Subject: News from Dr. Kevin Fickenscher
From: "The Fickenscher Files" <[email-masked]>
To: <[email-masked]>
Date: Sat, 31 Dec 2016 10:39:09 -0500 (EST)

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The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=0019ADvxM7ZBmHRMMZr748gL00NiA-8UsDk4hOitDK0-htHL85JJm5lAtmCazpNUhXfhj5FAY7toL3wk79I6IBYnAYkq6NT31M94UVR3gc2AvLqAH4J2vU6GL71VXTUYheimWjhD-dsg5_gA1pV3w5OXvacoJ28bINO5RmMTHAM-MPnZzFa4HwP_9YRMW-325P-&c=Ny_XvPbd3qReGCYs6W-nWn2PsA6vs50huZSA-p3sqANnQvQUpJkKQA==&ch=0WeTzwlrc8fx1DrZ79zi3OhPP1sm0H9g9eCxPH0K_gyPNnqaLQ_zSQ==]
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The Fickenscher Files, Vol. 4, Issue 17
Kevin M. Fickenscher [http://r20.rs6.net/tn.jsp?f=0019ADvxM7ZBmHRMMZr748gL00NiA-8UsDk4hOitDK0-htHL85JJm5lAlhzb_pyOqvQjnzTQ0gh99H4GQA1hb2M_bAm_AW4SlxusuzBHfUILdo-eeQnq6XC9gKMwpjkf_iKbWHqgF0aktnsFBULzYVgfW4TwchoK8qsdjoWp69RVkE2LtN6djyO100YnFt159Iy99hNedNT7_0q8by7gaBLCNyGrP4k2znEjZEHbbRX1TBGkwIF9DC07InMu6Hq24tP-qs-wrSK8BQ=&c=Ny_XvPbd3qReGCYs6W-nWn2PsA6vs50huZSA-p3sqANnQvQUpJkKQA==&ch=0WeTzwlrc8fx1DrZ79zi3OhPP1sm0H9g9eCxPH0K_gyPNnqaLQ_zSQ==],
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
"The days of the God-doctor are over. Between the role of genomics, a better understanding
of the human animal, and emergence of Internet technologies, we are moving toward
a future where 99% of our medical care will be a matter of self-management and self-responsibility."
Juhan Sonin, Principal at Involution Studios in announcing the release of their 
Determinants of Health [http://r20.rs6.net/tn.jsp?f=0019ADvxM7ZBmHRMMZr748gL00NiA-8UsDk4hOitDK0-htHL85JJm5lAh6UivfCYcaFVr1Ityxin6vBWKZrBFYAXd5Mg23pw19STChhoTu13HqYq_hczC5TSXjlZud6MJJSD2mXZnMGmKqpFSWC-lN72JZ1LyfFkrZJ5EU2N2Ruj1dAffWYGHCZz9iUvj7ClzCepcelU8ZHyT2hKvpbQfT8S9teKZyUbyjD2TxuYAfbGJ0Cz6FXdIpe5w==&c=Ny_XvPbd3qReGCYs6W-nWn2PsA6vs50huZSA-p3sqANnQvQUpJkKQA==&ch=0WeTzwlrc8fx1DrZ79zi3OhPP1sm0H9g9eCxPH0K_gyPNnqaLQ_zSQ==]
model which maps 29 macro-determinants and 66 micro-determinants that influence 
the health of an individual.
"We're really talking about replace and repair, rather than repeal. But we haven't
seen a full approach yet from the administration. Personally, this is me speaking...We're
basically optimistic we can create a better system together."
John Noseworthy, MD, President - The Mayo Clinic in comments following a meeting
 of President-elect Trump with leading health care executives from throughout the
USA.
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Consulo Indicium
Information for your Consideration...
