“The longer these (measles) outbreaks continue, the greater the chance measles will again get a sustained foothold in the United States.”

PART 1. April 30, 2019

PART 2. May 6, 2019. “We are getting very close to a tipping point. If (measles) cases continue to escalate, the U.S. could lose its elimination status…”

Assignment: Develop a continuum of evidenced based strategies for states focusing on avoiding measles cases (22 states are already “infected”)

New PART 2 after PART 1

PART 1. April 30, 2019

“The longer these (measles) outbreaks continue, the greater the chance measles will again get a sustained foothold in the United States.”

“The number of measles cases in the United States has risen to 695, the highest annual number recorded since the disease was declared eliminated in this country in 2000, federal health officials said on Wednesday.

The total has now surpassed the previous high of 667 set in 2014, according to the Centers for Disease Control and Prevention. The virus has been detected in 22 states.

Most cases are linked to two large and apparently unrelated outbreaks. One is centered in Orthodox Jewish communities in New York City and its suburbs; that outbreak began in October and recently spread to Orthodox communities in Michigan.

The other outbreak began in Washington State…

The New York outbreak was set off by Americans who had visited Israel, where cases have been spreading in Orthodox communities since early last year. City officials have taken extraordinary measures to crack down on resistance to immunization.

Mayor Bill DeBlasio declared a state of emergency and threatened residents of four Brooklyn ZIP codes with $1,000 fines if they refused to vaccinate.

Twelve summonses have been issued so far, the city health department said; people who do not answer them can be fined $2,000. City officials closed a yeshiva preschool for violating vaccination orders.

Rockland County, N.Y., the center of another outbreak, initially barred unvaccinated children from all indoor public places, including schools, malls, supermarkets, restaurants and houses of worship.

After a court blocked that order, the county instead barred from public spaces anyone who had measles symptoms or who had recently been exposed to the disease, threatening them with fines of up to $2,000 a day.”  (A)

“More than 1,000 students and staff members at two Los Angeles universities were quarantined on campus or sent home this week in one of the most sweeping efforts yet by public health authorities to contain the spread of measles in the U.S., where cases have reached a 25-year high.

By Friday afternoon, two days after Los Angeles County ordered the precautions, about 325 of those affected had been cleared to return after proving their immunity to the disease, through either medical records or tests, health officials said.

The action at the University of University of California, Los Angeles, and California State University, Los Angeles — which together have more than 65,000 students — reflected the seriousness with which public health officials are taking the nation’s outbreak…

“This is a legally binding order,” the county’s public health director, Dr. Barbara Ferrer, told reporters.”

Anyone who violates it could be prosecuted, she said, but added that it appears everyone is cooperating so far. She didn’t describe what penalties those who don’t could face.  (B)

Measles is making a comeback in 2019.

“Since January of this year, 22 states have experienced a total of 695 cases of measles, an infectious disease that was supposed to be eradicated almost two decades ago following an outbreak of more than 30,000 cases and a push to get everyone vaccinated — twice…

“This year is the worst since 2000.” said Dr. Sean O’Leary, a pediatric infectious diseases specialist working with the American Academy of Pediatrics. “There are more pockets now of parents who have chosen not to immunize their kids. And when someone with measles comes into that community, it spreads.”” (C)

CDC Measles Tracking by State



Pre-vaccine Era

In the 9th century, a Persian doctor published one of the first written accounts of measles disease.

Francis Home, a Scottish physician, demonstrated in 1757 that measles is caused by an infectious agent in the blood of patients.

In 1912, measles became a nationally notifiable disease in the United States, requiring U.S. healthcare providers and laboratories to report all diagnosed cases. In the first decade of reporting, an average of 6,000 measles-related deaths were reported each year.

In the decade before 1963 when a vaccine became available, nearly all children got measles by the time they were 15 years of age. It is estimated 3 to 4 million people in the United States were infected each year. Also each year, among reported cases, an estimated 400 to 500 people died, 48,000 were hospitalized, and 1,000 suffered encephalitis (swelling of the brain) from measles.

Vaccine Development

In 1954, John F. Enders and Dr. Thomas C. Peebles collected blood samples from several ill students during a measles outbreak in Boston, Massachusetts. They wanted to isolate the measles virus in the student’s blood and create a measles vaccine. They succeeded in isolating measles in 13-year-old David Edmonston’s blood.

In 1963, John Enders and colleagues transformed their Edmonston-B strain of measles virus into a vaccine and licensed it in the United States. In 1968, an improved and even weaker measles vaccine, developed by Maurice Hilleman and colleagues, began to be distributed. This vaccine, called the Edmonston-Enders (formerly “Moraten”) strain has been the only measles vaccine used in the United States since 1968. Measles vaccine is usually combined with mumps and rubella (MMR), or combined with mumps, rubella and varicella (MMRV). Learn more about measles vaccine.

Measles Elimination

In 1978, CDC set a goal to eliminate measles from the United States by 1982. Although this goal was not met, widespread use of measles vaccine drastically reduced the disease rates. By 1981, the number of reported measles cases was 80% less compared with the previous year. However, a 1989 measles outbreaks among vaccinated school-aged children prompted the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP) to recommend a second dose of MMR vaccine for all children. Following widespread implementation of this recommendation and improvements in first-dose MMR vaccine coverage, reported measles cases declined even more.

Measles was declared eliminated (absence of continuous disease transmission for greater than 12 months) from the United States in 2000. This was thanks to a highly effective vaccination program in the United States, as well as better measles control in the Americas region.

Photos reveal what it looks like to get the measles when there are no vaccines, by Hilary Brueck,


Complications (E)

Common complications from measles include otitis media, bronchopneumonia, laryngotracheobronchitis, and diarrhea.

Even in previously healthy children, measles can cause serious illness requiring hospitalization.

One out of every 1,000 measles cases will develop acute encephalitis, which often results in permanent brain damage.

One or two out of every 1,000 children who become infected with measles will die from respiratory and neurologic complications.

Subacute sclerosing panencephalitis (SSPE) is a rare, but fatal degenerative disease of the central nervous system characterized by behavioral and intellectual deterioration and seizures that generally develop 7 to 10 years after measles infection.

People at High Risk for Complications

People at high risk for severe illness and complications from measles include:

Infants and children aged <5 years

Adults aged >20 years

Pregnant women

People with compromised immune systems, such as from leukemia and HIV infection..

Healthcare personnel

Healthcare personnel should have documented evidence of immunity against measles, according to the recommendations of the Advisory Committee on Immunization Practices

“In asserting the constitutionality of vaccination mandates and coercive public health orders, public health lawyers generally look back to the Supreme Court’s 1905 case of Jacobson v. Massachusetts. In that case, the Supreme Court upheld a law mandating smallpox vaccination stating, “Upon the principle of self-defense, of paramount necessity, a community has the right to protect itself against an epidemic of disease which threatens the safety of its members.”

The Jacobson case is still the starting point for any discussion of the constitutionality of public health emergency powers, and courts in the modern era have continued to cite it in upholding state vaccine mandates…

The reason Jacobson endures, while other cases and public health practices from its era have been cast aside, is that its central message — “there are manifold restraints to which every person is necessarily subject for the common good” — remains as relevant today as it was in 1905. Public health still requires some limitations on individual freedom. Still, exactly what limitations Jacobson countenances, and how its reasoning should be applied in our own, very different era, are deeply contested and will assuredly be debated as the New York litigation continues.

Even if the courts conclude, as they might, that Jacobson supports the Rockland County and New York City orders, that doesn’t mean Jacobson provides the most effective model for stopping contemporary outbreaks. After all, in what other areas do public officials rely upon approaches that were used in 1905?..

No compromise is likely to be perfect, or fully effective. Many will likely fail. But the return of measles suggests that our old, tried-and-true methods of mandates and emergency orders don’t seem to be solving the problem of vaccine resistance. New tools are needed before more dangerous outbreaks of even more lethal diseases occur. “ (F)

‘Ninety-nine times our legislative bodies have passed such legislation. And that’s gone to the governors that have represented the entire political spectrum in the United States that have signed that legislation all for the benefit of our children and healthier communities. Now think about that — 99 times. That’s the epitome of democracy. Nothing that I can think of has been so profound in affecting the health of children, because those laws have obliged most children to be vaccinated…

But measles has been reintroduced into the Western Hemisphere in two countries; in the United States and Venezuela. What? Two different reasons. In the United States, it’s because some parents, whether for cultural reasons, misunderstood religious reasons, or kind of libertarian reasons, have withheld many children from vaccination creating pockets and communities of susceptible children…

I think every child should be vaccinated and I will now make a bold statement. I think there ought to be valid — valid — medical reasons for exclusion from vaccination. I’m not a friend of either personal belief or religious exemptions. We have three states that have such tight laws now: West Virginia, Mississippi, and California. I think they’re leaders and the rest of us should follow. I wouldn’t want any child to suffer measles or its complications.

I’ll remind you of one thing before I come to a close. Before we had [a] measles vaccine, 400 to 500 children died in the United States annually because of measles and its complications. That number now is zero.”… (G)

“Measles, a virus that invades the nose and throat, causing fever, cough and phlegm, is one of the most contagious pathogens on the planet. Before 1963, it infected some four million people every year in the United States alone. Nearly 50,000 of them would land in the hospital with complications like severe diarrhea, pneumonia and brain inflammation that sometimes resulted in lifelong disability. Of the 500 or so patients who died from these complications each year, most were children younger than 5.

Until recently, those numbers were a matter of history. The measles vaccine, which was introduced to the United States in 1963, drove the annual case count from four million to zero inside of four decades. Measles was officially eradicated in America in 2000 and was largely wiped from our collective memory soon after.

But in the shadow of that memory lapse, a different virus has spread: anti-vaccine propaganda and vaccine misinformation. Both have persuaded a small but growing number of parents that vaccines designed to inoculate against infectious diseases pose a greater health risk than the diseases themselves. As a result, these parents are skipping crucial shots for their children. And as the number of unvaccinated children grows, some vaccine-preventable diseases are making a comeback.

The Centers for Disease Control and Prevention has logged at least six measles outbreaks so far this year, across five states, involving more than 100 patients. In recent weeks, as those numbers have ticked upward, both houses of Congress have held hearings to discuss the issue, while more states have considered limiting vaccine exemptions for school-age children and several prominent social media platforms have pledged to block anti-vaccine propaganda and vaccine misinformation from their sites…

But the new rash of outbreaks has made clear that even small pockets of vaccine hesitancy and refusal can have grave consequences. And health officials say that if left unchecked, this outbreak crisis will only worsen…” (H)

 “The outbreak of measles in the U.S. and around the world is due largely to inadequate vaccination rates in some communities, not illegal immigration, as one popular meme on Facebook claims.

The meme shows a picture of a baby who appears to be infected with measles and says: “Thanks to a highly effective vaccination program the Measles virus was eliminated from the U.S. in 2000. Thanks to the immigrants who illegally cross the U.S. Mexican border, and the Democrats who refuse to stop them, the Measles virus has been declared a public health emergency in 2019.”

The first part of that claim is correct. Measles was eliminated in the United States in 2000 and it was eliminated across both North and South America in 2016…

The second part of the claim, however, is incorrect.

The virus has been brought into the U.S. by people who have traveled to places where there is an outbreak or where the disease is still common, such as parts of Europe, Africa, Asia, and the Pacific, according to the Centers for Disease Control and Prevention. From those travelers, the disease can then spread in U.S. communities that have unvaccinated people, according to the CDC.

For example, the New York City health department declared a public health emergency on April 9. That measles outbreak, which started in 2018 and spread in the Orthodox Jewish community, was brought on by travelers who had been in Israel, where a large outbreak is occurring, according to the Pan American Health Organization”… (I)

“The Washington state Senate narrowly passed a measure late Wednesday that would make it harder for parents to opt out of vaccinating their children against measles in response to the state’s worst outbreak in more than two decades.

The bill, which would eliminate personal or philosophical exemptions from the measles, mumps and rubella (MMR) vaccine, is a victory for public health advocates who had not expected it to make it to the floor…

The bill is expected to pass the House, where a nearly identical measure was approved last month, and be signed into law by Gov. Jay Inslee (D). It would be the first time in four years a state has removed personal exemptions in the face of growing anti-vaccine sentiment. California and Vermont removed personal exemptions in 2015. Other states have tightened vaccination requirements but have not removed exemptions…

The stricter rule would apply only to immunizations for measles, mumps and rubella. Parents would still be able to cite personal or philosophical exemptions to avoid other required school vaccinations for their children. Religious and medical exemptions will still be allowed for all vaccinations, including MMR.

Advocates and lawmakers were able to overcome strong lobbying by anti-vaccine groups, which are among the most vocal and organized in the country. Those groups mobilized hundreds of supporters, who telephoned and sent emails to lawmakers, turned out for public hearings and proposed poison-pill amendments, intended to weaken a bill or ruin its chances of passing…

Campaigns to toughen state requirements in Iowa, Colorado, Maine and Oregon also face strong opposition. Washington is one of 17 states that allow exemptions from required immunizations for personal or philosophical beliefs.”  (J)

California would give state public health officials instead of local doctors the power to decide which children can skip vaccinations before attending school under legislation proposed Tuesday to counter what advocates call bogus exemptions.

The measure would also let state and county health officials revoke medical exemptions granted by doctors if they are found to be fraudulent or contradict federal immunization standards. The proposal comes amid measles outbreaks in New York, Washington and elsewhere that are prompting states including Maine and Washington to consider ending non-medical exemptions.

California eliminated all non-medical immunization exemptions in 2016, as have Mississippi and West Virginia. The lawmakers want California to now follow West Virginia’s lead in having public health officials rather than doctors decide who qualifies for medical exemptions. Doctors would send the state health department the reason they are recommending the exemption and would have to certify that they examined the patient….(K)

“In a statement this week, U.S. Secretary of Health and Human Services Alex Azar reiterated a tactic that has proven ineffective at reaching skeptical populations in recent years: telling them what to do. “Vaccines are a safe, highly effective public-health solution that can prevent this disease,” he said. “The measles vaccines are among the most extensively studied medical products we have, and their safety has been firmly established over many years in some of the largest vaccine studies ever undertaken.”…

Research suggests that the reason informed people fall into conspiracy-theory mind-sets often has less to do with a lack of information than with social and emotional alignment. Facts are necessary, but not at all sufficient. Websites and YouTube videos where a federal employee in a suit states various statistics are unlikely to be effective against targeted disinformation campaigns that only need to plant the seed of doubt in the mind of people already skeptical of the medical establishment. The work of global inoculation requires first rebuilding a social contract, which means meeting people on the platforms where they now get their information, in the ways they now consume it.” (L)

“It was actually measles outbreaks in the 1960s that inspired a push to have states require children get inoculated before starting kindergarten. By the 1980s, all states had mandatory immunization laws in place. The idea behind these laws was simple: Near-universal vaccinations sustain herd immunity.

Still, there’s a lot of variation across the country when it comes to immunization requirements. Even though all 50 states have legislation requiring vaccines for students entering school, almost every state allows exemptions for people with religious beliefs against immunizations, and 17 states currently grant philosophical exemptions for those opposed to vaccines because of personal or moral beliefs. (The exceptions are Mississippi, California, and West Virginia, which have the strictest vaccine laws in the nation, allowing only medical exemptions.)

In these places, opting out can mean simply listening to a doctor or health official explain the benefits of vaccination or getting a signed statement about your religious beliefs notarized. It’s often harder for parents to sign their kids out of school for the day than to help them avoid vaccines.

In 45 states, even without an exemption, kids can be granted “conditional entrance” to school on the promise that they will be vaccinated, but schools don’t always bother to follow up…

California has made it tougher to opt out of vaccines — with mixed and instructive results

Some states have been moving to crack down on vaccine avoiders — most notably California — and the experience there is instructive for states that might want to close some of their loopholes…

There is indeed evidence from Mississippi and West Virginia that strict vaccine laws can work — but again, interpret it with caution.” (M)

“If the U.S. loses its “measles elimination” status, it will join Venezuela as the only other country in North and South America with this distinction. Measles was declared eliminated across the Americas in 2016, but within a year, an outbreak sparked in Venezuela that has persisted up to the current day.

For most Americans, these outbreaks are a bittersweet wake-up call about the importance of the measles-mumps-rubella (MMR) vaccine. Thanks to the success of vaccination programs, most people are unfamiliar with measles itself — which means they may be unsure about how to approach these outbreaks and protect themselves.” (N)

“And although the majority of people getting the illness now were never vaccinated, the expanding outbreaks have raised new questions about whether some older adults — including many of those born before the mid-1960s — should be revaccinated, along with some younger people uncertain of their immunization status.

According to the Centers for Disease Control and Prevention, people who were vaccinated prior to 1968 with an early version of the vaccine, which was made from an inactivated (killed) virus, “should be revaccinated” with at least one dose of live attenuated measles vaccine.

Today’s recommended vaccine is known as MMR and protects against measles, mumps and rubella.

“This recommendation is intended to protect those who may have received killed measles vaccine, which was available in 1963-1967 and was not effective,” according to this Q & A on measles from the CDC…”  (O)

PART 2. May 6, 2019

“We are getting very close to a tipping point. If (measles) cases continue to escalate, the U.S. could lose its elimination status…”

“ON AN OTHERWISE normal Thursday in November 2018, the doors to the Lowell Community Health Center in Massachusetts opened at 8 a.m., as they always do, and the first of 802 patients who would walk through those doors began trickling in…

This routine — a seemingly banal choreography repeated hundreds of times each day — continued until around 12:50 p.m., when a mother arrived with her two-year-old daughter. The child had measles, and suddenly, this was no longer an ordinary day. For virtually anyone not immune to the virus who crossed paths with the toddler, infection was almost certain, and so all of those places the child had been and the rooms where she may have coughed or sneezed became critical evidentiary artifacts in a crisis that had all the potential to spin quickly out of control.

Indeed, the arrival of mother and child set off a chain of events and triggered longstanding but rarely tested protocols aimed at containing a measles outbreak. It involved hundreds of staff not just at the Lowell Community Health Center, but also the Massachusetts Department of Public Health (DPH), the City of Lowell Health Department, and the local hospital — with thousands of emails and a weeklong flurry of activity that strained the center’s capacities to the limit…

That the center managed to contain the highly-contagious measles virus is a testament to its modernized records system, its staff’s military-style precision, and its location in a resource-rich region. But even here there were occasional missteps, bouts of confusion, and administrative second-guessing and finger-pointing. There were also 179 exposed people with no evidence of vaccination — even though the center tried to reach them — suggesting that the fallout at a less-prepared facility could be disastrous…

ON NOVEMBER 7, the child’s mother called the center for an appointment. She said her daughter had a cough and a rash and some sores in her mouth, and asked if they could come in.

Here, the staffer on the phone made the first crucial mistake. Lowell is an old New England mill town with weathered red-brick buildings interconnected by canals, and as a large suburb of Boston, it is heavily populated these days by immigrants; nearly 40 percent of the center’s patients don’t speak English. Protocol would have dictated that center staff ask the mother about recent travel while she was still on the phone, but that didn’t happen. Had the question been asked, staff would have learned that the mother and child had just returned from a month-long trip to an African country where measles is endemic. Although the toddler had received one shot of the measles, mumps, and rubella (MMR) vaccine at the center when she was one, and a single dose is supposed to be 93 percent effective, it may have been no match for the heavy exposure.

