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ridiculously-expensive-milk · 5 years

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The Day Our Bench Was Lonely - 02

Summary: As one would have expected, coming of age isn’t quite easy when you’re a Yato. Kagura goes to an Alien Hunter school and Okita longs at the sky.

Chapters: 2/?

chapter ii - penpals in space

There aren't many things Sougo find unsettling. After all, his boss and foster father are known as both a gorilla and an insufferable stalker while also leading the police force. That being said, Hijikata is more of a leader than Kondo—at least when it comes to the technical aspect of leading and being the pain-in-the-ass man of Gintama he excels at his job. For now. There's no telling when one of his assassination attempts will succeed and when the rise of Kaiser Okita Sougo de Sade II will finally happen.

Okita Sougo is a disturbed individual who is rarely surprised or startled, even when his boss comes in naked and marries a gorilla princess from outer-space, or when Hijikata-san slides away to a dark corridor sniffing mayonnaise like a cat on drugs. As a matter of fact, he's barely moved when he finds after a rather rowdy and drunken night, Kondo, the boss and a cardboard hobo together in a bed that's probably stained with suspicious night activity.

Yet it seems like his mind cannot help but notice how a certain red-haired brat hasn't shown up at their little destructive rendezvous. He doesn't really care at first. There are times where the Yorozuya somehow find a job and she's gone for a couple of days—often less since the Shinsengumi and the Yorozuya tend to meet in a twist of fate, making the trio as much as allies as they are foes to them. For the same reason, he and China forged a bond that is neither friendship nor hateful but something in-between. They hold a healthy rivalry wherein both can unleash their potential, get loose without consequences—besides the traumatised civilians and destroyed buildings—and waking up all the muscles and nerves of the body. Consequently, his body's been more than dull these weeks because she doesn't show up anywhere.

Whether it’s the park, Gran's candy shop or Kabuki-Cho that girl is nowhere to be found, even though he catches sight of the boss and Shinpachi-kun wandering around. He wonders if she's avoiding him, despite finding the idea absolutely aberrant since that person wouldn't ever run away from him: if he ever goes in the wrong path she'd dash at him in a furious battle cry.

He waits patiently for the whole week. That girl does have a complex family so perhaps a redeemed-terrorist brother or an overprotective father swooped in.

They share a pact of privacy, not that they talked or decided it. It happens that she doesn't ask him anything and he doesn't, either. Okita does not understand what she thinks about it but he's bad at chatting, much less with a female for he comes from a poor, rural region like Bushu. But he's a great swordsman, and much more agile with his sword than his words. It's not that they hate each other but there's simply no need for useless blabbering.

Or so he thinks. Until now. He’s truly puzzled by how far a brat like her could go to. In the middle of his though Okita is brought back by the familiar, deadpan-toned ringing of the phone nested in his pocket.

I have a Hijikata~ I have a tabasco~ Die Hijikata, Hijikata die~

With a sudden slowness, Okita catches the call and lie through his teeth, "Hijikata-san you shouldn't bother an upright policeman like me, I'm patrolling and this is an important duty for the citizens. But the trash's duty is to die, so die Hijikata-san."

Hijikata's voice comes through tired by his antics. "What upright policeman?! I'm sure you're somewhere skipping patrols again."

Children's laugh in the background and sat on his favourite bench under the comfortable shade of a tree, Sougo deadpans yet again. "I don't know what you mean."

Hijikata coughs, "anyway the princess and the Yorozuya are at the terminal. They want to go to the emergency transmission room and you have the keys, right? I don't care about the perm idiot but don't make the princess wait too much."

"Alright." He cuts the call and yawns. So much for slinking away of the patrols and going through suspect alleyways, nobody knows better than him. At the very least the Terminal isn't too far, Okita comforts himself with the idea that he'll reach the massive, monolith building in less than fifteen minutes if he doesn't get accidentally murdered like that one time.

And as planned, Okita arrives in less than fifteen minutes at the Terminal where he's welcomed by the princess and the boss though the latter looked like he just survived a near-death experiment.

"Thank you for being so fast Okita-san," the princess nods at him and smile. "I want to communicate with a ship in space so I need our best antenna, it's important to me."

