Subject: News from Dr. Kevin Fickenscher
From: "The Fickenscher Files" <[email-masked]>
To: <[email-masked]>
Date: Mon, 27 Jun 2016 09:08:53 -0400 (EDT)

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The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001mSquE-RKV5E3k8BmGNfMaHsHMw5FPDacuoiBrHXiVWtC7_6KKOOZppmQQ3NKBQS1BcaK2gBzClErz1ZxTkgsBUMFkzwBu1jxNrnTq6OTdQi4GiI_7zIz5sQfcLmQPsycjVw14j_J4AWUZYkvTEGwljS4D3OzXA0_Y-jz8h-Sqy-sawUVWybfgaDrZu-V0HD4&c=-WnTglBl6oQ_rph2XA_S1Yi0QxackqEpWCQDVHqbAYdMYlGheqNgPA==&ch=2aSpcbpaPpNlmC3FiG68qDetowRq8k2e5uiLx0pX9dJBILIo1uROVg==]
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The Fickenscher Files, Vol. 4, Issue 9
Kevin M. Fickenscher [http://r20.rs6.net/tn.jsp?f=001mSquE-RKV5E3k8BmGNfMaHsHMw5FPDacuoiBrHXiVWtC7_6KKOOZpnPm9ZmJum7ClF-MXhyMq6WGDp690Alp-dGzFpdeXSmKGk0Vj91UiFOWmw9KlzCNozTHkIihl2z9vo4kZ1DzxdbmJMFW2iWhGLevejBTY7semnyoRPJ8OfVuGWGowKpQ_ZT3Gr7eZ3o-g1a_M-bw8XDMR3efqEAtOpckC1R1LBuhXtL5srTUZjonXql3WbvnDFORxAabDKOdjZXbGG7KoRE=&c=-WnTglBl6oQ_rph2XA_S1Yi0QxackqEpWCQDVHqbAYdMYlGheqNgPA==&ch=2aSpcbpaPpNlmC3FiG68qDetowRq8k2e5uiLx0pX9dJBILIo1uROVg==],
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.
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Quote(s) Of The Week
Perspectives from around the world...
"If you live in the Republican conference ... I don't think Jesus could get everyone
to agree on everything."
Rep. Phil Roe [http://r20.rs6.net/tn.jsp?f=001mSquE-RKV5E3k8BmGNfMaHsHMw5FPDacuoiBrHXiVWtC7_6KKOOZpsEWG8lXfmlf3_EauhrWApBTjMjW1Lwef8r8pbn21AMykqNVy262K5s_ASkCKL-mDsR4Beu5corF9UeYhMy2SZgaBINu4KfmwqMYZmws_tnD0ynhLRRh8OgaBB9gK_qzlXsxZfF36hBe&c=-WnTglBl6oQ_rph2XA_S1Yi0QxackqEpWCQDVHqbAYdMYlGheqNgPA==&ch=2aSpcbpaPpNlmC3FiG68qDetowRq8k2e5uiLx0pX9dJBILIo1uROVg==],
MD (R-Tenn.), a physician member of the US House of Representatives who has been
 an active participant in the Republican task force meetings leading up to the release
of the Ryan Health Reform Plan
"I'm also in favor of what's called the public option, so that people can buy into
Medicare at a certain age."
Former Secretary of State Hillary Clinton (D-NY) in a speech before a group of supporters
in Virginia last week - marking a shift in her policy toward more of a single-payer
approach.
"After Trump went after the 'Mexican' judge from northern Indiana then (House Speaker)
Paul Ryan endorsed him, I decided that in fact this was not my party anymore."
George Will - a noted conservative (and, I might add "thoughtful") political commentator
- in comments on "Fox News Sunday" related to his decision to withdraw from the 
Republican Party.
"George Will, one of the most overrated political pundits (who lost his way long
 ago), has left the Republican Party. He's made many bad calls."
Donald Trump (Presumptive Republican Nominee for President of the USA) in a tweet
following George Will's announcement on Sunday that he is leaving the GOP
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Consulo Indicium
Information for your Consideration...
