Subject: News from Dr. Kevin Fickenscher
From: "The Fickenscher Files" <[email-masked]>
To: <[email-masked]>
Date: Thu, 2 Nov 2017 10:04:01 -0400 (EDT)

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The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001PTpiLjrRq7UgHqYUyej5tEY2Yn5lclatQnyBxpc_GdJ-cvdF75BAE6DJSM3VOobfIHG8sMBjAsF0-ep_7cIuzm9lVIAshyKTNCwj2WfXmQZV2tlMwn9wTnPUvQvzkAFv2PE6agv1LlCee5PnR8RMkjfo3KlCWhOaVlgCdzzUJJG8TuqCSme3nY0fKiLCsAxp&c=gnkfAYyL9lciS-mjZRR9ubXgVk9lRF8xSQ_p8DGzKuX1EJ8ZNekLUQ==&ch=B-tAnRtk31OkEodl7N71OteJ_DqSbKVq7yVaR8_YCOE5z6v5rVbvEA==]
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The Fickenscher Files, Vol. 5, Issue 9
Kevin M. Fickenscher [http://r20.rs6.net/tn.jsp?f=001PTpiLjrRq7UgHqYUyej5tEY2Yn5lclatQnyBxpc_GdJ-cvdF75BAEwhD0EVJ0lOgH15RSDC4lH2b6ObJ6N5jGAyAXlsQDvWLleqSivRqvhnvsipnLYlVpwE098EFgxcvgxJPNagNoWJ-jRwr8KZny3kYwcjgBoAPVwwgYUqH7nuphEp5Lf9HzF1x8CLqvn8_mMimPY99LHpikcMSutWIOA==&c=gnkfAYyL9lciS-mjZRR9ubXgVk9lRF8xSQ_p8DGzKuX1EJ8ZNekLUQ==&ch=B-tAnRtk31OkEodl7N71OteJ_DqSbKVq7yVaR8_YCOE5z6v5rVbvEA==],
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
"What the President is doing is destroying the ability of people to get health care,
right now!"
Senator Susan Collins (R-ME), in comments on CNN when asked about her reaction to
the Executive Order issued by Trump that dismantles portions of the Affordable Care
Act.
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Readings To Consider
Books and Articles worth a Review...
If you're in the reading mode, I have a couple of suggestions for your consideration.
 First, I encourage everyone to read the article "The New Reality of Old Age in 
America [http://r20.rs6.net/tn.jsp?f=001PTpiLjrRq7UgHqYUyej5tEY2Yn5lclatQnyBxpc_GdJ-cvdF75BAE9ARpzrD3cY-XeEKk-p5fSKKS_xIoxnF39AU6zVeEtzX4ybtgkpTFR5dOFiKTvtQBoYF5P-4nVuW6Af008gGz9piDeu9nodmBPIt-aY_NF2AMX1vmT7MN-JY7FawqAHV8087e2aS89ewQHeMsmDIPFRNbFIAlUDjhZ0CVxWZl58K2BNRXw6_JNerNKnfSwPFI-Y7VBNw-ozq_pZ1RNoVgXyC2VJZv-FrpYwCMmBOM2TCgnmsDuv-lVQ=&c=gnkfAYyL9lciS-mjZRR9ubXgVk9lRF8xSQ_p8DGzKuX1EJ8ZNekLUQ==&ch=B-tAnRtk31OkEodl7N71OteJ_DqSbKVq7yVaR8_YCOE5z6v5rVbvEA==]".
 It's one of those bring-it-down-to-reality articles about the plight of growing
 older in the USA.  In particular, the articles notes how much is changing.  Due
 to changes in retirement plans where IRAs dominate rather than pensions, an exceptionally
high number do not have sufficient resources.  As a result, people are working longer.
 The challenges are many and health care will no doubt be on the frontlines of this
evolving dynamic in American life.  As health care providers, we need to get better
prepared for the coming tsunami.
On the positive IT side of life, there's the article by Max Tegmark, a professor
 at MIT on "How to Make AI the Best Thing to Happen to Us [http://r20.rs6.net/tn.jsp?f=001PTpiLjrRq7UgHqYUyej5tEY2Yn5lclatQnyBxpc_GdJ-cvdF75BAE9ARpzrD3cY-Lh-VMq8RUG6EBdsLM4r8xs-m4cxoRpUEMJVLBW73l5d_C3PoEo-fG2kj357AaNuoK2lRwN5H9hek-wH48mcXezPSG93cjF3SNcguAk94chtffEq_4HP-Y20O8QBDOMUHeRlfbCrvV8EZ2g1XSbIKygKrO1RBN4IRDcoWDMEsztKCGa2hAuH1S-Aum2XKnnZjMg4QO9ZBs08RHQ47Y6Ie7jKZqIU3KSoC&c=gnkfAYyL9lciS-mjZRR9ubXgVk9lRF8xSQ_p8DGzKuX1EJ8ZNekLUQ==&ch=B-tAnRtk31OkEodl7N71OteJ_DqSbKVq7yVaR8_YCOE5z6v5rVbvEA==]".
