Monday, May 30, 2011

Time for Medicare to Quit Ignoring Primary Care

An article by Brian Klepper and Paul Fischer at Health Affairs has me all fired up.  Finally these two health experts are calling it like it is.  The Wall Street Journal, New York Times and EverythingHealth have written before about the way primary care is undervalued and underpayed in this country and how it is harming the health and economics of the United States.  A secretive, specialist-dominated panel within the American Medical Association called the RUC has been valuing medical services for decades.  They divvy up billions of Medicare and Medicaid dollars and all Insurance payers base their reimbursement on these values also.  The result has been gross overpayment of procedures and medical specialists and underpayment of doctors who practice primary care. (Internal Medicine, Family Medicine and Pediatrics).  These payment inequities have led us to a shortage of these doctors and medical costs skyrocket as a result.  As Uwe E. Reinhardt says; "Surely there is something absurd when a nation pays a primary care physician poorly relative to other specialists and then wrings its hands over a shortage of primary care physicians."

Klepper, Fischer and author Kathleen Behan make a bold suggestion.  Let's quit complaining about the RUC and their flawed methodologies.  Let's quit admiring the problem of financial conflicts of interest and the primary care labor shortage.  It's time for the primary care specialty societies - The American Academy of Family Physicians and the American College of Physicians (my addition) to pull out of the RUC.  Yes, just quit and do it in a public manner.

There would certainly be a negative public relations backlash when a prestigious specialty society says "We're mad as hell and not going to take it anymore".  The AMA would have to take notice as would CMS (Centers for Medicare and Medicaid Services).  If the American College of Physicians and the American Academy of Pediatrics would also defend it's primary care physicians, it would send a strong and powerful message.  Primary Care has been decimated and the RUC is to blame...pure and simple.

Klepper and Fischer say "We have had two decades of declining reimbursement that has gutted primary care's viability...".  We should all care because every modern Nation that exceeds our outcomes for lower cost does so by valuing primary care and supporting it as part of health care policy.  If we are really serious about health care reform and bringing costs under control, we first have to build the infrastructure of public health and that is strong, viable primary care for all Americans.

Sunday, May 29, 2011

Divorce rates higher in couples with long commutes

Researchers at Umea University in  Sweden found that divorce rates are 40% higher in people who have commutes greater than 45 minutes.  The study looked at 2 million households and found that long commutes were even more difficult for women.  The risk for divorce was highest during the first few years of commuting. 

We have been a commuting culture for decades...especially in large urban areas like LA, San Francisco, New York or cities that are just sprawling and spread out like Phoenix and even Oahu, Hawaii.  It doesn't take a scientist to tell us that getting up at the crack of dawn (or earlier) to get into a car or a train and travel a long distance to work every single day would be bad for your mental and physical health.  Time spent commuting is time that is NOT spent exercising, relaxing, playing with the kids, walking the dog or talking with your spouse.

But for those of you who want more scientific proof, a Gallup-Healthways Well-Being Index survey found that the average commute from home to work is 23 minutes.  Only 3% of U.S. workers commutes for more than an hour each day.  That may seem like a small number but 3.5 million Americans are extreme commuters logging in over 90 minutes each way.  Those who do report long commutes are more likely to complain of neck or back pain, high cholesterol and obesity.  The emotional states with negative emotions are also higher in people who commute longer. 

Many folks endure these commutes in order to buy homes that they can afford.  Now with the housing meltdown, perhaps couples will re-think their lives and find a place closer to work.  The money saved on commuting and the time saved could turn out to be a true win. 

Also think of the money saved by NOT re-entering the dating scene after the divorce.

Thursday, May 26, 2011

Why Health Care Costs So Much

It is my job at EverythingHealth to steer the reader to great information.  For this reason I am providing you with a Link to The New England Journal of Medicine article titled "The $650 Billion Dollar question - why does cost effective care diffuse so slowly?"  I have retitled it "Why Health Care Costs So Much".

The United States spends much more on health care than other industrialized nations with no improvement in outcomes or health status of it's citizens.  If we enacted some of the policies that other nations use, we would have $650 Billion to spend on education, infrastructure, social security and other societal needs.  Why can't we get there?

