Subject: News from Dr. Kevin Fickenscher
From: "The Fickenscher Files" <[email-masked]>
To: <[email-masked]>
Date: Tue, 19 Sep 2017 10:25:15 -0400 (EDT)

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The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001AWeT4e2K_UT3Gm85UceEjtGKwzS0S8-lyfP5AMBlVFyCD_kUzFGURNmvZrrl44Rd5XKw9dd2dOWgObwNaLCg40M6LjXgzKiBGyVa1xDEcwYnl9uzqkcYl3S1BSTvDSVG1-FFwCR4Ybx5dMvT56FoxPapIqc0HDlUBclYI5EmPqlwPpcPkEIAlYg-rlz0_iFY&c=52vNRpVveelt0QLvnZIt3IVCK5qv8NzgGkPTwZhnMm6y4c1A2Y232g==&ch=uzLFKhJMaoqF47WvjfpyJ0dZMcaqCmR_rF1yMaJYgp_nBPhwHY2JVw==]
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The Fickenscher Files, Vol. 5, Issue 8
Kevin M. Fickenscher [http://r20.rs6.net/tn.jsp?f=001AWeT4e2K_UT3Gm85UceEjtGKwzS0S8-lyfP5AMBlVFyCD_kUzFGURAP1nOUn7X87_ec6beu9pbx2XpTcE2QnesnC4F73FfqJ9TK30tWupZ8W-W3F4znFvtwNVIY3qahhU_wir7ozZuTf12NEehvtNvUbTYIVCI9WOWE-8NeHAy5XqNtFF48qhXedMHIwb3ITJQwIhvU7LOzlZ0kJJnoLTg==&c=52vNRpVveelt0QLvnZIt3IVCK5qv8NzgGkPTwZhnMm6y4c1A2Y232g==&ch=uzLFKhJMaoqF47WvjfpyJ0dZMcaqCmR_rF1yMaJYgp_nBPhwHY2JVw==],
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
"Mankind will find no cessation from evil until either the real philosophers gain
political control or else the politicians become by some miracle real philosophers."
Plato, The Republic, 326d
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Issues To Consider
Ideas worth a review...
Shame On Me!!  The Fall is here and I missed the opportunity to highlight a "summertime
issue".  But, then again, the school season is just starting so perhaps this review
is not missing the mark by too far.  What am I talking about?  It's an issue that
I was not aware of until my wife, Suzanne, brought it up as a major cause among 
dermatologists or, the "Reducing the Risk of Skin Cancer and Excessive UV Exposure
in Children" or SUNucate Act [http://r20.rs6.net/tn.jsp?f=001AWeT4e2K_UT3Gm85UceEjtGKwzS0S8-lyfP5AMBlVFyCD_kUzFGURFlIqYuXTbsPehyofYsL10t83zMDnvcT0khKEdFT65FyWxtJA2iRrNth9FiuhT_ySSmq2qduFHybpNJcPdpuOKrRehx_VagHOOmoVNRKqvkv7aDf8MMFGAf2rIwDnrMFFGfCWEvJr0k9cDtTz-lFijRSxdRuabH19tji-TpJT2ufH2-IR3e1izCE2gpJ24DQcHNCx-EAtU6pU9crwbEjpWFGcc4B0mjeuDzrfD-qwxq0q70ivP_-LFWkpURhaZY88h3_IC4f328DLXmO1pCSt37zRy9qF7xkbN87X4yNX5DJf_YsWP6j80Rze08n4CTYbWITIL8Sgnep&c=52vNRpVveelt0QLvnZIt3IVCK5qv8NzgGkPTwZhnMm6y4c1A2Y232g==&ch=uzLFKhJMaoqF47WvjfpyJ0dZMcaqCmR_rF1yMaJYgp_nBPhwHY2JVw==].
