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Interest-only mortgage risks 'not clear' to Australian borrowers
 A third of customers with interest-only mortgages may not properly understand the type of loan they have taken out, which could put many in "substantial" stress when the time comes to pay their debt, UBS analysts warn.

Amid a regulatory crackdown on interest-only loans, a new report by analysts led by Jonathan Mott highlights the potential for repayment difficulties with this type of mortgage.

Typically, an interest-only loan will allow a customer to only pay interest for the first five years. After that, they must start also paying principal, which raises their monthly payments substantially - or attempt to refinance.

However, the UBS analysts believe there is a real risk many consumers do not realise their mortgage payments will rise in this manner.

Output: A third of Australian homeowners may be unaware of the risks associated with interest-only mortgages, with a lack of financial literacy possibly to blame, according to a survey by UBS. Interest-only loans offer lenders an initial period when they pay off only the interest on the mortgage, but after that has elapsed, they must pay back the main loan as well, or refinance. Analyst Jonathan Mott said customers could face increases of between 30% and 60% at the end of interest-only periods, which could lead to "substantial stress". In 2015, the Australian Securities and Investments Commission questioned banks' credit standards in interest-only lending.


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Kazakhstan to earn $1bn from gas export deal with China
 October 04, 2017 11:09 am | Updated 11:11 am IST - ASTANA:

Kazakhstan has signed a trade agreement with China covering exports of 5 billion cubic meters of natural gas to the Asian giant for a year, a deal that is expected to generate $1 billion in earnings for the Central Asian country, JSC KazTransGas said on Tuesday.

“The contract was signed by JSC KazTransGas and PetroChina International Company Limited on September 30 in Beijing. Gas export deliveries are scheduled to begin on October 15,” the Kazakh company’s press service said in a statement, reports Efe.

“Expected export earnings will be around $1 billion,” JSC KazTransGas said.

The natural gas will come from fields in western Kazakhstan, as well as reserves at JSC KazMunayGas’s underground storage facilities.

Via the Khorgos border point

China will take delivery of the gas via the Khorgos border point, the most important trade frontier between the countries.

“The diversification of transit and export routes for gas transportation in Kazakhstan, as well as the increase in the volume of natural gas exports, are important strategic objectives for the country,” JSC KazMunayGas vice president of transportation and gas trading Kairat Sharipbayev said.

Exports of Kazakh gas to China are aimed at promoting beneficial bilateral relations focused on creating a common infrastructure and establishing trade and transport links in the Eurasian region, the statement said.

The agreement also calls for bolstering bilateral strategic energy relations, as indicated by the production of 25 per cent of Kazakh oil by Chinese companies.

Output: Kazakhstan will export 5 billion cubic metres of natural gas to neighbouring China as part of a new trade agreement, earning the central Asian nation an expected $1bn. JSC KazTransGas and PetroChina signed an agreement on 30 September and gas exports are due to start on 15 October. The deal aims to boost bilateral ties and focuses on infrastructure, trade and transport links.


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Amazon's Echo and Alexa launch in India, by invitation only
 Missed the GamesBeat Summit excitement? Don't worry! Tune in now to catch all of the live and virtual sessions here.

Amazon has announced that its smart Echo speakers and accompanying Alexa voice service are now available in India, but by invitation only.

Additionally, Amazon announced that the Echo will be landing in Japan “later this year,” according to a separate press release.

Those wishing to buy an Echo, Echo Plus, or Echo Dot in India can request an invitation to purchase a device through Amazon.in today, with local pricing coming in at ₹9,999 ($153), ₹14,999 ($230), and ₹4,499 ($69), respectively. The initial batch of devices is slated to start shipping from October 30.

Echo, echo, echo…

Following an invite-only period that kicked off more than three years ago, Amazon launched the Echo in the U.S. in July 2015 before extending it into Germany and the U.K. last year. India represents the fourth official market launch for Echo, and the first in Asia. The news comes just a week after Amazon unveiled a triumvirate of new Echo devices, including a second-generation Echo, the new Echo Plus, and the Echo Spot alarm clock.

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For now, Alexa — the digital voice-activated assistant that can understand and answer your questions — still only speaks English and German. English is, of course, an official language in India, but for the Indian launch Amazon said that Alexa will deliver a “customized Indian experience,” with an “all-new English voice” that understands and converses in local pronunciations and intonation. It will also support music titles, names, and places in additional non-English languages. And Indian developers are building skills for the local market, covering Saavn, Times of India, ESPNcricinfo, Ola, and FreshMenu, among others.

Rumors of an imminent Indian launch had abounded for some time. An Economic Times report from July noted that while English would be the predominant language at launch, Alexa would later be updated to include regional tongues, such as Tamil, Hindi, and Marathi. However, Amazon hasn’t given any indication that this is the case or when a language expansion may be expected.

Battle for the “next billion”

India has emerged as a key battleground for Western tech firms, with Apple committed to selling iPhones manufactured in Bengaluru, Google going all-in to target the “next billion” internet users across the country, Intel spending $178 million on a new “smart and green” R&D facility there, and Facebook showing growing interest. Last year, Amazon opened its first Indian AWS data center in Mumbai to help enhance data transfer speeds and to satisfy local data sovereignty concerns.

With the smart speaker market heating up, and both Google and Apple offering devices similar to the Echo, Amazon is keen to get a head start in what could prove a lucrative market for the fast-growing product line. The company revealed that the Echo Dot was its best-selling product on Prime Day in the U.S. this year, though that was probably largely due to its huge temporary discount.

Output: Amazon is releasing its Echo speakers and accompanying voice-activated assistant Alexa in the Asian market for the first time, with an invitation-only offer to Indian customers. Amazon said the Alexa device will have an all-new English voice and offer a "customised Indian experience", as a host of developers race to create skills covering Indian music service Saavn, the Times of India and ride-hailing firm Ola, among others. Shipping is due to begin at the end of October. India is Amazon's fourth market launch for Echo, and the country has become a hotbed for Western firms such as Apple and Intel.


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Canada welcomes Square's contactless payments technology
 US-based financial services company Square has launched a brand new contactless payment and chip reader in Canada.

The company announced the new product at a panel discussion led by Square CEO and Twitter co-founder Jack Dorsey. “One word to really describe Square…is the word access,” said Dorsey, during the panel. “Giving people access to the economy in ways that they previously had not. Our purpose is to build tools to help people enter the economy.”

The product is a white square that can be connected to the company’s Square Stand card reader. Customers will now be able to pay with their mobile devices, tap-enabled cards and chip-enabled cards.

Additionally, the company also announced that debit transactions — a much-requested feature — will be available in Canada. Customers will now be able to pay with their chip- and tap-enabled debit cards, as well as their credit cards.

In a roundtable discussion with media, Jesse Dorogusker — Square’s vice president of hardware — confirmed that the company’s credit card fee of 2.65 percent will not change. The company will also be waiving its $0.10 debit fee until the end of 2017. According to Dorsey, with the introduction of the new Square chip and contactless payment reader, the company is moving towards a “complete Square.”

Dorsey also briefly touched on the subject of bringing his company’s two other major products, the Cash app and the Square Cash Card, to Canada.

While Dorsey said that he would like to see the Cash app and Cash Card in Canada, “it’s a matter of doing the work.” “We would like to enable all of our products in every market,” said Dorsey. “It’s work, entering any market with a different product requires work on our side, it’s not just an okay from a partner. Connections that need to be made, code that needs to be written and hardware that needs to be tests — it’s work on both sides.”

The Square contactless payment and chip reader will be available through Square’s website for $59 CAD. The company said that the product will be available “in weeks” at retailers including Staples, Apple, London Drugs and Amazon.ca.

In April, Shopify released its own chip and POS reader as it sought to grab customers that may consider Square its first option.

This article was originally published on MobileSyrup

Output: Canadian consumers can now use contactless payments service Square. The US company's product allows customers to pay for goods and services using mobile devices, as well as debit and credit cards. The service is expected to be available soon in major retailers including Apple, London Drugs and Amazon. "Our purpose is to build tools to help people enter the economy”, said CEO Jack Dorsey.


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Singapore bank's customers can use Siri for B2B payments
 Singapore's OCBC Bank has integrated its business mobile banking app with Apple's Siri for use in voice-controlled funds transfers and account balance enquiries.

Available early next week to 120,000 Singapore-registered users of OCBC Bank’s internet business banking portal, the app will permit payments of up to S$20,000 to recipients on the SME payee list. Validation will be done via fingerprint authentication and One Time Passwords (OTP) sent via SMS.

OCBC in October last year rolled out Siri-based cash transfers to retail customers using its Pay Anyone P2P mobile app.

Praveen Raina, SVP, group operations & technology, OCBC Bank, says e-payments to other OCBC Bank business accounts and account balance enquiries are two of the more commonly-used business banking services.

“The e-payments push is not just about peer-to-peer payments, but encompasses business-to-business payments too," he says. "We have already made online and mobile banking easy for SMEs in order to encourage them to go cashless. Voice recognition technology is integral to this, and it is easy to envision the use of Siri to make e-payments, or to check account balances, becoming second nature to business owners."

Output: Singapore's OCBC Bank has integrated its business banking app with Apple's Siri for voice-controlled money transfers. From next week, 120,000 Singapore-registered business users will be able to make payments of up to SGD20,000 ($14,700) to recipients on their payee list. Payments will be validated with fingerprint authentication and a one-time password, sent via text message.


