Healthcares hyperinflation is driving the transformation of how care gets reimbursed resulting in a massive disruption in healthcare. For example, pharma companies will succeed or fail based not on how much drug they sell, but on how well their market offerings improve outcomes.As the largest spenders on R&D in healthcare, massive changes in the way pharmaceutical companies operate are going to have a profound effect on health technology while letting pharma adapt to marketplace changes. It is creating opportunityfor startup businesses that heretofore have been stymied when trying to make inroads into healthcare.In the past, I have frequently said that healthcare is where tech startups go todie. A combination of factors ranging from risk aversion to entrenched legacy vendors exerting account control to health IT not being viewed as a source of competitive advantage for healthcare providers has made it difficult for promisingnew companies to make a dent. In this three-part series, I will lay out the mostimportant dynamics transforming the opportunity for health technology startups.In Part I, I will highlight how Pharma 3.0 will drive a shift from traditional Life Science to HealthTech investing. In Part II, I will outline how healthcare providers will use HealthTech to differentiate and produce better outcomes. Ill wrapup the series laying out how many healthcare organizations are on a path to repeat mistakes the newspaper industry made beginning in the mid-90s. There are remarkable parallels that both spell peril for the incumbent healthcare providers ifthey repeat the newspaper companies mistakes and create massive new opportunities such as those I outlined earlier in pieces about The Most Important Organization in Silicon Valley No One Has Heard About and Hotwire for Surgery.Pharma 3.0 Will Drive Shift from Life Science to HealthTech InvestingE&Y has produced industry reports for the Pharmaceutical industry that provide acomprehensive look at pharmas history to outline its present condition. E&Y interviewed scores of innovators and senior executives to outline out a vision for what they call Pharma 3.0.The following is an excerpt from their nearly 100 page report entitled Progressions Building Pharma 3.0 (read the full report here):The Progressions report identifies several industry trends driving nontraditional companies into the sector, including health reform, health IT, comparativeeffectiveness, and the rising confidence in consumer power. These factors and others are prompting pharmaceutical companies to broaden their focus from producing new medicines to delivering healthy outcomes a shift that will be driven through creative partnerships and business model innovation.During my years working in health systems and hospitals, I rarely crossed pathswith the pharma industry even though we were ostensibly serving the same organization. The only time I saw pharma reps was noticing well-dressed folks in the cafeteria that were clearly the pharma reps. My time was spent in the IT and Patient Accounting departments where much of Health IT was relegated. Whereas HealthIT was viewed as a cost item to be minimized, pharma and Medical Device productsrepresented revenue generation and differentiation opportunities for healthcareproviders.In the flawed fee-for-service model that has driven healthcares hyperinflation, financial rewards incentivized activity (order a test, prescribe a drug, do a procedure, etc.) rather than positive health outcomes. For example, there are 60MMCT Scans done per year in the U.S. despite the fact that there isnt a radiologistin the world who believes anywhere near that volume is required. Nonetheless, we 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 to change reimbursement to reward positive health outcomes over mere activity. Inaddition, electronic medical records are helping reduce duplicate tests.Based on my past (non)experience with pharma, it has been remarkable the numberof pharma companies that are now proactively reaching out to software companieswho can help them enter with new services focused on outcomes that have little or nothing to do with what I would traditionally associate with pharma. Their strategies 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 responsible for the end-to-end health of a population of individuals with a particular disease. As I will touch on in the 3rd part of the series, this will have a profound effect on the competitive landscape for traditional health providers. Not manyhealthcare providers are prepared for this type of competitor.Like it or not, healthcare is like most arenas revenue (aka reimbursement) drives 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 developing 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 outcomeswill radically alter their behavior. They recognize the competitive threat. Asthe E&Y report stated, Pharma companies have expanded the number of pharma 3.0 initiatives by 78% since 2010. Yet non-traditional players have invested even morein Pharma 3.0. The sense of urgency with the pharma organizations Ive met with isremarkable.To date, IT investment in healthcare has been mostly limited to the administrative/reimbursement facets of healthcare (e.g., claims processing). The primary exception is the software that has been embedded into medical devices with little or no ability for the clinician to interact with the device. Theres a contrast with where money is actually spent in healthcare i.e., healthcare delivery versus therapeutics as outlined in a piece by angel investor and life science veteran Don 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 in2009. Of this, 84 percent was spent on healthcare delivery, which includes costs associated with clinicians and insurance companies. In contrast, only 16 percent was spent on therapeutics, including medical devices and drugs. Although venture investors traditionally have put their money into therapeutics rather than delivery, the balance is shifting.As Pharma companies recast themselves as health outcomes companies in response toanticipated reimbursement shifts, one can expect that venture capitalists and Pharma/Biotech will shift their investment focus from almost exclusively Life Sciences to integrated approach with Health Tech and an outcomes. Areas such as decision support, care coordination, patient engagement, etc. become paramount if one is going to address outcomes versus simply encouraging more activities that the legacy reimbursement model have incentivized.Increasingly the very survival of the pharmaceutical industry is predicated on creative alliances with nontraditional players such as IT companies. No longer will healthcare be where tech companies go to die for the startups with transformative products that may have languished in the past. The very survival of one ofthe most profitable industries in the world depends on it.In the New Yorker, Dr. Atul Gawande outlined how, at the turn of the 20th century, more than forty per cent of household income went to paying for food and foodproduction consumed nearly half the workforce. Starting in Texas, a wide array

of new methods of food production were tested. Long story short, food now accounts for 8% of household budgets and 2% of the workforce. As a wide array of smallinnovations ultimately led to the transformation of farming, so too is a rapidly building wave of innovative new care and payment models leading to similar breakthroughs in healthcare. I call this Nimble Medicine.Traditionally, attempting a new care or payment model meant long planning and development cycles. The cost and complexity of testing new models prevented many from being tried. Even today, the leading HealthIT vendor is known to charge $100million and up for its software. Amazingly, they require three months of training before they even let people use the software. This is a vestige of the do more, bill more model of reimbursement particularly given that healthcare is a supply-driven market (e.g., MDs who own a stake in imaging equipment order scans at three times the rate of MDs who dont). Spending nine figures doesnt sound so bad when you have capital projects planned in excess of $1 Billion. Perhaps we shouldrefer to the legacy model as the build more, do more, bill more model. Any healthanalyst will tell you that the cure for healthcares hyperinflation is NOT building more healthcare facilities. Its as if a fire department argued that the way tosolve a wave of structural fires was to buy more fire fighting equipment. Yes, that might help, however theres a much more cost-effective approach such as havingbuildings inspected for fire prevention capabilities.In their book, The Innovators Prescription, Clayton Christensen and Dr. Jason Hwang point out how applying technology into old business models has only raised costs.Innovator s Prescription - New tech into old modelsIn contrast, disruptive innovators such as WhiteGlove Health and Qliance rethought the care delivery and payment models from the ground up. Their results have been impressive. For example, Qliance has Net Promoter Scores higher than Googleor Apple, while reducing the direct costs of healthcare (i.e., their service coupled with a high deductible wrap-around policy) 20-40%. More impressively, theyhave reduced the most expensive downstream costs (surgical, specialist and emergency visits) 40-80%. Likewise, WhiteGlove Health already has 500,000 members andhas more 5-star reviews on CitySearch than any other organization in the country. In WhiteGloves S-1 filing, they highlight the importance of proprietary software they have developed to give them a cost and consumer experience advantage.The next wave of disruptive innovators are taking advantage of second-mover advantage as the wave of healthtech startups provide them off-the-shelf software that is an order of magnitude less investment than the first wave of innovators. Itsa couple orders of magnitude less expensive than legacy HealthIT. More importantly for the innovators is the speed that they can not only stand up the new technology but also easily iterate based on real world experience. Rather than months or years, its hours or days. This is a key component of Nimble Medicine.Consider the following scenarios: [Disclosure, my company, provides some of thetechnology components underlying these models which is why I have visibility into their strategy.]arriveMD has taken the lean practice model to an extreme by closing a bricksand 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 coupleweeks to put the technology into practice while running his practice, closing his stationary clinic, and outfitting his clinic on wheels.MedLion (aka The Most Important Organization in Silicon Valley No One Has Heard About) has created a fast-growing Direct Primary Care model with minimal capital investment. So far in 2012, they are opening clinics at the rate of one perweek. 