HEALTH CARE COSTS SOARING

THE GROWING MONSTER: HEALTH CARE COSTS

JAMA Dec 12. 2007

Health care today costs are 5% of our gross domestic product. It will rise to 20% by 2050. How can we contain this growing monster? How effective are each of our medical treatments? Which treatment is best?

Your treatment depends on the judgment of your doctor and the medical symptoms. Only one half of medical care is really based on supportive evidence. This explains why one half of the drugs disappear each year from the doctor’s arsenal.

Hospitals and doctors employed by hospitals encourage fee for service. This results in expensive procedures and treatments being performed as long as you or your insurance will pay for it. What incentive do you the patient have in seeking lower cost treatments if you only pay a tiny portion of the costs.?

Private companies don’t know what treatments work best for each patient and which treatments are ineffective. Medicare can’t determine which services should be covered.

HOW CAN WE BALANCE THE BENEFITS VS. THE RISKS?

Both the doctor and you the patient have to begin choosing fewer less expensive services. Insurance companies must change the way they pay and the way they cover drug devices and procedures that are cost effective.

Change the incentives. If the patient pays a part of the additional cost of a more expensive treatment, he can determine the need and benefit of the treatment.

Yet if there were an incentive to provide too little care, additional services would be eliminated with the burden on the patients with major health problems who might need these services. Their higher deductibles and high costs will limit the spending of those who don’t need medical services.

Reducing the medical costs in many chronic diseases may help the quality of care but it does very little to reduce costs of everyone’s medical care. There is now an attempt to target the management and care for those who need the most care. We can predict general risk but it is very hard to predict an individual risk. Insurance companies pool their customers who pay premiums and everyone wins.

HUMAN GENOMES AND YOUR MEDICAL RISKS

Synthetic genomes recently were constructed to include all the genes found in a naturally occurring bacterium. After mapping out the human genome eight years ago, Dr Venter is set to make artificial life forms with a minimum set of genes necessary for life. The science is rapidly pushing forward. Once the individual genes are mapped that are related to each disease entity, we will determine everyone who is at risk for any disease. Since we now can locate and isolate individual genomes, we can also find those who are at greatest risk.

Unfortunately some of us will become less attractive to insure. Now insurers can “genetic-cherry pick” and select coverage they will offer based on their specific risk. Screening programs are very expensive for both the government and the individual. Few with benefit and many are harmed.

Prevention medicine is really not working. Everyone thinks his or her doctor has all the answers, and will bail them out of any disease they might develop. Insurance enrollees switch insurances every 5 years so what could motivate them to pay for prevention 10-20 years down the road? Universal health care proponents say the shared risk might promise incentives to private insurance companies.

Tailored screening programs are being developed by public endeavors. If they can target the high risk populations they can efficiently screen them. To target your individual risk you must brunt the cost, the intense surveillance and also subsequent treatment. If you are found to carry a predisposing mutation, you will bear the increased insurance expense. Others will seek less expensive care, take their savings, and run.

Little does everyone know that we all have mutations and we all carry genomic risks for some disease. All of us are flawed with our genomes and we all need each other. Groups of patients will be identified who might benefit from a Big Pharma drug. Everyone with a disorder will randomly get some medication.

Insurance companies will want to pool their premiums to share the risk. No one company could cover the brand prophylaxis needed to improve medical care. Some will not even cover a drug that would help. Insurance profits would tumble if each of us got the right drug and the right dose.

Currently health care is rationed by one’s birth and income. Genetically based medicine will increase health costs by finding random risks for large number of people who will need high tech surveillance

We are all in the same boat and we share the medical boat ride together. Each of us is genetically flawed. Government health care is not a panacea for all the complex problems in our health care delivery system..

Yet what is our choice? What do you think?

Visit us @ www.americanacupuncture.com for more information.

WHAT? GRANDPA AND GRANDMA STILL DO IT?

 

WHAT?  GRANDPA AND GRANDMA STILL DO IT?

   We are all living longer.  What happens to sex when we age?  For every 5 women over 85 there are only 2 men. Sexuality emcompases attitudes, activity, behavior and ability to function.  In other words, having sex means you are healthy.