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Snap Accelerate helps start-ups to use Snapchat for advertising
 Snapchat launched an initiative Tuesday to help fledgling companies kick-start their advertising efforts on the messaging application.

Snap Accelerate is aimed at providing venture capital-backed startups, incubators and accelerator programs with access to benefits and services.

A Snap Inc. spokesperson said the company is open to startups at all stages of their development, adding that the initiative is best-suited for growth-stage mobile startups with digital expertise and performance-based, direct-response marketing strategies. Examples include mobile applications that are still in the process of acquiring users, mobile commerce startups and mobile game developers.

Snapchat is obviously a mobile-exclusive vehicle, and the company said 60 percent of its daily users create Snaps with their cameras on a daily basis, and the average user opens the Snapchat app 18 times per day and spends more than 30 minutes on it.

The

Output: Snapchat is launching a partners programme to support start-up companies that want to use the platform for their advertising campaigns. The initiative, called Snap Accelerate, is a similar concept to Facebook's FbStart programme, which launched in 2014 and has continued to expand. Snapchat is inviting applications from start-ups that are formulating direct response strategies, such as mobile commerce, app and game developers. Selected partners will get access to a range of services and benefits, including advertising credits, priority support and advertising tools, as well as invitations to private networking events.


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Grassley Pressing to Include Drug Pricing Measures in CHIP Reauthorization
 The Preserve Access to Affordable Generics Act targets deals between brand-name drugmakers and their generic counterparts to delay the market entry of competing drugs.

The CREATES Act would crack down on practices employed by some brand-name drugmakers to thwart generic competition.

Sen. Chuck Grassley, a senior member and former chairman of the powerful Senate Finance Committee, is pressing GOP leaders to tackle high drug prices in a critical bill to renew funding for the Children’s Health Insurance Program. Grassley (R-Iowa), who has tried for years to advance legislation targeting rising prescription drug costs to little avail, is pushing two bills as potential offsets for CHIP funding. Both measures have some bipartisan support, but neither has advanced in previous congressional sessions amid fierce pushback from the pharmaceutical industry. But with urgency on Capitol Hill to renew CHIP, which expired last week, Grassley is taking a shot at getting the bills — the CREATES Act and the Preserve Access to Affordable Generics Act — included in the reauthorization as partial offsets. The CREATES Act would crack down on practices employed by some brand-name drugmakers to thwart generic competition, while the Preserve Access to Affordable Generics Act targets deals between brand-name drugmakers and their generic counterparts to delay competing drugs from entering the market.

A similar affordable generics bill would reduce federal spending by roughly $2.4 billion over 10 years, according to an October 2015 estimate from the nonpartisan Congressional Budget Office. A previous version of the CREATES Act would reduce federal spending by roughly $3.3 billion over 10 years, according to Grassley‘s office in April. Experts on Grassley’s staff have talked with staff on the Senate Finance Committee and in leadership about the proposals ahead of a committee markup of the CHIP legislation on Wednesday, according to a senior GOP aide. Supporters from the health sector, which include health insurers, providers and patient organizations, say their chances have never been better, given public outrage at exorbitant drug prices, bipartisan desire to address the issue in Congress and interest in drug prices from within the Trump administration. The proposals have even united progressive advocacy group Public Citizen and the conservative FreedomWorks. Still, despite unprecedented momentum to tackle rising prescription costs, it is still far from certain whether Grassley will be successful. Senate Finance Committee Chairman Orrin Hatch (R-Utah) has not endorsed either measure and has sometimes sided with brand-name drugmakers on divisive pricing issues. Hatch’s office did not respond to a request for comment on Tuesday. “It is a delicate conversation between two chairmen who’ve been here for more than a cup of coffee,” Rodney Whitlock, Grassley’s former health policy expert, said in an interview Tuesday. Whitlock is now vice president of health policy at the consulting firm ML Strategies LLC. Political procedure also complicates Grassley’s effort. Both drug pricing measures have been referred to the Senate Judiciary Committee, which Grassley chairs, while the Senate Finance Committee has jurisdiction over CHIP. A spokesman for Senate Majority Leader Mitch McConnell (R-Ky.) directed a request for comment to Grassley’s office.

Output: Sen. Chuck Grassley, a senior member and former chairman of the powerful Senate Finance Committee, is pressing GOP leaders to tackle high drug prices in a critical bill to renew funding for the Children’s Health Insurance Program.


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IBM, UC San Diego launch aging-based AI center
 IBM and the University of California San Diego have launched an artificial intelligence project aimed at boosting the quality of life and independence for aging populations.

The partners have opened an Artificial Intelligence for Healthy Living Center on the campus of UC San Diego to bring together the technology, AI and life sciences knowledge for research into healthy aging.

[Also: AI-powered Viome raises $15 million to take on the microbiome]

They plan to develop technologies to further achieve the potential of AI and to boost cognitive health, which, in turn, will enable people to live independently longer and have a higher quality of life.

The project also aims to better understand the health implications of the human microbiome – the microbes that live in the human body.

The team will develop and employ machine learning algorithms for sensing, understanding, modeling, personalizing and informing.

[Also: How AI is transforming healthcare and solving problems in 2017]

The initiative will bring together researchers in computer science, engineering and medicine, including psychiatry. Over five years, researchers will study the impact a combination of daily habits, the environment, genetics and the microbiome have on the cognition of older adults. The goal: enabling older adults to live independently longer and have a higher quality of life.

“We’re committed to collaborating with the best minds in academia to inspire the next generation of scientists by providing access to leading-edge AI tools and expertise to solve real problems that impact human lives,” John Kelly III, IBM senior vice president, Cognitive Solutions and IBM Research, said in a statement.

Co-directors of the Artificial Intelligence for Healthy Living Center will be Ruoyi Zhou and Ho-Cheol Kim from IBM; and Tajana Rosing, a faculty member in the Jacobs School of Engineering’s Computer Science and Engineering Department, and Rob Knight, a faculty member in the Department of Pediatrics and Computer Science and Engineering and director of the UC San Diego Center for Microbiome Innovation.

Twitter: @Bernie_HITN

Email the writer: bernie.monegain@himssmedia.com

Output: IBM and the University of California San Diego have launched an artificial intelligence project aimed at boosting the quality of life and independence for aging populations.


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Altibbi wins $6.5m to expand employee telehealth in Middle East
 Altibbi has raised $6.5 million to support its digital health platform for the Arab world. Middle East Venture Partners and Dash Ventures led the round, with additional participation from TAMM, RIMCO Investments, Endeavor’s Catalyst Fund, and other undisclosed investors.

“We are fortunate to work with some of the reputable and supportive venture capital firms and strategic corporate VCs in the region, and confident that this partnership will further accelerate our efforts towards a more prosperous future with universal access to healthcare,” CEO Jalil Allabadi said in a statement. “The rapid growth of our company over the past years has clearly illustrated the ever-growing demand for innovative health solutions in our region, and we are delighted to witness first-hand how our products are solving real problems. Altibbi is proud to provide cutting-edge, inclusive health services and looks forward to further strengthening these solutions by offering the best connected health solutions the region has seen to date.”

Altibbi is primarily a telehealth company for the Middle East and North Africa (MENA) region. It works with employers to offer their employee 24-7 access to local primary care doctors. The app serves users in Saudi Arabia, Egypt, the United Arab Emirates, Kuwait, Bahrain, Qatar, Omar, Jordan, Iraq, and Palestine.

The company also has a free doctor Q&A platform where 12,000 doctors answer a combined 1,000 questions per day. Both of these features are offered online and through the company’s popular mobile app.

“The funding is fully dedicated to further growing the company, which has established an exceptional track record as a premier provider of trusted health and wellness information in the region, serving over 6 million people every month,” Ayman Sharaiha, cofounder and COO at Altibbi, said in a statement. “We believe there is a true opportunity to further build Altibbi’s portfolio of telehealth solutions for the benefit of companies and consumers in the region.”

Altibbi has partnered with Uber in the past, both to offer Uber users a free trial of the company’s telehealth service and to make that service available as a perk for drivers.

Output: Dubai-based health platform Altibbi has raised $6.5m in a funding round led by Middle East Venture Partners and Dash Ventures, and featuring participation from Tamm and Rimco Investments, among others. Altibbi works with employers based in the Middle East and North Africa, offering 24-hour telehealth services to employees, including a free Q&A platform boasting 12,000 doctors. The company said it serves more than six million people every month and aims to expand further.


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San Diego's hepatitis A outbreak continues to grow
 Add 20 more cases and 22 more hospitalizations to San Diego County’s ever-growing hepatitis A outbreak.

Tuesday afternoon the county Health and Human Services Agency bumped the outbreak’s confirmed cases from 461 to 481 and hospitalizations from 315 to 337. The death count associated with the outbreak, which started in November 2016, remained at 17 for a second straight week.

For the last two weeks, the health department has reported having more than 40 cases under investigation awaiting confirmation from the U.S. Centers for Disease Control and Prevention that they are of the same unique strains associated with other outbreak cases.

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No information on the number of cases under investigation was available Tuesday. All of those who have died during the outbreak have had underlying medical conditions such as liver disease. Most were also homeless and/or drug users.

Vaccination events continue throughout the city as public health officials focus on those at the highest risk of infection such as health and safety workers and those who work with homeless outreach organizations and food service workers.

Hepatitis A infection is seldom fatal unless other complications, such as liver disease or an autoimmune disorder, are already present.

