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CHRONIC Act, which expands Medicare coverage for telemedicine, passes in Senate
 Senate Bill 870, the Creating High-Quality Results and Outcomes Necessary to Improve Chronic Care Act of 2017, or CHRONIC Act for short, has passed in the Senate by a unanimous vote. Among other things, the bill, which was originally introduced in April by Senator Orrin Hatch (R - Utah), includes provisions that would expand Medicare coverage for telemedicine.

Along with expanding telemedicine coverage under Medicare Advantage Plan B in 2020 and giving Accountable Care Organizations more freedom to use telemedicine, key provisions in the CHRONIC bill extend the Centers for Medicare and Medicaid Services’ home-based primary care teams for people with multiple chronic conditions. The bill would extend this “Independence at Home” demonstration to two years and increase the maximum allowable number of Medicare beneficiaries in the program from 10,000 to 15,000.

One proposal in the bill would allow a patient’s home dialysis facilities to count as a recognized originating site for telehealth visits. Another eliminates location restrictions on telestroke consultations.

“The Finance Committee has been working hard to address and improve healthcare outcomes for Medicare beneficiaries with chronic conditions for the last two years,” Hatch said in a statement. “The CHRONIC Care Act is a culmination of a bipartisan, committee-wide effort, which included rigorous engagement and feedback from affected stakeholders. This legislation will improve disease management, lower Medicare costs and streamline care coordination services – all without adding to the deficit. Addressing these issues is critical for the increasing number of individuals who live with multiple chronic conditions and will age into the Medicare program over the next two decades. The CHRONIC Care Act is one of the few bipartisan healthcare bills to pass the Senate this Congress, and I urge my colleagues in the House to act quickly on this legislation and get it to the president’s desk to be signed into law.”

In the House, the various provisions of the bill have been presented as seperate pieces of legislation. HR 3727 is the bill that includes the telemedicine expansion under Medicare Advantage; it was approved by the House Ways and Means committee and now heads back to the floor. Similarly, HR 1148, which includes the telestroke provisions, has been approved by the House Energy & Commerce committee. Finally, the kidney dialysis provisions are contained in HR 3178, which the House passed back in July. Assuming all these measures pass, they can be unified with the Senate's CHRONIC Act in conference and head to the president's desk.

Output: Senate Bill 870, the Creating High-Quality Results and Outcomes Necessary to Improve Chronic Care Act of 2017, or CHRONIC Act for short, has passed in the Senate by a unanimous vote. Among other things, the bill, which was originally introduced in April by Senator Orrin Hatch (R - Utah), includes provisions that would expand Medicare coverage for telemedicine.


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Hospice in crisis
 It might seem odd to talk about “innovations in dying,” but in recent decades the hospice movement has become an important new pathway for the most difficult phase of life. As American health care has become ever more high-tech and expensive, the hospice model of home-based care for terminally ill patients has enabled millions of Americans to die peacefully in their own houses, without painful medical procedures—often greatly reducing stress on both the families and the health care system.

Now, however, the hospice model is coming under stress of its own. Some of that’s because the industry has changed, with a lot more for-profit hospice agencies and investor-owned chains, which are coming under scrutiny from regulators. But much of the stress comes from shifts in how we die, how we live—and with whom. These are big demographic changes that make the original conception of hospice harder to carry out as it was once intended.

With baby boomers aging and likely to live with serious illness for several years, understanding how best to take care of the aged and the dying is becoming an ever more pressing issue in America—emotionally, morally, and financially. “We need to address this very quickly,” said Joan Teno of the University of Washington, a prominent geriatrician who both practices and researches end of life care. “The tsunami of frail elderly people with complex multiple illnesses is coming.”

In theory, hospice would be an ideal system to deal with this tsunami. From the time it was developed in Britain in the 1960s and ‘70s, it represented a pushback against the over-medicalization of death, emphasizing comfort care and emotional support over disruptive medical interventions. It put great emphasis on family; hospice care is often delivered by close relatives rather than medical staffers. And it was originally designed with cancer in mind, at a time when cancer killed quickly.

Nowadays, however, dying itself has changed. Cancer isn’t the death sentence it was, and thanks to new waves of drugs that prolong life in late-stage disease, it can be hard to know when it’s time to stop treatment and emphasize pain relief. More than half of hospice patients have dementia, heart disease, and other slow-progressing disorders—and most of those have more than one such diagnosis, and a panoply of symptoms. That makes it harder to prognosticate just how much time someone may have left to live. Given that hospice care is generally available only to people likely to die within six months, prognosticating is important. Even to the practiced medical eye, it’s not always clear exactly when a patient is crossing that almost imperceptible line between “very sick” and “dying.”

Families, too, have changed since hospice took root in the U.S. health system. They tend to be smaller, and live farther apart. More women work–making it harder for them to take on traditional roles as full-time caregivers. And millions of old, frail Americans—divorced, widowed, or never married—now live alone without family nearby, or without family at all. The most isolated are sometimes called “the unbefriended.”

“We have different illnesses, and different social situations than the traditional hospice user,” said David Stevenson, an expert on aging at Vanderbilt Medical School.

What hasn’t changed is the basic payment system—a per diem system—and the basic regulatory framework. Hospice is largely covered by Medicare, which pays a flat daily rate—usually around $145 to $160, with some variation based on geography and length of stay. Hospices get paid more for limited spells of crisis care in the home setting (and “home” can include a nursing home or an assisted living facility) or when a patient does get inpatient hospice care, usually briefly, in a hospice house or hospice-designated bed or wing in a hospital.

No matter how good and caring the hospice team—nurses, aides, social workers and, as desired, chaplains—much of the work falls to the family. And even when the family is willing and well-equipped, as my own family was as we took care of my father with hospice in the final months of his life, it’s not so easy to die at home.

For those with less support—it can be monumentally difficult. But no less important.

“There are people who would literally rather die than leave home. And they are really left without a good option,” said Dr. Drew Rosielle of the University of Minnesota, who, like his fellow palliative care physicians, works hard to keep his patients safe at home as long as possible. “The patients who genuinely don’t have loved ones who can essentially move in with them—most of those people do not die at home.”

They end up getting care they don’t want, in a place they don’t want to be in—and it costs more. “The ER, a hospital bed or a nursing home. That is our long-term care system for people who don’t have a support system.” said Edo Banach, the new president and CEO of the National Hospice and Palliative Care Organization, who took the job knowing it’s time for some fresh thinking about hospice—and the rest of American health care.

Even strong advocates of hospice know that it’s time for changes to match the complex medical needs of today’s patients and the demographic realities of the country—as well as trends arising from long-term use of hospice in existing institutions like nursing homes. But in the near future, there aren’t a whole lot of fabulous solutions, at least not ones that don’t cost a lot of money.

This is where Washington might come in. But a comprehensive national long-term care program is so challenging economically and politically that hardly anyone in the capital even bothers talking about it. Medicaid offers long-term services and supports in the community or in nursing homes—but only to poor people, or people who become poor after spending all their money on care. Plus, congressional Republicans want to cut Medicaid, not grow it. The Obamacare repeal plans would take hundreds of billions from Medicaid, raising questions about how America plans to pay for its elder care as that bill rises.

By default, improvisation becomes policy. “We spend a lot of time cutting and pasting,” said Dr. Christian Sinclair, a former president of the American Academy of Hospice and Palliative Medicine, who is now practicing mostly outpatient palliative care at the University of Kansas Medical Center. And patching together care from friends, neighbors, some volunteers from church, is an increasingly inadequate response to the tidal wave of baby boomers now growing old. Can it be fixed?

IN SOME WAYS, hospice is a throwback to how we died before the surge of medical machinery and ICUs, and it can seem jarring that the movement would take root in contemporary America at all. When patients elect hospice, they must usually give up on curing or containing their disease—a difficult decision to make in a system that dangles the promise of a medical fix just within reach. In practice, people often turn to hospice for only a handful of days, at the very end, after using up a lot of expensive high-tech care that may have drawn out death more than it extended life.

Once they do elect hospice, a whole different philosophy of care begins. It’s more than easing physical pain and managing symptoms, though there’s that. It’s built around team-based care, both physical and emotional, and it’s intended to support the family as well as the patient. Surveys over the years, as well as Medicare’s new “Hospice Compare” quality project, have found high satisfaction rates with hospice care.

LEFT: Ann Mitchell, CEO of Montgomery Hospice House, sits on a bench in Rockville, Maryland. Mitchell has spent years trying to make hospice more humane. RIGHT: A memorial walkway at Montgomery Hospice House. | M. Scott Mahaskey/POLITICO

But dying people can require companionship around the clock—and the paid hospice team isn’t there 24/7, not even close. Families—or home aides when a family can afford to hire them—fill the gap. The care is complex and intensive, not in the sense of “intensive care,” but hands-on intense. “It’s a person who is dying,” said Ann Mitchell, the CEO of Montgomery Hospice outside Washington, a veteran of hospice since its early days. “That takes a lot of care and a lot of time.”

Family support is so crucial that some hospices won’t even try to arrange home care for someone on their own; the last big survey of hospices, conducted a decade ago, found that more than one in 10 hospices refused to take on a patient without a family caregiver. But most doctors and hospices work to keep that patient at home, safely. “We try to have a plan in place,” said Dr. Holly Yang, a hospice and palliative care physician at Scripps Health in San Diego, who like the other physicians interviewed for this article is engaged in both patient care and public policy.

Patients who are mostly on their own may do OK for a while, but decline is inevitable. They may not be able to prepare their meals, feed themselves, get out of bed—or manage their meds. They may experience acute pain, disorientation, shortness of breath. And when that happens, instead of calling the hospice nurse, the instinct is to call 911.

