18 October 2013

This Blog Is Closing

It has been a short run this time, but my health if more important. I have enjoyed some of the topics and comments to them. I have really appreciated the emails and wish to thank those people.

I will keep my blog here up and operating, as long as I am able.


17 October 2013

Urgent Care Centers, We Really Need Them

Again, when something is needed, we see the primary care physicians (PCPs) lining up against them and in states with strong medical boards, they are being prevented from coming into existence. I am talking about urgent care centers (UCCs). With the shortage of primary care physicians, the strain on most hospital emergency departments (ED), and rising health care costs, these urgent care centers operate as a great convenience to non-emergency cases.

Since PCPs do not have evening office hours, this only seems reasonable that UCCs can fill a great need in caring for people not needing the services of the ED. In addition, costs are less than the ED. The PCPs are claiming that this is hurting their people and safety is an issue. Some providers believe urgent care centers disrupt coordination and continuity of care. I say to these providers, then have practices that are open 16 hours per day, 7 days a week and there would not be the need for UCCs.

Others believe the concerns of PCPs may be overstated, given urgent care’s focus on episodic and simple conditions rather than chronic and complex cases. In the future, health coverage expansions under the national health reform may lead to greater capacity strains on both primary and emergency care, causing even more growth of urgent care centers. Hospitals view urgent care centers as a way to gain patients, while health plans see opportunities of containing costs by steering patients away from costly emergency department visits.

UCCs are not designed to handle car accidents or resuscitate patients at death's door, but they do treat minor injuries such as cuts and minor fractures, as well as the ear infections and strep throats of primary care. The Urgent Care Association of America puts the number of UCCs at 9000, with physicians or physician groups owning 35% of them. In addition, corporations own 30%, hospitals own 25%, and non-physician individuals or franchisors own 7%.

Rapid expansion of UCCs is often attributed to such factors as long wait times for primary care appointments, crowded emergency departments and patient demand for more accessible care, including after-hours appointments. UCCs provide care on a walk-in basis, typically during regular business hours, as well as evenings and weekends, though not 24 hours a day. UCCs commonly treat conditions seen in primary care practices and retail clinics, including ear infections, strep throat and the flu, as well some minor injuries, such as lacerations and simple fractures.

UCCs generally are not equipped to deal with trauma, provide resuscitation or admit patients to a hospital, all reasons for seeking ED care. UCCs are typically staffed by physicians, generally with backgrounds in primary care or emergency medicine, and some have nurse practitioners or physician assistants working under physician supervision.

Patient demand for more convenient access to care reportedly has increased, prompting renewed growth in urgent care centers. According to a recent study, approximately 60 percent of patients with a usual primary care physician (PCP) reported that their PCP practices do not offer extended hours, suggesting a niche for urgent care centers to fill.

16 October 2013

Patients Hurt by Biased Research

Yes, this goes without saying. The actions of our pharmaceutical manufacturers is almost criminal, no it is criminal. I say this because once the drug is approved for one use; the drug reps are promoting it heavily for “off-label” uses. Then they get FDA approval for these “off-label” uses and doctors happily promote their use and even have the philosophy that more is better.

This blog by Dr. Kenneth Lin, carefully lays out how pharmaceutical manufacturers convince doctors to overuse many drugs often to the harm of patients. He uses two common drugs that this has happened to, anemia drugs (Epogen, Procrit, and Aranesp, which mimic the actions of the hormone erythropoietin) and the diabetes drug rosiglitazone (Avandia). These two drugs were featured in recent articles by Peter Whoriskey in the Washington Post. The anemia drugs were developed to spare dialysis patients with severe anemia the inconvenience and risks associated with periodic blood transfusions.

Whoriskey also found that pharmaceutical companies moved aggressively to put these drugs into use in a far greater patient population, including those less likely to benefit from them.

The trouble would arise as the drug makers won FDA approval for vastly expanded uses, pushing it in larger doses, for milder anemia and for patients with a wider array of illnesses. Very quickly, the market included nearly all dialysis patients, not just the roughly 16 percent who required blood transfusions. The size of average doses would more than triple. And over the next five years, the FDA would approve it to treat anemia in patients with cancer and AIDS, as well as those getting hip and knee surgery.”

Doctors became motivated to give more doses of these drugs because the pharmaceutical companies were offering greater incentives, estimated between $100,000 and $300,000 annually for an oncologist. This created a seductive atmosphere and caused doctors to think if some of the drug was good, more had to be better. No checks were done and over prescribing continued.

Not until 14 years later did an independent researcher obtain access to the complete study report from the FDA and conclude that the NEJM authors had used statistical slight-of-hand to obscure an increased risk of heart attacks and death in the normal-hematocrit group. In the meantime, lobbyists working for the drug manufacturers successfully blocked efforts by Medicare administrators to stop paying for the higher (harmful) doses.”

This was the same tactic used by Glaxo Smith Kline in their promotion of Avandia and the manufacturer successfully stalled regulatory action in the US for three years, during which thousands of new patients were prescribed the drug.

This leads to the conclusion that the role of FDA members were to blame and let huge conflicts of interest stand in the way of protecting the public. The system of rotation from FDA to the pharmaceutical industry and them back to the FDA needs to stop and this should be outlawed with severe penalties for employees that do this. The next issue is passing a law that pays the salary of the FDA employees and pays for the supplies and operations to prevent pharmaceutical companies from having to kick in large sums of money to pay for the approval of their drugs. This practice also needs to be against the law with larger fines levied. These fines should be large enough to prevent companies from bribing FDA officials.

15 October 2013

Hospital Protocols Hinder Care

Hospital protocols do hinder and actually harm patients. I had a hard time believing the first part of this doctor's blog until I realized he was not joking. My next thought was why a hospital would treat a doctor in this manner. I would have guessed that a doctor and even a doctor's family would be expressed to the head of the line. I am happy to see that they receive the same poor treatment as the rest of us.

It is a shame that a few patients have required the need for hospitals to enforce strict protocols such as name and personal information before treatment can start. I understand the need for medical information to avoid allergic reactions and medical complications with medications the person is already taking. Yet, patients often arrive unconscious and unable to communicate and they are treated. I can appreciate the need for triage as the most serious patients should go to the head of the treatment line and that should never be disputed. Even this gets complaints from those that feel they are totally privileged and better than the rest.

In a way, it is probably the most fun way to spend a day sitting in an emergency department. It is surprising what happens and does not happen. This happened by accident one day when my daughter injured herself and my wife had taken her to the emergency department. I got there as soon as I was notified, but was refused to see my daughter because she was in treatment. After treatment was completed, I did not see my wife and daughter being moved to the hospital room since the exit used by patients was not visible from the waiting area, which I had been moved into.

This was before cell phones. There were mobile phones, but few people could afford them. So there I was, probably less than 40 feet from my wife and daughter and unable to have anyone look for them. In some ways, this seemed to be a hospital trick to keep families separated. Finally two of us decided to leave the emergency department and go into the hospital since we had not seen any of our families leave. Yes, both of our families had members admitted and we were not notified. For some reason they would admit that my daughter had been admitted to the hospital, but would not tell me which room. If it were not for my wife entering the hallway and upon seeing me, coming to get me, neither of us would have known. It turned out that his wife was in the same room as my daughter.

After some time we were able to convince our wives that we had been there since before noon and been told that we would see them later. The other fellow even guessed that they had been told that they would be informed when we arrived. I finally had to take my wife and his son down to show them the room where we had been kept. Still waiting were five other people that had been there at the time we were there. My wife knew one of the individuals and where his son was in the hospital and the rest were advised to start looking elsewhere in the hospital.

At that point, a nurse came by and asked that everyone be seated and quiet. I am afraid I was less than polite when I asked why we were being denied access to our families. I was told that they did not want too many people in the exam rooms. I said that we were still kept in the dark when our families were moved into the hospital. They were told they would be notified when we arrived, when we had been here for some time. At that point one of the doctors walked by and could tell we were very upset. He wanted to know what was happening. My wife spoke up and said the nurses were causing family stress by separating us from our families. Instead of notifying us when discharged from the ER or admitted to the hospital, those that had been diverted to this room were not informed.