It's As Bad As Zika and Ebola!  It's Called "The Opioid Crisis"- Sometimes the crisis
of the moment which seems to dominate the new cycle of the media relates more to
 public events and figures that are "out front" in the attention of the American
 public.  While Johnny Manziel - the former Quarterback for the Cleveland Browns
 - has gotten some attention, it wasn't until his father came out and said he either
needed to get treatment or he would die that his drug problem got significant attention
except for sports buffs.  But, for those of us in healthcare, we know that there
 is a looming crisis that is very significant and - on our front door: The Opioid
Crisis.  It's actually beginning to overwhelm our medical examiner and coroner offices
across the country.  The high number of overdoses is straining these hidden providers
who are often already stretched due to violence, inadequate facilities, budget constraints
and a shortage of trained forensic pathologists to supervise the labs. According
 to a reach report by Reuters [http://r20.rs6.net/tn.jsp?f=001mSquE-RKV5E3k8BmGNfMaHsHMw5FPDacuoiBrHXiVWtC7_6KKOOZpsEWG8lXfmlfJ_J6yX6QwetuhPqlh3kXK7htsBDVrVfnE1lx-W1p5lNcyxWo6i51gs6R4va5aji0DryyDqWn6ygfHp6jwj27ObziaFAZyxegCdDezCEjlUonRmLj2zL7i5C0L0gMDynAEchPTmmXUmKldvcXVZ50AofcLm2qSLppIidfyz7hCN663OmYKN5CXjdccnIBNx6MjpKye2NwsRDVGeI4cvJVeNVeMwOj05yvmiL7A9sfhWTEqVYMYBjdkqgtzp6r2grYtxGun6GNZkwJTzw_KbNIn_vO6xyg0oG8O6H_ABeVk_ldi90YgK87i9VqMSgWu5K9tlBXQPv5HKMJa67s28oLYIFFsoHfYx3Owz7kKUFv0BKBnm0lc1tz3JJHe65ZqgSKD6OgHsqR83kRP4Z5CnRLNRaFqVbdcp0VwnGz-FHUSV4SbRVmTGdhml8yt-oGE8zI54C-vqaCeW2u-6Ypf8IBwxuEti-ZZASoWCPlzcolOabOGxc3oNLgXm2CLtK89VV5WtQhhvwzWoUI2ROAhtqkf_qSvn7HmllLc6HhwRVm5lGgq0yeLX7pH-wYCt975uGuZVWQcrOplFYCfXxRU8p4KA==&c=-WnTglBl6oQ_rph2XA_S1Yi0QxackqEpWCQDVHqbAYdMYlGheqNgPA==&ch=2aSpcbpaPpNlmC3FiG68qDetowRq8k2e5uiLx0pX9dJBILIo1uROVg==],
the number of deaths from drug overdoses exceeded 47,000 people in 2014 - coming
 in as the fourth most common cause of death.  In addition, the number of heroin
 users in the USA has reached a 20-year high based on the most recent reports reaching
affecting about 1 million individuals in 2014 or 3X the number in 2003.
But, Let's Not Forget Zika - The Zika virus continues on its unabated march toward
North America.  Since it was first reported several months ago on the island of 
Puerto Rico, the virus has now been reported in more than 1,350 people who have 
tested positive, including 168 pregnant women (NOTE: The data I'm reporting is over
two weeks old so there is no doubt more cases will be reported as I write this note).
 And, as importantly, many more thousands of people have been infected without symptoms.
 Puerto Rico represents a test case for the USA in the fight against Zika because
it has a strong public health infrastructure - like the USA - rather than the weaker
capabilities which exist across much of South America.  The CDC has projected that
fully one-fourth of the 3.5 million residents - yes, that's 25% - of the Puerto 
Rican population will be infected by Zika through the remainder of 2016.
Republicans Make A Quasi-Run At Healthcare Reform - We've been hearing for months
- actually a couple of years - that the Republicans were going to introduce a bill
to "repeal and replace Obamacare".  Last week, they finally got around to sharing
their thoughts with the rest of us in a blueprint titled "A Better Way [http://r20.rs6.net/tn.jsp?f=001mSquE-RKV5E3k8BmGNfMaHsHMw5FPDacuoiBrHXiVWtC7_6KKOOZpsEWG8lXfmlf2QRy9sHytusSEk3ZP-pUvXstkudURm7xGiK_HE7gSoy9UZu0ER7M3gXFpDBr95I9Od-lR8gmje4SDqfjYjHqCmlZbAX8RdTEGC4eUd4FcL279JhNVSUM4IwECrE10fkQWMZTPEYq3JnLcaxQz64uzPb_hVSXqDJYm4hb3xTgjmi85-uDS4JHPvlfNf2jpRzt1m3dnufaz5A0mJc-qR7uvntKOQo53wqSGPqzRsVcWvhvy0PDjht_ug==&c=-WnTglBl6oQ_rph2XA_S1Yi0QxackqEpWCQDVHqbAYdMYlGheqNgPA==&ch=2aSpcbpaPpNlmC3FiG68qDetowRq8k2e5uiLx0pX9dJBILIo1uROVg==],"
which offers up the Republican alternative to the existing approach.  It appears
 Rep. Paul Ryan (R-WI) is trying to get ahead of the policy curve by getting the
 House positions on the table in advance of the Republican National Convention which
will be in a couple of weeks.  In addition to healthcare, Ryan's office has offered
up new positions on national security and combating poverty with additional proposals
related to tax expected soon.