Wordlessly, Okita guides them through the intricate hallways of the Terminal until they reach the inner core where the Altana flow the strongest. As they reach further in the giant building the doors become more and more secure and ending with shuttle doors that lock soundly behind them, though they're usually found on space ships to airlock.

"This is the emergency transmission room," Okita says as he passes the key—a card and enters the clean and neat room. As the name suggests, the transmission room is small and have one computer as well as some chairs laying around in a nearly all-white room that reminds him too much of a hospital. He switches on the computer in a flick of the finger and the panel brightens up. "Do you have the ID of the ship, princess?"

"Use this Sofa-kun," Gintoki scurries through her kimono and proffers him with a messy piece of paper that Okita can barely read, as the notes are obviously scrambled hurriedly.

Taking a minute or two deciphering Okita finally starts typing on the computer.

=====TRANSMISSION_REQUEST=====

MAS_CRIMSON

LOG_ik1151

=====REQUEST_END=====

...

Awaiting confirmation from MAS_CRIMSON

…

"What are you doing here, boss?" Okita slouches down onto the chair and yawns yet again, though the perm should probably be doing the yawning instead of him. His eyes are almost red from lack of sleep, not to talk about the big dark circles beneath them and the yellow, sickly tone of his skin. Okita has never seen Gintoki in this state.

"Using this too," Gintoki points the machine, "I asked Tama but apparently Gengai didn't put any antennas that connect to outer-space. That old man had one job."

"Why need that though?" He looks up the computer, the request is confirmed, "if you're smuggling some illegal SpaceBay goods I'll need to arrest you, boss."

"Doesn't Okita-san know?" Soyo interrupts with a surprised face, hand over the mouth and all. "Kagura-chan, she has gone to space."

Gintoki cocks an eyebrow as well, "that brat went off quickly and didn't really prepare anyone for this, not even her dear Gin-san so I guess Souichiro-kun you weren't spared either."

"...Space?"

"Yeah. Space." Gintoki rolls his eye, "she said she wanted to go to a school and become an alien hunter like the baldy. It was his idea, anyway."

"But fortunately Kagura-chan gave us her ship's ID and maybe her school's station too. She said it'd be like sending letters. Maybe you should give it a try as well Okita-san, I'm sure Kagura-chan wants to hear from you too!"

Sougo is tempted at first but his throat dries up, his stomach knots and he refuses. "I don't really care if that brat is in space," he lies through his teeth but it soothes his pride. It's amazing how he even bothered to tell her his farewell and she decides to skip right through it in return, not even bothering to get someone to warn him while he's scurrying the town like an idiot. Intense need for killing Hijikata suddenly surges through his mind, wanting desperately to release his anger. The irritation almost makes it to his face and he barely manages to hide his feelings before Gintoki starts grinning at him.

"Soda-kun—"

"It's Sougo."

Gintoki brushes it off in a dismissal wave, "all the same, all the same. Kagura's next break is going to be in two months, you know? It's fine if you want to chat with her."

Two months.

"I'm fine boss, she and I can always have a match after that. I can't say it's that easy for you though, you look like you haven't slept since she left."

And it's probably what happened.

Before Gintoki can retort the computer beeps in loudly, followed by white lines of codes scrolling through.

=====START_TRANSMISSION=====

LOG_ik1151 ... Encryption...

User_Kagura added to data...

...

Transferring messages (3)...

...

Transfer: ok, awaiting commands...

Two messages pops up on the panel: one for the princess and the other for the boss, they seem to be long and including few other friends or family—saving up on the number of messages she sent. That's almost too smart from her, considering her usually brash and reckless behaviour. And then, a third message pops up.

From: Kagura

To: Idiot

Subject: I'm in space, loser

[Message Encrypted]

It's for him. He's almost sure of it and it should make him angry that he identifies himself to an idiot but then again that's exactly the kind of things she'd pull off. Of course, she would, that's just how she is and it's infuriating that even for a fraction of seconds he felt hurt. Indeed, he has been fooled, because there's no way he's ever gonna be so mushy mushy with her, they simply aren't like that.

Okita let a grin distorts his face, he wants to reply and curse her right now and then.

"I thought you weren't interested, Solar-kun." Gintoki sounds too victorious for his taste.

"I'm not going to answer," his grin fades back to his usual poker face. "I have too much duties to play the pen pal of a brat."