One of those was an executive for a large area corporation and large employer and said that all contributions to this hospital would stop immediately. Several others wanted to know who was responsible for this and that the nurses on duty should all be removed from their jobs. To this, I added the nurses that would not tell us where our families were in the hospital. The doctor finally got quiet and called the administrator to the room. It took another hour to sort things out and supposedly get protocols corrected. The executive said that he was sticking by his word since people were not being held accountable for the mess and with the attitude of the staff could not be ignored. The administrator wanted a private meeting, but the executive said this would be an attempt to hide things from these families. Everyone was taken to the nurse station to find out if their relatives were admitted and even with the administrator telling them to get the information; it took almost 30 minutes, as it was clear, they were dragging their feet.

The local newspapers were notified and six months later, the hospital was sold to another hospital and policies changed. It was fortunate that our family did not need to use that hospital again and moved to another town about four months later.

I would encourage everyone to read the blog by the doctor here and another doctor about that doctor's blog here. It is a shame the protocols established by some hospitals cause more stress and harm to families than good will.

14 October 2013

Is All the Dementia Screening Necessary?

Before getting into this blog, I would like to include some points that the World Health Organization (WHO) has in their guidelines about assessing the value of a screening test.

#1. The condition should be an important health problem.
#2. There should be a treatment for the condition.
#3. Facilities for diagnosis and treatment should be available.
#4. There should be a latent stage of the disease.
#5. There should be a test or examination for the condition.
#6. The test should be acceptable to the population.
#7. The natural history of the disease should be adequately understood.
#8. There should be an agreed policy on whom to treat.
#9. The total cost of finding a case should be economically balanced in relation to medical expenditure as a whole.
#10. Case finding should be a continuous process, not just a “once and for all” project

The above are guidelines worthy of remembering and applying to many topics about screening. In the US, professional medical organizations and government agencies are making the determination of what screenings should be accomplished and many times when they are to be done. In my research, I have not discovered where the WHO says to harm patients to do the screening, create a stereotype that mandates screening, or order very costly screening for the sake of screening with little or no scientific evidence to back the screening.

Yet we have screenings happening based on the three items mentioned above that professional organizations and government agencies think need to be done. Other types of screening are not done because government is not mandating them and many of the doctors would not be current enough to know what to do if the screening result was positive.

The latest screening being mandated seems to be for dementia. This screening includes all types. I have to agree with one author that many of these screenings are poorly designed, poorly thought through, and often damaging or harmful to the frailest patients. However, with the government behind this and several of the medical associations, this will be difficult to stop.

11 October 2013

Urban Gardening, The Challenges

As more of us people with diabetes are told to eat more fresh produce, our supermarkets know that we are looking for fresh produce. Even then, the produce is several days old and not truly fresh as the grocery chains would like us to believe. Three or more days old are not fresh any longer. What are we to do if we don't live on an acreage and do our own gardening?

I wish I could do just that and be able to garden, but apartment living does not allow this to happen. Even the owner of the building won't allow gardening in the manicured lawns. No one near us will allow gardening and this means traveling to surrounding farms, which even many of them don't want. I finally located one farmer where we can get fresh eggs and some produce during the summer, but not enough to satisfy a family of two. Plus, the selection is limited to what they don't or can't process and not what some of our choices would include. This means no beans, no peas, and many other of my choices of vegetables. Plus many of the selections are past their prime when we are notified to come and harvest.

May I am just used to too many years of good fruits and vegetables harvested at their prime and canned or frozen beyond what we consumed in our daily meals. Mother and Dad always planned the plantings to spread out the harvest and prolong what we had fresh for the daily meals. Plus the canner was always kept busy once harvest started and the prime picking was for the daily meals or frozen.

This article was a pleasant surprise to find; however, many will not gain from this, but still is an interesting article even with the hazards it brings out. The concept of local food and urban gardening is gaining popularity as urban agriculture, with its benefits and obstacles, and is coming to many cities.

The benefits of urban agriculture are many. Urban gardens are often built on previously unused lots, increasing the beauty and value of the neighborhood. They provide recreation opportunities and a social network for the gardeners involved. Urban food production also means that healthy, fresh produce is readily available to city dwellers.”

The challenges that organizers and growers face need to be understood and conquered if urban gardens are to take hold and even be profitable. Many of the obstacles, planners and growers face include soil contaminants, water availability, and changes in climate and atmospheric conditions.

Of the contaminants found in urban soils, lead is the most prevalent. Even though there is concern about plants taking up lead from the soils, research shows plants take up very little and in fact, it is less than we are exposed to from drinking water. Practices such as washing food before eating and covering soils with mulch can decrease these risks. Finding reliable and safe water sources can be difficult for urban gardeners. Using drip irrigation that will deliver water where and when it is needed can conserve water.

10 October 2013

Can You Deal With the Elephants in the Exam Room?

First, it is necessary to identify the elephants that a discussion is hard for providers and patients to talk about with ease.

#1. Sex
#2. Costs of care
#3. Alternative treatments
#4. Advanced directives
#5. Digital technologies

I find I have no trouble in discussing any of the above or more, but studies show that they are often difficult for providers and patients to talk about and many just won't consider talking about them.

The first item above is important for both men and women with diabetes for a variety of reasons. Men often have sexual dysfunction or erection dysfunction quite often and this can affect how they feel about diabetes. In looking for studies, there are a few, but not worth the time because most are less than 10 men. Women have other problems and often dislike having sex because of yeast infections and often dryness making sex painful.

The second item above is very difficult to get providers to talk about because often they are not totally aware of what the actual costs are when providers are employed by the hospital. Hospitals have so many extras that are tacked on to a charge to get more from the insurance companies and/or Medicare/Medicaid. There are at least three free apps, which address health care costs.

The third item above is more difficult for patients because they are afraid of the reactions they will receive from their provider. Once the diagnosis is received by the patient, some will consider having the treatment prescribed by their provider, but others would like to consider complimentary treatment, which may include holistic, neuropathic, or homeopathic regimens. Often they won't discuss these with the doctor because they know from past experience that the doctor will ridicule them and dismiss the treatment. Often they just take the prescription or prescribed treatment and go to another doctor that will provide these.

The fourth item above is probably one of the more contentious topics as many providers just hand out papers to have the patient check the boxes for the advance directives for end of life care to meet federal mandates. In these situations, many patients just ignore these. If they are like me, I have seen physicians, hospitals, and families ignore the wishes of the patient and do what they want done, even with the advance directives on file. I have even seen family ushered out of a parent's room so they can follow their own policies against the directives.

The fifth and final item above is about mobile technologies. These can improve the doctor-patient relationship, but even then, doctors do not want them around and will ignore their use. Many patients use the internet and this often causes physicians to see this as a threat to them and upsetting the balance of their relationship with the patients. Fortunately, times are changing and with both shared decision making and digital health technology in present popularity, physicians are often forced to deal with this or lose patients.

Now it becomes necessary to state that both providers and patients need standards that medical app developers can follow. If they are reliable and effective digital tools, they can help prevent the elephants from being in the exam room discussion instead of making the elephants presence larger.

While the above discussion may not include all the elephants, often once they are recognized and the provider brings them up with the patient, they disappear and the tension is relieved. Often a partner or a caregiver can be the one to start the conversation and they can be the ones to carry these discussions. Read a doctors interpretation and thoughts about this topic here.

09 October 2013

Communications By Any Other Name - Worthless

You may wish to skip this blog. This is because I am overly critical of another blogger. I normally respect this blogger and she has much good to say, but that was not my take on this blog.

Again, I wonder why is it that doctors misunderstand communications. Every doctor has his/her interpretation of patient engagement. Now I will add the term “meaningful use” to patient engagement and say that most doctors are trying to hide behind the two phrases and are not concerned about communications with the patient. To quote Dr. Rob Lamberts, “Communication isn’t important to health care, communication is health care. Care is not a static thing, it is the transaction of ideas. The patient tells me what is going on, I listen, I share my thoughts with the patient (and other providers), and the patient uses the result of this transaction for their own benefit.”

I respect the definition by Dr. Lamberts, but anything in other definitions is bull, and the quicker we as patients understand this, the better off we will be. I covered his blog that Dr. Leslie Kernisan refers to, but do not understand why she had to muddy the waters even more. I will quote Dr. Kernisan to show this: “Here’s my current take:  Supporting patient engagement means fostering a fruitful collaboration in which patients and clinicians work together to help the patient progress towards mutually agreed-upon health goals.” Mutually agreed-upon health goals may not always be in the best interest of the patient.

She says everything but communication as if communication is a term to be avoided at all costs. Then she uses the term to bring people back to patient engagement. I quote, “Communication with patients is, of course, essential to all of this. This is why any innovation that improves a patient’s ability to access and communicate with healthcare providers is proudly labeled as “patient engagement.””