Wait And Why - Just in case you needed a kick in the pants to get moving on arranging
for that special experiential activity you've been meaning to plan or - more likely
- that you've committed to as part of your New Year's resolution - here [http://r20.rs6.net/tn.jsp?f=0019ADvxM7ZBmHRMMZr748gL00NiA-8UsDk4hOitDK0-htHL85JJm5lAh6UivfCYcaFRm8MjqtoKR58uV6GzriGePWrwbC9auIe7ur2lV1Q2P_zkL4sui4s6lbFZYGHrT1z6kCyWB2MxQofx-VihdbXdDe9MCGJyZ18hlfp_zTlEEJMkNsZa8C7YOgHh07UvC_BWd74EUSCbGBprXg6SZ92trSSchbbVNyBUHblCax4JbeTb3BFj1tCozBuKDjTvYe1AN-C8DOmTZZ0J2Y-SHfKq1ktvoIZbQkkyVBSQ-Ll1_M=&c=Ny_XvPbd3qReGCYs6W-nWn2PsA6vs50huZSA-p3sqANnQvQUpJkKQA==&ch=0WeTzwlrc8fx1DrZ79zi3OhPP1sm0H9g9eCxPH0K_gyPNnqaLQ_zSQ==]
is a good way to look at it.  It reduces your life to a page so that you gain a 
better perspective on what is important.  The site will help you place a sense of
"value" on the activity you hold close at hand every day.  Enjoy...
Trump Meets Senior Health Care Leaders - President-elect Donald Trump met with several
of the leading health care executives [http://r20.rs6.net/tn.jsp?f=0019ADvxM7ZBmHRMMZr748gL00NiA-8UsDk4hOitDK0-htHL85JJm5lAh6UivfCYcaFHukA3yFXdYZvywAPbRiaF7pSnqhQYw__qQcAnuXgkMako0oBo4IyU61XiW1SKSBo3VBgQ-86lcaqK6jScn1Y1Lp_n8xwD0HGsOV5OQOQuHopRatKuVBp_54c7pMhrScMV0PHMjgvY39IcGirSpVJBe5OrHdOgRz0swCLA77MUDxONNldFh_UbqyQGQfFiAQS03ExLKmTeU6AY0PTswYxceJMntPHkLowUIe9MGirOwu7ED7jwoDnJhe1XoAm7At7xGwgTnmrQzwLAHq1-eyHt00e8ojuXZN0_yXG3FIcOhbDfGFGO4FLGvTIawlNXrNT4g-QBtqax0vsR8NzHs0cqQ==&c=Ny_XvPbd3qReGCYs6W-nWn2PsA6vs50huZSA-p3sqANnQvQUpJkKQA==&ch=0WeTzwlrc8fx1DrZ79zi3OhPP1sm0H9g9eCxPH0K_gyPNnqaLQ_zSQ==]
in the nation recently in Florida to discuss a wide range of topics related to health
care as well as other issues. The group discussed such topics as how best to bring
jobs back to the United States, immigration, China, cybersecurity, taxes and the
 use of technology. Trump has had a series of such meetings with industry leaders
in the tech, finance and media worlds.  The health care group of physician leaders
included: John Noseworthy, MD (The Mayo Clinic), Paul Rothman, MD (Johns Hopkins
 Medicine), David Torchiana, MD (Partners HealthCare); and, Toby Cosgrove, MD (The
Cleveland Clinic). The most noteworthy comment coming out of the meeting was the
 notion expressed by Noseworthy (I just noticed the alliteration) that we - in the
health care field - are really looking at a "repeal and repair" approach.  This 
idea has been the mantra emanating from Congress over the last several weeks as 
the Trump Administration attempts to reposition from "repeal and replace".  We shall
see.  No details were forthcoming...
Join A Webinar On The Transformation Of Healthcare - As if you didn't have enough
to do already, consider joining me on January 18th at 1:00 PM EST for a webinar 
on the transformation of healthcare and the use of digital technologies.  The URL
to the registration page [http://r20.rs6.net/tn.jsp?f=0019ADvxM7ZBmHRMMZr748gL00NiA-8UsDk4hOitDK0-htHL85JJm5lAh6UivfCYcaFp3XRKDWBnPpr8rq_m7gQJrP1VpYpCmPG7sMLQ7KccaIagm9_dhbxO1oYLTxmF_9NSCFBfCxnThFhB7M_-EHC8F1GuONWTpaZ3w5EAkwMe5WjhAsWtEyVZNsdYAo-Lu8fUfoVVJrgSDQ6oMER5eUgbalA52QnUATf99lHlOnaXr0xJVrRng0hGQ==&c=Ny_XvPbd3qReGCYs6W-nWn2PsA6vs50huZSA-p3sqANnQvQUpJkKQA==&ch=0WeTzwlrc8fx1DrZ79zi3OhPP1sm0H9g9eCxPH0K_gyPNnqaLQ_zSQ==]
is up.  I will be discussing the strategic considerations required of leaders in
 moving toward value-based care as well as how digital transformation will alter
 the approach we take toward care delivery.