The Republican position comes on the heels of recent announcements by the Obama 
administration that over 20 million Americans have become insured as a direct result
of the Affordable Care Act or, "Obamacare".  That's a fair number of people who 
are now enjoying the benefits of coverage. So the question for many of the newly
 insured is: How will this affect me?  The Ryan plan recycles some Republican proposals
[http://r20.rs6.net/tn.jsp?f=001mSquE-RKV5E3k8BmGNfMaHsHMw5FPDacuoiBrHXiVWtC7_6KKOOZpsEWG8lXfmlfXyIIvzG1L-1lmN1BlHYqxk0YRzmf3XSbRf56rKOR6fcAs0--JjbxHEmRFUa0cB6YeoO2OCi493IG51mD2FSOjQ7QhxbC5dQ37iD8D0egfHo71YfQAJI9qMIElrFE28Vs067Zq6ZWolHfghnflZQweS5kxSoJM60xk0NMTKoZm3sxLdJ8hWw-FZF0IgcKxu3PDKKyXIGm0tc=&c=-WnTglBl6oQ_rph2XA_S1Yi0QxackqEpWCQDVHqbAYdMYlGheqNgPA==&ch=2aSpcbpaPpNlmC3FiG68qDetowRq8k2e5uiLx0pX9dJBILIo1uROVg==]
that have been around for a while like allowing consumers to buy health insurance
across state lines, expanding the use of health savings accounts and giving states
block grants to run the Medicaid program for the poor.  These provisions were to
 be expected.  For people are unable to obtain insurance through their jobs, the
 Ryan plan would create a refundable tax credit to offset the cost of purchasing
 insurance versus the Obamacare program which provides subsidies to some lower-income
people to purchase health insurance if they do not qualify for Medicaid. The difference
is that it will affect the cash flow of the poor because they will get their credits
back when they file their taxes.  So, the question is: Under the Republican program,
will the poor defer other more immediate expenses to obtain coverage in anticipation
of getting a refund after tax season?  I don't know the answer but, it seems like
a rather open ended question...  Other elements of the program include:

* In addition, the Ryan proposal would gradually increase the Medicare eligibility
age from 65 to be on par with the Social Security program which is currently at 
age 67.
* The so-called Cadillac tax would be retained with Republicans capping the tax 
deductibility of employer-based plans.
* Non-economic damages awarded in liability lawsuits would also be capped - something
the medical profession has long supported.
* The Republican plan would give far greater discretion to those states which have
started efforts to expand Medicaid but would preclude any new states from expanding
their programs.
How Close Is Interoperability? -Patrick Conway, MD, the Chief Medical Officer for
the Centers for Medicare and Medicaid Services (CMS) recently opened a conference
on health information technology with the statement that: "We're seeing a dramatic
shift in the health IT arena [with] the MACRA legislation that enabled us to pivot
to a more simple, flexible scoring paradigm with less burden and to be focused on
interoperability.  That pivot is in the right direction and we are now discussing
the details of them and what needs to be changed." That is a fairly bold statement.
