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“The body knows how to heal. It just needs the proper conditions.” ~Peter Levine After ten major reconstructive hip surgeries and almost six cumulative years in a full body cast, I emerged from childhood into my teenage years. My start in life was quite different from those around me. My body would never be like everyone else’s, and I was living in the aftermath of trauma. I not only had a slew of trauma symptoms but was also deeply wrestling with my identity and had massive amounts of shame, depression, and social anxiety. As you can imagine, I had a hard time fitting in and connecting with others. Feeling comfortable in my own skin was something I never knew. The discomfort I felt was unbearable, and I knew the only way to feel better in life was to try to figure out how to heal and get to the other side. I held on strongly to the belief that healing was possible, so naturally I started with talk therapy. Therapy is great, don’t get me wrong, but it wasn’t providing the relief I was searching for. I quickly realized that talking about my experiences helped to broaden and balance my perspective on things, but it wasn’t changing how I felt in my day-to-day life. So I went on a journey exploring and studying many forms of healing. I delved into energy healing, breathwork, art therapy, tantra, and Yamuna body rolling and finally found somatic experiencing. With much trial and error, I found my way. Some things worked and others didn’t. I learned that there isn’t a ‘one size fits all’ when it comes to healing. Anxiety and PTSD symptoms are never fun, and they show up in very specific and different ways for each person. I’ve learned that anxiety is energy that is deeply held in the body, and the way most people try and manage it is to brace their body to try and stop it from happening. This pushes it deeper into the body. It’s important to slowly allow this energy to move. To do so, we need to soften the body and open the energy channels. I have found these three somatic tools to be quite effective. Maybe they will be for you as well. Before starting each exercise, I highly recommend you ask yourself, “On a scale of one to ten, how anxious am I?” Give yourself a number, and then at the end of the exercise see if the number has decreased. 1. Slowly articulating the joint Starting with one foot, slowly move your foot in a circle ten times in one direction. Really focus your mind on the feeling of the ankle joint moving. Then switch directions. Do this for the other foot and ankle. If you are lying down on your back, you can do this again for the knee as you hold your thigh, slowly moving your lower leg in a circle ten times before switching directions. Then repeat on the other leg. If you are standing, you can place your hands on your knees and together slowly move your knees in circles. Again, remember to give your mind the job of focusing on the knee joints and feeling them move. This helps give the mind something to do while the body can move the energy that has been trapped inside of it. If standing, you will do this again, making hip circles ten times in both directions. After this, pause and notice how the lower body feels in comparison to the upper body. It’s crazy the difference you will feel. Next, you will do this with your wrists, making circles with your hands. You can do this one at a time or both hands—whatever you prefer. Then your elbows. And then your shoulders, continuing to do ten circles in one direction and then ten in the other. Lastly, you will do head circles in both directions. 2. Deep breathing with a voo exhale A voo exhale? What is that? That is exactly what I would be asking. Deep breathing is sometimes helpful, and sometimes it isn’t. But if you try making a voo sound for the entirety of the exhale, it can smooth the chest and abdomen, where most of the anxiety is felt. So, for this exercise, you will place one hand over your heart and one hand over your belly and take a deep breath. On the exhale you will make a voo sound, all the way to the end of the exhale, similar to saying om in a yoga class. As you do this, think about making the voo sound from your abdomen, not from your throat. This is an indigenous practice that actually has scientific effects in calming the vagus nerve and the sympathetic nervous system. It moves people into their parasympathetic nervous system, which is the rest and digest part of your nervous system. Making different sounds has different effects on the nervous system, and for anxiety and PTSD, the voo sound is the most effective. Go ahead and try this for five cycles and see how this is for you. It can be really calming. 3. Visual resourcing Resourcing is anything that is calming, supportive, or comforting for a person, and it can be done through many avenues. This includes things like talking to a caring, supportive friend, taking a hot bath, or using a weighted blanket. Visual resourcing is focusing on something visually pleasant. For some people this can be a sparkly or shiny object, and for others it can be watching the leaves gently blow in the breeze. Note that for some people, if they look off in the distance, it has an even greater calming effect, and that others might prefer looking at objects that are closer to them. Go ahead and look around you and find the most pleasant and pleasing thing to look at. Then hold  your gaze here and notice the effects this has for you. This somatic

THCB Gang Dec 19, 2024 Joining Matthew Holt on #THCBGang on Thursday December 19 at 1pm PST 4pm EST are three leaders in the patient movement Hugo Campos (@HugoCampos); Gilles Frydman (@GillesFrydman); and ePatient Dave deBronkart (@DavedeBronkart). They will be bring us up to speed on the very latest in patients using AI. You can see the video below live (and later archived) & if you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels. 2024-12-19 19:17:05

