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

“HEALTH CARE: The Senate plan calls for eliminating the individual mandate in the Affordable Care Act (”Obamacare”). This will gut the ACA just as much as outright repealing it as the Senate tried earlier in the year, and failed. Eliminating this mandate will cause 13+ million taxpayers, many of them Trump supporters, to lose their health insurance. The savings of some $338 billion by doing this will be used to pay for the tax plan and those wealthy Americans that will see their taxes go down. ..
MEDICARE and MEDICAID: Here is one that has not received much attention, but all those 65 and older that are on Medicare, take note: as a result of what the Republicans wish to force down voters’ throats, $25 billion will be slashed from Medicare. This is due to a 2010 law, called PAYGO (”pay-as-you-go) that requires ensuring any new legislation enacted during a term of Congress does not collectively increase estimated deficits. If there is an increase in the deficit (again, the tax plan will increase the deficit by $1.5 trillion) OMB (Office of Management and Budget) is required to order a sequestration to eliminate the overage. Medicare would not be immune from this. ..Medicaid subsidies would also get axed by $179 billion…(A)

“Senate Republicans’ proposed tax reform bill would increase Obamacare prices by an average of almost $2,000 per family in 2019, according to an analysis released Thursday.
And the tax bill would lead to 1.8 million more people lacking health insurance in California than currently, another 1 million people becoming uninsured in Texas, and more than 800,000 newly uninsured in New York and Florida each, the report said.
Cumulatively, 13 million more people nationally would become uninsured.” (B)

“ “I believe in the Affordable Care Act; it worked for me under the Obama administration,” said Sara Stovall, 40, who does customer-support work for a small software company. “But it’s not working as it was supposed to. It’s being sabotaged, and I feel like a pawn.”
Ms. Stovall said she might try to reduce her hours and income, so her family could qualify for subsidies on offer to poorer families to help pay for premiums.” (C)

“For those who are over the age of 64 or who live with the challenges of disability, this tax bill does not carry benefits. Instead it leads to a path towards poverty, unemployment, and potentially tragic loss of life.
The most significant proposal is the elimination of the medical tax deduction, as it will have immediate and devastating impact on the 8.8 million Americans who have claimed the benefit to help offset medical expenses, includes those dealing with the devastating consequences of medical crisis or disabilities.
Of those who claimed the deduction in 2015, nearly half earned less than $50,000 and almost 70 percent earned less than 75,000 annually, according to AARP…
In short, the medical expenses deduction has saved American families and lives by easing the financial burden on struggling individuals and families, and these middle class communities will feel the impact if it is discontinued….” (D)

“Were the ACA’s insurance mandate repealed absent a new policy to compel the purchase of coverage, the CBO projects that premiums would rise 10 percent for people who buy insurance on their own and more than 13 million Americans would lose or drop their coverage.
But a reduction in the number of people with insurance also translates to less taxpayer money spent to provide subsidies for premiums under the ACA. Ending the requirement as of 2019 would save the government an estimated $318 billion, helping to offset the cost of lowering the corporate tax rate….
The White House argues that the ACA’s insurance mandate isn’t popular and disproportionately affects low- and middle-income Americans who are forced to buy insurance that may be more expensive than they can afford.
“The President’s priorities for tax reform have been clear from the beginning: make our businesses globally competitive, and deliver tax cuts to the middle class,” White House spokesman Raj Shah said in a statement. “He is glad to see the Senate is considering including the repeal of the onerous mandates of Obamacare in its tax reform legislation and hopes that those savings will be used to further reduce the burden it has placed on middle-class families.”…
Insurers, hospital groups and disability advocates have spoken out forcefully against the health-care proposals in the bill. Hospitals and insurance groups wrote a letter to congressional leaders on Tuesday warning of dire health-care outcomes if the tax measure becomes law.
“Repealing the individual mandate without a workable alternative will reduce enrollment, further destabilizing an already fragile individual and small group health insurance market on which more than 10 million Americans rely,” said the letter, signed by six health-care groups, including the American Hospital Association and America’s Health Insurance Plans.” (E)

“A group of Republican senators met with President Trump at the White House on Thursday to push him to support a bipartisan ObamaCare fix, according to a Senate GOP aide….
Collins and another moderate, Sen. Lisa Murkowski (R-Alaska), have indicated that passing Alexander-Murray would help ease their concerns about the spike in premiums from repealing the mandate.
Getting Trump’s support for that measure would help ease its passage, especially through the House, where many Republicans are opposed to it as a bailout of insurance companies….
A major obstacle for the idea of pairing Alexander-Murray with repealing the mandate in tax reform, though, is that Democrats have rejected that trade. Senate Democratic Leader Charles Schumer (N.Y.) said this week that Democrats would block the Alexander-Murray bill if the GOP goes forward with repealing the mandate.
Several experts also say that Alexander-Murray, which is aimed at stabilizing markets by continuing key payments for insurers, would not cancel out the destabilizing effects of repealing the mandate, which could lead to a lack of healthy people signing up and a rise in premiums.
The Congressional Budget Office has found that repealing the mandate would increase premiums by 10 percent, but that markets would continue to be stable in almost all areas of the country. “ (F)

Alaska Republican Sen. Lisa Murkowski suggested Thursday that her vote on the current version of the Senate GOP tax overhaul is contingent on the passing of a separate bill to stabilize the individual health insurance market.
The tax legislation now includes a section to repeal the individual mandate in the 2010 health care law — a provision that opens up more than $300 billion in revenue — but could also threaten the viability of the overall law….
Murkowski believes legislation from the Senate Health, Education, Labor and Pensions leaders, Chairman Lamar Alexander and ranking member Patty Murray, is necessary before the mandate — which supporters of the law say is a critical foundation for the current insurance markets — is repealed.
“I think that there is a path and I think the path is a reasonable path,” Murkowski said of her support for the measure. “If the Congress is going to move forward with repeal of the individual mandate, we absolutely must have the Alexander-Murray piece that is passed into law.”
Without such a measure — which would, among other things, appropriate money for so-called cost-sharing subsidies — Murkowski says middle-class Americans may not receive the kind of tax relief the GOP is aiming to provide.
“There is a path forward. It just means that some who have said some nasty things about CSRs are maybe just going to have to acknowledge that, well, this might be the way that you thread this needle,” she said. “If that tax cut is offset by higher premiums, you haven’t delivered benefit.”
The Congressional Budget Office has estimated that removing the mandate could lead to millions more uninsured individuals over the next ten years and could raise health care costs for some, particularly sicker Americans.
Twelve Republican senators — along with every Democratic member — have come out in support of the Alexander-Murray bill, enough for it to pass under the regular 60-vote threshold in the chamber.” (G)

“Maine Sen. Susan Collins wants the Senate to strike a provision in the tax reform bill that would repeal the individual mandate because she fears it will cause what amounts to a tax increase on some families.
Speaking on CNN’s “State of the Union,” Collins, a crucial Republican swing vote in the Senate, said the measure, which would essentially cripple the Affordable Care Act by removing one of its key pillars, should be removed from the Senate’s version of the bill.
“I don’t think that provision should be in the bill,” she said. “I think the Senate should follow the lead of the House and strike it.”…
Collins said the measure must be taken out of the bill because it will end up causing families who have healthcare through the Affordable Care Act to pay more for their insurance.
“The fact is that if you do pull this piece of the Affordable Care Act out, for some middle-income families, the increased premium is going to cancel out the tax cut that they would get,” she said.” (H)

“On Sunday, Mick Mulvaney, President Trump’s budget director, said on CNN’s “State of the Union” that the administration supports repealing the mandate. Most people who owe the penalty earn less than $100,000 a year, he said, arguing that “there’s actually a benefit to folks” if the mandate goes away. But he added, “If it becomes an impediment to getting the best tax bill we can, then we’re O.K. with taking it out.”” (I)