 Unbeknownst to me, kids attending school are often not allowed to bring or use 
their own sunscreen without a prescription due to "medication bans" and fears by
 the school systems of legal entanglements.  It's outrageous.  Both the Centers 
for Disease Control and Prevention (CDC) and the US Preventive Services Task Force
have stated unequivocally that policies that prohibit hats or student possession
 of sunscreen can create barriers to the use of important sun protection methods
 and cause an increase in sun exposure - which is known as one of the most important
factors towards increasing the risk of skin cancer.  The SUNucate Act is an effort
to resolve this problem by creating legislative mandates to allow kids to use sunscreen.
 So, I encourage all of my readers to encourage your state legislators to introduce
the SUNucate Act.  It's moving forward in several states.  It harkens me back to
 the days when we started to educate kids about the use of seat belts.  I remember
it well.  My daughter, Kylene - when she would climb into the car after picking 
her up from school - would say, "Daddy, you're not wearing your seat belt."  After
three or four times of those types of admonishments, I started wearing seat belts.
 Now it is part of a routine I go through before starting my car.  That's what allowing
kids to wear sunscreen at school would do.  We will all be better for it because
 our kids will ask us if we have applied our sunscreen before going out in the sun.
 So, teach a child - educate a family!!
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The Occasional Random Rant
Thoughts for sharing because I must...
In August, we traveled to Greece for a holiday getaway with members of our family
to the island of Kythera.  It's part of the Peloponnese, the southern islands off
the coast of Greece.  While visiting, I picked up a copy of the Summer 2017 Edition
of
Kythera, the local newspaper.  It is a combined Greek and English newspaper focused
on local events and activities.  I was struck by the editorial that started with
 the Plato quote above.
The essence of the editorial focused on the future of the European Union.  They 
described Emmanuel Macron's presidential election in France as "...a flicker of 
light [that had] broken through the darkness of our 2017 chaotic world."  In particular,
the editorial highlighted Macron's statement that, "The difficulties of one are 
always the problem of all."  And, it cited how all members of the European Union
 needed to come together to solve problems.  Greece - in particular - has been very
heavily hit by economic suppression through the agreement that Alexis Tsipras signed
with the EU shortly after coming to office despite running on a platform that he
 would not "give in" to European demands.  By acquiescing, he lost the support of
the vast majority of Greeks and unemployment has gone even higher (now over 30%,
 primarily among younger workers) during what is now called the "economic downturn"
or "the austerity".  The editorial posted details on the problems with the austerity
plan and ended with the following statement:
"...But eight years into an economy in free fall and with little prospect of recovery,
the Greek people have succumbed to protest fatigue and a sense of defeat.  The European
Union has come full circle.  Just as it was created in the 1950s to provide peace
and economic prosperity to a territory in ruin, it must now once again forge alliance
for a democratic revival of its existence."
So, what does this have to do with the United States (where I live), generally, 
and health care, more specifically?  I don't want to simply the complexity of our
nation but much of the distress that we are now facing - it seems to me - is evolving
from economic dislocation and subjugation of certain segments of society.  For example,
while the vast majority of our cities and urban areas have enjoyed a substantial
 economic recovery, the hollows of West Virginia, the vast rural areas of the Great
Plains and other economically distressed areas of our country have wallowed in ongoing
financial depression.
Then, I heard a distressing fact that if we take all of the wage increases that 
have been given to factory and other entry level workers over the last decade, they
have been consumed by increases in health care costs. In other words, the hard working
women and men who are the foundation of our nation have not only seen no "recovery"
from the "Great Recession" but continue to be mired in situations that offer little
hope for recovery.  Is it any wonder that the benefits of the health care reform
 legislation are popular amongst this group?  Which takes me to the second point
 that I keep saying in lots of different ways. If we do not resolve the problems
 with our health care systems - despite how good it is in many ways - it will be
 the singular reason for bankrupting the nation!  How many times does this need 
to be raised as a reasonable challenge for getting us to engage as a nation in moving
forward rather than regressing backward?
However, I offer these thoughts with an addition.  In the USA, we have been woefully
inadequate in providing support to those who continue to suffer from the Great Recession.
 We have done virtually nothing to help them retrain so they could pursue other 
careers and jobs ...
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Consulo Indicium
Information for your Consideration...
