Tag Archives: bewell

20th Century History on Health Care and Insurance

A historian’s take on health care and insurance in the US:

Key points:

Health care in the US is primarily driven by an “insurance company model”.’
There actually was a “medical marketplace” in early 20th century.
One of the best in that marketplace was a “prepaid physician group” with profit sharing for docs.
Truman proposed universal health care.
A.M.A. fought government intervention.
A.M.A. decided that the best way to keep the government out of their industry was to design a private sector model: the insurance company model.
In the insurance company model, insurance companies would pay physicians using fee-for-service compensation.
Thus, physicians became allied with insurance companies – both striving to keep government out of health care. Fee for service was their chosen model.
The model worked to expand coverage: from 25% of the population in 1945 to about 80 percent in 1965.
Elderly did not get covered as well. Congress stepped in with Medicare in 1965.
Because of rising prices, insurers gradually took over. “To constrain rising prices, insurers gradually introduced cost containment procedures and incrementally claimed supervisory authority over doctors. Soon they were reviewing their medical work, standardizing treatment blueprints tied to reimbursements and shaping the practice of medicine.”
Innovation in lacking. Concierge medicine experiments show some promise, like Atlas is Wichita.

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JCR comments:
It’s always easier looking backward. If only 25% of the population have health insurance, it seems eminently sensible that driving that number up to, say, 80% would be a high priority goal.

That’s what America did: it adopted a high priority goal to increase health insurance coverage from 25% to 80%. It’s chosen method was a fee-for-service reimbursement model – the “insurance model”. We put insurance companies in the driver’s seat, and we encouraged them to work with employers and physicians groups.

They were the middle man:

Insurers made sure that their employer clients had the benefits they needed to attract employees, at a cost that was practical.
Insurers also made sure that their physician partners supplied the services that they needed, at prices that were practical.

So, with the insurer-as-middle-man-model, we achieved our goal of enrolling 80%, up from 25%. 80% of the American population had health insurance in 1965.

So – what’s wrong with that?

It’s mostly very good. But…

Looking backward, it is obvious now that what is wrong: it is the remaining 20%. These are the unemployed – or the seniors – or the ones who have such ugly health attributes that their health costs are truly exorbitant.

While America was getting the 80% “squared away”, the 20% were left to fend for themselves. They overran emergency rooms; they took beds in charity hospitals; they died.

In 1965, we adopted Medicare and Medicaid. Medicare addressed the 20% who were seniors.
Medicaid addressed the 20% who were poor, such as:

Low-income families
Pregnant women
People of all ages with disabilities
People who need long-term care

Most of this happened over time, not in 1965. State offerings vary.

In 1997, we adopted CHIP for children. This addressed the 20% who were kids. 11 million kids got coverage. They were from families with too much income to qualify for Medicaid.

in 2003, we adopted MMA “The Medicare Prescription Drug Improvement and Modernization Act of 2003”. Under the MMA, private health plans were offered, approved by Medicare “Medicare Advantage Plans’. An optional prescription drug benefit was offered (“Part D”)

In 2011, the Affordable Care Act was adopted.

So, the key question for today is: why is our health care system such a mess. Read on:

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CREDIT: NYT https://www.nytimes.com/2017/06/19/opinion/health-insurance-american-medical-association.html?emc=edit_th_20170619&nl=todaysheadlines&nlid=44049881&_r=0

The Opinion Pages | OP-ED CONTRIBUTOR
How Did Health Care Get to Be Such a Mess?
By CHRISTY FORD CHAPINJUNE 19, 2017
The problem with American health care is not the care. It’s the insurance.
Both parties have stumbled to enact comprehensive health care reform because they insist on patching up a rickety, malfunctioning model. The insurance company model drives up prices and fragments care. Rather than rejecting this jerry-built structure, the Democrats’ Obamacare legislation simply added a cracked support beam or two. The Republican bill will knock those out to focus on spackling other dilapidated parts of the system.

An alternative structure can be found in the early decades of the 20th century, when the medical marketplace offered a variety of models. Unions, businesses, consumer cooperatives and ethnic and African-American mutual aid societies had diverse ways of organizing and paying for medical care.

Physicians established a particularly elegant model: the prepaid doctor group. Unlike today’s physician practices, these groups usually staffed a variety of specialists, including general practitioners, surgeons and obstetricians. Patients received integrated care in one location, with group physicians from across specialties meeting regularly to review treatment options for their chronically ill or hard-to-treat patients.

Individuals and families paid a monthly fee, not to an insurance company but directly to the physician group. This system held down costs. Physicians typically earned a base salary plus a percentage of the group’s quarterly profits, so they lacked incentive to either ration care, which would lose them paying patients, or provide unnecessary care.