Remember meaningful use, doctors may not meet this if they use communication instead of meaningful use. Then we find out that Dr. Kernisan prefers to quantify patient engagement when she states, “Back to the examples of patient engagement cited above. What are the “right metrics around what constitutes real patient engagement”? Obviously, it will be difficult to agree on metrics if we don’t first agree on the definition.”

Sounds to me she is trying to calculate how to fit this into meaningful use. Tell me this isn't so, doctor! I am even more concerned now and have to wonder what it is about the word communications that doctors are unwilling to accept this, with the exception of Dr. Lamberts.

I become very uncomfortable when doctors use the term patient engagement around me and even more when they use the term in surveys sent out to attempt to get praise for their actions. I refuse to return these and when one doctor called me to find out why I had not returned the survey, I am afraid I was not too polite in my response. I also said that the phrase patient engagement had no standard meaning and communication was definitely not part of my appointment other than keeping my mouth closed except to answer questions.

Of course, the doctor disagreed. I asked him who had set the goals I was to use for my health. When he said we both had, I reminded him that I had not indicated I approved or disapproved of the goals he had laid out. I then told him where I disagreed and why. He quickly asked me to complete the survey and return it. I said I would and I would send one to the administrator and keep another copy for my records. “Click” was the next sound and it was more of a “bang.”

I did return the survey, but he is no longer a doctor on my team and that is by mutual agreement.

08 October 2013

Providers Label Patients as Second Class Citizens

I am glad someone is speaking out about what providers and the health information technologies (HIT) are doing to shut us out as patients. If doctors think that their pedestal is tarnished now, wait until patients really understand what they are doing and they may find that there may be some tar and feathers in the next round. Not only this, but also many doctor-patient relationships may come to an abrupt end.

Adrian Gropper, MD writes about Health IT Week – the Consumer Health IT Summit. He does not pull any punches and his blog should upset a few great doctors that understand the importance of communication. The rest probably are clapping their hands heartily and saying Amen.

Dr. Gropper says that the Health IT week demonstrated a double barrel strategy first to keep patient information segregated from provider information. Then by rebranding HIPAA as “Meaningful Consent” with no input from patients, this makes patients second-class citizens in Meaningful Use Stage 2 interoperability. Providers and regulators are working together to see that is stays that way.

Normally providers and IT people make comments, but they are strangely quiet after this blog. They seem to know that some patients read many of the blogs and they are careful not to disclose their opposition to Dr. Gropper telling all. Dr Gropper and several providers have laid out some of the background in a good discussion.

The segregation of patient information from “provider” information is the current federal regulatory strategy. It’s even more so in the states. By making patients into second-class citizens, the providers can avoid open scrutiny, transparent pricing, and independent decision support.”

Federal regulators then create a parallel system where information is delayed, diluted, and depreciated by lack of “authenticity”. This is promoted as “patient engagement”. For regulators, it’s a win-win solution: the providers support the regulation that enables their price fixing and many patient advocates get to swoon over patient engagement efforts.”

What is even more troubling is this. “The Model Notice of Privacy Practices legitimizes the practice of provider-to-provider health information exchange under the HIPAA Treatment, Payment and Operations (TPO) exemption. TPO is used by providers and health information exchanges to avoid patient authorization for sharing of private information.” This smacks of patient privacy being violated with no concern.

Another point made by Dr. Gropper is the intentions for emails between doctor and patient. Apparently, most providers, regulators, and HIT companies wish to keep emails out of the hands and use by patients. Dr. Gropper states that the regulators are making most emails an organization-to-organization system. This is part of the regulations for Meaningful Use Stage 2 certification.

This means that the original intent of Blue Button Plus, having secure communications between patient and provider, will be lost and transparency will be lost. This will also mean that hospitals and providers can avoid giving patients an independent decision support portal and a key independent communication channel.

Without transparency and independent decision support, the tools for reducing health care cost become limited. The market-based (as opposed to Medicare for all) foundation of ObamaCare cannot highlight unwarranted and overpriced services as long as the providers of those services maintain control of our personal information. This seems a merely politically expedient. If we accept an impotent Blue Button Plus and HIE exclusion via TPO we may be headed for a regulatory failure even larger than the sub-prime mortgage crisis.

Patients need to sharpen their skills and knives for the battle ahead. It won't be pleasant for all concerned.

07 October 2013

Statins May Indicate Reduced Dementia

These two studies raise more concerns than they solve. Why are larger doses of statins needed to reduce the risk of dementia. At the same time, other studies are finding more muscle and joint problems with the increased dosage of statins and more cases of type 2 diabetes.

This also raises the issue of which statins were being used by patient numbers, possible ethnic variables, and the correct dosage to cause the reduced dementia. I therefore agree with Professor Jose Gonzalez-Juanatey, University Hospital, Santiago de Compostela, Spain, who said, "These new data suggest that high-potency statins may reduce the incidence of dementia in patients with atrial fibrillation and in elderly patients. Nevertheless, before we can know for sure that statins may prevent dementia, a clinical trial confirming these findings is mandatory."

At the same time, Seth S. Martin, MD, Johns Hopkins Hospital, Baltimore, Maryland, who is conducting a systematic review of the literature on statins and cognition/dementia, said, “These current results fit in well with existing studies.”

This leaves things unsaid and especially what conflicts of interest have not been disclosed. While some statistics are shown for the different statins in the press release, no patient numbers are matched to the statins and an attempt to obtain to details of the two studies was unsuccessful. So I am left wondering who funded the study?

I am less concerned about these two studies having some solid evidence and the information not being cooked by Big Pharma than I was about the information I used in this blog. However, I remain concerned about conflicts of interest.

04 October 2013

Does the Public Need Medicare Education?

According to this Medpage Today article, YES. This Joslin blog also raises issues that people with Medicare and diabetes may not be aware are available. While I don't utilize them personally, some people may have the need of these services. Others that are in need of these services may not be able to receive them because of the shortage of certified diabetes educators in many areas of the US, and registered nutritionists are also in short supply. The CDEs are needed for the education and many doctors do not have them available or will not utilize them.

The medical nutrition therapy is a complementary benefit. You must be counseled by a registered dietitian or nutrition professional that is a Medicare provider. In addition, your physician must write a referral for you to receive this service. You should receive an individualized nutrition care plan and be monitored for changes in your diet and laboratory values.

Other preventive services are also funded by Medicare and should be utilized. My blog here covers this and a link to the list of preventive services.

The Medpage Today article takes off in another direction and has some comments that are not too complementary about Medicare. I do agree with the article that there is a need for public education when it comes to understanding what Medicare does and does not pay for and the why. We as Medicare beneficiaries will need to become more familiar with some of the provisions and reasons Medicare is tightening the purse strings.

Reform will need to happen and this may become painful in the pocket of many beneficiaries. I can only hope that the supplemental policies can cover the holes and not become too exorbitant in doing so. The following indicates current public opinion and are not completely on target.

Public opinion polls show that poor government management (30%), fraud and abuse (24%), and excessive charges by hospitals (23%) were top reasons voters cited for Medicare's rising costs. The cost of new drugs and treatments was the lowest-ranked reason, with 6% of respondents citing it.

Medicare's hospital insurance trust fund will be depleted by 2026 if current spending rates continue, the program's trustees said earlier this year. I am not sure where the author obtained the 2026, as I remember, probably incorrectly, the year of 2018 for Medicare to exhaust its funds under ACA.

“Increasing the public's understanding about how Medicare works, outside of just how to navigate the program as a patient, could raise the level public policy debate in the country, the authors said.” I think with the baby boom generation now increasing in the Medicare arena, that it is time for a public education campaign to begin.

03 October 2013

ED Use Might Go Up Under ACA

According to this article in Medpage Today, the author states that a study shows emergency department (ED) use could surge under ACA. This increase will happen under both the newly insured and those insured under Medicaid.

Causing some of this will be the shortage of primary care physicians and many states not accepting NPs, PAs, and Pharmacists to work in the primary care field independently.

Increases in California emergency department (ED) use were driven in large part by Medicaid patients. The researchers say this will be a precursor to increased burdens after the Affordable Care Act kicks in completely.

Many patients who will soon be insured under the ACA will be enrolled in Medicaid. While these people are generally healthier than current Medicaid enrollees, they may introduce a new and additional burden to treat undiagnosed and uncontrolled conditions.