 SEX AND ILLNESS

   Sexual activity changes as we age and get ill.  Losing a sexual partner, getting older and being in poor health, having an infection, chronic disease, diabetes,  high blood pressure, prostate or urinary problems, such as a sagging bladder or a shrunken vagina, hip or knee replacements, can all decrease sexual desires.  Sex may even be dangerous for persons with a compromised heart or other medical conditions.  Visit our web site www.americanacupuncture.com for more details on intimacy problems.

 SEX LIVES OF OUR SENIORS

    A study by Lindau in the New England Journal of Medicine reviewed the sex life of 3000 men and women.  In the 55-85 year range, 39% of men and 17% of women said they had sex within the last 12 months.  As people got older, women were less likely to have intimate relationships. Half of the sexually active people had sexual problems. Many problems are caused  by chronic medical conditions, and 25% of the aged avoid sex because of them.

    A 1970 study in Baltimore on Aging showed that men, who were very sexually active when younger, had the slowest decline in sexual activity as they aged.  This issue was not addressed in this latest study.

    Testosterone triggers the brain to promote sexual arousal and desires.  The brain center, locus ceruleus, responds to the free testosterone.  With age, vascular blood flow decreases in the erectile smooth muscle of the penis .  

 Grandpa sexier?  Amazingly, after 75, 80% of men and 40% of women still have sex until they are beyond 85.  Men tend to marry or remarry younger women and they take Viagra or Cialis to improve their sex lives.  Many do not have medical clearance.   Ironically, men also die at a younger age than women.

   In women, sexual desires drop because of complex menopausal problems, the end of fertility, decrease in estrogen resulting in shrinking of the vagina and dryness, and increased depression, 

    More women, as they age, find sex unimportant and no longer pleasurable. Unlike men, women don’t talk to their doctors about sex, often because their doctors are much younger than they are.  Only 38% of men and 22% of women ever discuss this problem with their doctor.

 THE PENDULUM HAS SHIFTED

    A good number of older people find sex an important part of staying healthy and keeping their relationships intimate. In the past, older adults kept their mouth shut about sex since younger people assumed they were not and should not be sexually active.  

   Should sex be forgotten, as seniors settle into later life?  Women show a decrease in sexual interest and responsiveness as they age, and they are often less depressed and less worried about such changes. The quality of their relationship with the opposite sex are more important than sex.  Many women find intimacy more rewarding than sex. 

 With Big Pharma targeting Viagra, Cialis, and Testosterone, for grandma and grandpa, more options are available. They want to talk about it.  Who will listen to our aging baby boomers?

What do you think?  NEW ENGLAND JOURNAL MEDICINE, AUG 23, 2007

 Visit us for more information @ www.americanacupuncture.com

HOW CAN WE GET BETTER HEALTH CARE?

CAN WE GET BETTER HEALTH CARE IN AMERICA?

                           NEW ENGLAND JOURNAL OF MEDICINE, SEPT. 20, 2007

   We spend more money on health care than any other nation.  Yet we rank poorly in nearly every category.  How can this be?  Too many Americans, don’t get the health care,  get it too late, or receive poor quality care.  The poor in american need more attention if we are ever to achieve better health care.

   Among 30 other nations, we are at the bottom on most standards.  The only place we lead is in life expectancy of our citizens over 65.  Perhaps this is due to universal Medicare coverage.  We rank 42nd among 190 nations in infant mortality and 46th in average life expectancy. We are not homogeneous like many countries.  A large discrepancy occurs in geographic areas, race, and ethnic groups. 

   There are five factors that must be considered: genetics, social circumstances, environment, behavioral patterns, and health care.  Behavioral causes account for nearly 40% of all deaths in America are due to smoking, obesity, and lack of exercise.  Is changing people's behavior the duty of the doctor?  We have changed people's behavior in America by requiring seat belts, smoking restrictions, and awareness of high saturated fat in our diets.

