Subject: News from Dr. Kevin Fickenscher
From: "The Fickenscher Files" <[email-masked]>
To: <[email-masked]>
Date: Tue, 27 Dec 2016 09:40:49 -0500 (EST)

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001TV-FZEatZC5k1Xgl5_CO-QHEBalC0CF2rBGHYCwrtPjYvGvFgA-mkk-30YOraDkswoZ0M-Ncvb_zhEc2wDYJgS15BwGyI8RNVxuMQxnZqs7BzpQExA5lVCsk_VEuTEmzOeDJtf_f-6JSeJ3rgJZsRshgx10SDOH37M8ktPcauD67vjLJQEGgbYYA7FxQ4OWR&c=2s0s6Aie-CM8zSaHrkLizc5jWWwzW3Q6597VHoETw6r-Br31zfhdqw==&ch=p8xKoRIxMipn-TgTx16GzWu1z2teh1y5WdiW5JRmd1LSx3idyl96LQ==]
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Fickenscher Files, Vol. 4, Issue 16
Kevin M. Fickenscher [http://r20.rs6.net/tn.jsp?f=001TV-FZEatZC5k1Xgl5_CO-QHEBalC0CF2rBGHYCwrtPjYvGvFgA-mkmqSb7y2jkFfBeF_18aqWwKZ1x-uIpHRjvDedxofZN5YFfzhXcOlYY0YbHuXUlZaQ8iLqosrZAcGzFA2T47pOzX7FgTvL69FnbbRbbByro_f8T1xZGbd-5_Nd9WYJazQdyLVXvamZ0wosKEqumaPDJ4q90vELHkyJp_0PW5S5JB4edQxEG6poRBlCtHgZlSUHmvtCd4c1_LxL_cbWZfxf4k=&c=2s0s6Aie-CM8zSaHrkLizc5jWWwzW3Q6597VHoETw6r-Br31zfhdqw==&ch=p8xKoRIxMipn-TgTx16GzWu1z2teh1y5WdiW5JRmd1LSx3idyl96LQ==],
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) - Or, Tit-for-Tats - Of The Week
"Enrollment is running ahead of last year.  Today's enrollment numbers confirm that
doomsday predictions about the marketplace are wrong."
Sylvia Burwell, Secretary - US Department of Health and Human Services, in announcing
continued growth in the number of individuals seeking insurance through the exchanges.
"This disaster of a law has led to massive premium spikes, less choice for patients
and a collapse of the exchange markets, and no amount of spinning from the White
 House can hide this ugly reality."
AshLee Strong, a spokeswoman for Speaker Paul D. Ryan (R-WI), Speaker of the House
- in a response to the announcement by Burwell.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Consulo Indicium
Information for your Consideration...
Just In Time For The After-The-Holidays Gift Giving Set - You medical types are 
probably wondering what you could do for one of your colleagues - right?  Well, 
just in time for the holidays is the announcement that the 80th volume of The Oxyrhynchus
Papyri [http://r20.rs6.net/tn.jsp?f=001TV-FZEatZC5k1Xgl5_CO-QHEBalC0CF2rBGHYCwrtPjYvGvFgA-mkixvk_Xfh5oMIgSetVdflGi8-v_qB4Yelje5TLIkd88fmEgXmVRHBxQv51GVbS_np-HLfBV74uPjs7RmFY8m8-mYU9N2tpFK-hevLDdN1Ys_S3WBzxz0fH3xwnVeEJabgf7ghoovdhXNL5sp4JUdDUT7zAeKqkzxD1o92oO3CXjnc6aoZMFqK0adYHpTiKLlus3RasdtHAwv4eqx0DajfR0=&c=2s0s6Aie-CM8zSaHrkLizc5jWWwzW3Q6597VHoETw6r-Br31zfhdqw==&ch=p8xKoRIxMipn-TgTx16GzWu1z2teh1y5WdiW5JRmd1LSx3idyl96LQ==]
which at 176 pages is available for you holiday shoppers at £85.00.  This is the
 largest collection of medical papyri published to date.  It includes manuscripts
from Hippocrates, Dioscorides and Gallen - to name a few of the more prominent medical
leaders.  These medical writings were among over 500,000 papyri which were discovered
in a dump just over a century ago. The papyri have already revealed original works
by Plato, Livy, Euripides, Sophocles, Herodotus and others.  The medical scripts
 contain some of the very earliest writings on the field and for that special someone,
you too can share them with a colleague.
