Five Ways I Detox Every Day

I follow a simple set of healthy, detox rituals every day — they are part of my lifestyle and I honestly can’t imagine life without them. I travel with them too! I don’t lose my s*** if something happens and I can’t do one of them (for example if I forget to bring my DSB on vacay), I simply get right back on track as the very next day.

These aren’t “rules” or “have-to’s”, they are habits that make me feel good and I know they are doing so much goodness for my body too.  These are habits I recommend to you, my joyous reader. 

I really believe that detox habits can be part of your every day! Not just once in a while.

In my latest video, I share five ways to detox every day. And I’ve outlined in more detail these rituals below. 

1. Drink a huge glass of water every morning when you wake up.

Health Benefits of Lemon and Water

Your body is approximately 60% water , your brain is 70% water and your skin is 64% water — have I convinced you already to drink more water?

If you’re a mama who is breastfeeding then you’re probably sipping water right now right?! ;)  

If you want to detox effectively, lose fat, get glowing skin, think smart then drink water my friend. It’s as simple as that! And continue drinking lots of it all day. Water helps the body eliminate toxins and waste more effectively. It improves your digestion and prevents constipation. It helps the kidneys cleanse with ease and is essential to life. You can go days without food, but you can’t live very long without water. 

Make your water more detoxifying by adding freshly squeezed organic lemon or a spoonful of raw apple cider vinegar

2. Add turmeric root to your diet. 

Turmeric Ginger Tea You might already know if you follow me on social media or you read this post that I take turmeric as a supplement every single day. But it also eat it often.

I love making this Turmeric Ginger Tea and in the summer I make an Iced Latte with turmeric. In the winter I love cooking up a pot of my Cauliflower Chickpea Stew. Turmeric has many incredible benefits from cancer prevention to stimulating liver detoxification. I’ve talked about it many times on the blog before so if you want more in depth then check out any of those recipes. 

Why do I do this? Because turmeric is a detox superfood. 

It is the most studied plant food in the world.


3. Eat more plant foods. 

Curry Cauliflower Quinoa Stew-02939

It’s no secret that I recommend a plant-based diet. Does that mean I’m suggested you turn vegan or vegetarian? Nope, but that’s cool if you are. Labels aside, I just want you to eat more plant foods.

If you look at the recipes on my blog, or in Joyous Health or Joyous Detox, you will see this is what I recommend and how my family and I eat every single day. It’s not a “detox” diet or a fad, it’s our lifestyle.  If you need some inspiration and guidance, then join the Joyous Online Detox in January!     

4. Dry Skin Brush, Daily 


I may not be able to get my hubs Walker to dry skin brush every day but I’ll still be singing the praises of it for all time because it’s a fabulous way to get your skin glowing and stimulate lymphatic drainage which means, detox baby! If you’ve got boobies then dry skin brushing should be as essential to your daily routine and brushing your teeth. I don’t mean to sound preachy here but it’s just that it’s so necessary. Russians have known about this for thousands of years, same with those who practice Ayurveda. 

You can read more about it here. I’ve done a lot of research to bring you only the best so this is the Dry Skin Brush I use and recommend. 

5.  Just breathe.


Last but not least is the one habit I can probably convince you to do because you’re already doing it! But… are you doing it with awareness is the question??

Your lungs are an organ of detoxification. Breathing with awareness brings you from fight or flight to rest and digest mode. The latter is the mode of your nervous system you want to spend most of your time in.

Breathing with awareness can be done a variety of ways. I recommend you choose two times per day that you’re going to breathe deeply and with awareness. It could be first thing in the morning before you jump out of bed and then again at night before you fall off to sleep. Breathe deeply for 2 minutes.

There you have it! My five ways to detox every day.

Before I go, I’ve got a new detox program launching soon that goes perfectly with my new book Joyous Detox. You can watch the video about it here. 

Wishing you joyous health, today and always!


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…


The post Five Ways I Detox Every Day appeared first on Joyous Health.

from Joyous Health

Millennials: The Greater Generation?

screen-shot-2016-12-30-at-9-44-14-amIn 1991, William Strauss and Neil Howe wrote the book Generations.  It was recognized then and today as remarkable.  The authors posit the history of America as a succession of generational biographies, beginning in 1584 and proceeds to the children of 1991.  Their theory was that each generation belongs to one of four types, and that these types repeat sequentially in a fixed pattern.

In a (now) fascinating passage in the Preface, they discuss the Boomer Generation, saying (remember it’s 1991) that “You may feel some disappointment in the Dan Quayles and Donald Trumps who have been among your first agemates to climb life’s pyramid, along with some danger in the prospect of Boomer Presidents…farther down the road.”  Later in the same paragraph:  “Perhaps you already sense that your Boomer peers, for all their narcissism and parallel play, will someday leave a decisive mark on civilization quite unlike anything they have done up to now.”  Spooky huh, as we embark on a Trump Presidency?

