Subject: News from Dr. Kevin Fickenscher
From: "The Fickenscher Files" <[email-masked]>
To: <[email-masked]>
Date: Tue, 30 Jan 2018 15:05:01 -0500 (EST)

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The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001soZ4dFX65XKoRuQuJx-seR65mbjHqyUycJPfLwLnVGtv4Ct_iegk_2Ntl_PPAc50V0vPg4feOndHJBlCjqAkuLIxcpQo1QjNR263mmMvTn69CwHC9QRE0i095_SFwlRGK6hR1AGfl3QhJb9SeMw8GnGznDKWBFol8PsQq_El5nnOqq8WZZMInz33F2UtqtQu&c=tgDW3xdopKgb7GrVJU7S46v3fppz6OL2pu7nkp0Qf55hci5sr2Rvlw==&ch=L2RKArBZGN0VkfC9yFMXoGGNIs5qV-FRTJ1r6weBKyQXHz_p8oLq1A==]
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The Fickenscher Files, Vol. 6, Issue 2
Kevin M. Fickenscher [http://r20.rs6.net/tn.jsp?f=001soZ4dFX65XKoRuQuJx-seR65mbjHqyUycJPfLwLnVGtv4Ct_iegk_4wsho6srUizFgu_zpcp12yA4sWXXJ_3-pCPDIq1OQiMoy37dMqkQLW-_pwsFgKd0n5atrr_WY9uTiy_eSY855TVOGBJnppRfKKTyvhUpPhvLCMGzPVTinlUfVmo_eDL5t8JuA6665Q1ZW4nSjR1rT16EVDlopTaMg==&c=tgDW3xdopKgb7GrVJU7S46v3fppz6OL2pu7nkp0Qf55hci5sr2Rvlw==&ch=L2RKArBZGN0VkfC9yFMXoGGNIs5qV-FRTJ1r6weBKyQXHz_p8oLq1A==],
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
"One of the things that Michelle figured out, in some ways faster than I did, was
part of your ability to lead the country doesn't have to do with legislation, doesn't
have to do with regulations, it has to do with shaping attitudes, shaping culture,
increasing awareness."
Former President Barack Obama in response to questions from David Letterman about
his lessons learned from working in The White House. Hmmmm...
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The Occasional Random Thought
Periodic thoughts with only peripheral - but definite - connections to health care...
Revisiting Thoughts From Ground Zero - I wanted to share these thoughts before we
get too far away from the news cycle of January 13th in Hawaii or, as I have come
to think of it - "The News From Ground Zero". First, to give my thoughts context
 - just know that we were there!! After a long flight across the USA, we elected
 to push the snooze button for just a few more winks rather than get to our early
morning start of a meeting. But, even though the snooze button had been pushed, 
we were out the door of our hotel room at just after 8:13 AM Hawaii time (NOTE: 
The observant reader will note that my watch in the following commentary runs about
5 minutes ahead of time. That's because I set my watch there so that I stay on schedule
J). As we reached the elevators and pushed the down button to head for breakfast,
Suzanne's phone startled us with an air raid siren warning and the alert - "BALLISTIC
MISSILE THREAT INBOUND TO HAWAII. SEEK IMMEDIATE SHELTER. THIS IS NOT A DRILL." 
 It was in all capital letters nonetheless which for those who are not frequent 
Twitter users is like shouting!! "...THIS IS NOT A DRILL" got our attention...
So, there we are heading down the elevator shaft to the lobby and I responded with
the consummate aplomb of an IT guy and a morning shrug by turning to Suzanne and
 saying, "Must be hackers!" When the lobby elevator doors opened, there was an evolving
swell of anxiety that filled the hallway with shouts of: "Does anyone know what's
going on?" "Is it really a drill?" "They said we should go back to our rooms and
 shelter in place!" - This is simply a sampling of the various thoughts and ideas
which were bantered about by all of the lobby goers. It was obvious; however, that
panic was beginning to set in. By now it was 8:17 AM when we reached an outdoor 
shortcut to the main lobby across the driveway. Now there were people not walking
fast but running about. They were shouting louder and going in all sorts of directions.
We looked at one another in disbelief. One passerby said, "There's no basement in
this hotel. Where do we go?" to no one in particular.
It was then that we saw the bellman who had accompanied us to our room the prior
 night and who had proudly told us he had worked at the hotel for 27 years. He must
know where to go. And, even if he didn't, he pointed us to a steel-reinforced door
with a prominent "Medical Clinic" sign with the Red Cross emblazoned across it. 
