News for today's 2018

ISRAEL, IRAN and the BALKANS Part 3

6:23 AM Tukiyooo 0

<br /> <br /><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><br /></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh0PpTkrDgEpuZB0Uihcbif_McMAasNMaCUH5Bo6I0CsEjCJiJH4B3akC3QjGF4RikDZdGhE04iY2111ptA_t7GY728A5L7yERx-yYEqpW5BRJHAjdpmjC4QcsTzwRZ6dl_zxnF5WWDHaDP/s1600/balkan-flags.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh0PpTkrDgEpuZB0Uihcbif_McMAasNMaCUH5Bo6I0CsEjCJiJH4B3akC3QjGF4RikDZdGhE04iY2111ptA_t7GY728A5L7yERx-yYEqpW5BRJHAjdpmjC4QcsTzwRZ6dl_zxnF5WWDHaDP/s320/balkan-flags.jpg" width="286" /></a></div><br />  <div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><br /></span></b></div><div class="MsoNormal" style="line-height: normal; text-align: center;"><span style="color: #134f5c;"><span style="font-size: large;"><b><span style="font-family: "Times New Roman","serif";">ISRAEL’S SECURITY CONCERNS IN THE BALKANS </span></b></span></span></div><div class="MsoNormal" style="line-height: normal; text-align: left;"><br /></div><div class="MsoNormal" style="line-height: normal; text-align: left;"> </div><div class="MsoNormal" style="line-height: normal;"><span style="font-size: x-small;"><span style="font-family: "Times New Roman","serif";">Adapted by Geopolitical Analysis and Monitoring from the original article written by Chris Deliso </span></span></div><br />  <div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><br /></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span style="color: #cc0000;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Executive Summary: </span></span></div><ul type="disc"><li class="MsoNormal" style="line-height: normal; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Organized crime in GREECE is a      much larger phenomenon to reckon with but bears no direct threat to ISRAEL      </span></b></li><li class="MsoNormal" style="line-height: normal; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">GREECE      and CYPRUS: significant vulnerabilities</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"></span></li></ul><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">The situation in maritime GREECE and especially in the divided island of CYPRUS to its southeast has a different flavor to it than the BALKANS. In GREECE, government rhetoric during the 1970’s and 1980’s fostered sympathies for the Palestinian and other Muslim causes, creating international relations for far-left and even student groups, some of which continue to this day. In CYPRUS – until very recently one hub of the no-questions-asked global financial system – the geographical proximity to the MIDDLE EAST has benefited terrorist groups and intermediaries (among many others) for decades.</span></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Indeed, the usefulness of CYPRUS as a logistics and financial base made it somewhat of a surprise that Hezbollah would be willing to risk this safe haven.</span></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><br /></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Background Information:</span></b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"></span><span style="color: #cc0000;"><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">CYPRUS: EMERGING GEO-STRATEGIC KEY PLAYER IN THE EASTER MEDITERRANEAN?</span></b></span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"> At:</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"></span></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><a href="http://news-these-days.blogspot.com.ar/2012/03/cyprus-emerging-geo-strategic-key.html">http://news-these-days.blogspot.com.ar/2012/03/cyprus-emerging-geo-strategic-key.html</a></span></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">and</span></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><a href="http://news-these-days.blogspot.com.ar/2012/02/geo-strategic-dynamics-in-eastern.html">http://news-these-days.blogspot.com.ar/2012/02/geo-strategic-dynamics-in-eastern.html</a></span></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><br /></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Nevertheless, as the recent terrorism conviction there indicates, Hezbollah in 2012 had an organized strategy involving surveillance of a hotel popular with Israelis, and was willing to risk its position on the island. Perhaps, <a href="http://www.haaretz.com/print-edition/news/israel-s-mossad-shin-bet-failed-to-identify-iran-terror-plot-1.412906">as <i>Haaretz</i> defense correspondent Amir Oren suggested</a> in February 2012, in the context of a multiplicity of botched attacks in ASIA, the “most worrying” aspect of those plots “was the evident drive to commit them even though they hadn’t been properly prepared.” With increasing focus on LEBANON and the SYRIA conflict, “the people available to carry out the attacks in INDIA, GEORGIA and THAILAND were probably not the star graduates of [IRAN’S] sabotage courses.” The testimony of the amateurish 24 year-old Hezbollah operative in the Cyprus trial indicates that this might have been the case there as well.</span></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><br /></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">As with GREECE and BULGARIA, CYPRUS is a popular holiday destination that benefited from the downturn in ISRAELI-TURKISH relations after May 2010. All three countries have recorded a strong increase in ISRAELI tourists since then, which unfortunately also makes them more tempting targets for Hezbollah. </span></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><br /></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="color: blue;">(<b style="mso-bidi-font-weight: normal;">Comment by Geopolitical Analysis and Monitoring</b>: For ISRAELIS, CYPRUS has been a popular tourist destination long before 2010, in fact as early as 1995 Israelis flocked in considerable numbers to CYPRUS to spend short term holidays on the Island )</span></span></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="color: blue;"> </span> </span></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">“Security specialists” who visited GREECE to assess tourist infrastructure security for a private consulting company came to the conclusion that a large majority of sites, be they the historical ones or the hotels, are not sufficiently secured, including large and expensive resorts.