Read here to understand the barriers.  It isn't simple.  Resistance to change and instituting cost effective care has many stakeholders including legislators, doctors, hospitals, drug and equipment manufacturers, academic training centers, insurance companies and even the media.  We, the public, are also to blame for not understanding that reform which lowers costs would benefit all of us.  There is no free lunch.  When the cost of care goes up for employers, that keeps our wages stagnant.  When millions are uninsured, the cost of their care is born by everyone and it is inefficient care.

The article authors tell us:  "Legislators, for their part, usually oppose reforms that would make U.S. health care more cost-effective because they seek campaign contributions from health industry stakeholders who benefit from the current inefficient arrangements. Any sector that stands to sustain losses if reform is enacted will fight harder to oppose change than the more diffuse potential winners will fight to support it."

Don't take my word for it.  Go to the article and read about the $650 billion opportunity if we just enacted some cost saving efficient processes and organized our care delivery differently.

Monday, May 23, 2011

Top Ten Greatest Public Health Achievements of this Century

The Center for Disease Control published the top ten public health achievements from 2001-2010, the first decade of the 21st century.  In no order they are:
  • Vaccine-preventable Diseases - new vaccines for herpes zoster, pneumonia, HPV and rotavirus have saved thousands of lives  When you add in the older vaccines for diptheria, pertussus, tetanus and measles/mumps millions of lives have been saved around the world.  (I saw diptheria in Haiti and it is horrible)   
  • Tobacco Control- We have been battling tobacco since 1964 but there is finally progress with more states enacting smoke-free laws and raising cigarette taxes.  By 2010, the FDA banned flavored cigarettes and established restrictions on youth access.  We have a long way to go.  Smoking costs us all about $193 billion a year on medical costs and loss of productivity. 

  • Motor Vehicle Safety -Enforcing seat belt and child safety legislation has reduced deaths from crashes.  Teen drivers have new policies too.
  • Cardiovascular Disease Prevention-During the past decade, age-adjusted heart disease and stroke deaths declined.  What worked? Treating hypertension, elevated cholesterol and smoking...along with improved treatment and medication.
  • Occupational Safety- Farm safety, crab fishing safety, patient lifting in hospitals, workplace associated injury have all improved over the last decade from improving working conditions.  OSHA regulations have helped workers.

  • Cancer Screening- Screening for colorectal cancer, breast and cervical cancer have reduced cancer death rates over the past decade.
  • Public Health Preparedness and Response- The terrorist acts of 2001 kicked this country into gear and tremendous improvements have been made in public health threats.  Even the 2009 H1N1 influenza pandemic was handled well due to increased surveillance and response.
  • Childhood Lead Poisoning Prevention-We don't think of this much anymore but in 2000 childhood lead poisoning was a huge public health issue, especially for children living in poverty.  By 2010, 23 states had laws that prevented lead poisoning.  The question is why not all 50 states?
  • Maternal and Infant Health-We actually do not perform well on maternal and infant health compared to other Western nations, but we have made strides in the number of infants born with neural tube defects (thanks to folic acid prenatal vitamins) and improvement in newborn screening for hearing loss and other disorders.
  • Prevention and Control of Infectious Diseases- Tuberculosis cases dropped by 30% and there has been a 58% decline in catheter related blood stream infections.  We are able to identify contaminated food rapidly and HIV screening has improved throughout the decade.  Did you know that in 2004, canine rabies was eliminated in the United States?
Although we hate the idea of big brother telling us how to live our lives, the fact is that encouraging healthy behavior through taxation or by shaping it through regulations actually works to create a healthier population.  It also saves billions of dollars in public cost.

    Saturday, May 21, 2011

    Answer to Medical Challenge

    This is a really good one and several of you got it right.  The answer is #1. Endometrioma.  (scroll to post on 5/19/2011 for the image)

    The woman's medical history was significant for dysmenorrhea (painful periods) and two recent laparoscopic resections of endometriomas. Histologic examination after resection of the nodule revealed the presence of endometrial glands and stroma. Endometriosis of the umbilicus, also called Villar’s nodule, is a rare presentation of extrapelvic endometriosis.

    Endometriosis is a condition where cells that line the uterus start growing in other areas of the body.  They are responsive to hormones and that is why she had intermittent bleeding. (that was the cue to the diagnosis).  Endometriosis is common but having tissue like this that goes beyond the pelvis is quite rare.

