Healthy communities 2016 composite esub

Healthy Hudson Valley AUGUST 11, 2016 • ULSTER PUBLISHING • HEALTHYHV.COM

Healthy Communities

e c a f w e n ? e e r h a T c h t l a e h f o

Local hospitals are choosing their regional affiliations, for better or worse.

Story by Lynn Woods

11, 2016 2 | August Healthy Communities

Health politics Community wellbeing is truly complex

by Paul Smart

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our local hospital may now be part of some bigger system with headquarters on either end of the mid-Hudson region, or with more complex affiliations to even larger institutions in New York City. Your family doctor’s bill may be being issued from elsewhere, too. The same goes for your insurance carrier, if you ever hear from them. Even your dentist may be moving among offices in three states.

The immediate public face of healthiness, meanwhile, may be becoming more local: the yoga class recommended by friends, new trails running through our towns and villages, the growing number of recommendations being made by the local health-food store, either in person or on its website.

The big movements regarding costs of everything from doctor visits to procedures and insurance premiums seems too combustible to speak about in the midst of our current political races.

How healthy do you feel?

Statistics demonstrate that almost half of all Americans are sick in some way, suffering from chronic diseases such as diabetes, hypertension or heart disease. An increasingly significant proportion of health expenditures come from treating a relatively small number of people. The final goal: to shift end-of-life care with an eye towards patient comfort and more resources for the other 95

PHOTO BY AMY TOENSING + MATT MOYER /HEALTH QUEST’S VASSAR BROTHERS MEDICAL CENTER

What’s the future of healthcare in the Hudson Valley? How shall we, as patients, prepare ourselves?

The trends, it seems, are toward greater prevention, which means healthier lifestyles. percent of healthcare needs.

Don’t look for death panels ready to let grandma slip away in the name of greater savings, as some expect. More likely is a giant shift in emphasis away from what Atul Gawande addressed in his bestseller, “Being Mortal,” as the propensity

Diabetes

for medicine to prolong life at all costs, without any eye to patient needs. Do expect an intensification of the new push towards societal health via the creation of hiking and biking trails, greater wellness incentives, and a host of other things on display throughout our region.

This issue provides a deep look into our hospitals’ latest alignments, the ways in which our local care professionals are seeking to fill gaps in coverage, and other healthcare issues. What’s a better beacon for personal wellbeing than our community’s health?

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| 3

Living with diabetes sugar is easily treatable if you take insulin and drink water to flush your body of ketones.

A student describes how life with type 1 differs from expectations

A

by Lily Comerford

A

s a 16-year-old girl with type 1 diabetes, I have a lot on my plate.

I can’t really say that living with the disease sets me back, because I’m too stubborn to let it. But it can make things a bit more complicated than it does for everyone else.

Mostly it sucks always wearing a bag to hold my diabetes supplies. My friends love to stuff their things in my bag.

Type 1 diabetes has shown me who are my true friends and those who that aren’t so true. I don’t really like to surround myself with people who don’t have any interest in learning about my illness, or with people that get uncomfortable when I test my blood sugar or take insulin.

I have heard the comments from people about things like that, people getting grossed out by the little bit of blood on my finger, or when I used to give myself injections. Some have even told me to put my things away, comparing the shots I give myself to shooting up heroin.

There are many who have been openly interested in learning about my diabetes. Those close to me will even nag me about it when they think I’m getting lazy. I’d rather be nagged than made fun of.

My type of diabetes is not something I would wish on anyone. Diabetes is not just a physical illness but a mental one. It is manageable, but there is no cure, no way to get out of the daily routine of simple things being not so simple anymore. The only thing I can do is push through and try to act like it doesn’t kill me every time to realize this isn’t something everyone else goes through.

My diabetes is almost like a purgatory. I’m not dying from it, but I’m not living like everyone else.

While I am thankful for my insulin pump, there are times where I just wish I could rip it off. That’s because it is a constant reminder to me that I am subject to my illness, and that there is nothing I can do about it.

W

hen most people hear the word “diabetes,” they put negative connotations on it. “Don’t eat too much sugar, you’ll get diabetes.” That isn’t the truth.

There are two types of diabetes, type 1 and type 2. They are quite different. The more commonly known kind, type 2, occurs in the body generally when someone is overweight and has a bad diet and exercise regimen. Inside the body, the pancreas, which exudes a hormone called insulin that controls and regulates blood sugar, still makes insulin (compared to type 1, in which the pancreas no longer makes insulin), but the insulin does not work the way it is supposed to, basically losing its effect. With the right diet, exercise, and bloodsugar-level management, a person with type 2 diabetes can recover, or at least stabilize their condition.

Type 1 diabetes is very different than type 2.

Type 1, also known as juvenile diabetes, commonly affects children and adolescents. It is a type of autoimmune disease, which means you get diabe-

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tes when your immune system attacks your own body — in this case, the pancreas. When this happens, the pancreas no longer makes insulin, and the body is no longer able to regulate blood sugars on its own. People like me with type 1 diabetes have to constantly monitor ourselves.

Since our bodies don’t make insulin, we have to get it via injections with syringes, insulin pens or insulin pumps. We do this throughout the day as we eat, giving ourselves insulin to process the carbohydrates we take in, and when our blood sugar is high. We also have to monitor our blood sugar multiple times a day, in the morning, at night, before meals, or just to check.

Monitoring blood sugar is important. It is dangerous when blood-sugar levels are too low or too high. Normal levels are between 80 and 180, and things get dangerous when levels are below 70 or above 250. When our blood sugar is low, our body has little glucose in the bloodstream to provide energy. This makes most people feel lightheaded, dizzy and shaky. In extreme cases, an abnormal blood sugar level can lead to fainting, serious complications and even if untreated in death.

Low blood sugar is easy to treat. Eating sugary drinks or foods can bring blood sugar levels back up quickly. If someone faints from low blood sugar, however, it is vital to call 911. Most type 1 diabetics carry a device called a glucagon, a syringe in a red case filled with a substance injected into the thigh that will bring blood sugar levels up while we wait for an ambulance. This is for emergencies only.

Very high blood sugar levels are even more dangerous. They can cause lifelong complications, and can lead to heath problems, coma and death.

High blood sugar is caused by eating without taking insulin or not taking enough, or just not properly managing your diabetes.

Levels that are 250 and above are considered high. When blood sugar is high, we have to check for ketones, an acid the body spills into the blood when it cannot process blood sugars. This dangerous condition can lead to ketoacidosis, a condition that can lead to diabetic coma and death. It happens because the body isn’t getting the glucose needed for energy. The body begins to burn its own fat to use for energy in replacement, spilling ketones.