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 thatmany individuals are using the emergency department as their primary care facility. This is because these individuals arent able to access a regular primary care provider. Unfortunately, many of them are unable to pay the high fees common in an ER. Rather than simply sending them to collections, they are setting up anaffordable alternative outside of the ER for non-emergent care. The technology setup takes less than a week to enable this new line of business. Theyve taken a lesson from wireless carriers who realize that more affordable packages can address a market need yet still be profitable.Sites such as 2nd.md have created virtual second opinion or e-consult marketplaces. Rather than flying from Alaska to San Francisco to get a critical secondopinion or consultation, the individual and their family can save time and money through a virtual encounter. In response, some physicians are realizing that they 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 thatallows intake of patient information (medical history, lab results, etc.), a virtual visit (e.g., using software from a company like Revation) and then followup documentation. The entire technology implementation doesnt take more than a couple of days. This has been applied in disciplines ranging from oncology to orthopedics to pediatrics and more.Even established organizations such as Catholic Health Partners are becomingmore nimble. For example, a when drug gets taken off the market for safety issues, they can immediately identify the subgroup of patients currently on the drugfor outreach, while simultaneously removing the drug from order preference lists and order sets, substituting with appropriate alternative medications. At onetime this took days and now it takes just hours.For those of us in the technology industry, theres striking parallels with what has happened in technology where centralization was followed by decentralization.For providers, lessons can be drawn regarding how some organizations were ableto make the transition from one generation to the next while many others faded from the landscape. The graphic below depicts the transition from the slide ruleto the mainframe and then back out to mobile devices.Innovator s Prescription - Decentralization followed centralizationIn an earlier piece (Healthcare Field of Dreams In Idaho: Health System Opens Innovation Center), I highlighted an innovation group that is building the next hospital a hospital without walls. Unlike a massive capital project necessary to build a traditional hospital, I expect that new wings of the virtual hospital will get built via a series of smaller projects. They have hired entrepreneurial peopleto bring the agility necessary in this new approach. This is a great example ofNimble Medicine.As healthcare goes through massive changes, health system CEOs would be well advised 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 dynamics were present:Owning printing presses was a de facto barrier to entry allowing newspapersunfettered dominance.Newspaper companies bought up smaller newspaper chains and took on huge debt.Newspapers were comfortable as oligopoly or monopoly enterprises allowing for slow, plodding decisions. Their IT infrastructure mirrored this with expensiveand rigid technology architectures.Newspaper leaders knew full well that dramatic change was coming and even made 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 unsustainable. The capital barrier to entry turned into a boat anchor while nimble entrantscreated a death-by-a-thousand-paper-cuts dynamic. Competitively, newspaper companies mistakenly worried about other media companies or even Microsoft, but theirundoing was driven by a combination of craigslist, monster.com, cars.com, eBay,and countless other marketing substitutes for their advertisers and there wereeasier ways to get news than newspapers. Generally, the newspapers digital groupswere either unbearably shackled or marginalized so that the frustrated digitalleaders left to join nimble new competitors. The enabling technology to reinventlocal media didnt come from legacy IT vendors whod previously sold to newspaper companies, but from no name technologies such as WordPress, Drupal and the like.The parallels with health systems today are striking. Consider the present dynamics:Until recently, complex medical procedures had to take place in an acute care hospital setting. Now they are being done more and more in specialty facilities that can do a high volume of particular procedures at a much lower cost. [Seearticle graphic.]Health systems have been aggressively buying up other healthcare providers and frequently taking on debt in the process. At the same time, health systems often have capital project plans that equal their annual revenues even though no expert believes the answer to healthcares hyperinflation is building more buildings. Consider the duplicative $430 million being spent in San Diego to build two identical facilities just a few miles apart as Exhibit A of the problem. Lookingat the history of other countries that shifted from a sick care to a health care system, more than half of the hospitals closed. They simply werent needed or werent appropriate.Just as newspapers were implementing multimillion dollar IT systems while nimble competitors were using low and no cost software to disrupt the local medialandscape, health systems are similarly implementing complex systems to automatethe complexity necessary in a multi-faceted system. Meanwhile, nimble competitors 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 health of a population. Imagine if a fraction of the 100s of millions being spent by mission-driven health systems on automating complexity was redirected towardsthe reinvigoration of primary care.The pace and scale of innovation at most health systems isnt up to the enormity of the task. The vast majority of health system innovation teams are constrained by how they have to fit innovation into an existing infrastructure. That approach rarely leads to breakthroughs, as its true intent is to make tweaks to a current system rather than a rethink from the ground up.Compared to newspapers, the scale and importance of the challenge is far greaterfor health systems so they must aggressively take action or risk their future viability.Prescription for Healthcare From a Newspaper Industry ExecutiveIn the midst of the newspaper industry carnage, there is one particular bright spot from an individual who has gone against the conventional wisdom that newspapers are doomed to fail. His name is John Paton and hes reinventing local media. Ill highlight some of what hes done to turn a bankrupt (financially and creatively)enterprise into a profitable, dynamic and rapidly growing enterprise attractingthe all-stars of the industry.There has been an expression in traditional media that analog dollars are turning 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 response at Digital First Media has been then start stacking the dimes. All of thatrequires a big culture change. A change that requires an adoption of the Fail Fast mentality and the willingness to let the outside in and partner. Partneringis vital to any media companys growth whether it is an established media companyor start-up. We are going to marry our considerable scale with start-up innovation to build success.Its worth noting that those digital dimes are often more profitable than the analogdollars of the past because much less overhead is required.The following is John Patons 3-point prescription for reinvention that led to a 5x revenue increase and halving of capital expenses. This resulted in his organization going from bankruptcy to $41 million in profit in two years.Speed to market: One new product launched per week [See Related Article: TheRise of Nimble Medicine]Scaling opportunity: Sourced centrally, implemented locally. Ideas can comefrom all over. Identify the best ideas/people from all overLeverage partners Feed the firehose of ideas from outside.Unfortunately, before John Paton was able to affect this level of change, scoresof newspaper employees lost their jobs while traditional newspaper executives dawdled. It is the rare leader that can create the sense of urgency necessary toaffect this scale of change before the enterprise is a hairs breath from extinction. As the old oil filter ad says, you can pay now or pay later of course, the cost is much greater if change is put off. The only question is whether health system leaders will have the courage to make the change before the inevitable crisishits with full force.Applying Reinvention Lessons into HealthcareThe following are some ideas and examples of how this approach can be applied totackle the enormous challenge facing health system leaders. [Disclosure: The company where Im CEO, Avado, provides enabling technology for some of the organizations mentioned which is why I have a view into their projects.]Fresh, Outside Perspective is ImperativeAs John Paton brought in outside advisors such as Jeff Jarvis and Jay Rosen, health systems would be well-advised to do the same. They can go a step further andpartner with innovators driving new models. They can be project managers or partners. Examples follow:Mike Berkowitz has been a pioneer in telehealth including running his own business, Telehealthcare.com. Large and small healthcare providers are hiring himto develop and implement their telehealth programs.Dr. Samir Qamar founded MedLion as a mass-market version of primary care. MedLion works with healthcare providers to transition from a do more, bill more model to a patient-centric, accountable model that is affordable yet produces impressive outcomes and a dramatically better bottom-line than a standard practice.Ken Erickson is the CEO of Employer Direct Healthcare. Hes working with providers to deploy bundled case rates. That is, rather than getting scores of billsfrom various providers and the accompanying morass, they enable a single, transparent cost for procedures. This also enables healthcare providers to tap new distribution models for their services.Communication is the Most Important Medical Instrument of the FutureJohn Paton has demonstrated an unprecedented level of communication in redefining the culture of his organization. This approach has set the tone for his organization. Imagine if that tone was set by healthcare leaders for their organizations. 