I thought to myself, "What an appropriate place for us." My self-thoughts continued,
"I might actually be helpful down here in a couple of minutes". There was a whole
group of us who nuzzled together to get inside the door and we walked into a cement
laden alley way that was obviously a passage way not only to the clinic but also
 to the laundry area. As we passed a large room of hotel staff, we noticed that 
there were 20 some staffers in a prayer circle saying a prayer with some in tears,
others in disbelief and most in mere shock at what was going on. It was now about
8:24 AM (NOTE: In times of stress, I'm a perpetual watch watcher J).
We settled on to a bench and the young woman sitting next to us was just starting
a conversation with someone - family we figured. And, it was. She was having a conversation
with her brother who just happened to be in the military and, just happened to be
stationed at the base in Honolulu and evidently had "No clue" as to what was going
on. She finished and reassured us (sort of) that the military had not been notified
of any incoming missile from North Korea. Well - this was a moment of truth!! I 
thought to myself, "If the military doesn't know about it, it must not be real."
 I then turned to Suzanne for the second time that morning and simply said, "Hackers".
We sat there on the bench for some time and as the young woman moved, we moved with
her just in case she got any further updates. At about 8:44 AM the same bellman 
came into the hallway and said, "There is no missile. You can all go back outside."
With looks of mutual self-assurance from the gathered crowd we stood up, walked 
down the hall, and up the stairs into the wonderful ambiance of Hawaii.
Heart rates slowed. Everyone took a deep breath. The smells of plumeria blossoms
 floated through the air. Tranquility seemed to descend over the chaos that only
 moments before had prevailed throughout much of Hawaii. As we walked over to the
breakfast site of our meeting - where breakfast had been promptly closed down by
 the hotel staff at the first sign of an incoming missile - we learned of many different
reactions. By now, it was 8:50 AM (on my watch) and the alarms had started once 
again but this time with an "all clear" message.
There are lots and lots of other stories which I could share from among the Ground
Zero attendees. Some were numbing and, even enthralling. There was the young woman
who sat on a chair in the lobby sobbing in some sort of PTSD type trance. There 
was the guy coming back from the beach that had decided to "Go see it all because
if you're going to go you might was well see it." There was the multitude of heads
shaking back and forth in disbelief. There were hugs and cheers from others with
 shouts of, "Oh, what a relief." And, there were even more nerdy compadres like 
me muttering under their breadth, "Hackers, I knew it!" (Actually, a far greater
 risk that many of the other scenarios).
There was also the quiet recognition by a number of us that if the event had happened
two years ago - we all (yes, pretty much "all") would have assumed an error - that
there was no way a missile strike would be on its way to Hawaii. But, this was the
era where the clashing egos of "Rocket Man" and "Orange Man" made the possibility
all too real. Such a point in time makes one realize that leadership at all levels
of our government is crucial. Leadership extends all the way from the on-call guy
in Hawaii who pushed the wrong button to the very top of our nation's government
 where some leader might push the wrong button. We came home from Hawaii a bit more
tired than usual not because of the missile strike but because we tried to cram 
too many meetings into too short of a time period. And, more importantly, we came
home realizing we have a very important goal before us as a people and as a nation
over the next several years - which is to re-establish our leadership credibility
as a people and as a nation. To realize that objective, we will all need to move
 from Ground Zero to Action Ground. That will take people voting. It will take energy.
It will take fortitude. Go for it...
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Consulo Indicium
Information for your Consideration...
The Irony Of It All - I don't usually quote directly from news clippings. But, I
 wanted to share the one from page 5 of THE WEEK, January 12, 2018 edition in the
"Only in America" section:
"Citizens can now carry guns into the chamber of Tennessee's state legislature, 
but can't bring home-made signs. Critics of the new policy say it's designed to 
curb the free speech rights of Tennesseans, in the wake of angry protests last year
over immigration, Medicaid expansion, and other issues. Legislators said they banned
"hand-carried signs and signs on hand-sticks because they represent a serious safety
hazard." (emphasis added).
If you didn't read it there first, you read it here...