It takes a while to get to this point, and most people would become aware of the condition before their body began spilling ketones. High blood

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A diabetic’s kit includes the means for testing one’s blood sugar levels, and for providing a means of bringing it into order despite the lack of naturally-produced insulin.

ll in all, it takes a lot to manage diabetes, especially type 1. Most people could read the information and grasp the concept of what it is, but could not imagine what it feels like. Diabetes is a constant battle. The highs and lows, figuring out how much insulin to take, remembering supplies. The list goes on.

But I am lucky, though in a twisted way. My body is very sensitive to highs and lows. Unlike those people who don’t feel those changes in their bodies, I easily notice when my blood sugar is low. I get shaky, lightheaded, dizzy and drained.

I usually catch lows before they get too low, so I can treat them quickly and move on with my day.

And when my blood sugar is high, I’ll usually get a headache and get very thirsty, so I will give myself insulin and drink water.

I was diagnosed at 13. In the three years I’ve had diabetes, I have only gone to the hospital once.

I wouldn’t call my transition easy, however. It was hard for me having to take shots, since I’ve never liked them, or checking my blood sugar because it meant hurting myself in order to live. I have good days and bad days. Some days go smoothly, and others are filled with ups and downs and discomfort.

I am thankful to have an insulin pump. I use the OmniPod insulin pump. Even with that, I have a difficult time.

School is difficult when you have diabetes. There isn’t a school day when I am not in the nurse’s office at least twice, which means being late to class or leaving early.

Having high or low blood sugars means I can’t really focus. I feel sick and uneasy, and someone has to take me to the nurse. I’ve gotten stuck walking across the whole school with low blood sugar, feeling dizzy and shaky. Sometimes I’ve missed important lessons or exams, which have set me back. It’s always awkward when something goes off during class, and when my insulin pump beeps loudly people have gotten rude. I’ve even been yelled at by teachers thinking I’m using my phone.

I push through and deal with it, because I really can’t do anything else.

People uneducated about my illness often appear openly ignorant — cracking jokes about how eating a few too many candy bars will give them diabetes, or that it is something only fat people have. I have been told, “But you aren’t fat” and “You’re so skinny, how do you have diabetes?”

I refuse to hide my illness, as many people do.

When other people get uncomfortable, I try extrahard to make sure they see the blood on my fingers, or the syringes I use to give myself insulin with. I’m not ashamed. In my opinion, those people should be ashamed of making me feel insecure about something over which I have no control.

Eric D’Entrone, M.Ed., CRC Regional Coordinator, Behavorial Services Cell: (646) 529-7609 | Fax: (718) 228-8489 E-Mail: edentrone@libertymgt.com 75 Seminary Hill Road, Carmel, NY 10512 www.armsacres.com | www.coniferpark.com

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Hospitals consolidate Healthcare changes will continue to accelerate

by Lynn Woods

F

aced with rising costs, declining government reimbursements for Medicaid and Medicare, and new federal mandates under the Affordable Care Act for better quality and greater efficiency at lower cost, hospitals are rapidly consolidating. In the mid-Hudson Valley three hospitals have affiliated with larger hospital networks in the past year: Kingston-based Health Alliance of the Hudson Valley has joined up with the Westchester Medical Center Health Network, Columbia Memorial in Hudson with Albany Medical Center, and St. Luke’s Cornwall, with campuses in Newburgh and Cornwall, with Bronx-based Montefiore Health System.

Becoming part of a larger hospital system is more of a survival strategy than a choice for smaller facilities struggling with high debt burdens and miniscule profit margins. “The average hospital profit margin is half a percent,” noted Josh Ratner, HealthAlliance of the Hudson Valley’s (HAHV) chief strategy officer. As a nonprofit, HAHV, along with the other hospitals in the region, “can’t raise private equity” to fund the increasing cost of infrastructure and equipment.

The consolidation of health insurance companies and nursing homes are further squeezing profits. “The only option is to look at your affiliation and streamline efficiencies,” said Ratner.

Is hospital consolidation a good thing or a bad thing? While proponents claim consolidation leads to cost efficiencies and a broader array of

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State funds augmented by major community fundraising have given Health Quest’s Vassar Brothers Medical Center a massive new entrance lobby, along with a multitude of enhanced services. services, critics say they have the opposite effect.

Consolidation is a double-edged sword, said local assemblyperson Kevin Cahill. “A study by the Robert Wood Johnson Foundation determined that consolidation in the healthcare industry almost invariably results in higher prices and increased costs,” said Cahill. “That being said, one of the reasons a consolidation is even necessary is the hospital did not have positive cash flow. It wasn’t working.”

With 1900 employees, HAHV is the largest em-

ployer in Ulster County. It is in the first stages of consolidating its two campuses into a single hospital at the Mary’s Avenue facility in Kingston, which will result in a reduction of the number of beds from 300 to 201. It projects deficits of $15 million each year, on an annual budget of $185 million, for the next four years, after which the consolidation, which also entails transforming the Broadway campus into a medical village, is complete. (The HAHV system also includes Margaretville Hospital.)

Cost consolidation

by Chris Rowley

A

significant proportion of American healthcare expenditures come from treating a relatively small number of people termed “medically complex.” About half of all healthcare spending comes from the care of five percent of patients. Once many, perhaps most, of those patients would simply have died. Today, with medical advances and “miracles,” they live. Under the current system, however, their care, like everyone’s care, is becoming unaffordable.

The Health Care Transformation Task Force, a consortium of patients, payers, providers and purchasers working to transform the U.S. healthcare system, has released a white paper addressing the issues related to this expensive population. Their primary recommendation is to move away from fee-for-service medical care to population-based payment. Under fee for service, payers reimburse for services regardless of their impact on patient health. There is little to discourage unnecessary services. Most patients are shielded from direct cost by insurance, and the fear of lawsuits drives doctors to order unnecessary tests.

Echoing the many other studies that have come to the same conclusion, the white paper sets out four alternative ways of paying for American medical care: fee for service with no link to quality or value, fee for service linked to quality and value, alternate models based on fee-for-service architecture, and populationbased payment.

The task force recommends moving the medically complex population from the first category into the fourth, “increasing provider accountability for both quality and total cost of care, with a greater focus on population health management, as opposed to payment, for specific services.”

The crucial difference is that “payment is not directly triggered by service delivery, so volume (of service) is not linked to payment. Clinicians and systems are paid and responsible for a long period, i.e. more than a year.”

This shift to value-based payment models will create incentives for care providers to innovate and develop programs that will supplement social services. New York State is in the midst of carrying out a structural transformation to implement such a system.

The paper attacks the multitude of conflicting public and private payment schemes for care management.

