Those of us who are truly lucky have more than one mother. They are the cool aunts, the elderly ladies, the family friends, even the mentors who whip us into shape. By my count, I’ve had at least eight mothers. One of the most important was Sally Adams Bascom Augenstern.....Click to read this beautiful story by Heather Cox Richardson
> The Lithium Gold Rush: Inside the Race to Power Electric Vehicles || by Gabriella Angotti-Jones : The New York Times
> Trump Spawned a New Group of Mega-Donors Who Now Hold Sway Over the GOP’s Future || by Isaac Arnsdorf : ProPublica
> How College Became a Ruthless Competition Divorced From Learning || Daniel Markovits : The Atlantic
The federal government must aggressively bolster primary
care and connect more Americans with a dedicated source of care, the National
Academies of Sciences, Engineering and Medicine warn in a major report that
sounds the alarm about an endangered foundation of the U.S. health system.
The urgently worded report, which comes as internists,
family doctors and pediatricians nationwide struggle with the economic fallout
of the coronavirus pandemic, calls for a broad recognition that primary care is
a “common good” akin to public education.
The authors recommend that all Americans select a primary
care provider or be assigned one, a landmark step that could reorient how care
is delivered in the nation’s fragmented medical system.
And the report calls on major government health plans such
as Medicare and Medicaid to shift money to primary care and away from the
medical specialties that have long commanded the biggest fees in the U.S. system.
“High-quality primary care is the foundation of a robust
health care system, and perhaps more importantly, it is the essential element
for improving the health of the U.S. population,” the report concludes. “Yet,
in large part because of chronic underinvestment, primary care in the United
States is slowly dying.”
The report, which is advisory, does not guarantee federal
action. But reports from the national academies have helped support major
health initiatives over the years, such as curbing tobacco use among children
and protecting patients from medical errors.
Strengthening primary care has long been seen as a critical
public health need. And research dating back more than half a century shows
that robust primary care systems save money, improve people’s health and even
“We know that better access to primary care leads to more
timely identification of problems, better management of chronic disease and
better coordination of care,” said Melinda Abrams, executive vice president of
the Commonwealth Fund, a New York-based foundation that studies health systems
around the world.
Recognizing the value of this kind of care, many nations —
from wealthy democracies like the United Kingdom and the Netherlands to
middle-income countries such as Costa Rica and Thailand — have deliberately
constructed health systems around primary care.
And many have reaped significant rewards. Europeans with
chronic illnesses such as diabetes, high blood pressure, cancer and depression
reported significantly better health if they lived in a country with a robust
primary care system, a group of researchers found.
For decades, experts here have called for this country to
make a similar commitment.
But only about 5% of U.S. health care spending goes to
primary care, versus an average of 14% in other wealthy nations, according to
data collected by the Organization for Economic Co-operation and Development.
Other research shows that primary spending has declined in
many U.S. states in recent years.
The situation grew even more dire as the pandemic forced
thousands of primary care physicians — who didn’t receive the government
largesse showered on major medical systems — to lay off staff members or even
close their doors.
Reversing this slide will require new investment, the
authors of the new report conclude. But, they argue, that should yield big
“If we increase the supply of primary care, more people and
more communities will be healthier, and no other part of health care can make
this claim,” said Dr. Robert Phillips, a family physician who co-chaired the
committee that produced the report. Phillips also directs the Center for
Professionalism and Value in Health Care at the American Board of Family
The report urges new initiatives to build more health
centers, especially in underserved areas that are frequently home to minority
communities, and to expand primary care teams, including nurse practitioners,
pharmacists and mental health specialists.
And it advocates new efforts to shift away from paying
physicians for every patient visit, a system that critics have long argued
doesn’t incentivize doctors to keep patients healthy.
Potentially most controversial, however, is the report’s
recommendation that Medicare and Medicaid, as well as commercial insurers and
employers that provide their workers with health benefits, ask their members to
declare a primary care provider. Anyone who does not, the report notes, should
be assigned a provider.
“Successfully implementing high-quality primary care means
everyone should have access to the ‘sustained relationships’ primary care
offers,” the report notes.
This idea of formally linking patients with a primary care
office — often called empanelment — isn’t new. Kaiser Permanente, consistently
among the nation’s best-performing health systems, has long made primary care
central. (KHN is not affiliated with Kaiser Permanente.)
But the model, which was at the heart of managed-care health
plans, suffered in the backlash against HMOs in the 1990s, when some health
plans forced primary care providers to act as “gatekeepers” to keep patients
away from costlier specialty care.