Had the staffer asked, mother and daughter would likely have been directed straight to an isolation room, intended for anyone with a contagious illness, on the center’s ground floor. Instead, they came to the center and disclosed to a medical assistant upon arrival that the child had contracted measles abroad…

At approximately 2 p.m., they gathered in a conference room to strategize and to connect with other officials via conference call. Health care organizations are required to have an emergency plan in place, and the center’s chief information officer, Henry Och — an infantry officer in the National Guard, with stints in Kosovo and Afghanistan — would play the role of incident commander…

 “If this happened in a school and not a health center — who’s responding, and how is it being managed?” Vigroux asked. “I think our community is not ready for that.” (A)

“Incidence of measles in Europe spiked dramatically from 2016-2018 in a handful of countries, led by the Ukraine, researchers found…

The World Health Organization’s (WHO) European Region, which contains countries outside of what is traditionally thought of as Europe, went from a little under 5,300 reported cases of measles in 2016 to nearly 83,000 reported cases of measles in 2018 — a fourteen-fold increase, the authors wrote in the Morbidity and Mortality Weekly Report…

When citing reasons for ongoing measles transmission, the authors pointed to factors that appear to be playing a role in the U.S.’s ongoing measles outbreak — namely “an accumulation of susceptible young children in marginalized communities with suboptimal coverage.” Other reasons included persistent measles virus reservoirs in WHO European Region countries “with limited resources and weak immunization systems.”

The majority of measles cases were from the Ukraine — which was previously cited by CDC researchers as one of the top three countries exporting measles to the U.S. In 2018, there were over 53,000 cases in the Ukraine, comprising two-thirds of all measles cases in this region. Second was Serbia, with around 5,000 cases (6% of the total) followed by France and Israel with about 2,900 cases each (each 4% of the total)…”  (B)

“New Jersey’s growing measles outbreak appears to have roots in Israel, New York City and New York’s Rockland County, according to Garden State officials.

Department of Health Commissioner Dr. Shereef Elnahal said a combination of travelers returning from countries where measles is rampant, and individuals crossing back and forth between neighboring states, is largely responsible for the situation in New Jersey. Fourteen Garden State residents have been diagnosed with the virus this year, in addition to the 33 infections detected last fall. Another case is expected to be confirmed this week.

But with New York City experiencing a more severe outbreak, with at least 420 cases, and another 200-plus diagnosed in nearby Rockland County, the threat of cross-border contamination is significant, Elnahal said. Most of the infections have been found within Orthodox Jewish communities in both states, including Ocean County’s Lakewood.

Since community members often travel back and forth for family visits, work or worship, Elnahal said “the transit between New York and New Jersey is the biggest concern now. And the collaboration with (local and state health officials in New York) has been critical.” International travelers have long been the source of viral infections in the United States, Elnahal said, but with more people refusing the vaccine there is a greater chance that infected voyagers can transmit the disease, which spreads quickly in communities with low immunization rates…

Exemptions are permitted for medical reasons (those with compromised immune systems are at risk) and also for religious reasons, although lawmakers in New Jersey and several other states are looking to eliminate the religious opt-out. Elnahal said all the religious leaders he has encountered, including prominent Jewish officials, have urged their followers to comply with vaccination laws.” (C)

“The country is experiencing the worst year for measles in a quarter century, according to the Centers for Disease Control and Prevention (CDC), with 704 reported cases. And New Jersey is right in the middle of an outbreak…

While it’s unlikely New Jersey would ever see hundreds or thousands of cases at once, the state could see localized epidemics with “pockets of people with low vaccination rates getting many infections,” Dr. David Cennimo, an infectious disease expert at Rutgers New Jersey Medical School, said via text

Cennimo said the state is already seeing a “disruption in medicine because of concern for measles.” Treating a measles patient is often tedious and cumbersome, he said.

“Measles is airborne, so people need to stay in special negative-pressure rooms. … These rooms aren’t plentiful,” Cennimo said in an email. “You cannot have a patient walking into a waiting room with measles without a mask on because they can infect everyone.”

Measles is so contagious that 90% of susceptible people exposed to an infected person will become infected, according to the CDC. If outbreaks continue, experts worry about measles patients walking among the public or in hospitals, potentially spreading the disease to vulnerable populations, like babies who’ve yet to receive the vaccine. Those with weakened immune systems, like cancer patients undergoing treatment, would also be at-risk.

Medical personnel may have to ramp up protocols for dealing with patients reporting vague symptoms like a rash or fever. They may have to meet potentially infected patients in the parking lot with masks, diverting staff from other serious health matters.

“All of this is cumbersome and, if it delays care, potentially dangerous,” Cennimo said. “It is difficult for your average primary care doctor or pediatrician to do all of this in a busy office. The measles rash is not very specific and can be confused with other viral rashes.”

He added, “This can really slow down the flow in an (emergency department).” “ (D)

“If you visited the South Plainfield Sky Zone Trampoline Park at 600 Hadley Road on the afternoon of April 22 or the River 978 Banquet Hall at 978 River Ave. in Lakewood on the night of April 23 you may have been exposed to measles, according to the state Department of Health.

A New Yorker with a confirmed case of the virus visited both locations, according to the DOH. The department is warning anyone who visited Sky Zone from noon to 5 p.m. April 22 or the banquet hall from 6 p.m. April 23 to 1 a.m. April 24 that they may have been exposed.

“Anyone who suspects an exposure is urged to call a health care provider before going to a medical office or emergency department,” the department’s statement read. “Special arrangements can be made for evaluation while also protecting other patients and medical staff from possible infection.”

Anyone who may have contracted the virus in this most recent incident may not develop symptoms until as late as May 14, according to the DOH.

On April 22, the DOH announced that a Middlesex County resident with “a highly suspect case of measles” had visited Rosalita’s Roadside Cantina on Route 9 in Marlboro on April 19. The DOH later issued an update, advising that the possible carrier had also visited a Manalapan LabCorp diagnostic center on April 17 and 19.” (E)

‘The return of measles may be an early warning sign of a resurgences of other vaccine-preventable diseases such as rubella, chickenpox and bacterial meningitis, some experts say…

The use of quarantines and other orders are driven in part by a growing concern that outbreaks of measles and other diseases could get worse, despite the availability of effective vaccines, some health experts said.

“I think there’s a sense of anxiety and even a little panic in the public health community” as officials see high levels of mistrust of government and science from a surprising number of people, said Lawrence Gostin, a Georgetown University public health law expert.

That anxiety has led to what Gostin believes are missteps by officials.

It’s one thing to isolate someone with measles or to quarantine someone who has been exposed, he said. Those people are infection risks, and short-term limitations of where they can go and who they can meet are legally and medically appropriate, Gostin said.

But it’s another thing to take the kind of step Rockland County initially did, in which unvaccinated kids were placed under house arrest — not because they were infection risks, but because their parents weren’t listening to public health officials, he said.

One community had success without taking such measures. Officials in Vancouver, Washington, declared an end Monday to a measles outbreak that began in January but apparently stopped at 71 cases a month ago. It was a much smaller community than New York City or Los Angeles and was tamed by an intense investigation and vaccination campaign that involved 230 health workers tracking down infected people and those they had contact with, at a cost of about $865,000.”  (F)

“California public health officials are warning moviegoers who went to see “Avengers: Endgame” and other films at an Orange County movie theater last Thursday that they may have been exposed to measles by a woman in the audience.

The woman attended a midnight screening of the “Avengers” blockbuster at the AMC Dine-In Fullerton 20 on Thursday from 11 p.m. to 4 a.m, the Orange County Health Care Agency said.

Everyone who was in the building may have been exposed, not just at that particular screening room, the agency said.

The warning also applies to people who went to buildings at 5 Hutton Centre Drive in Santa Ana from last Wednesday through Friday.

The woman, who is in her 20s, reported having recently traveled to a country with widespread measles activity, the agency added.” (G)

“A cruise ship was quarantined Tuesday in Saint Lucia after the island nation’s chief medical officer cited concerns that crew members and passengers possibly infected with measles might spread the highly contagious virus, causing an outbreak…

Quarantines are one of many measures used by public health officials to limit the spread of disease, especially to vulnerable populations, such as pregnant women, unvaccinated children, and those with weak immune systems.

According to the Centers for Disease Control and Prevention, a quarantine separates and restricts the movement of people who were exposed to a contagious disease to see if they become sick. This is different than isolation in which sick people are identified and separated from people who are not sick.

“Isolation is used to separate ill persons who have a communicable disease from those who are healthy. The most important thing is that a distance is created between the respiratory secretions of the infected person and others. The person on the cruise ship has to stay in their room and not come into contact with others, especially those who are not vaccinated,” said Dr. Mirella Salvatore, a travel medicine and infectious diseases expert at Weill Cornell Medicine and New York-Presbyterian…

Quarantine times vary, but typically last for at least 21 days — the typical the time from the moment of measles exposure to the time when signs and symptoms of the disease disappear — or until public health officials can prove that everyone is immune and safe.” (H)

“The cruise ship that was placed under quarantine by St. Lucia because of a confirmed case of measles onboard is bound for Curaçao. It’s not clear what will happen when the vessel, called the Freewinds, arrives there…

Health authorities in St. Lucia made the decision to quarantine the Freewinds after a female crew member was confirmed to have measles. There was concern that others onboard might have been infected and that measles could spread to the Caribbean island, which has been free of local transmission of the disease since 1990. St. Lucia’s Ministry of Health and Wellness said on Thursday it had provided 100 doses of measles vaccine to people on the ship…

As we reported Thursday, the Church of Scientology says its members rely on the advice and treatment of medical doctors, but several high-profile Scientologists have spoken out against vaccination.

Curaçao’s vaccination rate is 97% in children born since 2007, according to the Pan American Health Organization.” (I)

“Authorities in Curacao on Saturday boarded a ship that arrived in the Dutch Caribbean island under quarantine, to start vaccinating people to prevent a measles outbreak.

Health officials said only those who already have been vaccinated or have previously had measles will be free to leave the 440-foot (134-meter) ship Freewinds, which reportedly belongs to the Church of Scientology.

Curacao epidemiologist Dr. Izzy Gerstenbluth told The Associated Press that a small team is assessing more than 300 people aboard the ship, and that the process might take more than a day.

“We will go on board and do our job,” he said, adding that authorities have an international obligation to avoid spreading the disease. “If we allow that to happen, measles spreads in places where the risk of severe complications is much bigger, especially when we’re talking about poor countries where people have a lower level of resistance.” (J)

“New York City saw its first and only patient with the deadly Ebola virus 4½ years ago. Since then, emergency and health-care workers have been training for the next patient.

To test their preparedness for treating a patient with Ebola or another similar deadly infectious disease, fire, police, city and medical workers ran a drill, acting out the steps, over two days late last week, while nurses and doctors evaluated them.” (K)

“In order to prepare for viral outbreaks occurring in other parts of the world, New York City and State partnered with first responders in New Jersey to conduct an emergency exercise last week to transport a person pretending to be an Ebola patient to NYC Health + Hospitals / Bellevue. Agencies that participated in the drill included the Health Department, NYC Health + Hospitals, the Fire Department of the City of New York, New York State Department of Health, the Robert Wood Johnson University Hospital, and health and law enforcement agencies from New Jersey. The exercise entailed the transfer of a person pretending to be an Ebola patient from Robert Wood Johnson University Hospital in New Jersey to the Regional Ebola and Other Special Pathogen Treatment Center at NYC Health + Hospitals / Bellevue in New York City…

This exercise – the first of its kind between New York City and New Jersey – tested the health care system’s ability to safely move a patient to a clinical setting where Ebola can be most effectively treated. In particular, the exercise assessed the ability of participants to coordinate patient transportation to NYC Health + Hospitals / Bellevue, safely use biocontainment devices and personal protective equipment while caring for the patient, and appropriately decontaminate and dispose of equipment after transportation. Today’s unprecedented exercise involved over 70 staff from participating health care facilities and state and local agencies.”(L)

“Nearly 70 of the city fire department’s emergency medical techs and paramedics are not vaccinated for measles, according to sources…

The FDNY’s Bureau of Health Services went through all the immunization records after the outbreak, and realized that they had a population of unvaccinated members who were vulnerable to the disease.

The obvious danger was that they could contract the illness, officials said. But they could spread it as well.” (M)

“Maine could soon prohibit parents from citing religious or personal beliefs to avoid vaccinating their children, making the U.S. state one of a half dozen cracking down during the nation’s largest measles outbreak in 25 years.

State legislatures in New York, New Jersey, Oregon, Vermont, Minnesota and Iowa are looking at similar bills that would only allow exemptions from vaccinations for medical reasons as determined by the child’s doctor…

Maine has one of the lowest vaccination rates in the country, with 5 percent of kindergartners holding a non-medical exemption from vaccination, compared to a national average of 2 percent, according to CDC data.

The World Health Organization has said at least 95 percent of a community must be immunized against measles to achieve the “herd immunity” needed to protect those unable to get the vaccine such as infants and people with compromised immune systems.

No measles cases have been recorded in largely rural Maine since 2017, but state officials have been worried by outbreaks of whooping cough, another childhood disease that can be prevented by vaccination.” (N)

“The measles vaccines are among the most extensively studied medical products. The safety of both vaccines has been firmly established over many years in some of the largest vaccine studies ever undertaken. Before the vaccines’ approval, clinical data developed through animal studies and human clinical trials were evaluated by FDA scientists and clinicians.

In addition, the FDA pays careful attention in reviewing the quality of raw materials and other ingredients used to make vaccines, the production process, and the procedure for assessing their safety and efficacy. Like many medical products, measles vaccines have known potential side effects, but they are generally mild and short-lived, such as rash and fever.

The bottom line is that there are safe and effective vaccines that provide lasting protection against the measles virus. Both contain live, but weakened versions of the measles virus, which causes your immune system to produce antibodies against the virus without causing you to contract the illness. Should you be exposed to actual measles, those antibodies will protect you against the disease.” (O)

“The U.S. is experiencing the greatest spike in measles cases in 25 years, but Merck, the sole producer of the measles vaccine for the U.S., says it has production in hand…

“In response to the measles outbreak that has occurred this year, Merck has taken steps to increase U.S. supply of our MMR-II vaccine so availability of the vaccine is maintained,” the company said in an emailed statement today. The statement emphasized the safety and effectiveness of the vaccine has been scientifically affirmed over decades of use against the highly contagious and sometimes fatal disease…

Merck Chief Marketing Officer Mike Nally told Reuters in an interview that the company has upped production but that there has not been a big boost in orders in the U.S., even from the Centers for Disease Control and Prevention. The CDC provides vaccines through the government’s Vaccines for Children program…

 “As measles outbreaks have occurred in different parts of the world over the last few decades, we’ve always been able to surge capacity, and we feel confident about our ability to do so in the U.S,” Nally told the news service.” (P)

“In New York, which has seen hundreds of measles cases since last fall, the state’s Department of Health has given doctors the go-ahead to lower the vaccination age to six months in areas with ongoing outbreaks, according to Erin Silk, a spokesperson for the department. New York City Mayor Bill de Blasio has ordered that everyone — including babies as young as six months old — get their measles vaccinations. The measles vaccine is safe and effective, despite the thoroughly debunked myth that vaccines cause autism. An extra measles vaccine at six months is very safe, too, according to Peter Hotez, dean for the National School of Tropical Medicine at Baylor College of Medicine. It just isn’t the norm because, under typical, non-outbreak circumstances, the vaccine may not be as effective for babies that young. “However, some babies could still benefit from early immunization during a true measles outbreak,” he says in an email to The Verge.” (Q)

“After a measles outbreak in Brooklyn and Rockland County and amid growing concerns about the anti-vaccine movement, a pair of state legislators are proposing allowing minors to receive vaccinations without permission from their parents.

The bill would allow any child 14 years or older to be vaccinated and given booster shots for a range of diseases including mumps, diphtheria, whooping cough, tetanus, influenza, hepatitis B and measles, which seemed to be the primary reason for alarm after the recent outbreaks.

“We are on the verge of a public health crisis,” said one of the bill’s sponsors, Assemblywoman Patricia Fahy, a Democrat from Albany, citing lower-than-recommended inoculation rates in some communities, spurred by unconfirmed suspicions about vaccines causing autism. “We’ve become complacent over the last couple of decades.”

That sentiment was amplified recently by the World Health Organization, which listed “vaccine hesitancy” as one of the Top 10 global threats. In Rockland County, officials are reporting 145 confirmed cases of measles, with the vast majority of those afflicted aged 18 and under. Of those, four out of five have received no vaccinations for measles, mumps and rubella.. “ (R)

“U.S. doctors are tapping into their electronic medical records to identify unvaccinated patients and potentially infected individuals to help contain the worst U.S. measles outbreak in 25 years.

New York’s NYU Langone Health network of hospitals and medical offices treats patients from both Rockland County and Brooklyn, two epicenters of the outbreak. It has built alerts into its electronic medical records system to notify doctors and nurses that a patient lives in an outbreak area, based on their Zip code.

“It identifies incoming patients who may have been exposed to measles and need to be assessed,” said Dr. Michael Phillips, chief epidemiologist at NYU Langone Health.

Alerts in a patient’s medical record also prompt conversations with their visitors – who may also have been exposed to the virus – about their own health, prior exposure to measles and vaccination history.

Mount Sinai Health System in New York rolled out a similar program last week, said Dr. Bruce Darrow, its chief medical information officer.

Darrow said it was important because although a patient who comes from a measles-affected Zip code may have passed the screening, family members who visit may have been exposed.”

He said the alert system raises awareness for doctors and nurses “to be on lookout not just for our patients, but anybody who comes into the building.” (S)

“At first, the virus moved slowly through Orthodox communities in Jerusalem and Tel Aviv. Then in September, Dr. O’Connor said, a major outbreak in Ukraine supercharged Israel’s modest one — and probably led, indirectly, to outbreaks in Britain and in the United States.

Ukraine is suffering through a measles outbreak that began in 2017. The country has had almost 70,000 cases — more than any other country in recent years…

But the real problem appears to have begun at Rosh Hashana.

Each year on the holiday, tens of thousands of Orthodox men travel to Uman, a Ukrainian city where the grave of Rabbi Nachman of Breslov, founder of one branch of Hasidism, has become a popular pilgrimage site. (The festivities have been called the “Hasidic Burning Man.”)

Last year, Rosh Hashana fell in early September. Later that month, measles cases exploded in Israel, rising to a peak of 949 in October. The cause? Numerous pilgrims came back from Ukraine with the virus, experts believe.

New York’s outbreak began in October; the first patient was a child in the Bensonhurst section of Brooklyn who had visited Israel. At the same time, a measles outbreak began among Orthodox Jews in London.” (T)

“In 2000, the Pan-American Health Organization announced a monumental public health achievement: Widespread vaccination efforts, overseen by the Centers for Disease Control and Prevention, had effectively eliminated measles from the United States.

The disease, which before the vaccination era affected 3 to 4 million people in the U.S. each year, was now isolated to small, contained outbreaks connected to international travel.

This year’s record-setting outbreak threatens that achievement.

Since January, over 700 cases of measles have been reported in 22 states. Most of the affected have never been vaccinated. Sixty people have been hospitalized, and the case numbers continue to climb, although in some regions, like the Pacific Northwest, outbreaks have subsided.

Though the current numbers are dwarfed by the scale of cases in the first half of the 20th century, they’re still meaningful, says Rene Najera, an epidemiologist and editor of the vaccine education website History of Vaccines.

“We are getting very close to a tipping point. If cases continue to escalate, the U.S. could lose its elimination status,” says Najera.

A disease is considered eliminated from a country when it can no longer be contracted within its borders, though cases tied to international travel — like those that have happened since 2000 — can still occur.

Losing elimination status would mark a failure of one of the biggest public health achievements in our history.” (U)

“Why is handwashing so important?

Put simply, your hands are dirty. As they come into contact with various people, animals, foods, and surfaces, they pick up thousands of germs, bacteria, viruses and other assorted nastiness that can make you sick if they enter your body. “We touch our eyes, noses, and mouths with our hands more than we think, and this can allow direct inoculation of germs into our mucous membranes,” explains Janet Haas, PhD, RN, Director of Epidemiology at Lenox Hill Hospital. “We also use our hands to prepare and eat foods, so hands that are not clean can contaminate foods that we and others will eat.” But washing your hands has the power to minimize or even eliminate those risks—for you and those around you. For example, teaching people about handwashing can reduce diarrheal illnesses in immunocompromised people by up to 58 percent, according to the CDC. Another FYI: You should wash your hands immediately after touching these 10 things.