VA Cerner Deployment Paused - The U.S. Department of Veterans Affairs confirmed 
a "strategic pause" on further negotiations with Cerner Corporation related to the
deployment of the Cerner electronic health record (EHR) system pending an independent
assessment of the "interoperability requirements" needed by the VA from the new 
EHR system. In what some have described as a "spat [http://r20.rs6.net/tn.jsp?f=001soZ4dFX65XKoRuQuJx-seR65mbjHqyUycJPfLwLnVGtv4Ct_iegk_x09Z68EQ0dzYF5EG4_x9nPgegLrIFTB6JXHfoTE6yIzU6xnPXFLI3okvMInPDzGHb4JFJTmevzM_9Q3MZsnooITTqW2Yb0i1L95uLZOC2UATwHe5oijBIKwqdcnHCnHNR-bSAxmDhqSnn6g4ZqvSTmQFCMWNrsYJo3NTzDKKHZxbDMIRmgLqpbx9BpMkZ7ahWXFdE_rsLHDD3KoiMa4WZnDUL-b8Yjy5v0rsbCKZPHeE9lz6Pqd4iI=&c=tgDW3xdopKgb7GrVJU7S46v3fppz6OL2pu7nkp0Qf55hci5sr2Rvlw==&ch=L2RKArBZGN0VkfC9yFMXoGGNIs5qV-FRTJ1r6weBKyQXHz_p8oLq1A==]",
the VA contracted with neutral third-party - MITRE Corporation - to conduct the 
assessment.   In making the announcement to the US Senate Finance Committee, VA 
Secretary David Shulkin noted that, "My objective when it comes to healthcare for
our veterans is to have a fully integrated, interoperable, operationally efficient
healthcare system that's easy for veterans, employees and community partners to 
navigate." Well said!! Shulkin should hold firm on the question of interoperability.
It's not only important for the VA but it's important for the nation to begin hold
the EHR systems accountable for supporting interoperability. Go for it, David!! 
After all, for a project that will exceed an estimated $10B (which I think will 
actually end up being nearer to $20B at the end of the day), interoperability should
be at the top of the list.
Health Spending Continues To Rise But, Slows - In 2015, the rate of health spending
growth was 5.8%. In 2016, it grew at 4.3%. However, the rate of growth slowed and
according to the CMS Office of the Actuary, the growth that did occur was broadly
based across the entire industry base among the major payers (i.e. private health
insurance, Medicare, and Medicaid) and providers of services (i.e. hospitals, physician
and clinical services, and retail prescription drugs). The total percent of GDP 
allocated to health care continued to creep upwards from 17.2% in 2013 to 17.7% 
in 2015; and 17.9% in 2016. Also, health care spending actually grew a bit faster
than the overall economy by about 1.5% due in large measure to demographics and 
the expansion of the number of insured among the USA populace. Although there was
generalized growth among private health insurance, Medicare and Medicaid; the most
notable finding from the report was the fact that out-of-pocket spending such as
 copayments, deductibles, and spending not covered by insurance continued to grow
at a far faster rate. In fact, out-of-pocket spending grew 3.9% which was largely
attributable to the continuing shift by consumers to enroll in high-deductible health
plans. The other notable change was in the retail prescription drug spending which
slowed in 2016 to an increase of 1.3% compared to a 12.4% (2014) and 8.9% (2015)
 increase from prior years. Why? According to CMS, the reasons were "fewer new drug
approvals, slower growth in brand-name drug spending as spending for hepatitis C
 drugs declined, and a decline in spending for generic drugs." For a full read of
the report download a copy of the report at CMS.gov [http://r20.rs6.net/tn.jsp?f=001soZ4dFX65XKoRuQuJx-seR65mbjHqyUycJPfLwLnVGtv4Ct_iegk_x09Z68EQ0dzlLmNjf4pBLmXmsC75hSJF3rwRQH6O3N8bzgkgVCCu37dymtpDyCYP4VrnQkviHiZknwwafVksoI-biw2zrrx57gV1rF5UBBZz7BloPILpc-1MNAZbACNkGOqpq7ZPv_47G_l9UxYz8hEY9xZpFCjayz7c6rjZUfDr-SM91u9g8Z22aEtwqAyP_1iIzswnRBAtOrdSw4QlFrcGbaxN5QHAslL6vDPxYFIkBviFyRGGeH9OEAgS-rljA==&c=tgDW3xdopKgb7GrVJU7S46v3fppz6OL2pu7nkp0Qf55hci5sr2Rvlw==&ch=L2RKArBZGN0VkfC9yFMXoGGNIs5qV-FRTJ1r6weBKyQXHz_p8oLq1A==].
NET NEUTRALITY DAY APPROACHES - Let me say at the outset that I am an unabashedly
PRO net neutrality advocate. So, as you can imagine, I was disappointed when the
 FFC prevailed in vote of 3 - 2 to undo the rules established back in 2015. Under
those regulations, broadband was considered a utility under Title II of the Communications
act and the rules established to create a level playing field included:

* No blocking of websites or apps by Internet service providers,
* No throttling of transmission data based on the nature of the content,
* No Internet "fast lanes" where companies and/or consumers could pay a premium 
for the service and where large discriminations could be made against slow service.