Congratulations To Miss North Dakota!! - As many of my readers know, I'm from North
Dakota.  At the Miss America pageant [http://r20.rs6.net/tn.jsp?f=001AWeT4e2K_UT3Gm85UceEjtGKwzS0S8-lyfP5AMBlVFyCD_kUzFGURFlIqYuXTbsPn6kMh6wDNy_MmBpD3bA8atTv6OIDrBH14AH0lvuObvXObkAG0KIEDvxgE6KyeZGu0Z2c0AD6HgihdT8tAlv__Zekb0G9bHYc3x78qVBPFRXqzHZpD4DHpYmTasCHztnL5EEJpXCd3uSKktRNl-oWfExEyrLgJ0QE7u42oWvHGQLDSgUp5gi-Bhe3qMht-CGMtxhvkZExxXt6rIlevWP8uTxqL2XoAVWB5nQ57oQrpqd96mMoEnvstVSYA6lEL8wTTNdtE8Ohhho=&c=52vNRpVveelt0QLvnZIt3IVCK5qv8NzgGkPTwZhnMm6y4c1A2Y232g==&ch=uzLFKhJMaoqF47WvjfpyJ0dZMcaqCmR_rF1yMaJYgp_nBPhwHY2JVw==]
in Atlantic City, Cara Mund won the crown!!!  She did so after answering her onstage
interview question by pointing out that the Tweeter-in-Chief was wrong to pull out
of the Paris Climate Accord.  Does this portend a new Twitter war?  She's off to
 a good start from my perspective...

The DACA Shocka! - As has been widely reported, the Deferred Action for Childhood
Arrivals or, DACA was created by executive order under the Obama Administration 
in 2012.  The order allows an estimated 800,000 individuals who were brought to 
the United States illegally as children to remain in the country through an application
process. Most of these individuals have never known anything but life in the USA
 and frequently have no familiarity with their native countries' culture or language.
In an effort to urge Congress to pass a legislative replacement, the Trump Administration
announced that it was rescinding the prior executive order six months from now or,
around March 5th.  So, what's this got to do with health care?  Well...a lot!!

Surveys of DACA beneficiaries show that about 20% work in the healthcare and educational
sectors.  In healthcare, these workers range from home health aides and nursing 
assistants to nurses, pharmacists, medical students, residents, fellows and attending
physicians.  Simultaneously, projections indicate "that the economy will need to
 add hundreds of thousands of workers in these fields over the next five to 10 years
simply to keep up with escalating demand, caused primarily by a rapidly aging population."
 In a call-to-action, the CEO of the American Medical Association James L. Madara,
MD said in a letter to Congress that the decision to reverse DACA "fails to recognize
the enormous contributions of hundreds of thousands of individuals who are living,
working, and providing vital services in the United States, including healthcare
 services." He was joined by many of the specialty societies and the Association
 of American Medical Colleges (AAMC) in calling for a solution to the DACA questions.
 Their letters of concern highlighted not only the projected shortage of providers
but also the benefits the increasingly diverse U.S. patient population receives 
by having access to a diverse and culturally responsive health care workforce.  
If you want to weigh in, send your Congressional delegation a note on the bipartisan,
bicameral Dream Act of 2017 (S. 1615 and H.R. 3440) which provide for a permanent
solution to the issue.  It provides a legal pathway to permanent residency for undocumented
Americans brought to the USA as children.  Congress needs to step up and solve the
problem.  The time has come...

