Heading to PAX East

Truth be told I was a bit lukewarm about PAX this year. The usual crazy was rattling around my head like nuts and bolts in a tin pot. Why leave my house, there are people and things out there. Why would an old guy go? Why would anyone there want an old guy to ruin it for them? Finally the AirB&B I am staying at looks like a cell in Attica.

I started packing, pulled my PAX Passes out, and took a look at the schedule. Got my eye on the following sessions and events but will wait to see what Mig and Shaun are doing since they are gaming luminaries.

  • Being an Artist in the Game Industry
  • Penny Arcade Q&A
  • A Place at the (Gamers) Table: Native American Nerd Culture and the Rise of Indigenerd
  • Mario Teaches Nothing: Entertainment Games In Education
  • Hate is the Hobby
  • Roll Selection: The Art of Choosing Which Board Game to Play
  • Mass Effect: Andromeda YAS!!!!
  • Awesome Video Game Data
  • Kusoge! More of Japan’s Awesomely Awful Videogames

And that is just Friday. More tomorrow and perhaps an ongoing photo and comment on PAX from an old guys perspective

Healthcare Notes for March 6, 2017

Debt and Geography

Geography of Medical Debt from The Atlantic Monthly examines the prevalence of unpaid medical bills across the US state by state. This was from from a study out of the Urban Institute.

Approximately 25% of American Adults under the age of 65 had medical debt with the southern US being hit the hardest. Lowest rate of medical debt was Hawaii at 6% of adults. The highest was Mississippi at 37%. Nationally African-Americans and those between 25 to 34 years of age were most likely to have past-due doctors’ bills.

There is a high correlation between past-due medical debt and a state’s uninsured rate.

Debt and the uninsured
Medical debt and uninsured rates among adults, by state

The study lays out various reasons for the geography of medical debt.

  • High deductibles
  • Co-Pays
  • Services not covered
  • Insufficient savings
  • Balance Billing
“This study highlights a common criticism of Obamacare—and the overall health-care system—from both the right and left: People might be able to afford an insurance card, but they might still end up slammed with bills they can’t pay or don’t understand”

This issue of medical debt is a lingering issue that has as much harm for the patient and family as the illness. The current ACA replacement ideas are not addressing this issue. Health-savings account the high-deductible plans are not going to fix this issue. And tax credits are not weighted by income. Rich or poor get the same tax credit.

In the end healthcare is complex and there are no one size fits all or fixes all. It is a matter of what do we pick and choose to fix and who gets hurt. Right now with those in power it is singling out the poor to benefit the rich in matters of health.

EMR and Patient Understanding

Journal of Medical Internet Research published the following “Readability Formulas and User Perceptions of Electronic Health Records Difficulty: A Corpus Study” Jiaping Zheng, MS from the University of Massachusetts identified the objective of the study

The objective of our study was to explore the relationship between the aforementioned readability formulas and the laypeople’s perceived difficulty on 2 genres of text: general health information and EHR notes. We also validated the formulas’ appropriateness and generalizability on predicting difficulty levels of highly complex technical documents.”

Conclusions suggested that readability formulas’ were not ideal predictors of the reading difficulty of EHR by patients. The formulas correlated with each other yet they did not predict patient readability of EHR.

Two outcomes I see here. First, creating a new readability formula will likely not happen in the near future and if does happen I am not sure we can expect it to widely used for EHR and if the record needs to be fixed for readability will it be done. In a word no. Second, I see engaging patients with a HCP to give them a short 101 on how to read or what to read on and EHR specific to the patient and their medical needs. This later idea will help overcome that gap in understanding. But more important it will be another engagement tool between the patient and the physician. And that will yield better long term outcomes for patent health.

Millennials and Healthcare What’s not to love

The group we old folks love to hate have some interesting and telling views on healthcare. The Medical Futurist looked at a Gold Sachs research report about millennials and focused on the healthcare portion.

Millennials low hanging healthcare fruit, exercise more, eat smarter, smoke less. All good and they are app crazy for tracking training data (me too and I am old at the dirt on your floor). And millennials love to find food online. In the end they feel they are healthy scoring 3.5 out of 5 on the question How healthy do you consider yourself?

Here are some highlights

When asked if they think they care more about their health than their parents of grandparents.