 Dr. Tegmark points to some very relevant principles we need to adapt as AI becomes
a more ubiquitous part of our lives...
And, finally - but not lastly - I strongly encourage everyone to go out and buy 
the book, Principles [http://r20.rs6.net/tn.jsp?f=001PTpiLjrRq7UgHqYUyej5tEY2Yn5lclatQnyBxpc_GdJ-cvdF75BAE9ARpzrD3cY-3SCUtXiLoNlv2g32tHXHvuhfrFfW50GG3BaQLXazEOz0-mm-q8CJpUDTmClmDlQ1v8X36O5gfW_XaNrxJV0XupG58aJFIuG_eywNklu0OWsOctIcFtG-e0iue9B5sptV&c=gnkfAYyL9lciS-mjZRR9ubXgVk9lRF8xSQ_p8DGzKuX1EJ8ZNekLUQ==&ch=B-tAnRtk31OkEodl7N71OteJ_DqSbKVq7yVaR8_YCOE5z6v5rVbvEA==]by
Ray Dalios, the Founder of Brightwater, one of world's largest investment firms..
 Until recently, Mr. Dalios managed the firm which handles a portfolio of nearly
 $250B in assets.  His new book - just out - is on how defining and declaring what
one's "principles" are is the cornerstone of a successful life.  He raises many 
good points and shares lessons learned from his long experiences which while derived
from the financial world, apply to all of us.  It's a thick book but a worthy read.
 It will no doubt motivate you to consider writing down your own set of principles
as you go about your daily work...
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Consulo Indicium
Information for your Consideration...
Always Embracing New Rationales - The Journal of the American College of Cardiology
recently published astudy [http://r20.rs6.net/tn.jsp?f=001PTpiLjrRq7UgHqYUyej5tEY2Yn5lclatQnyBxpc_GdJ-cvdF75BAE9ARpzrD3cY-bR167YWBy_Llm3NY1B16c7qC4-rRGKrDO29H7S3Kj3Sd4djXo4eQrWti7d9O2z-B31154MijU74jokH0rC6HWBDuL44avIeQ4K8xUZD5LkEUbfeLwiDJdw41uGAMesr3b7qpAsy__rxYoege1vQUBxC-6ZB7z9Q2S6j0oTUaxyjeFESJkyV2abVC21uKKVgQ7UCOZUPgV1bXqh5CB1gXvAU5wcQkNEXzd7leob9ViUu7bWyQBdgPtWKdWyRjGEUutPo51VE1FoVvm5BpH6I-rbOOUA0rsgSIOjhZQZYKocj332xEuj5DJXHrfZ5ND0zebyiuWezGg80y3-2E84BitXOYfoDhJw96tq5f_JwmlebFeEOmvicpYvA4N4Qtrk-JiLuzZa5_qXcqUC6bdjXXqi9pP5loxxG_PgNeuIQC4ILtSHYLYc31JEX0sES9L8nSicPI6TK5Hy31HieHcbdSqh4-feUN8hYwFu7VAgaYwSe0-UfIJ0Z4DFeQ5H6POZ-qKPJDGN3nH4tm9CUKsV3EdSB5_lAkyjq0Zr3ayr2yF6IQjUlYOu35rqYKmSao12m98r014BfYcJIubTsZWchPsw==&c=gnkfAYyL9lciS-mjZRR9ubXgVk9lRF8xSQ_p8DGzKuX1EJ8ZNekLUQ==&ch=B-tAnRtk31OkEodl7N71OteJ_DqSbKVq7yVaR8_YCOE5z6v5rVbvEA==]noting
that "people who skip breakfast may be more likely to develop atherosclerosis...than
individuals who start each day with a hearty meal." I knew there was a reason that
a three egg omelet with ham and cheese followed by a bowl of oatmeal was a good 
thing! There was a small proviso noted in the study, however.  It seems that people
who skip breakfast also are more likely to lead unhealthy lifestyles such as being
overweight, having a poor diet, smoking and drinking more alcohol.  Well, at least
the omelet was not included in the poor habit side...