“The result is that patients with similar conditions and needs in the very same health system or practice may not be able to access the same level of care management,” said Diane Stewart of the Pacific Business Group on Health. “Patients with complex conditions should be eligible for effective care management regardless of payer, public or private.”

Jeff Micklos, executive director of The Health Care Transformation Task Force, said, “Well-designed population-based payment models have the potential to reorient care management to provide better outcomes to those patients who need it most, and thereby increase value.”

The task force includes six of the nation’s top 15 health systems and four of the top 25 health insurers, as well as leading national organizations representing employers, patients and families.

August 11, 2016 Healthy Communities $88.8-million grant didn’t hurt In a deep financial hole, HAHV submitted a proposal as part of a state program to provide capital funding for DSRIP projects. After an excruciating long wait, it was in March awarded a capital restructuring grant $88,756,441, the second highest in the state.

DSRIP, or the Delivery System Reform Incentive Payment Program, supports hospitals and other providers in improving how they provide care to Medicaid beneficiaries and other patients.

HealthAlliance submitted its proposal as part of a Westchester Medical Center-led partnership known as a preferred provider system. Several weeks later, HAHV’s affiliation with the Westchester Medical Center Health Network was announced.

HAHV officials have focused on the advantages of consolidation.

CEO David Scarpino told the Ulster County Regional Chamber of Commerce at its June 22 breakfast that the alliance with WMCHealth would provide HA with benefits of scale and possibly the creation of services in southern Ulster.

HA executives said the alliance with WMCHealth would bring in needed funding as well as boost the hospital’s ability to hire qualified doctors.

Access to capital is critically important, said Scarpino. He expects the affiliation to help HA attract and retain specialized physicians, which has been challenging due to its semi-rural location.

“The attractiveness of working for WMCHealth’s many community hospitals will allow us to recruit urologists, cardiologists and other specialists,” he said. Furthermore, the proximity of the MidHudson Regional Hospital — formerly St. Francis Hospital — in Poughkeepsie, also part of the WMCHealth network, expands the working opportunities for doctors at HAHV. “Our ability to purchase medical diagnostic equipment through Westchester Medical Center Health Network is huge,” added Ratner, noting the technology is not only expensive but needs to be upgraded constantly. He added that such conExperience relief from stress & pain Receive caring support for healing chronic pain, injuries & life trauma Specializing in Thai Massage: deep stretches, acupressure & energy work DSSOLHG RQ D ÀRRU PDW ZLWK FOLHQW FORWKHG

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Scarpino added that HA will be “looking at which systems in the WMCHealth system have best practices, which should improve our quality.” Specialties that HAHV doesn’t provide, such as pediatrics, can now be offered through a sister hospital in the WMCHealth network. Asked whether there might be layoffs, he said no, though noted that “rightsizing” has always been, and will continue to be, a goal.

In contrast to HAHV, WMCHealth is enormous, a $1.6-billion operation with ten hospitals, 12,000 employees and nearly 3000 attending physicians.

WMCHealth will occupy nine of the 17 seats on the merged board at HAHV and have final budget

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approval of HAHV. Institutional change Cahill is less effusive. “The relationship I had with local hospitals was cordial, but that channel of communication has been challenged by the WMCHealth relationship,” he explained. “HAHV had one or two members on the [New York State] Assembly representing them, but now 20 of us are represented on the WMCHealth network. WMCHealth now controls that money, and my ability and motivation has significantly changed. I’m watching it very carefully.”

Cahill cited the on-going dispute between WMCHealth and Empire Blue Cross/Blue Shield.

The blues have failed to recognize WMCHealth’s alliance with HAHV, refusing to pay HAHV the higher reimbursement rate of WMCHealth. Cahill cites this as an example of the dislocations that can occur under consolidation. Many state, county, and municipal employees who subscribe to Empire Blue Cross/Blue Shield are no longer covered for services at the local hospital, excluding emergency services.

According to Cahill, Empire Blue Cross/Blue Shield considers the relationship between HAHV and WMCHealth to be an affiliation, which would not qualify HAHV for the WMCHealth rates reimbursement, which would amount to 50 percent more a person. However, all other affiliates of WMCHealth are in the Empire Blue Cross/Blue Shield network at the WMCHealth. WMCHealth has filed a lawsuit against the insurance carrier for breach of contract.

The federal Affordable Care Act (ACA) has brought complications for the hospitals. “Most of the products in the ACA have a very large out-ofpocket deductible and the question is, who pays for that,” said Scarpino. “You’re assuming every individual will put money aside and have the resources, but they don’t.” Another major problem is the withdrawal of some managed-care companies from the exchange, such as Health Republic, which went bankrupt. The outstanding receivables due is $200 million statewide, and “the hospitals are not getting the money.”

HAHV’s Medicare reimbursement rate is significantly lower than that of Dutchess County and counties south of Ulster, which are categorized as part of the downstate metro New York area by the Centers for Medicare & Medicaid. The disparity forces HAHV to pay significantly lower salaries than does Health Quest, located across the river.

HAHV executives hope that being part of a much bigger system will give HealthAlliance the clout to be successful in finally lobbying the CMS to

change the rate formula — although Scarpino said that eventually, as the hospital moves to a value versus volume-based model, the discrepancy won’t matter.

How the world is changing The refitting of the Mary’s Avenue campus, including a new fast-track emergency department and a tower with the new beds, all of which will be private rooms, is expected to take three years, after which the Broadway campus will transition to a medical village. That facility will include a simulation training center and offices rented out not only to doctors and traditional healthcare practitioners but also to mental-health and alternative-care providers. There’ll be complementary community and retail uses, such as child care, transportation services, a hair salon and coffee shop. Health Alliance expects to spend about $240 million on the five-year transition.

The reduction in beds is expected to increase the occupancy rate from the current 50 percent for both campuses to 80 percent at the one facility.

While “we’re still living in a volume-based reimbursed world,” according to Ratner, the model of care is undergoing a profound change. Eventually, the hospital will be paid not based on length of stay but on a successful outcome once the patient has left the hospital.

The driver of that change is the New York State Department of Health, which is incentivizing hospitals to improve their performance and reduce stays through DSRIP, whose goal is to reduce Medicaid self-paid hospital admissions by 25 percent over a five-year period. The program is shifting hospitals away from a profit model based on how many beds they fill to how long they keep patients out of the hospital.

That means the hospital “will be proactively monitoring patients and managing their care, rather than waiting for a patient with a chronic disease to end up in our ED,” said Scarpino. Upon discharge, care for the patient will be coordinated to ensure the person is getting his or her meds, scheduling doctor’s appointments, and otherwise following up, he said.

