Healthcares hyperinflation is driving the transformation of how care gets reimbur

sed resulting in a massive disruption in healthcare. For example, pharma compani

es will succeed or fail based not on how much drug they sell, but on how well th
eir market offerings improve outcomes.
As the largest spenders on R&D in healthcare, massive changes in the way pharmac
eutical companies operate are going to have a profound effect on health technolo
gy while letting pharma adapt to marketplace changes. It is creating opportunity
for startup businesses that heretofore have been stymied when trying to make in
roads into healthcare.
In the past, I have frequently said that healthcare is where tech startups go to
die. A combination of factors ranging from risk aversion to entrenched legacy v
endors exerting account control to health IT not being viewed as a source of com
petitive advantage for healthcare providers has made it difficult for promising
new companies to make a dent. In this three-part series, I will lay out the most
important dynamics transforming the opportunity for health technology startups.
In Part I, I will highlight how Pharma 3.0 will drive a shift from traditional Lif
e Science to HealthTech investing. In Part II, I will outline how healthcare pro
viders will use HealthTech to differentiate and produce better outcomes. Ill wrap
up the series laying out how many healthcare organizations are on a path to rep
eat mistakes the newspaper industry made beginning in the mid-90s. There are rema
rkable parallels that both spell peril for the incumbent healthcare providers if
they repeat the newspaper companies mistakes and create massive new opportunitie
s such as those I outlined earlier in pieces about The Most Important Organizati
on in Silicon Valley No One Has Heard About and Hotwire for Surgery.
Pharma 3.0 Will Drive Shift from Life Science to HealthTech Investing
E&Y has produced industry reports for the Pharmaceutical industry that provide a
comprehensive look at pharmas history to outline its present condition. E&Y inte
rviewed scores of innovators and senior executives to outline out a vision for w
hat they call Pharma 3.0.
The following is an excerpt from their nearly 100 page report entitled Progressio
ns Building Pharma 3.0 (read the full report here):
The Progressions report identifies several industry trends driving nontradit
ional companies into the sector, including health reform, health IT, comparative
effectiveness, and the rising confidence in consumer power. These factors and o
thers are prompting pharmaceutical companies to broaden their focus from produci
ng new medicines to delivering healthy outcomes a shift that will be driven throug
h creative partnerships and business model innovation.
During my years working in health systems and hospitals, I rarely crossed paths
with the pharma industry even though we were ostensibly serving the same organiz
ation. The only time I saw pharma reps was noticing well-dressed folks in the ca
feteria that were clearly the pharma reps. My time was spent in the IT and Patie
nt Accounting departments where much of Health IT was relegated. Whereas Health
IT was viewed as a cost item to be minimized, pharma and Medical Device products
represented revenue generation and differentiation opportunities for healthcare
providers.
In the flawed fee-for-service model that has driven healthcares hyperinflation, f
inancial rewards incentivized activity (order a test, prescribe a drug, do a pro
cedure, etc.) rather than positive health outcomes. For example, there are 60MM
CT Scans done per year in the U.S. despite the fact that there isnt a radiologist
in the world who believes anywhere near that volume is required. Nonetheless, w
e incur that high cost and excess radiation in the fee-for-service that is the u

nderpinning of the legacy reimbursement model. Fortunately, theres a sea change t

o change reimbursement to reward positive health outcomes over mere activity. In
addition, electronic medical records are helping reduce duplicate tests.
Based on my past (non)experience with pharma, it has been remarkable the number
of pharma companies that are now proactively reaching out to software companies
who can help them enter with new services focused on outcomes that have little o
r nothing to do with what I would traditionally associate with pharma. Their str
ategies are varied and dynamic but they arent sitting on their hands. For example
, one shared how they recently entered into a 10-year agreement to be responsibl
e for the end-to-end health of a population of individuals with a particular dis
ease. As I will touch on in the 3rd part of the series, this will have a profoun
d effect on the competitive landscape for traditional health providers. Not many
healthcare providers are prepared for this type of competitor.
Like it or not, healthcare is like most arenas revenue (aka reimbursement) drive
s behavior. pharma has been extremely adept at maximizing revenue in the fee-for
-service environment. As one pharma exec said to me, We have spent billions on de
veloping and marketing our product but $0 on ensuring it is properly used.
As pharma companies strive to be a health outcomes industry, the focus on outcomes
will radically alter their behavior. They recognize the competitive threat. As
the E&Y report stated, Pharma companies have expanded the number of pharma 3.0 in
itiatives by 78% since 2010. Yet non-traditional players have invested even more
in Pharma 3.0. The sense of urgency with the pharma organizations Ive met with is
remarkable.
To date, IT investment in healthcare has been mostly limited to the administrati
ve/reimbursement facets of healthcare (e.g., claims processing). The primary exc
eption is the software that has been embedded into medical devices with little o
r no ability for the clinician to interact with the device. Theres a contrast wit
h where money is actually spent in healthcare i.e., healthcare delivery versus t
herapeutics as outlined in a piece by angel investor and life science veteran Do
n Ross in his piece Investor: Health tech is the next big opportunity.
How big is the healthtech opportunity? Data from the Centers for Medicare &
Medicaid Services (CMS) show that the U.S. spent $2.5 trillion on health care in
2009. Of this, 84 percent was spent on healthcare delivery, which includes cost
s associated with clinicians and insurance companies. In contrast, only 16 perce
nt was spent on therapeutics, including medical devices and drugs. Although vent
ure investors traditionally have put their money into therapeutics rather than d
elivery, the balance is shifting.
As Pharma companies recast themselves as health outcomes companies in response to
anticipated reimbursement shifts, one can expect that venture capitalists and Ph
arma/Biotech will shift their investment focus from almost exclusively Life Scie
nces to integrated approach with Health Tech and an outcomes. Areas such as deci
sion support, care coordination, patient engagement, etc. become paramount if on
e is going to address outcomes versus simply encouraging more activities that th
e legacy reimbursement model have incentivized.
Increasingly the very survival of the pharmaceutical industry is predicated on c
reative alliances with nontraditional players such as IT companies. No longer wi
ll healthcare be where tech companies go to die for the startups with transforma
tive products that may have languished in the past. The very survival of one of
the most profitable industries in the world depends on it.
In the New Yorker, Dr. Atul Gawande outlined how, at the turn of the 20th centur
y, more than forty per cent of household income went to paying for food and food
production consumed nearly half the workforce. Starting in Texas, a wide array

of new methods of food production were tested. Long story short, food now accoun
ts for 8% of household budgets and 2% of the workforce. As a wide array of small
innovations ultimately led to the transformation of farming, so too is a rapidl
y building wave of innovative new care and payment models leading to similar bre
akthroughs in healthcare. I call this Nimble Medicine.
Traditionally, attempting a new care or payment model meant long planning and de
velopment cycles. The cost and complexity of testing new models prevented many f
rom being tried. Even today, the leading HealthIT vendor is known to charge $100
million and up for its software. Amazingly, they require three months of traini
ng before they even let people use the software. This is a vestige of the do mor
e, bill more model of reimbursement particularly given that healthcare is a suppl
y-driven market (e.g., MDs who own a stake in imaging equipment order scans at t
hree times the rate of MDs who dont). Spending nine figures doesnt sound so bad wh
en you have capital projects planned in excess of $1 Billion. Perhaps we should
refer to the legacy model as the build more, do more, bill more model. Any health
analyst will tell you that the cure for healthcares hyperinflation is NOT buildin
g more healthcare facilities. Its as if a fire department argued that the way to
solve a wave of structural fires was to buy more fire fighting equipment. Yes, t
hat might help, however theres a much more cost-effective approach such as having
buildings inspected for fire prevention capabilities.
In their book, The Innovators Prescription, Clayton Christensen and Dr. Jason Hwa
ng point out how applying technology into old business models has only raised co
sts.
Innovator s Prescription - New tech into old models
In contrast, disruptive innovators such as WhiteGlove Health and Qliance rethoug
ht the care delivery and payment models from the ground up. Their results have b
een impressive. For example, Qliance has Net Promoter Scores higher than Google
or Apple, while reducing the direct costs of healthcare (i.e., their service cou
pled with a high deductible wrap-around policy) 20-40%. More impressively, they
have reduced the most expensive downstream costs (surgical, specialist and emerg
ency visits) 40-80%. Likewise, WhiteGlove Health already has 500,000 members and
has more 5-star reviews on CitySearch than any other organization in the countr
y. In WhiteGloves S-1 filing, they highlight the importance of proprietary softwa
re they have developed to give them a cost and consumer experience advantage.
The next wave of disruptive innovators are taking advantage of second-mover adva
ntage as the wave of healthtech startups provide them off-the-shelf software tha
t is an order of magnitude less investment than the first wave of innovators. Its
a couple orders of magnitude less expensive than legacy HealthIT. More importan
tly for the innovators is the speed that they can not only stand up the new tech
nology but also easily iterate based on real world experience. Rather than month
s or years, its hours or days. This is a key component of Nimble Medicine.
Consider the following scenarios: [Disclosure, my company, provides some of the
technology components underlying these models which is why I have visibility int
o their strategy.]
arriveMD has taken the lean practice model to an extreme by closing a bricks
and mortar clinic and replacing it with a clinic on wheels. Their founder, Dr.
Craig Koniver, visits patients at their home or workplace. It only took a couple
weeks to put the technology into practice while running his practice, closing h
is stationary clinic, and outfitting his clinic on wheels.
MedLion (aka The Most Important Organization in Silicon Valley No One Has He
ard About) has created a fast-growing Direct Primary Care model with minimal cap
ital investment. So far in 2012, they are opening clinics at the rate of one per
week. Theyve done this with a mix of a creative business model and enabling tech

nology that is well under 5% of the cost of what their competition has spent.
A company that is providing emergency physicians to hospitals has found that
many individuals are using the emergency department as their primary care facil
ity. This is because these individuals arent able to access a regular primary car
e provider. Unfortunately, many of them are unable to pay the high fees common i
n an ER. Rather than simply sending them to collections, they are setting up an
affordable alternative outside of the ER for non-emergent care. The technology s
etup takes less than a week to enable this new line of business. Theyve taken a l
esson from wireless carriers who realize that more affordable packages can addre
ss a market need yet still be profitable.
Sites such as 2nd.md have created virtual second opinion or e-consult market
places. Rather than flying from Alaska to San Francisco to get a critical second
opinion or consultation, the individual and their family can save time and mone
y through a virtual encounter. In response, some physicians are realizing that t
hey can set something up directly without having to pay a 3rd party intermediary
. Their technology need is essentially a light-weight (and low cost) system that
allows intake of patient information (medical history, lab results, etc.), a vi
rtual visit (e.g., using software from a company like Revation) and then followup documentation. The entire technology implementation doesnt take more than a co
uple of days. This has been applied in disciplines ranging from oncology to orth
opedics to pediatrics and more.
Even established organizations such as Catholic Health Partners are becoming
more nimble. For example, a when drug gets taken off the market for safety issu
es, they can immediately identify the subgroup of patients currently on the drug
for outreach, while simultaneously removing the drug from order preference list
s and order sets, substituting with appropriate alternative medications. At one
time this took days and now it takes just hours.
For those of us in the technology industry, theres striking parallels with what h
as happened in technology where centralization was followed by decentralization.
For providers, lessons can be drawn regarding how some organizations were able
to make the transition from one generation to the next while many others faded f
rom the landscape. The graphic below depicts the transition from the slide rule
to the mainframe and then back out to mobile devices.
Innovator s Prescription - Decentralization followed centralization
In an earlier piece (Healthcare Field of Dreams In Idaho: Health System Opens In
novation Center), I highlighted an innovation group that is building the next hos
pital a hospital without walls. Unlike a massive capital project necessary to bui
ld a traditional hospital, I expect that new wings of the virtual hospital will ge
t built via a series of smaller projects. They have hired entrepreneurial people
to bring the agility necessary in this new approach. This is a great example of
Nimble Medicine.
As healthcare goes through massive changes, health system CEOs would be well adv
ised to study what newspaper industry leaders did (or perhaps more appropriately
, didnt do) when faced with a similar situation. In the late 90s, the following dy
namics were present:
Owning printing presses was a de facto barrier to entry allowing newspapers
unfettered dominance.
Newspaper companies bought up smaller newspaper chains and took on huge debt
.
Newspapers were comfortable as oligopoly or monopoly enterprises allowing fo
r slow, plodding decisions. Their IT infrastructure mirrored this with expensive
and rigid technology architectures.
Newspaper leaders knew full well that dramatic change was coming and even ma
de some nominal moves, but didnt fundamentally rethink their model.
Depending on ones perspective, it was the best of times or the worst of times

to be a leader of local media enterprise.