Even if the hospice patient who is rushed to the hospital ends up back home, all those transitions likely made things worse. Care gets disrupted, protocols get changed, mistakes get made—and costs rise—with each handoff. “It impacts the quality of care,” said Teno, the geriatrician, who has studied care transitions extensively and who has been a medical director in nursing homes and hospice. “It’s crying out for someone to fix it.”

If the Medicare agency and Congress aren’t diving into reinvention of hospice, doctors and policy experts have some ideas of their own—though not always with clear-cut ways to pay for them. By and large, they are still in the “floating ideas” stage, not agenda items for Congress or the Medicare agency.

Some physicians interviewed suggested tiered payments, which would replace the one size fits all daily rates. In other words, they could pay more for a patient with a particularly complex condition, or for a patient who can’t stitch together the necessary social support system. Another idea is to create more flexibility on how Medicare defines “continuous care”—a higher level of care for which the hospice gets a higher rate. Right now “continuous care” means an eight-hour block of hospice-provided care. Some doctors think paying for smaller blocks, like four hours, might be more practical.

One researcher mused about shifting the myriad quality markers that Medicare and private health plans now require so they have a sharper focus on end of life, and rewarding those that do it well. Hospitals measure and refine, for instance, how quickly they can get a heart patient in to the room for cardiac procedures; why not do the same for getting a dying patient into the most appropriate and compassionate setting?

One doctor suggested that four or five hospice patients could live together, sharing the cost of caregivers, who know to quickly summon the hospice nurse, not an ambulance, when things get tough. It wouldn’t be the same as staying “at home” for patients who really wanted to live out their days in their own homes. But it could be a home-like substitute, and there are scenarios where the arrangement could make the caregiving costs more affordable for some.

Some experts see promise in using more inpatient care, whether in a freestanding “hospice house”—a more formal and regulated setting for care—or a section of hospital or nursing home. Hospice houses are more common than they were 20 years ago, but they are still not the norm. By 2015, the proportion of deaths in America that took place under inpatient hospice care rose to 8 percent, from zero in 1999, according to research recently published in Health Affairs. With soup on the stove, cookie dough in the fridge, and places for those who do have family and friends to gather, such houses don’t feel institutional. Mostly they’re used for a brief stay to control a crisis, or for a few days of respite care for family caregivers. But some who have studied hospice extensively, like Elizabeth Bradley, a health policy expert who recently became president of Vassar College, say it’s worth thinking about how this inpatient setting can take on a bigger role, at least toward the end. “It makes a lot of sense,” she said. “It’s not home—but it’s homelike. And it’s set up to pass you through the end of life.”

It’s appealing, but comes with its own cultural and financial challenges. For one thing, it’s not how most hospices, still attuned to home-based family care, see their mission, at least not now. Nor can they afford it under the equally home-centric Medicare fee structure, unless they have a lot of philanthropic support. “We’ve hit a few cases where we didn’t feel safe with the patient home situation, where we brought them in for a respite stay and we added routine days onto that because there was no safe discharge plan,” Dr. Patrick White, chief medical officer of BJC Hospice in Missouri, said of the 16-bed hospice house it opened a few months ago. “But it’s really frustrating for us that financially the hospice takes a huge hit for that. It’s not economically viable.” To get Medicare to even think about paying more for the inpatient model, there’d probably have to be a crystal clear economic case that it would save health care dollars elsewhere, and not be one more big bill tacked on to the last year of life.

ONE INNOVATION THAT does help people stay at home independently is telemedicine or telecare—health care delivered remotely, over the internet or by phone. Medicare doesn’t pay for telemedicine in most settings. But it’s catching on under the per-day payments that hospice gets, and under other “value-based” or lump-sum payments that are emerging.

It has also caught the eye of the Department of Veterans Affairs, whose administrator, David Shulkin, has declared it a top priority to allow veterans to die in their homes if they wish. “I want to be able to assure every veteran that it’s their right to do so,” said Shulkin, who calls this policy his “moon shot.” He’s working on getting more paid caregivers into the home, and expanding home technology as part of the solution.

Though the recent growth of telemedicine has often come to mean fancy apps, sensors, and monitors, with hospice it can be less expensive, as simple as a regular check-in phone call from a nurse trained to pick up on red flags or stress—heading off that 911 call, said Dr. White of BJC. “It’s cheap and simple—and it’s proactive, especially for patients with lower health literacy who may not have caught a sign or symptom.” For patients at home alone, it’s a layer of protection.

A hospice patient visits with family in an outdoor courtyard at Montgomery Hospice House on Sept. 12. | M. Scott Mahaskey/POLITICO

Tech is also showing promise in helping create hospice-like end-of-life care in remote areas, where people may just live too far from the nearest hospice organization to tap into its care. In an isolated rural stretch of Northern California, Dr. Michael Fratkin, founder of a company called Resolution Care, is “virtually visiting” seriously ill patients at home with a phone, a laptop, and free teleconferencing software. Many of Fratkin’s patients have scant family support; in addition to physical illness, some are dealing with poverty, food insecurity, and homelessness. He makes in-person visits, too, as do nurses and community health workers. The care he provides is not hospice, but it’s similar, paid for by Medicaid managed care plans in California and a few big insurers.

Recalling one patient, a veteran with liver cancer who lived way out in the country, Fratkin said: “I walked him through the last eight or nine months of his life, on the land where he lived it.” Fratkin ’s already getting a lot of interest from other doctors and health organizations, and his approach would easily fit into hospice. The technology is accessible enough for patients. “I’m not that much of a geek,” Fratkin said.

Another development in medicine, embodying some of the philosophy and benefits of hospice, is the relatively new specialty of palliative care. This is an option for patients with advanced diseases, instead of or prior to hospice itself. But palliative care patients don’t have to give up curative care, like chemotherapy, so the transition is less of a rupture, and more of a gentle slope. Similarly, some hospices now offer “open access” or “concurrent care,” allowing the patient to start hospice but to keep getting “regular” treatment.

Medicare’s Innovation Center is running a multi-year test of that approach for four diseases, including advanced cancer. The idea is that patients who get the symptom management and emotional supports of hospice and palliative care, and who come to better understand their own illness, make different choices. “If we walk earlier with that patient, and he or she starts realizing the burdens of treatment outweigh the benefits. … It’s a more humane way of doing it, and I think it will save money,” said Ann Mitchell of Montgomery Hospice. That money could then be used to meet all sorts of needs we don’t pay for now—like more help at home.

On a broader level, the steps needed to create the next iteration of hospice may dovetail with the steps being taken to address the bloated, expensive American health care system. “The focus isn’t just on diagnosis and medical tests and drugs and durable medical equipment, but on meeting the patients’ whole needs. That’s really where it’s at,” said Joe Rotella, a long-time hospice doctor now working with the hospice and palliative medicine academy, which has put forth its own ideas for reform. “We’re just kind of waiting for the system to catch up.”

A raft of experiments are under way aimed at shifting how we finance and deliver care; some are advanced through the more esoteric provisions of Obamacare, the ones the country hasn’t spent eight years fighting about. Others are linked to a bipartisan new law that will change how Medicare pays physicians—with an emphasis on value of care, not volume of care. Many of the ideas being tested and explored entail more and better management of chronic diseases—the slow-motion killers that, eventually, bring people to hospice’s door.

If these experiments bear fruit, we could move toward a system where families can be supported, not exhausted. Where patients can get the holistic approach pioneered by hospice, without “giving up” on more aggressive treatment. Where patients who understand their choices can get off the conveyer belt of high-tech medicine, and find whatever balance of curative and palliative care is right for them. For both those who are surrounded by family, and the “unbefriended,” it could become a little less hard to die at home.

Joanne Kenen is POLITICO Pro's health care editor.

Authors:

Output: It might seem odd to talk about “innovations in dying,” but in recent decades the hospice movement has become an important new pathway for the most difficult phase of life. As American health care has become ever more high-tech and expensive, the hospice model of home-based care for terminally ill patients has enabled millions of Americans to die peacefully in their own houses, without painful medical procedures—often greatly reducing stress on both the families and the health care system.


Instruction: create a high quality summary of the given input

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Senior medicine: When ‘more’ isn’t better
 Dr. George Taler still makes house calls, driving his scuffed green Toyota sedan from one apartment to another, carrying a blue satchel with a laptop, hand sanitizer and a few medical tools. Inside each apartment, he practices medicine with old-fashioned care, spending half an hour with each patient. He takes out a stethoscope, a blood pressure cuff, a pulse oximeter. And if all goes well, when the visit ends, the patient ends up getting less—not more—medical care than if she'd shown up at a medical office.

Visit No. 4 on a recent morning was Maggie Barnes, an 82-year-old stroke patient with diabetes, high blood pressure and high cholesterol. She sat in a wheelchair and shared some easy banter with a doctor she’d been seeing for more than a decade. “I feel good!” Barnes said.

“She’s got James Brown Syndrome,” Taler said, grinning. Barnes’ main worry is the wheelchair. It was six or seven years old and getting creaky—a piece had come off—and she was worried she’d fall out in the street. As for medications, Taler noted approvingly that she was down to one pill each for her diabetes, cholesterol, stroke and blood pressure, and not in pain.

For four decades, Taler, a senior physician at the MedStar Washington Hospital Center, has been trying to practice what he calls “slow medicine.” His clients are elderly people with chronic disease, individuals who typically cost the health care system around 10 times more than the average patient. And at the center of his philosophy is the idea—radical in today’s medical environment—that less can be much more.

Taler is an adherent of the guidelines of Choosing Wisely, a 5-year-old medical initiative based on the premise that the best outcomes often result from saying “no” to tempting procedures, tests and prescriptions. “Medications can be toxic as well as therapeutic,” he says. “It’s as important to cull the list on a monthly basis as it is to try new medications.”