To monitor that patient, the hospital might employ “a robotic outreach phone call,” said Ratner.

“We’re moving towards device monitoring,” such as a “fit bit” that can monitor blood pressure and other symptoms and signs. Scarpino said especially for cardiac patients, the follow-up is very easy.

“A doctor using a smart phone could read the values if you’re hooked up to a device.”

The emergency department will be designed to fast-track “those folks who don’t need to be here,”

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11, 2016 6 | August Healthy Communities

Consolidation in pharmaceutical sales

by Deb Graziano

I

have been a primary-care pharmaceutical sales representative here in the Hudson Valley for many years. The common denominator is change.

Those who embrace it and adapt quickly are the ones who most benefit.

For the pharmaceutical representative, change can come from realignment in product portfolio, a change of territory, or a new drug therapy. The size of my sales territory has been changed during a recent downsizing and corporate merger.

To cultivate a successful career in any sales field, access to your clients is both critical and imperative. In pharmaceutical sales, it is everything. Today’s pharmaceutical representative faces increasing challenges. As the industry has evolved, access has become more limited.

Pharmaceutical representatives face many challenges. Many consolidated medical offices have implemented new standards and varying procedures. At some offices, representatives are not even allowed in the door to speak to practitioners. Some of the larger offices go so far as prohibiting representatives on the premises. Many offices restrict available times to accept samples, literature, and clinical trial information. They limit the duration and availability of times to speak to the providers.

Doctor offices are consolidating into larger corporate medical conglomerates, with single-shingle medical practitioners now a tiny minority. Consolidation and mergers are part and parcel in the landscape for pharmaceutical companies, too. Consolidation has often triggered a domino effect that radiates outward to supporting and ancillary businesses, ultimately, in my view, limiting consumer choice.

Combined with the constantly evolving body of clinical knowledge required to effectively represent efficacious therapies, today’s pharmaceutical representative must also navigate constant changes in the size and direction of their employer’s sales force. The ever-changing landscape of the pharmaceutical industry has what Ratner calls “a behavioral health focus to redirect those ED patients who aren’t in a lifethreatening situation to be treated at more appropriate venues,� such as the office of a primary-care physician.

The medical village planned for the present Kingston Hospital facility is a reflection of the focus on more outpatient care and the move away from expensive, unnecessary hospital stays toward a more affordable, efficient option. It’s a recognition that more people are being treated in doctors’ offices, visiting emergency services at urgent-care centers, and getting their flu shots at the drug store.

Scarpino said the facility will boost economic development in Midtown Kingston. He said that the simulation facility at the medical village will offer training to Kingston High School students, which could lead to their careers in healthcare and seed new employees for the HAHV system. A major longterm backbone of the local institution has been that a third of HAHV’s practicing medical staff of family physicians have participated in the residency program at the HealthAlliance-affiliated Institute of Family Health.

Over at Health Quest Health Quest (HQ), which is comprised of Northern Dutchess and Putnam hospitals and Vassar Brothers Medical Center — the result of a regional merger that occurred in 1999 — is still independent. “We don’t have a need for any type of alliance,� said HQ CEO Robert Friedberg. “We’re successful and can grow. Cash comes from our system.� Plus, “HQ geographically and clinically is positioned to allow us to have the ability to serve the community pretty fully and develop the type of clinical programs the community needs to get access to care close to where they live or work.�

He attributed HQ’s six to nine percent annual growth rate to the fact the network is “very acutely focused on the critical needs of the community and driving our resources to meeting those needs,�

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ignited a perpetual ebb and flow of sales representatives downsized and left scrambling for new employment, sometimes at a competitor, and sometimes in related fields. Being laid off is part of the annual employee dialog. Colleagues whispers about when and what will happen next.

When a larger presence or voice is needed to cover the target market space, pharmaceutical companies often cultivate a growing reliance on outsourcing, using contract companies to supplement the sales force in the field. These contracts may be short-term or last for several years. This strategic movement of human capital enables timely adjustments to a field sales force.

The specific product portfolios of more than one drug therapy will have a hierarchy weighting that directly affects performance evaluation. For example, a representative’s assigned portfolio may have primary, secondary and tertiary weighted products in the sales bag.

Specialty representatives tend to have a larger geographic area to cover.

Sometimes these representatives have to stay overnight in a hotel so they have enough time to reach all of their customers. For the primary-care representative, geographic territory will be closer to home, and will typically include a small cohort of people working together as a team. Each representative’s product responsibility within the team may be unique. Members of the team may have overlaps in products represented, but the weighting of those products may vary greatly among team members. The team dynamic is simultaneously collaborative and competitive.

The Hudson Valley is a beautiful and ideal place to work, particularly for sales representatives who spend a lot of time driving. The beautiful towns and hamlets of the area allow sales representatives a greater understanding of the economy, heartbeat and texture of the community. The medical offices we call on allow us to connect to various healthcare professionals who work together to provide comprehensive care. The dedication and hard work I have seen put forward by physicians, nurses and office staff to take care of patients is humbling. I feel honored that my path in life has allowed me to meet so many special people.

which include new programs in cardiac care, including interventional neurosurgery for acute stroke care. “We do data collection, constantly looking at how this community is changing.�

In line with the trend, HQ also offers more outpatient services. It operates several urgent-care centers and includes physicians’ offices within its network. (It is not subject to the DOH’s DSRIP program mandates, since it treats too few Medicaid patients to qualify.)

Cost pressure is balanced out by the shorter hospital stays and lower rates of patient complications due to more effective drugs and technology, Friedberg said. The shorter hospital stays are being offset by “increased utilization of our in-patient and out-patient campuses, which looks like a market-share shift,� he added.

Future expansion will involve “large investments in clinical programming,� which will “address the community by putting resources into improving healthcare. There are a number of touch points with the health system involving population health and management. You’re going to see your physician for preventative care, and the ability to afford medications plays a role.�

Increasingly, there will be more cooperation between the health care provider, patient and family, he said. One program HQ is utilizing to stay in touch with patients who’ve been released is through Mobile Life, a local paramedical company in which the paramedic is in contact with the care manager. “They may send a paramedical to the patient’s house to talk if something has changed and they want to see the impact� before the situation turns into an emergency requiring a hospital visit, explained Friedberg.

HQ is investing a half-billion dollars in a new bed tower on the Vassar campus, which updates rooms designed in the 1950s and 1960s into exclusively private ones with more space for accommodating equipment and family members, Friedberg said. “There’s more of a team approach between the care provider and the patient’s family.�

One of the biggest challenges currently is the high insurance deductibles that have resulted with the implementation of the Affordable Care Act, said Freidberg. For many patients, “self-insuring is a very large portion of their care because they have high deductibles. People don’t understand the implications of having to meet a $5000 deductible

and having that available within the resources of their families.â€? In the past, when a patient lacked insurance, “we knew they fell under our charitycare policies or we’d work with them on a payment plan‌but now they’re technically insured and we have to figure out how to deal with that.â€?