High Tech Is Not Always The Best Tech - In a series of studies [http://r20.rs6.net/tn.jsp?f=001PTpiLjrRq7UgHqYUyej5tEY2Yn5lclatQnyBxpc_GdJ-cvdF75BAE9ARpzrD3cY-j6WzisqXd5tIArAvcQwamDTVhC-uqtLErd-nPdEg38dsln7mZ6BMYpvVS93tzdzpDVpsCaRRyxdlvMI_ybE4wLKV3b6DX4GK7AIfDjpoJpMsOG6fwt125wFyCXUG2bwYtxQVSS1gpuiBja29Ffj-EfLZ8ux0GR01ZqBW8TigBoM=&c=gnkfAYyL9lciS-mjZRR9ubXgVk9lRF8xSQ_p8DGzKuX1EJ8ZNekLUQ==&ch=B-tAnRtk31OkEodl7N71OteJ_DqSbKVq7yVaR8_YCOE5z6v5rVbvEA==]
completed by researchers at Princeton and the University of California at Los Angeles,
researchers noted that students who use laptops in class were different on several
fronts from those students who don't use computers. Specifically, they were more
 easily distracted or less interested in the material presented in the course.  
The students were required to watch a lecture and randomly assigned to either use
a laptop or takes notes the old fashioned way with pen and paper. The outcome of
 the study was clear: Understanding of the lecture, measured by a standardized test,
was substantially worse for those who had used laptops. The researchers hypothesized
that the reason was because students can type faster than they can write, a lecturer's
words flow straight from the students' ears through their typing fingers, without
stopping in the brain for substantive processing. On the other hand, students who
took notes had to process and condense the material in order for their pens to keep
up with the lecture. And, in a review of the notes from each group, the laptop users'
notes were more like transcripts than the summaries of the lectures from the handwritten
note group.  I share this because, ironically, the day after I read the article,
 I saw my personal physician.  For the first time amidst the meetings with many 
different physicians, he actually "talked" with me and "listened" to my reason for
the visit rather than sitting in front of the computer.  Not only was it more comforting,
I actually think he captured why I was there and what was on my mind.  There's something
here that we need to teach the up and coming crowd of younger physicians and clinicians.
 It's not about transcribing.  It's about capturing information to make better decisions...
The Canary In The Coal Mine: Health Care In Rural America - As many of my readers
know, my first professional experience was in working to develop and direct the 
Center for Rural Health at the University of North Dakota.  We had a mantra back
 then: So goes the hospital, so goes the town.  In other words, if there was no 
hospital, it was very likely that there would be no town in a decade or so.  Those
words still ring true today BUT, with a proviso...  I don't think it's about the
 building as much as it is about the "service".  It's clear that rural hospitals
 are at risk of closures across the nation, a symptom of the economics of small-town
America.  In fact, since 2010, 82 rural hospitals have closed [http://r20.rs6.net/tn.jsp?f=001PTpiLjrRq7UgHqYUyej5tEY2Yn5lclatQnyBxpc_GdJ-cvdF75BAE9ARpzrD3cY-HVljtBc2SKxkGwUlWe0D1OeIP-RRc9WG8louXXizHcLkgO9Yw63-sCFoaiP8KtdaD1uAUq5eIAasI5eep5qEMwpZpOXcS8zA2__RbQxEglxb1oUtPf3vWE4WHRJ-2mCrZmHw-NpQeYxYJb0ICQBgVzikCIvIr4dt8rRv8BKFFwO2S-36rHgeWcy-x9KqIxaRB3iFnDsfbL8=&c=gnkfAYyL9lciS-mjZRR9ubXgVk9lRF8xSQ_p8DGzKuX1EJ8ZNekLUQ==&ch=B-tAnRtk31OkEodl7N71OteJ_DqSbKVq7yVaR8_YCOE5z6v5rVbvEA==]
across the country with as many as 700 more that are "at risk" of closing over the
coming decade.  There are lots of reasons.  However, I think that the answer lies
in an idea that we put forward nearly 30 years ago - the rural hospital should evolve
to become the rural health center where care is coordinated and managed for people
residing in rural areas rather than episodically treated at institutions.  The problem
is the reimbursement systems have not supported such ideas.  As we move toward a
 "value-based" instead of a "volume-based" payment model, the opportunity lies before
us to shift the focus of these institutions to serve as more than just acute care
oriented facilities.  But, it will take work...