"Hah," Gintoki scoffs and raise his arms for more dramatic effect. "That's new from you Soda-kun, if Shinpachi's a virgin you are virgin from any work."

"Right back at you, boss." Okita rolls his chair away from the screen and stretches, "anyway princess you can use the computer, you should be able to read and answer her now."

While Soyo excitedly takes a seat in front of the computer and starts to furiously type on the keyboard Okita rummaged his pocket again for his phone. The model is black and printed with the golden pattern of their uniform and looks below-average, whereas the average citizen possesses a slim smartphone the Shinsengumi's is rather bulky. It has to survive their activity, to the weather and should they throw it their phone have probably more chance knocking someone cold and very much dead but that's not all. With the human's genius and Amanto technology they could create a slim and solid phone but what they have is much more.

Wifi

Network

Okita selects the latter and the name of the antenna— a series of number— shows up.

Unlike any ordinary citizen, the captains of the Shinsengumi have access to all the antennas of the Terminal, the antennas were of course powerful enough to be reachable anywhere from Japan as long as they have a computer to connect with.

Simply put, that computer was built small enough to fit in their pocket— in the form of a phone.

He opens the message, decrypting in the background and waiting patiently for each letter to start forming on his screen. On the other hand, the princess is giggling and without a doubt pleased by the surprisingly detailed message she received and after a series of furious assault on the keyboard, she leaves her seat for Gintoki.

Silence washes over the room.

Ten miserable lines that is barely sufficient for the silver perm.

"Is that really all she has to say?" Gintoki's voice drop down at near the subzero temperature and messes his hair in sheer frustration. "'Gin-chan I have a real room now'? I scrambled off all my pachinko money to pay for her food!"

"But I think Kagura-chan is doing her best." Soyo pipped in, her finger gently traced the screens, kanji by kanji, "your message doesn't have a lot of errors. The one she sent me is full of them, but I'm her best friend so it's ok. She probably wants you to be proud of her, Sakata-san."

Gintoki suddenly falls in a silence that Okita interpret as one desperate attempt at not tearing up in front of a princess and a rather sadistic policeman. All is well for the two of them, and they seem to be satisfied of the messages China sent but he, unfortunately, cannot say the same.

Okita stares blankly at the meagre, a mere three characters worth one-liner that is plenty enough to fill his body with confusion and anger, his irritation howling the deep of his heart in the form of soon-to-explode veins.

LOL

That brat.

He nearly crushes his precious, millions-of-yens-worth phone into thousand pieces as a wave of disappointment settles in his stomach. He doesn't know what he expected yet he's still angered by all the carelessness transpiring from the message yet a part of him knows it's just the way she is.

#okikagu #okita sougo #kagura #gintama #fanfic #scifi #english #romance #sakata gintoki #soyo tokugawa

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jennielim · 4 years

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toldnews-blog · 5 years

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New Post has been published on https://toldnews.com/health/surging-drug-prices-poised-to-become-hot-button-issue-in-2020-race/

Surging drug prices poised to become hot-button issue in 2020 race

This story is from Kaiser Health News.

The next presidential primary contests are more than a year away. But presumed candidates are already trying to stake a claim to one of health care’s hot-button concerns: surging prescription drug prices.

“This is a 2020 thing,” said Dr. Peter Bach, who directs the Center for Health Policy and Outcomes at Memorial Sloan Kettering Cancer Center in New York and tracks drug-pricing policy.

Spurred on by midterm election results that showed health care to be a deciding issue, lawmakers — some of whom have already launched presidential run exploratory committees — are pushing a bevy of new proposals and approaches.

Few if any of those ideas will likely make it to the president’s desk. Nevertheless, Senate Democrats eyeing higher office and seeking street cred in the debate are devising more innovative and aggressive strategies to take on Big Pharma.

“Democrats feel as if they’re really able to experiment,” said Rachel Sachs, an associate law professor at Washington University in St. Louis who tracks drug-pricing laws.

Some Republicans are also proposing drug-pricing reform, although experts say their approaches are generally less dramatic.

Here are some of the ideas either introduced in legislation or that senators’ offices confirmed they are considering.