Nominee Tracker - President-elect Trump has over 1,000 positions to fill in order
to round out his new Administration.  If you're into the who's-on-the-list-of-potential-appointees
[http://r20.rs6.net/tn.jsp?f=0019ADvxM7ZBmHRMMZr748gL00NiA-8UsDk4hOitDK0-htHL85JJm5lAh6UivfCYcaF5PGq48D40VptcklNuNuie0WwfSSoh0-FzjxipQ71N5_xdVP2Y3J79jmBSQHQlJBGtrkkHHmq3t-VebyCybuH9_On64EDZLfjtSebvoNvm0Le74mTiNwA6QeGXeOiW2ICreIk6DyeGg_LfZ-UFd0cUZ4wtWZ_NCdkPG9t2mDioMq9VlFYNQLs1cSEIH1gnxptruGJquEaSwxxVn08ip0K8Q==&c=Ny_XvPbd3qReGCYs6W-nWn2PsA6vs50huZSA-p3sqANnQvQUpJkKQA==&ch=0WeTzwlrc8fx1DrZ79zi3OhPP1sm0H9g9eCxPH0K_gyPNnqaLQ_zSQ==]
for the Cabinet and sub-Cabinet positions, check out The Washington Post tracker
 database.  It will keep you up-to-date on the various potential nominees and their
status...
The Debate About Telehealth -Health Affairs recently posted an article [http://r20.rs6.net/tn.jsp?f=0019ADvxM7ZBmHRMMZr748gL00NiA-8UsDk4hOitDK0-htHL85JJm5lAh6UivfCYcaF5mSWP7p7zJTrLcoxxT4SsfJ1f6gOptiuRDkphWuq4x1_RASLxRnGaPU6yRwra8SauzWgJQZZgX8qEubmbui2MTvCVRmrdA5RFKWL5jDmspDtgsKLc4jiMnHe3WZvCZbOL0vY2uOuiBtdYGmWA3avSFrO6sEDIOBDWngN-Kh4c-fDDBW8OK5cqsBUgZskZASadMfnQfBHb5Pg8sAVBFIlPwVsItER-_blYdjUtDi92tXUvj9dKXAypw==&c=Ny_XvPbd3qReGCYs6W-nWn2PsA6vs50huZSA-p3sqANnQvQUpJkKQA==&ch=0WeTzwlrc8fx1DrZ79zi3OhPP1sm0H9g9eCxPH0K_gyPNnqaLQ_zSQ==]
on their blog noting that "telehealth alone will not increase health care access
 for the underserved."  The authors noted while there is enthusiasm for the use 
of telehealth - it is the not the end solution for those aspiring to increase access
to basic services. I would agree except that the article could be misleading if 
you don't read the fine print. Tele-capability is not the only component for achieving
equity in access to care for underserved communities but, it is a vital component
- from my perspective.  Furthermore, it is an investment that requires time to see
results.  My thoughts follow...
I tend to "split hairs" on the tele-capability question by noting the difference
 between telehealth, telemedicine and telecare.  I offer the following definitions:

* Telehealth = the passive capture of biometric and digital health information for
self-monitoring and self-managing health and care needs to enhance the well-being
of the individual
* Telemedicine = the dynamic, real-time, remote interaction of healthcare professionals
with individuals seeking health services
* Telecare = the management of health using an integrated approach of direct, indirect
and remote interaction with individuals under protocol and/or guidelines to proactively
manage and deliver care on a virtual basis including professional and support services
back-up with a focus on enhancing health through increased quality, outcomes and
 efficiency while simultaneously reducing costs.
So, why am I splitting hairs?  Given the ongoing escalation in the cost of health
care, I believe it is important for industry leaders to understand where the clearest
return on investment can be derived in the tele-capability space.  While I'm a great
fan of those individuals who engage in monitoring their status through various telehealth
interventions, most of the self-monitoring systems have shown short-term impact 
but not long-term results (e.g. reminding us to exercise, counting our steps, etc.)
because, over time, our responses dissipate.  There are exceptions to the rule like
glucose monitoring which can alter the course of diabetes.
