Dying at Home


Alzheimer’s if the primary cause of dementia in the US. It current impacts 5.5 million


Incidence of Alzheimer’s by county in US

American adults, and that number is expected to increase to 13.8 million by mid-century.

What’s important is the shift in Alzheimer deaths from medical facilities to the home.

  • In 1999, 67.5% of Alzheimer’s deaths occurred in a nursing home or long term care facility; by 2014, that figure had fallen to 54.1%
  • In 1999, 14.7% of Alzheimer’s  deaths were in a hospital; in 2014, that had fallen to 6.6%.
  • In 1999, 13.9% of these deaths occurred at home; by 2014, this number had risen to 24.9%.
  • In 2014, 6.1% of the deaths were in hospice care.

What we can’t tell from these data are whether families are bringing loved ones home right before end of life, or whether they simply can’t afford the high cost of long term care facilities.

The data also don’t tell us the extent to which families are now relying on home health care services in lieu of nursing homes.

Sources: Taylor CA, Greenlund SF, McGuire LC, Lu H, Croft JB. Deaths from Alzheimer’s Disease — United States, 1999–2014. MMWR Morb Mortal Wkly Rep 2017;66:521–526. DOI: http://dx.doi.org/10.15585/mmwr.mm6620a1


ACA Repeal: Update


I’ve been quiet about the recent AHCA legislation. Frankly, the House bill isn’t good for ben_franklinmost Americans, but the assumption is that the Senate will heavily revise the bill before it has a chance for passage. So it’s hard to say what the final legislation will be at this point.

Then it goes to conference committee and the result will return to each chamber for a vote.  So this is a long way from being done.

There are a number of articles enumerating the problems in the House bill. The major issues are

  • Loss of health insurance for millions of Americans
  • Impact on the solvency of hospitals and clinics serving rural areas — where most of the poor live
  • Reductions in Medicaid coverage, especially for children
  • Allowing states to reduce coverage standards in insurance (depart from the ACA’s Minimum Essential standards) — reducing what the insurance buyer gets for their money
  • Raising costs drastically for consumers between the ages of 50 and 64 (1)

With all of these issues, we are still expecting the repeal bill to result in sharply higher premiums for health insurance.

The only positives in this bill are tax reductions for the wealthy.

My major concern is with health screening and checkups. The ACA recognized that the main way to reduce health care expenditures is through early detection and treatment of disease. Removing access to doctors means later detection and much higher costs.

Example: breast cancer, cost of treatment by tumor stage


0                                         $71,909

I/II                                      $97,066

III                                      $159,442

IV                                      $182,655 (2)

Reduction is access to health care is a commitment to higher medical spending or to reduction of life expectancy.


  1. Harris Meyer, “15 quick facts from CBO report on Obamacare repeal bill,” Modern Healthcare, 24 May 2017. http://www.modernhealthcare.com/article/20170524/NEWS/170529946?utm_source=modernhealthcare&utm_medium=email&utm_content=20170524-NEWS-170529946&utm_campaign=mh-alert
  2. Helen Blumen, Kathryn Fitch, Vincent Polkus, “Comparison of Treatment Costs for Breast Cancer, by Tumor Stage and Type of Service,” Am Health Drug Benefits. 2016 Feb; 9(1): 23–32.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4822976/

The Intelligent Patient


Medicine isn’t about just doing what the doctor tells you to do. Quality of life is ben_franklinsomething a doctor cannot determine. That’s a call that the patient has to make.

Let me explain by example. Prostate cancer is a difficult form of cancer, traditionally treated by removal of the prostate gland. The unfortunate side effects of that surgery are urinary incontinence, and erectile/sexual dysfunction.

A few years ago, it was discovered that some prostate cancers grow so slowly that the cancer would pose no meaningful threat to the patient. This led to an alternative approach to treatment called “watchful waiting” — basically, monitoring the growth of the cancer and doing nothing as long as the growth rate remains slow.

Now we have new research that  both documents the the impact of prostate surgery and raises questions about the value of it.

A paper presents follow-up research with prostate cancer patients, some of whom had undergone prostate cancer surgery. The follow-up was conducted approximately 19.5 years after the surgery. The key findings are:

  • Those who had the surgery reduced their risk of death from all causes by 5.5%. That is, 66.8% of those under watchful waiting died, as did 61.3% of those who had the surgery.
  • A separate analysis determined that patients characterized as “high risk” or “low risk” at the time of the decision about surgery saw no reduction in the risk of death. The entire benefit accrued to those in the “intermediate risk” category. However, due to complicating issues, there’s a debate about how much benefit even they received.