 Is it true?  His declaration comes in the shadow of Secretary Sylvia Burwell's 
pledge on the move toward interoperabililty [http://r20.rs6.net/tn.jsp?f=001mSquE-RKV5E3k8BmGNfMaHsHMw5FPDacuoiBrHXiVWtC7_6KKOOZpsEWG8lXfmlf13pTDC24XQMMeaGWFhfjuqKLWEQam9EvwTUV1fSVKExNEtSX7U1tdapSMZkBFO3Zo0DZwOthbHTl-lDJQAGTG-e2LTz1BAPjrW7SIJPuZCvIgS-auvY1XwUyR02QYmlBTtbSl6Trh1THuvW6NTDFJnh_OxGI-S69HN35xEXZp6Ue_kWPTP0UN6DjBsk9mkWijrFBqnPBPkynEHodY7bxOFaYeS3NsxNdkVV-2XwS35FEPHyrY0J_bg==&c=-WnTglBl6oQ_rph2XA_S1Yi0QxackqEpWCQDVHqbAYdMYlGheqNgPA==&ch=2aSpcbpaPpNlmC3FiG68qDetowRq8k2e5uiLx0pX9dJBILIo1uROVg==]
at the HIMSS 2016 conference several months ago. In support of her call, Cerner,
 Epic, Meditech and others who provide electronic health record capabilities have
agreed to enhance patient information accessibility by not blocking data exchange
and supporting the use of standardized application program interfaces [http://r20.rs6.net/tn.jsp?f=001mSquE-RKV5E3k8BmGNfMaHsHMw5FPDacuoiBrHXiVWtC7_6KKOOZpsEWG8lXfmlfLZuI_Jm3dYgrR76a2Yo9wiZGAs1P0F7ZUXMJxxBV58YnBt5XyiUxib07TI0U_ziVsinI0ItdE9VQjI2QEpJVB-eJJpEjil0ToBRvikJ5ERbf-8r9KuueKequ4Q0PmmoSMVRQMJI0DGGUt755tzTz3yFWf-A_jIrD&c=-WnTglBl6oQ_rph2XA_S1Yi0QxackqEpWCQDVHqbAYdMYlGheqNgPA==&ch=2aSpcbpaPpNlmC3FiG68qDetowRq8k2e5uiLx0pX9dJBILIo1uROVg==]
(APIs).  However, we have a long ways to go [http://r20.rs6.net/tn.jsp?f=001mSquE-RKV5E3k8BmGNfMaHsHMw5FPDacuoiBrHXiVWtC7_6KKOOZpsEWG8lXfmlfEgfJ1TGQoLWDlxK9WZk98aCbHa0AxgDL0e0wJbFRfSJPUUd8wJuBgLaOCDOrwTOvtpWUnjWYx-xc0J-oYpiSayDFZoo8AmxzXUwVwQnP9CReKVNofM003RLJG0knOnFpDzsuoJzqro24NF7FuJmJJCW7D5MXVdx6&c=-WnTglBl6oQ_rph2XA_S1Yi0QxackqEpWCQDVHqbAYdMYlGheqNgPA==&ch=2aSpcbpaPpNlmC3FiG68qDetowRq8k2e5uiLx0pX9dJBILIo1uROVg==]
before true interoperability is available.  The example in the hyperlink details
 a recent study that involved the participation of 11 pharmaceutical companies. 
 The study examined drug summaries from several different therapeutic areas that
 used five common online drug information compendia tools. In essence, there were
lots of errors, especially in warnings and precautions, dosage and administration
and patient education.  These are core elements of drug information that clinicians
rely upon in using any system.  Unfortunately, we too often assume that the information
"online" is accurate when - in fact - the study showed that there are frequently
 errors.  This issue cuts to the heart of interoperability.  To make it real - it
needs to be reliable.  That will most likely require further regulation, cooperation,
participation and involvement across the boundaries of the healthcare community.
  We're not there yet.  On some days, I even wonder if we will make interoperability
a reality. It needs to happen.  We need to redouble our efforts and go beyond the
rhetoric to the reality.  I'm not convinced we have the systems or organizations
 in place to make it happen but, we seem to be moving it forward - albeit at a very
slow pace.  So, the question is: How can we pick up the pace?  I'll keep checking
the literature for suggestions. More on this later...
End The Ban On Gun Research And More - It's common knowledge in the medical and 
health communities that Congress passed a ban about a decade ago on federally funded
gun violence research.  It's a ban that the American Medical Association (AMA) finally
called for after two years of debate on its stance on gun violence.  The AMA voted
to ask Congress to lift the ban.  The only problem is that Congress will most likely
ignore the perspective of the physicians especially since they are ignoring the 
perspective of nearly 90% of the American public who is calling for some no-brainer
changes in our accessibility to guns [http://r20.rs6.net/tn.jsp?f=001mSquE-RKV5E3k8BmGNfMaHsHMw5FPDacuoiBrHXiVWtC7_6KKOOZpsEWG8lXfmlf6SfNesPC_JhsrYcK8CoSnRnr94ohkiLfV1VtX29UI7Pm0h1glA_BlZO2mMMkkB3A5EzARbtr2gpT-hLLrnJbKg7sGa1sMQeE7pTdEdgx1AN5m1AxIOfsfQCLE6T8zKoWsyEzawHz6dTQtLjYWRphCatbHLLNvvRgCCEz2SN0_yXvG8QrDGLTY8cG4f4vqxgXthHL2oS7dbBGdMzbOx9stA66WBCBSZRUr3SnP0JBPqhb7Dihjs9RsAue1KkOqE2qLzFz579Qu-6cG6BOblXI207YgWaPfOgk6MHPurTg6NgctSB1ksWtzj7p4w1-Q1NmQq5CopUV5v_WGLlC3DdNQzwK2Ilo-uqeNJelTwwxLL-A3Wx4u5nRMsdltz2juS5XOfcoT3GRZk2l8O3WpZdJn4xxXWyK155nDcaY3h1IftQYYSHvkjgz3Xv69i1gTOC40-3FNQeyy38zcqNj9ZVp0k8wtHhh4RSakcRarYMOJlmKioilgbiDx6I6vUQoh8STFLGIeBFLh1wPW6Ce1sZ2iYeOsK2vehd5&c=-WnTglBl6oQ_rph2XA_S1Yi0QxackqEpWCQDVHqbAYdMYlGheqNgPA==&ch=2aSpcbpaPpNlmC3FiG68qDetowRq8k2e5uiLx0pX9dJBILIo1uROVg==].