The hepatitis A virus is shed in human feces and is transmitted when a person accidentally consumes a small amount of fecal matter left on food, drinks, drugs or other materials. Proper hand hygiene — washing with soap and warm water for at least 20 seconds after using the bathroom — is sufficient to kill the virus, though alcohol-based hand sanitizer may not be effective. Hepatitis A symptoms include jaundice (yellowing of the skin and the whites of the eyes), abdominal pain, fatigue, diarrhea, vomiting and nausea.

For information on where to get a hepatitis a vaccination, dial 2-1-1.

Health Playlist × On Now Video: Leaders urge public to help extinguish hepatitis outbreak On Now San Diego starts cleansing sidewalks, streets to combat hepatitis A On Now Video: Scripps to shutter its hospice service On Now Video: Scripps La Jolla hospitals nab top local spot in annual hospital rankings On Now Video: Does a parent's Alzheimer's doom their children? On Now EpiPen recall expands On Now Kids can add years to your life

paul.sisson@sduniontribune.com

(619) 293-1850

Twitter: @paulsisson

Output: Add 20 more cases and 22 more hospitalizations to San Diego County’s ever-growing Hepatitis A outbreak.  Tuesday afternoon the county Health and Human Services Agency bumped the outbreak’s confirmed cases from 461 to 481 and hospitalizations from 315 to 337. The death count associated with the outbreak, which started in November 2016, remained at 17 for a second straight week.


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High-deductible health care plans curb both cost and usage, including preventive care
 INDIANAPOLIS -- A team of researchers based at IUPUI has conducted the first systematic review of studies examining the relationship between high-deductible health care plans and the use of health care services. They found these plans reduce both the cost and the use of health care services, according to an article published in the October issue of the journal Health Affairs.

Those reductions are the result of a decrease in patient use of many types of medical services, including desirable services like preventive care or cancer screenings, said Nir Menachemi, a professor of health policy and management and chair of the Department of Health Policy and Management in the Indiana University Richard M. Fairbanks School of Public Health at IUPUI, who is one of the authors of the paper.

"For high-deductible health plans to work in the ideal, patients need to be educated on the fact that preventive care does not usually incur out-of-pocket costs in these types of plans," Menachemi said. "Traditional insurance plans shield patients from all of the financial decisions that are made. The fact that you are shielded financially from health care decisions makes you potentially more likely to over-consume services, which raises the average of care for everyone and increases premiums for everyone."

The review identified the most rigorous methodological studies previously published and ultimately summarized findings across 28 articles. The review found that high-deductible health plans were associated with a significant reduction in preventive care in seven of 12 studies and a significant reduction in office visits in six of 11 studies -- which in turn led to a reduction in both appropriate and inappropriate care.

High-deductible health plans have lower premiums but higher deductibles compared to traditional insurance plans. Many policymakers view high-deductible health plans as a way to curb health care costs by providing patients with incentives to make more cost-conscious health care decisions.

The review highlights the decline in use of preventive health care services under high-deductible plans, which another study has shown occurs when patients change their health care behavior and forgo needed care to save money.

However, few if any high-deductible health plans charge members for preventive screenings, suggesting patients didn't understand they could use these services at no cost, Menachemi said.

Given that nearly every health care reform proposal at the state and federal level involves some use of high-deductible health plans to manage costs and patients' demands for services, a synthesis of existing studies was needed to provide policymakers with the best available evidence as the U.S. moves toward a system increasingly centered on high-deductible health care plans, Menachemi said.

###

The article, titled "High-Deductible Health Plans Reduce Health Care Cost and Utilization, Including Use of Needed Preventive Services," is co-authored by Rajender Agarwal, director of the Center for Health Reform in Dallas, Texas, and a student in the Business of Medicine MBA program at IU's Kelley School of Business at IUPUI, and Olena Mazurenko, an assistant professor of health policy and management at the Fairbanks School of Public Health.

Output: A team of researchers based at IUPUI has conducted the first systematic review of studies examining the relationship between high-deductible health care plans and the use of health care services. They found these plans reduce both the cost and the use of health care services, according to an article published in the October issue of the journal Health Affairs.


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Interoperability shows progress, but it's slow progress at best
 A new Health Affairs report on the state of interoperability in healthcare reveals scant progress in spite of what the authors of the report called “substantial efforts.”

The researchers looked at 2014 and 2015 data and found that 2014 national data suggested that hospital engagement with interoperability were at low levels.

They examined the 2015 data for national trends in engagement in four areas of interoperability: finding, sending, receiving and integrating electronic patient information from outside providers. They found small gains in 2015, with 29.7 percent of hospitals engaging in all four domains compared to 24.5 percent in 2014.

[Also: NQF says interoperability goes far beyond EHR-to-EHR data exchange]

Sending information showed an increase of 8.1 percent while receiving information showed an increase of 8.4 percent.

But there were no changes in integrating systems, however. Hospitals’ use of data for patient care from outside providers was low, with only 18.7 percent of hospitals reporting they “often” used these data.

“Our results reveal that hospitals’ progress toward interoperability is slow and that progress is focused on moving information between hospitals, not on ensuring usability of information in clinical decisions.”

The researchers concluded that in 2015, fewer than 30 percent of hospitals engaged in the four primary areas of interoperability, a slight increase over 2014. Engagement in one domain, integrating outside information, was stagnant.

“This is a concern because integration is critical to data usability, and lack of integration was found to be a top barrier to the use of outside data in clinical care,” the researchers wrote.

On a high note, researchers found that each of the four domains of interoperability was positively associated with the availability and use of outside clinical information and that nearly half of hospitals were “often” or “sometimes” using this information in the delivery of patient care, there is still much room for progress, they wrote.

However, they pointed to issues with integrating information into existing EHR systems. Clinical workflows were the most commonly cited barriers for hospitals that were not routinely using external information for patient care. It further underscores the need to shift the policy focus from transmitting information to information usability

Twitter: @Bernie_HITN

Email the writer: bernie.monegain@himssmedia.com

Output: A new Health Affairs report on the state of interoperability in healthcare reveals scant progress in spite of what the authors of the report called “substantial efforts.”


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Medicare innovation can spur the next round of payment reform
 The economic imperative for better health care at a lower cost has never been more urgent. Changing the way that health care providers are paid is at the core of solving the problem. Bipartisan support has formed around the idea of flexibility and innovation in how care is delivered in conjunction with more accountability for results. But the journey toward implementing these new models of care and payment is a difficult one.

Success in these reforms means moving away from relying only or primarily on fee-for-service payments. The Centers for Medicare and Medicaid Services and, by extension, private payers rely on a highly complex system of fee-for-service prices. More than 47,000 different prices are listed for covered health care services, while many services and interventions that could lower costs and improve care — such as team-based approaches to care, telemedicine, and digital health services, personalized services based on new diagnostics and big-data capabilities, or spending time with a patient to develop a care plan that reflects their preferences — aren’t covered much or at all. Medicare prices are determined by thousands of pages of regulation and legislation.

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Since its creation in the Affordable Care Act, the Center for Medicare and Medicaid Innovation has led efforts at CMS to advance alternatives to fee-for-service. Working with CMS, and with states and employers, Medicare Advantage plans, Medicaid managed care plans, and commercial insurance plans are implementing new payment models that in many cases represent more fundamental reforms than Medicare has yet undertaken. But most payment reforms are still at relatively early stages, and private-sector innovators cannot make the shift without the government’s commitment to shift from volume- to value-based payments.

With so much at stake, the actions of the Department of Health and Human Services are closely watched. The recent revisions in a set of mandatory payment reform pilots caused some to worry about continued HHS commitment to payment reform. Recently, CMS provided more visibility into their intentions by publishing a request for information based on a set of principles and new areas of emphasis in payment reform.

The CMS information request makes two things clear. First, the current administration does intend to continue pursuing payment reform. Second, HHS leadership believes there is a way to go before we get it right.

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Both are welcome sentiments. Reform of a system that has existed for decades takes time and will require iterative improvement and learning. For example, some large consolidated hospital systems have only undertaken modest “shared savings” reforms, and continue to be paid largely on a volume basis while amassing considerable market power. Many providers have criticized extensive participation and reporting requirements that they believe divert effort from steps that could really improve outcomes that matter to patients. The CMS request signals new directions in payment reform that could address these and other challenges.

The announcement emphasizes greater patient and consumer involvement in reform efforts. Medicare Part D, in which consumers choose plans that enable them to save much more than in a traditional benefit structure, have resulted in large increases in the use of generic drugs and more price competition among similar brand-name drugs. Yet only a couple of the many provider-focused payment reform initiatives to date from Medicare’s innovation center let consumers pay significantly less by choosing providers and care models that are less expensive and meet their needs.

For competition on value to succeed, consumers will need help moving beyond the complex price system used by Medicare and private insurers. It is impossible for consumers to sort through thousands of specific prices, even if they were all publicly reported, to figure out the actual ballpark of their costs for a knee replacement procedure or cancer care. Payment reform is needed to drive transparency, consumer empowerment, and competition in all areas of health care.

Currently, shared savings in payment reforms are designed to go mainly to health care providers. What if future rounds of Medicare payment reform expanded opportunities to share savings with consumers and patients? They could use the quality and cost information that can go along with the payment reforms to choose high-quality and efficient provider groups for their overall care or for specialized care needs, say for cancer treatment, and can get savings that are not possible in Medicare today.

As with Medicare Part D, it is important to include steps like risk adjustment to encourage competition to improve care and lower cost for the sickest beneficiaries. Along with risk adjustment, Medicare support for broader reporting on a limited number of meaningful performance measures and regulatory flexibility to share savings with consumers could be powerful forces for driving change in health care.

