The last DOCTOR post was about overmedication with prescription drugs and how to talk to your doctor about “DESCRIBING”. “Describing” is tapering off of drugs no longer needed. *
This post is about a related problem, the non-adherence to prescription drugs and the often severe and adverse consequences of non-compliance.
Non-Adherence refers to those who: Failed to fill or refill a prescription; Missed a dose; Took a lower or higher dose than prescribed; Stopped a prescription early; Took an old medication for a new problem without consulting a doctor; Took someone else’s medicine; or Forgot whether they’d taken a medication. (A)
Physicians should confirm that each patient:
– Understands their medications by reviewing: brand or generic name; function; how, when, and length of time the medication is taken; possible side effects; foods, liquids and activities to avoid while on the medication; refills (if necessary); and medication storage.
– Physicians can ask: “This medication will be an additional expense, how does it fit into your finances?”
– Have family members or caregivers be part of the team to help with administration and provide reminders
– And finish with: “I have given you a lot of information, let’s review your understanding of the prescription(s). (B)
Here are some details on the non-adherence epidemic.
The numbers are staggering. “Studies have consistently shown that 20 percent to 30 percent of medication prescriptions are never filled, and that approximately 50 percent of medications for chronic disease are not taken as prescribed,” ….“This lack of adherence….is estimated to cause approximately 125,000 deaths and at least 10 percent of hospitalizations, and to cost the American health care system between $100 billion and $289 billion a year.” (C)
“Within two years of having a heart attack, nearly 1 in 5 people stop taking lifesaving cholesterol-lowering drugs known as statins, according to a new study. And nearly 2 in 5 end up taking the drugs in lower doses or less often than they should…” (D)
“Medications are dispensed with the expectation that they will be taken exactly as prescribed. However, most patients do not follow their doctors’ orders. Excuses take many forms: “The medication was too expensive,” “If 1 pill is good, then 2 pills should be twice as good,” or “I didn’t understand the directions on the label.”” (E)
“… Patients may be no adherent during different stages of their treatment. They may decide not to fill their prescriptions in the pharmacy and not start their treatment at all. Patients may use more or less than the prescribed treatment or use their medication at the wrong time. They may also discontinue treatment prematurely.” (F)
* “DEPRESCRIBING” – Is there an epidemic of prescription medicine overtreatment? Start CHOOSING WISELY http://doctordidyouwashyourhands.com/2017/04/deprescribing-is-there-an-epidemic-of-prescription-medicine-overtreatment-start-choosing-wisely/
(A) Medication Adherence in America:2013, http://www.ncpa.co/adherence/AdherenceReportCard_Abridged.pdf
(B) Teaching Patients about their Medications: The Keys to Decreasing Non-Compliance, https://healthcarecommunication.wordpress.com/2009/02/06/teaching-patients-about-their-medications-the-keys-to-decreasing-non-compliance/
(C) The Cost of Not Taking Your Medicine, by Jane Brody, New York Times, https://www.nytimes.com/2017/04/17/well/the-cost-of-not-taking-your-medicine.html?smprod=nytcore-ipad&smid=nytcore-ipad-share&_r=0
(D) Many people stop taking life-saving drugs after heart attacks, by Andrew M. Seaman, Washington Post, https://www.washingtonpost.com/national/health-science/many-people-stop-taking-lifesaving-drugs-after-heart-attacks/2017/04/21/705a28e8-253e-11e7-a1b3-faff0034e2de_story.html?utm_term=.14225b93cfe6
(E) Medication Nonadherence: Finding Solutions to a Costly Medical Problem, by Harold Gottlieb, Medscape, http://www.medscape.com/viewarticle/409940
(F) Definitions, variants, and causes of nonadherence with medication: a challenge for tailored interventions, by Jacqueline G Hugtenburg et al, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3711878/
It is up to you to ask your physician if you, or a family member, are on too many medications.
“If a patient were to hear something to the effect of ‘let’s get some lab tests,’ I would ask the clinician: How many and why?” …. “Once you order six or seven individual lab tests, the odds of one of them being a false positive already is about 20 percent. Just statistically. So if there are a lot of vials of blood being drawn [ask] ‘Why are we doing this? Why are each of these lab tests needed to help in my care?'” (A)
Too many meds may be caused by defensive medicine, different physicians prescribing without considering what the patient is already taking, and patient failure to remember all prescriptions.
