Subject: News from Dr. Kevin Fickenscher
From: "The Fickenscher Files" <[email-masked]>
To: <[email-masked]>
Date: Mon, 15 May 2017 10:26:02 -0400 (EDT)

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The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001q8xffJ4BifUAyY3VOgbKPCUyGOfFIBMA1fCd1b-eQ0CTo3FXKtPX_znMcIvVlbAaveMehd7VfIni1b3RkRYDExtZuHrHmEDshNVyrsWqnv3BiLKYhCEsQE4s8q-1gUBhXvTb7XR_1pdjE8OwuspM4Yxum63vtwqujn1aFBwYSbVubIwQAvghWwELrd9u_Vb0&c=vPj0ugTdpCABpG7fhgSsvZaaxgiO_qq5Var7Sm8TgC-cSOGEm4VULQ==&ch=B14ooffRZP2esNYqiUN8MBPttySqU_ofzXlii_BboeJmvj_V9uoYlw==]
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The Fickenscher Files, Vol. 5, Issue 5
Kevin M. Fickenscher [http://r20.rs6.net/tn.jsp?f=001q8xffJ4BifUAyY3VOgbKPCUyGOfFIBMA1fCd1b-eQ0CTo3FXKtPX_xnr0iiKFjjOLFZdEa4NadLWZGPRMxtUSx-OSCF-xAzti2xYhQ1AjqUr2rNNbWtaQ_Bwyy46S85ndDFkWbojcvBXoRqcRX0rQn7Sf5bKAvZYqpyoJBRsyUiCSSw76uTXgCArzG1iYrzmlSTme_YJDfJThbv9chUp7A==&c=vPj0ugTdpCABpG7fhgSsvZaaxgiO_qq5Var7Sm8TgC-cSOGEm4VULQ==&ch=B14ooffRZP2esNYqiUN8MBPttySqU_ofzXlii_BboeJmvj_V9uoYlw==],
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
"It's one of the widest spread attacks we've ever seen. We're entering an age known
as cyber-insecurity. There's going to be a huge response from the public now that
doctors and hospitals are being affected, there is going to be a huge shift in how
people think about this."
Michael Balboni, President of Redland Strategies, a cybersecurity consulting firm
in comments on the possibility of another attack similar to the recent attack on
 the health care community.
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Readings And Such To Consider
Books and Articles worth a Review...
First, this is not a reading.  Rather, In the relatively short time he's served 
as our Pontiff, Pope Francis has had a fairly significant impact on the thinking
 in the world.  He's clearly moving to shift the Catholic Church in new, less conservative
directions.  It is within that context that I URGE you to watch Pope Francis' Ted
Talk [http://r20.rs6.net/tn.jsp?f=001q8xffJ4BifUAyY3VOgbKPCUyGOfFIBMA1fCd1b-eQ0CTo3FXKtPX_xnr0iiKFjjOEuFlJ_7IBTnLco0DbeX58Ka5k9feIBqtQekqpmPh5qmFAIHOGliPe-47K2B_SZ4h8Nm7s7kP3EP0cWQfMn-pik7Tn8hqnvhpguNzZITXdzY2L6bhaJk663ApQgwBHemIyOy14dRc-WlgVXyd1bi98o2-mz_0dMt56wEq_L0IPN2wnsTW7Hwb3IJXr7ghE93m3RicdFdMi69Rpzaf7lGXefq-0OT_44g0JtXlSazTa5wEgP11NKCFeg==&c=vPj0ugTdpCABpG7fhgSsvZaaxgiO_qq5Var7Sm8TgC-cSOGEm4VULQ==&ch=B14ooffRZP2esNYqiUN8MBPttySqU_ofzXlii_BboeJmvj_V9uoYlw==]
which he recently gave.  It is not only captivating; he pulls us all up short in
 how we are focusing on the problems of the world.  It's worth a re-listen after
 the first listen.  Mark my words...
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Consulo Indicium
Information for your Consideration...
A Wake Up Call? - Some of us have been predicting the events of May 12th for a long
time.  While the damage assessment is pending as of this writing, it appears that
the hacker attack was not as damaging as it could have been.  In fact, it appeared
at first to be a health care cyberattack but has ultimately turned out to be a non-discriminate
attached that extended from hospitals, to schools, to automotive, to banks, and 
beyond. The attack basically exploited a malicious software stolen from the National
Security Agency which had evidently found a hole into the Microsoft operating system.
 The hackers were able to execute a cyberattack that self-replicated and hit over
104 countries throughout the world - and, growing.  It had a major impact on the
 British National Health Service [http://r20.rs6.net/tn.jsp?f=001q8xffJ4BifUAyY3VOgbKPCUyGOfFIBMA1fCd1b-eQ0CTo3FXKtPX_xnr0iiKFjjOVKDkskN7ae04G9v-498Knc7nwGF94BHiAY4QBhRU20VxJT7kZOE0xQtuNpKwz7Ft645LNI545HuciEpWws20HfRGrlrEA1bOxVC3K9gGkMTCrQIw0Rx2SzYqJSp-kW2fRv4HvUZ5peELqov12GRQG7LsVBB_f_8HzsiwKMVkJUtT5An5tKW3qg9vem-CUw3yuPqqFnqzks5373EHTewd-AoE8a2XHFoqj1tq5HRABwbvjcPWlBI5Ig==&c=vPj0ugTdpCABpG7fhgSsvZaaxgiO_qq5Var7Sm8TgC-cSOGEm4VULQ==&ch=B14ooffRZP2esNYqiUN8MBPttySqU_ofzXlii_BboeJmvj_V9uoYlw==]
where computer systems were closed down and patients diverted to unaffected facilities.