This contrasts with current examples of such financing arrangements. Where physicians earn a preset salary — for example, in Kaiser Permanente plans or in the British National Health Service — patients frequently complain about rationed or delayed care. When physicians are paid on a fee-for-service basis, for every service or procedure they provide — as they are under the insurance company model — then care is oversupplied. In these systems, costs escalate quickly.

Unfortunately, the leaders of the American Medical Association saw early health care models — union welfare funds, prepaid physician groups — as a threat. A.M.A. members sat on state licensing boards, so they could revoke the licenses of physicians who joined these “alternative” plans. A.M.A. officials likewise saw to it that recalcitrant physicians had their hospital admitting privileges rescinded.

The A.M.A. was also busy working to prevent government intervention in the medical field. Persistent federal efforts to reform health care began during the 1930s. After World War II, President Harry Truman proposed a universal health care system, and archival evidence suggests that policy makers hoped to build the program around prepaid physician groups.

A.M.A. officials decided that the best way to keep the government out of their industry was to design a private sector model: the insurance company model.

In this system, insurance companies would pay physicians using fee-for-service compensation. Insurers would pay for services even though they lacked the ability to control their supply. Moreover, the A.M.A. forbade insurers from supervising physician work and from financing multispecialty practices, which they feared might develop into medical corporations.

With the insurance company model, the A.M.A. could fight off Truman’s plan for universal care and, over the next decade, oppose more moderate reforms offered during the Eisenhower years.

Through each legislative battle, physicians and their new allies, insurers, argued that federal health care funding was unnecessary because they were expanding insurance coverage. Indeed, because of the perceived threat of reform, insurers weathered rapidly rising medical costs and unfavorable financial conditions to expand coverage from about a quarter of the population in 1945 to about 80 percent in 1965.

But private interests failed to cover a sufficient number of the elderly. Consequently, Congress stepped in to create Medicare in 1965. The private health care sector had far more capacity to manage a large, complex program than did the government, so Medicare was designed around the insurance company model. Insurers, moreover, were tasked with helping administer the program, acting as intermediaries between the government and service providers.

With Medicare, the demand for health services increased and medical costs became a national crisis. To constrain rising prices, insurers gradually introduced cost containment procedures and incrementally claimed supervisory authority over doctors. Soon they were reviewing their medical work, standardizing treatment blueprints tied to reimbursements and shaping the practice of medicine.

It’s easy to see the challenge of real reform: To actually bring down costs, legislators must roll back regulations to allow market innovation outside the insurance company model.

In some places, doctors are already trying their hand at practices similar to prepaid physician groups, as in concierge medicine experiments like the Atlas MD plan, a physician cooperative in Wichita, Kan. These plans must be able to skirt state insurance regulations and other laws, such as those prohibiting physicians from owning their own diagnostic facilities.

Both Democrats and Republicans could learn from this lost history of health care innovation.

Christy Ford Chapin is an associate professor of history at the University of Maryland, Baltimore County, a visiting scholar at Johns Hopkins University and the author of “Ensuring America’s Health: The Public Creation of the Corporate Health Care System.”
Follow The New York Times Opinion section on Facebook and Twitter (@NYTopinion), and sign up for the Opinion Today newsletter.

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Brian Hudes Comment:

I saw this one, as well.  The author lost credibility for me.   Ironically, what the author clearly doesn’t realize is that she is making an argument for the Kaiser Permenante model.  However, she unfairly and without any data makes the following claim: 

“Where physicians earn a preset salary — for example, in Kaiser Permanente plans or in the British National Health Service — patients frequently complain about rationed or delayed care”

Here’s a more balanced and comprehensive assessment supported by third party research:

Health Care Members Speak

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RECENT COMMENTS
Alex 21 hours ago
Patients are no longer patients, but “customers”.Insurance providers are publicly traded companies. Healthcare costs are meticulously…
T Bone 21 hours ago
Why in the “elegant” model of the old pre-paid doctor’s group would doctors not “ration” care? Sure they would. The solution is provider…
M Shea 1 day ago
I’ve worked in marketing for both healthcare insurance and a healthcare/hospital system. It’s ridiculous how much money is spent selling a…

Senior concierge services

“Elder concierge”, or senior concierge services, are blossoming as baby boomers age:

CREDIT: New York Times Article on Senior Concierge Services

https://www.forbes.com/sites/robertpearl/2017/06/22/concierge-medicine/amp/

The concierges help their customers complete the relatively mundane activities of everyday life, a way for the semi- and fully retired to continue to work.