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. Communications is the antidote to that avoidable disaster.Like local media executives in the late 90s, healthcare leaders can view the present situation as either the best or worst time to be in their role. The health system leaders who believe its the best of times would do well to ask WWJD What Would John Do? John Paton demonstrates how a strong leader can reinvigorate and reinvent 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 model of reimbursement are numbered as they have produced one of the most inefficient healthcare systems in the world. While there are many unknowns regarding thefuture model, one thing is crystal clear highly effective communication will separate the winners from the losers.The quantum improvement in the depth and breadth of communication seen in the consumer Internet and in the consumerization of the enterprise (iPhones, Yammer, etc.) has yet to fully impact healthcare. With healthcare representing nearly 20%of the economy, the stakes are so high that it is inevitable that communications will be a key driver separating the winners from the losers as the tectonic shifts in the landscape shake out. This will usher in an array of new technology entrants similar to consumer and enterprise arenas disrupting ineffective and expensive communication methods of the past. The stars are aligning to make this happen.I dont think you can overstate the importance of communication in clinical care. Even with devices, robotics, genomics and personalized care, it all rests, and depends on, clear communication.- Dr. Wendy Sue Swanson, MD, MBE, FAAPThe Individual (aka the Patient) is the Most Important Member of the Care TeamIts long been said that the most important member of the care team is the individual (or their family member).Quite simply, in a world where one is compensated on value and outcome, its nearly 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 drive 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, the individual and/or their family are clearly in control of actions that will drive the ultimate outcome. Whether adhering to an exercise, diet or prescription plan, the patient/family plays the central role in determining the outcome.The importance of this cant be overemphasized given that 75% of healthcare spendresults from chronic conditions. Decisions made while a condition is in low acuity can rapidly lead to high acuity flare ups that drive large medical bills. AsDr. Swanson states, the steering wheel should be attended by the patient. After all, 99+% of an individuals life is spent away from healthcare providers and no oneelse besides them is in the drivers seat.It is a good thing that there has been great focus put on improving communication between healthcare professionals through standards and incentives related to the new models being driven by private and federal insurance programs. The Patient Centered Medical Home and the Accountable Care Organizations are the two mosthigh profile of these. However, the communication focus has been about the patient 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 these systems is that the patient is merely a vessel to attach billing codes to nota core part of the care team. This legacy approach will prove to be a fatal flaw in the new reimbursement models. Throwing bodies (e.g., care coordinators) atthe problem can help, but will be at a disadvantage versus approaches that combine the best of human and technology driven communication methods.There are efforts being made to tweak legacy software to address these requirements. Unfortunately, they are as likely to meet the new imperatives as AOL, Microsoft and Yahoo have been at becoming market leaders in social networking. The reality is Facebook built social networking into their core design from the groundup and bolting a dramatically different approach onto an old system rarely works whether it is social networking or patient-provider communications.Good News for Forward Looking Healthcare OrganizationsI get knowing nods from my physician friends when I exclaim that I hear more frequently from my dogs vet than my doctor or my kids doctor. We realize why the historical reimbursement models have contributed to this dynamic. Considering that people retain less than 20% of what a doctor tells them, this lack of communication and patient retention is a brutal combination driving sub-optimal outcomes. The good news is there is a tremendous competitive advantage that a healthcare provider 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 imperativein the new models. Simplistic patient portals, however, wont get the job done. Iveyet to meet the physician or individual who thinks that just making lab resultsavailable to patients or allowing for secure messaging is changing the care paradigm.Whether out of desire or necessity, consumers are ready for improved communication so they can save on their healthcare costs. Its expected that roughly one-third 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. The 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 has happened in virtually every other sector. Dr. Patricia Salber wrote about DIYHealthcare to explain how far things have already come and to assert her opinion that this is just the tip of the iceberg.Thought-leading Physicians Are ReadyFortunately the economics and simplicity of the consumer Internet and SaaS havefinally come to healthcare. Once upon a time, sophisticated new software was first deployed in large enterprises. Today, greatly improved communication technologies begin with small organizations. Consider a physician like Dr. Craig Koniverwho uses various free (e.g., Evernote) and low-cost off-the-shelf software to manage his communications without employing any administrative staff. Dr. Kent Bottles wrote about reverse innovation in healthcare talking about offshore innovation making its way to the U.S., but its not just offshore healthcare that can bea source of innovation. Dr. Howard Luks, an orthopedic surgeon, is another example of an innovative individual physician that is more sophisticated than most large healthcare providers by simply using free and low cost software to communicate with current and prospective patients.As was highlighted in The Rise of Nimble Medicine, there is an explosion of disruptive innovators as well as innovation groups inside established healthcare organizations. In many respects, healthcare has been measured on production with an

almost factory floor-like model of producing as many widgets (i.e., procedures, appointments, tests, prescriptions, etc.) as possible. However with a shift to aservice model where success will be driven by factors such as satisfaction and health outcomes, smart healthcare providers recognize that systems optimized forproduction are ill-equipped to optimize for outcome. With that in mind, recognition grows that communication becomes the most important medical instrument of the future.Doctors, nurses and other health care providers in America work incredibly hardto deliver the best care possible to their patients. Unfortunately, an alarming number of patients are harmed by medical mistakes in the health care system and far 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 quality, safety, and affordability of health care for all Americans. The Partnership for Patients brings together leaders of major hospitals, employers, physicians, nurses, and patient advocates along with state and federal governments in a sharedeffort 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 hospital-acquired conditions would decrease by 40% compared to 2010. Achieving this goal would mean approximately 1.8 million fewer injuries to patients with more than 60,000 lives saved over three years.Help patients heal without complication.By the end of 2013, preventable complications during a transition from one care setting to another would be decreased sothat all hospital readmissions would be reduced by 20% compared to 2010. Achieving this goal would mean more than 1.6 million patients would recover from illnesswithout suffering a preventable complication requiring re-hospitalization within 30 days of discharge. Achieving these goals will save lives and prevent injuries to millions of Americans, and has the potential to save up to $35 billion across the health care system, including up to $10 billion in Medicare savings, over the next three years. Over the next ten years, it could reduce costs to Medicare by about $50 billion and result in billions more in Medicaid savings. This will help put our nation onthe path toward a more sustainable health care system.Building on Local and National WorkIn 1999, the landmark Institute of Medicine study, To Err is Human, estimated thatas many as 98,000 Americans die every year from preventable medical errors. Despite many successful efforts, this statistic has not improved much in the following decade. And many more patients get injured or sicker from preventable adverseevents after being admitted to a hospital.After more than a decade of work to understand and address these problems, promising examples of better practices exist, but patients too often are still injured in the course of receiving care. There is much more work to be done to preventunnecessary harm to patients.At any given time,about one in every 20 patients has an infection related to their hospital care.On average, one in seven Medicare beneficiaries is harmed in the course of theircare, costing the government an estimated $4.4 billion every year.Nearly one in five Medicare patients discharged from the hospital is readmittedwithin 30 days thats approximately 2.6 million seniors at a cost of over $26 billion every year.Hospital Engagement NetworksHospitals across the country will have new resources and support to make healthcare safer and less costly by targeting and reducing the millions of preventableinjuries and complications from healthcare acquired conditions. $218 million was awarded to 26 state, regional, national, or hospital system organizations to be Hospital Engagement Networks. As Hospital Engagement Networks, these organizations will help identify solutions already working to reduce health care acquiredconditions, and work to spread them to other hospitals and health care providers.