</span></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><br /></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Even were they to install a kind of police state, which they won’t, the varied terrain and maritime nature of the country would make it almost impossible to stop a serious [terrorist] outfit hell-bent on causing trouble, unless the intel is very precise and timely. Adding the large and impoverished illegal immigrant population, many of them Muslim, the vulnerability becomes evident and could be exploited.</span></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><br /></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">According to analyst Ioannis Michaletos, <span style="mso-spacerun: yes;"> </span>GREEK security services are on constant alert regarding possible attacks against ISRAELIS. “The authorities are keen to stop any possible attacks on ISRAELI targets in GREECE, thus even when low-ranking ISRAELI officials visit the country, security measures are beefed up,” he says. “One of the reasons of course is Hezbollah, along with other Islamist groups that may decide to strike.”</span></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">One high-profile case was the GREEK arrests in February 2011 of two “LEBANESE of Palestinian descent.” According to the <a href="http://www.israeldefense.com/?CategoryID=484&ArticleID=938">IsraelDefense website</a> “their assignment was to infiltrate terrorists from another organization by using fake passports.” Then, almost two months thereafter, the ISRAELI Counter-Terrorism Bureau in the Prime Minister’s Office “published a chilling warning to ISRAELIS traveling abroad to be especially vigilant in ‘MEDITERRANEAN Basin States’ such as GREECE, CYPRUS, TURKEY, and MALTA.” Although an attack did not occur, the ISRAELI security establishment would not have made such an announcement unless there was ample reason for suspicion.</span></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><br /></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">In regards to Hezbollah specifically, Michaletos notes a sort of ‘disappearing act’ trend that reflects on both heightened GREEK-ISRAELI security cooperation and on the group’s more urgent needs elsewhere. “Their biggest exposure was back in the 1980′s and 1990′s, but from 2001 to 2006 they significantly reduced their presence, while they have spread across the globe… and have increasingly redirected resources to SYRIA.”</span></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><br /></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><span style="color: #cc0000;"><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">ORGANIZED CRIME IN GREECE IS A MUCH LARGER PHENOMENON TO RECKON WITH BUT BEARS NO DIRECT THREAT TO ISRAEL </span></b></span></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><br /></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Since 2010 and “the convergence of Athens and Tel Aviv,” the GREEK security services have “started to pay close attention to the activities of all LEBANESE individuals in the country, so they themselves are keeping a very low profile.” This has led to some successes; for example, a cigarette-smuggling Hezbollah cell active in the country was dismantled in 2009. Still, as Michaletos reminds, “Hezbollah works through intermediaries and has local allies as well. Back in January 2007, when the AMERICAN embassy suffered a rocket attack by the leftist Revolutionary Struggle, the group’s proclamation of responsibility ended with ‘support to Hezbollah,’ indicating again a nexus between alleged GREEK leftist terrorists and the LEBANESE group.”</span></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><br /></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Further, he adds, “Hezbollah has on various occasions sold weapons to EUROPE via GREEK smugglers in CRETE, though there have been no arrests… and surplus ammunition from IRAQ found its way to GREECE via LEBANESE channels after 2003.”</span></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><br /></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">However, organized crime in GREECE is a much larger phenomenon in which the major players are BALKAN, NIGERIAN and PAKISTANI groups in areas including human and narcotics trafficking, document forgery, counterfeiting and racketeering.</span></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Such groups are not direct threats to ISRAEL, which (along with the US) is much more concerned with the influence and activities of IRAN in a country severely affected by financial crisis. <a href="http://www.bloomberg.com/news/2013-03-14/u-s-sanctions-greek-business-for-helping-iran-evade-sanctions.html">The US recently sanctioned</a> a GREEK businessmen allegedly involved in sanctions-busting ship-to-ship transfers of IRANIAN oil. On 14 March, the GREEK government announced a probe into a foreign company for its “involvement in an alleged covert shipping network operated on behalf of the IRANIAN government.” ISRAELI security experts have noted past cases of IRANIAN retributions for economic setbacks such as contracts cancelled under Western pressure, so it would not be without precedent for this to happen again here.</span></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><br /></div><div class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; text-align: justify;"><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">In general, however, our estimate is that GREECE and CYPRUS are not at the top of list of regional countries for IRANIAN-sanctioned or Hezbollah activity. Like BULGARIA, CYPRUS has attracted greater international security attention due to its recent Hezbollah case, so it is likely that any plots here would be deferred for now. In GREECE, a much larger country with a plethora of vulnerable targets, opportunity certainly exists but IRAN probably realizes that any attack on GREEK soil would endanger (licit and illicit) oil export to the cash-strapped country.</span></div>