Generations, even that early, suggests that Millennials will be a uniquely impactful generation, mostly in a positive way, much like what they call the “GI” Generation and most of us call the “Greatest Generation.”  Well… they fall in the same ordinal slot as the Greatest Generation given the following dates of birth for each generation:  Greatest Generation (1901-24); Silent Generation ((1925-43); Boomer Generation (1943-60); Gen-X (1961-81); and Millennials (1982-2000).  They have Boomers starting earlier than the traditional view, a position I very much agree with having been born in 1945.

Earlier this month, an article appeared in the Boston Globe titled Millennials Aren’t Lazy, They’re Workaholics.  That didn’t quite fit with my impression, so I started digging a bit. I of course went on line and found a definition in the Urban Dictionary:

Special little snowflake.

Born between 1982 and 1994 this generation is something special, cause Mom and Dad and their 5th grade teacher Mrs. Winotsky told them so. Plus they have a whole shelf of participation trophies sitting at home so it has to be true.

They believe themselves to be highly intelligent, the teachers and lecturers constantly gave them “A”‘s in order to keep Mom and Dad from complaining to the Dean. Unfortunately, nobody explained to them the difference between an education and grade inflation so they tend to demonstrate poor spelling and even poorer grammar.

At work, millennials believe themselves to be overachievers who just aren’t understood by their loser bosses. Even Mom said so when she showed up for the interview. They are the only generation in the universe to understand the concept of work life balance and to actually want to find a fulfilling career. All those Gen X losers just don’t get it what with hoping to keep their jobs and pay the bills but they are just corporate drone so who cares what they think? They should be smart like Millennials and get Mom and Dad to pay for that stuff until they can work out what they want to do with their lives and then get rich doing it.

We collectively nod, thinking, “Yes, that describes them.”  Then I dug deeper.  I actually interviewed several who gladly volunteered to tell me about themselves.  Not family of course.  I also listened to a number of lectures by Neil Howe, the co-author of Generations. Here is what I’ve found so far, and there is much more to find.

  • They are our most diverse generation
  • They are by quantum measures our most connected generation, far beyond just Facebook and text messaging
  • Their generation has seen significant declines in crime, teen pregnancy, drug use and alcohol use
  • They want and very much need structure and predictability, particularly in employment
  • They actually do not relish job-hopping and would prefer long term employment, under the right circumstances
  • They want to get married and have kids, but have enormous college debt
  • They actually enjoy being with their parents (who wouldn’t given how we’ve treated them?)
  • They know they’re special
  • They love teamwork and are not lone wolves

Simply put, they are not replicas of you and me.  They bear almost no resemblance to Gen X’ers.  Mr. Howe suggests that a Millennial son or daughter is the one most likely to drive their Gen X’er Dad to rehab.  Howe posits the critical importance of understanding that teamwork and community are core values for Millennials.  Technology didn’t shape their generation; they shaped the technology.  Millennials thrive on community and have the highest rates of community service.  Gen X’er’s, on the other hand, thought community service was punishment for an OUI.

I could go on.  The point is that they are, albeit special, sensitive, and high maintenance, very conventional.  And according to the Boston Globe article, very hard working.  The Globe article lacked supporting substantiation, so I looked for some.

Bruce Tolgan, author of It’s OK To Manage Your Boss, says “They will be the most high maintenance in the history of the world, but they may also be the most high performing.”

Then there is Gallup’s How Millennials Want To Work And Live.  Gallup confirms that today they are the least engaged employees of any generation, and the most likely to switch jobs if they are unhappy.  We already knew that didn’t we.  Millennial turnover costs US companies annually $30.5 Billion.  Ouch.

Jim Clifton, Chairman and CEO of Gallup, offers these six truths that he suggests must be respected by today’s businesses if they are to succeed in tomorrow’s world:

  • Millennials don’t just work for a paycheck—they want a purpose.
  • Millennials are not pursuing job satisfaction—they are pursuing development.
  • Millennials don’t want bosses—they want coaches.
  • Millennials don’t want annual reviews—they want ongoing conversations.
  • Millennials don’t want to fix their weaknesses—they want to develop their strengths.
  • It’s not just my job—it’s my life.

Now I will grant you I get some of these, but not all of them.  I get the first bullet which resonates with us Boomers, and particularly those who came of age in the 60’s.  As Studs Terkel wrote in his 1974 book Working, “Work is about a search for daily meaning as well as daily bread.” That resonates with most serious people, but particularly with Millennials.