More recently, however, a growing number of experts and
primary care advocates have shown that linking patients with a primary care
provider need not limit access to care.
Indeed, a new generation of medical systems that rely on
primary care to look after elderly Americans on Medicare with chronic medical
conditions has demonstrated great success in keeping patients healthier and
costs down. These “advanced primary care” systems include ChenMed, Iora Health
and Oak Street Health.
“If you don’t have empanelment, you don’t really have
continuity of care,” said Dr. Tom Bodenheimer, an internist who founded the
Center for Excellence in Primary Care at the University of California-San
Francisco and has called for stronger primary care systems for decades.
Bodenheimer added: “We know that continuity of care is
linked to everything good: better preventive care, higher patient satisfaction,
better chronic care and lower costs. It is really fundamental.”
Source: KHN (Kaiser Health News) is a national newsroom that
produces in-depth journalism about health issues. Together with Policy Analysis
and Polling, KHN is one of the three major operating programs at KFF (Kaiser
Family Foundation). KFF is an endowed nonprofit organization providing
information on health issues to the nation.
In some times and places, life is seen as a one-way expedition from birth to death. We progress linearly and don’t look back. In other times and places, life is circular, a never-ending round trip. We live, die, and live again....Read more
They knew the neighborhood would revolt. It was early May, and officials in this Northern California city known for its farm-to-table dining culture and pumped-up housing prices were frantically debating how to keep covid-19 from infiltrating the homeless camps proliferating in the region’s celebrated parks and trails. The number of people living homeless in Santa Rosa and the verdant hills and valleys of broader Sonoma County had surged, exacerbated by three punishing wildfire seasons that destroyed thousands of homes in four years....... Read more
"Repetition makes a fact seem more true, regardless of whether it is or not. It is a law of propaganda often attributed to the Nazi Joseph Goebbels. Understanding this effect can help you avoid falling for propaganda, says psychologist Tom Stafford".....
...."The key finding is that people tend to rate items they've seen before as more likely to be true, regardless of whether they are true or not, and seemingly for the sole reason that they are more familiar".... Click to read Tom Stafford's article published by the BBC on October 26, 2016
Kyunghee Lee’s right hand hurts all the time.
She spent decades running a family dry cleaning store outside Cleveland after emigrating from South Korea 40 years ago. She still freelances as a seamstress, although work has slowed amid the covid-19 pandemic.
While Lee likes to treat her arthritis with home remedies, each year the pain in the knuckles of her right middle finger and ring finger increases until they hurt too much to touch. So about once a year she goes to see a rheumatologist, who administers a pain-relieving injection of a steroid in the joints of those fingers.
Her cost for each round of injections has been roughly $30 the past few years. And everything is easier, and less painful for a bit, after each steroid treatment.
So, in late summer she masked up and went in for her usual shots. She noticed her doctor’s office had moved up a floor in the medical building, but everything else seemed just the same as before — same injections, same doctor.
Then the bill came.
The Patient: Kyunghee Lee, a 72-year-old retiree with UnitedHealthcare AARP Medicare Advantage Walgreens insurance who lives in Mentor, Ohio
Medical Service: Steroid injections into arthritic finger joints
Service Provider: University Hospitals Mentor Health Center, part of the University Hospitals health system in northeastern Ohio
Total bill: $1,394, including a $1,262 facility fee listed as “operating room services.” The balance included a clinic charge and a pharmacy charge. Lee’s portion of the bill was $354.68.
What Gives: Lee owed more than 10 times what she had paid for the same procedure done before by the same physician, Dr. Elisabeth Roter.
Lee said it was the “same talking, same injection — same time.”
Lee and her family were outraged by the sudden price hike, considering she had gotten the same shots for the far lower price multiple times in the years before. Her daughter, Esther, said this was a substantial bill for her mother on her Social Security-supplemented income.
“This is a senior citizen for whom English is not her first language. She doesn’t have the resources to fight this,” Esther Lee said.
What had changed was how the hospital system classified the appointment for billing. Between 2019 and 2020, the hospital system “moved our infusion clinic from an office-based practice to a hospital-based setting,” University Hospitals spokesperson George Stamatis said in an emailed statement.
That was a change in definition for billing. The injection was given in the same medical office building, which is not a hospital. Lee did not need or get an infusion, which requires the insertion of an IV and some time spent allowing the medicine to flow into a vein.
Nonetheless, that change allowed the hospital system to bill what’s called a “facility fee,” laid out on Lee’s bill as “operating room services.” The increasingly controversial charge — basically a room rental fee — comes without warning, as hospitals are not required to inform patients of it ahead of time.