These costs may represent a bigger picture of burdens on acute care across the U.S. under expansions to Medicaid under the ACA, according to David Howard, PhD, at the Department of Health Policy and Management at Emory University's Rollins School of Public Health in Atlanta.”

James McCarthy, MD, of the University of Texas Health Science Center at Houston, noted that additional healthcare burdens imposed by the ACA "will result in increased ED utilization in many markets because of inadequate primary care infrastructures to support the population."”

These two individuals that were not part of the study, state the problems patients will face under the Affordable Care Act (ACA). This is one more reason that I wrote my blog here to warn people about being careful of changing doctors at the present time. You don't want to be without a doctor when the problems start and the newly insured are looking for primary care physicians.

02 October 2013

Rodent Studies – Do They Really Mean Anything?

I admit I am tired of reading about studies involving rodents that are heralded as a breakthrough. Most often that is the last we hear about them and then we see no human trials or studies using the rodent data. To me this means there is no viability for these to move forward to humans and thus no meaning for the rodent studies recently heavily promoted.

Now we have two more rodent studies, one about an approved cancer drug that could treat diabetes and another that could potentially solve the loss of beta cell features that contribute to the onset of diabetes. Now will we see any human studies confirming these findings? It will be interesting, but doubtful.

The most interesting is the adapting of the cancer drug and this is probably the most promising as the researchers do state, "Anecdotally, there have been reports that diabetic patients who have been prescribed VEGF inhibitors to treat their cancer are better able to control their diabetes." They also state, "Much work remains to translate these mouse studies to human patients, but it will be interesting to explore VEGF inhibitors or drugs that can stabilize HIF-2alpha, such as prolyl hydroxylase inhibitors, for diabetes treatment, possibly in combination with pre-existing therapies to minimize toxicities."

"Targeting the Phd3/HIF-2 pathway represents a new therapeutic approach for the treatment of diabetes with little toxicity," said one of the researchers. "These studies indicate that Phd specific inhibitors, especially Phd3, should be more widely developed for clinical development."

The second article about the protein Nkx6.1, which is a beta-cell enriched transcription factor, is essential for maintaining the functional state of beta cells. The study shows that loss of Nkx6.1 in mice caused rapid onset of diabetes. Scientists have revealed the critical role of this protein in the control of insulin biosynthesis, insulin secretion and beta-cell proliferation.

The researchers have found that the loss of Nkx6.1 activity had an immediate on the expression of genes that give beta cells their ability to synthesize and release in insulin biosynthesis.

Whether this rodent study is worth the time reading is debatable.

01 October 2013

October Calendar of Monthly Events

Out of the many national topics for the month of October, I selected just two of the national month of October topics. The first is National Disability Employment Awareness Month (NDEAM).

In 1945, Congress enacted a law declaring the first week in October each year "National Employ the Physically Handicapped Week." In 1962, the word "physically" was removed to acknowledge the employment needs and contributions of individuals with all types of disabilities. In 1988, Congress expanded the week to a month and changed the name to "National Disability Employment Awareness Month." The theme for 2013 is "Because We Are EQUAL to the Task."

The Office of Disability Employment Policy (ODEP) was established in 2001 and assumed responsibility for NDEAM. ODEP has worked to expand its reach, scope, and make this a worthy national event.

This year's theme echoes the message of ODEP's ongoing Campaign for Disability Employment to promote positive employment outcomes for people with disabilities. They are striving to expand ideas about what youths with disabilities can do when they receive encouragement and support for their ambitions. Conducted in collaboration with business and disability organizations, the campaign emphasizes that, at work, it is what people can do that matters.

The second national event is Talk About Prescriptions Month (TAP Month). As a person with diabetes, prescriptions have become part of my life. While I don't like many prescriptions, I do need to take the medications. In reading some of the web sites about this, I like the fact that some straightforward ideas were presented.

"Too many times, people misuse medications, either by not following proper use instructions, or not taking them as directed by their physician, nurse practitioner, or physician assistant. This misuse often leads to other health problems. That's why NCPIE is launching the 3Rs for Safe Medicine Use program." Phillip Schneider, NCPIE Chairman. NCPIE stands for The National Council on Patient Information and Education and NCPIE

During ”TAP” Month, on October 15, 2013, NCPIE will launch a new national campaign called the Adherence Action Agenda (The A3 Project), with a particular emphasis on the need to call attention to and address improving adherence by Americans suffering from multiple chronic conditions (MCCs).

This theme was used in a prior year, but still in relevant today. The 3Rs for Safe Medicine Use, focusing on the following key safe medicine use messages for consumers and healthcare providers:
  1. Risk: recognize that all medicines (prescription and nonprescription) have risks as well as benefits; and you need to weigh these risks and benefits carefully for every medicine you take.
  2. Respect: respect the power of your medicine and the value of medicines properly used.
  3. Responsibility: take responsibility for learning about how to take each medication safely. Being responsible also means following this important rule: when in doubt, ask first. Your healthcare professional can help you get the facts you need to use medicines correctly.

Because most doctors bail on doing this, the pharmacists in many states are now required by law to provide this information.

The information at this link was last updated in October 2005, but is as important today as ever. Just understand that many doctors are listening to drug representatives and you need to be sure that the doctor has no conflicts of interest for prescribing a medication. There are some questions that need to be asked of the doctor, but be careful as some doctors are easily offended by the manner in which you chose to ask the question.

30 September 2013

Statins Are Linked to Cataract Development

Happy – no, but I am glad I questioned the science promoted in this blog and declared my belief that Big Pharma promoted the article and maybe even the research and they do not wish to have the results confirmed or denied. Sorry, but I couldn't accept the information as it is presented and viewed the information as unreliable and even possibly a farce.

This study confirms that the science has to be in error and the information was from less than reliable source. Big Pharma has to have been promoting it. This Medscape article does declare that there is a strong link between statins and their cause of cataract development. “At the recent European Society of Cardiology (ESC) 2013 Congress , Dr John B Kostis (Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ) presented the results of a random-effects meta-analysis, showing a 20% lower rate of cataracts with statin use compared with no statin use, with a more pronounced benefit seen when statins were started in younger patients.” At least they were able to identify Dr. Kostis and his academic school.

The meta-analysis published today, however, found the opposite. It matched 6972 statin users with nonusers within the San Antonio Military Multi-Market Area health system using propensity scores based on variables that increased the likelihood of receiving statins and increased the risk of developing cataracts. Statin users had to have been on the drugs for more than 90 days; simvastatin was prescribed in almost three-quarters of the patients.”

The author emphasizes that statins are very effective medications; therefore, side effects are to be expected. I am glad that this puts healthcare providers on notice and stresses that they should make sure there is justifiable indication to prescribed statins. Many doctors do not follow guidelines to confirm that the potential benefits outweigh the potential risks of side effects for individual patients.

The message for patients is one of understanding and that statins are a tool for treatment of heart disease and should not be stopped because of a small risk of association with other diseases. It is wise to commit to lifestyle changes, like stop smoking, and continue to be physically active than take a pill to lower your risk of heart disease. Until this can be accomplished, consult with your doctor to determine if it may be wise to remain on statins.

27 September 2013

In Medicine, More Is Not Always Better

What hospitals lobbied too hard to receive and prevent doctors in practice from receiving may have backfired on them. I say just deserts for your greed, hospitals. This New York Times article paints the correct picture. I can only call the tactics by hospitals as bullying tactics, not lobbying. What the Times article leaves out is the amount of money used to support congressional backers of the bill that favored the hospitals and now may need to be repeated. This of course will come out of the pockets of patients and taxpayers.

At least the Medicare Payment Advisory Commission is seeing the cost difference created by the hospitals with their “facility fee” addition to all submissions to CMS. This is done for hospital outpatient clinics that are part of the hospital and facilities where the hospital has established clinics by purchasing an entire physician practice.  A physician’s practice that is purchased by a hospital often stays in the same location and treats the same patients, but Medicare and Medicare beneficiaries pay more for the same services.

The 17-member Commission uses the following examples to show the disparities between hospitals and independent physician practices. An office visit for 15 minutes to an independent physician practice is reimbursed to the practice for $58 and the patient pays an additional $14.50 for a total of $72.50. The hospital receives $98.70 for the same consultation and the patient pays $24.68 for a total of $123.38 or a combined $50.88 more for the hospital.

Then consider a certain type of echocardiogram, Medicare and the beneficiary pay a total of $188 when this takes place in an independent physician practice. The same test done in the outpatient department of a hospital yields a total cost of $452. The hospital gains $264 over the physician practice. This hardly seems fair or justified for the patient.

