Direct Primary Care – Isn’t It Too Expensive?

A common criticism of direct primary care (membership/retainer/concierge practices) is the added expense – “isn’t it too expensive?” Ways to think about the cost are to prioritize expenditures and to consider potential savings that make it cost effective.
I gave examples of three direct primary care practices in an earlier post. Here is a recap of costs.
AtlasMD’s annual fee is $600 for a young adult and about $1400 for a family of four; Dr Neuhofel’s fee is $360-$600 annually for an individual and $1200 for a family of four and Drs Izbicki charge $780 per year per individual. All can be paid monthly.
As Jon Izbicki puts it, “Our monthly fee is less than what it costs to rent a parking space downtown for the month.” Even the more expensive retainer practices are still within reason for many.  $1500 is about $4 per day; $2000 is about $5.50. How many people spend that much per day at Starbucks? Or, consider the monthly/annual cost of a smart phone data contract with ATT or Verizon. According to the Wall Street Journal and quoting from a Department of Labor study, the average American family spends $2237 per year for internet, pay TV and telephone service. So, perhaps $1500 or $2000 – which is certainly real money – is not such an onerous expense when thinking in terms of prioritizing healthcare expenses relative to other expenses. Of course, it is an added expenseif you already have typical insurance.
But if you have a high deductible plan with a health savings account (HSA), you can pay for the membership/retainer with tax advantaged dollars and save considerably. And since the PCP will likely help you avoid expensive trips to the specialist, you will save those dollars as well.
I predict that (absent a significant change in insurer behavior) direct primary care will likely be the future of primary care payment. In each of them, it means that the patient will obtain real assistance to first prevent chronic illnesses from occurring; second, episodic care for those issues that pop up during the year; third, careful care of complex chronic illnesses and fourth, thorough coordination of the care of chronic illnesses, all at a reasonable cost which will be transparent. Fifth and importantly, a PCP who has the time to listen – to listen deeply with a return to relationship medicine.
Those who already have typical limited deductible insurance – commercial or Medicare – might argue that these various direct primary care models represent an added expense, not a savings. Correct, although the potential savings can actually be quite substantial. For example, each of the three practices referred to above make generic medications available at wholesale prices; considerable savings for many individuals.
Those who have no insurance – for whatever reason – will find that they can obtain good quality primary care at a reasonable price from one of the direct pay or membership practices. It will cost a lot less than going to an urgent care center or an ER. Recall from my earlier post that Dr Neuhofel’s practice has more than two thirds with no insurance.
Perhaps Medicare and Medicaid will decide that it makes eminently good sense to pay the retainer for their enrollees and thus ensure that their members gets superior primary care at a reasonable cost and meantime save Medicare and Medicaid enormous total dollars.
This concept applies equally to commercial insurers who have largely avoided paying the retainer. Some are collaborating with the insurer paying the retainer out of its premium.
What about employers? Many are converting their health insurance policies to high deductible, often with a deductible as high as $10,000 per person or family per year. For a family with members that have chronic illnesses, the costs of healthcare will be very substantial indeed at this level. Employees will arguably feel that their employer has walked away from them and saddled them with costs that they simply cannot bear. The company can partially offset the inherent anger this generates among its employees by paying the fee for a direct primary care practice. It is especially valuable for the individual with multiple chronic illnesses since quality primary care can mean much better health, many fewer tests, prescriptions, specialist referrals and hospitalizations.
I suspect that employers will be the major reason for direct primary care membership/retainer-based practice growth in the coming years as they will essentially demand that level of service for their employees – and in so doing they will be reducing their company health care costs as a result of high quality primary care.
The exact number of physicians in DPC practices is unclear but an estimate by Concierge Medicine Today in early 2014 pegs the known number at about 4000 with about 8000 others doing so but without fanfare. CMT also notes that many combine insurance with membership fees; not exactly DPC anymore but still an ability to limit the number of patients and give more attention to each.
More doctors will convert once the general population understands the advantages and begins to ask for it. There are many good reasons for an individual to connect with a direct primary care physician – better quality care, a return to relationship medicine and often a significant cost savings despite the fee.
TAGS  Direct primary care, primary care, primary care physicians, health insurance, healthcare costs, relationship medicine, concierge medicine, retainer based medicine

Palliative Care Teams – A Big Improvement in Quality of Life

During the healthcare reform debate there was the unfortunate reference to “death panels.” No such thing was ever in the proposals but it meant that an important part of medical care was set aside as too “toxic” to discuss. But end of life counseling is very important. Indeed it is good to have realistic discussions at the beginning of a serious illness; indeed it is only fair to the patient and the patient’s family.

Palliative care (I don’t like the term; it seems to imply only end of life care and so I prefer “supportive care”) is designed to achieve the best possible quality of care and the least suffering possible. This is not limited to pain management but also to psychosocial support, spiritual needs, the treatment of any symptoms, and assistance or at least support for decision making. It might be a complicated pain management program or a simple cup of tea in the afternoon to talk over important issues. Ideally it uses a team approach including physicians, nurses, social workers, psychologists, chaplains and others all working together. Palliative care teams have demonstrated their value in improving care and, interestingly, substantially reducing medical care costs.

There was a recent report of a controlled trail of palliative care. 151 patients with lung cancer entered a randomized trial when they first came to be treated in a thoracic oncology practice. It compared standard care to the same care plus a palliative care team. The results were clear that palliative care added to the patients’ quality of life; reduced the frequency of depression, the number of hospital days and even extended the survival by 2.7 months.

My experience, and others report the same, is that many physicians are uncomfortable with palliative care and tend not to refer their patients or if they do, not until very late in the patients’ course. Perhaps it gets at the deep inner concern that they do not want to be seen as “giving up” on the patient and perhaps it even forces them to admit that they cannot always cure every patient. Whatever, it is unfortunate because many people who could benefit from early referral to the palliative care team are not getting that benefit. Most large hospitals now have such teams; it behooves the patient or family to ask about them.

Saving Relationship Medicine with Direct Primary Care

The fundamental problem in health care delivery today is a highly dysfunctional payment system that leads to higher costs, lesser quality and reduced satisfaction. It also means less time between doctor and patient with the loss of “relationship medicine.” The core problem? Price controls and regulations that reduce the trust and core interactions between doctor and patient. The patient is no one’s customer and visit times are all too short. I have argued in the Washington Times as an Op-Ed that paying the doctor directly is better for all concerned.

I believe that some of the best attempts to improve this dysfunctional delivery system have been accomplished by primary care physicians themselves.   They have essentially said “I won’t take it any longer; this is not good for my patients or for me.” They have also said that it is time to “stop tinkering” and make a fundamental change. They have opted for a new, better system – direct primary care – rather than wait for others to fix it for them.

The concept with direct primary care is to reduce the number of patients in a PCPs practice so that each patient gets added time as needed. Often this means removing the insurance system as the payer from primary care and always it means a payment model that compensates the PCP directly by the patient. Direct primary care takes many forms. There are two principle payment systems. One is for the patient to pay the doctor directlyfor each visit, usually at a rate far below what would have been charged in the insurance model since the overheads of billing and coding have been eliminated. Many such PCPs post a defined price list – transparency. This is sometimes called direct pay or “pay at the door,” not unlike the way it was until a few decades ago before insurance morphed from being only for major medical or catastrophic issues to being essentially prepaid medical care.

The second model is for the patient to purchase a package of care for the year paid by the month or annually. This basic model comes with many variations and may be called membership, retainer or concierge. Despite the various names, they all have certain characteristics in common but there are many variations in how the practice functions.

All of these models offer a reduced patient to doctor ratio: instead of the typical 2500-3000+ patient panels, the PCP may adjust the number of patients to a low of 300 when the panel is very ill or to a high of about 800 for a panel that has mostly low risk patients. Some accept insurance and also charge the retainer; others just charge the monthly or annual fee.

With a reduced patient panel size, the PCP commits to offering same or next day appointments lasting as long as necessary, a comprehensive annual examination, email communications, and an invitation to contact the PCP on his or her personal cell phone 24/7. Some make house calls and nursing home visits for no extra charge; others add a modest fee. Some see their patients in the ER and some follow their patients in the hospital.

There may be an arrangement to obtain laboratory testing, imaging and procedures at highly discounted rates from selected vendors. Some practices offer a limited number of laboratory tests at no charge. Some PCPs are supplying medications at no or wholesale costs. For the patient on multiple prescription medications, the savings on drugs can more than offset the monthly/annual subscription cost of direct primary care.

Many only work with specialists who are willing to discount their fees for those of their patients who pay cash and have high deductible plans or no insurance at all.

Often regarded as highly expensive and only for the “elite,” the rich, or the “one percent,” in fact membership/retainer/concierge practices can be of quite reasonable cost and very appropriate for those with no or limited insurance and for those with modest incomes – “blue collar” concierge medicine.

Fees range from about $500 to $2000 or more per person per year. [I will ignore those doctors who charge a very high fee for “exclusive” services.] By some degree of common usage those on the lower price end often refer to their practices as direct primary care or membership whereas those at the higher end often refer to their practices as retainer or concierge. To the extent that there is any real difference, it is probably in the number of patients in the panel or seen per day, the extent of the annual evaluation and added values such as following one’s patients in the hospital and in the ER.

For those who have high deductible insurance policies from work or from the exchanges, connecting with a direct primary care physician can offer a significant savings. The individual and the physician now have a direct professional business relationship. The person begins to take a much more active role in the entire care process. And the doctor can allot meaningful time for patient interaction – a return to “relationship medicine.”

With little to hope that government or insurers will improve the lot of primary care physicians, direct primary care is a rational manner for PCPs to change the paradigm and return to relationship medicine. It means better medical care, less frustration and more satisfaction for doctor and patient alike and an encouragement to medical students to consider primary care as a career option. It also means that total medical care costs go down. A triple win.

Next post – more on the costs of direct primary care

Will “Medicare As We Know It” Persist Or Will It Change?

With the nomination of Congressman Paul Ryan last summer as the vice presidential candidate of the Republican Party, Medicare became front and center in the political discussions and, although there is less attention just now, it will return with a vengeance once again to dominate. To understand the dialogue requires an understanding of Medicare, how it works, where the money comes from, how it is spent and why there is such concern for its future costs. Here is an overview in a few bite sized pieces spread over 8 parts.  

Medicare was designed in 1965 to serve as “major medical” insurance to cover the unexpected large expenses of, say, surgery or hospitalization. Individuals paid out of pocket for routine care. Medicare has morphed over the years; it now covers preventive care, screening, annual exams and most routine care. This broadening of coverage, the relentless rise of healthcare costs and huge enrollee additions by baby boomers will continue to increase Medicare expenditures.  

Medicare covers about 50 million older Americans for general health care insurance and another approximately 8 million with coverage for disabilities and end stage renal disease.   

Medicare pays about 75% of covered services and about half of the total costs of health care for older Americans, i.e., it pays for only certain specified medical services or “covered” costs. The remaining 25% of covered services as defined by Centers for Medicare and Medicaid Services (CMS) is paid for either via a private Medigap policy and/or out of pocket by the beneficiary. Since 2004, prescription drugs have also been covered.  

Interestingly, Medicare is not true catastrophic insurance. For example, it pays in full for the first 60 days of hospitalization but then there is a co-pay of just under $300 for each of the next 30 days. There is no coverage after 90 days although each person is allotted a lifetime reserve of 60 days, each with a co-pay currently of just under $600 per day. 

Medicare is such a large part of the health care insurance market that it establishes two critical parameters for all of health care reimbursement. First, it sets the standard level for reimbursement which all other insurers ultimately follow.  

Second, Medicare does not pay it full share of the costs it does cover. Basically it pays some percentage below actual costs leading the providers – hospitals, doctors, or other  – to cost shift, i.e., charge their other patients who have commercial insurance a higher amount than costs to make up for what they did not receive from Medicare. What this means for the young person who has either a company sponsored health insurance plan or buys it directly in the individual market, is that he or she paying a “Medicare tax” over what the insurance would have otherwise cost. This is on top of the Medicare Trust Fund tax of 2.9%. 

Government estimates are that Medicare will increase its expenditures over the coming decade at a rate of about 4% per annum. This is greater than both inflation and the GDP rate of growth. Medicare which now accounts for about 15% of the federal budget will rise from almost $600 billion per year now to about $1 trillion per year by 2022 – levels that will severely strain the capability of the system. Indeed, it a growth rate that is just not sustainable; it will eventually bankrupt the federal treasury.