ISRAEL, IRAN and the BALKANS Part 3

ISRAEL’S SECURITY CONCERNS IN THE BALKANS Adapted by Geopolitical Analysis and Monitoring from the original article written by Chris De...

Kale chips are not potato chips and the beauty of mindfulness

5:20 AM Tukiyooo 0

For at least a year I've been reading on different blogs about delicious kale chips. I bought two big bunches of organic kale at Whole Foods and finally, yesterday, I set about making my fake potato chips. I found a recipe online that was five stars, it was kale, olive oil and sea salt. <br /><br />After carefully washing my kale, putting it in the salad spinner to remove all moisture, tossing it with the olive oil and sea salt, then spreading it out in a single layer on my biggest cookie sheet, baking ten minutes at 275 degrees, flipping each piece of kale over and baking another ten minutes, I sat down for what I expected to be a delicious treat.<br /><br />They were crunchy and beautiful. I took a bite and my conclusion, YUK! Are you kidding me?! I had a mouthful of nasty, powdery, KALE. Disgusting. I don't know how anyone could say they taste "just like potato chips". They tasted just like...well, baked kale. <br /><br />I went back and looked at the recipe and reviews again. I had followed it exactly and there were over a 1,000 reviews with an average of five stars out of five stars (allrecipes.com). I guess you really can't make a silk purse out of a sow's ear. I ended up crumbling the "chips" into my beef-barley soup I had made before I knew I had cancer. Beef is off my list of cancer-fight foods I can eat, but I had made this soup and froze it over a month ago. There's only about two ounces of beef per serving so I'm finishing it off since it's so good. Next time I'll make it with free-range organic chicken and chicken broth. The crumbled kale added a vegetable to my soup so that was good, but baked kale chips eaten as potato chips are an urban myth. <br /><br />Life is good right now. Even though I found out yesterday my husband's defense attorney is going to request a continuance of the June 11 criminal trial, which frustrates me, I'm still feeling the calm of peace after my cancer diagnosis. <br /><br />I'm really focusing on mindfulness these days which is truly amazing. It really makes you stop and smell the roses along the way. I even put the <a href="https://play.google.com/store/apps/details?id=com.googlecode.mindbell&hl=en" target="_blank">mindfulness bell app</a> on my cell phone (get it at the Google Play Store). It chimes at me periodically during the day. This makes me stop and take stock on where I am, what I'm doing and what I'm feeling. It amazing at how beautiful life is when you actually pay attention to it. <br /><br />I've missed too many wonderful moments in life because I was too busy to notice and rushing through life, as though it was something I just wanted to get through. I really think cancer changes a person's life for the better. It's hard to explain until you experience it, but I've really been appreciating the small moments of beauty in my life. Whether it's the beauty of a bouquet of simple pink carnations or my blooming cherry tree in my front yard or the sun on face during these gorgeous spring days or my kitty sitting on my lap, purring as I stroke his fur, it's all good, and I finally feel a peace and happiness I've never experienced before. It's as though the cancer has been a blessing. Mindfulness. Try it, you'll like it.