    Thursday, May 19, 2011

    California will release expensive medical prisoners

    I wrote previously about the Governor from Mississippi who released two sisters from prison because the cost of providing dialysis was more than the prison system could bear.  This seems to be a nationwide trend.  Under a state law signed by Gov. Arnold Schwarzenegger in September, prisoners who are in a highly incapacitated state and deemed to pose no threat to society can be released if the parole board approves.  The legislation was passed as a cost savings measure.

    The first prisoner up for release is Steven Charles Martinez, a 42 year old quadriplegic who needs total care.  He had multiple arrests before entering prison in 1998 after being convicted in a brutal rape and kidnap of a woman.  It was a very violent crime and he was sentenced to 157 years in prison.  While in prison,  two inmates attacked Martinez and stabbed him in the neck, lacerating his spinal cord and making him a quadriplegic who requires feeding, position change, oral care and cleaning of his body and bed due to incontinence.

    Both the warden and chief medical officer at the Corcoran prison have recommended he be released as he poses no threat to society in his current state.  So far the corrections department has recommended that the parole board deny his release due to the "vile nature" of his crimes who could use others to carry out his threats. The state Board of Parole hearing will begin next week.

    There are dozens of other incapacitated prisoners who would qualify for early release and will be up for hearings.

    I am slightly conflicted on this issue.  The cost of caring for these patients will not go away if they leave prison.  They will become Medicare/Medical eligible and still depend upon taxpayer's dollars.  But the care would be cheaper as prison care is much more expensive and special guards are required for all patients-even those in vegetative states when they receive medical care.

    Our prisons are designed to protect the public, but also to "punish" the offender.  Victim groups expect the offender to spend their remaining days locked up.

    This is one with no easy answers.  I don't want an aging child molester or violent murderer at home sitting comfortably on a sofa, watching re-runs of "CSI".  But spending millions on debilitated prisoners, when that money could be better spent on children and other needed health care should tilt the scale toward  financial stewardship and common sense.

    This Weeks Medical Challenge

    It's time again to test your diagnostic skill with the New England Journal of Medicine image challenge. (click on the image to see up close)   The nodule formed in this young woman in the umbilical (naval) area and bled intermittently.  What is the diagnosis?

    1.  Endometrioma
    2.  Metastatic adenocarcinoma
    3.  Omphalith
    4.  Umbilical hernia
    5.  Urachal cyst

    Give me your best answer as a comment and I will post the answer with fascinating learning points tomorrow.

    Tuesday, May 17, 2011

    Powerful Men with Powerful Flaws

    Arnold Schwarzenegger's revelation about his long-term  affair with his household employee that involved a child being born is the latest in a string of powerful men with career ending flaws.  Add to that the  shocking arrest this week of powerful Dominique Strauss-Kahn for allegedly raping a hotel maid and we must ask, "What the heck is going on with these guys?"

     I can't count the number of heartfelt apologies that have been rendered to the press by wandering husbands, as their beautiful wives stood quietly by.  Think back to a few; Jimmy Swaggert, Ted Haggard, President Clinton, Tiger Woods, Jim Baker, Gary Hart, Gov. Mark Sanford, Cong. Gary Condit, Gov. Elliot Spitzer. Sen John Edwards, Newt Gingrich...the list goes on and on.  What is it about these men of power that they take such risks with their family and career? Are powerful people more likely to cheat than men who aren't in the spotlight?

    One study published in Psychological Science claims the likelihood of infidelity increases the more powerful someone is.  The study looked at 1,561 readers of a Dutch business magazine and found that the higher someone was in the hierarchy, the greater the chance that they had cheated on their partner or intended to do so in the future.  The authors believe it is linked to confidence- the more power both men and women had, the confident they were and the more likely they were to cheat.

    When powerful men risk everything with careless behavior, it can't be explained away by just saying they were confident.  If you add in arrogance and a sense of superiority, you might be on to something.  Perhaps powerful men believe they can do things that other mortals are forbidden to do.  After all, they are special. Their egos are fed constantly.  Most of them have hoards of hangers-on and "yes-men" around them and where ever they go they are treated with respect and awe.  Power and money go together and these are men that do not worry about things we mere-mortals do.  They go first class for everything and that also can mean taking what they want, when they want it.

    The recklessness and risk-taking are beyond the imagination, yet they do it repeatedly, thinking they are above the law.  Breaking the rules may be an immediate thrill, but the long term consequences are felt by their wives, supporters and constituents.