First, the health care needs in rural America are a bit more onerous than for their
city kindred.  For example, 20% of adults [http://r20.rs6.net/tn.jsp?f=001PTpiLjrRq7UgHqYUyej5tEY2Yn5lclatQnyBxpc_GdJ-cvdF75BAE9ARpzrD3cY-hz6lY_oqeKYXqFNUwh_WbJ4FoCJzahXcRPPDklEUaB4Zt_o39X9sEUe71WavVi2Oq0qc1Xhci23YiP5gPfjT9P8cTXqA21NBuJ_XPe-_uAHlDACEeLpx3JN54m1oo6tKia_4c6CpDDmhn0KcC8_AaFXXGCDvC9Nv5TTi64u5JQnxFOQjv91Ea2QH_sNf5TMoxy7MkHyGMdjtz1O-MrWwBI3QQuGIfPju&c=gnkfAYyL9lciS-mjZRR9ubXgVk9lRF8xSQ_p8DGzKuX1EJ8ZNekLUQ==&ch=B-tAnRtk31OkEodl7N71OteJ_DqSbKVq7yVaR8_YCOE5z6v5rVbvEA==]
in the South report having poor or substandard health. To compound the problem, 
15% of non-elderly rural residents are uninsured [http://r20.rs6.net/tn.jsp?f=001PTpiLjrRq7UgHqYUyej5tEY2Yn5lclatQnyBxpc_GdJ-cvdF75BAE9ARpzrD3cY-hz6lY_oqeKYXqFNUwh_WbJ4FoCJzahXcRPPDklEUaB4Zt_o39X9sEUe71WavVi2Oq0qc1Xhci23YiP5gPfjT9P8cTXqA21NBuJ_XPe-_uAHlDACEeLpx3JN54m1oo6tKia_4c6CpDDmhn0KcC8_AaFXXGCDvC9Nv5TTi64u5JQnxFOQjv91Ea2QH_sNf5TMoxy7MkHyGMdjtz1O-MrWwBI3QQuGIfPju&c=gnkfAYyL9lciS-mjZRR9ubXgVk9lRF8xSQ_p8DGzKuX1EJ8ZNekLUQ==&ch=B-tAnRtk31OkEodl7N71OteJ_DqSbKVq7yVaR8_YCOE5z6v5rVbvEA==]
which is about 5% higher than the USA, in general. There are many considerations
 which need to be included in discussions on the future of health care in rural 
America.  One issue that has not gotten enough attention; however, is how technology
can be used to bolster the capability and availability of services.  Many of the
 basic problems which have historically been cared for in small, low-volume, rural
hospitals are what I would describe as basic, primary care acute problems.  It's
 Stage 1 and 2 congestive heart failure, it's treatment of an infection of the foot
with IV antibiotics, it's getting someone's blood pressure under control, it's any
number of basic problems.  These are the types of problems that are moving from 
the hospital to the living room.  They are the types of problems that can be managed
effectively through the use of "telecare" services where technologies are deployed
in the home or perhaps the skilled nursing facility.  But, these services need to
be proactively "managed" and - on occasion - they require face-to-face time.  This
is where the notion of transforming the rural hospital into a "community health 
resource center" rather than just an acute care facility becomes important.  We 
need more thinking along these lines.  If our nation simply does more of what we've
done in the past, we will fail the people who need the services.
Drug Overdoses Have Killed More Americans In 2016 Than The Vietnam War! - The data
is stark and it's not causing a public stir like prior American tragedies.  In September,
the CDC released preliminary data showing that more than 64,000 people died [http://r20.rs6.net/tn.jsp?f=001PTpiLjrRq7UgHqYUyej5tEY2Yn5lclatQnyBxpc_GdJ-cvdF75BAE9ARpzrD3cY-q4H-oUYb0AuxWkfLRyGXir_HQCN4gPFh8pYDr_50fsffHn52v2ci2vE3uDh8ERGTOuhk2ciVgQq58KKNGJJIiWfmFPbx3vwYcpbxKXye5xcCGHjv36aCrzCF63W_XC-8BBZcpcl_WG9LRv9jt_yB7pHbcMalNigDY1qCDmlKeYpNeJNfMFaIwrofv1wdMtK3CsjAERfTfsQ=&c=gnkfAYyL9lciS-mjZRR9ubXgVk9lRF8xSQ_p8DGzKuX1EJ8ZNekLUQ==&ch=B-tAnRtk31OkEodl7N71OteJ_DqSbKVq7yVaR8_YCOE5z6v5rVbvEA==]
of drug overdoses in 2016.  The Vietnam War killed 58,200 Americans across the entire
war effort. HIV/AIDS [http://r20.rs6.net/tn.jsp?f=001PTpiLjrRq7UgHqYUyej5tEY2Yn5lclatQnyBxpc_GdJ-cvdF75BAE9ARpzrD3cY-mdjkPReFJcHF96Ux_xr2CLn9khReRadz_greWDTujIdcaRIQK8p1TqgAcWHnW_qBCZagctK-zBHvSDuiFDNBxhfdvKlMYldHM2x1IZwkaGW-ElKgZ-hiSD2G2E4sIgj0A_mFJX4w-SF62EgDi-yfGw==&c=gnkfAYyL9lciS-mjZRR9ubXgVk9lRF8xSQ_p8DGzKuX1EJ8ZNekLUQ==&ch=B-tAnRtk31OkEodl7N71OteJ_DqSbKVq7yVaR8_YCOE5z6v5rVbvEA==]
in 1995 killed 50,682 people. Where's the outcry?  Where's the "let's-do-something-about-this-problem-now"
venting of frustration?  Instead, it seems that there is relative silence.  Governor
Paul Lapage (R-ME) from my adopted home of Maine in rejecting the availability of
naloxone without a prescription - which was passed by unanimous consent of the state
legislation (= both Republicans and Democrats) said, "Naloxone does not truly save
lives; it merely extends them until the next overdose." Or, my paraphrase, "...let
them die."