Facts of note:
“Around 10,000 people turn 65 every day in the United States, and by 2030, there will be 72 million people over 65 nationwide.
Some 43 million people already provide care to family members — either their own parents or children — according to AARP, and half of them are “sandwich generation” women, ages 40 to 60. All told, they contribute an estimated $470 billion a year in unpaid assistance.”
“elder concierges charge by the hour, anywhere from $30 to $70, or in blocks of time, according to Katharine Giovanni, the director of the International Concierge & Lifestyle Management Network”

Organizations of note:

“One start-up, AgeWell, employs able-bodied older people to assist less able people of the same age, figuring the two will find a social connection that benefits overall health.
The company was founded by Mitch Besser, a doctor whose previous work involved putting H.I.V.-positive women together in mentoring relationships. AgeWell employees come from the same communities as their clients, some of whom are out of reach of medical professionals
until an emergency.”

The National Aging in Place Council, a trade group, is developing a social worker training program with Stony Brook University. It wants to have a dedicated set of social workers at the council, funded by donations, who are able to field calls from seniors and their caretakers, and make referrals to local service providers.
The council already works with volunteers and small businesses in 25 cities to make referrals for things like home repair and remodeling, daily money management and legal issues.”

Village to Village Network, has small businesses and volunteers working on a similar idea: providing older residents and their family or caretakers with referrals to vetted local services.
In the Village to Village Network model, residents pay an annual fee, from about $400 to $700 for individuals and more for households. The organization so far has 25,000 members in 190 member-run communities across the United States, and is forming similar groups overseas as well.”

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Baby Boomers Look to Senior Concierge Services to Raise Income
Retiring
By LIZ MOYER MAY 19, 2017

In her 40 years as a photographer in the Denver area, Jill Kaplan did not think she would need her social work degree.
But when it became harder to make a living as a professional photographer, she joined a growing army of part-time workers across the country who help older people living independently, completing household tasks and providing companionship.
Elder concierge, as the industry is known, is a way for the semi- and fully retired to continue to work, and, from a business standpoint, the opportunities look as if they will keep growing. Around 10,000 people turn 65 every day in the United States, and by 2030, there will be 72 million people over 65 nationwide.
Some 43 million people already provide care to family members — either their own parents or children — according to AARP, and half of them are “sandwich generation” women, ages 40 to 60. All told, they contribute an estimated $470 billion a year in unpaid assistance.

Seven years ago, Ms. Kaplan, 63, made the leap, signing up with Denver-based Elder Concierge Services. She makes $25 to $40 an hour for a few days a week of work. She could be driving older clients to doctor’s appointments, playing cards or just acting as an extra set of eyes and ears for family members who aren’t able to be around but worry about their older relatives being isolated and alone. Many baby boomers themselves are attracted to the work because they feel an affinity for the client base.
“It’s very satisfying,” she said of the work, which supplements her photography income. Like others in search of additional money, she could have become an Uber driver but said this offered her a chance to do something “more meaningful.”
“We see a lot of women,” Ms. Kaplan said, “who had raised their families and cared for their parents out there looking for a purpose.”

Concierges are not necessarily social workers by background, and there isn’t a formal licensing program. They carry out tasks or help their customers complete the relatively mundane activities of everyday life, and just need to be able to handle the sometimes physical aspects of the job, like pushing a wheelchair.
Medical care is left to medical professionals. Instead, concierges help out around the house, get their client to appointments, join them for recreation, and run small errands.
While precise statistics are not available for the elder concierge industry, other on-demand industries have flourished, and baby boomers are a fast-growing worker population.
Nancy LeaMond, the AARP’s executive vice president and chief advocacy officer, said: “Everyone assumed the on-demand economy was a millennial thing. But it is really a boomer thing.”
Ms. LeaMond noted that while people like the extra cash, they also appreciate the “extra engagement.”
A variety of companies has sprung up, each fulfilling a different niche in the elder concierge economy.
In some areas, elder concierges charge by the hour, anywhere from $30 to $70, or in blocks of time, according to Katharine Giovanni, the director of the International Concierge & Lifestyle Management Network. Those considering going into the business should have liability insurance, Ms. Giovanni said.

