Can Social Impact Bonds Improve Healthcare?

It’s been established that an effective way to manage an individual’s health is to address the root cause of health complications, known as social determinants of health (SDOH).  Unfortunately, interventions that address SDOH often exist outside the scope of the traditional healthcare payment system. 

There is a relatively new methodology that can be used to increase spending on SDOH while transparently enforcing accountability and outcomes. Social impact bonds, also known as  “pay-for-success” models, are multi-stakeholder performance-based contracts.

The five key stakeholders and their roles are as follows:

1) Service Provider:  Agrees to conduct a program designated to yield a future outcome that is valuable to the payer.  (Usually a nonprofit organization.)

2) Investor:  Provides up-front working capital for the service provider to channel toward the designated program.  In exchange, the investor will receive a “success payment” if the committed outcome is produced on schedule.

3) Payer:  Commits to pay the service provider a “success payment” when the specified outcome is produced.  (Usually a government agency.)

4) Intermediary Organization:  Facilitates the SIB contract, establishes payment and financing terms, and supervises the service provider’s program.

5) Independent Evaluator:  Determines if the committed outcome was achieved upon conclusion of the contracted period.

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Leek Squash Soup

I fell in love with leeks the first time I cooked with them. I’d eaten them many times before but just never experimented with them in my own kitchen.

It was about 4.5 years ago when I made a Vichyssoise (chilled potato leek soup) for an Alive Magazine cooking video, which is an amazing recipe. But don’t judge me by my hairdo — I don’t know what was going on with my bangs lol. Prior to this cooking video, I hadn’t paid much attention to leeks. But now whenever I see them at the farmers market or receive them in my organics delivery I immediately feel inspired to make a soup.

This week I received 3 beautiful organic leeks in my organic delivery. As soon as I saw them I immediately thought of soup. 

Leeks

Soup recipes have been on my mind because it’s been pretty rainy and damp in Toronto lately and I just love warming up with a comforting bowl of flavourful and super healthy soup. For dinner on Sunday night we enjoyed this soup along with a wonderful salad Walker made

Leek Squash Soup

Leeks add such an incredible, yet not overpowering flavour to soup. And they have many wonderful healthy benefits. 

So why do you want to add leeks to your diet?

  • The most obvious reason is they are very tasty! They go well in soups with starches such as squash or potatoes. They are also lovely paired with fish or in a chicken noodle soup. And I know this might sound weird but I’ve even combined them with apples in a soup. There are many awesome combinations!
  • They are from the allium family, same as one of my favourite superfoods, garlic. This means they have many of the same benefits as garlic because they contain similar phytonutrients. 
  • Leeks are an excellent source of folate. This nutrient is very important for heart health, keeping your brain healthy (in studies this nutrient is often low in those who suffer from depression and anxiety) and of course pregnancy
  • One of leeks most notable phytonutrients is kaempferol, a polyphenol. Not only does this nutrient provide food for your intestinal bacteria, but it is also very anti-inflammatory. This nutrient also has anti-estrogenic activity too which makes leeks and all foods from this family a good choice for the prevention of breast cancer. 
  • Leeks are also a good source of manganese, calcium, vitamin B6, copper, iron, vitamin C and even omega-3 fatty acids.  

I haven’t even talked about the health benefits of squash in this post, but I’ve cooked with them many times before so you can read about their superfood status in my recent recipes including, Quinoa Stuffed Acorn Squash or my Butternut Squash Soup with toasted pumpkin seeds. 

I topped this soup with some pea shoots, goat feta cheese and pepper, but you can skip the cheese if you avoid dairy. It’s still just as darn tasty. 

Leek Squash Soup

Vienna was having so much fun with us as we were shooting this recipe. More often then not we try to do recipe shoots when she’s sleeping, but this didn’t happen today! We had some fun banging spoons together as Walker took the photos. 