You’re probably washing your hands wrong

Believe it or not, only 5 percent of people wash their hands in a way that actually gets them clean, according to a study in the Journal of Environmental Health. Haas says the trick is to rub soap onto every part of your hands, since the friction is what removes the germs from skin, and to wash for a long enough period of time. “Keep rubbing for 20 seconds, making sure to get soap between fingers and on the backs of hands—and don’t forget the thumbs!” she advises. “Avoid turning off the tap with your clean hands: A towel, a wrist or elbow is preferred to keep your hands clean.” .. (V)

“U.S. health officials are increasingly relying on an informal network of community groups, religious leaders, and local medical practitioners in their efforts to fight the biggest measles outbreak in the nation in more than 25 years. Standard public-health tools are falling short in the face of an aggressive antivaccination campaign, growing exposure to measles in countries such as Israel, and a longstanding distrust of government or other outside sources of information. Grassroots approaches are becoming more important in public health, with infectious-disease outbreaks around the world increasingly erupting in remote or insular communities, conflict zones, and other areas where disease fighters have to grapple with economic, cultural, or security challenges. CDC has formed a work group to seek new ways to counter an increasingly vocal antivaccine movement. Trusted sources within a community’s own networks “can be more effective than we can” in educating people about vaccination, says Nancy Messonnier, an expert on immunization and respiratory diseases at the agency.” (W)

Prequel: Project Management. The hardest part of getting started….is getting started

Preparing “Raw” Contemporaneous Cases  http://doctordidyouwashyourhands.com/2019/03/method-of-preparing-raw-contemporaneous-cases/

To see more cases go to Doctor, Did You Wash Your Hands?™   http://doctordidyouwashyourhands.com/

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Is it ethical for the public not be notified about new “super bugs” in hospitals so they can decide whether or not to go to affected hospitals?

“Last May, an elderly man was admitted to the Brooklyn branch of Mount Sinai Hospital for abdominal surgery. A blood test revealed that he was infected with a newly discovered germ as deadly as it was mysterious. Doctors swiftly isolated him in the intensive care unit.

The germ, a fungus called Candida auris, preys on people with weakened immune systems, and it is quietly spreading across the globe. Over the last five years, it has hit a neonatal unit in Venezuela, swept through a hospital in Spain, forced a prestigious British medical center to shut down its intensive care unit, and taken root in India, Pakistan and South Africa.

Recently C. auris reached New York, New Jersey and Illinois, leading the federal Centers for Disease Control and Prevention to add it to a list of germs deemed “urgent threats.”

The man at Mount Sinai died after 90 days in the hospital, but C. auris did not. Tests showed it was everywhere in his room, so invasive that the hospital needed special cleaning equipment and had to rip out some of the ceiling and floor tiles to eradicate it.

“Everything was positive — the walls, the bed, the doors, the curtains, the phones, the sink, the whiteboard, the poles, the pump,” said Dr. Scott Lorin, the hospital’s president. “The mattress, the bed rails, the canister holes, the window shades, the ceiling, everything in the room was positive.””  (A)

“Back in 2009, a 70-year-old Japanese woman’s ear infection puzzled doctors. It turned out to be the first in a series of hard-to-contain infections around the globe, and the beginning of an ongoing scientific and medical mystery.

The fungus that infected the Japanese woman, Candida auris, kills more than 1 in 3 people who get an infection that spreads to their blood or organs. It hits people who have weakened immune systems, and is most often found in places like care homes and hospitals. Once it shows up, it’s hard to get rid of: unlike most species of fungi, Candida auris spreads from person to person and can live outside the body for long periods of time.

Mount Sinai wasn’t the first hospital to face this task: a London hospital found itself with an outbreak in 2016, and the only way to stop it was to rip out fixtures…

Scientists still aren’t sure exactly where this happened or when. That’s one of the things they’re working on now, says Cuomo, because figuring out how the fungus evolved could help researchers develop treatments for it…

Although the “superbug” moniker might sound alarmist, Candida auris qualifies for two reasons, says Cuomo. First, all strains of the yeast are resistant to antifungals. There are three major kinds of antifungals used to treat humans, and some strains of Candida auris are resistant to all of them, while other strains are resistant to one or two. That limits the treatment options for someone who has been infected—someone who is probably already in poor health. The other reason is “this really scary property of not being able to get rid of it,” Cuomo says.” (B)

“Superbugs are a terrifying prospect because of their resistance to treatment, and one superbug that is sweeping all over the world is the Candida auris.

C. auris is a fungus that causes serious infections in various parts of the body, including the bloodstream and the ear.

While its discovery has been relatively recent in 2009, this fungus has already wreaked havoc in hospitals in more than 20 different countries, including the United States, United Kingdom, and Spain, among others.

In the United States, CDC reports a total of 587 clinical cases of C. auris infections as of February. Most of it occurred in the areas of New York City, New Jersey, and Chicago.” (C)

“The CDC issued a public alert in January about a drug-resistant bacteria that a dozen Americans contracted after undergoing elective surgeries at Grand View Hospital in Tijuana, Mexico. Yet when similar outbreaks occur at U.S. hospitals, the agency does not issue a public warning. This is due to an agreement with states that prohibits the CDC from publicly disclosing hospitals undergoing outbreaks of drug-resistant infections, according to NYT.

Patient advocates are pushing for more transparency into hospital-based infection outbreaks, saying the lack of warning could put patients at risk of harm.

“They might not get up and go to another hospital, but patients and their families have the right to know when they are at a hospital where an outbreak is occurring,” Lisa McGiffert, an advocate with the Patient Safety Action Network, told NYT. “That said, if you’re going to have hip replacement surgery, you may choose to go elsewhere.”..

The CDC declined NYT’s request for comment. Agency officials have previously told the publication the confidentiality surrounding outbreaks is necessary to encourage hospitals to report the drug-resistant infections.” (D)

“New Jersey is among the states worst affected by an increasing incidence of the potentially deadly fungus Candida auris, whose resistance to drugs is causing headaches for hospitals, state and federal health officials said on Monday.

There were 104 confirmed and 22 probable cases of people infected by the fungus in New Jersey by the end of February, according to the federal Centers for Disease Control and Prevention, up sharply from a handful when the fungus was first identified in the state about two years ago.

The state’s number of cases — now the third-highest after New York and Illinois — has risen in tandem with an increase, first overseas, and now in the United States, in a trend that some doctors attribute to the overuse of drugs to treat infections, prompting the mutation of infection sources, in this case, a fungus.

The fungus mostly affects people who have existing illnesses, and may already be hospitalized with compromised immune systems, health officials said.

Nicole Kirgan, a spokeswoman for the New Jersey Department of Health, said she didn’t know whether any of the state’s cases have been fatal, and couldn’t say which hospitals are treating people with the fungus because they have not, so far, been required to report their cases to state officials.

Although the fungus has been known to medical professionals in New Jersey for two or more years, it was not widely known to the public. Its profile was raised by a front-page story in The New York Times on Sunday describing its growing presence in overseas hospitals and, increasingly, in the U.S.

The best defense against spreading the fungus is rigorous handwashing, and disinfecting hospital rooms and equipment that have come into contact with a patient, Kirgan said.

But Dr. Ted Louie, an infectious disease specialist at Robert Wood Johnson University Hospital in New Brunswick, said many hospitals don’t know how to eradicate the fungus once it has occurred.

Some disinfectants commonly used in hospitals have proved ineffective in removing the fungus, Dr. Louie said, so hospitals have been urged to use other disinfecting agents, although it’s not yet clear which of them work, if any.

“This is a fairly new occurrence and we are still learning how to deal with it,” he said. “We have to figure out which disinfectant procedures may be best to try to eradicate the infection, so at this point, I don’t think we have good enough information to advise.”  (E)

“Adding to the difficulty of treating candida auris is finding it in the first place. The infection is often asymptomatic, showing few to no immediate symptoms, said Chauhan. The symptoms that do appear, such as fever, are often confused for bacterial infections, he said.

“Most routine diagnostic tests don’t work very well for candida auris,” he said. “They’re often misidenfitied as other species.”

The best way to identify candida auris is by looking under a microscope, which often takes time because it requires doctors to grow the fungus, Chauhan said.

As with most infectious diseases, the best course of action is good hygiene and sterilization protocol. Washing your hands and using hand sanitizer after helps to prevent transmission and infection, Chauhan said.

Doctors and healthcare workers should use protective gear, and people visiting loved ones in hospitals and long-term care centers should take proper precautions, he said.

The Center for Disease Control recommends using a special disinfectant that is used to treat clostridium difficile spores. The disinfectant has been effective in wiping out clostridium difficile, known as c. diff, and disinfects surfaces contaminated with candida auris, as well.”  (F)

“Hospitals and nursing homes in California and Illinois are testing a surprisingly simple strategy against the dangerous, antibiotic-resistant superbugs that kill thousands of people each year: washing patients with a special soap.

The efforts — funded with roughly $8 million from the federal government’s Centers for Disease Control and Prevention — are taking place at 50 facilities in those two states.

This novel approach recognizes that superbugs don’t remain isolated in one hospital or nursing home but move quickly through a community, said Dr. John Jernigan, who directs the CDC’s office on health care-acquired infection research.

“No health care facility is an island,” Jernigan said. “We all are in this complicated network.”

At least 2 million people in the U.S. become infected with an antibiotic-resistant bacterium each year, and about 23,000 die from those infections, according to the CDC…

Containing the dangerous bacteria has been a challenge for hospitals and nursing homes. As part of the CDC effort, doctors and health care workers in Chicago and Southern California are using the antimicrobial soap chlorhexidine, which has been shown to reduce infections when patients bathe with it. Though chlorhexidine is frequently used for bathing in hospital intensive care units and as a mouthwash for dental infections, it is used less commonly for bathing in nursing homes…

The infection-control work was new to many nursing homes, which don’t have the same resources as hospitals, Lin said.

In fact, three-quarters of nursing homes in the U.S. received citations for infection-control problems over a four-year period, according to a Kaiser Health News analysis, and the facilities with repeat citations almost never were fined. Nursing home residents often are sent back to hospitals because of infections.

In California, health officials are closely watching the CRE bacteria, which are less prevalent there than elsewhere in the country, and they are trying to prevent CRE from taking hold, said Dr. Matthew Zahn, medical director of epidemiology at the Orange County Health Care Agency. “We don’t have an infinite amount of time,” he said. “Taking a chance to try to make a difference in CRE’s trajectory now is really important.””  (G)

“The C.D.C. declined to comment, but in the past officials have said their approach to confidentiality is necessary to encourage the cooperation of hospitals and nursing homes, which might otherwise seek to conceal infectious outbreaks.

Those pushing for increased transparency say they are up against powerful medical institutions eager to protect their reputations, as well as state health officials who also shield hospitals from public scrutiny…

Hospital administrators and public health officials say the emphasis on greater transparency is misguided. Dr. Tina Tan, the top epidemiologist at the New Jersey Department of Health, said that alerting the public about hospitals where cases of Candida auris have been reported would not be useful because most people were at low risk for exposure and public disclosure could scare people away from seeking medical care.

“That could pose greater health risks than that of the organism itself,” she said.

Nancy Foster, the vice president for quality and patient safety at the American Hospital Association, agreed, saying that publicly identifying health care facilities as the source of an infectious outbreak was an imperfect science.

“That’s a lot of information to throw at people,” she said, “and many hospitals are big places so if an outbreak occurs in a small unit, a patient coming to an ambulatory surgical center might not be at risk.”

Still, hospitals and local health officials sometimes hide outbreaks even when disclosure could save lives. Between 2012 and 2014, more than three dozen people at a Seattle hospital were infected with a drug-resistant organism they got from a contaminated medical scope. Eighteen of them died, but the hospital, Virginia Mason Medical Center, did not disclose the outbreak, saying at the time that it did not see the need to do so.

Art Caplan, a bioethicist at the NYU School of Medicine, said the issue of full disclosure can be tricky, especially when large hospitals that see huge numbers of seriously ill patients are compared with smaller institutions. “If you’re a hospital of last resort, you’re going to see repeat customers with tough infections, many of them drug resistant,” he said.

Still, he thought there was a greater value in promoting transparency. Public awareness about the lives lost to drug resistant infections, he said, could pressure hospitals to change the way they deal with infection control.

“Who’s speaking up for the baby that got the flu from a hospital worker or for the patient who got MRSA from a bedrail?” he asked, referring to a potentially deadly bacterial infection. “The idea isn’t to embarrass or humiliate anyone, but if we don’t draw more attention to infectious disease outbreaks, nothing is going to change.” (H)

“Many have heard of the rise of drug-resistant infections. But few know about an issue that’s making this threat even scarier in the United States: the shortage of specialists capable of diagnosing and treating those infections. Infectious diseases is one of just two medicine subspecialties that routinely do not fill all of their training spots every year in the National Resident Matching Program (the other is nephrology). Between 2009 and 2017, the number of programs filling all of their adult-infectious-disease training positions dropped by more than 40 percent.

This could not be happening at a worse time. Antibiotic-resistant microbes, known as superbugs, are pinballing around the world, killing hundreds of thousands of people every year. The Times recently reported on Candida auris, a deadly new fungus that has infected hospital patients in Illinois, New Jersey and New York.

Everyone who works in health care agrees that we need more infectious-disease doctors, yet very few actually want the job. What’s going on?

The problem is that infectious-disease specialists care for some of the most complicated patients in the health care system, yet they are among the lowest paid. It is one of the only specialties in medicine that sometimes pays worse than being a general practitioner. At many medical centers, a board-certified internist accepts a pay cut of 30 percent to 40 percent to become an infectious-disease specialist.

This has to do with the way our insurance system reimburses doctors. Medicare assigns relative value units to the thousands of services that doctors provide, and these units largely determine how much physicians are paid. The formula prioritizes invasive procedures over intellectual expertise.

The problem is that infectious-disease doctors don’t really do procedures. It is a cognitive specialty, providing expert consultation, and insurance doesn’t pay much for that…

Infectious-disease specialists are often the only health care providers in a hospital — or an entire town — who know when to use all of the new antibiotics (and when to withhold them). These experts serve as an indispensable cog in the health care machine, but if trends continue, we won’t have enough of them to go around. The terrifying part is that most patients won’t even know about the deficit. Your doctor won’t ask a specialist for help because in some parts of the country, the service simply won’t be available. She’ll just have to wing it…

We must hurry. Superbugs are coming for us. We need experts who know how to treat them.” (I)

People visiting patients at the hospital, and most hospitalized patients, have little to fear from a novel fungal disease that has struck more than 150 people in Illinois — all in the Chicago area — a Memorial Medical Center official said Friday.

“For normal, healthy people, this is not a concern,” Gina Carnduff, Memorial Health System director of infection prevention, said in reference to Candida auris infections.

Carnduff, who is based at Memorial Medical Center, said only the “sickest of the sick” patients are at risk of catching or spreading the C. auris infection or dying from it.

Those patients, she said, include people who have stayed for long periods at health care facilities — such as skilled-care nursing homes or long-term acute-care hospitals — and who are on ventilators or have central venous catheter lines or feeding tubes…

Officials from both Memorial Medical Center and HSHS St. John’s Hospital said their institutions already are using the bleach-based cleaning solutions known to prevent the spread of C. auris and other infections.

The Illinois Department of Public Health’s website says more than one in every three people with “invasive C. auris infection” affecting the blood, heart or brain will die…

The state health department says 154 confirmed cases of C. auris and four probable cases have been identified, all in the Chicago area. Ninety-five cases were in Chicago, 56 were in Cook County outside of Chicago, and seven were spread among the counties of DuPage, Lake and Will.

Eighty-five of the 158 people making up the confirmed and probable cases have died, but only one death was “directly attributed” to the infection, Arnold said. It’s not known whether C. auris played a role in the deaths of the other 84 people, she said. (J)

“There is also the fact that some lab tests will not identify the superbug as the source of an illness, which means that some patients will receive the wrong treatment, increasing the duration of the infection and the chance to transmit the fungus to another person.” (K)

“Hospitals, state health departments and the Centers for Disease Control and Prevention are putting up a wall of silence to keep the public from knowing which hospitals harbor Candida auris.

New York health officials publish a yearly report on infection rates in each hospital. They disclose rates for infections like MRSA and C. Diff. But for several years, the same officials have been mum about the far deadlier Candida auris. That’s like posting “Wanted” pictures for pickpockets but not serial murderers.

Health officials say they’ll disclose the information in their next yearly report. That could be many months from now. Too late. Patients need information in real time about where the risks are…

Dr. Eleanor Adams, a state Health Department researcher, examined all the facilities in New York City affected by Candida auris over a four-year period. Adams found serious flaws, including “inadequate disinfection of shared equipment” to take vital signs, hasty cleaning and careless compliance with rules to keep infected patients isolated…”  (L)

“Remedies for curtailing the advance of C. auris are familiar. Health care facilities must undergo stringent infection controls, test for new cases and quickly identify any sources passing it along. Visitors and medical workers must wash their hands after touching patients or surfaces. The yeast spreads widely throughout patients’ rooms. Some cleanups have reportedly required removing ceiling and floor tiles.

C. auris isn’t simply an opportunistic infection. Its rise is additional evidence that becoming too reliant on certain types of drugs may have unintended consequences. Exhibit A is the overuse of antibiotics in doctors’ offices and on farms that encourages the development of drug-resistant bacteria. Researchers suspect a similar situation involving C. auris and agricultural fungicides used on crops. So far the origins of C. auris are unclear, with different clusters arising in different areas of the world.

There’s no need to panic. But vigilance is required to track C. auris and raise awareness in order to combat it. Officials typically are eager to spread the word about potential health crises, from measles to MRSA. In this case, the CDC issued alerts about fungus to health care facilities, but the New York Times encountered an unusual wall of silence while investigating superbugs such as C. auris. Medical facilities didn’t want to scare off patients.

Any attempts to hide the spread of a communicable disease are irresponsible. Knowledge leads to faster prevention and treatment. Patients and their families have a right to know how hospitals and government agencies are responding to a new threat. Medical workers also deserve to be informed of the risks they encounter on the job.

Battling the superbugs requires aggressive responses and, ultimately, scientific advancements. Downplaying outbreaks won’t stop their rise.” (M)

“The rise of C. auris, which may have lurked unnoticed for millennia, owes entirely to human intervention — the massive use of fungicides in agriculture and on farm animals which winnowed away more vulnerable species, giving the last bug standing a free run. Sensitised to clinical fungicides, C. auris has proved to be difficult to extirpate, and culls infected humans who cannot fight diseases very effectively — infants, the old, diabetics, people with immune suppression, either because of diseases like HIV or the use of steroids. The new superfungus has the makings of a future plague, one of several which may cumulatively surpass cancer as a leading killer in a few decades.

The origin of C. auris is known because it broke out in the 21st century, but the plagues from antiquity lack origin stories. Even their spread was understood only retrospectively, in the light of modern science. The father of all plagues, the Black Death, originated in China in the early 14th century and ravaged most of the local population before it began its long journey westwards down the Silk Route, via Samarkand. At the time, the chain of hosts that carried it would have been incomprehensible — the afflicting organism Yersinia pestis, the fleas which it infested, the rats which the fleas in turn infested, which carried it into the homes of humans….” (N)

“WebMD: Most of us know candida from common yeast infections that you might get on your skin or mucous membranes. What makes this one different?

Chiller: It’s not acting like your typical candida. We’re used to seeing those.

Candida — the regular ones — are already a major cause of bloodstream infection in hospitalized patients. When we get invasive infections, for example, bloodstream infections, we think that you sort of auto-infect yourself. You come in with the candida already living in your gut. You’re in the ICU, you’re on a broad spectrum antibiotic. You’re killing off bad bacteria, you’re killing off good bacteria, so what are you left with? Yeast, and it takes over.