Up at Columbia Memorial In the affiliation between Columbia Memorial Health (CMH) and Albany Medical Center, each institution will retain their own distinct boards of directors and trustees, executive leadership teams, medical staffs and employees. The partnership “will increase efficiencies,� said William Van Slyke, CMH’s vice president for patient experience and external affairs. “Group purchasing saves dollars, and more importantly, it allows us to be more cooperative and create more local access to more specialty care here in Columbia and Greene counties.� Citing an example, he said a neurosurgeon from Albany Med is now providing care also in Greene County. “The two benefits to the community are it increases local access to specialty care and allows us to function more efficiently and control costs. We anticipate we’ll recommend more opportunities to provide more services in our catchment area, and the affiliation improves our long-term sustainability,� said Van Slyke.

The hospital is one of the largest private sectors in the two-county area, supporting ten percent of the area’s jobs. The hospital has had “a very slight� net positive margin in the past two years, Van Slyke said. He said his hospital has seen some benefit under the ACA. He noted that while “70 percent of the newly insured are Medicaid, that’s better than not getting paid at all.� Under the ACA, “we’re not losing as much as we were before, but it’s not a panacea.�

CMH serves 100,000 residents in Columbia, Greene and Dutchess counties. It has 192 beds and 40 care centers. Albany Med, a teaching facility for Albany Medical College, has 734 beds and 7635 employees, including more than 450 doctors. It serves as the trauma center for the region.

Down at St. Luke’s Cornwall St. Luke’s Cornwall Hospital (SLCH), which has campuses in Newburgh and Cornwall, has partnered with Montefiore Health System. While St.

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August 11, 2016 Healthy Communities Luke’s currently has control of its own finances and services, in the future Montefiore will have more say over these, according to SLCH’s interim president and CEO Joan Cusack-McGuirk. Three members of St. Luke’s 17-member board are from Montefiore. Cusack-McGuirk was quoted in a press release that Montefiore specialists would provide care at St. Luke’s, filling in the gaps, while patients needing “enhanced care” will be referred to Montefiore.

St. Luke’s, which merged with Cornwall Hospital in 2002, has more than 1500 workers, making it one of the largest employers in Orange County, and 242 beds. Well-regarded Montefiore has ten hospitals, a total of 2069 beds, a network of 150 locations and the nation’s largest school-health program.

St. Luke’s has been operating at a loss. In 2014, it lost $7.4 million in revenue on a $177.6-million budget. Last month, it announced it was closing

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the underutilized emergency department at the Cornwall campus on October 1. SLCH is transforming the Cornwall facility, which includes a medical office building housing primary-care physicians, into an outpatient center, presumably similar to HA’s proposed medical village. The closing is in response to the state requirement to reduce unnecessary hospitalizations and ED visits, will save $3.2 million annually, according to a SLCH press release.

All ED services will be consolidated at the Newburgh campus ED, approximately five miles away.

Five urgent-care centers in the area will also help pick up the slack. “Two emergency departments within five miles of each other [is] a model that is no longer sustainable,” noted the press release.

Valet parking at the Newburgh campus is being expanded to the overnight hours, and the hours of the Newburgh ED fast-track will be expanded.

| 7

More consolidation is likely Cahill said the difficulties experienced by the health exchanges under the ACA would lead to the introduction of a public option. “Even Republican members of Congress will look at their constituents who want healthcare,” he said. “We have to find something for those folks to use for health care, which is the public option.”

Three to five years down the road, Cahill predicted there would be yet more consolidation, regionally or even nationally. “Big hospitals will end up dominating the industry” — just like the car manufacturers — “and they’ll deliver healthcare in a different way.” For now, “we need to be careful and watchful of which consolidations occur and why and how,” he said. “To the extent it brings efficiency and a more qualified management term, then it’s a good merger. But if they’re just trying to consolidate power and control a market, then be cautious.”

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11, 2016 10 | August Healthy Communities

In the fields Columbia County brings healthcare to migrant workers

by Paul Smart

C

olumbia County’s migrant health program, which also services portions of Dutchess, Greene and Rensselaer counties, gives a one-page pamphlet to anyone who asks about who they serve. It reads: “I looked him in the eye. ‘Do you like it here?’ I asked. His eyes seemed to focus on something very far away. ‘Sometimes,’ he said. ‘But Americans don’t like us here.’ ‘Do you miss your family?’

‘Oh yes,’ he said smiling. ‘Every day.’”

Clinical outreach coordinator for the program Mary Jason and acting program coordinator Beth Neale, both nurses, recently found their state funding has been extended from a year-to-year basis into a five-year cycle, within which they’re in their second year. They feel what they’re doing as the region’s only county-sponsored migrant health outreach program is important, both directly for the populations of Central Americans, Haitians and Jamaicans they service on farms that request them, and indirectly for the greater population the migrant workers come in contact with while they’re here.

The workers usually labor sunup to sundown seven days a week for the three months or more they’re here. Even lunches, the nurses say, are eaten while they’re working in orchards and fields.

Their program has to fit those working hours, as they set up clinics in the fields after work lets up.

Both coordinators pointed to the long, dedicated hours their longtime community health worker, Irish Falkner, had been putting into the program for decades.

The program started in 1994 when county health administrators noticed a need regarding the growing number of migrant workers employed on Columbia County farms. Meetings were set up with other county departments and outside agencies, including the local healthcare consortium,

PHOTO PROVIDED BY COLUMBIA COUNTY MIGRANT HEALTH PROGRAM

Migrant workers welcome the testing, treatment, and education provided by Columbia County’s Migrant Health Program and other non-profit agencies willing to lend a hand while they work long hours, seven days a week.

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e asked both coordinators about the health issues they deal with. Jamaicans, they noted, tend toward hypertension, requiring blood-pressure medicines and advice about how to remove heavy quantities of salt from their jerk seasonings. Quite a few of all nationalities show signs of diabetes or end up with severe dental needs. They get advice about stroke, heat exhaustion, and newer problems such as the Zika virus. Then there are the items that arise from the work itself: rashes, Lyme disease, muscular skeletal injuries, as well as all that can go wrong with kids and other family members in tow. Or mental-health issues.

One farm worker was having with fellow workers and overseers until it was ascertained that she’d run out medication for a bipolar disorder, Jason says.

