Subject: News from Dr. Kevin Fickenscher
From: "Dr. Kevin Fickenscher" <[email-masked]>
To: <[email-masked]>
Date: Tue, 24 Mar 2015 11:48:18 -0400 (EDT)

The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001lzxu2qLk80HqL8ELwMv94NTw6YCbcmYJxdY7rRi3Uukm_1MjKt67HPv-imMeKS5i2Ce8LjKj9d-38yVekVyXMC9QdsmDd8D-rjHDi0xJHJoHVwiB5J4K1CV5vbEL6dKxUc1SZ3O63nFzijMLb7cENy916Kbr2E41DcccMJ8I4N7v382gZ7uqfQ==&c=vbQPPAz9-VFxYpNhpHV1tYoLsDhH0nGh65rZ5LJOh4PF4WRXgUjH8Q==&ch=eyvuJROYcFj8VxIGss4fPi9vHff4NVhyg8JfKNyYR6WQLk-2U9s5eA==]
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Fickenscher Files, Vol. 3, Issue 27
Kevin M. Fickenscher [http://r20.rs6.net/tn.jsp?f=001lzxu2qLk80HqL8ELwMv94NTw6YCbcmYJxdY7rRi3Uukm_1MjKt67HIMBU71CWdAwSrm-tdXNNaElg0t0PXT9FmyzzotoEsOKzr0Ll22b0Ods71EFLnLnbqfvlDZuUQZmDRtIYVb_qlIPlEkFxYyjhdC4qQFAMJijAaLcgy9lzN1bASMp12bOYS61bEPPzNHEir6K_w_e1F-l6ba1ifG1JkjSJMCJjW3hV34DUQvIK-sHQszyiKUANrwVDVdVftLMaE4tehyn6EQ=&c=vbQPPAz9-VFxYpNhpHV1tYoLsDhH0nGh65rZ5LJOh4PF4WRXgUjH8Q==&ch=eyvuJROYcFj8VxIGss4fPi9vHff4NVhyg8JfKNyYR6WQLk-2U9s5eA==],
MD, CPE, FACPE, FAAFP
@MDKev

A compilation of information, thoughts, and perspectives on the issues of the day
related to healthcare, technology, and beyond - including the latest culinary explorations.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Quote(s) of the Week

Notable thoughts for your consideration...

"This plan is designed to preserve the company as a private company forever."

Judy Faulkner, CEO of Epic - a leading provider of electronic health record software
- in announcing that she has placed her billions of assets into a trust.

"It's hard for them to accept some of the evidence that we know exists for telehealth
service. All we can do is keep hammering away the low-risk nature of telehealth."

Clif Gaus - CEO, National Association of ACOs, on The Centers for Medicare and Medicaid
(CMS) announcement restricting telehealth payments to "next generation" ACOs rather
than all ACOs.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Consulo Indicium

Information for your consideration and reflection...

Hugging For Health - I was recently introduced to an article [http://r20.rs6.net/tn.jsp?f=001lzxu2qLk80HqL8ELwMv94NTw6YCbcmYJxdY7rRi3Uukm_1MjKt67HEujsAEEI8PkArD0dWJIMC1DtIdyD2qFrg6532codwYKArsxhWG2gGI4dzRxoghLVNjlS0XLL5REIQ8NaPKVNv-ui0ojQMh6ac85PK-CXIlSgQaNR7zwYVbV0uAwmFf2fIvJCOz7HnWNb9VTHL8tLSU=&c=vbQPPAz9-VFxYpNhpHV1tYoLsDhH0nGh65rZ5LJOh4PF4WRXgUjH8Q==&ch=eyvuJROYcFj8VxIGss4fPi9vHff4NVhyg8JfKNyYR6WQLk-2U9s5eA==]
that appeared late last year on the impact of hugging on health.  In essence, the
article states that a person's perceived "social support" seems to have a protective
affect against the pathogenic effects of stress. The study sampled 404 healthy adults
who were examined for their degree of social support and how often they received
 hugs to combat interpersonal stress-induced susceptibility to infectious disease.
The study showed that perceived support protected against the rise in infection 
risk as the frequency of conflict increased. The hugs explained about 32% of the
 attenuating effect on the individual's susceptibility to an infection.  Furthermore,
among infected participants, greater perceived support and more-frequent hugs each
predicted less-severe illness signs.  The study supports prior work [http://r20.rs6.net/tn.jsp?f=001lzxu2qLk80HqL8ELwMv94NTw6YCbcmYJxdY7rRi3Uukm_1MjKt67HEujsAEEI8Pk_XbkKlwo9v35DuBKHjpZ9TDOUUXPyru3vU2TSfObkRTlVDreUWX_u9orbo4XL1wlwL0p3BDCEfqOWhVVZZMh4dBh7-D0jP2SC4l1XY8aPtqUHAX-JMC6GH9HYKbK38f2qRVQw4dJpeRbPZB0H1E1bBIZjq94Iz6XTzFGswkYqG0YC7NGNEm4kw==&c=vbQPPAz9-VFxYpNhpHV1tYoLsDhH0nGh65rZ5LJOh4PF4WRXgUjH8Q==&ch=eyvuJROYcFj8VxIGss4fPi9vHff4NVhyg8JfKNyYR6WQLk-2U9s5eA==]
that has been done in the field as well.  So, I wonder what the impact would be 
of having physicians hugging their patients.  Is there an added effect?  I'll get
back to you on that one...