“After a while, every couple will get bored. That’s why trying new things together is key.” ~Unknown When life gets busy with work, kids, and the steady hum of daily responsibilities, it’s easy for relationships to fall into a familiar rhythm. Routines are comforting, but they can also lead to a kind of autopilot in love—a state where everything feels predictable and, eventually, a bit uninspired. My partner and I have a strong bond, but we’d both noticed that something felt… different. It wasn’t bad, but we missed that spark of excitement that had defined our early days together. So we decided to shake things up with some new, shared experiences. We didn’t make grand plans or book an extravagant vacation. Instead, we chose to weave newness into our relationship in small ways. We started trying little things that felt unfamiliar, even a bit challenging, to see if we could rekindle the thrill of discovery we’d had in the beginning. And what I discovered was that novelty—no matter how small—has a way of bringing you closer, helping you see each other in a new light and reminding you of why you fell in love in the first place. Here’s what I learned as we explored together and how these simple shifts helped us reconnect. 1. Reigniting Passion Through Novelty One of the first things we did was something simple but unexpectedly refreshing: We talked about what made us attracted to each other. I don’t mean the usual compliments but a real conversation about the things we loved, admired, and found endearing about one another. It felt strange at first—like a conversation we might have had in the early days of dating rather than years into marriage. But as we each shared what made us feel drawn to one another, it brought a sense of excitement back into our connection. Hearing my partner describe the little quirks and qualities they loved about me was like seeing myself through fresh eyes. It reminded me that attraction isn’t just about the initial spark but about the ways we keep noticing each other. Psychologists say that novelty can trigger the release of dopamine, the same brain chemical that floods our brains during those early, intense stages of love. For me, this little exercise felt like a reminder of why we fell for each other in the first place. Since that conversation, we’ve made it a habit to try new things together—whether it’s a different recipe, a walk in a new part of town, or even a conversation about something we’ve never discussed before. These little moments of novelty keep things exciting, reminding me that sometimes, all it takes is a fresh perspective to bring back the thrill. 2. Seeing Each Other in a New Light One evening, we decided to make a simple dessert together, but we turned it into something a bit more intentional. We dimmed the lights, put on some music, and treated the experience like a date night. At first, it seemed like an ordinary thing to do, but the way we slowed down, paid attention, and enjoyed the process made it feel special. Without our usual distractions, I found myself noticing things about my partner I hadn’t appreciated in a while—their laugh, their patience, the way they enjoyed small details. It’s funny how easily routine can make us forget the qualities that first made us fall in love. That evening, I felt like I was seeing my partner with fresh eyes. It reminded me that relationships are not only about supporting each other through life’s responsibilities but about genuinely enjoying each other’s company. After that night, I found myself feeling more connected, holding onto those little things I had seen in them that night, like a renewed spark in our relationship. 3. Building Connection Through Silent Presence One of the most surprising experiences was the time we spent just sitting in silence, holding hands, and focusing on our breathing. We’d decided to try it as a way to calm down after a busy week, but it turned out to be a much deeper experience than I expected. In that quiet moment, without any words or expectations, I felt a connection with my partner that I hadn’t felt in a long time. At first, it felt strange—like I was supposed to be doing something, saying something. But as I settled into the silence, I realized that sometimes, just being present together is enough. This kind of non-verbal connection has become a powerful part of our relationship. It showed me that we don’t always need to communicate through words or actions; sometimes, just being fully present can say more than anything. This experience taught us to find peace together, even when the world outside feels busy and overwhelming. 4. Rediscovering Vulnerability Through Playfulness One of the most fun moments came when we decided to share some of our most embarrassing stories with each other—things we hadn’t talked about in years. We laughed so hard that night, feeling a kind of lightheartedness that was rare amidst our usual routine. It was like peeling back layers and remembering the silly, imperfect parts of ourselves we don’t usually show. Sharing these vulnerable, sometimes awkward moments brought us closer. Studies show that vulnerability can strengthen trust in relationships, and that night, I realized that it’s not only deep conversations that build intimacy but shared laughter, too. That lightheartedness brought a fresh sense of joy into our relationship, reminding me of how much fun we have together when we let go of the serious sides of ourselves. 5. Finding Calm Together in Nature One of the most grounding experiences we’ve tried together has been spending time outdoors without any real agenda. We decided to take a walk in nature one day, moving slowly, letting ourselves relax, and just talking (or not talking) as we went along. It was peaceful, freeing, and a perfect escape from our busy lives. Being outside, away from everything, reminded me of