Are We Surprised?  The Girl Doctors Best the Boy Doctors - In a study that has sent
some ripples through the establishment, a pair of Harvard researchers reported in
JAMA Internal Medicine [http://r20.rs6.net/tn.jsp?f=001TV-FZEatZC5k1Xgl5_CO-QHEBalC0CF2rBGHYCwrtPjYvGvFgA-mkixvk_Xfh5oMVyAsdh1T94qDqSl8HBvPMdAnL_RlGDGMp6-cy7s7F0cGyDA3ebAlGhi6vFoC4OnR5Wq66Jla4g3UHELiL_kRaoW2c_RuPFpA_YjA8tI48OXssncE3Ao5UROa1GmEQh0Ttl60wsUUe-WEZ1hu3lqYgdzsPkk3le5DJaYnbu-O7iGozX4LBcemAQ==&c=2s0s6Aie-CM8zSaHrkLizc5jWWwzW3Q6597VHoETw6r-Br31zfhdqw==&ch=p8xKoRIxMipn-TgTx16GzWu1z2teh1y5WdiW5JRmd1LSx3idyl96LQ==]
that female doctors who care for elderly hospitalized patients get better results
than male doctors. The data are clear: patients were less likely to die and less
 likely to return to the hospital if they were cared for by women physicians. So,
the big question is: Why? There's not a clear answer although some analysts attribute
the results to the more emotionally intelligent approach taken by women in caring
for people based on their maternal upbringing.  They may apply to some of the guys
in medicine but it's not across the board.  So, there is no answer - at this point
in time.  But, the results are significant.  According to the authors, if the results
were extrapolated across the entire USA population, "...approximately 32,000 fewer
patients would die if male physicians could achieve the same outcomes as female 
physicians every year."  In the end, the study offered no guide on the "why" question.
 It requires further study!  That's always a good thing to say when we don't know
what to say...
But, there's this other issue that doesn't require further study.  Evidently, the
female physicians earn $19,876 or 8% less [http://r20.rs6.net/tn.jsp?f=001TV-FZEatZC5k1Xgl5_CO-QHEBalC0CF2rBGHYCwrtPjYvGvFgA-mkixvk_Xfh5oM7iJOM6tx_BiPZpTd-RPXbKaXxFxZwauvVL3Gun8yzzjsJMwrt5Xfi4T97v7--8yyalX1ZrK2m-5Szmn-MrBUZAFeaGi2-bfGxUAg3Fq-5MHxDkdKWiBN4rPIhSg7bPijqLx7ZFfXkXQqaVxEJS9G3kRRyaTo1X1uTMiGQv_e_9DY3DAlxzQaU0EDw-lASIHUhjNnoGLTzxs=&c=2s0s6Aie-CM8zSaHrkLizc5jWWwzW3Q6597VHoETw6r-Br31zfhdqw==&ch=p8xKoRIxMipn-TgTx16GzWu1z2teh1y5WdiW5JRmd1LSx3idyl96LQ==]
than their male counterparts for the same jobs in the same specialties.  Now - that's
a problem!  And, it does not require further study. The disparity has been traditionally
attributed to domestic duties and maternity leave.  I question that assessment -
 and, so does my wife - a practicing dermatologist.  So, in this case, "...requires
further study" is not necessarily a good thing to say.  Rather, it seems to be a
 denial of reality. Leaders need to change the reality...
Some Progress - But, Some Big Declines - The results are in from United Health Foundation's
2016 America's Health Rankings Report [http://r20.rs6.net/tn.jsp?f=001TV-FZEatZC5k1Xgl5_CO-QHEBalC0CF2rBGHYCwrtPjYvGvFgA-mkixvk_Xfh5oMB9NJECqmaF36yf3lP0_AfknrBGYjkTrlElQkyf2ch5EW2kwToYhQH_T9Rb0ZqUXiElsIqr5Qfdn6y1aJbczHGfxB2u_j4vxi6Gqxx5J-wHSf3otmbVTMQOtBnkeucv7he1pKDPW7fDWbNGfYabqzDErPZB3IumD4_EU2mMzB8CVSXfmVea6KBw==&c=2s0s6Aie-CM8zSaHrkLizc5jWWwzW3Q6597VHoETw6r-Br31zfhdqw==&ch=p8xKoRIxMipn-TgTx16GzWu1z2teh1y5WdiW5JRmd1LSx3idyl96LQ==]
which evaluates some 34 health outcome measures such as cardiovascular and cancer
deaths, various health status disparities; and, four "health determinants".  The
 rankings are done on a state-by-state basis.  For the fifth year in a row, Hawaii
ranked as the "healthiest" state in the Union and Mississippi ranked 50th which 
it has languished as either that position or 49th for 25 of the last 27 years since
the report was initiated.  Some findings of note included the following:

* Smoking rates among adult USA residents have declined by 41% since 1990,
* Medicare preventable hospitalizations declined by 35% over the past decade - but,
most dramatically in the last year from 2015 to 2016 by 13%,
* As a direct result of ObamaCare, the rate of uninsured in the USA declined by 
35% over the last five years,
* Drug-related deaths grew by 9% over the past five years with nearly ½ of the increase
coming in the period from 2015 to 2016; and,
* And, most disturbingly - obesity was 157% more prevalent in 2016 than it was in
1990 - when the study was started.