Drawing Attention To A Hidden Problem -We've got a problem in the USA that until
 recently has not gotten much attention - overuse and abuse of opioids.  The data
is compelling.  In 2013, opioids overdoses (e.g. OxyContin, Vicodin and Percocet)
were attributed to the deaths of over 16,000 people.  As pointed by Charles Lane
 in an opinion piece on the subject for The Washington Post [http://r20.rs6.net/tn.jsp?f=001lzxu2qLk80HqL8ELwMv94NTw6YCbcmYJxdY7rRi3Uukm_1MjKt67HEujsAEEI8Pk62_6ntr31thCND8i7FYNiQ-Vu3XW2QHRWT4OiUuXrI9h_qOmvZJ_1xsxNpwhGEgjn5SzujxcL6XIaQsjoUadJNp-hdD7P4jieZp0X5Wq5dfRJHPDQAMUUvrbCry9iNr2dj_-qWnigUifZ9UF60bLaNLz3nVEVeWp8Q3HTiGUuSWRb5hWW5TAxIS1r2KXgM-YoD5VduYVyTAwXR_QxkpRUen2Cm5_LSEdwrbgBLrT8mD7s9ihOvleJnfq4-aToj0aLL-4zlHVoar-9QRfV5UUrcU3Iudw6a-kO4IQ5VSzvZE=&c=vbQPPAz9-VFxYpNhpHV1tYoLsDhH0nGh65rZ5LJOh4PF4WRXgUjH8Q==&ch=eyvuJROYcFj8VxIGss4fPi9vHff4NVhyg8JfKNyYR6WQLk-2U9s5eA==],
"that's approximately half as many as died in traffic accidents [http://r20.rs6.net/tn.jsp?f=001lzxu2qLk80HqL8ELwMv94NTw6YCbcmYJxdY7rRi3Uukm_1MjKt67HEujsAEEI8PkkcVXhfaDYS5MrBRj4HbjJ91XPXNoucQ9eof3AOK0t30xy5IyzzbL4hnb4CFnb_69Ey0eV-UrxK0Gmp_AEsaHLU4N563tzuaGdeXB06pJ2vyNP-OS8cx3YJsF-fc4JRE03ngj7LnCbfxrXIl0i5FJYw==&c=vbQPPAz9-VFxYpNhpHV1tYoLsDhH0nGh65rZ5LJOh4PF4WRXgUjH8Q==&ch=eyvuJROYcFj8VxIGss4fPi9vHff4NVhyg8JfKNyYR6WQLk-2U9s5eA==]
that year, and about 2,000 more than were murdered [http://r20.rs6.net/tn.jsp?f=001lzxu2qLk80HqL8ELwMv94NTw6YCbcmYJxdY7rRi3Uukm_1MjKt67HEujsAEEI8Pkjq6SgKeha5rl2MJjr5LVSjMHOW9TuzdNISHpwAgTeNDGE3VVnvAoyYO5Gb25Hx3K-nNnfV7C5Cb6HbIz5C6t2XFZXXKcb_zjVKfkbj76MJEPaKdMqk6AzZeGrqKrOVy0JdJjBgFtOBw=&c=vbQPPAz9-VFxYpNhpHV1tYoLsDhH0nGh65rZ5LJOh4PF4WRXgUjH8Q==&ch=eyvuJROYcFj8VxIGss4fPi9vHff4NVhyg8JfKNyYR6WQLk-2U9s5eA==]."
 Those are compelling numbers that deserve the attention of the medical community.
 In particular, the medical community needs to become more involved since the primary
reason for the growth in opioid use and abuse relates to overprescribing.  In 2013,
the most recent year where data is available, over 200 million prescriptions for
 opioids were written, which is three times the number of two decades earlier.  
According to National Institutes of Drug Abuse [http://r20.rs6.net/tn.jsp?f=001lzxu2qLk80HqL8ELwMv94NTw6YCbcmYJxdY7rRi3Uukm_1MjKt67HEujsAEEI8PkD4VkLTRYM2SXOKu0erf2dCu6BpPhUQ2KgIqeMExQSKxs7GHuTfS7aXmIWmqzELmWlbB896SQ0x9WVmH2p0aPiKjJ1DE2olfOiOBqxot1DfWnGMagqYxD1FlXaADxUt79cfhx8_QQ4Nlcs7047AsKj17eFm4cVekpwlfdHTvr1zyArm5kwflduZdHWESOK89huq1FKC9-t_6rR5YJdrSorZ5zFr3K9hTxvtmnoKEYvU9gn7DgopcuhB26zo00SaeecKF8PhnHHg-YxnoqM_YQgwUx0fPvvv2XXf_kVX2cEi0=&c=vbQPPAz9-VFxYpNhpHV1tYoLsDhH0nGh65rZ5LJOh4PF4WRXgUjH8Q==&ch=eyvuJROYcFj8VxIGss4fPi9vHff4NVhyg8JfKNyYR6WQLk-2U9s5eA==](NIDA)
the USA accounts for almost 100% of world consumption of hydrocodone and 81% of 
oxycodone.  Surely, something should be done.