  • 43% Yes
  • 22% No
  • 36% Equally

The entire digital health apps and sensors was a bit of a surprise.

Do you use any health apps?

  • 15.7% I use regularly
  • 31.2% I have some on my phone/tablet but don’t use them regularly
  • 45.7% I don’t use any
  • 4.4% I don’t have a device

How would you feel about using sensors as well?

  • 28.9% I don’t care that much to try one
  • 17.4% I’d rather give a pass on it
  • 25.6% Neutral
  • 16.2% I’d rather give it a try
  • 11.7% I’d definitely like to have one
 The key take away here is that this segment of the population is much more socially motivated to drive others to a healthier lifestyle. It is not only talking with others it is urging them to use technologies to help.

When asked which can be more efficient in urging someone to a healthier lifestyle they responded:

  • 17.6% New health technologies
  • 69.6% Society’s impact
  • 12.8% Other

Social motivation is the primary driver for healthcare in this population. They seem to single out education from companies who sell products to having incentives built into medical insurance.

All of the above is fairly standard. There is nothing earth shattering here except the difference between previous generations and this one. The educational pump on healthier lifestyle and by extension healthcare is primed. It makes sense that healthcare communications and not just about healthier lifestyle. This audience will be more attuned to evidence on diagnosis and treatment. The key communicator should be there physician. Beginning now with a baseline of evidence based messages and continuing forward will bode will for improved outcomes and smarter healthcare consumers.

Healthcare Notes March 1, 2017

Just to troll myself. This is a mediocre post on healthcare I’ve found that interested me. So why am I posting it? Because I need to get my groove back on finding and posting value based healthcare and other noteworthy  pieces. It’s a one post at a time program.
A favorite healthcare blog Healthpopuli.com by Jane Sarasohn-Kahn had this: “Will Republican Healthcare Policy “Make America Sick Again? Two New Polls Show Growing Support for ACA”. If you are a healthcare junkie you know this. You’ve see clips from the town hall meeting were average citizens are not just protesting the repeal and replacement of the ACA but begging for help in staying healthy. Sarasohn-Kahn unwraps two recent surveys on how Americas view the ACA. They are from the Kaiser Family Foundation and Pew Research Center. The  KFF survey charts Approve/Disapprove polls for the ACA since 2010 with 48% favorable and 42% unfavorable in February 2017. Republicans as a group are against the ACA. Nothing new here. What is new are independents shifted to favorable on the ACA.
The PEW poll asked do you approve or disapprove of the healthcare law passed by Obama and Congress in 2010. The difference was greater than KFF poll with 54% approving and 43% disapproving.
The biggest difference in approval and disapproval was with younger Americans compared to older Americans. Younger adults, 65%, approve of the ACA vs. 31% who disapprove. College graduates are more likely to support the ACA than those with no college.
Sarasohn-Kahn points to a fact $1 in $5 is the healthcare economy. It is the health economy stupid.
This is just one of many many articles, posts, Tweets, and videos on the coming replacement of the ACA. In my mind I see we are moving past the yelling and lawsuits to repeal the ACA with no evidence other than a smoldering hatred for Obama. Today people are beginning to look at the evidence to think about what healthcare means personally. Of course this comes back to the reason why people learn, to solve a problem they have. The problem we are facing is if we loose the ACA and healthcare insurance we head back to being uninsured, dropped into high risk pools for pre-existing conditions, and medical bankruptcy. The good old days. It is hard to put the genie back in the bottle once we know we can receive health CARE.
FiercePharma had the following “Pharma groups to FDA: Stop that new off-label rule in its tracks” Back in August of 2015 NY State judge ruled in favor of Amarin Pharma to allow them to promote Vascepa off-label. After this ruling by the court Pharma was expecting the FDA to step back. The FDA rolled out a new rule on the subject of off label. The rule defines ‘intended use’ for drugs and devices would include ‘totality of the evidence’ standard. Pharma is worried that totality of evidence will drive more whistleblowers because they can use circumstantial evidence. Here is something I didn’t consider about free speech and sales forecasts:
“The chilling effect of such a standard is difficult to overstate,” the petition said. “For example, if a company engages in scientific exchange about off-label use, forecasts on- and off-label sales, and scales production to meet the combined demand, a prosecutor could decide that this evidence reflects an off-label intended use.”
I believe freedom of speech is important. It is also important that clear concise evidence be offered so physicians can make decisions to treat patients that will benefit the patients and not Pharma.