The USA Today article says a study found that tens of thousands of times each year, patients undergo surgery they don't need. This calls for patients to be more vigilant when procedures are recommended involving surgery. Yes, the author blames doctors that are bad apples, but often I wonder why patients don't seek a second opinion.

Yes, patients have part of the responsibility for pushing doctors to take action for them or their loved one, when in fact, doing nothing or medically treating a condition may be the better course of action. Also, consider that the current medical system does provide incentives to perform a costly procedure instead of medical management.

As a patient, we need to learn not to be so trusting of our doctors and seek one or more opinions. The money you spend for that second opinion may just prevent you from bearing the total cost of surgery when Medicare or your insurance says it was not necessary and refuses payment.

26 September 2013

FDA Now Against Hyperbaric Oxygen Therapy

The FDA likes to be embroiled in controversy and they chose to do it quite regularly recently. This time they choose hyperbaric oxygen therapy. As is so often the case, what they don’t tell you is more important than what they do tell you. Yes, they are correct in issuing the warning as hyperbaric oxygen therapy (HBOT) has not been clinically proven to cure or be effective in the treatment of cancer, autism, or diabetes.

HBOT is approved to treat thirteen conditions: decompression sickness, thermal burns, non-healing wounds, necrotizing soft tissue infections (a.k.a. flesh-eating bacterial disease), acute traumatic ischemias (e.g., crush injury, compartment syndrome), radiation tissue damage, smoke inhalation and carbon monoxide poisoning, air or gas embolism, severe blood loss anemia, refractory osteomyelitis, compromised skin grafts, and clostridial myonecrosis (gangrene).”

What surprises me is the Department of Defense claims. They say that the will not use HBOT off-label because they claim that they don't prescribe off-label use of medications and treatments for veterans. If this were true, then the DoD needs to stop using off-label antipsychotic drugs to treat traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD).

In a study conducted in Israel, the use of HBOT helped TBI that had existed for many years and successfully. Yet the US DoD is rejecting this help for veterans. Where is our humanity? Oh, right, it is an off-label use. Yet licensed physicians and healthcare institutions may legally use an FDA-cleared hyperbaric chamber to treat unapproved or “off-label” diseases and conditions, though it is illegal to promote or advertise such uses. A few doctors are already using HBOT off-label, but not nearly enough of them.

Part of the warning says, “Patients may incorrectly believe that these devices have been proven safe and effective for uses not cleared by FDA, which may cause them to delay or forgo proven medical therapies.” I wonder which proven medical therapies they are talking about, dangerous drugs and expensive, invasive surgeries?

This is part of the problem. The FDA tends to protect therapies that are non-natural and patentable, so that drug companies can afford to spend $1 billion on average for agency approval. Bringing these drugs through the approval process pays the agency’s bills, including salaries. Indeed much of the cost of the FDA is born directly by drug companies, which creates a huge conflict of interest.” Bold is my emphasis.

The final bit of information the FDA did not mention in their warning is that the patents on HBOT ran out years ago. This means that this therapy will not garner additional use approvals because the FDA cannot require money for approval. HBOT is a dead issue as far as FDA is concerned and human suffering can continue.

Congress needs to step in and limit the funds FDA can require for approvals and put some other restrictions and orders in place to encourage better actions. Otherwise like HBOT, other projects such as diabetes test strip accuracy won't be acted on either.

25 September 2013

Home Care Coming Under Scrutiny

Who is checking on the people who are minding our elders? While this is taken from information gathered in California, I know that it applies to many other states. if not all states. According to a new policy brief and related report by the UCLA Center for Health PolicyResearch, very little data exists to measure the care or quality of care provided by private home care providers.

Two of the provider organizations in California, In-Home Supportive Services (IHSS) and Home Health Agencies are subject to licensing, certification, and background checks. The other two offer none of these protections and are Home Care Agencies and individual caregivers, whether they provide services of housekeeping or other non-medical support.

Nadereh Pourat, the UCLA center’s director of research and author of the study stated, “Regulations within the private home care industry might help establish standards for caregiving that can ensure patient safety and quality of care.” This combined with a mandatory background check should be a minimum. I don't think licensing should be required, but a form should be filed with the local law enforcement agency so that in case of a robbery, death, fire, or other accident, they could know who might have been in the residence.

Of course, the policy brief was funded by the Service Employee International Union, and the Union of Long Term Care Workers. They desire the licensing and union membership to put in their coffers.

Then those wanting regulation want them also for this reason. Regulation could result in another important benefit, creating public data that could be studied to better understand the quality of care provided by home care agencies. Regulations by the state to create standards of care and provide for background checks is understandable, but for other purposes such as providing curiosity data should not be the goal of regulations.

Other states would be wise to consider similar actions to create standards.

24 September 2013

Cause of Disappearing Honeybees

Whether the agriculture industry is actually pushing this or not remains to be seen, but I do know many farmers are and actively doing this. This being the spraying of insecticides on crops to kill insects. It is unfortunate that honeybees and other pollinators (a term that includes native bees, honeybees, birds, bats, and other species of beneficial insects) are being affected by the insecticides. I would be more inclined to believe that the agricultural chemical business in cooperation with some of the large agricultural industries is behind this killing of the honeybees.

Yes, and this would include the corn industry as they are ready to increase their profits in high-fructose corn syrup to take the place of honey.

Since 2006, up to 40% of the bee colonies in the US have suffered Colony Collapse Disorder (CCD), in which honeybees die, disoriented, far from their hives. The honeybee pollinates a third of all the food we eat and contributes an estimated $15 billion in annual agriculture revenue to the US economy alone. Fresh fruits and vegetables, in particular, would simply not exist without honeybees.

At least 143 million of the 442 million acres—that is, nearly one-third—of US cropland is planted with crops treated with these neuroactive insecticides, which are related to nicotine and are highly toxic to bees. In the US, 100% of corn and canola is treated with neonicotinoids, as well as 65% of soybeans and almost all cotton, wheat, and smaller acreage crops. The pesticide expresses itself through the plants’ pollen and nectar—the honeybee’s favorite sources of food.

A recent Time magazine article notes a number of potential reasons for CCD, including deadly bacteria and viruses—but nearly all researchers agree that the main culprits are general chemical exposure and pesticides (neonicotinoids in particular). A study of honeybee pollen found nine different pesticides and fungicides in it on average.”

The agriculture industry doesn’t want their profitable pesticides tampered with: there are over 1,200 pesticides currently in use in the US, and many are made by the same companies that engineer the crop seeds. So instead, Big Farma has begun creating CAFO-like conditions for bees! It’s already happening on a small scale; many argue that it may be the only alternative if we don’t reign in the pesticides. “Bees may end up managed like cattle, pigs and chicken, where we put them in confinement and bring the food to them,” said one beekeeper and independent researcher quoted in the Time article. “You…do feedlot beekeeping.””

Monsanto, surprise, is working on other GMO “fixes” for CCD as well: they’re developing RNA-interference technology that will kill one of the viruses thought to be killing the bees, the Varroa mite, by interfering with the way the bees’ genes are expressed.

Because I have a very soft spot for bees and have kept bees as I explained in my blog here, I would appreciate those living in the US to support a new bill, HR 2692, “The Saving America’s Pollinators Act of 2013,” that has been introduced in the House by Rep. John Conyers, Jr. (D-MI) and Rep. Earl Blumenauer (D-OR). It would suspend the use of neonicotinoids until the EPA can prove that the insecticide “will not cause unreasonable adverse effects on pollinators.” This proof of safety would need to be in the form of published scientific research together with a completed field study. Please contact your representative and urge his or her support of HR 2692.

23 September 2013

Doctors Are the People Spreading Infections

While I know a few doctors that will disagree with me, they are the ones that don't use hand or equipment sanitation, refuse to wear gloves, and in general ignore good safety standards. Some of these same doctors are the ones insisting on touching patients and giving them comfort according to them. I say comfort my !@@, I would rather know that the stethoscope has been sanitized and see them wearing gloves, than using an unsanitized stethoscope and not wearing gloves.

Another writer on the internet and a patient advocate agrees with me. About two weeks ago now, I received an email from a wife asking me if she had been wrong in insisting that the doctor wash his hands, wear gloves in examining her husband who was in the hospital with second degree burns over approximately 25% of his body and third degree burns on about 5 percent.

