Subject: News from Dr. Kevin Fickenscher
From: "The Fickenscher Files" <[email-masked]>
To: <[email-masked]>
Date: Mon, 5 Nov 2018 14:31:41 -0500 (EST)

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001QXLNDtGMF0O31Zb1RSuoe_E5X5gGJZs7yLfLRCAoI8XsZ-6I-r_v43R4WsFJHCQyPcOMMnjTcizMXsg0afaIA1iivBi8turfrG3RkLr7DoHwES4M5KeQlALxL3A1r15nWHNGOjbe_vAmv32RQaHKpxG6dm0uxMM2cl5sfIKcBuoo-z32TryFp9y6VFrYKyqo&c=ECoH2cItBv7YqeRWbW91-o4huL0FGr-kp5EBWsXTl9VaF3dAe_Sigg==&ch=7J4Vy-ELYYh8SZGdec8sPO9OnzDaYyY0z3CRsWI1TO4Nl0A_Wxwf8A==]
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Fickenscher Files, Vol. 6, Issue 14
Kevin M. Fickenscher [http://r20.rs6.net/tn.jsp?f=001QXLNDtGMF0O31Zb1RSuoe_E5X5gGJZs7yLfLRCAoI8XsZ-6I-r_v49lgtSTnBZjfPsRRu-Ke40nqH3WgIUVZbwUpl-VZvmmVXOoqasV1l-wvnrKPeAzqaa1_HzT4-nqlrJ-3h5_Hy_WbBKdMbmTzf0iSeRagsCmIXgh_ypzYbPv2hpgbvMVe9HZz4e50OZaX-aIOy5bbgjOU8IFCebyB2A==&c=ECoH2cItBv7YqeRWbW91-o4huL0FGr-kp5EBWsXTl9VaF3dAe_Sigg==&ch=7J4Vy-ELYYh8SZGdec8sPO9OnzDaYyY0z3CRsWI1TO4Nl0A_Wxwf8A==],
MD, CPE, FACPE, FAAFP
@MDKev
A compilation of information, thoughts, and perspectives on the issues of the day
related to healthcare, technology, and beyond - including the latest culinary explorations.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Quote(s) Of The Week
"If we had the votes to completely start over, we'd do it. We're not satisfied with
the way Obamacare is working."
Senate Majority Leader Mitch McConnell (R-KY) in comments this past week on his 
continuing interest in giving ACA repeal another go...
"If you're in a tight election with a record of promoting something unpopular, you
can admit it and say it's the right thing to do, you can confess error and say you'll
never do it again, or you can lie. Republicans are taking the third option."
Norman Ornstein, a congressional scholar at the American Enterprise Institute - 
a non-partisan think tank based in Washington, DC
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Media and Issues To Consider
Books and Articles  and Thoughts worth a Review...
VOTE!!
It's not only a right,
it's also a responsibility.
A Change of Focus on Another Issue: Something Bigger Than Politics - Jonathan Swift
in 1711 said, "Vision is the art of seeing things invisible." We're there and we've
got the blinders on. In the last couple of months, we've heard a lot about the trade
difficulties with China and other countries, the "unfair" tariffs, the implication
of the tax cut passed into law by the Republican Congress - and, a host of other
 issues. Mudslinging seems to have become the mainstay. But, there's one issue you
may not have heard about which is the new, evolving threat to Maine's lobster industry.
Yes, this is not about health care (yet), it's about lobsters!! This brief missive
is about the severe bait shortage facing lobstermen (and, women). Now for a foodie
- like myself - this is a big issue and for us Mainers, it's not only a food issue,
it's an economic issue which makes it really BIG!!
You think I jest. I'm not!! In essence, regulators held this year's herring landings
at last year's levels - or, 50,000 metric tons - and, are planning to slash next
 year's quota of herring (= the most popular lobster bait) down to 30,000 metric
 tons. Why? Well, there is a record low number of newborn herring entering the fishery
off the coast of Maine. Why? In large measure it's because the Gulf of Maine is 
among the fastest-warming bodies of water [http://r20.rs6.net/tn.jsp?f=001QXLNDtGMF0O31Zb1RSuoe_E5X5gGJZs7yLfLRCAoI8XsZ-6I-r_v468ABznF-6eyrChkPaKa2TZB308gU-69ugc4yCb3faX8x3TMbUI_SXzn9F5iSXjtjrEgHbV8hXEkwvDH0a640EpmFrD5PU-RXS0Zg8rZrWGvilYHG6yfX4JrHQw9yRUI5BrMStw7IZBNbiXrxyviXAjr50zc-gn1hBMXhvR_5xS7ESZ-xOjIuF7dSbDkkg7O7iTEIkt8wfWQqbM0cXNTgzKcb_HMkWGJnrpS4RTBBtLTtdBo6_WT-N-XVpiq-Qozvg==&c=ECoH2cItBv7YqeRWbW91-o4huL0FGr-kp5EBWsXTl9VaF3dAe_Sigg==&ch=7J4Vy-ELYYh8SZGdec8sPO9OnzDaYyY0z3CRsWI1TO4Nl0A_Wxwf8A==]
across the entire globe. It's been local news since around 2015 and the problem 
is accelerating. Due to warming, the lobsters have already moved about 150 miles
 further north off the coast of Maine in search of cooler waters and, are expected
to move even further north. They're accompanied in their northerly travels by cod,
northern shrimp and a host of other species that dominated the waters in the Gulf
of Maine - including the herring! Then, on top of all of that China and Europe are