One start-up, AgeWell, employs able-bodied older people to assist less able people of the same age, figuring the two will find a social connection that benefits overall health.
The company was founded by Mitch Besser, a doctor whose previous work involved putting H.I.V.-positive women together in mentoring relationships. AgeWell employees come from the same communities as their clients, some of whom are out of reach of medical professionals until an emergency.
The goal is to provide consistent monitoring to reduce or eliminate full-blown crises. AgeWell began in South Africa but recently got a grant to start a peer-to-peer companionship and wellness program in New York.
Elsewhere, in San Francisco, Justin Lin operates Envoy, a network of stay-at-home parents and part-time workers who accept jobs like grocery delivery, light housework and other tasks that don’t require medical training. Each Envoy employee is matched to a customer, who pays $18 to $20 an hour for the service, on top of a $19 monthly fee.
The inspiration for the company came from Mr. Lin’s work on a start-up called Mamapedia, an online parental wisdom-sharing forum, where he noticed a lot of people talking about the need for family care workers. He decided to start Envoy two years ago, after his own mother died of cancer, leaving him and his father to care for a disabled brother.
The typical Envoy employee works a few hours a week, so it won’t replace the earnings from a full-time job. But it nevertheless involves more interpersonal contact than simply standing behind a store counter.
“It’s not going to pay the rent,” Mr. Lin said. “They want to be flexible but also make a difference.”

Katleen Bouchard, 69, signed up with Envoy three years ago, after retiring from an advertising career. She gets $20 an hour working a handful of hours a week with older clients in her rural community in Sonoma County, Calif. She sees it as a chance to be civic-minded. “It’s very easy to help and be of service,” Ms. Bouchard said.
Companies like AgeWell and Envoy are part of the growing on-demand economy, where flexibility and entrepreneurship have combined to create a new class of workers, said Mary Furlong, a Silicon Valley consultant who specializes in the job market for baby boomers. At the same time, many retirees — as well as those on the cusp of retirement — worry that market volatility may hit their savings.
The extra income from the job, Ms. Furlong said, could help cover unexpected expenses. “You don’t know what the shocks are going to be that interrupt your plan,” she added.
Other organizations are looking to help direct older residents to vetted local service providers.
The National Aging in Place Council, a trade group, is developing a social worker training program with Stony Brook University. It wants to have a dedicated set of social workers at the council, funded by donations, who are able to field calls from seniors and their caretakers, and make referrals to local service providers.
The council already works with volunteers and small businesses in 25 cities to make referrals for things like home repair and remodeling, daily money management and legal issues.
Another group, the Village to Village Network, has small businesses and volunteers working on a similar idea: providing older residents and their family or caretakers with referrals to vetted local services.
In the Village to Village Network model, residents pay an annual fee, from about $400 to $700 for individuals and more for households. The organization so far has 25,000 members in 190 member-run communities across the United States, and is forming similar groups overseas as well.
“We feel like we are creating a new occupation,” said Marty Bell, the National Aging in Place Council’s executive director. “It’s really needed.”
Twitter: @LizMoyer

Four Daily Well-Being Workouts

Marty Seligman is a renowned well-being researcher, and writes in today’s NYT about four practices for flourishing:

Identify Signature Strengths: Focus every day on personal strengths exhibited when you were at your best.

Find the Good: Focus every day on “why did this good thing happen”?

Make a Gratitude Visit: Visit a person you feel gratitude toward.

Respond Constructively: Practice active, constructive responses.

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CREDIT: Article Below Can Be Found at This Link

Get Happy: Four Well-Being Workouts

By JULIE SCELFO
APRIL 5, 2017
Relieving stress and anxiety might help you feel better — for a bit. Martin E.P. Seligman, a professor of psychology at the University of Pennsylvania and a pioneer in the field of positive psychology, does not see alleviating negative emotions as a path to happiness.
“Psychology is generally focused on how to relieve depression, anger and worry,” he said. “Freud and Schopenhauer said the most you can ever hope for in life is not to suffer, not to be miserable, and I think that view is empirically false, morally insidious, and a political and educational dead-end.”
“What makes life worth living,” he said, “is much more than the absence of the negative.”

To Dr. Seligman, the most effective long-term strategy for happiness is to actively cultivate well-being.

In his 2012 book, “Flourish: A Visionary New Understanding of Happiness and Well-Being,” he explored how well-being consists not merely of feeling happy (an emotion that can be fleeting) but of experiencing a sense of contentment in the knowledge that your life is flourishing and has meaning beyond your own pleasure.

To cultivate the components of well-being, which include engagement, good relationships, accomplishment and purpose, Dr. Seligman suggests these four exercises based on research at the Penn Positive Psychology Center, which he directs, and at other universities.

Identify Signature Strengths
Write down a story about a time when you were at your best. It doesn’t need to be a life-changing event but should have a clear beginning, middle and end. Reread it every day for a week, and each time ask yourself: “What personal strengths did I display when I was at my best?” Did you show a lot of creativity? Good judgment? Were you kind to other people? Loyal? Brave? Passionate? Forgiving? Honest?

Writing down your answers “puts you in touch with what you’re good at,” Dr. Seligman explained. The next step is to contemplate how to use these strengths to your advantage, intentionally organizing and structuring your life around them.