In using telemedicine, it seems to me that too much of the debate has been focused
on "who" will use the technology and interact with patients.  The "who" question
 is an age old one in the field of medicine.  When Laennec invented the stethoscope,
only physicians were allowed to use it.  Now, they are ubiquitous.  Or, think of
 the thermometer, now an antiquated device.  How about the blood pressure cuff -
 even though that technology is also quickly becoming antiquated J.  We need to 
move beyond the question of who to the question of "what".  What outcomes change?
 What interventions make a difference?  While clinician interaction can be and often
is crucial in facilitating effective care (e.g. telepsych is a good example), telemedicine
only touches the tip of the proverbial care delivery iceberg.
So - in my splitting hairs world - telecare is focused on the remote assessment 
and management of individuals.  My favorite example is the most common medical problem
admitted to any hospital throughout the world - congestive heart failure (CHF). 
 Roughly 1 in 5 of all admissions relate to this one medical problem.  And, with
 the effective deployment of a telecare program, I suspect that at a minimum 1/3
 of these patients could be treated in a preventive fashion rather than acutely.
  Why?  Because patients generally go into florid failure about 96 hours before 
they show up in the emergency room.  At that point, they need to be admitted to 
the hospital and treated acutely at great cost to society.  If instead, we were 
monitoring every CHF patient in their home or wherever they happen to be, I bet 
we would dramatically reduce the need for acute care admissions.  The reason?  Through
remote technology, we can now monitor not only weight, blood pressure, pulse, and
oxygen saturation level but, also we are on the verge of monitoring electrolytes.
 With that level of data, we could effectively and efficiently manage the care of
the CHF patient remotely and before they need to be admitted to the hospital.  It
seems to me that with the advent of "value-based care delivery", the need for such
programs will only increase.
The Health Affairs article evaluated the MAVEN Project [http://r20.rs6.net/tn.jsp?f=0019ADvxM7ZBmHRMMZr748gL00NiA-8UsDk4hOitDK0-htHL85JJm5lAh6UivfCYcaFRRpslfKQv545DdOa8LyL9NJzilswPfgAb4_laBRHdiAuDhNxmms2h_YO_2YeoYjcL1KTbLh-3Hidqr0QlY7_V7kREEz6NYxq5WQ9eRKQR20FjM_XBdFCBg==&c=Ny_XvPbd3qReGCYs6W-nWn2PsA6vs50huZSA-p3sqANnQvQUpJkKQA==&ch=0WeTzwlrc8fx1DrZ79zi3OhPP1sm0H9g9eCxPH0K_gyPNnqaLQ_zSQ==]
and Direct Dermatology [http://r20.rs6.net/tn.jsp?f=0019ADvxM7ZBmHRMMZr748gL00NiA-8UsDk4hOitDK0-htHL85JJm5lAh6UivfCYcaFP0ygqng1o3K5HO_zC8vl7Mx6KUJQzIqpSco5XAsSSbSqTxR5mKLNYhZcV1Ijq70k9nwIfP_QVmpG8cC5A4jHABuP-PVXE_krQNn3diK9a2gghiL-ZQL9uw==&c=Ny_XvPbd3qReGCYs6W-nWn2PsA6vs50huZSA-p3sqANnQvQUpJkKQA==&ch=0WeTzwlrc8fx1DrZ79zi3OhPP1sm0H9g9eCxPH0K_gyPNnqaLQ_zSQ==]
which are tele-medicine programs designed to increase access for the underserved.
The researchers - rather astutely learned that simply deploying telemedicine solutions
does not reduce the burden on those physicians if they work in a dysfunctional health
care system - which gets to my mantra over the last 20 years.  It's not the technology
- it's the process.  Too frequently, these technologies are deployed without considering
the necessary revisions related to the process of care delivery.  I encourage everyone
to read the article.  It has many good points.  However, the headline for the article
is wrong in my estimation.  It's not about the technology.  That is simply a tool
that needs to be used properly if efficiency and effectiveness are to be realized.
They point out correctly that "by identifying problems that require longitudinal
 care, telehealth may actually stress the health care system further."  So, it seems
that the focus should be on the "process" and "workflow" design which too frequently
get insufficient attention when new technologies are deployed.
