Barbarians at The Gate-What Consumers Can Expect from The Trump Administration

Now that President-Elect Trump’s opinions and omissions can create harmful consequences, this is your Jumping-Off-the-Cliff guide to staying informed, develop an action plan and mitigate damages from his reign. First, the cliff notes on his cabinet and chief staff members:

What’s at Stake	Nominee	Perspectives	Analysis
Your Health The Secretary of Health and Human Services controls the following agencies: Centers for Medicare and Medicaid, Food and Drug Administration, administers the Affordable Care Act, and grants more money for medical research than any other agency in the world.	Tom Price, Republican from Georgia, He is an orthopedic surgeon, and represents one of the healthcare sectors with expensive medical devices and lucrative profit margins for health systems. Resentful of the 3% medical device tax his industry pays to fund the Affordable Care Act for low-income Americans.	Wants to get rid of Obama Care and replace it with another insurance based payment system. Questions the value of the Centers for Medicare and Medicaid innovation through Demonstration Projects. He wants to reduce the footprint of government policy making in healthcare. Though he wants consumers to shoulder more responsibility for their health care, he questions the value of performance assessment as a component of government funding and oversight by government agencies. CMS’s Accountable Care Organization program has been successful and 31% of 2015 participants received bonuses. There are 400 healthcare systems participating in this program. Would he impinge on medical research by eliminating stem cell research as his predecessor George Bush did?	By defunding CMS, the nation would have no national bully pulpit to pressure healthcare suppliers, drug companies, and insurance companies on cost and accountability. Medicare is the most effective tool we have for making changes in U.S. healthcare with an integrated national platform. Medicare Shared Savings programs saved the CMS 1.6 million in 2015. (David Muhlestein, 2016) Would he repeal the Sunshine Act which requires federal reporting of pharmaceutical industry influence on universities and medical training to avoid conflicts of interest? (American Medical Association, 2016) Would he abolish the successful Accountable Care Organization Program which rewards health-driven clinical outcomes? He will also eliminate birth control under Medicaid plans.
Your Air and Water The Environmental Protection Agency sets standards for air & water quality, extracts fines from offenders, and litigates as required for compliance with federal and state laws.	Scott Pruitt, Republican Attorney General from Oklahoma and former senator, is decidedly not part of the beltway. He will drain the swamp and poison your well.	The EPA was created by the Nixon Administration and is responsible for improvements in air and water quality throughout the nation. Pruitt wants to gut the Clean Water and Clean Air Acts signed by the Obama Administration. Has pledged to dismantle the EPA and is in the back pocket of the oil and gas industry. He has been vociferous in his lawsuits against government regulations. Doesn’t think global warming is an issue. Wants to get out of the Paris Climate Change Accords, which were signed by 95 countries.	Carbon emissions are the greatest contributor to greenhouse gases causing global warming and the melting of the polar ice caps. Obama Administration clean air rules force power plants, especially coal powered ones, to reduce particulate emissions. The act established standards for emissions but allows flexibility for states to administer. States have already submitted plans for reaching targets.
Your Children’s Education  The Department of Education sets national standards for education (No Left Behind and Common Core), provides funding, and enforcement of standards.	Betsy DeVos, former chairwoman of the Michigan Republican Party, is from the Amway family of billionaires and has never attended a public school, nor have her children. She attended Calvin College, a private liberal arts college.   She is the sister of infamous military defense contractor, Eric Prince, founder of private mercenary group, Blackwater.	Wants to deconstruct the agency and give more responsibilities to states, counties, and individual districts to set curriculum. She is a huge supporter of charter schools, which are funded with public funds but operate like private schools. She advocates a school voucher system where the government would essentially provide support for private schools. In Michigan, 80% of the schools are run by private companies. She is does not believe in recognizing homosexuality.	Current Secretary of Education, John King, Jr, says there are a lot of charter schools which are doing poorly and are not taking the steps needed to improve performance. For a vision of what could happen to primary education in the country, look to the healthcare sector where competing private interests often increase costs and work against effective public health improvements.