Before long, owning massive capital assets and crushing debt became unsustainabl
e. The capital barrier to entry turned into a boat anchor while nimble entrants
created a death-by-a-thousand-paper-cuts dynamic. Competitively, newspaper compa
nies mistakenly worried about other media companies or even Microsoft, but their
undoing was driven by a combination of craigslist, monster.com, cars.com, eBay,
and countless other marketing substitutes for their advertisers and there were
easier ways to get news than newspapers. Generally, the newspapers digital groups
were either unbearably shackled or marginalized so that the frustrated digital
leaders left to join nimble new competitors. The enabling technology to reinvent
local media didnt come from legacy IT vendors whod previously sold to newspaper c
ompanies, but from no name technologies such as WordPress, Drupal and the like.
The parallels with health systems today are striking. Consider the present dynam
ics:
Until recently, complex medical procedures had to take place in an acute car
e hospital setting. Now they are being done more and more in specialty facilitie
s that can do a high volume of particular procedures at a much lower cost. [See
article graphic.]
Health systems have been aggressively buying up other healthcare providers a
nd frequently taking on debt in the process. At the same time, health systems of
ten have capital project plans that equal their annual revenues even though no e
xpert believes the answer to healthcares hyperinflation is building more building
s. Consider the duplicative $430 million being spent in San Diego to build two i
dentical facilities just a few miles apart as Exhibit A of the problem. Looking
at the history of other countries that shifted from a sick care to a health care sys
tem, more than half of the hospitals closed. They simply werent needed or werent a
ppropriate.
Just as newspapers were implementing multimillion dollar IT systems while ni
mble competitors were using low and no cost software to disrupt the local media
landscape, health systems are similarly implementing complex systems to automate
the complexity necessary in a multi-faceted system. Meanwhile, nimble competito
rs are implementing new models at a fraction of the cost and time. For example,
its well-known that a healthy primary care system is the key to increasing the he
alth of a population. Imagine if a fraction of the 100s of millions being spent b
y mission-driven health systems on automating complexity was redirected towards
the reinvigoration of primary care.
The pace and scale of innovation at most health systems isnt up to the enormi
ty of the task. The vast majority of health system innovation teams are constrai
ned by how they have to fit innovation into an existing infrastructure. That app
roach rarely leads to breakthroughs, as its true intent is to make tweaks to a c
urrent system rather than a rethink from the ground up.
Compared to newspapers, the scale and importance of the challenge is far greater
for health systems so they must aggressively take action or risk their future v
iability.
Prescription for Healthcare From a Newspaper Industry Executive
In the midst of the newspaper industry carnage, there is one particular bright s
pot from an individual who has gone against the conventional wisdom that newspap
ers are doomed to fail. His name is John Paton and hes reinventing local media. Il
l highlight some of what hes done to turn a bankrupt (financially and creatively)
enterprise into a profitable, dynamic and rapidly growing enterprise attracting
the all-stars of the industry.
There has been an expression in traditional media that analog dollars are turnin
g into digital dimes. Rather than lament that, heres John Patons response:

And it is true that print dollars are becoming digital dimes to which our res
ponse at Digital First Media has been then start stacking the dimes. All of that
requires a big culture change. A change that requires an adoption of the Fail F
ast mentality and the willingness to let the outside in and partner. Partnering
is vital to any media companys growth whether it is an established media company
or start-up. We are going to marry our considerable scale with start-up innovati
on to build success.
Its worth noting that those digital dimes are often more profitable than the analog
dollars of the past because much less overhead is required.
The following is John Patons 3-point prescription for reinvention that led to a 5
x revenue increase and halving of capital expenses. This resulted in his organiz
ation going from bankruptcy to $41 million in profit in two years.
Speed to market: One new product launched per week [See Related Article: The
Rise of Nimble Medicine]
Scaling opportunity: Sourced centrally, implemented locally. Ideas can come
from all over. Identify the best ideas/people from all over
Leverage partners Feed the firehose of ideas from outside.
Unfortunately, before John Paton was able to affect this level of change, scores
of newspaper employees lost their jobs while traditional newspaper executives d
awdled. It is the rare leader that can create the sense of urgency necessary to
affect this scale of change before the enterprise is a hairs breath from extincti
on. As the old oil filter ad says, you can pay now or pay later of course, the cos
t is much greater if change is put off. The only question is whether health syst
em leaders will have the courage to make the change before the inevitable crisis
hits with full force.
Applying Reinvention Lessons into Healthcare
The following are some ideas and examples of how this approach can be applied to
tackle the enormous challenge facing health system leaders. [Disclosure: The co
mpany where Im CEO, Avado, provides enabling technology for some of the organizat
ions mentioned which is why I have a view into their projects.]
Fresh, Outside Perspective is Imperative
As John Paton brought in outside advisors such as Jeff Jarvis and Jay Rosen, hea
lth systems would be well-advised to do the same. They can go a step further and
partner with innovators driving new models. They can be project managers or par
tners. Examples follow:
Mike Berkowitz has been a pioneer in telehealth including running his own bu
siness, Telehealthcare.com. Large and small healthcare providers are hiring him
to develop and implement their telehealth programs.
Dr. Samir Qamar founded MedLion as a mass-market version of primary care. Me
dLion works with healthcare providers to transition from a do more, bill more mode
l to a patient-centric, accountable model that is affordable yet produces impres
sive outcomes and a dramatically better bottom-line than a standard practice.
Ken Erickson is the CEO of Employer Direct Healthcare. Hes working with provi
ders to deploy bundled case rates. That is, rather than getting scores of bills
from various providers and the accompanying morass, they enable a single, transp
arent cost for procedures. This also enables healthcare providers to tap new dis
tribution models for their services.
Communication is the Most Important Medical Instrument of the Future
John Paton has demonstrated an unprecedented level of communication in redefinin
g the culture of his organization. This approach has set the tone for his organi
zation. Imagine if that tone was set by healthcare leaders for their organizatio
ns. I have heard it said that between 80% and 93% of what a doctor says to a pat

ient is forgotten. In a world where provider reimbursement is based on outcome,

rather than activity, this is a recipe for reimbursement disaster. Communication
s is the antidote to that avoidable disaster.
Like local media executives in the late 90s, healthcare leaders can view the pres
ent situation as either the best or worst time to be in their role. The health s
ystem leaders who believe its the best of times would do well to ask WWJD What Wo
uld John Do? John Paton demonstrates how a strong leader can reinvigorate and re
invent a lumbering giant into a nimble organization.
The future of medicine in the U.S. is clear. The days of the do more, bill more mo
del of reimbursement are numbered as they have produced one of the most ineffici
ent healthcare systems in the world. While there are many unknowns regarding the
future model, one thing is crystal clear highly effective communication will se
parate the winners from the losers.
The quantum improvement in the depth and breadth of communication seen in the co
nsumer Internet and in the consumerization of the enterprise (iPhones, Yammer, e
tc.) has yet to fully impact healthcare. With healthcare representing nearly 20%
of the economy, the stakes are so high that it is inevitable that communication
s will be a key driver separating the winners from the losers as the tectonic sh
ifts in the landscape shake out. This will usher in an array of new technology e
ntrants similar to consumer and enterprise arenas disrupting ineffective and exp
ensive communication methods of the past. The stars are aligning to make this ha
ppen.
I dont think you can overstate the importance of communication in clinical car
e. Even with devices, robotics, genomics and personalized care, it all rests, an
d depends on, clear communication.
- Dr. Wendy Sue Swanson, MD, MBE, FAAP
The Individual (aka the Patient) is the Most Important Member of the Care Team
Its long been said that the most important member of the care team is the individ
ual (or their family member).
Quite simply, in a world where one is compensated on value and outcome, its nearl
y impossible to have success without recognizing the importance of the patient.
Consider the diagram in this article. It is clear and appropriate that the system
i.e., the collection of healthcare providers is in control of decisions that dri
ve outcomes in high acuity cases such as when one is unconscious in the hospital
. In contrast, in low acuity situations such as managing a chronic condition, th
e individual and/or their family are clearly in control of actions that will dri
ve the ultimate outcome. Whether adhering to an exercise, diet or prescription p
lan, the patient/family plays the central role in determining the outcome.
The importance of this cant be overemphasized given that 75% of healthcare spend
results from chronic conditions. Decisions made while a condition is in low acui
ty can rapidly lead to high acuity flare ups that drive large medical bills. As
Dr. Swanson states, the steering wheel should be attended by the patient. After al
l, 99+% of an individuals life is spent away from healthcare providers and no one
else besides them is in the drivers seat.
It is a good thing that there has been great focus put on improving communicatio
n between healthcare professionals through standards and incentives related to t
he new models being driven by private and federal insurance programs. The Patien
t Centered Medical Home and the Accountable Care Organizations are the two most
high profile of these. However, the communication focus has been about the patie
nt not with the patient. Having worked in and seen literally hundreds of healthI

T systems, the fact is the fundamental purpose of the patient as envisioned by t

hese systems is that the patient is merely a vessel to attach billing codes to not
a core part of the care team. This legacy approach will prove to be a fatal fla
w in the new reimbursement models. Throwing bodies (e.g., care coordinators) at
the problem can help, but will be at a disadvantage versus approaches that combi
ne the best of human and technology driven communication methods.
There are efforts being made to tweak legacy software to address these requireme
nts. Unfortunately, they are as likely to meet the new imperatives as AOL, Micro
soft and Yahoo have been at becoming market leaders in social networking. The re
ality is Facebook built social networking into their core design from the ground
up and bolting a dramatically different approach onto an old system rarely work
s whether it is social networking or patient-provider communications.
Good News for Forward Looking Healthcare Organizations
I get knowing nods from my physician friends when I exclaim that I hear more fre
quently from my dogs vet than my doctor or my kids doctor. We realize why the hist
orical reimbursement models have contributed to this dynamic. Considering that p
eople retain less than 20% of what a doctor tells them, this lack of communicati
on and patient retention is a brutal combination driving sub-optimal outcomes. T
he good news is there is a tremendous competitive advantage that a healthcare pr
ovider can realize if they choose to focus on improved communications for the 99
+% of the time when a patient isnt staring them in the face.
Not only can this opportunity provide a competitive advantage, it is imperative
in the new models. Simplistic patient portals, however, wont get the job done. Ive
yet to meet the physician or individual who thinks that just making lab results
available to patients or allowing for secure messaging is changing the care par
adigm.
Whether out of desire or necessity, consumers are ready for improved communicati
on so they can save on their healthcare costs. Its expected that roughly one-thir
d of the workforce will be permanent freelancers, contractors, consultants, etc.
with zero expectation of employer-provided insurance. Even those with employerprovided insurance, are picking up an ever-growing percentage of the premium. Th
e current average is 30% of the costs are picked up by an employee (up from 10%
in the recent past). This coincides with the rise of consumer empowerment that h
as happened in virtually every other sector. Dr. Patricia Salber wrote about DIY
Healthcare to explain how far things have already come and to assert her opini
on that this is just the tip of the iceberg.
Thought-leading Physicians Are Ready
Fortunately the economics and simplicity of the consumer Internet and SaaS have
finally come to healthcare. Once upon a time, sophisticated new software was fir
st deployed in large enterprises. Today, greatly improved communication technolo
gies begin with small organizations. Consider a physician like Dr. Craig Koniver
who uses various free (e.g., Evernote) and low-cost off-the-shelf software to m
anage his communications without employing any administrative staff. Dr. Kent Bo
ttles wrote about reverse innovation in healthcare talking about offshore innova
tion making its way to the U.S., but its not just offshore healthcare that can be
a source of innovation. Dr. Howard Luks, an orthopedic surgeon, is another exam
ple of an innovative individual physician that is more sophisticated than most l
arge healthcare providers by simply using free and low cost software to communic
ate with current and prospective patients.
As was highlighted in The Rise of Nimble Medicine, there is an explosion of disr
uptive innovators as well as innovation groups inside established healthcare org
anizations. In many respects, healthcare has been measured on production with an

