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Oh Baby: Infant Denied Health Coverage Due To Weight

If you still think we don’t need healthcare reform in the U.S., consider this: A 4-month-old baby is being denied health coverage by an insurer in Grand Junction, Colo., because the baby is too fat, the Denver Post reports. Details: The 4-month-old boy is in the 99th percentile for his age in height and weight. He is being exclusively breast fed by his mother and has grown from around 8 pounds 4 ounces at birth to nearly 17 pounds. Four. Months. Old. Pediatrician deemed him healthy. Parents are healthy and relatively fit, and  also have a healthy 2-year-old boy.

And people say the government is going to destroy our healthcare system?

OK, let’s be reasonable: Chances are, once the wildfire of press around this spreads sufficiently the company will rescind its decision and offer this lad coverage. (And, for the record, he could be covered by the family’s prior insurer but the parents decided to shop around because that firm raised the family’s rates by 40 percent after the boy was born.)  And, no, I don’t know of other cases where someone was denied coverage for the “pre-existing condition” of having been born hungry. So in the interest of fostering adult-level debate let’s acknowledge that this is probably a VERY isolated case and does not reflect the ethos of all insurers everywhere.

But still: A fat baby getting denied coverage is beyond ridiculous. Read more »

Where Docs Agree on Health Care Reform

Asking a bunch of doctors and nurses what they want out of health care reform is like asking a group of teens what toppings they want on a pizza: You’re going to get a lot of different answers, with the loudest proclamations reserved for what they don’t want.

Such a group came together July 17 at the National Press Club in Washington, D.C. at an event called Putting Patients First, hosted by Better Health. The unanimous conclusion: Get government out of the health care delivery continuum.

Val Jones, M.D., CEO of Better Health, said, “I don’t think people outside the doctor-patient relationship should be making life and death decisions” on behalf of the patient or doctor. Rep. Paul Ryan (R-Wis.), the event’s keynote speaker, said government has an obligation to establish conditions for free markets to thrive. Ryan blamed insurance companies for the problems with health care today – essentiually stating that insurers dictate the care that providers can deliver – and he called for a solution that does not involve heavier government.

“Government bureaucracy is not the answer to insurance bureaucracy,” Ryan said. The government’s failure to control costs in Medicare and Medicaid “shows us we should get government out of the way and put more faith in the market. Providers should compete against each other for our business.”

Ryan claims that the so-called ‘public option’ in President Obama’s proposed health care reform initiative would allow the government to be “referee and player in the same game,” and that companies hoping to compete for consumer health care dollars would be at an unfair disadvantage. Obama’s plan would result in “cookie-cutter standards” for determining individual patient care, set unfairly low reimbursement rates and create an economic barrier to young talent hoping to enter the medical profession.

Ryan added that Obama’s plan offers no incentives for people to get and stay healthy, which would lower health care costs. But offering reduced insurance rates to a consumer who, say, quit smoking or lost excess weight “would be illegal” under Obama’s plan, Ryan noted. “So there’s no incentive” for people to take better care of themselves. Ryan has a plan that he says would include a “carrot and stick” provision to reward people for maintaining a healthy lifestyle.

Between two expert panels, Robert Goldberg, Ph.D., co-founder of the Center for Medicine in the Public Interest, showed a video, complete with scary background music, of  patients in Canada and the U.K. complaining about abhorrent wait times to see doctors and government-mandated denial of life-saving treatments. Goldberg concluded that government-run health care in the U.S. would yield a similar system, with patients wasting away in the long shadows of a bureaucratic monster while doctors and nurses stood by, helplessly bound by the new rules. (One panelist later noted that polls show 70 percent to 80 percent approval among Canadians for that country’s health care system.)

The event did yield some progressive ideas for improving the U.S. system.

Alan Dappen, M.D., associate clinical professor at Virginia Commonwealth University School of Medicine, Department of Family Practice, and founder of DocTalker, a practice in Fairfax, Va., has moved a huge chunk of his patient consultation onto the phone. Patients still pay for his time – just as they would for  an office visit – but the system is much more efficient than having every patient come in for every ailment. “If you have a tick bite or an ear infection I don’t necessarily have to see you,” he says. Further, he says, the documentation for treating such minor ailments “should not go through 30 people” at an insurance company to ensure the doctor is paid or the patient is reimbursed. “That’s just ridiculous.”

Dappen has been practicing this way for eight years and says it takes on average 10 minutes to solve a patient’s issue over the phone. “Most of our patients are helped to satisfaction,” he said. And as a result of the time saved on patient visits, he added, he has time to do house calls – and is the only doctor in Fairfax County who does so.