This is part 3 of Jeff Goldsmith’s history of managed care. If you missed it read Part 1 & Part 2 By JEFF GOLDSMITH Two major changes in health insurance ensued as the US health system entered the 21st century- a strategic shift of health cost risk from providers to patients and the emergence of machine driven managed care. Insurers Shift Strategy from Sharing Risk with Hospitals and Doctors to Markedly Implicating their “Patients’. After the 2008 recession, employers and their health plans shifted strategy from putting physicians and hospitals at risk through delegated risk capitation to putting patients at risk through higher patient cost sharing. In the wake of the recession, the number of patients with high deductible health plans nearly quintupled–to over sixty million lives. By 2024, 32% of the lives in employer-based plans (50% among small employers’) were in high deductible plans regardless of patient economic circumstances.    The stated intention of the High Deductible Health Plan movement was to encourage patients to “shop” for care. In real care situations, however, patients found it difficult or impossible to determine exactly what their share of the cost would be or which providers did the best job of taking care of them. For an extensive review of the literature on how healthcare “consumers” struggle to manage their financial risk, read Peter Ubel’s 2019 Sick to Debt: How Smarter Markets Lead to Better Care. Employers and insurers,  working together to “empower consumers”,  rapidly shifted “self-pay”  bad debts onto their provider networks. Some 60% of hospital bad debts are now from patients with insurance. Instead of “shopping for care”, consumers found themselves saddled with almost $200 billion in medical bills they could not pay, and hospitals and physicians ended up eating most of it.     This escalating “insured bad debt” problem forced providers to hire revenue cycle management (RCM) consultants to revise and strengthen their policies regarding patient financial responsibility, “revenue integrity” (meaning crossing all the “t’s” and dotting all the “I’s” in each medical claim and making sure care is coded properly) and rigorously monitoring the flow of claims to and from their major insurance carriers. As a result many providers found themselves spending 10-15% of their total operating expenses on RCM!  Medicare Advantage Enables Insurer Market Dominance The movement from Ellwood’s vision of regionally-based provider sponsored health plans to market dominance by huge national carriers was cemented by the emergence of Medicare Advantage as the most significant and profitable health insurance market segment. In 2013, Medicare Advantage accounted for 29% of total Medicare spending. A decade later, in 2024, it was 54% (of roughly a trillion dollar program). And until a federal crackdown on MA coding and payment policies by the carriers, it was a 5% margin business, significantly more profitable than commercial insurance, ObamaCare Exchange or managed Medicaid businesses. As Medicare Advantage emerged as the largest health insurance market, it was dominated by a cartel of large publicly traded carriers.  Six publicly traded carriers (United, Humana, CVS/Aetna, Elevance/Anthem, CIGNA and Centene) accounted for 69% of MA’s 34.6 million enrollment as of November 2024.  Kaiser, the “founder” of the movement, added another 5.5%. The top two MA plans, United and Humana, account for almost 46% of MA’s enrollment! Sixty percent of United and CVS/Aetna’s health insurance premium flow and 90% of Humana’s now come from this single program, according to a recent Bank of America analysis. However, owing to the aggressive promotional activism of consultants and private equity financed “management services organizations”, the median MA plan enrollment is less than 2000 lives (!). During the 2010’s, Medicare Advantage became an industry in and of itself. An amazing number of small hospital and physician sponsored plans are fighting over less than a quarter of MA enrollment, and, predictably, losing money on every subscriber (negative 5% margins are typical).  Some communities have as many as forty MA plans competing for their share of this lucrative market.  The Rise of Machine Driven Managed Care The huge national carriers rely, in turn, on a complex network of contractors to manage their Medicare Advantage care management and payment. A shadowy industry populated with billion dollar high tech firms no one in the care system had ever heard of–with names like Emdeon (now Change Healthcare,), Equian,  MultiPlan (taken private by Carlyle in 2024), naviHealth, Signify and Cotiviti–emerged to service health plans with automated systems to review hospital and physician claims prior to payment.  These firms used AI driven machine learning to analyze and process the flow of hundreds of billions of dollars in medical claims. A significant fraction of those claims are denied, either because of data errors in the claims themselves, or because AI rules engines kicked them out for not conforming to constantly evolving medical necessity criteria. Prior authorization, a forty-year-old HMO expense control tool for managing “elective care”, has been augmented by “prospective pre-payment review” applied after hospitals have admitted and cared for patients and submitted insurance claims. According to the American Medical Association, each practicing physician in the US is required to submit 45 prior authorization requests for their patients each week.   Hospitals saw, in some cases, a doubling of claims denials or repricing in just a twelve to eighteen-month period after 2016 based on these automated “prospective” reviews. This surge of machine-driven denials played a major role in the mysterious 39% plummet in hospital operating earnings seen in 2016 and 2017.  A key factor in the wave of denials was the increased centrality of hospital emergency admissions as the main gateway to complex and expensive inpatient care. Upwards of 70% of patients in many health systems are admitted through the emergency room and care is rendered to those patients on an urgent basis.    With primary care physicians withdrawing from hospital practice, decisions to admit patients to hospitals were increasingly made by employed physicians or physician contractors to the hospital, many of whom are “out of network” with the insurance carriers, and under limited control by the hospitals themselves.      After-the-fact denials by insurers often result in unexpected higher bills to patients with high deductible plans as well as significant new administrative expenses for hospitals to track and contest the surge of denials.  UnitedHealth Group Makes its Move Following the more than