So why are Millennials important?  Because by 2020, they will make up 50% of the workforce.  They are slowly but surely filling the ranks of middle and upper management of organizations across the country.  Rampant misconceptions of Millennials by Boomers and Gen-Xers significantly hinder companies’ opportunities over the next two decades to thrive. Millennials are a reality of our workplace, so we must first understand them, and then inspire them, because they have the capacity to be the engine that drives the future.  What comes through the studies and the literature is that the Millennials, over time, will dominate our workforce and have the potential to do great things if they are enabled.

Their lack of engagement is not completely their fault.  Well, we know that nothing is their fault.  [I just couldn’t help myself.]  It is to a significant extent the result of a failure of leadership from the front line managerial level up to the CEO.  The truth is that Millennials are dying for leadership.  A slightly different kind of leadership, yes, but leadership.  They want to work for ethical companies, and yes, they need feedback.  Not so surprising.  They got that all their lives up to now, usually sugar-coated.

The point?  As Neil Howe says in one of his talks, if people are viewed primarily in light of their faults, leadership becomes almost impossible.  THAT is what we have today in our workplaces.  Don’t fall prey to that trap when it comes to Millennials.  To motivate and inspire any group of employees, leaders must know what they want and need.  For Millennials, leverage their specialness by letting them know that special things are expected from them.  They are into teamwork, so use them in teams.  They have long term time horizons, and actually are not excited about changing jobs every 18 months.  So give them structure and glide paths.  They need regular feedback, so do reviews more informally and at least every month rather than once a year.  In person.  Give them a reason to stay and thrive.

There is so much more to say here, and my learning curve is steep.  What does this have to do with healthcare?  Everything.

from THCB

Internet Self-Diagnosis: Mapping the Information Seeking Processes

We’ve all been there. It’s early morning, and you wake up feeling groggier than usual, sensing the onset of a sore throat and a runny nose. Before crawling out of bed, you grab your smart phone and, naturally, Google “groggy sore throat runny nose symptoms.” Hundreds of results pop up, suggesting various illnesses and links to seemingly promising remedies. How could anyone filter through page after page of links, ranging from everyday allergies to deadly diseases?

Many of our health choices are made outside the doctor’s office. The simple decision of whether symptoms are severe enough to warrant visiting a healthcare provider is one of them. For some patients, that decision is easy, because regardless of the severity of symptoms, from a simple cough to leg pain, getting in to see a healthcare provider is easy. Unfortunately, many people still struggle to find a healthcare provider, get an appointment, and/or obtain transportation. These individuals are left to turn to other health information resources, such as the Internet, to determine whether their symptoms are severe enough to navigate these barriers.

The “digital divide” has become a catchphrase for how differences in educational, social, and economic backgrounds can affect access to web-based tools and services, as well as the general ability to use the Internet.

That divide has serious healthcare consequences: Though the web is not intended to replace traditional medical care, it may offer one of the few available sources of information for those with limited access to health services. While patients who regularly visit a provider are privy to the diagnostic processes of medical professionals, web-based tools may be critical in weighing the severity of symptoms for those with fewer resources and less access. 

The way the Internet is used to investigate and self-diagnose health concerns led my colleagues and me to look deeper into how individuals navigate web-based health information – and how individual experiences and abilities may influence this process.

Against this backdrop, my colleagues and I sought to explore how the digital divide may influence the way individuals seek health information and arrive at health decisions. Our study, “Characterizing internet health information seeking strategies by socioeconomic status: a mixed methods approach,” focused directly on how individuals of different educational, economic, and social backgrounds navigate web-based health information.

To begin, we created two clinical situations, each involving an acute illness of different clinical severity. We then developed two ways for measuring individuals’ information-seeking behavior – one focusing on decision-making processes, the other on the depth of information searched.

Drawing on academic literature related to the psychology of judgment and decision-making, we identified and classified two approaches for the decision-making processes used by individuals when searching the Internet for health information. System 1 processing involves the use of biases and heuristics (e.g., a “rule of thumb”), while System 2 processing is characterized by a careful evaluation of the information presented. System 2 processing, the systematic approach, most resembles the diagnostic process taught to medical professionals as well as information-processing strategies found in other studies to be associated with higher-quality decisions. Participants who had less education and were more reliant on social services, lower socioeconomic status (lower-SES), were more likely to engage in less complex and more intuitive searches.

Our exploration of the depth of searching by individuals making health decisions uncovered real differences in complexity. Those who had higher education and less need for support from social services, higher socioeconomic status (higher-SES), engaged in a more complex and expanded search process; they widened their searches to increase their information input. As a result, higher-SES individuals were exposed to additional information as well as a larger number of options for their decision-making.