both threatening a tariff on lobster [http://r20.rs6.net/tn.jsp?f=001QXLNDtGMF0O31Zb1RSuoe_E5X5gGJZs7yLfLRCAoI8XsZ-6I-r_v468ABznF-6eyksQdLmG9YMLB54MkmZ85HEXAQzmeJ3Kf29ZWC1umGQfFn-I78SysLzzk3Akvb5_ZS9OuQHKU1n_717aOWDRUegfyKNmzZTfVn8NR3Jxw7gni0IU4VCyXGUvS0K-RQge-nsXnAz3le9o6Q3Ae_yDKq3FSoQjN3BitlgyPd-nHvRgIO5craG5lx5NApo1o0LyqpPtNAmHbBGlcYACGwWXht_cOMvaeTqb8USFN6XWd5Rezn2NB9OYkBA==&c=ECoH2cItBv7YqeRWbW91-o4huL0FGr-kp5EBWsXTl9VaF3dAe_Sigg==&ch=7J4Vy-ELYYh8SZGdec8sPO9OnzDaYyY0z3CRsWI1TO4Nl0A_Wxwf8A==]
from the USA. Need I say more?   Well, just a bit more...
There is a controversy on what to do about the herring which takes us into a much
longer discussion even further away from health care (NOTE: occasionally, that's
 a sanity improvement strategy). Leave it to say that there's a big debate on how
to proceed between the New England Fisher Management Council, the Maine Lobstermen's
Association and the National Oceanic and Atmospheric Association (NOAA) on what 
to do. But, unlike debates in other parts of our society, this one is civilized 
and - more importantly - trying to find a solution. The fly in the ointment is that
the problem is global warming [http://r20.rs6.net/tn.jsp?f=001QXLNDtGMF0O31Zb1RSuoe_E5X5gGJZs7yLfLRCAoI8XsZ-6I-r_v468ABznF-6eyR9rp_zk2OMGvjNbKPLEvbVuoGcCG58hsw2Wu2fgIbG6FYvck38zjbjj0HCik88Uh8Q8XMaJsPlF-h-3ex7CU-vE_NpU1dbtZFJgoKn0Xkp_0iwnvd_p8XKQqQ6TOzhQhP-uNYIyQvasDK88d9UdHwgXLRHMaYusEZm9SibaQa93AEgm1N377s8uIWoR8jLbQIp18Y5BGf1x8W79m-BW9xv7UDY1mSPBbcRSrdS9oLHfZtmji3DWJVPGPBUtL3cEoqRkImN4r7ubjQilzHjlaLDwKJQpl7B4n&c=ECoH2cItBv7YqeRWbW91-o4huL0FGr-kp5EBWsXTl9VaF3dAe_Sigg==&ch=7J4Vy-ELYYh8SZGdec8sPO9OnzDaYyY0z3CRsWI1TO4Nl0A_Wxwf8A==].
Yes, you heard it here - global warming. Now, that is an issue that I hope we can
all rally around. Several weeks ago, I noted the invasion of ticks at our southern
border due to "global warming" and the diseases that were beginning to show up. 
Now, it's lobsters and herring. It's a climate issue today. It will be a health 
care issue tomorrow. Mark my word...
Kudos to the American College of Physicians (ACP) - The ACP is one of the largest
associations of physicians and a leader among such organizations on all considerations
related to health care. Of note, they just updated their firearms policy paper, 
"Reducing Firearm-Related Injuries and Deaths in the U.S. [http://r20.rs6.net/tn.jsp?f=001QXLNDtGMF0O31Zb1RSuoe_E5X5gGJZs7yLfLRCAoI8XsZ-6I-r_v468ABznF-6eybtVUfeT8brplXZIYqEilQezbFEbw7wb_sYI3mBzlSjrBMHuRHA80obSSffaHb4tvsJOWESmuci-XzurLSFF-B0Xx8oNjIFRE5ivIBg1555ccXbny5SBMDJmv1ITvgvQlNn7cQ1tfcORfHvdjG2K_pHhi9wXK8VP9HhKv3uHfnPypM5i5QTWTLU1uQVo-Dg9HaUKE7KNeKOTS03y4-oE7n7jJDFCU_LVC_seJZN2mtkndZvbM9p6sJg==&c=ECoH2cItBv7YqeRWbW91-o4huL0FGr-kp5EBWsXTl9VaF3dAe_Sigg==&ch=7J4Vy-ELYYh8SZGdec8sPO9OnzDaYyY0z3CRsWI1TO4Nl0A_Wxwf8A==]"
which includes nine (9) evidence-based strategies to help reduce firearms-related
injuries and deaths by keeping guns out of the hands of those at risk of harming
 themselves or others. The new recommendations include such ideas as passing laws
to prohibit individuals with a history of domestic violence - including those under
restraining orders - from buying or possessing firearms. There is even a call to
 allow family members to seek an immediate court order for removing guns from a 
family member who is at risk of using firearms to inflict harm on themselves or 
others. After the experiences of the last couple of weeks - YET AGAIN - at the Tree
of Life Synagogue in Pittsburgh, Pennsylvania and the yoga studio shooting in Tallahassee,
Florida we clearly need to address firearms violence and hate crimes which are happening
far, far too frequently across the country. Do we make this a healthcare industry
issue as well?
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Consulo Indicium
Information for your Consideration...
Factoid - By 2020, the total volume of medical information will double every 73 
days [http://r20.rs6.net/tn.jsp?f=001QXLNDtGMF0O31Zb1RSuoe_E5X5gGJZs7yLfLRCAoI8XsZ-6I-r_v468ABznF-6eyvhAWl5k_87H2-YipzRgZyQgPwyT7pjs3bboz0bAUv_pDVkqF5kWRhSOdl9X5TVkO0z7EEiU8jbVBFdC0u8GgwQMnscG1JygsJPVkNTCIeIKN66SiX-0Kk_1JggOKYdGU1Kbf6_ag_XNWkl0Fx9evUw==&c=ECoH2cItBv7YqeRWbW91-o4huL0FGr-kp5EBWsXTl9VaF3dAe_Sigg==&ch=7J4Vy-ELYYh8SZGdec8sPO9OnzDaYyY0z3CRsWI1TO4Nl0A_Wxwf8A==].
So, the question becomes - how do we teach our young physicians, nurses and other
health care providers to stay abreast of the latest and best approaches in care 
delivery? It's not just automating information. It's not just "augmented intelligence".
The issue demands our immediate attention...