 It was disproportionate in that some parts of the NHS were affected more adversely
than others.  In large measure the facilities that were adversely affected had not
kept their Microsoft software operating system up-to-date.  The attack [http://r20.rs6.net/tn.jsp?f=001q8xffJ4BifUAyY3VOgbKPCUyGOfFIBMA1fCd1b-eQ0CTo3FXKtPX_xnr0iiKFjjOlLTr1rnWlanZLUwamlWRy3uTgK6iuu-zje_5ur5Q9xn6b_Ad1mIbABXMRy5kvmAZWaaeKUlU7Voi7B3kE6OCMu1LN9w8MwqmN-fR931IrNUyrExFyNOvX_3tza8f9H-aS3Ms1cBhO0gu5Rm0lxMvgdZZfkNGKYNzDFQayIawn6gDCUldKIImXaBdfsEGoAhrrpz8EZw9vhZRsurWQBgXgw==&c=vPj0ugTdpCABpG7fhgSsvZaaxgiO_qq5Var7Sm8TgC-cSOGEm4VULQ==&ch=B14ooffRZP2esNYqiUN8MBPttySqU_ofzXlii_BboeJmvj_V9uoYlw==]
spread across the internet and was transmitted by email.  And, while it was the 
most widespread ransomware attack it was done in a way that encouraged those who
 were affected to pay the costs and move on with a bounty of only $300.00 paid in
Bitcoin to an anonymous account.  In addition, it was a world-wide phenomenon.  
With all of the debate in recent weeks about Russian attacks on the 2016 Presidential
elections, there were murmurs of "there-go-the-Russians" as a first response.  But,
in fact, according to Kaspersky Lab [http://r20.rs6.net/tn.jsp?f=001q8xffJ4BifUAyY3VOgbKPCUyGOfFIBMA1fCd1b-eQ0CTo3FXKtPX_xnr0iiKFjjOMZiTv2OQ4AY2sCHXndL1aEAOmJ2YlbkcXyATS7bvyKiaj8Ojz1Rf6UqXogdjVzEciGMj1-MG-ow276uYI7ZYiv20uAS_ti9UrWlGdKT_ALTNUGdgaREszoODNszs9oLn_LVY6r9IRJWtaLJgW50dbxxrc_144cEo9Zhbh973eZVD55I_bA5PfV9-pNow84KkFuZqU9z_Nnb74QlkqyJ5mqDZWCkUApIF4O0nkbAQeYU=&c=vPj0ugTdpCABpG7fhgSsvZaaxgiO_qq5Var7Sm8TgC-cSOGEm4VULQ==&ch=B14ooffRZP2esNYqiUN8MBPttySqU_ofzXlii_BboeJmvj_V9uoYlw==]
- a Russian cybersecurity firm - and other cyber-firms, Russia was the worst-hit
 country followed by Ukraine, India, Taiwan, the UK (notice that I've already implemented
Brexit, J) and Europe. The reports of attacks extended across the world to Australia,
China, Latin America and Africa.  No region of the world was left untouched by this
attack.
While the attack seemed to be the largest ransomware assault to date affecting the
health care community, it is by no means the only one nor, the last one.  It evidently
began with the arrival of a simple phishing email to unsuspecting computers in health
care organizations like the one used by the Russian hackers in the Democratic National
Committee attack last year.  The ransomware, referred to as "WannaCry", then spread
from computer system to computer system and locked up patient records to the consternation
of health care providers.  As I told a friend - it's one thing to have your financial
accounts frozen at the bank, or to have the communications network go down.  It's
a whole other thing to have the computer systems freeze in the middle of surgery
 - as they did in the UK - or, to have your car potentially hijacked when you're
 driving down the road (proven but not part of this ransomware attack), or...or...or.
 We are in the digital age and we should expect that these types of attacks are 
going to become more common place. To prevent them, we need to start applying appropriate
cybersecurity measures [http://r20.rs6.net/tn.jsp?f=001q8xffJ4BifUAyY3VOgbKPCUyGOfFIBMA1fCd1b-eQ0CTo3FXKtPX_xnr0iiKFjjOPfdyedMQKHwWHJURnl6KL_3Zl82ha40N3VASrm6K1N1_4ORkuRzfHUzy0PyyJrRK1VhIvy4ADj2eOxIYGFTEFNAxhx6r1YC9Tv4Yc61oAXmtraJ0KyoDUtlbXX3caShTa8qKaKlWErSP345WpazrAyZ2-N7uORjoLFXi4WDgnVGZD-5d9YmaiR-sTqyMlFOD5ltC1pgnKOQ=&c=vPj0ugTdpCABpG7fhgSsvZaaxgiO_qq5Var7Sm8TgC-cSOGEm4VULQ==&ch=B14ooffRZP2esNYqiUN8MBPttySqU_ofzXlii_BboeJmvj_V9uoYlw==].
 One of the first is "keep your software up-to-date".
So, what are the lessons learned.  #1: Cybersecurity in health care is a much bigger
deal than most folks in the health care community realize.  It deserves our attention.
 #2: While this had a crippling effect on some hospitals - it could have been much
worse.  #3:  This is a wake-up call.  Pay attention!