Bring On The Joe! - As a coffeeholic, I'm always pleased when I come across the 
seemingly increasing number of articles citing the benefits of coffee consumption.
 The most recent is an article [http://r20.rs6.net/tn.jsp?f=001lzxu2qLk80HqL8ELwMv94NTw6YCbcmYJxdY7rRi3Uukm_1MjKt67HEujsAEEI8PkJAv05UcDaSc9DZkYfuWiJq8J-kKl7Hxbz_Lf2YLbc5xr9_Cdhvcg52RcCHpMfgRB9rRgGd0b1TPjpTUtExMQ0QNrOh3ymk1EZL8D61rgCMcR6HX5ezXJGqPSllqf4Gp3jinsaLQ9wvZbTJYODKBlOpinoaawvaQTukf-tJ4a44m50gwBSKt-kHoo-xpudg4MXLDQ8SVgaFk7LR-kq6COAUoiC6PlZxEi&c=vbQPPAz9-VFxYpNhpHV1tYoLsDhH0nGh65rZ5LJOh4PF4WRXgUjH8Q==&ch=eyvuJROYcFj8VxIGss4fPi9vHff4NVhyg8JfKNyYR6WQLk-2U9s5eA==]
in The Los Angeles Times which reported on research which found that people who 
drank more than six cups of coffee each day appeared to be less likely to develop
multiple sclerosis. And, the rate of difference between the MS victims and the control
group was not inconsequential.  The coffee drinkers has a MS occurrence rate that
was 33% less likely than non-drinkers.  The international study corroborates another
study by Kaiser Permanente in the USA which had similar results. So, bring on the
Joe!

Future Health

Delivering care in the new virtual world...

Telehealth Payments Expand, Not Quite - CMS made an announcement recently which 
will help move the needle on the use of telehealth services when it announced that
payments for services using telehealth technology will be allowed for "next generation"
Accountable Care Organizations (ACOs).  The problem is that the first generation
 ACOs are primed and ready to begin using the technology but will evidently be disallowed
under the Medicare ruling.  The decision exhibits the schizophrenia of CMS in pushing
forward with new models of care while simultaneously throttling back or putting 
on the brakes.  The data are very clear and compelling on the use of telehealth 
services.  If you're of the same opinion, you may want to become involved with the
Alliance for Connected Care, the leading telemedicine lobbying group that is advocating
that CMS waive [http://r20.rs6.net/tn.jsp?f=001lzxu2qLk80HqL8ELwMv94NTw6YCbcmYJxdY7rRi3Uukm_1MjKt67HEujsAEEI8Pkv-bNDHr4uwArzV3XnHUevlJUcoghFtl2OPJcI9VsejJ-IPQjSrUkNURSWeyhWmkimyvSXhUIIZY7ImKKG4qWTSXH4BCatG-h1mlUgaCBISdc8f4DJBYNvF4-L-wMJg4oUEz-M2A5dLGo5mtYl7T8rzK_WB0ehZcAuchAYFhxvhiTGRt1x4A4uLBeBRvqzeWE0Xr4kCj9hZJBHqgSSmTBzL70o6g-fdZ1iNAhs7Tr_SLes4Xcxia_VNTp2QdCAJgd&c=vbQPPAz9-VFxYpNhpHV1tYoLsDhH0nGh65rZ5LJOh4PF4WRXgUjH8Q==&ch=eyvuJROYcFj8VxIGss4fPi9vHff4NVhyg8JfKNyYR6WQLk-2U9s5eA==]
its restrictions on telemedicine for all Medicare ACOs.