Make a public option for generic drugs. The government could manufacture generics (directly or through a private contractor) if there is a shortage or aren’t enough competitors to keep prices down. This comes from a bill put forth by Sen. Elizabeth Warren (D-Mass.) and Rep. Jan Schakowsky (D-Ill.).

Let Medicare negotiate drug prices. This idea has many backers — what differs is the method of enforcement. Sen. Sherrod Brown (D-Ohio) has suggested that if the company and the government can’t reach an agreement, the government could take away the company’s patent rights. A proposal from Sen. Bernie Sanders (I-Vt.) and Rep. Elijah Cummings (D-Md.) would address stalled negotiations by letting Medicare pay the lowest amount among: Medicaid’s best price, the highest price a single federal purchaser pays or the median price paid for a specific drug in France, the United Kingdom, Germany, Japan and Canada.

Pay what they do abroad. Legislation from Sanders and Rep. Ro Khanna (D-Calif.) would require companies to price their drugs no higher than the median of what’s charged in Germany, Japan, France, the United Kingdom and Canada. If manufacturers fail to comply, other companies could get the rights to make those drugs, too. Penalize price-gouging. This would target manufacturers who raise drug prices more than 30 percent in five years. Punishments could include requiring the company to reimburse those who paid the elevated price, forcing the drugmaker to lower its price, or charging a penalty up to three times what a company received from boosting the price. Backers include Sens. Richard Blumenthal (D-Conn.), Kamala Harris (D-Calif.), Jeff Merkley (D-Ore.) and Amy Klobuchar (D-Minn.).

Import drugs. A Sanders-Cummings bill would let patients, wholesalers and pharmacies import drugs from abroad — starting with Canada, and leaving the door open for some other countries. Sen. Chuck Grassley (R-Iowa) and Klobuchar have a separate bill that is specific to patients getting medicine from Canada alone. Abolish “pay-for-delay.” From Grassley and Klobuchar, this legislation would tackle deals in which a branded drugmaker pays off a generic one to keep a competing product from coming to market.

This flurry of proposed lawmaking could add momentum to one of the few policy areas in which conventional Washington wisdom suggests House Democrats, Senate Republicans and the White House may be able to find common ground.

“Everything is up in the air and anything is possible,” said Dr. Walid Gellad, co-director of the Center for Pharmaceutical Policy and Prescribing at the University of Pittsburgh. “There are things that can happen that maybe weren’t going to happen before.”

And there’s political pressure. Polls consistently suggest voters have a strong appetite for action. As a candidate, President Donald Trump vowed to make drug prices a top priority. In recent months, the administration has taken steps in this direction, like testing changes to Medicare that might reduce out-of-pocket drug costs. But Congress has been relatively quiet, especially when it comes to challenging the pharmaceutical industry, which remains one of Capitol Hill’s most potent lobbying forces.

One aspect of prescription drug pricing that could see bipartisan action is insulin prices, which have skyrocketed, stoking widespread outcry and could be a target for bipartisan work. Warren’s legislation singles out the drug as one the government could produce, and Cummings has already called in major insulin manufacturers for a drug-pricing hearing later this month. In addition, Rep. Diana DeGette (D-Colo.), the new chair of the House Energy and Commerce Oversight and Investigations Subcommittee, has listed prescription drug pricing as a high priority for her panel. As co-chair of the Congressional Diabetes Caucus, DeGette worked with Tom Reed (R-N.Y.) to produce a report on the high cost of insulin.

To be sure, some of the concepts, such as drug importation and bolstering development of generic drugs, have been around a long time. But some of the legislation at hand suggests a new kind of thinking.

House Speaker Nancy Pelosi (D-Calif.) has labeled drug pricing a top priority, and the pharmaceutical industry has been bracing for a fight with the new Democratic majority.

Meanwhile, in the GOP-controlled Senate, two powerful lawmakers — Sen. Lamar Alexander (R-Tenn.) and Grassley — have indicated they want to use their influence to tackle the issue. Alexander, who chairs the Health, Education, Labor and Pensions Committee, has said cutting health care costs, including drug prices, will be high on his panel’s to-do list this Congress. Grassley runs the Finance Committee, which oversees pricing issues for Medicare and Medicaid.

“The solution to high drug prices is not just having the government spending more money. … You need to look at prices,” Gellad said. “These proposals deal with price. They all directly affect price.”