Factoid 02 - Medical researchers are actively studying the retina as an early-warning
system for onset of not only diabetes - which is well known - but, also dementia,
multiple sclerosis, Parkinson's disease, Alzheimer's, schizophrenia and more. I 
think I'll invent a mirror that can be used for this purpose. Darn. I bet someone
is already working on it...
Exercise: An Old Idea Giving Shape to Better Outcomes - As we all know, falling 
is the bane of growing older. Balance and proprioception become more difficult as
we age. In one of my JAMA articles that was lying on the floor waiting for me to
 read it - when I picked it up - I learned that an old form of aerobic training 
has become the new model. In the September 10, 2018 issue of JAMA Internal Medicine
[http://r20.rs6.net/tn.jsp?f=001QXLNDtGMF0O31Zb1RSuoe_E5X5gGJZs7yLfLRCAoI8XsZ-6I-r_v468ABznF-6eywDx8_EaM_XQq14ATcxyJPU1CN0--rc8gEVXLebRwpSgDEU645sLGmZ9lDre2-YiuupsWIWm2aF0gZjWRYQlepS7-9iiQPuoDTmTFSA__ROZgIG6ZI8h6hJQA7OY7xjZOWPE9LUN1_m8=&c=ECoH2cItBv7YqeRWbW91-o4huL0FGr-kp5EBWsXTl9VaF3dAe_Sigg==&ch=7J4Vy-ELYYh8SZGdec8sPO9OnzDaYyY0z3CRsWI1TO4Nl0A_Wxwf8A==],
tai chi was found to be more effective than balance and strengthening exercises 
in preventing falls among adults. The study came from Oregon with a randomized selection
of older adults (primarily white women, average age = 78) who engaged in a twice
 weekly program of tai chi for 60 minutes. After 6 months of training, the tai chi
group was found to have significantly fewer falls than the traditional exercise 
and the control groups. The end result: move slow, keep focused and do tai chi!!
 Now, about that yoga exercise for cleansing the mind...
On The Upside-01: Healthcare Groups Oppose Rule Penalizing Use of Public Benefits
by Immigrants - The Trump Administration via the Department of Homeland Security
 proposed arule [http://r20.rs6.net/tn.jsp?f=001QXLNDtGMF0O31Zb1RSuoe_E5X5gGJZs7yLfLRCAoI8XsZ-6I-r_v468ABznF-6eytAOiWF7h4Ty0L7Iaw74mitFv02CdfsVwkdJulrSOzwTTGX8998UXK1H2ZEMlD8nHwjDp_nJLtB-ltoUNIHIuNtcmwgjcuYLtwD4BbD3GrS-s3zaZJ3Fys2XKMhGCHMMWy2Ez08CZcm6Q6KK1Z5sPgsyK_UwKuXKfeWvcpFx5NBAckA3jczdFAnS0cyMGSVKBOSdZoZb0-KbuPOb8HsemAMFIQhISTIWKj7LLc5rqCuk=&c=ECoH2cItBv7YqeRWbW91-o4huL0FGr-kp5EBWsXTl9VaF3dAe_Sigg==&ch=7J4Vy-ELYYh8SZGdec8sPO9OnzDaYyY0z3CRsWI1TO4Nl0A_Wxwf8A==]
last month that would penalize legal immigrants for using government benefits like
Medicaid. It's a rule that rang the alarm bells among a wide range of healthcare
 and public health organizations. Stepping up to the plate in opposition to the 
rule were the American Hospital Association, America's Essential Hospitals, the 
American Academy of Family Physicians and the American Academy of Pediatrics. Beyond
the medical groups, there was a broad coalition of advocacy groups seeking to block
the rule. According to experts in the field, literally hundreds of thousands of 
children and other members of low-income legal immigrant families would be forced
out of participating in public programs that provide nutrition, housing and healthcare
services. The opposing medical groups cited the ensuing public health dangers as
 a major consideration in why the rule was ill-advised. Kudos to the health care
 leaders and advocates for drawing the line!!!
...And, for those who think I'm not a middle-of-the-roader...
On The Upside-02: CMS Proposes Telehealth Expansion for Medicare Advantage Plans
 - The Trump Administration via the Centers for Medicare and Medicaid Services made