The use of tele-medicine technologies can facilitate effective care delivery decisions
in about 20% of all consultations between a primary care provider and a specialist
according to research on the effectiveness of the interventions [http://r20.rs6.net/tn.jsp?f=0019ADvxM7ZBmHRMMZr748gL00NiA-8UsDk4hOitDK0-htHL85JJm5lAh6UivfCYcaFggVScgs3kaixIBP2mL_B11_3h6Z9kbUNQ-OW8Hl2me_2IIBLJ598wfbHnjUYzP-BGqgLxqVX8Sv3gx6q1wKeL7Zgi459PTSZKvxwEKdAX8sQS1x2qNpsZbjwzCVR1uQYGLe672bXtlTkiwLYtuhT6w==&c=Ny_XvPbd3qReGCYs6W-nWn2PsA6vs50huZSA-p3sqANnQvQUpJkKQA==&ch=0WeTzwlrc8fx1DrZ79zi3OhPP1sm0H9g9eCxPH0K_gyPNnqaLQ_zSQ==].
 An even larger percent of the care decisions could be resolved using direct telemedicine
capability between the patient and a specialist.
So, to be clear - I'm a huge proponent of tele-capability which embodies the "-health",
"-medicine" and "-care" components - working together in a symbiotic fashion.  Such
an approach clearly requires new models of care delivery.  If we simply deploy technology
on top of existing processes, we will get more processes rather than less which 
will decrease efficiency, hamper quality and absolutely increase cost.  These are
not part of the health care equation we are all working toward.
The Airline Industry Outpaces Health Care, Again!! - While there were a number of
high profile crashes in 2016 such as the Colombia plane crash [http://r20.rs6.net/tn.jsp?f=0019ADvxM7ZBmHRMMZr748gL00NiA-8UsDk4hOitDK0-htHL85JJm5lAh6UivfCYcaFJ9D8ofglcqzSE-3aBMO7vZyQiT2nu1vy3_5zY25Vz2m17yecByHcQoVfJcuoY4UwLKp3wGSd8x8qM-YjvvLrkVtBgg58B_O7Sf4qZVkFy1mh9T8eY_HzxS_8FrwOhEtWnbiXDfeTauQwtyTFnpWTh3X5qwMhxFCC231QMhf5LCh__N-DH3U8BWLrGYEUS0AAhKZ00mpg69vZIgX1EWTBmmwQ-SzPhwuF&c=Ny_XvPbd3qReGCYs6W-nWn2PsA6vs50huZSA-p3sqANnQvQUpJkKQA==&ch=0WeTzwlrc8fx1DrZ79zi3OhPP1sm0H9g9eCxPH0K_gyPNnqaLQ_zSQ==]
which claimed 71 lives, including most of a Brazilian soccer team; or, the more 
recent Russian airline crash that claimed the lives of many prominent workers involved
in services for Syria and an internationally recognized choir - 2016 is still recognized
as one of the safest years in modern aviation history [http://r20.rs6.net/tn.jsp?f=0019ADvxM7ZBmHRMMZr748gL00NiA-8UsDk4hOitDK0-htHL85JJm5lAh6UivfCYcaFG7fYmCUk-8MGvZkhVZQPL5qEZW-7DEm5oSU_pJXMzY5bwSfgVbBeXPGrnWnt2MC07Wj3IoI4PM5lwvqYaxcKj50AcbNkqdyymdXGRF5oDxMWyFYLfhpZK8dNRZE9_0d_x1mplQD_VwLug5YUbw_clFjh053GEb3sqZcwLk6XoPPerG9i8dKBq2TdCK5fhPL3&c=Ny_XvPbd3qReGCYs6W-nWn2PsA6vs50huZSA-p3sqANnQvQUpJkKQA==&ch=0WeTzwlrc8fx1DrZ79zi3OhPP1sm0H9g9eCxPH0K_gyPNnqaLQ_zSQ==].
AND, in the USA - it was the first year in history where there we no (= none, nada)
crashes in the commercial sector. But, even if the civilian sector is taken into
 consideration, the Aviation Safety Network [http://r20.rs6.net/tn.jsp?f=0019ADvxM7ZBmHRMMZr748gL00NiA-8UsDk4hOitDK0-htHL85JJm5lAh6UivfCYcaFac7KmUQzT2dDyLtiHMXr58BnwcPdrNyBpBXWN_wM1E3VdufPPb7YGSafkyDsrl5YIt1sm0D6EGPhYV6w8HH98zZsGgpBXnJ9-HGrS8pXJ2kA_UjiQ5J6ess15iEnkahc&c=Ny_XvPbd3qReGCYs6W-nWn2PsA6vs50huZSA-p3sqANnQvQUpJkKQA==&ch=0WeTzwlrc8fx1DrZ79zi3OhPP1sm0H9g9eCxPH0K_gyPNnqaLQ_zSQ==]
still reports that worldwide in 2016 there were only 18 civilian plane accidents
 which accounted for 320 deaths. The only year where there were fewer deaths was
 in 2013 when 265 deaths were recorded in the civilian sector.  Now - to make the
case even stronger - we need to consider this data in the context of the industry
where volume has exploded over the last 50 years.  In 1970, there were 310 million
passengers who took commercial flights worldwide which grew to 3.5 billion in 2016.