Next – Where the money comes from and why it costs so much.

A Humble Opinion

Book Review – Readers of my posts know that I am a strong advocate for primary care and especially a primary care physician (PCP) that provides each patient with sufficient time. Time for the PCP to listen, to think, to treat and to prevent. This allows the patient and doctor to reclaim relationship medicine, a standard tenet of care in the past but now largely lost in our financially driven medical care system.
Dr Jordan Grumet is a primary care physician in Ohio who tries to assure his patients of a strong relationship, one in which they can build trust. Recently he has reduced his practice to about 600 patients and become “concierge.” Now he has more time for his patients and even some time for his family. For years he has written a blog entitled “In My Humble Opinion” in which he records his thoughts of events in his practice, in his home life and in his wide ranging mind. His posts are thoughtful, thought provoking, engaging, emotional and educational. Recently he published book curated from his posts and arranged into meaningful sections such as “The Grateful Death” or “In Sickness or in Sorrow.”
Dr Grumet’s book is a must read for anyone who cares – cares about their health, cares what they or their family receive from medical professionals, cares about what the doctor or nurse offers to  their patients. I have read Dr Grumet’s blog intermittently for the past few years. Always it leaves me with the sense that here is a real human being doing what he does best – caring for patients, one at a time and in the process trying to care for himself and his family. His book title – “I Am Your Doctor” – implies not a fact but a responsibility that he accepts when you come to him. The cover picture is equally powerful – a hand holding another’s, a clear and compelling symbol that this is a physician who wants to have a real relationship with you, his patient. Relationship medicine has largely been lost to today’s business and economic imperatives but doctors like Grumet are trying their best to retain it in their everyday practice. Dr Grumet brings us back to the true calling of what it is to be a physician and in his humble manner but compelling writing style reminds us that physicians are human with of the frailties and foibles as everyone else – the longings, the joys and the sorrows. But especially they want to be there with you as you experience those joys and sorrows, those exhilarations and frustrations that come with life, living and eventually dying. Here are two excerpts:
“Two weeks from now I will tell a man he is going to die. He will sit calmly in my exam room as he shifts his weight from side to side. Although his hair has grayed and his body has weakened, his face will sparkle with youth and vibrancy. He’ll stare deeply into my eyes and I’ll detect a hint of mirth. “We’re all dying, my friend.” He will draw in a deep breath and put his hand on my shoulder. “The trick is learning how to live!” 

“It’s not exactly Dr. Jekyll and Mr. Hyde, but everybody knows my level of patience varies from time to time. So I was surprised to find myself happily telling the emergency room that I would assess the patient shortly. The kids were horsing around on the playground, and I knew I would have to call my wife and ask her to come home. It would be my second 45-minute trip to the hospital on an otherwise busy Saturday afternoon. For some reason today, I was able to sublimate the automatic annoyance and return without emotional drama. I slowed down, calmly listened to the patient and reassuringly put a plan into place. Driving home, I felt both relieved and saddened by the joy that overcame me. Why didn’t my life’s work make me feel this way all the time? I guess it starts with one simple fact. I blame myself for every heart attack, stroke or new diagnosis of advanced cancer. As disturbing as that sounds, how could I not?”

Read this book and you will want him to be your doctor. Or at least you will want to find a primary care physician like him who practices real relationship medicine the way he does and who assures you that you will have his or her  undivided attention

Nanomedicine – A Key Component to the Future of Medicine

Nanotechnology is making fast advances in medicine. I have written about it before here and in “The Future of Medicine – Megatrends in Healthcare.” A nanometer is one billionth of a meter. New science and technology based on the nanometer refers to the ability to manipulate individual atoms and molecules to build machines on a scale of nanometers or to create materials and structures from the bottom up with novel properties.Nanotechnology, according to the National Science Foundation, could change the way almost everything is designed and made, from automobile tires to vaccines to objects not yet imagined. The concept is to prepare “smart objects” that can invade small spaces and target specific parts of the body. Some researchers expect nanoscience to have a profound impact on the way medicine is practiced.
Here is a an infogram that gives a nice overview, compliments of  its originator, Marcela De Vivo and her sponsor Associates Degree in Nursing.


Paying Primary Care Physicians Directly is Advantageous

I wrote an Op Ed for the Washington Times that ran today suggesting it is advantageous to us as patients when we pay our primary care doctors directly rather than depend on insurance. This returns us to the position of being in a direct professional financial contractural relationship with our PCP. It leads to better care, greater satisfaction and ultimately a major reduction in total health care expenses.

Here is the link

Lung Cancer Part 4 – Drug Therapy

Lung cancer causes 160,000 deaths each year – more than the next four cancers combined. Diagnostic and treatment options have improved greatly in the past decade and continue to advance at a rapid rate. Among the most important advances have been: Learning that chemotherapy combinations of a platinum-containing drug produce substantial improvements in tumor shrinkage, quality of life and extension of life. Second, these combinations, when added to surgery and/ or radiation for early stage disease, improve survival and increase cure rates. Third, the introduction of “Targeted” drug therapies have led to often dramatic tumor shrinkage and increased disease free survival. Patients who develop lung cancer which has spread still generally die within a year of diagnosis but progress is apparent and improvements are developing quickly.
Drug therapy for lung cancer had been disappointing until recent years. The combination of platinum containing compounds such as cisplatin or carboplatin with drugs like premetrexed, docetaxel, paclitaxel or gemcitabine have substantially improved the response rates, progression-free survival and the overall duration of survival as well as reduce symptoms from lung cancer.  Most patients will have substantially less pain, less difficulty breathing, and reduced cough, among relief of other symptoms as well. Whereas only 10% of patients with advanced non-small cell lung cancer (NSCLC) will live for one year with “supportive care” alone, approximately 50% will survive one year with current chemotherapy. However, virtually all patients with advanced lung cancer still die within 3 years of diagnosis.   So a major advance but still a long ways to go.
For patients with limited small cell lung cancer (SCLC) or those with localized or locally advanced NSCLC, chemotherapy has a vital and potentially curative role. In combination with radiation therapy, approximately 25-30% of patients with localized SCLC or NSCLC can be cured. In selected patients with localized NSCLC, surgery may incrementally improve outcome, though this is controversial. The use of multimodality therapy in these diseases has been one of the major advances in oncology in the past 25 years.
Another major advance in drug therapy of lung cancer today is the development of so called “targeted” drugs. Many cancers have mutations or rearrangements in their DNA that in turn produce an abnormal protein – a protein that can initiate cancer, lead to its proliferation or its metastatic potential. These are changes in the DNA of the tumor itself that are critical to the initiation and progression of the cancer, hence the term “driver” mutations. A targeted drug is one that attacks or binds these abnormal proteins that are directly causing or encouraging the growth of the tumor. Among patients with lung adenocarcinoma (which represent about 40% of lung cancers), about 17 percent have a mutation of a tyrosine kinase receptor gene called EGFR (epidermal growth factor receptor), about 22 percent have KRAS (Kirsten rat sarcoma viral oncogene ) mutations and perhaps 5 percent have an EML4 (echinoderm microtubule-associated proteinlike4) rearrangement with the ALK (anaplastic lymphoma kinase) gene. There are at least seven other of these mutations or rearrangements, each occurring uncommonly and it is likely that many more will be detected in the years to come. These three mutations/rearrangements appear to be mutually exclusive and occur very rarely in the other forms of non-small cell lung cancer (NSCLC), i.e., squamous cell and large cell tumors. Since these DNA gene changes direct the formation of abnormal proteins, inhibiting the protein action by a targeted drug can lead to shrinkage of the cancer or slowing of its progression, often with rather dramatic success.
These driver mutations make it possible to categorize many adenocarcinomas based on molecular variations. It is instructive to appreciate that although a group of tumors may appear identical by histology under the microscope, they are actually distinct subtypes of lung cancer with different responses to the available therapies. This helps to explain why patients with equivalent staged and histologic tumors may respond much differently to the same treatment. It is clear that at least adenocarcinoma (and presumably squamous and large cell will follow suit shortly) should be molecularly typed before undertaking treatment.
Patients whose tumors have one of these mutations have a greater likelihood of responding to the corresponding targeted receptor inhibitor. Among the EGFR tyrosine kinase inhibitors are the new drugs erlotinib (Tarceva), gefitinib (Iressa) and afatinib (Tomtovok). Though these drugs may be dramatically effective in reducing disease burden, it is important to note that drug resistance will develop over time in virtually all patients. The average patient experiences about one year of benefit for erlotinib and similar agents. There are some patients (about 5-10%) who may benefit for several years. Newer drugs are under development that can be used once resistance develops. A recent trial compared erlotinib to the current standard chemotherapy of platinum-based therapy for initial treatment of EGRF positive adenocarcinoma patients. The median progression-free survival was 10.4 versus 5.1 months.
There are no targeted drugs for KRAS at this time however there is one for those with ALK rearrangements. Crizotinib (Xalkori) was approved by the FDA based on results among patients with EML4-ALK fusions who had a better than 50 percent response rate that persisted for nearly a year despite this being second line treatment (i.e., the patient had already received prior therapy and had had their disease progress before trying this drug). Compared to standard combination chemotherapy, the response rate was 65 percent compared to 20 percent and side effects were generally modest. Only 3 -5 percent of lung cancer patients have the ALK+ gene rearrangement so that equates to maybe 50,000 patients worldwide per year. But for these relatively few patients, crizotinib has become the new standard for first line therapy. There are also some additional new drugs in the pipeline that are ALK+ inhibitors. These may prove effective for those that develop resistance to crizotinib as essentially all of these tumors eventually will do.
A separate approach is to target the growth of blood vessels since the tumor needs a steady supply of nutrients to persist and progress. Affecting such “angiogenesis” might prove of value. Bevacizumab (Avastin) is a monoclonal antibody that attacks vascular endothelial growth factor (VEGF), a molecule that encourages the growth of small vessels. It has been found to add a few months to progression free survival when used with cisplatin and paclitaxel for non-squamous NSCLC. Overall survival was increased from 10.3 months with cisplatin and paclitaxel alone to 12.3 months with the three drug combination. Avastin has not demonstrated any advantage when added to other chemotherapy regimens. The current approach is to use it as first line therapy with a platinum based combination of drugs and after maximum response to continue it until relapse or progression of disease. Avastin costs about $100,000 per year.
There are multiple messages here.
·         First, the combination of platinum-based combinations has markedly improved the treatment of late stage lung cancer.
·         Second, chemotherapy combined with radiation for early stage disease offers an increased opportunity for cure.
·         Third, certain patients, principally those with adenocarcinoma, will have one of these “driver” mutations in their tumor DNA. Knowing what is driving the cancer may be the most important development of recent years.
·         Fourth, new drugs have and continue to become available that inhibit these abnormal proteins resulting in meaningful shrinkage and occasional complete responses.
·         Firth, the responses, although heartening, can be but are usually not long lasting and come with various toxicities that can be quite serious.
·         Equally important, sixth, knowing that a specific mutation exists – or does not exist – can save a patient time, the expense and the toxicities of receiving a drug that is destined to be inactive.
·         Seventh, and quite important, the technologies to test for these mutations are new and not fully understood as yet. It is clear that it is not a matter of pushing a simple “on/off” switch. But it is a definite start with improvements of a degree and duration not seen previously in this disease.
·         Eighth, it may well be, just as with cancer chemotherapy, that combinations of targeted drugs or targeted compounds plus standard chemotherapy will be found to be more effective and lead to more long lasting responses.
·         Finally is the issue of cost. Combinations such as platinum/paclitaxel or platinum/gemcitabine are inexpensive as the drugs are off patent. But the new targeted drugs are each highly expensive. This raises the question of whether and when this level of expense is justified for a relatively short period of time without the cancer progressing or with such limited added survival. Some countries such as the British have refused to cover the expense of Avastin for lung cancer citing that it does not cure but is highly expensive. In the USA, some commercial insurance likewise will not pay for some of these highly expensive drugs. The pharmaceutical companies maintain however that the response rates justify the costs and that the prices are appropriate given the expense of developing these new compounds.
Although there is obviously room for improvement, it is clear that there has been major progress in the drug treatment of lung cancer. The rate of development of new approaches has been rapid and can be expected to continue.
The next and last of this series will discuss the importance of multi-disciplinary care, palliative care and seeking high levels of expertise combined with compassion and caring.