STOP SMOKING PRESSURES HAVE WORKED

    In 1955,  57% of people smoked.  Today its 23%.  There are still 45 million smokers in America and tobacco kills 435.000 of them annually.  These people die 14 years earlier than the non-smokers and the last 10 years of their lives are spent with shortness of breath, cardiac problems, and numerous pains.  

   Smoking mothers have premature infants. The majority of smokers are in the lower incomes, have a mental illness, or are substance abusers.  Some segments of America already have low rates of smoking. Physicians 2%, post graduates 8%, and residents of Utah 11% and California 14%.

THE OBESITY CHALLENGE

   It is not as possible biologically to stop eating as it is to stop smoking.  There is no addictive analogue to nicotine in food.  There also is no second hand exposure to obesity.  The food industry is less concentrated than the tobacco industry.  We really have no tools to treat obesity. 

   We could designate favorite foods and penalized foods, subsidize some foods, and even increase taxes on other foods.  Labels with more accurate caloric labeling of content and ingredients, especially with fast foods, could also be implemented..  Yet, all  this is politically unpalatable.  Schools could ban sale of soft drinks and provide more nutritious choices, and more physical education in schools would also help.

WHAT CAN WE CHANGE?

Well, we certainly  can’t change our genes.  Poor people die earlier and many others have more disabilities than those in higher incomes.  They have unhealthy behavior in part because of inadequate food choices and lack of recreations opportunities. 

   Yet other countries have their poor people.  Social policies as education, taxation, transportation and housing have health consequences.  There is a widening gap between the rich and poor.  All this may increase the health problems we have in America today.

   Heath care receives a great amount of money and a lot of attention.  Heart disease care has accounted for half of the 40% drop we have seen in mortality.  Premature deaths now only account for 10% of the death rate.  We spend 16% of our gross domestic dollars, over one trillion dollars,  on health care.  Other countries spend less than 10%. 

   The poor represent most of the 45 million Americans that lack medical insurance.  This leads to poor health. But environmental factors are also very very important.  Lead paint, polluted air and water, dangerous neighborhoods, and lack of outlets for exercise, also contribute to premature death in our society.

   We lead the world in diagnostic and therapeutic medical technologies.  We also outspend all other countries in the use of alternative medicines, cosmetic surgeries, and health cures.  We get all excited about particular illnesses that affect all income segments of America as aids, breast cancer, and virus infections.

   We emphasize the value of individual responsibility and this makes us reluctant to intervene in changing behavioral choices of people.   The poor will continue to be underrepresented and not much is likely to change. One consolation is that our country has never been healthier, even though it trails other countries.  It would be certainly to our advantage however to improve our health care.  This would result in a more productive workforce, reduce the monetary costs of medical care, and also improve people’s lives. 

We are number one in wealth, in Nobel Prize winners, and in military strength.

Why can’t we be number one in health?

 Visit us @ www.americanacupunture for much more information.                      

 

 

 

 

 

WHY IS MOM LOSING HER HAIR?

What causes hair loss in women?      NEJM ]OCT 18, 2007                       

   More than one third of women lose significant hair in their lifetime.  It is very emotional to the patient and often underplayed by doctors.

   Hair is the second fastest growing tissue of the body next to bone marrow. It may be the first system of disease.

Background:  The scalp has 100,000 hairs.  Ninety percent of these are actively growing.  They are anchored in the fat under the skin and are not easily pulled out.  Hair is constantly regenerating on the scalp. Each hair shaft lasts 3-7 years, falling out and replaced by a new hair.

Discussion: The scalp loses 100 hairs a day. One can lose 300 hairs a day after major surgery, rapid weight loss, nutritional deficiency, high fevers, hemorrhages, or hormonal changes as thyroid.  It is also seen after starting new medications. Hair loss lasts up to 6 months after removing the cause.

   Localized hair loss (alopecia areata) is seen as round patches.  It frequently is reversible.  It is thought to be autoimmune.  It can also be caused by severe bacterial infections, fungus infection, or hair pulling and braiding.

   If other hairy areas (as eyebrows, eyelashes, pubic, armpits, or body hair) are losing hair it is usually a systemic cause, as thyroid dysfunction, new medication, surgery, after a baby, or some illness.  It can also occur in strict vegetarian diets and iron deficiency.