I've said it before and will say it again: It is far safer to board a plane - any
plane (although I'm absolutely "safe" on a commercial USA flight) than it is to 
walk into your local emergency room or, even the best emergency room in the country,
wherever that is.  The good news for all of us is that air travel - on both a domestic
and global basis - continues to get safer and safer.  Why?  There are several elements,
including new technology deployed on plane to support pilots as they fly the airplane,
continuing improvement in safety procedures, and increased collaboration between
 the airlines and the aviation governing bodies around the world where the focus
 has been on improving aviation infrastructure [http://r20.rs6.net/tn.jsp?f=0019ADvxM7ZBmHRMMZr748gL00NiA-8UsDk4hOitDK0-htHL85JJm5lAh6UivfCYcaFu7uuaK_3y6dS8v1V75e1GZ28Gb565z_wjeL5EUuQpBvH1P6HVuC99Y688KkjgD0zwNOzgmAOl8jHsQFHpMULedicxVhH7eiiA7Gyh0d-GFpqBkLenZoWyfnY2ngLgdBgUO0a7gYiLFvplZG2DTXjJqgEZ9ewhNMhgFPjPlGvPg6d-wMJFI2gpw==&c=Ny_XvPbd3qReGCYs6W-nWn2PsA6vs50huZSA-p3sqANnQvQUpJkKQA==&ch=0WeTzwlrc8fx1DrZ79zi3OhPP1sm0H9g9eCxPH0K_gyPNnqaLQ_zSQ==]
in the developing nations. I would also argue that aviation benefits from the consolidation
that has occurred in the industry over the last 50 years.  Health care still remains
"mom and pop" in many locations.  In the USA, the Federal Aviation Administration
(FAA) believes much of the credit for increased safety to the Commercial Aviation
Safety Team, a public-private partnership established in 1998.  Since its formation
in 2008, USA commercial aviation fatalities have decreased by 83%!! The time has
 come for the health care industry to step up to the plate and implement a similar
system or model initiative for improving our results. If you are interested in joining
me in this effort, send me a note at [email-masked] [mailto:[email-masked]].
Finally, the odds of dying in a crash have been on the decline. This year, the rate
of plane-crash fatalities was 1 out of every 10,937,500 passengers. The only safer
year was 2013 with 1 death out every 11,501,886 passengers. So, are you buying tickets
for a trip or headed to the ER?
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Fine Anni Praedixerat - Or, End of Year Predictions
Going out on the limb (as usual) to share my thoughts on the future of health care...
End of Year Predictions - Every year for the last decade of the Fickenscher Files
[http://r20.rs6.net/tn.jsp?f=0019ADvxM7ZBmHRMMZr748gL00NiA-8UsDk4hOitDK0-htHL85JJm5lAtmCazpNUhXfhj5FAY7toL3wk79I6IBYnAYkq6NT31M94UVR3gc2AvLqAH4J2vU6GL71VXTUYheimWjhD-dsg5_gA1pV3w5OXvacoJ28bINO5RmMTHAM-MPnZzFa4HwP_9YRMW-325P-&c=Ny_XvPbd3qReGCYs6W-nWn2PsA6vs50huZSA-p3sqANnQvQUpJkKQA==&ch=0WeTzwlrc8fx1DrZ79zi3OhPP1sm0H9g9eCxPH0K_gyPNnqaLQ_zSQ==]
I've provided my predictions for "what's coming" - not necessarily in the next year
- but, over the coming years.  So, here goes.  Let me know your thoughts...