The CMS request for information provides an opportunity to consider payment reforms that are administratively simpler. For example, performance measurement is not only essential for competition and consumer empowerment but is also a promising area in which CMS can reduce burdens on clinicians. Health care providers and patient advocates alike have criticized existing performance measures as not sufficiently meaningful or practically relevant to patient care. Private payers and employers are also interested in supporting more meaningful, comparable performance measures, such as important clinical outcomes, as well as patient-reported measures of how well they are functioning with a disease. Through public-private collaboration, CMS could lead efforts to make key, consistent measures widely available.

It is clear that we can expect emphasis on needed payment reforms in areas of specialized care that account for substantial disease burdens and costs, such as degenerative joint diseases, complex cardiovascular diseases, chronic gastrointestinal diseases, and cancer. Many specialty-care providers have limited options to participate in Medicare’s existing major payment reforms. Payment models that exist for some surgical procedures and cancer care could be expanded to more chronic disease management and additional types of specialized care.

The CMS announcement rightly emphasizes the inclusion of drugs and other innovative medical products in payment reform efforts. Current fee-for-service payments for drugs and devices are often not transparent to consumers or providers and do not align with provider efforts to shift from volume-based to value-based care. Some product manufacturers have begun implementing outcome-based payments and other value-based payment reforms with private insurers and health care organizations. HHS support for such efforts is very timely.

CMS could provide more support for state-led payment reform efforts that include public and private payers. Many states, such as Arkansas, Tennessee, and Ohio, are in the process of implementing such models. Building on some existing multi-payer reforms, CMS could take a big step toward helping these reforms succeed by providing more clarity about how Medicare can align its measures and payments with those used by a preponderance of the private- and state-based insurance plans. Such reforms could be particularly helpful in Medicaid, supporting care for complex patients and those with behavioral or social factors influencing their costs.

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Finally, CMS could accelerate progress by supporting clinicians and private payers in sharing insights about how health care providers can implement new approaches to delivering care. Public-private and multi-stakeholder collaborations can share the tools and best practices to help them succeed.

Continued momentum is important. While CMS gathers input on these potentially valuable next steps, payment reform needs to continue. The alternative to progress on payment reform is rising pressure to try to control costs through more complex and tightly regulated fee-for-service prices, which encourages providers and patients to focus on the volume of services rather than on developing innovative approaches to staying well, heading off disease complications, and incorporating new biomedical breakthroughs at a more sustainable overall cost.

CMS needs to lean forward by providing a clear and predictable path for expanding the most promising measures, including making reforms mandatory after a period of successful voluntary participation. By turning its recent request for information into clear steps for promoting competition to improve outcomes and lower costs — instead of further reliance on complex fee-for-service price regulation — CMS can use its unique influence to enable health care innovations needed to meet our nation’s health and economic challenges.

Mark McClellan, M.D., is director of the Robert J. Margolis, MD, Center for Health Policy at Duke University. He served as FDA commissioner from 2002 to 2004. Mike Leavitt is founder of Leavitt Partners. He served as the secretary of the United States Department of Health and Human Services from 2005 to 2009 and is a former three-term governor of Utah.

Output: The economic imperative for better health care at a lower cost has never been more urgent. Changing the way that health care providers are paid is at the core of solving the problem. Bipartisan support has formed around the idea of flexibility and innovation in how care is delivered in conjunction with more accountability for results.


Instruction: create a high quality summary of the given input

Input:
Tom Price may be gone, but the Trump administration's sabotage of Obamacare is moving ahead at full speed
 Former Health and Human Services Secretary Tom Price may be gone, but the scorched earth he left behind on Obamacare is still smoking.

Health and Human Services Secretary Tom Price is gone, ushered out of office last week after being caught causing $1 million in unnecessary taxpayer expense by chartering private planes and taking military aircraft around the country and the world instead of flying commercial, like normal people.

This looks like a case in which the right thing has happened for the wrong reason — or at least for an incomplete reason. The grounds for Price’s ouster should have been his atrocious management of the most important program under his jurisdiction, the Affordable Care Act. Instead of acting to make Obamacare work better for all Americans, Price took every step within his power to undermine the law in ways that will cost American families millions of dollars.

What’s worse, Price’s campaign will keep chugging along without him. Indeed, much of the damage from his tenure already has been done and can’t be reversed for this year or next.

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Minnesota’s experience with its 1332 waiver application has been ... nightmarish. — Minnesota Gov. Mark Dayton to former Health and Human Services Secretary Tom Price

Whether Price’s departure will change the administration’s approach to the Affordable Care Act isn’t clear, but the signs are not encouraging. Price’s stance dovetailed neatly with that of his boss, President Trump, whose disdain for the healthcare law and near-total lack of understanding for how it works have been clear since the presidential campaign.

Some commentators have expressed hope that Seema Verma, currently the head of the Centers for Medicare and Medicaid Services, might be the front-runner to replace Price and that she’d be less antagonistic toward the Affordable Care Act. It’s hard to know what makes them think so. Verma is a protege of Vice President Mike Pence, who hasn’t exactly been a defender of Obamacare.

As an Indiana bureaucrat when Pence was governor, Verma fashioned a program that expanded Medicaid for that state, but she has been silent on the attack on the ACA coming from within the Health and Human Services Agency. During her confirmation hearing in February, she seemed to rationalize cutting maternity care from the list of essential health benefits required of all health plans under the ACA, which suggests either that she has no idea how insurance works, no regard for the difficulties of finding maternity coverage in the pre-Obamacare era, or is willing to say just about anything to please her right-wing masters in the administration.

My colleague Noam Levey reported in May that Verma was complicit in an outrageous White House extortion attempt, when she told insurance executives that the administration would fund cost-sharing reduction payments to insurers — which Trump has been threatening to withhold — if the insurers would support repeal of the Affordable Care Act. This went over very badly with the executives, and Health and Human Services denied the story.

As head of the health agency, Price managed to tick off even Republican state administrations, which were doing their part to make the Affordable Care Act work better. Consider the experience of the bright-red state of Oklahoma. State officials worked closely with Price’s office for months to gain approval for a so-called 1332 waiver under the ACA. Their goal was to set up a reinsurance program with federal funding to help insurers manage the cost of high-risk enrollees so that premiums in the individual market could be lower.

In March, Price had sent a letter to governors specifically urging them to consider 1332 reinsurance waivers and providing a road map toward expedited federal approval. But then Price pulled the rug out. According to a blistering letter sent Friday to Price and Treasury Secretary Steve Mnuchin by Oklahoma Health and Human Services Secretary Terry Cline, the state and the feds had reached an agreement on Oklahoma’s application by Sept. 22. Formal approval, Cline was told, would be coming the following Monday.

Instead, Cline learned that day that approval “would not be provided, with no reason for the delay or a time frame for approval.” The state had no choice but to withdraw its application. “The lack of timely waiver approval,” Cline told Price and Mnuchin, “will prevent thousands of Oklahomans from realizing the benefits of significantly lower insurance premiums in 2018.”

As it happens, Price’s inaction will cost the federal government dearly. Cline indicated that 100,000 of the 130,000 Oklahomans in the individual market are insulated from higher premiums by federal subsidies, which rise as premiums rise. But 30,000 middle-class households in the state will have to pay the higher rates themselves, if they can — “in a market many … were forced to leave because premiums are unaffordable,” Cline wrote.

Price also hogtied Minnesota’s effort to create a similar reinsurance program. State officials thought they had a deal in which the federal Health and Human Services Agency would provide more than $200 million over two years to fund the program — only to learn in mid-September that in return for the appropriation, Price’s agency would cut $369 million from its funding for MinnesotaCare, a low-income health plan the state used to cover residents who made too much to qualify for Medicaid, but not enough to afford insurance on the individual market.

“In a complete turnaround and contrary to all previous direction from your agency,” Gov. Mark Dayton told Price in a Sept. 19 letter, “we have now been informed that Minnesota would lose more federal Basic Health Plan funding than we would receive in federal support for reinsurance.” He added: “Minnesota’s experience with its 1332 waiver application has been … nightmarish.”

These actions, especially the treatment of Oklahoma, have “magnified suspicions that the Department of Health and Human Services is more interested in undermining the Affordable Care Act than partnering with the states to stabilize the individual market for the nearly 20 million Americans,” former Pennsylvania and Oregon Insurance Commissioner Joel Ario observed over the weekend.

During his tenure, Price was responsible for issuing a string of dishonest and disingenuous statistics about the Affordable Care Act marketplaces and, tacitly or explicitly, endorsed the lies told about the system by Republicans such as House Speaker Paul Ryan (R-Wis.).

Price didn’t stop there in his campaign to destroy the Affordable Care Act. Under his supervision, Health and Human Services has cut the open enrollment period for plans sold through the federal exchanges, HealthCare.gov, from three months to six weeks; instead of running from Nov. 1 through the end of January for plans effective in 2018, it will run only until Dec. 15. Last-minute enrollees — who are legion — will discover too late that their deadline has passed. The only means of avoiding that is to run a vigorous marketing and outreach program — but Price cut the budget for that by 90%, claiming through department flacks that previous experience suggested that outreach had “diminishing returns,” an assertion contradicted by hard evidence. Health and Human Services also says it will shut down HealthCare.gov for 12 hours every Sunday but one during open enrollment — making it inaccessible for a good portion of the weekends when applicants would normally be signing up.