 Proposals like no guns for the terror watch list crowd not only make sense, it's
hard to imagine the thinking of those who are against such approaches.
The Trump Black List - Donald Trump caused quite a stir in the media recently when
it was reported [http://r20.rs6.net/tn.jsp?f=001mSquE-RKV5E3k8BmGNfMaHsHMw5FPDacuoiBrHXiVWtC7_6KKOOZpsEWG8lXfmlfiQCjGgLhzvddQBIfybR35Oh0GzfQMFFfI_4KiZO_LeRdhtrYQMF85nV9WqY1blK7CUKixy8UcrgCrZRQuX-WFbtYGeQwEau6n-qg4Ffp3WMFAjnJeiOw7NXY34cn9yzUihFAXG263yw=&c=-WnTglBl6oQ_rph2XA_S1Yi0QxackqEpWCQDVHqbAYdMYlGheqNgPA==&ch=2aSpcbpaPpNlmC3FiG68qDetowRq8k2e5uiLx0pX9dJBILIo1uROVg==]
that several news outlets were "black listed" by his campaign.  Among those listed
were The Washington Post, Univision, BuzzFeed, Politico, The Daily Beast, The Huffington
Post, and The Des Moines Register. A notable exception to the list was The Fickenscher
Files.  I guess my reporting has not reached the level of awareness yet among the
campaign.  However, I keep checking my email and snail mail every day.  So, I'll
 keep on reporting.  See "The Bad" below...
California Follows The Lead Of Hawaii On Smoking - California passed a law that 
recently went to effect that is likely to ramifications across the nation over the
next couple of years.  The state raised the age limit [http://r20.rs6.net/tn.jsp?f=001mSquE-RKV5E3k8BmGNfMaHsHMw5FPDacuoiBrHXiVWtC7_6KKOOZpsEWG8lXfmlf-d705g12CmqRaZWq6waxkyQaYKMa12jxJTQSiNSrndjOwZRk5BAh1xPJ-iwQwhpiHAHAFoUKNSVAffjrFoDdKM_WLtEGhocK4iyZTOId2Pu4WPC9lBH-fRGm87cevwuB-0S-uF8Onhw=&c=-WnTglBl6oQ_rph2XA_S1Yi0QxackqEpWCQDVHqbAYdMYlGheqNgPA==&ch=2aSpcbpaPpNlmC3FiG68qDetowRq8k2e5uiLx0pX9dJBILIo1uROVg==]
for buying tobacco products from 18 to 21 and, banned the use of e-cigarettes from
public places like hospitals, schools and restaurants.  Hawaii was the first state
to adopt the new legislation but California followed quickly and, as a bellwether
state, it will likely have an impact nationally.  The Institute of Medicine is predicting
that the new law, if passed nationally, would further drop the smoking rate from
 around 19% of the populace to about 12%.  As you can imagine, a lot of organizations
have lined up in support of the legislation along with a couple of anti-smoking 
advocates - like me! The law that takes another bold step to limit smoking takes
 effect Thursday.
Cancer Moonshot Off And Running - In the January State of the Union, President Barack
Obama announced that the USA was going to initiate a "cancer moonshot" and after
 making the announcement, turned around at the podium of the House of Representatives
to Vice President Joe Biden and asked him to take the lead.  Recently, Vice President
Biden made a major move forward by announcing the launch of a first-of-its kind,
 open-access cancer database.  The new database will allow researchers to develop
more effective cancer treatment approaches by collecting information to better understand
the disease process.  The Genomic Data Commons will be a part of the National Cancer
Institute (NCI) and, collect raw genomic and clinical data from more than 12,000
 patients as a starter kit.  In addition to detailed analytic data on the molecular
composition of the cancers, the Commons will also collect information on which treatments
were used and how patients responded. He noted that the intent is to move away from
research based on "the cult of the individual" and rather to focus research on combining
the knowledge, skills and capabilities from across the entire nation who are focused
on cancer research.  He called it "team science" noting that "...There has got to
be a better way." The initial bolus of data for the program will come from existing
NCI programs like the Cancer Genome Atlas (i.e. generating genomic maps of changes
in 33 types of cancer as patients undergo treatment) and the Therapeutically Applicable
Research to Generate Effective Treatments or, TARGET program (i.e. focused on pediatric
cancer.  So, it appears that we are off and running.  It's going to be an interesting
journey that I anticipate will harvest unique findings in the coming decade, if 
we continue to support the effort.  Let's hope we do...