USA Uninsured Rate Continues To Decline - According to a recent Census Bureau report,
the percent of the population who lacked health insurance declined from 9.1% to 
8.8% over the period of  2015 to 2016. While the decline was welcomed news, the 
Wall Street Journal [http://r20.rs6.net/tn.jsp?f=001AWeT4e2K_UT3Gm85UceEjtGKwzS0S8-lyfP5AMBlVFyCD_kUzFGURFlIqYuXTbsPfmTgaNR_uAXWf5boivvyHdEFIi2grDUVRy-BD5tbKgUwBV4MoWvHV81CUKhobkF14Zw_8tT4lxBkbMFP_7m-u1rxZ3rOHr3SO81OixQKO1floZe5G-XpnK3ZC7PqcIwsZ228SPiZdew6O0H10uyWIyTwOcYlK5ZnrSXamJ0mwNlYTzV8HqCfmS1fUlYJ42bvNhklwolimcGIK_S257pXJQBFJkSzIpoPHZheOfKtRdUVM2nQa7ReeQeZkChTppG7Ux9vGKM2mthxMTMtMtT6tEVRaT-zmVgfqMbs06RMIWsToITInmcm_wGsKoRTcwJawv0pGiatLR06apOT4t9IWxmZ1bU6Y49NZ4_QCvz1p_MHWAbpMhPTCDkiebpoZK032QpHmm9FVLgW1XDOpV55mAJm3YSPHlS7qSWvqHSeGJhRZzuc8pVu419t0_AOSE3RVT79HHKURvJcZ6dcB395LAJtRamdMzkY-RdDDCP1aLJ142Qc8RIDefBOEa4fhyEWuDEvrHe5iAT9HqwDWTkfJTUTdqZ9aDKICREtixMXCiCUH2U4r7_wA9C0GOZoDdGcMqivCDLdTFRouU49IY8b-g==&c=52vNRpVveelt0QLvnZIt3IVCK5qv8NzgGkPTwZhnMm6y4c1A2Y232g==&ch=uzLFKhJMaoqF47WvjfpyJ0dZMcaqCmR_rF1yMaJYgp_nBPhwHY2JVw==]
argued that the continuing decline in the uninsured rate was due primarily to the
fact that we are seeing more Americans reaching the age of 65 and becoming eligible
for Medicare. Regardless, the USA now has about 28+ million who remain uninsured
 - the lowest number in many, many decades or, as far back as I can remember J.
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Future Health
Delivering care in the new virtual world...
Is Digital Health Dead? - My friend and colleague, Rob Coppedge who is one of the
leaders in the health tech investor space, was widely reported to have said at a
 tech investor's conference recently that "digital health is dead".  I was surprised
so I got a transcript of his comments since he is one of the thought leaders in 
the investor community related to digital where over  $16 billion has been invested
in more than 800 digital health companies since 2014.  That is a chunk of change.
 Here is what he said in his introductory remarks:
Let me be clear: I believe strongly in the need for substantive, consumer-centric
transformation of the health care system and have been a long-term proponent of 
the power of entrepreneurs to catalyze and drive these difficult changes. Despite
this, I truly struggled to prepare for a recent presentation on the future of venture
capital investing in the "digital health" space. The group I addressed expected 
another digital health pep rally - but, after much reflection, the best I could 
bring them was an explanation of why, despite the countless blog posts and questionable
survey data to the contrary, I believe the digital health party is over and why 
those of us focused on long-term systemic transformation should be happy to put 
this hype cycle behind us...
He goes on to say:
...The macro-trends, industry challenges and consumer needs still exist - in fact
most have gotten worse during the ramp up of digital health investment. And without
question, innovators, entrepreneurs and investors will be critical developers of
 solutions to these endemic challenges. We just need a new way forward - to support
the development of the next generation of great healthcare companies that our industry,
and our country, needs...
I encourage you to read Rob's entire presentation [http://r20.rs6.net/tn.jsp?f=001AWeT4e2K_UT3Gm85UceEjtGKwzS0S8-lyfP5AMBlVFyCD_kUzFGURFlIqYuXTbsPMK-nxP7kVfMIvR8KKVYhmgiJzMsfGJSN6q4P-MpyjR5jPPO-bjSJMHKDcXknPyJqQFU-vqtwExu_pk0zAo-LMzAibMkwKbnwbg3Xi5_JDfHd6cM7flZdCV1CcaHXXzCoiLbpScqTpgZczp5h5gfra4S2SEsY21O09lsq1wUn9RlgVFU432eCpnHPmkYSuhGNmlncXSIVrM4loKVwYI9uDawSNeZK6QOO&c=52vNRpVveelt0QLvnZIt3IVCK5qv8NzgGkPTwZhnMm6y4c1A2Y232g==&ch=uzLFKhJMaoqF47WvjfpyJ0dZMcaqCmR_rF1yMaJYgp_nBPhwHY2JVw==]
to the investors.  He is absolutely right that "...better mousetraps are not enough".
