Consulo Indicium - 11/14/19

Information for your Consideration…

And, Are We Surprised? – The big health care news of the past week was the front page article by The Wall Street Journal that Google has coupled with Ascension Health – the second largest health care system in the nation – on “Project Nightingale.” In essence, the partnership between the two entities is an effort for Google to develop and enhance its artificial intelligence and machine learning platform in understanding patient data; and, for Ascension to work on developing better protocols and guidelines to gain efficiencies, effectiveness and quality in care delivery.  The project has now triggered a federal inquiry on whether or not all of the HIPAA requirements were met or are being met by the deal.  Quite frankly, knowing a bit about the players on both sides of that aisle, I will be very surprised if the HIPAA requirements are not being met.  In fact, there is no reason that Ascension cannot have a “business associate” relationship with Google.  In fact, the HHS requirements state:

 The Privacy Rule allows covered providers and health plans to disclose protected health information to these “business associates” if the providers or plans obtain satisfactory assurances that the business associate will use the information only for the purposes for which it was engaged by the covered entity, will safeguard the information from misuse, and will help the covered entity comply with some of the covered entity’s duties under the Privacy Rule. Covered entities may disclose protected health information to an entity in its role as a business associate only to help the covered entity carry out its health care functions – not for the business associate’s independent use or purposes, except as needed for the proper management and administration of the business associate. 

The key factor will be the highlighted area noted above on whether Google is doing anything in terms of “independent” use of the data.  Again, I would be surprised.  More importantly, from a generic standpoint, I fully anticipate that these types of arrangements will become more prevalent in the next couple of years.  The Google-Ascension partnership is the first.  I strongly suspect that the Amazon-XXX, Microsoft-YYY, Dell-ZZZ and other similar partnerships are not too far away from announcements as well.  In fact, I’ll go one step further: it is through these types of partnerships that we will gain a better toe-hold on how to manage costs more effectively, deliver more efficient care and enhance the quality of care we provide.  It will be the new norm.  If there are concerns about privacy – as there should be – the focus should be on resolving those issues.  In fact, I’ve argued for some time that the entire HIPAA framework needs to be revisited.  HIPAA was enacted in 1996 – nearly 24 years ago or, a quarter of a century.  During that time period the technology, the care delivery models and the cost of care have all exploded!!  So, are we surprised? If we are, then we’ve been living under a rock.  It’s time to deal with the real issues of privacy in an era of transparency. 

Perhaps It’s My Age – I was struck by a report from the Global Coalition on Aging (GCOQ) and United Nations Department of Economic and Social Affairs (UN DESA) along with several other organizations who report on a 21st century megatrend – the skyrocketing rates of vision loss and visual impairment among the growing numbers of elderly.  The report was introduced by having the dinner guests blindfolded for their entire meal so that they could learn first hand the impact of visual disruption.  Christine Ha, an American celebrity chef who is blind cooked the meal and explained for the guests the dynamics of blindness in visually dominated cultures.  Vision loss is, indeed, a major cause of morbidity among the elderly because of falls, social isolation, and withdrawal.  I know that in my household, I have become the leading voice for “more light” and “bigger print” – along with “louder, clearer talking”.  Hmmm, perhaps I’m next?

Canada To The Rescue – Not! – In the last couple of months, a number of advocates have suggested that given the shortage of certain prescription drugs and cost of those same drugs in the USA (even generics) that we should turn to Canada as a source of supply.  However, Kirsten Hillman, the Acting Ambassador to the United States issued a statement this past week stating: “Not only are we too small of a market, Canada cannot increase its domestic pharmaceutical drug supply to meet U.S. demand. Canada remains dedicated to working with the U.S. to improve our citizens’ health and well-being, recognizing that Canada’s priority is to ensure a steady and solid supply of medications at affordable prices for Canadians.”  We need a similar perspective on our side of the border… 

And, Speaking Of Shortages – It seems absolutely crazy that a drug which has been in use since 1922 – when the first person (a young boy) was injected with insulin – is increasingly unavailable OR, beyond the financial reach of diabetic patients! Yet that is the case.  A recent study was published in the New England Journal of Medicine highlighting this increasingly important problem. Today, the price of 100 units of insulin is about $18.00.  And, for the average 150 pound person that amount of insulin will last about 2 days with the cost of insulin running about $270+/month.  That is a chunk of change by any standard. The issue is the insulin is a “biologic” drug which requires more sophisticated capabilities in production.  The drug companies are arguing that their costs keep going up but the naysayers are suggesting that the price increases are going up at a rate far faster than inflation or other associated costs.  There are a number of pieces of legislation at both the state and federal level which are intended to level the playing field and create penalties for drug increases on these generic drugs that go beyond the inflationary production factors.  The issue is that insulin is not the only drug.  There are any number of generic antibiotic medications (e.g. plain old tetracycline) which continue to be effective treatments where the same phenomenon is occurring.  This is real and deserves our special attention. 