almost factory floor-like model of producing as many widgets (i.e., procedures, a

ppointments, tests, prescriptions, etc.) as possible. However with a shift to a
service model where success will be driven by factors such as satisfaction and h
ealth outcomes, smart healthcare providers recognize that systems optimized for
production are ill-equipped to optimize for outcome. With that in mind, recognit
ion grows that communication becomes the most important medical instrument of th
e future.
Doctors, nurses and other health care providers in America work incredibly hard
to deliver the best care possible to their patients. Unfortunately, an alarming n
umber of patients are harmed by medical mistakes in the health care system and f
ar too many die prematurely as a result.
The Obama Administration has launched the Partnership for Patients: Better Care,
Lower Costs, a new public-private partnership that will help improve the qualit
y, safety, and affordability of health care for all Americans. The Partnership fo
r Patients brings together leaders of major hospitals, employers, physicians, nu
rses, and patient advocates along with state and federal governments in a shared
effort to make hospital care safer, more reliable, and less costly.
The two goals of this new partnership are to:
Keep patients from getting injured or sicker.By the end of 2013, preventable hosp
ital-acquired conditions would decrease by 40% compared to 2010. Achieving this g
oal would mean approximately 1.8 million fewer injuries to patients with more th
an 60,000 lives saved over three years.
Help patients heal without complication.By the end of 2013, preventable complicat
ions during a transition from one care setting to another would be decreased so
that all hospital readmissions would be reduced by 20% compared to 2010. Achievin
g this goal would mean more than 1.6 million patients would recover from illness
without suffering a preventable complication requiring re-hospitalization withi
n 30 days of discharge.
Achieving these goals will save lives and prevent injuries to millions of Americ
ans, and has the potential to save up to $35 billion across the health care syst
em, including up to $10 billion in Medicare savings, over the next three years. O
ver the next ten years, it could reduce costs to Medicare by about $50 billion a
nd result in billions more in Medicaid savings. This will help put our nation on
the path toward a more sustainable health care system.
Building on Local and National Work
In 1999, the landmark Institute of Medicine study, To Err is Human, estimated that
as many as 98,000 Americans die every year from preventable medical errors. Des
pite many successful efforts, this statistic has not improved much in the follow
ing decade. And many more patients get injured or sicker from preventable adverse
events after being admitted to a hospital.
After more than a decade of work to understand and address these problems, promi
sing examples of better practices exist, but patients too often are still injure
d in the course of receiving care. There is much more work to be done to prevent
unnecessary harm to patients.
At any given time,about one in every 20 patients has an infection related to thei
r hospital care.
On average, one in seven Medicare beneficiaries is harmed in the course of their
care, costing the government an estimated $4.4 billion every year.
Nearly one in five Medicare patients discharged from the hospital is readmitted
within 30 days thats approximately 2.6 million seniors at a cost of over $26 bill
ion every year.
Hospital Engagement Networks
Hospitals across the country will have new resources and support to make health
care safer and less costly by targeting and reducing the millions of preventable
injuries and complications from healthcare acquired conditions. $218 million wa
s awarded to 26 state, regional, national, or hospital system organizations to b
e Hospital Engagement Networks. As Hospital Engagement Networks, these organizat
ions will help identify solutions already working to reduce health care acquired
conditions, and work to spread them to other hospitals and health care provider
s.

Hospital Engagement Networks will work to develop learning collaboratives for ho

spitals and provide a wide array of initiatives and activities to improve patien
t safety. They will be required to conduct intensive training programs to teach
and support hospitals in making patient care safer, provide technical assistance
to hospitals so that hospitals can achieve quality measurement goals, and estab
lish and implement a system to track and monitor hospital progress in meeting qu
ality improvement goals.
In addition to the Hospital Engagement Networks, $10 million has been awarded to
three organizations to create a curriculum in patient safety for the Hospital E
ngagement Networks, engage Medicare, Medicaid and Childrens Health Insurance Prog
ram beneficiaries, their families and caregivers and others in specific activiti
es supporting the aims of the Partnership for Patients, and evaluate the impact
and effectiveness of the Partnership for Patients.
Medicare Drug Discounts
The Affordable Care Act includes benefits to make your Medicare prescription dru
g coverage (Part D) more affordable. It does this by gradually closing the gap i
n drug coverage known as the "Donut Hole."
What This Means for You
Starting January 1, 2011, if you reach the coverage gap in your Medicare Part D
coverage, you will automatically get a 50% discount on covered brand-name drugs.
You receive the discount when you buy them at a pharmacy or order them through
the mail, until you reach the catastrophic coverage phase.
You will also get a 7% discount on generic drugs while in the Donut Hole.
You can expect additional savings on your covered brand-name and generic drugs w
hile in the coverage gap until the gap is closed in 2020. See the schedule below
for information on what youll pay for drugs while you are in the coverage gap:
2012: youll pay 50% for brand-name drugs and 86% for generic drugs
2013: 47.5% for brand-names and 79% for generics
2014: 47.5% for brand-names and 72% for generics
2015: 45% for brand-names and 65% for generics
2016: 45% for brand-names and 58% for generics
2017: 40% for brand-names and 51% for generics
2018: 35% for brand-names and 44% for generics
2019: 30% for brand-names and 37% for generics
2020: 25% for brand-names and 25% for generics
Some Important Details
You can get the new savings starting in 2011 if all of the following are true:
Youre currently enrolled in a Medicare Prescription Drug Plan (including employer
group health and waiver plans) or a Medicare Advantage Plan that includes presc
ription drug coverage.
You dont get Extra Help. This is a Medicare program to help people with limited r
esources pay drug costs.
You have already reached the coverage gap.
You dont need to do anything to get the discount. If you have reached the coverag
e gap and you dont get a discount when you pay for your brand-name prescription,
you should review your next Explanation of Benefits (EOB) notice. You can work w
ith your drug plan to make sure that your drug records are correct.
Although you will pay only 50% of the price for the brand-name drug, the entire
drug cost will count toward the amount you need to qualify for catastrophic cove
rage.
You have options when it comes to finding health insurance.
It is free for consumers to request health insurance quotes from licensed health
insurance agents and brokers. A good health insurance agent will advise you on
your private-market health insurance options from different insurance carriers a
nd different plan types. They should understand your health, family and financia
l profile, and guide you towards a health plan that best serves your needs. Thei
r job is to assist you in making the best health insurance decision for you and
your family, and you should work with only the agents who have your interests at

heart. You may speak to several agents to determine who can serve you the best.
You have options when it comes to finding health insurance.
It is free for consumers to request health insurance quotes from licensed health
insurance agents and brokers. A good health insurance agent will advise you on
your private-market health insurance options from different insurance carriers a
nd different plan types. They should understand your health, family and financia
l profile, and guide you towards a health plan that best serves your needs. Thei
r job is to assist you in making the best health insurance decision for you and
your family, and you should work with only the agents who have your interests at
heart. You may speak to several agents to determine who can serve you the best.
Group health insurance is purchased by employers to provide health care benefits
for themselves and their employees. The insurance contract is between the emplo
yer and the insurance company and the employer is responsible for paying the mon
thly premium to the insurance company. An employer may require a partial contrib
ution of premium payment from the employees, which will be deducted from the pay
roll of each employee that chooses to enroll in the group health insurance plan.
Group health care insurance is usually the best option available to persons tha
t have the fortune of being employed by a company that offers this benefit to th
eir employees.
Who Should Consider Group Health Care Insurance
From the perspective of a business owner, offering group health insurance to you
r employees is a great way to maintain company loyalty and keep your workforce h
ealthy. In some states employers with a minimum number of employees are required
by law to offer employee health benefits. More and more states are considering
similar laws in order to reduce the number of uninsured residents in their state
. Small employers with just a few employees can also qualify for group health in
surance.
For persons that have a group health insurance policy available to them through
their place of employment, choosing to enroll in this coverage typically require
s little thought. This is especially true if you and your family members do not
currently have health insurance. For the employee, the monthly premium will be l
ess than you would pay through other types of health insurance, since your emplo
yer will be responsible for paying the majority of this premium. Depending on th
e percentage of the premium your employer pays when adding your dependents to yo
ur group coverage, this option may also be best for your family. You will need t
o consider the costs and benefits of this option and compare it to the options a
vailable under an individual/family health insurance plan.
How to Find Group Health Insurance
In each state there are several different insurance companies that offer group h
ealth plans. You can explore these options by requesting quotes online from many
websites that specialize in health insurance. All of the insurance companies ha
ve websites that may provide details about the many different group health plans
that they have available. You will also find agent or broker websites where you
can complete a brief questionnaire that is necessary for providing your company
with an accurate quote on group health care insurance. There are also referral
services that can put you in contact with one or more insurance agents in your a
rea that offer group health insurance quotes and expert advice. For those that do n
ot have a good understanding of health insurance, it is recommended that you wor
k with a professional that can explain the many different policy terms and help
you compare your options from several different insurance companies. There are m
any factors to consider in choosing the right group health plan that is an affor
dable expense to your business while providing your employees with adequate heal
th care benefits.
To request quotes for group health care, you will need to provide the birthdates
of each of your employees, as well as information for each of their family memb
ers that might also wish to be included on the policy. You will also need to kno
w what percentage of the premium will be paid by the company for employees and t
heir dependents. It is best to compile this information and make sure it is accu
rate in advance of requesting a group health insurance quote.
The Cost of Group Health Care Insurance

