July 22nd, 2009 by SteveSimmonsMD in News, Opinion, Primary Care Wednesdays, Uncategorized
Tags: Primary Care Wednesdays
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Robert Blendon, Professor of Health Policy and Political Analysis at the Harvard Kennedy School of Business, speaking on funding for Health Care Reform, July 8, 2009
“Potential sources for this (health care reform) are new taxes on people or businesses, substantial short-term savings from the existing Medicare and Medicaid programs, or increasing the deficit”
After Last week’s passage of Health Care reform plans by committees in the House and Senate, attention has turned to the Senate Finance and House Commerce Committees to see how congress will pay for reform in a deficit neutral way, as mandated by President Obama. The price tag over ten years–$1.2 Trillion–is paired with the observation that a shortage of $240 billion currently exists. This assumes that $948 billion already has been found.
The only way to ‘find’ $948 billion without increasing the deficit is to increase taxes on businesses and the wealthy or by reimbursing less for services provided through Medicare and Medicaid. I will leave the never-ending tax-rate argument for political pundits, and instead focus this post on short and long-term savings from Medicare and Medicaid because I believe paying less for services than it costs to provide them will negatively impact the quality of medical care in this country.
I was surprised to learn of a battle being waged between the executive and legislative branches on the issue of “long-term savings” from Medicare, as it relates to “Medicare Payment Authority”. White House Chief of Staff, Rahm Emanuel, has called Medicare payment Authority, “the least talked about, most important issue on the table” and clarified its’ importance by stating, “Structures that fundamentally alter the long-term costs are a must for real health-care reform.” This issue does not follow party lines with a mix of Republicans and Democrats being in opposition or support of the President, irrespective of party affiliation.
Our Congressional Representatives have the power to set Medicare Payments, outside of any pre-set rules or regulations by simply passing legislation. The Washington Post describes this power as “one of their most valued perks….a powerful tool on the campaign trail”. President Obama’s administration wants to either transfer payment authority to MedPac (the Medicare payment advisory commission) or create an independent Medicare Advisory Council, reporting to the executive branch so lawmakers can no longer tailor Medicare spending to address local concerns.
Before leaving office, Senator Ted Stevens secured a permanent 35 percent increase in Medicare payments for Alaskan physicians only. The political benefits to an incumbent running for reelection need not be explained while it is easy to see the inefficiency in such a system. At a time when politicians are admonishing those working in the Health Care Field to be more efficient, I would urge congress to take a dose of their own efficiency medicine and support the current administration in their efforts to curtail long-term spending by surrendering this power.
According to the White House, $622 of the $948 billion will come from short-term savings squeezed out of existing Medicare and Medicaid programs through one of two ways: by improving efficiency (309 billion) or enacting policy changes (313 billion). The Medicare Fact Sheet posted on the White House website, states that one policy change will have the added benefit of encouraging efficiency: “incorporate productivity adjustments into Medicare payment updates”. This policy change measures the productivity of the entire U.S. economy, as measured by subtracting the hours worked from the amount of product created and extrapolates it to Health Care (a profession which does not produce “products”). This idea justifies the withholding of 110 billion dollars from “providers” with an unexplained benefit stated in the closing sentence describing this policy, “This adjustment will encourage greater efficiency in health care provisions”.
I found it difficult to believe that anyone could suggest paying less would encourage greater efficiency in caring for the infirm and old until Boston Medical Center, a hospital serving thousands of indigent residents, sued the state of Massachusetts one week ago, charging that the state is now reimbursing only 64 cents for every dollar spent treating those covered under Medicaid or Commonwealth Care (the state subsidized insurance program for low-income residents). This should be of great concern to us all since the House’s plan adds 11 million people to Medicaid and cuts funding while reformists tout Massachusetts as an example worth following, being the only state with universal coverage today. Before state wide reform was enacted this hospital had operated for 5 years without a loss. However, when the hospital showed losses over two years of 138 million dollars, state officials observed the hospital had a 190 million dollar reserve (not for long it appears) and suggested that Boston Medical could reduce costs by operating more efficiently.