Kale chips are not potato chips and the beauty of mindfulness

For at least a year I've been reading on different blogs about delicious kale chips. I bought two big bunches of organic kale at Whole F...

If this was a pill, you’d do anything to get it - Washington Post

4:36 AM Tukiyooo 0

<base href="data:"><div style="font-family: Helvetica; font-size: 14px; color: black; text-align: left; "><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">When Ken Coburn has visitors to the cramped offices of Health Quality Partners in Doylestown, Pa., he likes to show them a graph. It's not his graph, he's quick to say. Coburn is not the sort to take credit for other's work. But it's a graph that explains why he's doing what he's doing. It's a graph he particularly wishes the folks who run Medicare would see, because if they did, then there's no way they'd be threatening to shut down his program.</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">The graph shows the U.S. death rate for infectious diseases between 1900 and 1996. The line starts all the way at the top. In 1900, 800 of every 100,000 Americans died from infectious diseases. The top killers were pneumonia, tuberculosis and diarrhea. But the line quickly begins falling. By 1920, fewer than 400 of every 100,000 Americans died from infectious diseases. By 1940, it was less than 200. By 1960, it's below 100. When's the last time you heard of an American dying from diarrhea?</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">"For all the millennia before this in human history," Coburn says, "it was all about tuberculosis and diarrheal diseases and all the other infectious disease. The idea that anybody lived long enough to be confronting chronic diseases is a new invention. Average life expectancy was 45 years old at the turn of the century. You didn't have 85-year-olds with chronic diseases."</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">With chronic illnesses like diabetes and heart disease you don't get better, or at least not quickly. They don't require cures so much as management. Their existence is often proof of medicine's successes. Three decades ago, cancer typically killed you. Today, many cancers can be fought off for years or even indefinitely. The same is true for AIDS, and acute heart failure and so much else. This, to Coburn, is the core truth, and core problem, of today's medical system: Its successes have changed the problems, but the health-care system hasn't kept up.</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Kenneth Thorpe, chairman of the health policy and management school at Emory University, estimates that 95 percent of spending in Medicare goes to patients with one or more chronic conditions — with enrollees suffering five or more chronic conditions accounting for 78 percent of its spending. "This is the Willie Sutton rule," he says. "If 80 percent of the spending is going to patients with five or more conditions, that's where our health-care system needs to go."</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Health Quality Partners is all about going there. The program enrolls Medicare patients with at least one chronic illness and one hospitalization in the past year. It then sends a trained nurse to see them every week, or every month, whether they're healthy or sick. It sounds simple and, in a way, it is. But simple things can be revolutionary.</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Most care-management systems rely on nurses sitting in call centers, checking up on patients over the phone. That model has mostly been a failure. And while many health systems send a nurse regularly in the weeks or months after a serious hospitalization, few send one regularly to even seemingly healthy patients. This a radical redefinition of the health-care system's role in the lives of the elderly. It redefines being old and chronically ill as a condition requiring professional medical management.</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Health Quality Partners' results have been extraordinary. According to an independent analysis by the consulting firm Mathematica, HQP has reduced hospitalizations by 33 percent and cut Medicare costs by 22 percent.</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Others in the profession have taken notice. "It's like they've discovered the fountain of youth in Doylestown, Pa.," marvels Jeffrey Brenner, founder of the Camden Coalition of Healthcare Providers.</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Now Medicare is thinking of shutting it off.</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; "><strong style="margin: 0px; padding: 0px; ">Lucrative potential</strong></p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">The origin of Doylestown's fountain of youth is not particularly mysterious or mythic. It can be found on Page 93 of the 1997 Balanced Budget Act. Under "Subchapter D — Other Projects," there are two pages of dull legislative language authorizing Medicare "to conduct demonstration projects for the purpose of evaluating methods, such as case management and other models of coordinated care, that (A) improve the quality of items and services provided to target individuals; and (B) reduce expenditures."</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">In the health-care world, however, these yawn-inducing paragraphs sounded like the beginning of a revolution — or, perhaps, a gold rush.</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">The project was remarkable in two ways. First, it used the gold standard of experimental design: Randomized-controlled trials. Each of the 15 programs — of which HQP was one — would see some seniors enrolled in the program and some left out. The assignment would be random, and the groups similar — that would let the researchers be certain that whatever differences they saw between the groups were attributable to the care they received rather than, say, the company's success at signing up healthier seniors. "We did it that way so nobody would ever question the validity of the findings," says Randall Brown, a senior fellow at Mathematica Policy Research, the outside evaluator Medicare hired to judge the programs.