Your Money The Department of the Treasury, oversees revenue collection through the IRS, and sets standards for currency and financial management for the nation.	Steve Mnunchin, former Goldman Saks executive and Hollywood film financier, is a Wall Street banker insider, who graduated from Yale.	No information is available for his position on the landmark Dodd-Frank Act which created liquidity standards for banks to prevent the financial collapse of the nation and the world. If the U.S. government hadn’t bailed out AIG Insurance, General Motors, Fannie Mae, Freddie Mac, and a host of banks the depression would have been much more severe. (ProPublica.org, 2016)	He is well-educated and more liberal than Trump’s Cabinet picks, but hews from the hedge fund world, which contributed to the 2007 economic collapse of the mortgage banking industry. The question is, will that experience inform better safeguards or is this a fox-in-the-hen-house scenario? Investment banks are chaffing to go back to the Wild West of deal making.
Your Liberty The Attorney General of the United States, oversees the administration of federal laws, court system, and enforcement for anti-trust and civil rights laws.	Jeff Sessions, Attorney General, Republican Senator from Alabama, and former Attorney General of Alabama. He was rejected by the Reagan Administration for a federal judicial appointment because of racist views.	Has a reputation of being anti-immigrant, anti-Muslim, and anti-gay (LBGTQ). One of the most conservative members of Congress often at odds with his own party. Is a supporter of the stop and frisk ethos.  Widely considered to have anti-minority views.	Concerns are; the gerrymandering of redistricting, potential repeal of the voting rights act, enforcement of election laws, and actions against those using their first amendment rights for protest and free assembly.
Your National Parks The Secretary of the Interior oversees the vaunted National Parks system, national forests, and all public lands, including the Bureau of Indian Affairs.	Ryan Zinke is a Republican freshman senator from Whitefish, Montana who is a former navy SEAL commander.	One of his most alarming views is he considers climate change to be unsettled. We don’t know anything about his governance perspectives. However, at least he is not a beltway insider. Montana has many tribal lands, including the Flathead Indian Reservation.	Maybe we could swap Zinke for Perry, because I would rather trust a military officer with protecting our nuclear plants. Concerns are he will use public lands as private sector resources for industry versus preservation.
Your World The Secretary of State is 4th in line to the presidency and is chief negotiator of foreign policy on behalf of the nation, also responsible for coordination and security of diplomatic posts. This person is a foil for the president.	Rex Tillerson, current chief executive of Exxon, is retiring this month. He has lucrative financial interests in countries which are considered enemies, including Russia.	Tillerson has a fifteen-year relationship with Putin, czar of Russia and advocates loosening of economic sanctions. Unlike other Trump nominees, he favors climate change action, including the carbon cap taxes on emissions. He also favors supporting the 2015 Paris Accords for Climate Change Action. He probably would favor the Keystone Pipeline completion.	The far-flung oil and gas interests of Exxon  and his personal wealth would be impacted by actions of the federal government. No one has the potential for more conflicts of interest except Trump. He would have the ability to push back against the dogma from uninformed views of other cabinet nominees, especially on energy and climate issues.
Transportation The Secretary of Transportation oversees highway safety and road construction projects.	Elaine Chao is former head of the Department of Labor and married to Senate Majority leader, Mitch McConnell.	One of Trump’s centerpiece platforms is the rebuilding of America, so Chao will be responsible for contract letting, management, and other infrastructure requirements.	Chao is perhaps the most experienced member of the cabinet, as she ran a large government agency under the Bush Administration.
Keeping the Lights On The Secretary of Energy has oversight of the nation’s nuclear arsenal, also sets policy on utilization of resources to develop and maintain the nation’s energy grid.	Rick Perry, is the former Texas Governor, failed presidential candidate, and middling Dancing with the Stars Contestant.	The only qualification Mr. Perry has for energy expertise, is his support of wind power in his home state. He has no scientific background and has suggested the Department of Energy could be eliminated. The current Secretary of Energy, Ernest Moniz is a nuclear physicist.	Perry wasn’t a strong advocate for Trump so perhaps the president elect is an advocate of recreational pot as there is no other explanation for this appointment.