Rich Fogoros, M.D., a former professor of cardiology and cardiac electrophysiology and longtime practitioner and researcher who is now a consultant and writer, suggested that primary care physicians go “off the grid” – i.e. refuse to participate in any insurance plan. That, Fogoros said, will force regulators and insurers to acknowledge that current practices by insurance companies have destroyed the doctor-patient relationship.

Kevin Pho, M.D., an internal medicine physician in Nashua, N.H., and author of the blog Kevin, M.D., said the most common complaint he hears from his patients is how little time they get to spend with him during a typical visit. “We are incentivized to see as many people as possible,” Pho said, not to provide the best care possible for each patient. One solution: hourly pay for doctors, siilar to the ‘billable hours’ system used by lawyers.

James Herndon, M.D., an orthopaedic surgeon and chairman emeritus of the Department of Orthopaedic Surgery at Partners health care (an integrated health system founded by Massachusetts General Hospital and Brigham and Women’s Hospital) in Boston, Mass., voiced concern about doctors in hospitals who won’t take care of the uninsured and underinsured. The doctors “keep pointing them elsewhere until they end up in the trauma unit, which is the last resort,” he said. “I would mandate that [all doctors on staff] see their share” of those patients.” Herndon added that he favors “public support,” such as some form of a tax, to ensure doctors are compensated for providing that care. He also conceded that the health care industry has become too profit focused. “The CEO of United Health made $1.2 billion” in one recent year. “We need to get rid of excess profit in insurance.”

Kim McAllister, R.N., the author of Emergiblog, said that, no matter which plan emerges from the ongoing debate in Washington, “People will circumvent it by showing up in the emergency room.” She recounted a story of a patient in California who went to the emergency room for a headache – twice – because he couldn’t get a timely appointment with his physician. She favors a health care savings account model under which each consumer could then “decide what provider they see and when they see that person.” McAllister suggested allowing the money to roll over from year to year – another nod to rewarding healthy lifestyles – although she strongly implied that allotments would be scaled based on a person’s income.

And this hit a point on which most of the participants seemed to agree: For consumers who really cannot afford health care in a free-market system, the government should have funds available to help them pay.

Health Care Reform: More Than The Money

Much of the debate this week over health care reform centers on the money: Will reform place undue burden on some silos of the health care sector? Will we need new taxes on the middle class to fund this thing? Will providers choose to pass on added costs (to consumers and others) rather than change habits to become more efficient?

Fair questions, all. This is America and money is king. But far more important right now is enacting measures that require wholesale changes in health care training, delivery, tracking and accountability.

A Bipartisan Model

At a press conference in Washington, D.C., a bipartisan triad of former Senate majority leaders yesterday unveiled a model of what those changes could look like. Former Sens. Howard Baker, Tom Daschle and Bob Dole, all of whom are among the founders of a think tank called the Bipartisan Policy Center, released a broad spectrum of policy suggestions that includes mandatory health insurance for all Americans, zero premiums for people in poverty and a revised payment system that rewards providers who heal the sick and prevent illness in the well.

Baker, Daschle and Dole insist their plan is “budget neutral” – i.e. will break even over 10 years. And, like seasoned parents trying to teach their kids to play nice, they highlighted compromises made in drafting the plan.

Daschle, for example, wanted a public plan (government-run health care) but said he “compromised significantly” on that issue (the proposal as released includes a moderate public plan run by states with federal seed money). Dole opposed mandatory health insurance for every American but he backed away from that.

As Dole said at the briefing, “If we can’t compromise…how can we expect to get a bill passed?”

Nice gestures and sound bites but, as Baker, Daschle and Dole readily acknowledge, they have no legislative power – or riled up constituents lighting up their phones – so it remains to be seen if their goodwill will inspire similar flexibility in current members of congress.

The fairly detailed plan consists of four pillars.

1. Promote high-quality, high-value care by:

  • Investing in information technology that will greatly raise efficiency in the system – and reduce medication and hospital errors;
  • Developing reliable measurements on how to define “quality care” and how to ensure patients are receiving it;
  • Reforming provider payments in Federal programs to reward high-value care;
  • Focusing on prevention of chronic diseases – like diabetes and heart disease – by rewarding providers for early recognition of risk factors and effective intervention.
  • Investing in the healthcare workforce (for example, through enhanced training and continuing education).

2. Make health insurance available, meaningful and affordable by:

  • Guaranteeing coverage, even to the very poor – for example, no premiums for those at or below the poverty line and tax credits for those living at up to 400 percent of the poverty line.
  • Guaranteeing access regardless of health status – i.e., no more denial of coverage for pre-existing conditions!
  • Creating state or regional insurance exchanges so consumers and businesses could easily comparison shop for plans.