“We Don’t Need Compliance, We Need Collaboration” and Personalized Learning

The Health Care Blog posted the following “Population Health Isn’t Working Out Quite the Way They Said It Would. What’s Going On?” Authored by Hilary R. Hatch, Ph.D. from Vital Score, Inc.

I agree with all that Hatch presented especially the headline quote. It is all about collaboration. Her primary premiss is that we are putting patients into categories by conditions (i.e. diabetes, heart disease, etc.) when patients with the same conditions are different. She gives the example of depression and notes that for her depression is a billing condition and not relevant to treatment planning for a vast array of patients, those in mourning, postpartum moms, isolated geriatric patient, etc. Hatch further addressed how population health is failing in the physicians office.

“When the population health need gets attention, is it at the expense of the individual’s need? Care plans driven by population health diagnostic categories are more formulaic, symptom-focused and may ignore root causes. As such, they are less likely to be successful. Then, when patients fail in flawed care plans, we indulge in blaming and name-calling: “non-compliant” or “non-adherent.”

Hatch continues her logic with the thought that non-adherence is resistance by the patient to different forces such as cost, the patient sense the drug or therapy is not working, and other factors. Her solution and rightly so is to help patients ‘choose their own adventure’ to identify their pathways to health and success.

“…when people self-identify needs and self-refer to services, their participation rate increases up to 20x. People own their choices because their choices are personally driven for their own benefit. It’s not only better for workflow, it’s better for outcomes.”

In my opinion Hatch argues clearly and is spot on when it comes to motivating patients. It is all about self-identified goals and management from the bottom up (patient) not the top down (HCP). But I would add to this the work of Malcolm Knowles who studied how adults learn. If we understand and use adult learning we can improve patient motivation.

Knowles characterized adult learning as follows:
  1. Self-concept: As a person matures his self concept moves from one of being a dependent personality toward one of being a self-directed human being
  2. Experience: As a person matures he accumulates a growing reservoir of experience that becomes an increasing resource for learning.
  3. Readiness to learn. As a person matures his readiness to learn becomes oriented increasingly to the developmental tasks of his social roles.
  4. Orientation to learning. As a person matures his time perspective changes from one of postponed application of knowledge to immediacy of application, and accordingly his orientation toward learning shifts from one of subject-centeredness to one of problem centredness.
  5. Motivation to learn: As a person matures the motivation to learn is internal

This can be summed up in the simple idea, adults will only learn when they are seeking solutions to problems they have. I posted this a couple of years ago on Knowles.

What Hatch is addressing can be seen as HCP and the healthcare system not helping patients identify the problems they are having and demonstrating solutions to those problems. The idea is to aid patients in becoming motivated through learning and self-identifying problems they may not realize they or others with similar conditions are having. As much as HCP want to be educators (Hatch’s top down idea) HCP must focus on learning what the needs/problems patients are having specific to              their conditions. Personalized healthcare focused on the problems/needs/motivations of a patient is as important as matching a patient genetics to treatment, it needs to become personalized learning for the patient. You know the whole give him a fish teach her to fish thing.

John Wick Chapter 2: A Furious Fun Feast

I saw John Wick Chapter 2. Fast, fabulous, frenetic, feast of furious fun. And it was good, though that body count was similar to watching Miguel or Ben my Destiny pals on a strike. High triple digits. A couple of points to make
The fight scenes both hand to hand and gun battles were masterpieces that reminded me of Balanchine, Nureyev, Fonteyn, Graham, or Baryshnikov. Though I there were some scenes that felt Rodgers and Astaire. Sheer magic.
Their moves as magical as John Wick
Pure art and balance like John Wick
A glitch of sorts in the film that was a bit jarring. Of course John Wick 2 took place in NYC. Of course there MUST be a NYC Subway chase and fight. So they (Wick & Bad Hombre) start fighting and shooting I think 42nd street. Suddenly they are at the Oculus WTC downtown in the PATH station, without taking a train. Next they they fight their way onto a PATH train and the announcer is saying ‘next stop for the A Train is Canal Street’. That is uptown. The PATH does not go to Canal Street. Then it is announced Rector Street next stop, which is downtown…wtf. The guys next to me in the theater are cracking up. Okay suspend reality for a good film.
There was a scene where Wick is selecting weapons similar to Bond with Q. This guy is called the Sommelier and is located in a wine cellar. Well done. And the sections of weapons are matched to meal courses, of course. I was all Jelly. I want that for me when selecting weapons in Destiny for PvP or PvE. I know I can watch videos read Wiki’s but, I want to be hand served.
A good flick…