Next Steps

Now is the time to study the issues for which you are most passionate and draft whitepapers and reach out to your elected officials. I have already reached out to my elected representatives on several points since November 8^th and have also published several opinions in the New York Times. This article is my third posting since the election and my 99^th since I started this column. The election of caustic Trump to one of the most influential positions in the world has not dulled my sense of liberty, but inspired more insights and energy to inform readers about critical resourcing issues. And this is the healthpolicymaven signing off and encouraging you to share this article with all who value their democracy.

Roberta Winter is a freelance journalist who publishes under the trademark healthpolicymaven, which has been in continuous use since 2007. She is a public policy and healthcare book reviewer for the New York Journal of Books, a technical writer, and author. Her consumer guidebook to the U.S. healthcare system was published by Rowman & Littlefield in 2013. https://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972

Other Articles On the Republican Agenda To Jettison the Affordable Care Act
http://healthpolicymaven.blogspot.com/2016/06/republican-plan-to-replace-obamacare.html

http://healthpolicymaven.blogspot.com/2016/01/top-10-things-from-affordable-care-act.html

http://healthpolicymaven.blogspot.com/2015/10/affordable-care-act-program-shows.html

 References:

American Medical Association. (2016, December 16). Physician Financial Transparency Reports (Sunshine Act). Retrieved from American Medical Association : https://www.ama-assn.org/practice-management/physician-financial-transparency-reports-sunshine-act

David Muhlestein, R. S. (2016). Medicare Accountable Care Organization Results for 2015: The Journey Toward Better Quality and Lower Costs Continues. Health Affairs. Retrieved December 16, 2016, from http://healthaffairs.org/blog/2016/09/09/medicare-accountable-care-organization-results-for-2015-the-journey-to-better-quality-and-lower-costs-continues/

ProPublica.org. (2016). Bailout Recipients December 12, 2016. ProPublica.org. Retrieved December 15, 2016, from https://projects.propublica.org/bailout/list

 

Reducing Opioid Use And Back Pain With Ipod And Neurotransmitter

New Treatment for Back Pain Using an Ipod and Neurotransmitter

Opioid addiction cost the U.S. 79 billion dollars in 2013. (Silverman, 2016) This article reviews an alternative treatment for lower back pain, besides prescription opioids.  In a review of all emergency admissions between 2004 and 2008, two million people in the United States were found to have sought treatment for lower back pain each year. Back pain is also the second most common cause of workplace absenteeism and disability. (Waterman BR, 2012)  A 1992 North Carolina survey of chronic lower back pain, defined as those who have experienced this problem for three months or longer, found that 3.9% of survey respondents reported debilitating back pain. The survey was repeated in 2006 and the incidence of lower back pain had increased across all sectors and had risen to 10.2% of the population. (Janet K. Freburger, 2009) The treatments for this health curse can be invasive and ineffective, often leading to prescription drug addiction to opioids, but new technologies have created a minimally invasive pain treatment for the millions of people suffering from lower back pain. This article highlights what a determined Oregon resident, is doing to treat her lower back pain, through participation in a high tech clinical trial using an Ipod and a neuro transmission device for pain control.

The Patient

Fran had experienced years of back problems and was diagnosed with scoliosis and spinal stenosis.  Spinal stenosis is the most common reason for back surgery for adults over the age of 65. Her back problem became much more pronounced on a European vacation, where she found herself racked with pain and struggled to regain movement of her left leg. In 2009, she tried steroid treatment and found the first injection was effective, but the second one failed to ease her pain. She also tried physical therapy but it did nothing to relieve her pain. However, when the pain returned, she even tried other medications like Lyrica and Gabapentin for a while, but found it had adverse side-affects. She finally had some surgery which opened areas of her spine that inhibited the nerves.  After surgery her pain had virtually disappeared.  Three years later the pain returned, like a poker in her left buttocks radiating down her left leg and ultimately down her right leg as well. After another MRI was performed it was determined that the constrictions were beginning again.  Ultimately, she returned to her back specialist, who suggested she enroll in a clinical trial for lower back pain treatment to see if it might help relieve some of the pain. Her orthopedic specialist indicated the next surgery would be a difficult one as two discs would need to be replaced.