Group health insurance rates are determined by many factors, including plan type
, age and gender of employees, geographical location and health status. Plan typ
es range from comprehensive HMO plans to high-deductible catastrophic health pla
ns. The more comprehensive the coverage, the greater the risk that the insurance
company will have to pay claims. Since rates are based on the risk to the insur
ance carrier, these plans with more complete coverage will be the most expensive
. When shopping for a group health plan, you will find a vast array of plan and pr
emium options. Naturally, you will want to find the best possible coverage for t
he best possible price. The best thing to do is set a budget for your monthly he
alth insurance costs and look for the best coverage for that price.
Applying for Group Health Insurance
Once you have found the best health plan for your business, you will need to sub
mit an employer application for coverage. Since group health insurance is guaran
teed to all eligible businesses, there will only be a few health questions. Most
of the questions on the application are used to determine if the company meets
the guidelines for enrolling in a group health plan. Among other things, the ins
urance company will need to know how many employees are to be included on the po
licy and how long the company has been in business. Payroll records will need to
be submitted along with the application in order to prove the eligibility of al
l persons to be added to the group plan. Only persons that appear on the payroll
records, and immediate family members, can be included on the original applicat
ion. An experienced health insurance agent can guide you in determining the elig
ibility and recorded documentation that will need to be submitted to the insuran
ce company.
Depending on the overall healthiness of those that are to be included on your gr
oup health plan, the insurance company may adjust the rates to offset the costs
that will bear when accepting a high-risk group. The maximum percentage increase
is set by state regulations and will vary by state.
If you are a fulltime student between the ages of 17 and 29, student health insu
rance may be right for you. In fact it may even be required of you. There are se
veral options for student health insurance, you may look for private student hea
lth insurance on the open market, or you may opt for the student health insuranc
e plan offered by the institution you are attending. Expect to pay more for priva
te student health insurance of course, but generally these student policies carr
y greater benefits than those provided by the university.
Whichever you choose, even if your particular school does not require it, studen
t health insurance is a great way to ensure academic success. Student health insu
rance typically covers:
Regular medical exams
Payments for catastrophic care
And emergency procedures
How do I get a student health insurance quote?
Nowadays it is really simple to get free quotes online. You merely have to provi
de some simple personal information in a completely secure fashion, to receive a
free student health insurance quote.
You may be asked to provide:
Weight/Height
Tobacco usage history
Your Address
Phone number
Gender
Email address
Date of birth
Today most colleges and universities, require health insurance. The good newsis t
hat as such most schools are affiliated with top heath insurance providers, and
because of the relatively low-risk involved in this group - rates for student he
alth insurance are generally low. Private student health insurance is another opti
on. Private student heath insurance is usually purchased by:
Those who need a more specific kind of coverage
Individuals with pre-existing medical conditions

Students who are interested in spending a term studying abroad

Or individuals who think that the coverage offered by the college or university
does not fulfill their needs.
Private health insurance tends to be a little bit pricier but offers additional
benefits that most university health plans do not - for example, dental, vision,
and prescription coverage.
Comparing carriers
The easiest way to compare different carriers is online. Using online comparison
tools you can quickly see which company offers the best benefits for you needs
and budget. When you know your options, the better the chances that you will pur
chase the health plan with the most benefits at the best rates.
When getting any student health insurance quote, make sure you understand your po
licy thoroughly before purchasing. If you are unsure about anything that is or i
s not covered, speak to an agent or your schools benefits advisor.
Eligibility
Most insurance companies do not offer student health insurance to individuals wi
th pre-existing medical conditions. Exclusions may be made for certain preexisti
ng conditions.
Student health plans are generally available to individuals between the ages of
17 to 29. Depending on the insurance company and state, some other exclusions an
d requirements must be met in order to obtain student health coverage.
If you are interested in student health coverage do not hesitate to look for mor
e information and obtain a free student health insurance quote online. Remember
it is always important to know your options to make an informed decision about h
ealth insurance.
Medicare supplement insurance, also known as Medigap insurance, is a private hea
lth insurance option designed to provide additional benefits above those offered
through Medicare Part A and Part B. When searching for Medicare supplement insu
rance quotes you will only have twelve possible options to consider. This will s
implify the process as other types of health insurance have well over 100 differ
ent options. The available Medigap options have been structured by the federal g
overnment to provide additional health care coverage where it is most needed. By
limiting the options, the confusion of choosing the right supplemental plan is
greatly reduced.
If you are eligible for Medicare Part A, you are able to purchase a Medigap plan
if you do so during the open enrollment period, which is the six month period i
mmediately following your enrollment in Medicare Part A. You must also be enroll
ed in Medicare Part B to qualify for Medicare supplemental insurance. You are no
t obligated to purchase a supplemental plan during this open enrollment period,
but failure to do so could cause problems later on if you change your mind or ex
perience medical problems that would justify this additional coverage.
Make an informed decision about Medigap insurance
It is essential for you to be well informed when shopping for Medigap insurance
coverage. Knowing your options and understanding the included benefits decreases
the likelihood of later discovering that you are underinsured. A very helpful t
ool is to compare the different companies that offer this type of coverage. Diff
erences between insurance companies can include:
Participating provider network
Premium charges
Financial strength
Customer Service history
Keep in mind that with this type of coverage it is really simple to compare rate
s because of the standardized polices. Even though policies have the same benefi
ts (for example Plan F from Humana will have the same benefits as Plan F from Bl
ue Cross) premium quotes may vary.
Which Medicare Supplemental Plan is best for you?
Before making any decision you should try to best determine and anticipate your
likely future health care needs. Because different Medigap insurance plans provi
de different benefits, make sure you understand each one of these benefits and h
ow they might relate to your health status. For example, if you are interested i

n benefits for preventive health care you should lean towards one of the policie
s that offer this benefit.
Once you decide which Medicare Supplemental Plan will best fit your needs, the n
ext step is to find out which insurance companies offer this Plan so that you ca
n compare their rates. Working with a health insurance broker that is licensed t
o sell Medigap insurance plans from multiple insurance companies is a great plac
e to start. You will not pay an additional fee for the convenience of working wi
th a broker because the premiums are determined by the insurance company and cant
be altered.
How do I get Medicare Supplement insurance quotes?
Getting a Medicare Supplement insurance quote online is now a simple and secure
process. Keep in mind that sometimes personal information is required in order t
o provide you with your list of plan options. The information listed below shoul
d be sufficient enough for any broker to provide you with a quote:
Your name
Your age
State of Residence
Zip Code
Medicare Part A and Part B enrollment
Phone number
Medicare Supplement insurance quotes tips
Start your researching a quote requests at least 3 months in advance of becoming
Medicare eligible. Rates are subject to change and could adjust slightly by the
time that you are qualified to enroll in a Medigap plan. So, have a first choic
e and a second choice plan for back up.
Visit the Medicare.gov website to make sure that you are looking at all of the o
ptions available in your state. They have a very useful Plan Locator tool that wil
l provide you with a comprehensive list.
Work with a licensed broker in your state that represents the majority of the in
surance companies on the list you have obtained from Medicare.gov. If you cant fi
nd an agent for all of your Plan options, you may need to contact the insurance
carrier directly.
Purchasing process for a Medicare Supplemental Plan
Once you have chosen the right Medicare Supplemental Plan, you will need to comp
lete the application and approval process. This can be simple if done timely and
accurately.
Filling the application
Your agent or broker that assisted you with selecting the right Plan will also b
e able to provide you with the necessary enrollment application. Every insurance
company has their own application, so make certain that the application agrees
with the insurance company that you have selected. These applications are usuall
y quick and easy to complete and are just 2-3 pages in length.
The application can be delivered to your agent, who will submit it on your behal
f. An initial premium payment may be required along with the application. Always
make the check payable only to the insurance company.
Receiving Approval and ID Cards
If your application is completed properly, approval should only take 5-10 busine
ss days. You will receive notice of approval prior to receiving your insurance I
D cards, which will typically arrive 2-3 weeks later. Your coverage will always
become effective on the first day of the month following the date that your appl
ication was submitted.
You know how important health insurance is to protect you and your family from u
nexpected accidents and illnesses. For those times when you are in transition, t
here is no need to put yourself or your family at risk. Did you know that health
insurance companies offer short-term health insurance quotes?
When to consider short-term health insurance as an option?
There are several life circumstances when you should consider shopping for short-t
erm health insurance, for example:
If you are currently in between jobs, on a new job waiting for a medical coverag
e to kick in, a recent graduate, if you are retired but not yet 65, or if your e

mployer does not offer any type of health insurance, and you have no other optio
ns.
Keep in mind that as the name implies short-term health insurance is only a solu
tion for a limited period of time. These policies, also called Gap Insurance, are
commonly renewable for a total of 36 months, you can always reapply, but there i
s no guarantee of acceptance.
Are short-term health insurance quotes affordable?
Because of the nature of the policies and benefits offered, short-term heath ins
urance is one of the most affordable private health coverages you can buy. Rates d
o vary from state to state but generally range from $150 to $390 per month. For
example, a single male non-smoker under the age of 30 could generally expect to
pay at the bottom end of that range. A single female nonsmoker under 30 could pa
y as little as $140 a month or less. Of course rates increase as you get older a
nd if you smoke. Also, rates depend on the benefits provided, your geographic ar
ea, and the amount of out of pocket contributions you are willing to make.
Getting short term health insurance quotes
Online is a great way to shop for short-term health insurance quotes. Many websi
tes offer free quotes, and tools to compare rates on short-term health insurance
from several major carriers in your area. Simple questions are usually asked to
be sure you are given the right short-term health insurance plan to meet your p
articular needs.
By getting quotes from multiple sources using these online health insurance tool
s you have a great opportunity to compare the rates and benefits of different sh
ort-term health insurance providers side by side. Then you can make an informed
and educated decision.
Eligibility
There are several requirements for you to be eligible for short term health insu
rance:
You must be under age of 65
There is no coverage for pre-existing conditions
You cannot already be covered by another insurance policy
Also understand that short-term health insurance plans can be somewhat more limi
ted in benefits than full term polices. Dental, vision, and maternity coverage,
is usually not provided with short- term insurance policies.
Suggestions
Before making any decision, get to know more about the options offered for short
-term health insurance that suites your needs.
Whenever possible we recommend that you make your payment directly to the insura
nce company instead of paying your agent or broker. If you must pay your agent,
be sure you get a receipt.
Payments for short-term health insurance can usually be made monthly or in full.
You can save money with the lump sum if you can afford it, but there is always th
e option of dividing your quote into monthly payments.
Good oral health is important - not only to your teeth but to your overall healt
h as well. But most health insurance plans do not include dental insurance, maki
ng dental insurance one of the most common types of private health insurance pur
chased by individuals. Dental insurance can help prevent small dental problems f
rom developing into large ones by helping to pay for routine exams and checkups.
And of course dental insurance can help defray the cost of highly expensive cos
metic and restorative dental procedures, should they be necessary.
The good news is dental insurance is more affordable today than you might think.
Most quality dental insurance plans will offer coverage for Cleanings, Crowns, O
ral surgery, Orthodontia, X-rays, and more.
Dental health insurance options
Dental health insurance is available for individuals, small businesses, and fami
lies. There are two main types of dental health insurance: indemnity plans and m
anaged care plans.
An Indemnity plans is a traditional fee for service health plan. It will be a bit
more costly than a managed care plan, but it has far fewer limitations, and you
may choose any dentist.

Managed care plans in dentistry function just as they do with medical insurance
where a group of dentists operate as a PPO or DHMO. Just as a typical PPO or HMO
, you will have to choose your dentist from a list of participating providers. W
hile they offer less flexibility in terms of seeing dentists in or out of the net
work, managed care dental plans are usually less costly than indemnity plans.
Guidelines to shop for a dental health insurance quote
The key to finding affordable dental coverage that is right for you and your fam
ily is to make sure you understand your needs and financial concerns. Before look
ing for dental health insurance, now is a good time to evaluate your annual dent
al bills. How much do you and your family spend on dental care per year? Do you
think your children will require orthodontic care, has anyone in the family been
diagnosed with gum disease, or requires extensive dental restorations for missi
ng or broken teeth?
Other factors to consider before purchasing dental health insurance:
Monthlypremiums vary from state to state and levels of coverage.
If you are considering a managed care plan, you might want to make sure your cur
rent dentist or dental care specialist is in the network. If not, and staying wi
th them is important to you, you may want to consider an indemnity plan. Most man
aged care plans will not cover any work done by a provider outside of the networ
k, except in the case of certain emergencies.
Be sure you understand what treatments are covered and which are not under any d
ental health insurance plan you look at. Routine dental visits, x-rays, and clea
nings are almost always covered. Very few dental health insurance plans offer fu
ll coverage for cosmetic dentistry, root canals, crowns, and braces, although mo
st plans do offer partial coverage. Remember the more costly the monthly premium
s the more services that will be covered.
Getting a dental health insurance quote
As always, the best way to compare dental insurance companies is online. The onl
y questions usually asked is the state you live in or your zip code. Then you wi
ll be provided with quotes from various dental insurance companies. You will be
able to compare rates and services, and find out much more valuable information,
that will allow you to make an informed dental insurance purchase.
Beyond the doctors and nurses who provide you with high-quality health care, VHA
offers tools and information to help you reach your optimal health. Tools like
My HealtheVet enable you to manage your medical priorities through an online pre
scription refill service, personal health journal, and links to Federal and VA b
enefits. Use the health support services listed below to maintain your physical
and mental wellness.
It would be easy to confuse Dr. Mitch Katz with any other doctor at the Roybal C
omprehensive Health Center in East Los Angeles. His desk in a closet-sized, wind
owless office is littered with patient records, X-rays and cans of Diet Coke.
His everyman demeanor belies his stature. As director of the county s Department
of Health Services, Katz, 52, oversees Los Angeles public hospitals and clinic
s, the health care of last resort for millions of low-income Angelenos. He overs
ees 22,000 employees and a $3.7 billion-dollar budget.
Los Angeles, the nation s second-largest city, has some 2 million uninsured resi
dents. It has long had one of the most disorganized systems, too. While fixing i
t, Katz, the former director of San Francisco s health department, insists on se
eing patients at this public health clinic one afternoon a week.
It s a demand that struck many as odd, if not impossible. How would Katz have ti
me to treat patients with a system in ruin? It s part of Katz s plan to fix the
system one clinic at a time.