So, essentially all of this was undone by the FCC decision. The telecoms were out
front and positive after the announcement with their advocacy that a "light touch"
was a more appropriate model for managing the Internet. However, there is a widespread
fear that splintering of the Internet will occur. In fact, it's already happening
overseas where different "services" with different "levels" of capability are already
being offered in the market place for social, messaging, video and other services
where no net neutrality rules apply.
As it relates to "pay-to-play" schemes, we already have a problem in the USA. If
 you haven't been to rural America recently, you may not realize that the service
levels and speeds of Internet capability vary considerably across the nation and
 between urban and rural areas especially. This is unwarranted. This is particularly
apropos to health care because of the increasing reliance upon Internet connectivity
to provide telecare, remote management and other similar tele-technology dependent
services. The disparity makes an existing problem even worse. It's an issue that
 deserves our special consideration. I'm going to keep my eye on it.
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The Weekly Whisk
Musings from a foodie...
Usually, I'm writing about some upscale place that I've visited in recent weeks 
as part of my travels but this week, I decided to go in another direction. Specifically,
I elected to consider "comfort food" and the burger is about as comfortable as it
gets. The week before last I was in San Francisco for various meetings and stayed
across the street from Pearl's Deluxe Burgers [* * * * *]. It's just a couple of
 blocks off of Union Square so it's easy access. Burger shops seem to be all the
 rage in urban centers around the nation. Pearl's offers up an assortment of burgers
with the usual toppings and choices. The good part is that you design your burger.
Be forewarned - it's a cash only business unless you order online and there are 
not that many places to sit. So, if you in the mood for being taken care of in an
ambiance of warmth - consider something else. On the other hand, if you've got burger-on-the-mind
and you're in San Francisco - head to Pearl's. It'll be worth it and the lines move
quickly. Check it out at Pearl's Deluxe Burgers - 708 Post Street - San Francisco,
CA 94109 - (415) 409-6120 - https://www.pearlsdeluxe.com/ [http://r20.rs6.net/tn.jsp?f=001soZ4dFX65XKoRuQuJx-seR65mbjHqyUycJPfLwLnVGtv4Ct_iegk_x09Z68EQ0dzRAr-7GJVCEFzAmk_LyhsLwqceN105m2cYkeT9lVJEnnBNuf53EGnOlbw0DZ-F2Y_3K82o2shMSY8oZqoAbi5nWBBYom-SvcqbxnRC4upgOycjs90XenATA==&c=tgDW3xdopKgb7GrVJU7S46v3fppz6OL2pu7nkp0Qf55hci5sr2Rvlw==&ch=L2RKArBZGN0VkfC9yFMXoGGNIs5qV-FRTJ1r6weBKyQXHz_p8oLq1A==].
Give 'em a try. You will NOT be disappointed!!!
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The Good, The Bad, And The Ugly
The ongoing saga...
The Great - Senator Lindsay Graham was right..."American is an idea, not a race."
The Good - Special CounselRobert Mueller appears to be getting ready to move forward
with something, which is good news. The country needs to deal with whatever is there
and get moving again.
The Bad - The comments emanating from The White House are causing angst not only
 in the USA but also throughout the world.
The Really Bad - The fact that nearly 1 million Puerto Rican's continue to be without
power nearly five months following the hurricane is a travesty of travesties!! These
folks are American citizens. Would we tolerate such ineptitude in any other state
in the Union? And, now - Puerto Rico is totally under water financially and unable
to make payments on any of its debt.
The Ugly - The information coming out on the meddling by Russians is more than disturbing.
What it means is that we need to do a far better job at all levels of American enterprise
- government, corporate, individual - in managing our cybersecurity. That will take
time and concerted effort. Let's hope the message is not lost in the cacophony of
other discussions and debates...
The statements in The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001soZ4dFX65XKoRuQuJx-seR65mbjHqyUycJPfLwLnVGtv4Ct_iegk_2Ntl_PPAc50V0vPg4feOndHJBlCjqAkuLIxcpQo1QjNR263mmMvTn69CwHC9QRE0i095_SFwlRGK6hR1AGfl3QhJb9SeMw8GnGznDKWBFol8PsQq_El5nnOqq8WZZMInz33F2UtqtQu&c=tgDW3xdopKgb7GrVJU7S46v3fppz6OL2pu7nkp0Qf55hci5sr2Rvlw==&ch=L2RKArBZGN0VkfC9yFMXoGGNIs5qV-FRTJ1r6weBKyQXHz_p8oLq1A==]
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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