ACA Then, Now, and Tomorrow. Measuring Success or Failure.

New Web Site. New effort. Old news updated. The ACA then and now.

I was looking at my archives and found Notes & Links: October 21, 2013. I posted a piece that Dan Munro a healthcare contributor at Fobes had on Obamacare Numbers Success or Failure? Munro noted that there were 476,000 health insurance application were filled through ACA Federal and State exchanges. Since then we can say a few more Americans have applied with over 20 million people have health insurance either through public o private options. As of December 24, 2016 there were 11.5 million people who used the federal marketplace to buy health insurance. 8.9 million renewed their coverage or bought new plans to replace existing plans. 2.6 million new people enrolled. It was so cute that Munro ends that piece from 2013 noting that the ACA is the single biggest target on Obama’s back. You think.

Fast forward to Munro article in Forbes Trump Acknowledges That The ‘Replacement’ Of Obamacare Will Span Years. This was pulled from President Trumps interview with Bill O’Reilly. Besides the fact Trump is seeing that the ACA can’t be just turned off without doing great harm to millions of Americans. Ultimately in rich and ironic way the GOP is being forced think about outcomes that are not tied to punishing former President Obama. GOP oh my. Which brings me to my final thought here.

As the ACA is repealed, replaced, or repaired there will be reams of pages written about the harm these actions will have on the sick, the old, and the young. There will be competing projections of what these changes will produce. For now the little we know about what will be done or considered is not enough to get our outcomes arms around.

I would like to imagine that someone, some academic institution, some group of thinkers will set up a site to track key healthcare outcomes retrospectively from the beginning of the ACA to its ‘repair’ and then going forward. Surely there will be measures of those who have and don’t have health insurance and measures of cost of health insurance and more. I am hoping we can get into the granular data that may takes years to revel a trend.

Just to throw out some ideas: Measure standards of care treatments and their outcomes for specific conditions. Compare Repaired ACA to Pre-Repaired to Non-ACA health insurance. Will we see worse outcomes in one group vs. the other group?. Are treatments offered as first line differ between measured segments? Is the life expectancy for similar diseases and patients shorter or longer between segments?

I am not a statistician nor an epidemiologist (obviously). So I’m not sure any of this can be done. Should it be done? Yes, because this is the type of evidence (not alternative facts) that the fix and repair GOP made into law. We need to know if it’s keeping Americans alive and healthy. This GOP driven destruction of Americas health is similar to the Death Panels feared in 2012 by the GOP. Now they get to enact their dream, thinning the herd of poor, sick, and non-GOP voters.

Bonus link, One World In Data. Really great charts and graphs on healthcare.

Our World in Data
Life expectancy vs. health expenditure over time 1970-2014

Grief is the Space Between Memories Known and Unknown

“Now would be a good time to have end-of-life discussions with Donna,” the Hospice Rabbi said. “What does she want for her funeral? What are her regrets? Did she find joy in her life?”

Joy? I failed her. All I could do was think of that.

I hesitated for a day. Then next afternoon, alone in the room with Donna, I looked at her in the bed and said, “Donna, perhaps you want to talk about your funeral.”

She looked over at me and said, “Don’t be a maudlin pussy.” Then she rolled onto her side and fell asleep.

I smiled. That was the woman I married 28 years ago, life and death on her terms, her way, take no prisoners, with no doubt about what was needed. She was not dead yet.

This occurred about a week to ten days prior to Donna’s death. Yet my grief was an orchard in full bloom and thriving finding nourishment from the memories of our life together. It took seed when she was diagnosed with Stage IV cancer two plus years earlier. After she died it sunk it roots deep and remains part of me. Many may see my grief as a failure to launch away from the pain. You know that entire finding closure meme which is denial said pretty. I will not deny my grief nor Donna.