Just before leaving office, Price ordered the health agency’s 10 regional directors not to participate in state-based open enrollment events, an unprecedented withdrawal of federal support.

Administration sabotage of the individual insurance market is tied to more than half of the average 36% premium increases sought by insurers in 20 states analyzed by Charles Gaba of ACASignups.net. Gaba reckons that nine percentage points of the increase are due to actual medical inflation and 2% from the reinstatement of an Obamacare tax on insurers that had been suspended for two years. But five percentage points are accounted for by the administration’s signals that it won’t aggressively enforce the individual mandate, which requires everyone to carry health coverage; and another 17 points from uncertainty over the cost-sharing reimbursement payments.

Most of this could not have been done by Price alone, at least not without the tacit connivance of President Trump. The campaign to kill the Affordable Care Act marketplaces by neglect and interference won’t end with the end of Price’s tenure as health secretary. There would be no improvement without a firm, proactive effort by his successor, and the chances of that happening look to be nil.

Keep up to date with Michael Hiltzik. Follow @hiltzikm on Twitter, see his Facebook page, or email michael.hiltzik@latimes.com.

Return to Michael Hiltzik’s blog.

MORE FROM MICHAEL HILTZIK:

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Las Vegas: The harvest of unspeakably lax gun laws

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Output: Health and Human Services Secretary Tom Price is gone, ushered out of office last week after being caught causing $1 million in unnecessary taxpayer expense by chartering private planes and taking military aircraft around the country and the world instead of flying commercial, like normal people.


Instruction: create a high quality summary of the given input

Input:
Turmoil in Washington adds uncertainty to health insurance enrollment
 People sign up for Obamacare at AltMed Health Services in Los Angeles in 2015. This year’s signups are complicated by the uncertainty surrounding federal support for cost-sharing subsidies.

Usually, the autumn ritual of selecting the right health plan for the coming year is quite predictable. The options are there on the table, and there is usually little thought that things might change dramatically after you make a decision.

Not this year.

President Trump tweeted this summer that he might end cost-sharing subsidies to health insurance companies if Congress can’t get together on long-promised plans to repeal and replace the Affordable Care Act, or Obamacare. So open enrollment in California this season — which begins Nov. 1 and runs through Jan. 31 — comes with an unprecedented edge of unease.

Dave Jones, California’s health insurance commissioner, does not attempt to sugarcoat the effect that so much heated rhetoric has had on the task of getting insurance companies to offer affordable rates to consumers, especially in the private health insurance market now dominated by the Covered California health insurance exchange.

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“This has been the most unstable and challenged health insurance market in my tenure as a public servant,” Jones said. “The degree of uncertainty and instability that the Trump administration has injected into the market this year cannot be understated.”

That turmoil has most directly affected the 1.4 million Californians who buy exchange plans and about 1 million more estimated to purchase individual coverage plans off-exchange.

It is this group, plus 3.8 million California adults enrolled in Medi-Cal since it was expanded in 2014, whose coverage has been the subject of political debate for several years.

While attempts to repeal and replace the Affordable Care Act have failed, there are still several steps the president could take to undermine the controversial program.

Already the new administration has said it would not enforce the penalties assessed for those who don’t buy health insurance. And Trump’s decision to target out-of-pocket cost-reducing payments to insurance companies also introduced a fair bit of volatility.

There has also been talk that the federal government will not support outreach efforts to some types of potential policyholders, especially those in Latino communities. Enrollment there is often seen as critical to bringing in enough healthy people to offset the costs incurred by older and sicker Americans who are much more likely to sign up for coverage.

On Aug. 1, Peter Lee, Covered California’s director, said the average increase for exchange plan premiums in 2018 will be 12.5%. He attributed about 3% of that bump to insurance company uncertainty about whether or not the new administration will undermine existing Affordable Care Act programs.

In some cases, Lee said, policyholders will be able to limit their premium hikes to less than 4% by moving into a different plan within their home market. In Los Angeles, seven carriers are offering plans. Premium increases in the region range from 10% in Orange County to 13% in Los Angeles.

Of course, the individual healthcare market is only a small fraction — about 9% in California — of the overall health insurance pie. The largest segment, representing 45% of all Californians in 2015, according to the Kaiser Family Foundation, get their coverage from an employer. Those plans generally hold enrollment in the fall.

An additional 38% is enrolled in a government program such as Medicare and Medi-Cal.

It’s a little harder to peg just how much premiums for employer-sponsored plans will increase in 2018.

Every year the National Business Group on Health surveys large employers nationwide to get a sense of how much costs will increase in the coming year. This time around, the nonprofit announced that costs were up about 5%, a number that should roughly translate to the premium increase that employees of large companies will see in 2018, according to Brian Marcotte, the business group’s president and chief executive.

A separate survey by the Kaiser Family Foundation and the Health Research & Educational Trust found that premiums for employer plans rose 3% this year, to an average $18,764. That cost is usually divided between employers and workers.

Marcotte said employers are continuing strategies that have gradually come to the fore over the last few years to contain healthcare costs as much as possible. Most companies, he said, are building in income-based premiums for employees. Gone are the days when the premium list was the same for everyone on the payroll.

“That means if you make more, you end up paying a higher monthly premium,” Marcotte said.

And there has also been a big increase in the number of employers offering “self-directed health plans” that combine high deductibles with special health savings accounts that the employer funds to help defray costs. The average contribution, Marcotte said, is $650 per year for an individual and $1,000 per family. Average deductibles for these plans, he added, are $1,500 per individual and $3,250 per year for family coverage.

“Today we have 90% of large employers offering self-directed plans with attached health savings accounts and 40% are offering these as their only option in 2018,” Marcotte said.

Sisson writes for the San Diego Union-Tribune.

Output: Usually, the autumn ritual of selecting the right health plan for the coming year is quite predictable. The options are there on the table, and there is usually little thought that things might change dramatically after you make a decision.


Instruction: create a high quality summary of the given input

Input:
With Affordable Care Act’s Future Cloudy, Costs for Many Seem Sure to Soar
 In Florida, the average rate increase will be about 45 percent, according to state regulators. And in New York, where officials said prices would still be below where they were before the law took effect, premiums were expected to increase by an average of about 14 percent. Many states have not made insurers’ rate increases public, and experts said the rise in costs for consumers could run from 10 percent to nearly 60 percent.

There are exceptions. Minnesota, which sought a federal waiver to address the high cost of premiums, said this week that prices for plans sold on the state exchange there would remain stable or drop significantly in 2018.

Those who qualify for federal subsidies, a group that accounts for about 85 percent of the roughly 10 million people who buy insurance through the marketplaces created under the health law, will largely be shielded from the higher prices.

Regulators in Florida and New York said that residents of those states who qualified for the most generous subsidies could see lower prices next year, depending on which plan they buy. In some places, the least expensive plans could become free after customers apply their subsidies. (Deficit hawks will probably complain about the higher federal outlays for subsidies.)

People who earn too much to qualify for financial assistance will feel the brunt of any increases. Because many insurers raised prices most sharply on plans that are attractive to people who receive the most generous subsidies, those unable to get subsidies may have to shop for plans that are not affected or look beyond their state marketplaces for lower-priced options.

Output: Health insurers are aggressively increasing prices next year for individual policies sold under the federal health care law, with some raising premiums by more than 50 percent.


Instruction: create a high quality summary of the given input

Input:
Researchers develop better way to break down lignin
 TEM image of Ce-P-Pd elemental map. Credit: Igor Slowing

In every plant—from trees to crops—there exists a substance that makes up its wood or stems, fiber, and cell walls. This substance is a complex natural polymer called lignin, and it is the second largest renewable carbon source on the planet after cellulose.

This natural abundance has drawn high interest from the research community to chemically convert lignin into biofuels. And if plant life really does hold the building blocks for renewable fuels, it would seem that we are literally surrounded by potential energy sources everywhere green grows.

But untangling the complex chains of these polymers into components, which can be useful for liquid fuel and other applications ranging from pharmaceuticals to plastics, has presented an ongoing challenge to science and industry.

There are currently two common ways of processing lignin. One requires an acid plus high heat, and the other is pyrolysis, or treating with high heat in the absence of oxygen. Besides being energy-consuming processing methods, the results are less than optimal.

"You end up with individual molecules that are unstable and reactive, and they easily re-polymerize. It's kind of a horrible mess, really," explains Igor Slowing, an expert in heterogeneous catalysis at the U.S. Department of Energy's Ames Laboratory. "We need to be able to deconstruct lignin in a way that is economically feasible and into stable, readily useful components."

Slowing and other scientists at Ames Laboratory are working to reach that commercialization goal, experimenting with chemical reactions that decompose lignin models at low temperatures and pressures. There are already known ways of salvaging useful byproducts out of lignin through the addition of a stabilization process. But Slowing and his research team took both the decomposition and stabilization processes further, by combining the two into one multi-functional catalyst, using phosphate-modified ceria.

"Our process does the breaking of lignin-like material and the stabilization in a single step in very mild conditions," said Slowing. "The interesting thing is that though there are two different types of chemical processes happening in a single material, they appear to be working synergistically, and are able to do that at a lower temperature."

In another experiment, Slowing's research team was able to process a related material, phenol, into useful industrial precursors for nylon production. This work used a catalyst made of ceria and palladium doped with sodium, which increased the reactivity of the process significantly. They also eliminated the use of hydrogen, which is produced from steam-treatment of natural gas, and used an energy-conserving alcohol-based hydrogenation process instead.

