Minemyer,
(G) Flu season in N.J. could be worst in recent years, new data shows, by Erin Petenko and Spencer Kent,
(H) Flu everywhere: NY had worst week ever, by Natasha Vaughn,
(I) Planes and the flu: 6 things to know to help you stay healthy while flying,
(J) Flu response will be maintained during shutdown, officials say, contrary to previous plan, by ERIN MERSHON,

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Government Shutdown. “The CDC would furlough key staff amid one of the most severe flu seasons in recent memory….”

“The last government shutdown — which lasted for 16 days in October 2013 — sheds light on just how far flung are the consequences of congressional inaction, especially for health companies and public health workers. STAT talked to former officials at the FDA, CDC, and NIH about how that shutdown affected the work they could do…
In 2013, the CDC shuttered most of its annual seasonal influenza program during the shutdown. It largely stopped tracking disease outbreaks across the country, ceasing communications with the local officials and clinicians who help the federal workers connect the dots when an outbreak might be growing. It stopped testing most incoming samples and specimens to ensure safety, and it largely stopped monitoring infections at airports around the country, according to documents and former agency staffers…” (A)

(A) How a government shutdown could affect drug safety, flu response, and more, by ERIN MERSHON and IKE SWETLITZ,

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“Think hospitals are under a strain now, from a slightly bad flu season? Wait until a really bad one hits.”

“In a press briefing on Friday, Dr. Dan Jernigan — director of the influenza division in the CDC’s National Center for Immunization and Respiratory Diseases — confirmed that the outbreak can legitimately be called an epidemic. “We have very specific criteria where we can say the epidemic is beginning and ending based on when flu activity goes above a certain baseline. So we’ve clearly passed that baseline back in November and we’re at the peak of it now,” he said.” (A)

Weekly US Map: Influenza Summary Update – highlight and click on

During week 1 (December 31, 2017-January 6, 2018), influenza activity increased in the United States.
Geographic Spread of Influenza: The geographic spread of influenza in 49 states was reported as widespread; Guam and one state reported regional activity; the District of Columbia reported local activity; the U.S. Virgin Islands reported sporadic activity; and Puerto Rico did not report. (B)

“Think hospitals are under a strain now, from a slightly bad flu season? Wait until a really bad one hits.
Experts agree the U.S. is not ready for a bad epidemic, or even for some other disaster that would affect hospital supplies. And funding cuts mean even a little strain has a bigger impact than in years past…
“Each year, the healthcare system gets a thinner and thinner veneer of preparedness,” said Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota.
“It takes less and less impact for a healthcare system to go from routine to crisis.”..
Yet, every year, school systems and hospitals get caught short. There are spot shortages of drugs that fight flu such as Tamiflu and for the past three years, there’s been a shortage of certain preparations of saline solution — a hospital staple.
This year, the saline shortage has been made even worse by Hurricane Maria’s devastation in Puerto Rico, the U.S. territory where 40 percent of the saline supply is made…
Infectious disease experts have been urging the U.S. government to do more to keep the country prepared for outbreaks of diseases such as a new strain of flu, Ebola and severe acute respiratory syndrome, or SARS…
Influenza specialists say repeatedly that the chance of a new flu pandemic is 100 percent. Flu mutates constantly, and a major new strain emerges about every 20 years. The last one was H1N1 “swine” flu in 2009, which was fairly mild, but worse epidemics are probable.
No country can be ready without having stockpiles of drugs, vaccines and equipment, plans for deploying them and someone with the authority to make fast decisions…
Last year’s budget provides just $57 million for influenza pandemic planning.
“I think it is in part a sense that until it’s a downright crisis, everybody assumes everything is OK,” Osterholm said. “ (C)

“The huge numbers of sick people are also straining hospital staff who are confronting what could become California’s worst flu season in a decade.
Hospitals across the state are sending away ambulances, flying in nurses from out of state and not letting children visit their loved ones for fear they’ll spread the flu. Others are canceling surgeries and erecting tents in their parking lots so they can triage the hordes of flu patients…
Connie Cunningham and her staff at Loma Linda University Medical Center were triaging so many flu patients after New Year’s that they assembled what looks like a giant, brown camping tent in their emergency room parking lot. Several hospitals in California are treating flu patients in so-called “surge tents” intended for major disasters.
So many people are showing up sick with the flu that Loma Linda hospital put up this giant tent to treat patients in.
On a recent weekday morning, Cunningham walked through the tent, lined with folding chairs and patient beds that are separated by sheets hung from the ceiling.
Cunningham, executive director for the hospital’s emergency services, said she’d thought they would dismantle the tent after a few days, but staff are still treating 60 more patients each day than usual, she said.
“In my career, I’ve never seen anything like this,” she said…
Many hospitals also say they’re too full to accept any more patients or ambulances.
And when paramedics are allowed to drop off patients at a hospital, the emergency room is often so crowded that there aren’t available staff members to transfer care to. So the emergency responders can’t get back on the road to answer incoming 911 calls, said Kay Fruhwirth, L.A. County’s assistant director of emergency medical services.
“If there’s not a nurse available, and/or a bed — it’s usually an ‘and’ — they’re waiting there with the patient,” she said. (D)