The above example demonstrates the willingness of government bureaucrats, inexperienced in providing actual medical care, to give flippant advice while failing to appreciate how fiscal efficiency, doing more with less, impacts medical efficiency, caring for the ill effectively. To be sure, something must be done to curtail run-away costs in health care and I agree with the president when he says, “The status quo is unsustainable. Reform is not a luxury, but a necessity”. However, reform needs to focus on sustainable Short-term and Long-term savings in such a way that prevents hospitals and doctors from having to make a choice between providing sub-standard care or going out of business. Furthermore, I would hope that Congress take an honest look in the mirror regarding long-term savings before only enacting short-term savings which could negatively impact the care available to us all.
Until next week, I remain yours in primary care,
Steve Simmons, MD
July 10th, 2009 by Jonathan Foulds, Ph.D. in Uncategorized
Tags: Cigarettes, Hollywood, Marlboro, Movies, Pediatrics, Product Placement, Psychology, R-Rating, smoking, teens, Tobacco
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As many of you may know, the famous tobacco control scientist and advocate, Professor Stan Glantz, has over the past few years been focusing on the issue of depictions of smoking in movies. Part of the concern stems from good evidence that young people are highly influenced by movies due to their cultural value and glamorous nature.
The other part stems from a history of use of “product placement” in movies. This refers to the movie producers agreeing to include a specific product in their movie in return for some incentive (typically money). A famous example of this is a letter from Sylvester Stallone agreeing to smoke particular brands of cigarettes in his movies for $500,000. So when one combines the financial power of the tobacco industry with product placement we end up with a hell of a lot more gratuitous smoking in movies than is necessary.
Of course the movie companies and many movie enthusiasts argue about the need for art to imitate life etc., etc. However numerous examples demonstrate that to be a lot of nonsense. Professor Glantz points to depictions of Marlboro cigarettes being dragged around or used by aliens in movies like Men In Black. Is it really true that those aliens prefer Marlboros and so showing the brand was necessary for the movie to be accurate? Mmm….I doubt it.
My favorite example comes from the film “A Beautiful Mind”. The movie stars Russell Crowe in the lead role portraying the (still living and working) Princeton University professor, John Nash. In real life, John Nash suffered from schizophrenia but did not smoke. In the movie he suffered from schizophrenia, but smoked. I’m not sure why the producers changed this aspect of reality or what it added to the movie.
But these are details. Professor Glantz’ main point is that movies made to be viewed by kids do not need to include smoking, and therefore should be given an R rating if they do, just as they are if they depict illicit drug use. Note that an R doesn’t stop people under 17 from seeing the movie in a movie theater. It just means they need to be accompanied by an adult. It also doesn’t ban smoking from movies, it just means that movies with smoking in them will receive an R rating, just as sex, drugs, cursing and certain types of violence will get a movie an R rating. Of course the movie industry is very clear that a large part of its audience is kids and particularly teens. The net effect of the rating changes professor Glantz is recommending would be that gratuitous smoking will be taken out of many movies and particularly those aimed at kids.
I must admit that I didn’t initially pay much attention to this proposal, and my natural inclination was to doubt whether it really was worth the effort. But while I was at the UK National Smoking Cessation Conference in London last week I heard Professor Glantz talk about this idea and I came around to thinking its maybe not as extreme as I first thought. In fact he convinced me that it’s a reasonably sensible idea that would likely result in thousands fewer teens taking up smoking. Sometime soon the full audio recording of Professor Glantz’ presentation will be posted on the conference website along with his slides. I’ll post the link when its available, but for now those interested in this subject may want to check out the following website:
http://smokefreemovies.ucsf.edu/
This post, Should Movies With Smoking In Them Receive An R-Rating?, was originally published on
Healthine.com by Jonathan Foulds, Ph.D..
June 22nd, 2009 by Medgadget in Uncategorized
Tags: Radiology, SonoSite, Technology, Ultrasound, Voice Activated
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SonoSite just released their SonoRemote for controlling the company’s M-Turbo and S Series ultrasounds during interventional procedures like joint injections or central line placements. In addition to traditional style buttons, the remote control features voice recognition and can be programmed to understand commands in any language. So now you can hold the probe in one hand and the syringe in the other, and not have to fiddle with reaching over to the unit to take snapshots or change parameters.