 In addition, the health care community has "antibodies" to the many new developments
that are part of the digital health care movement.  In essence, I have come to the
conclusion that while working with established health care organizations is important
- building the capabilities to deliver digital health services needs to evolve from
the outside in rather than from the inside out.  In addition, if the move toward
 value-based care delivery remains at the forefront as a direction for health care
then the need for digital health services will increase even more.  A system that
is volume-based simply demands "doing" things to people rather than making them 
better.  Value-based care will absolutely require new methods for care delivery,
 ongoing support and care management capability.  The foundation of a digital health
service will be critical - especially given the evolving crisis where we are projected
to have a large deficit of care providers to delivery service.  Read the article.
 It's worth the effort.  Ponder his thoughts.  I believe he is pointing us in the
right direction - away from the hype and toward the reality that is arriving on 
the horizon.  Stay tuned...
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The Weekly Whisk
Musings from a foodie...
As my long-term readers know, food and the elements of service are among the hallmarks
of my critiques of restaurants from around the world.  My travels over the last 
week have taken me from a three burger day (hamburgers at each of three meals) in
rural - no, remote - Nebraska to the little "find" I was introduced to in Santa 
Barbara.  If you are ever near Santa Barbara, I would most definitely recommend 
a stop at The Stonehouse [http://r20.rs6.net/tn.jsp?f=001AWeT4e2K_UT3Gm85UceEjtGKwzS0S8-lyfP5AMBlVFyCD_kUzFGURFlIqYuXTbsPz3GtSutrnZ9s8KATEivhvwy1o9Yk9QTzKQg8f1hdlGevPOS0s0z67AjMLo8I5jwWrpA0yOlFRUhDsyTQjBZ_i0RtP0Y9YzR0F83rkQU5yuZP8CFnR3oIMg==&c=52vNRpVveelt0QLvnZIt3IVCK5qv8NzgGkPTwZhnMm6y4c1A2Y232g==&ch=uzLFKhJMaoqF47WvjfpyJ0dZMcaqCmR_rF1yMaJYgp_nBPhwHY2JVw==]
at San Ysidro Ranch [* * * * *].  Our evening dinner there was the hallmark of a
 long week of travel.  Now, at the outset, I'll let you know that they lost one 
star for a very simple (even forgivable) error.  As always, I was dressed in black
as was one of my compadres at the table.  She received a black napkin but, I did
 not!  The horror J.  The rest of us had simple cream colored napkins.  But the 
star was not lost for that reason.  The reason was that of the six people at the
 table, I was the only one that was forgotten when they served the bread.  I had
 to make a special request.  Again, the horror J.  So - one star down, The Stonehouse
did a wonderful job thereafter.  The highlight of the appetizers was the Hudson 
Valley Foie Gras accompanied with Pickled Rainier Cherries, Red Veined Sorrel, Toasted
Pistachios and a wonderful Vanilla Bean Sauce.  It was outrageous!!  For the main
course, I had the Pan Crusted Halibut accompanied with Gnocchi (one of life's most
wonderful experiences, if done properly - and, they were) with Artichoke Hearts,
 Asparagus, Lacques Olives and a Basil Sauce.  But, the  pièce de résistance, was
the Chocolate Soufflé.  As one member of the group described the dinner, it was 
"...sublime sufficiency."  Truer words were never spoken.  The Stonehouse is ranked
as one of America's Top 100 Restaurants and the #1 Hotel in America.  It's where
 John and Jackie Kennedy stayed for their honeymoon.  I can see why...  So, you 
should definitely consider The Stonehouse - San Ysidro Ranch - 900 San Ysidro Lane
- Santa Barbara, CA  93108 - (800) 368-6788 - [email-masked] [mailto:[email-masked]].
Go for it!  You will not be disappointed...
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The Good, The Bad, And The Ugly
The ongoing saga...
The Good - The coming together we are experiencing across the nation in support 
of the victims of Hurricanes Harvey and Irma - and, possibly others down the road.