Leek Squash Soup

I have tried to give her this soup a couple times and she’s not into it lately. In fact, the last 10 days have been weird with her eating. She’s just not into much other than mama milk and fruit! I will keep trying and not get discouraged.. babies can be picky. However, she is into food styling as you might have seen on my recent instagram stories he he he!

viennasquash1

She loved feeling the butternut squash. I’m sure if I could translate her babbles she’d be telling me how to arrange them for a beautiful photo!

And now that I’ve babbled, I should share this recipe with you!

Leek Squash Soup

Leek Squash Soup
2016-10-30 20:13:01
Print

Ingredients
  1. 1 butternut squash, chopped** (approximately 3-4 cups)
  2. 3 leeks, washed and chopped* (approximately 2 cups)
  3. 2 tbsp coconut oil
  4. 1 can, 400mL organic full-fat coconut milk***
  5. Sea salt and pepper to taste
  6. Feta cheese and pea shoots for garnish
Instructions
  1. Preheat oven to 350F degrees. Place butternut squash into a baking dish, add 1 tbsp coconut oil and season with sea salt and pepper. Cover with a lid and bake for 1 hour or until squash is fork tender.
  2. Meanwhile, sauté the leeks on medium in coconut oil until tender, about 7-8 minutes. Set aside and wait for squash to finish baking.
  3. Once the squash is done and cooled slightly, place both ingredients into a food processor or blender, add coconut milk and blend until creamy. Or, place all ingredients into a large soup pot and blend with an immersion blender.
  4. Reheat the soup before eating. Just don’t heat it too hot otherwise the good fat will curdle in the coconut milk. Add any seasonings you wish. If you want it to be a thinner consistency just add a bit of water.
Notes
  1. *You can peel the squash ahead of time with a veggie peeler if you are cutting it into cubes before cooking. The other option is to slice it in half lengthwise and bake it flesh side down. Then you can just use a spoon to scoop out the squash. I find it’s easier to cook it without peeling and just scoop it out.
  2. **You can use the whole leek (including the green leaves) if you wish. Just make sure you wash them well because there is often soil nestled inside the leeks.
  3. ***I used Cha’s Organic coconut milk, the flavour is divine!
  4. Serves 4.
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So there you have it, Leek Squash Soup. I hope you enjoy it and be sure to tag me #joyoushealth on instagram or tag my facebook page if you make it so I can see your creation!

Have a joyous week!

Joy

Joy McCarthy

Joy McCarthy is the vibrant Holistic Nutritionist behind Joyous Health. Author of JOYOUS HEALTH: Eat & Live Well without Dieting, professional speaker, nutrition expert on Global’s Morning Show, Faculty Member at Institute of Holistic Nutrition and co-creator of Eat Well Feel Well. Read more…

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Et Tu, Dr. Noseworthy?

 

 

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MACRA and the New Quality Payment Program: Most Frequently Asked Questions

November 2 | 2-3 PM EST      / With THCB 

On Oct. 14 the Centers for Medicare and Medicaid Services (CMS) released detailed regulations for implementation of the Medicare Access and CHIP Reauthorization Act (MACRA). With so many changes to the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (APM) track, we at Health Catalyst have heard many questions and comments. This is understandable, as the substantial 962-page proposal has grown to the 2,398-page final rule. Also, since nearly all providers will be subject to the new Quality Payment Program (QPP), understanding MACRA and what it means for providers is imperative.

Earlier this year, Bobbi Brown, Health Catalyst Vice President of Financial Engagement, gave us a better understanding of the MACRA proposal. With the help of Dorian DiNardo and Dr. Bryan Oshiro, Bobbi is back to share her insights into the MACRA final rule and its implications for providers in a highly engaging question and answer format. Bobbi and the team will share the most frequently asked questions they have received since the announcement and their answers to them.

Some of the questions covered will be:

  • Do I need to report individually or as a group?
  • How should physicians prepare for MACRA?
  • How do I qualify for an APM?
  • What should be the implementation plan?

We look forward to you joining us. Click here to register.