On a recent morning, Katz sits opposite his patient, a middle-aged man who is a
bundle of nerves. Katz speaks Spanish with his native Brooklyn accent and patien
tly explains the possible causes of the man s tumor and what he hopes a visit to
a lung specialist will reveal.
"I wanted him to know that he would never be abandoned or alone figuring it out,
" he explained. "My view is that this lowers people s anxiety levels and they do
n t wind up in the emergency room because now they re very frightened about what

they have. They need a plan."

Katz s primary aim though, and what he came to Los Angeles to do, is to steer lo
w-income Angelenos away from the overburdened emergency rooms they ve long relie
d upon and into primary care clinics where costs are lower, chronic diseases can
be managed and problems, like a tumor, can be detected earlier.
He says that when he took the job, "they sent me the LA org chart, I said where
s primary care? They said, Well, it s under the hospitals. [I said] Well, that
may explain why you have a problem with primary care!"
It didn t take long for that to change: In the last six months, his team has ass
igned nearly 250,000 people to a primary care doctor at county clinics, he says.
"In fact, I didn t have to hire a single additional doctor," he says. "What I d
id is say: No, we re not running this anymore as a drop-in, see-who-you-see-and
-no-one-is-responsible system. "
Katz s predecessors promised many of the same reforms, but government observers
here say they were stymied by a Board of Supervisors which often governs Los Ang
eles like five competing fiefdoms.
But Michael Cousineau, a professor at the University of Southern California s Ke
ck School of Medicine, says those supervisors are scared of what s to come. Unde
r the health law, many of those currently uninsured are expected to be covered b
eginning in 2014. When that happens, the federal government will reduce the extr
a money they now give to public hospitals to offset the burden of caring for the
se patients.
One report commissioned by the county put it bluntly: If L.A. loses its paying c
ustomers and is left treating only undocumented immigrants, the financial surviv
al of its health system is at stake. Cousineau argues that to move the system fr
om one of "last resort to a system of choice is not going to be an easy thing. B
ut the price of failure is thousands of people losing their jobs, closing of hea
lth centers and hospitals. So that s what the supervisors have to grapple with."
Gloria Molina, who represents East Los Angeles, is one of the supervisors each o
f whom represents more voters than many U.S. Senators do. She expresses confiden
ce in Katz. "I was one that was worried he was just going to be another guy that
just took us so far and then would leave us," she says. "But instead he s had t
he most daunting challenges, and he s meeting all our expectations."
One test of Katz s vision for remaking the L.A. public health system is taking p
lace at the heart of where it all went terribly wrong. The Martin Luther King Ju
nior-Harbor Hospital in South Los Angeles closed in 2007 after the quality of ca
re had deteriorateddramatically and one woman died of egregious errors.
It has re-opened as a clinic where patients with chronic diseases are counseled
by a team of nurses and medical assistants. The clinic s nurse manager Kimberly
Thomas says customer service is now a top priority. "They ll bring patients who
have diabetes and high cholesterol then bring them in again and look at their la
bs and see if they re improved or gone down," she says. Patients love the gifts
they get if they improve their test results, she adds.
Assigning low-income patients to a medical home makes for better medicine, but w
hether it engenders good will and loyalty when these same patients gain insuranc
e is an open question. And this may, in fact, be Katz s greatest challenge: givi
ng Angelenos a reason to believe in what the county can offer.
"Someone will talk to me about their medical problems, and I ll start asking the
m about what s going on in their marriage, with their kids, in their home and pe
ople will begin to cry," says Katz. "People will begin to tell you amazing thing
s about what are really the issues. And often the physical symptom both to you a
nd to them is just the opening salvo in a conversation that they want to have wi
th someone who cares about them."
This story by Sarah Varney is part of a reporting partnership that includes KQED
, NPR and Kaiser Health News.
A growing number of health experts are warning of potential collateral damage if
the Supreme Court strikes down the entire 2010 Affordable Care Act: potential c
haos in the Medicare program.
"The Affordable Care Act has become part and parcel of the Medicare system, enco
uraging providers to deliver better, more integrated, better coordinated care, a

t lower cost," says Judy Feder, a public policy professor at Georgetown Universi
ty and former Clinton administration health official. "To all of a sudden elimin
ate that would be highly disruptive."
Sara Rosenbaum, a professor of health law and policy at George Washington Univer
sity, puts it a bit more bluntly: "We could find ourselves at kind of a grand st
opping point for the entire health care system."
And it s not just Democrats warning of potential problems. Gail Wilensky, who ra
n Medicare and Medicaid under President George H.W. Bush, says she doesn t think
it s likely that the court will strike down the entire health law. But if it do
es, she says, "it seems like it takes everything with it, including those aspect
s that are only very peripherally related to the expansion of coverage."
So why are experts so worried?

One reason is that the law changed the payment rates for just about every type o
f health care professional who treats Medicare patients. Every time Medicare set
s a payment rate, it needs to cite a legal authority. And for the past two years
, says Rosenbaum, that legal authority has been the Affordable Care Act.
So if the law is found unconstitutional, she says, every one of those changes "d
oesn t exist anymore because the law doesn t exist."
And the result? "You have agencies sitting on two years of policies that are up
in smoke," she says. "Hospitals might not get paid. Nursing homes might not get
paid. Doctors might not get paid. Changes in coverage that have begun to take ef
fect for the elderly, closing the doughnut hole might not happen. We don t know.
"
And many of those facilities serve not just Medicare patients but the rest of th
e population, too. Hence, the spillover could affect the health care system as a
whole.
That s what has the nation s community of health care providers watching nervous
ly to see what the court does. Many would speak only on background or wouldn t a
ddress the subject at all.
One of the few groups willing to address the subject was the American Medical As
sociation. In a statement, the AMA s president-elect, Jeremy Lazarus, says, "Wit
h the countless hours of work already done to implement this new law, it is hard
to imagine the full impact of it disappearing."
At best, the situation would be legally murky, says Dan Mendelson. He s CEO of t
he health consulting group Avalere and oversaw health programs for the Clinton a
dministration s Office of Management and Budget.
"In a lot of ways, it s a political never-never land," he says. "We have no idea
really what this would look like because we don t have a precedent."
Actually, says Wilensky, there is a bit of a precedent: For the past few years,
Congress inability to fix a glitch in the formula for paying doctors for Medica
re has more than once resulted in brief lapses in funding authority.
"So we ve had these kinds of smaller-version what happens if Congress does or d
oesn t do something. This would be much bigger. And it would be extremely disru
ptive," she says.
Rosenbaum says there could be an even bigger problem: Medicare might be looking
at hundreds, if not thousands, of policies that are suddenly null and void. She
says it s not at all clear that the agency has the authority to go back to the p
olicies that were in effect before the law was passed.
"This is a conversation that s happening between the Supreme Court and Congress,
" she says. Medicare officials would "have to sit there and wait to see what Con
gress wants to do."
What makes it an even bigger potential mess, says Mendelson, is that the health
law has fundamentally changed almost every aspect of the way the Medicare progra
m now does business. And undoing that would be almost unimaginably difficult.
"I think it s more akin to Alice in Wonderland," he said. "That we re going down
the rabbit hole and nobody really knows what it s going to look like inside."
But in the next few months, they may find out.
A curious and good thing has happened on the road to Obesity Nation: the share o
f the U.S. adult population with high cholesterol has dropped.

Data just out from the Centers for Disease Control and Prevention show that only
13.4 percent of adults in this country have high cholesterol, according to data
collected in 2009 and 2010.
A decade earlier, 18.3 percent of adults in the U.S. had high cholesterol.
High cholesterol starts at 240 milligrams of cholesterol per deciliter of blood.
Having high cholesterol more than doubles the risk of a heart attack compared w
ith desirable total cholesterol, which is less than 200 milligrams per deciliter
.

The government had set a public health goal of getting the proportion of adults
with high cholesterol down to 17 percent or less by 2010.
Lately, the obesity wave appears to have leveled off, but at a pretty high mark.
Some two-thirds of American adults are obese or overweight.
Being overweight can raise your cholesterol. So what gives?
"Experts believe it s largely because so many Americans take cholesterol-lowerin
g drugs, but dropping smoking rates and other factors also contributed," the Ass
ociated Press reports.
Drugs called statins, such as Lipitor and Zocor, lower cholesterol and are enorm
ously popular. Last year, 264 million prescriptions were dispensed for drugs to
reduce cholesterol, according to data from IMS Health.
But some are asking whether it s such a good idea to prescribe statins to people
who haven t had a heart attack already. The Food and Drug Administration said i
n February that the drugs instructions should note reports of memory loss and d
iabetes among people taking them.
The agency said, however, that the new information shouldn t scare people away f
rom taking statins. The drugs s value in preventing heart disease is clear, FDA
said.
But Dr. Otis Brawley, chief medical officer for the American Cancer Society, fir
ed up hundreds of them at the annual meeting of Association of Health Care Journ
alists over the weekend with a no-holds-barred critique of the U.S. health syste
m.
Brawley has a book out, How We Do Harm: A Doctor Breaks Ranks About Being Sick i
n America, that makes his case in full. But in a sometimes dizzying speech in At
lanta, Brawley ripped the health establishment from top to bottom. It was bracin
g stuff.
The group just posted a video about the event.
Here are some of the highlights, as tweeted by journalists at the meeting, if yo
u prefer.
The American College of Physicians isurging patients with newly diagnosed diabet
es and back pain not to opt for the latest-and-supposedly-greatest.
It s part of a new campaign to steer patients (and their doctors) to what the Co
llege of Physicians calls "high value care," and away from expensive tests and t
reatments that aren t any better and often are worse.
That may seem like common sense. But it s a departure, and maybe a surprise, to
hear a mainline physician group name names when it comes to drugs that shouldn t
be first choices and even steer patients to non-physician competitors.
Instead of highly touted diabetes brands such as Actos, Januvia and Avandia, the
physicians group says, patients with type 2 diabetes should start out on a tri
ed-and-true generic.
"The best first choice usually isn t one of the newer, heavily advertised" drugs
, says a new brochure put out by the College in cooperation with Consumer Report
s magazine. "It s metformin, a drug that has been around for nearly two decades.
"

"A month s supply of generic metformin typically costs only about $14 compared w
ith about $230 to $370 for Actos and about $265 for Januvia," the brochure point
s out.
Metformin "lowers blood sugar levels more than newer drugs do," the brochure say
s. It also reduces "bad cholesterol," while newer drugs don t, and sometimes eve
n raise it.