Given the drug industry’s full-throated opposition to virtually any pricing legislation, Sachs said, “it is not at all surprising to me to see the Democrats start exploring some of these more radical proposals.”

Still, though, Senate staffers almost uniformly argued that the drug-pricing issue requires more than one single piece of legislation.

For instance, the price-gouging penalty spearheaded by Blumenthal doesn’t stop drugs from having high initial list prices. Letting Medicare negotiate doesn’t mean people covered by other plans will necessarily see the same savings. Empowering the government to produce competing drugs doesn’t promise to keep prices down long term and doesn’t guarantee that patients will see those savings.

“We need to use every tool available to bring down drug prices and improve competition,” said an aide in Warren’s office.

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

#Canada #contest #doctor #election #Health #health care #health conditions #health news #health symptoms and treatments #medical articles #medical news #New York #oncall wellness #prescription drugs #U.S. Democratic Party #U.S. Republican Party

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gachagon · 10 months

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Kaiser's in his "I can't win, but you can lose" phase uh oh...!

It's also interesting to note that Kaiser sees this game as a battle between him and Isagi, and truthfully in the beginning it definitely seemed like one. But now, Isagi is so fixated on just trying to beat Barou and stay ahead of the game, that he doesn't even seem to care about Kaiser or Ness or any of the silly drama they had in the previous chapters.

I wrote earlier in my post about how "Kaiser doesn't know what Isagi's thinking" that Kaiser misunderstands every little action Isagi takes in games. He presumes that Isagi is anxious when he gets quiet, when it's the opposite. He seemingly has no idea how him and Isagi keep going for the ball at the same time. He's annoyed because they're always on the same page, and while Isagi sees that as the two of them working together, Kaiser only sees competition. He sees someone who is directly competing against him rather than someone he could potentially work together with.

And it's also cool how in the above image, Isagi was thinking this about someone else entirely, but its framed like the two of them are facing off against one another. Essentially Kaiser is losing to Isagi in this game, there's no doubt about that. And the reason for it is because Isagi is so fixated on other players, that he won't even pay Kaiser any attention during the game.

Isagi isn't using Kaiser to make plays, or stealing balls from Kaiser, and I don't think they've even spoke to one another that often during the whole match. With that in mind, it does make sense no why Kaiser looks like he's ready to murder someone in that panel because he's stuck in a one sided rivalry with someone who he believed was easy to beat.

And here kaiser is again making predictions for what he thinks Isagi will do. So far in the game he has been right about what plays Isagi will make, but that's just because the two of them are thinking the same things (so they incidentally end up playing the same way). Kaiser might only be thinking this is what Isagi's plan is because that's what he would do.

But we know already from Isagi's conversation with Hiori that our star player...really has no fucking clue what they're gonna do next lmao:

Though who knows, Kaiser and Isagi are still on the same page just unwillingly:

Maybe if they finally work together in this game they have a chance of winning it. Bastard Munchen is SO disorganized though (by design) with different players all trying to just beat one another alongside the other team. They need to be able to at least see the field in the same way or else they won't be able to keep up.

#bllk #blue lock manga spoilers #blue lock meta #bllk meta #isagi yoichi #micheal kaiser #hiori yo #kaisagi

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dinafbrownil · 4 years

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California To Widen Pipeline Of Psychiatric Nurse Practitioners

Jane Gunter, a nurse practitioner in Tuolumne County, California, has long wanted to specialize in mental health so she can treat patients who have anxiety, depression and more complicated mental illnesses.

Her county, a rural outpost in the Sierra Nevada foothills with a population of about 54,000, has only five psychiatrists — “a huge shortage,” she said.

But Gunter, 56, wasn’t about to quit her job at the Me-Wuk Indian Health Center in Tuolumne and relocate to some distant campus for two years to get certified as a psychiatric nurse practitioner.

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Then, in February, she learned that the University of California was launching a new program to provide that certification online in just one year. She fired off her application, and last month she received an acceptance letter.

“Sometimes I think, ‘What are you doing?’” Gunter said, referring to the online classes that will take over her nights and weekends once the program starts. “But I care about the community.”