Hospital Engagement Networks will work to develop learning collaboratives for hospitals and provide a wide array of initiatives and activities to improve patient safety. They will be required to conduct intensive training programs to teachand support hospitals in making patient care safer, provide technical assistanceto hospitals so that hospitals can achieve quality measurement goals, and establish and implement a system to track and monitor hospital progress in meeting quality improvement goals.In addition to the Hospital Engagement Networks, $10 million has been awarded tothree organizations to create a curriculum in patient safety for the Hospital Engagement Networks, engage Medicare, Medicaid and Childrens Health Insurance Program beneficiaries, their families and caregivers and others in specific activities supporting the aims of the Partnership for Patients, and evaluate the impactand effectiveness of the Partnership for Patients.Medicare Drug DiscountsThe Affordable Care Act includes benefits to make your Medicare prescription drug coverage (Part D) more affordable. It does this by gradually closing the gap in drug coverage known as the "Donut Hole."What This Means for YouStarting January 1, 2011, if you reach the coverage gap in your Medicare Part Dcoverage, 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 throughthe 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 while in the coverage gap until the gap is closed in 2020. See the schedule belowfor 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 drugs2013: 47.5% for brand-names and 79% for generics2014: 47.5% for brand-names and 72% for generics2015: 45% for brand-names and 65% for generics2016: 45% for brand-names and 58% for generics2017: 40% for brand-names and 51% for generics2018: 35% for brand-names and 44% for generics2019: 30% for brand-names and 37% for generics2020: 25% for brand-names and 25% for genericsSome Important DetailsYou 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 employergroup health and waiver plans) or a Medicare Advantage Plan that includes prescription drug coverage.You dont get Extra Help. This is a Medicare program to help people with limited resources 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 coverage 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 with 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 entiredrug cost will count toward the amount you need to qualify for catastrophic coverage.You have options when it comes to finding health insurance.It is free for consumers to request health insurance quotes from licensed healthinsurance agents and brokers. A good health insurance agent will advise you onyour private-market health insurance options from different insurance carriers and different plan types. They should understand your health, family and financial profile, and guide you towards a health plan that best serves your needs. Their job is to assist you in making the best health insurance decision for you andyour 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 healthinsurance agents and brokers. A good health insurance agent will advise you onyour private-market health insurance options from different insurance carriers and different plan types. They should understand your health, family and financial profile, and guide you towards a health plan that best serves your needs. Their job is to assist you in making the best health insurance decision for you andyour family, and you should work with only the agents who have your interests atheart. 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 benefitsfor themselves and their employees. The insurance contract is between the employer and the insurance company and the employer is responsible for paying the monthly premium to the insurance company. An employer may require a partial contribution of premium payment from the employees, which will be deducted from the payroll 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 that have the fortune of being employed by a company that offers this benefit to their employees.Who Should Consider Group Health Care InsuranceFrom the perspective of a business owner, offering group health insurance to your employees is a great way to maintain company loyalty and keep your workforce healthy. In some states employers with a minimum number of employees are requiredby law to offer employee health benefits. More and more states are consideringsimilar 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 insurance.For persons that have a group health insurance policy available to them throughtheir place of employment, choosing to enroll in this coverage typically requires little thought. This is especially true if you and your family members do notcurrently have health insurance. For the employee, the monthly premium will be less than you would pay through other types of health insurance, since your employer will be responsible for paying the majority of this premium. Depending on the percentage of the premium your employer pays when adding your dependents to your group coverage, this option may also be best for your family. You will need to consider the costs and benefits of this option and compare it to the options available under an individual/family health insurance plan.How to Find Group Health InsuranceIn each state there are several different insurance companies that offer group health plans. You can explore these options by requesting quotes online from manywebsites that specialize in health insurance. All of the insurance companies have websites that may provide details about the many different group health plansthat they have available. You will also find agent or broker websites where youcan complete a brief questionnaire that is necessary for providing your companywith an accurate quote on group health care insurance. There are also referralservices that can put you in contact with one or more insurance agents in your area that offer group health insurance quotes and expert advice. For those that do not have a good understanding of health insurance, it is recommended that you work with a professional that can explain the many different policy terms and helpyou compare your options from several different insurance companies. There are many factors to consider in choosing the right group health plan that is an affordable expense to your business while providing your employees with adequate health care benefits.To request quotes for group health care, you will need to provide the birthdatesof each of your employees, as well as information for each of their family members that might also wish to be included on the policy. You will also need to know what percentage of the premium will be paid by the company for employees and their dependents. It is best to compile this information and make sure it is accurate 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 types range from comprehensive HMO plans to high-deductible catastrophic health plans. The more comprehensive the coverage, the greater the risk that the insurancecompany will have to pay claims. Since rates are based on the risk to the insurance 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 premium options. Naturally, you will want to find the best possible coverage for the best possible price. The best thing to do is set a budget for your monthly health insurance costs and look for the best coverage for that price.Applying for Group Health InsuranceOnce you have found the best health plan for your business, you will need to submit an employer application for coverage. Since group health insurance is guaranteed to all eligible businesses, there will only be a few health questions. Mostof the questions on the application are used to determine if the company meetsthe guidelines for enrolling in a group health plan. Among other things, the insurance company will need to know how many employees are to be included on the policy and how long the company has been in business. Payroll records will need tobe submitted along with the application in order to prove the eligibility of all persons to be added to the group plan. Only persons that appear on the payrollrecords, and immediate family members, can be included on the original application. An experienced health insurance agent can guide you in determining the eligibility and recorded documentation that will need to be submitted to the insurance company.Depending on the overall healthiness of those that are to be included on your group health plan, the insurance company may adjust the rates to offset the coststhat will bear when accepting a high-risk group. The maximum percentage increaseis set by state regulations and will vary by state.If you are a fulltime student between the ages of 17 and 29, student health insurance may be right for you. In fact it may even be required of you. There are several options for student health insurance, you may look for private student health insurance on the open market, or you may opt for the student health insurance plan offered by the institution you are attending. Expect to pay more for private student health insurance of course, but generally these student policies carry greater benefits than those provided by the university.Whichever you choose, even if your particular school does not require it, student health insurance is a great way to ensure academic success. Student health insurance typically covers:Regular medical examsPayments for catastrophic careAnd emergency proceduresHow do I get a student health insurance quote?Nowadays it is really simple to get free quotes online. You merely have to provide some simple personal information in a completely secure fashion, to receive afree student health insurance quote.You may be asked to provide:Weight/HeightTobacco usage historyYour AddressPhone numberGenderEmail addressDate of birthToday most colleges and universities, require health insurance. The good newsis that as such most schools are affiliated with top heath insurance providers, andbecause of the relatively low-risk involved in this group - rates for student health insurance are generally low. Private student health insurance is another option. Private student heath insurance is usually purchased by:Those who need a more specific kind of coverageIndividuals with pre-existing medical conditions