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Guest Post: Hearty Autumn Maple Salad

One thing I love about the change from summer to fall is the warm colours and feelings it brings with it. I love the flavours that autumn brings, which are all incorporated into this awesome and satisfying salad. Roasted, spiced butternut squash is paired with juicy, fresh apples and crunchy walnuts, while the dried cranberries and dates provide a sweet and warming touch. Balsamic Maple Dressing pairs well with this salad, and is one of my favourites as it really ties the fall flavours together, which is why it’s included in this salad recipe! Try picking up some maple syrup from a local farmer at the market, or at least make sure you are buying real maple syrup. You can have this salad on a normal autumn day, or add it as a side for a holiday dinner!

Hearty Autumn Maple Salad
2016-10-13 15:53:33
Print

Salad
  1. 3 cups raw butternut squash, peeled and diced in 1cm cubes
  2. ¼ cup coconut oil, melted
  3. 1 tsp cayenne pepper
  4. 2 tsp cinnamon
  5. 1 small yellow onion, thinly sliced
  6. 1/2 cup green lentils, rinsed
  7. 1 cup walnuts
  8. 10 dates, chopped
  9. 1 cup dried cranberries
  10. 2 fall apples, diced
  11. 8 oz baby spinach, washed
Maple Balsamic Dressing
  1. 2 Tbsp balsamic vinegar
  2. 2 Tbsp maple syrup
  3. 2 Tbsp olive oil
  4. 1 Tbsp Dijon mustard
  5. Salt and pepper to taste
Instructions
  1. Preheat oven to 400°F.
  2. Toss butternut squash in 2 Tbsp coconut oil, cayenne pepper and cinnamon and bake for 30 minutes, flipping occasionally.
  3. While the butternut squash is roasting, heat 2 Tbsp of coconut oil in a large frying pan on medium heat. Add the onions and cook for 20 minutes, stirring occasionally until browned.
  4. Meanwhile, place the rinsed lentils in 1.5 cups of water and bring to a boil. Simmer for 15-20 minutes until al dente.
  5. Whisk together balsamic vinegar, maple syrup, olive oil, Dijon mustard and salt and pepper.
  6. Toss them with the walnuts, dates, dried cranberries, apples and dressing and serve over spinach.
  7. You can serve Sweet Autumn Salad warm or chilled.
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What are your favourite fall flavours? Share them with us in the comments below!

Jesse Lane Lee

Jesse Lane Lee, BSc, CNP is a cheerful Holistic Nutritionist, motivating speaker, cookbook author, and founder of JesseLaneWellness.com. On her website she shares holistically delicious recipes for free and hosts interactive live online cooking classes. She is the author Jesse Lane Wellness Cookbook Healthy Dairy Free Desserts which contains over 30 healthy dessert recipes with vibrant pictures. Jesse Lane will teach your how to have your chocolate without pudding on weight with her 15 page Guide to Natural Sugar Substitutes. Get it for FREE at http://ift.tt/22Ccs6A

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Premium Hikes in the Exchanges: Not Good News, But Not the End of Obamacare Either

OK.  Yes, this is bad.  The Obama administration is being disingenuous if it tries to spin it any other way.   And, as has been clear for several months, this hands Hillary a “nasty” issue (pun intended). 

The “this,” of course, is the administration’s announcement on Oct. 24—after weeks of speculation and anticipation—that premiums in the exchanges will rise by an average 22% for 2017 coverage (if both state- and federally-run exchanges are included in the count.)

Despite the fact that tax subsidies will significantly soften the blow for the vast majority of people buying health insurance in the exchanges, millions of families will still be adversely affected.  

Specifically, about 2 million people who will buy coverage through the exchanges in 2017 will not get subsidies because their incomes are too high.  You could argue: hey, they can afford it.  But it’s still a pretty big hit when your monthly premium goes from $500 a month to $625.   