(A) The GOP Tax Plan-A Wolf In Sheep’s Clothing, by Miles J. Zaremski,
(B) GOP tax bill would spike Obamacare premiums nearly $2,000 for families, trigger Medicare cuts, by Dan Mangan,
(C) Middle-Class Families Confront Soaring Health Insurance Costs, by ROBERT PEAR,
(D) The GOP tax bill will be a health care burden on American families, by JANNI LEHRER-STEIN,
(E) 4 ways the Republican tax plan could change health care, by Dylan Scott,
(F) Trump met Senate Republicans on ObamaCare fix, by PETER SULLIVAN,
(G) Murkowski Suggests Tax Vote Depends on Stabilizing Individual Health Insurance Market, by Joe Williams,
(H) Susan Collins wants repeal of Obamacare mandate out of Senate tax reform bill, by Kyle Feldscher,
(I) Will Cutting the Health Mandate Pay for Tax Cuts? Not Necessarily, by KATE ZERNIKE and ABBY GOODNOUGH,

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When physicians opt out of Medicare they should reimburse Medicare for paying for their training

So like me, you pay into Medicare for 40+ years, only to find once enrolled that an increasing number of physicians have “opted out” of Medicare. And more and more often Medicare beneficiaries are finding that their long time physicians don’t accept Medicare and either have to switch doctors or pay their trusted doctors out-of-pocket.
It is easy to find articles encouraging doctors to stay out of Medicare. Here’s an interesting quote: “Medicare beneficiaries would likely be shocked to learn that Medicare contractor employees, who have only a high school education and no medical training, sit in judgment over physicians as to what is and is not medically necessary for Medicare patients. It is a strategy designed to save costs for the Medicare program.” (A)
Lost in the discussion is the fact that Medicare reimburses hospital for the training of residents who are paid during their period of training.
We are legally obligated to pay into Medicare, but it is fairly simple, without penalty, for a physician to opt-out.
It is possible for a physician to finish Medicare subsidized training and immediately opt-out. Or opt-out anytime thereafter.
So if physicians opt out of Medicare maybe they should have to reimburse Medicare accordingly, since we, the patients, paid for their training through the Medicare payroll tax.
“Medicare Direct Graduate Medical Education (DGME) Payments
Clinical settings are key sites for the education of future physicians. Typically, teaching hospitals and associated ambulatory settings provide such an educational environment for the training of resident physicians (“residents”). Residents have graduated from medical school and then go on to complete several years of supervised, hands-on training in a particular area of expertise, such as primary care or surgery. This phase of their training is called “graduate medical education” (GME).
Hospitals that train residents incur real and significant costs beyond those customarily associated with providing patient care. The Medicare program makes explicit payments to teaching hospitals for a portion of these added costs through direct graduate medical education (DGME) payments.
Purpose of the DGME Payment
The DGME payment compensates teaching hospitals for “Medicare’s share” of the costs directly related to the training of residents…The added direct costs of GME incurred by teaching hospitals include: stipends and fringe benefits of residents; salaries and fringe benefits of faculty who supervise the residents; other direct costs; and allocated institutional overhead costs, such as maintenance and electricity. Other direct costs include, for example, the cost of clerical personnel who work exclusively in the GME administrative office…” (B)

Is your doctor participating, non-participating, or opted-out?
“A doctor who takes Medicare assignment agrees to accept the Medicare-approved amount as full payment. In general, there are three categories of Original Medicare doctors:
Participating doctors are doctors who accept Medicare and always take assignment. Participating doctors are required to submit a bill (medical claim) to Medicare for care you receive. Medicare will process the bill and pay your doctor directly for care that he/she provided to you.
If you see a participating doctor, you are only responsible for paying a 20% coinsurance for Medicare-covered services. Most doctors who treat patients with Medicare are participating doctors.
Non-participating doctors are doctors who don’t routinely take assignment. Like participating doctors, non-participating doctors are required to submit a bill (medical claim) to Medicare for care you receive. However, you generally need to pay non-participating doctors directly for the full cost of care you receive. Medicare will process the bill and reimburse you directly for Medicare’s share of the cost of care you receive (generally 80% of Medicare’s approved amount for most medical services).
If you see a non-participating doctor, you may pay up to 15% of the Medicare-approved amount for non-participating providers, on top of a 20% coinsurance for care you receive. This extra 15% is called the limiting charge….
Opt-out doctors are doctors who have formally opted out of the Medicare program. Opt-out doctors can charge their Medicare patients whatever they want. These doctors do not submit any bill (medical claims) to Medicare and are not subject to the Medicare law that limits the amount doctors may charge patients.
If you see an opt-out doctor, you pay the entire cost of your care (except in emergencies). The doctor should have you sign a private contract that states that you understand you are responsible for the full cost of the services. Medicare will not pay for any of the cost of services you receive from an opt-out doctor.” (C)

It is easy for a physician to opt-out.
Opting Out of Medicare: A Guide for Physicians,

(A) Opting Out of Medicare, by Lawrence R. Huntoon,
(B) Medicare Direct Graduate Medical Education (DGME) Payments,
(C) Paying for the doctor when you have Original Medicare,

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

“The move to tuck the repeal of the so-called individual mandate into the tax overhaul is an attempt by Republicans to solve two problems: math and politics. Repealing the mandate, a longstanding Republican goal, would save hundreds of billions of dollars over the next decade. That would free up money that could be used to expand middle-class tax cuts or help pay for the overall cost of the bill, which can add no more than $1.5 trillion to the deficit over 10 years. It could also help secure the votes of the most conservative senators, enabling lawmakers to pass the bill along party lines.
If it becomes law, the repeal would save more than $300 billion over a decade but result in 13 million fewer Americans being covered by health insurance by the end of that period, according to the Congressional Budget Office. Republicans said on Tuesday that they would use the savings — which stem from reduced government spending to subsidize health coverage — to pay for an expansion of the middle-class tax cuts that lawmakers had proposed.
On Tuesday evening, the chairman of the Senate Finance Committee, Orrin G. Hatch, Republican of Utah, was expected to release an amendment that would add the repeal of the mandate to the Senate’s tax plan. On the House side, members of the Rules Committee met Tuesday evening, one day earlier than scheduled, to pave the way for a floor vote on Thursday. (A)

“Now it turns out that getting rid of the mandate could help Republicans as they tackle the difficult math of tax reform. According to a recent Congressional Budget Office estimate, eliminating the mandate could lower the deficit by $338 billion over a decade. A third of a trillion dollars can help pay for a lot of tax cuts. Which is why Senate Republicans, trying to find funding and keep their promise to dismantle Obamacare, are now vowing to add a mandate repeal to their tax bill. (B)

“President Donald Trump said Monday that he will nominate former pharmaceutical executive Alex Azar as secretary of the U.S. Health and Human Services Department….
Azar in February, during an interview on CNBC in February, said “The remarkable thing here is Obamacare is failing completely on its own terms.”
Speaking about what was then a prospective Republican Obamacare repeal-and-replacement bill, Azar said there was a consensus among Republicans and Democrats that the government should play a role in expanding insurance coverage and subsidizing its purchase by individuals. But he suggested that the way to do that was one other than Obamacare’s system.
And Azar was firm in his prediction that the GOP bill would become law within months.
“There will be a piece of legislation passes this year that is called ‘the repeal of Obamacare,’ ” Azar said. “I don’t know what’s going to be in the substance of it, but there will be a piece of legislation that says that.”
Azar was wrong about that. Republican leaders in Congress repeatedly fail to pass repeal-and-replace bills, despite controlling both the Senate and the House.
Azar has previously said he does not believe the expansion of Medicaid has been successful, saying he would have preferred to use government money through “private-sector vehicles” to deliver health care.” (C)