Students who are interested in spending a term studying abroadOr individuals who think that the coverage offered by the college or universitydoes not fulfill their needs.Private health insurance tends to be a little bit pricier but offers additionalbenefits that most university health plans do not - for example, dental, vision,and prescription coverage.Comparing carriersThe easiest way to compare different carriers is online. Using online comparisontools you can quickly see which company offers the best benefits for you needsand budget. When you know your options, the better the chances that you will purchase the health plan with the most benefits at the best rates.When getting any student health insurance quote, make sure you understand your policy thoroughly before purchasing. If you are unsure about anything that is or is not covered, speak to an agent or your schools benefits advisor.EligibilityMost insurance companies do not offer student health insurance to individuals with pre-existing medical conditions. Exclusions may be made for certain preexisting conditions.Student health plans are generally available to individuals between the ages of17 to 29. Depending on the insurance company and state, some other exclusions and 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 more information and obtain a free student health insurance quote online. Rememberit is always important to know your options to make an informed decision about health insurance.Medicare supplement insurance, also known as Medigap insurance, is a private health insurance option designed to provide additional benefits above those offeredthrough Medicare Part A and Part B. When searching for Medicare supplement insurance quotes you will only have twelve possible options to consider. This will simplify the process as other types of health insurance have well over 100 different options. The available Medigap options have been structured by the federal government to provide additional health care coverage where it is most needed. Bylimiting the options, the confusion of choosing the right supplemental plan isgreatly reduced.If you are eligible for Medicare Part A, you are able to purchase a Medigap planif you do so during the open enrollment period, which is the six month period immediately following your enrollment in Medicare Part A. You must also be enrolled in Medicare Part B to qualify for Medicare supplemental insurance. You are not 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 experience medical problems that would justify this additional coverage.Make an informed decision about Medigap insuranceIt is essential for you to be well informed when shopping for Medigap insurancecoverage. Knowing your options and understanding the included benefits decreasesthe likelihood of later discovering that you are underinsured. A very helpful tool is to compare the different companies that offer this type of coverage. Differences between insurance companies can include:Participating provider networkPremium chargesFinancial strengthCustomer Service historyKeep in mind that with this type of coverage it is really simple to compare rates because of the standardized polices. Even though policies have the same benefits (for example Plan F from Humana will have the same benefits as Plan F from Blue 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 yourlikely future health care needs. Because different Medigap insurance plans provide different benefits, make sure you understand each one of these benefits and how 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 policies that offer this benefit.Once you decide which Medicare Supplemental Plan will best fit your needs, the next step is to find out which insurance companies offer this Plan so that you can compare their rates. Working with a health insurance broker that is licensed to sell Medigap insurance plans from multiple insurance companies is a great place to start. You will not pay an additional fee for the convenience of working with a broker because the premiums are determined by the insurance company and cantbe altered.How do I get Medicare Supplement insurance quotes?Getting a Medicare Supplement insurance quote online is now a simple and secureprocess. Keep in mind that sometimes personal information is required in order to provide you with your list of plan options. The information listed below should be sufficient enough for any broker to provide you with a quote:Your nameYour ageState of ResidenceZip CodeMedicare Part A and Part B enrollmentPhone numberMedicare Supplement insurance quotes tipsStart your researching a quote requests at least 3 months in advance of becomingMedicare eligible. Rates are subject to change and could adjust slightly by thetime that you are qualified to enroll in a Medigap plan. So, have a first choice and a second choice plan for back up.Visit the Medicare.gov website to make sure that you are looking at all of the options available in your state. They have a very useful Plan Locator tool that will provide you with a comprehensive list.Work with a licensed broker in your state that represents the majority of the insurance companies on the list you have obtained from Medicare.gov. If you cant find an agent for all of your Plan options, you may need to contact the insurancecarrier directly.Purchasing process for a Medicare Supplemental PlanOnce you have chosen the right Medicare Supplemental Plan, you will need to complete the application and approval process. This can be simple if done timely andaccurately.Filling the applicationYour agent or broker that assisted you with selecting the right Plan will also be able to provide you with the necessary enrollment application. Every insurancecompany has their own application, so make certain that the application agreeswith the insurance company that you have selected. These applications are usually 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 behalf. An initial premium payment may be required along with the application. Alwaysmake the check payable only to the insurance company.Receiving Approval and ID CardsIf your application is completed properly, approval should only take 5-10 business days. You will receive notice of approval prior to receiving your insurance ID cards, which will typically arrive 2-3 weeks later. Your coverage will alwaysbecome effective on the first day of the month following the date that your application was submitted.You know how important health insurance is to protect you and your family from unexpected accidents and illnesses. For those times when you are in transition, there is no need to put yourself or your family at risk. Did you know that healthinsurance 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-term health insurance, for example:If you are currently in between jobs, on a new job waiting for a medical coverage 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 options.Keep in mind that as the name implies short-term health insurance is only a solution for a limited period of time. These policies, also called Gap Insurance, arecommonly renewable for a total of 36 months, you can always reapply, but there is no guarantee of acceptance.Are short-term health insurance quotes affordable?Because of the nature of the policies and benefits offered, short-term heath insurance is one of the most affordable private health coverages you can buy. Rates do vary from state to state but generally range from $150 to $390 per month. Forexample, a single male non-smoker under the age of 30 could generally expect topay at the bottom end of that range. A single female nonsmoker under 30 could pay as little as $140 a month or less. Of course rates increase as you get older and if you smoke. Also, rates depend on the benefits provided, your geographic area, and the amount of out of pocket contributions you are willing to make.Getting short term health insurance quotesOnline is a great way to shop for short-term health insurance quotes. Many websites offer free quotes, and tools to compare rates on short-term health insurancefrom several major carriers in your area. Simple questions are usually asked tobe sure you are given the right short-term health insurance plan to meet your particular needs.By getting quotes from multiple sources using these online health insurance tools you have a great opportunity to compare the rates and benefits of different short-term health insurance providers side by side. Then you can make an informedand educated decision.EligibilityThere are several requirements for you to be eligible for short term health insurance:You must be under age of 65There is no coverage for pre-existing conditionsYou cannot already be covered by another insurance policyAlso understand that short-term health insurance plans can be somewhat more limited in benefits than full term polices. Dental, vision, and maternity coverage,is usually not provided with short- term insurance policies.SuggestionsBefore 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 insurance 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 the option of dividing your quote into monthly payments.Good oral health is important - not only to your teeth but to your overall health as well. But most health insurance plans do not include dental insurance, making dental insurance one of the most common types of private health insurance purchased by individuals. Dental insurance can help prevent small dental problems from 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 cosmetic 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, Oral surgery, Orthodontia, X-rays, and more.Dental health insurance optionsDental health insurance is available for individuals, small businesses, and families. There are two main types of dental health insurance: indemnity plans and managed care plans.An Indemnity plans is a traditional fee for service health plan. It will be a bitmore costly than a managed care plan, but it has far fewer limitations, and youmay choose any dentist.