According to some estimates, as much as a fifth of U.S. medical care is unnecessary. This represents $250 billion annually—and perhaps more important, it means patients are undergoing hundreds of thousands of procedures and prescriptions that have no benefit, and quite possibly cause them some harm. A third of medical care goes to the elderly, though they make up just 14 percent of the population. Older people with chronic illnesses stemming from obesity and age tend to get a lot of pills and procedures that aren’t helpful. Since they are more frail, they are most likely to suffer severe harm from things like drug side effects and surgeries that go wrong.

Choosing Wisely is one of the tendrils of reform that have been creeping into the U.S. health care system over the past several years as government and private-sector leaders try to find the points where cost control and better care can actually go hand in hand. The American Board of Internal Medicine Foundation started the Choosing Wisely initiative in earnest in 2012; the board’s members, largely general practitioners, had started to worry about the expanding costs and contradictions of medicine, and thought they could reduce waste by encouraging physicians and patients to talk about what care was needed, debunking the notion that more is automatically better.

So far, 80 U.S. clinical and pharmaceutical specialty societies have joined their campaign, each creating lists of five to 10 things that their members shouldn’t do—at least without thoughtful discussion with the patient. The American Gastroenterology Society recommends against colonoscopies more often than once every 10 years; the allergy and immunology society agreed that doctors should avoid prescribing antihistamines as first-order treatment of severe allergic reactions. The American Academy of Ophthalmology recommends its members not to require preoperative tests like electrocardiograms before eye surgery unless the patient has a known heart condition. The program, which publishes resources on a website and provides patient information through Consumer Reports, amounts to a broad-based effort to figure out what patients don’t really need, and then ensure they don’t get it.

But for doctors like Taler, who try to integrate those ideas into their practice, it’s clear that much of U.S. medicine is not embracing the principles of Choosing Wisely, which is colliding with a whole host of issues in medicine, from payment systems to the scattered way many patients receive their medical care, to a prevailing culture in which both doctors and patients have trouble saying “no” to more medicine.

It’s important that this change succeed, Taler said. With health care accounting for a swelling chunk of the U.S. economy—about 18 percent at last count – something has to give. If doctors and health systems can’t better shepherd our resources, bean counters may do it for them—in a way that no one likes.

ITS PROPONENTS SEE Choosing Wisely as an attempt to bridge the divide between two driving philosophies in U.S. medicine—the idea of physician autonomy built upon an almost mystical “physician-patient dyad,” as a recent writer described it, and a century’s worth of momentum toward evidence-based improvement and standardization of medicine.

In theory, doctors’ goals and patient health should be perfectly aligned. But in practice, for a variety of reasons including patient demands, lack of clarity or scarcity of evidence, in practice, doctors often employ procedures and medications that haven’t been shown to help much—and they don’t like being told how to practice in their fields.

Earlier efforts to tamp down on excessive care ran aground on those rocks—and on the American medical system’s aversion to making decisions based on cost. Physicians and patients alike bridled at the Health Management Organizations, or HMOs, where, in the pre-Obamacare days, cost-conscious reviewers meddled intensely in medicine, deciding when insurance would pay for a drug or procedure. More recent efforts to trim spending have been merged with care improvement schemes called Accountable Care Organizations, where physicians are more in the driver’s seat, and get bonuses or penalties depending on how efficient their care is—and how well their patients do overall.

Dr. Robert Jayes, with George Washington University Medical Faculty Associates, makes a house call in September for an 84-year-old patient recovering from a fall last year in her Washington, D.C., residence. | M. Scott Mahaskey/POLITICO

The Affordable Care Act and the 2015 Medicare payment reform measure known as MACRA both push in this direction, with the government trying to encourage better medicine by increasingly paying for value—as best it can define this elusive quality—instead-of-individual services. Choosing Wisely takes a different, purely voluntary tack: A “bottom up” approach led by physician organizations rather than being foisted on doctors by the government.

“It’s a movement of clinicians taking responsibility for an issue that’s about overuse, but also better quality and safety and doing no harm,” said Daniel Wolfson, executive vice president of the American Board of Internal Medicine Foundation. “The byproduct is that it reduces cost. So we think we have solved the quality-safety-cost issue in a unique way that begins with cultural change.”

Individual hospitals have incorporated specific guidelines with success. Doctors at the Dartmouth-Hitchcock Medical Center in New Hampshire reduced unnecessary preoperative tests from 23 percent to 4 percent over a three-month period by incorporating Choosing Wisely guidelines into the electronic records their doctors use, according to a recent study. Certain behaviors targeted for cessation by the campaign—such as threading tubes through the nose and throats of patients suffering from advanced Alzheimer’s disease in order to feed them—have declined dramatically, said Joan Teno, a University of Washington physician who works with the elderly. She attributes that change largely to the Choosing Wisely campaign.

It has also attracted skeptics, including physicians who feel it’s another threat to their autonomy—this time coming from professional societies, rather than the government as practitioners of the art of medicine. Others have pointed out that some of the Choosing Wisely recommendations have been withdrawn—including an American College of Cardiology recommendation for a heart attack treatment procedure—and say it is foolhardy to issue a blanket “no” against procedures that the next wave of research may bring back into favor.

Neither the government nor insurers were able to provide data on the extent to which Choosing Wisely has cut unnecessary medicine across the country. In part, this is because it simply hasn’t penetrated the system thoroughly: A survey last year at a Massachusetts health system—presumably among the more well-versed communities in medical research found about only half of primary care physicians and a third of specialists had even heard of Choosing Wisely.

If Choosing Wisely has a cheering section, it’s the geriatricians, doctors like Taler and Teno who specialize in elderly care. Geriatrics first became a major specialty in Britain, where today its practitioners constitute the largest single group of primary care physicians. In the United States, the specialty is far smaller and has more of a consulting role. In many instances, the geriatrician acts as a firefighter called in when an elderly patient’s medical care has spun out of control.

Geriatricians like Taler come in, talk to the patient, examine their pills and make recommendations that ideally are aimed at the whole patient, not just his or her heart or lungs or pancreas. With a frail elderly patient who may not have many years to live, some of the established drugs and procedures don’t make sense anymore.

Are a diabetic patient’s other doctors pushing too hard to lower his blood sugar, raising the risk of a faint, which could result in a broken hip? Is an orthopedist recommending arthroscopic surgery—a procedure, research shows, that doesn’t cure arthritis? All those expensive Mohs procedures to remove precancerous growths—given how slow-growing they are, is it always worth the time, expense and strain on the patient to remove them so carefully?

“A lot of what we do is try to prevent harm by other providers,” said Sei Lee, associate medical director at the University of California Center for Geriatric Care in San Francisco. “The cultural norm in geriatrics is that we are trying to do more with less. We try to protect our patients from some of the iatrogenic harms. We were the choir when Choosing Wisely came out.”

“Often I’m arguing with a cardiologist who says, ‘This person’s blood pressure target is X, we should get him there.’ And my argument is, ‘He’s already on three medicines and we’ve gotten him from terrible to almost there. What’s the marginal benefit of adding a fourth medicine to get him to an optimal reading?’”

For doctors like Taler and Lee, a program aimed at voluntary moderation is a godsend: It bolsters their belief that it’s a good idea to keep patients out of the hospital and off multiple pills, and offers guidelines to other specialists that can prevent conflicts. It still isn’t easy, though: Patients and physicians often resist the recommendations for entirely practical reasons. Tranquilizers may lead to brain fog and falls, but “anyone who has taken a benzodiazepine and slept better at night and not fallen or had a car accident will say ‘I didn’t see the harm,’” says Paul Mulhausen, an Iowa geriatrician. Anti-psychotic drugs have often been abused to exert control over elderly dementia patients, but they sure come in handy when an older spouse is trying to care for an angry Alzheimer’s patient at home rather than commit him to an institution.

Some elderly patients don’t understand why they’re being told they no longer need mammographies or colonoscopies—or they do understand, and don’t like the implications. The regular procedures, like their frequent visits to the doctor, offer the psychological sense of normalcy and imply a kind of optimism that there’s life in them yet. “My 95-year-old mother is always saying, ‘When you get old they just throw you away,’” says geriatrician Joanne Lynn. “They just throw you away.’”

AND THEN THERE'S the entirely predictable obstacle to Choosing Wisely that arises in the medical specialties themselves. “The answer is money,” says Taler. “What was the question?”

Certain medical groups have been hesitant to declare as “wasteful” procedures that can be quite profitable. For example, the Choosing Wisely list for orthopedic surgeons includes somewhat ancillary issues: “Don’t use glucosamine and chondroitin to treat patients with symptomatic osteoarthritis of the knee” is one item; “Don’t use post-operative splinting of the wrist after carpal tunnel release for long-term relief” is another.

Left off the list is arthroscopic knee surgery, the most commonly performed orthopedic procedure in the United States, yet one that helps only a slim percentage of patients—and is of almost no value to the frail elderly patients who suffer most from arthritis.

In recent years, physicians have had another reason not to follow Choosing Wisely recommendations—they come into conflict with other “quality improvement” measures sponsored by the government or private insurers. Some doctors shun wise choices because making them risks penalization by Medicare.

An example is pushing for low blood sugar levels in diabetic patients. The Centers for Medicare & Medicaid Services’ new payment schema punishes physicians treating patients under Medicare if they fail to achieve a 9 percent HbA1c level, a measure of blood sugar. Other programs push for 7.5 percent. This goal, enshrined in quality improvement programs run by Medicare and many insurers, is based on a landmark 1993 study showing that the lower thresholds protected patients with juvenile diabetes from suffering kidney, eye or nerve damage, said Victor Montori, an endocrinologist at the Mayo Clinic. Subsequent research on adult-onset diabetes patients without symptoms did not duplicate that result, however—and yet the standard remains for all diabetes patients. Doctors who ignore it risk payment cuts or poor “star ratings” in published reports.

