MassCare to Attend IHI Conference Orlando


The four-day conference has been the home of quality improvement (QI) in health care, bringing together health care visionaries, improvement professionals, world leaders, industry newcomers, and beyond.

The IHI National Forum is the premier "meeting place" for people committed to the mission of improving the quality and value of health care. The annual event draws more than 5,000 attendees from around the world from a variety of organizations and job titles.

MassCare will be exhibiting at this event. Come visit us at Booth #103.

For more Information, clink here.


Pharmacists and Annual Wellness Visits

Medicare Part B provides for its members an annual wellness visit (AWV), given by a Medicare Part B–approved practitioner such as a physician, physician assistant, nurse practitioner, and clinical nurse specialist or a medical professional, such as a pharmacist, who is working under the direct supervision of a physician.1 Patients are eligible if they are members for at least 12 months and have not yet had a visit in the past 12 months.2 There is no co-payment for an eligible Medicare Part B member, and the visit is not subject to a patient’s deductible.2

Pharmacists are continuing to expand their role as health care providers with more direct patient care opportunities. Pharmacists working under the supervision of a physician can provide an AWV, which is an exam that focuses on the patient’s health, allowing them the opportunity to develop a personalized approach to health care and disease prevention.

During an AWV, pharmacists should do an overview of the patient’s family, immunization, medical, social, and surgical histories and compile an updated list of current providers. Routine measurements such as blood pressure, height, and weight should be taken. In addition, the pharmacist should perform necessary screenings, including detection of any cognitive impairment, depression, fall risks, and functional ability. A patient’s list of current OTC or prescription medications should be reviewed and documented. Pharmacists can provide patients with a better understanding of their medications, and they are in a unique position to address and resolve any medication issues. Upon reviewing a patient’s overall health, a pharmacist can provide individualized health advice and recommendations. Patients should also be provided with a schedule that reviews the Medicare Part B– covered preventive services that they may require in the next 5 to 10 years, such as immunizations and various screenings. A comprehensive list of these covered screenings can be found on the Medicare website.2

An annual physical is different from an AWV, as it consists more of a physical examination that includes the auscultation, inspection, palpation, and percussion of the body. Providers who perform these services are gathering information through their senses to determine whether there is a problem. An annual physical is not a service that falls under an AWV, and it is not covered under the Medicare Part B benefits. The cost for services not covered by Medicare Part B can be billed by a supplemental insurance but is ultimately the patient’s responsibility if it is not covered.2

There may seem to be similarities. However, it is important to distinguish between the 2 exams and especially important for the patient to classify the visit as a Medicare AWV so the practitioner can properly bill for the services.

In a physician’s office or a physician-based clinic, a pharmacist may bill services to a physician, using incident-to billing, as long as 9 requirements that Medicare sets forward are met.3 The billing codes used for these services include the Healthcare Common Procedure Coding System code, G0438 for an initial AWV, with a short descriptor of “annual wellness first,” and G0439 for a subsequent AWV, with a short descriptor of “annual wellness subseq.”4

The 9 requirements are:

  • The patient must be seen by the physician first for an evaluation or a service covered by Medicare.

  • An authorization for the service must be provided by the physician in the medical record.

  • The physician must regularly see the patient at a frequency that is fitting for the management of their course of treatment.

  • The service provided by the pharmacist is within a physician’s or Medicare Part B provider’s office or clinic.

  • The service must be medically appropriate to be given in the provider’s office or clinic.

  • The service provided must be within the pharmacist’s scope of practice.

  • The services and supplies must be furnished in accordance with applicable state law and adhere to other laws that affect the services.

  • A physician or a Medicare Part B–approved practitioner must be on the premises when the incident-to services are performed.

  • The pharmacist must be an employee, contracted or leased, of the physician or Medicare Part B–approved provider.

An AWV with a pharmacist can have a significant impact on patient outcomes. In a 3-month study evaluating 300 patient records, clinical pharmacists completed an average of 5.4 interventions, made 272 referrals, ordered 183 diabetes and lipid screenings, offered 370 vaccinations, and made 24 medication and dosage changes during the AWV.5

In supporting the salary of a pharmacist, a study determined that 1070 AWVs a year, which is about 6 visits a day, would be enough to cover this additional cost for a medical practice. This target was more feasible in a larger practice, which would require a lower percentage of total patients. Pharmacists in this setting have the added benefit of providing a patient with a comprehensive medication review while using only about 40% of their time.6

Results from a 2013 US Department of Health & Human Services report showed that just 11% of eligible patients across the nation took advantage of their covered AWV.6 In medical practices in which few physicians have the time to reach most of their Medicare Part B–eligible patients, a pharmacist will not only help in this task but also add value through this collaborative effort between the 2 health care professions.


  1. Centers for Medicare & Medicaid Services. Covered medical and other health services. In: Medicare Benefit Policy Manual. Rev 235, 2017. Guidance/Guidance/Manuals/Downloads/bp102c15.pdf. Accessed January 26, 2018.

  2. Physical exam or wellness visit? What Medicare covers. Medicare Made Clear website. wellness-visit- what-medicare- covers-2/. Published April 12, 2016. Accessed January 16, 2018.

  3. American Society of Health-System Pharmacists. Pharmacist billing for ambulatory pharmacy patient care services in a physician-based clinic and other non-hospital- based environments- FAQ. care-practitioner/docs/sacp-pharmacist-billing- for-ambulatory-pharmacy-patient-care-services.pdf. Published May 2014. Accessed January 26, 2018.