Consulo Indicium - 10/18/19

Information for your Consideration…

Toto’s Perspective – Or, How My Dog Keeps Me Calm – Toto is not only the little dog in The Wizard of Oz but also my best buddy at home.  Toto is a Glen of Imaal Terrier – the newest breed to be recognized by the American Kennel Club (AKC) – and, my best buddy.  Every morning when I awaken, I am greeted with his wonderful dark eyes and steady gaze with the clear message, “Dad, it’s time to go out!”  And, so we go out.  So, what’s this got to do with health care?  There is a new study published in Circulation that found dog owners to have healthier cholesterol levels, lower blood pressures and milder stress responses than those who did not own dogs (NOTE: There was no control group of “cat owners” :-)  ).  In addition, there was a second study by a group of Swedish researchers which reported that people who suffered a heart attack or a stroke and owned a drug appeared to have a lower risk of a second heart attack or stroke than those who did not. I’m sure that Toto was aware of these studies as he is a very prescient dog.  And, even more, he’s the best four-legged companion I’ve ever had in my entire life.  If I’m lucky and Toto sticks around with me, I should live a long time…

But, What About Cats? – Not to be outdone, there was a recent article (what is it with the pet thing anyway?) on the emotion response to watching cat videos online. In a cohort of nearly 7,000 Internet users who watch cat videos (yes, it’s a growing social media phenomenon, along with dog videos.  Anyone out there watching turtle videos?), the study revealed a significant relationship between viewing, personality types and level of enjoyment in watching cat videos as a factor in happiness of the individual.  Hmmmm…I’m sure my cat – Willie Nelson hasn’t seen the study otherwise he would have put it in front of me as a counter to my focus on Toto the Wonder Dog! 

ECRI Institute Top 10 Health Tech Hazards Released – For the last 13 years, the ECRI Institute has released an annual “Top 10 Health Technology Hazardslist containing a rank order on the biggest health technology concerns of the year. The list is derived after a comprehensive review of ECRI's incident investigations plus additional medical device testing and a review of both public/private incident report databases. It’s an important list because it doesn’t just provide a Top 10 but also suggests practical strategies for the health care community to implement for reducing risks.

  1. Surgical Staplers – The potential for the malfunction and misuse of surgical staplers ranked number one on the list. In a statement by the ECRI Institute, they noted "Injuries and deaths from the misuse of surgical staplers are substantial and preventable. We want hospitals and other medical institutions to be in a better position to take necessary actions to protect patients from harm." According to Medical Device Reports (MDRs) released by the US Food and Drug Administration (FDA), over the period of 2011 through 2018, there were more than 41,000 individual MDRs regarding surgical staplers and staples for internal use. The reports noted 366 deaths, more than 9000 serious injuries, and more than 32,000 malfunctions.
  2. Point-of-Care Ultrasound (POCUS) – As relatively new technical devices, it appears that use is outpacing appropriate policies and practices to avoid misuse or misdiagnosis. The problems are wide ranging and it is clear this will become a major focus for FDA scrutiny in the coming year. 
  3. Office-based Sterilization Procedures – ECRI noted that the failure to consistently and effectively clean, disinfect and/or sterilize contaminated items to reduce patient exposure to virulent pathogens is an ongoing problem. Training was noted as a big issue along with the use of protocols and guidelines for use of equipment. 
  4. At-Home Hemodialysis – The use of central venous catheters (CVC) for at-home hemodialysis is an increasing problem because of the growth of the service. With an increase in the push for home treatment by the federal government and insurers , ECRI noted that the risks for this procedure may outweigh the benefits. Further study is on the horizon.
  5. Robotic Procedures – The use of robots for surgical procedures – among other capabilities in care delivery – is growing by leaps and bounds. However, the procedures and policies related to these devices haven’t kept pace with use.  The end result is an increasing number of problems.  Specifically, the report calls out the need not only for better defined procedures but also improved training, credentialing, and privileging surgeons and operating room staff in the use of the technology.  And, I would argue that the same is needed outside of the surgical suite as well.
  6. Alarm Overload – One the unintended consequences in the use of all sorts of technology is the frequency of alarms, alerts, and notifications. In many cases, the alarms overload clinicians to the point where they are ignored – either intentionally or unintentionally. 
  7. Cybersecurity – While there are clearly ongoing risks in controlled environments like hospitals and clinics, there is a much more significant concern when it comes to the connected home or remote health environment. Service interruptions, device intrusions or infections and delayed- or mis-diagnosis are increasing problems.
  8. MRI Use and Implants – The report found that there is an ongoing problem with missing implant data when patients are undergoing MRI scans. The lack of this type of information creates a hazard and/or delay in the use of MRI scans.  Again, protocols and training are at the top of the list of solutions.
  9. Medication Errors – You would think the problem of medication errors would go away. The technology is there but, if it’s not used properly, errors can continue. 
  10. Insufficient Service Management – It’s amazing what a few loose nuts, bolts or wires can do in devices that are increasingly used to manage care delivery. The possibility of injury accidents or harm to patients, clinicians, and others is on the increase and needs attention. 