“To define yourself is to limit yourself. Without labels you remain the infinite being.” ~Deepak Chopra Living with both ADHD and anxiety feels like trying to navigate life with your mind constantly racing in a thousand directions at once. It’s frustrating and exhausting, and, at times, it feels like success is out of reach. But here’s the truth: success is possible. Even when it feels like your brain is working against you, with the right strategies and support, you can thrive. As a nurse practitioner who has lived with undiagnosed ADHD and anxiety for much of my life, I’ve experienced the struggles that come with both. I’ve been labeled lazy, unteachable, and a lost cause. But I’ve also learned how to break through those labels and find success on my own terms. It’s not easy, but it’s absolutely achievable. The Early Years: ADHD and Anxiety in School Growing up, ADHD wasn’t something people talked about. Kids who had trouble focusing were often written off as lazy or troublemakers. I was one of those kids, but I wasn’t the hyperactive type, so my struggles flew under the radar. My teachers assumed I wasn’t trying hard enough, but the truth was, I was trying as hard as I could. If a subject didn’t grab my interest, my brain simply couldn’t focus. The frustration of not being able to retain information or focus made school incredibly difficult. Teachers labeled me as lazy or unteachable, and those labels stuck. By the time I reached high school, I was so far behind that showing up to class felt pointless. My grades were posted for everyone to see, and every time, I was at the bottom of the list. It felt like the world was constantly reminding me that I was a failure. As my anxiety grew, I started skipping class regularly. Why show up just to feel like I was being judged? I was already seen as the kid who couldn’t keep up, and every time I walked into a classroom, it felt like a reminder of how far behind I was. The anxiety of being judged, combined with my ADHD, made it impossible to succeed in that environment. Hitting Rock Bottom With no support system in place and a constant sense of failure hanging over me, I turned to unhealthy coping mechanisms. Drugs and alcohol became my escape from the pressure, anxiety, and feelings of inadequacy. The constant emotional beatdown from teachers, peers, and my own inner voice was too much to bear. I began to believe that I really was a lost cause. No one seemed to care about my potential, and I certainly didn’t see it myself. Eventually, I was kicked out of my public high school. At the time, it felt like the end of the road for me, but in reality, it was the best thing that could have happened. Finding a New Path: The Alternative School After being kicked out of public high school, I was sent to an alternative school, a place for the so-called “bad kids.” This school had a reputation for being where the rejects went—those who were expected to drop out, end up in jail, or get pregnant. But what I didn’t expect was how this environment would change my life. At the alternative school, the teachers didn’t care about my past failures. They didn’t look down on me for my low grades or judge me for being behind. Instead, they saw my potential. They worked with me one-on-one, offering me the chance to catch up and even get ahead. For the first time in my life, I felt like someone believed in me. One teacher in particular recognized my talent for writing and encouraged me to join the school newsletter. I started taking on more responsibility and eventually became the editor. For the first time, I started to see myself as capable and smart. College and Career: Finding Success Despite ADHD and Anxiety After graduating from the alternative high school, I had a newfound sense of confidence. For the first time, I believed that college might be an option for me. I started at a community college and eventually transferred to a university, where I earned a bachelor’s degree in journalism and communication studies. However, after working in journalism for a while, I realized that it wasn’t my true passion. I pivoted and went back to school to pursue a career in nursing. Earning my associate’s degree in nursing was one of the hardest things I’ve ever done, but it was also the most rewarding. For seven years, I worked in the emergency department, where the fast-paced environment kept my ADHD in check and the constant reminder of life’s fragility put my anxiety in perspective. Managing ADHD and Anxiety in Adulthood While I had found success in my career, my ADHD and anxiety didn’t magically disappear. In fact, they became even more noticeable when I transitioned to working as a nurse practitioner. The COVID-19 pandemic brought an intense level of pressure, and my anxiety skyrocketed. I found myself overthinking every decision, double- and triple-checking my work, and seeking reassurance from colleagues constantly. It became clear that I needed to develop better strategies for managing both my ADHD and anxiety. Through a combination of medication, mindfulness practices, and a strong support system, I’ve been able to keep both in check. What Works for Me: Strategies for Managing ADHD and Anxiety Over the years, I’ve found that managing ADHD and anxiety requires a holistic approach. Medication has been a helpful tool, but it’s not the only answer. I’ve also incorporated practices like meditation, gratitude, and positivity into my daily routine, all of which help me manage my symptoms. Meditation in particular has been a game-changer. It helps me calm my racing thoughts and stay grounded, especially when my anxiety starts to creep in. Practicing gratitude keeps me focused on the positive aspects of my life, which helps counter the negative self-talk that can sometimes accompany