Here’s what you can do.
(1) Start by carrying a list of your prescription with you and show it to every physician every time, as well as others who prescribe like dentists and podiatrists. Include on the list over-the-counter supplements such as allergy medicine, probiotics, and pain relievers.
(2) Next, there are many drug on line interaction checkers to use e.g. WebMD http://www.webmd.com/interaction-checker/default.htm RxList http://www.rxlist.com/drug-interaction-checker.htm Medscape http://reference.medscape.com/drug-interactionchecker
(3) Then go to CHOOSING WISELY http://www.choosingwisely.org which seek to reduce overtreatment, and incorporate these recommendations into practice guidelines, local best practices, and decision support systems.
And, most importantly, tell your primary care practitioner every time you get a new prescription from another doctor or start a new over-the counter product.
NOW read the rest of this post to understand why this is so important!
“The point of prescription drugs is to help us get or feel well. Yet so many Americans take multiple medications that doctors are being encouraged to pause before prescribing and think about “deprescribing” as well.
The idea of dropping unnecessary medications started cropping up in the medical literature a decade ago. In recent years, evidence has mounted about the dangers of taking multiple, perhaps unnecessary, medications.” (B)
Here are some examples:
“When it comes to treating seniors with diabetes, new research suggests that doctors often don’t cut back on medications, even when treatment goals are surpassed.
The study found that when people had potentially dangerous low blood sugar levels, just 27 percent had their medicines decreased. And when blood pressure treatments lowered blood pressure levels too much, just 19 percent saw a reduction in their medications.” (C)
“….efforts to curb excessive antibiotic use toward outpatient and long term care settings. As many as 70% of nursing home residents receive at least one course of antibiotics each year, but up to 75% of those prescriptions are unnecessary, or the wrong drug, dose or duration of treatment is given, according to the CDC. UTIs are a commonly over-diagnosed in seniors, relying on vague symptoms of confusion or bacteria in the urine, leading to antibiotic overuse. “(D)
“The study…, found that in older adults aged 70 or older, taking blood pressure medication was linked to a higher risk of serious falls. (Serious falls as in, falls that caused an ER visit for a fracture, a dislocated joint, or a brain bleed. Serious stuff indeed!)” (E)
WHAT YOU SHOULD DO:
“Avoiding overdiagnosis and overtreatment also means letting go of some longstanding notions, such as the doctor always knows best; more treatment is better; and that improved technology and early screening will definitely lead to better outcomes..”
“How can we decrease overtreatment? Reducing the use of screening or diagnostic testing that relays more information than requested, increasing the use of surveillance or watchful waiting when small or lower-risk abnormalities are detected, and performing studies to determine the extent of benefit (if any) of treating abnormalities…(F)
(A) Signs of Overtreatment: How to Avoid Unnecessary Care .What to know before saying “yes” to more tests, procedures or prescriptions, by Michael O. Schroeder, http://health.usnews.com/health-news/patient-advice/articles/2015/08/18/signs-of-overtreatment-how-to-avoid-unnecessary-care
(B) How Many Pills Are Too Many? by Austin Frakt, New York Times https://www.nytimes.com/2017/04/10/upshot/how-many-pills-are-too-many.html?smprod=nytcore-ipad&smid=nytcore-ipad-share
(C) Too Many Seniors With Diabetes Are Overtreated by Serena Gordon, http://www.webmd.com/diabetes/news/20151029/too-many-seniors-with-diabetes-are-overtreated-study-suggests#1
(D) CDC warns of overdiagnosis and overtreatment of UTIs in seniors, https://www.univadis.com/viewarticle/cdc-warns-of-overdiagnosis-and-overtreatment-of-utis-in-seniors-316988?s1=news
(E) Blood pressure medications linked to serious falls: What you can do, by Leslie Kernisan, http://betterhealthwhileaging.net/falls-blood-pressure-medications-elderly/
(F) Improving Quality by Doing Less: Overtreatment, by Jessica Herzstein and Mark Ebell, http://www.aafp.org/afp/2015/0301/p289.html
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.
As our economy takes off, there are still many left behind or in need of a helping hand – including veterans with disabilities, those with behavioral health and addiction challenges, the undocumented without access to health services, refugees seeking a new start, and many, many more.