The Clinical Trial

In August 2016, Fran became a participant in a clinical trial called medical neuro trans stimulation, which has been approved by the Centers for Medicare and Medicaid, and is now eligible for insurance reimbursement. This clinical trial is run through St. Jude’s Medical Neuro Transtimulation program and it consists of a portable pain controller, operated with a pain management Ipod app, wireless data transmission, and electrodes implanted adjacent to the participant’s spine. The sensors are portable generators which transmit signals to the neuro system through the spine. (St. Jude Medical, n.d.) Fran’s sensors were installed by a board certified orthopedic spine surgeon in the Portland Oregon area. (Oregon Spine Care, 2016)  Fran’s bionic machine is run by an Ipod and an electrical stimulation device, which responds to implanted metal sensors. The electrical stimulation generator is implanted in her waist area and is programmable by a medical specialist and reset by a magnet called a patient controller. The Ipod allows her to choose from pre-selected programs, or a continuous feed, and various levels of intensity for pain management. The programmable levels of pain management are determined by the St. Jude clinical trial procedures for each patient participating in the study.

Reducing Opioid Dependence

Neurotransmitters work by stimulating the electrical impulses between cells, which provide information to the brain and interpret sensations, such as pain or pleasure. During the early phases of opioid drug use, the neuro transmission normalizes as the drug wears off, but over time, when the addiction starts, the cellular material changes creating permanent abnormalities in cell communication. (Sherman, 2007) Thus, addiction is born from exposure, continuous use, and cellular damage from the invading drug.

With the access to individual pain monitoring programs through portable electronic devices, like Ipods, patients can use reduced amounts of the highly addictive opioids, such as OxyContin. According to the Centers for Disease Control and Prevention, 78 people die daily from opioid overdoses and 60% of these are from prescription medicine, not called pain killers by accident. (Centers for Disease Control and Prevention, 2016) Imagine losing your entire family in a day, that is the scourge of this epidemic, which claims 30,000 lives each year.  Given the highly addictive nature of the manufactured opioid drugs, the use of the TENS treatment could have lifesaving implications for chronic pain sufferers.

Centers for Medicare and Medicaid Approved TENS Treatment

In 2012, the Centers for Medicare and Medicaid (CMS) approved Transcutaneous Electrical Nerve Stimulation (TENS) for treatment of chronic low back pain for participants in clinical trials. In 2015, CMS approved insurance reimbursement for the TENS treatment for patients participating in clinical trials. This treatment is the use of electrical impulses, stimulated through a hand held electronic device, to send signals to the brain's neuro pain center. CMS will provide reimbursement for this type of treatment if it is shown to provide a meaningful reduction in chronic lower back pain or an improvement in function for these patients. In order to participate in the clinical trial, the patient must have had persistent chronic lower back pain for at least three months. CMS also stipulated that the study group and the control group must each receive the same concurrent treatments to validate the results and control for bias. (Centers for Medicare and Medicaid, 2015) Clinical Trials for Transcutaneous Electrical Nerve Stimulation are now being conducted at medical centers throughout the United States to assess real world effectiveness for patients. The initial investigative trial in 2008, which was to scientifically determine if transcutaneous electrical nerve stimulation worked, included eight scientific study sites throughout the country. (Center Watch, 2008)

Impact on National Population

Back surgeries are one of the selected procedures for higher scrutiny under the Centers for Medicare and Medicaid and the deployment of the neuro electrical stimulators and attendant handheld devices have the potential to save Medicare millions of dollars annually in unnecessary and ineffective back surgeries. This of course would drive treatment patterns for private sector insurance reimbursement as well. CMS has identified lower back pain as a diagnosis to monitor and it will begin paying physicians for clinical performance via value-based payments starting this year. (Baird, 2016)Technical expert panels were chosen in March of 2016 to review current treatment for lower back pain and make recommendations for treatment protocols based on improvements in patient health. (Centers for Medicare and Medicaid, 2016)