a362-page proposal [http://r20.rs6.net/tn.jsp?f=001QXLNDtGMF0O31Zb1RSuoe_E5X5gGJZs7yLfLRCAoI8XsZ-6I-r_v468ABznF-6eyGVglCYc4RIffoWLV5vJULQobcYWoy4Sp-Ur03IJOlqPx_1tZ5yB_wU_-cGQtja3ncqxZ-IERfKVzQNktkcJOGMbQttDlVZezKuPA7DV7gj7a66QyyQ2dEclH_i057sh1Onp6fdxwvLaFt91_6DZkfqx-syL-ZycFyUA-7c30KxNkTW7neK0b8w==&c=ECoH2cItBv7YqeRWbW91-o4huL0FGr-kp5EBWsXTl9VaF3dAe_Sigg==&ch=7J4Vy-ELYYh8SZGdec8sPO9OnzDaYyY0z3CRsWI1TO4Nl0A_Wxwf8A==]
to eliminate geographical restrictions on telehealth access in Medicare Advantage
(MA) plans by 2020. The change would enable those plans located in urban areas to
use connected health technology services as a core component of their approach. 
Furthermore, the proposal would allow members access to telecare services in the
 home as well as through medical service locations. The proposal was posted by CMS
last week and will be available for comments through December 31st. The proposal
 emanates from language in the Bipartisan Budget Act of 2018 [http://r20.rs6.net/tn.jsp?f=001QXLNDtGMF0O31Zb1RSuoe_E5X5gGJZs7yLfLRCAoI8XsZ-6I-r_v468ABznF-6eyNiWQtIr7yVRQ3_h1FqTxczZACO4ml-Cb5eNMT4fGFBgAwa8ATPZslGaBF212E1gAxcrzHRCjnBNAej4Ck_IdaAg5BvdFFKxA5DPqQig3JsRClZVsO3gJy10AJtoeqVYFWi0Vs9SIlfA-XbUHN5Q7imKPlwbapLuRd8Or1K4DBNUlnLyqJxTHFuSz0WkWDGaaSaUaxrZD1H1-FIxatw90lA==&c=ECoH2cItBv7YqeRWbW91-o4huL0FGr-kp5EBWsXTl9VaF3dAe_Sigg==&ch=7J4Vy-ELYYh8SZGdec8sPO9OnzDaYyY0z3CRsWI1TO4Nl0A_Wxwf8A==]signed
into law by President Donald Trump earlier this year, which included provisions 
to increase the use of telehealth and telemedicine by MA plans. In issuing the proposal,
CMS stated that it believes the change "...will increase access to patient-centered
care by giving enrollees more control to determine when, where, and how they access
benefits." One of the benefits will be cost savings in care delivery to the tune
 of about $4.5 billion dollars over the next decade once implementation begins. 
In other news, the Department of Agriculture announced [http://r20.rs6.net/tn.jsp?f=001QXLNDtGMF0O31Zb1RSuoe_E5X5gGJZs7yLfLRCAoI8XsZ-6I-r_v468ABznF-6eys7izabLPDQ91Knhi6RDnd9m9HqYsE5ScIRBTiOg5AcM_9EjsI87p608Q5eBYJxg5ikqQhSOd2k2uOkdG2rxHYWZmKQiW8IpfAxpleVyFlIlhjZjB_lwBImAL0MnK7yfUc9-3sKODO3nli54wK3oAuh7APDIBJvrP5UPYKRjfUOs2J2xfUGx2llJqMnff56RB1sj4Vv24wzLVW5_nsmUkvvU6CHHBbhVSGjrLtbunDl79kX3xoLbHCLYEDFdCVqC9GfGV9s4eqQUTxDwMiOv7cdM0pgECmPbjn_sa0OIFurA6CeyoF-dxLnUeuFZEahvjPH8eml1U6OV2x6i9UG_B_1y9Y8ChSw-lZe7eVet4A7NGZI54PlNGtFKOR11lvxo8XUjUbL-Kv47E0uUCXcOyCnAL2_aBIIlzSlLQBlVJXqxX54ApWqPdppGFEg__hfCmrZIxjS0G4z-OS-S5qVez3w==&c=ECoH2cItBv7YqeRWbW91-o4huL0FGr-kp5EBWsXTl9VaF3dAe_Sigg==&ch=7J4Vy-ELYYh8SZGdec8sPO9OnzDaYyY0z3CRsWI1TO4Nl0A_Wxwf8A==]
over $39M in learning grants related to telehealth and telemedicine. Kudos to the
Trump Administration leaders at CMS!!
Rural Hospital Closures Spike - The General Accounting Office (GAO) noted recently
in a late September report [http://r20.rs6.net/tn.jsp?f=001QXLNDtGMF0O31Zb1RSuoe_E5X5gGJZs7yLfLRCAoI8XsZ-6I-r_v468ABznF-6eyL6RAjoD0Vgvo10pIASfPgpifnJs2-0owpds78barhO68wUmgeEfglhHLpVhGpu42Ma8MsYg0o4YST7ePXpmEI8nunPs3hgsms7TFLEWfbQ9-iNF9_yk57JaDmtGpYVyrs2Jz8BbVO5E=&c=ECoH2cItBv7YqeRWbW91-o4huL0FGr-kp5EBWsXTl9VaF3dAe_Sigg==&ch=7J4Vy-ELYYh8SZGdec8sPO9OnzDaYyY0z3CRsWI1TO4Nl0A_Wxwf8A==]
that a total of 64 rural hospitals closed between 2013 and 2017 which is more than
twice as many closures as the previous five-year period. The number did not include
the eight that closed and then reopened. Emily Rappleye, the Managing Editor of 
Becker's Hospital Review, wrote a very concise list of "10 things" to remember about
these closures. Rather than synthesize her thoughts, I'm quoting her in the following
excerpt from her article in early October. Here are the "10 things":