In a study by Dr. Seligman and colleagues published in American Psychologist, participants looked for an opportunity to deploy one of their signature strengths “in a new and different way” every day for one week.

“A week later, a month later, six months later, people had on average lower rates of depression and higher life satisfaction,” Dr. Seligman said. “Possible mechanisms could be more positive emotions. People like you more, relationships go better, life goes better.”

Find the Good
Set aside 10 minutes before you go to bed each night to write down three things that went really well that day. Next to each event answer the question, “Why did this good thing happen?”
Instead of focusing on life’s lows, which can increase the likelihood of depression, the exercise “turns your attention to the good things in life, so it changes what you attend to,” Dr. Seligman said. “Consciousness is like your tongue: It swirls around in the mouth looking for a cavity, and when it finds it, you focus on it. Imagine if your tongue went looking for a beautiful, healthy tooth.” Polish it.

Make a Gratitude Visit
Think of someone who has been especially kind to you but you have not properly thanked. Write a letter describing what he or she did and how it affected your life, and how you often remember the effort. Then arrange a meeting and read the letter aloud, in person.

“It’s common that when people do the gratitude visit both people weep out of joy,” Dr. Seligman said. Why is the experience so powerful? “It puts you in better touch with other people, with your place in the world.”

Respond Constructively
This exercise was inspired by the work of Shelly Gable, a social psychologist at the University of California, Santa Barbara, who has extensively studied marriages and other close relationships. The next time someone you care about shares good news, give what Dr. Gable calls an “active constructive response.”

That is, instead of saying something passive like, “Oh, that’s nice” or being dismissive, express genuine excitement. Prolong the discussion by, say, encouraging them to tell others or suggest a celebratory activity.

“Love goes better, commitment increases, and from the literature, even sex gets better after that.”

Julie Scelfo is a former staff writer for The Times who writes often about human behavior.

High costs of health care

I found this NYT story to be scary and illuminating. God save this country. Frankenstein lives….they are called CPT codes … And CPT consultants and CPT courses and CPT mavens and AMA licensing of CPT (biggest source of revenue).

New York Times Article on High Costs of Health Care

Hospitals have learned to manipulate medical codes — often resulting in mind-boggling bills.

Microbiome Update

CREDIT: https://www.wsj.com/articles/how-disrupting-your-guts-rhythm-affects-your-health-1488164400?mod=e2tw

A healthy community of microbes in the gut maintains regular daily cycles of activities.
A healthy community of microbes in the gut maintains regular daily cycles of activities.PHOTO: WEIZMANN INSTITUTE
By LARRY M. GREENBERG
Updated Feb. 27, 2017 3:33 p.m. ET
4 COMMENTS
New research is helping to unravel the mystery of how disruptions to the bacteria in our gut, caused by an unhealthy diet or irregular sleep, can lead to a number of diseases.

Such research could someday result in new treatments for obesity, diabetes and other metabolic conditions by restoring the health of the gut-microbe community, known as the microbiota. Researchers are exploring how to do this through individualized diets and mealtimes or other interventions.

When gut microbiota are healthy, they maintain regular daily cycles of activities such as congregating in different parts of the intestine and producing metabolites, molecules that help the body function properly. A disruption of the gut’s circadian rhythms is communicated through the bloodstream and upsets many of the body’s other circadian clocks, especially in the liver, one of the main metabolic organs, according to a studyby Israel’s Weizmann Institute of Science published in the journal Cell in December.

The gut’s circadian rhythms and those in other organs “dance together in a very profound way and go up and down in coordination with each other,” says Eran Elinav, a physician and immunologist at the Weizmann Institute and one of the study’s lead investigators. “By controlling the gut microbiota, you can modify many physiological capabilities” throughout the body, he says.

DeathEd

I recently did a post on “elderhood” ( http://johncreid.com/2017/02/elderhood/ This post is a follow-up to that.

CREDIT:
https://www.nytimes.com/2017/02/18/opinion/sunday/first-sex-ed-then-death-ed.html?emc=edit_th_20170219&nl=todaysheadlines&nlid=44049881

First, Sex Ed. Then Death Ed.

By JESSICA NUTIK ZITTER•FEB. 18, 2017

FIVE years ago, I taught sex education to my daughter Tessa’s class. Last week, I taught death education to my daughter Sasha’s class. In both cases, I didn’t really want to delegate the task. I wanted my daughters and the other children in the class to know about all of the tricky situations that might await them. I didn’t want anyone mincing words or using euphemisms. Also, there was no one else to do it. And in the case of death ed, no curriculum to do it with.

When Tessa heard I’d be teaching sex ed to her fellow seventh graders, she was mortified. My husband suggested she wear a paper bag over her head, whereupon she rolled her eyes and walked away. When the day arrived, she slunk to the back of the room, sat down at a desk and lowered her head behind her backpack.