3. Emphasize and support personal responsibility and healthy choices by:

  • Mandating purchase of insurance.
  • Offering premium reductions for healthy behaviors.
  • Creating a public health and wellness fund – $50 billion over 10 years – to invest in evidence-based prevention and wellness programs (through schools, community organizations, state agencies and even employers).

4. Develop a workable and sustainable approach to health care (this is the money part) by:

  • Charging companies – 1 to 3 percent of payroll – that do not offer insurance to employees.
  • Modernizing delivery and payment systems.
  • Reducing payments to home health and skilled nursing facilities “to address overpayment and inappropriate utilization concerns.” This is in line with recommendations from Med PAC.
  • Creating an approval pathway for generic versions of biologics.

Looking Beyond the Money

The total plan would cost $1.2 trillion over 10 years. Again, the former senators insist that their plan would pay for itself, through savings from increased efficiencies and fees for certain players.

I will not delve into the money debate because, honestly, it is over my head and best left to experts. But I do know human behavior, and I know that good habits are very hard to establish and bad ones even tougher to break.

And, to me, that means that whatever legislation emerges from congress better include strict and crystal clear requirements to prod insurance companies, hospitals, doctors, nurses et al to act in the best interest of patients, at all times and without loopholes to do otherwise.

Sharing the stage yesterday with the former senators was Mark McClellan, director of Engelberg Center for Health Care Reform and Leonard D. Schaeffer Chair in Health Policy Studies at the Brookings Institution.

McClellan, who has a deep health policy resume, including a stint as Food and Drug Administration commissioner and administrator of the Centers for Medicare & Medicaid Services, said this about Medicare: “We don’t get there by cutting provider payment rates and assuming they can do the rest. Payments are tied to measureable improvements in value [and] in care.” If your patients get better results and you slow down costs, he added, you get paid more. “Not the opposite like we have today.”

New Standards for Hospitals?

This is soothing to hear, and I’d like to add one brief rant on a related topic: Health care reform legislation must include strong mandates for reforming how we run our hospitals.

In 2008 two patients – one in Brooklyn, N.Y., and another in Goldsboro, N.C. – died in waiting rooms after being neglected for hours by hospital staff. In the Goldsboro case, a security camera records workers sitting in the waiting room playing cards while the patient, who had not been fed or attended to in 22 hours in the hospital, slumps in a nearby chair. In the Brooklyn case, a camera captures a woman collapsing and convulsing on the floor – after 24 hours in the waiting room; two guards and a member of the hospitals medical staff stop to observe her briefly before walking away.

While those tragic cases may be extreme, tales abound nationwide of substandard hospital operations – including medication and procedural errors, physical and sexual abuse of patients, rodent and roach infestation and general filth. Some hospitals in this country have infection rates that top 20 percent, meaning more than one-in-five patients leave the hospital with an infection they acquired during their stay.

Yes, this is only one part of the big picture, and yes, many other silos of the health care system are equally ripe for attention. But I would hope that whatever legislation emerges from congress includes elevated standards for training all hospital staff, not just doctors and nurses, along with strict accountability measures and some way of penalizing hospitals that are not clean, orderly and welcoming to patients.

I caught Sen. Daschle after the briefing and asked him about this issue. He repeated much of what had been said on improving health care in general – tying payment to value, ensuring transparency, and relying on evidenced-based research to set policy – but he also told me this: “We need to encourage hospitals and doctors to use a more episodic [approach] to health care rather than a procedural [approach]. That will help.”

Translation: The system must reward providers who treat the whole patient and improve overall health/outcomes over time. Doctors should be paid to keep people well, not to keep people sick and in treatment, as is often the case under the current system.

Half-speed in the NBA: Is it dangerous?

Midway through the third quarter of an April 2 NBA game between the Cleveland Cavaliers and Washington Wizards, a Cleveland guard tossed a lob pass toward the rim. Most of us sitting in the Verizon Center, in downtown Washington, D.C., had an idea what was about to happen.

Lebron James, the 24-year-old heir apparent to the NBA’s Best Ever moniker, elevated from the left baseline, caught the pass and, as he floated through the lane like a bird on wing, dunked the ball behind his head. The crowd roared its appreciation and even some of the Wizards’ players nodded in approval.

But the theatrical dunk, which came at a point when Cleveland was trailing by double digits, was one of only a small handful of highlights James – the leading candidate for league MVP for the 2008-2009 NBA season – had produced to that point in the contest.