What’s new with Candida auris is that it doesn’t act like the typical candida that comes from our gut. This seems to be more of a skin organism. It’s very happy on the skin and on surfaces.

It can survive on surfaces for long periods of time, weeks to months. We know of patients that are colonized [meaning the Candida auris lives on their skin without making them sick] for over a year now.

It is spreading in health care settings, more like bacteria would, so it’s yeast that’s acting like bacteria” (O).

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Project Management. The hardest part of getting started….is getting started

Every major project (worth doing) is unique! But there is no “magic bullet” Project Management template. However, one way of starting any project is by reaching a consensus on “anchor concepts” which can serve to keep the project on track (and can be revised during the project).

Assignment: Your program is up for a CAHME accreditation visit and you are chairing the “preparation” committee. What are the “anchor concepts?

Following are some “anchor concepts” examples for different types of projects:

In July of 2009 the Mayor of Hoboken asked me to initiate a H1N1 “Swine Flu” Task Force. We started with a set of questions based on reports from communities that had already experienced a Swine Flu surge:

Health Officer: Where vaccination sites should be established? Is there a special plan to monitor restaurants and food shops where flu-related safety guidelines need to be strictly enforced? Who will start preparing a Community Education plan?

Hospital: What is the back-up plan if hospital becomes “contaminated” and is closed to admissions, or if nursing staff is depleted by flu-related absenteeism, etc.? ICU triage? Availability of respirators?

OEM:  off-site screening centers if hospital ER is on overload

Hoboken Volunteer Ambulance Corps:  “mutual assist” plan

Hoboken Police Department & Hoboken Fire Department: back-up plan if the ranks get depleted by the flu

BOE: criteria in deciding whether or not to close schools

Stevens Institute of Technology: surveillance and plan for (college) students

“Field Manual” for the Mayor

An umbrella agency allocated money to 18 different Food Distribution programs in three categories – “meals on wheels”, food pantries, congregate meals – $1 million/ year; & separate pots of money for housing stability, and aging in the community. There had been no review of the allocation in ten years, just automatic renewals. There was no “organizational memory” on why this program was initiated.

We started with some agency – Food Distribution Principles:

Agency is committed to providing basic supports to the most vulnerable in the Jewish community.

Food insecurity exists within the Jewish community and the Agency is committed to a programmatic response.

Funded food programs should reflect Best Practices in the field.

Agency is committed to kashrut. (kosher food)   

In order to address the needs of all those who are vulnerable, the relative size of needy groups should be considered in the distribution of funds.

The rationale for continued Agency funding should be clearly articulated if there are similar nearby programs with available capacity.

Agency funded food programs duplicating similar nearby programs should be open to merger opportunities.

Agency should provide kosher food to those who request it. However given the higher cost of kosher food, a facilitating process should connect those who do not require kosher food to other accessible food programs. 

Food programs funded by the Agency should be nutritionally sound, fully compliant with their regulatory agencies, be certified or accredited if there are certification or accreditation programs in place, and be active members of industry associations.

Funded agencies should have and enforce an effective Conflict of Interest policy.

A Health and Social Services Agency reviewed whether it should change accreditation agencies. We started with a set of assumptions:

“Price” should not be the singular criteria to change Accreditation. Neither should staff effort required.

HSSA should be in the main stream of Accreditation with other similar leading HSSAs in the United States – this is not an area to be a pioneer

Evaluation criteria should be developed first and then a number of Accreditation alternatives should be reviewed

Only “Evidenced-Based” options should be considered. “Best Practices” is not sufficient.

If and when the field is narrowed, HSSAs using these Accreditation vehicles should be contacted for feedback

Any change should not in any way compromise the “rebranding” initiative – check with our consultants

Make sure any change does not affect the professional staff’s certification, licensure, and “credibility“

Make sure any change does not affect HSSA’s reimbursement from any source

Be comfortable that any change will be acceptable to key “funders

HSSA was considering new revenue streams, more specifically “for profit” partnerships to support its NFP mission. So we started with Principles for Social Entrepreneurship Projects – HSSA:

Projects must be consistent with (and enhance) the Mission and Vision of HSSA

Our Mission: Guided by the wisdom and values of our tradition of respect for all people, HSSA provides innovative, compassionate and outstanding social services to enhance the independence and well-being of individuals and families throughout all stages of life.

Our Vision: HSSA will be the premier Agency within the area providing for the social services and mental health needs of the greater community with unparalleled professionalism, humanity and respect for all who seek its support.

Projects must not adversely affect the reputation, “brand”, integrity, fund-raising capability or tax-exempt status of HSSA.

To the greatest extent possible HSSA should seek to identify and replicate successful projects at other similar agencies.

Any new SEP should contribute at least $100,000 a year to the Agency’s bottom line, within a 3 year start-up period.

Priority should be given to Joint Ventures where partners provide start-up funding and take the financial risk and the Agency provides its “name”, experience and reputation (and gets a lower but steady long term income stream).

Project development costs must include the cost of staff time on the project.

“Clients first.”

….who among us can escape the lonesome time? When hours are as days. When the past becomes more real than the future. And thoughts of getting old are replaced by the anxiety of feeling old. New generations move in as old friends fade away. That’s the lonesome time. The time more than any other when people need people. When people need to be needed.

Senior Camps was founded in 1969 to provide overnight camping services to children and adults.

There were initially six summer sessions – each two-weeks long, serving more than 1,400 people annually by 1976.

1982 was a very good year for the agency – more than 4900 people within 43 weeks of programming, including the summer programs, holiday programs, children’s camping, and trips to Florida, California and Israel.

The agency was doing well financially in 1987 with $1,850, 000 in assets earning interest.

In late 1980’s, the agency began to run significant yearly deficits in part because of the capital money being put back into facilities.

In 1991, the property tax was reinstated on both camps at an annual cost of $66,000.

By 1993 the surplus dropped to $30,000.

Time for a new strategic plan…..

Possible Review Questions for Strategic Planning Committee –  May 6, 2010

1.   Review evolution of Mission Statement over time.

a) Does it need any reconsideration in light of the current “sustainability” challenge?

b) What are Camp’s core values?

c) What is our vision for the future?

d) What defines camp? As a Vacation Center?

e) Does Camp actually offer (as the byline says), to energize mind, body and soul?

f) Who is the actual Camp “customer”? Why do they come?

g) Does Camp have a loyal customer base?

h) What describes a camping experience? A vacation experience?

2.   Profile the competition – location, program, amenities, Jewish or secular, cost, “sizzle” etc – any  easy “copycatting we can do”?

a) What are essential facility upgrades to compete?

b) What are essential programs that we should look to add to stay competitive? More active?

c) Can we play-up our spa concept/health and wellness?

3.   What unique groups should be targeted? Jewish? Secular? Special Needs? Special Interests?  How can we expand our marketing efforts with limited resources and staff time?

4. How do we find more groups to partner with in order to sell our product wholesale?

5.  How can we expand off-season use?

6.  How many weeks of Senior Camping are necessary for Camp to still be Camp?

a) Should we look at offering shorter/less defined stays – i.e. more hotel like?

b) How do we become attractive to the Baby Boomers?

7.  What are the impediments to successful Camp fundraising?

8.  Are there grant-writing opportunities for tuition subsidies and/ or capital funds?

9. What’s in a name? Does Camps name work? no!

10. How do we define ourselves in terms of who we serve – i.e. Orthodox, Conservative, Reform, non-Jews, etc.? How do we successfully meet the needs of all of these communities?

11. Can we/should we expand our programming into the Orthodox community?

12.  Is there sufficient diversity on the Board to address the current challenges?

13.  Is Camp being actively marketed to other affiliated seniors agencies?

14. Can the “Jewish” Internet be used to market Camp?

15. How will we measure progress and success (metrics)? 

16. Should we consider running other travel programs?

17.  Are there any Bylaw changes needed (e.g., committee structure, attendance requirements, term limits)?

18.  Should there be a special “free” weekend for various JCC execs, other Jewish agency execs, Rabbis who can send groups – so they can experience Camp?

Strategic Initiatives –  June 2010

1)  Mine affiliated agencies for “wholesale” opportunities

2)  Reach further into the Russian speaking community, both for additional clients and for possible funding streams or grants for scholarships 

3)  Identify possible alliances within the Orthodox communities for both senior groups through the Young Israel Synagogues and for programs to serve younger adults and families

4)  Contact Aspergers, Autism and other special needs organizations to test Camp’s special needs potential

5)  Develop marketing plan for reaching families who might hold family summer-camp sessions at Camp, such as reunion websites and Grandparents.com, and email to USA-Federation email list

6)   Explore joint ventures with non-northeast synagogues, Ys and other institutions that might plan NE Jewish heritage tour with a week at Camp

7)   Research Grant opportunities from Jewish family foundations

8)   Develop donor list for annual donor funding

9)    Develop a marketing plan using existing “best” Jewish web-sites and newsletters, including separate web pages for each Strategic Initiative adopted

10)   Presentations to Executive Director groups, e.g., Jewish Family Services,  ED groups in New Jersey and New York

11)   Identify changes made by successful senior camps

12)   Is it time to change the name of Camp? 

13)   Board Self-evaluation

14)   Recruit graduate program interns in various fields to assist with the “leg work” and planning

“The Strategy” – Three Camps

Camp will be reorganized as 3 separate camp structures

Vacation Center – Our current program for senior adults

Camp for Adults with Disabilities

Retreat Center – More structure and outreach for our already established retreat and rental program.

In April 1991, Hudson Cradle was started to help alleviate the boarder baby crisis. Boarder babies are infants healthy enough to be discharged from the hospital, but do not have a safe place to call home. Hudson Cradle welcomed our first infant resident in March 1992. Hudson Cradle provides care to approximately 42 babies each year. Hudson Cradle is licensed as a Children’s Group Home

2007 Issues

Senior members on the Board of Trustees too long

New Board members join and then leave quickly

Need a Board/ management,  transition/ succession plan

No Strategic Plan

1.   Mission: Is the current Mission Statement still timely and appropriate?

2.   JCMC Affiliation: Is the current arrangement with JCMC still appropriate and working effectively?

3.   Clinical Services: Does HC provide an appropriate and Evidenced Based scope of clinical service to the babies? Are formal affiliation agreements in place for each of these clinical services if not available on-site?

4.   Outcomes: Is it agreed we need to better track outcomes while the babies are at HC Cradle and after they leave?

5.   Program: Should HC expand its program scope beyond residential care? If so are there gaps in care in Hudson County that HC might consider providing?

6.   Cribs: do we have data to demonstrate a real need for more cribs?

7.   Space: how much additional space is needed on-site for the current mission/ program?

8.   Facilities: what immediate facilities improvements are needed regardless of mission/program, e.g., maintenance, life safely etc?

9.   Disaster Plan: Is it agreed HC needs Contingency Plans if the building needs to be evacuated?

10. Contingency Plan: Is it agreed that HC needs a “baby transfer” plan if HC suddenly runs out of money?

11. Jersey City Medical Center/ Greenville: what, if any, are the implications of the closure (or changes) to Greenville and the cutbacks in pediatrics at JCMC?

12. Marketing Plan: why does HC need a Marketing Plan? and/or

13. Development Plan: How can HC’s successful Development efforts be expanded to include the local (Waterfront?) corporate sector?

HUDSON CRADLE – ’08 Strategic Plan (11/29/07)

A. Mission Statement

Hudson Cradle is a Group Home providing full, nurturing care to homeless infants with special health and developmental needs (“boarder babies”). In addition, Hudson Cradle provides counseling, education, and support services to birth or foster parents to prepare them to live as a family. Hudson Cradle also provides outreach and educational services to the community.

B. Strategic Principles

1.  Does the New Jersey Department of Children and Families consider HC an essential Agency “waivered” under the Court order? If so, will DCF agree to give HC 18 months’ notice of future discontinuation of referrals/ admissions? And, will DFC give HC an enhanced reimbursement rate to support the enriched nurse staffing and additional hospital visits necessary to care for the sicker infants being referred?

2.  HC will develop and implement an Evidenced Based Outcomes Dashboard for current and future services.

3.  HC should expand its Mission to include a range of non-residential community services to infants-at-risk. What services should be considered?

4. While continuing residential services, and adding community services, HC should consider becoming an Umbrella Organization for mission compatible small not-for-profits in Hudson County.

5.  The effectiveness of the current contract with Jersey City Medical Center should be monitored as the Medical Center continues it’s restructuring.

6.  Contingency plans should be developed given the announced closing of Greenville Hospital.

C. Facilities

1.  Consideration of moving to a new facility and/ or expanding the number of cribs is deferred.

2.  Review life-safety compliance, immediate repair requirements and space needs for current programs; and then develop a facilities improvement/ expansion plan for the current HC site.

D. Disaster Management

1.  Prepare and stock an “Emergency Medical Kit”.

2.  Create a “pick up and go” medical information file for each infant in residence, and personnel file for each staff member.

3. Design, implement and monitor compliance of a flu prevention protocol (e.g., babies, staff, Board members, visitors, volunteers))

4.  Develop emergency plans for various possible major incidents: chemical, natural, terrorist, bioterrorist, radiological.

5.  Prepare criteria and plans for “Shelter in Place” and various evacuation options.

6.  At least quarterly prepare copy computerized financial data for off-site storage; also scan, for off-site storage, critical documents such as tax-exempt letters, group home license etc.

E. Development/ Marketing

1. Complete historical profile of HC fund-raising accomplishments (as well as previous donors who no longer contribute).

2. Set goal for fund-raising share of HC annual budget.

3. Establish permanent Development Committee in the By-Laws, then

4. Prepare and Annual Development Plan.

5. Prepare job description for a HC Development position including rationale for its being full time or part (and how it will be funded).

F. Board of Trustees

1. The Board should adopt a “Statement of Board Member Responsibilities.”

2. The Nominating Committee should prepare matrix of expertise and term limit dates of current Board members (and additional expertise the Board needs), then,

3. Recruit new qualified potential candidates for Board membership until the matrix is filled.

4. The Chairman and the CEO should develop an Orientation program for new Board members.

5 The Executive Committee should prepare templates for Annual Board Evaluation and individual Board member self-evaluation.

6. At least once a year the Board should discuss a Board Leadership Succession Plan.


1. The Board should approve a current CEO job description (including educational, clinical and experience requirements for any future CEO).

2.  A format for the CEO’s Annual Evaluation should be prepared by the Chairman and approved by the Board.

3.  At least once a year the Board should review a CEO succession plan.


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“President Donald Trump declared that the GOP will now be the “party of health care…”

On March 26, 2017 I posted an obituary on REPEAL & REPLACE after  House Speaker Paul Ryan said his party “came up short” in a news conference minutes after pulling the GOP healthcare bill off the House floor, acknowledging that ObamaCare will stay in place “for the foreseeable future.””

Yet on December 20th, 2017 the INDIVIDUAL MANDARE was repealed. ““When the individual mandate is being repealed that means ObamaCare is being repealed,” Trump said…“We have essentially repealed ObamaCare, and we will come up with something much better…” (WRECK & REJOICE)

During the ten months between REPEAL & REPLACE and WRECK & REJOICE I posted over seventy updates. You can find links to this chronology further down on this post.

Now there is an opportunity to track four ongoing and competing health care strategies.

  • Medicare for All
  • Court challenges of the Affordable Care Act
  • The new Democrats plan
  • The next Republican plan


What was once seen as a long-shot pitch from Vermont independent Sen. Bernie Sanders during his 2016 presidential campaign is now a proposal that at least four of his Senate colleagues also vying for the party’s 2020 nomination supported during the last Congress. The issue is driving the national political health care debate…

Democrats are already contending with industry groups hoping to shift the focus back to strengthening the current system. Most drug companies, hospitals and insurers oppose Medicare for All, which undoubtedly complicates progressives’ efforts. The party’s left wing is pushing a bold, pricey plan carrying political risks that make Democratic leaders shudder. Despite all the inevitable political hurdles, getting a single-payer law enacted may look easy compared to implementing it…

A single-payer health care plan would significantly change every sector of the health care industry. Hospitals and doctors would need to adjust to a new payment system, the insurance industry would shrink to a fraction of its size, and the government would bring drug companies to the negotiating table to determine prices.

The 2010 health care law left in place most of the existing health care infrastructure in the U.S. Still, experts warn that the lessons from that more incremental transition show how dramatic it would be to shift to a single-payer system.

Supporters aren’t intimidated by the seismic nature of the change. The hope is not just to ensure that everyone has coverage, but also to take on health care companies seeking to maximize their profits, said Adam Green, a co-founder of the Progressive Change Campaign Committee, a political action committee that supports liberal candidates.

“Medicare for All boils down to two things,” Green said. “One is universal coverage. The other is corporate accountability.” (A)

“Here’s where the Democratic candidates stand on Medicare for All:

Sen. Elizabeth Warren (Mass.)

Warren co-sponsored Sanders’s Medicare for All proposal in 2017. But she has said that the broader goal is “affordable health care for every American,” and that there are “different ways” to achieve that objective.

She has previously backed legislation that would allow people to buy into a Medicaid-based public option on state insurance markets.

Sen. Cory Booker (N.J.)

Booker co-sponsored Sanders’s Medicare for All legislation. But he has also rejected that private health insurance be eliminated under such a health care system and has also expressed support for a more incremental approach in which Medicare eligibility is expanded.

Booker has also signed on to legislation that would lower the Medicare eligibility age to 50, as well as a proposal to allow people to buy into a Medicaid option through state insurance marketplaces.

Sen. Kamala Harris (Calif.)

Harris is among a handful of 2020 Democrats who signed on to Sanders’s Medicare for All bill and has said that she would support eliminating private health insurance altogether.

Harris has also co-sponsored proposals that would lower the age of Medicare eligibility to 50 and create a Medicaid option on state insurance markets that people currently ineligible for the program could buy into.

Sen. Bernie Sanders (I-Vt.)

Sanders has long been the most vocal advocate in the Senate for a Medicare for All system and helped popularize the concept during his insurgent bid for the White House in 2016.

He said in an interview on MSNBC on Tuesday night that he would not support any Democratic legislation on health care other than his own Medicare for All proposal. Sanders also reiterated his past assertion that lawmakers should “get rid of” private insurance under such a plan.

Sen. Kirsten Gillibrand (N.Y.)

Gillibrand supports a Medicare for All proposal and co-sponsored Sanders’s 2017 legislation seeking to implement such a plan.

She’s also signed on to measures lowering the age of eligibility for Medicare to 50 and creating a public health care option through Medicaid on individual state insurance marketplaces.

Former Rep. Beto O’Rourke (Texas)

O’Rourke has said he backs “universal health care.” But unlike some of his more progressive challengers, he’s thrown his support behind a different kind of proposal, dubbed Medicare for America, that would allow Americans to join a public Medicare-based plan, while preserving the option to remain on employer-based insurance.

“It responds to the fact that so many Americans have said, ‘I like my employer-based insurance. I want to keep it. I like the network I’m in. I like the doctor that I see,’ ” O’Rourke told The Texas Tribune earlier this month.

Sen. Amy Klobuchar (Minn.)

The Minnesota senator has refused to explicitly support Medicare for All, offering up a more incremental approach to health care reform that would involve creating a public, Medicaid-like option.

On Medicare for All, Klobuchar has said that it is “something we can look to for the future,” but that she wants “action now” — a nod to the likely challenges such a sweeping proposal would face.