The other part about the crisis is that the year-over-year increase is also high.
 The number of deaths in 2016 represented a 21% increase over the prior year with
opioid overdoses contributing ¾ of all deaths.  The primary cause is both heroin
 and the potent synthetic opioids such as fentanyl with the latter by far the bigger
problem.  The CDC report states that "Fentanyl is driving the sharp increases in
 opioid-related fatalities.  Between 2015 and 2016, fentanyl related deaths nationwide
increased 103%, to a new total of 20,145. By contrast, heroin-related deaths increased
17%, to a total of 15,466."
"Eh, Houston.  We've got a problem!"  Need I say more?  So, I was disheartened by
the half-hearted announcement by the Trump Administration saying we have a "crisis"
Uh...no kidding! While the declaration is important, it also rang hollow.  Why? 
 There were no resources attached to it.  Simply making declarations does not solve
problems.  It may be good for the evening news but in the hills and hollers of West
Virginia, the rolling hills of Maine and New Hampshire or, on the prairie in the
 vast Central Plains - where the crisis is quite real - the availability of no resources
(i.e. money) will result in no solution.  I could go on a rant but that wouldn't
 contribute much to the debate.  Instead, I suggest that the few Democrats and Republicans
in Congress that actually like one another and which want to solve problems should
get together and come up with a solution.  Senator Barrasso (R-WY) and Senator Heitkamp
(D-ND) are you listening?  Reach across the aisle.  That's how we will solve this
problem.  More later because this epidemic is not going away anytime soon...
And, Then There Is The Forgotten Epidemic - The CDC recently released the Annual
 Sexually Transmitted Disease Surveillance Report revealing that the USA had more
than 2 million reported cases of chlamydia (1.6 million cases), gonorrhea (470,000
cases) and syphilis (28,000 cases) reported in 2016.  It was the highest number 
on record.  Not only were the year-over-year trend increases of concern but also,
the growth of the epidemic was alarming because of increasing drug resistance.  
For example, there is a growing threat of drug resistance to the only remaining 
treatment regimen recommended for gonorrhea: dual therapy with ceftriaxone and azithromycin.
The essence of the CDC recommendations for curbing the increase is better screening,
more rigorous follow-up and education.
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Future Health
Delivering care in the new virtual world...
CHRONIC Care Act Passes Senate And Other Telehealth Actions - We're finally seeing
some action in Congress with the passage by the US Senate of the Creating High-Quality
Results and Outcomes Necessary to Improve Chronic Care Act ( [http://r20.rs6.net/tn.jsp?f=001PTpiLjrRq7UgHqYUyej5tEY2Yn5lclatQnyBxpc_GdJ-cvdF75BAE9ARpzrD3cY-jD13DpZNaEm2MqTxVUPiQxkrM2glsqxMOi-FdXDxR2RDMAzhSVrQU8LBhByvhqrxYb3Is1reO3zTS5DliIWYOkLdywdZNRIh1sf37cBUqXX5v_kn1TqQH-qaS0IppS6nXO45QVY2F-l3rWatXmKillJPBNANB_W_I68OX42QeGY=&c=gnkfAYyL9lciS-mjZRR9ubXgVk9lRF8xSQ_p8DGzKuX1EJ8ZNekLUQ==&ch=B-tAnRtk31OkEodl7N71OteJ_DqSbKVq7yVaR8_YCOE5z6v5rVbvEA==]S.870
[http://r20.rs6.net/tn.jsp?f=001PTpiLjrRq7UgHqYUyej5tEY2Yn5lclatQnyBxpc_GdJ-cvdF75BAE9ARpzrD3cY-jD13DpZNaEm2MqTxVUPiQxkrM2glsqxMOi-FdXDxR2RDMAzhSVrQU8LBhByvhqrxYb3Is1reO3zTS5DliIWYOkLdywdZNRIh1sf37cBUqXX5v_kn1TqQH-qaS0IppS6nXO45QVY2F-l3rWatXmKillJPBNANB_W_I68OX42QeGY=&c=gnkfAYyL9lciS-mjZRR9ubXgVk9lRF8xSQ_p8DGzKuX1EJ8ZNekLUQ==&ch=B-tAnRtk31OkEodl7N71OteJ_DqSbKVq7yVaR8_YCOE5z6v5rVbvEA==]).