A New Way To Improve Primary Care Yet Reduce Total Costs

PCPs in the current reimbursement model are obliged for business reasons to see too many patients per day which of course means less time per patient. PCPs are frustrated and patients are less satisfied. With less time it is hard to build a strong doctor – patient relationship and without it there is less opportunity to build trust. Readers of my posts know that I am a strong advocate for primary care and for granting the PCP added time per patient but doing so with no decrement in income. Here is an innovative experiment by an insurer to incent PCPs to offer more time to those patients with chronic illnesses while enhancing preventive care to all. 

Added time and good care coordination will improve the quality of care for the individual patient with a chronic illness and yet will reduce costs by eliminating excess specialists visits, tests, procedures and, by improving care quality, it will reduce the need for hospitalizations. That was the assumption underlying a program by a large not for profit BlueCross/Blue Shield plan – CareFirst. Fundamentally the plan incents PCPs with opportunities for increased income in return for giving added time and good care coordination to those with chronic illnesses along with enhanced preventive care to all patients. 

The insurer calculated that about 80% of their medical expenditures went towards the care of just 15% of patients. These were patients with complex chronic illnesses. Knowing that primary care physicians receive about 5% of total healthcare expenditures it was hypothesized that they are in a position to strongly impact much of the other 95%. The insurer also wanted to raise awareness of healthy lifestyles to assist all of their enrollees to remain healthy. So the agenda was to create incentives for PCPs to have an impact to reduce the total cost for those with chronic conditions while improving the care and concurrently maintain the health of the remaining enrollees. 

Oversimplified, the new program works like this. PCPs form into actual or virtual groups or panels of 5 to 10 and enter into an agreement with the insurer which then increases their reimbursement by 12% for each visit. The insurer also agrees to pay the physician within one business day, reducing the doctor’s need for working capital.  

An actuarial analysis of the PCP group’s patients is done using claims data from the prior year to create an anticipated “global budget” for the coming year.  The 15% or so of patients that need chronic illness care coordination are “flagged.” The PCP’s obligation is to give those patients whatever added time is needed per visit, to create a complete care plan and to post it in an electronic medical record (for which the PCP gets an additional $200). This serves as automatic preauthorization; no further calls will be needed for tests, procedures, etc. – a major time saver for the PCP and the office staff. The concept also anticipated that with extra time per patient, the PCP would be able to handle most issues including those of patients with complex chronic illnesses, reducing the need for specialist referrals. Finally, the insurer makes available a nurse “care coordinator” at its expense  to call the patient as often as necessary to check on medication use, medication side effects, weight gain or whatever else the PCP has built into the care plan. The expectation starting out was that this approach of incentives for giving the patient with a chronic illness the intensive primary care and the care coordination needed would enhance quality yet reduce the overall expenditures for that patient.  

If, at the end of the year, the PCP groups’ total claims came in under the projected global budget, the members of the virtual group would get back a portion of the savings. With these incentives, it was anticipated that the PCP would be sure to carefully coordinate care so that there were no excess specialist visits, no unneeded tests or procedures and, with better care overall, less ER visits and less hospitalizations. The end result, it was hoped from the start, would be higher quality care, lower total expenditures for that care, enhanced income for the PCPs and a more satisfying practice. It could be a win for everyone. Now three years in, the plan seems to be working. The physicians are pleased with the added income and the insurer is pleased that total costs have dropped. 

The whole concept was to coordinate the care that the patient receives with the expectation that the patient will be better served, the providers will be more satisfied and the total costs will be reduced. It is a transformational change in how the PCP functions. It is an equally huge transformational change for the insurer –a change that accepts that extensive primary care with care coordination costs extra money but recognizes that the end result is better quality at a lower total cost.  

After two years, it was reported that it saved $136 million with the 297 panels of 3,600 PCPs that had joined the program caring for about one million individuals. All of the PCPs enjoyed the added income in their reimbursements and two thirds received end of year incentive payments as a result of the savings. Overall the average PCP in the program received about 29% more than they otherwise would have under the standard fee schedule.  

At the end of three years and with enough data to be actuarially credible, there have been quite definite improvements in ten measures such as costs per member per month, number of emergency visits, admissions per 1000 members, length of stay, cost per admission, and readmissions within 30 days after discharge, etc. while maintaining or improving quality measures. Not all panels of PCPs were as successful as others and those that were tended to be successful in each of the three years in the program. At the end of the third year, about 60% of the panels were granted an incentive award for beating their projected global budget. The successful panels tended to be those in small private practices and, interestingly, had sicker patients under care yet they maintained higher quality scores. Another important finding was that some specialists tended to much higher utilization (and therefore costs) than others despite similar patient problems. PCPs who tended to refer to high utilization specialists were much less likely to achieve an end of year incentive payment. 

Of course, there are some questions to raise. If the PCP is spending more time with these patients but still has the same total size practice, then where is the time coming from? Does it mean less time for other patients? PCPs have now learned which specialists expend more dollars per patient than others. Will their referrals gravitate to these specialists regardless of known or perceived quality? Patients will likely in the future be offered incentives for choosing the PCPs that are most effective with this program; is that appropriate? And what about those PCPs who have converted their practices to direct primary care? They are actually saving the insurer considerably, probably much more than the incented PCPs in this program. The insurer should consider paying all or part of the DPC fee for their insureds since the insurer is benefiting substantially yet at no cost to itself. 

Perhaps the most important outcome, from my perspective, is the recognition by a major insurer that it is possible to create a new incentive-based approach to reimbursement – in this case within the old fee-for-service model – which actually costs more for primary care (up from about 5% of total costs to about 7-8% of total costs) yet significantly reduced those total costs of carewhile improving quality. 

Note: I talked to CareFirst’s CEO, the former chairman of the board and a vice president about the program but I have no financial relationship; this program is used for illustrative purposes only and is not meant to be an endorsement.

Protocol Medicine – It Is Time For Doctors To Recognize Their Value

We hear that doctors do not like “protocol medicine” – they do not want to follow a “cookbook” when every patient is different. It is not a good understanding of the issues.

Some years ago when I worked in a branch of he National Cancer Institute and then the University of Maryland Cancer Center, we admitted many patients with acute leukemia. The treatment approach including the necessary special tests to obtain, chemotherapy drugs, steps to prevent infection, prevent kidney problems, etc was complicated. So I wrote out a set of admission orders, had them typed up, xeroxed and kept at the nurses’ station. When a new patient was admitted, the physician took one of those order sheets and either accepted each individual order or made changes. But the doctor now would not forget something important such as a drug, its dose or the number of times per day. This worked much better than depending on memory yet any specific order could be eliminated or modified as needed for the individual patient. This was not a “cookbook” but rather an improvement in both safety and quality.

Peter Pronovost and colleagues from the Johns Hopkins Bloomberg School of Public Health have worked on designing similar protocols for ICU patients for those needing the insertion of a central intravenous catheter to reduce the frequency of hospital acquired infections. This is basic stuff like gown and glove, use a disinfectant on the skin, use sterile materials, etc. It works; the infection rate falls by 60% if the guidelines are followed. Indeed in the Michigan hospitals where the technique was evaluated, the rate dropped to zero.

Remarkably, many doctors at hospitals across the country rebel at having those steps to follow using the same argument of “protocol medicine.” And equally remarkably, most hospital executives are hesitant to insist. They will need to become more assertive and physicians must accept the new standards. It is a matter of rights and responsibilities.

If physicians want the public (and elected representatives) to be supportive of malpractice tort reform, they will first have to accept “protocol or “cookbook” or “checklist” approaches that are tried and proven to improve quality and safety.

Cheap Drugs From Canada– Good Idea?

The price of drugs comes from a perverse system and what you as a patient pay is equally perverse. Let’s consider a few examples.
Older people often develop actinic keratosis on their scalp as a result of years of ultraviolet rays from the sun. They can progress to skin cancer so it is good to treat them. A dermatologist can remove them with liquid nitrogen or the individual can apply a prescription drug that kills the cells in the AKs. The drug most commonly used for decades is an anticancer drug – 5-flurouracil or 5-FU. Applied topically it can be very effective. 5-FU was developed before I went to medical school which is now 50 years ago. It is obviously off patent and not difficult to manufacture. But the branded topical called Efudex costs about $300 retail. Wow! There is a generic but it is also expensive, albeit at half the price of about $150. It is a large tube and will last a long time but it is a lot of money none the less. It is not a high volume drug and there are only two manufacturers so the competition is minimal enough to keep the price high. And even with the generic, there is a large middleman profit between what the manufacturer sells it for and what the pharmacy ultimately charges you (or your insurer.)
Staying with dermatoligic issues, rosacea can be cosmetically bothersome with redness, papules, acne-like pustules on the face and coarsening of the nose (rhinophyma.) Its cause is unknown and there is no really good treatment. One approach has been to use an antibiotic called doxycycline taken orally in the usual “antibiotic” dose of 100mg. It seems to have an anti-inflammatory effect rather than an antibiotic effect in the skin and often can clear the face. It is a very inexpensive capsule at about 30 cents each. But it can also have an adverse effect on the bacteria in the gut and possibly lead to overgrowth of yeasts. A new approach is a 40mg capsule branded as Oracea which is both regular doxycycline and a sustained release form so that the blood level stays low and relatively constant over the day; perhaps it will have less likelihood of adverse problems. It has been tested and found to be reasonably effective for rosacea and hence approved for market by the FDA. But it is on patent and costs about $10 per dose or $300 per month– a drug that the patient will probably have to take forever to keep their face clear. That adds up – fast. Instead one might consider using the standard 100mg doxycycline but only for a few days whenever a flare-up begins. Low cost and limited side effects, if any.
Steroid creams are commonly used for rashes. I was once given a prescription for betamethasone for a small rash. Why betamethasone rather than over the counter hydrocortisone? “It is stronger and will work faster,” said my doctor. But, since I had a high deductible insurance policy, I had to pay the entire bill which proved to be a remarkable $67. An over the counter tube of hydrocortisone at the same pharmacy, enough to last a whole family for years and years, costs only $1.98. Sometimes it pays to accept a slower cure.
Let’s say you need an acid suppressor for reflux esophagitis [acid reflux or GERD.] There are multiple drugs called proton pump inhibitors on the market, some off patent and now over the counter and others still on patent and only available by prescription. They are all effective. The differences among them are minimal. Your doctor could tell you to go to the grocery store and pickup Prilosec for about $30 for a month’s supply. Or, he or she could give you a prescription for Nexium. It would cost about $150 for a two week supply. But your insurance will pay for it except for your co-pay of, say, $15. So your doctor will probably suggest Nexium since it will cost you less. But the overall system is paying out a huge amount more than necessary. What a perverse system. 

If you are the one paying for the drug because you have a high deductible plan or no plan at all then you start to ask questions. Sometimes you can find a generic equivalent like the fluorouracil example but sometimes the generic is still expensive. That is you might start to look elsewhere. 

What about buying drugs from Canada? Same drug but at a better price. I checked and found the topical fluorouracil branded Efudex for $75 including $10 for shipping. That is a lot better than the generic price here of about $150 and way better than Efudex at about $300. For the doxycycline, using the same web checker, I found a 50mg dosage (albeit not sustained release) that costs about $17 per month. Oracea 40 mg capsules can be found in Canada for about $2.00 each if you buy more than 50 at a time. Both are quite a difference from $3600 for a year’s supply. Nexium can be found for about $1.00 a pill, way less than in the United States but it is just as easy to go to the local grocery store and buy Prilosec for much less still. As for betamethasone, it is $25 with a $10 shipping fee. A lot less but over the counter hydrocortisone is still only $1.98! 

But buyer beware. We have a very carefully monitored market in the United States through the FDA. We benefit greatly from its regulations and its careful scrutiny of each new drug before it can be marketed. IN the United States, the drug can be traced from the manufacturer to the distributor to the pharmacy to you so you can be certain it is the real thing. And companies that manufacture overseas must follow the same stringent requirements as in the USA in order to sell here. The FDA’s concern is not to protect the drug companies profit from competition but to protect us (you and me) from the unscrupulous. The concern is that the drug bought from Canada (or elsewhere) may not actually be the drug it is said to be. Witness the highly expensive drug Avastin used to treat certain cancers. A counterfeit was somehow entered onto distribution in the USA from somewhere else- except that it was not Avastin. It was not a drug at all. A lot of unsuspecting doctors and patients were duped. So it behooves us to carefully balance the pros and the cons.  