  4. Centers for Medicare & Medicaid Services. Annual wellness visit (AWV), including personalized prevention plan services (PPPS). MLN Matters. Education/Medicare-Learning- Network- MLN/MLNMattersArticles/Downloads/MM7079.pdf. Published 2011. Accessed January 26, 2018.

  5. Alhossan A, Kennedy A, Leal S. Outcomes of annual wellness visits provided by pharmacists in an accountable care organization associated with a federally qualified health center. Am J Health Syst Pharm. 2016:73(4):225-228. doi: 10.2146/ajhp150343.

  6. Park I, Sutherland SE, Ray L, Wilson CB. Financial implications of pharmacist-led Medicare annual wellness visits. J Am Pharm Assoc (2003). 2014:54(4):435-440. doi: 10.1331/JAPhA.2014.13234.

  7. Betty Lu, PharmD, is a graduate of Temple University School of Pharmacy and a fellow of global medical affairs for Massachusetts College of Pharmacy and Health Sciences University/ Becton, Dickinson and Company in Boston.

  8. Jennifer D. Goldman, RPh, PharmD, CDE, BC-ADM, FCCP, is a professor of pharmacy practice at Massachusetts College of Pharmacy and Health Sciences (MCPHS) University in Boston, a faculty preceptor of the MCPHS University/Becton, Dickinson and Company fellowship in medical affairs, and a clinical pharmacist at Well Life in Peabody, Massachusetts.

The Benefits of Staff Bonuses

When patients walk into a medical group's office, the first people they meet are the staff members. Studies have shown that with today's managed care, patients spend most of their time in a medical practice interacting with non-physicians, from front desk staff to nurses. So it's important that staff members be motivated to provide the kind of quality service and care that keep patients coming back.

Fiber Is Good for You. Now Scientists May Know Why.

From (Follow Carl Zimmer on Twitter @carlzimmer)

A diet of fiber-rich foods, such as fruits and vegetables, reduces the risk of developing diabetes, heart disease and arthritis. Indeed, the evidence for fiber’s benefits extends beyond any particular ailment: Eating more fiber seems to lower people’s mortality rate, whatever the cause.

That’s why experts are always saying how good dietary fiber is for us. But while the benefits are clear, it’s not so clear why fiber is so great. “It’s an easy question to ask and a hard one to really answer,” said Fredrik Bäckhed, a biologist at the University of Gothenburg in Sweden.

He and other scientists are running experiments that are yielding some important new clues about fiber’s role in human health. Their research indicates that fiber doesn’t deliver many of its benefits directly to our bodies.

Instead, the fiber we eat feeds billions of bacteria in our guts. Keeping them happy means our intestines and immune systems remain in good working order.

In order to digest food, we need to bathe it in enzymes that break down its molecules. Those molecular fragments then pass through the gut wall and are absorbed in our intestines.

But our bodies make a limited range of enzymes, so that we cannot break down many of the tough compounds in plants. The term “dietary fiber” refers to those indigestible molecules.

But they are indigestible only to us. The gut is coated with a layer of mucus, atop which sits a carpet of hundreds of species of bacteria, part of the human microbiome. Some of these microbes carry the enzymes needed to break down various kinds of dietary fiber.

The ability of these bacteria to survive on fiber we can’t digest ourselves has led many experts to wonder if the microbes are somehow involved in the benefits of the fruits-and-vegetables diet. Two detailed studies published recently in the journal Cell Host and Microbe provide compelling evidence that the answer is yes.

In one experiment, Andrew T. Gewirtz of Georgia State University and his colleagues put mice on a low-fiber, high-fat diet. By examining fragments of bacterial DNA in the animals’ feces, the scientists were able to estimate the size of the gut bacterial population in each mouse.

On a low-fiber diet, they found, the population crashed, shrinking tenfold.

Dr. Bäckhed and his colleagues carried out a similar experiment, surveying the microbiome in mice as they were switched from fiber-rich food to a low-fiber diet. “It’s basically what you’d get at McDonald’s,” said Dr. Bäckhed said. “A lot of lard, a lot of sugar, and twenty percent protein.”

The scientists focused on the diversity of species that make up the mouse’s gut microbiome. Shifting the animals to a low-fiber diet had a dramatic effect, they found: Many common species became rare, and rare species became common.

Along with changes to the microbiome, both teams also observed rapid changes to the mice themselves. Their intestines got smaller, and its mucus layer thinner. As a result, bacteria wound up much closer to the intestinal wall, and that encroachment triggered an immune reaction.

After a few days on the low-fiber diet, mouse intestines developed chronic inflammation. After a few weeks, Dr. Gewirtz’s team observed that the mice began to change in other ways, putting on fat, for example, and developing higher blood sugar levels.

Dr. Bäckhed and his colleagues also fed another group of rodents the high-fat menu, along with a modest dose of a type of fiber called inulin. The mucus layer in their guts was healthier than in mice that didn’t get fiber, the scientists found, and intestinal bacteria were kept at a safer distance from their intestinal wall.

Dr. Gewirtz and his colleagues gave inulin to their mice as well, but at a much higher dose. The improvements were even more dramatic: Despite a high-fat diet, the mice had healthy populations of bacteria in their guts, their intestines were closer to normal, and they put on less weight.

Dr. Bäckhed and his colleagues ran one more interesting experiment: They spiked water given to mice on a high-fat diet with a species of fiber-feeding bacteria. The addition changed the mice for the better: Even on a high-fat diet, they produced more mucus in their guts, creating a healthy barrier to keep bacteria from the intestinal walls.