Are trans neurotransmitters effective? A 2008 peer reviewed study, published by Health and Human Services found that electrical stimulation through neurotransmitters was effective for treating joint pain for Rheumatoid Arthritis. This noninvasive non-addictive pain treatment requires adequate dosing and intensity for effectiveness. (Josimari M. DeSantana, 2008) Ongoing research for other applications for TENS therapy continues, but not all procedures are approved for reimbursement by the CMS. This intersection of technology and science appears to have a tremendous upside in lives saved, overall improvement in patient health, and reduction of ineffective surgeries. Instead of hearing, “Mom, you forgot your medicine, now it is Mom, you forgot your pain pad.”

This article was written by Roberta E. Winter and may be widely distributed with appropriate attribution of course.This article in no way provides medical advice and is intended for educational purposes only.

Roberta E. Winter is an independent healthcare analyst and writer and the author of Unraveling U.S. Healthcare-A Personal Guide, Rowman & Littlefield, 2013. 

References

Baird, C. (2016). Top Healthcare Stories for 2016-Pay for Performance. Committee for Economic Development.org. Committee for Economic Development.org. Retrieved October 19, 2016, from https://www.ced.org/blog/entry/top-healthcare-stories-for-2016-pay-for-performance

Center Watch. (2008). Clinical Trial Details-Transcutaneous Electrical Nerve Stimulation. Boston: Center Watch. Retrieved September 2016, 28, from http://www.centerwatch.com/clinical-trials/listings/external-studydetails.aspx?StudyID=NCT00709748

Centers for Disease Control and Prevention. (2016, October 25). Understanding the Epidemic: Drug Overdose Deaths Hit Record Numbers in 2014. Retrieved from Centers for Disease Control and Prevention : https://www.cdc.gov/drugoverdose/epidemic/

Centers for Medicare and Medicaid. (2015). Transcutaneous Electrical Nerve Stimulation for Chronic Lower Back Pain. Coverage With Evidence Development Decision Memo, U.S. Department of Health & Human Services, Centers for Medicare and Medicaid. Retrieved September 28, 2016, from https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=256

Centers for Medicare and Medicaid. (2016, October 19). Technical Expert Panels-2016. Retrieved from Centers for Medicare and Medicaid (CMS).gov: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/TechnicalExpertPanels.html

Janet K. Freburger, P. P. (2009, February). The Rising Pravalence of Chronic Low Back Pain. Arch Internal Medicine, 169(3)(February 9, 2015), 251-258. doi:https://dx.doi.org/10.1001%2Farchinternmed.2008.543

Josimari M. DeSantana, P. P. (2008). Effectiveness of Transcutaneous Electrical Nerve Stimulation for Treatment of Hyperalgesia and Pain. Current Rheumatology Report. doi:PMC2746624

Oregon Spine Care. (2016, October 5). Oregon Spine Care. Retrieved from http://www.oregonspinecare.org/our-team/robert-tatsumi-md

Sherman, C. (2007). Impact of Drugs on Neurotransmission. National Institute of Drug Abuse. Retrieved October 3, 2016, from https://www.drugabuse.gov/news-events/nida-notes/2007/10/impacts-drugs-neurotransmission

Silverman, R. E. (2016, November 16). Employers Tackle Abuse of Painkillers. The Wall Street Journal, pp. B-5.

St.. Jude Medical. (n.d.). Neuromodulation products. Retrieved October 3, 2016, from https://professional.sjm.com/sitecore/content/professional/products/neuro/scs/paddle-leads

Waterman BR, B. P. (2012, January 12). Low back pain in the United States: incidence and risk factors for presentation in the emergency setting. Spine, 12(1), 63-70. doi:doi: 10.1016/j.spinee.2011.09.002. Epub 2011 Oct 5.