Why does it cost less in Canada or other countries for the same drug? Because the other countries tell the drug company that it can only sell the drug at a set upper price limit. If that limit is still within the pharmaceutical manufacturer’s marginal cost per unit of drug, then they will agree and sell at that level. In America, we are effectively paying for the entire R&D cost of bringing a new medication to market along with the company’s marketing cost and still giving it a huge profit potential. Rather than import the drug from Canada, we should just expect the company to sell here for the same price as there. But they do not have to and so they do not. Right now, Americans effectively pay for the R&D costs of new drugs while others get a discount because their governments insist. So should ours. It would bring the price down and negate the need to look to Canada or elsewhere.

How to do that without imposing price controls or getting the government into further regulatory policies. I wrote in the Future of Health Care Delivery that the federal government should simply say that it (through it drug purchases via Medicare, Medicaid, the military and Veterans Administration) will only buy medications from drug companies that sell it for the same price here as overseas. The drug company still can sets whatever price it wants but since the government buys at least half of the drugs sold in the USA, it should have an impact and quickly.

Curing Medicare

Book Review.This might seem like a curious title for a blog post but it reflects a very serious national need. Medicare is the central method for financing medical care for those over 65. It brings major value but it has serious deficiencies. We are frequently reminded that the Medicare Trust Fund will shortly run low of money. Enter Dr Andy Lazris a gerontologist with over 25 years of experience caring for the elderly. In his book – Curing Medicare – he lays out the issues that truly need to be addressed if America’s seniors are to “Age Gracefully.”
Dr Lazris and I live in the same community but had never met nor knew of each other. A retirement community executive, knowing I was writing a book about primary care, urged me to meet him. Before our meeting the next week, I ran into an acupuncturist I have known for some time. He also spontaneously suggested I meet Dr Lazris and so did the CEO of a major nursing home chain. Each said Lazris was a terrific doctor, a humanist, a real “gem” and an all-around nice guy. With such a buildup it would have been easy to be disappointed. But I certainly was not.
Although he sees any adult patient, his practice is largely composed of elderly individuals living in retirement communities, assisted living or nursing facilities. He limits his practice to about 600 patients so each can get the time needed and deserved. He is at once humorous and wise, light hearted and dead serious. He clearly understands the needs of the elderly and likewise understands how Medicare works – including how it impedes care and encourages aggressive care when a more benign or palliative approach would be better medicine and certainly more humane. As he puts it, “sometimes less is more.”
Curing Medicareshould be a must read by anyone who is over 65 and anyone who has loved ones that are growing older, in other words it is important for most of us to understand what he teaches us. Medicarehas been a major medical and financial boon to most elderly individuals but it has some serious deficiencies and it behooves us to understand them. Dr Lazris writes from his personal experience and gives many patient vignettes to back up his observations. A major point is that it is often best to not diagnose and treat aggressively (or “thoroughly” as he puts it) but to use a more palliative approach. But Medicare in both its payment systems and its regulatory approach essentially dictates aggressive medicine, indicated or not. Whether in the home, an assisted living facility, a nursing home or the hospital, the pressures are for being “thorough”, often to the patients’ detriment if not outright harm. And such aggressive diagnosis and therapy are what make costs go sky-high. These and other problems are fully presented and discussed in a way that we can all understand and appreciate along with his commonsense recommendations for reforming Medicare.
Recently, Health and Human Services secretary Silvia Burwell announced that Medicare will shift from the current fee for service reimbursement methodology to one that rewards value, i.e., reduced costs yet improved quality. On the surface that appears like a responsible direction. But is it? In an Op-Ed in the Baltimore Sun, Dr Lazris lays out some critical issues that lead one to question the HHS rationale. He uses points and concepts discussed in detail in his book so a quick read at this link will be of interest to many potential book readers.
Overall, Dr Lazris presents us with an elegant approach to the care of the elderly, one that he personally uses as best he can despite the restrictions imposed by Medicare’s payment and regulatory dictums. He offers us commonsense suggestions on how Medicare could be vastly improved, offering patients much better quality of care yet at the same time offering Medicare (and our tax dollars) enormous savings. I recommend his book highly.
Next Time – Another book review – I Am Your Doctor by Jordan Grummet

Aging Gracefully – Part 1 The Normal Aging Process

It is possible to slow the aging process.  No there is no Fountain of Youth and no, there is no pill that’s been discovered.  It’s all about lifestyle and this means starting at an early age and sticking with it through the years. 
I was recently invited to give a talk to a group of about 100 individuals contemplating moving to a continuing care retirement community.  The topic – is it possible to slow the aging process?  I titled it “Aging Gracefully.”  Here are my thoughts divided into three major categories:  the normal aging process, slowing the aging process, and (in a post to follow) obtaining the very best comprehensive health care.  The talk was picked up by the Howard Times of the Baltimore Sun; the reporter’s article is available at this link:
 “Old parts wear out.”  That’s normal aging.  It’s universal, it’s progressive and, at least as we know it today, it is irreversible.  Most organ functions decline by about 1% per year.  Fortunately our organs have a huge redundancy and so we can afford the declines without illness.  But eventually if we live long enough and the process continues at the usual rate a point is reached at which functional impairment or actual disease presents. 
Let’s use bone mineral density and cognitive function as examples.  During our childhood and teenage years our bone mineral density increases and with it our bone strength.  It reaches a peak at about age 20 and plateaus and then by age 35 starts a slow but inexorable decline of about 1% per year.  Should we live long enough we will reach a point which we can call the “fracture threshold” meaning that if we fall it’s possible to break a leg or a bone in our back.  Of course that 1% decline per year is an average.  Some people decline faster and some people decline more slowly.  We’ll come back to that point.  The same goes for cognitive function.  We’re at a peak at about age 20 and then there is a long plateau with a slow decline such that by the time we’re in our 80’s or 90’s most people have some noticeable decline in cognition. 
There are certain impairments that come with aging such as reduced vision, reduced hearing and reduced mobility.  We might not consider these as true diseases.  However there is also an increased prevalence of chronic illnesses such as heart failure, cancer, chronic lung and kidney disease and diabetes.  They often manifest in older ages but they actually originated many years ago.  For example coronary artery plaque buildup begins in childhood but may not manifest itself as a heart attack until the late 60’s.  Similarly lung cancer is on average diagnosed at age 72 but the cause began way back as a teenager when the person first went back behind the garage for a smoke. (BTW, not all lung cancers are due to smoking but for those that are, it was a long slow process over time.) 
These chronic illnesses are largely due to our adverse behaviors, our lifestyles.  The four big behaviors that need to be addressed are nutrition, exercise, chronic stress and tobacco.  We could add other factors but especially inadequate dental hygiene and excessive alcohol. All too many of us have poor nutrition (e.g. packaged and processed foods, lack of fresh fruits and vegetables, etc.) and at the same time we eat too much of it.  Most Americans don’t get an adequate amount of exercise.  It seems that everyone has some level of chronic stress and 20% of Americans smoke. 

To summarize, there is a normal aging process wherein organs reduce their function by about 1% per year. This rate of decline is related, in part, to our lifestyles beginning when we are quite young. There are also age-prevalent chronic diseases that are also life style driven. Our personal agendas need to include attention to healthy living so that we can preserve wellness.

Next time – Slowing the Aging Process


Genomics – a Revolution in Medicine – Part 2

In the previous post I discussed the field of pharmacogenomics. Today I will focus on

Disease classification
Disease prognostication
Early and rapid diagnosis
Prediction of diseases to develop later in life

Genomics is proving to be very valuable in disease classification, especially with cancer. A pathologist’s evaluation looking at a microscopic slide has been the basis for most cancer classification – separating out breast cancer from lung cancer but then sub classifying each such as small cell and non-small cell lung cancer or the various subcategories of lymphomas. To this was added some years ago histochemical analysis to learn if a breast cancer was high in estrogen or progesterone receptors and then molecular diagnosis to find, for example, if the tumor had a high complement of the receptor Her2neu – each being important markers for the approach to treatment. Now genomics is adding an ability to delve much more deeply and find what the DNA mutations are in the individual tumor and how they are similar or different from others. This in turn is leading to searches for new drugs, as discussed last time.

This same work allows for early prognostication. Consider 100 women with breast cancer that appear by all the usual criteria to be the same type and of the same early stage. We know that most of them will respond well to current therapy of surgery, radiation locally and, in certain circumstances, systemic chemotherapy or hormonal therapy. But a small percentage will have a relapse. The problem is that there has been no way to determine in advance who is at risk of relapse. Genomics has begun to answer this problem. Analyzing the genomics of the tumor at the time of diagnosis, it is possible to separate these women into a good prognosis group and a poor prognosis group. The former rarely relapse and one might even consider if they need the same level of aggressive therapy as they are now getting. And the latter group is at high risk of recurrence; they are obvious candidates for clinical trials of alternate approaches to determine if relapses can be reduced. One such genomic prognostic test has been approved by the FDA and others are in the works for multiple cancers.

Genomics can be used for early diagnosis, especially in the field of infectious diseases. Remember the gentleman who flew to Italy on his honeymoon but who had tuberculosis? It led to an international concern that he might have infected others and that his TB might be of the drug resistant variety. One of the problems was that it takes about six weeks to grow the TB bacteria in the laboratory and then, if present, another six weeks to test for antibiotic susceptibility. But genomic tests can speed that process up to just hours. The TB bacteria (Mycobacterium tuberculosis) has a characteristic genomic profile so, if present in a sample from the patient, it can be detected within hours. And since antibiotic susceptibly is driven by the bacteria’s genes, they can be analyzed at the same time. A huge improvement in time to diagnosis and getting the right drug started from the beginning.
We might want to know if we are predisposed to develop a certain disease later in life. It is possible that genomics can be of real assistance here; indeed this has been a major “promise.” It turns out that most of the common, important diseases such as diabetes and coronary artery disease have not one but vast numbers of genes that have some impact on their development. So we will not find a simple answer for many of these. But as more is learned it is very possible that each of us will be able to learn our relative risk to some important and common illnesses. If you knew, for example, that you were at increased risk of heart disease, it might be a stimulus to you to be more diligent in eating a Mediterranean style diet, exercising more often and looking for ways to control stress- and it would be an added inducement to stop smoking. Similarly, if you were at risk for early onset colon cancer, you might be more careful to eat a diet high in fiber and low in fat and begin having colonoscopies at an earlier age.

These are just some of the advances coming from genomics; expect to see many more because genomics represents a true revolution in medicine and we have only seen the beginning.

Here is a video on medical megatrends

Gluten – It’s Not Just The Bread – 1

Gluten is a mixture of proteins found in wheat, rye, barley, spelt, kamut and a few other grains. Gluten which means glue in Latin is the substance that gives bread its texture and elasticity. It’s what gives bread that sticky pull which is so nice when you break a good French baguette; it’s what gives a muffin its spongy characteristic and it helps form those little cells in warm bread that soaks up butter.
Gluten is not found in rice, corn, quinoa, amaranth or tiff. Despite its name, buckwheat does not contain gluten. Oats are gluten free but often raised near wheat or processed in mills that also grind wheat so they can be and often are cross contaminated.

There are three (possibly more) illnesses caused by gluten – celiac disease, gluten allergy and gluten sensitivity. Celiac disease is a serious life-modifying and often life-threatening disease. It is an autoimmune disease meaning that gluten sets up a reaction in a predisposed individual such that the body attacks its own cells. Not only can it cause gastrointestinal damage leading to malabsorption but it can lead to problems in multiple other organs in the body. Previously rather uncommon with no more than one person in 300 having the disease, today about 1% of Americans have celiac disease and the incidence appears to be rising still. It occurs in people who have a genetic predisposition, these being about one third of the population. But within that group of predisposed individuals, only some will develop celiac disease for reasons that remain unclear.

Gluten allergy is uncommon, affecting less than 1% of the population. It’s an allergy similar to how some people develop G.I. symptoms from, say, shellfish. Usually the reaction comes on quickly after eating, can be quite severe often with abdominal pain, nausea, vomiting and diarrhea. The reaction stops once the offending allergen (gluten) has passed out of the body.