“Vice President Mike Pence is exerting growing influence over the American health care system, overseeing the appointments of more than a half-dozen allies and former aides to positions driving the White House’s health agenda.
On Monday, President Donald Trump nominated Alex Azar, a former Indianapolis-based drug executive and longtime Pence supporter as Health and Human Services secretary. If confirmed, Azar would join an Indiana brain trust that already includes Centers for Medicare & Medicaid Services Administrator Seema Verma and Surgeon General Jerome Adams. Two of Verma’s top deputies — Medicaid director Brian Neale and deputy chief of staff Brady Brookes — are former Pence hands as well, as is HHS’ top spokesman, Matt Lloyd.
Yet another Pence ally — Indiana state Sen. Jim Merritt — is in the running to be White House drug czar.
Pence’s sway with the policymakers controlling Obamacare, Medicare and Medicaid comes at a time when Trump and Congress continue to struggle with the repeal of the Affordable Care Act. But Pence and his cadre are driving a national agenda dominated by the kinds of conservative, anti-regulatory policies he embraced as Indiana governor.” (D)

“Azar has called Verma “one of the leaders in reinventing Medicaid.” He shares her view that the health care program for low-income Americans has to be put on a more “sustainable” financial footing, and states should be given more accountability and responsibility for running the joint federal/state program.
On the individual insurance market, the other major aspect of health care restructured by the Affordable Care Act, Azar has echoed the Trump administration’s view that the market is failing.
“Obamacare is going down right now,” Azar told Fox News in July. “It is an almost impossible market to do from an insurance perspective.””
He’s said the regulations need a “top-to-bottom comprehensive rewrite” to impose “as much free market, localized flexibility as humanly possible.” (E)

“There’s one set of eyes that President Trump’s appointees absolutely cannot ignore as they set about trying to reshape Obamacare and enact sweeping new changes to the government’s health-care programs.
They belong to Joe Grogan, director of health programs at the White House’s Office of Management and Budget.
You’ve probably never heard of Grogan — but you should know who he is. Grogan, perhaps more than any other member of Trump’s administration, holds the power to nix or give the nod to hundreds of regulations shaping how the federal government runs Medicare, Medicaid, the Affordable Care Act marketplaces, the FDA, the CDC and all the other sub-agencies contained within the sprawl of the Department of Health and Human Services.
Without Grogan’s assent, for example, the Centers for Medicare and Medicaid Services wouldn’t have been able to essentially wipe out steep and long-term drug discounts received by charity and rural hospitals. Last month’s rule change to the 340B program — viewed by many as rather gutsy on the part of CMS because it infuriated hospitals — had to get past Grogan’s desk at OMB, just like every other regulation change the administration wants to make.” (F)

“As Republican lawmakers worked on Monday toward a delicate compromise on a $1.5 trillion tax cut, President Trump threw himself back into the discussion, suggesting that Republicans could reduce taxes even further by repealing the Affordable Care Act’s mandate that most people have health insurance.
In recent weeks, Mr. Trump has called for including the repeal of the individual mandate in the tax bill. Doing so would save more than $300 billion over a decade and would allow Republicans to boast that they took a step forward in dismantling a law that continues to haunt them.” (G)

President Donald Trump remains intent on undoing the Obamacare individual mandate one way or another.
Encouraged by Trump, a group of congressional conservatives want to add repeal of the mandate to the GOP’s overhaul of the tax code. But other Republicans fear the toxic politics of Obamacare could jeopardize the tax fight, and so far have kept repeal language out of both Senate and House versions of the tax package.
That means it could be left to Trump to act unilaterally to neutralize what polls consistently show to be the most unpopular part of the Affordable Care Act.
Most legal observers believe the administration has the necessary authority to interpret the law and substantially weaken enforcement of the tax penalty levied on most Americans who fail to obtain coverage. The downside is that unraveling the mandate might ultimately make it harder for Republicans to follow through on their long-standing promise to repeal and replace Obamacare.
The White House has drafted an executive order to scrap the individual mandate, but is waiting to see if Congress opts to go first, multiple media outlets reported this week. House Ways and Means member Jim Renacci (R-Ohio) worked behind the scenes to add a repeal provision to tax legislation moving to the House floor, according to a source close to the talks.
The White House denies that any executive action is imminent.
“We are always looking for ways to provide relief from Obamacare,” said a spokesman in an email. “The longstanding issues with the mandate would be best resolved legislatively.” (H)

“After cutting funds for nonprofit groups that help people obtain health insurance under the Affordable Care Act, the Trump administration is encouraging the use of insurance agents and brokers who are often paid by insurers when they help people sign up.
The administration said in a recent bulletin that it was “increasing partnerships” with insurance agents and viewed them as “important stakeholders” in the federal marketplace, where consumers are now shopping for insurance. But some health policy experts warned that a shift from nonprofit groups, which are supposed to provide impartial information, to brokers and agents, who may receive commissions for the plans they recommend, carries risks for consumers.
“Insurance agents can educate consumers about the marketplace, and that is a good thing,” said Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute. “But I worry that they work on a commission and therefore have a financial incentive to steer consumers to particular products, which may or may not be in the consumer’s best interest.”” (I)

“Buried in almost every version of the Republican health care legislation this year was a little provision that would have enabled states to make a major change to their Medicaid programs, by requiring people to work if they’re going to get coverage. When those bills died, it appeared that Medicaid work requirements died with them.
But this week, Seema Verma, the head of the Centers for Medicaid & Medicare Services and a longtime supporter of work requirements, sent a strong message that work requirements are back on the table. In a speech to the country’s Medicaid directors, Verma lambasted the Obama administration’s approach to Medicaid, calling it a “tragic example of the soft bigotry of low expectations,” and argued that requiring Medicaid beneficiaries to work would improve the program.
The speech doesn’t result in any immediate policy changes, but CMS is reviewing at least seven waiver proposals from GOP-led states that would impose work requirements on their Medicaid populations. The details around each waiver vary and it’s unclear whether Verma, who helped design a work requirement policy in Indiana that was rejected by the Obama administration, will ask states to tweak their submissions or when she will approve the first waiver. But her speech this week was a clear sign that big changes are coming to Medicaid — even without any help from Congress.” (J)

“For years, red states have effectively been subsidizing part of health insurance for blue states.
By declining to expand their Medicaid programs as part of the Affordable Care Act, many of those states have passed up tens of billions of federal dollars they could have used to offer health coverage to more poor residents. That means that taxpayers in Texas are helping to fund treatment for patients with opioid addiction in Vermont, while Texans with opioid problems may have no such option.
If they did, they could collect billions of federal dollars to help them cover more low-income residents.
Now new estimates prepared by the consulting firm Avalere Health for The Upshot give a sense of just how much states are giving up. Texas could collect around $42 billion in Medicaid over a decade if it opted in, according to the Avalere analysis. Tennessee could pull in around 5 percent of its state budget next year. Altogether, Avalere estimates that the 18 states that have still not expanded Medicaid could give up more than $180 billion over the next 10 years.” (K)

(A) Senate Plans to End Obamacare Mandate in Revised Tax Proposal, by THOMAS KAPLAN and JIM TANKERSLEY,
(B) Obamacare’s Insurance Mandate Is Unpopular. So Why Not Just Get Rid of It?, by Margot Sanger-Katz,
(C) Trump nominates former drug company executive Alex Azar as next Health and Human Services secretary, by Dan Mangan,
(D) Pence’s health care power play, by By ADAM CANCRYN,
(E) Who is Alex Azar? Former drugmaker CEO and HHS official nominated to head agency, by Maureen Groppe,
(F) The Health 202: The Trump appointee you’ve never heard of who’s reshaping health policy, by Paige Winfield Cunningham,
(G) Trump Again Wades Into Tax Debate, Suggesting Repeal of Obamacare Mandate, by ALAN RAPPEPORT and THOMAS KAPLAN,
(H) Trump may use executive power to weaken Obamacare’s individual mandate, by Paul Demko,
(I) Trump Administration Guiding Health Shoppers to Agents Paid by Insurers, by ROBERT PEAR,
(J) 5 things Trump did this week while you weren’t looking, by DANNY VINIK,
(K) What Red States Are Passing Up as Blue States Get Billions, by MARGOT SANGER-KATZ and KEVIN QUEALY,