One way that fiber benefits health is by giving us, indirectly, another source of food, Dr. Gewirtz said. Once bacteria are done harvesting the energy in dietary fiber, they cast off the fragments as waste. That waste — in the form of short-chain fatty acids — is absorbed by intestinal cells, which use it as fuel.

But the gut’s microbes do more than just make energy. They also send messages.

Intestinal cells rely on chemical signals from the bacteria to work properly, Dr. Gewirtz said. The cells respond to the signals by multiplying and making a healthy supply of mucus. They also release bacteria-killing molecules.

By generating these responses, gut bacteria help maintain a peaceful coexistence with the immune system. They rest atop the gut’s mucus layer at a safe distance from the intestinal wall. Any bacteria that wind up too close get wiped out by antimicrobial poisons.

While some species of gut bacteria feed directly on dietary fiber, they probably support other species that feed on their waste. A number of species in this ecosystem — all of it built on fiber — may be talking to our guts.

Going on a low-fiber diet disturbs this peaceful relationship, the new studies suggest. The species that depend on dietary fiber starve, as do the other species that depend on them. Some species may switch to feeding on the host’s own mucus.

With less fuel, intestinal cells grow more slowly. And without a steady stream of chemical signals from bacteria, the cells slow their production of mucus and bacteria-killing poisons.

As a result, bacteria edge closer to the intestinal wall, and the immune system kicks into high gear.

“The gut is always precariously balanced between trying to contain these organisms and not to overreact,” said Eric C. Martens, a microbiologist at the University of Michigan who was not involved in the new studies. “It could be a tipping point between health and disease.”

Inflammation can help fight infections, but if it becomes chronic, it can harm our bodies. Among other things, chronic inflammation may interfere with how the body uses the calories in food, storing more of it as fat rather than burning it for energy.

Justin L. Sonnenburg, a biologist at Stanford University who was not involved in the new studies, said that a low-fiber diet can cause low-level inflammation not only in the gut, but throughout the body.

His research suggests that when bacteria break down dietary fiber down into short-chain fatty acids, some of them pass into the bloodstream and travel to other organs, where they act as signals to quiet down the immune system.

“You can modulate what’s happening in your lung based on what you’re feeding your microbiome in your gut,” Dr. Sonnenburg said.

Hannah D. Holscher, a nutrition scientist at the University of Illinois who was not involved in the new studies, said that the results on mice need to be put to the test in humans. But it’s much harder to run such studies on people.

In her own lab, Dr. Holscher acts as a round-the-clock personal chef. She and her colleagues provide volunteers with all their meals for two weeks. She can then give some of her volunteers an extra source of fiber — such as walnuts — and look for changes in both their microbiome and their levels of inflammation.

Dr. Holscher and other researchers hope that they will learn enough about how fiber influences the microbiome to use it as a way to treat disorders. Lowering inflammation with fiber may also help in the treatment of immune disorders such as inflammatory bowel disease.

Fiber may also help reverse obesity. Last month in the American Journal of Clinical Nutrition, Dr. Holscher and her colleagues reviewed a number of trials in which fiber was used to treat obesity. They found that fiber supplements helped obese people to lose about five pounds, on average.

But for those who want to stay healthy, simply adding one kind of fiber to a typical Western diet won’t be a panacea. Giving mice inulin in the new studies only partly restored them to health.

That’s probably because we depend on a number of different kinds of dietary fiber we get from plants. It’s possible that each type of fiber feeds a particular set of bacteria, which send their own important signals to our bodies.

“It points to the boring thing that we all know but no one does,” Dr. Bäckhed said. “If you eat more green veggies and less fries and sweets, you’ll probably be better off in the long term.”

A High-fat Diet May Facilitate Weight Loss: 6 Reasons Why You Must Start Having Fats Today

The study has identified a pathway to prevent fat cell fat cells from growing larger, which can further prevent weight gain and obesity.

In a bid to lose weight many of us fall for several myths and assumption along the way. One of them is avoiding fats. Did you know? Fats are one of the three macronutrients which is essential to sustain a healthy life. Fats helps developing nerve sheath coating, human tissues are made up of fat, hence ruling out fats completely from the diet can never be a good idea. According to a latest study, a high-fat diet may also aid healthy weight loss. The study has identified a pathway to prevent fat cell fat cells from growing larger that leads to weight gain and obesity.

According to the U.S based study published in journal e life, conducted by Washington University in St. Louis U.S; by activating Hedgehog pathway in fat cells in mice- you could feed the animals a high –fat diet without making them overweight. 

According to the researchers, the pathway discovered by the team may act as a new therapeutic target for treating obesity. The researchers explained that the fat accumulation is mainly due increased fat cell size and each fat cell grows bigger so that it can hold larger fat droplets
When the fat cells begin to expand, that is when the person tends to gain weight- as opposed to having more fat cells. The team focused on the so-called Hedgehog protein pathway that is active in many tissues in the body.

For the animal study, the group of researchers engineered mice with genes that activated the Hedgehog pathway in fat cells when those animals ate a high-fat diet. The findings revealed that after about eight weeks of eating the high-fat diet, control animals whose Hedgehog pathways had not been activated became obese.  On the other hand, mice that had been engineered with genes to activate the pathway were fine in terms of their weight gain. They did not gain any more weight than those control animals that consumed normal diets.

The researchers believe that the Hedgehog pathway could have prevented obesity by inhibiting the size of the fat cells and prevented them from collecting and storing fat droplets

Here is a list of benefits that you could derive from eating good fats derived from nuts, lean meat, fish, avocados and ghee. 