While there were significant differences in the complexity of searches, we found that there were no significant differences between lower-SES and higher-SES individuals in whether the Internet search influenced an accurate guess at the cause of the symptoms. For this scenario, the complexity of the search did not result in better overall guesses at the symptoms. This may have to do with previous experiences with the symptoms and the hypothetical nature of the scenario. Overall, participants used three heuristics – the influence of prior clinical or symptom-related experience, how credible the source of information is to the participant, and whether the information found is consistent with other information they encountered during their search – to “fill in” information and guide their process of seeking health information.

We are concerned by the reliance on heuristics and the narrowing of searches by individuals of increased vulnerability, because the way they search for information reduces their exposure to information and results in fewer options for decision-making. Our next step will be to seek to determine what kinds of tools will facilitate more meaningful interaction and engagement for everyone. One big hope involves employing Web 2.0 gamification techniques to guide decision-making and to keep information seekers readily engaged in the decision-making process.

from THCB

Most Popular Posts of 2016

I hope you had a chance to check out my Most Popular Recipes of 2016 this week! In today’s post, we dug up the hot topics and most popular articles of 2016 using Google Analytics. Not surprisingly, you guys were most interested in the top foods to buy organic and how hormones relate to weight gain.

I also noticed you guys were loving my dry shampoo DIY post! I had a hunch that would be the case given all the social media posts I see about this awesome dry shampoo. If you haven’t tried it yet, you’ve got to!

And just like the recipe posts, it’s clear there are lots of mamas reading my blog because baby food intro and 10 things every woman needs to know before giving birth were also in the top 5. Please do comment below and let me know what you want to learn more about because these topics definitely surprised me! I had no idea so many mamas were reading my blog. 🙂 

Before I share the top 5, be sure to check out the most popular posts from 2015 and 2014. 

5. 10 Things Every Woman Needs to Know Before Giving Birth


 Read more…

4. Part 5 of PMS: Hormones, Weight Gain and Water Retention



Read more…

3. Baby Food Introduction

Baby Food Read more…

2. How to Make Natural Dry Shampoo 

dry shampooRead more…

1. The Clean 15 and Dirty Dozen for 2016


 Read more…

There you have it, the most popular posts of 2016. I wonder what next year will bring? Tell me what you want to read or learn about below! Thank you so much for being a reader of my joyous blog. You are the reason I do this and I love hearing what you think because it helps me figure out posts to share here. 

Have a happy new year and we’ll chat in 2017!


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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from Joyous Health

The Art of the Deal: Coming Soon to Rx Prices

During the campaign, President-elect Trump said “(w)hen it comes time to negotiate the cost of drugs, we are going to negotiate like crazy.”

While the President-elect’s pronouncements can’t always be taken at face value, this one should be.

In its December 7, 2016 prescription drug report to Congress, HHS reported Medicare (Parts B and D) and Medicaid Rx expenditures equaled $165.5 billion in 2014. Total 2014 retail and non-retail Rx spending was $424 billion.

HHS also reported that Rx spending “has been rising more quickly than overall health care spending . . . [and in] recent years, growth in prescription drug spending has accelerated considerably”.

If the reported annual rate of growth in 2014 (12%) holds for 2015 and 2016, Medicare/Medicaid’s Rx spending and total Rx costs in 2016 will exceed $200 billion and $500 billion, respectively.

As fiscal pressures to control healthcare costs build, Rx prices may be the ripest big ticket item on the table.

As the Trump Administration looks for bipartisan support for an ACA replacement, Rx prices could also provide some glue.

Last week, 20 Senators (18 Dem., 2 Ind.) sent a letter to the President-elect encouraging him to seek legislation lifting Medicare Part D’s ban against HHS negotiating drug prices.

If there’s the same level of Democratic support in the House, Democratic votes could more than more than make up for Republicans who reject negotiating authority as price controls.

It’s doubtful the President-elect thinks negotiating Rx prices means imposing price controls. He’d likely call it smart business.

There isn’t a private company in the world that would forego the negotiating strength its market clout gives the federal government.

Given the scale of the government’s pharmaceutical purchases, it would take an Assistant HHS Secretary a nanosecond (in DC time) to negotiate significant reductions in the cost of drugs.

A few presidential tweets could tee this up.

During its 2009 negotiations with the Obama Administration, pharmaceutical companies agreed to some limits on drug costs, and the Administration agreed not to seek authority to negotiate drug prices as part of the ACA.

The Administration said these concessions totaled $80 billion over 10 years.

In the negotiations, Big Pharma was represented by Billy Tauzin. If one of Washington’s most seasoned hands cut this deal with the Obama Administration, Trump likely believes big money remains on the table.

We shouldn’t kid ourselves–this change would reduce the pace of Rx innovation and could dampen employment in this sector of the economy.

As the President-elect looks for some near-term opportunities to control healthcare costs, however, it looks like he has Rx drug pricing in his sights.