1.     Cybersecurity is one of the most important challenges facing the health care
industry. The attention to "cybersecurity" in the media generally is well deserved,
especially for health care.  Andy Slavitts, MD, Administrator for CMS, describes
 health care as the "trifecta" of data because it includes personal, medical and
 financial information on millions of individuals.  It's literally a treasure trove
of information that could be mined for nefarious purposes.  Importantly, the health
care industry is ill-equipped to handle the challenge.  There are many elements 
that point to the very significant vulnerability of health care.  I put it on my
 list as #1 for a reason...

2.     Value-based reimbursements will only expand - The current fee-for-service
 (FFS) system is going the way of the solo general practitioner.  While there will
no doubt always be some form of FFS in the USA, the dominant form of insurance is
clearly shifting - as it should - towards a value-based reimbursement model.  However,
it's clear that no dominant form has evolved.  With the new Trump Administration
 taking the reins, I predict that the states will be pushed into a role of serving
as the "laboratories of democracy" where experimentation on approaches and models
will be considered.  Then - after a number of years - "the model" will percolate
 forward and be adopted on a national basis.

3.     The majority of risk will shift to provider organizations with insurance 
companies providing back-office, administrative services only (ASO) support to the
providers - Even though the final model for value-based reimbursement is not clear,
the "risk" is shifting rapidly to the provider sector.  By placing the risk at the
doctor's door, the critical decision makers will become more team managers than 
individual practitioners - yet, they are not prepared to assume that role.  It is
therefore incumbent upon the health professions to re-evaluate educational training
if we are to be successful in overhauling the care delivery system. Nearly three
 decades ago, a colleague - in explaining the forces that drive the health care 
system - imprinted on my brain the mantra of health care: "It's not the money, it's
the money!"  In fact, over the last 25 years, I've learned that the health care 
system is incredibly good at finding the money.  As the risk shifts to the providers,
many of the changes I'm describing in this blog will become reality because of the
inherent incentives of the payment system.  Watch and see...

4.     The shortage of primary care providers will become a crisis requiring a re-evaluation
and change in the role and function of providers across the board - Over the next
5 - 7 years, roughly 1/3 of all the primary care providers in the USA will either
retire, become disabled or die.  When you stop and think about it, the change stands
to reason.  After all, the demographics of the professions reflect the demographics
of society.  At a time when we are experiencing a population surge among the elderly
- we really cannot afford to see the loss of provider capacity.  And, I would argue
that simply seeking to churn out more of the same (i.e. physicians only) will not
solve the problem.  On a good day, it takes 11 years to generate a PCP - 4 years
 of college, 4 years of medical school; and 3 years of residency.  We don't have
 time to simply crank up the current model. The care delivery model requires revision
if we are going to meet the expectations of society - and, ourselves!!

5.     Telecare will become a dominant strategy for delivering care - I have a whole
section preceding my predictions related to "telecare".  That portion of the blog
outlines my thinking on why telecare will become a dominate strategy for care delivery.

6.     The health care industry will be upended through the deployment and use of
"make-a-drug/body-part-as-you-need-it" technology - I'm sure that most of you have
heard about the new "3D printers" that manufacture various products on the fly as
needed under real-time specifications for creating pistons, bearings, and a multitude
of other devices.  However, you were you aware that scaffolds are now made for noses,
ears, fingers and even other body parts?  That's what the Wake Forest Institute 
for Regenerative Medicine (and others) are doing. These scaffolds are constructed
in such a way as to allow normal cells to infuse around the scaffold so that at 
the end of the day, you have a normal appearing body part.  Amazing! Furthermore,
there are now products in the formative stages of development that use 3D printer
devices for making medications-to-order.  By bringing together the right ingredients
at the right time, it will soon be possible to make customized medications at the
pharmacy or anyplace - even at home.  It's only a matter of time...

7.     Academic programs will either will subsume or be subsumed in large, regionally-based
integrated delivery organization or move toward community-based educational models
- The traditional academic medical center is imperiled, from my perspective. First,
the capping of dollars for medical education has been a major concern for academic
centers and rightfully so. Second, the inherent "inefficiency" of medical education
programs in delivering care - where dollars are generated - means that most academic
centers are not as "competitive" in the free market, especially in a value-based
 reimbursement model.  Third, the keys to the knowledge are no longer exclusively
held by the "Ivory Tower".  Instead, knowledge is widely distributed throughout 
the world so that from an outcomes/care delivery/quality/cost perspective - there's
no competitive advantage at the academic medical center. And, with further discussion,
we could come up with four, five and six...