(Also: Washington Gov. Jay Inslee; Former Colorado Gov. John Hickenlooper; Rep. Tulsi Gabbard (Hawaii);South Bend, Ind., Mayor Pete Buttigieg; Former San Antonio Mayor Julián Castro; Andrew Yang; Marianne Williamson; Former Rep. John Delaney (Md.) (B)

“CMS Administrator Seema Verma wrote in an op-ed for The Wall Street Journal that “Medicare for All” proposals would harm seniors’ access to care by bringing all Americans into a system created to support just older adults…

“The monetary cost of Medicare for All is surpassed by its moral cost,” she writes. “The plan would strip coverage from more than 180 million Americans and force them into government insurance. It will resemble the Veterans Administration, which has been plagued by unreasonable wait times, poor customer service, provider shortages and little accountability in the administration of care.”” (C)

“The Trump administration is siding with Obamacare opponents who argue that it is unconstitutional and should be scrapped entirely, initiating a new, more aggressive assault on the health care law that will assure the issue will be squarely at the forefront of the 2020 presidential campaign.

The Justice Department shifted its stance, after arguing last year that some parts of the 2010 law — but not all of it — should be struck down in a case brought by the state of Texas. A federal district judge voided the law in a December ruling that is now under appeal.

In a filing late Monday night, the Justice Department said that President Barack Obama’s signature legislative achievement should be wiped out.

“The Department of Justice has determined that the district court’s comprehensive opinion came to the correct conclusion and will support it on appeal,” DOJ spokeswoman Kerri Kupec said in a statement.

The filing draws renewed attention to Trump’s and the Republican Party’s stance that Obamacare, formally known as the Affordable Care Act, should be eliminated. That would include subsidies for coverage and rules popular with voters such as preventing insurers from discriminating against those with pre-existing conditions, limits on coverage and coverage for preventative care.” (D)

“The Affordable Care Act was already in peril after a federal judge in Texas invalidated the entire law late last year. But the stakes ramped up again this week, when President Trump’s Justice Department announced it had changed its position and agreed with the judge that the entire law, not just three pieces of it, should be scrapped.

A coalition of states is appealing the ruling. If it is upheld, tens of millions more people would be affected than those who already rely on the nine-year-old law for health insurance. Also known as Obamacare, the law touches the lives of most Americans, from nursing mothers to people eating at chain restaurants.

Here are some potential consequences, based on estimates by various groups.

Of the 23 million people who either buy health insurance through the marketplaces set up by the law (11.4 million) or receive coverage through the expansion of Medicaid (12 million), about 21 million are most at risk if Obamacare is struck down. That includes 9.2 million who receive federal subsidies.

On average, the subsidies covered $525 of a $612 monthly premium for customers in the 39 states that use the federal marketplace, HealthCare.gov, according to a new report from the Department of Health and Human Services. If the marketplaces and subsidies go away, a comprehensive health plan would become unaffordable for most of those people and many of them would become uninsured.

States could not possibly replace the full amount of federal subsidies with state funds.

Medicaid, the government insurance program for the poor that is jointly funded by the federal government and the states, has been the workhorse of Obamacare. If the health law were struck down, more than 12 million low-income adults who have gained Medicaid coverage through the law’s expansion of the program could lose it.

In all, according to the Urban Institute, enrollment in the program would drop by more than 15 million, including roughly three million children who got Medicaid or the Children’s Health Insurance Program when their parents signed up for coverage…

As many as 133 million Americans — roughly half the population under the age of 65 — have pre-existing medical conditions that could disqualify them from buying a health insurance policy or cause them to pay significantly higher premiums if the health law were overturned, according to a government analysis done in 2017. An existing medical condition includes such common ailments as high blood pressure or asthma, any of which could require someone buying insurance on their own to pay much more for a policy, if they could get one at all…

The 156 million Americans who get coverage through an employer, as well as the roughly 15 million enrolled in Obamacare and other plans in the individual insurance market, are protected from caps that insurers and employers used to limit how much they had to pay out in coverage each year or over a lifetime. Before the A.C.A., people with conditions like cancer or hemophilia that were very expensive to treat often faced enormous out-of-pocket costs once their medical bills reached these caps.

While not all health coverage was capped, most companies had some sort of limit in place in 2009. A 2017 Brookings analysis estimated that 109 million people would face lifetime limits on their coverage without the health law, with some companies saying they would cover no more than $1 million in medical bills per employee. The vast majority of people never hit those limits, but some who did were forced into bankruptcy or went without treatment…” (E)

““President Donald Trump declared that the GOP will now be the “party of health care.” The problem? His party doesn’t have a health care plan. Congressional Republicans, who failed to repeal and replace Obamacare when they controlled both chambers, were completely blindsided this week by the Trump administration’s surprising decision to back a court ruling that would throw out the entire Affordable Care Act, including the popular protections for people with pre-existing conditions.

The move baffled many in the GOP, who believe the issue cost them the House in the last election. And Axios first reported that House Minority Leader Kevin McCarthy (R-Calif.), a Trump ally, even voiced his concerns over the administration’s decision directly with the president. Republicans from across the spectrum would prefer to focus on more narrow health care issues that are an easier lift, like lowering prescription drug prices.” (F)

“House Democrats are rolling out a plan to strengthen the Affordable Care Act that would expand federal insurance subsidies and reverse the Trump administration’s attacks on the health care law — but avoids the party’s internal fight about more ambitious proposals to extend health coverage…

The Democratic bill is a smorgasbord of provisions to expand health care and undo the Trump administration’s regulatory actions to weaken the ACA:

It expands the tax credits available under the law, both reducing costs for lower-income families and expanding eligibility so middle-class Americans can receive federal assistance.

It creates a national reinsurance program to offset high medical bills for insurers and thereby keep premium increases in check.

It rolls back Trump actions expanding skimpier health insurance plans, giving states the freedom to undermine the law’s benefits requirements, and cutting enrollment outreach funding…

The rest of the bill is a string of more technical provisions: creating a national reinsurance program, fixing the so-called “family glitch” that barred some families from accessing tax subsidies, and, importantly, reversing the Trump administration’s regulatory agenda. The Democratic bill rolls back or otherwise curtails Trump’s expansion of short-term insurance plans not required to meet the ACA’s protections for preexisting conditions. It also requires the administration to spend federal money on enrollment outreach, after Trump officials cut that budget dramatically over the past two years…

Notably missing from the Democratic bill is a public option or Medicare buy-in, the introduction of a government health care plan to compete with the private insurance offerings of the ACA’s marketplaces…

House Speaker Nancy Pelosi has sounded skeptical notes about single-payer and urged Democrats to focus on strengthening Obamacare, their winning message in the midterms, so this new bill doesn’t come as a surprise. Leadership is taking a more deliberate approach to their party’s more ambitious health care ideas, where there is not yet a consensus within the ideologically diverse Democratic majority.” (G)

““Mitch McConnell has no intention of leading President Donald Trump’s campaign to transform the GOP into the “party of health care.”

“I look forward to seeing what the president is proposing and what he can work out with the speaker,” McConnell said in a brief interview Thursday, adding, “I am focusing on stopping the ‘Democrats’ Medicare for none’ scheme.”

The Senate majority leader spent untold weeks and months on the party’s health care quagmire in 2017, when the GOP controlled both the House and the Senate and still failed to repeal Obamacare. The episode caused endless headaches for Republicans as their replacement plan fell apart first, followed by the so-called “skinny” plan they slapped together at the last minute.

Now in divided government, with the Senate majority up for grabs next year and McConnell himself running for reelection, another divisive debate over health care is the last thing McConnell needs. But that’s exactly where Trump is taking Republicans after his administration endorsed a wholesale obliteration of the law in the courts earlier this week.

So the Kentucky Republican and his members are putting the onus on the president to figure out the next steps.

McConnell’s clear reluctance toward trying to draft a sweeping health care bill in the Senate reflects his political instincts: that it’s better to focus on perceived Democratic weaknesses — the left’s push on “Medicare for All” — than to struggle to unify his own party on a plan almost certain to be rebuffed by Senate Democrats and House Speaker Nancy Pelosi (D-Calif.). “ (H)

“The White House is quietly working on a healthcare policy proposal to replace the Affordable Care Act, according to multiple sources with knowledge of the matter.

While it is not clear how far along the process is, work on a proposal has been going on for months. The effort appears to belie criticism that Trump’s decision to restart the debate on healthcare, an issue Democrats used to their advantage in the 2018 midterms, was an error committed without forethought.

“The White House, mainly through the National Economic Council, has been engaged on thinking about health care reform for a while now, and they have been engaged with a group of center-right health policy groups to talk about various proposals and ideas,” a conservative health policy analyst told the Washington Examiner.

The analyst said the administration has been “having conversations” on healthcare policy and has reached out to numerous think tanks, including the Heritage Foundation, the Mercatus Center, and the Hoover Institute…

Policy leaders at several conservative think tanks confirmed to the Examiner that a healthcare plan is indeed the works. They said a proposal would take concepts from the Graham-Cassidy bill, by Sen. Lindsey Graham, R-S.C. and Sen. Bill Cassidy, R-La., and the Health Care Choices proposal, which was signed by many conservative policy leaders, including the Heritage Foundation and former Sen. Rick Santorum, R-Penn. One analyst said a White House proposal would most likely be brought up in the Senate first.

Heritage Foundation Director of Domestic Policy Studies Marie Fishpaw noted that the president has already included concepts from the Health Care Choices proposal in his 2020 budget.

The proposal, according to Fishpaw, “would lower premiums by up to a third, lowering costs while also protecting people with pre-existing conditions.” It would replace federal payments to insurance companies with grants for each state, giving individual states more leeway to determine how to use the money.

One conservative policy analyst said that although the White House is definitely “exploring” the healthcare issue, it does not seem ready to unveil a proposal…

Trump has already asked a group of Senate Republicans, including John Barrasso of Wyoming, Rick Scott of Florida and Cassidy to come up with a replacement for Obamacare. But other Senate Republicans, including Sens. Roy Blunt of Missouri, John Kennedy of Louisiana and Majority Leader Mitch McConnell, have indicated an unwillingness to get moving on the issue until Trump puts forth his own proposal.

“I’m anxious to see what the White House is going to recommend in terms of a healthcare delivery system that looks like somebody designed the damn thing on purpose,” Kennedy said.” (I)

“President Donald Trump on Monday night backed away from his push for a vote on an Obamacare replacement until after the 2020 elections, bowing to the political reality that major health care legislation cannot pass in the current Congress.

Trump’s statements come a week after his administration announced that it now agreed with a judge’s ruling that the entire Affordable Care Act should be scrapped. The opinion was a dramatic reversal from the administration’s previous stance that only portions of the act could not be defended.

Trump’s latest move allows him to wait on the issue as legal challenges against the health care law, also known as Obamacare, make their way through the federal court system. If it’s ultimately overturned, Trump can claim he made good on a campaign promise in time for his 2020 re-election campaign — though he would then face the prospect of an estimated 20 million Americans losing their health insurance on his watch, with no Republican replacement in the legislative pipeline. If it’s upheld — as it has been in previous Supreme Court challenges — he can rail against a “liberal” court system…

Trump unsettled Republican lawmakers last week by putting the spotlight back on the thorny issue of repealing and replacing Obamacare, vowing that his party would turn to replacing the health care law as his administration backed a federal court ruling striking down the law in its entirety. Republican congressional leaders quickly sought to distance themselves from Trump’s latest drive, mindful that passing such a proposal would be virtually impossible in a divided Congress…

Trump said Thursday he’s asked Republican senators to work on a replacement to the Affordable Care Act, but no such group appears to exist. Multiple Republican senators who Trump name-checked said they were not a part of a working group, but had spoken with the President about health care recently.

And on Wednesday, Marc Short, Vice President Mike Pence’s chief of staff and the former White House legislative affairs director, claimed on CNN that “the President will be putting forward plans this year” to replace Obamacare through Congress.

White House officials were quick to tell CNN that Short had gotten ahead of White House deliberations.

The White House has yet to decide whether it will take the lead on crafting an Obamacare replacement, they said, or whether the President will punt to Republican lawmakers.” (J)


From REPEAL & REPLACE to WRECK & REJOICE (from Obamacare to Trumpcare)


March 26, 2017

LESSONS LEARNED: TrumpRyanCare Obits

March 29, 2017

Let’s prohibit Congressmen from insurance reimbursement for Prostate Screening and Treatment

May 6, 2017

Repeal and DESTROY Obamacare

May 24, 2017


June 16, 2017

REVISE and RECALIBRATE Obamacare. Prevent Republican’s “mean” plan.

June 23, 2017

Is there more “heart” in the Senate health care bill? Or is it “meaner” than the House bill?

June 29, 2017

Perry Como sang “There’s no place like home for the holiday”….except for Republican Senators with their TrumpCare albatross

July 4, 2017

REPEAL NOW/ REPLACE LATER: “Nothing like rolling a hand grenade into ongoing negotiations…”

July 6, 2017

Cruz health care bill amendment – “….healthy people could get coverage although that coverage might not protect them if they got sick and sick people would have to pay an unaffordable amount for coverage.”

July 9, 2017

SLOW DOWN & START OVER (policy) versus REPEAL & REPLACE (politics)

July 12, 2017

What would Albert Einstein have said about TrumpCare? “The definition of insanity is doing something over and over again and expecting a different result.”

July 13, 2017

Is the new Senate health proposal a responsible bill or just “stuff” to get 50 votes?

July 15, 2017

Republican Talking Points on the new Senate Health Care Bill. Democratic Party response – “Senate Republicans spent the past two weeks putting lipstick on a pig”

July 16, 2017

Last week Senator McCain said the “Senate healthcare deal could be reached by Friday ‘if pigs fly’” (A). Now he has a deciding vote on the Republican “junk insurance” bill!

July 17, 2017

“Laws are like sausages, it is better not to see them being made.” (Otto von Bismarck). Or not made…two conservative Republican Senators kill TrumpCare….for now

July 18, 2017

After another day of Republican health care bill fiascos: “President Trump: ‘Let Obamacare Fail…I’m Not Going to Own It’

July 19, 2017

Are Republicans going to LET Obamacare die or MAKE it die? How can the individual market exchanges be stabilized?

July 20, 2017

“The vote is a reward to the ultras who sabotaged repeal and replace by allowing them to posture one more time as purists who have not forsaken the true faith.”

July 21, 2017

“McConnell is still planning votes on health-care legislation next week. But many things have to go right for his strategy to succeed, and not all of them are within his control.”

July 22, 2017

“….. the parliamentarian has taken an already very difficult process for enacting health care legislation in the Senate and made it nearly impossible….”

July 23, 2017

New York Daily News editorial: Senate Republican vote –“An embarrassment wrapped in cruelty wrapped in political disaster.”

July 24, 2017

Rep. Blake Farenthold (R-Texas) suggested….that he’d like to duel with female senators he blames for the Senate’s failure to repeal and replace ObamaCare

July 25, 2017

“These are the moments legislatively when you get creative. We’re getting creative.”

July 26, 2017

“It is clear that Mr. McConnell does not much care which of these proposals the Senate passes…. — he just wants to get a bill out of the Senate.”


July 27, 2017

Senator Graham said he could not support a “half-assed” plan that he called “politically” the “dumbest thing in history.”

July 28, 2017

The House and Senate played “dodgeball” not wanting to be held accountable when twenty million people, their constituents, would lose access to affordable care.

July 29, 2017

What Congress, President Trump and Former President Obama are saying about healthcare

August 6th

“.. here’s the first thing I thought about: feel better, Hillary Clinton could be president..” (Senator McConnell) (A) “McCain Voted Against Health Care Bill…Because it Would ‘Screw’ Arizona.” (B)

August 10, 2017

“In politics you can tell your friends from your enemies, your friends are the ones who stab you in the front”.* Look at what the Republicans are saying about each other now about health care

August 16, 2017 |

The Trump administration “blinks”; provides Obamacare funding


August 23, 2017

For 17 years I was President and CEO of a safety net hospital. TrumpCare will “disinsure” twenty million+ people and devastate the hospitals we all depend on.


August 23, 2017

Trump told a GOP senator she could only ride on Air Force One if she voted for the healthcare bill.

September 3, 2017

TrumpCare. “If you don’t know (`or care`) where you’re going, any road will get you there.” – Lewis Carroll

September 8, 2017

“Republican plans to replace Obamacare are fading fast, but that doesn’t mean Congress is done with health care.

September 16, 2017

“Senators on the health committee are working over the weekend to try to reach an agreement on a stabilization bill for Obamacare…”

September 19, 2017

President Trump would sign the Graham-Cassidy bill if the legislation to repeal Obamacare makes it to his desk…. IT JUST MIGHT MAKE IT THERE!

September 20, 2017

TRUMPCARE. “This is the choice for America, Mr. Graham said on Tuesday: “Socialism or federalism when it comes to your health care.””

September 21, 2017

President Trump tweeted he ”.. would not sign Graham-Cassidy if it did not include coverage of pre-existing conditions. It does! A great Bill. Repeal & Replace.” IT DOESN’T!

September 22, 2017

“It ain’t over till it’s over.” (Yogi Berra). But, John McCain said he “cannot in good conscience vote for the Graham Cassidy proposal.”

September 23, 2017

TrumpGrahamCassidy. “Perhaps one of the biggest challenges for the bill will come next week when the Senate parliamentarian — an umpire of sorts for the chamber’s rules — takes a look at the bill…”

September 24, 2017

White House Director of Legislative Affairs Marc Short is defending the proposed Graham-Cassidy bill — – by countering criticism that the bill does not provide coverage for those with pre-existing conditions.

September 25, 2017

TRUMP/ GRAHAM/ CASSIDY. “If there’s a billion more going to Maine … that’s a heck of a lot,” Cassidy said.

September 26, 2017

“I personally think it’s time for the American people to see what the Democrats have done to them on health care,” said Senate Finance Committee Chairman Orrin G. Hatch (R-Utah).

September 27, 2017

Last minute Sunday night Graham Cassidy revisions included.. a pretty sweet deal for the state of Lo uisiana, home of one of the bill’s sponsors Sen. Bill Cassidy.

September 28, 2017


September 29, 2017

“Senate Republicans Commence Health Care Blame Game” – pointing fingers at each other. (But..Is a bipartisan deal next?)

October 1, 2017

Senator Cassidy a candidate for Health and Human Services Secretary?

October 2, 2017

Access to health care….should be considered “privileges” for those who can afford them

October 8, 2017

Trump: “I want to focus on North Korea not ‘fixing somebody’s back’,…Let the states do that.” As “synthetic repeal” of ObamaCare is underway.

October 12, 2017

Trump’s Executive Order: “By siphoning off healthy individuals, these junk plans could cannibalize the insurance exchanges.”

October 15, 2017

Trump vows to rip apart Obamacare piece by piece

October 18, 2017

“… President Donald Trump on Wednesday backed away from a bipartisan deal on healthcare reached by two senators…

October 31, 2017

Ending the subsidy for copays/ deductibles would increase the subsidy for premiums ..and ObamaCare enrollment would grow

November 9, 2017

President Trump and Republican congressional leaders falsely claim that Obamacare… is in a “death spiral.”

November 14, 2017

Senate Republicans include repeal of Obamacare’s individual mandate in the tax bill

November 20, 2017

The Republican deal with itself: repeal the Obamacare individual mandate and stabilize the individual health insurance market?

November 26, 2017

“The White House is trying kill Obamacare. Americans are throwing it a lifeline.”

November 30, 2017 | Edit

“The Senate tax bill is really a health care bill with major implications for more than 100 million Americans…..

December 2, 2017 |

“..Conference Committee “may not change a provision on which both houses agree, nor may they add anything that is not in one version or the other,”…

December 6, 2017

“…House and Senate Republicans will likely scrap Obamacare’s individual mandate in their final tax bill.”

December 8, 2017

..congressional Republicans aim to reduce spending on federal health care programs to reduce America’s deficit

December 10, 2017

Note to Sen Collins: Look Around the Poker Table- If You Can’t See the Patsy, You’re It! *

December 14, 2017

“..the compromise tax bill from House and Senate negotiators will end the health law’s requirement that all individuals buy insurance or pay a fine….”