As I started in, 13 girls watched me with trepidation. I knew I needed to bring in the words they were dreading right away, so that we could move on to the important stuff. “Penis and vagina,” I said, and there were nervous giggles. A pencil dropped to the floor. With the pressure released, I moved on to talking about contraception, saying no, saying yes, pregnancy, sexually transmitted diseases, even roofies. By the end of the hour, hands were held urgently in the air, and my daughter’s head had emerged from behind her backpack.

Sexual education programming was promoted by the National Education Association as far back as 1892 as a necessary part of a national education curriculum. As information spread and birth control became increasingly available, unwanted pregnancies dropped, and rates of S.T.D.s plummeted. In this case, knowledge really is power.

I believe that this is true of death, too.

I am a doctor who practices both critical and palliative care medicine at a hospital in Oakland, Calif. I love to use my high-tech tools to save lives in the intensive-care unit. But I am also witness to the profound suffering those very same tools can inflict on patients who are approaching the end of life. Too many of our patients die in overmedicalized conditions, where treatments and technologies are used by default, even when they are unlikely to help. Many patients have I.C.U. stays in the days before death that often involve breathing machines, feeding tubes and liquid calories running through those tubes into the stomach. The use of arm restraints to prevent accidental dislodgment of the various tubes and catheters is common.

Many of the patients I have cared for at the end of their lives had no idea they were dying, despite raging illness and repeated hospital admissions. The reasons for this are complex and varied — among them poor physician training in breaking bad news and a collective hope that our technologies will somehow ultimately triumph against death. By the time patients are approaching the end, they are often too weak or disabled to express their preferences, if those preferences were ever considered at all. Patients aren’t getting what they say they want. For example, 80 percent of Americans would prefer to die at home, but only 20 percent achieve that wish.

Many of us would choose to die in a planned, comfortable way, surrounded by those we love. But you can’t plan for a good death if you don’t know you’re dying. We need to learn how to make a place for death in our lives and we also need to learn how to plan for it. In most cases, the suffering could have been avoided, or at least mitigated, by some education on death and our medical system. The fact is that when patients are prepared, they die better. When they have done the work of considering their own goals and values, and have documented those preferences, they make different choices. What people want when it comes to end-of-life care is almost never as much as what we give them.

I am a passionate advocate for educating teenagers to be responsible about their sexuality. And I believe it is past time for us to educate them also about death, an equally important stage of life, and one for which the consequences of poor preparedness are as bad, arguably worse. Ideally this education would come early, well before it’s likely to be needed.

I propose that we teach death ed in all of our high schools. I see this curriculum as a civic responsibility. I understand that might sound radical, but bear with me. Why should death be considered more taboo than sex? Both are a natural part of life. We may think death is too scary for kids to talk about, but I believe the consequences of a bad death are far scarier. A death ed program would aim to normalize this passage of life and encourage students to prepare for it, whenever it might come — for them, or for their families.

Every year in my I.C.U. I see dozens of young people at the bedsides of dying relatives. If we started to teach death ed in high school, a student visiting a dying grandparent might draw from the curriculum to ask a question that could shift the entire conversation. She might ask about a palliative care consultation, for example, or share important information about the patient’s preferences that she elicited during her course. High school, when students are getting their drivers’ licenses and considering organ donation, is the perfect time for this. Where else do we have the attention of our entire society?

Last week, my colleague Dawn Gross and I taught our first death ed program in my daughter’s ninth-grade class at the Head-Royce School, a private, progressive (and brave) school in Oakland. In the classroom, we had some uncomfortable terms to get out of the way early on, just as I did in sex ed — death, cancer, dementia. We showed the teenagers clips of unrealistic rescues on the TV show “Grey’s Anatomy,” and then we debunked them. We described the realities of life in the I.C.U. without mincing words — the effects of a life prolonged on machines, the arm restraints, the isolation. Everyone was with us, a little tentative, but rapt.

And then we presented the material another way. We taught them how to play “Go Wish,” a card game designed to ease families into these difficult conversations in an entertaining way. We asked students to identify their most important preferences and values, both in life and as death might approach. We discussed strategies for communicating these preferences to a health care team and to their own families.

We were delighted by their response. It didn’t take them long to jump in. They talked openly about their own preferences around death. One teenager told another that she wanted to make sure she wasn’t a burden to her family. A third said he was looking forward to playing “Go Wish” with his grandfather, who recently had a health scare.

Dawn and I walked out with huge smiles on our faces. No one had fainted. No one had run out of the class screaming. The health teacher told us she was amazed by their level of engagement. It is my hope that this is only the first step toward generating wide public literacy about this phase of life, which will eventually affect us all. The sooner we start talking about it, the better.