For more information about the ECRI Institute and the Top 10 annual ranking check out their website. For those who are involved in the technology side of health care, the ECRI is an important resource for staying abreast of the changes and challenges in the use of technology. 

Fast Versus Slow? – A new article in JAMA Network found that walkers who dawdled was a warning sign that you might be aging faster than you think!  For some time, walking speed has been known as a predictor of life expectancy for people in the 70’s and 80’s.  Slow walking has been previously associated with an increased risk of hospitalization and dementia.  So, I guess those fast walkers at the airport are the ones who will inherit the earth.  I wonder if it counts that I was once a fast walker but now tend towards ambling.  The paper did not address this important aging issue :-) . 


Consulo Indicium - 9/19/19

Information for your Consideration…

The Number of Holes – When I saw this picture, it caused me to pause.  A picture is worth a thousand words.  Check it out.

Remembering JFK – In the midst of our national debate on immigrants, I was sent a clip of President John F. Kennedy’s 1963 address to the Anti-Defamation League 50th Anniversary Celebration.  In the speech, the America I grew up comes to the forefront.  My Great Grandfather left Germany to get away from Bismarck’s army.  He dodged the German draft to come to America, to homestead a farm, to raise four kids who raised their kids which allowed one of them to become a doctor to help people.  That’s the essence of the American dream.  We all – except for our Native Americans – were immigrants to this wonderful land.   

Education versus Warnings – A recent report in the Washington Post noted that the Food and Drug Administration (FDA) has proposed a new requirement for cigarette packaging that would include graphic images of the injury cause by smoking “along with vivid descriptions” on cigarette packages. What type of graphic images?  Does “amputated toes”, “black-tinged lungs,” or “a sickly boy in an oxygen mask” offer an image?  In the past the FDA has been blocked from requiring such images because of the courts siding with tobacco companies arguing that such practices constitute a violation of First Amendment rights.  But, warnings have been around since 1966.  So, the question is where to draw the line?  From my perspective – as a former smoker of four packs per day in college (yes, stupidly – four packs per day), I think graphic warnings are just fine. Even better would be a short clip watching someone try to breathe due to emphysema from smoking (you might pick up on the fact that I’m an avid anti-smoker!!).  And, the same applies to vaping.  There has been precious little research on vaping and only hypothetical benefits offered.  If we want to get “in your face” about smoking and/or vaping – I’ve suggested for years that we should admit people to the hospital, give people chest pain and, the vast majority would quit smoking.  How’s that for a graphic, in-your-face approach?  In five or ten years, I bet that we will look back on vaping as a menace as deep and disheartening as the opioid crisis of today.  We are allowing it to be created.  We must get ahead of the curve…