Gary Mendoza is CEO of Health eWay, healthcare’s mobile first platform. He served as California’s HMO regulator in the mid-90s and was the Republican candidate for Insurance Commissioner in 2002.

from THCB

Dithering: How MedPAC Perpetuates Failed Managed care programs

The Medicare Payment Advisory Commission (MedPAC) is supposed to give Congress good advice about Medicare. MedPAC is good at telling Congress that the managed care experiments Congress keeps foisting on Medicare are not saving money. But MedPAC is terrible at telling Congress why these experiments are failing and whether they can be salvaged. The Medicare Advantage program is the longest-running example of MedPAC’s chronic inability to explain to Congress why a managed care program isn’t working and what should be done about it. The ACO and MACRA programs are two other examples.

MedPAC’s meandering discussion about converting Medicare into a voucher program, which began three years ago, illustrates the problem. I’ll focus on that discussion in this post.

MedPAC’s willingness to identify and discuss shortcomings of managed care programs creates the impression that it is offering Congress good advice on what to do about them. But that impression is an illusion. What MedPAC does after identifying a problem may accurately be called dithering – refusing to state clearly that a problem MedPAC has identified cannot be fixed and, therefore, the managed care program in question will never function well or at all. By dithering, MedPAC avoids the discomfort of being the bearer of bad news to Congress and the managed care movement.

MedPAC concedes risk adjustment is essential … and impossible

To illustrate how MedPAC dithers on fundamental issues, I call your attention to chapters 1 and 2 of the commission’s June 2014 report to Congress. Chapter 1, entitled “Synchronizing Medicare policy across payment models,” presents what MedPAC called its “initial exploration” of a proposal to convert Medicare into a “premium support” or voucher program. (p. 4) The “payment models” MedPAC seeks to “synchronize” with a voucher program are Medicare’s traditional fee-for-service (FFS) program, the Medicare Advantage (MA) program, and the new ACO program.

MedPAC began discussing “synchronization” via vouchers in the fall of 2013. The underlying idea is that giving all Medicare recipients vouchers and instructing them to use those vouchers to shop among the three Medicare programs will somehow “synchronize” – make more fair and efficient – both the “quality measures” applied to the three programs and the payments made to the insurers in the MA program and to the clinics and hospitals in the FFS and ACO programs. Once this “synchronization” occurs, the “value” of the insurance offered by the three “payment models” will somehow be exposed for all to see, this in turn will allow Medicare recipients to bestow their vouchers on the program with the highest value, and, presto, competition will then sort out which of the three programs is the most efficient. No need for MedPAC commissioners and staff to tie their brains in knots trying to determine from high above the earth which of the programs is more efficient. No need, in other words, for MedPAC to tell Congress the MA and ACO programs are more expensive than the FFS program, are causing other side effects such as consolidation and physician burnout, and should be terminated. MedPAC’s staff and commissioners can sit back in their hovercraft at 80,000 feet and watch the Earthlings, goosed by the “invisible hand” of competition, choose winners and losers.

MedPAC offers its initial thoughts on this wondrous vision in Chapter 1 of its June 2014 report. In this chapter MedPAC states that the vouchers (the subsidies Medicare recipients will receive to help them pay their premiums) must be accurately risk adjusted for any voucher program to work. The justification for this statement is obvious: (1) If the vouchers assigned to sicker Medicare recipients are not adjusted upward to reflect the higher cost of insuring sicker people, insurers and providers will have an incentive to avoid sicker people and to ration care to the sicker people they cannot avoid; and (2) the “competition” unleashed by the voucher program will not reveal which of the FFS, MA, and ACO programs are more efficient, but will reveal instead how well insurers and providers avoid and screw the sick.

But in the very next chapter, Chapter 2 (which is adorned with the happy title, “Improving risk adjustment in the Medicare program”), MedPAC admits CMS’s current risk adjustment method – a method developed over the last 15 years to adjust payments to MA plans – is terribly inaccurate and, to make matters worse, there is no hope of improving it. (So why was the chapter entitled, “Improving risk adjustment….”?)

I’ll discuss Chapter 2’s dismal findings in more detail in a moment. But let me stop here and ask an obvious question: Shouldn’t MedPAC have closed Chapter 2 by warning the reader that the voucher program discussed in Chapter 1 must be shelved because accurate risk adjustment is not possible? Or better yet, shouldn’t MedPAC have held off even discussing a voucher program until that fine day when CMS has developed an accurate risk adjuster? MedPAC did neither. They outlined a voucher program, noted that accurate risk adjustment is essential to such a program, then stated that accurate risk adjustment is not possible … and then just walked away.

How bad is CMS’s risk adjuster?