  1. A high fat diet is extremely satiating and also keeps your blood sugar level stable. When you embark on a low fat diet in an attempt to lose weight, you may end up hungry and dissatisfied, thus ending up craving for sugary snacks.

  2. Increased fat intake promotes a healthy gut too. Healthy fats work with your gut bacteria to protect the gut barrier that works hard to regulate your immune response and flush out all the toxins and chemicals.

  3. Good fats are good for brain health; our brain is composed of omega-3 fatty acids and docosahexaenoic acid (DHA). A deficiency of fats can lead to stress, anxiety and other mood disorders. So, feel good about adding good fats to your diet and vice versa!

  4. Eating good fats will not make you fat. If you choose to eat healthier fats, in controlled portions, your body will eventually learn to burn fat, instead of sugars, further inducing weight loss. A high-fat diet can also curb hunger and cravings that mostly leads to overeating.

  5. Fat is a crucial element for your body's absorption of the fat-soluble vitamins. Adding fats to your diet will help boost the absorption of vitamins that further help in strengthening your bones, boosting your immune system and protecting your heart health.

  6. A high fat diet benefit includes boosting energy levels. Good fats keep you on your toes throughout the day without having to feel hungry. If you eat a diet centered on carbohydrates, you will experience raises in insulin levels. This rise and then subsequent drop in insulin levels will make you feel tired and lethargic.

Improving Medication Adherence for Chronic Disease Management — Innovations and Opportunities

Adherence to prescribed medications is associated with improved clinical outcomes for chronic disease management and reduced mortality from chronic conditions (1). Conversely, nonadherence is associated with higher rates of hospital admissions, suboptimal health outcomes, increased morbidity and mortality, and increased health care costs (2). In the United States, 3.8 billion prescriptions are written annually (3). Approximately one in five new prescriptions are never filled, and among those filled, approximately 50% are taken incorrectly, particularly with regard to timing, dosage, frequency, and duration (4). Whereas rates of nonadherence across the United States have remained relatively stable, direct health care costs associated with nonadherence have grown to approximately $100–$300 billion of U.S. health care dollars spent annually (5,6). Improving medication adherence is a public health priority and could reduce the economic and health burdens of many diseases and chronic conditions (7).

Understanding Medication Nonadherence

Medication adherence is a complex behavior influenced by factors along the continuum of care, relating to the patient, providers, and health systems (8). Patient-related factors include unintentional factors, which often worsen with increasingly complex medication regimens (e.g., forgetting to take medication or obtain refills, or inadequate understanding of dose or schedules); and intentional factors (e.g., active decision to stop or modify a treatment regimen based on ability to pay, beliefs and attitudes about their disease, medication side effects, and expectations for improvement) (9) (Figure). Additional patient-related barriers include lack of engagement in treatment decisions, impaired cognition (e.g., related to aging or disease), substance abuse, depression, and other mental health conditions. Provider-related factors include barriers to communicating with patients and their caregivers, complex dosing regimens, and limited coordination of care among multiple providers. Health care system and service delivery factors include limited access to an appropriate provider for prescriptions or refills, restricted drug coverage, high costs and copayments, unclear medication labeling and instructions, limited availability of culturally appropriate patient education materials, and inadequate provider time to review benefits, risks, and alternatives to prescribed medications.

Innovative Strategies to Improve Medication Adherence for Chronic Disease Management

Successful efforts to improve rates of adherence often incorporate multiple strategies across the continuum of care. A proven cost-effective strategy to reducing unintentional nonadherence is the use of pillboxes and blister packs to organize medication regimens in clear and simple ways (10). Combining the ease of packaging with effective behavioral prompts, such as electronic pill monitors that can remind patients to take their medication and provide messages to health care providers when a scheduled drug-dose is missed, supports increased medication adherence (11).

Interventions that include team-based or coordinated care have been shown to increase adherence rates. In a recent study, patients assigned to team-based care, including pharmacist-led medication reconciliation and tailoring; pharmacist-led patient education; collaborative care between pharmacist and primary care provider or cardiologist; and two types of voice messaging (educational and medication refill reminder calls) were significantly more adherent with their medication regimen 12 months after hospital discharge (89%) compared with patients not receiving team-based care (74%). Patients reported that team-based care improved their comfort in asking clarifying questions, raising concerns about their medication regimen, and collaborating in developing their treatment plan (12,13).

Lowering economic barriers to prescribed medications also improves adherence rates. In 2007, Pitney-Bowes Corporation employees and beneficiaries with diabetes or vascular disease increased their medication adherence rates increased by 3%–4% after the company eliminated or reduced health plan copays for cholesterol-lowering statins and the antiplatelet medication, clopidogrel (used to prevent heart attacks and strokes), compared with beneficiaries insured by another health plan with the same third-party prescription drugs administrator that did not reduce or eliminate copays for the same medications. These improvements, while modest, could result in significant cost savings in the prevention of acute events (e.g., hospitalizations) and progression of major chronic conditions if scaled to larger populations (14).

System-based strategies that address health disparities can improve clinical goals or reduce disease burden. For example, medication adherence is crucial for persons infected with human immunodeficiency virus (HIV), because treatment lowers the amount of virus circulating in the blood, which improves the patient’s health and reduces the risk of transmitting HIV to others by >90% (15). Interventions, such as CDC’s Data to Care (16) strategy, that identify and re-engage nonadherent patients in care by linking them through the health department, their care providers, or both, improve the health of the individual and achieve the public health benefit of reducing HIV transmission (17).