Neale adds that those who stay into the autumn get flu shots. Water bottles get distributed regularly, along with eye drops, tweezers for ticks, and pesticides. Inspections of worker housing ensure that food is handled properly, including for lunches taken into the fields. “You never know where they’re moving on to,” she adds. “Good health is needed wherever they work.”

Babies have been born in the migrant-worker camps, which are separately inspected by another Columbia County health group. Occasionally, a

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such as Legal Aid, have asked if they can accompany us to the fields, and we decline their offers because we don’t want to undermine the relationships we’ve built.” In the past year, they’ve made an exception for healthcare navigators, who can help longer-term workers find the insurance needed for anyone staying over 90 days.

Neale added that all Jamaican workers have their papers in order, having had to go through the U.S. Department of Labor for H2A visas to be able to work on American farms.

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founded in 1998 to create a network of health and human-service providers serving the rural community in first Columbia and later Greene County, which saw its sole hospital closed in the early 1990s. “The ongoing mission we gave ourselves was to provide healthcare and provide prevention training to migrant workers while working on local farms,” Neale said.

Farm owners must ask for services first. “They want their workers in good health,” Jason said.

“The workers come here with tunnel vision, ready to work an entire season so they can send money back home. They don’t like to leave the fields if there’s a chance they can be earning. And they usually move on from work here to similar jobs elsewhere around the country after harvest.”

Irish Falkner makes first contact with them in groups, meeting people early, and then returning until she gains their trust. Returning workers provide testaments on her and the program’s behalf.

She introduces workers to visiting health professionals for blood work, other tests and screenings, health discussions, and lessons in prevention.

“We don’t ask about papers. We want the workers to trust us,” Jason continues. “Other groups,

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August 11, 2016 Healthy Communities worker has ended up in hospital, under the care, if possible, of a doctor they’ve already met in the fields.

“Specialty care isn’t covered by our grant, although we can help a worker apply for emergency Medicaid,” Jason said, remembering a recent case of appendicitis.

Neale talked about numbers: The program serves over 400 workers a year. It works with nine farms, for now, scattered across Columbia County and reaching into Dutchess and Rensselaer counties. The one farm in Greene County that had been part of the program has since decided to hire only local farm help, as an experiment.

F

ield clinics include six or seven specialists, including educators and the county’s new representative for the state’s emerging Healthy Neighborhoods program, which helps people identify and solve potential health problems in their homes.

“Last year we started in February,” Jason explained. “It always depends on the weather and when crops are going to go in. There’s always work, though, from maintenance jobs like trimming trees to picking and packing. There’s also a growing number of return workers, some now in their eighties.”

“They’re all hard workers,” Neale said. “The farm owners need experience, and these men and women have it. We’re all very proud of this program, as is everyone in our county government.”

Both women talk about how much healthier a population is when issues are treated quickly, be

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they illnesses or mental health challenges. They point out how the people they serve “are in our community.” “They go to Walmart to send money home,” she said. “To keep this population healthy keeps the whole population healthy.”

It would be a much greater cost to the taxpayers if these people were not being treated, Neale said.

“And it’s a unique project in New York State. We go to state conferences, and the only things similar are a few programs in the western part of the state.”

“On a county level we can work with smaller agencies to fill in the gaps in our healthcare,” Jason said. “We get groups such as the Lions Club to donate the materials we need, pro-lifers to help

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with our STD screenings …. We work to make our program a manifestation of the caring these workers know they’ll find in our country.”

On both sides of the river, stretching from Columbia County’s pioneering program to the nonprofit efforts elsewhere, it’s a start to fill in our many gaps in community healthcare.

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11, 2016 12 | August Healthy Communities es

Yogastock, NY How one community’ ty’s practice keeps growing wing

By Kimberly Truitt

A

s the saying goes, s, you can’t swing a cat without hitting ing a yogi around here. It’s an odd thing to say in relation to yoga, because yogis strive for the betterment of collective and individual natures, including our relationship with cats. . But it’s funny and accurate.

The hamlet of Woodstock has two dedicated yoga studios, Shakti and Euphoria, with almost

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Regular additions beyond the fixed schedule of courses include live music, workshops, and guest teachers from downstate and around the world.

Additional yoga is occasionally offered in town

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at Mountainview Studio, which is not exclusively a yoga studio, and at the Woodstock Recreation Center, which currently offers “gentle” yoga once per week. During the school year, kids get afterschool yoga at Woodstock Elementary, and outside of town there is yoga at 28 West Gym in West Hurley, Chichester Yoga in Chichester, and at the Emerson Resort and Spa in Mt. Tremper. Menla Mountain Retreat Center is in Phoenicia.

There’s more yoga in Kingston and throughout the Hudson Valley. Across the river, Omega Institute for Holistic Studies, which is like a sleepaway camp for adults, offers yoga workshops, teacher trainings, and courses in meditation. At Kripalu in Stockbridge I did many hours of teacher training with Shiva Rea. In August, Sharon Gannon and David Life lead Jivamukti Yoga Intensives from their home studio in Woodstock. The annual Ahimsa Yoga and MuNeil Schneider

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August 11, 2016 Healthy Communities sic festival at Hunter Mountain is in November.

This area is blessed with no shortage of yoga. If I left anybody out, I’m sorry.

M

y yoga journey began when I was a student in New York City. Even before my first class, something in my body intuitively recognized yoga as a desirable pattern. I began my first yoga teacher training after moving upstate to Hudson. It was my way to heal and reward my body for enduring labor twice. Mine was a kid-friendly yoga studio, and during class the owner’s son was often building forts in the back out of spare blocks and bolsters. I often brought my own kids with me to practice until the youngest couldn’t handle it any more and began running circles under my downward-facing dog.

She’s now ten. I recently asked her what yoga was, no small question, one often deeply polarizing within the yoga community. My daughter’s response, as good as anyone’s, was in four parts: Yoga is stretching in funny poses. Yoga helps clear your mind. Yoga is a bunch of chanting. And yoga is fun.

In 1994, according to a Yoga Journal poll, there were an estimated six million yoga practitioners in the U.S. Only two million were self-identifying “regular” practitioners Today there are 36.7 million practitioners in the U.S., up from 20 million in 2012. The numbers worldwide are pf course far higher.

With that growth has come money. Yoga is now an estimated $16-billion-per-year industry absorbed into mainstream fitness culture. We have yogis with $200 yoga mats and $100 yoga pants practicing in air-conditioned studios stripped of Sanskrit and religious iconography practicing alongside spinning classes and treadmills. This isn’t necessarily a bad thing, but the optics are worth noting. It’s a far cry from the renunciate sadhu (ascetic) in saffron robes and few possessions chanting verse on the bare earth.