Now let’s take a closer look at Chapter 2 in MedPAC’s June 2014 report. It illustrates the two behaviors I’m talking about – identifying problems honestly and accurately, and dithering about those problems. Early in that chapter MedPAC repeats the warning it offered in Chapter 1 – that accurate risk adjustment is “vital” if competition via a voucher system is going to reward the most efficient of Medicare’s three programs. [1] MedPAC then tells us CMS’s adjuster, known as a “hierarchical condition category” (HCC) adjuster, has an R-squared value of only .12, which means the HCC method explains only 12 percent of the variation in spending among Medicare recipients. [2]

To drive home how bad an R2 of .12 is, MedPAC presents Table 2-1. This table shows how much CMS’s HCC adjuster overestimates the cost of healthy people and underestimates the cost of sick people. The table shows, for example, that the adjuster pays MA insurers 62 percent too much for the average person in the healthiest quintile and 30 percent too much for the second healthiest quintile. It’s not till you get into the fourth quintile – people between the 60th and 80th percentile – that the adjuster pays too little (5 percent too little). For those between the 95th and 99th percentile, it underpays by 18 percent, and for the sickest one percent it underpays by 29 percent.

MedPAC spends the rest of Chapter 2 examining three ways to improve CMS’s very crude adjuster and concludes “the alternative approaches we evaluated either do not improve the performance of the CMS–HCC model or could create other problems, including less incentive for plans to manage care and hold down costs, penalizing plans that do so, and increasing incentives to upcode.”  (p. 33)

So let’s stop here and give MedPAC credit for clearly describing a serious and intractable problem – it’s not possible to risk-adjust CMS’s lump sum payments to MA plans or anyone else accurately. But then let’s look at what doesn’t happen. MedPAC refuses to retract the happy voucher vision it presented in Chapter 1. The end of Chapter 2 would have been an obvious place for MedPAC to do that – to state that the voucher proposal discussed in Chapter 1 must be shelved because accurate risk adjustment is neither technologically nor financially feasible. A simple “never mind Chapter 1” would have sufficed. But MedPAC doesn’t do that. MedPAC just walks away from their own absurd logic: “Premium support” is a great way to “synchronize” payment to Medicare’s three programs; accurate risk adjustment will be necessary for “premium support”; but accurate risk adjustment is not possible. [3]

What word should we use to describe such irresponsible behavior, such illogical thinking? I have chosen “dithering.” There may be a better label for such baffling behavior, but right now I can’t think of it. I invite readers to submit suggestions.

Dithering over “Quality Measurement”

Risk adjustment of payment is not the only issue MedPAC must resolve to make vouchers work. Other issues include:

  • Accurate risk adjustment of the “quality measures” that MedPAC intends to inflict on the three Medicare programs,
  • accurate “attribution” of Medicare recipients to ACOs and to individual doctors in the FFS program,
  • rational definition of the geographical areas that will constitute the “markets” within which the FFS, ACO and MA programs will compete for vouchers, and
  • making all this complexity mesh with the insanely complex rules MACRA imposes on the FFS and ACO programs.

As was the case with the risk-adjustment-of-payment issue, the commission identifies these other issues as problems, then just floats away.

A conversation commissioners had at their October 7, 2016 meeting illustrates this pattern. The agenda item for this meeting was “Quality measurement and premium support.” The question for the day was how to subject the FFS, MA and ACO programs to uniform measurement of quality. The staff presented five “quality measures” for discussion, including emergency department visits, readmission rates, and a novel and grandiose “measure” called “healthy days at home,” which the staff said represented “the number of days within a year that a local area’s beneficiaries are alive and did not have interactions with the health care system that imply less than optimal health.” (p. 6 of the transcript of the morning session.)  

Midway through this session commissioner David Nerenz pleaded with the other commissioners to start demanding accuracy in risk adjustment. I quote a portion of his remarks to give you an idea of how cavalierly the commission has treated this issue to date and the level of Nerenz’s concern.

[W]e don’t think sharply enough about exactly what it is that we think we’re measuring…. (p. 39)

[T]he question that I want us to be looking at in all these measures [is], What is the signal-to-noise ratio? …. We almost never ask that about quality measures that we use. But if you just think about it in a signal-to-noise framework, when we measure the outcome, only maybe 5 percent of the variance in the outcome [is] influenced by the signal that we’re after. It really can be that weak. And all this other stuff is floating around in there…. [W]e have to take the issue of risk adjustment so seriously when we’re focusing on outcomes….