Advances in health information technology can also improve medication adherence. In a 2011 study, providers using electronic prescribing (e-prescribing) increased first-fill medication adherence by 10% compared with those using paper prescriptions (18). Some e-prescribing software can monitor prescriptions dispensed or unfilled in near real-time, as well as send patients prompts when a new or refill prescription is available. These data allow providers to review current medication use with patients during office visits, identify gaps or barriers to adherence, and discuss workable solutions.

Health information technology can also be used to show real-time impact of medication use on chronic conditions. Reliant Medical Group, a multispecialty group practice in Massachusetts, provided home blood pressure monitors to 200 of its patients. Patients uploaded blood pressure readings into their electronic health record. At office visits, providers were able to display trends of patients’ blood pressure, discuss barriers if blood pressure was not controlled and patients were not adherent, or add alternative drugs or lifestyle changes if pharmacy data indicated patients were adherent but their blood pressure was still poorly controlled. In addition, health information technology systems enabled providers to view medication coverage by insurer and choose lower cost medications. Reliant also made complex prescribing algorithms easier to follow by establishing and incorporating treatment protocols for hypertension into the electronic health record. Using these and other strategies (Box), Reliant improved its hypertension control rate from 68% in 2011 to 79% in 2014 and was recognized as a Million Hearts Hypertension Control Champion in 2015 (19).

Opportunities in Medication Adherence Outcomes

Although a range of interventions have demonstrated improved medication adherence and health outcomes during the study period, few studies have shown that these benefits were maintained over time (20). Interventions that can sustain patient medication adherence are needed. One priority for developing sustainable strategies to improve medication adherence includes standardizing research methodology for both clinic and research settings. Currently, studies use a variety of measurement methods. Varying study methodologies prevents comparability across interventions, hinders wide application into clinical practice, and limits efforts that focus on patients with the greatest burden and need. Standardization might also help to understand both the dose-response and effectiveness of interventions over a longer time, increasing sustainability and reducing a waning effect at follow-up time points (21).

In addition, patient-specific tailored approaches to identifying reasons for nonadherence and aligning intervention efforts to address identified needs are needed. Outcomes might also be improved by recognizing populations at increased risk for nonadherence and addressing the broader reasons for their nonadherence, such as low health literacy. Health literacy is lower among the elderly, racial and ethnic minorities, and persons living in poverty (22). Interventions to improve medication adherence could be more effective if patient’s health literacy, cultural background, and language preference and proficiency are taken into account when designing communication and patient education materials.

Conclusion and Comments

Medication adherence is critical to improving chronic disease outcomes and reducing health care costs. Successful strategies to improve medication adherence include 1) ensuring access to providers across the continuum of care and implementing team-based care; 2) educating and empowering patients to understand the treatment regimen and its benefits; 3) reducing barriers to obtaining medication, including cost reduction and efforts to retain or re-engage patients in care; and 4) use of health information technology tools to improve decision-making and communication during and after office visits. Understanding root causes of medication nonadherence and cost-effective approaches that are applicable in diverse patient populations is essential to increasing adherence and improving long-term health impact.

Conflict of Interest

Dr. Ho reports grants from Veterans Health Administration during the conduct of the study; personal fees from Janssen, Inc., personal fees from American Heart Association, outside the submitted work. Dr. Garber reports grants from Agency for Healthcare Research and Quality during the conduct of the study.

Corresponding author: Andrea B. Neiman,, 770-488-8255.


1Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, CDC; 2Rush University, College of Nursing, Chicago, Illinois; 3Veteran’s Administration Medical Center, Denver, Colorado; 4University of Colorado Denver; 5Reliant Medical Group, Worcester, Massachusetts; 6U.S. Public Health Service Commissioned Corps, Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC; 7Office of the Associate Director for Science, CDC.