Not-for-profit health and social service agencies are often the only source of case management services for these people are major contributors to our communities. They always need our support but perhaps more so now than ever with the “soft” program cuts proposed in the Trump administration budget to pay for increased military spending.
“If you are not part of the solution, you are part of the problem.” And part of the solution is to volunteer.
We celebrate the selfless individuals around our country who channel their civic virtues through volunteerism… devoted to a cause bigger than themselves….. ~Barack Obama
“Volunteering offers vital help to people in need, worthwhile causes, and the community, but the benefits can be even greater for you, the volunteer. Volunteering and helping others can help you reduce stress, combat depression, keep you mentally stimulated, and provide a sense of purpose. (A)
The smallest act of kindness is worth more than the grandest intention. ~Oscar Wilde
Don’t expect someone to come knocking on your door asking you to volunteer. You have to do it yourself.
Where to begin? “We live in a world where technology can connect us with new opportunities in almost every area of life, from who to date to what to have delivered for lunch. And while these choices can enhance and enrich our lives, people with time, skills and a desire to do good are also looking to technology to help them make a difference in the lives of others.” (B)
Here are some links to get started: web sites that match organizations looking for volunteers with folks look for nearby volunteer opportunities.
Create the Good http://createthegood.org/
Do Something https://www.dosomething.org/us/about/who-we-are
Even if it’s a little thing, do something for those who have need of a man’s help, something for which you get no pay but the privilege of doing it. For, remember, you don’t live in a world all your own. Your brothers are here too. ~Albert Schweitzer
I usually toss my Explanation of Benefits (EOBs) into a basket, then later throw them out without any review.
I have Medicare with secondary coverage from United, and I get sequential Explanations of Benefits (EOBS) from each.
Here are some of the reasons I can’t figure out whether or not my claims have been processed correctly.
– The Medicare and United EOBs are different and it is difficult to try to link them
– Each has a separate deductible and it’s hard to track
– Some secondary insurers “outsource” certain categories of service such as rehab/chiropractic generating additional EOBs
– I also get a periodic Medicare Part D report, for the Prescription Drug benefit
– If Medicare doesn’t pay then United won’t either even if United would pay if it was primary. For a given provider the secondary co-pay is different depending on whether or not the provider is in or out of network, no matter that Medicare pays
– Every provider codes claims differently so similar service at two providers may be coded and billed differently.
– When I got PT in two different places one charged me $20 per visit, the other calculated a co-pay for each visit.
– I am going to a chiropractor who accepts Medicare and is out-of-network for United so I will not know my out-of-pocket costs until I get both EOBs.
– Medicare and United have different appeal procedures. If I can’t link the EOBs it’s impossible to know where to appeal
Here’s a personal frustrating example:
In early December I received a bill and paid $205 for a lab test done at a reference laboratory. No insurance claims had been processed.
After I followed up, in March I got an email: “I contacted XXX and spoke with ZZZ. Per ZZZ Medicare processed and made payment on one of the charges but denied the other (processed the $82.00 charge denied the $123.00 charge). He is confirming the reason for the denial for the second charge and will work with Medicare regarding processing it for payment. Currently you have a credit of $73.38 however Empire has not processed and paid for the $8.62 coinsurance applied by Medicare. ZZZ will submit that as well.”
As of April 9th, still not resolved.
We are “collateral damage” in a war between hospitals and insurance companies. *
The obvious but unlikely solution is universal coding/ claims/ EOB by all providers, integrated to simplify tracking of a claim through primary and secondary insurers.
to learn more about EOBs you might look at:
What is an EOB? http://www.medicalbillingandcodingu.org/what-is-an-eob/
Understanding Your Explanation of Benefits http://www.patientadvocate.org/index.php?p=441
Understanding Your Explanation of Benefits (EOB) – How to Decipher Your Explanation of Benefits https://www.verywell.com/understanding-your-eob-1738641
Two “must read” articles:
Markups On Care Can Fatten Hospital Budgets — Even If Few Patients Foot The Full Bill, by Chad Terhune. Kaiser Health News. http://khn.org/news/markups-on-care-can-fatten-hospital-budgets-even-if-few-patients-foot-the-full-bill/
Those Indecipherable Medical Bills? New York Times. by Elisabeth Rosenthal. https://www.nytimes.com/2017/03/29/magazine/those-indecipherable-medical-bills-theyre-one-reason-health-care-costs-so-much.html
Living in the rarified world of VIP access to health care maybe it’s time for a non-randomized clinical trial, with Congressman being in a study group where they have to pay out-of-pocket fee-for-service with no reimbursement, for prostate screening and treatment.