</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">The second unusual feature was that the secretary of Health and Human Services had the authority to scale it up. Typically, Congress keeps tight hold of the reins on these kinds of experiments. But not this time. As long as the programs were increasing quality without increasing costs, the secretary could "continue the existing demonstration," "expand the number of demonstration projects," or even "issue regulations to implement, on a permanent basis, the components of the demonstration project that are beneficial to the Medicare program." It was, for an experiment of this type, an extraordinary, and extraordinarily rare, amount of authority.</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">That made it potentially very, very lucrative. A midsize care-management company that proved itself in this demo could, theoretically, get the green light to provide services to every chronically ill Medicare patient. Everyone understood the implications immediately: There were billions of dollars on the table. And there were plenty of for-profit companies who were certain they'd be able to get them.</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">"I was at conferences when this was all getting underway," Brenner says. "These huge vendors from these really big companies had gotten into this. I remember all these really well-dressed people strutting on the stage. They thought they were going to get access to the gold mine of health care. I remember seeing them speak and thinking, 'I can't be this dumb.' I couldn't understand how their models would work. I've never seen a telephone call change behavior."</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Their models — and their telephone calls — didn't work. Program after program either failed to help patients, save money or both. "You'll see some disease management programs out there led by MBAs or people who used to be doctors and are now businessmen," Brown says. "They're totally different kettles of fish. They tend to be telephonic, and the telephone centers might be in California or Missouri. They don't work. We've shown it time and time again."</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">But Health Quality Partners, with its emphasis on continuous nurse-to-patient contact, did work. Of the 15 programs, four improved patient outcomes without increasing costs. Only HQP improved patient outcomes while cutting costs. So Medicare extended it again and again — now it's the only program still running under the demo. But Medicare has notified Coburn that it intends to end HQP's funding in June.</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Medicare's official explanation is carefully bureaucratic. "The authority that CMS had to conduct this specific demonstration, which predated the health care law, did not allow us to make the program permanent and limited our ability to expand it further," says Emma Sandoe, a spokeswoman for the Centers on Medicare and Medicaid Services. "As we design new models and demonstrations, we are integrating lessons from this experience into those designs."</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Every expert I spoke to — as well as a plain reading of the law — disagrees. If they wanted to make HQP permanent, or scale it up in a big way, Medicare has the power to do so. Then there's this: "Thanks to the health care law, we can now test new, innovative models for delivering health care and expanding models that show promise," Sandoe continues. "With this new authority, we can take best practices to scale and provide more incentives to deliver high-quality health care at lower costs."</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Medicare is referring to the newly created Center for Medicare and Medicaid Innovation, which gives the program power to create and expand projects without congressional authorization. This authority could also be used to create projects based on HQP's lessons. It's not. Instead, Medicare has created a raft of projects and experiments meant to move the system from fee-for-service toward pay-for-quality — with the hope that if they can get the payment incentives right, then the market will have reason to support programs like HQP.</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">To Health Quality Partners and its defenders, Medicare's decision is ludicrous. "We're spending tens of billions of dollars now on Medicare innovation where Medicare already discovered something amazing and now they're forgetting what they discovered?" Brenner says. "It's an amazing government moment."</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">But to Medicare, it's not so much forgetting as being realistic. After all, HQP worked, but most of the programs in the demonstration didn't. It notes that HQP is a relatively small program that only ever treated a couple of thousand people. For a program the size of Medicare, working to scale up a small operation like HQP seems less likely to deliver a big return than working to change the payment structure that governs the entire system.</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">This drives Coburn crazy. "People always ask if what we do is scalable. Well, define scalable. It's less difficult than open-heart surgery, which is one of the most common surgeries in the country, and it's more difficult than giving a vaccine. There's this amazing double standard in medicine. For the kind of thing we do, if it's more difficult than making a phone call once in awhile, then it's not scalable. But you provide enough economic incentives and all of a sudden every hospital has an open-heart surgery program."