Helix.com takes genomics commercial

I believe that genomics just advanced …. headed to commercialization. Read on.

I received this as a gift, and just registered my saliva sample. “Geno 2.0”. As with ancestry.com, the “hook” is they promise a profile of your ancestry. Clever – does not over-promise.

Cost …. $149?

Took 10 minutes. Very cool box, like something from Apple. Inside was an equally cool, self-addressed, stamped box. Fancy test tube inside. Coded carefully – right on the sample tube. Protected for shipment … Nice. Netflix started with a kit like this.

They have 800,000 samples so far. Partnered with National Geographic, Duke, bunch of others. I registered separately – online. Great privacy policy.

This is only the beginning….like the Internet when AOL was the only game in town, and Amazon only sold books.

Go to Helix

Helix seems to be a venture-backed company – Kleiner, Warburg Pincus, and Mayo are shown as investors.

The essence of their value proposition seems to be “products that will be offered by our partners in the future.” These products will obviously draw upon the database that is being accumulated.

Solid Scientific Advisory Board.

Duke shown as partner. National Geographic as well.

Genography.com seems to be another of their sites? Partner.

Human connection lies at the heart of human well-being.

See NYT article below: if these facts are anywhere close to right, a community-based BeWell Center has an opportunity to do a whole lot of good by simply being an organizer of volunteer outreach. Low or no cost, big impact, great from a philanthropy POV. Meals on Wheels, elderly check-ins, classes, etc. “Research confirms our deepest intuition: Human connection lies at the heart of human well-being.”

“Social isolation is a growing epidemic — one that’s increasingly recognized as having dire physical, mental and emotional consequences. Since the 1980s, the percentage of American adults who say they’re lonely has doubled from 20 percent to 40 percent.

About one-third of Americans older than 65 now live alone, and half of those over 85 do. People in poorer health — especially those with mood disorders like anxiety and depression — are more likely to feel lonely. Those without a college education are the least likely to have someone they can talk to about important personal matters.
A wave of new research suggests social separation is bad for us. Individuals with less social connection have disrupted sleep patterns, altered immune systems, more inflammation and higher levels of stress hormones. One recent study found that isolation increases the risk of heart disease by 29 percent and stroke by 32 percent.
Another analysis that pooled data from 70 studies and 3.4 million people found that socially isolated individuals had a 30 percent higher risk of dying in the next seven years, and that this effect was largest in middle age.”

Research confirms our deepest intuition: Human connection lies at the heart of human well-being.

Iora Health – Update …$75 million Series D (moving toward 65+?)

Here is an update on Iora Health ….. the Cambridge, Mass innovator in Health Care supporting primary care services in 34 US locations. I first began tracking them when I was tracking Turntable in Ls Vegas, which is one of their sites.

Few points:

1. I see no big announcements about closings….interesting (there are rumors the Harken Health and Turntable will cease their partnership with Iora)
2. They just raised $75 million in a Series D financing ….. really interesting. The lead investor was the Singapore State fund Temasek … also interesting (big dogs). Apparently all existing investors stayed in the Series D – a good sign. Series C was $48 million, and the dollars before that (in A and B) were $13 million, I think. So that means that they have now raised $146 million…..that is a ton of money for a venture backed company! This tells me that they are telling investors what I believe to be true….that Year 1 hurts because the subscriber base in building but years 2 and onward can be profitable……but I have found no docs that say this.
3. They say they have 34 “primary care practices”…..looked at their backup for this. Here is what they (seem to) have:

18 sites are Medicare only Advantage Plans for 65+ only —— 16 sites partnering with Humana and 2 partnering with Tufts. So Humana is their big partner, but only to support their Medicare advantage plan for seniors.

1 corporate site for Hartford Health Care employees only

3 “fund” sites —— one for cooks and one for carpenters and one in Queens for “Grameen members”…..must be a credit union for each trade maybe?

6 sites with Harken/United Health ….. but very interesting that they are not listed on their official website…. they just take about 6 sites in ATL.

1 community site – Turntable in Las Vegas

2 pilot sites

31 sites total

4. My guess: the Series D raise of $75 million is going to be dedicated to Medicare Advantage plan expansion, through Humana, Tufts, and a few others. My hunch is that they do not see how to make the community model work…moreover, they see the ramp up as being needlessly painful. My hunch is that the Medicare Advantage model is profitable in Year 1, which investors would love! My hunch is that they have figured out to make these site smaller, more manageable, more care flow positive from the start, and that they are ultimately most profitable sites. Humana and other big dogs probably see them as a way to keep health care costs down……..while maintaining or improving senior outcomes. Anyone else have a guess or facts on this????