How Graphic Can Graphic Be? A new study [http://r20.rs6.net/tn.jsp?f=001mSquE-RKV5E3k8BmGNfMaHsHMw5FPDacuoiBrHXiVWtC7_6KKOOZpsEWG8lXfmlf0J2rGIU91mTWoqrxQr-v2Td0WPLy5du62MYfOUWq4pYutw1O0bBDHP2nHWt0BSzv_ghoSn6qBBZuwJAx6ryI3OvcbCcarYRbpSDPGOpWtpKo-JLc1JtgF7ZobnV5NWyWrXkjeexDMJvOBIvjcqYHXvTfthteZHzPMCsxU4dRbG5S5W6xGl9XLMHWryOO3kt3DiuJvU_sXx4SfHRrinHwb5nXUT8smU2AqaMd4SYElftBdljFR3kAxGmolJn29Zh_VH-pkfZjc-chqM7s3gafGqyxeiHoG-csqg7q32yQ9XYMXMzQnUI8f-sh_1K3T2V4gHCpZNyAvIvGEHc13cUiKE3cGXgZq8SYycsdWUhkIRdCAwCwI_mL6qWbMXFZxkqxwK3y78WxCyT4RWxl6JRxmCHVpKdLs_GAn7XFkXxgYJBCCdO3Xc0jgwV8ebhtDkKoxc8x8vcLyXX-K1uJQw6c98P0y8QV-THzkEk5Po1d0RccbBjOuatmySuiqBT7mk2_zJcmPJiRz6vAGzRMO69eUpx-7hmeteKw-_1AsJFE_gGqAPP-MWlCqoZjGlN0WOntfaxADAvNiw52CvXQRPsIvw==&c=-WnTglBl6oQ_rph2XA_S1Yi0QxackqEpWCQDVHqbAYdMYlGheqNgPA==&ch=2aSpcbpaPpNlmC3FiG68qDetowRq8k2e5uiLx0pX9dJBILIo1uROVg==]
was recently published in JAMA Internal Medicine reporting that smokers were more
likely to try and more successful at actually quitting if they are given cigarette
packs with graphic warnings compared to a control group of smokers who were simply
given cigarette packs with only text warnings.  The move toward more graphic warnings
was mandated under the US Tobacco Control Act of 2009 several years ago but has 
not been implemented because of a pending case where a federal court struck down
 the mandate.  The mandate called for photo warnings on cigarette packs.  The researchers
noted that 40% of the smokers who got cigarette packs with graphic warnings tried
to quit during the study period compared to 34% of smokers who only got the text
 warnings.  Those smokers receiving the graphic warnings were also more likely to
quit smoking.  So, here's an idea.  How about instead of graphic visual warnings,
we require cigarette packs to be loaded with graphic "verbal" warnings - you know,
like those birthday cards that when you open them up, they play a song and announce
"Happy Birthday".  How about every time you pull a cigarette out of the pack you
 hear, "Hey, are you crazy?  Wanna die, then go ahead a smoke a cigarette!"  The
 technology is there.  Once we get through the morass of a lawsuit (by the tobacco
industry) transferring the "warnings" from visual to verbal should be easy.  After
all, a warning is a warning!
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Approaches To Alternative Care Delivery
Ideas and thoughts on how care delivery can be transformed...
The Pricing Of Health Care Insurance Plans - As usual, it seems that organizations
all over the country are engaged in the ongoing discussions related to the price
 of health care insurance.  It's a topic that doesn't go away despite all of the
 changes we've made through the implementation of the Affordable Care Act [http://r20.rs6.net/tn.jsp?f=001mSquE-RKV5E3k8BmGNfMaHsHMw5FPDacuoiBrHXiVWtC7_6KKOOZpsEWG8lXfmlfSepI_tIOEpQhvncdtaIG5bbc6k19qhC6Mt1qM4R_6NcmnnuUV7FFIbVaHRU8K9pL-YNfzbxQegB3TATix19ESg2VClCQSmAXHoGMFaasyd93n4wul27dN3lQPIB2Onj4BzOyPmRyiOjm2o9uECwwmC6saYPZM7LhVWWdHbGxPsg9SNE8h3qXlw==&c=-WnTglBl6oQ_rph2XA_S1Yi0QxackqEpWCQDVHqbAYdMYlGheqNgPA==&ch=2aSpcbpaPpNlmC3FiG68qDetowRq8k2e5uiLx0pX9dJBILIo1uROVg==].