Hospitals say they charge the fee to cover their overhead for providing 24/7 care, when needed. Stamatis also noted the cost of additional regulatory requirements and services “that help drive quality improvement and assurance, but do increase costs.”
But facility fees are one reason hospital prices are rising faster than physician prices, according to a 2019 research article in Health Affairs.
“Facility fees are designed by hospitals in particular to grab more revenue from the weakest party in health care: namely, the individual patient,” said Alan Sager, a professor of health policy and management at the Boston University School of Public Health.
Lee’s insurance had changed to a Medicare Advantage plan in 2020. The overall cost for the appointment was nearly three times what it was in 2017 — before insurance even got involved.
The National Academy for State Health Policy has drafted model legislation for states to clamp down on the practice, which appears to have worsened, Executive Director Trish Riley said, as more private practices have been bought by hospitals and facility fees are tacked onto their charges.
“It’s the same physician office it was,” she said. “Operating in exactly the same way, doing exactly the same services — but the hospital chooses to attach a facility fee to it.”
New York, Oregon and Massachusetts are pursuing legislation to curtail this practice, she said. Connecticut has a facility fee transparency law on the books, and Ohio, where Lee lives, is considering legislation that would prohibit facility fees for telehealth services.
But Riley noted it’s difficult to fight powerful hospital lobbyists in a pandemic political climate, where hospitals are considered heroic.
The Centers for Medicare & Medicaid Services has attempted to curtail facility fees by introducing a site-neutral payment policy. The American Hospital Association sued over the move and plans to take the case to the Supreme Court.
Resolution: Lee’s daughter, Esther Lee, was furious with the hospital over the fee. Her mom, who is fiercely independent, finally brought her the bill after trying for weeks to get the billing office to change it.
“This is wrong,” Esther Lee said. “Even if it was a lot of money for services properly rendered, then of course she would pay it. But that’s not the case here.”
When Lee called her doctor’s office to complain, they told her to talk to the billing department of the hospital. So Lee, with Esther’s help, repeatedly called the billing department and filed a complaint with Medicare.
“I don’t want to lose my credit,” Kyunghee Lee said. “I always paid on time.”
But after receiving a “final notice” in February, and then being threatened with being sent to collections, the Lee family gave up the fight. Esther Lee paid the bill for her mother. But she’s worried her mom will delay getting the shots now, putting up with the pain longer, as she knows they are more expensive.
The Takeaway: When planning an outpatient procedure like an injection or biopsy, call ahead to ask if it will happen in a place that’s considered a “hospital setting” — even if you think you understand the office’s billing practices. Ask outright if there will be a facility fee — and how much — even if there’s not been one before. If it’s an elective procedure, you can search for a cheaper provider.
One easy place to scout for more affordable care is the office of a doctor whose practice has not been bought by a hospital. It is the hospital, not your longtime doctor, that is adding the fee, said Marni Jameson Carey, executive director of the Association of Independent Doctors.
“This is one of the terrible fallouts of consolidation,” Carey said.
Stephanie O’Neill contributed to the audio version of this story.
Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
Billions of people in the world are living in poverty. Adjusted for the purchasing power in each country, 85% of the world population live on less than $30 per day.
In an earlier post I said that ‘if we want global poverty to decline substantially then the economies that are home to the poorest billions of people need to grow.’ In this post I want to make this statement more concrete. I will look at the depth of global poverty today to get a quantitative sense of just how much the global income distribution would need to change to reduce global poverty substantially. Continue reading
Working from home is a dream come true for some people and a nightmare for others. It all depends on your perspective. In the wake of the coronavirus pandemic, some people who started working remotely were happy about the changes. For one thing, working from home saved them time and money that would have been spent on commuting to work every day.
However, the most important advantage of working from home is that it will keep you safe from getting infected by the novel coronavirus. Right now, this is the only reason that counts. Thankfully, software developers have the privilege of working from home. This has propelled some of them to consider relocation from Silicon Valley to more affordable cities in Texas.
Tech Talent Flee From Silicon Valley
Do you know that there are more than 225,300 high tech workers in Silicon Valley, San Francisco? To put this into perspective, there are 387,000 high tech jobs in the entire country. So, if there are 225,300 high-tech jobs in Silicon Valley, then you can understand why it is the best hub for web developers around the world. Unfortunately, the city is at risk of losing its position as the number one destination for tech talent. This is primarily because of two things: talent relocation and company relocation.