Virtual Reality Depicting Real Health - If you embrace technology, you'll be   interested
in this piece for the Voice of America [http://r20.rs6.net/tn.jsp?f=001q8xffJ4BifUAyY3VOgbKPCUyGOfFIBMA1fCd1b-eQ0CTo3FXKtPX_xnr0iiKFjjOQT8y9u8Cnb-GR2naX19PDt3V4OrdUjczD6UKacqvdudYjTuZ1hSrsRIJ8WkJF1CPZrs1f9lMg_g9dp89NhDh5ORE8wA7VO1iPOGxJe29hBiw2wnlhVitqEciY37fJUGn&c=vPj0ugTdpCABpG7fhgSsvZaaxgiO_qq5Var7Sm8TgC-cSOGEm4VULQ==&ch=B14ooffRZP2esNYqiUN8MBPttySqU_ofzXlii_BboeJmvj_V9uoYlw==]
about the use of virtual reality as a tool   for training health care providers 
and treating patients.  The Virtual Reality Show was recently held   in London and
featured a host of virtual reality games and applications. Among the most   interesting
were those related to health and medicine.  From training health care personnel 
on   cardiac resuscitation to surgical cardiac valve replacements to programs   
designed to help PTSD - the VR Show included lots of cutting edge   technology. 
 It's coming.  The anatomy lab of yore is becoming history   - along with lots of
other "real" training to be replaced by "real" training   of a different sort.  
It's actually   quite impressive...
Controlling   Alzheimer's By Blocking Gene Activity - As my readers know -   because
of the increasing frequency of my blog notes on the problem - I've   become focused
on Alzheimer's over the last couple of years.  The Spring 2017 issue of the Alzheimer's
  Disease Research Review had a very interesting piece on new research that has 
  recently been announced.  First, there   are clear sex differences in the incidence
of the disease.  Men have 1 in 11 odds of getting the   disease versus women whose
odds are worse at 1 in 6.  The reason for the difference has been   unclear until
recently.  Dr. Enrico   Glaab from the University of Luxembourg analyzed brain samples
from about 650   deceased men and women - some with the disease and some who did
 not have the   disease.  The findings were very   interesting.  Evidently, there
is a   specific gene - ubiquitin-specific   peptidase 9 (USP9) - that has been tied
to the presence of   Alzheimer's.  The level of USP9 is   lower in men and appears
to have an interaction with another gene that   regulates the "tau" proteins - which
are found in much higher levels in   Alzheimer's brains.  The researchers found 
  that blocking the USP9 gene resulted in a significant reduction in the   activity
of the tau gene.  The end   result is a potential path forward for an anti-Alzheimer's
drug treatment   that targets the genes controlling USP9 production.  Now, wouldn't
that be nice J.  I'll keep an eye on this potential path   forward...
Preventive Medicine: What's Good For The Goose Is Good For the Gander - It may come
as a surprise to some but - then again - not.  Ahem, physicians are just like everybody
  else!  What is notable in much of the   recent research on physician attitudes
 and perspectives about their role in   health care is the evolving body of research,
which is documenting an   increase in the rate of physician burnout.    While there
are many ongoing responses to burnout, the result is that   too frequently physicians
simply hang it up and quit practice.  The phenomenon is particularly acute among
   the Boomer physicians.  In a commitment   to try and do something about the problem,
the American Medical Association   and a number of CEOs from large systems recently
came together and made a joint commitment to address the   physician burnout problem
[http://r20.rs6.net/tn.jsp?f=001q8xffJ4BifUAyY3VOgbKPCUyGOfFIBMA1fCd1b-eQ0CTo3FXKtPX_xnr0iiKFjjO3NdNEpWGJ4gy4sU5sPdaveBKEmwb_QPDiJvxl9m6DNCJr0kov9i8OvVvKZHAsvy8BLYcDy71TTn-KKupLlk-bel8hHgW8BH1yDVo3aEVBg1sCJ9L0mER8V-uKIWQyQ_gVyQYSZk45KHspbP-DXYJItFAYi_oP1Qm3a-a0M5-kcwptpgoYYpy-bflb_chwqisg-W1BYFmirU0cruXfxytib3KXi_WQibp2DWI6iWgYl0MGTpLQjW2I8gEiuERb1-l&c=vPj0ugTdpCABpG7fhgSsvZaaxgiO_qq5Var7Sm8TgC-cSOGEm4VULQ==&ch=B14ooffRZP2esNYqiUN8MBPttySqU_ofzXlii_BboeJmvj_V9uoYlw==].
   They published their commitment in the Health Affairs Blog which appears regularly
on contemporary   issues.  The specific commitments by   the Association and the
 health system leaders included the following 11   actions, as follows:

1. Regularly measure the well-being of our        physician workforce at our institutions
using one of several        standardized, benchmarked instruments.
2. Where possible, include measures of        physician well-being in our institutional
performance dashboards along        with financial and other performance metrics.
3. Evaluate and track the institutional costs        of physician turnover, early
retirement, and reductions in clinical effort.
4. Emphasize the importance of leadership skill        development for physicians
and managers leading physicians throughout        our organization.
5. Understand and address more fully the        clerical burden and inappropriate
allocation of work to physicians that        is contributing to professional burnout.
6. Support collaborative, team-based models of        care where physician expertise
is maximally utilized for patient        benefit, with tasks that do not require
 the unique training of a        physician delegated to other skilled team members.
7. Encourage government/regulators to address        the increasing regulatory burden
that is driving inefficiency,        redundancy, and waste in health care and to
 proactively monitor and        address new unnecessary and/or redundant regulations.
8. Encourage and support the AMA and other        national organizations to work
 with regulators and technology vendors to        align technology and policy with
advanced models of team-based care and        to reduce the burden of the EHR on
 all users.