 However, the pricing changes are highly variable with some geographies experiencing
large increases and other more stable pricing.  What gives?  The Robert Woods Johnson
(RWJ) Foundation and the Urban Institute got together to collaborate on a research
project [http://r20.rs6.net/tn.jsp?f=001mSquE-RKV5E3k8BmGNfMaHsHMw5FPDacuoiBrHXiVWtC7_6KKOOZpsEWG8lXfmlf5JrfoJnryVDNbP0ytNErUowU7trY7FvXED88rbCPP2aLBoQ8pCANNiiLe67Nk_2i1BQpNRtpIA4xRuFhpy8oXlD72UF5eML7aQPwRq62B5dyLSDgs8dWITbLrD-lgwODuwYdilznVF3-kk4DHlRQ90xr8Npdzzamkigp_REoFVIbDovSmDC1mM-J8euNhWqM&c=-WnTglBl6oQ_rph2XA_S1Yi0QxackqEpWCQDVHqbAYdMYlGheqNgPA==&ch=2aSpcbpaPpNlmC3FiG68qDetowRq8k2e5uiLx0pX9dJBILIo1uROVg==]
in an effort to identify the reasons for the price increases and why the variability
was so great. One of the important findings from their research - from my perspective
- was included as part of the report, stating: "We conclude that a national average
rate of premium increase is a fairly meaningless statistic since different markets
are having very different experiences."
The report noted that only five states experienced a decrease of premiums this year
compared to 2015 with 12 states experiencing increases of more than 20%, on average.
The states with the largest increases were mostly located in the Midwest (my home
state of North Dakota among them) with Oklahoma topping the list with an increase
of 41.8% this year.  At the other end of the spectrum was Indiana (also a Midwestern
state) where prices decreased by 12.1%.  So, geography doesn't seem to be the reason
(SEE the Table for more details).

So, what were the reasons?  Well, it seems that the biggest reason for the difference
in prices was competition.  In essence, geographies with more competitors had significantly
lower premiums and significantly lower rates of increase than the geographies where
competition was more extensive.  The other factor that came as a surprise from the
research was that if the rating area had a Medicaid insurer competing in the marketplace,
the geography had lower premiums and rates of increase.  What this means is that
 if the Medicaid program is not present in the market, the rates of increase will
be higher because the private insurers will of necessity be required to carry the
burden for insuring the populace.  Given that many of the largest insurers have 
dropped out, the number of geographies where there are fewer choices is increasing
and therefore, it is likely that these areas will face further, continuing price
 increases in the years ahead.  The lesson:  Competition is good!
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Article Of The Week
Information for your Consideration...
"The Unseen [http://r20.rs6.net/tn.jsp?f=001mSquE-RKV5E3k8BmGNfMaHsHMw5FPDacuoiBrHXiVWtC7_6KKOOZpsEWG8lXfmlf6upKFSi0h1C1ej2IZcLzqz3_Rdn1sFQ4rN7UJ3lQT1L5uC3C9np_CpUUyCBJyvx9_BKHwd6v3xLncu7bzq_c3lUfXFroV9rRDL_pSOPoWxD2VGZpB2_13aVD6aMtZPpm9Wg632zWoQNuLQnFYld9sKT6C-LjkOKQ1UBKkSOVeg8=&c=-WnTglBl6oQ_rph2XA_S1Yi0QxackqEpWCQDVHqbAYdMYlGheqNgPA==&ch=2aSpcbpaPpNlmC3FiG68qDetowRq8k2e5uiLx0pX9dJBILIo1uROVg==]"
is one of those lay articles that you must read.  It is from June 20, 2016 issue
 of The New Yorker.  It discusses the search by a group of microbiologists for the
answer to the Great Plate Count Anomaly - where many, many plated bacteria simply
do not grow despite the fact that they exist.  I predict that the "macrobiome" is
going to be one of the most important explorations of the 21st Century and this 
article outlines why it is so important.  A definite read...
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The Weekly Whisk
Musings from a foodie...
We were down on the panhandle of Florida last week and a friend invited us to dinner.
Bijoux [http://r20.rs6.net/tn.jsp?f=001mSquE-RKV5E3k8BmGNfMaHsHMw5FPDacuoiBrHXiVWtC7_6KKOOZpsEWG8lXfmlfQJtm9hek4kqIiVKsKo0B3coGJ3AdVYEVyp49_Ij2BFuun_ZuDnAtlE102j_uSA4mF94SG6u13-RSW9jmLXAnZwS30K-X8pMkWi2KaAV19fQBsP3VTRQlNg==&c=-WnTglBl6oQ_rph2XA_S1Yi0QxackqEpWCQDVHqbAYdMYlGheqNgPA==&ch=2aSpcbpaPpNlmC3FiG68qDetowRq8k2e5uiLx0pX9dJBILIo1uROVg==]
[* * *] is located on US Highway 98 near the wonderful white sand beaches of Destin.