So they can experience what life was like for 20 million Americans before Obamacare.
Some specifics of the trial. They must get care in their districts. No “professional courtesy” from local physicians. No free PSA. Go to the ER if further tests are needed and become “self pay”, or apply for “charity care” and/ or work out a payment plan for the hospital charges, radiologist, urologist +++
THEN in a year come back to Washington and revise the Obamacare algorithms to assure its sustainability.
For which they might start be reading How to Build on Obamacare by Paul Krugman of the New York Times.
“Actually, though, health care isn’t all that complicated. Basically, you need to induce people who don’t currently need medical treatment to pay the bills for those who do, with the promise that the favor will be returned if necessary.
Unfortunately, Republicans have spent eight years angrily denying that simple proposition. And that refusal to think seriously about how health care works is the fundamental reason Mr. Trump and his allies in Congress now look like such losers.
But put politics aside for a minute, and ask, what could be done to make health care work better going forward?”
To see some solutions read the rest of the article by clicking on https://www.nytimes.com/2017/03/27/opinion/how-to-build-on-obamacare.html?smprod=nytcore-ipad&smid=nytcore-ipad-share&_r=0
To understand why “Repeal and Replace” was a flop click on LESSONS LEARNED: TrumpRyanCare Obits at http://doctordidyouwashyourhands.com/2017/03/lessons-learned-trumpryancare-obits/
And, worth reading:
Is Obamacare a Lifesaver? By Ross Douthat, New York Times https://www.nytimes.com/2017/03/29/opinion/is-obamacare-a-lifesaver.html?smprod=nytcore-ipad&smid=nytcore-ipad-share
“Repeal and Replace” was a political play!
After eight years of whining, “there was no there there”, no Republican plan!
Following is a sequence of obituary snippets explaining what happened and why.
Ryan: ObamaCare will be law for ‘foreseeable future’
“GOP leadership and the White House had spent weeks attempting to bring skeptical Republicans on board. Conservatives argued the bill didn’t go far enough to repeal ObamaCare, while moderate lawmakers worried about backlash in their districts from those who came to rely on ObamaCare.”
THE HILL. Ben Kamisar
Why Trumpcare Failed
“After making repeal of that law their top legislative priority for the past seven years, Republicans now join the much longer list of failures because, during all that time, they never reached a consensus. Rather than come up with a plan the party could unite behind, and with the ACA filling the space where bipartisan consensus could be had, they splintered and entrenched. You can’t bridge that divide. (For their own political sakes, they’re lucky they didn’t.)”
“Freedom Caucus members have a cold vision of health care reform, but a coherent one. They believe that the government being involved in health care, either through regulation or subsidies, is the factor driving up prices, and undoing all of that architecture is what’s necessary to allow market forces to drive down prices. Being coherent in this way on health care policy means accepting the trade-offs that your vision entails, and Freedom Caucus members accept that this approach would leave a lot of vulnerable people in the lurch, left to the care of charities and communities. They have an odd belief that a vast majority of the American public shares this vision despite representing only a small percentage of the House of Representatives.”
Slate. Jim Newell http://www.slate.com/articles/news_and_politics/politics/2017/03/all_of_the_reasons_why_trumpcare_failed.html
In Major Defeat for Trump, Push to Repeal Health Law Fails
“The Republican bill would have repealed tax penalties for people without health insurance, rolled back federal insurance standards, reduced subsidies for the purchase of private insurance and set new limits on spending for Medicaid, the federal-state program that covers more than 70 million low-income people. The bill would have repealed hundreds of billions of dollars in taxes imposed by the Affordable Care Act and would also have cut off federal funds to Planned Parenthood for one year.
Mr. Ryan had said the bill included “huge conservative wins.” But it never won over conservatives who wanted a more thorough eradication of the Affordable Care Act. Nor did it have the backing of more moderate Republicans who were anxiously aware of the Congressional Budget Office’s assessment that the bill would leave 24 million more Americans without insurance in 2024, compared with the number who would be uninsured under the current law.