The online certification program, conducted jointly by the nursing schools at the University of California-San Francisco, UCLA and UC-Davis, was scheduled to start in the fall, but it has been postponed until January because the on-site clinical hours required as part of the training are not possible during the COVID-19 shutdown.

Despite the delay, the potential expansion of psychiatric care is opportune given the expected increase in mental health problems due to the social isolation and financial stress stemming from the pandemic.

The need for more mental health nurses is about to be bigger than ever, said E. Alison Holman, a health psychologist at UC-Irvine who studies emotional responses to collective trauma.

“We now have 30 million Americans who have lost their jobs, who have no income — and how are they going to pay rent? How are they going to buy food?” Holman said. “And then you have to stay home. This event is rolling out like a long, chronic stressor.”

Even before the current crisis, California faced a serious shortage of mental health professionals, especially in rural areas. California’s psychiatrists and psychologists are approaching retirement age in large numbers, and fewer medical students are choosing psychiatry.

A UCSF study projected that the state would have 41% fewer psychiatrists than needed by 2028. More than half of Californians with mental illness receive no treatment, according to a February 2019 report by the California Future Health Workforce Commission.

UC’s online mental health nurse practitioner program is one of the solutions recommended by the commission, a statewide, multisector panel that created a master plan to address the Golden State’s shortage of health care workers.

The program is expected to put 300 more mental health NPs into California communities, particularly rural ones, over the next five years. Applicants such as Gunter, who live in underserved rural areas, will be given priority in the hope that they will stay in their communities upon completion of the training, said Deborah Johnson, a UCSF nursing professor who is co-director of the program.

Forty spots are available for the class that begins in January, and not all have been filled yet, Johnson said. Applications are being accepted until June 1, and 65 additional spots will open in fall 2021 and each fall thereafter for three more years, she said.

The UC system received a $1.5 million grant from the California Health Care Foundation to develop, design and launch it. But tuition is expected to make it self-sustaining. (Kaiser Health News, which produces California Healthline, is an editorially independent publication of the foundation.)

Applicants for the new program must already be advanced practice nurses, which means they hold either a master’s degree or doctorate in nursing. More than 27,000 NPs now practice in California, but only 1,200 are certified to treat psychiatric patients.

Three hundred more psychiatric NPs won’t completely fill the growing mental health care need, but they are expected to treat nearly 400,000 patients over a five-year period.

Though the online program means working nurses won’t have to leave their jobs and their lives to relocate, they will still face challenges.

For one thing, their certification will require 500 hours of supervised clinical training with patients in hospitals, jails or schools. And some applicants live in communities where such opportunities may not be available, which could require them to commute long distances to meet the requirement.

Another challenge is that, even after nurse practitioners are certified, state law requires they find a medical doctor to supervise them. Havilyn Kern, a school nurse in Nevada City, California, quit her job two years ago so she could spend three days a week at UCSF — 155 miles away — to train as a psychiatric nurse practitioner.

She graduates in June, so the new online program is too late for her. Kern, who plans to work in her own community, hopes she will find a psychiatrist in the Bay Area willing to tele-supervise her.

“It shouldn’t have to be this way,” said program co-director Johnson. “California is so archaic. It’s the most restrictive state in the western portion of the country.”

Twenty-eight states plus Washington, D.C., allow nurse practitioners to work autonomously. Santa Rosa Assembly member Jim Wood, a Democrat, has introduced a bill, AB-890, that would allow California NPs to practice without doctor supervision. It passed the Assembly in January and is pending in the Senate.

“If AB 890 passes, it will certainly help fill the loss of specialty physicians such as psychiatrists everywhere, including in underserved areas,” Wood said.

But that’s a big “if.”

California’s powerful doctors’ lobby, which has repeatedly scuttled similar legislation, is aggressively fighting it again. They argue that letting NPs order tests and prescribe medications independently would “dilute care.”

Doctors also have a financial incentive to keep things the way they are. It restricts competition, and they bill NPs between $5,000 and $15,000 a year to review their charts and prescriptions every few months, according to a report by the California Health Care Foundation and UCSF.

Johnson suggested it is time for a change.