The question for the patient (not the doctor): is the surgery worth the pain and side effects for a 5.5% decreased risk of dying?

The recommendation of the doctors presenting these results is the separation of diagnosis and treatment decisions. A specific course of treatment should not be an “automatic” follow-on to a diagnosis.

My point in writing this is that the cost/benefit analysis you have to apply to this decision is true for other diseases and treatments as well. Ultimately, you as the patient need to decide what’s right for you. And, as always, consult other independent medical professionals for second and even third opinions.

CAVEAT: As always, I’m not a doctor. I’m a researcher. My role is to make you aware of items you should know or consider in making decisions, but I’m not making the decision for you, or providing medical, legal or financial advice. Your life is yours to control and manage.


  1. Roger Li, MD, Ashish M. Kamat MD, and Wayne B. Duddlesten, Professor, MD Anderson Cancer Center, “AUA 2017: Radical prostatectomy versus observation for early prostate cancer: follow-up results of the prostate cancer intervention versus observation trial,” conference presentation, 2017 AUA Annual Meeting – May 12 – 16, 2017 – Boston, Massachusetts, USA

Sleep Loss and Weight Gain — How It Works


One of the hallmarks of a good theory is that it defines a mechanism that makes the theory work. Understanding the “why” is critical.ben_franklin

If you ask most nutritionists, you’ll probably hear about how important good sleep habits are to health. You might hear that sleep is important to managing weight and that people who are well rested aren’t as hungry.

Now we are starting to get the rest of the story. A team of researchers at Upsala University (Sweden) have developed a body of research about the impact on short and interrupted sleep on the body.

The behavioural data reveal that metabolically healthy, sleep-deprived human subjects prefer larger food portions, seek more calories, exhibit signs of increased food-related impulsivity, experience more pleasure from food, and expend less energy.

How does this happen? Sleep loss . . .

  • Shifts the hormonal balance from hormones that promote fullness, such as GLP-1, to those that promote hunger, such as ghrelin.
  • Increases levels of endocannabinoids, which promote appetite.
  • Alters the balance of gut bacteria, which has been widely implicated as key for maintaining a healthy metabolism.
  • Reduces sensitivity to insulin (management of blood sugar levels).

The researchers want to conduct longer duration studies to assess long term effects of sleep loss. In the mean time, they’ve given us an initial assessment of what happens.

If you’re in a situation in which you can’t get adequate sleep, then you need to control carefully what you eat to offset these effects to the extent possible. You may want to consult a doctor or nutritionist about specific steps you should take.

Sources:  European Society of Endocrinology. “Sleep loss affects your waistline.” ScienceDaily. ScienceDaily, 22 May 2017. <www.sciencedaily.com/releases/2017/05/170522081109.htm>.

Childhood Weight, Adult Depression and . . . Bullying? Time to Connect the Dots?


Being narrow-minded affects people in a broad range of occupations, including ben_franklinacademia. Most people working in one field don’t see what people in related field are doing. Truth literally “falls between the cracks” separating different areas of work.

The people to whom we ascribe brilliance, like Steve Jobs, are those who are able to gather information from a broad array of sources and disciplines and connect the dots to form a coherent picture that others can’t see. Others fail to see the same because they don’t look. They limit what they see to the portion of the world in which they live and work.

Now for an example . . .

In an earlier blog, I reported on research linking being a victim of bullying to depression and health issues in high school. (1) The theory is that the impact of bullying can last well into adulthood.

A new study by Deborah Gibson-Smith from VU University Medical Center in the Netherlands and colleagues reports on a link between being overweight as a child and adult depression. The study doesn’t explain how extra pounds as a child effect adult emotions; it simply reports a statistical relationship. (2) The premise is that it has something to do with self-image.

My theory: Overweight children get bullied, and that bullying causes negative attitudes and behaviors that can linger into adulthood. It’s a simple idea, testable, and provides a concrete mechanism for converting excess weight as a child into adult depression.

However, because we have one group studying the effects of weight, and a different group studying the effects of bullying, apparently no researchers have tried to connect these dots.