8.     Genomics comes of age - There are any number of major academic medical centers
that are exploring how best to accelerate our knowledge in the use of genomic data
for improving health.  It's clear that if we take the genomic code that is embedded
in all of us and compare it against the functional findings of our illnesses and
 proclivities, we are going to discover elements of health that we did not even 
know existed.  The entire "precision medicine" movement which is at the formative
stages now will accelerate appreciably as funds begin to infuse the efforts from
 both industry and government.  Witness the efforts of the VA to start the "Million
Man" project to capture the genetic code of one million veterans.  The findings 
will have ramifications across the board.  Couple that data with private or academic
efforts to create similar data bases and its clear we are on the cusp a HUGE, accelerated,
transformational revolution in our understanding of health and disease.  It's going
to be an exciting time.  I predict we will see companies evolve that are larger 
and more significant than the computer and social media empires which have evolved
over the last decade.

9.     The microbiome is recognized as an essential foundation of good health - 
It is increasingly clear that the little "germs" that live inside of us in our gut,
on our skin and elsewhere - are actually beneficial.  It's only when the microbiome
gets out of kilter that these little "germs" tend to cause problems.  What we are
finding - again, through genomic research on the types of germs that inhabit our
 bodies - is that the microbiome can impact our health in very significant ways.
  It aids food digestion, it supports the immune system, it creates efficiency in
how we consume calories - or, not.  There are a whole host of impacts on us that
 are only now being discovered.  Over the next five years, we should anticipate 
that a focus on the microbiome will have transformative effects on how we care for
people.

10. The transformation of health care will have a common thread of new, disintermediating
technologies as an underlying platform which will demand change in traditional practices
- I've said it before, but I'll say it again: As we develop ever larger data bases
that combine data from disparate sources, we are going to discover patterns of care
that we did not even know existed. Combining electronic health data, with genomic
data, with personal microbiome data, with social media, with open source government
records, with whatever-kind-of-data-you-can-imagine will create knowledge that is
unparalleled in the history of medicine.  In fact, it's a bit hard to imagine what
discoveries we will be uncovering.  But, it seems to me that a couple of intuitive
insights are already on the horizon such as: the long-term impact of diet will be
found to alter our body in ways we did not even imagine; the path to addiction will
become a more predictable phenomenon; the spread of disease by vectors will become
much more manageable; the proper investments by government will be uncovered which
will help society redirect funds away from activities that show no effect on "health"
toward those that do change health.  And, the list goes on...
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Weekly Whisk
Musings from a foodie...
I've been at home for several weeks so from the quick food department, I offer the
following; Saute mushrooms in 4 tablespoons of butter until browned and softened.
 Then, set aside.  Make patties that are about ½+" thick from 90% fat free hamburger.
 Take English muffins and fork split (just like Thomas' suggests) and toast to your
desired crispness.  Slather mayo on both sides of the muffin.  Place pickles (you
pick the type you like best) on the bottom side.  Grill the burgers so they are 
crisp and slightly darkened on both sides.  Place the burgers on the bottom bun,
 add mushrooms and cheese of choice (if it's fresh Swiss from Wisconsin - go for
 it!).  Use condiments of choice.  Great burger, doesn't take too long and can be
repeated the next day...J [* * * * *]
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Good, The Bad, And The Ugly
The ongoing saga...
The Good - The New Year is here.  Let's move toward dialogue...
The Bad - The Obama-to-Trump transition seems to have a few rough spots.  Let's 
hope for the sake of the country - and, the world - that there are no dropped batons
in the passage from one administration to another.
The Ugly - The credit card bills come due in another 15 days and the Green Packers
- while alive - are struggling.
The statements in The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=0019ADvxM7ZBmHRMMZr748gL00NiA-8UsDk4hOitDK0-htHL85JJm5lAtmCazpNUhXfhj5FAY7toL3wk79I6IBYnAYkq6NT31M94UVR3gc2AvLqAH4J2vU6GL71VXTUYheimWjhD-dsg5_gA1pV3w5OXvacoJ28bINO5RmMTHAM-MPnZzFa4HwP_9YRMW-325P-&c=Ny_XvPbd3qReGCYs6W-nWn2PsA6vs50huZSA-p3sqANnQvQUpJkKQA==&ch=0WeTzwlrc8fx1DrZ79zi3OhPP1sm0H9g9eCxPH0K_gyPNnqaLQ_zSQ==]
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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