Whither The Rural Hospitals - In a stark call to action by the National Rural Health
Association [http://r20.rs6.net/tn.jsp?f=001TV-FZEatZC5k1Xgl5_CO-QHEBalC0CF2rBGHYCwrtPjYvGvFgA-mkixvk_Xfh5oMn2TVM2NY2uY7h9VPP5VHhkVDSeiQqc7u09A0f3BhXZh6qi2N9fRKRr64Iy-5NTKK9fMc8qOFo5JF0CC7OhFGgcHUf4Ego5D9N3lW9rQcpG7oiK3oBjWHQ2M6k0g_5NBbTu7QwIbJ0OpmGH3WsiPac9SCQAGIImAdjBlRJXeX0FbsPfp1r4u5gpVjhcf7qdJWGxYCj2K6jnhebLdhXvUDSw==&c=2s0s6Aie-CM8zSaHrkLizc5jWWwzW3Q6597VHoETw6r-Br31zfhdqw==&ch=p8xKoRIxMipn-TgTx16GzWu1z2teh1y5WdiW5JRmd1LSx3idyl96LQ==]
(NRHA), nearly 30% of the nation's 2,000 or so rural hospitals are likely to close
in the next two years. For example, in the state of Louisiana 58% of the rural hospitals
are considered vulnerable.  But, it's not just in Louisiana - it's all over the 
country.  According to Alan Morgan, chief executive of the National Rural Health
 Association (NRHA), the current crisis started in 2010 when over the past six years,
74 rural hospitals ended up closing.  Furthermore, in 2013 the association notes
 that more than one-third of rural hospitals were operating at a deficit. For an
 old rural health advocate like myself, "it's déjà vu all over again" - to quote
 Rodney Dangerfield.  In the early 1980s I served as the President of NRHA after
 it was first formed and hospital closures was one of our mantras.
So, why is the crisis happening again?  It seems that it ironically relates to the
implementation of the Affordable Care Act (ACA). While the ACA increased access 
to care across the country it has also clearly moved the reimbursement system away
from a traditional fee-for-service model which has been the foundation for many 
rural hospitals - especially the "critical-access hospitals".  These rural facilities
are reimbursed 101% for each service that a Medicare patient uses in the hospital.
 And, it's important to note that the rural hospitals are very heavily dependent
 upon Medicare since the primary utilizers of these facilities are the elderly. 
On top of those issues, the ACA also required the adoption of electronic health 
records and extensive reporting but the rural facilities were given no relief or
 special assistance.  The changes were coupled with the fact the Medicare has cut
their rates at least 8 times since implementation of ACA - again, without any special
dispensation for the rural hospitals.
These reimbursement problems have been compounded by the lack of Medicaid expansion
in some states, the ongoing decline in the availability of primary care providers
moving to rural areas as well as the expansion of electronic care delivery modalities.
Long story short - the rural hospitals are in trouble.  So, much like the 1980s 
there is likely going to be a movement to reconsider the payment and other support
systems for rural hospitals.  Of the 2,078 rural hospitals in the USA, 673 - or,
 just over 32% - are vulnerable to closure.  My prediction is that there will be
 a call for action among the Senators and Representatives in the coming legislative
session...