</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Brenner puts it more vividly. "There is a bias in medicine against talking to people and for cutting, scanning and chopping into them. If this was a pill or or a machine with these results it would be front-page news in the Wall Street Journal. If we could get these results for your grandmother, you'd say, 'Of course I want that.' But then you'd say, what are the risks? Does she need to have chemotherapy? Does she need to be put in a scanner? Is it a surgery? And you'd say, no, you just have to have a nurse come visit her every week."</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; "><strong style="margin: 0px; padding: 0px; ">Making the house call</strong></p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Here's what I thought would happen when I went with Patty Graefe, a Health Quality Partners' nurse, on her daily rounds: I thought I would see a highly skilled medical professional showing off her success stories. I thought I would meet seniors who were overwhelmed by their illnesses a few years back, but since signing up for the program, were now carefully protecting their health. Nothing else, I figured, could possibly justify the numbers HQP seemed to be producing.</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Instead, I met Paul and Betty Bradfield.</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Getting to the Bradfield's house is harrowing. You drive over a stone bridge that looks neither wide enough nor structurally sound enough to support a car. You nose up a curving road that has been cut into a steep hill. You walk past a giant pile of wood into the sort of old, rickety farmhouse that quickens the step of kids on Halloween. It's a place I might be scared to live. It's a place I'm definitely scared to find Paul and Betty living.</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Paul, at 83, suffers from serious heart failure and mild cognitive impairment. A year ago, he climbed a ladder to change a birdfeeder at 10 o'clock at night. He fell, breaking his neck. Betty, at 80, is legally blind and has diabetes.</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">The Bradfields are warm hosts, and clearly glad to see Patty. But their situation isn't good. "I messed up on my medication this week," Paul says, shortly after we walk in the door. He's not sure how. It's possible he took a double dose. Or it's possible that he skipped a dose. And he's already thrown away the evidence. "I'm not worried about the mess-up," Graefe says kindly. "I just need to figure out if you took a double dose." She makes a note to call Paul's doctor.</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Graefe has been a nurse for 28 years. She has worked in cardiac wards and with patients in rehab. She has been in hospitals, in call centers, and now on home visits. "This is the best nursing I've ever done in my life," she says. "And that's because it's really all about nursing."</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">As a hospital nurse, Graefe worried she wasn't able to build the trust she needed with her patients. "I dealt with a lot of heart failure," she says. "A patient would come in, filled with fluid. You'd ask them whether they were taking their medicine. Or if they were eating right. The patient gets almost defensive because we always assume they're doing something wrong. I found that the hospital setting wasn't the best place for these conversations."</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">I asked a half-dozen seniors what difference Health Quality Partners made in their lives. Every one of them began the same way: They could ask their nurse questions, they said with evident relief. They could get help understanding and navigating their doctor's orders. They didn't feel like they were being a burden if they needed to ask one more thing, or have their medications explained to them again.</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Physicians are brusque, and harried, and they talk quickly and confidently, and chronically ill seniors often leave with complicated instructions and a hazy understanding of how to follow them. "In a doctor's office, a lot of people, especially older people, feel pressure to get out because they know the doctor is busy and they're a bit intimidated," says Bill Allen, a friendly 78-year-old who is also a patient of Graefe's. "Because she's here in our home, you can feel more free to ask her anything. It's great."</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">As a nurse, Graefe's style is practical and nonjudgmental. It seems obvious that chronically ill seniors should take their medicine. But Graefe doesn't see the situation as quite so black-and-white. "You have to find out why a patient isn't taking their medicine," she says. "In the case of heart failure, the water pill has a lot of side effects. Imagine losing control of your bladder. Not being able to go out because you always need a bathroom. We're talking about adults here."</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">This is, to me, the surprise of accompanying Graefe on her rounds. Despite the years-long relationships, she's not turned her patients into highly effective self-<br style="margin: 0px; padding: 0px; ">caregivers. Everyone we see admits to missing their medicine or making bad diet decisions or slacking on exercise routines. Graefe just laboriously pushes them to make slightly better decisions on the margins. The Bradfields, for instance, are, after years of cajoling, finally readying themselves to enter assisted living — something that might not have happened at all without Graefe's nudging.