Research continues. "Both of these results were very promising, and our next step is to combine the two experiments into one, and achieve lignin deconstruction using hydrogen from a renewable source," said Slowing.

More information: Nicholas C. Nelson et al, Phosphate modified ceria as a Brønsted acidic/redox multifunctional catalyst, J. Mater. Chem. A (2017). DOI: 10.1039/C6TA08703E Nicholas C. Nelson et al. Transfer hydrogenation over sodium-modified ceria: Enrichment of redox sites active for alcohol dehydrogenation, Journal of Catalysis (2017). DOI: 10.1016/j.jcat.2016.12.018 Journal information: Journal of Materials Chemistry A

Output: US Department of Energy researchers are developing a way to convert lignin, the world's second largest renewable carbon source after cellulose, into biofuels. Decomposing the complex natural polymer into stable components useful for liquid fuel, pharmaceuticals and plastics in an energy-efficient manner has long challenged scientists. But Ames Laboratory researchers have now combined the decomposition and stabilisation processes into one multi-functional catalyst, which deconstructs lignin into more readily useful components.


Instruction: create a high quality summary of the given input

Input:
Staff training intervention doesn't impact fall prevention
 (HealthDay)—An intervention targeting gaps in staff communication and coordination (complexity science-based staff training intervention [CONNECT]) does not improve the impact of an evidence-based falls quality improvement program (FALLS), according to a study published online Oct. 2 in JAMA Internal Medicine.

Cathleen S. Colón-Emeric, M.D., from Duke University Medical Center in Durham, North Carolina, and colleagues conducted a cluster-randomized trial in 24 nursing homes receiving CONNECT followed by FALLS (intervention) or FALLS alone (control). Nursing home staff completed surveys at baseline as well as three, six, and nine months; 1,545 staff members completed surveys (734 [37 percent] and 811 [44 percent] of eligible staff in intervention and control facilities, respectively). Medical records were abstracted for 1,794 residents with at least one fall in the six-month pre- and post-intervention windows.

The researchers found that after FALLS, neither the CONNECT nor the FALLS-only facilities improved the mean count of fall reduction activities (3.3 versus 3.2 of 10); there was no difference between the groups in the adjusted median recurrent fall rates (4.06 versus 4.06 falls/resident/year). Overall, staff communication measures (mean, 0.03 points on a five-point scale) and communication timeliness (mean, 0.8 points on a five-point scale) improved modestly. Wide variation was seen across facilities in intervention penetration.

"New approaches to implementing evidence-based care for complex conditions in the nursing home are urgently needed," the authors write.

Copyright © 2017 HealthDay. All rights reserved.

Output: An intervention targeting gaps in staff communication and coordination (complexity science-based staff training intervention [CONNECT]) does not improve the impact of an evidence-based falls quality improvement program (FALLS), according to a study published online Oct. 2 in JAMA Internal Medicine.


Instruction: create a high quality summary of the given input

Input:
More Than One-Third of Older Adults Use Sleep Medications
 Most older adults don’t talk to their health care provider about sleep difficulties, even though more than one-third reported using some type of medication to help them sleep at night, according to results from the National Poll on Healthy Aging.

The poll was conducted by the University of Michigan Institute for Healthcare Policy and Innovation, sponsored by AARP and Michigan Medicine. The results are based on answers from a nationally-representative sample of 1065 older adults who answered questions online.

Of the respondents, who were aged 65-80 years old, with sleep problems, 36% reported using a type of sleep medication either regularly (31%) or occasionally (23%). This included prescription sleep medications, prescription pain medications, OTC medications, and herbal/natural sleep aids. Among occasional users who had trouble sleeping at least 3 nights a week, OTC sleep aids were the most common choice. Those who regularly used sleep medications relied on prescription drugs.

Despite the associated health risk, 23% of respondents who reported sleep troubles 3 or more nights a week and use a prescription sleep aid indicated long-term use of these drugs.

Almost half (46%) of the poll’s respondents said that they had trouble falling asleep 1 or more nights per week, and 15% reported having trouble 3 or more nights per week. Twenty-three percent who had trouble sleeping said that it was due to pain, and 40% responded that their overall health was fair or poor. Other reasons reported for sleep difficulties included having to get up to the use the bathroom at night and worry or stress.

More than half of older adults (54%) believe poor sleep is a normal part of aging. Poll results indicated that many individuals don’t view sleep issues as a health problem, which is the most common reason that the respondents said they hadn’t talked to their health care providers about sleep. For pharmacists, this highlights an opportunity to ask older patients about sleep habits and counsel on appropriate sleep aids while reducing prolonged use and potential risks.

Reference

National Poll on Healthy Aging. Healthy Aging Poll website. http://www.healthyagingpoll.org/report/october-2017-trouble-sleeping-dont-assume-its-normal-part-aging Published September 2017. Accessed October 3, 2017.

Output: Most older adults don’t talk to their health care provider about sleep difficulties, even though more than one-third reported using some type of medication to help them sleep at night, according to results from the National Poll on Healthy Aging.


Instruction: create a high quality summary of the given input

Input:
Munich Re Africa and Wits are latest clients to drop KPMG
 The University of Witwatersrand (Wits) has become the latest client to drop KPMG as their auditor.

Wits said in a statement on Wednesday the university council had decided on Friday not to renew its contract with KPMG for internal auditing and financial risk management services at the end of the current financial year.

The decision was taken after meetings with new KPMG CEO Nhlamu Dlomu‚ international KPMG representatives and members of the University Council’s Audit and Council Risk committees.

"The committees acknowledged that KPMG did take some actions‚ including releasing the CEO‚ COO and a number of senior partners to mitigate the reputational damage that it suffered as a result of its relationship with Gupta associated companies and its complicity in the SARS report but felt that KPMG had not gone far enough‚" Wits said.

"Further‚ it was agreed that KPMG had not been sufficiently transparent and that it is hard to reconcile KPMG’s conclusion that no one did anything illegal‚ when senior individuals have been dismissed and the SARS report has been retracted. In these circumstances‚ the Council believes that it would have been prudent to acknowledge the ethical and legal lapses of KPMG’s senior management team."

PWC will remain the university’s external auditors.

Wits joins the parliament‚ the Parmed board‚ the African branch of the Germany's Munich Re‚ Sygnia Asset Management‚ Sasfin and Hulisani as some of the companies that have dropped KPMG South Africa as other clients re-evaluate their relationship and pressure mounts on KPMG.

Output: University of Witwatersrand (Wits) and Munich Re Africa are the latest clients to drop KPMG as their auditor due to its relationship with Gupta-associated companies along with its complicity in the SARS report. This follows South African firms Sasfin and Hulisani dropping KPMG last month, along with the South African parliament; Barclays Africa and Standard Bank are also said to be considering dropping the auditor.


Instruction: create a high quality summary of the given input

Input:
Planning for Medicare in 2018
 This year, the government will spend $609 billion to cover 58 million Medicare beneficiaries.

Those numbers lump everybody together into one monolithic group, but that’s not the case when Oct. 15 arrives. That date opens a 54-day window where each individual covered by the program gets to make changes to how they receive the Medicare benefit they paid for through regular payroll deductions during their working years.

And there are plenty of choices. In San Diego County alone, 24 different prescription drug plans are available with another 23 Medicare Advantage plans offered by third-party providers.

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Many who are already enrolled in a plan they like simply let Medicare’s open enrollment window close without taking any action. David Weil, director of San Diego’s Health Insurance Counseling & Advocacy Program, said that is a mistake. Everyone should at least take a look at the options available to them every year, he said, especially if they are taking prescription drugs.

“For most people, this is the one time during the year when they can make changes. But you don’t want to make those changes without doing your homework first,” Weil said.

There are also a few changes that are coming your way whether or not you decide to take a look around during Medicare’s open enrollment window.

Today, most Medicare beneficiaries are paying a $109 monthly Part B premium, while those who enrolled in 2017 pay $134 per month. Medicare was able to charge more to new enrollees but was unable to spread overall cost increases to the already enrolled due to “hold harmless” provisions in the federal laws that underpin the government’s largest health care benefit. However, those same laws allow a broad-based premium adjustment anytime the government grants a cost-of-living increase to Social Security benefits, and Weil said it looks like it will happen in 2018.

“It’s likely that, across the board, people who are paying $109 per month now will see an increase, and those who are paying $134 will see a little bit of a drop. We won’t know for sure until November,” Weil said.

That’s when Medicare is expected to announce basic Part B premiums for 2018.

There is also a bit of intrigue around another significant change in how everyone will use Medicare next year. In April, the U.S. Centers for Medicare & Medicaid Services will mail new Medicare cards to every one of the nearly 60 million Americans receiving benefits. These new cards will feature 11 randomly selected numbers and letters called a Medicare “Beneficiary Identifier” that will replace your existing health insurance claim number.

Why are they doing this? Well, your old number is based on your Social Security number and because it appears on all Medicare-related paperwork, it was often used to defraud seniors. The new number, because it’s randomly selected, carries no such risk of inadvertently providing your Social Security number to thieves.

However, in an ironic twist, those same thieves are using this change for one last burst of malfeasance. In San Diego and across the nation, reports are surfacing of Medicare beneficiaries receiving calls from scammers who demand their personal information and, in some cases outright payment, to get their new card.

“In some cases we have reports of people calling up and telling them they can get their number embossed on a nice metal plate if they provide information over the phone,” Weil said.