9. Encourage and support the AMA and other        national organizations in developing
further initiatives to make        progress in this area by compiling and sharing
best practices from        institutions that have successfully begun to address 
burnout, profiling        case studies of effective well-being programs, efficient
and satisfying        changes in task distribution, and outlining a set of principles
for        achieving the well-being of health professionals.
10. Continue to educate our fellow CEOs as well        as other stakeholders in 
the health care ecosystem about the importance        of reducing burnout and improving
the well-being of physicians as well        as other health care professionals.
11. Support and use organizational research at        our centers to determine the
most effective policies and interventions        to improve professional well-being
among our physicians and other health        care professionals.
You Heard It Already But...- The vote on TrumpCare finally came in - for the   US
House of Representatives - with a squeaker at 217 in favor and 213 against,   which
allowed passage of the American Health Care Act (AHCA).  What seemed impossible 
just a mere seven   weeks ago, finally became a reality.    But, it wasn't without
some degree of trepidation and angst.  According to media report. Reince Preibus,
  the White House Chief of Staff, was on full alert in working with Speaker   Paul
Ryan (R-WI), to gain passage of the legislation.  The bill (Mea Culpa - I have not
yet read the full legislation) essentially   was a slightly modified version of 
the former bill that was previously struck   down with two substantive changes: 
 1)   the bill that passed allows the states to apply for waivers from the ACA-mandated
  requirements including waivers which allow insurers to impose health status   
underwriting on individuals (i.e. "pre-existing conditions") who don't   maintain
continuous coverage; and, 2) the bill adds $8 billion in funds to   fund high-risk
pools in states that seek such waivers.  These two provisions have caused   significant
concerns across the board because of the broad definition of a   pre-existing condition
generally employed by the insurance industry.  In addition, the $8 billion is viewed
as a   rather paltry sum of funding for the potentially large number of people that
  would be affected or, those who obtained insurance under the Obama program   and
would now be without coverage.
While   there is not final valuation on the latest version of the AHCA which passed
  the House, the Congressional Budget Office (CBO) did weigh in on the cousin   
of the bill which failed to pass a month ago.    In that bill, the CBO score [http://r20.rs6.net/tn.jsp?f=001q8xffJ4BifUAyY3VOgbKPCUyGOfFIBMA1fCd1b-eQ0CTo3FXKtPX_xnr0iiKFjjO1jGEDrXKCKDhlUSaXJOboaKHbh6rHpxKvo-Bqjeknlia2a59CBMakq6OAVS-UsKo1MjDq0ZklgD5oSGPg5_kj6DS1jPV8PcaDQn7COA2lBIcDAuUowKNkuXsnNhIGoKXkYVmX7798vGMjyGvI4VARxwYwLKpDudP&c=vPj0ugTdpCABpG7fhgSsvZaaxgiO_qq5Var7Sm8TgC-cSOGEm4VULQ==&ch=B14ooffRZP2esNYqiUN8MBPttySqU_ofzXlii_BboeJmvj_V9uoYlw==]
of   the prior AHCA estimated that by 2026 the number of uninsured Americans would
  reach about 24 million, federal funding for Medicaid would fall by 25%; and,  
 the number of individuals with employer-sponsored insurance would be reduced   
by 7 million people.  Those numbers   caused considerable heartburn among both liberals
and conservatives for a   piece of legislation that is increasingly viewed as a 
right.  By all accounts, most experts do not expect   the new scoring to be much
 different once it is completed sometime over the   next couple of weeks because
 except for the two changes described above, all   else remains the same [http://r20.rs6.net/tn.jsp?f=001q8xffJ4BifUAyY3VOgbKPCUyGOfFIBMA1fCd1b-eQ0CTo3FXKtPX_xnr0iiKFjjOdmsu9X-WUHC7darSO8mFJLbwdZHu0ohCFSS9f2b8vEGCMWdaL61umyXiGzBgeqfn8hXyBE6E_OxRJ3Eb8DFGEwlrj0oCRjf_02cCbV-UV1vvnZElw5wd4PUZwFWutdSvkahUJRXW8XVCqQFbU2tX_pkfSRnd_SXr9UyI_kolBxM=&c=vPj0ugTdpCABpG7fhgSsvZaaxgiO_qq5Var7Sm8TgC-cSOGEm4VULQ==&ch=B14ooffRZP2esNYqiUN8MBPttySqU_ofzXlii_BboeJmvj_V9uoYlw==].
While the   debate is only now just getting started in the US Senate, most of the
policy   wonk observers expect significant modifications before any vote is even
   considered.  Plus, the Senate is a much   more temperate organization (at least
historically) so that we should anticipate   a full vetting of the bill before passage
rather than the rush job we   witnessed on the House side.