Top 10 Healthcare Technologies - The annual South by Southwest conference is always
an interesting venue for considering where technology is going in healthcare.  The
confab brings together the latest and greatest in innovative technological advancements
that can be applied.  This year, Phillips - a major healthcare technology company
and sponsor of the SXSW program presented [http://r20.rs6.net/tn.jsp?f=001lzxu2qLk80HqL8ELwMv94NTw6YCbcmYJxdY7rRi3Uukm_1MjKt67HEujsAEEI8PklcKFEcw5gF2T-Xdg1aC6WdyRVOts7pVhtsiant0uRVIeGjzNYypKQXRRY5YMYkRmsMO0n4czFUIJbl6IQBaX08GaQQlYxuqr2caRaUGgJ7h1g28jHGqT4z-rU5MzclPPDeibLWuDuxM2QJCCyN2wCUiwqIVA7k8qwo8n5f_F510MD5hFh5Y1Gw==&c=vbQPPAz9-VFxYpNhpHV1tYoLsDhH0nGh65rZ5LJOh4PF4WRXgUjH8Q==&ch=eyvuJROYcFj8VxIGss4fPi9vHff4NVhyg8JfKNyYR6WQLk-2U9s5eA==]
their annual top 10 list of technology trends in healthcare.  Here's the list:

1.  Wearable technology - It is argued that 80% of consumers would benefit from 
the use of wearable technology because of its "convenience" factor.
2.  Connected devices: Use of remote monitoring and support, reduces readmissions
and reuse of services by margins greater than 30%
3. EHRs: 71% of physicians now use EHRs with 85% of those meeting meaningful use-certification.
4. Telehealth: 70+% of patients would be comfortable communicating with their doctor
using text messages, emails or video instead of seeing them face-to-face.
5. Predictive analytics: It is projected that over 80% of standard tasks (e.g. blood
pressure, glucose levels, temperature) as well as more complex testing (e.g. genomics)
will dramatically change patterns of care.
6. Population health management: About 70% of providers report positive patient 
care benefits from population health initiatives.
7. mHealth apps: 71% of millennials want their providers to use mobile apps - what
about the Boomers?
8. Data security: The issue ranks high among consumers, more than convenient access
health records and physician notes.
9. Partnerships: One in four Fortune 50 companies entered a new healthcare partnership
in 2014 - Now, that is a statement in and of itself...
10. Cloud-based technology: The cloud as a method for storage is expected to grow
at a 20% annual rate through 2017, reaching $5.4 billion in annual revenue.Mississippi
Leads The Way - The Great State of Mississippi, which seems to be a perennial "near
the bottom" on virtually all health rankings, is at the top in the field of telemedicine,
according to an article in Politico [http://r20.rs6.net/tn.jsp?f=001lzxu2qLk80HqL8ELwMv94NTw6YCbcmYJxdY7rRi3Uukm_1MjKt67HEujsAEEI8PklFMLP4Kuu18lIurTdmouUFZxiPlgN3gtyrGeb-ZC9F1WW-qg6PR3XiFW7zaYscAwEQ35h54JWLgIw4vtOEJBS84b-d1b0tGZF4R1QSCieDe5_k43H8XePfeISLh4MnoaAbgNHyiLs4AjcYbKwALpa3aNeWLqrufVI06XpC68p0Ebsslnwepmqs8DOySfnujDev5qHHJpxWafSXYUdjlSGVpdnCFUrZMV&c=vbQPPAz9-VFxYpNhpHV1tYoLsDhH0nGh65rZ5LJOh4PF4WRXgUjH8Q==&ch=eyvuJROYcFj8VxIGss4fPi9vHff4NVhyg8JfKNyYR6WQLk-2U9s5eA==].
 Kudos go to the University of Mississippi Medical Center's Center for Telehealth
which has led the way with over 160 outreach connections to rural areas of the state.
 The Center is providing more than 8,000 telemedicine visits/month ranging from 
remote monitoring of chronic health problems (e.g. congestive heart failure, hypertension,
diabetes) to the use of robots for examining premature babies.  What can I say -
 Keep it up!  Show us the way!  Kudos to Mississippi!