Finally - A Repeal And Replace Idea! But, Is It Real? In the past week, the House
Republicans in an effort to quell criticism about their "repeal and replace" strategy
called for the nation to adopt a health law which would guarantee "universal access"
to health care and coverage although it would not ensure that everyone actually 
had some type of insurance. The House leadership told journalists, "Our goal here
is to make sure that everybody can buy coverage or find coverage if they choose 
to." However, "finding" health insurance has always been relatively easy.  The issue
historically speaking has been whether what was found was affordable.  The Democrats
argue that repealing the Affordable Care Act would create a gap for millions of 
American citizens because they would forgo purchasing health insurance [http://r20.rs6.net/tn.jsp?f=001TV-FZEatZC5k1Xgl5_CO-QHEBalC0CF2rBGHYCwrtPjYvGvFgA-mksF-oTChvjdAc2mOaRv4p-Hx2mzMtPoK0u3KGW4nAQLaytwDziNE5N_pyACkos8NrSKpfr7N8DxPSlpEg5FcOkW5fqlDp5BUkxQc70_LG_Dp3zSBigYr3zb0w1wxUzw2tt0c7ZhWgIM28OPdFgMV354b_K1nNfXN4yze7Ui_7MjFy4e1rP7nRQmT8YrPa4LJ96G--MQuPt5z_QIpHWsiA0CXttgannaRwxJ9Rblwb198bDYS2r8AF9ti7NBnlJ_F8pQBc-_LI9mevjO-LzQB08xSEsHVW_V1052Nj2vUvvzj&c=2s0s6Aie-CM8zSaHrkLizc5jWWwzW3Q6597VHoETw6r-Br31zfhdqw==&ch=p8xKoRIxMipn-TgTx16GzWu1z2teh1y5WdiW5JRmd1LSx3idyl96LQ==].
You would expect that the Democrats would weigh in and they did by focusing on the
fact that 20 million people have coverage under ACA who previously had no insurance.
 Even the conservative leaning American Medical Association (AMA) indicated that
 "any new reform proposal should not cause individuals currently covered to become
uninsured."  The Republicans went one step further when Representative Kevin Brady
(R-TX) and the Chairman of the Ways and Means Committee pledged, "We can reassure
the American public that the plan they are in right now, the Obamacare plans, will
not end on Jan. 20," the date for Donald J. Trump's [http://r20.rs6.net/tn.jsp?f=001TV-FZEatZC5k1Xgl5_CO-QHEBalC0CF2rBGHYCwrtPjYvGvFgA-mkixvk_Xfh5oMltmYC_2eIpzDdgsP9npmlqlrgebC-eem2fFSV4AGJxGN-ib8QEFHvpdb2H8LDIdjxCxsPavYu38IDqxi3q3Vz3rcHU0F9gnpbsKQEZ9rcPk7POK9l_fe4T3ynwSjeQYKsJ98BU6mVr6NJjIFx2ckD5J1OXiUlG5-fay8G0jYH-Y=&c=2s0s6Aie-CM8zSaHrkLizc5jWWwzW3Q6597VHoETw6r-Br31zfhdqw==&ch=p8xKoRIxMipn-TgTx16GzWu1z2teh1y5WdiW5JRmd1LSx3idyl96LQ==]
inauguration.  We await the details...
Meanwhile, reports emanating from the Hill note that Republicans and the incoming
Trump administration are coming together around a strategy of "repeal and delay 
[http://r20.rs6.net/tn.jsp?f=001TV-FZEatZC5k1Xgl5_CO-QHEBalC0CF2rBGHYCwrtPjYvGvFgA-mkixvk_Xfh5oMtgDUFKbo0gW8VmlimZ72Yg1zLdxgF6-0i3QidKZJ1P91SpIdesRht4jFl2nisiuvdt3Q9ZN3HfVsPGmcwz-YPnUjTzoVhK3D9JUMxz_j5Y-CMlDet-sUARTKC5jPkuRzjdmaXXHgf-G3IEggOadvKuCPqFCdSBpLXnY-d4od6N2mZ4F_fgYIXPWmKbPrkG-G_v0zTIFExHwAH-lo0qms5ImFpePcQYg-hFqSHw9qOsT02dwGfCzBpFkepxVbbSO9QmZulNLgpL_YWpYC_j2giWzcQnzcfKM5WVh0hmNh4UA=&c=2s0s6Aie-CM8zSaHrkLizc5jWWwzW3Q6597VHoETw6r-Br31zfhdqw==&ch=p8xKoRIxMipn-TgTx16GzWu1z2teh1y5WdiW5JRmd1LSx3idyl96LQ==]."