Gluten sensitivity (or gluten intolerance) affects perhaps 10% and possibly more of the population. It ranges from rather mild to quite severe. The most common symptom is abdominal discomfort (“bellyache,” nausea, bloating) in two thirds of affected individuals. The next most common symptoms do not relate to the GI tract – eczema, “foggy mind,” headache and fatigue, all occurring in about a third of individuals. One third develop diarrhea when they eat gluten. Other less common symptoms are depression (20%), anemia (20%), numbness in hands or feet (20%), acid reflux and joint pains in about 10%.  The severity of the symptoms seems to depend upon how much gluten is ingested at one time. The more one eats, the worse the symptoms. For some people the symptoms dissipate within just a few hours but, for others, problems such as diarrhea, reflux or even abdominal discomfort can persist for days or even weeks.

In a continuing care retirement community of about 2000 residents where I live, Charlestown probably has about 20 with celiac disease, a few with gluten allergy and 200 or so with gluten intolerance/sensitivity. Many will not be aware of the connection between their symptoms and gluten ingestion. The diagnosis is often missed by physicians because the symptoms can be vague. Many problems cause abdominal discomfort and many of the symptoms of gluten associated disease are not related to the GI tract, such as headaches or rash.

There are no medicines or pills to take. Whether it is celiac disease, allergy or gluten sensitivity, the only effective approach is to totally avoid gluten.

Can You Get a Prompt Appointment With Your Doctor?

Having trouble getting an early appointment with a doctor? It’s a common problem. Here is one company’s proposed solution.

It takes an average of 20.5 days to get an appointment with a physician, according to a study by Merritt Hawkins & Associates and related to me by the principals at ZocDoc, a startup company. That’s a long time. ZocDoc aims to fix that problem with a rapid appointment scheduled on line.

Perhaps your need is not urgent in the classical sense but imagine you were just told your mammogram was suspicious and that you should see a surgeon for a biopsy. Waiting three weeks just to be seen (plus another wait for the scheduled biopsy date) will seem like a lifetime of anxiety,  but a company called ZocDoc has set out to improve patients’ access to care by making the market for doctors’ appointments more efficient, to the benefit of patients and doctors alike.

But if the doctor is booked up what can you do except wait it out? It turns out that physicians have a 10-20% cancellation rate. Maybe someone’s serious problem got better on its own. Maybe they went to the ER instead of waiting. Or maybe he or she just forgot because the appointment was made so long ago. For whatever reason, the doctor has many last minute openings; but you don’t know about them.

Cancellations mean no income for that time slot, but the physician’s fixed costs of office rent, staffing, insurance, etc. don’t go away. So he or she would like to fill those empty time slots if possible. 

In response, ZocDoc has created a software system that works with physician’s scheduling systems. Basically, patients go online and insert the particular type of physician they need to see (e.g., primary care, ENT, dermatologist, etc.) as well as their location. ZocDoc scans the real-time schedules of the physicians meeting that search criteria and allows patients to instantly book an appointment online. ZocDoc tells me that 40% see a doctor within 24 hours and 60% will be seen within 72 hours. And, although ZocDoc does not presently put you on a waiting list, you can always check back on ZocDoc and see if an earlier time slot becomes available.

My only concern is that you as a patient are best served with a single primary care physician (PCP) with whom you have a long standing personal relationship. He or she knows you, your medical status and the issues of work and family. Going to a different PCP for a one time problem is not the best medicine – although I would agree that it is far superior to a long wait in the emergency room.

The specialist situation is somewhat different however. Usually, your PCP is the best person to make a referral. As your advocate, the PCP wants you to be well served with quality care and so will generally refer you to a specialist that the PCP knows by years of personal experience is not only competent but respectful of patients. And if the PCP is really on your side, he or she will personally call the specialist, explain the reason for the referral and, when appropriate, ask for an early appointment.

But if you can’t get to your PCP for many days and you just fell and have a swollen ankle, ZocDoc could presumably get you into an orthopedist’s office quickly. Or to a surgeon for that breast biopsy. Getting to see that orthopedist or surgeon in one to three days rather than three weeks would be a godsend – getting appropriate therapy for the sprained ankle or just relieving three weeks of anxiety waiting for a biopsy. 

ZocDoc appears to be at first glance a game changing approach. If they are correct it will make a major transformation in the delivery of medical care. It will be interesting to watch ZocDoc and see how it evolves.

Notes – ZocDoc was noted in a Wall Street Journal article today on innovation. I have no financial relationship with ZocDoc; I learned about it serendipitously. There is more about the delivery of health care in my new book The Future of Health Care Delivery-Why It Must Change and How It Will Affect You.

The Strength To Accomplish Incredible Things

Illnesses, like cancer, can be devastating but hope springs eternal and love and caring can be healing no matter what the final outcome. Fortunately in this family crisis, the outcome was incredibly positive in many ways and led to the strength to accomplish incredible things. My posts are usually my own work. But I am posting this very beautiful and positive story sent by a husband turned caregiver. 

“Lessons Learned through Caregiving

In August of 2005, my family changed forever. Our daughter, Lily, was born, and my wife Heather and I could not have been more excited to be new parents. However, three months later, our lives changed again. On that day, Heather was diagnosed with malignant pleural mesothelioma, and I got a new, unexpected job. I became a caregiver for a cancer patient. Instead of dealing with the chaos of the holiday season as planned, we began to deal with a new type of chaos – fighting cancer.

My life as a caregiver began as soon as Heather was diagnosed. Completely overwhelmed, shocked and unable to make any decisions, Heather looked at me for help. I knew I had to be there for her as best I could, and I made the first essential decision, that of where Heather would receive treatment. We were given several options, but one in particular stood out.  It was Dr David Sugarbaker, a mesothelioma specialist in Boston, known for his work with patients with my wife’s type of cancer. I told our local doctor to get us to Boston. 

I had to cut my hours in my full-time job, and Heather left her job. Instead of working my 9-5, I turned into a full time caregiver. I scheduled our trips and drove to doctors’ appointments. I was also still a full-time dad, caring for three month old Lily.

Life became a challenge. Everything was turned upside down, and I was often uncertain and worried. My to-do list turned into a whirlwind of overwhelming emotions, and I couldn’t just give up. I let myself surrender to the bad days, but I never gave up hope. Although I often felt helpless, I knew I had to stay strong for Heather. The support we received made me feel hopeful. People we didn’t even know were offering all kinds of help, giving us less to be anxious about. That outpouring of support helped keep me sane.

All of our hard work, perseverance, and refusal to give up paid off. After surgery and multiple treatments for mesothelioma, Heather beat the odds as this short video demonstrates and defeated this awful disease, a rare feat accomplished by far too few. After seven years, she is still cancer free, and has been able to see Lily grow into a beautiful young lady. 

I have since been able to balance the tasks of going back to school while raising a family. Being a caregiver and standing by my wife through cancer gave me the strength and the courage to pursue this dream of mine, two years after Heather’s diagnosis.  The stress and time management skills that I learned helped me to succeed and graduate with high honors.  I was even given the great privilege of speaking at graduation. During my graduation speech, I shared the greatest lesson that I learned as a caregiver to someone with cancer. I told the audience that within each of us is the strength to accomplish incredible things, as long as we never give up hope, and always keep fighting for the ones we love.”  

Cameron Von St James, July 17, 2013

Aging Gracefully – Part 2 Slowing The Aging Process

Can we slow the aging process?  The answer is a definite yes and it all has to do with our lifestyles and behaviors.  Here is a quiz.  What percent of Americans can answer yes to all five of the following statements?

Here’s a clue.  We know that about 20% of Americans smoke so the highest answer you can give to this question is that 80% could answer yes to all five.  The actual answer may surprise you.  It did me.  Only 3% of Americans can answer yes to all five! 

Let’s return to bone mineral density.  The way to slow BMD decline is to exercise and to eat a nutritious diet.  (Vitamin D supplements may also be necessary for those in temperate climates who get little sunshine on their skin.) So instead of a 1% decline per year it can be more of a ½% decline per year.  On the other hand for couch potatoe that decline won’t be 1% but it may be more like 1½ to 2% per year.  The same goes for cognition.  There are certain adverse factors such as vascular conditions and the metabolic syndrome (a precursor to diabetes) and also the chemicals released through chronic stress that speed up cognitive decline.  But there are also protective factors which we can control ourselves.  These include being physically active, intellectually challenged, and socially engaged.  It may be a surprise that physical activity is important for cognition but it has been clearly demonstrated to be critical.  Intellectual challenge is different than reading a book, even a complex book.  That’s not a challenge.  But if you belong to a book club and have to actively defend your perspective and point of view that then becomes a challenge.  Socially engaged means being involved as a human being with other human beings.  This is something that is frequently lost during older years if isolation develops due to limited mobility, inability to drive, etc. 

So the essential steps of slowing the aging process are: Avoid tobacco and remember it’s never too late to quit.  Reduce chronic stress because the chemicals released from stress have a very adverse effect on many physiologic systems such as immune function.  Eat a nutritious diet.  Do cognitive exercises which challenge your intellect.  Remain socially well connected. Physical exercise should include aerobic activity of about thirty minutes five days per week (just simple walking is adequate); resistance or weight training 2-3 times per week and balance exercises 2-3 times per week. 


To summarize, there is a steady slow loss of physiologic function in most of our organs over time. It is possible to slow this 1% decline and with it the ultimate functional impairments. It is also possible to avoid or certainly delay age-prevalent diseases.  But in both cases it’s up to us.  It’s up to us to adjust our lifestyles and we preferably need to do so beginning at a young age. That said, it is never too late to begin a preventive program.  We can slow physical decline with exercise, diet and reducing stress.  We can avoid many diseases by not smoking. We can slow cognitive decline with physical activity, intellectual challenges and social engagement.  It’s worth it.

Next post – The importance of comprehensive primary care in managing the aging process.

Further Disruptive Changes in Health Care Delivery

Technology to lower costs rather than accelerate them. Smart phones to increase physician and other providers’ productivity. Fewer primary care physicians but more involvement by nurse practioneers and others. And increasing appreciation of the value of integrative medicine. These are but a few of the disruptive changes in care delivery that are coming. 

In my last post I observed that  the health care delivery system will change in coming years – quite unrelated to reform – and gave the most important drivers of change and how these changes will often be disruptive, transformative or both. Here are a few more. 

We think of new technologies as exacerbating health care costs. But it is also quite correct to look to technology to reduce costs or at least slow the growth of expenditures. There will become a new value proposition for technology. Today and tomorrow technology wil be accepted if it to helps health care professionals to 1) compensate for shortages, 2) enhance their responsiveness to patients 3) control costs and 4) improve quality and safety. 

Smart phones with wireless connectivity and multiple apps are a good example of technology to assist, compensate, enhance responsiveness and improve quality. Increasingly, physicians are becoming very reliant on their phones as a shortcut to knowledge, to stay well informed, to argue and debate among themselves and perform many other functions. 

Robotics can likewise benefit all four parameters. A good example is how robots have made the hospital pharmacy more efficient while substantially safer. One robot selects pills via bar code; another prepares intravenous medications and solutions more accurately then a technician and a third transports medications to the nursing unit using wireless technology – sort of like R2D2. This frees up the pharmacist to do what he or she does best such as watching for drug-drug interactions, proper dosing, and critical higher order functions.  

But the coming changes are not just in technology but in the distribution and work of providers. With shortages of physicians, especially primary care physicians, appropriate integration of nurse practioneers and physician assistants can not only partially compensate but provide quality interaction with patients, augment preventive programs and enhance care coordination for those with chronic illnesses. And although there is considerable controversy as to appropriate scope of practice, it is certainly clear that the interaction of PCPs with NPs and PAs can enhance the totality of patient care.  Similarly, expect to see more mental health delivered by psychologists and social workers; visual care by optometrists; and hearing care by audiologists. 

Consumers (patients) will press for and expect a more integrative approach from their PCP and other providers. Patients today increasingly search out and use practioneers of acupuncture, massage, chiropractic, yoga, mind body techniques, energy channeling (Healing Touch, Therapeutic Touch, and Reiki) and other complementary medical modalities. More and more medical students are graduating with at least some understanding and training in the use of these approaches. And the acceptance by already practicing physicians is growing, albeit slowly in many cases.  