This is part 2 of Jeff Goldsmith’s history of managed care. If you missed it read Part 1 By JEFF GOLDSMITH The late 1990s crash of HMOs opened the door to a major consolidation of the health insurance market controlled largely by national and super-regional health plans. While HMOs by no means disappeared post-backlash, the “movement” begun by Ellwood and Nixon fell far short of national reach. HMOs never established a meaningful presence in the most rapidly growing parts of the US- the Southwest, South and Mid-Atlantic regions, as well as the Northeast. The exemplar, Kaiser Permanente, damaged its financial position with an ill-considered 1990’s (McKinsey-inspired) push to become a “national brand”. Today, over 80% of Kaiser’s 13 million enrollment is still in the West Coast markets where it began 80 years ago!  HMOs Go Public and Roll Up Two little noticed developments accelerated the shift in power from providers to payers. One was the movement of provider sponsored health plans into the public markets. PacifiCare, the most significant hospital sponsored health plan owned by the Lutheran Hospital Society of Southern California, was taken public in 1995. A subsequent merger with FHP health plan destabilized the newly public company.  After PacifiCare crashed post the 1998 Balanced Budget Act cuts, and struggled to refinance its debt, it was acquired by United Healthcare in 2005, bringing with it a huge sophisticated, delegated risk contracting network. United then bought Sierra Health Plan based in Nevada in 2007, including its large captive medical group, its first medical group acquisition. Following these acquisitions, United rolled up PacifiCare’s southern California based at-risk physician groups in the late 00’s, and then capped off with its purchase of HealthCare Partners, the largest of all, 2017 from DaVita in forming the backbone of today’s $110 billion Optum Health.     United’s buying BOTH sides of the delegated risk networks-plan and docs-in high penetration managed care markets is not fully appreciated by most analysts even today.  It has meant that as much as 40% of Optum Health’s revenues, including almost $24 billion in capitated health insurance premiums, come from competitors of United’s health insurance business.   However, of greater strategic significance was Humana’s decision in 1993 to exit the hospital business by spinning its 90 hospitals off as Galen.  Humana’s unsentimental founders, David Jones and Wendell Cherry, concluded that the intense physician push back against their growing health plan meant that their two business were fundamentally incompatible, and they chose to retain ownership of the higher margin and less complex business. Galen hospitals began a lengthy and sad journey through multiple owners-Rick Scott’s ill-starred Columbia/HCA, Tenet, and then multiple others. Today, Humana is the second largest “player” in the Medicare Advantage market, and had a market cap north of $60 billion (until a month or so ago).   HIPAA Sets Stage for 24/7 Electronic Surveillance of Medical Decision Making The other little remarked development provided the technical foundation for a payer controlled care system- the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  Up until the mid-1990s, healthcare claims were paper and fax transmitted, costly and unreliable. Though HIPAA is mainly known for its confidentiality protections for patient data, its Administrative Simplification provisions set data standards to encourage electronic submittal and payment of medical claims.  HIPAA encouraged the emergence of electronic data interchange through dedicated T-1 lines, hardwired ancestors of today’s VPNs–high capacity, secure physical links between hospitals and their major payers. HIPAA markedly accelerated the use of electronic data interchange (EDI) in healthcare, to the great advantage of health insurers.   HIPAA spawned a whole ecosystem of small companies who served as financial intermediaries between health insurers and care providers–aggregating, transmitting and processing medical claims and paying  providers for their care.  These companies proliferated during the first Internet investment bubble, which began after Netscape’s historic IPO in 1995.   When the Internet bubble burst in 2000, these companies were sold by their private equity and venture owners in an ensuing multi-year fire sale.  PPO Growth Burns Down the Commercial Rate Structure While the HMO movement faltered, provider-centric delegated-risk capitation gave way to broad panel “preferred provider organization” (PPO) managed care which paid physicians and hospitals a discounted fee-for-service, and overlaid external utilization controls like prior authorization. The PPO movement markedly diluted physician economic power. PPOs were basically an industrialized version of traditional Blue Cross, only without physician or hospital governance input.  PPO health plans threatened to exclude local providers that did not grant them significant discounts. Independent physicians had zero leverage in this transaction. Hospitals who discounted their rates in the panic to avoid being excluded discovered that their pricing concessions yielded no growth in volume or market share, just reduced revenues. This late 1990s pricing panic burned down hospital commercial rate structures in the West and Southwest, as far east as Chicago, Minneapolis and St. Louis, and accelerated the trend to system consolidation.    The ObamaCare Festival of Technocratic Enthusiasm At the same time, Medicare moved aggressively to get providers into a new, less politically inflammatory version of managed care for large regular Medicare market (e.g. the non-Medicare Advantage portion).  The 2010 Affordable Care Act’s main event was to expand health coverage to the working poor through a partial nationalization of the individual insurance market and an aggressive expansion of Medicaid. This coverage expansion was a huge success, bringing new coverage to 30 million Americans.  But in a muted afterthought, recognizing continuing health cost pressure, ObamaCare also sought to revive, for one last time, for regular Medicare,  the Ellwood/Enthoven vision of a transformed,  at-risk care system. Having concluded that the closed panel, capitated integrated care system model could not be reached in a single impossible transformation, as the Clintons attempted and failed to do, it would sow the seeds of capitation through a “managed care” lite model called Accountable Care Organizations.     There were two ACO concessions to the post-HMO backlash environment. First, Medicare patients were not forced into managed care plans (or even told they were in them), and providers would be insulated from downside financial risk for a lengthy period. ACO membership was a statistical construct, not a consensual patient panel; patients would be assigned to ACOs if their primary