Does that make sense?


  1. Crain, “Bullying and Depression.”
  2. European Association for the Study of Obesity. “Being overweight in childhood may heighten lifetime risk of depression.” ScienceDaily. ScienceDaily, 18 May 2017. <www.sciencedaily.com/releases/2017/05/170518221006.htm>.



NIH on COPD: Missing the Point, Too


When you politicize science — or try to — you create new opportunities to waste taxpayer ben_franklinmoney.

The NIH has announced a new “National Action Plan” to combat COPD, the third leading cause of death in the US.

The third leading cause of death in the United States, chronic obstructive pulmonary disease, or COPD, affects 16 million Americans diagnosed with the disease and millions more who likely do not know they have it. The disease, which costs Americans more than $32 billion a year, can stifle a person’s ability to breathe, lead to long-term disability, and significantly affect quality of life. (1)

In building the action plan, NIH assembled workshops involving patients, medical professionals, academics, and pharmaceutical industry representatives.

That’s the problem.

COPD isn’t curable, but it may be preventable. However, to prevent it, you have to focus on causes, not treatments after the disease has developed. What are the causes?

  • Smoking — 20 to 30% of smokers develop COPD according to the Mayo Clinic, although others may have reduced lung function (4)
  • Long term exposure to industrial dust and chemical fumes (e.g., the famous “black lung” of coal miners)
  • Long term exposure to air pollution
  • Premature birth with lung damage
  • Genetics

Some authorities try to put the entire blame for COPD on the cigarette industry. That’s a simple answer, and as usual with simple answers, it’s probably not correct. Mayo’s analysis is probably more prudent, splitting blame between cigarettes and environmental factors.

Here’s the issue:

  • The workshops didn’t include representatives of the industries creating the pollution that causes COPD. Where are reps for the auto, power, chemical or cigarette industries?
  • Further, the current administration has made a clear statement that environmental issues don’t matter.

We can anticipate that this initiative will focus on more expensive treatments instead of prevention. That simply drives healthcare costs higher without solving anything.


  1. National Institutes of Health, “COPD National Action Plan aims to reduce the burden of the third leading cause of death,” press release, 22 May 2017. https://www.nih.gov/news-events/news-releases/copd-national-action-plan-aims-reduce-burden-third-leading-cause-death
  2. WebMD, “COPD (Chronic Obstructive Pulmonary Disease) – Causes,” undated. http://www.webmd.com/lung/copd/tc/chronic-obstructive-pulmonary-disease-copd-cause
  3. Ann Pietrangelo, “Everything You Need to Know About Chronic Obstructive Pulmonary Disease (COPD),” Healthline, 25 October 2016. http://www.healthline.com/health/copd
  4. Mayo Clinic, “COPD – symptoms and causes,” undated. http://www.mayoclinic.org/diseases-conditions/copd/symptoms-causes/dxc-20204886

The Small Business HRA


As some readers know, I’m a market researcher doing a transition to a second life in health insurance. It’s not the most profitable line of insurance, but I really enjoy helping people. That’s what makes me feel  good. And as my grandfather said, do something well or don’t do it.


For most purposes, a “small business” is anything with 50 or fewer full time employees or FTEs.  If you have one of those, you have a great opportunity to offer health insurance benefits without breaking the bank. The HRA is one option; the hybrid self-insured approach is another. Either can be significantly less costly than traditional group insurance, although neither is a universal solution.

I’m not wedded to a particular type of insurance. A good advisor should listen to you, research the options that are best solutions for your needs, and present the options to you with both their pros and cons. Nothing’s perfect, and one-size-fits-all is a myth.

What’s essential is that you know the choices available to you. Both the costs and benefits of some of the options may be quite different than what you expect.

I found the following blog article from Zane Benefits. It’s a good review of the HRA and how it works. Some of the terminology is arcane (thank you, Congress!).  If you find things you don’t understand, talk with me.

A big thank you to Caitlin for permission to repost this.

How the QSEHRA Works for Employees Without Minimum Essential Coverage

When Congress passed the 21st Century Cures Act in December 2016, it created a new health plan for small businesses—the Qualified Small Employer Health Reimbursement Arrangement (QSEHRA), or Small Business HRA.How the QSEHRA Works for Employees Without Minimum Essential Coverage

Under a QSEHRA, businesses with fewer than 50 full-time employees can reimburse their staff for individual insurance premiums and qualified out-of-pocket medical expenses. The business sets a monthly allowance for employees, verifies and approves employee expenses, and then reimburses them from that allowance.