[http://r20.rs6.net/tn.jsp?f=001PTpiLjrRq7UgHqYUyej5tEY2Yn5lclatQnyBxpc_GdJ-cvdF75BAE9ARpzrD3cY-jD13DpZNaEm2MqTxVUPiQxkrM2glsqxMOi-FdXDxR2RDMAzhSVrQU8LBhByvhqrxYb3Is1reO3zTS5DliIWYOkLdywdZNRIh1sf37cBUqXX5v_kn1TqQH-qaS0IppS6nXO45QVY2F-l3rWatXmKillJPBNANB_W_I68OX42QeGY=&c=gnkfAYyL9lciS-mjZRR9ubXgVk9lRF8xSQ_p8DGzKuX1EJ8ZNekLUQ==&ch=B-tAnRtk31OkEodl7N71OteJ_DqSbKVq7yVaR8_YCOE5z6v5rVbvEA==]
 As, an aside, I often wonder who stays up at night to come up with these catchy
 names of the bills winding their way through Congress. But, putting that aside,
 aside, the CHRONIC Care Act would change how Medicare reimburses chronic conditions
in some significant ways.  It would expand in-home care for seniors, provide better
options for physicians to support coordination of patient care and, importantly,
 offer additional telehealth coverage under the Medicare Advantage, including telestroke
and home-dialysis.  Notably, the US Senate passed the bipartisan bill unanimously
and it basically expanded programs created by the Affordable Care Act (ACA) - a 
piece of legislation that has been at the forefront of Republican efforts to dismantle.
 However, it seems that there was a desire to make it a bit better and solve some
problems with it before continuing the battle to dismantle ACA.  Oh well...so goes
politics.
In other action over the US House side, a bill passed the House Ways and Means Committee
by voice vote to increase direct spending by $46 million over the period of 2018-2022
and decrease direct spending by $4 million over the period of 2018-2027.  The legislation
is part of the Increasing Telehealth Access in Medicare Act (H.R. 3727 [http://r20.rs6.net/tn.jsp?f=001PTpiLjrRq7UgHqYUyej5tEY2Yn5lclatQnyBxpc_GdJ-cvdF75BAE9ARpzrD3cY-i288AngbT9xWua_iSH5u_JRLUYTcSreJowc-C-Lr860Yp1ffxAB5XqC9c_hbEurZvj3pXpNWjLCYuY9MNO31FGhG3AjWWdmjeyw2qVvwkA59dOnVTn0Ptb9L7PxqaZB3_QUX3w9TumlULta4Z28tcmGkinvfuQbK0odih0v2RKM=&c=gnkfAYyL9lciS-mjZRR9ubXgVk9lRF8xSQ_p8DGzKuX1EJ8ZNekLUQ==&ch=B-tAnRtk31OkEodl7N71OteJ_DqSbKVq7yVaR8_YCOE5z6v5rVbvEA==])
which is also focused on Medicare Advantage programs and would allow the plans to
reimburse for telehealth at a rate comparable to in-person visits. At the present
time, telehealth services are reimbursed at a rate of 50 - 70% of the in-person 
rate, which we advocates have argued diminishes the requisite investments by the
 health care systems to make telehealth available.  The reason for the increase 
then decrease in spending is that the telehealth legislation is anticipated to make
health care services more efficient - something I've been advocating for years. 
 In fact, the Congressional Budget office analysis [http://r20.rs6.net/tn.jsp?f=001PTpiLjrRq7UgHqYUyej5tEY2Yn5lclatQnyBxpc_GdJ-cvdF75BAE9ARpzrD3cY-CW4xQE8L6_-v-TA9cx0BqaTrXa-pV1cCWV_clFVLa3-c5pRoBGw-eg6PlUQbH6U2hL4OauThViF7A6k3lOp8mnrq1jujRkASvaEmil02JKZipiPxLwdRMeVW_OL_JyfVq1gGr27P1OpKoeAb4v2Yi9NjEGs6zZ-fxTGswJIVxKm8vI9z-mF4AqGYpEkMVJci&c=gnkfAYyL9lciS-mjZRR9ubXgVk9lRF8xSQ_p8DGzKuX1EJ8ZNekLUQ==&ch=B-tAnRtk31OkEodl7N71OteJ_DqSbKVq7yVaR8_YCOE5z6v5rVbvEA==]
estimates that the savings will be in excess of $80 million over the next 10 years.