What's Hot and What's Not On The Technology Front - For starters, there are three
hot markets in the digital health space; San Francisco (25% of digital health venture
funding) Boston (9%) and New York (7%).  The growth of the Bay Area seems to be 
- in part - due to the support derived for new companies getting venture support
 with mentor ties back to Kaiser, the local Universities (e.g. UCSF and Berkeley)
and, a plethora of pre-existing digital healthcare companies. According to Rock 
Health [http://r20.rs6.net/tn.jsp?f=001lzxu2qLk80HqL8ELwMv94NTw6YCbcmYJxdY7rRi3Uukm_1MjKt67HEujsAEEI8PkTsR0ww799Yk7vh7-QLx-H8_sC_gCvVt5e1sWNPDLZItZuyCFtcp8cTaLuUjQOEhxAIGFQvGMJC5y_RrTg_QINwg-fY4AkEtAlOBEprCDmPM=&c=vbQPPAz9-VFxYpNhpHV1tYoLsDhH0nGh65rZ5LJOh4PF4WRXgUjH8Q==&ch=eyvuJROYcFj8VxIGss4fPi9vHff4NVhyg8JfKNyYR6WQLk-2U9s5eA==],
the big winners on the investment front are telemedicine, at-home diagnostics and
devices with over $4B (Rock Health) to $6+B (StartUp Capital) invested in digital
health over the last year.  Those are impressive numbers.  But, the investments 
are not just limited to the purely technical side of healthcare.  The fastest growing
new tech venture is Zenefits [http://r20.rs6.net/tn.jsp?f=001lzxu2qLk80HqL8ELwMv94NTw6YCbcmYJxdY7rRi3Uukm_1MjKt67HEujsAEEI8PkfiQu8flWdNHKxq375-_TwLT4lhGERlHbAvM5NgyvJWjdmL6HhE0wOgoeXM1zjFkADRSiu0yOMlRplfbEL7clErAnzSJdIACJIXtGAEbFZikgenUMc1UumLKrFmh7qA5Ywfk0Q1fwtPqf0OeCGojOBxThptqe2yNr7VLLl4Sg8ZGjRDtAE63WxJAA67d7aBlsEM0b_KoyRf9OLy4OREWI0hD9hHMQKlQVEbcqwyuH4kQAnnrWE9VC-g==&c=vbQPPAz9-VFxYpNhpHV1tYoLsDhH0nGh65rZ5LJOh4PF4WRXgUjH8Q==&ch=eyvuJROYcFj8VxIGss4fPi9vHff4NVhyg8JfKNyYR6WQLk-2U9s5eA==],
which is changing the landscape for health insurance brokerages and human resources
benefits management.  The company grew 20X, hitting $20M in 2014 with expectations
that it will reach $120M in 2015.  Now, that is fast growth and, liquid gold. Another
company that has gotten lots of attention is Omada Health [http://r20.rs6.net/tn.jsp?f=001lzxu2qLk80HqL8ELwMv94NTw6YCbcmYJxdY7rRi3Uukm_1MjKt67HEujsAEEI8PkCRD-I0nVpXaPM4bqRCWefMeLigWRZhUCJZhZV5-WO8eHInWEZ0x3IU20GJmWB92jpXdVS1irHMEYP7Xp4LaIaAL6GhK39nYCNIUVRMnJJ-0=&c=vbQPPAz9-VFxYpNhpHV1tYoLsDhH0nGh65rZ5LJOh4PF4WRXgUjH8Q==&ch=eyvuJROYcFj8VxIGss4fPi9vHff4NVhyg8JfKNyYR6WQLk-2U9s5eA==].
 With backing from Andreessen Horowitz (a venture capital firm),Kaiser Permanente
Ventures, U.S. Venture Partners and the Vertical Group - Omada is off to a fast 
start in the use of digital tools, social networking and coaching (= "digital therapeutics")
to help care for pre-diabetic patients who want to change their behavior by losing
weight loss and engaging in healthier lives.  And, there are more...

Rock Health is predicting a shakeout in the not-to-distant future and, I would concur.
 We have many, many "products" coming to market but not enough "solutions".  In 
my experience, healthcare leaders (i.e. buyers of these systems) want a solution
 to their problems. For those organizations attempting to move beyond the four walls
of the hospital, the need for "solutions" is dire.  The need for moving care to 
the home and other non-acute care settings is growing dramatically as we move from
a volume-based to a value-based care delivery model.  Products don't solve problems.
 They complicate the lives of healthcare leaders.  Whoever develops a solution will
be a winner in my book!  Stay tuned...
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Some Comments On King Vs. Burwell

Thoughts on the potential impact of The Supremes decision on ObamaCare mandates...