Aggressive blood sugar control is especially questionable in frail older patients whose diabetes is not going to be the thing that kills them. If blood sugar gets too low, it can lead to fainting, dizziness and falls that cause broken arms or hips. And when multiple drugs are needed to reach the low threshold, as is often the case, the regimens can become cumbersome and the likelihood of bad side effects rises.

When the American Geriatric Society tried to include easing of blood sugar control in its Choosing Wisely campaign, however, some endocrinologists became concerned and managed to water down the recommendations after a lengthy email back-and-forth, according to a geriatrician who was involved in making the list. The final list includes only a soft recommendation against the use of multiple anti-diabetes drugs.

“Quality and performance measures often lead to overtreatment,” said Kenneth Covinsky, Lee’s colleague in the UC-San Francisco geriatrics program. “They say, ‘We’re going to penalize you if your blood sugar levels are too high.’ Well, they are actually not too high. The guidelines were developed for people in their 50s and they are influenced by the drug companies.”

“If the patient’s going to be angry, insurance is going to pay and the doctor doesn’t want to get dinged, it’s a perfect storm to make sure you get extra mammograms, cancer screenings and aggressive control of asymptomatic conditions like hypertension and diabetes,” said Lynn.

THE CHOOSING WISELY campaign has its contradictions and challenges, but it seems to be helping to move physicians in the direction that American medicine overall is taking, if haltingly and uncertainly under the Trump administration, which has hinted that it wants to slow the reform experiments incorporated into the ACA.

As long as the government has purchased health care from physicians—and today the government is by far the largest payer—it has paid them by the specific services they render, evidenced in the thousands of so-called CPT codes that doctors use in billing. Increasingly, though, medicine has moved toward “value-based care,” in which payments are based not on the quantity of diagnoses, prescriptions and procedures, but rather on quality, based in part by measuring patient outcomes. A percentage of the federal payments to the new accountable care organizations is based on outcomes and evidence of good medical stewardship—including wise medical choices. Although Choosing Wisely per se is not enshrined in the payment schemes, they do depend more on holistic, “full-patient” views of medical care, which includes saying “no” to tempting but wasteful tests and procedures.

Dr. George Taler arrives at the home of Maggie Barnes in Washington, D.C., on Sept. 20. Barnes has diabetes, high blood pressure and high cholesterol, but had recently simplified her medications and was upbeat. “I feel good,” she said. | M. Scott Mahaskey/POLITICO

Though slowly, health care is moving in the direction of using less to do more. “I can’t think of a health care system that’s not interested in reducing utilization,” says Scott Halpern, a professor of epidemiology, bioethics and health policy at the University of Pennsylvania.

Taler, who started making house calls on his own initiative in the 1970s after seeing it done in England during a medical school fellowship there, has had a number of benefactors over the decades. For the last five years his practice, MedStar Total Elder Care, has been partially funded through a congressionally mandated demonstration project that also includes 13 other medical centers around the country. Funding runs out next month but Taler expects a new bill to extend the program for another two years.

“If Congress doesn’t want to support the triple aim [of better patient experience, population health and lower costs], I’ll go to an office and make money instead,” Taler said (he wasn't speaking literally).

The federal Medicare and Medicaid offices has reported that the 14 pilot sites, which see about 10,000 patients total, saved the health care system $32 million in two years. That number is open to some debate, he admits, because the analysis is based on a counterfactual—the quantity of trouble and medical expense his patients would have suffered without someone looking after them the way he does. And there are ambiguities involved.

He ordered the new wheelchair for Maggie Barnes because the old one was damaged enough to cause her to worry that she might fall out of it. Taler was not sure she needed a new wheelchair; the old one still rolled. By some calculus, his decision might be seen as a bit extravagant. As her doctor, though, Taler saw that Barnes’ wheels were vital to her, and her peace of mind an important part of her care.

WHILE SOME DOCTORS are slow to pick up the Choosing Wisely recommendations, there’s also a vanguard of health care organizations already moving on to more radical measures. An example is run by Farzad Mostashari, a former Health and Human Services official who heads Aledade, a company that sets up and oversees accountable care groups in 17 states. Its physicians get bonuses for good outcomes, rather than numerous procedures, and Aledade uses a special technique to screen out doctors who game the system by doing unnecessary procedures.

“We’ll ask a gastroenterologist, ‘If you were an unscrupulous gastoenterologist, what would you be doing?’” Mostashari said. The company uses that knowledge to look through a doctor’s billing claims. When it finds specialists who do things motivated by padding their billable procedures rather than best medicine, they are excluded from Aledade’s networks, he said.

Although his company is attempting even more aggressive waste-cutting, Mostashari said he appreciates Choosing Wisely. “It provides consensus support for the fundamental understanding that more is not better,” he said. “That sounds trivial, but it’s a hard concept.”

In the meantime, Taler waits for American medicine to catch up with him.

“What we’re doing is a bleeding edge operation,” he said as he drove from Barnes’ apartment to the next patient. “We’re losing money, but it’s where health care is going. And when the payment system changes, it will be coin of the realm.”

Arthur Allen is the eHealth editor for POLITICO Pro. Joanne Kenen contributed to this report.

This article was written with the support of a journalism fellowship from New America Media, the Gerontological Society of America and the Commonwealth Fund.

Authors:

Output: Dr. George Taler still makes house calls, driving his scuffed green Toyota sedan from one apartment to another, carrying a blue satchel with a laptop, hand sanitizer and a few medical tools. Inside each apartment, he practices medicine with old-fashioned care, spending half an hour with each patient. He takes out a stethoscope, a blood pressure cuff, a pulse oximeter.


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1 in 3 Seniors Take Sleep Aids, Despite Dangers
 During normal sleep, you cycle through REM and four stages of non-REM (NREM) sleep numerous times a night. Stage 1 of NREM sleep is the lightest, while stage 4 is the deepest. When you're repeatedly interrupted and can't cycle normally through these types and stages of sleep, you may feel tired, fatigued, and have trouble concentrating and paying attention while you're awake. Sleepiness puts you at greater risk for car wrecks and other accidents.

What Are Sleep Disorders? Circadian Rhythm Disorders Typically, people sleep at night -- thanks not only to the conventions of the 9-to-5 workday, but also to the close interaction between our natural sleep and alertness rhythms, which are driven by an internal "clock." This clock is a small part of the brain called the suprachiasmatic nucleus of the hypothalamus. It sits just above the nerves leaving the back of our eyes. Light and exercise "reset" the clock and can move it forward or backward. Abnormalities related to this clock are called circadian rhythm disorders ("circa" means "about," and "dies" means "day").

Output: One-third of older Americans take something to help them sleep, but most don't discuss their sleep problems with a doctor, a new survey finds.


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Housing charity warns against Corbyn-backed total rent controls
 Eye-catching retail offers on housing have become a party conference tradition, as much part of the furniture as the stuffy airless room or terrible phone signal.

Today Jeremy Corbyn stepped up to the plate with his.

A centrepiece of this was some intriguing language around rent control. He said:

“And we will control rents…Rent controls exist in many cities across the world and I want our cities to have those powers too and tenants to have those protections.”

This is clearly a play for the hard-pressed private renters that, as we’ve argued before, were so crucial in the Conservatives losing their majority.

The exact detail is unclear, but the language suggested it could go further than what was in the 2017 manifesto.

So is this the right or wrong move?

To make sense of it, it’s worth knowing that there’s two basic ways you can ‘control’ private rents.

The first is essentially capping increases. The landlord is free to set the initial rent but the increases are restricted. This could be done, as we’ve campaigned for, through changing the law to make the standard tenancy a five-year contract where the landlord sets the initial rent but increases are linked to inflation.

It’s this that was in the 2017 manifesto, and indeed the 2015 manifesto (where it unhelpfully gained the moniker of ‘Venezuelan rent controls’, making it sound slightly more dramatic than it really was).

It could make a real difference.

The second approach is indeed more dramatic. It involves completely dictating the entire rent. A local authority, for instance, would tell landlords they can’t charge more than £10 per square metre, or no more than £500 a month for a one bed, and so on. In reality it would force rents down, not limit their increase.

Corbyn has expressed support for this approach before, so it may be where he wants to take things. Or it could be somewhere in the middle.

So what’s Shelter’s view?

Essentially, controlling increases is fine. There’s a variety of ways you can do this, of which the best is probably Labour’s current policy.

But setting the entire rent can cause big problems. And those problems come with big risks that could hurt the people Labour say they care about – those on low incomes.

We’ve looked at this in some detail over the years. There is no crystal clear picture. But the evidence, summarised in the table below, suggests that old fashioned controls – setting the rent, not just controlling the increase – would force a significant number of landlords to sell their home, as they could make more money that way.

Now, that might be good for middle earners – a glut of homes suddenly for sale might become available.

But this is where the risk comes in for low earners. They can’t afford to buy and increasingly rely on the private rented sector. As landlords sell up, they would be left with fewer places to live.

In the absence of a much larger supply of council and social housing, that risks pushing people into homelessness.

This is probably not a gamble worth taking.

A more flexible, local approach might mitigate some of the risks. But we’d strongly suggest that this idea of controlling rents, as it develops, restricts itself to regulating increases.

All that said, it’s no wonder old fashioned rent controls are very popular. People are desperate for big solutions after years of fiddling around the edges by governments of all stripes. One of my main take aways from conference was the disparity of the discussion between the traditional fringe scene and the Momentum-run The World Transformed outside. At the former, well-meaning people talked about big problems but too often pushed incremental tinkering. At the latter, people talked in radical language with bold solutions.