 The beach was great and Bijoux was quite good.  It combined the Southern hospitality
with Cajun/Creole cookin'.  The menu had all of the traditional Southern foods like
red beans and rice, hush puppies and the like.  The seafood was great.  In fact,
 the cobia [http://r20.rs6.net/tn.jsp?f=001mSquE-RKV5E3k8BmGNfMaHsHMw5FPDacuoiBrHXiVWtC7_6KKOOZpsEWG8lXfmlf9AHiJur63epPdyCNTAakhCiihr7Mr7hTNCZ17OEyEEbPhj85IOUzyjpW4eO18ZtMTpA2HSfP62acVQpcXkajpw56ulPAAexwTUv57KNhi9_qWKBS_nufBECIN0WWu1nB&c=-WnTglBl6oQ_rph2XA_S1Yi0QxackqEpWCQDVHqbAYdMYlGheqNgPA==&ch=2aSpcbpaPpNlmC3FiG68qDetowRq8k2e5uiLx0pX9dJBILIo1uROVg==]
was cooked to perfection.  As a thicker cut of white fish, many restaurants don't
seem to get it right.  Either the fish is dried out or underdone.  In this case,
 it was perfect (most likely done in a steam oven after a brief saute - but, I'm
 guessing).  Regardless, if you get down to the panhandle area and are in the region
of Destin, I would definite consider Bijoux.  The only problem was the noise level
which got a bit high as the crowd thickened.  Consider it if you're close: Bijoux
- 9375 US Highway 98 West - Suite 22 - Miramar Beach, Florida 32550 - (850) 622-0760
- www.bijouxdestin.com [http://r20.rs6.net/tn.jsp?f=001mSquE-RKV5E3k8BmGNfMaHsHMw5FPDacuoiBrHXiVWtC7_6KKOOZpsEWG8lXfmlfKm-tEb6Pjc2V3MA_vcfvW2n2YAOMUfVh50cmY8_KOQbw1SWXXFj1fLQfSWlumy95wLE6I_pUuaT_yZWVsWYNvc252fTQT3heZFEXUtm9Yq34HqY4-gJUFg==&c=-WnTglBl6oQ_rph2XA_S1Yi0QxackqEpWCQDVHqbAYdMYlGheqNgPA==&ch=2aSpcbpaPpNlmC3FiG68qDetowRq8k2e5uiLx0pX9dJBILIo1uROVg==]
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The Good, The Bad, And The Ugly
The ongoing saga...
The Great - There's hope!!!  Kenneth Shinozuka - a 17 year old inventor - has developed
a wearable sensor (= Safewander [http://r20.rs6.net/tn.jsp?f=001mSquE-RKV5E3k8BmGNfMaHsHMw5FPDacuoiBrHXiVWtC7_6KKOOZpsEWG8lXfmlf5j4SKqoKXbsPoB6p-PfKZoqDzby6vkP2IKJ8XkusPjJtgpeJISIsdh_fYMxqnA2tsriQQG1qVH8ZnM-18CgpmfdAZwxrI8WYUYJLM4xencrhY97L-Immqg==&c=-WnTglBl6oQ_rph2XA_S1Yi0QxackqEpWCQDVHqbAYdMYlGheqNgPA==&ch=2aSpcbpaPpNlmC3FiG68qDetowRq8k2e5uiLx0pX9dJBILIo1uROVg==])
that alerts caregivers when individuals get out of bed.  It's the beginning of "telecare"
where technology can be used to engage family members in helping to care for their
loved ones through the alerts.
The Good - It's sad but it's true - Prince's death has caused a marked increase 
in understanding and appreciation of the fact that we have an opioid crisis in the
USA. The drug that killed him - Fentanyl - is 50 to 100 times more potent than morphine
and 30 to 50 times more potent than heroin - and, in the wrong hands very dangerous.
His death has changed the lackadaisical attitude about the crisis...  Let's hope
 so...
The Bad - The ongoing tenor of the USA Presidential campaign is disturbing at best.
 When are we going to move toward discussing and debating the important issues of
the day and the policy positions of the leaders rather than calling candidates names
like "Crooked Hillary"?  If it continues, it's a demagogue rather than a leader 
on display...
The Ugly (or, The Really Bad) - The Brexit vote to "leave" the European Union (EU)!
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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