It Will All Come Down To An "S" - In Washington, all of the policy wonks are awaiting
the final decision of The Supremes in the King v. Burwell case.  The decision - 
which is expected in June - could very likely decide the fate of the Affordable 
Care Act (ACA). The case centers around whether or not federal tax subsidies can
 be provided to those seeking insurance through the health insurance exchange established
in the states by the federal government.  There are 37 states that have elected 
to forego the implementation of health insurance exchanges.  As a result, the federal
government stepped in and implemented federal exchanges at the stage level.  However,
the wording around the issue of tax subsidies was muddy and unclear - even if the
intent was clear.  So, The Supremes were asked to step in and offer an opinion.

The King v. Burwell lawsuit cuts to the core of some central tenets of the ACA. 
 First, the individual mandate, which requires most Americans to obtain health insurance
or pay a tax penalty, is challenged.  If that weren't enough, the employer mandate,
which requires large employers to offer their employees affordable insurance or 
face a tax penalty, is also challenged.  And, finally, the role of the exchanges
 established and the subsidies that are to be provided under the ACA to make health
insurance coverage affordable, are challenged. Why?  Because, over 85% of individuals
who applied for coverage through the exchanges in 2015 are expected to be eligible
for the subsidy.  Based on the data to date, it is the primary reason that we've
 seen a fairly dramatic decrease in the number of uninsured in the USA, dropping
 from a high of 18% in mid-2013 to 13.4% last year and now at 12.9% according to
 the latest Gallup Poll [http://r20.rs6.net/tn.jsp?f=001lzxu2qLk80HqL8ELwMv94NTw6YCbcmYJxdY7rRi3Uukm_1MjKt67HEujsAEEI8Pk4ro8_QBil0q8_kMxu733y8T-9UfDwXWhiJVD-RqIEmUi4I5YypZN56hpxVIUEQGfhfKe3fMJ0HY2b0Nfvgqq-fm0ucbJxdf0wS75rYTNpsL3fm9lhzbFLW8wznh-L4L-9z-Ak0wV3eEu7AAKBNArLrN5bMaizCtW&c=vbQPPAz9-VFxYpNhpHV1tYoLsDhH0nGh65rZ5LJOh4PF4WRXgUjH8Q==&ch=eyvuJROYcFj8VxIGss4fPi9vHff4NVhyg8JfKNyYR6WQLk-2U9s5eA==]
in January, 2015.

In essence, a successful petition before the High Court would render meaningless
 the individual mandate since there would be no penalty for those who remain uninsured.
 That will wreak havoc with the insurance industry who have made it clear that they
need to relatively healthier uninsured to balance off those who have insurance. 
While the suit was brought in Virginia, if upheld - it would apply across all 37
 states that deferred in creating state exchanges to the federal government.  In
 addition, it would also render the employer mandate meaningless since that clause
is tied to penalties through the use of tax credits for employers. Long story, short
- a negative decision creates a quagmire that the ACA would likely not recover from
given the current political climate in Washington.  It would force the health care
industry into "The Age of Ongoing Uncertainty" or, "The Black Hole of Healthcare
 Reform".

The essence of the lawsuit revolves around whether or not the Internal Revenue Service
(IRS) exceeded its authority granted by Congress under the ACA by allowing premium
tax credit subsidies to be used for enrollees in both the state-based and the federal
exchanges. The contention by the petitioners is that Congress intentionally restricted
the use of subsidies to state exchanges as an inducement to encourage the states
 individual exchanges and keep the federal government out of the exchange business.
 The argument harkens back to the notion of states' rights versus federalism - an
ongoing debate in this country for over two centuries.

The Obama Administration defends its use of subsidies on the basis that it is acting
on behalf of the states by establishing an exchange and that the phrase, "such exchange,"
[NOTE: the singular rather than the plural] represents "a term of art" meant to 
encompass both state-based exchanges and the federal exchange. The Administration
goes on to argue that accepting the Petitioners' rationale would prohibit individuals
from enrolling in the federal exchanges. Why?  Because only "qualified individuals"
can purchase insurance through an exchange, and "qualified" individual is defined
as an individual who "resides in the state that established the exchange." If the
federal government established the exchange (as opposed to a state), no individual
would be "qualified" to obtain coverage through such federal exchange. So, in fact,
it really does come down to the interpretation of an "S"!!