Integrative medicine means more attention to the whole person – family history, social situation, work environment, and how all of these plus stress, eating, smoking and drug preferences interact with the patient’s illnesses. A “prescription” for high cholesterol may still include a statin but it might well also include a trip to a nutritionist, a personal trainer, a program for stress reduction, etc. The end result is better medicine yet completely coordinated by the primary care physician.  

Health care delivery is transforming. It will come in fits and starts but it is and will continue to change. Hopefully most of the changes will be for the betterment of patients and providers alike.

Replacing the Aortic Valve Without Open Surgery!

Aortic stenosis (a narrowing and hardening of the heart’s aortic valve) is not uncommon among older individuals. It begins without symptoms and progresses for years but, about 50% will die within 2 years once the fitst symptoms develop. The standard approach is to surgically replace the aortic valve which will improve both heart function and survival. Unfortunately, about 30% of symptomatic individuals cannot undergo surgery because of older age, other heart problems or other medical conditions that render surgery too risky.

A new approach is called transcatheter aortic value implantation (TAVI.) In this procedure, a catheter is inserted into the large femoral artery in the groin and run up to the heart. From the catheter, the patient’s valve is opened wide with an inflatable balloon. Then a bioprosthetic value made from bovine pericardium affixed to a stainless steel support frame is deployed into place via another balloon catheter and secured to patient’s own aortic valve base.

A randomized study of 358 patients with aortic stenosis not considered surgical candidates was completed comparing TAVI to standard therapy at 21 medical centers and reported in the New England Journal of Medicine on October 21, 2010. The results were clearly favorable. Standard therapy was noted to not alter the natural history of aortic stenosis with 51% dead in one year. TAVI was superior with improved cardiac symptoms and good hemodynamic performance of the new valve which persisted for at least the first year of follow-up and with 31% dying during that year, a substantial decline in mortality.

But there is never a “free lunch” and TAVI was associated with a 5% risk of serious stroke (compared to 1% in the control group) and multiple vascular complications, the latter apparently related to the requirement for a large catheter placed into the femoral artery. Further MRI studies of patients suggest that many have new perfusion defects of the brain after TAVI suggesting that emboli from the new valve may be rather common.

But all things considered the improvement in symptoms and the reduced death rate (it took only 5 patients treated with TAVI to avoid one death by 1 year) argue that TAVI is now the appropriate therapeutic approach for those with aortic stenosis who cannot otherwise undergo surgery. Hopefully, coming improvements in the device will lead to fewer complications.

The big question – will this become the approach of choice for those who otherwise are candidates for standard surgery for aortic valve replacement?

Employer-Sponsored Comprehensive Primary Care

Patients need doctors that take time to listen which means a limited number of patients under care. Employers need programs that reduce costs and ideally improve the health of their staff. These apparently disparate needs can come together in a new model for effective company-sponsored primary care programs.

Those of you who have followed this series know that I am an advocate for PCPs finding ways to have a smaller patient panel so that each patient can receive more time for comprehensive primary care. When properly designed, company-sponsored primary care clinics can do just that.

Some employers are turning to outside firms such as QuadMedto initiate care models that can serve both smaller patient panels yet reduce their total costs toward healthcare. Although there are many such firms (or local practices) that will take on the role, real success hinges on a program that is well organized and allocates adequate time for the PCP to give truly comprehensive primary care. It also means that the employer has accepted the concept that it is no longer just trying to hold the line on healthcare costs but is actually looking at employee health as a strategic business imperative.

Successful programs tend to include not only PCPs, NPs, nurses and other providers but, if the employee base is large enough, a pharmacy, laboratory, and radiology suite. Other key resources are health coaches and nutritionists to maintain wellness and reduce risk factors. The typical employer in these arrangements is generally self-insured, has a large enough employee base to justify the clinic resources and is committed to employee health and wellness while wanting to reduce its total costs of health care.

A full service primary care clinic is funded by the company at or very near to the employer’s site of business. Services include routine episodic care but also extensive preventive care, intense management of those with chronic illnesses and care coordination when a patient does need to visit a specialist and sufficient time with the provider that trust can develop; in other words, this is comprehensive primary care not just limited function urgent care centers.

Employees are informed that they are welcome but not required to utilize the clinic and do so at no cost or perhaps a modest fee per visit. Some but not all employers make the clinics available to family members. Each participating individual is assigned a primary care physician (PCP) or in some cases a nurse practitioner or physician assistant. The PCP/NP/PA is paid by salary by the vendor company, not fee-for-service. In the programs that truly develop comprehensive primary care, the PCP/NP/PA has a limited number of patients in his or her panel, does a full initial evaluation usually lasting 60 minutes or more and then sees the individual thereafter as often as necessary for as long as necessary.

The expectation is that the patient and PCP/NP/PA will develop a long term trusting relationship just as they would in a private office setting. Individuals can schedule appointments often on the same or next day and there may be extensive use of mobile technologies, an electronic medical record, telemedicine and other advanced techniques. For those individuals with a chronic illness, the clinic nurses often work with the PCP to coordinate care and (often and hopefully always) the PCP communicates directly with any specialist before referring and after the visit.

The clinic manages wellness and preventive programs with health coaching and lifestyle behavior management. This might include but is not limited to nutrition counseling, fitness counseling, stress management and smoking cessation. It depends on the provider company selected to develop and manage the clinic, but if the employer already has an effective wellness program ongoing with another provider, the primary care company may agree to partner with that wellness provider to create seamless programs. It can thus be an employer wellness program and a comprehensive primary care program rolled into one. It may even be population health to the extent that the PCP and the team proactively interact with each participant to address risk factor and incipient chronic illnesses rather than waiting for an employee/patient to call or visit with a problem. To repeat, a very key ingredient is assigning no more than a reasonable number of employees and family members to each PCP/NP/PA. What is “reasonable”? – it depends – on average age, whether many individuals have chronic illnesses, etc.

Some provider companies such as WeCare TLCcall their model “medical risk management,” a term generally thought of in medicine as programs and policies to reduce the potential for malpractice claims. Here however it has a completely different meaning. It is called medical risk management because the driving principle is identification and management of ongoing medical problems while at the same time addressing potential health risks for the future. It is really an employer-sponsored (although not directly involved) companywide approach to population health management. It is taken from the concept of enterprise risk management which seeks to identify and mitigate corporate risk as a strategic advantage. It is management of risk not just from a downside perspective but from an upside or positive perspective as well. The employer therefore needs to be thinking about health risk management as a strategic perspective, not just as a tactical effort. In other words, a healthy workforce is available to be productive and a healthy workforce creates a very substantial savings in medical costs for both the company and the employee.

Note that it is not just “episodic” visits but rather comprehensive primary care in a medical hometype model with proactive population health concepts.

The provider company and the employer usually agree up front to a set of performance measures such as utilization/penetration of the clinic (are employees actually using it), patient satisfaction (do they like what they get), quality outcomes (standard measures used nationally such as blood pressure control, diabetic control, immunizations up to date, etc.) and of course functioning within budget and a return on the employer’s investment at a pre-agreed level. Companies that engage in these clinics, provided that the services are actually comprehensive in nature as described, tend to find that their return on investment very good.

Since in these models of comprehensive primary care where the employer fully pays for the primary care services, there can be a significant savings for the employee (patient) and family members.  Importantly, the employer pays the bills, perhaps offers incentives for participating but is otherwise kept at a distance. The PCP and other staff members work for the provider company, not for the employer, and cannot be expected to share patient information. The employee gets quality healthcare with a strong emphasis on maintaining wellness, active prevention and on chronic illness early detection, management and care coordination. The result is a healthier workforce leading to greater productivity, greater workforce satisfaction, reduced or no employee costs for primary care and reduced or at least limited health insurance cost increases for both employers and employees.  Definitely a triple win.

But there are potential downsides to consider. Some KevinMD readers will certainly comment that it is best to keep the employer completely out of healthcare. Another downside would be if the employer wanted to be intrusive and learn medical information about individuals. A third would be the loss of a trusted PCP when a person leaves the company for other employment. So in the end, each person offered the option needs to make an informed decision.

Note: I have interviewed principals at both QuadMed and WeCare but have no financial or arrangements with either. They are used as examples only; their use does not represent an endorsement.

Your Genes Need Not Be Your Fate: Nutrigenomics To The Rescue

Genomics Part 4 — Medical Megatrends 

Are you concerned about a family history of heart disease? Or cancer? Worried that you genes will be your fate? We know that good dietary habits are generally good for us but can foods affect our genes? The new science of nutrigenomics suggests that they can. 

Nutrigenomics is about using what you eat to change your gene expression (meaning how your genes function) to optimize your health.  

Nutrigenomics is the science of how bioactive chemicals in foods and supplements alter the molecular expression and/or structure of an individual’s genetic makeup. It is apparent that one size does not fit all when it comes to nutrition. We have become aware of the limitations of population-wide advice such as the food guide pyramid. Second generation approaches have proliferated with pyramids tailored for children, the elderly, ethnic groups, vegetarians, etc. Although these attempts are steps in the right direction, they do not take full advantage of the breakthroughs in biomedical science. Fortuitously, this realization has come at a time of great expansion of knowledge with the genomics/informatics revolution. 

Nutrigenomics is a young science and built around the revolution in genomics. As such, the science is still evolving. The excitement about nutrigenomics comes from a growing awareness of the potential for modifications of food or diet to support health and reduce the risk of obesity and many deadly chronic diseases.  

Nutrigenomics will become a critical part of the entire “personalized medicine” concept that is revolutionizing medical practice as discussed in detail in The Future of Medicine – Megatrends in Healthcare. Personalized (or “custom tailored”) nutrigenomics medicine is an approach that means it is possible to have a direct impact on long term health and longevity by very specific dietary manipulations. Nutrition will no longer be “one size fits all.” 

Nutrigenomics offers hope to those who know they have a strong family history of heart disease, cancer, diabetes, obesity, and most likely many other diseases as well. At the same time it takes away the excuse of “everyone in my family is overweight so I am too.” One no longer needs to be fatalistic in this regard and hope may lie at the end of a fork.  

Nutrigenomics is not a phenomenon, a fad, or a technique to use in a vacuum. It is best as part of a total approach to lifestyle management. 

It is increasingly apparent that various foods directly affect critical genes – turning them off or on as the case may be – and thereby directly impacting the development of atherosclerosis, diabetes, many cancers and obesity, among others. The foods that we consume play a role in how genes that affect our health are expressed, or “turned on” and “turned off”.  

For example, we know that broccoli is good for us because it is one of the most nutrient dense foods that we can consume. One of the reasons that consuming broccoli may enhance our health is that many of the nutrients in broccoli have been shown to turn on genes that protect from disease and turn off genes that increase the risk of disease. For example, a nutrient in broccoli called sulforaphane has been shown to turn off genes that cause many forms of cancer. The omega-3 fatty acids found in salmon, grass-fed beef, walnuts, flax seeds, and fish oils appear to turn on genes that protect against heart disease and its risk factors. These are just a few examples of how eating a nutrient dense diet can improve health by turning on genes that protect from disease and turning off genes that cause disease.  

It is important to realize that processing foods removes or destroys phytonutrients. Hence, processed foods contain less or no phytonutrients, and this lack of phytonutrients along with chemicals that directly affect our cells’ genes explains, in part, why overconsumption of processed and ultraprocessed foods contributes to chronic disease. 

See the Future of Medicine – Megatrends in Healthcare for a fuller discussion of the implications of genomics. And watch for new developments in this fast moving new science. 

Remember, nutrigenomics has made it clear that your genes need not be your fate! Just because you have a family history of a certain disease does not mean that you are also destined to become a victim.

“Why Are Medicare Costs Rising So Fast? – It’s Actually Not Complicated”

My last post was the beginning of a primer on Medicare. Medicare covers about 50 million older Americans for general health care and covers about 75% of covered services or 50% of total health care costs of these seniors. Medicare, as the largest single insurer, sets the standard for reimbursement rates across all insurers. It tends to pay slightly less than costs, leading hospitals and doctors to cost shift or charge others a higher rate. Medicare costs are increasing at about 4% per year and will reach $1 trillion by 2022, an unsustainable cost to the government (tax payer). 

There are multiple “parts” to Medicare. Part A is principally for hospital care; Part B is for largely for physician costs and Part D is the prescription drug benefit. Part C or Medicare Advantage is a private insurer managed care alternative to Part A which incorporates Part B and often Part D into one plan. 