December 17, 2017

“ the move is a winner for Republicans, who.. would otherwise have little to show for 7 years of…repeated efforts to kill Obamacare..”

December 19, 2017

“….57 % of Americans now approve of Obamacare. Only 29 % approve of the GOP’s tax cuts.”

December 20, 2017

By ending the Individual Mandate Republicans are “showing they have no clue how insurance works.”…or don’tcare…

December 21, 2017

President Trump: “When the individual mandate is being repealed that means ObamaCare is being repealed”

December 23, 2017

“It leaves us with two laws… Call the first one Obamacare… Call the second one Trumpcare”

January 10, 2018

“wreck and rejoice” – has consequences. BTW, there is a congressional exemption from ObamaCare

January 24, 2018

GOP Rep. Blames Obamacare For Sexual Harassment Allegations

April 25, 2018

From REPEAL & REPLACE to WRECK & REJOICE (from Obamacare to Trumpcare)

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From REPEAL & REPLACE to WRECK & REJOICE (from Obamacare to Trumpcare


April 25, 2018 | Edit

On March 24th, 2017. “Speaker Paul Ryan (R-Wis.) on Friday said his party “came up short” in a news conference minutes after pulling the GOP healthcare bill off the House floor, acknowledging that ObamaCare will stay in place “for the foreseeable future.””

Yet on December 20th, 2017 the INDIVIDUAL MANDARE was repealed. ““When the individual mandate is being repealed that means ObamaCare is being repealed,” Trump said…“We have essentially repealed ObamaCare, and we will come up with something much better…”

“Andy Slavitt, who served as the acting administrator for the Center for Medicare and Medicaid Services under President Barack Obama, warned late Friday night that Republicans may try to repeal and replace Obamacare once again before the 2018 midterm elections. “Republicans have been meeting in secret to bring back ACA repeal,” he writes…

… Santorum and others may think that there will be a “blue wave” in 2018 no matter what, so this may be the last time the GOP has the opportunity to get rid of Obamacare. And that might make Republicans desperate enough to try again.” (R)

At the end of this post there are links to a series of over 60 posts tracking the activity between March 24th and December 20th. Laws are like sausages,” goes the famous quote often attributed to the Prussian Chancellor Otto von Bismarck, “it is better not to see them being made.”

In 2018, mostly under-the-radar, efforts are continuously underway to continue to undermine what’s left of ObamaCare.

“Republicans, having failed to repeal Obamacare, have stumbled, almost accidentally, into replacing it. For better and for worse, and with little coherent vision at work, they are making Obamacare their own. And over time, they are likely to embrace it…,

Congress has already repealed several unpopular parts of the law as part of last year’s tax legislation — most notably the individual mandate, which now expires at the end of this year, but also the Medicare cost-control board (known as the Independent Payment Advisor Board).

The executive branch has exerted its own influence on the law. In October of last year, President Trump signed an executive order calling for the expansion of association health plans and limited-duration insurance, in hopes of creating a secondary market for health plans that are cheaper and less regulated, and this year, the administration released extensive proposals for each. The administration also stopped paying the law’s cost-sharing reduction subsidies, which reimburse insurers for low-income beneficiaries. And the Department of Health and Human Services has begun allowing states to attach work requirements to Medicaid, making the program more bureaucratic, but possibly enticing red states that have so far declined to expand the program to do so…

Having failed in their repeal effort, Republicans are now in something of an arranged marriage with the health care law. These alterations are being made in a predictably haphazard fashion, with little in the way of guiding theory, but the cumulative effect is to turn Obamacare into a law that they can, if not love, at least learn to live with.”(A)

“Bigger changes are coming. The administration has proposed regulations that would allow so-called short-term health plans to be offered for nearly a year of coverage. Those plans aren’t subject to any Obamacare rules in most states, and are likely to be marketed aggressively. They are likely to cover fewer health services and be available only to the healthy — but at a lower price. Another pending rule would expand the availability of association health plans, a form of group insurance purchasing that may be attractive to small businesses looking for cheaper, less comprehensive options….

People buying those plans may face some unpleasant surprises. The plans are likely to require applicants to fill out detailed health histories, and to exclude those with prior illnesses. They also are likely to exclude or limit services — like addiction treatment, maternity care or prescription drugs — that all Obamacare plans require. Association plan buyers have tended to have problems with fraud. And some short-term plans have a history of declining to pay for serious illnesses after the fact.

But even if the new plans serve their customers well, their popularity could leave the remaining markets a bit shakier. Because the short-term plans will be open only to the healthy, the remaining customers will tend to be sicker, and more expensive to insure.” (B)

“It’s been well documented that the Trump White House has filled federal agencies with bureaucrats whose life work is destroying the very agencies they’ve been assigned to. But one is in a better position than her fellows to threaten the health of millions of Americans—and she’s been working at that assiduously.

We’re talking about Seema Verma, who as administrator of the Centers for Medicare and Medicaid Services also is effectively the administrator of the Affordable Care Act. In the Trump administration, that has made her the point person for the Trump campaign to dismantle the act, preferably behind the scenes…

Still, Verma had spent enough time in the healthcare field that observers thought she might not be totally egregious as CMS administrator. But then, during her confirmation hearing in February 2017, she let on that she didn’t see why maternity coverage really needed to be mandated for all health policies, since “some women might want maternity coverage, and some women might not want it…

It wasn’t an auspicious start. But since then she has lived down to our expectations. Verma never has concealed her hostility to Medicaid — especially Medicaid expansion, a provision of the ACA. Her animosity is fueled at least in part by ignorance (willful or otherwise) about the program. Back in November, on the very day that voters in Maine and Virginia were demonstrating full-throated support at the polls for expanding Medicaid in their states, Verma was unspooling a string of misleading statistics and suspect assertions about the program to support a policy of rolling back enrollment.” (C)

“Passing two measures aimed at stabilizing the Affordable Care Act marketplaces by infusing insurers with more funds would lower monthly premiums by 20 to 40 percent and prompt an additional 3.2 million people to get covered, says an attention-grabbing independent analysis released yesterday by the firm Oliver Wyman.

These measures – which would pay insurers for extra cost-sharing discounts for the low-income and reimburse them for their most expensive customers – are currently stuck in political limbo as leaders on Capitol Hill consider whether to include them in a massive, must-pass spending bill next week.

The bills have become emblematic of inter and intraparty disputes over how to approach a world with most of the ACA still in place. Democrats are bitter that Republicans are still chipping away at parts of the law by repealing its individual mandate and changing other provisions through the executive branch…

And Republicans can’t even agree among themselves how to handle the law now that they’ve failed to entirely wipe it from the books. (D)

“Republicans campaigned for roughly a decade, promising voters they would dismantle former President Barack Obama’s landmark health care legislation; but one of their own senators is trying to keep it alive through the 2018 election cycle…

Sen. Lamar Alexander, R-Tenn., along with Sen. Patty Murray, D-Wash., is using the deadline to sway leadership to include a proposal that would fund politically contentious Obamacare subsidies through 2019. The proposal would provide $10 billion a year for three years for these subsidies…

Additionally, the proposal would give states greater Obamacare waiver flexibility and would broaden consumer eligibility for “copper” plans. Abortion-covering health insurance plans would not receive subsidies under the proposal…

Republicans are either not thrilled about Alexander’s proposal, calling it a bad idea and one that could hurt the party going into 2018, or they think it could be one way to provide taxpayers some relief from the financial burdens Obamacare imposed.” (E)

“The House passed the $1.3-trillion omnibus spending package meant to keep the government running until Sept. 30 in a vote of 256-167, leaving the Senate barely 35 hours to get the same legislation approved by Friday at midnight to avert a shutdown.

The bill boosts funding for the National Institutes of Health, the CDC, and the Department of Veterans Affairs (VA) as well as other key agencies, but keeps funding flat for the Centers for Medicare and Medicaid Services…

The bill also does not include the health insurance stabilization bill from Sen. Lamar Alexander (R-Tenn.) and Sen. Susan Collins (R-Maine). They had wanted the omnibus package to include measures restoring for 3 years the cost-sharing reduction subsidies (monies that help insurers defray out-of-pocket costs for low-income enrollees), establishing 3 years of reinsurance (monies that help pay for the sickest of patients and keep premiums from spiking) at $10 billion per year, and streamlining the 1332 waiver process to allow states more flexibility in health plan design.” (F)

“The Trump administration hopes to move forward with a rule expanding alternatives to ObamaCare plans by this summer, Secretary of Labor Alex Acosta said Monday. The rule allows small businesses and self-employed individuals to band together to buy insurance as a group in what are known as association health plans. “We hope to have that by this summer,” Acosta said Monday during a tax reform event alongside President Trump in Florida.” (G)

“In 2012, the Supreme Court of the United States upheld Obamacare in a 5-4 ruling, with Chief Justice John Roberts writing the majority opinion. Many Obamacare opponents believe Roberts used contorted reasoning to save the law by labeling Obamacare’s individual mandate penalty a tax.

Now, six years later, 20 states have seized on the Roberts ruling to ask the courts again to undo Obamacare. These states filed a lawsuit indicating that because the December 2017 tax reform bill repealed the individual mandate penalty, there’s no longer any legal rationale for the mandate. They also argue that because there’s no “severability clause” in Obamacare, the entire law must be struck down.

If this sounds confusing, read on to unpack what’s going on with this latest attempt to undo Obamacare through the courts.

The Obamacare mandate was ruled a tax…

Opponents of the law argued Congress didn’t have the power to require individuals to purchase a product from private insurers, while the Obama administration argued authority for the mandate came from the Commerce Clause, which gives the federal government power to regulate commerce “among the several states.”” (H)

“Gov. Scott Walker has asked for a federal waiver to operate a state-based reinsurance plan designed to stabilize the state’s individual health insurance market and hold down premiums under the Affordable Care Act.

Following a 44 percent average spike in Obamacare premiums this year, Walker’s office estimates the $200 million program would lower premiums by 11 percent from what they otherwise would have been, amounting to a 5 percent decrease in premiums compared to 2018.

Under the plan, the state would pay $34 million for reinsurance in 2019, while $166 million would come from federal funds…

“We are taking action to address the challenges created by Obamacare and bring stability to the individual market,” Walker said. “Our Health Care Stability Plan provides a Wisconsin-based solution to help stabilize rising premiums in order to make health care more affordable for those purchasing in the individual market. With Washington D.C. failing to fix our nation’s health care system, Wisconsin must lead.” (I)

“The American Academy of Family Physicians and other doctor groups have unleashed detailed critiques of Trump’s effort to introduce cheaper health insurance with skimpier benefits….

“Insurers could reduce or eliminate certain essential health benefits to avoid vulnerable, expensive patients by excluding specific services,” AAFP board chair Dr. John Meigs, Jr., a family physician from Alabama wrote in a letter last week to U.S. Health and Human Services Secretary Alex Azar.

“In doing so, insurers could potentially make plans more expensive for people with long-term chronic conditions or with sudden medical emergencies,” Meigs said. “Inadequate benefits could leave this population with too little coverage to meet their health care needs.” (J)

“The Affordable Care Act (aka Obamacare) banned any hospital, doctor, or insurance company who receives federal funding from discriminating against or denying services based on sex; the Obama administration made it clear in 2016 that provision included transgender and gender-nonconforming patients…

These benefits and protections are heading for oblivion though, according to the Times. The Trump administration is pointing to a January 2017 ruling from a Texas federal judge who said the 2010 law did not cover gender identity or presentation.

“Congress did not understand ‘sex’ to include ‘gender identity,’” Judge Reed O’Connor ruled. In the Affordable Care Act, he said, Congress “adopted the binary definition of sex.” (K)

“As Republicans careen toward the midterms with tax reform under their belts and not much else, rumor has it that a small group of Republican senators are working with the White House and former Sen. Rick Santorum (R-Pa.) to revive the debate over ObamaCare repeal.

Their purpose is laudable. But, privately, conservatives across Capitol Hill are expressing concern that the proposal may not do enough to dismantle ObamaCare’s regulatory structure, reduce its colossal spending, or allow freedom to innovate outside the law’s stifling framework…

The bill’s premise — to devolve much of the health-care spending to the states — is a good starting point. But its implementing details are still unknown, leaving conservatives to wonder if the new bill will actually repeal ObamaCare and reform the health-care marketplace, or if it will simply recast much of the law’s worst elements with a few minor tweaks…

Voters are still waiting for a full repeal effort. Anything less will not suffice as a solution for candidates who will soon be elected on a message of repeal. Nor will it suffice for a party who has spent years making the same promise.” (L)

“Less than a year after the GOP gave up on its legislative effort to repeal the law, Democrats are going on offense on this issue, attacking Republicans for their votes as they hope to retake the House majority…

ObamaCare’s favorability in polls has improved since the repeal push last year, with more now favoring the law than not. A Kaiser Family Foundation poll in March found that 50 percent of the public favors the law, while 43 percent holds an unfavorable view.

GOP strategist Ford O’Connell said the political winds have shifted on the issue, turning ObamaCare into a subject Democrats want to tout and many Republicans want to duck.

“I don’t think it’s seen as a winning issue,” he said. “It’s also an issue that tends to fire up the Democratic base more so than the Republican base.”” (M)

“While Republican moves to overhaul Social Security, Medicare or Medicaid appear unlikely — at least for this year — Democrats are increasingly warning about the prospect because of the deficit concerns created by the tax plan. The GOP argues Democrats want to distract from the fact that they did not support the tax overhaul, the signature Republican achievement of Trump’s first year in office.

Democrats’ ability to sell voters on their vision for health care and warn about the possibility of cuts to Social Security and Medicare could prove crucial for candidates, such as Manchin, who are trying to win in red areas…

Polling suggests Trump and the GOP’s efforts to reshape the American health-care system have not resonated with voters. Thirty-six percent of respondents to the Economist/YouGov poll said they strongly disapprove of how the president has handled health care, compared with only 15 percent who said they strongly approve.” (N)

“People have voted with their enrollment decisions: A sizable number of Americans do not get insurance from their employers and value the coverage on Obamacare’s markets. That refutes the GOP myth that the program forces Americans to purchase junk insurance that they do not want. A recent Kaiser Family Foundation poll found that these consumers seek to guard against major medical costs, to gain the peace of mind that comes with insurance and to obtain coverage for chronic medical care, suggesting that the law serves important and durable needs.

Another fictional Republican claim is that Obamacare has been collapsing. A Kaiser study this year found that insurance markets stabilized in 2017, despite Mr. Trump’s best efforts to undermine the law. This comports with findings from the Congressional Budget Office and a range of other independent analysts…

Obamacare continues to serve an important need. What’s sad to see is how easy it would be to make it even more useful, if Republicans would focus on improvement instead of sabotage.” (O)

“What’s the secret of Obamacare’s stability? The answer, although nobody will believe it, is that the people who designed the program were extremely smart. Political reality forced them to build a Rube Goldberg device, a complex scheme to achieve basically simple goals; every progressive health expert I know would have been happy to extend Medicare to everyone, but that just wasn’t going to happen. But they did manage to create a system that’s pretty robust to shocks, including the shock of a White House that wants to destroy it…

What this says to me is that if Republicans manage to hold on to Congress, they will make another all-out push to destroy the act — because they’ll know that it’s probably their last chance. Indeed, if they don’t kill Obamacare soon, the next step will probably be an enhanced program that lets Americans of all ages buy into Medicare.” (P)

“At the outset, Obamacare had three central features:

• Insurers could not charge higher prices to people with pre-existing conditions.

• Those without coverage had to pay a penalty to the government (the “mandate”).

• Low-income people would be eligible for subsidies.

The first two provisions were necessary to prevent the death spiral, and government couldn’t mandate insurance purchases without adding subsidies for the poor.

Despite a bumpy rollout and some frustrations over shrinking choices and rising prices at health care exchanges, Obamacare was working remarkably well by most important metrics. Program costs were much lower than expected, and the uninsured rate among nonelderly Americans fell sharply — from 18.2 percent in 2010 to only 10.3 percent in 2018.

This progress is now imperiled.

The mandate — by far the program’s least popular provision — was repealed as part of tax legislation passed in December 2017. And because economists predict that its absence will slowly rekindle the insurance death spiral, we’re forced back to the policy drawing board… (Q)


(A) The G.O.P. Accidentally Replaced Obamacare Without Repealing It, by Peter Suderman https://www.nytimes.com/2018/03/12/opinion/republicans-obamacare-health-care.html

(B) Republicans Couldn’t Knock Down Obamacare. So They’re Finding Ways Around It., by Margot Sanger-Katz, https://www.nytimes.com/2018/04/11/upshot/republicans-couldnt-knock-down-obamacare-so-theyre-finding-ways-around-it.html

(C) How Trump’s Obamacare administrator is taking a hatchet to Obamacare, by Michael Hiltzik, http://www.latimes.com/business/hiltzik/la-fi-hiltzik-obamacare-verma-20180417-story.html

(D) The Health 202: Republicans could lower Obamacare premiums. But will they?, by Paige Winfield Cunningham, https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2018/03/13/the-health-202-republicans-could-lower-obamacare-premiums-but-will-they/5aa6a81330fb047655a06c0d/?utm_term=.923a4143e8d5

(E) Senate May Fund Obamacare Subsidies With This Sneaky Move, by Robert Donachie, https://www.dailysignal.com/2018/03/15/senate-is-going-to-fund-obamacare-subsidies-with-this-sneaky-move/

(F) House Passes Spending Bill Without Obamacare Fix, by Shannon Firth https://www.medpagetoday.com/publichealthpolicy/healthpolicy/71945

(G) Trump Official: Alternative to ObamaCare Plans Likely This Summer, by Peter Sullivan, http://galen.org/2018/obamacare-watch-newsletter-4-20-18/

(H) States Take Another Run at Undoing Obamacare Through the Courts, by Christy Bieber, https://www.fool.com/investing/2018/04/22/states-take-another-run-at-undoing-obamacare-throu.aspx

(I) Amid rising Obamacare premiums, Walker seeks federal waiver for reinsurance program, by op 5 percent, by Lauren Anderson, https://www.biztimes.com/2018/ideas/government-politics/amid-rising-obamacare-premiums-walker-seeks-federal-waiver-for-reinsurance-program/

(J) Doctors Attack Trump’s Short-Term Health Plans Ahead Of Comment Deadline, by Bruce Japsen, https://www.forbes.com/sites/brucejapsen/2018/04/22/doctors-attack-trumps-short-term-health-plans-ahead-of-comment-deadline/#9049bad3fb10

(K) Trump to Allow Anti-Trans Discrimination in Health Care, by BY NEAL BROVERMAN, https://www.advocate.com/transgender/2018/4/22/trump-allow-anti-trans-discrimination-health-care

(L) Republicans have a long way to go toward fully repealing ObamaCare, by Rachel Bovard, http://thehill.com/opinion/healthcare/383722-republicans-have-a-long-way-to-go-toward-fully-repealing-obamacare

(M) GOP in retreat on ObamaCare, by BY PETER SULLIVAN, http://thehill.com/policy/healthcare/384032-gop-in-retreat-on-obamacare

(N) It’s not all about Trump: Democrats’ midterm chances ride on health care and Social Security, too, by Jacob Pramuk, https://www.cnbc.com/2018/04/16/not-just-trump-health-care-social-security-could-define-2018-midterm-elections.html

(O) Americans are sticking by Obamacare. If only the GOP would stop trying to kill it., https://www.washingtonpost.com/opinions/americans-are-sticking-by-obamacare-if-only-the-gop-would-stop-trying-to-kill-it/2018/04/15/9b817832-3c2b-11e8-a7d1-e4efec6389f0_story.html?noredirect=on&utm_term=.e10e892994e9

(P) Obamacare’s Very Stable Genius, by Paul Krugman, https://www.nytimes.com/2018/04/09/opinion/obamacare-trump.html

(Q) Back to the Health Policy Drawing Board, by ROBERT H. FRANK, https://www.nytimes.com/2018/03/16/business/back-to-the-health-policy-drawing-board.html

(R) Health Policy Expert Says Republicans Have ‘Secret’ Plan to Repeal Obamacare, by Cody Fenwick, https://www.alternet.org/news-amp-politics/health-policy-expert-says-republicans-have-secret-plan-repeal-obamacare 000000000000000

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Renaissance Master Caravaggio Didn’t Die of Syphilis, but of Sepsis,

Doctor, Did You Wash Your Hands?™   http://doctordidyouwashyourhands.com/

Just after the death of his beloved wife Barbara, former President George H.W. Bush was hospitalized in the intensive care unit with sepsis.