  1. Vrijens B, De Geest S, Hughes DA, et al. ; ABC Project Team. A new taxonomy for describing and defining adherence to medications. Br J Clin Pharmacol 2012;73:691–705. CrossRef PubMed
  2. DiMatteo MR. Variations in patients’ adherence to medical recommendations: a quantitative review of 50 years of research. Med Care 2004;42:200–9.CrossRef PubMed
  3. Cutler DM, Everett W. Thinking outside the pillbox—medication adherence as a priority for health care reform. N Engl J Med 2010;362:1553–5.CrossRef PubMed
  4. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005;353:487–97. CrossRef PubMed
  5. Iuga AO, McGuire MJ. Adherence and health care costs. Risk Manag Healthc Policy 2014;7:35–44 . CrossRef PubMed
  6. Viswanathan M, Golin CE, Jones CD, et al. Interventions to improve adherence to self-administered medications for chronic diseases in the United States: a systematic review. Ann Intern Med 2012;157:785–95. CrossRef PubMed
  7. National Center for Health Statistics. National health expenditures, average annual percent change, and percent distribution, by type of expenditure: United States, selected years 1960–2014. Hyattsville, MD: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2015.
  8. Gellad WF, Grenard K, McGlynn EA. A review of barriers to medication adherence: a framework for driving policy options. Santa Monica, CA: RAND; 2009.
  9. Lehane E, McCarthy G. Intentional and unintentional medication non-adherence: a comprehensive framework for clinical research and practice? A discussion paper. Int J Nurs Stud 2007;44:1468–77. CrossRef PubMed
  10. Ruppar TM, Delgado JM, Temple J. Medication adherence interventions for heart failure patients: a meta-analysis. Eur J Cardiovasc Nurs 2015;14:395–404. CrossRef PubMed
  11. Checchi KD, Huybrechts KF, Avorn J, Kesselheim AS. Electronic medication packaging devices and medication adherence: a systematic review. JAMA 2014;312:1237–47. CrossRef PubMed
  12. Lambert-Kerzner A, Havranek EP, Plomondon ME, et al. Perspectives of patients on factors relating to adherence to post-acute coronary syndrome medical regimens. Patient Prefer Adherence 2015;9:1053–9. CrossRef PubMed
  13. Ho PM, Lambert-Kerzner A, Carey EP, et al. Multifaceted intervention to improve medication adherence and secondary prevention measures after acute coronary syndrome hospital discharge: a randomized clinical trial. JAMA Intern Med 2014;174:186–93. CrossRef PubMed
  14. Choudhry NK, Fischer MA, Avorn J, et al. At Pitney Bowes, value-based insurance design cut copayments and increased drug adherence. Health Aff (Millwood) 2010;29:1995–2001. CrossRef PubMed
  15. Cohen MS, Chen YQ, McCauley M, et al. ; HPTN 052 Study Team. Antiretroviral therapy for the prevention of HIV-1 transmission. N Engl J Med 2016;375:830–9. CrossRef PubMed
  16. CDC. Data to care. Using HIV surveillance data to support the HIV care continuum. Atlanta, GA: US Department of Health and Human Services, CDC; 2017.
  17. Crepaz N, Dong X, Chen M, Hall HI. Examination of HIV infection through heterosexual contact with partners who are known to be HIV infected in the United States. AIDS 2017;31:1641–4. CrossRef PubMed
  18. Surescripts. The national progress report on e-prescribing and interoperable health care. Arlington, VA: Surescripts; 2011.
  19. Million Hearts. Reliant Medical Group strategizes for the road to success. Empowering patients to control hypertension. Atlanta, GA: US Department of Health and Human Services, CDC, Million Hearts; 2017.
  20. Demonceau J, Ruppar T, Kristanto P, et al. ; ABC project team. Identification and assessment of adherence-enhancing interventions in studies assessing medication adherence through electronically compiled drug dosing histories: a systematic literature review and meta-analysis. Drugs 2013;73:545–62.CrossRef PubMed
  21. Bosworth HB, Granger BB, Mendys P, et al. Medication adherence: a call for action. Am Heart J 2011;162:412–24. CrossRef PubMed
  22. Lewey J, Shrank WH, Bowry AD, Kilabuk E, Brennan TA, Choudhry NK. Gender and racial disparities in adherence to statin therapy: a meta-analysis. Am Heart J 2013;165:665–78. CrossRef PubMed



Download the full article here


5 Hearty Mushroom Recipes Under 400 Calories

As the Winter holidays approach, we thought you might enjoy a few heart-healthy recipes that incorporate earthy, funky mushrooms which are in peak season right now!

There are so many varieties to choose from — portobello, cremini, chanterelles and shiitake, and mushrooms are hearty vegetables that many vegetarians substitute for meat in dishes. Each of these five recipes — all under 400 calories — makes the most of the season’s star fungi, with four being vegetarian.


This recipe comes together in less than 25 minutes. It’s adaptable to your pantry — if you don’t have egg noodles, use another kind of pasta, and if you’re out of tarragon, swap in basil, oregano or thyme. Recipe makes 4 servings.

Nutrition (per serving): Calories: 339; Total Fat: 11g; Saturated Fat: 3g; Monounsaturated Fat: 5g; Cholesterol: 65mg; Sodium: 532mg; Carbohydrate: 27g; Dietary Fiber: 1g; Sugar: 1g; Protein 29g


With less than 350 calories and bursting with flavor thanks to fresh herbs, hazelnuts and champagne vinegar, this panzanella makes a satisfying side dish or light dinner. Recipe makes 3 servings.

Nutrition (per serving): Calories: 336; Total Fat: 11g; Saturated Fat: 2g; Monounsaturated Fat: 10g; Cholesterol: 0mg; Sodium: 240mg; Carbohydrate: 37g; Dietary Fiber: 4g; Sugar: 8g; Protein: 6g


Ideal for a festive brunch or easy dinner party, this dish is ready in less than 30 minutes. The mushroom sauce tempers the rich fontal cheese with melt-in-your-mouth polenta. If you can’t find fontal or fontina cheese, use provolone, gruyere or gouda. Recipe makes 4 servings at 1 gratin each.

Nutrition (per serving): Calories: 374; Total Fat: 18g; Saturated Fat: 3g; Monounsaturated Fat: 7g; Cholesterol: 43mg; Sodium: 518mg; Carbohydrate: 37g; Dietary Fiber: 4g; Sugar: 9g; Protein 17g


Marinating the portobello mushrooms in this dish adds a bright balsamic-ginger flavor. Serve on a bun for a complete meat-free meal or as a hearty side. Recipe makes 4 servings at 1 mushroom each.

Nutrition (per serving): Calories: 373; Total Fat: 18g; Saturated Fat: 2g; Monounsaturated Fat: 13g; Cholesterol: 0mg; Sodium: 544mg; Carbohydrate: 29g; Dietary Fiber: 12g; Sugar: 9g; Protein: 18g


Give beef the night off by swapping it for shiitake, baby portabella and cremini mushrooms in this vegetarian take on stroganoff. Served with a creamy sauce over egg noodles, it’s the perfect dish for a chilly fall day. Recipe makes 4 servings at 1 1/2 cups each.

Nutrition (per serving): Calories: 391; Total Fat: 8g; Saturated Fat: 4g; Monounsaturated Fat: 2g; Cholesterol: 19mg; Sodium: 341mg; Carbohydrate: 66g; Dietary Fiber: 4g; Sugar: 12g; Protein: 15g

Air pollution and exercise: Is it safe to train outside?