“Resentment is like drinking poison and hoping the other person dies.” ~Saint Augustine For years, I was unknowingly poisoning myself in nearly every relationship—whether romantic, work-related, or friendships. It always followed the same pattern: I’d form a deep attachment, throw myself into the relationship, and give endlessly, hoping that if I gave enough, they’d appreciate and value me. But instead, it felt like they just took and took, leaving me secretly seething with anger and frustration while I smiled on the outside. I was doing all the running—couldn’t they see that? Couldn’t they see how hard I was trying? Over time, the exhaustion would set in. Eventually, I’d burn out from the one-sided effort and just give up, walking away hurt and angry, convinced they had wronged me. Each time, I added another person to my mental list of people I couldn’t trust. With each disappointment, I trusted fewer and fewer people. To protect myself, I started putting up walls, convincing myself I didn’t need anyone. I told myself I was fine on my own. I’d always be the first to step in and help family or friends, but I wouldn’t allow them to help me. I refused to be vulnerable because, to me, vulnerability meant risking rejection. I believed I could do it all on my own—or at least that’s what I told myself. When COVID hit, isolation wasn’t a choice anymore—it was forced upon me. Suddenly, I was alone, with no one to turn to because I had pushed everyone away. That’s when I realized just how much resentment had poisoned my life. Fed up with the weight it placed on my life, I decided to confront it head-on. I let myself fully feel the resentment, allowing it to wash over me like a wave. It wasn’t easy—leaning into those emotions was painful, raw, and uncomfortable. But in that moment, I realized I wasn’t just angry with a few people—I was carrying resentment for almost everyone in my life, even my own mother! The bitterness had been poisoning me for years, and it became clear that it wasn’t just affecting my relationships—it was poisoning my peace. That’s when I made the decision to stop drinking the poison. I realized that I had been giving so much power to other people—power over my emotions, my happiness, and even my health. But I didn’t have to. I didn’t need to wait for anyone to apologize or change; I was responsible for my own healing, and I wasn’t going to let others’ actions control my life anymore. Self-Realization: The First Step to Letting Go Self-realization was the first, and perhaps most difficult, step in battling my resentment. For the first time in my life, I stopped running from the pain and leaned into it instead. I started using EFT (Emotional Freedom Techniques) to peel back the layers of emotions I had been burying for years. Through tapping on specific points, I was able to release trapped feelings and bring clarity to the surface. Each tapping session was like lifting a weight off my chest, but it was also incredibly uncomfortable. I had to confront memories I had long avoided and acknowledge the emotions I had hidden from for so long. What shocked me the most was realizing that I had never given anyone a chance to correct the wrongs I thought they had done. I assumed people knew I was upset, and when they didn’t magically pick up on it, I silently resented them. Saying that now, it sounds so ridiculous—how could I have expected people to read my mind? Yet for years, that’s exactly what I did. So, I began reframing the narrative. Instead of focusing on how others had let me down, I asked myself: What could I have done differently in those situations? How could I have influenced a different outcome? The more I reflected, the more I realized that I had the power to change the dynamics of my relationships. It was a breakthrough—I didn’t need to wait for someone to change or apologize. I had the power to heal myself. Testing My New Mindset Soon after this realization, I had an opportunity to test my new mindset. I had invited my mum and sister on a weekend getaway, something that meant a lot to me. A few weeks before the trip, they both backed out. The old me would have smiled and said, “No problem, that’s fine,” while secretly adding their names to my mental list of people who had wronged me. But this time, I did something different. I spoke up. I calmly explained how much it hurt that they were canceling on something so important to me. To my surprise, neither my mum nor my sister had any idea their actions would hurt me. They explained that, because I had always been so independent, they didn’t realize how much this trip meant to me. For the first time, we had a genuine, open conversation about our feelings, and it actually brought us closer. Instead of silently seething and letting resentment build, I communicated honestly, and the outcome was liberating. I realized that so much of the pain I had carried in the past could have been avoided if I had just voiced my feelings. That conversation was a powerful reminder that I have the power to shape my relationships, and that sometimes people just don’t know how we feel unless we tell them. Moving Forward: Letting Go and Staying Free After learning to let go of years of resentment, I realized that staying free required new habits. I needed to guard against falling back into old patterns, so I came up with a few strategies to help. First, I ask myself three key questions: 1. Is this really worth my peace? 2. Did they intend to hurt me, or could there be another explanation? 3. What can I do differently in this situation? These questions help me pause, reflect, and reframe my thoughts