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The new Jersey City Medical Center (2004) was constructed above the 100 year flood plain – then came Sandy, Harvey & Irma

In 2012 “The hospitals in Hudson County were the hardest hit by the superstorm, with Hoboken University Medical Center and Palisades Medical Center temporarily closed. While Jersey City Medical Center’s first floor was inundated, it moved patients to the second floor and remained open.
“Fortunately for us, we were able to maintain our generator,” Scott said, noting that the water came within inches of the generator fuel pumps. After the storm, the hospital raised the pumps eight feet above the high-water mark.
Jersey City Medical Center also is planning a series of raised embankments, automatic floodgates, and waterproofed walls to head off future disaster. The plans are inspired by Lourdes Medical Center in Binghamton, New York, which has used a similar system to keep water out.” (A)

“It’s been over a month since the last of Maria’s Category 4 hurricane-strength winds swept over Puerto Rico, but there is still damage yet to come…..Even with the aid of the federal government and the military, a health-care system facing multiple threats might not be able to protect some of the island’s most vulnerable citizens.
Many of those people are facing hard choices in Puerto Rico’s hospitals, which are at the front lines of disaster-relief efforts. While most hospitals have recovered from the storm’s early blows—which knocked most of them out of commission and left a few others dependant on generators—they have had to make do with shortages of power, water, and supplies; personnel crunches; and intensifying health-care needs from accidents and emergent diseases. Last week, a photograph posted by former Governor Alejandro García Padilla on Twitter showed doctors performing surgery by flashlight. From what physicians on the island tell me, such scenarios are common, as is physicians working double and triple shifts—circumstances made even more remarkable by the fact that the doctors themselves are victims of the storm.…. (B)

“…Over the weekend, the island’s power company fired a key contractor working to restore electrical service. The cancellation of the $300 million contract with Whitefish Energy, after the Federal Emergency Management Agency and other agencies expressed significant concerns about the deal, is expected to further delay the return of power throughout Puerto Rico.
The Puerto Rican government has prioritized getting power back to hospitals. Many smaller clinics and doctor’s offices, like other businesses on the island, still don’t have electricity.
Take, for instance, San Patricio Medflix, a diagnostic imaging center in greater San Juan. The center has state-of-the-art MRI, CT and nuclear medicine equipment.
Problems with a diesel generator recently led to the cancellation of 70 patients’ appointments, says Dr. Fernando Zalduondo Dubner, medical director of San Patricio Medflix in San Juan, Puerto Rico.
With Puerto Rico’s electric grid down since Sept. 20, the diesel generator, housed in a metal box the size of a shipping container, has been the sole source of power for his four-story medical complex.
Fuel has been a big problem. The generator consumers about 500 gallons of diesel a day…. (C)

“Waterborne illnesses are on the rise in Puerto Rico in the wake of Hurricane Maria — and health professionals fear the storm’s aftermath could unleash an epidemic on the devastated island.
The death toll from the storm rose to 51 on Tuesday, with the two latest victims dying of leptospirosis, a bacterial disease usually spread by contact with contaminated water, Puerto Rico Public Affairs Secretary Ramon Rosario told The Associated Press….
The disease is transmitted via exposure to the urine of infected animals, but humans are most commonly infected by coming in contact with contaminated water, especially through skin abrasions and the nose, mouth and eyes, according to World Health Organization…
The disease has a wide range of symptoms including high fever, headache, chills, vomiting and diarrhea, but some may have no symptoms at all, according to the CDC. Leptospirosis is treated with antibiotics, but without treatment it can lead to kidney damage, meningitis, liver failure and death, according to the CDC.” (D)

“Students and faculty from Ponce Health Sciences University (PHSU) in Ponce, Puerto Rico have been the sole providers of aid for residents in southern and central Puerto Rico who hadn’t received assistance since Hurricane Maria landed five weeks ago. Since the crisis began, the students/faculty have provided medical and psychological support services – and delivering privately donated goods and supplies – to the residents, most of whom lost their homes and all of their possessions in the hurricane.
“Every day, PHSU students, doctors, psychologists, public health professionals, staff, and community volunteers have been tirelessly delivering privately donated medicine, water, and food – and providing critical care medical attention – to our neighbors in rural mountain towns,” says Dr. David Lenihan, CEO of PHSU. “They’re clearing roads, wading through waterways, and going door-to-door to offer their help. In many cases, they’ve been the first responders who have made contact with, and offered assistance to, these remote areas since Maria made impact.”
PHSU restored operations and classes on October 9, and is one of only a few universities in Puerto Rico that have reopened since Maria hit. (E)

“We cannot weaken the EPA as hurricanes are growing worse…
When hurricanes hit, EPA’s emergency response staff, scientists and engineers are essential to keeping people safe. The agency helps prevent and monitors toxic releases and chemical spills from industrial facilities and Superfund sites, and helps inform the public about any local environmental dangers. EPA also helps local communities protect drinking and wastewater systems from sewage leaks and works to get them working again….
The situation in Puerto Rico and the U.S. Virgin Islands is much more severe. Millions of our fellow Americans do not have electricity, reliable clean drinking water or functioning sewage treatment. St. John has not had electricity since early September. On St. Thomas, the street lights don’t work, the smell of diesel generators lingers in the air and if you are indoors you often smell mold.
Keeping up with these kinds of challenges is hard enough for the EPA. But remarkably, the Trump administration and its allies have been working to cut funding for many of the EPA’s most important disaster-relief programs.” (F)

“Five years after Hurricane Sandy struck on Oct. 29, 2012, much of the region’s inundated infrastructure has been repaired and some of it has been improved. But most of the big plans to stormproof New York City remain just that: plans. And throughout the planning, the city has continued to advance toward the water, with glass high-rises stretching across the riverfront in Queens, Brooklyn and the Far West Side of Manhattan.
“Each year we don’t get a hurricane here we know we’ve dodged a bullet,” said Robert Freudenberg, the vice president for energy and environment at the Regional Plan Association, an urban research group. “We’re racing the clock still to try and prepare for another storm like Sandy.”…
A bright flash that could be seen from Brooklyn signaled the failure of a substation on the site and heralded the long blackout that began minutes later. More than seven million gallons of salt water poured into the Canarsie Tunnel, which carries L trains under the East River. Twelve blocks north, the sprawling Bellevue Hospital Center complex, New Yorks’ flagship public hospital, had to be evacuated for the first time because it had no power, elevator service or drinking water….
At Bellevue, a wall will be built behind the hospital as part of a flood barrier along the East River. “We would really rather shelter in place than evacuate,” said Roslyn Weinstein, a vice president for operations for NYC Health & Hospitals, the city’s public health system…
After Sandy, NYC Health & Hospitals was awarded $1.7 billion in federal aid to repair and improve three of its 11 public hospitals — Bellevue, Coney Island and Metropolitan in Manhattan — and a skilled nursing center on Roosevelt Island. Since then, electrical systems and generators have been moved out of basements and elevators and loading docks protected with waterproof panels.
Near Bellevue, NYU Langone Medical Center, which had to evacuate 300 patients, got $1.1 billion in federal aid. But the privately run hospital refused to say how it has spent that money, making it difficult to assess if the hospital is any better prepared today.” (G)