If The Supremes rule in favor of the Administration, ACA will roll forward and we
are likely to enter a period of "tweaking" that I have been predicting for some 
time. For those who are longer in the tooth, we will remember the "tweaking" that
occurred with Medicare and Medicaid in the 1970s and early 1980s - and, still goes
on toward as the situation warrants.  But, the essence of Medicare has remained 
intact. That's one scenario.  The other is that the Petitioner's prevail, and that's
where my other prediction is likely to come true.  Let me repeat it in case you 
missed it up above: It would force the health care industry into "The Age of Ongoing
Uncertainty" or, "The Black Hole of Healthcare Reform".   If you're into the nits
and nats of the arguments, check out the Denton [http://r20.rs6.net/tn.jsp?f=001lzxu2qLk80HqL8ELwMv94NTw6YCbcmYJxdY7rRi3Uukm_1MjKt67HEujsAEEI8PkUo1Tv7Oz3ylQ4VEcsnrgo2o0G4n30e0jknhTXi__YOd7l26Rkl8MXFcyboN-2Nuu4SHXz0lDrKafG7b4Jt45gej3X1pcJPgHhY4ma3vp5p8N-Qwrr6KgT3wkNzTgFbnL074Z7tQFerXLA36CqfRVDSGGQCZ28GzOFgntmzR2OGawqx-LgSq9iBy3_eE8vZIlnNtBq-NV7i-Yhcapa86OJTUSkyk4Zm3tTc3pbypxsMLzphGMQ0lm2Q==&c=vbQPPAz9-VFxYpNhpHV1tYoLsDhH0nGh65rZ5LJOh4PF4WRXgUjH8Q==&ch=eyvuJROYcFj8VxIGss4fPi9vHff4NVhyg8JfKNyYR6WQLk-2U9s5eA==]
law firm or the Brookings Institute [http://r20.rs6.net/tn.jsp?f=001lzxu2qLk80HqL8ELwMv94NTw6YCbcmYJxdY7rRi3Uukm_1MjKt67HEujsAEEI8PkddhKhreNxXgWQ9Yl-TjV_rwXpeURlK2P_bSEWiGIGTprgFjs523hteujh4Gw16VU2NfwFK5AxTSMDN4IpitXODysvaDp3Z45nNZwi4o6SLri4Da3PxX51sI2rmCgpg2yewUi8OVmy7li5dwwSudjuMGwfVQFC9ioDujAI878y7PBwMv5krKh5qmDgM1G4Fif21L8qffkmyfuzBtdRTOf8NzH1Q-j707d75DqmBFKL8FbmCmcx-9gAir0W2TPgZtmaz1P7tUvgxrxgZ5azk12M0u5QarmHpiyu876URlNmKjFuZXT259EnAE4VkITv4JzPI8zqNLZpT7S1dM-NFoA4jUYnLGb6Hp19r2dIKy2Es3qW7GlkgXgIiLf53MRFe_jhguU8_id7xnAC97KtQLAZK_ZIDfBKpaNUUUttkPmrx-HhtS8zqbSrPFhP-PTIuUJF-LLX5C5FjlgWBWTmleuGi-5ZhIe8xvDUU57O1NysmWD7gFWRYWx2-vsQFcxc4KZ2bNQn2tJ9bRvQKyuno94WKVACooHXS0R66j_X4gRry0_x-HrVhn1Jp3IUn9O1ckIIO_lmrZuhise7eSNfSK5CdkOAOHnqaatb6drCdIWmPe24XTLHZHqdekmjgwpDkzdLAh77UpuKu-KyHRr29VvlQ==&c=vbQPPAz9-VFxYpNhpHV1tYoLsDhH0nGh65rZ5LJOh4PF4WRXgUjH8Q==&ch=eyvuJROYcFj8VxIGss4fPi9vHff4NVhyg8JfKNyYR6WQLk-2U9s5eA==]
overviews of the case.  I think it is one of the better reviews.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Weekly Whisk

Musings from a foodie...