    I think John Edwards summed it up in his self-examining statement on ABC's Nightline:

    "This is what happened," he told a stone-faced Bob Woodruff. "I grew up as a small town boy in North Carolina. And I came from nothing, worked very hard, dreamed that I'd be able to do something hopeful and helpful to other people with my life. I became a lawyer. Through a lot of work and success, I gained some acclaim as a lawyer. People were telling me, 'Oh you're such a great person, such a great lawyer, such a talent. You're gonna go—there's no telling what you'll do.' And this was when I was 30, 31 years old. Then I went from being a senator— young senator—to being considered for vice president, running for president, being a vice presidential candidate, becoming a national public figure. All of which fed a self-focus, an egotism, a narcissism that leads you to believe that, that you can do whatever you want. You're invincible. And there will be no consequences."

    Sunday, May 15, 2011

    Real Food Doesn't Need Hype

    The article from The New York Times about "Foods with Benefits" is a great read.  (Don't click this post first and then read the article).  It talks about what consumers are seeing at the grocery aisles as well as in advertising.  Food is being packaged and advertised as a miracle for good health.  They say certain foods can lower cholesterol, fix irritable bowel, cause weight loss or act as an antioxidant.  The large food manufactures like Kellogg, General Mills, and Dannon advertise packaged foods and exaggerate their claims.  Since everyone in America now knows that our diets are unhealthy, these appeals to eat more healthily have a big audience...$37.3 billion big for foods that "improve body function".

    So this gives me a chance to promote something that I have no financial interest in what-so-ever.  We just bought a Vitamix at Costco and this one electronic machine is going to save us thousands of dollars on juice, smoothies and other "healthy" foods.  The Vitamix looks like a blender but its industrial high speed action allows fruits and vegetables to be blended to smooth perfection.  There is no need for processed foods or sugar additions.  Most of a persons shopping can be done in the produce aisle and natural sweeteners like Stevia (and vanilla stevia...yum) make a any drink delicious.

    I know I sound like a commercial but imagine starting your day with a drink that contains a handful of spinach, some apple, kale and grapes.  No waste or pulp and the vitamins are intact.  That is what the Vitamix is doing for my family.

    The Vitamix is expensive but lasts for years and you'll never go to Jamba Juice again. 

    Michael Pollan says "Eat food. Not too much. Mostly plants."  Our personal health cannot be separated from the health of the food chains of which we are part.  The American supermarket is a confusing place and made more so by deceptive advertising and product placement.  It shouldn't be so hard to eat well.  Perhaps we just need to simplify it a bit.

    Tuesday, May 10, 2011

    NSAIDs are a problem for Cardiac Patients

    New information published in Circulation advises against using any nonsteroidal anti-inflammatory drugs (NSAIDs) in patients who have had a prior heart attack.  These over-the-counter drugs are commonly used  like Advil, Aleeve, Diclofenac, Ibuprofen.  Using NSAIDs for even as little as one week was associated with a 45% increase for death or recurrent myocardial infarction (MI).  The researchers could not identify a period that seemed to be safe, no matter how short.

    The study used the Danish National Patient Registry and identified 83,675 patients who had a first MI between 1997 and 2006.  The average age was 68 years and 65% were men.   All the NSAIDs (except Naprosyn) used during the observation period were associated with an increased risk for death or new heart attack.  Diclofenac (brand name Voltaren) was the worst. 

    Readers should not go away thinking NSAIDs cause heart attacks.  This study looked at patients who had already had an MI.  But for those patients, the over-the-counter pain relievers should be avoided.  Many patients with heart disease also have arthritis or other pain syndromes.  We need to come up with safe treatments for pain or use "safer" NSAIDs like low dose Naprosyn or Ibuprofen only when the benefit is weighed with the risk.

    Just because something is sold without a prescription does not mean it is without risk.  Tell your doctor every medication you take.

    Saturday, May 7, 2011

    Best and Worst Place to be a Mother in the World

    Happy Mothers Day to mothers everywhere.  It is an important day for us to honor women and acknowledge the incredible hard work of mothering. There are some places in the world where being a mother is positively life threatening.  The worst place to be a mother is Afghanistan.