She stated that she had to wear a special gown and gloves when visiting her husband and she was aware of at least two other patients in adjacent rooms that had MRSA and did not want it spread to her husband. I emailed her back immediately and told her by all means and stand between her husband and the doctor until she knew that the doctor has sterilized his stethoscope, hands, and put gloves on. The next day I received another email saying that the doctor had refused to see her husband and had sent a nurse practitioner in while he remained out in the hall. She stated that the NP had washed her hands and gloved up before taking the stethoscope out of the sealed packaging and then examined her husband.

After they had finished rounds the NP had returned to thank her for correcting the doctor even though he refused to do any of what she had requested. The NP stated as she left that he had seen both MRSA patients before entering her husband's room.  That made the wife feel much more positive about what she had insisted on and she knew she would stand her ground until she was sure there were no more MRSA patients on that floor. A week later because of his improvement, he was transferred to another hospital and she was thankful because everyone there followed sanitation rules and had set the rules she was to watch for herself and other visitors.

Yet the author of the blog that got me wrapped up in this, does not like gloves and apparently other safety precautions and feels that human contact is essential. I am sorry Dr. Sibert, but I think I could not let you be my doctor or anesthesiologist in this case. Just stay out of the operating room if you are afraid of wearing gloves. To my way of thinking, you are the unclean person.

20 September 2013

New Physicians Want 35 Hour Work Week?

This blog is derived from this blog written by Leslie Kernisan. She makes many points that I can agree with and I list them first followed by points I have.

Points of agreement: (Read the blog for Dr. Kernisan's explanations.)

#1. If the 35-hour work week will mean more thorough and better care, then make this happen.
#2. If the newly minted PCPs would truly take care of the Medicare beneficiaries, this could be a great purpose.

The following are a listing of Dr. Kernisan's tasks she performs regularly:

#3. Following up on 6+ chronic conditions and 12+ medications, in an integrated whole-person fashion.
#4. Following-up on the work of multiple specialists, many of whom hadn’t explained their thinking to the patient and family.
#5. Resolving the conflicts inherent in attempting to follow clinical practice guidelines in patients with multiple conditions. (See this JAMA article to understand how well intentioned practice guidelines could cause serious problems for elderly patients.)
#6. Adjusting care plans as a function of goals and what seems feasible for the patient. It is pointless to recommend chronic disease management per best practices if it doesn’t seem feasible to the patient and family.
#7. Explaining why certain commonly requested interventions – antibiotics, diagnostic tests, specialty consults – might not be helpful.
#8. Helping patients and families prioritize and identify a few key health issues to work on at any given moment.
#9. Helping patients and families evaluate the likely benefits and burdens of possible medical approaches.
#10. Helping patients and families cope with the uncertainties of the future.
#11. Weighing in on family conflicts.

Now I have left out one factor that I feel doctors should not become involved in and I am admitted tired to hearing them.

A point of disagreement and points not covered which need to be considered

#1. Addressing end of life planning. I have seen doctors, hospitals, and family side-step this so often that I place no value in these discussions. My own family has shown their own opposition about my wishes for end of life. With rationing on the horizon, doctors and hospitals are turning a deaf ear. I realize that medical supplies and other factors are not infinite, but still rationing is the buzz-word at the CMS and in the Congressional arena. Read this blog - http://bobsdiabetes.blogspot.com/2011/08/cms-threatening-more-euthanasia.html And this blog - http://bobsdiabetes.blogspot.com/2013/05/medicare-enforcing-healthcare-rationing.html

#2. The physician shortage will be here and is in many areas of the country. It will take more than a decade to correct for this as it is, even if the 35 hour-work-week becomes a reality.

#3. Let us stop squabbling about who may be able to help during the shortage. Many doctors are urging their state medical boards to prevent NPs, PAs, and Pharmacists from practicing unsupervised. Most medical professional organizations are also filling the printed pages, the internet, and air with their opposition to these professions. Even if allowed to practice, there will still be a shortage as many of them have gone the specialist route in search of better wages. I feel fortunate that I have at present two NPs that I see on a regular basis. Even though my state allows them to practice independently, they still work under the supervision of MDs. My blog - http://bobsdiabetes.blogspot.com/2012/11/are-doctors-lobbying-themselves-out.html

#4. Many state medical boards have even limited PCPs and Family Physicians and what they can practice, at the request of specialists and their whining. Licensing boards are also limiting what some para-professionals can and can not do. Because some doctors have seen the need for education in the diseases of cancer, diabetes, MS, and others, they have taken patients knowledgeable in these diseases and spent time and occasionally money to train them as peer mentors or peer-to-peer workers to assist them in educating their fellow patients. A few state medical boards are now trying to even stop this from happening. This blog - http://diabetestopics.blogspot.com/2013/09/are-doctors-threat-to-their-own.html

#5. PCPs are even trying to prevent organizations hired by the hospitals to enter patient's homes after a hospitalization and assist patients in need. Many of these patients seldom see a PCP, don't have one, or cannot get an appointment to see one soon enough after being discharged from the hospital to prevent rehospitalization. This blog - http://diabetestopics.blogspot.com/2013/09/pcps-are-putting-themselves-in-bad-light.html

#6. With the tsunami of new patients coming January 1, 2014, many doctors and specialists are cleaning house of undesirable patients that might prevent them from receiving the incentives from CMS that they feel they are entitled to receive. This blog - http://bobsdiabetes.blogspot.com/2013/09/changing-doctors-now-may-not-be-best.html

#7. With the CMS program for assisting obese patients now underway, most hospitals have established the weight-loss clinics into the bariatric clinic to charge a fee to do an evaluation. This evaluation is to determine if the bariatric clinic can convince these patients to go the bariatric surgery route, thus gaining the surgeons and hospital more money. If not, these patients are deemed unfit to accomplish weight loss and not accepted into the program. This blog - http://bobsdiabetes.blogspot.com/2013/05/medicares-obesity-program-has-problems.html

#8. Even the doctors now have DSM5 for medication for every conceivable mental health issue and are to forget counseling from a positive perspective to enable their patients to take charge of a mental health problem and overcome it. Medications are now the only answer. This blog - http://diabetestopics.blogspot.com/2013/09/the-dehumanizing-of-patients.html

#9. I have no idea if this is just my corner of the world, or is more widespread, but when a patient questions a procedure, operation, or medication, we are told we more than likely have cancer and need to see the oncologist. Four doctors have thrown this in my face in the last five months even after I have been given a clean bill of health by a VA oncologist after two different days of tests and procedures. Then when I tell them this, they just say that the VA is not the most reliable. Only one doctor has thanked me for going through the tests and eliminating the concern about my elevated white cell count. No blog – yet.

#10. More doctors will need to enter the realm of contract medicine to fulfill patients' needs, as doctors are more and more becoming employees of hospitals. Because hospitals are driven by the bottom line, little will change under the ACA and patients will continue to be treated only when they have a disease, illness, or injury requiring a doctor's care or that of a specialist. Heaven help the patient with hypertension or diabetes if the hospitalist decides to “tune-up” these patients when they are hospitalized for an unrelated disease or illness. This blog - http://diabetestopics.blogspot.com/2013/09/another-reason-to-be-careful-of.html

#11. More and more doctors believe and rely on faulty studies. They become very defensive when a patient becomes a “micro-expert” and knows the difference. This is especially true for some diseases and illnesses. This blog - http://bobsdiabetes.blogspot.com/2013/06/ada-relies-on-faulty-studies-not-good.html

#12. Some patients are even excited about the prospect of being able to see a doctor less often and become able to write their own prescriptions. There would be some restrictions some patients will not be able to meet. This blog - http://diabetestopics.blogspot.com/2013/07/some-patients-may-not-need-doctors-as.html

#13. Dr. Kernisan has covered “patient engagement” in her blog - http://thehealthcareblog.com/blog/2013/09/12/patient-engagement-on-metrics-and-meaning/ I am concerned about a problem I encounter all too frequently, the doctor version of patient engagement. The doctor asks the questions using his/her technical language and the patient is often unable to answer because they do not understand the question. I lose out because I do ask what a term means in lay language and the doctor often fumbles my question and out the door goes patient engagement. One part of patient engagement remains out in the cold because most doctors will avoid allowing patients to access their medical records. Hopefully, meaningful use will be denied for these doctors. Even one of the physician clinics had signs up in every exam room about access to EHRs and to ask the receptionist for a form and password. When asked, the receptionist says that it is not available yet. My translation – to let the inspector see this to pass meaningful use.