</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Because she has been to patients' homes so many times before, she can see when something has changed and things are about to go very wrong. And she's got the personal relationship to intervene. Allen, who suffers from lung problems but hates to take medicine, recalls a bad cold he had a few weeks ago. "Because of Patty's insistence, I ended up using the — what do you call it? — the nebulizer. I probably wouldn't have done it without her. And I probably would have ended up with pneumonia again. I'm sure that's what got me through." It also saved Medicare money, and perhaps saved Allen's life.</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">We think of the hospital as a place people go to get better. At Health Quality Partners, the view is that a hospital is a place where seniors get worse. "Being in the hospital for three days or five days sets them back to a point where they'll never regain what they were," says Sherry Marcantonio, chief program architect of HQP. "That's where the scales tip. That's where people end up needing a nursing home." Keeping seniors out of the hospital, which is a core focus of its program, cuts costs and saves lives, but it also preserves quality of life — a measure often ignored in these discussions. There's a good argument to be made that if a program like HQP cost slightly more than traditional Medicare but cut hospitalizations by a third, it would still be worth it. The point of health care, after all, is to keep people healthy. But HQP saves money — and lots of it.</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">If there is a secret to the success of Health Quality Partners at preventing hospitalizations, it's this: No one else is checking in with the Bradfields or the Allens every week. Medical technology — from pills to devices to surgical procedures — is so advanced and so competitive that making further gains requires enormous investment and rarely brings high returns. But the exciting field of knocking-on-the-Bradfield's-<wbr style="margin: 0px; padding: 0px; ">farmhouse-door is almost totally empty. Medicine has been so focused on what doctors can do in the hospital that it has barely even begun to figure out what can be done in the home. But the home is where elderly patients spend most of their time. It's where they take their medicine and eat their meals, and it's where they fall into funks and trip over the corner of the carpet. It's where a trained medical professional can see a bad turn before it turns into a catastrophe. Medicine, however, has been reluctant to intrude into homes.</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">For the most part, the medical system treats the old very much like it treats the young. It cares for them when they're sick and ignores them when they're well. Coburn's basic insight is a discomfiting one. He doesn't really believe in "better," at least not for elderly, chronically ill patients. He wants someone going over frequently to see if they're depressed, if their color is good, if they understand their medications, if there's anything they need. This isn't medicine so much as it's supervision.</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">At another time, these functions would have been filled by the family, who would be right in the other room, and who would know if their mother looked different than she had a few weeks ago. But few of today's elderly live with their children. Many don't even live in the same state, or they don't have any contact with their children, or they don't have children.</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">A recent study in the Proceedings of the National Academy of Sciences found that after adjusting for demographic factors and underlying health, social isolation increased the likelihood of death among the elderly by a stunning 26 percent. "People with few social contacts may not have people around them who can give them advice, recommend that they go to a doctor with symptoms, ensure that they maintain healthy lifestyles, or perhaps they don't have anyone around when they experience acute symptoms," says Andrew Steptoe, the lead author on the study.</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">We've been conditioned by "Grey's Anatomy" and hospital rooms to believe that saving lives is a complicated, heroic business. And it is — after people get very sick. But keeping them from getting very sick doesn't necessarily require the discovery of new molecules. It requires someone who has a relationship with them to stop by once a week to see how they're doing. The problem is, it's hard to make money off it.</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; "><strong style="margin: 0px; padding: 0px; ">The uneven legacy</strong></p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">If you go into the hospital for heart surgery and you end up getting a central-line infection, you'd hope that the hospital would be penalized for it. The opposite, in fact, is true. According to a new study in the Journal of the American Medical Association, surgical complications increase the margin the hospital makes on the patient by 330 percent for the privately insured and 190 percent for Medicare patients.</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">This, too, is a legacy of a health system built for acute care. Hospitals make money when they do more to patients. They lose money when their beds are empty. Put simply, Health Quality Partners makes hospitals lose money. "There's no doubt that it's a hit to the bottom line," says Rich Reif, the former CEO of Doylestown Hospital, which worked with HQP.