And even our language – you know, we talk about these things as measures of quality. Well, that … makes sense if … something like 70 percent or so of the variance in the outcome is explained…. Then I can say, okay, that’s a measure of quality. But as soon as that R-squared starts to drop down, then I think the word “measure” begins not to be quite right. But we keep using it, and we get trapped in our language…. (pp. 41-42)

Five or six other commissioners agreed with Nerenz’s criticism. Nevertheless, I predict that Nerenz’s tutorial will turn out to have been a waste of breath. The brutal fact is the staff cannot improve the accuracy of quality risk adjustment at the “payment model” level any more than they can improve cost risk adjustment. But I predict the staff, with Chairman Crosson’s blessing, will keep asking the commission to endorse “healthy days at home” and other trendy “measures” of quality; Nerenz and one or two other commissioners will object once or twice more, then they’ll go quiet; and sometime early next year the commission will vote for a voucher proposal to Congress that assumes accurate adjustment of quality “measures” is possible when everyone knows it isn’t. The commission will keep their voucher proposal vague and they’ll avoid explicitly endorsing it, but it will be clear they think a voucher program could work.

Dithering at 80,000 feet: A cure for cognitive dissonance

I’ll close with one more example of dithering over an issue that must be solved if a voucher program is to work. In response to a question posed by Commissioner Alice Coombs at the October 7 meeting about how MACRA’s Merit-based Incentive Payment System (MIPS) would work within a voucher program, staff director Mark Miller said: “You know, a lot of what we’re headed towards here is a chapter in June [meaning a chapter in the June 2017 report to Congress] that kind of goes through high-level design issues, and so exactly all the MIPS interactions and everything. [The preceding dead end is in the original]. Just to be very direct, for the purposes of this paper, we haven’t thought that through yet….[T]his is just a conceptual conversation.” (p. 22) [4]

Notice the words “high-level design” and “conceptual.” Any bets on whether MedPAC will ever bring their hovercraft down to Earth and actually “think through” how MIPS is supposed to work in a voucher system?

Congress and the public do not need an advisory commission that merely goes through the motions of advising. We need a MedPAC that is willing to state clearly that Medicare’s managed care programs are not working and should be replaced by an entirely different approach, an approach that focuses on specific evidence-based services, not faith-based, aspirationally defined organizations such as HMOs, ACOs and “medical homes.”

[1] Here is how MedPAC articulated, in Chapter 2 of the June 2014 report, why accurate risk adjustment of expenditures is essential to a voucher program: “A final issue to consider is how payment inaccuracies related to level of health care costs affect equity among MA plans, FFS Medicare, and accountable care organizations (ACOs). If payment equity among these three sectors is a goal, risk adjustment that results in more accurate payments for high-cost and low-cost beneficiaries is vital. For example, if the MA sector can attract low-cost beneficiaries and avoid high-cost beneficiaries, the risk-adjusted payments in the MA sector would exceed what their enrollees would cost in ACOs or FFS Medicare. The result would be program spending that is higher than if all beneficiaries were in FFS Medicare.” (p. 23)

Three pages later MedPAC repeats this warning: “If we desire financial neutrality among FFS Medicare, MA plans, and … ACOs, over-prediction for low-cost beneficiaries and under-prediction for high-cost beneficiaries could present a problem. If MA plans have high shares of low-cost beneficiaries, payments in the MA sector that are risk adjusted with the existing CMS–HCC model would exceed what Medicare would pay for their enrollees in ACOs or FFS Medicare.” (p. 26)

[2] CMS adopted the HCC risk adjuster in 2004. Prior to that, its risk adjuster predicted a measly 1 percent of the variation in expenditures (which means the taxpayer has vastly overpaid MA insurers for a long time). The HCC method implemented in 2004 had an R2 of .11 (see Pope et al. here According to MedPAC’s June 2014 report, the version of the HCC method CMS began to use in 2014 has an R2 of .12. (p. 30)

[3] Here is how Chapter 2 of the June 2014 report actually ends: “Therefore, we may need to consider administrative measures to address the imprecision of the CMS–HCC model and incentives for plans to engage in selection. One possibility is penalties for disenrollment of high-cost beneficiaries. Also, CMS may be able to obtain helpful information about factors that contribute to disenrollment through surveys of disenrollees and evaluating disenrollees for changes in their risk factors over time.” (p. 33) In other words, CMS is saying the only idea they can come up with that might reduce the favorable selection into MA plans encouraged by CMS’s crude risk adjuster would be to punish MA insurers for driving sicker people back to Medicare’s FFS (and therefore ACO) programs.

For two reasons, this is a pathetic response. First, MedPAC offers not a shred of evidence for this suggestion and does not elaborate on it. Is it possible to detect and punish “excess” disenrollment of sicker people? What would it cost to do this well? If it’s possible, would it have any effect on the effective R2? We get no answers. The chapter just peters out here. Second, even if CMS could devise a way to punish MA plans for “excess” disenrollment of sicker people, that would do nothing to alter favorable selection into MA plans in the first place. Nor would it reduce the incentive MA plans have to upcode, which is another problem MedPAC recognizes and has become very good at dithering over.