When you find the reason, you solve the problem!

Can drug make me bleed?

CAN  DRUGS  CAUSE  ME TO BLEED?

NEJM AUG 9.2007

         Many drugs cause bleeding problems. Drugs implicated include Hydrodiuril,Motiin, diazepam, and sulfas Other most familiar drug causes are heparin, chemo drugs, and immune suppressing drugs.  Over 100 drugs can cause this disorder. Antiepileptic corporate, cardiac agent amrinone, and the antibiotic linezolid cause low grade platelet suppression in up to 30% of the patients.

 Drug induced platelet suppression can be overlooked and be even fatal if not considered.  In the present of the sensitizing drug The drug reacts with the antibody and makes immune complexes that targets platelets and destroys them. Stopping the drug resolves the bleeding.

  Drug induced antibodies are the culprits that cause drug induced bleeding but be hard to prove.  Often sepsis or autoimmune causes are thought as the cause.  It takes 2-3 episodes before drugs are considered.  The drugs cause destruction of platelets in the blood. 

 Quinine, which was used to treat malaria, was known to cause thrombocytopenic 140 years age.  It was discontinued, but until recently was given to treat muscle cramps.  Anyone can have the bleeding at any age and any sex. 

  Usually the drug is taken for a week before symptoms occur.  Patchy hemorrhages under the skin are the first symptoms.  Lightheadedness, chills and fever and nausea precede the bleeding.  Stopping the drug resolves the symptoms in 1-2 days.

 The best treatment is to stop a drug when suspicious of skin hemorrhages.  Cortisone, immune globulins and plasma exchanges are used but of little help.  Once you are sensitized to a drug never use it again.

 When suspicious, or have skin bruising, check with your doctor.

 This condition can be fatal.  DRUG USER BEWARE!

                             

 

 

SPINAL STENOSIS-OPERATE OR NOT

I have spinal stenosis. Should I have surgery or not?

NEJM MAY 31,2007

Spinal stenosis is the most common reason for back surgery in people over 65. Slipped vertebra (called degenerative spondylolisthesiss) occurs in women over 50 and has no symptoms. Bone and soft tissue narrow the spinal canal. When walking or standing, there is pain in the butt or legs. Sitting or curling up the back usually eliminates the pain. It is also often found in patients without symptoms that have MRI studies for other reasons.

A large study was reviewed in the New England Journal of Medicine to evaulate results combined from several medical centers. The study was called SPORT. 150 patients had surgery and another 150 did not.

When MRIs confirmed the problem and symptoms were present for at least 12 weeks, it was found that there was no advantage in doing surgery. There also was no harm not doing surgery..

Those who had surgery noted their back pain was relieved in 33% of the cases and 55% also had leg pains disappear. Ten percent who had surgery had tears in the dural canal and 12% were reoperated in two years?

Those who coped out of surgery had more cortisone epidurals, had similar physical therapy, and had no activity restrictions. This may have accounted for their improvements similar to the surgically treated patients.

What is your decision?

WHERE IS MY GENERAL SURGEON?

WHERE IS MY GENERAL SURGEON?

We turn out 1000 general surgeons every year in America.  They each had 4 years of medical school, 5 years of residency, and many have added a year or two of research. They start practice at around age 34 and are at least 250 K in debt  They care for emergencies, traumas, and perform many kinds of operations.  They are probably the most well rounded surgical clinicians. Yet today, 70% of them pursue  specialized training.  That leaves only 300 general surgeons annually to practice general surgery.  The remainder of the  general surgeons average 55 years of age and soon will retire.

Why do these fine doctors want to sub-specialize?  

They want to limit the number and kinds of procedures they perform.  The more refined the expertise the more financial payoff.  They can even charge more for the same procedure they did as a general surgeon.  Graduating doctors today don’t want to work 90 hours a week with little family time.  Hence they join large hospital groups, are on call less, and get paid more.  Very few have the entrepreneurial spirit.   As residents they work 80 hours a week, and when they see a sick patient needing stabilization, they must turn the care to someone else.  Their surgical problems are worse with a growing elderly population, but they work fewer hours.