“Still, the fact remains that every single year there is a flu epidemic. The principle behind these perennial epidemics is “persistence through plasticity,” said Dan Jernigan, MD, MPH, the director of the CDC’s Influenza Division. To put it simply, the influenza virus is always mutating to get around the vaccine and people’s natural immunities. “These constant changes do allow for adaptation,” he said. This adaptation makes it really hard to match a virus to the flu strain that’s circulating.
So with H3N2 as the major flu strain getting people sick this season, it’s possible you’ll get sick. And if you do, it’s likely you’ll receive antiviral drugs. The CDC recommends drugs belonging to the class called neuraminidase inhibitors, which block the enzyme that the influenza virus needs to reproduce. Clinical trials have shown that neuraminidase inhibitors are effective against both influenza A and influenza B, unlike the older M2 inhibitors. This is good for flu patients because you could still come down with one of the other common flu strains.
Here’s the thing, though: There haven’t been any double-blind placebo-controlled trials of these antiviral drugs on influenza cases, says Alicia Fry, MD, MPH, the chief of the CDC Influenza Division’s Epidemiology and Prevention Branch. They do show some significant positive results, though. According to Fry, early treatment with antiviral drugs does improve outcomes — something that can be seen even without placebo trials. It reduces mortality in adults, it reduces the severity of the illness in children, and it reduces the duration of sickness. (E)

“The most optimistic assumption among government experts is that the season peaked a few weeks ago, marking the apex of what was already an early and severe outbreak. However, such an outlook requires observers to ignore that outpatient doctor visits have continued to climb (albeit more slowly) in the first week of 2018, yielding the most flu cases ever for this time of the year.
Even if the hopeful assessment by the U.S. Centers for Disease Control and Prevention bears out, there will still be another 11 weeks to 13 weeks of flu circulating across the country. “In general, we see things peaking right about now, but that means there is still a whole lot more flu to go,” Jernigan said. “In addition, there are other strains of influenza still to show up that could be a major cause of disease.”
That may already be happening. The CDC is starting to see infections caused by the H1N1 strain of the virus in states grappling with high levels of the H3N2 strain, the predominant version this season. In addition, Jernigan said yet another type of flu, caused by the influenza B viruses, is still expected to show up later in the season.
H3N2 has compounded the damage usually wrought by the annual flu outbreak. It’s known for both its severity and ability to evade the protection provided by vaccinations that are typically more effective against the other types of flu…
The CDC’s latest method to categorize the severity of a flu outbreak, which takes into account indicators including hospitalizations, outpatient visits and deaths across an entire outbreak, already places the current season in the top three. During the 2014-2015 flu season, there were more than 700,000 hospitalizations. The current outbreak is matching the beginning of that period, though it’s unclear what the remainder of the season will look like, Jernigan said. Last year’s entire season saw more than 600,000 hospitalizations.
“You didn’t have this all-at-once phenomena that we’re getting now, where hospitals are having lots of cases all at once all across the U.S.,” he said. Jernigan was forthright about the agency’s inability to accurately predict the intensity of the influenza season.
“We are always expecting there to be an unusual season,” he said. “We are rather humbled by this virus. We are always preparing for a severe season and welcome a less severe season, but it’s difficult to predict what will happen.” (F)

“A modeling program called FluSurge developed by the Centers for Disease Control and Prevention to help hospitals plan generates some pretty sobering scenarios, he noted. In a bad pandemic, hospitals might have four times more people in need of a ventilator than they have ventilators, and far too few intensive care beds for the seriously ill.
“So there would be a big mismatch between demand for care, lifesaving care, and the ability to provide it,” Inglesby said. “We would have a huge problem in this country.”
The problem with influenza relates to the way it attacks, sickening large numbers of people in a relatively short period of time.
A hospital can plan for how much cancer care it will need to deliver based on the size of the nearby population and estimates of rates of various cancers. Affected people will seek care over the course of any given year.
But with flu, most of the severe illness happens in the space of a few weeks in any one location. The pressure that puts on a health system is exacerbated by the fact that some of the people needed to care for the sick fall ill themselves.
Getting help from elsewhere — as a community will often do in the case of a major medical disaster — isn’t really an option during flu epidemics, because other places are either dealing with their own or steeling themselves for a wave that’s about to hit. In the first week of this month, the entire continental United States was reporting widespread flu activity…
But the inability to predict the intervals between flu pandemics makes it easy for officials to shift preparedness efforts into the “should do” instead of the “must do” column.
There were nearly 40 years between the 1918 and 1957 pandemics; then the 1968 pandemic hit 11 years later. And then there was a 41-year interval before 2009. There is virtually no way to tell when the next will occur.
If anyone knew for sure that the next pandemic was coming soon, then society would begin planning aggressively, Inglesby said. “But since we have uncertainty about the timing and severity of the next pandemic, we’re kind of in this relatively modest national effort to prepare hospitals, which is doing what it can with the resources available.” “ (G)