There are other variations of these scams which have callers impersonating Social Security or insurance company employees. In all cases, experts advise hanging up and not providing any information even if the caller already has certain information about you such as your date of birth or Social Security number.

Medicare does not call and request this type of identifying information from its beneficiaries. Once the new ID number is in place, beneficiaries will have a 21-month grace period during which they can use either their old number or the new one.

The one site you must know

Visit www.medicare.gov/find-a-plan to enter your information and see what’s available in your specific ZIP code. There is even a place for you to enter up to 25 different prescription drugs and have the website show you only those plans which include everything you’re taking.

If you’re not an Internet person, that’s OK too. Anyone living in San Diego County can call the Health Insurance Counseling & Advocacy Program at (858) 565-8772 for help. Imperial County residents have their own line at (760) 353-0223.

Health insurance brokers are also available to help, and because they are paid through commissions on the plans they sell, they offer assistance at no cost to you. You can find an agent at www.nahu.org.

Medicare’s makeup

Here is a refresher on Medicare’s four essential parts. It pays to remind yourself what these mean before starting your research:

Part A: Hospital insurance. Everyone gets it if they or their spouse has worked in the United States for at least a decade. There is no premium.

Hospital insurance. Everyone gets it if they or their spouse has worked in the United States for at least a decade. There is no premium. Part B: Health insurance. This covers doctor visits, medical equipment and a vast range of other outpatient services. The government charges a monthly fee, and they deduct it from your Social Security check if you receive one.

Health insurance. This covers doctor visits, medical equipment and a vast range of other outpatient services. The government charges a monthly fee, and they deduct it from your Social Security check if you receive one. Part C: This is not a separate benefit but rather a special section which allows private companies to administer a person’s Medicare benefit through Medicare Advantage plans. In San Diego County there are usually dozens of options, many offered by familiar names such as Sharp, Scripps, Kaiser and SecureHorizons.

This is not a separate benefit but rather a special section which allows private companies to administer a person’s Medicare benefit through Medicare Advantage plans. In San Diego County there are usually dozens of options, many offered by familiar names such as Sharp, Scripps, Kaiser and SecureHorizons. Part D: This part of Medicare pays for prescription drugs and has its own monthly premium on top of what you pay for Part B.

There is another key to understanding Medicare: There are two different flavors, Original and Advantage. Our “Turning 65” article describes the differences between the two.

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paul.sisson@sduniontribune.com

(619) 293-1850

Twitter: @paulsisson

Output: This year, the government will spend $609 billion to cover 58 million Medicare beneficiaries. Those numbers lump everybody together into one monolithic group, but that’s not the case when Oct. 15 arrives. That date opens a 54-day window where each individual covered by the program gets to make changes to how they receive the Medicare benefit they paid for through regular payroll deductions during their working years.


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Governments relying on consumer debt risk a financial crisis: IMF
 The International Monetary Fund has issued a warning to governments that rely on debt-fuelled consumer spending to boost economic growth, telling them they run the risk of another major financial collapse.

In a report before the IMF’s annual meeting in Washington next week, it said analysis of consumer spending and levels of household debt showed that economies benefited in the first two to three years when households raised their levels of borrowing, but then risks began to mount.

Once growth becomes dependent on household debt, it can be a matter of two to three years before a financial crash, the IMF said in its annual report on the global financial system.

The study follows a series of warnings about rising levels of household debt in the UK from financial regulators and debt charities.

In a blogpost accompanying the report, one of the authors, Nico Valckx, warned: “Debt greases the wheels of the economy. It allows individuals to make big investments today – like buying a house or going to college – by pledging some of their future earnings. That’s all fine in theory. But as the global financial crisis showed, rapid growth in household debt – especially mortgages – can be dangerous.”

He added: “Higher debt is associated with significantly higher unemployment up to four years ahead. And a one percentage point increase in debt raises the odds of a future banking crisis by about one percentage point. That’s a significant increase, when you consider that the probability of a crisis is 3.5%, even without any increase in debt.”

Earlier this year the IMF cut its forecast for the UK’s GDP growth in 2017 by 0.3 percentage points to 1.7% and it is expected to reduce its prediction further next week when its global outlook is published. The uncertainty created by the Brexit vote and negotiations to leave are likely to be blamed, along with a reliance on consumer spending, which has slowed this year.

The Bank of England, which regulates the banking sector, said last month that the UK’s banks could incur £30bn of losses on their lending on credit cards, personal loans and for car finance if interest rates and unemployment rose sharply.

The debt charity Stepchange has warned that 6.5 million people have used credit to pay for basic items such as food after a change in their circumstances. And MPs have called for an independent commission to examine the effects of rising household debt levels in the UK.

Household debt levels fell in relation to the UK’s national income (GDP) immediately following the 2008 crash from a peak of almost 170% to below 140%. But in the last two years the figure has begun to creep upwards, fuelling concerns that the UK’s GDP growth is already dependent on consumer borrowing.

Valckx said countries with high levels of debt were able to reduce the risks by introducing strict limits on levels of borrowing and tight regulations on the banking sector.

“Countries can mitigate the risks by taking measures that moderate the growth of household debt, such as raising the down payment required to purchase a house or the fraction of a household income that can be devoted to debt repayments,” he said.

Most of the risk relates to the mortgage market, which is 10 times the size of the consumer debt market in the US and the UK. In the UK, the level of mortgage debt relative to GDP has remained stable since 2008.

However, the number of borrowers has become smaller as large numbers of older homeowners pay off their mortgages and high property prices limit the number of first-time buyers entering the market.

Output: Governments relying on consumer debt to fuel economic growth run the risk of causing another financial crisis, warns the International Monetary Fund's annual report. "As the global financial crisis showed, rapid growth in household debt – especially mortgages – can be dangerous," says one of the authors Nico Valckx, adding that “higher debt is associated with significantly higher unemployment up to four years ahead. And a one percentage point increase in debt raises the odds of a future banking crisis by about one percentage point. That’s a significant increase, when you consider that the probability of a crisis is 3.5%, even without any increase in debt.”


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Email marketers now able to add Spotify playlists into campaigns
 by Jess Nelson , October 3, 2017

Would you have opened that deleted email this morning if it had contained a playlist of Tom Petty’s greatest hits?

Email marketers can now incorporate Spotify albums and playlists into their campaigns, with the recent release of Spotify Email Widget by StoryPorts.

StoryPorts is a marketing automation platform that can pull content from more than 30 online content feeds such as Facebook or Twitter to populate interactive email campaigns. The company can now pull Spotify content into HTML email templates, and the company is compatible with any ESP or automation platform including HubSpot, Pardot, and MailChimp.

StoryPorts’ Spotify widget is easy to use and developed with a drag-and-drop design. The company claims that the widget is responsive, so album artwork and play buttons display in every email client or device.

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The playlist does not yet play in the email client. Instead, listeners who click on a track are then taken to the Spotify mobile application or desktop client to listen to the song selected.

Although StoryPorts’ widget is not yet fully integrated, it’s apparent why the company’s musical clients requested such a feature. StoryPorts works with Warner Music Group, Sony Music Group, and Universal Music Group -- all labels looking to promote the music talents of their roster.

But it’s not just record labels that could benefit from adding music to their email campaigns. Music has been shown to influence shopping behaviors and pace, tempo and genre can all influence consumers’ emotions.

It’s not just brick-and-mortar stores that can influence customers to shop with music -- email marketers would be smart to do the same.

Output: Ohio-based marketing automation platform StoryPorts has added Spotify to its roster of online content feeds, enabling marketers to liven up email campaigns and attract potential customers with music. The drag-and-drop Spotify Email widget adds album artwork and play buttons to HTML email templates, while readers who click on them are directed to Spotify's mobile app or webpage. StoryPorts numbers Warner Music, Sony Music and Universal Music among its clients.


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Redrow Redrow chosen as partner on former school site in Oldham
 Redrow Homes has been picked as construction partner to redevelop the former Counthill school site in Oldham, beating three rival bidders.

Oldham Council approved Redrow Homes as its developer for the site at a cabinet meeting on 18 September.

The housebuilder beat rival bidders Barratt, Countryside Properties, and Willmott Partnership Homes to the project, according to council minutes.

Barratt had proposed to build 94 homes at the site, with 27 detached homes, 36 semi-detached homes and 31 townhouses, with prices ranging from £183,000 to £280,000; while Countryside’s bid included 56 detached and 22 semi-detached homes, priced between £184,000 and £290,000.

Willmott Parternship Homes’ proposals included 45 detached houses, 32 semi-detached houses and six mews properties, with prices ranging between £130,000 and £285,000.

Redrow’s winning bid will see the company build 50 detached and 10 semi-detached homes on the site, with 38 four-bed homes and 22 three-bed homes. Sale prices will be between £200,000 and £315,000.

The housebuilder is due to start on site early next year, with Redrow also providing highway improvements to Haven Lane and Counthill Road, alongside parking for the nearby Waterhead Academy sports hall, as part of the project.

The site was earmarked for development in 2014.

Cllr Jean Stretton, leader of Oldham Council, said: “We are committed to making the borough a place where people want to live, work and do business in so we are delighted Redrow Homes share our vision and are on board as our development partner.

“The firm is one of the biggest housebuilders in the country and over the years it has produced high quality and sustainable homes at sites across the UK.

“These principles match our hopes of creating a flagship neighbourhood in a location where people will be attracted to live.

“As part of their bid Redrow Homes committed to creating apprenticeship positions and using local suppliers and subcontractors, so as our construction partner, they will be helping the local economy grow.”