"A gas chamber."

That’s how New Delhi’s chief minister, Arvind Kerjrival, described the smog that recently blighted the Indian capital.  

Last week, the city saw levels of air pollution that were 30 times the World Health Organisation’s recommended limit, prompting calls to temporarily ban large vehicles, close schools, and – in what seems an eminently sensible move - cancel a half marathon.  Nevertheless, at the time of writing, the Airtel Dehli Half Marathon is still scheduled to go ahead as planned.

Are we killing ourselves by exercising outdoors in polluted areas? Or do the benefits of exercise protect us from any negative health impact of breathing polluted air? Let’s examine the evidence.

Types of air pollution

Polluted air contains different types of harmful constituents.  Below are the main ones:

  • Particulate matter, as its name suggests, refers to tiny particles of solids and liquids suspended in the air. They’re made up of various materials: metals, carbon, hydrocarbons formed from burning, biological matter such as pollen, dust from minerals, sea salt, sulfate, nitrate and ammonium. A lot of the items on this list are produced (either directly, or through secondary chemical reactions in the air) from man-made processes: the industrial combustion of fossil fuels and friction from vehicle brake pads/tires being two such culprits. But, Mother Nature is also culpable – sea spray, wildfires and volcanoes all generate particulate matter.

We can see some particles with the naked eye, but the more pernicious particulate matter is too fine to see.  There’s good reason for this: whereas larger particles are filtered by hairs in the nose and upper respiratory tract, smaller particles can enter deeper inside the lungs and even penetrate the bloodstream, causing all sorts of damage to your respiratory and cardiovascular system. Scientists classify these smaller, more harmful particles into three groups:

  •  PM10 – ‘coarse particles’ have a diameter between 2.5 and 10 µm (micrometers/microns). They can enter your airways (trachea, bronchi, bronchioles).
  • PM2.5 – ‘fine particles’ have a diameter less than 2.5 µm (micrometers/microns). These particles can get into your air sacs (alveoli).
  • PM0.1 – ‘ultrafine particles’ have a diameter less than 0.1 µm. After getting into the air sacs of your lungs, they may pass into the bloodstream.


  • Nitrogen dioxide (NO2) is a pollutant gas produced by power plants, domestic heating, and motor vehicles: the much-maligned diesel engine being a major source in urban areas. NO2 can irritate your airways, exacerbate lung conditions such as asthma, and increase susceptibility to respiratory infections.   
  • Sulfur dioxide (SO2) is another pollutant gas, released from power plants that burn fossil fuels, petroleum refineries, and industrial cement manufacturers. As well being an irritant gas, SO2 also contributes to the formation of another air pollutant, ozone.
  • Ozone (O3) is a gas found higher up in the Earth’s atmosphere, where it absorbs harmful UV radiation. Closer to the ground, it is formed from chemical reactions involving sunlight and man-made pollutants such as nitrogen dioxide and hydrocarbons. This ground level ozone can irritate lungs, and hamper the respiratory system’s immune defenses. 

Health risks of air pollution

So, just how bad is air pollution? According to the World Health Organization (WHO), air pollution is linked to 7 million premature deaths (under the age of 70) worldwide each year. In the UK, PM2.5 particulate matter is thought to contribute to 29,000 premature deaths per year. When nitrogen dioxide exposure is factored in, this figure rises to a staggering 40,000.

Unlike inhaling a lethal gas (e.g., hydrogen cyanide), air pollutants do not cause deaths directly. Rather, they increase the risk of and exacerbate cardiovascular and respiratory illnesses, such as heart attack, stroke, atherosclerosis, bronchitis, asthma and COPD (chronic obstructive pulmonary disease). “How?” you may ask. It’s complicated, but current research suggests that air pollutants cause oxidative stress (a process where damaging free-radical molecules build up in the body), which leads to inflammation and narrowing of the linings of airways and blood vessels. 

It all sounds pretty grim. What’s also troubling, however, is that exercise could make us even more vulnerable to the health risks of air pollution. Well, in theory at least.

Exercising in air pollution

There are four main reasons why exercise might worsen the health effects of air pollution.

  1.  Whenever you exercise, the amount of air you inhale each minute (your minute ventilation rate) increases.  By extension, you also inhale more air pollutants. Indeed, studies show that high-intensity exercise can raise the fraction of particulate matter deposited in your lungs by between 6 and 10-fold. 
  2. Air flows through your airways more quickly during exercise, which may carry pollutants deeper into your lungs, increasing the risk of ultrafine (PM0.1) particles being absorbed into the bloodstream.
  3. At a certain exercise intensity (around 100W of exercise output), you start to breathe mainly through your mouth rather than through your nose, meaning inhaled air bypasses your nose’s inbuilt filtration system, allowing larger particulate matter into your lungs.
  4. Strenuous exercise impairs the ability of your hairs lining your airways (cilia) to clear pollutants.

So, exercising in polluted areas must be bad for you, right? Not necessarily. 

Juggling risks and benefits

It’s certainly true that air pollution can negatively impact both health and athletic performance. Studies of elite athletes suggest that dilation of blood vessels (vasodilatation) and the ability to change heart rate in response to training demands (heart rate variability) are impeded by inhaling air that is high in particulate matter. It’s worse for people with asthma and existing respiratory and cardiovascular disorders – (if you suffer from any of these, it’s wise to consult your physician before exercising in polluted areas).