1. "This has happened before. Between 1985 and 1988, 140 rural hospitals closed,
 accounting for about 5 percent of the rural hospitals in existence in 1985. These
closures are credited to the then-new financial pressures of the Medicare Inpatient
Prospective Payment System created in 1983.
2. "Comparatively fewer urban hospitals closed. Forty-nine urban hospitals closed
between 2013 and 2017, accounting for about 2 percent of all urban hospitals in 
2013. The 64 rural closures accounted for 3 percent of rural hospitals in 2013.
3. "Most closures - 77 percent - occurred in the South. Texas accounted for 22 percent
of the closures between 2013 and 2017, more than the entire Midwest (11 percent)
 combined.
4. "The hospitals that closed were predominantly for-profit. Thirty-six percent 
of the hospitals that closed between 2013-17 were for-profit, though for-profit 
hospitals accounted for just 11 percent of rural hospitals in 2013.
5. "The hospitals that closed were also predominately designated Medicare Dependent.
Of the 64 hospitals that closed between 2013-17, 25 percent were designated Medicare
Dependent hospitals, though just 9 percent of rural hospitals were Medicare Dependent
in 2013.
6. "Financial issues were the root cause of most closures. The GAO notes rural hospital
closures typically occurred when hospitals had negative margins and were unable 
to cover fixed costs.
7. "Declining levels of inpatient care often aggravated the hospitals' financial
 standing. These declines stemmed from increased competition from federally qualified
health systems and other larger health systems, as well as a declining rural population
overall. The report notes 2010-16 was the first period of rural population decline
in American history.
8. "Medicare payment reductions were also a major factor in the closures. The GAO
notes the average rural hospital in 2016 counted on Medicare for 46 percent of gross
patient revenue. Medicare payment reductions across the board contribute to negative
margins for rural hospitals, while reductions in Medicare bad debt payments also
 add financial pressure.
9. "Medicaid payments are a boon to rural hospitals. Supporting past research, the
GAO found rural hospitals in Medicaid expansion states were far less likely to close
than those in states that had not expanded Medicaid as of April 2018.
10. "More than half of the closed hospitals converted into another type of healthcare
facility, such as urgent care, primary care or emergency services. Forty-seven percent
ceased all services."
Hmmm - Social Media Use by Physicians - When I was going to medical school, we didn't
have to worry about things like social media. Facebook,Instagram, Twitter, Snapchat
and all the rest didn't exist because there was no access to the Internet. It's 
didn't exist, yet! So, if you haven't read the AMA Code of Medical Ethics [http://r20.rs6.net/tn.jsp?f=001QXLNDtGMF0O31Zb1RSuoe_E5X5gGJZs7yLfLRCAoI8XsZ-6I-r_v468ABznF-6eytBICArhLa43ZK-pPC59X7jFqHaUSD9iU8T_8ezhBTY3MVbMKGiQMhw6S2UVi402qDAugLCEnLqv4JO4hm61H-boD-eCf785wl9rs4eAzu4Pu99kgX5rs9oNepEPRt8eqZxaf8VmVbhltAEjJWNp1eyjmZlC0gfPb&c=ECoH2cItBv7YqeRWbW91-o4huL0FGr-kp5EBWsXTl9VaF3dAe_Sigg==&ch=7J4Vy-ELYYh8SZGdec8sPO9OnzDaYyY0z3CRsWI1TO4Nl0A_Wxwf8A==]
 you may want to consider a closer read in lieu of yet another endless evening of
"working the web". The Code recognizes that there is real value in the use of social
media and - at the same time - a special need for caution among the physician community
in how it is used. It's becoming more and more of an issue. The AMA is also now 
offering a credit-eligible CME course, Boundaries for Physicians: The Code of Medical
Ethics [http://r20.rs6.net/tn.jsp?f=001QXLNDtGMF0O31Zb1RSuoe_E5X5gGJZs7yLfLRCAoI8XsZ-6I-r_v468ABznF-6ey2-n5DLI0TVbI3O12GWo3UJgNbo6SKjhg821UdIdH8CXMz3vrywOl-uQJwLR6wSjpKVvlym-GdWb1BIlKab2ArLwEf1J8f9VZTzq6TemusCXNV1OGa6Hj-GcPqvAVxIlpAFvzOpIDNJ2kx0dXAjgAbw==&c=ECoH2cItBv7YqeRWbW91-o4huL0FGr-kp5EBWsXTl9VaF3dAe_Sigg==&ch=7J4Vy-ELYYh8SZGdec8sPO9OnzDaYyY0z3CRsWI1TO4Nl0A_Wxwf8A==],
which provides guidance to physicians for identifying and understanding how to maintain
proper boundaries with their patients and to articulate and understand the underlying
importance of those boundaries to the practice of medicine. The module is not only
available for CME credit but is also free to members or $20 for non-members. It's
worth it.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Future Health
Delivering care in the new virtual world...
Deferred until the next issue in a couple of weeks  J
================================================================================