SO WHAT IS THE PROBLEM?

The public has more inadequate access to health care with the new value systems of young doctors.  The greatest reason for their early retirement and change in careers is their unfavorable work environment.  Managed care constantly changes the rules, reimbursements are uncertain, and professional liability is huge.

 Funds are redistributed, since there  is not enough money to spread around, and the non surgical doctors are paid more.  A surgeon with 30 years experience is paid the same as a young surgeon with 1-year experience.  They can't  charge the patients for any services they render after surgery  for 90 days.  All other doctors can charge for visits. So they send the post op patient to another doctor who will get paid for the office visits.  

Small hospital can’t survive without general surgeons.  They do 40% of all the surgeries.  The sub specialists are no longer secure in their skills in general surgery.  Seventy five percent of hospitals now report an inadequate supply of on call surgeons.

Soon small hospitals may be forced to close their doors when the general surgeon disappears from the scene.  Can this trend be reversed?  

What do you think?

 

SHOULD EVERYONE HAVE A C-SECTION?

SHOULD EVERYONE HAVE A C-SECTION?

A battle is raging over the safest way to deliver a baby. Some want everyone to have a C-section and others want a $75 million dollar study with a lottery determining who gets a C-section and who delivers vaginally. I don’t know who would be the winner either way. Does the patient have a choice and can she dictate how she wants to deliver. Who has the medical degree?

Having been an obstetrician for over 37 years I remember C-section rates of 3% for first deliveries and combined rates of under 6%. But in those days we had mentors who showed us how to deliver breeches, how to be patient, how to use forceps safely and how to give anesthetics.

Those days are gone. Today’s obstetricians are under 45 and have sharpened their surgical skills Most mentors over 45 have quit delivering babies and have become full time gynecologic surgeons. Thanks to the fears of frivolous litigations.

Thing have changed. C-section rates in 2006 were 31%, a rise from 2004 of 26%. Maternal death have comparably risen to 14 per 100,000 from long time rates under 10 per 100,000.

More doctors recommend C-section and their patients obediently accept their recommendations. “Mary your baby looks big! We could do a C-section.” There still are no guarantees that you will have an uncomplicated delivery and that your child will go to Harvard.

C-sections are not safer than vaginal deliveries. and have many risks. Some risks are: higher cardiac arrests, infections, hysterectomies, higher infertility post operatively, more frequent readmissions to hospital within 30 days, and placental complications rise with each C-section.

Whys the big push to recommend Sections? Thoughts go through the obstetrician’s mind: I am not paid for all this waiting. If I do a C-section I am done, get paid twice as much, can finish my office hours, and above all will not likely be sued.

Other factors come into play. Is my hospital small? Do I have residents to watch my patients while I am at the office or if the patient develops a problem? Can I rely on my hospital staff on midnights, weekends and holidays to be well staffed? And above all will I be sued if my patient happens to deliver vaginally and doesn’t have an IQ of 200.

Vaginal deliveries have always been safer, but today I don’t know.

What do you think?

DELAYS IN DEFIBRILLATION DURINGCARDIAC ARREST

DEFIBRILLATION IN CARDIAC ARREST  NEJM DEC 2007

Kansas city researcher Dr. Chan has stirred up a hornet's nest with his study on cardiac arrests in hospitals and shocking the heart back to beating (defibrillation).    It seems the doctors have 2 minutes after the heart stops for good success.  A delay to about six minutes lower the survival rate to about 7%. Most big hospitals responded in 1 minute, but one third of them took longer than the critical 2 minutes.

            Around 500,000 patients have cardiac arrests in the hospital.  Only about 30% of the patients survive long enough to make it home.  Small hospitals  (250 beds) had most of the delays, along with arrests occurring on weekends or after hours (when the regular staff is off), and for some reason black patients have a high rate of delays.

Many public places have defibrillators on their premises.   Who will respond in 2 minutes and who is qualified or has the guts to put the paddles on the patients?  And lastly, will the legal community rationalize that such a delay is possibly malpractice?