Managed care plans in dentistry function just as they do with medical insurancewhere 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. While they offer less flexibility in terms of seeing dentists in or out of the network, managed care dental plans are usually less costly than indemnity plans.Guidelines to shop for a dental health insurance quoteThe key to finding affordable dental coverage that is right for you and your family is to make sure you understand your needs and financial concerns. Before looking for dental health insurance, now is a good time to evaluate your annual dental bills. How much do you and your family spend on dental care per year? Do youthink your children will require orthodontic care, has anyone in the family beendiagnosed with gum disease, or requires extensive dental restorations for missing 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 current dentist or dental care specialist is in the network. If not, and staying with them is important to you, you may want to consider an indemnity plan. Most managed care plans will not cover any work done by a provider outside of the network, except in the case of certain emergencies.Be sure you understand what treatments are covered and which are not under any dental health insurance plan you look at. Routine dental visits, x-rays, and cleanings are almost always covered. Very few dental health insurance plans offer full coverage for cosmetic dentistry, root canals, crowns, and braces, although most plans do offer partial coverage. Remember the more costly the monthly premiums the more services that will be covered.Getting a dental health insurance quoteAs always, the best way to compare dental insurance companies is online. The only questions usually asked is the state you live in or your zip code. Then you will be provided with quotes from various dental insurance companies. You will beable 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, VHAoffers tools and information to help you reach your optimal health. Tools likeMy HealtheVet enable you to manage your medical priorities through an online prescription refill service, personal health journal, and links to Federal and VA benefits. Use the health support services listed below to maintain your physicaland mental wellness.It would be easy to confuse Dr. Mitch Katz with any other doctor at the Roybal Comprehensive Health Center in East Los Angeles. His desk in a closet-sized, windowless 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 Departmentof Health Services, Katz, 52, oversees Los Angeles public hospitals and clinics, the health care of last resort for millions of low-income Angelenos. He oversees 22,000 employees and a $3.7 billion-dollar budget.Los Angeles, the nation s second-largest city, has some 2 million uninsured residents. It has long had one of the most disorganized systems, too. While fixing it, Katz, the former director of San Francisco s health department, insists on seeing 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 time to treat patients with a system in ruin? It s part of Katz s plan to fix thesystem one clinic at a time.On a recent morning, Katz sits opposite his patient, a middle-aged man who is abundle of nerves. Katz speaks Spanish with his native Brooklyn accent and patiently explains the possible causes of the man s tumor and what he hopes a visit toa 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 don 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 low-income Angelenos away from the overburdened emergency rooms they ve long relied upon and into primary care clinics where costs are lower, chronic diseases canbe 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 wheres primary care? They said, Well, it s under the hospitals. [I said] Well, thatmay 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 assigned 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 did 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 observershere say they were stymied by a Board of Supervisors which often governs Los Angeles like five competing fiefdoms.But Michael Cousineau, a professor at the University of Southern California s Keck School of Medicine, says those supervisors are scared of what s to come. Under the health law, many of those currently uninsured are expected to be covered beginning in 2014. When that happens, the federal government will reduce the extra money they now give to public hospitals to offset the burden of caring for these patients.One report commissioned by the county put it bluntly: If L.A. loses its paying customers and is left treating only undocumented immigrants, the financial survival of its health system is at stake. Cousineau argues that to move the system from one of "last resort to a system of choice is not going to be an easy thing. But the price of failure is thousands of people losing their jobs, closing of health 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 of whom represents more voters than many U.S. Senators do. She expresses confidence in Katz. "I was one that was worried he was just going to be another guy thatjust took us so far and then would leave us," she says. "But instead he s had the 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 place at the heart of where it all went terribly wrong. The Martin Luther King Junior-Harbor Hospital in South Los Angeles closed in 2007 after the quality of care had deteriorateddramatically and one woman died of egregious errors.It has re-opened as a clinic where patients with chronic diseases are counseledby a team of nurses and medical assistants. The clinic s nurse manager KimberlyThomas says customer service is now a top priority. "They ll bring patients whohave diabetes and high cholesterol then bring them in again and look at their labs and see if they re improved or gone down," she says. Patients love the giftsthey get if they improve their test results, she adds.Assigning low-income patients to a medical home makes for better medicine, but whether it engenders good will and loyalty when these same patients gain insurance is an open question. And this may, in fact, be Katz s greatest challenge: giving 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 them about what s going on in their marriage, with their kids, in their home and people will begin to cry," says Katz. "People will begin to tell you amazing things about what are really the issues. And often the physical symptom both to you and to them is just the opening salvo in a conversation that they want to have with 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 ifthe Supreme Court strikes down the entire 2010 Affordable Care Act: potential chaos in the Medicare program."The Affordable Care Act has become part and parcel of the Medicare system, encouraging providers to deliver better, more integrated, better coordinated care, a

t lower cost," says Judy Feder, a public policy professor at Georgetown University and former Clinton administration health official. "To all of a sudden eliminate that would be highly disruptive."Sara Rosenbaum, a professor of health law and policy at George Washington University, puts it a bit more bluntly: "We could find ourselves at kind of a grand stopping point for the entire health care system."And it s not just Democrats warning of potential problems. Gail Wilensky, who ran Medicare and Medicaid under President George H.W. Bush, says she doesn t thinkit s likely that the court will strike down the entire health law. But if it does, she says, "it seems like it takes everything with it, including those aspects 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 of health care professional who treats Medicare patients. Every time Medicare sets 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 "doesn t exist anymore because the law doesn t exist."And the result? "You have agencies sitting on two years of policies that are upin smoke," she says. "Hospitals might not get paid. Nursing homes might not getpaid. Doctors might not get paid. Changes in coverage that have begun to take effect 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 the population, too. Hence, the spillover could affect the health care system as awhole.That s what has the nation s community of health care providers watching nervously to see what the court does. Many would speak only on background or wouldn t address the subject at all.One of the few groups willing to address the subject was the American Medical Association. In a statement, the AMA s president-elect, Jeremy Lazarus, says, "With the countless hours of work already done to implement this new law, it is hardto imagine the full impact of it disappearing."At best, the situation would be legally murky, says Dan Mendelson. He s CEO of the health consulting group Avalere and oversaw health programs for the Clinton administration s Office of Management and Budget."In a lot of ways, it s a political never-never land," he says. "We have no ideareally 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 Medicare 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 doesn t do something. This would be much bigger. And it would be extremely disruptive," she says.Rosenbaum says there could be an even bigger problem: Medicare might be lookingat hundreds, if not thousands, of policies that are suddenly null and void. Shesays it s not at all clear that the agency has the authority to go back to the policies 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 Congress wants to do."What makes it an even bigger potential mess, says Mendelson, is that the healthlaw has fundamentally changed almost every aspect of the way the Medicare program 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 downthe 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 of the U.S. adult population with high cholesterol has dropped.