Yoga is, in fact, “stretching in funny poses.”

The idea is to improve strength, flexibility and mobility. It’s keeping the breath rhythmic and smooth, important at any age but particularly as we grow old.

A friend of mine said that toward the end of his life her teacher, Yogi Bhajan, told her he regretted not being able to touch his toes. He said that he had let the physical part of his practice slip, and that had been a mistake. Some former yoga practitioners of my acquaintance who have come to rely more on the meditative aspects of the practice acknowledge that their bodies have suffered.

Conversely, we also have practitioners who focus primarily on the physical. There is a definite propensity toward that approach in the yoga that’s been absorbed into fitness culture.

Yoga helps clear your mind. “Yoga bliss” is what we informally call it. Also “union.” It’s similar to the sensation you might feel after quick 5 or 10K run with good friends. But not exactly. With yoga it’s less accidental and nearly always more focused.

This why we chant and work with drishti points (an altar) for gazing outward in order to reveal the inward. Collective practice is useful in this way, too. Think of an array of metronomes all click-

ing at their own odd pace. In time all of them will mysteriously align and click in unison. I’ve witnessed this myself in my own practice both as student and teacher.

Because our bodies are conditioned by our habits and our thought processes, we bring ourselves to class with a unique energetic conditioning sometimes resistant to the collective flow. But we will eventually sync up despite ourselves.

The sync is almost exclusively dependent upon the breath, or prana. Everyone who hasn’t been living under the proverbial rock is by now familiar with the many studies and extensive research tracing the calming and healing effects of breath work. It is often said that without full and proper attention to the breath you’re not doing yoga, but merely exercise.

| 13

better, basically.

It turns out that this is especially true if the chant is in the original Sanskrit rather than translated into English. That is a result of the energetics of sound. “Om.” for example, is a “seed syllable” with no translatable meaning. Its infinite meanings defy compartmentalization.

Yoga is fun. The yoga community of Woodstock is vibrant. Explore for yourself.

Yoga is a lot of chanting like “om.” Yes, we do that. And sadly it’s why some choose gyms over yoga studios. While I don’t fault anyone for that choice, let me offer some reasons why you should reconsider your aversion and opt for yoga studios and teachers who chant. Chanting helps calm the mind. Sound has neurological effects and stimulates the production of endorphins. Research finds that it helps the left and right sides of the brain communication more effectively and create new neural pathways. And this makes you feel

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11, 2016 14 | August Healthy Communities

WIKICOMMONS

Theories about how we learn to care for each other are varied, but consistently dominated by a sense that empathy and compassion are key human traits. How to access and better our means of accessing these vital elements are the stuff of philosophy, religion, and even our laws.

Finding our empathy Finding one’s compassion is a key to maturing

By Harry Matthews

L

ife, as we slog through it, has a funny way of being oddly circular in its vagaries, its twists and turns. Growing up, we evolve from totally dependent little piles of need and stink eventually to learning how to care for ourselves.

Then, just when it seems that we’ve finally learned how to look after our own health, we often find ourselves having to start taking care of others, whether children, a partner, siblings, or our aging parents. And with luck, by the time our own care is needed the unregulated selfishness that most likely accompanied our twenties and thirties will have given way to a deeper sense of purpose, connectedness, and of course empathy.

Unless you are a complete sociopath, empathy might seem like an easily accessed human emotion. It may take years of going through our own rough experiences, however, to finally be able to reach deep enough into our humanity to understand and sense another’s pain and suffering, and to want to help.

I have definitely struggled finding my own empathy. Looking back, my life up to the age of twelve was innocent enough, but my teen years were rough, due in part to two things: being a target for local bullies in my high school whom I often

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found myself in scrapes with, and losing two of my closest friends at age 16. I believe now that these experiences only made me angry and defensive, as opposed to deepening my empathy. My circle of friends at the time were an often-crass group of wits who relied on sarcasm. Pointing out faults in others was our main form of entertainment. This made me see weakness in others, including illness, disease and even genetics, as a liability. Ultimately I didn’t really like people. Mostly I didn’t like myself. It’s hard to be empathetic when you’re a selfhating misanthrope. Luckily, that phase didn’t last.

In my late teens I was lucky enough to spend four months in Nepal. Most of the time I was studying in Kathmandu, but for one month I walked through the mountains, staying in a number of small Nepali/Tibetan villages high up in the Himalayas. Other than what I had gleaned reading Kerouac and Ginsburg, this was my first real introduction to Buddhism and to village life.

It all amazed me. Viewing myself in contrast to these families, these multigenerational villagers all looking after each other, began to drive out my humanity-killing sarcasm and self-loathing.

Watching the care they took with each other, how protective and nurturing they were, made my life seem wanting of so much I didn’t have.

B

ack home in the States the “me” generation of the mid-1980s was in full swing, in shockingly stark contrast to the selflessness I had experienced in those remote villages.

Not that my parents weren’t loving and nurturing. They were. But American society at that time

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seemed hell-bent on brazen success that left little place for empathy. Though I knew I wanted my life to be more in line with what I had experienced in Nepal, I had no idea how to go about it. I obviously had some growing up to do.

Living a somewhat rough and tumble existence in the city throughout my 20’s and 30’s meant I bore little responsibility for anyone other than myself. It wasn’t until quite recently that I had ever even had health insurance. Due to the reasons that I either couldn’t afford it, didn’t have a job that offered it, or just didn’t care, I was unperturbed by this obvious sign of not completely taking on the full brunt of adulthood. Like many in their bloom of youth I felt invincible, and luckily rarely got sick.

As I now approach a half-century (what!?!) in age, that feeling of invincibility has thankfully left me, and now I and almost everyone I know is insured. With this new feeling of “vincibility” (I recently lost a minor organ to a local surgeon’s deftly wielded knife), I wonder what my parents must be going through as they settle into their early eighties. And as we age and our bodies break down, turning their literal backs on us, how can we not feel some fear on a daily basis of what will go wrong next? And when that next thing inevitably happens, who will be there for us, to care for us and to nurse us? Will we be shunted off to a nursing home, or worse? Will family step up? Will I step up?

As a great example of selflessness and pure empathy my partner Catherine cared for both her parents separately through cancer, Parkinson’s, dementia, and other horrors of old age, sickness, and death, feeding and bathing them, changing diapers, etc., right to the point of their passing with dignity quietly in her arms. I wonder if I will have that level of strength, that commitment to those who fed and bathed and changed me, when it is their time to receive the same care they freely gave to me. I pray that I do.

I

believe this is what I witnessed in those mountains over 30 years ago that had such an impact on me. It was a society based on a deep connectedness and generational commitment to family and loved ones: no matter what happens, when the time comes we will stand up and not let them down. That this is what is most important in life.