Voice or touch activated
Programmable to your voice and language
Adjust system controls from a radius of 10 meters
No need to break the sterile field
Drop-tested to 3 feet
Works with M-Turbo® and S Series™
Press release: SonoSite Begins Customer Shipments Of Ultrasound Remote Control
Product page: SonoRemote
Flashbacks: M-Turbo™: New Portable Ultrasound from SonoSite ; SonoSite S-ICU™ Ultrasound Tool; S-Nerve™ from SonoSite; The SonoSite® MicroMaxx™; Titan
*This blog post was originally published at Medgadget*
May 7th, 2009 by Stacy Stryer, M.D. in Uncategorized
Tags: anorexia, bulimia, eating disorder, food, kids, Stacy Beller Stryer, stacy stryer, teens
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I was thumbing through the newspaper today while my teen was eating breakfast before school. Watching her measure out a serving size of cereal “just for the fun of it” makes me a tad bit nervous, considering she doesn’t have an ounce of fat on her. I quickly searched for the health section – it gives me an idea of what my patients will ask about during the work day (such as the “swine” flu), and it can also be a good starting point for blog ideas.
The front page of the health section Tuesday had a picture and quote from a beautiful teen who had died of bulimia several years ago. She looked familiar. My eyes scanned down to the name below the quote, and upon recognizing the name, my eyes immediately welled with tears. She had been my patient years ago, and I didn’t know she died. She was a great, sweet, smart teen who was well aware of her bulimia and the possible consequences. And she died.
At the very least, eating disorders can ruin their own lives and those of their families. And they kill. Although statistics vary based on the study, about 0.5% to 1% of teens and women in the United States have anorexia nervosa, an illness that involves significant weight loss and food refusal. About 1% to 3% of young American women have bulimia, a condition that includes regular binging and purging. Over 1 million males have an eating disorder and the numbers are climbing. Eating disorders are difficult to treat, especially once a pattern has been established and it has become a “way of life.” The earlier they are recognized, the more likely treatment will be successful.
These days, children have unrealistic expectations of what they should look like and how much they should weigh. Think about it. Their role models have changed dramatically over the past several decades. Girls and teens are exposed to ultra-thin, beautiful women wherever they turn – on TV, in magazines, music videos, and movies. And if that weren’t enough, moms, aunts, sisters and other teens and adults they know talk about food all the time – about eating too much, counting their calories, watching their weight, feeling “fat.” It’s no wonder that almost one-half of first through third grade girls want to be thinner and that over 80% of 10 year olds are afraid of being fat!
Our country’s obsession with food and it’s trickling down effect is readily apparent when we look at the results of the Youth Risk Behavior Survey for middle schoolers, a survey conducted in 10 states in 2005 (see end of blog) . By 6th grade, almost half of the students surveyed were trying to lose weight (even though only 14 to 18% were actually overweight), 5 to 7% vomited or took laxatives due to weight concerns, and 10 to 20% didn’t eat for at least 24 hours because they wanted to lose or didn’t want to gain weight! And we can’t forget that boys develop eating disorders, too. They tend to be diagnosed later than girls, possibly because we aren’t expecting to see males develop these illnesses.
What can we do? Society must take some responsibility for the large number of teens and adults with eating disorders. Genetics appears to play a role also. While these factors are out of our control, others are not. First of all, we can build our children’s self-esteem and confidence with regards to their academic and moral aptitude, rather than their outer appearance. We can make sure that we don’t discuss weight and eating around our children and that we act as good role models by eating well and maintaining a normal weight. We can limit TV, movies, and fashion magazines in our home and spend time together as a family. We can try to make our expectations for our children realistic and feasible. We can watch our children and teens closely for signs of an eating disorder, particularly if they are involved in sports, such as ballet, gymnastics, and wrestling, which focus on specific body types. And, if we are concerned about them, we can immediately make an appointment for them to be seen by their pediatrician and therapist to be weighed and to discuss any concerns. I can assure you it won’t be a wasted visit, even if your child turns out to have a healthy weight and eating habits. Don’t ignore signs of an eating disorder, as one of my patients did in the past. Upon hearing that her daughter weighed a mere 70% of her ideal body weight, her mom said that she was fine and that she, too, had gone through a similar “phase” when she was a teen. Eating disorders are real, and they kill.