[4] An article published in the November 7, 2016 CQ Healthbeat gives you some idea of how MedPAC will articulate its support for “synchronization” via vouchers. They will claim they are neutral, but they’ll make statements indicating the issues MedPAC raises are solvable and a voucher program can work.

from THCB

National Health Expenditures Continue to Accelerate in 2015

In 2009 a youthful Barack Obama addressed a joint session of congress on health care on a cold fall evening.  The country was still recovering from the great financial crisis, and the new President was now attempting to turn the nation’s eye to health care. As he had done many times before, Obama spoke powerfully of the tragedy of millions of citizens with ‘no access’ to health care, but spoke practically of the unsustainable and untenable economics of health care.

Finally, our health care system is placing an unsustainable burden on taxpayers.  When health care costs grow at the rate they have, it puts greater pressure on programs like Medicare and Medicaid.  If we do nothing to slow these skyrocketing costs, we will eventually be spending more on Medicare and Medicaid than every other government program combined.  Put simply, our health care problem is our deficit problem.  Nothing else even comes close.  Nothing else.  (Applause.)

Now, these are the facts.  Nobody disputes them.  We know we must reform this system.  The question is how. “

These were the indisputable facts, he said.  ‘Nobody disputes them’.

With this argument the groundwork was set to completely change healthcare as we knew it.  What choice did we have, after all?  We we were all heading off of a cliff unless something was done.  And something had to be done right now.  The only problem was that we actually weren’t rushing off of some fiscal health care cliff in 2009.  We were actually in the throes of a great inexplicable slow down in health care spending that extended back to 2001.  The years from 2009 to 2013 actually represent the slowest growth in healthcare spending… ever.  Annual growth rates that at one point had averaged almost 11% in 1989, barely broke the 4% mark between 2009 and 2013.  Even more importantly, annual health care costs were rising slightly slower than the annual increase in GDP, and so, for a brief period in time, the health care piece of the national pie actually did not increase.

That was until 2014 when the Affordable Care Act started enrolling patients.  Directly as a result of the ACA (CMS conclusions – not mine), the annual growth rate in health expenditures went from 2.9% in 2013 to 5.3% in 2014.  CMS recently released the 2015 numbers, and they are worse.  Annual spending on health went up to 5.8% in 2015, and continued to outpace GDP growth (Figure 1).  Healthcare costs are, once again, on the rise and are clearly accelerating.


Figure 1. National Health Expenditure growth rate

The very program instituted to solve the problem of cost, succeeded in bending up the national health care cost curve.  Some choose to debate this point, but the data here is clear.  Federal Health expenditures in 2014 and 2015 increased dramatically relative to all other expenditures.  (Figure 2).  It could certainly be coincidence that federal expenditures rose rapidly the same year millions of Americans gained health care coverage, but I doubt it.


Figure 2. National Health Expenditures by Sponsor

Politics being politics, the most transparent administration in history said this about this data dump from CMS.


Andy Slavitt, the director of CMS, is technically correct because he’s picked out per-enrollee Medicare spending which continues to increase at historically low levels (1.7% in 2015).  Conveniently ignored is annual growth in private health insurance cost (7.2%) that is almost double the rate of growth in 2009, and growth in Medicaid – both expanding dramatically after 2014 due to expanded enrollment with Obamacare.  The expansion in Medicaid does not come cheap. In 2015 Medicaid accounts for $545 billion in spending and grew at an alarming 11.6% in 2014, slowing down only slightly to 9.7% in 2015. (Table 1)


Table 1.

For all this, the uninsured share of the population dropped by a whopping 5%.  About half of the coverage came via the private marketplace, and the other half came via Medicaid expansion.  While there is no doubt that some benefited greatly – specifically those uninsured with pre-existing medical conditions – millions of citizens found themselves paying a pretty penny for insurance that was expensive to use.  Total out-of-pocket spending for individuals which includes co-pays, deductibles, co-insurance and spending on non-covered services reached an otherworldly 338 billion dollars as more citizens were guided to plans with greater cost ‘sharing’.  While it is unfair to compare spending in developing countries for a variety of reasons, it provides some measure of scale to understand that India – a nation of 1.2 billion people – spent a total of 96.3 billion dollars on health care in 2013.

Six  years have passed since the ‘affordable’ care act passed.  Those responsible for this new world order are now strident partisans striving valiantly to show their value. Unfortunately, finding value in this new world is as hard as finding the Emperor’s new clothes.  The only indisputable fact is that eight years after candidate Obama promised efficient, sustainable healthcare, we now spend more than ever on health care at an accelerating pace. A course correction is desperately needed.  One hopes the new administration will be up to the task.

Anish Koka is a cardiologist based in Philadelphia.

from THCB