NOTE: I thought it more important to encourage everyone to vote - regardless of 
your perspective - than to discuss the future. The here and now is right in front
of us...
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Weekly Whisk
Musings from a foodie...
Sometimes the best food is right in front of you - and, you don't even see it. Not
for months...or, years...or, decades...or, even half a century! So, it was brought
to my attention that one of the places where I have become a regular, frequent devotee
- Markie's Place and Grill [** * * * * ] - had been waiting to be mentioned in one
of my reviews for a long time. When the thought was shared (by none other than Markie
himself) I was chagrined that I had not thought of it.
Markie's is a very special place where friends and family come together all the 
time. Most recently, when I stopped by, Markie was serving a potpourri of meats 
brushed with a special thyme sauce (he would not share the recipe when I first asked).
He was busily engaged in preparing some special chicken parmesan sausages, chicken
French apple sausage, spinach feta sausage and - the piece de resistance - pork 
tenderloin. Boy oh boy were they good but, it was all in the thyme sauce. And, I
 had to work hard to get the recipe. But, before I digress, just note that the meats
were accompanied by an assortment of vegetables including squash, mushrooms, Belgium
endive and mild peppers.
So, back to the sauce. Knowing Markie I knew the dinner would be simple but elegant.
After much cajoling, he finally shared that it consisted of 5 tablespoons of olive
oil, 3 tablespoons of balsamic vinegar, 1 ½ teaspoons of freshly crushed thyme, 
2 cloves of garlic with salt and pepper to taste. It was liberally brushed on everything
that was grilled. And, it was not that difficult to concoct.
But, after the meats and vegetables, there was "Mom's Potato Salad". It was exquisite.
You see "Markie" is my brother and he made this special dinner as a reminder of 
what family is all about. And, he kept repeatedly reminding me how he wanted to 
make it into my restaurant review. So, I'll give him five stars with an extra big
star for being my brother. You made it buddy. You were always there, I just forgot
to recognize it. Love ya!! I'd share the address but then he would be overwhelmed
with outsiders trying to get in so, I'll keep it a (sort of) secret. With a last
 name like "Fickenscher", I'm sure you can find it. BTW - the appetizers were rice
crackers with American cheese - an All-American, Midwestern boyhood favorite...
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