 Bad events bring together good people.
The Bad - Even though it is a bit of a hassle, I've become a big fan of recycling
over the last bunch of years.  In Kittery, we have to place all of our recycling
 items "in their proper bins" or the recycle managers get after you!  But, recycling
still remains too low.  For example, on plastic - Europeans recycle 30%; the Chinese,
25%; and, the Americans, only a mere 9%.  Come on, folks - get with it!  Help ole'
Mother Earth and the environment out...
The Really Bad - In the first 200 days of 2017, USA gun deaths were up 12% over 
2016 or, 8,539 deaths (excluding suicides). Firearm injuries were up 8% or, 17,043.
 And, the number of children shot by a gun increased 16% to 394.  What's it take?
The Internationally Bad - The ups and downs of policy coming from the current Administration.
 One minute the USA is headed in this direction.  The next morning through yet another
Tweet, the USA is headed in a different direction.  It may work in business but,
 such approach to policy reduces our collective credibility to zero in the international
community...
The Ugly - According to CBS News [http://r20.rs6.net/tn.jsp?f=001AWeT4e2K_UT3Gm85UceEjtGKwzS0S8-lyfP5AMBlVFyCD_kUzFGURFlIqYuXTbsPpWgbcPciXAsHZVtKgDMB5kpxtqSlYok3nI14IJYtwk3HSvd76GREnaYv9l8hoqWr5lD2mkXBM_EzVMAkNMXvyQVnME1O2RvYnMvRX1g1lTUrloqdEvjb9Vl5B0FO8ibmEneKqSxVAQC7IgKserFOlhRCqXfXN491B0N4I6bLgQBleW5KcAgHcWr3FXzfSwbFI5Gmqu58nSs=&c=52vNRpVveelt0QLvnZIt3IVCK5qv8NzgGkPTwZhnMm6y4c1A2Y232g==&ch=uzLFKhJMaoqF47WvjfpyJ0dZMcaqCmR_rF1yMaJYgp_nBPhwHY2JVw==],
there are 30 million jobs in the USA that pay more than $35,000/year for those workers
who do not have a four-year college degree.  However, there are 75 million workers
in the USA without four-year college degrees.  The gap is far too large!  And, I
 bet (but, do not know) that most of those workers in the gap reside in the non-urban
areas of the USA that have seen the slowest recovery since The Great Recession. 
 It's part of the inequality gap that exists in the USA.
The statements in The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001AWeT4e2K_UT3Gm85UceEjtGKwzS0S8-lyfP5AMBlVFyCD_kUzFGURNmvZrrl44Rd5XKw9dd2dOWgObwNaLCg40M6LjXgzKiBGyVa1xDEcwYnl9uzqkcYl3S1BSTvDSVG1-FFwCR4Ybx5dMvT56FoxPapIqc0HDlUBclYI5EmPqlwPpcPkEIAlYg-rlz0_iFY&c=52vNRpVveelt0QLvnZIt3IVCK5qv8NzgGkPTwZhnMm6y4c1A2Y232g==&ch=uzLFKhJMaoqF47WvjfpyJ0dZMcaqCmR_rF1yMaJYgp_nBPhwHY2JVw==]
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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Name | Company | Phone | Email [mailto:[email-masked]] | Website
[http://r20.rs6.net/tn.jsp?f=001AWeT4e2K_UT3Gm85UceEjtGKwzS0S8-lyfP5AMBlVFyCD_kUzFGURNmvZrrl44Rd5XKw9dd2dOWgObwNaLCg40M6LjXgzKiBGyVa1xDEcwYnl9uzqkcYl3S1BSTvDSVG1-FFwCR4Ybx5dMvT56FoxPapIqc0HDlUBclYI5EmPqlwPpcPkEIAlYg-rlz0_iFY&c=52vNRpVveelt0QLvnZIt3IVCK5qv8NzgGkPTwZhnMm6y4c1A2Y232g==&ch=uzLFKhJMaoqF47WvjfpyJ0dZMcaqCmR_rF1yMaJYgp_nBPhwHY2JVw==]
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