‘After every natural calamity, American politicians make big promises. They say: We will rebuild. We will not be defeated. Never again will we be caught unprepared.
But they rarely tackle the toughest obstacles. The hard truth, scientists say, is that climate change will increasingly require moving — not just rebuilding — entire neighborhoods, reshaping cities, even abandoning coastlines.
Resettling neighborhoods, making certain places off-limits to development, creating dikes and reservoirs is difficult, both financially and politically. It takes longer than most election cycles. Memories fade. Inertia sets in. Residents just want to get their lives back to normal. Politicians want votes, not trouble.
After Hurricane Katrina in 2005, New Orleans, for better and worse, used its cataclysm as an opportunity to reboot, not just fixing levees but overhauling public schools, hospitals and many neighborhoods. It was a wrenching process….”
“Three 500-year floods in three years means either we’re free and clear for the next 1,500 years,”… “or something has seriously changed.” (H)

“Hurricane Sandy “filled up Hoboken like a bathtub,” the mayor of that New Jersey city told reporter Eric Jaffe. The storm flooded 1,700 homes, knocked out the power grid and did $100 million worth of local damage….
Planners envision a combination of “hard” and “soft” infrastructure: “Hard” flood walls will protect high-risk sites along the riverfront. Meanwhile, a “soft” system of parks, green roofs and terraced wetlands will act like sponges, soaking up water long enough to keep the sewer system from being overwhelmed; remaining runoff will be held in a combined park/water-storage site until the storm passes, when pumps will return floodwater back into the river.” (I)

“ “This project serves as a model for how to address threats from storm surge in urban areas,’’ said Department of Environmental Protection Commissioner Bob Martin. His agency collaborated with the city, HUD, and the state Department of Community Affairs in developing the project.
The proposed system will utilize natural higher ground to maximize protection and will be designed to blend in seamlessly with the urban streetscape. It will provide protection for critical infrastructure such as the North Hudson Sewerage Authority, as well as public-safety facilities and three fire stations and a hospital.
The project calls for construction of a flood-resistant structure stretching from 19th Street in Weehawken and extending south to Hoboken, slightly inland from the river. An additional flood-resistant structure will be built along the southern end of Hoboken.” (J)

(B) Puerto Rico’s Dire Health-Care Crisis, by VANN R. NEWKIRK II,
(C) Lingering Power Outage In Puerto Rico Strains Health Care System, by JASON BEAUBIEN,
(D) Puerto Ricans at Risk of Waterborne Disease Outbreaks in Wake of Hurricane Maria, by DANIELLA SILVA,
(E) PHSU Medical Students/Faculty Have Been Sole Providers of Aid to Rural Towns in Southern Puerto Rico,
(F) We cannot weaken the EPA as hurricanes are growing worse, by JUDITH ENCK,
(G) Five Years After Sandy, by PATRICK McGEEHAN and WINNIE HU,
(H) Lessons From Hurricane Harvey: Houston’s Struggle Is America’s Tale, by MICHAEL KIMMELMAN,
(I) After Hurricane Sandy, Hoboken works on plan to avoid future flood damage, by Nancy Szokan,
(J) Feds to Fund Massive Flood-Control Project for Hoboken, Nearby Towns, by Tom Johnson,

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

“And there’s no Obama-era policy that he (President Trump) has fought harder to kill than the former President’s signature piece of legislation, Obamacare. After countless failed attempts at killing the bill through legislative means, Trump decided he’d try to kill it by starving it. Its marketing budget? Yeah that went bye-bye. The idea was that if fewer people knew about the enrollment period, then fewer people would sign up for the service, and therefore the pools wouldn’t be full of enough healthy people, who won’t use their coverage much, to offset the cost of the sick people, who will have to use it constantly. It’s a plan that is equal parts devious and terrifying. Which is why it delights me to tell you that it doesn’t seem to be working.
According to The Hill, Obamacare signups during the first few days of enrollment have set new records and have surprised many in the industry.
The surge in sign-ups, which was confirmed by an administration official, comes despite fears from Democrats that enrollment would fall off due to the Trump administration’s cutbacks in outreach and advertising.
On the first day of enrollment alone, Nov. 1, one source close to the process told The Hill that more than 200,000 people selected a plan for 2018, compared with about 100,000 last year. More than 1 million people visited that day, compared to about 750,000 last year, the source said.” (A)

Among Donald Trump’s more pernicious and oft-repeated lies is that the Affordable Care Act (ACA) is imploding. It isn’t. But to the extent that problems are mounting, they are largely his doing. In March, the nonpartisan Congressional Budget Office (CBO) concluded that “in most areas,” Obamacare’s exchanges were stabilizing, and that most enrollees who received subsidies wouldn’t see their premiums increase significantly. Six months later, the CBO issued another report that, according to CNN, named “several policies the White House is pushing” that will lead “to rising premiums and decreased enrollment in individual insurance markets over the next year.”…
Trump seems to think he knows what he’s up to. He has said on multiple occasions that, as premiums spike and enrollment falls, congressional Democrats will be forced to come to him with hats in hand to negotiate some sort of replacement for Obama’s signature law. That’s a bad misreading of public opinion, which tends to hold the party in the White House responsible for virtually everything. Indeed, a Kaiser poll conducted in August found that 60 percent of respondents think Trump and Republicans would be “responsible for any problems with the ACA going forward,” compared with just 28 percent who said the same of Obama and Democrats.” (B)

“Choosing health insurance can be a hassle under the best of circumstances. But if you get your coverage from an Obamacare health insurance exchange, it’s more important than ever to shop around this year.
There are a lot of changes in store for consumers who buy coverage from or state-run health insurance exchanges, such as Covered California and New York State of Health. Premiums will be higher for most people, as usual.
And actions taken by President Donald Trump have driven prices even higher than they would’ve been ― and have made the shopping process more complicated, even for existing exchange customers.
Those actions will make health insurance too expensive for many consumers. But it will also mean better insurance for the same price for others ― or skimpier insurance that could even be free. That may seem strange, and that’s because it is strange, and complicated, which highlights how crucial it is for shoppers to do their homework this year.
Long story short: People who signed up for mid-range “Silver” plans in the past will need to shop around because it might be a worse deal now. A consumer might assume that a Bronze plan is the least expensive, Gold and Platinum are the most costly and Silver is in the middle, and that the generosity of the benefits matches the price. That’s how the law had intended it to work, but it’s not necessarily the case anymore.
In one Los Angeles ZIP code, for example, a 40-year-old could pay $352.59 a month for an unsubsidized Gold plan with zero annual deductible, which is just $13.35 more than a Silver plan from the same health insurance company that comes with a $2,500 deductible. The lowest-cost unsubsidized Bronze plan in that part of the city costs $263.67 and has a $6,300 deductible.” (C)

“It’s time to select a health insurance plan for 2018! Whether we get covered through an employer or the Affordable Care Act exchanges, we’ll be told to carefully review our options to find a plan that will give us the best coverage for the least amount of money.
We will be told we need to shop.
“I encourage you to shop around,” Senator Jeanne Shaheen, Democrat of New Hampshire, told her Facebook followers who are choosing plans from the A.C.A. marketplaces. The human resources giant Mercer wrote last year, “This open enrollment, think of employees as shoppers.” The American Diabetes Association, the American Institute of Architects, the Robert Wood Johnson Foundation and Aetna all use the terms in their literature or on their websites.
Make it stop!
This is not shopping. Shopping is a fun activity, like choosing a pie from the bakery or picking out cereal at the supermarket. The farthest thing from “shopping” is the arduous annual ritual of reviewing the complex and all but impossible to decipher health insurance options.
That’s partly because insurers do their best to make the experience as miserable as possible. Many of them offer up less-than-accurate lists of providers and participating institutions. They reserve the right to deny you coverage of a service, and you won’t know if they have until the day you need it — and maybe after the fact. Prospectuses are complex, and few of us fully understand them. Only 9 percent of Americans can properly define all four of these rather vital phrases: health plan premium, health plan deductible, out-of-pocket maximum and coinsurance, according a survey recently released by United Healthcare.” (D)