Data just out from the Centers for Disease Control and Prevention show that only13.4 percent of adults in this country have high cholesterol, according to datacollected 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 with desirable total cholesterol, which is less than 200 milligrams per deciliter.The government had set a public health goal of getting the proportion of adultswith 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-lowering drugs, but dropping smoking rates and other factors also contributed," the Associated Press reports.Drugs called statins, such as Lipitor and Zocor, lower cholesterol and are enormously popular. Last year, 264 million prescriptions were dispensed for drugs toreduce cholesterol, according to data from IMS Health.But some are asking whether it s such a good idea to prescribe statins to peoplewho haven t had a heart attack already. The Food and Drug Administration said in February that the drugs instructions should note reports of memory loss and diabetes among people taking them.The agency said, however, that the new information shouldn t scare people away from taking statins. The drugs s value in preventing heart disease is clear, FDAsaid.But Dr. Otis Brawley, chief medical officer for the American Cancer Society, fired up hundreds of them at the annual meeting of Association of Health Care Journalists over the weekend with a no-holds-barred critique of the U.S. health system.Brawley has a book out, How We Do Harm: A Doctor Breaks Ranks About Being Sick in America, that makes his case in full. But in a sometimes dizzying speech in Atlanta, Brawley ripped the health establishment from top to bottom. It was bracing stuff.The group just posted a video about the event.Here are some of the highlights, as tweeted by journalists at the meeting, if you prefer.The American College of Physicians isurging patients with newly diagnosed diabetes 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 College of Physicians calls "high value care," and away from expensive tests and treatments that aren t any better and often are worse.That may seem like common sense. But it s a departure, and maybe a surprise, tohear a mainline physician group name names when it comes to drugs that shouldn tbe first choices and even steer patients to non-physician competitors.Instead of highly touted diabetes brands such as Actos, Januvia and Avandia, thephysicians group says, patients with type 2 diabetes should start out on a tried-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 Reports 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 with about $230 to $370 for Actos and about $265 for Januvia," the brochure points out.Metformin "lowers blood sugar levels more than newer drugs do," the brochure says. It also reduces "bad cholesterol," while newer drugs don t, and sometimes even raise it.

When it comes to back pain, it s usually not a good idea to get an x-ray, CT scan 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 your doctor about other options," back pain sufferers are advised. Maybe they should see a chiropractor or an acupuncturist, the brochure says.Steven Weinberger, CEO of the American College of Physicians, says many patientscome into doctors offices with the expectation they re going to get a high-tech imaging study to diagnose their back pain."Their neighbor might say, When I had back pain I had an MRI, so maybe you didnt get the best care, " Weinberger told Shots. "We re saying the reflex reaction doesn t represent the best care."The group plans to put out a series of other pull-no-punches pieces of advice oncommon conditions."In these days of crisis in health care costs," he says, "the medical professionshould take its ethical and professional responsibility to do what we can to reduce costs while not compromising care."Weinberger says that doing the right thing make take courage, "because physicians have financial incentives" to prescribe less cost-effective care, and so do hospitals. So, of course, do pharmaceutical companies.But Sethu Reddy, the U.S. medical director of Merck, maker of the diabetes drugJanuvia, idn t sound too threatened."Cost is one factor," Reddy told Shots. "But there are four or five other factors that the doctor has to weigh in. He can t just automatically say that this isthe automatic option for every new patient."Reddy pointed out that, on the very day the physicians group urged newly diagnosed type 2 diabetics who need drugs to start with metformin, US and European diabetes specialists issued new guidelines that are less prescriptive."More than any other previously reported guidelines," notes diabetes expert William Cefalu, the new position statement "emphasizes that one size clearly does not fit all."n Republican-dominated Nebraska, government leaders often line up together, butlately a political tornado has ripped through this orderly scene.A political showdown over taxpayer funding of prenatal care for illegal immigrants has produced some unusual political splits and alliances in the statehouse ofthe Cornhusker State."I am extraordinarily disappointed in your support of taxpayer-funded benefits for illegal aliens," said Republican Gov. Dave Heineman as he read a letter he wrote to fellow Republican Mike Flood, speaker of Nebraska s officially nonpartisan Legislature.Heineman was referring to a bill he subsequently vetoed that would restore publicly 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 couldnt use Medicaid funds, though it offered to continue funding under another program. Heineman frames the issue as one of the benefits to illegal immigrants.Flood, a leading abortion opponent, says pregnant illegal immigrants will ultimately give birth to babies who will be U.S. citizens. He says providing them withprenatal care is consistent with his opposition to abortion."If I m going to stand up in the Legislature and protect babies at 20 weeks fromabortion, and hordes of senators and citizens are going to stand behind me, andthat s pro-life, then I m going to be pro-life when it s tough, too," Flood said.The issue has exposed a fault line between anti-illegal-immigrant sentiment andanti-abortion groups, but it s also brought together an unusual coalition. Amongthose supporting the bill is the politically influential Nebraska Right to Lifeorganization."We don t want to distinguish that because ... of a baby s circumstances or in whose 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 Interest, which advocates for immigration reform and access to universal health care. Jennifer 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 their children is appropriate."Still, Heineman, backed by what Republican Party polls say is a clear majority of voters, remains adamant in his opposition, though he calls himself strongly anti-abortion."Most Nebraskans and I agree, we support prenatal care, but in the case of illegal 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 polls in support and say the savings from avoiding intensive care for babies born without prenatal care would outweigh the costs of the program.With the governor turning up the political heat, the question now is whether enough legislators will vote to override the veto. That vote is scheduled for Wednesday.Surrogacy is an idea as old as the biblical story of Sarah and Abraham in the book of Genesis. Sarah was infertile, so Abraham fathered children with the couples maid. Today, there are many more options for people who want to grow their families 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, andI wanted to repeat the process," she says, "and my husband and I won t be having more children of our own."Widofsky sits in the lobby of a fertility clinic in Reston, Va., where she s being tested to find out if she s a good candidate. Surrogacy runs in her family: Her 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, and 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 paid. Some women do it for family or a friend. Today, though, most surrogates getbetween $20,000 and $25,000 to bear a child for someone else.Why