If you want a very special treat when you head out to the San Francisco Bay Area,
plan a trip to Copita Tequileria y Comida [http://r20.rs6.net/tn.jsp?f=001lzxu2qLk80HqL8ELwMv94NTw6YCbcmYJxdY7rRi3Uukm_1MjKt67HEujsAEEI8PkpGBxrg0biFnsk7mSgX-4yAVwN3W8LhWn3UFpzBrv_Y6GJXXo391zIL5phxn0ewXpD2AlYHj2Uu8H6GKnzZtmsZNDQG4zyJlUBg70r04M8TbAETbHm0FtDQ==&c=vbQPPAz9-VFxYpNhpHV1tYoLsDhH0nGh65rZ5LJOh4PF4WRXgUjH8Q==&ch=eyvuJROYcFj8VxIGss4fPi9vHff4NVhyg8JfKNyYR6WQLk-2U9s5eA==]
[«««««]  in Sausalito.  Executive Chef Gonzalo Rivera and Sous Chef Raul Plascencia
have clearly taken modern Mexican cooking to a new level!  BTW - I haven't given
 a 5 star rating in a while. When I heard that our group leader had decided on Mexican,
I was not excited.  I had expectations of the usual fare but, was totally surprised
and can hardly wait until I'm back home in the Bay Area so I can arrange another
 visit!

Since our group was large, we decided to order tapas style for the whole table and
had no regrets throughout the entire lunch.  We started with two outstanding starters.
 First, we were treated with Papas Bravas, roasted and fried kennebeck potatoes 
accompanied with fried jalapenos dusted with a cumin-arbol chile and accompanied
 with an avocado crema.  At the same time, our waiters brought us a ceviche cocktail
of lobster, bay scallops and red snapper infused with a tomoato, orange and chile
serrano sauce and avocado.  It was amazing!!  It was also spicy but in that wonderful
modern Mexican style that blends spice with sweetness.  The second setting were 
two different types of tacos.  The fried pork belly coupled with pickled red onions,
pumpkin seed and a hoja santa mole with cilantro.  But, the highlight of the entire
luncheon were the pork carnitas with pickled veggies, a tomatillo habanero salsa
 and a cilantro infused lime sauce.  Whoa, were they good.

So, don't forget.  When you get to the Bay Area, make reservations at Copita - 739
Bridgeway - Sausalito, CA 94965 - (415) 331-7400.  This is some of the best Mexican
food I've tasted in a long, long time.  And, consider a bike ride over the Golden
Gate from the city as a pre-lunch exercise.  It gets you ready for the chips and
 guacamole - which is also outstanding!!
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Good, The Bad, And The Ugly

The ongoing saga...

The Great - I feel vindicated.  9 out of the Top 10 tech trends outlined by Philips
are areas I've been talking about for several years.  I missed the fact that 25%
 of the Fortune 50 companies were planning to invest in digital health products.

The Good - The Green Bay Packers is retaining two of the best players in the league
at their respective positions: wide receiver Randall Cobb [http://r20.rs6.net/tn.jsp?f=001lzxu2qLk80HqL8ELwMv94NTw6YCbcmYJxdY7rRi3Uukm_1MjKt67HEujsAEEI8PkV-b6ifWpbFlA64XsB2jTxh3s0sKYx6XxF_OvAPFxDv91E9o4zew5ly3_F9MVBkYoECIU_Y58S61rpijZEqTb3SLSuqS27pehYPqGwULNv7-I3gGgU2az3o9OGZ7Skx0f&c=vbQPPAz9-VFxYpNhpHV1tYoLsDhH0nGh65rZ5LJOh4PF4WRXgUjH8Q==&ch=eyvuJROYcFj8VxIGss4fPi9vHff4NVhyg8JfKNyYR6WQLk-2U9s5eA==]
and right tackle Bryan Bulaga [http://r20.rs6.net/tn.jsp?f=001lzxu2qLk80HqL8ELwMv94NTw6YCbcmYJxdY7rRi3Uukm_1MjKt67HEujsAEEI8PkCc9YdXYWl7FqDJ8oohoi0U4SFE2ySUbBl7yhwg0b1OhahidTKKML4d7DmUZhU4tfHmbTYKqPzZjz2PWtN4YGXj_Wv-LeFVOQjKQqIlpeLmPoZRGQG3yKzR0nrrIjfJ06&c=vbQPPAz9-VFxYpNhpHV1tYoLsDhH0nGh65rZ5LJOh4PF4WRXgUjH8Q==&ch=eyvuJROYcFj8VxIGss4fPi9vHff4NVhyg8JfKNyYR6WQLk-2U9s5eA==].
It's looking like a great season ahead!!

The Bad - Regardless of your perspective on Senator Ted Cruz (R-TX), his announced
entry into the 2016 Presidential race means that attention of the media will now
 shift to the perennial horse race between Republicans and Democrats.  I wish Mr.
Perot were around for another go...

The Ugly - The shooting of a fellow traveler on the freeway in Texas is more than
bad.  At this writing, they still have not found the offender.

The statements in The Fickenscher Files are the personal views of Kevin Fickenscher,
MD and do not reflect the views or policies of any organization with which he is
 affiliated.
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