“We are the workhorses,” she said. “Oh, my God, there is so much need. This new program could not come at a more important time.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

from Updates By Dina https://khn.org/news/california-to-widen-pipeline-of-psychiatric-nurse-practitioners/

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maxihealth · 5 years

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“Telehealth is a digital distribution channel for health care” – catching up with Roy Schoenberg, President and CEO of American Well

Ten years ago, two brothers, physicians both, started up a telemedicine company called American Well. They launched their service first in Hawaii, where long distances and remote island living challenged the supply and demand sides of health care providers and patients alike.

It’s ten years later, and I sat down for a “what’s new?” chat with Roy Schoenberg, American Well President and CEO. In full transparency, I enjoy and appreciate the opportunity to meet with Roy (or very occasionally Ido, the co-founding brother-other-half) every year at HIMSS and sometimes at CES. In our face-to-face brainstorm this week, we covered a wide range of topics, starting with some historical context to get to the “new and now.”

That launch of AmWell in Hawaii was with a payer, a unit of Blue Cross. The company’s early bet and first strategic choice was to work with payers. That segment is a significant business now, Roy explained. The company works with virtually every major payer-player, and 45 Blue Cross Blue Shield plans as well. This is a core business for AmWell.

The company’s second strategic choice was to “put the technology in others’ hands,” Roy described, with AmWell’s services, “baked into other businesses.” Doing so in this way could help health/care ecosystem stakeholders to innovate their own business and pricing models. AmWell invested in making their own technology easier to tie into other businesses’ infrastructures and architectures. Consider the plethora of EHR systems, scheduling idiosyncrasies, physician adoption and workflow considerations, and patient matching challenges, for example.

On the health system (provider) side, there is substantial pressure to reduce costs and at the same time, provide innovative services. These services are increasingly ambulatory and mobile, based on both cost and consumer preferences. AmWell’s customers cover about 150 million lives. Don’t mistake that for “reach,” Roy warned me when I quickly calculated, “So, you reach 50% of the U.S. population.” It’s a potential consumer/patient market that AmWell could serve, but not every person with access to telehealth services takes advantage of that supply side.

Remember the Field of Dreams effect? “If you build it, they will come?” In telehealth, even with employers covering the service as a workplace benefit, most employees still don’t “benefit from the benefit.” We discussed this disconnect on our panel today at HIMSS19, addressing digital traction in consumerization of health care.

Dr. Peter Rasmussen explained that there are many reasons consumers don’t yet engage in virtual health services. In some systems, like Kaiser-Permanente, at least 50% of encounters are done via non-traditional channels: via secure email with clinicians, via video chat, and asynchronous chat, for example. Intermountain and Mercy Virtual, too, conduct lots of visits via telehealth means. However, some recent market research estimates have identified very low, single digit consumer market adoption.

A major limiting obstacle for providers has been licensure, where a doctor peer of Peter’s in Cleveland cannot provide a second opinion for a patient in rural Kentucky for a rare cancer due to the Ohio physician’s lack of license in the Bluegrass State. I noted that in the EU, this isn’t a problem for physicians operating in different countries, from the far north to the Mediterranean south.

On the consumer side, a Jetsons-style telehealth visit with a clinician on a screen can seem too Star Trek tricordery, whether small on a phone or on a large-screen PC monitor. But once a patient-consumer experiences that virtual visit, most people want to repeat the telehealth encounter. Here, Jane Jetson is very happy to be able to access a telehealth visit for her son, Elroy — and true enough, back here in the digital health Stone Age, Moms with young children are particularly keen on virtual visits especially on nights and weekends.

To smooth organizations’ way to offer telehealth, American Well offers an SDK, a software development kit. This package drops into the client’s technology. Samsung, for example, build an American Well ap into their phone. New York Presbyterian Hospital has an app for telehealth from American Well. AmWell SDKs have also been used by Medtronic, Cerner, and Philips, among others. The Apple Heart Study used the SDK.

“American Well is like the Intel inside,” Roy agreed with my analogy.

In a new HIMSS19 announcement, Netsmart uses the AmWell SDK for a behavioral health opioid program, announced today.

On our panel today, Greg Orr from Walgreens, Jessica Gelzer from Heal, and Dr. Rasmussen of Cleveland Clinic discussed the blurring between the traditional physician and the newer digital side. In retail , this is happening, with the poster child of Amazon invoked at every health care meet-up over the past year and ongoing.