There is more to grief. Let me defend grief, specifically defend my grief and hopefully your grief. Grief is life’s artesian aquifer. It flows from within, bored out of the loss of a loved one.It is part love and light. It holds promise to satisfyingly quench our loss. To sustain us.

Grief should not be seen as a proper place or an improper place. It is the space between memories of the past and hope for the future. Those are distant points on a compass that intersects within us. At times where it overlaps may be a soft and subtle or hard and painful. No matter it creates a newness within us offering a fresh look that what was, what is, and what may be. If choose not shy from it or ignore it can open up new memories and new understanding.

I have written about grief and will continue to. Grief has its own narrative arc and begins as thumping numbing recognizing that what once is is now was. It moves with us and becomes dullness. We need to take grief and partner with it, in a sense embrace its strength and aching to create new.

Maine Public has a piece by Patty Wight. ‘If It’s All About You, There’s No Reward:’ Coping with Grief by Helping Others

She relates the story of Floyd Hastings and the death of his wife. How Hastings like many of us who face the loss of a loved one sought to give back to those who helped us care for our loved one. I remembered the chemo lab nurses and hospice staff for years following Donna’s death. I have posted about Donna and podcast on grief and how I’ve managed it well and not so well. I am volunteering. All of this as a way to pay forward what I’ve learned.

That is what we do but more to my premiss, our grief is a light within us to guide us to a better understanding of what was, is, and will be. Below are some links to my podcasts on the topic and posts. But stay tuned more to come.

Podcast 39: The Organic Nature of Grief. An Observer Effect

Podcast 37: The Insipid Nature of Grief, The Horse Latitudes

Post: Domesticating the Feral Nature of Grief

Post: Inside Out a Compendium of Loss and Grief


Pretzels: Life’s Twists & Turns A Bronx Tail

Time moves forward and we as humans move with time. Time and our lives get twisted as we move though life. Whether it’s paddling forward with the current to find a shoreline where we stop to explore. Or being carried downstream passing the point where familiar become unfamiliar. That is the polynomial equation of life: time, age, and reflection.

These past few years being carried by events surrounding me. Not powerless to changes as much as listless and supine. Donna became ill, passed away, my business and work became nonexistent. Meaning and purpose that were once part of life became abstract thoughts and longings for a time that was. This is aging. Many have written about aging especially the site Time Goes By. His thoughts and reflections on this and other aging topics are well considered and highly reflective. Yet there are moments or small events that buoy one to feel, all is not lost as we approach out expiration date.

Bronx Baking Company is one of these moments for me. I want to 1. Reflect on this company and its owner who I personally know and relate it to me then and now. 2. Give a shoutout to a fabulous company and product.

Alexis is the founder and owner of Bronx Baking. I met her through the space I was renting a desk at during Donna’s illness and death. When we first met she was mulling over the idea of a Bakery. I was struck by her drive and brains. And her Bronx attitude. She takes no shit. Kind of fits into my reference point for women.

Alexis was born and raised in the Bronx on Arthur Ave. She has an enthusiasm verging on aggressive for the Bronx. So the location was set for her. Next came the product, real German style pretzels. Alexis set out to find recipes, talk to German Bakers, test, sample, and do it all over until they were perfect. And then she started baking. At first small. Then in a shared space. And now her own space. When she opened her own space she bought equipment, cleaned the space, set it up, and tested production. To her getting here feels like forever and feels like failure delayed. For me watching it is so fast and just another step to proving your meaning and purpose. All the while she was selling product to new customers. Improving the recipe. Solving delivery problems. Snaking a grease trap. Managing account receivable. Tweeting, Instagraming, Facebooking, and more. Metaphorically those pretzels are made with sweat and tears. Metaphorically, ok. A delicious pretzel.

I could go on. There is really nothing unique here for anyone that started and ran a small business. Big deal. Or not. Consider the fact that in the US about 3% to 4% of Americans start a business. Failure is part and parcel of owning a small business as is working your ass off, having debt, and loosing sleep every night. As I said, an average day nothing special for a business owner.