He spent a good portion of his on-court minutes on the periphery, loping up and down the court with little urgency, distributing passes and setting an occasional pick but otherwise leaving the driving and scoring burden to his teammates.

The Wizards held on to win, despite a late flourish by James that left him with 31 “quiet” points.

The outcome hardly mattered: The Wizards were nearing a merciful end to a season that tied the franchise’s worst-ever record. The Cavaliers had all but wrapped up the top seed in the Eastern Conference for the playoffs.

Loafing or saving energy?

But from a health perspective, the on/off performance of James raised a question: How is it that NBA players – and many other professional athletes – are able to switch gears so readily and (seemingly) with few physical repercussions? How can someone go “half speed” without risking injury and still appear competitive on a court with some of the world’s best athletes?

I posed this question to Nick DeNubile, MD, who served as an orthopedic consultant to the Philadelphia 76ers for more than 10 years, and is author of Framework: Your 7-Step Program for Healthy Muscles, Bones and Joints (Rodale Books, 2005).

DeNubile made an important distinction between going half-speed and being tentative. If you’re tentative – in any sport at any time – that’s when you risk injury.

“You need to be relaxed,” DeNubile said, to ensure that all of your faculties are there when you need them (for example, to leap to the rafters of an arena and throw down a reverse dunk). But “relaxed” doesn’t mean you’re not ready to go full speed on a moment’s notice. It’s similar to the difference between a cat stalking prey (relaxed but alert and focused, ready to strike) and a skier standing atop a cliff, doubting that he can navigate the leap (frightened and tense, and becoming increasingly less focused).  Skilled athletes can go partial speed and still stay relaxed, DeNubile notes.

But this doesn’t apply to all sports. Diving, for example, or pitching a baseball require a focused anaerobic punch that would be very difficult to perform lackadaisically.

Why players hold back

For NBA players, the decision to occasionally temper their effort is not always bad.

“Recovery is so important for the players [and] metabolic recovery can vary from athlete to athlete,” DeNubile said.

“A lot of players come into the season three-quarters fit and use the season to get in shape for the playoffs. You’re better off if you come into the season fit,” but in an 82-game season even some of the fittest players have low-intensity nights. They may do it for selfish reasons – a contract dispute, for example. But in most cases they do it because they have to keep some reserves in the tank to stay competitive throughout a season that, for playoff teams, can span almost three-quarters of the year.

DeNubile recalled the 2001 NBA Finals, when his 76ers faced the Los Angeles Lakers.

“When we went to finals some players were dangerously over-trained,” he explained. “We did blood work [on the team] and you could see the guys who were on the brink. When you push too hard the body can start to break down. It’s the reverse effect” of training well.

DeNubile didn’t name players who were over-trained but he did cite Allen Iverson as one player who rarely gives reduced effort. “Every game of the year he’s giving 100 percent, 150 percent, diving for loose balls, playing as hard as he can,” DeNubile said. “That guy is incredible. He just doesn’t have an off switch.”

Somehow Iverson has stayed competitive for 12 (and counting) NBA seasons, defying predictions from many analysts that his all-out, physical style of play would result in a truncated career.

Are you over training?

Most of us will never play professional sports. But that doesn’t mean we can’t learn from those who do.

While the great majority of Americans is in no danger of over training (see: obesity epidemic, 21st century), some of us become addicted to strenuous exercise and tend to push ourselves harder than we should. One easy marker to check for over-training is your resting heart rate. Check it in the morning, right after you wake up, DeNubile says. (If you fear you are already over-trained, take a week off and see if that morning heart rate drops by 10 to 15 percent; if yes, you were likely over-training.)

Most are NBA players are incredibly fit and have resting heart rates around 60 beats-per-minute.

“When you see it start to bump up 10 beats per minute, that’s one of the signs over overtraining,” he says. “Or if a player says he’s getting a good night’s sleep but is still feeling tired.”

This made me wonder how much fuel NBA players burn during a game.

Interestingly, they’re burning about the same number of calories – 10 to 12 calories per minute – as you or I would during vigorous exercise. But because they are so fit their bodies use available energy stores much more efficiently than would a less-fit body, and thus they can accomplish more physically with less energy.

But DeNubile says that doesn’t make NBA players immune to basic exercise risks. “It can get dangerous when you’re tank starts to get low. People who sweat big can get dehydrated. You’ll see a player come off [the court] and he’s not happy about how he was playing or whatever and the trainer will offer him water or Gatorade and he’ll wave it off. That always worries me.”

These guys need to replenish lost fluid just like the rest of us. It’s nice to know we have at least that in common.

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