One Surrogate Wanted To HelpWhitney and Ray Watts are the parents of 3-year-old J.P. Whitney carried twins for Susan and Bob de Gruchy."To me, being a surrogate it s like you re carrying someone else s dreams," shesays.That s part of what could make some people scratch their head. After all, it s easier to believe that a woman would give up a child from her womb for money rather than a desire to help.Whitney, 25, says her parents went through infertility nightmares, and that gaveher determination to help someone make a family. She says she didn t think about bonding with the baby."It was [in vitro fertilization]. It was their embryos," she says. "You just know they are not yours. You re just keeping them for a time to let them grow and then give them back to their parents, because they were never my babies. It s just my uterus that s keeping them."Not Doing It For The MoneySitting next to each other, 27-year-old Ray looks adoringly at his wife; they finish each other s sentences when they speak. The Wattses say they were looking for a couple they could connect with."It was very important to us to have a relationship with them," Whitney says. "Yes, it s a business contract in a sense, but it s so much more than that." Her husband agrees."Had Susan and Bob just wanted to pay money and get a kid, that would have beena deal breaker right away," he says.

ltiple people create a child, the law doesn t always make it clear who the legalparents are.The issue of money, though, is real. It makes some people feel uneasy because motherhood is not typically financially compensated. Whitney Watts says she lookedinto 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 tknow, through an agency," she says. "It wouldn t feel appropriate ... because you 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 turned out, she spent 55 days on bed rest at the hospital.Elaine Gordon, a clinical psychologist in Los Angeles, counsels couples on family-building, including surrogacy, and on the issue of payment."I think people automatically feel that if money is involved then there is no altruism involved, and that s not necessarily true," she says. "We are all compensated for the work we do, and we still want to do good work even though we are compensated."Gordon says many surrogates tell her the experience of having a child for someone 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 Center first thing to stop TEDMED.I heard conflicting reports about what happened this morning, but the show wenton 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 Arnold made sure everyone was really awake by telling us what a blast her lab workis: "I have fun forcing molecules to have sex."In nature, she said, "proteins aren t designed, they re evolved." That s where sex 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 and doing it smartly she hopes by figuring out which elements have a fighting chance 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 to 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 therealm of risk, arguing that the current system of regulation is holding back progress 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 patients take bigger risks when the alternative is looming death.The researchers are interested in speeding up access to stem-cell treatments, even though both acknowledged there are big unanswered questions about their safety and effectiveness. But as Glass summed up, "This is an emergency. The house ison fire."Finally, back to the morning session for one of the more provocative talks. University of California, Davis Jonathan Eisen urged everyone to get to know theirpersonal microbes: We re all colonized from head to toe. The mass of microbes each of us carries around, in fact, is greater than the mass of our brains, he said.Some microbes help us, and others can hurt us. Miscommunication between our bodies and the microbes that live with us may make us sick. Fixing that snafu couldmake us well.Some old-time vets, Eisen said, already use a concoction called "poo tea," a diluted mixture of fecal matter from a healthy animal, to effectively treat sick animals.But we re only beginning to grasp how microbes affect human health. "We need a full field guide to microbes that live in and on us."It may sound counterintuitive, but a panel of experts from the Institute of Medicine has concluded that the best way to slow the nation s breakneck spending onmedical 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, according to the IOM panel, the public health workforce could renew its historic role in looking at population rather than individual health care, and thus "offerefficient and effective approaches to improving the nation s health."Currently, said Marthe Gold, professor of Community Health and Social Medicine at the City College of New York and chair of the panel, the U.S. spends only about 3 percent of the $2.5 trillion it spends on health care overall on public health. It has a history of "unpredictable, inadequate and uncoordinated funding."Yet "public health also has a track record of achievement in vanquishing the historic causes of death and disease," she said, from early successes like ensuringclean water and sanitary food to more recent campaigns to get people to stop smoking or use seat belts.The public health infrastructure has taken a hit during the recent economic downturn: Roughly one-fifth of the local public health workforce has been lost through attrition and layoffs. Renewing that infrastructure could have a profound impact on slowing the rate of growth in health spending, the panel argues.For example, public health measures including community-based outreach could help reduce adult obesity by 50 percent, the panel says. Sounds ambitious, but as the panel notes, that s about the same relative reduction in smoking rates that resulted from the "public health community s multifaceted attack on smoking" in the past few decades. It would also save the U.S. an estimated $58 billion in health care spending.In order to meet those goals, the panel says every public health agency would need to be able to deliver a "minimum package of services." That would include what it calls "foundational" services, such as the ability to do basic disease surveillance and communicate with the public, and "programmatic" services, such as injury prevention and communicable disease prevention.But to get there, the federal government would need to at least double the $11.6billion it invests each year in public health activities, according to the panel s estimates.Which brings us to that pesky tax.Panel member George Isham, medical director at HealthPartners in Bloomington, Minn., acknowledged that "it s difficult to propose any kind of increase in taxation." But the group considered a number of different financing mechanisms beforesettling on a minimal tax on medical transactions as the best solution: It s a tax related to the goal; it would raise sufficient funds; and it would not have abad economic consequence. In short, said Isham, "it s an investment we can t afford 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 arthritis, it s third on the list of chronic health issues for seniors.Yet traditional Medicare coverage doesn t include the cost of hearing aids, andmost private health plans follow suit. That leaves it to many people to scrape up the money on their own.That s no small task, since hearing aids can cost a few thousand dollars and generally have to be replaced every four to six years.Legislators in both houses of Congress over the past decade have repeatedly proposed 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 notmoving ahead anytime soon. "We continue to gain support of the bill, but therehas been no legislative activity," says Ingrida Lusis, director of federal and political advocacy at theAmerican Speech-Language-Hearing Association. Both billshave 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 five years to people age 55 or older or to families who bought one for a dependent. People with incomes over $200,000 would be ineli