 So, how does that work?  In essence, they would pass a bill to kill selected provisions
of ACA law by a certain date.  The date would be off in the future at some date 
but would allow the Republicans time to develop a replacement bill before that date
arrives.  While it would be quicker to simply repeal the health law outright, the
Republicans can't make that happen.  Why?  Because such a bill would require 60 
votes in the Senate to fend off Democrats' delaying tactics, and there are only 
52 GOP members. So, to accomplish the change, they need to pass a "budget reconciliation
[http://r20.rs6.net/tn.jsp?f=001TV-FZEatZC5k1Xgl5_CO-QHEBalC0CF2rBGHYCwrtPjYvGvFgA-mkixvk_Xfh5oMn6MD1ZLZHDPLDNqWtVxYGMUGK0ThPNrrwWrknNX2sI2N5mKZl3q9_AW3m0VPmQ8vdm4Znf_NsuziKoeoUZJXXoR79fUqpQrsfD9Z1XxsOUSInH2TrZwZvZl_KvvYDz6r2CZjD-4ZL7HoLlccB6YNgq0b2KZOlIcw6_SvuWhHa8iOjExg5jI_bTy4jxqcf2Rw&c=2s0s6Aie-CM8zSaHrkLizc5jWWwzW3Q6597VHoETw6r-Br31zfhdqw==&ch=p8xKoRIxMipn-TgTx16GzWu1z2teh1y5WdiW5JRmd1LSx3idyl96LQ==]"
measure which will not repeal the entire law.  Instead, it focuses on only those
 portions of the ACA that directly impact federal spending. A reconciliation measure
only requires 51 votes.  And, so it is "like sands through the hourglass, so are
 the days of our lives [http://r20.rs6.net/tn.jsp?f=001TV-FZEatZC5k1Xgl5_CO-QHEBalC0CF2rBGHYCwrtPjYvGvFgA-mkixvk_Xfh5oM3wjA-my6XP8L1iAj_4vKXPwRiKLbH61iXzK93n0S-x3n26zwt02qlJe42y76yNT6E5R73tvrLnxHAjAbwE1LCOeX1OsuG9mVsNA2F2cLa69EP9o5Kqy26qlZZzG066qBQhg79nwSlSceJA-0icDqDGiIV8jl1_56w_OrOHQZVK8=&c=2s0s6Aie-CM8zSaHrkLizc5jWWwzW3Q6597VHoETw6r-Br31zfhdqw==&ch=p8xKoRIxMipn-TgTx16GzWu1z2teh1y5WdiW5JRmd1LSx3idyl96LQ==]."
In The Meantime - Value-Based Models Are Difficult For Small Practices -The General
Accounting Office (GAO) recently weighed in on the challenges faced by small and
 rural physician practices with the new move toward valued-based reimbursement models.
 The report [http://r20.rs6.net/tn.jsp?f=001TV-FZEatZC5k1Xgl5_CO-QHEBalC0CF2rBGHYCwrtPjYvGvFgA-mkixvk_Xfh5oMYF7uDuwXB17XFAPgYec4uMiY1gSOy1nr8uAGbYOD31a1WWSO6OOhrqYLgKcilNkBkqyb9MA-YI-W9d5_Hq74kGl5o8uqv6VUv6r0D2562tgLnL4RhEU4I4nqo-V3obGXkdFLdlbl-h8=&c=2s0s6Aie-CM8zSaHrkLizc5jWWwzW3Q6597VHoETw6r-Br31zfhdqw==&ch=p8xKoRIxMipn-TgTx16GzWu1z2teh1y5WdiW5JRmd1LSx3idyl96LQ==]describes
the challenges faced by small practices as those with 15 or fewer physicians and/or
those located outside of an urban area. It defined the value-based models under 
five broad categories, including: financial resources and risk management; health
IT and data; population health management care delivery; quality and efficiency 
performance measurement and reporting; and effects of model participation and managing
compliance with requirements.  From the report and other initiatives that have been
undertaken by the Centers for Medicare and Medicaid Services, it's increasingly 
clear that the small and rural practices need "special" attention and, that urban
models do not necessarily translate easily to the outlying areas.  One of the biggest
issues in the population health movement is how best to deliver such care when time
and distance are major impediments for the care delivery programs.  For those who
are interested in the road blocks faced by these practices, the GAO report is a 
quick read and provides a blueprint on where the focus should be related to remedial
steps in solving the problems.
2015 Personal USA Health Spending At $10,000 Per Person - The Department of Health
and Human Services recently announced that USA healthcare spending "increased last
year at the fastest rate since the 2008 recession, reaching $3.2 trillion, or an
 average of nearly $10,000 a person." The HHS report attributed the increases to
 the expansion of Medicaid eligibility and enrollment. Are we surprised?