There was clearly lots of angst related to the bill.  Among those opposing the bill
were the AARP [http://r20.rs6.net/tn.jsp?f=001q8xffJ4BifUAyY3VOgbKPCUyGOfFIBMA1fCd1b-eQ0CTo3FXKtPX_xnr0iiKFjjOLMtrdXLLi3VQfdpPDGySTQBdDaZisrt5GAx9KbdguUI0MNdNXWAyvapR45ew4RlwAWMOy6QZz1He_fdz_X92ZmD5VotdrxZGGFT6sYHgA27cvgOxBECcZfCPseEQYbmh&c=vPj0ugTdpCABpG7fhgSsvZaaxgiO_qq5Var7Sm8TgC-cSOGEm4VULQ==&ch=B14ooffRZP2esNYqiUN8MBPttySqU_ofzXlii_BboeJmvj_V9uoYlw==],
the American Medical   Association [http://r20.rs6.net/tn.jsp?f=001q8xffJ4BifUAyY3VOgbKPCUyGOfFIBMA1fCd1b-eQ0CTo3FXKtPX_xnr0iiKFjjOVaj-NKRYRiFsAJ36FVw908y2PGJiMM3XOiDKJf9V6vEU8Zqe5vRTwfbon86bZA5RHv7SfZ10RQrTye_skfmGUlfIcEaAQeNQ8szVhDUR5x46wLv8NZgLhvE0mQ-egxutaFfS0ssjasTVQZ7hnKjVV0XSNiynnhT9&c=vPj0ugTdpCABpG7fhgSsvZaaxgiO_qq5Var7Sm8TgC-cSOGEm4VULQ==&ch=B14ooffRZP2esNYqiUN8MBPttySqU_ofzXlii_BboeJmvj_V9uoYlw==],
America's Essential   Hospitals [http://r20.rs6.net/tn.jsp?f=001q8xffJ4BifUAyY3VOgbKPCUyGOfFIBMA1fCd1b-eQ0CTo3FXKtPX_xnr0iiKFjjOGz7izY9U2yBh09GtuoODHpeYW-PXypmQmi3kEqXU4sCg7gkSIOzcPkCLHF_T9GH0h5zzjcP3-3rVqkOJLdI8qWKjD4uWr1U3tCTSxZCQZ6Vf3FD2DPp0JS_bF9vnge-3Grjcu1bJv_5zO4QpsE_ZvXCcncCCescT&c=vPj0ugTdpCABpG7fhgSsvZaaxgiO_qq5Var7Sm8TgC-cSOGEm4VULQ==&ch=B14ooffRZP2esNYqiUN8MBPttySqU_ofzXlii_BboeJmvj_V9uoYlw==],
American Hospital   Association [http://r20.rs6.net/tn.jsp?f=001q8xffJ4BifUAyY3VOgbKPCUyGOfFIBMA1fCd1b-eQ0CTo3FXKtPX_xnr0iiKFjjO8TIHrqJNf2vo34WHcqlitfVCTIZP1S6LUJDol2ebvQ1YymFrU_-tRx51saA55Hx7NSb12PoVZ6l6kCyLoKafqWBkD21I4qWNJrsPYnL5iiRKDinkyD321Ac3yKxiNtKJZ9mtkprjXEkaFDMeYhdyyQPNDeBeJyKJ&c=vPj0ugTdpCABpG7fhgSsvZaaxgiO_qq5Var7Sm8TgC-cSOGEm4VULQ==&ch=B14ooffRZP2esNYqiUN8MBPttySqU_ofzXlii_BboeJmvj_V9uoYlw==],
Association   of American Medical Colleges [http://r20.rs6.net/tn.jsp?f=001q8xffJ4BifUAyY3VOgbKPCUyGOfFIBMA1fCd1b-eQ0CTo3FXKtPX_xnr0iiKFjjOn0lqZKuLG5J1EGr4YzUasRmDNUOZ9ykr23N28AJNioQ-palMZ4PXduHRbCLcc51S7GXqR5JMvUrIg0HsykwQlwHLTxuoAlPN1lTrpKCykRKAXa7XvIyievdhROoWrWfbaY7p7mviFhKj7-uSx78RoS0IaZFBb6d-dxaNxV_mOGA=&c=vPj0ugTdpCABpG7fhgSsvZaaxgiO_qq5Var7Sm8TgC-cSOGEm4VULQ==&ch=B14ooffRZP2esNYqiUN8MBPttySqU_ofzXlii_BboeJmvj_V9uoYlw==],
Catholic   Health Association of the United States [http://r20.rs6.net/tn.jsp?f=001q8xffJ4BifUAyY3VOgbKPCUyGOfFIBMA1fCd1b-eQ0CTo3FXKtPX_xnr0iiKFjjOafQjVKvmBc4xvKhvKQzQqHcp2TfZwe5HcSdhr4CeLfAETxLNKbx_bGul5fO7RvucbSaziaHVH30BSRZEZ9f5Fx5KnG6KGjlazCM7vt5mMoGQ9W27FyCc4c9w_NmAvY1f3EgQ5-yyhULdEj3H3RtgFjHltzbexvHrLueXCjXnHTPb9MvAtcHqUg==&c=vPj0ugTdpCABpG7fhgSsvZaaxgiO_qq5Var7Sm8TgC-cSOGEm4VULQ==&ch=B14ooffRZP2esNYqiUN8MBPttySqU_ofzXlii_BboeJmvj_V9uoYlw==],
Children's Hospital   Association [http://r20.rs6.net/tn.jsp?f=001q8xffJ4BifUAyY3VOgbKPCUyGOfFIBMA1fCd1b-eQ0CTo3FXKtPX_xnr0iiKFjjOBjZaKdCHlp_wqmN_LqU6-mubi6jFh1y3EsHo49gp4_pk31ox1cvqfACNnmMoFKX2Q6BijheRMI9lby8Ju4-TaG91g2W7dgIjfEtFWiyMyaSMk7lOl5IHUjCDzQHIna-m-JRNKTbGOGonHglj5o237_YfKq7ppmKJvOxlhecqV0Y=&c=vPj0ugTdpCABpG7fhgSsvZaaxgiO_qq5Var7Sm8TgC-cSOGEm4VULQ==&ch=B14ooffRZP2esNYqiUN8MBPttySqU_ofzXlii_BboeJmvj_V9uoYlw==],