“Rep. Kevin Brady, R-Texas, and Sen. Orrin Hatch, R-Utah, on Thursday introduced bills that would temporarily suspend the individual mandate under Obamacare, and fund the cost-sharing reduction payments President Trump said he would nix through 2019.
CBS News first obtained the text of Brady’s bill. (Here is the text of the bill as of 7:47 a.m. Wednesday.) Brady is the chairman of the House Ways and Means Committee, and Hatch is the chairman of the Senate Finance Committee
The Healthcare Market Certainty and Mandate Relief Act of 2017 places a moratorium on the individual mandate requiring Americans to have insurance from after December 31, 2016 until January 1, 2022, and retroactively nullifies the employer mandate from December 31, 2014, until Jan. 1, 2018.
The legislation also directs the federal government to fund cost-sharing reduction payments for the next two years. Last month, Mr. Trump abruptly announced he would end the cost-sharing reduction payments, which are payments the federal government makes to insurers under Obamacare to keep health costs low for low-to-middle-income families. The legislation, however, prohibits such payments to be given to an issuer of a health plan that includes abortion coverage.
The legislation also increases the maximum contribution limit for health savings accounts.” (E)

“President Trump on Wednesday suggested using the GOP tax bill to repeal ObamaCare’s individual mandate.
“Wouldn’t it be great to Repeal the very unfair and unpopular Individual Mandate in ObamaCare and use those savings for further Tax Cuts,” Trump tweeted.
The idea is being pushed by Sen. Tom Cotton (R-Ark.) and also has the backing of House Freedom Caucus Chairman Mark Meadows (R-N.C.).
Meadows said Wednesday he supports repealing the mandate in tax reform and thinks “ultimately” it will be included because he is going to push for it. He said he has been talking to Cotton about it.
A Cotton spokeswoman told The Hill that Cotton and Trump spoke by phone about the idea over the weekend and “the President indicated his strong support.” (F)

“President Donald Trump and Republican congressional leaders falsely claim that Obamacare, aka the Affordable Care Act, is “exploding” or in a “death spiral. To be sure, the health care law’s marketplaces – where people who lack job-based health insurance, are too young for Medicare and aren’t poor enough for Medicaid can buy comprehensive health insurance – have been Obamacare’s political Achilles heel. They don’t ensure that everyone who liked the health plan they had before the Affordable Care Act would be able to keep it or find a comparable plan in the marketplaces.
But a large and rising majority of enrollees are satisfied with their coverage.
And contrary to critics’ claims, the marketplaces are functioning and, as my Center on Budget and Policy Priorities’ colleagues Aviva Aron-Dine and Tara Straw explain, they’ll continue to provide affordable comprehensive coverage to millions of Americans, despite Trump administration sabotage that has driven up the “sticker price” of 2018 exchange premiums and will likely depress sign-ups in the open enrollment period that began this week.
Critics who focus on the sticker price ignore two key facts. First, most marketplace consumers are protected from rate hikes because they qualify for premium tax credits that help them pay for health insurance and that rise when premiums rise. Second, lower-income marketplace consumers are further protected by the health care law’s limits on how much of their income they will have to pay for deductibles and co-payments.
Insurance companies will participate in the marketplaces if they think they can make money based on the premiums they collect and the likely covered expenses of their policyholders. Obamacare’s individual mandate, which requires people to have insurance or pay a penalty, is there to increase marketplace enrollment and provide greater stability for insurers.” (G)

(A) Despite Donald Trump’s Best Efforts, Obamacare Signups Are Setting New Records This Year, by JACK MOORE,
(B) Everything Trump Is Doing to Sabotage the Affordable Care Act, by Joshua Holland,
(C) Under Trump, Obamacare Shopping Is Even More Confusing. We’re Here To Help, by Jeffrey Young,
(D) Choosing a Health Insurance Plan Is Not ‘Shopping’, by HELAINE OLENNOV. 2, 2017,
(E) New GOP bill would halt Obamacare individual mandate, restore subsidy payments,
(F) Trump suggests repealing ObamaCare mandate in tax bill, by NATHANIEL WEIXEL,
(G) Obamacare Isn’t Exploding, by Chad Stone,

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a hand held device (was used) to measure the germ-count on some of New York City’s dirtiest surfaces

“In an episode of Gross by Men’s Health, the magazine’s editor in chief Matt Bean uses a handheld device to measure the germ-count on some of New York City’s dirtiest surfaces. Test results show that the most bacteria lives on Citi Bike handlebars, which prove to be 45 times more germy than subway train hold-bars. The second most disgusting surface turned out to be Starbucks door handles — ahead of a self-help internet kiosk, taxicab door handles, and a doorknob at Grand Central Station.
While most of the bacteria found on these surfaces are harmless, nothing above a germ count of 50 should touch your food. The Citi Bike handle scored a 1,512 and Starbucks received a 1,090 in contrast to subway trains, which measured in at a mere 35. (A)

“Now, that’s just one Starbucks . . . and there’s no guarantee any of those germs were ones that could make you really sick.
But, again, it’s a good reminder that we live in a FILTHY world . . . and soap and hand sanitizer exist for a reason.” (B)

There is not enough public awareness of the growing problem of hospital acquired infections, and in fact, infections in all medical settings from nursing homes to blood drawing centers.
“University of Michigan researchers reported in a 2014 study that infections – both those acquired inside and outside hospitals – would replace heart disease and cancer as the leading causes of death in hospitals if the count was performed by looking at patients’ medical billing records, which show what they were being treated for, rather than death certificates.” (C)

“In recent years, it’s become painfully clear to everyone working in medicine that frequent hand washing is crucial to stopping the spread of infection in hospital settings. Nowadays, every hospital and clinic posts signs that remind doctors and other health professionals to clean or sterilize their hands in between seeing every patient.
Doctors’ hands, though, aren’t the only things that come into contact with sick patients over and over again. The trusty stethoscope, one of the most basic and important tools in a physician’s kit, can touch dozens of patients during a day and is sanitized much less often than a pair of hands—potentially raising the risk for cross-transmission of harmful bacteria and other microbes between patients.
“Physicians forget to clean their hands quite frequently, even in the best places,” … “When they forget to clean their hands, they certainly forget to disinfect their stethoscope. And from my experience, even those who are really good models of hand hygiene likely forget to clean their stethoscopes most of the time.” “ (D)

“While stethoscopes can transmit the same germs as unclean hands, none of the doctors in a recent study bothered to clean them between patients.
And that was the case even after an educational intervention about the importance of stethoscope hygiene in preventing infections: Zero doctors wiped off the stethoscope between patient encounters, according to a study published in the July issue of the American Journal of Infection Control, the journal of the Association for Professionals in Infection Control and Epidemiology (APIC)….
The bad results were especially confounding because the institution checks second-year medical students’ compliance in an evaluation that demonstrates competency in performing a complete history and physical.
Infection control guidelines from the Centers for Disease Control and Prevention also say reusable medical equipment, such as stethoscopes, must undergo disinfection between patients.” (E)

“Your doctor may not necessarily tell you everything you need to know about HAIs before you’re admitted to the hospital. Here are facts you should know to safeguard your health — and maybe even save your life. 1. Healthcare-associated infections are alarmingly common. 2. You could come down with an infection that’s resistant to antibiotics.3. You could be a carrier of a drug-resistant bug and not even know it. 4. Hospital-acquired infections don’t only develop in patients who have surgery. 5. Taking antibiotics when they’re not needed increases your risk of a future healthcare-associated infection. 6. You can find out how your hospital’s infection rate compares with others. 7. Common objects in a hospital can be contaminated with disease-causing germs. 8. Surfaces like bed rails and hospital elevator buttons need to be kept clean, too. 9. Many hospital-associated infections are preventable. 10. Hospitals make a concerted effort to lower the rate of HAIs among their patients.” (F)

There are “three published reports describing the transmission of hepatitis B virus and hepatitis C virus in dental settings since 2003. ……(another report) described a 2015 outbreak of Mycobacterium abscessus infection at a pediatric dentistry practice.
In most cases, investigators have failed to link a specific lapse of infection prevention and control practice with a particular transmission. However, reported breakdowns in basic infection prevention practices included unsafe injection practices, failure to heat-sterilize dental handpieces between patients, failure to monitor (e.g., conduct spore testing of) autoclaves, and failure to maintain dental unit waterlines.” (G)

“What should a patient look for in a dental office for assurance that the dentist and staff are taking proper precautions to prevent cross-infection?
1) Do you heat-sterilize all your instruments, including handpieces (“dental drills”), between patients?
2) How do you know that the sterilizer is working properly?
3) Do you (wash your hands and) change your gloves for every patient, in front of the patient?
4) Do you disinfect the surfaces in the operatory between patients?
5) If you are unclear on or uncomfortable with the precautions your dental practice takes to protect you during treatment, talk to your dentist or dental team member about your concerns and ask to see the office’s instrument processing area. (H)
Do you have any idea about infection control in your dentist’s office? I ask the dentists and hygienist to wash their hands in front of me before they put on gloves and start a procedure.