Each of us and our employer pays 1.45% (total of 2.9% combined or for a self-employed worker) of earned income into the Medicare Trust Fund each year for Part A. Beginning in 2013, the tax is 3.8% on earned and unearned (i.e., salary or wages plus interest, dividends and capital gains excluding interest on municipal bonds) income above $200,000 for a single person and $250,000 for a married couple. The money paid in is not invested and set aside for use when the individual reaches 65. Mostly it goes to pay for the hospitalization costs of today’sbeneficiaries – it is a generation transfer tax. As the population continues to age and continues to live longer, there will a relatively smaller working population to pay the annual bills. It is estimated that the current 50 million enrollees will expand to 80 million by 2030 and the ratio of workers to enrollees will drop from 3.7/1 to 2.4 /1. So the combination of rising healthcare costs, more beneficiaries living for longer times and a relative shrinking of the taxable base means that the Trust Fund will ultimately become insolvent.  

Medicare enrollees tend to have chronic illnesses; 85% have at least one and 50% have three or more. Aging brings on chronic impairments (“old parts wear out”) such as impaired vision, hearing, mobility, dentition, bone strength and cognition. Additionally, enrollees also suffer from the chronic illnesses largely but not entirely the result of life styles. These include obesity, hypertension, heart disease, diabetes, chronic lung disease, cancer and many others.  Chronic diseases are inherently difficult to manage, will last a lifetime (some cancers excepted) and are expensive to treat. Chronic illness results in over 70-85% of claims paid. 

But these chronic illnesses consume more than they need to for a few very clear reasons.  First has been a lack of quality preventive care and attention to wellness. Second has been the lack of careful care coordination. These patients need a full multi-disciplinary team of providers to assure complete care (e.g., the diabetic patient will need an endocrinologist, nutritionist, exercise physiologist, podiatrist, ophthalmologist and others over time). But any good team needs a quarterback and the logical choice, the primary care physician, has been marginalized by Medicare for years. The result is that PCPs only allot about 15 to 20 minutes per patient visit (which translates into about 10-12 minutes of actual face time) – not nearly enough time to deal with multiple chronic issues, multiple prescriptions let alone take the time to call a specialist to explain the rationale for a referral and seek a prompt appointment for the patient. 

These are the basics of Medicare and the major reasons for continuing cost escalations. The increasing costs mean that it makes little sense to promise “Medicare as we know it” to persist in its current state into the future. Change is mandatory. The question is not whether there will be change but how to make changes in a manner that protects the medical and the financial health of the beneficiaries both today and into the future while keeping the benefits affordable. The Democrats and the Republicans both agree that change is mandatory but they offer widely divergent approaches to cost containment.  

The next post will evaluate the actual costs of Medicare for the average retired couple.

Reasonable Goals for Health Insurance Coverage and Defining Medical Necessity

Health care should be a right but it needs to be paired with some responsibility – some share of the cost, especially for routine care, and some attention to maintaining a reasonably healthy life style. To do so will not only lead to better health but reduced expenses overall – positive outcomes for all.
One of the major goals of the Affordable Care Act is to reduce the number of uninsured from the current about 50 million people (or 16+% of the US population) by both offering Medicaid to many more individuals and creating state-based insurance exchanges for individuals who cannot obtain insurance at their worksite. Medicaid will be available for those at <133% of the federal poverty rate (currently $22,050). The insurance exchanges will be available to everyone but those with income below 400% of the poverty level ($88,200 for a family of four) will be eligible for tax credits based on actual income. Unlike Medicaid which has essentially no cost sharing by the individual, insurance from the exchanges will be purchased at one of four levels – 60, 70, 80 or 90% of the approved covered expenses will be paid by the insurance; the remainder will be the individuals’ responsibility. Higher deductibles will likely correspond to lower premiums.

The Institute of Medicine (IOM), at the request of the Department of Health and Human Services, formed a committee to consider the process for defining “essential health benefits” which ultimately will translate into what is covered or not by the insurance from the exchanges. The IOM, wisely in my opinion, emphasized he need for affordability rather than just comprehensiveness. They argued that coverage should be “evidence-based, specific and value promoting over time.” They proposed that medical necessity should be based upon clinical appropriateness, best scientific evidence and a likelihood of providing an “increased health benefit…that justifies an added cost.” [For a fuller discussion of the IOM recommendations, see John Iglehart’s article in the New England Journal of Medicine, Oct 20, 2011]

These seem like wise and sensible proposals. Too often there has been a “push” to insist on very comprehensive coverage, little attention to evidence-based criteria and little or not cost sharing by the patient.

My own hope is to see insurance that carries high deductibles to encourage each of us to personally monitor our health expenditures. When we have our own money at stake, we are more likely to ask our physician if that MRI, procedure or specialist visit is really needed of if it is “just to be complete.” That high deductible may also encourage us to maintain a better life style and maintain our health. That is good for us and reduces the overall costs further.

My new book discusses these topics in detail – “The Future of Health Care Delivery, Why It Must Change and How It Will Affect You” will be published in Feb, 2012 by Potomac Books

Your Lifestyle Can Prevent Sudden Cardiac Death

Adhering to a moderate yet healthy lifestyle can reduce the risk of sudden cardiac death by about 90% according to a new study. It is well known that high blood pressure, high cholesterol, and diabetes correlate with coronary artery disease. Life style factors do as well – a combination of a Mediterranean style diet, moderate regular exercise, appropriate weight and non smoking all correlate with less coronary artery disease, less stroke, less high blood pressure, less diabetes, less cancer and multiple other chronic conditions and lower (or later) mortality overall.

These same factors have now been demonstrated to also reduce risk for sudden cardiac death, i.e., a sudden arrhythmia that leads to death in less than an hour from symptom onset.
S. E. Chiuve, etal of Harvard and the Brigham and Women’s Hospital in Boston (JAMA, July 6, 2011, p62) evaluated sudden cardiac death (SCD) among 82,000 participants in the Nurses Health Study between 1984 and 2010. 321 individuals had SCD during those 26 years at an average age of 72.

The authors set out four criteria for low risk lifestyles: not smoking, BMI <25, exercise >30 minutes per day and being in the top 40th percentile of the alternate Mediterranean diet score. In essence, the latter is a diet rich in fresh vegetables and fruits, nuts, whole grains, legumes and fish with moderate intake of alcohol.

The results were clear. The more risk factors, the greater the rate of SCD. Stated differently, “a low risk life style (not smoking, exercising regularly, having a prudent diet and maintaining a healthy weight) was linearly and inversely associated with risk of SCD among women.” Those women who had all four low risk lifestyle attributes experienced a 92% lower risk of SCD compared to those who had no low risk attributes. This suggests that the vast majority of SCD could be prevented by life style modifications.

The study authors point out that although 80% of women do not smoke today, adherence to the other three factors is low. Less than 40% of middle aged women have a BMI <25, 25% drink light to moderate alcohol and only 22% exercise regularly. And although the data on diet habits is limited, a simple observation of what is purchased in the supermarket is telling.

It is evident from this study – and many others – that managing lifestyle factors can prevent serious chronic illnesses including coronary artery disease, cancer, stroke, high blood pressure and diabetes along with sudden cardiac death. This is true even for those with a genetic predisposition – “your genes need not direct your fate.”

Smokers Die Ten Years Sooner Than Nonsmokers

We all know that smoking is bad for our health. But how bad is bad? The answer is very bad. It takes a decade off of life.
Death rates are about 3 times higher for smokers than nonsmokers. The chance that a young person will live to age 80 is about 70% for nonsmokers but about 35% for smokers. Stated differently, a smoker loses about 11(women) to 12 (men) years of life compared to nonsmokers.
Now that women have been smoking for long periods of time, their risks match those of men who smoke. “Women who smoke like men die like men who smoke.” Women’s relative risk of developing and dying from lung cancer (compared to nonsmoking women) is about 25, same as for men. For chronic lung disease, the relative risks are 23 and 25 for women and men, respectively. For ischemic heart disease the relative risks are 2.9 and 2.5 and for stroke they are 2.1 and 1.9.
These are the results presented from two studies of very large populations of Americans published January 24, 2013 by the New England Journal of Medicine, one by Prabhat Jha and colleaguesand another by Michael Thun and colleagues. Each analyzed different populations but arrived at essentially the same conclusions. 
Alarming as these numbers appear, there is hope. Those who quit smoking will gain back substantial years of life, with more years gained the sooner one ceases smoking. For example, in Jha’s analysis, those who quit in the age range 25-34 reverted almost to the nonsmoker status – they gained back 10 years of life. Stopping between 35-44 years of age gained 9 years and between 45-54 years of age the gain was 6 years.
It is never too late to quit and the benefits are clearly substantial.


A Vision For Health Care In America

In researching  The Future of Health Care Delivery – Why It Must Change and How It Will Affect You, I had in depth interviews with over 150 leaders from across the country including hospital CEOs and COOs, practicing community and academic physicians in both primary care and specialty areas, pharmacists, nurses, insurance executives, health care consultants and many others. But I found what I think is a very good vision and resulting model right at home in Howard County, Maryland.

County Executive Ken Ulman and former health officer Peter Beilenson, MD, MPH created “Healthy Howard” to assist those without insurance.  Their concept was to provide primary care access for all, an extensive network of specialists, community and tertiary care hospitals and a basic electronic medical record. Methods were built in to maintain costs as low as possible. But part of the basic premise was that with these “rights” for the patients came certain “responsibilities” – some limited payment participation and some requirements toward practicing healthy living as well as compliance with treatment recommendations. It structured a good balance between patient rights and responsibilities, between care delivery and a working payment system, between access and effective care.

Howard County, between Baltimore and Washington, is a fairly affluent county with excellent providers and a highly regarded community hospital. Despite affluence, there are uninsured individuals and families. Some could afford insurance but choose to spend their dollars elsewhere. Some are the young invincibles who don’t feel they need it. Others work in the service industry where their employer does not provide insurance and they cannot afford to carry the entire burden. And some are simply indigent.  The question was how to provide for this disparate group in an effective yet equitable manner that would render good quality care at a moderate cost.

Healthy Howard is a county-assisted, community based not for profit organization which collects a modest fee, on a sliding income scale, from its members. In return, each individual gets unlimited access to a primary care physician (PCP). The office employs a care coordinator who works with the PCPs to assist those patients who have complex chronic illnesses such as chronic lung disease, cancer, or diabetes with complications. There is also a pharmacy benefits manager located in the PCP office to assist patients find drugs at the most reasonable price in the community. They work with the physicians to find generics, discuss other effective agents with the doctor or even contact the manufacturer if appropriate to get a reduced price for an indigent patient.

Of course some patients will need to see a specialist physician. Healthy Howard has developed an agreement with the county’s specialists to accept, gratis, these patients with the understanding that the program will allocate the patients across all the specialists in a given field (e.g., cardiology or orthopedics) so that no one physician has an excessive burden.  Howard County General Hospital, being part of a unique system in the state of Maryland, has always accepted indigent patients but under the agreement with Healthy Howard, the hospital forgoes any attempt to collect from these patients.  Further, since the hospital is part of the Johns Hopkins Health System, an agreement was reached with Hopkins to accept any patient that needs tertiary care at no charge.

These might be termed the “rights” of the patients. But there is also some participation required in order to be part of Healthy Howard; these are the corresponding “responsibilities. In addition to the modest sliding scale fee, each patient is assigned a health coach with whom he or she must meet on a regular basis. The coach works with the patient to develop a plan for healthy living. This might include attending a smoking cessation program, attending a gym for exercise or working on a diet plan. Together patient and coach develop a plan of action with benchmarks at various intervals. The patient meets with the coach periodically to compare actual results to the benchmarks.

The coach is there not just to measure results but to assist and to help break down barriers. Sometimes just some encouragement is all that is needed; sometimes referral to a specialist such as a nutritionist is helpful; and sometimes a more involved approach is required. As Mr. Ulman described to me, imagine an overweight lady who wants to participate in a fitness program at the local health club – to which Healthy Howard has worked out a special free arrangement. But she says cannot attend because her daughter is a single working Mom and so she, the grandmother, must babysit the child. No problem, the coach finds a fitness center that also has built in day care, breaking down the barrier that had to date prevented success.  The idea is that the plan will help overcome barriers yet still expect responsibility to meet objectives.