Without the companies and the hundreds of thousands of tech workers in Silicon Valley, the city is going to lose its title as the foremost destination for tech gurus in the United States. This makes it one of the most technologically innovative places in the world but it also makes it one of the most expensive. House rent in the Valley is unrealistically high and it's only going to keep increasing. Tech jobs pay more money than many other jobs in Silicon Valley. However, tech workers aren't satisfied with spending all the money they have on daily expenses.
A small one-bedroom apartment in Silicon Valley costs over $2,000 monthly. By the time you factor in food and other expenses, you might spend over $5,000 just to survive in Silicon Valley every month. This isn't something the average worker can afford. Some of the tech workers who can afford this expensive lifestyle don't think the Valley is worth all the hype. Since they can now work from home, many of these workers have decided to leave the expensive city for more affordable places.
Why should any average worker pay $5,000 monthly to survive when they spend $2,000 for the same standard of living in another city? The primary reason why many of these tech workers remained in Silicon Valley for this long is because of their jobs. Now that they no longer have to go to the office, they want out of the city. Some of them have already indicated an interest in moving to Texas while many others have moved out already.
Coronavirus is Changing Tech Salaries
As tech talent and companies flee Silicon Valley, they inspire even more people to leave the overpriced city. However, tech companies that are remaining in Silicon Valley aren't ready to let their talent relocate, remote work, or not. Facebook and other companies have given their workers ultimatums. They have the choice to remain in Silicon Valley and keep their fat salaries or relocate and face cuts. The salary cuts depend on the company but Facebook is threatening to remove up to 10% of the salary of remote workers. Some other companies claim that they will cut between 8% to 20% depending on where their workers choose to go after leaving the Valley. The cheaper the cost of living in the new place, the higher the salary cut.
Covid-19 is changing tech salaries in the United States and every other part of the globe. Many similar things have been happening in tech companies around the world, but the most pronounced rate of relocation is in Silicon Valley. Tech companies like Oracle and Hewlett Packard have also left the Valley for Texas. Even Elon Musk has moved from his Silicon Valley home to the Lone Star State. If companies keep leaving the Valley, it will no longer be the most popular tech hub in the world.
Most of us entered the Internet Age with high hopes and expectations of what it could bring to us. Now, we find an online world dominated by corporations in pursuit of increased revenues, profit, and higher valuations. A world, where we, the users of the services are the product, where disinformation reigns, radicalization is rampant, rage is out in the open and where every day our privacy slips away. Read the Atlantic article "How to Put Out Democracy’s Dumpster Fire"
Covid-19 infections from variant strains are quickly spreading across the U.S., but there’s one big problem: Lab officials say they can’t tell patients or their doctors whether someone has been infected by a variant.
Federal rules around who can be told about the variant cases are so confusing that public health officials may merely know the county where a case has emerged but can’t do the kind of investigation and deliver the notifications needed to slow the spread, according to Janet Hamilton, executive director of the Council of State and Territorial Epidemiologists.
“It could be associated with a person in a high-risk congregate setting or it might not be, but without patient information, we don’t know what we don’t know,” Hamilton said. The group has asked federal officials to waive the rules. “Time is ticking.”
The problem is that the tests in question for detecting variants have not been approved as a diagnostic tool either by the Food and Drug Administration or under federal rules governing university labs ― meaning that the testing being used right now for genomic sequencing is being done as high-level lab research with no communication back to patients and their doctors.
Amid limited testing to identify different strains, more than 1,900 cases of three key variants have been detected in 46 states, according to the Centers for Disease Control and Prevention. That’s worrisome because of early reports that some may spread faster, prove deadlier or potentially thwart existing treatments and vaccines.
Officials representing public health labs and epidemiologists have warned the federal government that limiting information about the variants ― in accordance with arcane regulations governing clinical labs ― could hamper efforts to investigate pressing questions about the variants.
The Association of Public Health Laboratories and the Council of State and Territorial Epidemiologists earlier this month jointly pressed federal officials to “urgently” relax certain rules that apply to clinical labs.
Washington state officials detected the first case of the variant discovered in South Africa this week, but the infected person didn’t provide a good phone number and could not be contacted about the positive result. Even if health officials do track down the patient, “legally we can’t” tell him or her about the variant because the test is not yet federally approved, Teresa McCallion, a spokesperson for the state department of health, said in an email.
“However, we are actively looking into what we can do,” she said.
Lab testing experts describe the situation as a Catch-22: Scientists need enough case data to make sure their genome-sequencing tests, which are used to detect variants, are accurate. But while they wait for results to come in and undergo thorough reviews, variant cases are surging. The lag reminds some of the situation a year ago. Amid regulatory missteps, approval for a covid-19 diagnostic test was delayed while the virus spread undetected.