“Five precautions to make waiting rooms as safe as possible for patients: Make hand sanitizer accessible in high-traffic areas; Offer an antiviral face mask to patients and healthcare workers; Use germ-killing wipes on high-contact surfaces; Review containment plans and keep patients with flu-like symptoms away from others.” (I)

The “Gold Standard” in hand hygiene during the collection of blood specimens has 22 steps, including Perform Hand Hygiene four times. (J)
I have never seen any phlebotomist complete all these steps! In fact most of the steps are done in another room. But I do insist they wash their hands in front of me before the put on gloves then start the procedure immediately with no intermediate steps.

Each of us needs to be our own Infection Control Officer and feel comfortable that every practitioner takes infection control seriously!

Some related posts
It’s okay and important to ask your doctor “DID YOU WASH YOUR HANDS?”

President Garfield didn’t die from an assassin’s bullet, but rather from a doctor’s dirty hands.

(A) Starbucks Door Handles Are 31 Times More Germy Than New York City’s Subways, by Taylor Rock,
(B) A Door Handle at Starbucks Has More Germs Than a Subway Pole, by Jesse Reynolds,
(C) No one knows how many patients are dying from superbug infections in California hospitals,
(D) Doctors’ Stethoscopes Can Transmit Bacteria As Easily As Unwashed Hands, by Joseph Stromber,
(E) (C) The dirty (and dangerous) truth about doctors’ stethoscopes, by Joanne Finnegan,
(F) (D) 10 Things Your Doctor Won’t Tell You About Hospital Infections by Rosemary Black, (
(G) Preventing Disease Transmission in Dental Settings,
(H) (F) five questions that patients should ask their dental care providers about infection control practices,
(I) (G) 5 ways to prevent infection spread in waiting rooms, by Heather Punke,
(J) (H) Blood Collection Hand Hygiene Practice Guidelines,

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Is “Silicon Valley” – artificial intelligence – disrupting and taking over the health care system?

“For a year and a half — and more urgently for much of the last month — I have warned of the growing economic, social and political power held by the five largest American tech companies: Apple, Amazon, Google, Facebook and Microsoft.
Because these companies control the world’s most important tech platforms, from smartphones to app stores to the map of our social relationships, their power is growing closer to that of governments than of mere corporations….” (A)

“If there is to be a health-care revolution, it will create winners and losers. Andy Richards, an investor in digital health, argues that three groups are fighting a war for control of the “health-care value chain”.
One group comprises “traditional innovators”—pharmaceutical firms, hospitals and medical-technology companies such as GE Healthcare, Siemens, Medtronic and Philips. A second category is made up of “incumbent players”, which include health insurers, pharmacy-benefit managers (which buy drugs in bulk), and as single-payer health-care systems such as Britain’s NHS. The third group are the technology “insurgents”, including Google, Apple, Amazon and a host of hungry entrepreneurs that are creating apps, predictive-diagnostics systems and new devices. These firms may well profit most handsomely from the shift to digital….
Large hospitals, some of which count as both incumbents and traditional innovators, will also be affected. The rise of telemedicine, predictive analytics and earlier diagnoses of illnesses are expected to reduce admissions, particularly of the emergency kind that are most lucrative in commercial systems. The sickest patients can be targeted by specialist services, such as Evolution Health, a firm in Texas that cares for 2m of the most-ill patients across 15 states. It claims to be able to reduce the use of emergency rooms by a fifth, and inpatient stays in hospitals by two-fifths.” (B)

“Why are Google, Apple and others so keen on health care? How are these companies altering the healthcare space? Moreover, what does the future relationship between these players and health care look like? Here is all you need to know about the love affair between tech companies and health care:
Why the Sudden Interest?…Here are a few reasons why an increasing number of tech companies are breaking into the healthcare sector:
Disruption: Health care has always been, and still is, a sensitive and hugely complex universe. This industry is begging for innovative solutions in the marketplace that can make health care easier to navigate—for both patients and providers. As Intel general manager Michael Jackson says, “The opportunity exists because of disruption. There are fewer industries being disrupted more right now than health care.”
Talking about business opportunities in health care, Unity Stoakes, founder of StartUp Health, says, “The companies that are best placed to take advantage of these changes are those that really understand consumers.”
Who knows consumers better than Apple, Nokia, Google and Samsung do?
Affordable Care Act: Obamacare has given an impetus to data-driven medicine. In fact, the Affordable Care Act requires that data on cost and quality should be made freely available. The focus on big data, as well as consumers’ growing comfort with tracking their daily habits, has cleared the way for the introduction of wearable technology, mobile apps and other high-tech digital applications.” (C)

“So what do we get for these extravagant private and public costs? A system where it takes weeks to see a doctor face-to-face, where more than 6,500 locales are officially deemed to have too few medical professionals to meet patients’ needs, and where U.S. health outcomes are consistently mediocre compared with those of many of our developed-nation peers (and even some of the less developed ones).
This status quo is ripe for disruption. And while true reform will require all the relevant parties—government, industry, and health care consumers themselves—to make major adjustments, an insurgent group of digital health companies is doing its best to drag American medicine into the 21st century kicking and screaming.
That means superseding physical constraints like having an actual hospital by harnessing the power of mobile technology, making the act of taking your medicine less of a hassle, and peering into our very biological building blocks to wage war on the most intractable maladies….
Welcome to the digital health revolution.” (D)

“The prospect of the giant Internet retailer entering the business is beginning to cause far-reaching reverberations for a range of companies, roiling the shares of drugstore chains, drug distributors and pharmacy-benefit managers, and potentially precipitating one of the biggest corporate merger deals this year.
On Thursday, the pressure was plain to see. A report that Amazon had received pharmacy-wholesaler licenses in a dozen states triggered a fast and steep selloff that wounded the likes of McKesson Corp., AmerisourceBergen Corp. and Cardinal Health Inc….
Executives in the drug industry say that Amazon could use its expansive online reach and its logistical muscle to threaten companies that ship and sell medicines to consumers and cut pricing deals with drug makers.
“Size and scale-wise, they can disrupt anywhere they want to disrupt,” said Chip Davis, president of the Association for Accessible Medicines, a trade group for generic medication, in an interview Thursday.” (E)

“Drugstore operator CVS is in talks to buy health insurer Aetna for a proposed $200 per share or more, sources familiar said. The $66 billion or greater deal would be the largest ever in health insurance history, according to an analysis of Thomson Reuters data….
“They needed to defend the business from encroachment by Amazon,” RBC Capital Markets analyst George Hill told CNBC. “Amazon’s ability to impact the business over the near to mid term is low, but the ability to impact the stock is high.”
CVS would lose the ability to control its own destiny if it didn’t do something, Hill added. “This could be $260 billion in revenue [in 2019].”…
CVS has already been trying to establish greater control in its corner of the health care industry. In 2007, the company acquired Caremark pharmacy benefit manager, which has more than 75 million plan members.” (F)