The Good, The Bad, And The Ugly
The ongoing saga...
The Great - We can breathe the wonderful Fall air for a day before starting a new
election cycle...
The Good - In my last blog, I noted that I couldn't think of anything "Good" so 
I asked my readers to send me their thoughts. Here are a couple of responses:

* "I am heartened by the younger generation who will, I fervently hope, make the
 needed cultural, social, and economic changes - unless they too become seduced 
by power and privilege. Sadly, our generation has failed in spite of "the summer
 of love", etc.
* "Things that are good: 1) Scrapping the TPP, 2) A $1 trillion infrastructure plan,
3) Guaranteed paid leave; and, 4) Laws to encourage women in STEM
The Bad - The divisiveness of American politics. Thank goodness, the mid-term elections
are over but, then again, the next Presidential election cycle starts next week...argh!!
The Ugly - How many shootings does it take before we put in place some common sense
gun laws for all Americans? Check out the most recent Gallup Poll [http://r20.rs6.net/tn.jsp?f=001QXLNDtGMF0O31Zb1RSuoe_E5X5gGJZs7yLfLRCAoI8XsZ-6I-r_v468ABznF-6eyOKgNS_wWEaDvlXIpHtqhOQxvLJul4SCVSQ3kR8bUKd4H33naOt8hkYqEps6lTyeA21FbL_m3GS1v6xdqr7a4TdQ2dseNIHTC4iwGKWEU9XGcGAg8gSCyDD_HKZJLCrzKfwjVckg1leU=&c=ECoH2cItBv7YqeRWbW91-o4huL0FGr-kp5EBWsXTl9VaF3dAe_Sigg==&ch=7J4Vy-ELYYh8SZGdec8sPO9OnzDaYyY0z3CRsWI1TO4Nl0A_Wxwf8A==].
It shows that two issues: background checks and evaluating those who might be a 
threat are overwhelmingly support by the American public. So, why not just those
 two?
The statements in The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001QXLNDtGMF0O31Zb1RSuoe_E5X5gGJZs7yLfLRCAoI8XsZ-6I-r_v43R4WsFJHCQyPcOMMnjTcizMXsg0afaIA1iivBi8turfrG3RkLr7DoHwES4M5KeQlALxL3A1r15nWHNGOjbe_vAmv32RQaHKpxG6dm0uxMM2cl5sfIKcBuoo-z32TryFp9y6VFrYKyqo&c=ECoH2cItBv7YqeRWbW91-o4huL0FGr-kp5EBWsXTl9VaF3dAe_Sigg==&ch=7J4Vy-ELYYh8SZGdec8sPO9OnzDaYyY0z3CRsWI1TO4Nl0A_Wxwf8A==]
are the personal views of Kevin Fickenscher, MD and do not reflect the views or 
policies of any organization with which he is affiliated.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Name | Company | Phone | Email [mailto:[email-masked]] | Website
[http://r20.rs6.net/tn.jsp?f=001QXLNDtGMF0O31Zb1RSuoe_E5X5gGJZs7yLfLRCAoI8XsZ-6I-r_v43R4WsFJHCQyPcOMMnjTcizMXsg0afaIA1iivBi8turfrG3RkLr7DoHwES4M5KeQlALxL3A1r15nWHNGOjbe_vAmv32RQaHKpxG6dm0uxMM2cl5sfIKcBuoo-z32TryFp9y6VFrYKyqo&c=ECoH2cItBv7YqeRWbW91-o4huL0FGr-kp5EBWsXTl9VaF3dAe_Sigg==&ch=7J4Vy-ELYYh8SZGdec8sPO9OnzDaYyY0z3CRsWI1TO4Nl0A_Wxwf8A==]
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