That doesn’t make all those solutions good ideas. But it does lay down a challenge to come up with alternatives on the same scale. This includes the government – if nothing else Corbyn’s speech today has firmly put the ball back in the government’s court.

So in that spirit, here are three alternatives:

Firstly, end the freeze on housing benefit and re-link it back to rents. This would make an instant difference to those on lower incomes, stemming the tide of families being made homeless after falling on hard times only to find they don’t get enough financial support to keep a roof over their head. The NAO recently pointed this out. But bafflingly it’s a call Labour have still refused to back, including in Corbyn’s speech today, despite spending pledges in other areas. Secondly, build a new generation of good quality homes at low rents – both for those at the sharpest end and workers on low wages. This could be council housing or others models, such as living rent. Done well, this would provide a better alternative to the private rented sector for families on all kinds of incomes, rather than tinkering with trying to force for-profit landlords to change their behaviour. Thirdly, reform the housebuilding system so it builds more homes people want. This would involve radical reform of the land market. For more see our New Civic Housebuilding work.

All of these are big solutions that would make a difference and send a signal to voters. All of them will help those on low incomes as well as middle incomes. And all of them are a safer bet than old fashioned rent control.

Output: Total control of rents, backed in the past by Labour leader Jeremy Corbyn, would increase the risk of homelessness, UK housing charity Shelter has warned. It supports the Opposition party's current policy of restricting private rent rises by linking them to inflation but warns that seeking to dictate the entire rent would hurt those on low incomes. Such controls would prompt many landlords to sell, reducing the supply of affordable homes for low earners and raising the likelihood of homelessness.


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Wandercraft close to unveiling walking-aid exoskeleton
 There's a reason you've never seen fully autonomous exoskeletons that help the disabled walk without crutches: Building one is crazy hard. But the founders of a Paris-based startup called Wandercraft are uniquely qualified to do it. They're roboticists who happen to have loved ones in wheelchairs, giving them both the expertise and motivation to develop an exoskeleton that helps users walk again. After years of development, they're nearly ready to show it to the public, following a round of promising patient trials.

Wandercraft ran successful preliminary trials with a handful of clients using "Atalante," its latest prototype. "There was such a strong emotional response from our test subjects," said Managing Director Matthieu Masselin. "For a lot of them, it was the first time they had been able to walk since their accidents."

A lot of companies have tried to develop exoskeletons for paraplegics, but models from Ekso Bionics, ReWalk and others require crutches, which heavily stress patients' shoulder muscles. That limits training and rehab sessions, as patients often need days to recover from muscle fatigue.

Gallery: Wandercraft exoskeleton for paraplegics | 10 Photos

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Paraplegics want a device that lets them be vertical and walk a bit, preferably as often as possible. That would help them deal with a host of medical problems that able-bodied folks don't experience, like cardiovascular issues, pressure sores, incontinence, loss of muscle tone and depression, to name a few.

Being able to stand and walk without the discomfort of crutches would not only provide a huge psychological boost but also help reduce or eliminate many of those symptoms. "Our friends in wheelchairs told us, 'OK, if there was a device that would enable us to be able to walk again, there is no price that I wouldn't pay,'" said Masselin.

Without crutches, assistive exoskeletons (or "exos," as the team prefers to call them) are orders of magnitude more complex. Wandercraft's latest device, the fourth-generation model, weighs nearly 130 pounds (60kg) and must have perfect, humanlike balance so it won't fall over and injure the patient. "We discovered that stability and the human gait are some of the hardest problems we've ever encountered in robotics," Masselin said.

Unlike most current exos, which are more like motorized braces, the Wandercraft is a rigid, robotic structure. It has multiple powerful, compact electric motors at the hips, knees and ankle joints. A large battery is fitted at the back, along with an Intel Core i7-equipped microcomputer that does the complex math needed to ensure the machine can balance and walk.

Building a robot is hard enough, but attaching a human to it multiplies the degree of difficulty. "If the exo bends the knee, it has to stop before the knee of the person breaks, obviously," Masselin noted.

To make such a complex device work, the company recruits top roboticists, mechanical engineers and coders -- all fields in high demand. It must also enlist folks from biomedical, medical, biomechanical and other diverse areas and train them to work with the development team. To top it off, the exoskeleton and the code have to conform to medical protocols, and Wandercraft must run an elaborate regulatory gauntlet before patients can ever use it.

After five years of dealing with those nearly overwhelming challenges, the company finally tested its Atalante exo with patients. They're not ready to show video to the public yet -- for reasons I'll explain shortly -- but I was able to see it in action during a private showing.

Patients are first attached to the device by straps that are specially designed to distribute pressure evenly, at the waist, hips, knees and ankles. Those can fully support users' weight while their feet are placed on metal walking pads with rubber grips.

You start by sitting in the device and then make a gesture to stand up by bending at the waist. That activates motors that automatically drive the exoskeleton to a standing position. Walking can then be cued either by patient gestures or automatic programs started by the therapist.

The gait movement is obviously slow, but patients can take multiple steps without any crutches or external assistance. They assume a slightly bent posture, but it looks far more comfortable than the demonstration I saw of Ekso Bionics' system back in 2013. I'd describe the motion as controlled lurching, but keep in mind that such tech has never been tried and many of the test subjects hadn't risen from their wheelchairs in years. With time, patients would develop more skill, and the exoskeleton is bound to get smoother.

Gallery: Wandercraft patient photos | 19 Photos

/19 Gallery: Wandercraft patient photos | 19 Photos

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Despite the limitations, Wandercraft, and particularly the patients, saw the trials as a success. "It was huge for the team, because we'd been working so hard on this device for many years," Masselin said. "But for those people, real users, it was even stronger, emotionally speaking, because they could really see the potential of the device. And a lot of them told us they were sad to have to stop the test."

Despite their obvious enthusiasm, Wandercraft is quick to tamp down expectations. "Showing people too early what you're doing and giving them grand visions that you are not going to be able to deliver after that, we think is very, very negative," said Masselin. "We don't want to stress people by giving them false hope." For those reasons, it plans to show doctors and physical therapists video of the device in action before the public sees it.

The company just received a much-needed €15 million ($17.6 million) funding boost and has a careful plan to deliver its exoskeleton to market. The design and development is now finished, so Wandercraft is entering the specification phase to define exactly how patients and medical personnel can use it. By the end of the year, Wandercraft will unveil its exoskeleton via a demonstration video to the public.

The next step after that is the so-called CE Marking, or European equivalent of FDA certification. It hopes to receive that sometime in 2018. Afterwards, it can sell the suit in Europe for use in medical facilities under the strict supervision of trained specialists. The company expects to put its first exeoskeletons in medical facilities by the end of 2018. It will eventually chase FDA approval so it can market the device in the US.

Wandercraft Managing Director Matthieu Masselin with "Atalante"

Wandercraft has bigger dreams though. Next, it wants to build a lighter, fully autonomous version of its suit for personal use by paraplegics. Once users strapped it on, they could go out of their homes and walk in a park or other uncrowded location. That requires even more advanced tech, as the suit would need to be able to handle obstacles like stairs. As it stands right now, even a pebble can throw off such devices.

The company has taken on a risky and possibly not financially rewarding type of product. And yet it has recruited some insanely talented young people, including Physics Olympiad-caliber employees. So why would these folks do it, when there are more potentially lucrative opportunities in AI, self-driving and other areas?

The answer might lie on the company's LinkedIn page, of all places. When you see the callow money-centric culture of some major companies, Wandercraft's recruiting call is life-affirming. "You will have stunning colleagues, chosen because they are selfless team players and not lone geniuses," it reads. "We make advanced technology exo[skeletons]s that help mobility impaired persons and impact their health and happiness -- not pizza delivery apps."

Output: A recent €15m ($17.56m) funding boost has brought Paris-based mobility-tech start-up Wandercraft closer to unveiling a robotic exoskeleton that can help paraplegics move about in an upright position. The semi-autonomous Atalante prototype moves in response to gestures or muscular stimuli from its wearer. This follows a round of "promising patient trials" of the device and the release of images of it in action.


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Insurers can use social media to investigate fraudulent claims
 This photo caused an insurance company to revoke a U.S. woman’s insurance policy. (The Doctors CBS)

Horror stories of people losing their jobs from poorly thought out social media posts aren’t uncommon. If you’re not careful, what you post on Facebook, Twitter or Instagram could also cost you your insurance coverage, too.

According to US Insurance Agents, insurers are now checking social media for relationship statuses, information on pets and to determine if you’re a smoker.

Selfies showing risky behaviour, including photos that appear to be taken while driving, could also come against you.

Even photos of your property that have been geotagged with its location could be used to argue negligence on your part.

Insurance company Nationwide cancelled Melina Efthimiadis’ application for a personal umbrella liability insurance plan when they believed she had an ineligible dog breed that she failed to disclose.

Nationwide used a photo found on her Facebook page to argue that she has a potentially dangerous Rottweiler mix breed, but her dog, Zeus, was actually a lab/hound mix.

Nationwide went back on their cancellation once finding out Zeus was eligible, but by then it was too late and Efthimiadis went with another company.

She said the experience has caused her to rethink what she post on social media.

“It’s sad that you can’t post pictures of your beloved pet on your own Facebook page and have it public,” she told ABC 11. “Unfortunately, I had to go and change some of my pictures just to feel more comfortable about it.”

While the Insurance Bureau of Canada, which deals with home, auto and business insurance companies, told Yahoo Canada Finance that they weren’t aware of any of their member companies collecting information on clients from social media posts, the Canadian Life and Health Insurance Association said publicly available social media posts are a tool, alongside others like physical surveillance, data mining and predictive analysis, that could be used in fraud investigations.

“It’s not that there’s going to be action based on someone’s social media,” Karen Voin, vice president of group benefits and anti-fraud at CLHIA, said. “It’s going to be part of an overall investigation.”