Less well understood and hardly mentioned in the media coverage is that some 7 million people buy “off-exchange” individual insurance.  Premiums for many if not most in this group are going to spike up, too, and from an already more expensive base.   (Off-exchange policies have to comply with ACA requirements and are for the most part comparable to policies sold on the exchanges.)

According to a blog by Katherine Hempstead posted Oct 24, the average off-exchange policy costs $314 in 2016, compared to an average $279 for an unsubsidized on-exchange silver premium.  Deductibles were higher, too, for the off-exchange policies, averaging above $3,000.   

We don’t yet know what the 2017 increases are for off-exchange coverage because no one has done that analysis.  It’s a tough analysis, too, because there are—wait for it—over 13,000 unique ACA-compliant individual market products nationwide sold off-exchange.  (Additionally, there were nearly 30,000 small group plans nationwide in 2016, of which nearly 90 percent were “off exchange” according to Hempstead’s piece.)   

To quote from her blog:  we badly need to better understand “the extent to which the individual market is appropriately priced… in both market segments.  While the federal and state exchanges….have done much to present comprehensive information to consumers about on-exchange plans, similar information has thus far been lacking for off-exchange and small group plans.”   

Despite the bad news, Republican lawmakers’ fulminations about this year’s premium hikes being the beginning-of-the-end for Obamacare are vastly overstated. 

As has been noted in most of the coverage, the range of the percentage increase varies widely from state to state.  In 10 states, for example, premium increases are 7 percent or less.  In two (Indiana and Massachusetts), premiums are actually decreasing.

Also, the states (mostly red/Republican-led) where consumers are getting hit the hardest are, predictably, those that have not expanded Medicaid and where lawmakers did nothing to create their own exchange or help get people enrolled.   

So, Republican lawmakers still opposed to the ACA in those states are being even more disingenuous than Obama administration officials—since their actions have ended up hurting their own citizens.   All for the sake of political posturing.  As a recent Kaiser Family Foundation analysis found: of the 27 million people who still don’t have health insurance in the U.S., about 5.3 million would be eligible to buy coverage through an exchange and qualify for a federal tax subsidy. 

Several million more would gain Medicaid coverage if the 19 states that have not expanded that program do so—especially Texas and Florida, which have large pockets of low income, uninsured people.    

The other reasons some exchanges are struggling have been widely discussed, including on THCB.   And ideas for fixes are starting to emerge and be debated at the state and federal level.  For example, several states are now debating taking urgent action in 2017 to create reinsurance pools to shore up their exchanges. 

See Peter Lee’s excellent Oct. 24th blog on how and why California’s exchange has succeeded to date and his advice for addressing problems in other states.  Peter runs the California exchange

The overall challenge is political, of course.  If Hillary becomes president and the Senate remains split (as expected), repealing Obamacare continues to be a legislative non-starter.  Republicans (state-level and in Congress) will then have to decide whether to work with the new administration to fix flaws in the exchanges and help millions of families….or persist in their opposition.  We can only hope sanity prevails.    

Addendum:  For a detailed portrait of predicted exchange enrollment in 2017, see ASPE’s 17-page policy brief released Oct. 19.  ASPE is HHS’ Office of Assistant Secretary for Planning and Evaluation.   

Steven Findlay is an independent healthcare journalist, policy analyst, researcher and consumer advocate.    

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Precision Primary Prevention

By SAURABH JHA MD

 

If you’re going to indulge in anticipatory medicine, it is best to anticipate those at highest risk. An elegant study by Wald et al in the NEJM shows how precision primary prevention can be done. The researchers screened toddlers, who presented routinely to their general practitioners for vaccinations, for an uncommon, but not rare, familial predisposition to high cholesterol known as heterozygous familial hypercholesterolemia (FH), in which premature cardiovascular death can be deferred by statins and lifestyle changes. Blood drawn from the toddlers by a heel prick was tested for serum cholesterol and genetic mutations indicative of heterozygous familial hypercholesterolemia (FH). The parents of toddlers who met criteria for FH were also tested for cholesterol and genetic mutations. Obviously identifying affected parents, and increasing their longevity, is also beneficial for their children.