Federation of American   Hospitals [http://r20.rs6.net/tn.jsp?f=001q8xffJ4BifUAyY3VOgbKPCUyGOfFIBMA1fCd1b-eQ0CTo3FXKtPX_xnr0iiKFjjOxykuWz8fwo53Qh4WKaVUoQ9mNzXm9-nunJFIT86ywk3IHH4pCJjYAW5oBzdOsJXIsPKgmcPf7npL1kafgE58lO8hCs0jX0tLwskKLEbCtGQR5Hx_AC4gEMrPkKvVZK2Bbl9m2-oRdUWMNJLS9sBgvrqJKmsgg-L9&c=vPj0ugTdpCABpG7fhgSsvZaaxgiO_qq5Var7Sm8TgC-cSOGEm4VULQ==&ch=B14ooffRZP2esNYqiUN8MBPttySqU_ofzXlii_BboeJmvj_V9uoYlw==],
and National Association of Psychiatric Health Systems [http://r20.rs6.net/tn.jsp?f=001q8xffJ4BifUAyY3VOgbKPCUyGOfFIBMA1fCd1b-eQ0CTo3FXKtPX_xnr0iiKFjjO4uZwKZH92d2r-1SogNyokL1r0UFEU37rhEf_fhM3qvQHpq3iO3aXEVds7laS6HDITNSsaSdTrFspTq6pYrlUQXTWjPCfpnEGaUE7E8v9IlR8sQuSkBLYlkTody6cUsCepvojwDjHKEDQgVVHYdPo8p3DthAgq54i9tTG5BzMEmFP9Bt0ds5KoZtcb9ImiVUq&c=vPj0ugTdpCABpG7fhgSsvZaaxgiO_qq5Var7Sm8TgC-cSOGEm4VULQ==&ch=B14ooffRZP2esNYqiUN8MBPttySqU_ofzXlii_BboeJmvj_V9uoYlw==].
But, it wasn't just   the health care providers, various conservative groups, including
Heritage Action [http://r20.rs6.net/tn.jsp?f=001q8xffJ4BifUAyY3VOgbKPCUyGOfFIBMA1fCd1b-eQ0CTo3FXKtPX_xnr0iiKFjjOL_Ux-moA6v9oj8ZJb7RQMEhWjev8SXRA1yW_4CPL12hxJyQDVSHEn0LvUsyqFG7YMHMlTFbSeGeGvz3YN9i9I_HplbYTRh2JRZA8IhC9lgHl0SuFT3csO5fxci9Ens2XT8AJ_ZOHvYw=&c=vPj0ugTdpCABpG7fhgSsvZaaxgiO_qq5Var7Sm8TgC-cSOGEm4VULQ==&ch=B14ooffRZP2esNYqiUN8MBPttySqU_ofzXlii_BboeJmvj_V9uoYlw==],
the Cato Institute [http://r20.rs6.net/tn.jsp?f=001q8xffJ4BifUAyY3VOgbKPCUyGOfFIBMA1fCd1b-eQ0CTo3FXKtPX_xnr0iiKFjjO7lVqaq7qnSTCSlDF6kB6Jy5rhOqUnHW3ImG1hva5asH9-aQo1FQ7hiCfguPLn8EIvqxGtlnHDUxp4x4LN9g_wsFywDBzEsylJMVrwrT0NkAGIJ0tYGV1XkaD0YRHfTj2JheN25UiXQY=&c=vPj0ugTdpCABpG7fhgSsvZaaxgiO_qq5Var7Sm8TgC-cSOGEm4VULQ==&ch=B14ooffRZP2esNYqiUN8MBPttySqU_ofzXlii_BboeJmvj_V9uoYlw==],
Americans for   Prosperity [http://r20.rs6.net/tn.jsp?f=001q8xffJ4BifUAyY3VOgbKPCUyGOfFIBMA1fCd1b-eQ0CTo3FXKtPX_xnr0iiKFjjOUws3QljHjf1muC9WvKSByCYztKq7G8PHVLC8pAqQYyssN_RIDT1htWNkm3FPPEdDT2Z-hu_FGbTpN0jo0WFRgbb8beUbu9wzZNpG4v7od4k9atqlQLWUKWTDXpU2vmFTBw1WkDs4NXB7k2a6H5ox7w==&c=vPj0ugTdpCABpG7fhgSsvZaaxgiO_qq5Var7Sm8TgC-cSOGEm4VULQ==&ch=B14ooffRZP2esNYqiUN8MBPttySqU_ofzXlii_BboeJmvj_V9uoYlw==],
FreedomWorks [http://r20.rs6.net/tn.jsp?f=001q8xffJ4BifUAyY3VOgbKPCUyGOfFIBMA1fCd1b-eQ0CTo3FXKtPX_xnr0iiKFjjOWzXkPyqx2tapaAB6vf_82SjiFrSE1J0fmFojaSYYVm2DROGI56sODL93vBGDt6wszq469rYmRfo8Rn6c6yKcG_2SrIju3an7Dy9EIOn8u6InbDWbzIZu2XA8ArYvv0lPZxVUsidNK8w=&c=vPj0ugTdpCABpG7fhgSsvZaaxgiO_qq5Var7Sm8TgC-cSOGEm4VULQ==&ch=B14ooffRZP2esNYqiUN8MBPttySqU_ofzXlii_BboeJmvj_V9uoYlw==],
and the Tea Party Patriots [http://r20.rs6.net/tn.jsp?f=001q8xffJ4BifUAyY3VOgbKPCUyGOfFIBMA1fCd1b-eQ0CTo3FXKtPX_xnr0iiKFjjOSYfbC_Do8iH_gT8eBqbjpLFmimWtaD9DNuuIyKRYPj5vNFKQuDUZeCVpyXIQc1Qc-yfy4_XAHBLHFQLLucUOZ0cquF-3ElhiyM89LJVE_qH8UkjUOlqa2T7BtE3jMoivcTC1W8vIrYKWoR_0yiQ4xw==&c=vPj0ugTdpCABpG7fhgSsvZaaxgiO_qq5Var7Sm8TgC-cSOGEm4VULQ==&ch=B14ooffRZP2esNYqiUN8MBPttySqU_ofzXlii_BboeJmvj_V9uoYlw==]
all opposed the bill   as well. The politics of the moment seems to have pushed 
it through the   House.  Now, it is on to the   Senate.  I would   anticipate that
"something" will pass the Senate.  At this stage; however, it's anybody's   guess
as to exactly what.  We'll   continue to keep our fingers on the pulse even if it
gets a bit thready in   the coming weeks J...