“A company making “smart thermometers” that upload body temperatures to its website claims to be tracking this year’s flu season faster and in greater geographic detail than public health authorities can.
This year’s flu season — which the Centers for Disease Control and Prevention considers “moderately severe” — has left Missouri and Iowa the “sickest states in the country,” said Inder Singh, the founder of
California has had its worst outbreak in five years, with nearly 1 percent of the state exhibiting flu symptoms on Jan. 2, he added. By contrast, New York, New England and the Southeast have had relatively mild seasons so far, but cases are rising and should peak in two weeks.
Mr. Singh’s data paints a different picture from that of the C.D.C., which held a news conference Friday to announce that flu activity was “widespread” across the continental United States, which is unusual. (Hawaii’s outbreak is smaller, the agency said.)…
The C.D.C. data comes from hospitals and clinics that report how many cases of “influenza-like illness” they treat. Delays can result if clinic statisticians are busy or if state health departments do not pass on the figures quickly.
Kinsa, by contrast, is able almost instantly to spot fever spikes in states — or even in cities and neighborhoods. More than 500,000 households now own its smartphone-connected oral and ear thermometers, Mr. Singh said, and the company gets about 25,000 readings each day.
(Of course, the company cannot measure hospitalizations, deaths, or which strains of flu are circulating, or consistently distinguish flu from other febrile illnesses.)
Kinsa’s technology was approved by the Food and Drug Administration in 2014 and gathered data in subsequent flu seasons; the company hopes to soon publish a study by outside experts assessing its accuracy in measuring the seasonal spread.
Those experts, Mr. Singh said, found the data to be more accurate than Google’s Flu Trends, which Google shut down three years ago after it missed the peak of the 2013-2014 season.
Google tracked internet searches for terms like “flu,” “fever” and so on, but could be misled by, for example, searches triggered by news coverage.” (H)

“One of the best defenses against the flu starts with tissue and hankerchiefs, two Northwest Indiana health professionals say.
For tissues, don’t use them twice. For hankies, don’t use them at all.
Donna E. Ricard, nurse practitioner with Franciscan Senior Health & Wellness at the Dyer Medical Pavilion, and Laura Matthys, manager at Franciscan Senior Health & Wellness, are emphatic about maintaining good hygiene to avoid spread of the virus. That means washing hands, using hand sanitizer, covering the cough and tossing tissues in the trash.
Some seniors need to break their habit of keeping tissues in their sleeves, according to Matthys. Matthys and Ricard both highly recommend everyone use a tissue once and throw it in the trash.
“And no hankies!” scolds Matthys. She’s not joking. Matthys recognizes there is a generation of men and women who still carry handkerchiefs in their purses and pockets.
Though many seniors have made it a lifelong habit to use a hanky instead of tissue, they may not realize how unsanitary it is — especially if they lend them to a friend, the health professionals said….
As the Indiana Department of Health reports widespread influenza-like illnesses, healthcare providers urge everyone to get a flu shot, be fastidious about washing their hands, covering their mouths when they cough and — as Ricard and Matthys said — remembering to throw away used tissues.” (I)

“In 2015, during an interview on the former Opie & Jim Norton radio show, Trump was asked if he gets the flu shot every year, and said no:
“I’ve never had one… Thus far I’ve never had the flu. I don’t like the idea of injecting bad stuff into [my] body, which is basically what they do…I’ve never had a flu shot, and I’ve never had the flu…I have friends that religiously get the flu shot and then they get the flu… I’ve seen a lot of reports that the last flu shot is virtually totally ineffective.”
He also said: “I’ve passed on it, but that doesn’t mean [other] people should.” “ (J)

Note: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.

(A) Watch how the flu became an epidemic, by SUSAN STEADE,
(B) 2017-2018 Influenza Season Week 1 ending January 6, 2018,
(C) Flu stresses hospitals, shows we’re not ready for emergencies, by MAGGIE FOX,
(D) California hospitals face a ‘war zone’ of flu patients — and are setting up tents to treat them, by Soumya Karlamangla,
(E) A Monster of a Flu Season Has the CDC Hunkering Down on Strategies, by Peter Hess,
(F) Why the Deadly 2018 Flu Season Could Get Even Worse ,
(G) A severe flu season is stretching hospitals thin. That is a very bad omen, By HELEN BRANSWELL,
(H) ‘Smart Thermometers’ Track Flu Season in Real Time, by DONALD G. McNEIL Jr. ,
(I) Don’t want to get the flu? Stop using hankies, experts say, by Nancy Coltun Webster,
(J) Did President Donald Trump Get the Flu Shot?, by ALEXANDRA SIFFERLIN,

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