He recovered and left the hospital, but too often this potentially deadly condition takes lives.  In 2017 alone, 1 in 3 people who died in a hospital had sepsis.

The Centers for Disease Control tracks the disease and its complications.  Last year, it found at least 1.7 million cases diagnosed in the United States.

What is sepsis?  Sepsis is the body’s extreme response to common bacterial infections.  Things as simple as an infected skin cut, a urinary tract infection or illness affecting your lungs can trigger it. If you don’t get proper medical attention quickly, it can lead to tissue damage, organ failure and death.

It can strike anyone, but children, the elderly and those with chronic health problems are most at risk.

To help you know your risk and to avoid putting yourself or your family at risk, check out the CDC’s fact sheets on how to protect yourself. (W)


Assignment: Learn everything you can about sepsis than make sure your local hospital uses Artificial Intelligence to diagnose (and even recommend treatment for) sepsis?

“Do not take that slight cut on your knee or a bruise on your elbow lightly for they can land your health in a complicated state called sepsis. Sepsis occurs when an existing infection causes the immune system to flare up intensely. As a result, your body swells up severely blocking the blood flow to your organs. While the symptoms take 24 -48 hours to manifest, do watch out for signs of fever, shortness of breath, unbearable pain, and a racy heart. Although bacterial infections are said to be the major cause of the disease, there are other culprits to watch out for.” (A)

Physicians will accept pathogen coverage of 80% to 90% from their preferred empiric antibiotic regimen when managing patients with mild and severe sepsis, respectively, from bacterial infections, survey results showed.

The survey of internal medicine physicians in Canada also showed that physicians perceived that their preferred empiric antibiotic regimen would cover 90% of the offending pathogens in each clinical scenario of sepsis.

Researchers said the findings could be used to inform clinical guidelines and improve prescribing practices.

According to Alex M. Cressman, MD, MSc, from the University of Toronto and Sunnybrook Health Sciences Center, and colleagues, prescribers must balance “early empiric antibiotic coverage and the antimicrobial stewardship goal of minimizing unnecessary broad-spectrum treatment” when choosing an antibiotic regimen. They suggested a need for treatment thresholds to aid physicians in choosing empiric antibiotic regimens for patients with serious bacterial infections.

 “Using a scenario-based survey of general internists and infectious disease specialists across Canada, we characterized physicians’ perceived likelihood of adequate coverage achieved by their preferred empiric antibiotic regimens for patients with mild and severe sepsis,” Cressman and colleagues wrote. “We also identified physicians’ minimum acceptable thresholds of adequate coverage for these patients.”..

According to Kollef and Burnham, treatment bundles can overlook important factors. Specifically, treatment bundles for sepsis tend not to assess antibiotic necessity, dosing strategies and antibiotic duration, and the in vitro activity of the antibiotic regimen. They highlighted the success that rapid molecular diagnostics has had in expediting patient evaluation for sepsis, ensuring effective, early antibiotic therapy and reducing the unnecessary use of broad-spectrum agents.

“Further work is needed to understand their work in a broader context that includes other front-line antibiotic prescribers,” Burnham and Kollef wrote. “Empiric antibiotic prescribing will continue to be a moving target, but with advances in [rapid molecular diagnostics], the ideal scenario of minimizing antibiotic use while maximizing excellent patient outcomes moves closer to realization, including in critically ill patients.” (B)

Hospitals have a hard time meeting the CMS’ sepsis treatment requirements.

The national average compliance rate for the Severe Sepsis and Septic Shock Early Management Bundle is barely 50%, according to the most recent data on Hospital Compare. The measure was adopted in July 2015 to improve hospitals’ identification and treatment of the life-threatening condition. More than 200,000 people die each year from sepsis.

WellSpan Health, an integrated delivery system based in York, Pa., has blown past that average, recently boasting an 85% compliance rate for the bundle. WellSpan executives credit a year-old quality improvement initiative that involves leveraging the electronic health record and a remote patient monitoring team to identify and treat patients with sepsis early…

To address alert fatigue, WellSpan established a remote surveillance team to monitor sepsis alerts and patients’ vital signs 24/7. The Central Alert Team operates much like air traffic controllers do, with the nurses monitoring patients at five hospitals, allowing them to review and intervene when necessary.

“The idea of the alert team is to facilitate early recognition and communication with the care team at the bedside, so they launch appropriate interventions,” Delaveris said.

Alerts go to the Clinical Alert Team rather than nurses at the bedside. Using patient record data on hand, nurses on the alert team will determine if an alert should be elevated to the next level. If so, they contact the patient’s physician or nurse directly to let them know the sepsis bundle should be activated.

Because the nurses only reach out to the bedside team when they see something amiss, the clinicians take their alerts seriously, Delaveris said. WellSpan also introduced the nurses to the clinicians they’d be working with so “it’s not just someone calling from the sky. We wanted to build a relationship and trust,” he added.

At least one registered nurse with intensive-care and emergency department experience is on duty at any given time monitoring patients for sepsis.

The nurses also continuously monitor the patients they see as at risk for sepsis to ensure the clinical team is following all of the bundle’s steps. WellSpan opted to use the bundle from the Surviving Sepsis Campaign, which is closely aligned with the CMS requirements. The bundle has multiple steps that need to be accomplished within designated time periods.” (C)

“Know the risks. Spot the signs. Act fast. Merit Health Wesley has worked for the past few years to integrate evidence-based clinical practices into the medical management of sepsis and reduce risk in the community by educating the public about the illness.

Merit Health Wesley is the first in Mississippi to achieve The Joint Commission’s Gold Seal of Approval for Sepsis Care.

“This achievement is a symbol of quality that reflects our hospital’s ongoing commitment to providing safe and effective patient care,” said Debbie Johnson, vice president of quality and clinical transformation and patient safety officer. “We endeavor to provide the highest quality of sepsis care through a comprehensive, multi-disciplinary approach to sepsis management and long term recovery.”

The sepsis management team at Merit Health Wesley has reduced the risk of sepsis by limiting the progression of sepsis. They are focusing on early diagnosis and rapid, efficient and effective treatment. Key elements of the hospital’s process are medical staff-approved sepsis protocols, a team approach with focused patient handoffs, regular reviews of designed process compliance, and accountability meetings to review outcomes. Merit Health Wesley chose to authenticate their best practices and process improvements by pursuing certification.

Since as many as 87 percent of sepsis cases start in the community, Merit Health Wesley has also implemented a community outreach and education plan. Patients and their families, nursing homes, emergency management staff and other care providers are educated to increase their awareness of sepsis and common early warning signs, as well as, evidenced based standards of care for rapid treatment, all key to improved outcomes and survival.” (D)

“Massachusetts Institute of Technology researchers have developed a machine-learning system that could help clinicians decide when to treat patients for sepsis in the emergency room.

Sepsis is one of the most common reasons for readmission to the hospital and one of the most common causes of death in the ICU. The researchers suggest that most of the ICU patients are admitted through the emergency room.

Treatment typically begins with antibiotics and IV fluids at a couple liters at a time, according to the researchers. Sepsis shock can happen if a patient’s body doesn’t respond well to treatment, which results in blood pressure dropping dangerously low with organ failure. Once that happens, the patient goes to ICU where clinicians can reduce and stop fluids to start vasopressor medications to raise and maintain blood pressure.

However, giving a patient fluids for too long could cause more organ damage. The researchers say that vasopressor intervention could be helpful and has previously been linked to improved mortality in septic shock. But administering vasopressors too early can cause heart arrhythmias and cell damage, leaving clinicians with an unclear answer on when to administer treatment.

MIT researchers have developed a model to alleviate that problem. The model learns from health data on emergency-care sepsis patients and can predict if a patient will need vasopressors within the next few hours.

In a study, the researchers compiled a dataset for ER sepsis patients. When they tested the algorithm, the model was able to predict the need for a vasopressor more than 80% of the time…

The machine-learning system could be used in a bedside monitor to track patients and send alerts to clinicians in the ER about when to start vasopressors and reduce fluids.

“This model would be a vigilance or surveillance system working in the background,” Thomas Heldt, the study’s co-author, said. “There are many cases of sepsis that [clinicians] clearly understand, or don’t need any support with. The patients might be so sick at initial presentation that the physicians know exactly what to do. But there’s also a ‘gray zone,’ where these kinds of tools become very important.”

Other models have been built to predict who is at risk of developing sepsis or when to administer vasopressors in the ICU. The MIT-developed model is the first one to be trained on data from the ER.

“[The ICU] is a later stage for most sepsis patients. The ER is the first point of patient contact, where you can make important decisions that can make a difference in outcome,” Heldt said…

 “The model basically takes a set of current vital signs, and a little bit of what the trajectory looks like, and determines that this current observation suggests this patient might need vasopressors, or this set of variables suggests this patient would not need them,” Prasad said.

The researchers hope to expand their work to make more tools that can predict in real-time if patients in the ER would initially be at risk for sepsis or septic shock.

“The idea is to integrate all these tools into one pipeline that will help manage care from when they first come into the ER,” said Prasad.

The researchers also say that the system could help clinicians in emergency room departments in major hospitals focus on patients who are most at-risk of developing sepsis.

“The problem with sepsis is the presentation of the patient often belies the seriousness of the underlying disease process,” Heldt said. “If someone comes in with weakness and doesn’t feel right, a little bit of fluids may often do the trick. But, in some cases, they have underlying sepsis and can deteriorate very quickly. We want to be able to tell which patients have become better and which are on a critical path if left untreated.” (E)

Jonathan Perlin, MD, president of clinical services and chief medical officer at HCA Healthcare, calls sepsis an “overwhelming infection” that can lead to severe organ failure and even death. He says the key to survival is early recognition and aggressive treatment.

“It’s a medical emergency that should be treated as aggressively as a heart attack or stroke,” Dr. Perlin said. “At HCA, we’re pleased to be able to rally the data of more than 28 million patients every year to help control sepsis, one of the most challenging diagnoses inflicted on patients, and ultimately, better inform patient improvements and outcomes.”..

For every hour of a delayed sepsis diagnosis, it increases the chance of death between 4 and 7 percent…

How does SPOT work?

Hospital computers, through “machine learning”, are trained by ingesting millions of data points on which patients do and do not develop sepsis. Those computers monitor clinical data every second of a patient’s hospitalization.  When a pattern of data consistent with sepsis risk occurs, it will signal with an alert to trained technicians who call a “code sepsis.”

The bedside nurse responds, begins evaluating the patient, and if sepsis is not “ruled out,” treatment begins immediately.

“SPOT is operating with 100 percent sensitivity, that is, all true sepsis positives have been identified,” he said, “allowing caregivers to fully focus on those patients who need intensive monitoring and support.”

More than 5,500 lives have been saved over the last three years as a result of the stop severe sepsis program, the national standard that relies on detecting sepsis at the cusp of deterioration, and HCA’s new technology SPOT.

“The doctors and nurses tell us there were some patients SPOT detected that we would’ve known about,” Perlin said. “More importantly, it told us time and again those patients we didn’t appreciate that were headed towards sepsis.”

HCA celebrated in August 1 million patients followed by SPOT. (F)

“Durham, N.C.-based Duke University Hospital in November will launch Sepsis Watch, a system that uses artificial intelligence to help identify patients in the early stages of sepsis, according to IEEE Spectrum.

Duke University Hospital will deploy the system in its emergency department before extending it to the general hospital floor and intensive care unit.

“The most important thing is to catch cases early, before they get to the ICU,” Suresh Balu, project lead and director of the Duke Institute for Health Innovation, told IEEE Spectrum.

The Sepsis Watch system can identify cases based on numerous variables, including vital signs, lab test results and medical histories. The AI’s training data consists of 50,000 patient records and more than 32 million data points. While operating, the system pulls information from medical records every five minutes to evaluate patients’ conditions, which offers real-time analytics physicians can’t provide.

When the AI system detects a patient who may be in the early stages of sepsis, it alerts a nurse on the hospital’s rapid-response team who will either dismiss the alert, place the patient on a watch list or contact a physician about starting treatment. The system will also walk staff through a sepsis treatment checklist using protocols outlined by the Surviving Sepsis Campaign.

“The model detects sepsis,” Mark Sendak, MD, physician and data scientist, told IEEE Spectrum. “But most of the application is focused on completing treatment.”

Electronic health records can help identify hospitalized patients at risk of death, according to a new study in The American Journal of Medicine.

Inpatients’ conditions can deteriorate quickly; the faster the intervention, the better the patient’s chances of survival. The researchers, from Arizona based Banner Health, created an algorithm that looked for at least two out of four systemic inflammatory response syndrome (SIRS) criteria, plus at least one of 14 acute organ dysfunction parameters. The algorithm continually sampled the EHR data in real time of 312,214 patients in 24 Banner Health hospitals, and contained an alert to notify the physician of the risk of death when a patient triggered it.

The alert identified a majority of the high risk patients within 48 hours of admission and enabled early and targeted medical intervention. The patients who triggered the alert had a “significantly high” chance of dying in that hospital stay compared to patients who didn’t trigger the alarm.” (G)

“.. the technology that goes by the name AI Clinician, described today in a paper in Nature Medicine, doesn’t diagnose—it makes decisions. It takes all the information about a patient with sepsis and recommends a course of treatment.

“It’s not mimicking the perceptual ability of the doctor, where the doctor sees certain symptoms and says the patient is going into septic shock,” says Aldo Faisal, an associate professor of bioengineering and computing at Imperial College London and one of the paper’s authors. “It’s really cognition that is captured here. We’re not just making the AI see like a doctor, we’re making it act like a doctor.”

The researchers didn’t try out their system on real patients; the technology isn’t ready for the clinic yet. Instead, they trained and tested AI Clinician on medical record databases from intensive care units (ICUs) in the United States. They first used 17,000 cases to teach the model about sepsis treatment, and then had it issue recommendations for 79,000 cases.

Overall, the treatments that the AI recommended were more likely to keep patients alive than those administered by the human doctors… 

Part of the treatment is to give patients intravenous fluids and drugs called vasopressors that constrict the blood vessels and increase blood pressure: These actions ensure that blood is reaching the organs. However, there’s considerable debate about how much to give, and when.

The researchers trained AI Clinician to issue recommendations on fluids and vasopressors. Gordon says these basic recommendations are just a start, and that the team has already been working on a model that includes more treatment factors…

Theoretically, an AI could control electronic pumps that deliver IV fluids and medications. “It would be the most personal doctor you can imagine, relentlessly watching over you,” Faisal says…

Essentially, reinforcement learning comes down to trial and error. The trainers establish a goal—such as winning a game, achieving a high score, or keeping a sepsis patient alive—and link it to a reward. (In this case, the AI was programmed to maximize credits, and it earned credits for each patient that stayed alive and lost credits for those that died.) The AI tries out a sequence of actions at random, and if it achieves its goal, it gets the payoff. Over many repetitions, it learns which combinations of actions are most likely to result in the reward.” (H)

“After finding inefficiencies and a high potential for error in their sepsis treatment process, University of Utah Health, a four-hospital system based in Salt Lake City, partnered with clinical communication solutions provider Spok to help improve sepsis response…

Dr. Horton began to identify problems in sepsis response while evaluating patients with fevers. “When I was consulting for a fever, I’d go see a patient, get into their chart and find they had abnormal vital signs that had been there for several days,” he said. “Our EHR imports those notes every day, but there were no discussions about those vital signs.”

At patient bedsides, nurses would take vital signs and continue this process for four or five other patients, making the first vital signs up to an hour old by the time they were entered into the computer. “If this was an emergent case, we’d already lost an hour,” Dr. Horton said. “There may not be communication about those vital signs, they may just sit in the computer waiting for the nurse to see them and a provider may not get back to them quickly.”

Some of the health system’s providers couldn’t put the pieces together to say it was sepsis, Dr. Horton said. “And as we started looking into it, we realized we had no real process in place at our institution to address sepsis as a leading cause of death.”

If there was a way to get the vital signs in the notes sent to a provider who knows what to do with them, the hospital could ensure patients aren’t slipping through the cracks, Dr. Horton said.

To address this issue, University of Utah Health leveraged their EHR system with Spok Care Connect, which takes the EHR’s sepsis alert or a critical test result and sends it to the right clinicians’ mobile device automatically.

The alert contains the information clinicians need to act right away, including who the patient is, their room number and their modified early warning score, or MEWS. MEWS is a physiological test that prevents delays in the intervention or transfer of critically ill patients. The alert is sent in seconds, allowing the care team to respond faster.

University of Utah Health’s EHR automatically uses vital signs entered to calculate the MEWS score. If the MEWS is sufficiently high, Spok sends that MEWS alert as a message to either the charge nurse or the rapid response team. When vitals are outside normal range, the recipients get a notification to begin intervention on that patient right away.

“What was helpful for us was having all our sepsis data in one place — we can look at the data and take it back to our providers to tell them what we’re seeing,” Dr. Horton said. “If you have an EHR-based algorithm, patients’ illness can be detected earlier on and resuscitated earlier on.”

The data University of Utah Health collected also allowed them to look at the odds of septic patients getting antibiotics within the first 24 hours, Dr. Horton said.

“For all sepsis patients, we saw a length of stay that was decreased by 10 percent and because of that our total direct cost decreased by 10 percent.”

“We can have the best hospital in the world, but if you don’t know what vital signs are, and if the vital signs aren’t entered into the computer in real time, then that patient is losing, and the institution is losing,” Dr. Horton said.” (I)

“.. a new alert system, pioneered by doctors at Cambridge University Hospitals and part of a two-year pilot, has led to a seven-fold increase in the number of patients getting life-saving drugs.

The alert system works by constantly analysing patients’ observations, as recorded by staff on handheld devices.

This includes temperature, pulse, blood pressure and level of consciousness taken at various stages as patients are assessed in A&E.

If the observations suggest a patient might have sepsis, a text message appears on the hand-held device and doctors can treat the patient.

The alert system was introduced at Addenbrookes Hospital in 2016. In July 2015, only 11 per cent of patients with possible sepsis were given antibiotics within an hour of arriving at A&E. This increased to 76 per cent by August 2016.” (J)

“New York state hospitals’ adherence to sepsis protocols increased and sepsis mortality declined after reporting became mandatory, researchers said.

The analysis of sepsis reporting data from 185 New York hospitals from April 2014 through June 2016 found that sepsis protocols were initiated in 81.3% of eligible patients, most often in emergency care settings.

Risk-adjusted deaths declined from 28.8% to 24.4% (P<0.001) among patients for whom a sepsis protocol was initiated, reported Mitchel M. Levy, MD, of Brown University/Rhode Island Hospital in Providence, and colleagues in the American Journal of Respiratory and Critical Care Medicine…

While hospitals have some flexibility in developing their sepsis protocols, the law requires:

•             Blood cultures followed by antibiotics and measurement of blood lactate levels within 3 hours of presentation in patients with severe sepsis (“3-hour bundle”)

•             Administration of intravenous fluids (30 cc/kg), vasopressors and re-measurement of lactate within 6 hours in patients with septic shock, defined as systolic pressure <90 mm Hg or lactate level ≥4 mmol/L (“6-hour bundle”)..