Last year, I had the opportunity to put this into practice for the first time.

A very dear friend of ours, Phil, returned from a month in Florida complaining of pains in his side. Six months earlier a doctor had told him that he had a minor blockage in his gall bladder

Healthy Communities August 2016 An Ulster Publishing publication Editorial WRITERS: Lily Comerford, Deb Graziano, Harry Matthews, Chris Rowley, Paul Smart, Kimberly Truitt, Lynn Woods EDITOR: Paul Smart COVER: photo courtesy of Health Quest's Vassar Brothers Medical Center, photo by Amy Toensing & Matt Moyert LAYOUT BY Joe Morgan Ulster Publishing PUBLISHER:

Geddy Sveikauskas Genia Wickwire DISPLAY ADS: Lynn Coraza, Pam Courselle, Pamela Geskie, Elizabeth Jackson, Ralph Longendyke, Sue Rogers, Linda Saccoman PRODUCTION MANAGER: Joe Morgan PRODUCTION: Diane Congello-Brandes, Josh Gilligan, Rick Holland CLASSIFIED ADS: Amy Murphy, Tobi Watson CIRCULATION: Dominic Labate ADVERTISING DIRECTOR:

Healthy Communities is one of four Healthy Hudson Valley supplements Ulster Publishing puts out each year. It is distributed in the company’s four weekly newspapers and separately at select locations, reaching an estimated readership of over 50,000.

Its website is www.healthyhv.com. For more info on upcoming special sections, including how to place an ad, call 845-334-8200, fax 845-334-8202 or email: info@ulsterpublishing.com.

August 11, 2016 Healthy Communities and that he should do a juice cleanse. He did the cleanse and thought nothing more of it.

Upon his return, he started feeling sick again and went for some tests in Albany. He ended up spending three days there, being poked and prodded, tested and re-tested. A week later, he asked me to drive him back to Albany to get the results.

A very kind doctor teared up as he told us that Phil had stage 5 gall-bladder cancer. It had spread to other organs. He needed to put his affairs in order.

They gave him three to six months to live.

On the drive home, Phil made the decision to pass on the chemotherapy the doctor had offered.

He didn’t want to go out that way. (Phil was quite handsome, had been a Broadway dancer, and didn’t want to go out in a sterile hospital room breathing out of tubes.)

Upon his arriving back at his home. Catherine and I and two other friends set into action. We gathered around him, spending every day at his house. We cooked and prayed, hummed mantras, sang songs, made sure he got his meds, and generally tried to make him as comfortable as possible as the disease quickly took greater hold.

Three months later almost to the day, as we sat around him singing quietly, holding each other Family Practice

while we softly cried, he breathed out his last breath and died. The hospice worker who had been paying weekly visits watched as we said prayers over him, blessed and washed his body. and sang a few last songs. None of us knew quite what we were doing, but whatever it was was right.

“I’ve never seen anything quite like this,” she said. “It’s beautiful.”

In that moment I knew that this was what I had wanted to be like all along. I had finally been able to do it. I felt blessed to have had the opportunity and wondered whether I could do it again, with one even closer to me.

In the end, don’t we all just wish for compas-

sion and empathy from our fellow humans? Who doesn’t want a little care if we are lucky enough to reach our dotage?

Though I’ve been a fiercely independent person my whole life, as I start to feel the slings and arrows of unforeseen longevity pierce the oncefierce armor of my “vincibility,” I pray that at some time in the not-too-distant future a relative might step up for me, and be there in my time of need.

I guess I better start being a little nicer to them, no?

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Health briefs Response to addiction New York State’s Department of Financial Services issued a guidance letter late in July to “ensure that insurers do not unfairly discriminate against individuals facing mental-health disorders,” reminding the state’s private health insurers of their responsibility “to provide the same level of coverage for mental-health and substance-use disorders as for medical or surgical care.” The idea behind the new push comes as studies have

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found that those facing addictions keep running into barriers to recovery programs, including lessthan-adequate recovery programs.

DFS’s letter notifies insurers of the need for compliance with the federal Mental Health Parity and Addiction Equity Act. The agency is also seeking input from the public as part of a comprehensive review of compliance issues, and has promised to evaluate comments to help “determine future guidance or directives that will ensure consistency in the application of mental health and substance use disorder benefits for all health insurers.”

Submit comments directly to DFS at mentalhealthparity@dfs.ny.gov.

Vets lead the charge Compounding, or the clinically-tested manipulation of FDA-approved drugs and vitamins to specifically meet a patient’s individual needs, was once the mainstay of medicine. In the spring of 2015 the federal Food & Drug Administration published new draft guidance that greatly increases the number of instances where the FDA no longer plans to initiate enforcement action against state-licensed pharmacies, licensed veterinarians, and registered “outsourcing facilities.”

The 153-year-old American Veterinary Medical Association has pushed for the changes. “Com-

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pounded preparations can sometimes provide effective therapies for treating painful or life-threatening medical conditions in animal patients,” a statement released by the AVMA noted last month. “Compounding is a needed tool and provides much-needed therapeutic flexibility for veterinarians, especially considering the wide range of species and breeds veterinarians treat.”

The FDA has not changed its position that compounding from bulk drug substances remains illegal, with expanded allowances. It is not yet known when the FDA will issue its final guidance on compounding animal drugs from bulk drug substances.

What’s up with flossing?

Call it a perfect summer story: An Associated Press inquiry complete with FOIL requests found that the government had quietly shifted its longheld policy regarding flossing teeth based on the fact that the practice had never been properly researched. But then the pushback started. Some in the scientific and dental communities started pointing out how the sort of blind studies usually used to gauge effect are nearly impossible when it comes to flossing. On the one hand, you definitely know if you’re flossing. On the other, many who tell their dentists that they do floss don’t.

The American Dental Association joined the debate earlier this month, noting that, “Cleaning between teeth with floss and the use of other tools such as interdental brushes is an important oral hygiene practice and, along with professional cleanings and tooth brushing, has been shown to disrupt and remove plaque.” The ADA has since highlighted the rest of the U.S. Department of Health and Human Services’ statement that called flossing “an important oral hygiene practice” and said that the guidelines’ lack of mentioning it did not imply otherwise.

The primary new emphasis has been shifted from what you do to remove bad stuff from your mouth to “the nutrition-based recommendation to reduce added sugars.” The American Dental Association added that it remains important to maintain oral health by “brushing for two minutes, twice a day with a fluoride toothpaste, cleaning between teeth once a day with an interdental cleaner, and regular dental visits advised by your dentist.”

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