QSEHRAs are administered on a tax-free basis for small businesses. Employees are also spared from income tax—provided they’re covered by an insurance policy with minimum essential coverage (MEC).

Hundreds of small businesses across the country have already found relief through the QSEHRA, both from the cost and administration time associated with group health insurance and from the damage of not offering health benefits at all.

However, what businesses may not realize is that even employees without MEC can benefit from the QSEHRA.

In this article, we’ll walk you through what the 21st Century Cures Act says about QSEHRA participation and MEC requirements, how your uninsured employees can access the benefit, and how to compliantly administer the plan for both insured and uninsured employees.

QSEHRA Employee Eligibility Requirements

Title 18 of the 21st Century Cures Act outlines QSEHRA eligibility requirements for individuals. Generally, eligibility for the benefit is quite broad; a person simply needs to work for—or be the spouse or dependent of someone who works for—a qualified small business offering a QSEHRA.

However, small businesses can exclude employees who fall into any of the following categories:

  • Part-time and seasonal employees
  • Employees who have not completed 90 days of service
  • Employees younger than 25
  • Union employees (unless the relevant collective bargaining agreement provides for eligibility)
  • Nonresident aliens with no U.S. source income

Beyond that, employees are eligible for the QSEHRA “after the employee provides proof of coverage for the payment of, or reimbursement of … expenses for medical care.”

In this context, “proof of coverage” means proof that the employee incurred an expense covered by the QSEHRA. This means that any employee who meets the above requirements and submits proof of an eligible expense qualifies for the QSEHRA benefit—regardless of whether they have MEC.

Where MEC does matter is in determining how the benefit will be taxed.

Accessing Tax-Free Benefits

One of the advantages of a QSEHRA is its tax-free status for both small businesses and employees. Businesses administering a QSEHRA won’t be subject to payroll taxes for the reimbursements they issue employees, and employees won’t have to pay income or payroll tax on the reimbursements they receive.

Small businesses will receive these tax advantages regardless of the coverage status of their employees.

Employees, however, must have MEC if they want to receive tax-free reimbursement. Without MEC, any reimbursements received through the QSEHRA may be considered taxable and includable in the employee’s gross income.

Receiving Value from the QSEHRA Without MEC

Even without some of the QSEHRA’s tax advantages, employees without MEC can receive value from the benefit.

The QSEHRA allowance helps uninsured employees or those on cost-sharing plans like Medi-Share pay for a variety of medical expenses. Physical exams, prescription and nonprescription drugs, and premiums for dental and vision policies are all eligible for reimbursement under the QSEHRA, along with many other expenses.

While employees without MEC must pay some tax on these reimbursements, the up-front benefit from their employer significantly defrays the cost of their health needs.

And, when employees do gain MEC, they’ll be able to slip seamlessly into the tax-advantaged benefit.

Administering the QSEHRA for Employees Without MEC

Small businesses offering a QSEHRA must make employees aware of the potential tax consequences of going uninsured.

Title 18, Section 4(A) of the 21st Century Cures Act requires small businesses to notify employees of the QSEHRA benefit each year. In addition to informing employees of the amount of their benefit and explaining how it affects premium tax credits, the notice must explain that employees could be subject to a tax penalty if they fail to maintain MEC during the year.

The notice must also explain that any reimbursements made through the QSEHRA while the employee isn’t covered under MEC may be includable in the employee’s gross income.

Small businesses are under no legal requirement to track employees’ tax liability for QSEHRA benefits.


The QSEHRA is the only formal small business health plan that offers an immediate benefit to uninsured employees. And, unlike simply grossing up employee wages, the QSEHRA gives businesses the peace of mind that comes with knowing their funds are being spent on employees’ health needs.

Employees without MEC can still access their allowance, and, because of the tax advantages enjoyed by those with MEC, the QSEHRA provides incentive for all employees to purchase full coverage.

Sources:  https://www.zanebenefits.com/blog/how-the-qsehra-works-for-employees-without-minimum-essential-coverage#0001.0001.0000.0000.0000.0000.0000.0000.0000.0000