Steve Greenhalgh, managing director for Redrow Homes (Lancashire), added:

“As well as providing much needed, high quality new homes in a fantastic location, the new development will also bring significant community and economic benefits.

“These include a raft of new apprenticeships as well as work for local subcontractors and suppliers. We’re keen to begin construction early next year.”

Output: Oldham Council has chosen Redrow Homes as the developer for the former Counthill school site in the town. The company's winning bid for the project involves the construction of 50 detached and 10 semi-detached houses from early next year, which will be marketed at between £200,000 and £315,000. Redrow will also make highway improvements and add parking facilities near the site, and will also engage a number of apprentices from the area.


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Google faces trial in dispute over AdWords discount and targeting
 by Wendy Davis @wendyndavis, October 3, 2017

In a blow to Google, a federal judge has ruled that the company must face trial for allegedly overcharging a search advertiser.

U.S. District Court Judge Edward Davila ruled last week that Rick Woods, a Fayetteville, Arkansas-based attorney who used AdWords to market his legal practice, could proceed with claims that Google failed to give him a promised discount on at least three ad clicks, and that Google failed to geotarget the ads as promised.

The ruling stems from a lawsuit brought by Woods in 2011. He alleged that he used AdWords from September of 2009 through early 2011 to market his legal practice. During that time, Google allegedly reneged on a promise to give Woods a “smart pricing” discount -- which was supposed to reduce his cost-per-click when ads were served on sites within Google's publisher network.

He also said he was charged for clicks originating in Pennsylvania, Texas and Japan -- despite Google's alleged representations that the ads would be targeted to users in Arkansas.

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Google unsuccessfully argued that it was entitled to summary judgment, or a ruling in its favor before trial. The company contended in papers submitted two years ago that Woods received the smart pricing discount for all ads other than mobile ads, which were excluded from smart pricing when Woods advertised.

Woods countered that he purchased "text" ads, not mobile ads.

Davila ruled that there was a factual dispute about the meaning of "mobile ads," and whether ads purchased by Woods that were displayed on mobile web browsers were excluded from the smart pricing discount.

Given the factual dispute, Woods was entitled to take his claim to trial, Davila ruled.

Google also argued that it disclosed to advertisers that location targeting was sometimes based on people's search queries, as opposed to geolocation data.

Davila ruled that even though Google disclosed its practice on a help page, Woods was entitled to have a jury decide whether he relied on Google's statements that ads would appear in certain locations.

"A reasonable jury could conclude that Woods saw and relied on Google’s statement that ads would be targeted to users in a specific geographic area; that Google in fact charged for clicks on Woods’s ads outside of the designated geographic areas; and that Woods was charged for these clicks," Davila wrote.

Output: A US federal judge has ruled Google must face trial in a lawsuit brought by Arkansas attorney Rick Woods. District Court Judge Edward Davila said Woods, who had used Google's AdWords to promote his business between 2009 and 2011, alleged the company had not given him a discount on certain ad clicks and, despite requesting his ads only be shown in Arkansas, was charged for clicks from other locations. Google said the discounts Woods asked for did not cover mobile ads and contended that location targeting was more often based on search queries than geolocation data.


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'Ultra-precise' drone uses GPS and phone for 'anywhere' deliveries
 Drone deliveries -- the impatient consumer's Holy Grail -- have been in the pipeline for some time, and while Amazon is pioneering the cause, (although Rival 7-Eleven has completed nearly 100 aerial deliveries to date), its model is still somewhat encumbered by factors at odds with the advantages drone delivery technically offers. Recipients need to be present at an address, for example. Now, though, Cambridge Consultants -- the team that brought us intelligent bins and Renaissance doodling -- has developed a drone delivery system that'll get you your stuff anytime, anywhere, in a matter of minutes.

Let's imagine you're out having a nice walk in the middle of the countryside when you start feeling peckish. Using Cambridge Consultants' DelivAir app, you'd place an order for a snack, and the delivering drone would use GPS and your smartphone signal to navigate to your location, periodically asking for location updates during its flight, until it's within visual range. Once it arrives, you point your mobile phone flash LED to the sky, where it'll blink a coded pattern to let the drone know it's delivering to the right person. Then, while staying a safe height above the ground, the drone lowers the package into your very hands using a stabilising winch, which you then unhook. The drone then makes its merry way back to base, and you've got your snack, or whatever else it is you urgently need in the middle of countryside.

Of course, there are multiple applications for this type of service, fervent consumerism aside. It could be used to take a puncture repair kit to a stranded cyclist, or essential supplies to remote areas as part of disaster relief efforts. There's life-saving potential, too; DelivAir could swiftly get EpiPens or defibrillators to people in urgent need. "Drone delivery is fast and ideal for something that is needed immediately. In that case, a consumer wants a delivery directly to them as a person – not to a location," said Nathan Wrench, head of the industrial and energy business at Cambridge Consultants. "Our DelivAir concept has the potential to revolutionize the delivery process, by removing the address restriction that other drone technologies are limited by."

Indeed, DelivAir's ultra-precise delivery concept makes perfect sense for drone application, but as is the case with Amazon, 7-Eleven and other drone delivery champions, there are still question marks hanging over the mainstream roll out of this kind of service. Instant gratification is a shopper's dream, but a once-blue sky dominated by hundreds of buzzing delivery machines sounds decidedly dystopian. Still, unlike Amazon's plans to rain packages out of the sky, at least DelivAir's concept -- which places the package neatly in your hands -- retains some social decorum.

Output: Developers at Cambridge Consultants have created a drone delivery system that delivers to a person's physical location, rather than a traditionally assigned address. The DelivAir app uses GPS and a smartphone signal to periodically track its target, with a coded pattern from the phone's flash LED system used to verify the recipient. In addition to consumer deliveries, potential applications noted include delivering puncture kits to stranded cyclists, disaster relief, and life-saving medical deliveries.


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Redrow Community objects to 160 home development in Allerton Priory
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Developers Redrow have described community objections to a development of 160 new homes on the old Allerton Priory site as “misguided.”

A public inquiry started today into the controversial housing plan within a 33-acre field, dubbed by campaigners “possibly the most beautiful green space in Liverpool.”

It follows Liverpool council’s planning committee rejecting the proposals, sparking an appeal by Redrow , who have now asked for an independent Government-assigned planning inspector to make the final decision.

This morning, Paul Tucker QC, for Redrow, told the inquiry: “Perspective is everything.

“On the one hand the appeal site is being painted as a precious area of parkland linked to Allerton Priory whose survival is crucial to the fabric of the mosaic of open land in South Liverpool.

“Whereas, on the other hand, it is a rare opportunity to bring forward a much needed form of accommodation on one of those rare sites in the city which could be used for new family housing in order to help to diversify the city’s housing stock.

“It will be passionately submitted, no doubt, that the proposed housing is not needed and that the appeal site is a parcel of land whose loss will seriously impoverish the heritage of the city (and possibly its wildlife) and that what is proposed therefore comprises unsustainable development.

“With all due respect to those perspectives, viewed dispassionately they are misguided.

“To the contrary it is firmly submitted that the appeal proposals comprise sustainable development and that the planning balance decisively weighs in favour of the grant of permission.”

The Allerton Priory application does not form part of the council’s £205m deal with Redrow as their preferred housing partner to build 1,500 homes and bring up to 1,000 properties back into use over the next five years.

Liverpool council, with David Manley QC representing them, have made it clear the local authority does not want the blueprints to go ahead, and Mayor Joe Anderson has previously given his backing to the Save Allerton Priory campaign.

The public inquiry, sitting at Liverpool’s Cunard Building, is set to last at least three weeks, with a break in late October meaning it runs into November.

Mr Tucker, for Redrow, said: “{This} is undeveloped land adjacent to two roads within South Liverpool.

“The boundary wall and the extensive mature vegetation are highly visible features when viewed from Allerton Road or Woolton Road.

“Beyond those features, there are occasional glimpsed views of the fields beyond which comprise the appeal site.

“The fields themselves do not comprise an important part of the street scene from either the adjacent land or from the parkland which lies to the east of the appeal site.

“In landscape terms, as Mr Grimshaw {landscape expert for Redrow} demonstrates, the appeal site presently exhibits little visual influence beyond those well treed borders.

“It is, with respect, an affectation to suggest that the change within the appeal site will have a harmful effect to the amenity of public views beyond it.

“As ‘passive’ open space, therefore, the appeal site’s attributes are grossly overstated other than when viewed cartographically or from the air.

“The appeal site has in the past been used as private open space for the children of the school whose playing fields once extended across it, but there has never been any lawful unrestricted public access to the appeal site.

“Thus, any value that the site may have to those who have unlawfully accessed as “open space” should be afforded no weight...

“Rather, the appeal proposals will provide free public access to almost six hectares of open land and and offer a benefit in accordance with the open space policies of the plan.”

Adrian Thompson, representing Save Allerton Priory (SAP), told the inquiry that SAP would speak about “the harm the appeal scheme would cause to the visual amenity value of the Green Space and Green Wedge.”

The inquiry continues.

Output: A three-week public inquiry has been opened to examine objections to UK housebuilder Redrow's plans for a 160-home development on the Grade II-listed Allerton Priory site in Liverpool. The company said it was an opportunity to construct a "much-needed form of accommodation" and called protesters "misguided". The city council’s planning committee initially rejected the proposal, prompting Redrow to appeal and request a final decision from an independent, government-assigned planning inspector.