Specific Results of the YRBS for Middle School Students
Across states, the percentage of students who were overweight ranged as follows:
• 6th grade: 14.4% to 18.7% (median: 18.6%)
• 7th grade: 10.0% to 15.8% (median: 14.0%)
• 8th grade: 8.0% to 14.9% (median: 13.0%)
Across states, the percentage of students who described themselves as slightly or very overweight ranged as follows:
• 6th grade: 19.6% to 26.7%
• 7th grade: 24.7% to 29.7%
• 8th grade: 24.2% to 29.7%
Trying to Lose Weight
Across states, the percentage of students who were trying to lose weight ranged as follows:
• 6th grade: 40.7% to 48.4% (median: 46.8%)
• 7th grade: 42.7% to 51.9% (median: 44.2%)
• 8th grade: 41.6% to 49.6% (median: 45.9%)
Ate Less Food to Lose Weight or to Keep From Gaining Weight
Across states, the percentage of students who ever ate less food, fewer calories, or foods low in fat to lose weight or to keep from gaining weight ranged as follows:
• 6th grade: 35.0% to 47.9% (median: 41.4%)
• 7th grade: 39.1% to 47.5% (median: 41.6%)
• 8th grade: 41.1% to 47.5% (median: 46.6%)
Went Without Eating for 24 Hours or More to Lose Weight or to Keep From Gaining Weight
Across states, the percentage of students who ever went without eating for at least 24 hours to lose weight or to keep from gaining weight ranged as follows:
• 6th grade: 10.0% to 19.2% (median: 15.6%)
• 7th grade: 13.9% to 18.3% (median: 16.6%)
• 8th grade: 18.1% to 21.6% (median: 19.5%)
Vomited or Took Laxatives to Lose Weight or to Keep From Gaining Weight
Across states, the percentage of students who ever vomited or took laxatives to lose weight or to keep from gaining weight ranged as follows:
• 6th grade: 4.8% to 7.5% (median: 6.3%)
• 7th grade: 4.0% to 6.2% (median: 4.7%)
• 8th grade: 6.4% to 8.2% (median: 7.3%)
May 6th, 2009 by Joshua Schwimmer, M.D. in Uncategorized
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As of this writing, there are over 400 medical applications in the iTunes App Store. Whether you’re a health care provider or patient, and whether you 
have an iPhone or iPod Touch or not, it’s worth exploring the impressive range of applications available for this new mobile platform. (Later this year, when iPhone 3.0 is introduced, these applications will be able to interact directly with compatible medical devices, like glucometers and blood pressure monitors.) Here’s a brief introduction to three medical apps in the iTunes App Store.
Diagnosaurus. Many medical specialties—and Internal Medicine in particular—require working through a “differential” of possible causes of a patient’s clinical presentation. Diagnosaurus ($.99) provides a polished interface for searching differential diagnoses for over 1000 conditions, divided by organ systems, symptoms, and diseases. As a bonus, at the end of each list is provided a list of links to related differentials. For example, “acute hepatiis” and “cholestatis” are listed at the end of “AST/ALT increased.” Much like Wikipedia, you can spent half an hour browsing and clicking through links. For $.99, it’s a steal.
ICD9 Consult. Health care providers must frequently scramble to come up with ICD9 codes for unusual or complex diagnoses in order to bill appropriately. ICD9 Consult ($29.99) is an excellent solution for those moments when you don’t have time to consult a thick book or spend time seaching online for the right code. It allows you to easily search through the different codes or browse by type of disorder (infections, circulatory, respiratory, etc.) or procedure. At $29.99, it’s not cheap, but if it saves you enough time, it’s worth it.
WellAdult. The guidelines for optional clinical preventive services for adults—when to perform cholesterol tests or colonoscopies, for example—are scattered among many different expert organizations and are sometimes contradictory. WellAdult ($2.99) provides an easily navigatable database of recommendations from all major organizations for adults of different ages. Click on “Women Ages 50 – 64,” for example, and you can easily compare the reommendations of different organizations for testing lipids, blood pressure, vaccinations, and cancer screening. For $2.99, this app is well worth it.
*This post, Medical Apps For The iPhone: Diagnosaurus, ICD9 Consult, and WellAdult, was originally published on Healthline.com by Joshua Schwimmer, MD.*