 

Researchers defined familial hypercholesterolemia in two ways.

  1. Elevated cholesterol and a gene mutation – phenotype positive, genotype positive group.
  2. Elevated cholesterol on two occasions but no mutation – phenotype positive, genotype unknown group. It was assumed that children in this group have genetic mutations which we’re presently unaware of.

 

The mutations (there are 48), present in 37 out of 10,095 children, were picked up in 20/37 children when high cholesterol was defined at the 99.2nd percentile, and in 32/37 children when high cholesterol was defined at the 95th percentile. The more stringent threshold for high cholesterol missed 46 % (nearly half), and the less stringent missed 14 %, of carriers of known mutations for FH. The frequency of the “phenotype positive, genotype unknown” – i.e. those who had elevated cholesterol on two occasions, but did not have the known mutations for FH, was 8 out 10, 095 children (0.08 %) – I suspect this number may be higher when screening is rolled out en masse.

 

What threshold for “high cholesterol” should be used? If we’re going to screen for familial hypercholesterolemia there’s no point missing half the children who carry the mutations. It makes sense using the lower threshold of 95th percentile of population serum cholesterol to define hypercholesterolemia.

 

At first, it seems we’re throwing a wide net to catch rare trout. However, the net is no wider than other screening nets. Applying the more liberal threshold for elevated cholesterol, 40 cases of FH were found in 10 095 kids, which is a number-needed-to screen (NNS) of 250. When you include the parents who, unbeknownst, had FH or high cholesterol, that’s an NNS of 125 – hardly an unrespectable NNS compared with cancer screening – for smokers at high risk for lung cancer, the NNS is 320 with screening with low dose CT.

 

There are still uncertainties because of the “inverse problem” which haunts genomics. Just because people who die prematurely from CV disease have certain genetic mutations which elevate cholesterol, doesn’t mean that everyone with that genetic mutation will die prematurely. This genotype-phenotype-outcome mismatch is nicely explained by Siddhartha Mukherjee in The Gene.

 

The authors make clear that mutation alone doesn’t maketh risk and cholesterol must also be elevated to define familial hypercholesterolemia. Because we must assume that anyone with a mutation and high cholesterol may die prematurely – we must assume something –  and that they’d benefit from lifestyle changes and statins, inevitably, some will be overtreated. The natural histories of the “phenotype positive, genotype positive” and “phenotype positive, genotype unknown” – by natural history, I mean how many in these cohorts die prematurely and at what age – is a knowledge gap that’ll likely, and unsurprisingly, be permanent. Would you volunteer your child, who just had FH detected, to remain untreated to study this intriguing question for mankind? I wouldn’t.

 

The study asks a probing philosophical question. Is familial hypercholesterolemia a disease or a risk-factor, or is the distinction between risk factor and disease a distinction without a difference? It will be tempting to start adolescents with FH on statins, whilst encouraging them to swing on monkey bars. It is hard to see how statins can be avoided in adolescents known to have FH, and for their management to be largely lifestyle based. Prescribing exercise to children at high risk of premature death from cardiovascular disease sounds good in theory, but if participating in sports requires a doctor’s prescription, how successful can that prescription be? I mean getting off the couch surely doesn’t need shared decision making, and whether the children get off the couch, sooner or later, their parents might ask for pharmacological means to reduce their risk of premature death, which I believe would be wholly justified.

 

I’ve been told by some cardiologists that in those genetically-predisposed to high cholesterol, running, or swinging on monkey bars, though helpful, won’t alone reduce their risk of dying early, at least not without a little help from statins. I always take cardiologists at their word. What choice have I? My life could depend on them.

 

Nevertheless, statin-skeptics should occasionally suspend their skepticism. The group uncovered by Wald and colleagues is an apt group for suspending skepticism about statins and primary prevention.

(Saurabh Jha is a radiologist and contributing editor. He can be reached @RogueRad)

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