A Sad Commentary: The Collapse Of The American Dream - The December 8 issue of The
Washington Post [http://r20.rs6.net/tn.jsp?f=001TV-FZEatZC5k1Xgl5_CO-QHEBalC0CF2rBGHYCwrtPjYvGvFgA-mkixvk_Xfh5oM7FQjfBYfGU_t5yv3xiU-gTsxHmhktszztWvmHeTwYrVXtVT4QmBOM8yoDgnkO8OIDppC8pXlmGxmeHxbt8PtvE1x7MpjD-G2qecy1_WvamRgiWRNYsnDVLTz7aA94rh8B8uxGKytOFq0jZnqvrVAn8AoecnwFK6t76LxUn1dIZQ6J2dzF5Ytp6pMZVUpC5bsN92Nl3REIjDIqJxSzlu71OsnanYubeh43ZWY9qbbINsp0v3ZqTIkRw1ZO5OPCKk_v0UKxWN7qFuJnvIaoHMzjrAWwHpDAWf2R9Z58B6Zr1w8Vedofl3OvWbdAca81aBEAnH77e836jK1S2-12cVR2BADq_4GWxofSmppiES1QyI7iSkyTN4OTQ==&c=2s0s6Aie-CM8zSaHrkLizc5jWWwzW3Q6597VHoETw6r-Br31zfhdqw==&ch=p8xKoRIxMipn-TgTx16GzWu1z2teh1y5WdiW5JRmd1LSx3idyl96LQ==]
had a stark assessment of the rising income inequality which has apparently eroded
the ability for American children to grow up and earn more than their parents.  
The research [http://r20.rs6.net/tn.jsp?f=001TV-FZEatZC5k1Xgl5_CO-QHEBalC0CF2rBGHYCwrtPjYvGvFgA-mkixvk_Xfh5oMLfcJKHezGQgNpiRRKmrE8gbSwfT4jTZDgr-UOjeFDkHlOZJtVoVHvZP6idMXtHuwDg506aqG1p9pQIvfud6p1FGehL0v1qxLBQAMUkLOvUOp0HYK4wp9WO46A-p1VqSe&c=2s0s6Aie-CM8zSaHrkLizc5jWWwzW3Q6597VHoETw6r-Br31zfhdqw==&ch=p8xKoRIxMipn-TgTx16GzWu1z2teh1y5WdiW5JRmd1LSx3idyl96LQ==]
- conducted by a diverse group of economists and sociologists from leading USA universities
- estimated that while 92% of children born in 1940 went on to earn more than their
parents after adjusting for inflation, only half the children born in the 1980s 
were able to accomplish that feat.  This means that the "American Dream" is at risk
and, it appears to be where much of the disconnect is now occurring between the 
different segments of our society. The evidence for this point is the fact that 
the steepest fall-off occurred among children born in the middle class, and for 
those born in the industrial Midwest.  It's also disconcerting that 70% of the decline
experienced from the boomers to the millennials in reaching the American Dream is
explained by the rising concentration of income among the richest Americans while
a slowdown in economic growth explained a mere 30%.  I encourage everyone to not
 only read the article but also to review the research.  This is a seminal piece
 - from my perspective - that deserves wider debate and discussion.  We need to 
consider what policies need to be altered, shifted or changed to accommodate our
 longer term interests for the sake of our children and our children's children 
and beyond.  Rather than pointing fingers at one another - how about solving the
 problem.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Future Health
Delivering care in the new virtual world...
Health Care Organizations Go Mobile - Red Hat, an open-source software vendor, recently
released a new survey of over 200 health care organizations that showed 82% of them
from across the USA, France, Germany and the United Kingdom had a mobile strategy
in place. The survey results were up from 52% the previous year, which is a remarkable
increase.  In addition to the positive respondents to this year's survey, 78% of
 the organizations indicated they are achieving positive return on investment (ROI)
from their mobile apps. The survey indicated that the focus of the health care apps
deployed to date are primarily for doctors (59%), patients/members (55%) and technicians
(44%). And, the concerns?  As you would expect, app security (98%), data encryption
(30%), and end-to-end HIPAA compliance (29%) were among the chief concerns. These
results speak to the larger issue of creating, fostering and support "open systems".
 Imagine what the world would be like if the health care industry adopted an "open
Digital Health Platform."  It would radically alter the landscape and move us more
rapidly to where the world wants to go.  So, why the resistance?  I think it is 
because the legacy systems would be the big losers in such a development.  But, 
the time has come.  Are we ready?
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Weekly Whisk
Musings from a foodie...