By JEFF GOLDSMITH Healthcare payment in the US has evolved in decades-long sweeps over the past fifty years, as both public programs and employers attempted to contain the rise in health costs. Managed care in the United States has gone through three distinct phases in that time- from physician- and hospital-led HMOs to PPOs and “shadow” capitation via virtual networks like ACOs to machine-governed payment systems, where intelligent agents (AI) using machine learning are managing the flow of  healthcare dollars.  This series will explore the evolution of managed care in 3 phases.   Phase I- Health Maintenance Organizations and Delegated Risk Capitation In response to a long run of double-digit health cost inflation following the passage of Medicare in 1965, the Nixon administration launched a bold health policy initiative- the HMO Act of 1973- to attempt to tame health costs. The Nixon Administration intended this Act to provide an alternative to nationalizing healthcare provision under a single payer system, as supported by Senator Ted Kennedy and other Democrats.   The goal of this legislation was to restructure healthcare financing in the US into risk-bearing entities modeled on the Kaiser Foundation Health plans- a successful group-model “pre-paid”  health plan founded in the 1940s and based on the Pacific Coast. These plans would accept and manage fixed payments for a defined population of subscribers, and offer an alternative to what was perceived as an inflationary, open-ended fee for service payment system. In varying forms, this has been the central objective of “progressive” health policy for the succeeding fifty years.  The HMO Act of 1973 provided federal start-up loans and grants for HMOs, much of which went to community-based healthcare organizations and multi-hospital systems. It also compelled employers to offer HMOs as an alternative to Blue Cross and indemnity insurance. While a few HMOs either employed physicians directly on salary (staff models like the Group Health Co-Operatives), or contracted on an exclusive basis with an affiliated physician group (like Kaiser’s Permanente Medical Groups), many more delegated capitated risk to special purpose physician networks- Independent Practice Associations (IPAs)- whose physicians continued in private medical practice.  By 1996, according to the Kaiser/HRET Employee Benefits Survey, HMOs covered 31% of the employer market (roughly 160 million employees and dependents), and the federal government had begun experimenting with opening the Medicare program to HMO coverage. The impact of HMO growth on overall US health spending remains uncertain, because health spending as a percentage of US GDP continued growing aggressively during the next fifteen years,  before levelling off during the mid-1990’s around the Clinton Health Reform debate. Two things brought the HMO movement to a crashing halt in the late 1990’s.  One was a political backlashfrom workers and their families who were simply assigned to HMOs by their employers, rather than choosing them themselves. This unilateral assignment violated a fundamental principle of HMO advocates like Paul Ellwood, who championed consumer choice as an organizing principle of the movement.     Employees and their families so assigned found their access to care narrowed both by limited panels of providers (that may or may not include their family physicians) and by the mechanical application of medical necessity criteria to their care, such as 48 hour hospital stays after a routine obstetrical delivery.  Women, who are the pivotal actors in managing their families’ health and were growing increasingly confident of their political influence, went ballistic.  The other political force that helped quash the HMO movement was angry pushback from physician communities, particularly specialists, who bitterly resented the invasion of their professional freedom by prior authorization and medical necessity reviews, as well as pressure to reduce their fees in order to be included in HMO networks. A major concurrent financial blow to HMOs was a sharp downward adjustment in Medicare payment rate for health plans in the Balanced Budget Act of 1998.  By 2014, HMO’s share of the total commercial market had shrunk to only 13%, well less than half of its peak. They were replaced by preferred provider organizations, broad networks of physicians and hospitals in a region operating under negotiated rates and claims review systems. HMO enrollment increasingly tilted toward publicly funded patients under Medicaid and Medicare.  Capitation of primary care physicians under delegated risk shrank by two-thirds from 1996 to 2013 millennium as the HMO share of insured lives contracted. While the HMO industry shrank nationally, Kaiser saw its enrollment grow to almost 13 million, dominant on the Pacific Coast but a negligible presence elsewhere.    United Healthcare ended up acquiring not only a lot of HMOs (Oxford Healthcare, Sierra Healthcare, METRA, PacifiCare, etc.) in the aftermath of the managed care backlash, but also the risk-bearing physician groups that accepted delegated risk from those HMOs (Kelsey Seybold, Healthcare Partners, Atrius, Reliant, etc), which today form the backbone of Optum Health. Most of the capitated payment in Optum Health (almost $24 billion in 2024) comes from health plans other than United itself!  Our second essay will focus on the second phase of managed care development- the dominance of the PPO and the rise of “value based care’ after the 2010 Affordable Care Act.  Jeff Goldsmith is a veteran health care futurist, President of Health Futures Inc and regular THCB Contributor. This comes from his personal substack 2024-12-17 07:37:00