When it comes to back pain, it s usually not a good idea to get an x-ray, CT sca
n or MRI, says another new pamphlet that carries the College of Physicians brand
.
"If you don t feel better after four weeks or so, it might be worth talking to y
our doctor about other options," back pain sufferers are advised. Maybe they sho
uld see a chiropractor or an acupuncturist, the brochure says.
Steven Weinberger, CEO of the American College of Physicians, says many patients
come into doctors offices with the expectation they re going to get a high-tec
h imaging study to diagnose their back pain.
"Their neighbor might say, When I had back pain I had an MRI, so maybe you didn
t get the best care, " Weinberger told Shots. "We re saying the reflex reactio
n doesn t represent the best care."
The group plans to put out a series of other pull-no-punches pieces of advice on
common conditions.
"In these days of crisis in health care costs," he says, "the medical profession
should take its ethical and professional responsibility to do what we can to re
duce costs while not compromising care."
Weinberger says that doing the right thing make take courage, "because physician
s have financial incentives" to prescribe less cost-effective care, and so do ho
spitals. So, of course, do pharmaceutical companies.
But Sethu Reddy, the U.S. medical director of Merck, maker of the diabetes drug
Januvia, idn t sound too threatened.
"Cost is one factor," Reddy told Shots. "But there are four or five other factor
s that the doctor has to weigh in. He can t just automatically say that this is
the automatic option for every new patient."
Reddy pointed out that, on the very day the physicians group urged newly diagno
sed type 2 diabetics who need drugs to start with metformin, US and European dia
betes specialists issued new guidelines that are less prescriptive.
"More than any other previously reported guidelines," notes diabetes expert Will
iam Cefalu, the new position statement "emphasizes that one size clearly does no
t fit all."
n Republican-dominated Nebraska, government leaders often line up together, but
lately a political tornado has ripped through this orderly scene.
A political showdown over taxpayer funding of prenatal care for illegal immigran
ts has produced some unusual political splits and alliances in the statehouse of
the Cornhusker State.
"I am extraordinarily disappointed in your support of taxpayer-funded benefits f
or illegal aliens," said Republican Gov. Dave Heineman as he read a letter he wr
ote to fellow Republican Mike Flood, speaker of Nebraska s officially nonpartisa
n Legislature.
Heineman was referring to a bill he subsequently vetoed that would restore publi
cly funded prenatal care for women in the country illegally. Until two years ago
, Nebraska was one of about 15 states providing that benefit.

Nebraska dropped the coverage when the federal government said the state couldn
t use Medicaid funds, though it offered to continue funding under another progra
m. Heineman frames the issue as one of the benefits to illegal immigrants.
Flood, a leading abortion opponent, says pregnant illegal immigrants will ultima
tely give birth to babies who will be U.S. citizens. He says providing them with
prenatal care is consistent with his opposition to abortion.
"If I m going to stand up in the Legislature and protect babies at 20 weeks from
abortion, and hordes of senators and citizens are going to stand behind me, and
that s pro-life, then I m going to be pro-life when it s tough, too," Flood sai
d.
The issue has exposed a fault line between anti-illegal-immigrant sentiment and
anti-abortion groups, but it s also brought together an unusual coalition. Among
those supporting the bill is the politically influential Nebraska Right to Life
organization.
"We don t want to distinguish that because ... of a baby s circumstances or in w
hose womb that baby resides that dictates whether that baby receives care or not

," said Julie Schmit-Albin, the group s executive director.

Another supporter is the Nebraska Appleseed Center for Law in the Public Interes
t, which advocates for immigration reform and access to universal health care. J
ennifer Carter, the center s public policy director, says the immigrants are our
"neighbors" and should be helped.
"They re in our communities and they re helping contribute to our communities,"
Carter said. "So we believe providing this kind of prenatal care coverage to the
ir children is appropriate."
Still, Heineman, backed by what Republican Party polls say is a clear majority o
f voters, remains adamant in his opposition, though he calls himself strongly an
ti-abortion.
"Most Nebraskans and I agree, we support prenatal care, but in the case of illeg
al immigrants, it should be done by churches, private organizations, charities,
private individuals not the use of taxpayer funds," he said.
Supporters of the bill, on both sides of the abortion debate, cite their own pol
ls in support and say the savings from avoiding intensive care for babies born w
ithout prenatal care would outweigh the costs of the program.
With the governor turning up the political heat, the question now is whether eno
ugh legislators will vote to override the veto. That vote is scheduled for Wedne
sday.
Surrogacy is an idea as old as the biblical story of Sarah and Abraham in the bo
ok of Genesis. Sarah was infertile, so Abraham fathered children with the couple
s maid. Today, there are many more options for people who want to grow their fa
milies and for the would-be surrogates who want to help.
Macy Widofsky, 40, is eager to be a surrogate.
"I have very easy pregnancies. All three times have been flawlessly healthy, and
I wanted to repeat the process," she says, "and my husband and I won t be havin
g more children of our own."
Widofsky sits in the lobby of a fertility clinic in Reston, Va., where she s bei
ng tested to find out if she s a good candidate. Surrogacy runs in her family: H
er mother was a surrogate when Widofsky was 12, and the experience left a mark.
"I was very impressed then that she was willing to help a family out this way, a
nd I didn t realize at the time how uncommon that was," she says.
Widofsky s mom did what s called "compassionate" surrogacy, meaning she wasn t p
aid. Some women do it for family or a friend. Today, though, most surrogates get
between $20,000 and $25,000 to bear a child for someone else.
Why One Surrogate Wanted To Help
Whitney and Ray Watts are the parents of 3-year-old J.P. Whitney carried twins f
or Susan and Bob de Gruchy.
"To me, being a surrogate it s like you re carrying someone else s dreams," she
says.
That s part of what could make some people scratch their head. After all, it s e
asier to believe that a woman would give up a child from her womb for money rath
er than a desire to help.
Whitney, 25, says her parents went through infertility nightmares, and that gave
her determination to help someone make a family. She says she didn t think abou
t bonding with the baby.
"It was [in vitro fertilization]. It was their embryos," she says. "You just kno
w they are not yours. You re just keeping them for a time to let them grow and t
hen give them back to their parents, because they were never my babies. It s jus
t my uterus that s keeping them."
Not Doing It For The Money
Sitting next to each other, 27-year-old Ray looks adoringly at his wife; they fi
nish each other s sentences when they speak. The Wattses say they were looking f
or a couple they could connect with.
"It was very important to us to have a relationship with them," Whitney says. "Y
es, it s a business contract in a sense, but it s so much more than that." Her h
usband agrees.
"Had Susan and Bob just wanted to pay money and get a kid, that would have been
a deal breaker right away," he says.

ltiple people create a child, the law doesn t always make it clear who the legal
parents are.
The issue of money, though, is real. It makes some people feel uneasy because mo
therhood is not typically financially compensated. Whitney Watts says she looked
into compassionate surrogacy doing it for free but it didn t feel right.
"I would do compassionate [surrogacy] for a friend, but not for someone I don t
know, through an agency," she says. "It wouldn t feel appropriate ... because yo
u don t know what you are going to do until you get there."
Whitney says she didn t want to put her family through financial stress. As it t
urned out, she spent 55 days on bed rest at the hospital.
Elaine Gordon, a clinical psychologist in Los Angeles, counsels couples on famil
y-building, including surrogacy, and on the issue of payment.
"I think people automatically feel that if money is involved then there is no al
truism involved, and that s not necessarily true," she says. "We are all compens
ated for the work we do, and we still want to do good work even though we are co
mpensated."
Gordon says many surrogates tell her the experience of having a child for someon
e else is so powerful that they want to do it again.
It takes more than a convoy of fire engines and an evacuation of the Kennedy Cen
ter first thing to stop TEDMED.
I heard conflicting reports about what happened this morning, but the show went
on a few minutes late once D.C. s bravest were satisfied we d all be safe.
After a snappy tune from the@songadaymann (Jonathan Mann), Cal Tech s Frances Ar
nold made sure everyone was really awake by telling us what a blast her lab work
is: "I have fun forcing molecules to have sex."
In nature, she said, "proteins aren t designed, they re evolved." That s where s
ex comes in to mix up genetic material. "Sex is an innovation-generation machine
," she said.

And in the lab she s speeding that process up by shuffling genes artificially an
d doing it smartly she hopes by figuring out which elements have a fighting chan
ce of producing proteins that actually work and maybe even do something useful.
Later on, I heard more than one person suggest that it would have been helpful t
o have a session on the risks and ethical implications of work like this.
In the afternoon, Emory s Jonathan Glass and Nick Boulis dove headfirst into the
realm of risk, arguing that the current system of regulation is holding back pr
ogress in the search for treatments for amyotrophic lateral sclerosis. It s time
, they say, for regulators such as the Food and Drug Administration to let patie
nts take bigger risks when the alternative is looming death.
The researchers are interested in speeding up access to stem-cell treatments, ev
en though both acknowledged there are big unanswered questions about their safet
y and effectiveness. But as Glass summed up, "This is an emergency. The house is
on fire."
Finally, back to the morning session for one of the more provocative talks. Univ
ersity of California, Davis Jonathan Eisen urged everyone to get to know their
personal microbes: We re all colonized from head to toe. The mass of microbes ea
ch of us carries around, in fact, is greater than the mass of our brains, he sai
d.
Some microbes help us, and others can hurt us. Miscommunication between our bodi
es and the microbes that live with us may make us sick. Fixing that snafu could
make us well.
Some old-time vets, Eisen said, already use a concoction called "poo tea," a dil
uted mixture of fecal matter from a healthy animal, to effectively treat sick an
imals.
But we re only beginning to grasp how microbes affect human health. "We need a f
ull field guide to microbes that live in and on us."
It may sound counterintuitive, but a panel of experts from the Institute of Medi
cine has concluded that the best way to slow the nation s breakneck spending on
medical care is to impose a tax on every health care transaction.
That tax amount TBD, but possibly a half-percent or so would go to replenish the

coffers of the nation s state and local public health agencies. In so doing, ac
cording to the IOM panel, the public health workforce could renew its historic r
ole in looking at population rather than individual health care, and thus "offer
efficient and effective approaches to improving the nation s health."
Currently, said Marthe Gold, professor of Community Health and Social Medicine a
t the City College of New York and chair of the panel, the U.S. spends only abou
t 3 percent of the $2.5 trillion it spends on health care overall on public heal
th. It has a history of "unpredictable, inadequate and uncoordinated funding."
Yet "public health also has a track record of achievement in vanquishing the his
toric causes of death and disease," she said, from early successes like ensuring
clean water and sanitary food to more recent campaigns to get people to stop sm
oking or use seat belts.