“Apple appears to be preparing a major move into the health care industry, expanding from its platform of fitness and clinical trial enrollment apps into an area that could include FDA-regulated sensors, advanced clinical decision support and even electronic health records.
The tech giant is cementing partnerships with big health systems and hiring scores of health care professionals. While the company is keeping mum about its plans, techie fans hope Apple will become the agent of transformation that makes patients, rather than providers or EHR vendors, the guardians of health data.” (G)

“Now Microsoft is joining the ranks of tech companies working to take on healthcare’s thorniest issues with its ambitious Healthcare NExT initiative. Launched this week, the program aims to leverage Microsoft tools like the cloud and artificial intelligence to solve a slew of issues in the health system.
It’s a departure from the company’s previous healthcare projects, which have focused on data-based patient programs like Microsoft Health.
The new initiative will set up partnerships between Microsoft’s AI and Research organization and players in the healthcare industry, starting with a huge collaboration with the University of Pittsburgh Medical Center.
The idea is that Microsoft’s research and technology expertise will work with UPMC’s product development experts to build tech solutions that are shaped by the needs they are serving. This kind of synergy between the realities of everyday healthcare and the products designed to solve them has long been a stumbling block in healthcare tech initiatives.” (H)

“Wal-Mart Stores and Quest Diagnostics announced a partnership Monday that will bring Quest’s laboratory testing services to 15 Walmart locations in Florida and Texas by the end of the year.
The centers will initially provide testing services, but they may expand to include other “basic” healthcare services over time, the companies said.
“By providing laboratory testing and healthcare services where people also shop, we will make it easier for Walmart customers and their associates to get the quality diagnostic insights they need in convenient locations,” Steve Rusckowski, Quest Diagnostics’ CEO, said in a statement.
George Riedl, president of Walmart Health and Wellness, described Walmart as a “one-stop shop” for everyday health and wellness needs.
The partnership signals Walmart’s continued expansion in the healthcare space and a comprehensive patient-centered focus on healthcare delivery that strives to keep broader populations healthy. The company expanded its efforts to place retail clinics at its stores in 2014 through a collaboration with QuadMed, with a focus on preventive care and management of chronic conditions—some of the biggest drivers of rising healthcare costs.” (I)

“Google announced expanded partnerships with three blue-chip academic medical centers this past week, where bioinformaticians will explore how its machine learning technology can be deployed in clinical settings to mine EHR data for improved outcomes.
“Machine learning is mature enough to start accurately predicting medical events – such as whether patients will be hospitalized, how long they will stay, and whether their health is deteriorating despite treatment for conditions such as urinary tract infections, pneumonia, or heart failure,” said Google Brain Team researcher Katherine Chou in a blog post.
“Advanced machine learning can discover patterns in de-identified medical records to predict what is likely to happen next, and thus, anticipate the needs of the patients before they arise,” she added.
Google Brain is especially interested in putting machine learning to work predicting and preventing healthcare-associated infections, medication errors and hospital readmissions.” (J)

“On Thursday, the (Facebook) New York-based health unit hosted an invitation-only breakfast for pharmaceutical marketers to learn about targeting users for their clinical trials.
CNBC viewed a copy of the invitation, which asked participants to attend a presentation on the company’s “new clinical trials strategy.”
Facebook is already widely used by clinical trial recruiters. The sector is a massive revenue opportunity for the company. Research firm eMarketer estimates that pharma and health-care marketers will spend $3.1 billion on digital advertising by 2020, up from $1.9 billion last year.
According to a person who attended Thursday’s event, Facebook detailed how drug marketers can and can’t target users. The source requested anonymity because Facebook did not make the details public.
Facebook’s health team explained that users can’t be targeted based on health conditions like insomnia. This is not limited to clinical trials.
Marketers can target people by demographics and their expressed interests, or likes. Millions of health groups have organically popped up on Facebook for people with a variety of health conditions, though marketers can’t use that data in their outreach.” (K)

“One of IBM’s tentpole program within health care is the Watson for Oncology application developed in partnership with New York’s Memorial Sloan Kettering Cancer Center (MSK).
Some MSK oncologists have a highly specific expertise in certain cancers. By training Watson to think like they do, that knowledge expands from one specialist to any doctor who is querying Watson. That means that a patient can get the same top-tier care as if they traveled directly to the center’s offices in Manhattan. IBM’s Watson provides the framework to learn, connect, and store the data, while MSK is imparting its knowledge to train the computer.
The app, which can be run on an iPad or other tablet, is able to pack in all the expertise of MSK oncologists into one place so that any doctor anywhere is able to provide elite cancer care. This is significant for patients who live in areas without world-class medical services, like lower-income countries or rural America.” (L)

Artificial intelligence already found several areas in healthcare to revolutionize starting from the design of treatment plans through the assistance in repetitive jobs to medication management or drug creation. And it is only the beginning.
Mining medical records: The most obvious application of artificial intelligence in healthcare is data management….
Designing treatment plans: Watson for Oncology has an advanced ability to analyze the meaning and context of structured and unstructured data in clinical notes and reports that may be critical to selecting a treatment pathway. ..
Precision medicine: …Deep Genomics aims at identifying patterns in huge data sets of genetic information and medical records, looking for mutations and linkages to disease.
Drug creation:…Atomwise uses supercomputers that root out therapies from a database of molecular structures. “ (M)

Just six months after El Camino Hospital in Silicon Valley implemented artificial intelligence technology, the rate at which patients suffered dangerous falls dropped 39 percent. The key, alongside additional fall prevention strategies, was a software program that predicts which individuals are most likely to fall by combing over electronic health records for risk factors and merging the data discovered there with real-time tracking of patients.
“Every time a patient pushes a call light or hits a bathroom or bed alarm, it’s recorded,” says Cheryl Reinking, chief nursing officer at El Camino. The software takes that information and compares the rate at which a patient is requesting assistance to data such as what surgeries he’s had or which medications have been prescribed.
These data are all processed through “machine learning” – a form of artificial intelligence whereby computers take in new information and perform tasks based on it without being reprogrammed to do so. In this case, the program “learns” if a person may be more likely to fall based on his behavior and treatments. “Then it pushes an alert to the nurse saying ‘your patient in room 2308 is at risk right now for falling,'” Reinking says, after which that individual might be moved closer to the nursing station or monitored via video.” (N)

President Trump, “Nobody knew that health care could be so complicated.”

(A) The Upside of Being Ruled by the Five Tech Giants, by Farhad Manjoo,
(B) A digital revolution in health care is speeding up,
(C) Why Tech Giants Like Google and Apple Are Moving into the Healthcare Space,
(D) Prepare for the Digital Health Revolution, by Sy Mukherjee,
(E) Amazon Threat Causes Shakeout in the Health-Care Industry, by Robert Langreth , Jared S Hopkins , and Spencer Soper,
(F) CVS Health’s surprising deal for Aetna? It’s all about Amazon, by Evelyn Cheng and Thomas Franck,
(G) Rumors, expectations surround Apple expansion into health care, by DARIUS TAHIR,
(H) Microsoft’s new healthcare initiative, and the challenges of bridging tech and health, by CLARE MCGRANE,
(I) Quest Diagnostics, Walmart partner to offer lab testing services in stores, by Alex Kacik,
(J) Google strikes several hospital partnerships for machine learning research. Stanford Medicine, UC San Francisco and University of Chicago Medicine to help Google Brain fine-tune predictive analytics to spot patterns in EHRs, by Mike Miliard,
(K) Facebook brought drug marketers together to educate them on targeting consumers, by Christina Farr,
(M) Artificial Intelligence Will Redesign Healthcare, by Arlene Weintraub,
(N) Hospitals Utilize Artificial Intelligence to Treat Patients, by Arlene Weintraub,

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