</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Reif's answer for why he worked with a group that cost him money is simple: His hospital was unusual. In 1895, 14 women came together to form Doylestown's "Village Improvement Association," which was dedicated to "the health and beauty" of the community. The association actually owned Doylestown Hospital, and its mission was the hospital's mission. "I did get some heat from my senior management team," Reif says. "When you're doing annual budgets you see reduction in revenue. But I could always come back and say, 'Wasn't that our responsibility?' "</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">But not all hospitals are run by the local Village Improvement Association. Many seek to turn a profit. That makes models like Health Quality Partners something of a threat. "If we scaled what Ken is doing," Brenner says, "you would probably shut down a third of the hospitals in the country. It's a disruptive innovation. It just guts the current business model."</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">This is where Medicare's focus on changing that payment model could help programs like HQP. It's pushing providers to band together into accountable care organizations, or ACO, that get a flat fee for all care related to a patient. If they spent less, they could keep the difference. In theory, this should push them to partner with tested organizations like HQP that have a proven ability to help them spend less. But many experts are skeptical that ACOs will be the game changer Medicare hopes.</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">"I don't have a lot of confidence in the ACOs working out," Mathematica's Brown says. "None of the ACOs you talk to are willing to say which hospital they'll close. And the only way to save big money in a system is to reduce hospitalizations. That means you need fewer hospital beds. You can't make money off of an empty hospital. So until they're talking about closing some local hospitals to realize the gains from reducing hospitalization, they're not going to be saving much money."</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">Robert Berenson, a Medicare expert at the Urban Institute, is also skeptical. "To understand ACOs, you have to go back to the physician group practice demo. That was the basis for the ACOs. It was the model adopted into law in the Affordable Care Act. It was these 10 multispecialty groups, and the idea was we'll pay you fee-for-service and if your total spending comes in under the control group's costs, you get to share the savings. Everybody thought it was a great success, but when the results came in, it didn't save any money at all. The one exception was a plan called Marshfield, perhaps because it wasn't based in a hospital and so could keep people out of hospitals."</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">This is a tough truth of the health-care system: It's got a lot of incumbents, and a lot of fixed costs, and reforming the way care is delivered will mean creating a lot of losers. "This is about power and money," Brenner says. "The largest group in the top one percent of income in America are physicians."</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">The chronic-care focused system that Coburn is pioneering is more about nurses than doctors, more about home visits than hospitals, and more about human interaction than high-tech intervention. A system based on managing chronic care is a truly different system from the one we have today. Health Quality Partners was lucky to find a hospital that wanted to work with it. But many hospitals wouldn't want to work with a program dedicated to sharply reducing their revenue stream. And without cooperation from the hospital and a patient's doctors, the HQP model would fail.</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">The only payer with the size and the incentives to push something like HQP is Medicare. "For them to say it's not their responsibility to scale a program like this is ridiculous," Brenner says. "They send market signals all the time. One day it's an experimental oncology procedure and the next day everyone is using biologicals. That's because of them and what they pay. They're the ones who scale this stuff. It feels to me like they're scared to pull a lever on a very clear market signal. But if they said here's Ken Coburn's model, here's the code for it, here's how much we'll pay for it, and, by the way, we'll overpay for it, because we think it's important, the marketplace would drive that."</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">They could stop far short of that, of course. They could begin another demonstration project that took the lessons of HQP and used them to seed 15 more programs. There is, after all, a flip-side to the skepticism over whether the program can scale. It's possible Coburn's model, which has been run on a shoestring budget, could, with real resources, be improved. Coburn is quick to agree. "I really think we're just at base camp. There are so many contributors to health the system isn't addressing right now. As proud as I am of what we're doing, I think we're just scratching the surface of this stuff."</p><p style="margin: 0px 0px 15px; padding: 0px; color: rgb(0, 0, 0); font-family: Times; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; orphans: 2; text-align: -webkit-auto; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-size-adjust: auto; -webkit-text-stroke-width: 0px; ">It wouldn't cost Medicare very much to find out. Quests for the fountain of youth have been launched from far flimsier maps.</p></div><a href="http://www.washingtonpost.com/blogs/wonkblog/wp/2013/04/28/if-this-was-a-pill-youd-do-anything-to-get-it/?">http://www.washingtonpost.com/blogs/wonkblog/wp/2013/04/28/if-this-was-a-pill-youd-do-anything-to-get-it/?</a><div style="font-family: Helvetica; font-size: 14px; color: black; text-align: left; "><br class="webkit-block-placeholder"></div>

If this was a pill, you’d do anything to get it - Washington Post

When Ken Coburn has visitors to the cramped offices of Health Quality Partners in Doylestown, Pa., he likes to show them a graph. It's n...

ISRAEL, IRAN and the BALKANS Part 3

Kale chips are not potato chips and the beauty of mindfulness

If this was a pill, you’d do anything to get it - Washington Post

Ads

Archive