The public health infrastructure has taken a hit during the recent economic down
turn: Roughly one-fifth of the local public health workforce has been lost throu
gh attrition and layoffs. Renewing that infrastructure could have a profound imp
act on slowing the rate of growth in health spending, the panel argues.
For example, public health measures including community-based outreach could hel
p reduce adult obesity by 50 percent, the panel says. Sounds ambitious, but as t
he panel notes, that s about the same relative reduction in smoking rates that r
esulted from the "public health community s multifaceted attack on smoking" in t
he past few decades. It would also save the U.S. an estimated $58 billion in hea
lth care spending.
In order to meet those goals, the panel says every public health agency would ne
ed to be able to deliver a "minimum package of services." That would include wha
t it calls "foundational" services, such as the ability to do basic disease surv
eillance and communicate with the public, and "programmatic" services, such as i
njury prevention and communicable disease prevention.
But to get there, the federal government would need to at least double the $11.6
billion it invests each year in public health activities, according to the pane
l s estimates.
Which brings us to that pesky tax.
Panel member George Isham, medical director at HealthPartners in Bloomington, Mi
nn., acknowledged that "it s difficult to propose any kind of increase in taxati
on." But the group considered a number of different financing mechanisms before
settling on a minimal tax on medical transactions as the best solution: It s a t
ax related to the goal; it would raise sufficient funds; and it would not have a
bad economic consequence. In short, said Isham, "it s an investment we can t af
ford not to make."
Now they just have to convince the rest of the nation of that.
Hearing loss is all too common.
Some 35 million people have trouble hearing. After high blood pressure and arthr
itis, it s third on the list of chronic health issues for seniors.
Yet traditional Medicare coverage doesn t include the cost of hearing aids, and
most private health plans follow suit. That leaves it to many people to scrape u
p the money on their own.
That s no small task, since hearing aids can cost a few thousand dollars and gen
erally have to be replaced every four to six years.
Legislators in both houses of Congress over the past decade have repeatedly prop
osed a tax credit that could provide at least a modicum of financial help.

Bipartisan bills are pending again in both the House and Senate, but they re not
moving ahead anytime soon. "We continue to gain support of the bill, but there
has been no legislative activity," says Ingrida Lusis, director of federal and p
olitical advocacy at theAmerican Speech-Language-Hearing Association. Both bills
have been referred to committee, but no action has been taken.
The House bill would provide a tax credit of up to $500 per hearing aid every fi
ve years to people age 55 or older or to families who bought one for a dependent
. People with incomes over $200,000 would be ineligible for the tax credit. It h
as been estimated to cost about $300 million.

The Senate bill provides for a similar tax credit but with no restriction on age
or income.
One hearing aid user, Kathy Borzell, 62, of Sapphire, N.C., estimates she s spen
t $25,000 out of pocket over the past 20 years buying hearing aids for both ears
.
Although $500 may only be a fraction of the cost most people spend on hearing ai
ds, advocates say it would let policymakers send a message to those needing hear
ing
By now it s hardly news that the U.S. spends more than every other industrialize
d country on health care. But a new study suggests that at least when it comes t
o cancer care, Americans may actually be getting decent value.
The study, in April issue of the policy journal Health Affairs, isn t the first
to suggest that U.S. patients do better than their European counterparts when it
comes to surviving most types of cancer. Other studies have shown that the U.S.
approves cancer drugs faster than most nations across the pond.
But this study, by researchers from the University of Chicago and the University
of Southern California and partially funded by the cancer drugmaker Bristol-Mye
rs Squibb,actually attempted to quantify what the U.S. gets for the additional m
oney it spends.
And what it found is that for most types of solid tumor cancers, particularly br
east and prostate cancer, even after considering the higher costs, U.S. patients
experienced greater survival gains than patients in Europe.

And those costs did grow. Between 1983 and 1999, the period covered by the study
, U.S. spending on cancer care grew 49 percent (in 2010 dollars). By comparison,
spending in the 10 European countries included in the study grew by 16 percent.
But for patients diagnosed between 1995 and 1999, average survival from time of
diagnosis in the U.S. was 11.1 years, while in Europe it was 9.3 years.
"Using conservative market estimates of the value of a statistical life, this st
udy presented evidence that U.S. cancer survival gains are worth more than the c
orresponding growth in the cost of U.S. cancer care according to the most recent
data available for analysis," the study s authors wrote.
There are some significant caveats, of course. One is that that "most recent dat
a" ends in 1999. And, they note, "important changes in cancer care have occurred
in the past ten years, including the introduction of expensive new drug treatme
nt and increased use of diagnostic imaging."
So, the authors point out, it will take still more research to determine if toda
y s increased spending is still worth it, and what specific aspects of cancer ca
re are driving the U.S. s improved survival rates.When Lisa Galloway was trying
to decide what kind of radiation treatment to undergo after surgery for early br
east cancer, she jumped at the chance to get a newer, quicker approach.
Instead of dragging on for weeks, the newer form of radiation, called brachyther
apy, only takes five days.
"Five days compared to 33 days, I was like, Yay! " says Galloway, 53, of Silve
r Spring, Md. "So I wanted it so badly. I got it I got my wish."
But there s an intense debate under way about whether the approach is being used
too widely before there s clear evidence it s as effective as the traditional a
pproach.

"I see the rush to brachytherapy is somewhat inappropriate because it has not ye
t been proven in a randomized trial to be as effective as a standard treatment,"
says Bhadrasain Vikram of the National Cancer Institute.
Traditional post-surgical treatment for early breast cancer often involves deliv
ering radiation to the breast externally at relatively low doses over about six
weeks. The new approach involves delivering higher doses in a more targeted way
from inside the breast over a shorter period of time.
To get ready for brachytherapy, a surgeon temporarily implants a small device ca
lled a catheter in the spot where the tumor was removed. The device houses a bun
dle of tiny, flexible tubes that protrude from the side of the breast.
For each treatment, a technician connects each of the tubes from the implant to

a radiation machine. That allows the doctor to deliver high doses of radiation t
o specific spots inside the breast.
The radiation comes from a tiny pellet that s at the end of a very thin wire. On
e by one, the radiation-tipped wire snakes in and out of each tube in the implan
t. Patients get treated twice a day for 10 days. Each session takes a few minute
s.
In recent years, the popularity of the therapy has soared, rising from less than
1 percent of patients in 2001 to 10 percent in 2006, Vikram says.
"It was a tenfold increase over a five-year period," he says.
Vikram worries that there s not enough proof yet that brachytherapy is as effect
ive as what doctors have been using for years. And, he notes, there are some big
concerns: "that the tumor will recur and women will need more mastectomies, and
/or the tumor may spread to other parts of the body and kill the woman, or it ma
y have more toxicity in the long term."
Those fears spiked in December when Benjamin Smith of the M.D. Anderson Cancer C
enter in Texas unveiled the results of a big study at a scientific meeting in Sa
n Antonio.
"We found that the decision of whether or not a patient was treated with brachyt
herapy or whole breast irradiation was the single most important predictor of wh
ether they had a mastectomy within five years of their cancer diagnosis," Smith
says.
Mastectomies were rare no matter what kind of radiation women got. But they were
about twice as common among the women who got brachytherapy, Smith and his coll
eagues found. That s a red flag that brachytherapy might not be snuffing out the
cancer as well, Smith says.
"The most plausible explanation for our data is that women treated with brachyth
erapy were at increased risk of having a recurrence of cancer in their breast,"
he says.
Smith and his colleagues also found that women getting brachytherapy were more l
ikely to experience minor complications, such as infections and bleeding.
"When you put together significantly increased risk of a lot of different compli
cations and a treatment that s slightly less effective potentially than whole br
east irradiation, then you start to wonder, What is the role of this treatment?
And have we adopted it too quickly before we really understand how to use it co
rrectly? " Smith says.
He and Vikram say women should get brachytherapy for breast cancer only as part
of carefully designed studies.
Other doctors disagree. For one thing, they say the data Smith used are old, com
ing from when doctors were just starting to learn how to do brachytherapy for br
east cancer. In addition, they argue, other studies indicate brachytherapy is ef
fective, at least for some patients: mostly older women with very small tumors t
hat haven t spread.
"We have data that shows that in appropriately selected patients that are treate
d with five-day treatment, the outcome is very good and the toxicity is very low
," says Douglas Arthur of the American Brachytherapy Society.
In addition to being more convenient, the more targeted approach avoids some com
plications.
"Less radiation means less side effects. They don t get fatigue. They don t get
the darkening, reddening, tenderness of the skin related to external beam radiat
ion," says Martin Keisch of the University of Miami Hospital. "You don t get tha
t with the internal radiation you are receiving with brachytherapy."
Galloway s doctor, Sheela Modin of Holy Cross Hospital in Silver Spring, acknowl
edges that there are still questions about brachytherapy.
"At this point, we re being very conservative, based on the data that s availabl
e right now. And in select patients, and they tend to be older women, that this
is a reasonable approach," Modin says.
"I don t do everybody. It would only be someone who has early stage breast cance
r," she says
For her part, Galloway wasn t crazy about walking around with the brachytherapy
implant. And she says it was kind of weird to feel little jolts of vibration dur

ing the treatment. But she was relieved to get her radiation treatment over quic
kly.
"I m very happy, yeah, very happy," says Galloway, who got the implant taken out
after her final day of treatment.
A large federally funded study is trying to clarify the risks and benefits of br
achytherapy for breast cancer. But the results won t be out for years.
The Food and Drug Administration has warned people about the many dangers of buy
ing medications from foreign pharmacies over the Internet. While some sites migh
t offer high-quality medicines, there are plenty that sell bogus and potentially
dangerous products.
But a recent economic analysis suggests that while there s good reason for the s
afety warnings, the FDA s stance on the matter might go too far. Many Americans
don t fill their prescriptions because they can t afford to, the study says, and
some legitimate foreign pharmacies may offer medicines at prices lower than tho
se of verified U.S. suppliers.
"A blanket warning against any foreign website may deny consumers substantial pr
ice savings," states the report from the National Bureau of Economic Research.

Researchers Roger Bate, Ginger Zhe Jin and Aparna Mathur looked at how different
online pharmacies compared in terms of drug safety and cost savings. They went
to dozens of websites and ordered medications widely used by Americans: Viagra,
Celebrex, Lipitor, Nexium and Zoloft.
They obtained 328 drug samples from 41 online pharmacies based in the U.S., Cana
da, Australia, Europe or Asia. They found the foreign suppliers the same way man
y consumers do: by doing a search on Google and Yahoo.
Eight of the websites were U.S.-based providers verified by the National Associa
tion of Boards of Pharmacy, LegitScript.com, PharmacyChecker.com or the Canadian
International Pharmacy Association. Those websites were classified as Tier 1 an
d sold high-quality, authentic drugs. (The researchers established the drugs au
thenticity through detailed, chemical analyses.) Another group classified as Tie
r 3 was made up of unverified, mostly foreign providers that sometimes shipped f
ake versions of one of the drugs, Viagra.
But there was a middle group of mostly foreign suppliers that had been verified
by two agencies dubbed Tier 2 that sent drugs that were authentic and cost much
less than at Tier 1 pharmacies.
In fact, the Tier 2 drugs were, on average, 52.5 percent cheaper (including ship
ping and handling) than the Tier 1 medicines. The only exception was Viagra, whi
ch was the same in drug safety and price for both groups.
"In the U.S., tens of millions of Americans go without prescribed medication due
to cost each year," the study says. "For most uninsured Americans, lower priced
drugs from foreign online pharmacies are an attractive option and for many a ne
cessary one."
"In light of this," the researchers asked, "we wonder whether a blanket warning
against foreign websites has limited price competition between U.S. and foreign
websites, and whether a more open and educational policy could make better use o
f the existing verification services for consumer savings in authentic drugs."
Still, people shouldn t rush online and buy from a pharmacy that hasn t been che
cked out. The FDA strongly recommends verification from the National Association
of Boards of Pharmacy.
Plus, as Nancy Shute has reported in Shots, people searching for prescription dr
ugs even on legitimate websites can sometimes fall victim to hackers and scams.
Sidney Wolfe, director of Public Citizen s Health Research Group, tells Shots th
at despite the study s findings, he has concerns about the safety of the product
s from foreign pharmacies. When drugmakers develop and sell generic copies of ex
isting brand-name drugs, he says, regulators require them to prove the copies ar
e not only chemically identical but work the same way inside the body a concept
known as bio-equivalence.
If the drugs from foreign websites could be shown to be the same in terms of bio
-equivalence as drugs from verified suppliers, he says, "we would strongly suppo
rt it."