I watched Alexis. I helped her with some marketing. I tried to be a cheerleader. All the while in my mind I kept thinking I was there once. My friends were there once. This is so inspiring to see and know that what we did in old timey days still feels the same. The damn the torpedo and full fucking steam ahead let’s do this lives in the Bronx, in her pretzels, and in Alexis. It lives in those that create an app or drive for Lyft. It lives in those who want to find a way to thrive and not submit. And there my friends is the importance of this. My life’s meaning and purpose may be on the wane either from external issues or from my own being stuck in this emotional amber of life. Watching Alexis and Bronx Baking and in a small way being part of it and it is thrilling. I relieve what once was. I get motivated to do this and that. I am learning new things. Being in the presence of my past is keeping me centered on the present. Helping Alexis and Bronx Baking helps me. And she gives me a pretzel once in a while.

Why Bronx Baking?

Bronx Baking sells some serious real German style pretzels and pretzel bread. They are sold locally in NYC at bars and restaurants. Where great beer is made. Alexis offers them retail (here). Do yourself a favor, you like beer? A pretzel is a must have side dish. Get some for yourself and see. You can thank me later.
This month the food court Eataly is featuring Bronx Baking products. You can find Bronx Baking on Instagram Bxbakingco, Twitter @BxBakingCo Facebook and Pinterest.

Welcome Back Bioc.net

It has been nearly a year since my last blog entry. I’d love to say I’ve been busy. Not so sure, at some point (age related) life becomes glacial in serving up burnt offerings. It becomes less of what is placed in front of you and more about, what you harvest, gather, uncover, and find. God helps those who help themselves and you got to help yourself prior to your expiration date. It’s been a year of sorting this out. Rest assured I am not all that self actualized. More on that later.

Here is the new site with all the old blog posts, podcasts, photos, etc. When Donna was going through chemotherapy and I was a part time gig worker and a full time caregiver. I moth balled my business. The web site I had was now in my responsibility to maintain and keep alive. Donna may be dying but I was not. At least not outwardly.

I went to Square Space and built (cobbled) a new site. That new site is now previous site. It was fine. It was mine. It was where I leaned to do new shit. Since it was on Square and my ISP is Pair.com I had to have someone create a DNS and MX set up so my email and etc. would work. I also needed a bunch of network work arounds. I was clueless how it worked. But it worked. It kept busy posting and podcasting. All the while I cared for Donna and then gave into grief.

Sometime mid 2016 my hero and all around amazing social media/SEO Baby Mozart (aka Shaun) kept telling me Square is okay but for SEO and all that a web site can do it is not readily available nor robust enough on Square. Baby Mozart said in no uncertain terms go WordPress. Host it on your ISP. So mid 2016 to 1st Q 2017 that is what Shaun did and I breathlessly watched as if I was a spectator at a BMX competition.

Shaun ported my old site to the new WP build. Got the DB built, added plugins, and so on. All magic to me. He found my podcast plugin blubrry, I ported over my podcasts. Just to note blubrry was so helpful and professional. Big recommend here.

Now it’s October. Ready to go. Not so fast. I was technologically bound up like an opioid users’ bowel. I feared if I did this switch from Square to WP at Pair I was going to break the Internet. Not a joke. I made about eight calls to Pair tech support, cried to Shaun, and lit a shit load of candles and sage sticks.

Well I did it. The Internet didn’t break. Shaun held my hand. Videos are teaching me about WP. Still learning.

Is there a lesson here? I am sure, but it verges on whinny and maudlin. There is a take away or two: 1. Look closely before jumping in. 2. Break shit you can always fix it. 3. Those in tech support have the patience of saints.

The Organic Nature of Grief, An Observer Effect: Podcast 039

This process of grief feels like a hamster on a wheel. Sometimes it feels seems the clouds have parted and there is the brightness of understanding in the light braking through. Taken in the whole the path is ongoing and changing. It is slow, it is fast, it and above all else it gives me a chance find a balance in today while adjusting the past. The distance in the rear view mirror is longer than the view through the windshield.



This Too Shall Pass: When I Say So

Richard A. Friedman, MD

Podcast #36 My Idiosyncratic Fingerprint of Grief: Grief to Knowledge

Hold Still by Sally Mann