I've been partial to Thai food for some time.  The problem is that most of the time
while it's good, it's also a bit mediocre.  So, I was very pleasantly surprised 
when a good friend suggested that we go to a "nice Thai place" near the Pentagon
 in DC. Rincome Thai Cuisine [http://r20.rs6.net/tn.jsp?f=001TV-FZEatZC5k1Xgl5_CO-QHEBalC0CF2rBGHYCwrtPjYvGvFgA-mkixvk_Xfh5oMSkpdSTqBPa-GGPEycJ4Zg-DCca9RlK7YQR3YA9a0w4w0ey_7P9PgVWgMeCOGftDyZC37o63AKDBTf0-4xBpUPYR_jSzI52bonRuCw5TSdL7FoHpTY5joQA==&c=2s0s6Aie-CM8zSaHrkLizc5jWWwzW3Q6597VHoETw6r-Br31zfhdqw==&ch=p8xKoRIxMipn-TgTx16GzWu1z2teh1y5WdiW5JRmd1LSx3idyl96LQ==]
[* * * * *] went far beyond my expectations.  First, the choices were multiple and
consistent with traditional Thai cuisine.  It was a slow night and Mihee - the owner
- had time to come over to make sure we were set.  The menu ranges from poultry,
 to beef, pork, seafood and vegetable combinations. You cannot go wrong.  And, the
crème de la crème was the Mango and Rice with a Coconut Cream topping - that is 
to die for...  In fact, it was so good, that I ordered a second one to take back
 to my hotel room.  It's the best Thai I've experienced in a long time.  Check it
out and ask for Mihee.  Tell her Kevin sent you!! Rincome - 3030 Columbia Pike -
 Arlington, VA 22204 - (703) 979-0144 - www.rincomethai.com [http://r20.rs6.net/tn.jsp?f=001TV-FZEatZC5k1Xgl5_CO-QHEBalC0CF2rBGHYCwrtPjYvGvFgA-mkixvk_Xfh5oMSkpdSTqBPa-GGPEycJ4Zg-DCca9RlK7YQR3YA9a0w4w0ey_7P9PgVWgMeCOGftDyZC37o63AKDBTf0-4xBpUPYR_jSzI52bonRuCw5TSdL7FoHpTY5joQA==&c=2s0s6Aie-CM8zSaHrkLizc5jWWwzW3Q6597VHoETw6r-Br31zfhdqw==&ch=p8xKoRIxMipn-TgTx16GzWu1z2teh1y5WdiW5JRmd1LSx3idyl96LQ==]
- [email-masked] [mailto:[email-masked]]
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Good, The Bad, And The Ugly
The ongoing saga...
The Good - The holiday season is upon us and it's a time for family and friends.
  Enjoy!
The Bad - The shooting of the 3 year-old child in Little Rock in a road rage incident
is not only "bad" but, it represents a very sad depiction of the USA culture. When
are we going to do something?
The Ugly - The rising tide of anxiety and fear among American citizens that - from
my perspective - is causing us to look for reasons in all the wrong places.
The statements in The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001TV-FZEatZC5k1Xgl5_CO-QHEBalC0CF2rBGHYCwrtPjYvGvFgA-mkk-30YOraDkswoZ0M-Ncvb_zhEc2wDYJgS15BwGyI8RNVxuMQxnZqs7BzpQExA5lVCsk_VEuTEmzOeDJtf_f-6JSeJ3rgJZsRshgx10SDOH37M8ktPcauD67vjLJQEGgbYYA7FxQ4OWR&c=2s0s6Aie-CM8zSaHrkLizc5jWWwzW3Q6597VHoETw6r-Br31zfhdqw==&ch=p8xKoRIxMipn-TgTx16GzWu1z2teh1y5WdiW5JRmd1LSx3idyl96LQ==]
are the personal views of Kevin Fickenscher, MD and do not reflect the views or 