Nevertheless, exercise confers several benefits for cardiovascular and respiratory health – reduced inflammation, lower blood pressure, improved blood flow, to name just a few. And the good news is that these benefits are generally thought to outweigh the adverse risks of air pollution. Put simply; it’s better to go out for a jog in downtown New York than sit inside on the sofa. 

Exercise may also directly protect against the pollutants in inhaled air. Physically fit people with a low resting heart rate (below 70 beats per minute) seem to be resistant to blood pressure rises induced by increasing inhaled particulate matter. If you need help getting fit, why not check out our Get Fit plan.

Of course, the exact risk-benefit ratio of exercising outdoors varies according to the amount of exercise you do and the local levels of air pollution in which you do it. There may indeed be a ‘break-even point’, after which exercise in polluted air becomes deleterious to overall health. According to one study, for someone who cycles 30 minutes a day, this break-even point comes at a background level of PM2.5 pollution of 160µg/m3. To put that figure in context, only the cities of Zabol in Iran (with a PM2.5 of 217µg/m3), and Gwalior (176 µg/m3) and Allahabad (170 µg/m3) in India, have average levels of pollution above this. (As for New Dehli, last Monday saw PM2.5 levels of 438 µg/m3).

So, whether you’re in New York (9 µg/m3), Los Angeles (11 µg/m3), London (15 µg/m3), Toronto (8 µg/m3) or Sydney (8 µg/m3), the typical advice would be: get out there and exercise! Just try your best to avoid busy roads with lots of traffic and check the day’s air quality index before you head out the door

Use Annual Wellness Visits to Amplify Overall Quality

Whether you are delivering primary care through a multi-state integrated system or a rural independent practice, benefits abound in optimizing this fully reimbursed Medicare service.

Despite primary care providers' celebration when the Centers for Medicare & Medicaid Services began paying for the preventive service now known as the Annual Wellness Visit (AWV) in 2011, the majority of PCPs continue to forgo those dollars.

But according to our Clinic Clients who have made a concerted effort to promote and perfect the service, revenue is far from the only benefit of a strong AWV strategy.

Success Key No. 1: Educate Providers

Nationally, in 2016, 19.8% of eligible Medicare Part B beneficiaries utilized the AWV, according to a CMS report, despite the fact that CPT codes G0438 for the initial visit and G0439 for a subsequent AWV are paid 100% by Medicare and can be combined with another visit with the addition of a modifier.

The barriers to higher uptake are mostly cultural. In particular, there is a common perception among physicians that the service is unnecessary. Doctors often argue, for example, that the questions raised in the AWV about recommended cancer screening and immunization are already raised during the course of regular primary care.

Oftentimes, providers also experience or fear seniors being dissatisfied with coming to the office for a visit that involves no physical exam. An important first step for MassCare was just getting physicians acquainted with what it is. After that it's really about removing as many impediments as possible to getting it done.   MassCare accomplishes this by hiring and installing a Medical Assistant (MA) and PharmD within the Clinic to schedule and manage all aspects of the AWV program.

MassCare has developed a complete toolkit that explains what should be included in an AWV, how to bill for it, and when and why a copay might be required.

The toolkit started as an internally developed communication outlining the reason for prioritizing the AWV, as well as, a summary of the documentation requirements and tips for coding the visit. It also includes some tools available from the CMS Learning Network and others including potential workflows, scripts, explanatory articles, and other tips.

This includes education on coding, the EHR workflows we developed, a scheduling/registration workflow, and scripting to encourage patients in the office, and over the telephone to get an AWV.

Success Key No. 2: Engage Patients

Sometimes the most challenging part of the AWV is selling it to the patient. From a flow standpoint it can initially be a struggle, and a lot of that is getting patients to come in specifically for that wellness visit. For that generation, it's a new thing. To them, you go to the doctor when you're sick. It doesn't make sense to them to come to the doctor when they feel fine.

MassCare has found much success in scheduling AWVs in conjunction with other follow-up and acute visits. Patients who come in for a diabetes follow-up visit, for example, can undergo their AWV the same day.

For many seniors, especially those with transportation problems, the twofer visit has a social appeal as well. It's their chance to get dressed and get out of the house. And if they're coming on one of the senior buses they get to visit with peers. They seem to appreciate the fact that they're not just in and out for a so-called eight-minute visit.

Once patients participate in one or two recurrent AWVs, their engagement in their overall health seems to be on an upswing.

Success Key No. 3: Take a Team Approach

The team approach is supported by MassCare's collaborating team of MA and Pharmacist. We've designed the program so that it can managed successfully between our MA and PharmD. For example, MAs will often call patients before their AWV and ask several screening questions then. So when they come in, it's a shorter time in the clinic. But even a full AWV takes an average of 30 minutes total. Another key to efficiency is that care teams review a patient's EMR prior to any visit and know of any issues, such as an elevated A1C level, before walking into the room. The MA or PharmD is fully prepared by the time she/he gets the patient out of the waiting room, and reviews the recommendations with them while walking back out.

Success Key No. 4: Connect to Quality

With an average reimbursement of $172 for an initial AWV and $111 for subsequent AWVs, the revenue can add up for primary care practices of all sizes. But the value is best measured in terms of benefit to the patient. CMS is asking us to be good stewards by making this available, and we want to make sure we're delivering the aims they intended when they created the opportunity to do an AWV.

Success Key No. 5: Celebrate Success

With the wrinkles ironed out, AWVs can also have a positive impact on providers and employees.

By providing proactive care, Clinic staff can easily observe the positive impact they have on patients enrolled in the AWV program. This fact increases overall staff morale, while also increasing patient satisfaction, Quality Scores and Clinic revenue.