What do you think?

EARLY HOSPITAL DISCHARGES AND READMISSIONS

EARLY HOSPITAL DISCHARGES AND READMISSIONS IHS , University Colorado

The biggest medical risk on hospital discharge is having preventable complications that land them back in the hospital.  It costs the hospitals money and causes unnecessary harm to the patients, many of whom are elderly.  Eighteen percent of Medicare patients are readmitted within 30 days of their discharge.

Five million patients are readmitted each year with a third of them readmitted within 90 days of discharge. Many of them have no clue what to do when they leave the hospital.

THE PROBLEM 

The hospital does not get paid for any follow up care or service.  There are many doctors on the case and no one seems to be captain of the ship.  No one identifies which patients are at greatest risk of returning to the ER.  No one at home is instructed on how to monitor and educated their sick family member, and even what medication to take. 

Poor communication between the patient and the medical staff on the case seem to lead to the problems.  There is little follow up care.  Who can get through the red tape of calling your doctor and getting an appointment when you deem necessary.  Could the staff make the appointments for the doctor’s office before discharge?

Fortunately there are pilot studies in Chicago and Philadelphia to offer transitional care service.  Until someone pays for this, I think the patients may have to higher a nurse be their omnibudsman.

Like they say down South:  “You all come back real soon!”.

What do you think?

TV DRUG COMMERCIALS

Should drug companies advertise prescription drugs directly to the consumer?

It is certainly shown that direct advertising of prescription drugs pays off in sales and also overuse of the drugs.  Several heavily advertised drugs were withdrawn from the market because of serious side effects. The FDA has been criticized for not strictly enforcing this problem.

Ten years ago the drug industry spent 11 billion dollars in consumer advertising.  In 2005 it was 30 billion dollars. Advertising starts about 1 years after FDA approval of a drug.  FDA letters of warning dropped from 142 in 1997 to only 21 in 2006.

It is felt that we the consumers will bear the increased costs in the form of higher drug prices.  When a drug is only available for a year its safety profile is not known and doctors themselves have little expierence of the drug’s safety. The FDA in 1999 reviewed 64% of the ads before they were released.  In 2004 they only reviewed 32% of the ads. 

Should there be more regulation of direct consumer ads?

What do you think?

                                                NEW ENGLAND JOURNAL MEDICINE, AUG 16, 2007

DOCTORS AND DRUG COMPANIES NOT SO COZY NOW

DOCTORS AND DRUG COMPANIES NOT SO COZY NOW   NEJM NOV 01, 2007

         For years drug companies have been giving doctors gifts, drug samples, sponsored lunches, free educations seminars, consulting fees, free trips and free food.  
All this designed to influence physician prescribing behavior.  The cost: over $19 billion each year.

        The Senate introduced on Sept 6,2007 a bill that would require drug companies and manufacturers of medical devices with incomes over $100 million to disclose the amount of money they give doctors.  The bill is called “ The Physician Payment Sunshine Act” to let the sun shine in so that the public would know about the monetary relationship. Drug companies and doctors have and to increase the transparency.

         Because the drug company lobby is so strong in Washington, the bill has almost no chance of passing.  However, large medical centers like Stanford, University of Michigan, University of Pennsylvania and others have been stimulated to police themselves.  Boston University prohibits clinicians from accepting gifts.  Others have banished industry food activity from their campuses, drug selection committees must be free of financial ties, drug representatives are being barred from hospitals, no more free samples, no free lunches for the staff, and more stringent restrictions on the drug industry.

         The results of these actions may be:

Cheaper generic versions of a drug may be prescribed.

Doctors will more likely adhere to evidence based practice guidelines.

Off label generics will be used rather than drug samples.

Harder for drug companies to enroll patients in manufacturers clinical trials.

Less doctor advise on drug development.

Hopefully the $19 billion dollars saved by the drug companies will be passed along to the patients in lower prices.  I fear the drug companies are indirectly educating the patients to become doctors are now spending it on TV ads.

         Anyway, let the sun shine in.  Christmas is over dear doctor.!