Rise of Fascism in the United States-Post Trump Election

The Rise of Fascism in the United States

In the aftermath of the unruly election and the debacle of Trump’s ascendency to the highest office in the land, this represents the public repudiation of decency and respect for women. Throughout his campaign he referred to women in derogatory terms and physical evidence was presented about his sexual assaults on women. However, like a flashback to the nomination of Clarence Thomas to the Supreme Court, the victims of his sexual harassment, were treated as criminals.

As a child, I was acutely aware of my lower status as a girl, but I concentrated on being studious and working 20% harder than everyone else at every job, such was my desire to live an independent life. I was grabbed and groped in vocational agriculture class and the teacher did nothing, because he wished I wasn’t there. These humiliations and many others were something I endured because I knew no one would intervene on my behalf. I believed in women’s rights and the promise of equality.  I went to “college night” in my rural high school alone, riding my bicycle 10 miles on rural roads. When I approached my parents about my desire to go to college, my father suggested I consider secretarial school. But I was undaunted, I used my own money (I started working and paying into the Social Security system at age 13) and bought a greyhound bus ticket into the twin cities and attended my college admissions interview alone. Of course, I was accepted, what higher education institution wouldn’t include someone who wanted an education so fiercely? When I was in college, I marched for the ill-fated Equal Rights Amendment, with a Spanish girl I was mentoring.  Note to Phyllis Schlafly (RIP), your shared bathroom fear failed, as they are called family bathrooms and are wildly popular today.

 I obtained my first full-time job for Prudential,  because they were under court order to integrate their sales forces with women. Of course, I was paid less than the men, but this was a strategic error on their part, because I always made my goals, making it hard to get rid of me. I regularly received notes from the regional manager, Bill Friedman on my performance. This was in the face of a sexist division manager, Claude Cosseau, who refused to put my legal hyphenated name on my business cards. His boss, Albert Tarabini, insisted on treating all women as ciphers and all “decision makers” were deemed to be male. When I did not agree with the sales manager, Greg Freitag’s aggressive tactics in a client interview and suggested a better approach I was admonished with, “What is wrong with you-is it the wrong time of the month?” I do recall that the men of color were particularly supportive, especially Juan Barrios.

 Later, when I began my career in the employee benefits field, I was the first female account executive for the firm, an atmosphere which included a level of inebriation at corporate events equaled only by the Russian landscape.  In one particularly humiliating situation, one of the account executives told a graphic joke about fellatio in front of a senior executive and me. As the only female executive in the firm I had to grin and bear it.  I was propositioned by married executives in the firm, but this was practically an everyday thing in the business world. So, I left this firm for another one, which paid better.

As I became more successful in my field and exerted leadership for business development, this gained attention, but for women this is always the double-edged sword. I was ultimately fired for questioning my male manager’s approach to the implementation of a customer management system. Still having plenty of moxie, I took the firm to court and was awarded a modest settlement for discriminatory practices and wrongful dismissal. I used that money to start my own firm, which I ran for nearly nine years, until I decided to work on healthcare reform.

 As a single mom, I attended a top ten public university, one of the best schools in the world, to prepare myself for advocacy and healthcare improvement work. Subsequently, I have slaved away for over a decade, mostly for free, researching and providing unbiased useful healthcare information for everyday people, in the hopes this will inform better decision making. In my upbringing, I was taught that to pursue a higher calling, regardless of compensation was a good and just thing. However, it appears the tide has turned against the elevation of humanity and self-interest is the only currency that matters.

Though I would like to say that girls can be anything to which they aspire, this has been tempered by the election of a misogynist to the presidency and it would be wise to explain to your daughters, nieces, and sons what that word means, as women like me have lived it our entire lives. My son, raised by a single mother, like Presidents Clinton and Obama is all too aware of the hatred and opportunism toward women having witnessed it throughout his life. So, to those who think that it is only women who suffer from this bilious resentment, don’t forget their children. And this is the healthpolicymaven signing off with a heavy heart. Feel free to share this article with people who value civility and have not given up on the tattered democracy of the United States.