Regardless   of what happens, the writing is on the proverbial wall on a couple 
of   points. First, we are   moving toward "value-based models of care delivery".
 While the details are still being worked   out, everyone should anticipate that
 the glory days of fee-for-service   payment structures will become a thing of the
past.  While all of the insurers are tinkering   with approaches, the gorilla in
 the room is Medicare so everyone in health care should   be working on a strategy
for managing risk in the Medicare population. Second, consolidation will   continue
driven in large measure by the need for clinical alignment.  Once we get through
 this stage of debate   (over the next year or so), I predict that the evolution
 of large regional   systems will portend the move toward seminal national systems.
 Then, as they say "Let the games   begin". Finally, the   consumers will be in 
charge!  Whether   it's airlines, taxis, hotels, books, legal services, food or 
anything else -   the one lesson we should take home is that health care is in for
some real   transformation.  Mark my words,   the consumer of services is in charge.
   We should listen to them, weight their needs - and, respond!!  Those who wait
 to figure this one out will be   left out in the cold.  And, for a kid   from North
Dakota - "cold" means that you are frozen, not chilled.  These are three very good
reasons for kick   starting change in your health care organization.  And, there
 are more opinions where that   came from J.

Coffee, Coffee, Coffee!! -  There's a new study on the street that is REALLY important
for those of us who are Coffeaholics.  The new study [http://r20.rs6.net/tn.jsp?f=001q8xffJ4BifUAyY3VOgbKPCUyGOfFIBMA1fCd1b-eQ0CTo3FXKtPX_xnr0iiKFjjO1ToXTI9OtvngmKWo7TQ3oSFaJcNpC72Z5ozg6e9uJRgl4KTOP2GXqOVhcArWyBSp2Eud_Cbh-rXAeiMo8ck1nl97_SxY_n0Vo4m6akXKUoxgJb_o9V_NuzstGqYQF_un5Ze3y8ide3ltABzoz6xv68gqbbwjNJQiPQt9qGpLG7Tl9zDLJy-UU9jfEUI5riR-FJa8_tpdn813ByUcRw4ooaMp1xi827_5VIx8NwXIbRlWm-HptCD66wYIRfjpJEQDGke1xH32EmhsUeH_DChQZQ==&c=vPj0ugTdpCABpG7fhgSsvZaaxgiO_qq5Var7Sm8TgC-cSOGEm4VULQ==&ch=B14ooffRZP2esNYqiUN8MBPttySqU_ofzXlii_BboeJmvj_V9uoYlw==]
reports that the cup-a-joe - or should I say "joes" - we consume may actually boost
longevity.  Even the decaf drinkers had a positive result.  Specifically, the study
- reported by the Harvard School of Public Health - found that those who consumed
3 - 5 cups of coffee per day had a 15% reduction in their risk of premature death
compared to those who drank less.  There's also a decreased risk of stroke [http://r20.rs6.net/tn.jsp?f=001q8xffJ4BifUAyY3VOgbKPCUyGOfFIBMA1fCd1b-eQ0CTo3FXKtPX_xnr0iiKFjjO-RlUi3gjzwUSw6KUOqAXcpZzz8KI-xWMLLDRvhYxjbevIocSWgaE8SggsBVJNp3BWh4uqB5w7vbeznKBjV510iG2nNRt4wdqw3o1Cgc2gwRnGgDQ4Ssn3hitN-1ziB2XvkVJRsweUK70UHBXz05_KfnklQHwnh4STLwY2iy5NNQM3UoZtuexdccTiRh7h7-0QmfAFYGEcAbfmy-A76cpPD_y7C6A_a1gqa72Wdn7V5VBjDcwGLzg_Q==&c=vPj0ugTdpCABpG7fhgSsvZaaxgiO_qq5Var7Sm8TgC-cSOGEm4VULQ==&ch=B14ooffRZP2esNYqiUN8MBPttySqU_ofzXlii_BboeJmvj_V9uoYlw==]
and even some results showing a positive impact of Type II diabetes by lowering 
the incidence.  And, there's even reports about enhanced cognitive function [http://r20.rs6.net/tn.jsp?f=001q8xffJ4BifUAyY3VOgbKPCUyGOfFIBMA1fCd1b-eQ0CTo3FXKtPX_xnr0iiKFjjOgtuQFaj4uU6W6f8TQS33PDnDM6DGec1nJ4i2vRkvtztsjYmzXpK3wiXy8P_jpyPv9OIvHgtx-rps3EDyxoGtnshKfnoThZQm9K5EX9ghYAspgnUEpmOuZ4Z5aE8NTvj3AygFhycQehk=&c=vPj0ugTdpCABpG7fhgSsvZaaxgiO_qq5Var7Sm8TgC-cSOGEm4VULQ==&ch=B14ooffRZP2esNYqiUN8MBPttySqU_ofzXlii_BboeJmvj_V9uoYlw==]
and mood enhancement - although the amount of coffee consumed for those effects 
was only about 2 cups a day L.  Stay tuned...