The limitations also put lab professionals and epidemiologists in a bind as public health officials attempt to trace contacts of those infected with more contagious strains, said Scott Becker, CEO of the Association of Public Health Laboratories. “You want to be able to tell [patients] a variant was detected,” he said.
Complying with the lab rules “is not feasible in the timeline that a rapidly evolving virus and responsive public health system requires,” the organizations wrote.
Hamilton also said telling patients they have a novel strain could be another tool to encourage cooperation ― which is waning ― with efforts to trace and sample their contacts. She said notifications might also further encourage patients to take the advice to remain isolated seriously.
“Can our investigations be better if we can disclose that information to the patient?” she said. “I think the answer is yes.”
Public health experts have predicted that the B117 variant, first found in the United Kingdom, could be the predominant variant strain of the coronavirus in the U.S. by March.
As of Tuesday, the CDC had identified nearly 1,900 cases of the B117 variant in 45 states; 46 cases of B1351, which was first identified in South Africa, in 14 states; and five cases of the P.1 variant initially detected in Brazil in four states, Dr. Rochelle Walensky, the CDC director, told reporters Wednesday.
A Feb. 12 memo from North Carolina public health officials to clinicians stated that because genome sequencing at the CDC is done for surveillance purposes and is not an approved test under the Clinical Laboratory Improvement Amendments program ― which is overseen by the U.S. Centers for Medicare & Medicaid Services ― “results from sequencing will not be communicated back to the provider.”
Earlier this week, the topic came up in Illinois as well. Notifying patients that they are positive for a covid variant is “not allowed currently” because the test is not CLIA-approved, said Judy Kauerauf, section chief of the Illinois Department of Public Health communicable disease program, according to a record obtained by the Documenting COVID-19 project of Columbia University’s Brown Institute for Media Innovation.
The CDC has scaled up its genomic sequencing in recent weeks, with Walensky saying the agency was conducting it on only 400 samples weekly when she began as director compared with more than 9,000 samples the week of Feb. 20.
The Biden administration has committed nearly $200 million to expand the federal government’s genomic sequencing capacity in hopes it will be able to test 25,000 samples per week.
“We’ll identify covid variants sooner and better target our efforts to stop the spread. We’re quickly infusing targeted resources here because the time is critical when it comes to these fast-moving variants,” Carole Johnson, testing coordinator for President Joe Biden’s covid-19 response team, said on a call with reporters this month.
Hospitals get high-level information about whether a sample submitted for sequencing tested positive for a variant, said Dr. Nick Gilpin, director of infection prevention at Beaumont Health in Michigan, where 210 cases of the B117 variant have been detected. Yet patients and their doctors will remain in the dark about who exactly was infected.
“It’s relevant from a systems-based perspective,” Gilpin said. “If we have a bunch of B117 in my backyard, that’s going to make me think a little differently about how we do business.”
It’s the same in Washington state, McCallion said. Health officials may share general numbers, such as 14 out of 16 outbreak specimens at a facility were identified as B117 ― but not who those 14 patients were.
There are arguments for and against notifying patients. On one hand, being infected with a variant won’t affect patient care, public health officials and clinicians say. And individuals who test positive would still be advised to take the same precautions of isolation, mask-wearing and hand-washing regardless of which strain they carried.
“There wouldn’t be any difference in medical treatment whether they have the variant,” said Mark Pandori, director of the Nevada State Public Health Laboratory. However, he added that “in a public health emergency it’s really important for doctors to know this information.”
Pandori estimated there may be only 10 or 20 labs in the U.S. capable of validating their laboratory-based variant tests. One of them doing so is the lab at the University of Washington in Seattle.
Dr. Alex Greninger, assistant director of the clinical virology laboratories there, who co-created one of the first tests to detect SARS-CoV-2, said his lab began work to validate the sequencing tests last fall.
Within the next few weeks, he said, he anticipates having a federally authorized test for whole-genome sequencing of covid. “So all the issues you note on notifying patients and using [the] results will not be a problem,” he said in an email.
Companies including San Diego-based Illumina have approved covid-testing machines that can also detect a variant. However, since the add-on sequencing capability wasn’t specifically approved by the FDA, the results can be shared with public health officials ― but not patients and their doctors, said Dr. Phil Febbo, Illumina’s chief medical officer.
He said they haven’t asked the FDA for further approval but could if variants start to pose greater concern, like escaping vaccine protection.
“I think right now there’s no need for individuals to know their strains,” he said.
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