Consulo Indicium - 8/5/19

Information for your Consideration… 

Washington, We’ve Got A Problem – Arash Mostaghimi, MD recently published information in the British Medical Journal on the exploding costs of WHO “essential medicines”.  At present, there are 265 such medications on the list which is used by Medicare Part D.  Among the essential medicines, the growth in spending went from $11.9Bn (2011) to $25.8Bn (2015) or a 116% increase over a four-year period.  Over that same period of time, out-of-pocket expenses by patients totaled $12.1Bn increasing from $2.0Bn (2011) to $2.9Bn (2015 or, a 47% increase.  In addition, the introduction of novel or new drugs accounted for about 58% of the cost increase versus 22% of the increases attributed to existing drugs.  Nonetheless, this is only for the “essential medicines”.  The cost question for drugs – largely because of federal policies which limit Medicare’s ability to negotiate with the drug companies – in an increasing problem.  We need to get much more serious about negotiating drug prices BUT, that’s not the only point.  Costs in Medicare are growing faster than ALL other elements of society’s costs – education, entertainment, transportation – pick your favorite one!!  If we don’t get a handle on the problem, my generation runs the risk of bankrupting the nation BUT, I actually don’t think the Millennials will let that happen.  So, let’s get on with the solutions…

A Distressing Trend – From 1999 to 2016, the rate of suicide in the US has increased by 28%.  It’s now the 10th most common cause of death.  More importantly, it’s a trend that seems to cut across all the demographic although there is an equally disturbing increase among young girls, age 10 – 19, by 70% according to CDC data.  Why?  No one really knows at this point although there is a phenomena referred to as “suicide contagion”.  For example, in the months following Robin Williams’ (“Nanu, Nanu”) suicide in 2014 there was a 10% spike in such suicides across the nation. Economic crisis seem to cause an increase.  But, I’m wondering about our “connectivity” as a society.  Getting together and talking things over was once a group exercise.  Now, the answer always seems to be “online”.  There is a certain disconnect by using online sources.  I remember several years ago I was at the airport awaiting a plane departure – one of my more common activities in those days – when I looked up to the laughter of a group of young people.  But, they weren’t talking with one another.  They were online, engaged in some activity together, heads turned down with all of their stimulus coming from a screen – not through interaction “real time” with people.  I wonder?  Are we becoming disconnected?  Is the technology separating us?  Now, don’t think I’m “old school” because I’m a huge fan of technology but, I’m wondering!  It’s an issue that needs to be considered…

Walking, Walking, Walking – But, It’s More Than Walking – It seems that walking is all the rage these days as a way for getting us sedentary types out of our hibernation cocoons which are attached to computers and other electronic devices – and, someplace where walking at a rapid clip is accomplished.  The earphones are elective.  But, the question is for how far?  And, for how long?  A recent JAMA Internal Medicine article reviewed the literature in an attempt to find an answer.  The data shows that while 10,000 steps is nice there is no cardiovascular improvement beyond the 7500 steps/day quota.  There was step-wise mortality improvement from 2700 to 4400 to 5900 steps but, beyond 7500, improvements leveled off.  And, if a slightly lower number stimulates you to go after it – you’ll benefit.

But, it’s not just walking that’s important.  It’s the use of weight-bearing exercise that involves the large muscles of the legs.  In a recent report, studies show that use of these muscles stimulates the production of stem cells in the brain which are thought to review our neuro-capabilities!  So, not only do we live longer but, we can also think longer.  When this study is replicated and more effectively disseminated, we’ll probably all be out there taking those big steps to lean on those big muscles. After all, without a brain – what’s it all worth?  If you still want to be a pumpkin and sit around, good luck!

Putting Job Stress Aside To Consider Job Security – There was a recent JAMA Network article on the state of the health and health care workforce in the United States. The US Bureau of Labor Statistics recently noted that the demands of an aging population and the increased rate of health insurance coverage by Americans has resulted in a large increase in demand for health care workers. Between 2014 and 2024, the increase in health care jobs will grow by 19% - the biggest increase for any occupational segment in their database. But, while numbers are important – it is equally important to consider how the workforce actually “works together”.  As we move from value-based reimbursement (I am of the opinion that is a “when” not an “if” question), collaboration becomes the watchword of health care teams.  We’re still not training for that outcome.  So beyond, “more” workers, we also need to be including “how” workers work.  

Crossing The Line Into Advocacy:  I’m Appalled! – The pediatricians have spoken and I’m with them!  In findings that were published online in JAMA Pediatrics, the pediatricians stated: “Millions of children stand to lose health and nutrition benefits if…[a]...proposed rule that influences immigrants’ legal status in the U.S. is finalized by the Trump administration.” According to the report, at least 1.3 million children with a least one existing, life-threatening condition such as asthma or cancer risk losing their benefits if the rule goes through in its current form where it designates these kids as “public charges”.  In essence, the new rule states the “public charges” are ineligible for government health benefits like safety-net programs such as Medicaid and the Children’s Health Insurance (CHIP) program.  Researchers note that even families who would not be affected are likely to pull out or not apply out of fear and confusion.  What kind of country are we evolving toward?  So, I would like anyone who disagrees with me to do the following:

  • Go to church or, to synagogue, or to your local community center, or, to your favorite gathering place where friends gather – or,
  • Go to the nearest park where your neighbors commune or, Better yet, go to the office and call a meeting

In each of these situations, I want you to either stand up and explain (no shouting is needed) your position.  Explain it thoroughly so that everyone you know will know your position.  Don’t post it because I don’t want you to hide behind the veil of social media.  Don’t sit quietly by and let those of us who are appalled take the stand and rant and rave. Simply explain – why on earth you would allow such a policy to be made the law of the land.  Make a stand and explain.  Make us listen. You can even send me a message.

Why Children? – We’ve come so very far as a nation but we seem to be backsliding a lot.  When my Great Grandfather emigrated from Bavaria, Germany in 1887 with his wife and two young children (with more on the way once he arrived) because he wanted to avoid conscription for Bismarck’s wars (i.e. he was a draft dodger), there was a paucity of health care services available.  I’m not sure what they did for health care more than a century ago upon arrival in the USA or if we had adopted the policies in place.  However, I’m confident that he had heard about the plaque on the new dedicated “Statue of Liberty” that was positioned in New York’s harbor as a welcome for emigrants from around the world (SEE “Quotes” above). 

So, it was very disturbing to learn that the Administration recently made a proposal that will increase the odds that immigrants will be deemed ‘public charges’ ineligible for government health benefits. The policy will have a hugely adverse impact on an estimated 1.3 million children throughout the nation who will likely become uninsured.  Why?  Because it is highly that many immigrants will simply disenroll their children from safety-net programs like Medicaid and the Children’s Health Insurance Program (CHIP) out of fear – “even those for those whom the rule would not apply.” I know that not everyone will believe my posts on this topics so I encourage you all to review the George W. Bush Presidential Center website on the topic of immigrants.  They provide a fair overview of the problem.  And, taking it out on children is definitely not the answer!!


Consulo Indicium - 6/12/19

Information for your Consideration…

Support For Seeing Another Day – Are you getting a tad older?  Is the memory slipping just a bit too much – forgotten names, missed appointments, details lost, etc.?  Want to be healthier?  Do you need some data to encourage your patients to get off their duff?  A recent study reveals that moderate exercise such as simply walking or pedaling a stationary bicycle can make a huge difference in our long-term mental sharpness.  After only six months of moderate exercise, participants in the study had marked improvements in executive function which includes our ability to focus, to organize our activities, regulate our behavior and achieve our goals – all laudable capabilities that we all want to retain.  For more information on the study, go to WebMD for references and details.

Then, there is the physical side of the house.  A recent JAMA Open Network article reported a study of >300,000 AARP members. It showed that people who engage in “leisure-time physical activity (LTPA)” and who started in midlife (35% lower mortality) had comparable results to those who maintained such activity throughout their life (36% lower mortality) – compared to those who never engaged in physical activity.  That speaks volumes to the fact that it is never too late to start!  It does not have to be excessive exercise either.  For example, walking and moderate exercise will help to turn back the clock a bit for older adults and, it seems to help in increasing mental acuity.  In support of the “moderate exercise” theme, a separate piece in The New York Times reported that “dog owners are about four times more likely than other people to meet today’s physical activity guidelines, according to a large-scale new study of dogs and exercise.”  When Toto the Wonder Dog (my constant companion when I’m home) heard this news, his tail wagged even more than usual.  He’s incredibly excited about the “more walking” part.  He loves to walk and explore.  Now, about that travel side of my life… 

On A Healthy Note – Researchers at the Beth Israel Lahey Health – a Boston-based health care academic and care delivery system – reported a compound in Brussels sprouts, broccoli or other cruciferous vegetables can block an enzyme that drives the occurrence of human cancer. That’s consistent with the message my wife gives (pretty much every day) to “eat green vegetables”.  Another consideration includes eating more fruits and vegetables.  Put the two together and studies are showing a nine-year reduction in brain age, according to James Blumenthal, Ph.D. from Duke University.  In particular, the DASH diet has been called out as a successful strategy on the dietary side.  The diet includes not only fruits and vegetables but also whole grains, reduction in healthy unsaturated fats and a low sodium, sugar, and meat but high dairy diet. The result is that walking a dog every day and eating the right stuff keeps you younger and healthier longer. So, that means potatoes don’t count. What’s a German boy from North Dakota to do?  Argh! 