THCB Gang Dec 16, 2024 Joining Matthew Holt on #THCBGang on Monday December 16 at 1pm PST 4pm EST are patient safety expert Michael Millenson, physician, entrepreneur and technologist Shantanu Nundy; and Digital Health and Emerging Med-Tech Practice Co-Founder at Marsh & McLennan, Beracah Stortvedt. You can see the video below live (and later archived) & if you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels. 2024-12-16 20:21:10

“Stay in the moment. The practice of staying present will heal you. Obsessing about how the future will turn out creates anxiety. Replaying broken scenarios from the past causes anger and sadness. Stay here, in this moment.” ~Sylvester McNutt For two years, I studied and practiced meditation. I listened to podcasts, chanted mantras each morning, sat quietly while exploring my default mode network, and traversed Eastern mysticism under the guidance of a licensed clinical psychologist who taught me how to use deep diaphragmatic breathing to stimulate my vagus nerve and lower my resting heart rate. This helped me recover from panic attacks, which I started having as a result of existential dread. After a series of nights with intrusive thoughts about death and dying, and painful memories related to my childhood, I decided to learn how to meditate so my thoughts would bother me less. It’s important to examine our feelings and emotions in order to determine what to do with them. While meditating, as you nonjudgmentally observe your thoughts, the goal is to let the thought pass and then go back to the present moment with a mantra. However, after your meditation session is over, it’s also important to catalog for yourself if a thought or memory keeps surfacing, and what feelings or emotions might be present with that experience, so that you know what to work on in your personal development. For myself, I found that many of the childhood memories that kept surfacing during meditation were related to my mother. Not surprisingly, much of my early writing as a poet includes themes and ideas related to my mother and other family issues. It was only once I started to really tackle these memories that I realized that they were attached to painful emotions directly linked to my childhood. Once I gave myself the space I needed to examine my memories as artifacts from my life—ones to be accepted and not ones that I wanted to give power to—I was able to work through them and come out on the other side. In order to do this, I started journaling, speaking about my experiences more with trusted advisors and through my creative work, and keeping up with meditation practices, which I did judiciously for three to four hours every morning. One childhood memory that used to bother me a lot before I worked through it was from a time when I was about seven or eight years old. I remembered it vividly, as the memory would keep resurfacing each day. A friend of mine and I were sitting on the floor of my bedroom, talking, when my mother came into the room. She commented sternly about how my clothes weren’t put away yet, since she’d told me having my friend over was contingent on that. She then, without saying another word, picked up every article of clothing and proceeded to throw each of them at me while I was on the floor. My friend and I were speechless. Afterwards, when my mother left the room, my friend helped me pick them up. What I realized by nonjudgmentally accepting my memory is that this experience had become a trauma point for me, one that I carried with me into my adult life until I started dealing with the emotions that were hardwired into my brain related to the event. Only once I started meditating and kept seeing this memory resurface again and again—thereby noticing that I even had the memory and emotions in the first place—was I able to deal with the fact that this instance caused me to feel wronged because of how unfair it was. I felt humiliated. I felt ashamed. How could she have done something like this, I wondered? However, once I began naming my feelings one by one, I found that the bodily sensations and experiences of the emotions surrounding the memory began to fade. I even found the courage to speak with my mother about my childhood using nonviolent communication strategies as discussed in the book Nonviolent Communication, written by Marshall B. Rosenberg, PhD with a foreword by Deepak Chopra. The most rudimentary format of nonviolent communication entails communicating about conflict by saying, “When I hear you say X, I feel Y, because I need Z,” which makes the other person more likely to be able to receive your communication without being reactive or defensive. I found great success with this approach, and while my mother and I are not close by any means, this communication approach strengthened our relationship and my relationship with myself. Now, most, if not all, of my painful childhood memories are no longer traumatic for me, including the one about my clothing. This memory and the emotions that used to be attached to it are literally nonissues for me now, years later. And yet, the most important form of communication that I found for myself is the communication with the self, all brought on by a healthy meditation regimen. So, how does one meditate with the goal of nonjudgmentally observing one’s thoughts, letting them go, and returning to the present moment in order to be successful with processing painful childhood memories and to gain more self-awareness overall? The technique that my psychologist taught me is that, at the same time as doing deep diaphragmic breathing to stimulate the vagus nerve and promote inner calmness (eight seconds in, pause, then eight seconds out), it’s good to have an intention in mind that you can chant in your head as inner dialogue. He also suggested audiating for stronger results, or putting the mantra to music in your mind, which I found was even more intellectually stimulating and led to greater mental clarity. The idea is to try to clear your mind of all thoughts except the mantra, which you have going on repeat. I chose the mantra “Hamsa” for each breath, which means “I am that which I will become,” representing personal development. When my thoughts wandered while I