See my notes below:

===========NOTES on IORA Health ==========
October 16, 2016

US-based Iora Health has closed a $75-million Series D financing in a round led by Singapore state fund Temasek Holdings. Other investors who participated in the round include Iora Health’s existing institutional investors .406 Ventures, Flare Capital Partners, F-Prime Capital, GE Ventures, Khosla Ventures, Polaris Partners, and Rice Management Company. “We are honored to have Temasek join Iora on our journey to transform healthcare,” said Rushika Fernandopulle, MD, MPP, co-founder and CEO of Iora Health. “Temasek’s investment in Iora will accelerate our vision of fixing health care delivery which is one of the largest business and social problems, not just in the US, but globally.

Iora Health has built a different kind of health system that delivers high impact, relationship based care. With 34 primary care practices in 11 US markets, Iora serves diverse populations with an increasing focus on the most under-served and complex patients — including people aged 65 years and older on Medicare. Iora’s innovative model delivers an exceptional patient experience, with coordinated care that drives better clinical outcomes and significantly lower costs than the traditional healthcare system. Iora will use the new capital to drive further expansion and efficiencies in the model

Read more at: http://www.dealstreetasia.com/stories/55411-55411/

================

Iora Health lands $28M from GE Ventures, Khosla Ventures and others
Jan 26, 2015, 9:58am EST Revised Date/Time Publish Updated Jan 26, 2015, 2:06pm EST
Iora Health, a Cambridge startup aiming to “reinvent primary care” with a novel model for payment and delivery of care, said Monday that it raised $28 million in Series C funding from new investors including Foundation Medical Partners, Rice Management Co., GE Ventures and Khosla Ventures.

Existing investors included Boston’s .406 Ventures, Fidelity Biosciences and Boston-based Polaris Partners. Iora Health will use the additional financing to fund rapid expansion to continue delivering transformative health care, according to the company. The company has raised $48.2 million in total and plans to double its current workforce of 140.
Iora Health has developed a different health care operating system that starts with primary care, driving patient experience, engagement and clinical outcomes, while reducing overall health care costs, according to the company.
“We’re humbled by the great interest in our Series C financing and we are honored to have such a great group of new investors join our current ones.,” said Rushika Fernandopulle, co-founder and CEO of Iora Health, in a statement. “In the last four years, Iora Health has grown from a start up with an idea of how to improve health care to serving and improving the lives of thousands of patients across the U.S. We are excited to grow with this round to continue to deliver on our mission to restore humanity to health care.”

Iora Health currently manages eleven primary care practices across the U.S. for distinct patient populations including employee groups, Medicare Advantage patients and union members and their families. Iora sponsors include the Culinary Health Fund, Dartmouth College, the Freelancers Union, Grameen PrimaCare, Humana, King Arthur Flour, Lahey Health, the New England Carpenters Benefits Fund and Turntable Health.
The company, founded in 2011, last raised a $13 million round of funding two years ago from existing investors including Zappos CEO Tony Hsieh.

================== IORA Practices from their website =====

Source: http://www.iorahealth.com/practices/list-of-offices/

SPONSOR: CULINARY HEALTH FUND (serves workers who participate)
Las Vegas, NV 89104
SPONSOR: DARTMOUTH COLLEGE (Dartmouth Health Connect is a primary care practice in Hanover)
Hanover, NH 03755

SPONSOR: GRAMEEN PRIMACARE (for Grameen Members)
Queens, NY 11372

SPONSOR: HARTFORD HEALTHCARE (employees and family members)
Hartford, CT 06106

SPONSOR: Harken Health and United Health Care
Metro Atlanta (6)

SPONSOR: NEW ENGLAND CARPENTERS BENEFITS FUNDS
Dorchester, MA 02125

SPONSOR: TUFTS HEALTH PLAN (for 65+ members of Preferred HMO plans)
2 LOCATIONS
Medford, MA 02155
Hyde Park, MA, 02136

SPONSOR: HUMANA (All seem to support only Humana Medicare Advantage Plan)
16 LOCATIONS

Aurora, CO 80012
Littleton CO 80123
Arvada, CO 80003
Glendale, CO 80246
Lakewood, CO 80214

Federal Way WA 98003
Shoreline, WA 98133
Seattle, WA 98144
Renton, WA 98057
Tucson, AZ 85712 (2)
Mesa AZ 85206 (2)
Glendale, AZ 85302
Phoenix, AZ 85032 (2)

SPONSOR: TURNTABLE HEALTH
Las Vegas, NV 89101

Pilot Program Renaissance Health
Arlington, MA

PIlot Program Intensive Outpatient Care
Program Partner: The Boeing Company