And, A Long-Term Health Note – It was very disturbing to learn that scientists are reporting the monthly peak amount of carbon dioxide in the Earth's atmosphere in 2019 jumped by a near-record amount to reach 414.8 parts per million (ppm) in May.  The level is the highest level on record and – what is even more disturbing – the highest level in the past 3 million years. And, oh by the way, the accumulation of carbon dioxide in the atmosphere is due to global warming.  So, what is the data that the naysayers are citing?  And, what are the health implications?  They range from the change of ecosystems to biomes to all manner of life on earth.  And, what are we doing about it?  Not as much as what is needed.  “Health” is a broad issue.  It’s not just human health but also “health” of the place where we live.

Kudos To The Derms – I recently received a copy of the American Academy of Dermatology position paper on “artificial intelligence” (AI) and was very pleased to see that they have adopted “augmented intelligence” (AuI) as the model for big data analytics in health care.  I’ve been arguing for some time that we need to be thinking of these tools as sources for “clinically augmented intelligence”.  But, in fact, the Derms are correct.  It goes beyond the “clinical” to include all the non-clinical elements in the lives of the people for whom we provide care.  It’s where they travel, it’s what they eat, it’s the social determinants of health, and more.  So, kudos to my Derm colleagues.

When Trade Wars Might Affect Healthcare – Unbeknownst to most of us, the pharmaceutical companies over the last couple of decades have moved most of their production overseas. In particular, the US makes almost none of its own antibiotics anymore – yes, I said “none”.  That’s an ominous declaration because it creates a health risk but also a national security risk.   And, the problem is not confined to unavailability.  It is also an increasing problem with generics that are made overseas that are not equivalent to the original drugs.  The result can be devastating.  Check it out in an article that appeared in the Boston Globe by Katherine Eban.  The details are chilling.  It’s an issue that deserves the greater attention of the medical community. 

Rural Inequities Continue – A new poll reported in U.S. News & World Report and conducted by the Harvard Chan School of Public Health, the Robert Wood Johnson Foundation and National Public Radio found that 1 in 3 rural Americans struggle to afford health care. If the health care component is combined with housing and food, the figure jumps to 4 of 10 “…rural adults have struggled to afford medical bills, housing or food in recent years.” Furthermore – and, not surprising – about a fourth of rural adults “have skipped health care at some point because they lacked either financial or physical access to care.” The rural inequity – which I’ve been blogging about for over a decade now, continues.  We seem to take a couple of steps forward and then fall backwards…

 But, It’s Not Just Rural Folks: Racial Inequities Continue As Well – In testimony before the US House Ways and Means Committee, Patrice Harris, MD, President of the AMA noted that racial disparities and social determinants of health represent a “maternal mortality crisis” for the nation.  She cited studies which show that contributors to the crisis include:

  • Lack of insurance or inadequate coverage prior to, during, and after pregnancy,
  • Increased closures of maternity units in rural and urban communities,
  • Lack of inter-professional teams trained in best practices,
  • Structural determinants of health, such as public policies, laws and racism that produce inequities in the social determinants of health, such as education, employment, housing and transportation,
  • Stress exacerbated by discrimination that can result in hypertension, heart disease and gestational diabetes during pregnancy; and,
  • Clinicians not listening to black women, resulting in missed warning signs and delayed diagnosis.

Dr. Harris noted in her testimony that, “At the provider and institutional levels, there is a growing body of evidence demonstrating that implicit and explicit biases exist that negatively impact the quality of health care equity and patient safety and drive these inequities.” In citing the issues, she called for a program to address maternal mortality and depression. The AMA also called for policy to encourage local and state health departments to develop material mortality surveillance programs along with support for research on best practices to reduce poor material mortality and morbidity in racial and ethnic minorities. 

Directing Care To Improve Care – In a major move to enhance the accuracy of diagnosis of employees, Walmart recently announced that it has selected 800 imaging centers which will be used by their employees in the future. In an internal study, the company found there was a high rate of error in the readings of CT scans and MRIs at certain centers providing imaging services. In an effort to curb misdiagnosis and improve care, they decided to direct the care to selected centers across the nation.  The trend towards directing care to those organizations that have better outcomes is not confined to imaging centers nor to Walmart. It’s happening across the board.  As transparency increases, the health care industry should anticipate that the trend will only accelerate.  And, I believe, it will be good for health care across the board. 

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