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Weekly Whisk
Musings from a foodie...
Just north of Boston near the sea coast is a farmstead - Applecrest Farm which opened
a Bistro a number of years ago.  When you travel there, you traverse through the
 countryside along rural, tree-lined roads until you finally come to the farm. Applecrest
Farm Bistro [* * * *] is a true farm-to-table restaurant.  Chef Derek Clough has
 done a great job in establishing the reputation for this up and comer in the Greater
Boston Area.  He cooks with a taste and spice forward approach.  You can almost 
hear the cows mooing J.  I wasn't sure what to expect but I was definitely and pleasantly
surprised!!  We started with their house-made charcuterie and regional cheeses. 
 It was incredible.  The edibles ranged from Duck Confit with poached quince to 
pasteurized cow's and goat's milk to organic raw cow's milk cheeses...  The starters
were equally good with the usual sampling of salads.  I had the pancetta-wrapped
 local cod, which was good although a touch overcooked for my taste. It was accompanied
with grilled parsnips and fennel which was a great combination.  But the highlight
of the evening was the order of bacon-wrapped meatloaf served with roasted broccoli,
mashed potato and a mushroom demi-glace.  For those of us who look back on those
 Sunday evening meals of meatloaf with fondness - this was a real treat.  I tried
to switch but was only able to garner a sampling.  Next time - I'm going for meatloaf!!
 If you are north of Boston, it's definitely worth the trip.  Besides - following
dinner you can amble through the Applecrest Store and pick up all those items for
some good old fashioned home cooking.  Go for it!! Applecrest Farm Bistro - 133 
Exeter Road - Hampton Falls, NH 03844 - (603) 926-0006 - http://farmbistro.com/
I can't believe I missed my other favorite of the last two weeks - Borobudur [http://r20.rs6.net/tn.jsp?f=001q8xffJ4BifUAyY3VOgbKPCUyGOfFIBMA1fCd1b-eQ0CTo3FXKtPX_xnr0iiKFjjOguTP2CUfvPfQSbOSaRgM8WN0VQbf63gOH11SgfQ8gRwXHktGT9wKrA6-yaWwznRUywagFofAAb1kOLSgoDYvIlwJ_dblY41y4bwyNu1EBDwO0O7D5TINyA==&c=vPj0ugTdpCABpG7fhgSsvZaaxgiO_qq5Var7Sm8TgC-cSOGEm4VULQ==&ch=B14ooffRZP2esNYqiUN8MBPttySqU_ofzXlii_BboeJmvj_V9uoYlw==]
in San Francisco.  Having lived there for nearly a decade, I had never been to the
restaurant. But, on a recent visit, it was suggested by a colleague that grew up
 in Indonesia as "...the place to go."  I was blown away by this small, "journey
 of taste" restaurant near Union Square.  I had only two of the items listed on 
the extensive Indonesian menu but, they were outstanding.  The Roti Prata (a pan-fried
layer bread served with curry dipping sauce) could have been the whole experience.
 It was topped by the Lamb Curry.  And, there were so many other choices of soups,
salads, beef, lamb, seafood and the like on the menu - that I'm going back on my
 next visit to San Francisco. Borobudur - 700 Post Street - San Francisco, CA  94019
- (415) 775-1512 - www.borobudursf.com [http://r20.rs6.net/tn.jsp?f=001q8xffJ4BifUAyY3VOgbKPCUyGOfFIBMA1fCd1b-eQ0CTo3FXKtPX_xnr0iiKFjjOguTP2CUfvPfQSbOSaRgM8WN0VQbf63gOH11SgfQ8gRwXHktGT9wKrA6-yaWwznRUywagFofAAb1kOLSgoDYvIlwJ_dblY41y4bwyNu1EBDwO0O7D5TINyA==&c=vPj0ugTdpCABpG7fhgSsvZaaxgiO_qq5Var7Sm8TgC-cSOGEm4VULQ==&ch=B14ooffRZP2esNYqiUN8MBPttySqU_ofzXlii_BboeJmvj_V9uoYlw==]
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Good, The Bad, And The Ugly
The ongoing saga...
The Great - Brazil announced this past week that the Zika virus is no longer an 
official public health crisis where the number of cases in 2017 has been reduced
 by 95% from 2016.
The Good - Coffee, Coffee, Coffee (See above note!)
The Bad - The cyber-attacks on the health care community are a warning sign.  We
 should take note.
The Ugly - The ongoing divisiveness in the US Congress and, American politics in
 general.
The statements in The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001q8xffJ4BifUAyY3VOgbKPCUyGOfFIBMA1fCd1b-eQ0CTo3FXKtPX_znMcIvVlbAaveMehd7VfIni1b3RkRYDExtZuHrHmEDshNVyrsWqnv3BiLKYhCEsQE4s8q-1gUBhXvTb7XR_1pdjE8OwuspM4Yxum63vtwqujn1aFBwYSbVubIwQAvghWwELrd9u_Vb0&c=vPj0ugTdpCABpG7fhgSsvZaaxgiO_qq5Var7Sm8TgC-cSOGEm4VULQ==&ch=B14ooffRZP2esNYqiUN8MBPttySqU_ofzXlii_BboeJmvj_V9uoYlw==]
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
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The Fickenscher Files | PO Box 840 | Kittery | ME | 039