Similarly, The Workplace Safety and Insurance Board says social media activity maybe looked at as “a tool to corroborate evidence of wrongdoing,” but last year that only occurred in a handful of claims.

Output: Social media is a tool that insurers can use to investigate claims when there's a suspicion of fraud, according to the Canadian Life and Health Insurance Association. Public social media posts can be used in tandem with other data sources, like physical surveillance, to assess the validity of a claim, the association added. Insurers are also reportedly checking clients' pets, relationship statuses and health habits via social media platforms.


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Millennials prefer humans to robo-advisers: LendEDU
 Dive Brief:

As tech savvy as millennials are, they still want to talk finances with a real human being over a robo-adviser, says LendEDU. An online marketplace for student loan refinancing, LendEDU polled 502 millennials, age 18 to 34. All respondents said they were saving for retirement, and robo-advisers' popularity has grown substantially.

But when asked who would manage their money best and who would make mistakes in doing so, LendEDU says 51.6% of millennials said a robo-adviser is more likely to make errors versus 48.4% who thought a human adviser would be more likely to make mistakes.

The LendEDU survey also found that most millennials (62.4%) think robo-advisers are more likely to lose their money. Only 37.7% of respondents thought a traditional adviser would do so.

Dive Insight:

Robo-advisers have garnered substantial attention as of late for their affordability and accessibility. But as in many cases of automation, it's hard to completely replicate the human touch.

Millennials are proving to be as savvy about saving for retirement as they are about technology. The largest generation in the workplace is reportedly the biggest savers when it comes to retirement. The 2016 Willis Towers Watson's Global Benefits Attitudes Survey found that millennials are willing to pay more for secure retirement benefits.

Although a 2016 Financial Finesse study said women millennials were 28% behind their male counterparts in saving for retirement, the generation as a whole is surpassing boomers' savings levels. Employee Benefits Adviser reported in late 2016 that millennials are out-saving boomers, who got caught in the transition employers have made from defined benefits plans to defined contribution plans, such as 401ks.

Millennials have expressed the desire to learn more from their employers about investing for retirement. And because 35% of millennials are willing to turn down a job offer because of inadequate benefits, according to an Anthem survey, employers who accommodate them might have an edge in recruiting and retaining these young workers.

Output: Many young investors prefer human advisers to robo-advice platforms, US-based online marketplace for loan refinancing LendEDU has noted. More millennials believe robo-advisers are more likely to make a mistake than their human counterparts, with 52% saying they thought humans were less fallible. A majority of millennials surveyed by LendEDU also said robo-advisers were more likely to lose their money than human advisers.


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Early results promising for Alexa orders: Domino's
 Domino’s is letting people order pizza through voice-controlled devices, and the early results are promising.

One in five customers who can order a pizza with one click through the pizza chain’s Easy Orders option has asked Amazon Alexa instead, two months after making the feature available there, said Nick Dutch, head of digital for Domino’s UK.

Domino’s introduced Easy Orders in 2013 and debuted the feature on Alexa at the end of July. To use it, customers must create a Easy Order account, which lets them save their favorite order and submit it through platforms including Domino’s website and app, Facebook Messenger and Google Home. The pizza chain sees Easy Orders as a way to apply Amazon’s one-click shopping model to pizza ordering and aggressively promoted its Alexa skill in the summer to get people to buy and track their orders this way.

Domino’s doesn’t break out voice or Easy Order sales as a percentage of its online earnings, but Dutch said the initial orders on Alexa proved it “backed the right horse.”

Voice could be key to Domino’s growing the Amazon-style model, given it is looking for the next big sales channel after desktop and mobile. The pizza maker has opted to sell direct to customers rather than through online delivery companies like UberEats and Deliveroo, which could leave it exposed should its online sales dwindle and those companies continue to grow.

Domino’s same-store sales in the 26 weeks ended June 25 declined 13 percent from the previous year. While voice, and more broadly, Easy Orders aren’t a quick fix to the decline, they simplify the ordering process, making it easier to get people to buy. It worked so well for Amazon that it patented its 1-Click process in 1999 and fought hard to prevent others from copying the process until the patent expired earlier this month.

“The reality is right now there aren’t millions of people who are doing that [making voice orders],” said Dutch, speaking on Sept. 27 at a We Are Social event. “We’re building for the future, and we need to leverage this [early growth] … in the hope that over time, more people use the technology.”

Domino’s immediate focus is on growing direct sales from voice-controlled devices with options such as letting customers pick different toppings and locating their nearest store. At some point, however, the company will need to consider search ads, particularly if comScore’s prediction that 50 percent of all searches will be done by voice by 2020 comes true.

Elsewhere, Diageo and Unilever have recently revealed their own plans for voice searches. Unilever’s Cleanipedia Amazon Echo skill, which answers questions about home cleaning with a direct link to e-commerce, now has 15,000 users in the U.K., where it debuted. The consumer goods company plans an 11 percent increase in investment in voice.

Output: Pizza chain Domino's has said that early results from its voice-activated delivery ordering system are encouraging. Domino's began offering the service through Amazon's Alexa device in July, and now reports that one in five customers using the chain's one-click service did so through the system. The service is the latest milestone in the company's move towards an "Easy Order" service, modelled after Amazon's one-click functionality. Other companies including Unilever and Diageo are developing voice searches for their products.


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Google's sister company expands drone research
 The Google sister company behind the self-driving car is teaming up with the ACT's Rural Fire Service for its latest research project.

In recent months the company - called "X" - has been trialling an automated drone delivery system at Fernleigh Park in Googong.

Project Wing co-leader James Ryan Burgess with the delivery drone. Credit: Sitthixay Ditthavong

Now the initiative, called Project Wing, is moving to Royalla to ramp-up its testing in collaboration with the ACT Rural Fire Service.

Project co-leader James Ryan Burgess, from San Francisco, said hundreds of homes in the Royalla region could soon benefit from the automated drone technology.

Output: The Google sister company known as X has partnered with the Australian Capital Territory's Rural Fire Service to expand its research into drone delivery tech. Founded in 2010, X has been responsible for a number of notable achievements, including driverless cars and Google Glass. “Project Wing” will involve testing routine drone deliveries in the locality of Royalla, and gathering feedback from the local community on their attitudes to the new technology. The project also aims to explore how drones might be able to assist fire fighters in difficult-to-reach places.


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Texas state workers left without doctors after insurance switch
 Source: Blue Cross Blue Shield of Texas

Source: Blue Cross Blue Shield of Texas

AMARILLO, TX (KFDA) - Thousands of state employees in the panhandle are having to search for new doctors following a change in their health insurance plan offered by the state.

People in our area who now have Blue Cross Blue Shield HealthSelect insurance have been calling their doctors only to learn they will not accept this new plan.

All state employees were switched to this plan on September 1st.

The decision was made by the Employees Retirement System of Texas (ERS), which is aware that thousands of people in the panhandle are struggling to use this program and are working to solve it.

Some panhandle residents are now having to travel to to see specialists no longer available in Amarillo under their new insurance, which is not easy for most people.

"We have to rely on going to Lubbock, which is a two hour trip, maybe an hour and a half if I drive fast," said one concerned HealthSelect carrier. "My husband, he doesn't get around too well, so I have to take off a day when we go to Lubbock."

Some local doctors have already changed their plans to include HealthSelect coverage, like all Texas Tech doctors, Family Care Clinic of Pampa, and Amarillo Stat Care.

"I probably had about 10 calls before, starting in July that they needed me to switch to continue to see me," said Kayla Mabery, FNP-C and Owner of Amarillo Stat Care. "I found out we were not in network, and actually switched my plans with Blue Cross Blue Shield to include HealthSelect."

One health insurance creditor said he thinks more doctors aren't signing up to cover HealthSelect because they think it's a low-reimbursement plan.

"I think a lot of providers get confused when they hear Blue Cross Blue Shield HMO they think of another HMO product that Blue Cross has called Blue Advantage HMO and that's the product for Obamacare plans," said Bryan Williams, President of Moxie Healthcare Solutions. "So I think when doctors hear Blue Cross HMO they automatically assume it's the Obamacare network and they don't want to take that one because the reimbursement is so poor on that plan."

Some doctors in Amarillo will not be working to adjust their plans.

Amarillo Medical Specialists sent a letter to their patients (pictured below) stating they would not be taking HealthSelect insurance because of the low reimbursement.

State Senator Kel Seliger said he's gotten lots of calls to his office about the plan and is working with ERS and Blue Cross Blue Shield to fix this problem.

"If people can't use their insurance, it's the same as having no insurance," said Seliger. "Everyone's been responsive so far. We have an ongoing dialogue with the Employees Retirement System and with Blue Cross and we're expecting some time next week to start getting an explanation."

Blue Cross Blue Shield has declined to comment on the matter.

Mabery reminds patients that it's up to them to check with their doctors any time there's a change in insurance to make sure they're still covered.

Copyright 2017 KFDA. All rights reserved.

Output: State employees in the Texas panhandle are scrambling to find a doctor, with some forced to travel for hours to see a specialist, after the Employees Retirement System of Texas switched their insurance plan on 1 September. Thousands of people, now under the Blue Cross Blue Shield HealthSelect plan, are learning some doctors won't accept it. "I think when doctors hear Blue Cross HMO they automatically assume it's the Obamacare network and they don't want to take that one because the reimbursement is so poor," said Bryan Williams, president of Moxie Healthcare Solutions. ERS is said to be working to find a solution.


Instruction: create a high quality summary of the given input

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China, Serbia to boost IT ties on Information Silk Road
 BELGRADE - China-Serbia cooperation on the development of Information Silk Road is due to start with exchanges in fields of electronic trade, logistics and market information, smart cities and online tourism, representatives of the two countries agreed on Wednesday in Belgrade.