    Childbirth in Afghanistan is  primeval.  One in 8 women in Afghanistan die during pregnancy or childbirth, more than any place in the world.  Unicef says 52 babies out of every 1,000 die within two weeks of birth and 134 die before their first birthday.  The deaths occur because of obstructed labor, having children too young and vitamin D deficiency from staying indoors and covered up.  Most of the women - 87%- deliver with no skilled help because women cannot leave home without a male and there are  so few midwives to help.  Poverty and illiteracy are dangerous for women.   (folks, read that paragraph again and just think about what it would be like to be pregnant in Afghanistan)

    Being a mother in Afghanistan is a true act of courage.

    The top place to be a mother is Norway.  Women are well educated and the maternal and infant death rate are the lowest in the world.  Number two is Australia with low child mortality.   Sweden and Iceland are also ranked very high because of their female education and generous maternal and child benefits that allow women to be home with their babies without incurring financial disaster.

    In case you are wondering, the United States ranks lowest of all developed countries (#31).  We are equal to Latvia for under 5 mortality and we have the least generous maternity leave policy - both in terms of duration and percent of wages paid.  I think most mothers in the U.S.  could tell you this if you asked! 

    But even so, we have it great compared to the mothers of Sierra Leone and the Democratic Republic of Congo, where mothers and babies have been brutalized for decades.

    Honoring mothers is a wonderful thing.  How much better it would be to really enact changes that support mothers and children around the world.  Increasing education levels for women and girls and providing access to maternal and child health care and advancing women's economic opportunities would be the best mothers day present of all.

    Here are some ways you can help support women and mothers.  Happy Mothers Day.

    Women for Women International
    Kiva Loans
    Womans Initiative

    Friday, May 6, 2011

    Answer to Medical Challenge

    The answer to yesterday's medical challenge is....drumroll.....

    #4 -  Sugar

    Plain granulated sugar can be applied to the mucosa of the prolapsed structure (such as the ileum in this case) to promote the osmotic shift of fluid out of the edematous tissue.  In this case, within 2 minutes, the edema had diminished sufficiently to allow spontaneous reduction of the prolapse.

    Thanks to all who made guesses.  Brilliant  readers, all of you!

    Wednesday, May 4, 2011

    The Hardest Image Challenge

     Q:  A prolapse such as this can be effectively reduced by applying what common household substance to the tissue?
    1.  Baking powder
    2.  Flour
    3.  Salt
    4.  Sugar
    5.  Tea

    This is the hardest image challenge from the New England Journal Of  Medicine that I have seen.  Fellow physicians, and EverythingHealth readers, I want you to go out on a limb and give me the answer. 

    For you non-physicians, this is a colostomy and that is a piece of bowel that is outside of the body.  It is connected and can be pushed (reduced) back in where it belongs.  Also, it is not really painful for the patient, although it looks really really bad.

    Make your choice and the answer will be posted tomorrow.  (click on the image for a better view)

    (Sign up on the right side of this page as a subscriber to get an email link for new posts!)

    Monday, May 2, 2011

    Pay It Forward With Organ Donations

    With all of the news focus on Osama Bin Laden's death and memories of 9-11, it is time for a feel good story.  We have one compliments of Loyola University Medical Center in Illinois.   A total of 7 kidneys have been donated by perfect strangers and 5 of them were from hospital employees.  Loyola has set up a "Pay it Forward" program to inspire others to do the same.  When a person gets a good Samaritan kidney, it is hoped that a relative or friend who was not a match for that person will donate to someone else.  The new relative continues the chain by donating to yet another stranger.

    Since the program started last year, 18 donors have contributed to 95 organ transplants through the National Kidney Registry.  Of all needed organs, kidneys are most in demand and every year thousands of Americans die while waiting for one.  Stranger donations are relatively rare.

    The first altruistic donation was made by Dr. Susan Hou, the medical director of the renal transplant program.  She was the first U.S. physician to donate a kidney to a patient.  Her administrative secretary followed That allowed him to get off dialysis return to a normal life with his young children. Following that was the credentialing coordinator who  donated a kidney,  and then a registered nurse who also donated to a stranger.   Not to be outdone, the administrative director of the Graduate Medical Education Program and the manager of the clinical lab also donated kidneys as an act of giving and life.

    I would say that is an organization with a culture of community service!!!

    April is National Donate Life month. To learn more about becoming an organ donor, visit

    When to Use Urgent Care

    We all know that Emergency Departments are over-crowded with long waits and exorbitant fees.  Free standing Urgent Care is a great solu...