19 September 2013

Demand Continues for Primary Care Doctors

The demand for primary care doctors is here now and will for many years to come. With the demand for these doctors increasing in many rural or less doctor dense areas, recruiters cannot fill the needs. Merritt Hawkins, a national health care consulting and recruitment firm, speaks to some of the issues, but not all. This firm along with two other staffing companies spans the lower 48 states and includes rural and major metropolitan areas.

As we become more aware of the needs for doctors in the rural areas and many underserved areas of medicine, all three recruiting firms have found that hospitals and medical groups are continuing to seek primary care physicians, nurses, and assistants. However, this is the first year that the request for geriatricians out paced the demand of previous years. This is also the first time that this specialty has entered into the firms' top 20 of the most recruited.

Travis Singleton, senior vice president at Merritt Hawkins, stated that, “It is interesting that our youngest doctors are treating our oldest patients, but I think that some of it is just reclassification, it was happening already.” Other specialties, such as radiology and anesthesiology, despite being among the most competitive and desired positions a decade ago, did not make the top-20 list for 2013.

Dr. Atul Grover, an internist and chief public policy officer at the Association of American Medical Colleges, says, “I think people are starting to look at the market and get nervous, because of Medicare payment changes that impact doctor's pay and the growing emphasis on preventive medicine.”

I think the “growing emphasis on preventive medicine” has many doctors making changes because they are afraid of preventive medicine and know little about it, after having practiced only treating people already ill or in need of treatment for a disease or chronic illness.

I have been made aware of two towns about an hour and one-half distant of recently loosing two primary care doctors because their agreement with the towns had been fulfilled. Both headed for hospitals in larger cities where they will become hospitalists and at a much higher wage and less hours.

Many doctors are taking different jobs to satisfy a work-life balance and not the hectic almost 24/7 hours and paperwork of meeting the needs of their current jobs. According to the three staffing firms, hospitalists ranked third on the top 20 list.

Even with the health care law's attempt to curb the high cost of emergency care, Merritt Hawkins reports an increased demand for emergency department (ED) doctors. With patients finding fewer primary care doctors available to meet their needs, patients will continue to turn to the ED as a last resort or for convenience.

This points out the increasing need for doctors to be trained that will serve in vulnerable communities and the need for incentives for them to continue to practice in these communities. However, the doctors that left these communities for large cities continue to lobby to prevent NPs, PAs, and Pharmacists who have remained in these communities from being able to practice unsupervised.

Therefore, it will be necessary for patients in these underserved areas to lobby their state legislatures in opposition to the state medical boards. Also these same patients in some communities to will need to lobby for restrictions on telemedicine to be lifted. The next decade will be interesting as the powers that exist now may see their popularity disappear and be replaced by the very groups they are muzzling now. And, I feel that the patients may play a large part in this.

18 September 2013

Security Now a Concern for Insurance Exchanges

Now lawmakers become concerned about the ability of the system to protect personal health records and other private information. If our congressional people would have been concerned about this when they should have been concerned, maybe we would not need these concerns now. Unfortunately, we still would, as Congress is not far sighted enough, only to the next election and their reelection. That is what all the posturing is about.

Yes, cyber security needs to be a concern, but this will never be fully addressed, as Congress does not wish to offend the NSA because they will be the largest consumer of the information. The data hub, which is scheduled to go live October 1, will process names, dates of birth, Social Security numbers, health conditions, and several other pieces of personal information which at best will be very insecure.

Representative Patrick Meehan, a Pennsylvania Republican is on target when he questioned how CMS completed its security assessment nearly a month ahead of schedule after the agency had “for three years failed to meet a single deadline.” The hub, as it is called, will store little information, instead accessing information in other databases as needed. This means that once the hub is breached; all the other sources will be accessible. Data breaches at the hub would do “irreparable harm” to users, said Stephen Parente, director of the Medical Industry Leadership Institute at University of Minnesota. There hasn’t been enough security testing on the hub, which is a “massive IT project with literally no technical precedent,” he added.

Others are doing their best to downplay the security aspect and I feel are doing more harm than good. It is not a matter of if, but when the security breaches will happen. I say breaches and they will probably come in rapid succession once they start and the U.S. Department of Health and Human Services will probably do its best to cover this up and this is where the concern needs to be.

17 September 2013

Hospitals May Lose for Hospital-Acquired Infections

Hospitals are beginning to put standards and safety measures in place to prevent hospital infections. With the Centers for Medicare and Medicaid Services (CMS) and now other insurance companies refusing to pay for hospital-acquired infections (HAIs), this has forced the issue and hospitals are taking notice. When hospitals have their bottom line at issue, they will take action, which is a good thing for patients,

Although hospitals have balked at safety standards for decades, being able to put a dollar value on associated costs could help providers and payers justify investing in prevention measures. Even with implementation of quality improvement initiatives, an estimated $9.8 billion is spent each year for treating HAIs. This was the finding of a study published online September 2 in JAMA Internal Medicine.

Quoting from the abstract, “With surgical site infections contributing the most to overall costs (33.7% of the total), followed by ventilator-associated pneumonia (31.6%), central line–associated bloodstream infections (18.9%), C difficile infections (15.4%), and catheter-associated urinary tract infections (<1 i=""> This is something that should not be ignored.

"Not paying for hospital-acquired infections or errors are an important part of the movement toward paying for quality, not quantity, of care," Mitchell H. Katz, MD, director, Los Angeles County Department of Health Services in California, concurs in an accompanying editorial. This study, however, will enable hospital administrators to better prioritize their spending by allowing them to compare the costs of interventions with the savings accrued by avoiding infections.”

Patient safety should have always been a priority, but has not been as long as hospitals were able to be reimbursed for their lack of safety procedures.

16 September 2013

Some Doctors Don't Care About Patients, Only $$$

Apparently some doctors that are members of the Society of General Internal Medicine (SGIM) really do not care about their patients with diabetes, only the money that they can receive for helping patients develop the complications. Rather sad that doctors will work so hard to cause harm to a group of patients. Don't get me wrong, as some of the doctors that are members of the SGIM do not agree with their policy listed in Choosing wisely.

I will continue to vent about those that do support "Don't recommend daily home finger glucose testing in patients with Type 2 diabetes mellitus not using insulin.” This tells me that they don't feel that the progression to complications can be stopped and they do not want to continue trying to educate these patients. Just including this on the list of choosing wisely shows they don't care about these patients.

I have had an email from one of the doctors that has peer mentors expressing his concern for how limited this will make his work. I emailed him a copy of my blog that will appear on http://bobsdiabetes.blogspot.com/ on September 17 and he agreed that he sees this as true, but admitted he did not think insulin will be the only answer. He did think that insulin will be one of the solutions. He is concerned that test strips will disappear as a tool to assist in the management of diabetes for those on oral medications. He is also concerned about his fellow doctors and why they voted for this item.

I did email him back saying that these doctors will be considered doing harm by me. His comment back was that I was on insulin and why would I be concerned. I said because they are still people with diabetes and deserve advocacy even if they don't realize the problems coming at them. He does agree with the ideas that most type 2 patients on oral medications do need more than one test strip per day and people on insulin do need more than three tests strips per day.

He commented that he will not prescribe any of the sulfonylureas for people on Medicare or Medicaid that are limited to one test strip per day. He will not be responsible for causing hypoglycemia when the patient cannot test often enough to correct the episode. He does ask patients to notify him immediately after if they have hypoglycemia and correct it. He has his peer mentors reinforce this in the education and works with these patients using email to discover why they had an episode of hypoglycemia. He needs to use a telephone for three patients because they do not have internet service.

I did ask him if it may be a case that most doctors that are members of SGIM did feel that diabetes was progressive and this may have caused them to vote this way. He admitted that most of them probably do think this, but have caused this by their attitude and not doing any education. He felt that since he started using peer mentors for education, the patients of his are doing significantly better in managing their diabetes. He had been very uncertain about using shared medical appointments (SMAs), but the fact that he has peer mentors doing education while he sees patients individually in another room is working very well and he has had only one patient that walked out of a SMA. He concluded that he will carry on the good cause and work to prevent his patients from being denied test strips.

13 September 2013

Statins May Prevent Cataracts

Apparently, the drug companies are getting nervous about how long statins are going to survive on the market. With the side effects of causing diabetes, muscle wasting, and a few other problems, they should be. Now they are studying new areas in hopes that this will encourage people to remain on statins. Therefore, I read this article with a lot of skepticism and wondering if we will see more studies confirming this study. I would also call attention to this article in Medscape declaring statins linked to musculoskeletal injury and this article in WebMD linking statins to muscle/joint problems.