policies of any organization with which he is affiliated.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Name | Company | Phone | Email [mailto:[email-masked]] | Website
[http://r20.rs6.net/tn.jsp?f=001TV-FZEatZC5k1Xgl5_CO-QHEBalC0CF2rBGHYCwrtPjYvGvFgA-mkk-30YOraDkswoZ0M-Ncvb_zhEc2wDYJgS15BwGyI8RNVxuMQxnZqs7BzpQExA5lVCsk_VEuTEmzOeDJtf_f-6JSeJ3rgJZsRshgx10SDOH37M8ktPcauD67vjLJQEGgbYYA7FxQ4OWR&c=2s0s6Aie-CM8zSaHrkLizc5jWWwzW3Q6597VHoETw6r-Br31zfhdqw==&ch=p8xKoRIxMipn-TgTx16GzWu1z2teh1y5WdiW5JRmd1LSx3idyl96LQ==]
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

STAY CONNECTED:

Facebook [http://r20.rs6.net/tn.jsp?f=001TV-FZEatZC5k1Xgl5_CO-QHEBalC0CF2rBGHYCwrtPjYvGvFgA-mkk-30YOraDkswoZ0M-Ncvb_zhEc2wDYJgS15BwGyI8RNVxuMQxnZqs7BzpQExA5lVCsk_VEuTEmzOeDJtf_f-6JSeJ3rgJZsRshgx10SDOH37M8ktPcauD67vjLJQEGgbYYA7FxQ4OWR&c=2s0s6Aie-CM8zSaHrkLizc5jWWwzW3Q6597VHoETw6r-Br31zfhdqw==&ch=p8xKoRIxMipn-TgTx16GzWu1z2teh1y5WdiW5JRmd1LSx3idyl96LQ==]

Twitter [http://r20.rs6.net/tn.jsp?f=001TV-FZEatZC5k1Xgl5_CO-QHEBalC0CF2rBGHYCwrtPjYvGvFgA-mkk-30YOraDkswoZ0M-Ncvb_zhEc2wDYJgS15BwGyI8RNVxuMQxnZqs7BzpQExA5lVCsk_VEuTEmzOeDJtf_f-6JSeJ3rgJZsRshgx10SDOH37M8ktPcauD67vjLJQEGgbYYA7FxQ4OWR&c=2s0s6Aie-CM8zSaHrkLizc5jWWwzW3Q6597VHoETw6r-Br31zfhdqw==&ch=p8xKoRIxMipn-TgTx16GzWu1z2teh1y5WdiW5JRmd1LSx3idyl96LQ==]

LinkedIn [http://r20.rs6.net/tn.jsp?f=001TV-FZEatZC5k1Xgl5_CO-QHEBalC0CF2rBGHYCwrtPjYvGvFgA-mkk-30YOraDkswoZ0M-Ncvb_zhEc2wDYJgS15BwGyI8RNVxuMQxnZqs7BzpQExA5lVCsk_VEuTEmzOeDJtf_f-6JSeJ3rgJZsRshgx10SDOH37M8ktPcauD67vjLJQEGgbYYA7FxQ4OWR&c=2s0s6Aie-CM8zSaHrkLizc5jWWwzW3Q6597VHoETw6r-Br31zfhdqw==&ch=p8xKoRIxMipn-TgTx16GzWu1z2teh1y5WdiW5JRmd1LSx3idyl96LQ==]

Pinterest [http://r20.rs6.net/tn.jsp?f=001TV-FZEatZC5k1Xgl5_CO-QHEBalC0CF2rBGHYCwrtPjYvGvFgA-mkk-30YOraDkswoZ0M-Ncvb_zhEc2wDYJgS15BwGyI8RNVxuMQxnZqs7BzpQExA5lVCsk_VEuTEmzOeDJtf_f-6JSeJ3rgJZsRshgx10SDOH37M8ktPcauD67vjLJQEGgbYYA7FxQ4OWR&c=2s0s6Aie-CM8zSaHrkLizc5jWWwzW3Q6597VHoETw6r-Br31zfhdqw==&ch=p8xKoRIxMipn-TgTx16GzWu1z2teh1y5WdiW5JRmd1LSx3idyl96LQ==]

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Forward this email
http://ui.constantcontact.com/sa/fwtf.jsp?llr=svyssnfab&m=1105336033970&ea=[email-masked]$&a=1126783851488

This email was sent to [email-masked] by [email-masked].

Update Profile/Email Address
https://visitor.constantcontact.com/do?p=oo&m=001oshdCZaoslvWED8bsIAHcg%3D%3D&ch=d97b8ec0-5fcb-11e3-85fd-d4ae528ed502&ca=0bc864d4-253a-473b-b952-33b8f40b111e

Instant removal with SafeUnsubscribe(TM)
https://visitor.constantcontact.com/do?p=un&m=001oshdCZaoslvWED8bsIAHcg%3D%3D&ch=d97b8ec0-5fcb-11e3-85fd-d4ae528ed502&ca=0bc864d4-253a-473b-b952-33b8f40b111e

Privacy Policy:
http://www.constantcontact.com/legal/service-provider?cc=about-service-provider

Online Marketing by
Constant Contact(R)
www.constantcontact.com

The Fickenscher Files | PO Box 840 | Kittery | ME | 039