Cancer Confirmed To Be Partially Due To Random Events- In a study that I missed 
back in March (I'm trying to catch up on my readings), it was reported in  [http://r20.rs6.net/tn.jsp?f=001PTpiLjrRq7UgHqYUyej5tEY2Yn5lclatQnyBxpc_GdJ-cvdF75BAE9ARpzrD3cY-toxJ6OniHzybxjcvZ9aGMgwJj0-Aqajb86C4GdGtMG_TO31TIU2y5r82pAjPEjwRsy6OKqs0k_eUu4bFCBvE8PNtmYucnn3X-kjYTXcESypT9Upo5FY3IZ9o46sKb9anHxvXtAAt_2oBaUckc_N9bA==&c=gnkfAYyL9lciS-mjZRR9ubXgVk9lRF8xSQ_p8DGzKuX1EJ8ZNekLUQ==&ch=B-tAnRtk31OkEodl7N71OteJ_DqSbKVq7yVaR8_YCOE5z6v5rVbvEA==]Science
[http://r20.rs6.net/tn.jsp?f=001PTpiLjrRq7UgHqYUyej5tEY2Yn5lclatQnyBxpc_GdJ-cvdF75BAE9ARpzrD3cY-toxJ6OniHzybxjcvZ9aGMgwJj0-Aqajb86C4GdGtMG_TO31TIU2y5r82pAjPEjwRsy6OKqs0k_eUu4bFCBvE8PNtmYucnn3X-kjYTXcESypT9Upo5FY3IZ9o46sKb9anHxvXtAAt_2oBaUckc_N9bA==&c=gnkfAYyL9lciS-mjZRR9ubXgVk9lRF8xSQ_p8DGzKuX1EJ8ZNekLUQ==&ch=B-tAnRtk31OkEodl7N71OteJ_DqSbKVq7yVaR8_YCOE5z6v5rVbvEA==]
that 66% of all cell mutations that could cause cancer result from DNA errors when
the cells are simply replicating.  In other words, the changes which cause cancer
are not necessarily tied genetic risk or environmental factors - they are simply
 the result of the luck of the draw or "bad luck".  The study was a follow-up to
 a similar study with similar results done in 2015 that had a lot of detractors 
because of its methodology. Here are the essential findings of the new study:

* 5% of cancers are caused by inherited genetic risks.  An example would be the 
BRCA gene which causes a marked increase in the risk of breast and ovarian cancer
in women;
* 29% of cancers result from mutations caused by environmental factors, such as 
cancer-causing viruses (e.g. cervical cancer) and sun exposure (e.g. melanoma); 
and,
* 66% of genetic mutations are simply random errors that occur as part of the process
of cellular replication by an individuals' DNA.
So the question is: How do we prevent cancers that are caused by mutations? Short
answer - we don't know!  So, even those folks that are living in hiding from all
 environmental or personal pathogens are still at risk of cancer.  Now, this does
not mean we should simply forego any action.  The repeat study clearly shows that
42% of total cancer cases could be prevented by lifestyle and environmental improvements.
 So, don't smoke, stay out of the sun unless you're wearing sunscreen, be careful
about what you eat - and, you know the routine...  Stay tuned.  I'm sure there will
be more research on these topics.
Getting Older, Getting Focused - As the preceding note suggests, as you get older
the number of accumulated "random" DNA mistakes start to add up and your risk of
 cancer starts to get higher.  So, that accounts for 66% of cancers.  However, another
42% is under your control to a large degree.  First, there's diet, which can have
a marked impact on your life.  I would suggest that you consider reading the latest
version is the Canadian Brain Health Food Guide [http://r20.rs6.net/tn.jsp?f=001PTpiLjrRq7UgHqYUyej5tEY2Yn5lclatQnyBxpc_GdJ-cvdF75BAE9ARpzrD3cY-eNck6INCxlj0UjlXLXbFGna8PQmTOyhU_GVKOTkQ8oXz7ybl8S4awe3OCzhp0uNFBpj_Ln9N3Rcqim6fS8TGgePg9YQaqkG5slgqMSr__NnBWina1eVF1NxqLkUHWXSOs9nd8s1RljexTqn8kcfgZ6nsUvHkQ5GtnwGyueChBueKgeQ1llrfNBAhTI3Unc9tDxY9rz_CCW5HZmYKLEChNuAVYkenit1A&c=gnkfAYyL9lciS-mjZRR9ubXgVk9lRF8xSQ_p8DGzKuX1EJ8ZNekLUQ==&ch=B-tAnRtk31OkEodl7N71OteJ_DqSbKVq7yVaR8_YCOE5z6v5rVbvEA==]
which provides a good overview on dietary considerations.  Even though the precise
impact of nutrition on the brains of older adults is not known, it's clear that 
at a macro level diet is important.  For example, poor diets can increase the risk
of developing obesity, diabetes, hypertension, cardiovascular disease, and a host
of other problems.  All of these problems can affect cognitive function. In fact,
my wife has a new mantra: Six cups of fruits and vegetables every day - no exceptions.