At the opening of the conference "Information Silk Road for Informational Interconnection," Wu Hao, deputy general manager of the department for High-Tech industry at the National Development and Reform Commission of China and Tatjana Matic, state secretary at the ministry of trade, tourism and telecommunications of Serbia, signed a plan of activities on the implementation of the Memorandum of Understanding (MoU) on Information Silk Road in front representatives of IT companies of both countries.

The aim, according to Wu, is to motivate deeper and wider cooperation in the field of information technology between governments, institutions and companies of the two countries within the Information Silk Road, a platform aimed to break down barriers in communication and facilitate flow of information between Asian and European nations.

Wu said that the agreement with the Serbian ministry will help "achieve results for the 21st century" with the participation of companies from the two countries.

Matic said that the MoU with China represents an opportunity to advance cooperation in trade, tourism and telecommunications, as well as other fields such as health services and economy.

"We have decided to create pilot zone for economic cooperation within the Information Silk Road, where each side will give its suggestions and propose cities which will become part of this zone. We will also create a database of all joint projects that we are going to realize. One of the key points is also to establish an international industrial alliance within the Information Silk Road at the Institute for the Information Silk Road in China in order to promote companies within the sector of the digital economy," she explained.

Matic predicted that the implementation of the MoU will create a stable digital foundation for the greater inclusion of Serbia in the Belt and Road Initiative and highlighted smart cities, telemedicine, broadband networks, satellite services and new industries as some of the areas of cooperation.

"We believe that the implementation of this agreement will give a key contribution to the cooperation between Serbia and China in the area of information and communication technologies, and that this will motivate more companies to become actively involved into the establishment of the Information Silk Road," Matic concluded.

Output: Trade representatives from China and Serbia have met in Belgrade to discuss boosting ties in e-commerce, logistics and market information, smart cities technology and online tourism. They agreed to begin talks as part of the so-called Information Silk Road project - a platform aimed at pulling down communication and information barriers between European and Asian countries.


Instruction: create a high quality summary of the given input

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tZero launches ICO joint venture with RenGen and Argon
 tZERO, the fintech arm of online retail giant Overstock.com focused on blockchain technology, has embarked on a joint venture with RenGen and Argon Group to transform the Initial Coin Offering (ICO) market.

The companies have teamed up to launch an Alternative Trading System (ATS) for the trading of security tokens issued in ICOs in compliance with SEC and FINRA regulations (Joint Venture).

Blockchain-based digital tokens is a rapidly emerging asset class, witnessing tremendous growth. This is evidenced by the fact that these tokens have raised over $2 billion so far this year alone and cryptocurrencies overall (including digital tokens) have a current market cap of $137 billion.

However, global regulatory authorities including the U.S. Securities and Exchange Commission (SEC), the Canadian Securities Administrators (CSA), and the Monetary Authority of Singapore(MAS), among others, have recently issued guidance on how ICO tokens may be subject to securities laws. The SEC has made clear that any digital token with an income stream is a security, and furthermore that security tokens may only be traded on an ATS or a National Securities Exchange.

The joint venture aims to redefine the way the ICO market looks at security tokens and enhance liquidity to accelerate development.

“tZERO has been at the forefront of the blockchain revolution for years, working closely with regulators since 2015 – launching the world’s first SEC compliant ATS for blockchain assets, the first private blockchain bond offering, and the first ever public issuance of a blockchain security,” said Patrick M. Byrne, CEO of Overstock. “Now, by combining our expertise with Argon's advisory services and RenGen's electronic trading, deep liquidity and market making capabilities, we are in a position to launch the only U.S. SEC compliant token trading venue.”

According to the official release, the joint venture will be built in an exclusive collaboration that draws on the distinct strengths of each company, combining tZERO’s blockchain-based trading platform with RenGen’s ability to provide liquidity, market making and algorithm technology, and the Argon Group’s premier ICO advisory experience and security token clients. It will also take advantage of SaftLaunch for AML and KYC capabilities.

“This Joint Venture allows us to continue achieving our goal of leveraging our existing U.S. equity market infrastructure and smart order routing technologies within the blockchain space,” said Joe Cammarata, President of tZERO.

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Output: Fintech tZero, together with RenGen and Argon Group, is seeking to launch an alternative trading system allowing security tokens issued in an initial coin offering to be traded in compliance with regulations laid out by the US Securities and Exchange Commission and the Financial Industry Regulatory Authority. The system will make use of tZero's blockchain trading technology with RenGen serving to provide liquidity for the platform. It will also make use of Argon's ICO advisory experience. ICOs have raised more than $2bn this year and cryptocurrencies have a market cap of $137bn.


Instruction: create a high quality summary of the given input

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Pinterest shares 'visual search' tool with US retailer Target
 "One is growing the user base .... and the second, of course, is creating an advertising product that really works — to bring in new customers, that's very measurable, that lets people see emerging consumer trends and merchandise against them."

"Really, the company's focused on two things," CEO Ben Silbermann told CNBC's Julia Boorstin in an interview that aired on " Closing Bell. "

Social media upstart Snap may have braved the public market, but as of Tuesday, Pinterest doesn't have an IPO announcement in the works, the CEO said.

Pinterest, which makes money through advertising, announced that Target's app will use Pinterest's "visual search" tool. In essence, it would let users who are out and about take a picture of any product and receive a list of similar items at Target.

Silbermann declined to share Pinterest's revenue figures (which would be revealed during a public offering). But he said the Target partnership is an example of the kind of deal that supports Pinterest's massive valuation — pegged at $12.3 billion by CB Insights.

"Target was one of the earliest advertisers on the platform," Silbermann said. "It means they've seen really good results."

Pinterest's concept — which allows users to collect and categorize images, the way one might use a corkboard — is often adopted by users planning big events like a wedding or a remodel. But Silbermann said Pinterest's technology learns users' tastes, and generates suggestions to keep users hooked.

Earlier this month, Pinterest said it had 200 million monthly users.

Silbermann also said Pinterest's "safe" and "positive" environment — which tends more toward culture, recipes and fashion and away from politics and "memes" — has been an attraction for advertisers "over the last couple of years."

"It's been one of the reasons why we've been able to make a lot of progress with our advertisers," Silbermann said.

Output: Customers of US retailer Target will be able to use Pinterest's "visual search" function to take a picture of a product when they are out and about and then receive details of similar merchandise stocked by Target, in a deal announced by Pinterest. The deal came as Pinterest's CEO, Ben Silbermann, said the company is focusing on developing "an advertising product that really works", citing the platform's "safe" and "positive" ethos as a strength for attracting brands. The company reported 200 million monthly users and has been valued at around $12bn by analysts, but has no immediate plans to go public.


Instruction: create a high quality summary of the given input

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Revenues from video are a mirage for most publishers
 Publishers are pivoting to video, hoping it’ll pay off in ad dollars. But despite the big view numbers they’re generating, the revenue is often a mirage.

The majority of those views take place off those publishers’ own platforms and occur on platforms that have tons more scale (Facebook, Instagram and YouTube) and have optimized themselves around video. That could be because, like BuzzFeed or NowThis, they deliberately built their business on social distribution.

The chart below illustrates the gap. For these publishers that have made a big push into video lately, most of their views take place off their own site.

“It’s a terrible trap,” said Andy Feinberg, CEO of Brightcove, which powers video players on publishers’ sites. “[Publishers] have to be on these platforms to retain their audiences and make sure their brand is being presented to a broad audience, and their competitors are there. But the ability to monetize on these platforms is not the same as their ability to monetize on their owned-and-operated platforms. Their CPMs are low; their revenue streams are suffering.”

Second, the big view numbers publishers are getting off their own sites are somewhat deceptive because for various reasons, not all those videos can be monetized. Facebook is testing mid-roll ads in publishers’ videos, but video has to run at least 90 seconds to be eligible for the test — and viewers have to make it to the break. That doesn’t help publishers that specialize in short videos, which often is true of news clips. The mid-roll test is still just a test, and publishers who are participating in it have said they’re only making a little money on it at this point.

Then, there are self-imposed limits. Case in point is Bleacher Report. It can sell ads against all the videos it runs on its own site. But most of its views take place on Instagram, Facebook and YouTube, and while marketers pay to sponsor those videos, Bleacher Report is careful to limit the sponsorships it runs on video-heavy Instagram to about one out of four videos, so it doesn’t turn off viewers with a constant stream of “brought to you by” messages. Publishers participating in Facebook’s mid-roll test took a similar position since mid-roll was new.

“On social, if every video has a ‘brought to you,’ it might diminish the [user experience],” said Keith Hernandez, Bleacher Report’s svp of strategy. “And you’re not the only publisher that’s in someone’s feed.”

When publishers do monetize their distributed video, it’s not as lucrative for several reasons. There are measurement gaps by companies that track social video, which limits publishers’ ability to sell their video audience to advertisers. There’s an issue of whether the video ad gets counted as being seen, which is dubious given how fast people scroll through their news feeds. Then, publishers have to take into account the share of revenue that the host platform keeps (45 percent in the case of Facebook’s mid-roll ads, the same as YouTube’s split).

Bleacher Report said the CPM on its social video is roughly half what it gets on its own site. For USA Today, the ad rate on social video is one-third to one-half what it gets on its own site. One video exec at another premium publishing company said that while video on the publisher’s own site can command a $70 CPM, on Facebook and YouTube, the effective ad rate drops to around $20.

The conundrum publishers face is that they have to go where the audiences are, even though the monetization lags. The Washington Post makes money on 80 percent of its video on Facebook and all its YouTube video, but because of the platforms’ tracking limitations and their revenue share, “the monetization still has a lot of room to grow,” said Micah Gelman, director of editorial video at the Post.