Sales of the nation s two most popular prescription painkillers have exploded in
new parts of the country, an Associated Press analysis shows, worrying experts
who say the push to relieve patients suffering is spawning an addiction epidemi
c.
From New York s Staten Island to Santa Fe, N.M., Drug Enforcement Administration
figures show dramatic rises between 2000 and 2010 in the distribution of oxycod
one, the key ingredient in OxyContin, Percocet and Percodan. Some places saw sal
es increase sixteenfold.
Meanwhile, the distribution of hydrocodone, the key ingredient in Vicodin, Norco
and Lortab, is rising in Appalachia, the original epicenter of the painkiller e
pidemic, as well as in the Midwest.
The increases have coincided with a wave of overdose deaths, pharmacy robberies
and other problems in New Mexico, Nevada, Utah, Florida and other states. Opioid
pain relievers, the category that includes oxycodone and hydrocodone, caused 14
,800 overdose deaths in 2008 alone, and the death toll is rising, the Centers fo
r Disease Control and Prevention says.
Nationwide, pharmacies received and ultimately dispensed the equivalent of 69 to
ns of pure oxycodone and 42 tons of pure hydrocodone in 2010, the last year for
which statistics are available. That s enough to give 40 5-mg Percocets and 24 5
-mg Vicodins to every person in the United States. The DEA data records shipment
s from distributors to pharmacies, hospitals, practitioners and teaching institu
tions. The drugs are eventually dispensed and sold to patients, but the DEA does
not keep track of how much individual patients receive.
The increase is partly due to the aging U.S. population with pain issues and a g
reater willingness by doctors to treat pain, said Gregory Bunt, medical director
at New York s Daytop Village chain of drug treatment clinics.
Sales are also being driven by addiction, as users become physically dependent o
n painkillers and begin "doctor shopping" to keep the prescriptions coming, he s
aid.
"Prescription medications can provide enormous health and quality-of-life benefi
ts to patients," Gil Kerlikowske, the U.S. drug czar, told Congress in March. "H
owever, we all now recognize that these drugs can be just as dangerous and deadl
y as illicit substances when misused or abused."
Opioids like hydrocodone and oxycodone can release intense feelings of well-bein
g. Some abusers swallow the pills; others crush them, then smoke, snort or injec
t the powder.
Unlike most street drugs, the problem has its roots in two disparate parts of th
e country Appalachia and affluent suburbs, said Pete Jackson, president of Advoc
ates for the Reform of Prescription Opioids.
"Now it s spreading from those two poles," Jackson said.
The AP analysis used drug data collected quarterly by the DEA s Automation of Re
ports and Consolidated Orders System. The DEA tracks shipments sent from distrib
utors to pharmacies, hospitals, practitioners and teaching institutions and then
compiles the data using three-digit ZIP codes. Every ZIP code starting with 100
-, for example, is lumped together into one figure.
The AP combined this data with census figures to determine effective sales per c
apita.
A few ZIP codes that include military bases or Veterans Affairs hospitals have s
een large increases in painkiller use because of soldier patients injured in the
Middle East, law enforcement officials say. In addition, small areas around St.
Louis, Indianapolis, Las Vegas and Newark, N.J., have seen their totals affecte
d because mail-order pharmacies have shipping centers there, said Carmen Catizon
e, executive director of the National Association of Boards of Pharmacy.
Many of the sales trends stretch across bigger areas.
In 2000, oxycodone sales were centered in coal-mining areas of West Virginia and
eastern Kentucky places with high concentrations of people with back problems a
nd other chronic pain.
But by 2010, the strongest oxycodone sales had overtaken most of Tennessee and K
entucky, stretching as far north as Columbus, Ohio and as far south as Macon, Ga
.

Per-capita oxycodone sales increased five- or six-fold in most of Tennessee duri

ng the decade.
"We ve got a problem. We ve got to get a handle on it," said Tommy Farmer, a cou
nterdrug official with the Tennessee Bureau of Investigation.
Many buyers began crossing into Tennessee to fill prescriptions after border sta
tes began strengthening computer systems meant to monitor drug sales, Farmer sai
d.
In 2006, only 20 states had prescription drug monitoring programs aimed at track
ing patients. Now 40 do, but many aren t linked together, so abusers can simply
go to another state when they re flagged in one state s system. There is no fede
ral monitoring of prescription drugs at the patient level.
In Florida, the AP analysis underscores the difficulty of the state s decade-lon
g battle against "pill mills," unscrupulous doctors who churn out dozens of pres
criptions a day.
In 2000, Florida s oxycodone sales were centered around West Palm Beach. By 2010
, oxycodone was flowing to nearly every part of the state.
While still not as high as in Appalachia or Florida, oxycodone sales also increa
sed dramatically in New York City and its suburbs. The borough of Staten Island
saw sales leap 1,200 percent.
New York s Long Island has also seen huge increases. In Islip, N.Y., teenager Ma
kenzie Emerson says she started stealing oxycodone that her mother was prescribe
d in 2009 after a fall on ice. Soon Emerson was popping six pills at a time.
"When I would go over to friends houses I would raid their medicine cabinets be
cause I knew their parents were most likely taking something," said Emerson, now
19.
One day she overdosed at the mall. Her mother, Phyllis Ferraro, tried to keep he
r daughter breathing until the ambulance arrived.
"The pills are everywhere," Ferraro said. "There aren t enough treatment centers
and yet there s a pharmacy on every corner."
The American Southwest has emerged as another hot spot.
Parts of New Mexico have seen tenfold increases in oxycodone sales per capita an
d fivefold increases in hydrocodone. The state had the highest rate of opioid pa
inkiller overdoses in 2008, with 27 per 100,000 population.
Many parts of eastern California received only modest amounts of oxycodone in 20
10, but the increase from 2000 was dramatic more than 500 percent around Modesto
and Stockton.
Many California addicts are switching from methamphetamine to prescription pills
, said John Harsany, medical director of Riverside County s substance abuse prog
ram.
Hydrocodone use has increased in some areas with large Indian reservations, incl
uding South Dakota, northeastern Arizona and northern Minnesota and Wisconsin. M
any of these communities have battled substance abuse problems in the past.
Experts worry painkiller sales are spreading quickly in areas where there are fe
w clinics to treat people who get hooked, Bunt said.
In Utica, N.Y., Patricia Reynolds has struggled to find treatment after becoming
dependent on hydrocodone pills originally prescribed for a broken tailbone.
The nearest clinics offering Suboxone, an anti-addiction drug, are an hour s dri
ve away in Cooperstown or Syracuse. And those programs are full and are not acce
pting new patients, she said.
"You can t have one clinic like that in the whole area," Reynolds said. "It s a
really sad epidemic. I want people to start talking about it instead of pretendi
ng it s not a problem and hiding."
Ukraine s healthcare system consists of a state-run medical establishment provid
ing free or low-cost healthcare and numerous private clinics providing generally
better service at higher cost. The private healthcare insurance industry plays
much less of a role than, say, in the United States.
Healthcare for foreigners
Emergency medical insurance Foreigners are encouraged to buy emergency healthcare
insurance from UkrInMedStrakh (or Prosto Strakhuvannya) for the duration of thei
r stay in Ukraine. In some cases for instance, in order toregister with the OVIR

 this insurance is mandatory. Fortunately, the it is not terribly expensive (rou

ghly $100 USD for one year). The insurance card includes a 24-hour hotline with
English speaking staff, and the procedure for determining what sort of thing con
stitutes an "emergency" seems to be fairly lenient. For instance, the author rec
eived a free check-up for a bad cold, as well as a knee X-ray for a minor knee i
njury from backpacking. However, after the initial visit you may have to pay for
subsequent treatment, and definitely for most medications.
Read more about this emergency medical insurance
Standard free state healthcare Theoretically foreign residents can obtain free hea
lthcare at clinics associated with their place of temporary residence, but this
might be restricted to foreigners who are registered with the ZHEK and have a pr
opiska, or registered address. This typically includes those who are in Ukraine
for studies, legalemployment, or permanent residency. Some foreigners will find
service through standard state channels to be sub-standard, especially if comple
x medical procedures are necessary. Furthermore, there will be much more checkin
g of documents.
Private clinics Fortunately, Ukraine has plenty of private clinics where one can g
et adequate healthcare with fast service, very little waiting, and no documents.
You can just walk in and schedule an appointment. These clinics are generally o
riented towards the middle class (think "70 to 95 percentile"). Here are some pr
ices that seem to be fairly representative of Kiev in summer 2010 (given in USD)
:
$19 - Visit to a general (family) doctor with an initial examination $36 - house v
isit of general doctor with initial examination $13 - Follow-up visit in office $19
- Visit to a gynecologist with an examination $9 - Applying stitches to a wound (
price per stitch) $11 - Local anesthesia $13 - Thyroid ultrasound $5 - TB fluorograph
y $11 - Back X-ray $9 - Certificate of health allowing you to visit swimming pools $6
- General blood test $4 - General urine test
It is important to find a clinic and doctors that you like. You can generally fi
nd a good clinic and good doctors by talking to friends or by looking for review
s online (in Russian or Ukrainian). The author has had very positive experiences
so far with patient doctors willing to spend quite a bit of time with their vis
itors. It does not feel like a conveyor belt like in the overbuilt, overly burea
ucratic U.S. healthcare system. Paperwork is quick and easy. You ll need to each
speak fluent Russian or Ukrainian or go to the doctor with a friend who does. M
any doctors know some English, but probably very few are in a position to talk t
o you in English.
VIP clinics This includes the American Medical Center and similar clinics where pa
tients pay American prices for English-speaking staff and the very latest hi-tec
h equipment.
We founded CareCloud, a provider of web-based software and services for medical
groups, in 2009. We launched the company to be a force of change: a business foc
used on eliminating administrative waste and inefficiency by connecting doctors,
patients, and other key stakeholders into a fully integrated digital healthcare
ecosystem.
CareCloud was successful in securing funding because investors responded strongl
y to our mission of lowering the costs of care and increasing quality To date, C
areCloud has raised over $24 million in capital from angel investors and leading
Silicon Valley venture capital firms like Norwest Venture Partners and Intel Ca
pital.
In less than three years, doctors in over thirty U.S. states are modernizing the
ir medical practices and delivering better care to their patients through the Ca
reCloud platform. Ourcompanys rapid growth has spurred the creation of well over 1
00 South Florida jobs and more than 20 in other locations in the United States. M
any more jobs will be created in coming years.
The recent passing of the JOBS Act will provide emerging companies and start-up
ventures like ours with increased access to vital capital. Itlowers the barriers
young companies face as they seek funding and will enable new entrants to enter
the market more easily. Like all industries, healthcare benefits from competition

and a free market.

Specifically, startups seeking seed capital can now access crowdfunding as a mea
ns to simply get started. This will allow more ventures and subsequently more job
s to be created. Not all ventures have the potential to command billion dollar va
luations, and therefore attract venture capital. However, these ventures may be w
orthy of smaller investments to get started and realize potential as they grow a
nd prosper.
This is an exciting time to be a member of the startup community, especially in
South Florida. More and more start-ups are emerging here in all sectors, so the
JOBS Act legislation could not have come at a better time. The growing interest
in entrepreneurship, coupled with this legislation, means more entrepreneurs wil
l have greater access to capital. That ultimately means more jobs and opportuniti
es in South Florida and beyond.
We live in unprecedented times. We now have incredible tools and enablers to buil
d companies, we will once again have abundant capital and a culture of creation,
we have an incredible amount of entrepreneurship best practices available to al
l of us, and we have an amazing support system in Silicon Valley and beyond. Alth
ough it was a thrill to attend President Obamas JOBS Act signing ceremony, it wil
l be an even bigger thrill to watch the results of the JOBS Act reap improvement
s on the startup community and the economy at large. I look forward to watching
more entrepreneurs disrupt business as usual in their industries with the help of
this legislation.