Healthy Howard, as its name implies, will mean healthier participants a few years down the road. The primary care physicians, with help from the coaches, will give attention to prevention thus lessening the burden of chronic illness in the future. And they will give careful care coordination for those with chronic illnesses now- thus lessening the current cost burden by reducing the need for specialist visits, excess tests and imaging and unnecessary drugs

And it worked. Now a few years in, there has been a 35% reduction in ER visits and a 50% decline in hospital admissions. Enrollees are healthier and more behaviorally motivated to maintain good health. Sufficient success to substantiate the awarding of a federal contract to utilize these principles  to create a state-wide consumer operated health insurance plan (a CO-OP) for the ACA Maryland insurance exchange based on the principles of 1) having the vast majority of care provided by primary care, 2) using bundled or capitated provider compensation and 3) using evidence-based medicine.

Healthy Howard, as its name implies, means healthier participants. Its great value is as a vision of health care delivery that incorporates improved quality, reduced costs and excellent access in return for a modest fee and a commitment to living a reasonably healthy lifestyle. Rights and responsibilities working together. It is a good vision to use as a starting point.

Integrative Medicine Part V – Busting Stress


Stress is with us all the time. Issues at work or at home, getting a traffic ticket, the grocery store out of your favorite yogurt. Life has stresses. We can go to the doctor and ask for a pill or we can learn to deal with our stresses effectively without much medication.


Acute stress is normal and can even be lifesaving – seeing a truck barreling down the road at us. But when stress is chronic it becomes a major cause of ill health.


Chronic stress builds up when the demands upon us become greater than our resources to respond in an effective manner. Stress tends to become cumulative. You can handle the first stressor and even the second, but when the third one occurs, even if it was rather minor, it tips over your balance point. Since we cannot completely escape stress, our agenda must be to boost our resources – to “fill up our cup” as Delia Chiaramonte, MD of the University of Maryland Center for Integrative Medicine liked to term it during her “Busting Stress” workshop at the Center’s recent Health and Wellness Conference held in Baltimore, MD.


Integrative medicine does not avoid traditional “western” medical approaches such as medications. But it does look at the whole person to determine if there are other parts to the “prescription” that might be equally or even more valuable. The agenda is to maintain health and further develop wellness.


There are external and internal sources of stress. Our boss ignored our hard work or disparaged our report – these are obvious external stresses. If they become too much it may be best to just look elsewhere for a new job and escape the situation.


But other stresses are internally mediated. We might convert an event into a thought that in turn leads to a negative feeling that in turn causes stress. Imagine that a loved one is late to get home and has not called. That is the event. The thoughts can be quite different. One thought might be that he was in an accident resulting in a stressful feeling of anxiety. Or perhaps this event leads to the thought that he is having an affair – leading to a feeling of hurt. Or perhaps the thought is that he just didn’t care that he was late and didn’t bother to call – leading to a feeling of anger. Perhaps more likely he is just stuck in bad traffic and doesn’t have his cell phone with him – in that case you might have a feeling compassion. The three stressful feelings came from your thought interpretation of the event. The question you need to ask yourself is what is the likelihood of any of these thoughts being correct?


You need to restore rationale thinking. Do this by labeling the irrational thought and then refute it with a new thought like “I have no evidence of an accident; he is probably just stuck in traffic.” Then detach yourself from the thought with the recognition that “this is an anxious thought, not a rational thought.” Finally, do something to distract yourself like playing with the kids.


To “fill up your cup” Dr Chiaramonte suggests considering these approaches. Begin a “gratitude ritual.” This means to take a time each day for gratitude perhaps while falling asleep or perhaps at dinner time. Think about what is good in life – today – maybe a spring flower, a smile from your loved one, the bright eyes of your child. It can’t be a rote thought however. Make it different every day. Amazingly enough, it works. It will increase your happiness and correlates well with general health and well being.


Here is a line from the song “Counting My Blessings” sung by Bing Crosby and Rosemary Clooney in the movie “White Christmas.” “When my bank roll is gettin’ small, I think of when I had none at all, and I fall asleep counting my blessings…” This is the concept of gratitude.


A second approach is to aggressively try to be a “benefit finder” rather than a “fault finder.” It’s an approach in which you rethink and with doing so decrease your emotional reactions. Instead of the thought, “I have a vision problem that limits me” you might instead think of, “I still have one good eye and the world looks good to me.”


Sleep is important. You feel more stressed if you are sleep deprived. Most of us get too little sleep. Fill your resource cup with added sleep. And the gratitude ritual at bed time will help you sleep more soundly.


Food is equally as important. Things to avoid are processed foods with high levels of carbohydrates and fats (of course, these are the ones that taste so good to us!) like doughnuts, macaroni and cheese or pizza. Instead get more high quality proteins and skip the refined sugars as in sodas.


And add in some exercise. Just moderately paced walking each day will not only decrease your stress but will improve your cardiovascular health, bone health and overall add to your sense of wellness.


This may sound like a lot of effort. Actually it’s really not. It doesn’t take much time; it improves your physical health; and it will allow you to cope much better with stress. Better to “fill your cup” than rely on an anti-anxiety medication.

Ultraprocessed Foods Lead to Chronic Illnesses

Much of today’s foods are “ultraprocessed,” lead to obesity and its ultimate diseases such as diabetes, coronary artery disease, hypertension, many cancers and worsening of diseases such as osteoarthritis.

Ultraprocessed foods originate from just a few grains, namely corn, wheat and soy but these then undergo extensive chemical and mechanical manipulation resulting in compounds that humans have never eaten before. Just look at the ingredients list on many store products and notice first how many ingredients are listed and second how few of them you recognize. Further they are concentrated as to sugars, salt and calories while deficient or totally lacking in the fiber, micronutrients and phytochemicals found in fresh or frozen grains, vegetables fruits and unadulterated meats and fish.

David Ludwig MD, PhD of Boston Children’s Hospital wrote a cogent article on ultraprocessed foods in the April 6, 2011 edition of the Journal of the American Medical Association and upon which the proceeding was based. He explains that there have been three major breakthroughs in food technology. The first came perhaps 2 million years ago with the development of stone tools and the use of fire for cooking. This allowed the human who did not have the running speed of large carnivores nor the digestive tract attributes of herbivores like cattle and sheep to expand his diet. The second big technology breakthrough was domestication of grains – agriculture. This led to civilization in the sense of larger more stable communities because domesticated grains such as wheat and corn greatly increased calories available and no longer required migration to hunt or gather. He makes the interesting observation that human stature dropped a few inches with this change because grains carry fewer micronutrients and protein per gram than do animal meats and nuts.

The industrial Revolution was the third breakthrough technology which led to refined flours and concentrated sugars along with grain-fed rather than grass fed cattle, sheep and hogs. Such animals are heavy with saturated fats although their protein content and ready availability has resulted in a return of greater stature in recent generations. More recently have come ultraprocessed foods.

These ultraprocessed foods are high in calories from sugars and fats – often hydrogenated and trans fats – yet low in micronutrients. They are found in supermarkets’ “middle aisles” as processed foods such as cereal with added sugar, cheese “spreads”, “macaroni and cheese,” soups high in salts and calories, “sticky buns,” and of course sugared sodas. And ultraprocessed foods are readily available in many fast food outlets where a muffin may have 400 calories with high contents of sugars and saturated fats. A bacon cheeseburger, large fries and large soda can contain well more than one half of a day’s caloric needs yet be deficient in nutrients.

Ludwig concludes with “the problem is the creation of a dietary pattern based on factory-made, durable, hyper-palatable, aggressively marketed, ready-to-eat or heat foodstuffs composed of inexpensive, highly processed ingredients and additives. Reducing the burden of obesity-related chronic disease requires a more appropriate use of technology that is guided by public health rather than short-term economic benefit.”

What can we do? We need to cut back on the ingestion of these ultraprocessed foods. But this will not be easy. For this to work I believe we need incentives. After all, that bacon cheese burger tastes good – sugar and fat are pleasing in our mouths. So we need more than just knowledge that we are eating well and thereby preventing future disease while improving our health. Knowledge is important because most people just do not realize the extent of the harm that comes from over consumption of ultraprocessed foods. With knowledge we can follow the advice of Pollan in his “In Defense of Food” to never buy a product that has more than five ingredients or has ingredients that we have never heard of or cannot pronounce. But knowledge alone is just not incentive enough to overcome the temptations.

Some thoughts: Government can help with how it subsidizes agriculture, incenting the growth of a broader array of crops and not marking the fattest meat as “prime.” And it can continue to insist that restaurants, especially fast food outlets, display calorie counts. Business can help with wellness programs that reduce the employee share of health insurance premiums in return for weight reduction or exercise programs. Insurance can offer incentives as well. Schools can offer only quality foods – good in itself but also a lesson in good dietary habits for our children in their formative years. And we each need to create our own incentives – as I typed this I also ate a chocolate chip cookie. I enjoyed it but have set myself a limit of one per day. My treat for finishing this blog post.

Using Genomics to Improve Treatment of Lung Cancer

Drug companies can use genomics to create targeted drugs like imatinib (Gleevec) and trastuzumab (Herceptin.) Physicians can then use the results of genomic studies to guide prescribing. As discussed in prior posts, a person with Philadelphia chromosome-positive (i.e., having the BCR-ABL translocation with its aberrant tyrosine kinase) chronic myelocytic leukemia will likely respond to Gleevec. And a woman whose breast cancer shows high levels of the Her2neu receptor will likely respond to Herceptin. There would be no reason to treat a Philadelphia chromosome-negative CML patient with Gleevec nor a breast cancer patient without Her2neu receptors with Herceptin.

Recently the treatment of lung cancer has advanced considerably as a result of genomic analysis of the tumor and the development of targeted drugs. Lung cancer is divided into a number of different categories based on the microscopic appearance under the microscope. One type is called small cell and the others are usually “lumped” together as “non small cell” lung cancer because the former is treated much differently than the latter group. The non small cell lung cancers can be genomically evaluated to determine if there are certain common genetic mutations such as KRAS, EGRF, MEK and other mutations or the EML4-ALK translocation.

Patients with the EML4-ALK translocation respond reasonably well to the tyrosine kinase inhibitor crizotinib (somewhat similar to the one used for CML). As with the translocation seen in CML, this is a fusion gene that occurs during a translocation of two parts of two chromosomes that lead to a portion of the normal EML4 gene being fused next to the normal ALK tyrosine kinase gene. When this happens the new gene transcribes a variant tyrosine kinase protein which leads in part to the development or progression of lung cancer. Studies to date indicate it to occur mostly in the subtype called adenocarcinoma, in those with prior treatment, in younger patients and those who have no or a minimal smoking history. Although this represents just a small subset of all lung cancer patients, treatment of them in a Phase 1 trial with crizotinib resulted in a confirmed response in 57% (47 of 82) of patients with another 33% (27 of 82) having stabilized disease. [Kwak et al, New England Journal of Medicine, Oct 28, 2010] Although not a randomized trial, it is well known that most second line treatment regimens have no better than a 10% response rate so this would appear to be a breakthrough of sorts. Certainly it is not a panacea, nor a cure. But with minimal side effects these patients received some useful benefit and probably will have a lengthened survival Further studies will need to be done but if it is correct that about 5% of lung cancer patients have this fusion gene, then about 9000 patients per year would potentially benefit form crizotinib or similar ALK kinase inhibitors. Concurrently, one would not choose to use this drug in patients without this fusion gene and its abnormal protein. It also appeared that some patients had a further mutation such that crizotinib was not effective in them. [Note: Crizotinib is not yet approved by the FDA so access to the drug is via clinical trials.]

Patients who have the EGRF mutation appear to be distinct from those who do not as to response to the drugs erlotinib (Tarceva) and gefitinib (Iressa). EGRF is a tyrosine kinase that when mutated appears to play a role in lung cancer development and progression. Those who do have this mutated gene and its transcribed protein will respond to these two drugs in about 70% of cases with progression free survival of about a year and total survival of about two years. This would appear to be superior to standard drug therapy used today. Without this mutation, the patient will do much better treated with chemotherapy. So the treatment of a new patient with lung cancer today should include genomic analysis of the tumor so that the patient can receive the most appropriate first line treatment and then reanalysis later to determine if there are further mutations or translocation that would direct second line treatment options.

This is just one more example of how genomics is making medical care more custom-tailored, one of the five key medical megatrends.