Years ago, Feinberg said, publishers were happy to take YouTube’s money to run their video on the platform. This helped train audiences to watch video on YouTube and the like, instead of publishers’ own sites. The technology costs of serving video on your own site are decreasing, but it’s expensive to make high-quality video, and monetization still lags on social video. Progressive publishers are starting to think of social as a discovery vehicle, a place to put their less timely, less premium video, while keeping their more valuable video for their own sites.

Other publishers like the Post cope by not expecting distributed video to drive their business. Bleacher Report values engagement it gets on videos over mere views because it can use engagement as a selling point to advertisers.

“The inclination is that every video view needs to be monetized and also that video view is the North Star metric for success,” Hernandez said. “I say, quality of user experience is key. You want an active, not passive, viewer that’s so excited about what you’re doing that they want to share it.”

Output: Publishers seeking to boost revenues from video are being caught in a "terrible trap", as large viewing figures are not translating into big revenues, according to industry insiders. Issues such as an inability to effectively monetise videos on third-party sites, viewability problems and the percentage of revenue snapped up by hosting platforms have combined to put a dent into publishers' CPMs and revenues. Publishers are much better able to monetise video on their own platforms, but, unfortunately for most of them, the vast majority of views take place on third-party sites such as Facebook, where their revenues are much less.


Instruction: create a high quality summary of the given input

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Trivago buys AI personalisation firm tripl to boost slowing sales
 In 2022, over 90% of all digital display ad dollars will transact programmatically.

Thanks to a growth in connected TV (CTV), 2022 marks the first year that video will surpass nonvideo formats in programmatic ad spending.

Do you work in the Advertising, Media, and Marketing industry? Get business insights on the latest tech innovations, market trends, and your competitors with data-driven research.

2021 was a big year for digital advertising. Year-over-year (YoY) growth in digital ad spending far exceeded expectations, due in part to prosperity in programmatic display.

Programmatic display advertising is booming, with marketers increasing their spend despite lingering uncertainty as third-party identifiers are slowly phased out. Programmatic will continue gaining ground in years to come, as advertisers, ad tech platforms, and publishers collectively work toward a new normal.

What is programmatic digital display advertising?

Programmatic digital display advertising includes digital display ads transacted or fulfilled via automation, including everything from publisher-erected APIs to more standardized real-time bidding technology. It includes native ads and ads on social networks like Facebook and Twitter.

Programmatic digital display ad spending in 2022

Programmatic also owes its 2021 growth spurt to the burgeoning connected TV advertising market, which, in addition to bringing more video inventory to the web, has been increasing its use of automation since 2017.

Although growth in programmatic digital display ad spending will slow in 2022, advertisers will spend a healthy $123.22 billion. As a testament to its flexible nature and continued growth in connected TV (CTV), programmatic display will maintain a growth rate just over 2 percentage points higher than that of the total digital ad market through 2023.

In 2022, over 90% of all digital display ad dollars will transact programmatically. Within mobile display ad spending, programmatic crossed the 90% threshold in 2019, thanks largely to social media’s influence. Since then, the share of CTV digital display ad spending shifting into programmatic channels has increased dramatically as advertisers continue to shed the burden of insertion orders in favor of automated purchasing avenues.

Programmatic display advertising with video

2022 marks the first year that video will surpass non-video formats in programmatic ad spending. CTV is the primary driver behind that shift. Without CTV, video would account for just 39.7% of programmatic digital display ad spending. Programmatic CTV will sustain its double-digit ad spending growth next year as well.

Most programmatic video ad spending goes to mobile—65.2% in 2022. Ad spending against non-video formats on mobile will still account for more than half of mobile programmatic display ad spending through 2023. However, given recent growth of social video advertising and increasing interest in TikTok among advertisers, it’s likely that video will continue to gain share of mobile programmatic display.

Programmatic advertising forecast

Retail media networks are set to become the third big wave of digital advertising. In programmatic, this means more ad supply that is close to the point of purchase with the added benefit of consumer data.

Dozens of retail media networks have launched over the past few years, with virtually every leading digital marketplace, mass merchandiser, national grocery chain, category-specific retailer, and delivery provider getting into the game.

Output: German online travel comparison site Trivago has acquired Hamburg-based tripl, which has developed an artificial intelligence-driven algorithm that offers customers personalised travel recommendations based on their social media data. The move is in response to the slowly declining share of the online hotel booking market in Europe and Asia, now at 70%, as people increasingly book directly with hotels. The tripl purchase followed a hike in ad spend across Germany and France. However, the company's "tube takeover" campaign on the London Underground has backfired somewhat. Commuters have said being constantly confronted by an advertisement featuring the same person made them feel as if someone was "stalking" them.


Instruction: create a high quality summary of the given input

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Sprint trials signal-boosting drone tech
 Sprint is taking cell service airborne by mounting lightweight cellular radios to drones.

The wireless carrier said this week that it has successfully adapted its Magic Box signal boosting technology to fit on a drone and provide temporary cell coverage over as many as 10 square miles. The company tested the setup, which uses a lighter version of the mini cell tower and a drone from CyPhy Works, last week in Texas, 30 miles outside of Dallas.

Sprint launched the Magic Box earlier this year. The box, which is the size of a shoe box, normally sits in your house to improve indoor 4G LTE service using Sprint's 2.5GHz spectrum. Unlike other signal boosters, Magic Box doesn't require a broadband connection. Instead, it uses a dedicated cellular channel to the nearest Sprint cell tower.

Now Sprint has adapted the technology to use it on a drone and temporarily increase network capacity during special events, like a concert or a sports contest, or to restore cell phone service following a disaster like a hurricane, said Günther Ottendorfer, COO of technology at Sprint. Wireless carriers often use cell towers on wheels and other temporary equipment to boost capacity at special events or to provide additional network coverage when permanent infrastructure has been damaged.

Ottendorfer said a drone equipped with a cellular signal booster is just another tool the carrier can use to improve and restore service. The advantages include faster deployment and a wider area of coverage, because the drone can be deployed up to 400 feet in the sky.

He added that more needs to be done to make the Magic Box equipment lighter, but he expects Sprint to be using the technology in its network next year.

"It's an exciting proof of concept," he said.

Wireless carriers have already begun using drones in the wake of big disasters. Following Hurricane Harvey, which devastated areas around Houston and the Gulf coasts of Texas and Louisiana, all four major US wireless carriers flew drones in flooded areas to assess damage to towers and other infrastructure. Sprint is one of the first carriers to adapt a cellular radio to use a drone to provide cellular coverage. AT&T last year announced plans to connect drones to its 4G LTE network. The carrier tested its so-called Flying COW in February, transmitting and receiving high speed data from a drone.

First published Sept. 27 at 3:35 p.m. PT.

Update Sept. 28 at 4:26 p.m.: Adds information about AT&T's connected drone program.

Output: Kansas-based wireless carrier Sprint is working on a drone which allows temporary mobile phone coverage for up to 10 square miles. The drone would carry a downsized version of the company's Magic Box, a device for boosting mobile signal in homes, allowing it to act as an improvised cell tower. More work needs to be done to make the Magic Box lighter, but the device could be used in disaster scenarios or to temporarily increase network capacity during large sporting or entertainment events, said Sprint's COO Günther Ottendorfer.


Instruction: create a high quality summary of the given input

Input:
Zuckerberg responds to Trump's accusation of Facebook bias
 United States president Donald Trump has declared that Facebook was always against him and tossed it into the same bucket as The New York Times, which he regards as fake news, and The Washington Post, which he says is biased against him because it's owned by Amazon's Jeff Bezos.

Facebook was always anti-Trump.The Networks were always anti-Trump hence,Fake News, @nytimes(apologized) & @WaPo were anti-Trump. Collusion? — Donald J. Trump (@realDonaldTrump) September 27, 2017

As is Trump's habit, his allegation of collusion was offered without a shred of evidence. Perhaps that is why Facebook founder Mark Zuckerberg's response comes off as a little terse.

“I want to respond to President Trump's tweet this morning claiming Facebook has always been against him,” he opens, going on to opine that “Trump says Facebook is against him. Liberals say we helped Trump. Both sides are upset about ideas and content they don't like.”

Zuckerberg adds that the mere presence of Facebook meant that “ Every [election] topic was discussed, not just what the media covered.” He also laid on his usual “we host so many conversations about everything and that's awesome because it builds communities” line.

But he also felt the need to defend Facebook.

In one such passage he notes that “Campaigns spent hundreds of millions advertising online to get their messages out even further. That's 1000x more than any problematic ads we've found.”

The other says “after the election, I made a comment that I thought the idea misinformation on Facebook changed the outcome of the election was a crazy idea. Calling that crazy was dismissive and I regret it.”

Zuck goes on to say: “This is too important an issue to be dismissive. But the data we have has always shown that our broader impact - from giving people a voice to enabling candidates to communicate directly to helping millions of people vote - played a far bigger role in this election.”

Comment

Zuckerberg appears to be arguing that fake news and deliberately divisive ads did impact the 2016 US elections, but less so than the dialog on Facebook. But he ignores the fact that dialog on Facebook is not always the civil exchange of ideas he promotes. There's also no comment on the fact that Facebook was late to implement effective filters for hate speech or fake news, but did take the time to screen pictures of womens' breasts as they are deemed too offensive for members to view. ®

Output: Facebook CEO Mark Zuckerberg has hit back at a tweet from US President Donald Trump, in which he accused the social media site of being biased against him. In a post on his own Facebook page, Zuckerberg wrote: "Trump says Facebook is against him. Liberals say we helped Trump. Both sides are upset about ideas and content they don't like". He went on to say the platform saw discussions about a range of topics related to the election, far beyond what was reported in the media.