The budget office also warned that in the short run, the Republicans’ legislation would drive insurance premiums higher. For older Americans approaching retirement, the cost of insurance could have risen sharply.”
New York Times. ROBERT PEAR, THOMAS KAPLAN and MAGGIE HABERMAN
Why Republicans failed to repeal Obamacare
“Let me briefly try to answer this question: How did Republicans fail to repeal and replace the Affordable Care Act? In no order, and off the top of my addled mind at the end of a crushing week:
— They hated Obamacare but they never understood the Affordable Care Act. This is the uber-explanation for much of what follows. Hating Obamacare became just what you did on the right. It didn’t mean you understood it, beyond maybe getting that it was a government program and thus paid for by taxes. It certainly (and this turned out to be very important) didn’t mean you had any ideas about what it did, how it worked or how many people were benefiting from it … or how to replace it.”
The Washington Post. Jared Bernstein
The Trumpcare Con Implodes
“Passing the bill would have also made a joke of Republican promises that, given the chance, they would replace Obamacare with something that would result in cheaper, better insurance for more people. Trump himself went much further, guaranteeing “insurance for everybody” at government expense. The American Health Care Act was diametrically opposed to those supposed goals.
And that’s what really matters, after all: The practical effects of huge changes to the health care system for those who actually need to use it, alongside the faith Americans can have that their elected officials are making promises they will at least attempt to keep.
Instead, the GOP, from Trump on down, spent years claiming they had a magic plan to make everyone’s health care better, and then tried to bang through a bill in just a few weeks that would have covered fewer people, who would have had to pay much more for whatever care they got, without even reducing the deficit conservatives pretend to care about by all that much. They didn’t even bother waiting for the Congressional Budget Office to assess the final product, so little did they care for the real-world effects it might have.”
U.S.News. Pat Garofalo
Three Real Reasons “TrumpCare” Failed
“Why was the bill so unpopular? First and foremost it’s because most people hate the underlying Republican philosophy pertaining to health care. And they hate it for good reason: it doesn’t work.
We tried the GOP philosophy of allowing the “competitive” market to provide the “most wonderful health care plan in the world” and it produced a system that resulted in per person health care costs twice as high as the rest of the industrial world and outcomes that were worse. That was the world of pre-ACA health care.
The “unfettered market” allowed insurance companies to discriminate against people with pre-existing conditions – and to define one of those “pre-existing conditions” as simply being a woman. It allowed them to enforce lifetime caps on coverage – so if you got really sick you were simply out of luck.”
The Huffington Post. Robert Creamer
The cruel double standard that may have saved Obamacare
“But others cite another factor: The face of Obamacare is now white.
More Americans now realize Obamacare helps millions of working class whites and that it’s not — as once portrayed by conservatives — a form of welfare pushed by the first black president to help people of color, historians and scholars say. The media landscape is filled with images of the furrowed brows of anxious white residents at congressional town halls who fear they will suffer if they lose Obamacare, says Judy Lubin, a sociologist and adjunct professor at Howard University in Washington.
“When you see white working-class Americans saying that I’m benefiting and my family is getting help from the Affordable Care Act, you start to hear ‘repair’ not ‘repeal,'” Lubin says. “Whites standing up in support of a policy changes the dynamics of the conversation.”
CNN. John Blake
“For seven years — seven years — Republicans thundered about the evils of Obamacare, yearned for the day when they could bury it and vowed to do precisely that once the ball was in their hands.
Last week proved that this had all been an emotional and theatrical exercise, not a substantive one. The ball was in their hands, and they had no coherent playbook. No real play. They scurried around the Capitol with their chests deflated and their tails between their legs.
For the entirety of his campaign, Donald Trump crowed about his peerless ability to make deals, one of which, he assured us, was going to be a replacement for Obamacare that would cut costs without leaving any Americans in the lurch.
Last week proved that there was no such swap, that he hadn’t done an iota of work to devise one and that he was spectacularly unprepared to shepherd such legislation through Congress. As his promise lay in tatters at his feet, he gave a delusional interview to Time magazine about what an infallible soothsayer he is, then tried to shift the blame to Democrats, who, he said, would soon be the ones hankering for an Obamacare replacement.”
New York Times. Frank Bruni
Trump: I never said repeal and replace would come in 64 days
“Yet asked if he would talk to Democrats now that Republicans are moving on, Trump said no.