 First, you need to know that six cups is a lot.  Second, it's important to keep
 your wife happy. I've learned that the hard way J...
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Weekly Whisk
Musings from a foodie...
I recently had a trip to Houston - actually, on the day the Astros beat the Dodgers
13 - 12 in an incredible game of ups and downs, home runs and a run through of most
of the pitchers from both teams!  While the game was starting, we headed to Americas
[* * * *] a restaurant established by the famed chef, Michael Cordúa in the heart
of River Oaks - a subsection of Houston.  First, everyone in Houston seemed to be
upbeat.  They are "recovering" from Hurricane Harvey.  So, that was welcomed good
news!
What is striking about the restaurant is the layout and design.  Located on the 
second floor of a shopping center, the entrance to the restaurant transports you
 into a different world. It was designed by Jordan Mozer in a very contemporary 
fashion with extensive wall art.  I'm not sure what the message was (J) but the 
design was quite enticing.  The restaurant brings together the cuisines of South,
Central and North American cultures extending from the tip of Chile to the northern
reaches of Alaska. Cordúa is very well known for his interpretations of authentic
Latin cuisine and Americas boldly offers his perspective.  Ranked in 2008 as one
 of the "50 Best New Chefs of all Time", Cordúa is definitely worthy of a stop if
you're in the Houston area.
Our table started with some small lamb chop lollypops which were very good.  They
were marinated in a slightly spicy sauce and barbecued to perfection.  As a mostly
"fish eater", I then went with the grouper which was quite good.  He layered the
 filet over a coconut infused rice.  All in all, it was a good dinner.  If you're
in Houston and close by, it would be worth a stop.  But, it wasn't an overwhelming
culinary experience.  The best part of the evening was connecting with old friends.
 So, any dinner with old friends is always a good dinner.  Check it out:  Americas
- 2040 West Gray, Suite 200 - Houston, TX  77019 - (832) 200-1492 - www.americasrestaurant.com
[http://r20.rs6.net/tn.jsp?f=001PTpiLjrRq7UgHqYUyej5tEY2Yn5lclatQnyBxpc_GdJ-cvdF75BAE9ARpzrD3cY-f1pmG4czJlO21nPKDxvOZXHFtYLt0BTbliinCPCuCf3Db8yESljmB1k0SmJCVvW-YHmvHeTvfey9mqCJ1MnF0GUA_WEQQECX8qRNa6uTWkFnO6JIB7tvQW5MsbYPpis_&c=gnkfAYyL9lciS-mjZRR9ubXgVk9lRF8xSQ_p8DGzKuX1EJ8ZNekLUQ==&ch=B-tAnRtk31OkEodl7N71OteJ_DqSbKVq7yVaR8_YCOE5z6v5rVbvEA==].
Enjoy...
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Good, The Bad, And The Ugly
The ongoing saga...
The Great - I remember the Watergate Hearings in the US Senate as if they had occurred
yesterday.  I was in college and when I wasn't studying, I was watching the hearings
- literally every afternoon.  My important lesson from that time was that our nation
is built on a set of principles - principles that hold true through fortune and 
crisis.  I am confident that our nation will ultimately embrace the long held values
and principles which have made us great. We are great but, just a bit tarnished.
The Good - The Trump Administration's decision to declare the opioid crisis as a
 national emergency.
The Bad - The lack of funding for the opioid crisis!! Let me say that one more time
- THE LACK OF FUNDING FOR THE OPIOID CRISIS!!
The Ugly - The charges against Paul Manafort and his associates related to the investigation
by Special Counsel Robert Mueller will no doubt set the country on edge.  Let's 
hope it does not paralyze us.  The nation has many issues it needs to face...
The statements in The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001PTpiLjrRq7UgHqYUyej5tEY2Yn5lclatQnyBxpc_GdJ-cvdF75BAE6DJSM3VOobfIHG8sMBjAsF0-ep_7cIuzm9lVIAshyKTNCwj2WfXmQZV2tlMwn9wTnPUvQvzkAFv2PE6agv1LlCee5PnR8RMkjfo3KlCWhOaVlgCdzzUJJG8TuqCSme3nY0fKiLCsAxp&c=gnkfAYyL9lciS-mjZRR9ubXgVk9lRF8xSQ_p8DGzKuX1EJ8ZNekLUQ==&ch=B-tAnRtk31OkEodl7N71OteJ_DqSbKVq7yVaR8_YCOE5z6v5rVbvEA==]
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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The Fickenscher Files | PO Box 840 | Kittery | ME | 039