Of course the authors did not call for further studies and we are not told where or if the study was published since it may not be peer-reviewed. This makes me even more a doubter of the results of the study. Professor Kostis is the only person quoted in the article and no educational institution or information is given about this professor.

Professor Kostis states, “We therefore investigated the relationship of statins and cataracts in a meta-analysis of 14 studies selected after detailed review of the medical literature. To our knowledge, this is the first meta-analysis on the topic. The meta-analysis included 2,399,200 persons and 25,618 cataracts. The average duration of treatment was 54 months and average age was 61.”

Yes, this is a lot of people and cataracts, but I am not sure it is of value. The more I analyze the report the more I have doubts about the source, Stone Heart Newsletters.  Professor Kostis is never identified or associated with an institution. Is this a study and where was it published? None of this information is included in the article

I will still blog about this, but only from the standpoint of this being another poor example of research and coverage by a fair source. I made a comment to this at the bottom of the article, but I have been ignored and received no answer. Therefore, it is my belief that Big Pharma promoted the article and maybe even the research and they do not wish to have the results confirmed or denied. Sorry, but I can't accept the information as it is presented and have to view the information as unreliable and even possibly a farce.  I also wonder if the benefits will now outweigh the risks

12 September 2013

The Dehumanizing of Patients

When the first discussion took place in June 2012 and then when the Diagnostic and Statistical Manual (DSM5) was published in December 2012, I have been reading what has been published by other writers and psychiatrists and psychologists have been saying or writing. Finally, an author that I am able to understand and more importantly agree with has written a blog about topics covered in DSM. Much of the discussion on mental health really dehumanizes patients and throws medications at patients when this may not be the best.

I would ask that you read his blog for you own understanding, as I am biased and pleased that he sees his patients as humans and how they respond to positives given to them rather than just a diagnosis and another medication to solve the problem. Medications may be necessary for some mental health issues, but the wholesale prescribing of medications will only lead to dependence on medications and not a treatment, which will help the patient manage their lives in a positive way.

Because of the way Dr. Dan Peters describes things, much of the following will be quoted. “The questions that eat at me during my day as a psychologist and at night as a person searching for answers are:

#1. Is it possible to accurately identify mental health “issues,” “illness,” or “disorders?” versus extreme ranges within the sphere of the human condition?
#2. Even if it is possible to identify these conditions, does it determine the course of “treatment” or “intervention?”
#3. If so, is there a “treatment” for every identified “condition?”
#4. Does it mean there is a treatment that works?
#5. Do you need a diagnosis to get help?

Without going into detail about some of the changes in the newest edition of the DSM, some diagnostic categories have been added and some diagnosis “thresholds” have been lowered. This means that you need fewer symptoms to “meet diagnostic criteria.” Here are some examples of concerns with the new DSM-5:

#1. Temper tantrums will now be diagnosed as Disruptive Mood Dysregulation Disorder
#2. Normal forgetting will now be diagnosed as Minor Neurocognitive Disorder
#3. Gluttony will be diagnosed as Binge Eating Disorder
#4. Grief will be diagnosed as Major Depression
#5. First time substance users and college partiers will get a diagnosis of Substance Use Disorder
#6. Everyday Worry will be diagnosed as Generalized Anxiety Disorder”

The following is important and very meaningful. “And what’s the number one treatment for all of these diagnoses? Medication. In my 20+ years of working with children, adolescent, adults, and families, I have found some simple and profound truths. First, if you talk to people about what is wrong with them and causally assign diagnostic labels to explain them, they feel badly about themselves and it plays into their low self-esteem, self-confidence, and self-worth. Next, if you help them to better understand their strengths and weaknesses, and help them to develop tools to cope with life, all of the aforementioned increases. Lastly, if you focus on their strengths, rather than their “deficits,” “disorders,” and “illness,” they become aware of neglected and unknown aspects of themselves that they can and do use to navigate life and meeting their goals.” Bold is my emphasis.

I ask that all mental health and medical providers, educators, administrators, adults, and parents think critically when making or accepting a diagnosis.
Ask yourself:

#1. What is the purpose of making or accepting a diagnosis?
#2. Does it fit my or my client’s experience?
#3. How will I explain the diagnosis to my client?
#4. What does this diagnosis mean to me (client)?
#5. Will this diagnosis help my client (help me) achieve my goals?
#6. Does the diagnosis explain a normal human emotion or condition?
#7. What are all the possible helpful interventions? Can medication wait?
#8. What is right with my client? What is right with me (client)?

Those of us in the field of mental health and medicine have a minimal obligation to do no harm. Further than that, we have an obligation to improve the life conditions of our clients. Our current mental health and insurance system makes this very hard, but nothing in life that is worth anything is easy.”

I am very thankful he included “do no harm” in the above paragraph and from the tenor of his blog, I understand him to mean just that. Many of his colleagues may not care when they find it easier to pass out pills. Don't misunderstand me, some mental health issues do require medications, but as Dr. Peters points out, medication does not solve all problems or should it be the end-all for all mental health issues.

11 September 2013

Are Laws Needed to Control Diabetes?

With the ever growing population of people developing diabetes, some are turning to legal remedies for stopping the tide and the role that law can play in serving as an effective health tool. Honestly, I had never thought legal remedies would be applied, but the more I read about this study the more I realized that some of the most useful legal remedies are not even mentioned in the press release. When the American Diabetes Association has legal tools available to use against discrimination, why should there not be other legal tools available.

I may be criticized for this, but without legal remedies to force doctors to become current in their knowledge, prevention, and diagnosis of diabetes, patients will continue to bang their heads against the wall. Doctors are the first line of defense and as long as they continue to ignore diabetes, this diabetes epidemic will continue. If stiff legal penalties are required to bring doctors into the twenty-first century, so be it.

The law can be a critical tool for health improvement as long as it does not jeopardize our freedom rights. Assessments reported in a new study published in the American Journal of Preventive Medicine indicates that federal, state, and local laws give only partial support to guidelines and evidence-based interventions relevant to diabetes prevention and control. Bold is my emphasis.

It is sad indeed that nearly 26 million people in the US have the disease and about one-fourth are not aware they have diabetes. Facing about 30 percent (about 1 in 3 people) having diabetes by 2050, it is time for action. Risk factors for type 2 diabetes include limited access to nutritious food, limited opportunity for physical activity, socio-economic conditions, and genetic disposition. While many well-crafted guidelines and recommendations for diabetes intervention exist, the incidence and prevalence of diabetes continues to escalate.

Lead author, Anthony D. Moulton, PhD, Laboratory Science, Policy and Practice Program Office, Office of Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, GA, states, "Laws, including statutes, ordinances, and government agency rules and regulations, can support interventions to prevent and control disease in various ways."

Dr. Moulton continues, "Laws can help shape environments to reduce exposure to some type 2 diabetes risk factors and encourage preventive behaviors, and laws can authorize or require provision of prevention-oriented information designed to change the behaviors and cultural norms that affect risk."

Investigators analyzed the laws further to determine whether they contained provisions that require, incentivize, or encourage healthcare providers, insurers, employers, schools, child care centers, restaurants, government agencies, and others, to take action consistent with a given guideline.
Investigators concluded that:
  • Implementation of guidelines for evidence-based interventions for diabetes prevention and control is incomplete
  • Many opportunities exist for exploring uses of law to improve adoption”

Dr. Moulton's conclusion is also worth quoting, "Laws that are demonstrated to be effective, designed to support proven public health and clinical interventions, and well implemented can give crucial support to strategies that address public health priorities and to wider adoption of evidence-based guidelines. Law is a key tool for scaling and sustaining effective interventions at the national level. Public health practitioners and policymakers nationally can intensify their exploration and evidence-based application of law to help slow and potentially reverse the accelerating threat posed by the diabetes epidemic."

Dr. Moulton does not state this, but I think until doctors educate themselves about diabetes and step up to the challenge, we will not achieve any reduction in the diabetes epidemic. Doctors that make statements, such as – “Watch what you eat, your blood sugar is a little high,” or “Curb your sugar intake,” should be penalized for not making a diagnosis or giving a complete description of what the blood glucose readings mean for the patient. ONLY then will we see a possible slowing of the number of diabetes cases. The 15 minute office visit or less, will do nothing to slow the diabetes epidemic and blaming the patient needs to end.