“I think we have to let Obamacare go its way for a little while, and we’ll see how things go. I’d love to see it do well, but it can’t. I mean, it can’t,” Trump said. “It’s not a question of, ‘Gee, I hope it does well.’ I would love it to do well. I want great health care for the people of this nation, but it can’t do well. It’s imploding and soon will explode, and it’s not gonna be pretty. So the Democrats don’t wanna see that so they’re gonna reach out when they’re ready. And whenever they’re ready, we’re ready.” “
POLITICO. Nolan D. McCaskill
With GOP Plan Dead, Trump Weighs Other Ways to Reshape Health Care
Republicans have ability to make changes to Affordable Care Act but do so at their own risk
“With the collapse of Republicans’ health plan in the House on Friday, the Trump administration is set to ramp up its efforts to alter the Affordable Care Act in one of the few ways it has left—by making changes to the law through waivers and rule changes.”
Wall Street Journal. Stephanie Armour
As a former hospital CEO, with many colleagues at nearby hospitals, I had quick access to the best medical care.
Now, as a Medicare enrollee, I am finding it more and more difficult and time-consuming to find doctors who will take Medicare. And, of course, I don’t want to sacrifice quality for price.
When a physician opts out of Medicare, ”The physician must sign and file an affidavit agreeing to forgo receiving any payment from Medicare for items or services provided to any Medicare beneficiary for the following 2-year period…”
Most significantly, if getting care from an opted-out physician the beneficiary (me or any other Medicare enrollee): “gives up all Medicare payment for services furnished by the “opt out” physician; agrees not to bill Medicare or ask the physician to bill Medicare; is liable for all of the physician’s charges, without any Medicare balance billing limits; acknowledges that Medigap or any other supplemental insurance will not pay toward the services; and acknowledges that he or she has the right to receive services from physicians for whom Medicare coverage and payment would be available. http://www.aafp.org/practice-management/regulatory/medicare.html
I have paid into Medicare for 45 years and, like many of you, now or later, don’t want to pay full out-of-pocket charges where doctors have opted out of Medicare. Why pay life-time premiums for Medicare than get care from non-Medicare providers.
One can inadvertently wind up with a big bill even when vigilant. For example:
– Go to an Emergency Room where the hospital takes Medicare but the ER group does not. http://www.cbs5az.com/story/23063821/emergency-room-doctors-may-not-take-insurance-even-if-hospital-does
– Your primary care physician takes Medicare but refers you to specialists who don’t.
– When you are admitted to the hospital for surgery and the surgeons takes Medicare and the anesthesiologist which you had no say in selecting (and perhaps radiologist and pathologist) does not.
– And when the surgeon is assisted by another surgeon, which you were not told about, who does not take Medicare.
– You assume your MediGap insurance will cover an expense because like I was, you aren’t aware that MediGap insurance only clicks in for Medicare approved care.
Now blaming it on Obamacare and perhaps in anticipation of Trump/ Ryan Care, the Minneapolis Star Tribune, in an article by Jeremy Olson reported that:
“Mayo Clinic’s chief executive made a startling announcement in a recent speech to employees: The Rochester-based health system will give preference to patients with private insurance over those with lower-paying Medicaid or Medicare coverage, if they seek care at the same time and have comparable conditions.
“Mayo will always take patients, regardless of payer source, when it has medical expertise that they can’t find elsewhere, said Dr. John Noseworthy, Mayo’s CEO. But when two patients are referred with equivalent conditions, he said the health system should “prioritize” those with private insurance.”
Let’s make sure that access to Medicare is not further compromised by health care providers.
“DHS questions whether Mayo policy violates law”
Recent reports say that Mayo Clinic will give preference to privately insured patients under a new policy, which is under scrutiny by the DHS.
The Minnesota Department of Human Services is probing the Mayo Clinic for possible violations of civil- and human-rights laws by putting a higher priority on patients with commercial insurance.
Jonathan M. Metsch, Dr.P.H.
Clinical Professor, Preventive Medicine, Icahn School of Medicine at Mount Sinai
Adjunct Professor, Management, Zicklin School of Business, Baruch College, C.U.N.Y.
Adjunct Professor, Rutgers School of Public Affairs and Administration & Rutgers School of Public Health