STAY CONNECTED:

Facebook [http://r20.rs6.net/tn.jsp?f=001QXLNDtGMF0O31Zb1RSuoe_E5X5gGJZs7yLfLRCAoI8XsZ-6I-r_v43R4WsFJHCQyPcOMMnjTcizMXsg0afaIA1iivBi8turfrG3RkLr7DoHwES4M5KeQlALxL3A1r15nWHNGOjbe_vAmv32RQaHKpxG6dm0uxMM2cl5sfIKcBuoo-z32TryFp9y6VFrYKyqo&c=ECoH2cItBv7YqeRWbW91-o4huL0FGr-kp5EBWsXTl9VaF3dAe_Sigg==&ch=7J4Vy-ELYYh8SZGdec8sPO9OnzDaYyY0z3CRsWI1TO4Nl0A_Wxwf8A==]

Twitter [http://r20.rs6.net/tn.jsp?f=001QXLNDtGMF0O31Zb1RSuoe_E5X5gGJZs7yLfLRCAoI8XsZ-6I-r_v43R4WsFJHCQyPcOMMnjTcizMXsg0afaIA1iivBi8turfrG3RkLr7DoHwES4M5KeQlALxL3A1r15nWHNGOjbe_vAmv32RQaHKpxG6dm0uxMM2cl5sfIKcBuoo-z32TryFp9y6VFrYKyqo&c=ECoH2cItBv7YqeRWbW91-o4huL0FGr-kp5EBWsXTl9VaF3dAe_Sigg==&ch=7J4Vy-ELYYh8SZGdec8sPO9OnzDaYyY0z3CRsWI1TO4Nl0A_Wxwf8A==]

LinkedIn [http://r20.rs6.net/tn.jsp?f=001QXLNDtGMF0O31Zb1RSuoe_E5X5gGJZs7yLfLRCAoI8XsZ-6I-r_v43R4WsFJHCQyPcOMMnjTcizMXsg0afaIA1iivBi8turfrG3RkLr7DoHwES4M5KeQlALxL3A1r15nWHNGOjbe_vAmv32RQaHKpxG6dm0uxMM2cl5sfIKcBuoo-z32TryFp9y6VFrYKyqo&c=ECoH2cItBv7YqeRWbW91-o4huL0FGr-kp5EBWsXTl9VaF3dAe_Sigg==&ch=7J4Vy-ELYYh8SZGdec8sPO9OnzDaYyY0z3CRsWI1TO4Nl0A_Wxwf8A==]

Pinterest [http://r20.rs6.net/tn.jsp?f=001QXLNDtGMF0O31Zb1RSuoe_E5X5gGJZs7yLfLRCAoI8XsZ-6I-r_v43R4WsFJHCQyPcOMMnjTcizMXsg0afaIA1iivBi8turfrG3RkLr7DoHwES4M5KeQlALxL3A1r15nWHNGOjbe_vAmv32RQaHKpxG6dm0uxMM2cl5sfIKcBuoo-z32TryFp9y6VFrYKyqo&c=ECoH2cItBv7YqeRWbW91-o4huL0FGr-kp5EBWsXTl9VaF3dAe_Sigg==&ch=7J4Vy-ELYYh8SZGdec8sPO9OnzDaYyY0z3CRsWI1TO4Nl0A_Wxwf8A==]

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Forward this email
http://ui.constantcontact.com/sa/fwtf.jsp?llr=svyssnfab&m=1105336033970&ea=[email-masked]$&a=1131550968165

This email was sent to [email-masked] by [email-masked].

Update Profile/Email Address
https://visitor.constantcontact.com/do?p=oo&m=001oshdCZaoslvWED8bsIAHcg%3D%3D&ch=d97b8ec0-5fcb-11e3-85fd-d4ae528ed502&ca=2ea1e162-afde-4103-8cbf-c1fcc2e6d48e

Instant removal with SafeUnsubscribe(TM)
https://visitor.constantcontact.com/do?p=un&m=001oshdCZaoslvWED8bsIAHcg%3D%3D&ch=d97b8ec0-5fcb-11e3-85fd-d4ae528ed502&ca=2ea1e162-afde-4103-8cbf-c1fcc2e6d48e

Privacy Policy:
http://www.constantcontact.com/legal/service-provider?cc=about-service-provider

Online Marketing by
https://mlsvc01-prod.s3.amazonaws.com/2b2692b5101/939a640f-ed3e-455d-a484-5055539351c1.png
http://www.constantcontact.com/index.jsp?cc=

The Fickenscher Files | PO Box 840 | Kittery | ME | 039