Greater hospital compliance with 3-hour and 6-hour bundles was associated with shorter length of hospital stay as well as with increased survival…(K)

“Despite the controversy, the proof in the literature is overwhelming,” he said. “The question I have when I debate this is, ‘Where would you want your loved one to be treated — at a hospital that is known to be continuously working toward meeting these measures or at a hospital that doesn’t agree with them?'”

Twenty-seven states fall below the national average for appropriate sepsis care, according to sepsis performance data added to CMS’ Hospital Compare website in July.

Nationally, the average percentage of patients who received appropriate care for severe sepsis and septic shock is 49 percent, according to Hospital Compare.

The sepsis performance measure is based on data from the first quarter of 2017 through the third quarter of 2017. The preview period for this change spanned from May 4 to June 2. The first full year of sepsis data will be available by October.

Here are the states ranked by the percentage of patients who received appropriate care for severe sepsis and septic shock, ordered from highest to lowest: • New York: 45 (L)

“Sepsis is a major cause of death in U.S. hospitals, yet timely and effective sepsis care can reduce the risk of death,” Chanu Rhee, MD, MPH, assistant professor of population medicine at Harvard Medical School and Harvard Pilgrim Health Care Institute, said during a presentation.

Previously, Infectious Disease News spoke with Konrad Reinhart, MD, chair of the Global Sepsis Alliance, about the global rise of sepsis. Although he said there have been improvements in coding standards in the last 5 years, before that “the medical system was not doing a good job of accounting for cases of sepsis.”

Rhee and colleagues found that the reliance on claims data may be hindering sepsis surveillance, research and quality improvement. Likewise, Rhee said variations in hospital diagnosis, documentation and coding practices may make it difficult to benchmark hospital sepsis outcomes using claims data.

“Administrative claims data have important limitations,” Rhee said. “We know they have low-to-moderate sensitivity when identifying sepsis and, more importantly, recent analyses have suggested that claims-based trends are biased by changing diagnosis and coding practices over time.”..

Rhee explained that varying claims data between hospitals limits its use when comparing sepsis rates and outcomes.

“I would be the first to acknowledge that there is no true gold standard for sepsis,” Rhee said. “However, the EHR clinical criteria, I believe, are more objective and consistent.” (M)

“The Sepsis Alliance is using the month of September to educate the public and care providers about the dangers of sepsis and the need to take quick action. By using the TIME acronym, it serves as a reminder to seek medical attention as soon as symptoms are present.

Temperature – Higher or lower than normal.

Infection – May have signs and symptoms of an infection.

Mental decline – Confused, sleepy, difficult to rouse.

Extremely ill – “I feel like I might die,” severe pain or discomfort.

If you have a combination of any of these symptoms, see your medical professional immediately, call 911, or go to a hospital with an advocate and mention concerns about sepsis.” (N)

“A local hospital is using a lighter approach to educate staff on a critical problem.

Nurses and doctors at Penn Presbyterian had to solve clues, just like an escape room game, to properly diagnose and treat a mock patient with sepsis – a life-threatening response to an infection. And to save him, they had an hour to complete all the tasks.

A nurse developed the exercise to make colleagues more aware of how to detect and treat sepsis.

And some of the equipment in the room was just used as a decoy – trying to make staffers more attentive and think as they would have to in a real-life situation. No doubt this will help them and their patients in the future. (O)

“I have been on active surveillance (AS) for prostate cancer since December 2010. But though I generally am a compliant patient, I increasingly have become resistant to MRIs and biopsies.

I have had five biopsies since 2010. Only a single core out of 60 has revealed any cancer — less than one millimeter back in 2010. It was never seen again.

In the beginning, I had annual biopsies; lately, I have been on a biopsy vacation.

When I heard about potential sepsis, I became uncertain about being needled.

I worry about the potential, though rare, for deadly infections. My hospital takes steps to prevent infections (they have a low rate in prostate biopsies, one infection in 6,000 patients vs one in 1,500 nationally), but sepsis is a killer.” (P)

“When someone is admitted to the hospital, they expect to get better. Instead, nearly 100,000 people in the United States are dying each year because of healthcare-associated infections (HAI), which is more than breast and prostate cancer fatalities combined.

Those who acquire HAIs but survive are forced to stay in the hospital for significantly longer than those who do not receive an infection, racking up medical bills that likely could have been avoided.

According to the Center for Disease Control (CDC), there are four common types of HACs:

Catheter-associated urinary tract infection (CAUTI): This is a type of infection that can occur in any part of the urinary system. The biggest risk factor for a CAUTI is using a catheter for too long. Doctors should remove them as soon as they are no longer needed to minimize this risk.

Central line-associated bloodstream infection (CLABSI): CLABSI is a serious infection that occurs when germs enter the bloodstream through a central line, which is a tube that doctors place near large veins to give medications or fluids or collect blood for testing.

Surgical site infection (SSI): An SSI is an infection that occurs after a surgical procedure at the part of the body where the surgery took place.

Ventilator-associated pneumonia (VAP): VAP is lung infection that develops in individuals while they are on ventilators to help them breathe.

Many HAIs are a result of a doctor failing to follow proper medical procedures. Making errors during surgery, using poor hand hygiene, using materials that are not sterile, improper insertion of a catheter or central line, and failure to remove devices in a timely manner are just some of the ways medical providers can cause HAIs.” (Q)

“Early Recognition of Sepsis across the Continuum. “To facilitate timely diagnosis and management, healthcare organizations across the continuum should have protocols for response when sepsis is suspected, much as they do for chest pain.”” (R)

“In a recent national survey of more than 1,300 EMS providers, the National Association of Emergency Medical Technicians (NAEMT) in association with the Sepsis Alliance found that although nearly all respondents (98%) consider sepsis a medical emergency, only about half (51%) feel very confident in their ability to recognize symptoms of sepsis—the body’s life-threatening response to an infection…

Unfortunately, more than one third of EMS providers surveyed say that sepsis isn’t a key priority within their organization, and 33% say their organization isn’t well prepared for patients with sepsis. Furthermore, 25% state that while they know patients have sepsis, physicians don’t like to diagnose them with it, and 58% say when patients are showing signs of sepsis, not all hospitals initiate a sepsis protocol.” (S)

“UK researchers have developed a test they say might quickly identify sepsis, a potentially fatal complication from an infection.

Scientists at Scotland’s University of Strathclyde developed an experimental microelectrode device that analyzes a patient’s blood and provides results as quickly as 2.5 minutes. Current testing methods for sepsis can take up to 72 hours.

This is important given that every hour without diagnosis and treatment increases the chance of dying.” (T)

Can You Really Get Sepsis from Trying on Shoes Without Socks?  (U)

Famed Renaissance painter Caravaggio didn’t die of syphilis, as some historians long thought.

Instead, it appears that the talented Italian artist — who had a reputation for gambling, drinking, sleeping with prostitutes and even murder — died of a sword wound that developed a nasty infection, leading to deadly condition called sepsis, a new study finds. Sepsis is the body’s overwhelming and life-threatening response to an infection.

A team of French and Italian scientists made the discovery by digging up and analyzing what they believe are the skeletal remains of the revolutionary painter, who died at age 39 in 1610. [Photos: Renaissance Husband’s Heart Buried with Wife]..

Over the years, historians have speculated how the artist died. Caravaggio had a fever at the time his death, prompting some to guess that he had malaria or even brucellosis, an infection that people can get from eating unpasteurized dairy products.

To investigate, the researchers searched the cemetery reported to hold Caravaggio’s remains. They looked for a skeleton that was about 5 feet, 4 inches (1.65 meters) tall and between 35 and 40 years of age.

Nine skeletons in the cemetery met these criteria, but only one dated to the beginning of the 17th century, according to radiocarbon dating, the researchers said. Even more revealing were the high levels of lead in the bones, “which was a discovery of great importance since Caravaggio was known to be careless when using lead for painting,” the researchers wrote in the study, published online Sept. 17 in the journal The Lancet.

The research team also analyzed the individual’s DNA and found that it matched the genetic profile of other men with the name Merisi or Merisio, who are believed to be Caravaggio’s relatives.

Satisfied they had Caravaggio’s remains, the researchers next analyzed his teeth and found the bacteria Staphylococcus aureus hiding within the remaining blood vessels of the artist’s teeth. This bacterial infection likely led to Caravaggio’s sepsis, the researchers said.

“[The cause of death] resulted from sepsis secondary to superinfection of wounds after a fight in Naples, a few days before the onset of symptoms,” they wrote in the study.” (V)

“The cost of treating patients who develop sepsis in the hospital rose by 20% in just three years, with hospitals spending $1.5 billion more last year than in 2015, according to a new analysis.” (X)


“…of the 1.5 million Americans who develop sepsis each year, nearly 260,000 die from it.”


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Syllabus. Health Care “Transformational” Management (2013)

BUS 9100:  Business and Society

Health Care “Transformational” Management 


 1. RESPONDING TO HEALTHCARE REFORM – A Strategy Guide for Health Care Leaders, By Daniel B/ McLaughlin, HAP  ACHE Management Series  Read one chapter per week starting with Chapter 1, Week

 2. Harvard Case Studies

The Cradle Dilemma, kel511

 Performance Management at Intermountain Healthcare, HBS 9-609-103

 Newton-Wellsley Hospital, HBS 9-609-088

 Evidence-Based Management, HBS R0601E

 What More Evidence Do You Need?, HBS R1005X

 Collaborating to Improve, HBS 9-608-054

 Jeanette Clough at Mount Auburn Hospital, HBS 9-406-068

 3. Additional readings posted on Blackboard; Web sites are also assigned for some sessions. 

 4. “Doctor, Did You Wash Your Hands?” http://hoboken.patch.com/blogs/metsch-on-health-care  

Visiting Professors
(* Program Graduate)

Jeffrey Kraut*

Senior Vice President for Strategy of the North Shore-LIJ Health System and Associate Dean for Strategy for the Hofstra North Shore-LIJ School of Medicine

 – “North Shore-LIJ Health System’s strategy to  maintain  its leadership position under health care reform”?

Frank Goldstein*

Vice President, Physician Services, Meridian Health

 – “Converting hospital based physician practices from FFS to Patient Centered Medical Homes“

Annette Catino*

President & CEO, QualCare Alliance Networks, Inc.

– “Obamacare from the Payers perspective“

Carmine Asparro*

Principal in charge of the managed care consulting practice, OnPoint Partners

– “Provider and health plan strategies with Health Insurance Exchanges“

David Florman*

Partner of Florman Tannen LLC

–  “Population health management – organizational transformation in the health care reform era“

Jeffrey Menkes*

Senior Vice President ,System Network Development, Montefiore Medical Center

– “Lessons Learned as a  “seller” now “buyer” under Obamacare“

Joel Seligman

President and CEO of Northern Westchester Hospital

 – “Northern Westchester Hospital Center’s strategy to  maintain  its leadership position under health care reform“

Lee Perlman

Executive Vice President of Administration and Chief Financial Officer of the Greater New York Hospital Association;  President of GNYHA Ventures, Inc.; and CEO of Happtique

 – “Creating Value: GPOs and the Business and Politics of Health Care”

Section Objectives

To learn the basics about the American health care system

To understand the implications of the Affordable Care Act

To learn to use the Case Study method as an analytical tool

To start using an “evidence-based” approach to management

To  be a successful contributor in small group  meetings

To get comfortable  being a discussion leader

To meet and interact with industry leaders (your future bosses)

To begin a personal  career diary of  “Lessons Learned”

Section Paradigm

Using the CASE STUDY METHOD the course presentations by Professor Metsch and the Visiting Professors address COMPLEX PROBLEMS and the value of LESSONS LEARNED.

Case Study types: original Case Studies prepared by Prof. Metsch; Case Studies presented by senior health administrators (Visiting Professors); and iconic Harvard Case Studies.

Sessions are comprised of two complementary parts paired to integrate the Case Studies with Student Learning Outcomes and the Course Objectives. 

The Case Study Method

Cases attempt to reflect the various pressures and considerations that professionals of all varieties confront in the workplace.

Using complex, realistic open-ended problems as a focus, cases are designed to challenge you and help you develop and practice skills that you may need in your future careers.

Cases are also an excellent way to see how abstract principles learned in class are applied to real world situations.

Remember that case assignments involve a different kind of learning than other assignments. There is no one single answer and sometimes even the issue is deliberately not stated clearly.

Complex Problems

situations where the decision-maker must integrate or reconcile at least two competing priorities that may not be linear or complementary

having to reach agreement on goals while simultaneously evaluating options

where goals are clear but political support is not

where the definition of the problem keeps changing and consensus has to constantly be reestablished

where there are so many variables it is difficult to determine the actual possible outcomes

various combinations/ permutations of the above

Lessons Learned
  Start a diary of 3 Lessons Learned each week from the following categories:

•       –  the Visiting Professor and/ or ProfM 

•       –  the course text – RESPONDING TO HEALTHCARE REFORM

•       –  the articles posted on Blackboard or articles you find yourself

•       –  a Harvard Case Study (but only if different from the LLs you used in your 8 slide set)

•       –  an experience at work or elsewhere


                              •       USE 3 DIFFERENT CATEGORIES EACH WEEK!

•       For Week 12 use LLs from Final Case Study presentations ONLY (but not your own)     

                              •       Post on Blackboard after each class & email to jonathan.metsch@baruch.cuny.edu 

•       then synthesize them into a Lessons Learned essay after the last class

Objective of Case Study Analysis =

To develop an evidence based theme (“thread”) through the slide set so the conclusion (“policy recommendation” or “project plan”) is accepted

How to Structure Your Harvard Case Study Homework Assignments
& Final Case Study Project

USING POWERPOINT (one slide on each of the following)

1.            Introduction, Situation, Background -This section describes the reason for the case study.

2.            Problem – This section states the main problems which need to be resolved. Some case studies include charts and graphs to illustrate key points.

3.            Questions/ Issues*

4.            Solution – This section describes the solution in detail, what changes were made, and the impact. Some case studies include charts and graphs to illustrate key solutions.

5.            Evaluation – This section recap the main benefits of the solution and the impact/ outcomes/ results. 

6.            Lessons Learned!

7.          Anchor Concepts

8.          Overlay 2013 ACA and “transformational” (if case was taking place today)

*Note: For final Student Case Presentations – #3  Questions/ Issues for class discussion before presenting #4 Solution

Week 1 – December 3rd

Case Study Method 1

Professor Metsch

“Project Management – The Hardest Part about Getting Started………… is Getting Started”

  (7 health care related vignettes with break-out groups to understand and practice case study analytics)

1.  Getting Started – “The First Day”

2.  Program Planning – Hoboken H1N1 “Swine Flu” Task Force

3.  Service Recovery – Hospital ER

4.  Professional Status – When the Nurse Wants to be Called “Doctor”

5/6.  Resource Allocation –  Food Sustainability Programs

7/8/9. NFP Board of Trustees – Program Evaluation, Changing Accreditation Agencies, New Service Opportunities

10. Joining a NFP Board of Trustees – What should you know?



Week 2 – December 10th

Case Study Method 2

Professor Metsch

Hudson Cradle,

Jubilee Center, &

Hudson County Child Abuse Prevention Center 

( 3 integrated health care related vignettes with break-out groups to further understand and practice case study analytics)

Homework*  The Cradle Dilemma kel511

(a health care related NFP CEO grapples with its “mission” in a turbulent environment)

Week 3 –December 17th

Case Study Method 3

Professor Metsch

Jersey City Medical Center (1989-2013)

( an original case study based on Dr. Metsch’s 17 year tenure as President and CEO of LibertyHealth/ Jersey City Medical Center, with break-out groups; to finish practicing case study analytics)




Jersey City Medical Center + Images of America + Len Vernon

Then scroll down and click on

Jersey City Medical Center – Google Books Result


Leonard F. Vernon – 2004 – ‎History

Leonard F. Vernon. IMAGES of America JERSEY CITY MEDICAL CENTER . 1,1 1.1 . . – . IMAGES of America JERSEY CITY MEDICAL CENTER Ono …

Week 4 – January 7th

Frank Goldstein

Vice President, Physician Services, Meridian Health

 – “Converting hospital based physician practices from FFS to Patient Centered Medical Homes”

(a case study on one system’s journey from fee-for-service to “population” health)

Homework*  Performance Management at Intermountain Healthcare HBS 9-609-103

(a mega system’s data driven approach to Medicare reimbursement) 

Week 5 – January 14th

Joel Seligman

President and CEO of Northern Westchester Hospital

 – “Northern Westchester Hospital Center’s strategy to  maintain  its leadership position under health care reform“

(A case study addressing the future of a high quality, free-standing, suburban community hospital)

Case Study Method 4 –

Professor Metsch

Restructuring a Failing Public Hospital in Hoboken

(a policy case study about how to stabilize a city-owned hospital)


New Jersey Commission on Rationalizing Health Care Resources, Final Report 2008


Commission on Health Care Facilities in the 21st Century


Week 6 – January 21st

Annette Catino

President & CEO, QualCare Alliance Networks, Inc.

– “Obamacare from the Payers perspective“

(Insurance Reform versus Healthcare Reform)

Homework * Newton-Wellesley Hospital HBS 9-609-088

(a CEO faces the challenge of multiple physician payment methods in one hospital)

Week 7 – January 28th

Jeffrey Kraut

Senior Vice President for Strategy of the North Shore-LIJ Health System and Associate Dean for Strategy for the Hofstra North Shore-LIJ School of Medicine

 – “North Shore-LIJ Health System’s strategy to  maintain  its leadership position under health care reform”?

(A case study on the transformation of the Health System’s clinical and business models to succeed under value-based health reform.)

Case Study Method 5

Professor Metsch

Evidence Based Decision Making

(fostering a framework for inter-disciplinary collaboration) 


Evidence-Based Management – HBS R0601E

What More Evidence Do You Need? – HBS R1005X

Week 8 – February 4th
David Florman

Partner of Florman Tannen LLC

–  “Population health management – organizational transformation in the health care reform era“

(a health care consultant presents case studies on organizational adaptation)

Homework*  Collaborating to Improve HBS 9-608-054

(a hospital Chief Medical Officer’s efforts to introduce a new quality paradigm)

Homework*  Collaborating to Improve HBS 9-608-054

(a hospital Chief Medical Officer’s efforts to introduce a new quality paradigm)

Week 9 – February 11th

Lee Perlman

Executive Vice President of Administration and Chief Financial Officer of the Greater New York Hospital Association;  President of GNYHA Ventures, Inc.; and CEO of Happtique

 – “Creating Value: GPOs and the Business and Politics of Health Care“

(a senior health care trade association executive discusses creating new revenue streams for its members)

Case Study Method 6

Professor Metsch

The role of the Board of Trustees  

(a series of vignettes on “best practices” of NFP Boards of Trustees)



Week 10 – February 18th

Carmine Asparro

Principal in charge of the managed care consulting practice, OnPoint Partners

– “Provider and health plan strategies with Health Insurance Exchanges“

(a health care consultant presents cases on client HIE strategies)

Homework *  Jeanette Clough at Mount Auburn Hospital HBS 9-406-068

(a hospital CEO leads a  financial “turn-around” then faces new sustainability challenges)

Week 11 – February 25th

Jeffrey Menkes

Senior Vice President ,System Network Development, Montefiore Medical Center

– “Lessons Learned as a  “seller” now “buyer” under Obamacare“

(a senior health system executive discusses “selling” a hospital to a system, now expanding the continuum of care for a mega-system)

Case Study Method 7

Professor Metsch

“Associated Camps”

(a case study of failed strategic planning)

Week 12 –March 4th  

Student Case Study Presentations

– Groups of 3 -set by the class –

(but different from Harvard groups and any groups from first trimester courses)


Due: January 7th

First PP Draft: February 4th

Second PP Draft: February 25th

Case Presentations: March 4th

Post Final on Blackboard on: March 5th

Week 13

Final Lessons Learned Essay ,

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