I believe this is “omnichannel” in retail, and it’s happening in health care deliery, too.

Roy’s Amazon-analogy pointed me to the concept of “inventory.” Amazon shows us that stuff doesn’t have to live on Amazon’s warehouse shelves. “You don’t need to own it, but to route it,” Roy explained.

So for that industry disruptor, the key tactic is to develop and implement skills around inventory distribution.

Thus, the quote in the title of this post: as Roy asserted, “telehealth is the distribution channel for health care services.”

And here’s the next money quote and lightbulb moment: “We have to let go; we can’t be the product.”

In sense of the services available in the “inventory,” those, too, have expanded since the start of offering a physician visit. Today, specialists are part of the AmWell physician network, as well as womeen’s health experts, nutrition counselors, weight loss coaches, lactation support, and the fast-growing area and need on the demand side for behavioral health.

Health Populi’s Hot Points: Live telemedicine visits are more prevalent among younger urban-dwelling consumers, with lower adoption among rural, older residents, Rock Health learned in its fourth and lattt digital health consumer survey.

This means that some of the very people who most need access to health care services — rural, older, frailer health citizens — aren’t tapping into virtual visits. As Dr. Rasmussen pointed out, there can be may reasons a person doesn’t engage in telehealth: cultural, financial, or trust/privacy. I would also add in the role of of connectivity and broadband as a social determinant of health, clearly a barrier to adoption in rural areas that can lack connection to the last mile, and to the last person/patient.

In the growing health ecosystem landscape of retail health for patients-as-payors, attending to social determinants of health is at least as important as paying attention to health care services and specialty care access. I expect that AmWell will expand its footprint and services from the nutrition and weight loss areas to other behavioral and social factors that play so integrally into peoples’ overall health and wellness.

At HIMSS19 we see some exhibitors that will support this kind of consumer engagement and ecosystem build-out: AWS (Amazon Web Services), Google, Microsoft (with announcements for the Azure cloud collaborating with Walgreens, for example), and Salesforce bringing CRM capabilities to health and social services.

Ten years from now — even three years from now — I cannot forecast what new-new collaborations and services Roy and I will talk about. I’m certainly doing scenario planning on this for my advisory work.

But of one thing I am sure: in that decade-away scenario, the home will certainly be the hub of health.

The post “Telehealth is a digital distribution channel for health care” – catching up with Roy Schoenberg, President and CEO of American Well appeared first on HealthPopuli.com.

“Telehealth is a digital distribution channel for health care” – catching up with Roy Schoenberg, President and CEO of American Well posted first on https://carilloncitydental.blogspot.com

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titheguerrero · 5 years

Text

“Telehealth is a digital distribution channel for health care” – catching up with Roy Schoenberg, President and CEO of American Well

To smooth organizations’ way to offer telehealth, American Well offers an SDK, a software development kit. This package drops into the client’s technology. Samsung, for example, built an American Well app into their phone. New York Presbyterian Hospital has an app for telehealth from American Well. AmWell SDKs have also been used by Medtronic, Cerner, and Philips, among others. The Apple Heart Study used the SDK.

“American Well is like the Intel inside,” Roy agreed with my analogy.

In a new HIMSS19 announcement, Netsmart uses the AmWell SDK for a behavioral health opioid program, announced today.

On our panel today, Greg Orr from Walgreens, Jessica Gelzer from Heal, and Dr. Rasmussen of Cleveland Clinic discussed the blurring between the traditional physician and the newer digital side. This is happening in retail, with the “A” word “Amazon” invoked at every health care meet-up over the past year and ongoing.

This omnichannel phenomenon is now retail-reality, and it’s happening in health care delivery, too.

So for that industry disruptor, the key tactic is to develop and implement skills around inventory distribution.

Thus, the quote in the title of this post: as Roy asserted, “telehealth is the distribution channel for health care services.”

And here’s the next money quote and lightbulb moment: “We have to let go; we can’t be the product.”

But of one thing I am sure: in that decade-away scenario, the home will certainly be the hub of health.

The post “Telehealth is a digital distribution channel for health care” – catching up with Roy Schoenberg, President and CEO of American Well appeared first on HealthPopuli.com.

Article source:Health Populi

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realselfblog · 5 years