Vol. 133 October 1, 2015 What Year Is This? 1984??

October 1, 2015


“Have you seen the video? You must see the video?” -Carly Fiorina on CNN


I must admit that the Republican Presidential debates have been occasionally entertaining as the non-Trumps gradually reveal a little of their own personalities in trying to counter his H-U-G-E one. But sometimes the posturing for a sound bite or a differentiating headline has so grossly distorted the facts that alarm bells go off in my head. Wait, you say, isn’t that normal for a political campaign? Of course it is, but as a physician I can’t help but cringe watching rabid political attacks based on distorted, misleading, and even deliberately misstated “medical information”.

“Planned Parenthood is profiting from selling baby parts obtained from abortions”.

  1. The 1988 Fetal Tissue Transplantation Panel, appointed by President Reagan, after reviewing decades of research stated that there was no evidence that the possible use of fetal tissue for medical research had ever helped persuade a woman to have an abortion.
  2. Only a few Planned Parenthood affiliates in three Western states have arrangements to provide fetal tissue from abortions to researchers.
  3. Permission for donation of fetal tissue cannot be sought from a woman until after she has decided to end the pregnancy.
  4. By law, the fetal tissue can not be sold for profit. A sum of $30 to $100 may be reimbursed to the health care providers/facility (not to Planned Parenthood, not to the patient) to cover costs of tissue recovery.
  5. By law, there is no federal reimbursement for the abortion procedure itself.
  6. Use of the unique characteristics of fetal tissue has allowed successful research for decades in the development of life-saving , disease-preventing vaccines. “Virtually every person in the country has benefitted from research using fetal tissue.” (1)

“Use of fetal tissue is unethical.”

  1. Just today the pediatric neurosurgeon running for President answered a question in New Hampshire about Planned Parenthood with, “Tearing babies apart? Is that what you mean? The medical ethics of selling body parts and manipulating babies in order to preserve certain body parts? It’s illegal.” Besides mixing “legal’ in with “ethical’, two different concepts, Dr. Carson has also apparently forgotten that he participated in a 1992 medical research study using tissue from aborted fetuses. (2)
  2. “The research use of fetal remains is ethical.” said Reagan’s 1988 panel.
  3. The Committee on Pro-Life Activities of the National Conference of Bishops has written “it may not be wrong in principle for someone unconnected with an abortion to make use of fetal organ from an unborn child who died as a result of an abortion.” (3)

“Planned Parenthood is in the abortion business.”

  1. Three per cent (3%) of the 10.6 million services delivered annually by Planned Parenthood were related to abortion procedures in 2014. That does represent over 320,000 abortions, so I can understand why believers in “zero abortions” might be upset, but Planned Parenthood services are much broader:
    42% for sexually transmitted disease tests (including HIV tests),
    34% for contraception services,
    11% for pregnancy tests,
    and 9% for cancer screening and prevention.
  2. “The inconsistent or incorrect use of contraception accounts for nearly half of unintended pregnancies and half of those end in abortion.” (4)
  3.  78% of the people served lived at or below the 150% federal poverty level.
  4. “We strongly support Planned Parenthood not only for its efforts to channel fetal tissue into important medical research but also for its other work as one of the country’s largest providers of healthcare for women, especially poor women.” (5)

“Have you seen the video? You must see the video?” -Carly Fiorina on CNN

  1. The Video” of Planned Parenthood physicians describing how they obtained fetal tissue is a heavily and deceptively edited compilation of 30 months of taping obtained by actors who misrepresented themselves and asked leading questions.
  2. “The Other Video” and pictures of a bucket of dead baby parts being sorted out by a technician has nothing to do with Planned Parenthood and is from “stock footage” from an anti-abortion organization.

I have no association with Planned Parenthood, and I am not an advocate of abortion as “a means of contraception”.
I am dismayed when information about a major health care provider and a valuable medical research resource is so distorted in such a believable fashion for political means.

In New Hampshire Dr. Carson decried political correctness and likened it to “group-think in Nazi Germany”.  In our present state of political polarization, demand for political correctness, a discouraged middle-class, growing fear of foreigners and scapegoating of immigrants, and even a popular, narcissistic candidate with a distinctive hair style, could “It” happen here?

1.  NEJM 373:10, September 3, 2015 , p.890
2.  Boston Globe, Oct. 1, 2015, B4
3.  Biomedical Politics 1991
4.  Guttmacher Institute 2014
5.  Editors of the NEJM, Sept. 3, 2015



Vol. 128 July 1, 2015 Obamacare is Five Years Old. Can It Walk and Talk?

July 1, 2015


“From a historical perspective,
5 years is a very short time.
Many of the key insurance provisions have been
in effect only since October 2013.” (1)

Now that the Supreme Court has decided that a key provision in the Affordable Care Act of 2010, the federal subsidy of health insurance for eligible citizens, is legal, the infancy of Obamacare is over. It looks like it is here to stay. How is the toddler doing? What has it done? Luckily, The Commonwealth Fund just published a summary of ACA effects so far. (1)

The Commonwealth Fund is a private foundation formed in 1918 with Harkness family money made from the early oil business, (Shell Oil).

“The Commonwealth Fund has sought to be a catalyst for change by identifying promising practices and contributing to solutions that could help the United States achieve a high-performance health system. The Fund’s role has been to establish a base of scientific evidence on what works, mobilize talented people to transform health care organizations, and collaborate with organizations that share its concerns. The Fund’s work has always focused particularly on the challenges vulnerable populations face in receiving high-quality, safe, compassionate, coordinated, and efficiently delivered care.”

This health-care-focussed fund and think tank reports that it is too early to see many benefits of the ACA, but lists some of its immediate, observable effects.

Access to care:

  • 7.0 to 16.4 million young adults from chronically uncovered populations ( hispanics, blacks, and those with low incomes) have gained health insurance coverage since 2010 (different survey methods and timing cause the difference in results).
  • 11.7 million Americans selected a health plan through the health insurance marketplaces established by the ACA. 87% of those people were eligible for federal subsidies of premiums.
  • 10.8 million additional Americans have enrolled in Medicaid since the ACA was passed.
  • 3 million previously uninsured young Americans have gained coverage through the ACA extension of dependent coverage to age 26.
  • 8-12 million Americans have benefitted from the ACA’s regulation that prevents insurers from discriminating against people with preexisting conditions.
  • 75% of those newly insured seeking appointments with primary care or specialist physicians have secured one within 4 weeks or less.

Delivery-System Reform:
“ The law constitutes one of the most aggressive efforts in the history of the nation to address the problems of the health care delivery system through funding many divergent experiments though lacking a coherent strategy.” (1)  The Commonwealth Fund report lumped the efforts into four categories.

1. Changes in Payments:
Reduce readmissions – There are 150,000 per year fewer Medicare hospital readmissions within 30 days of discharge partly attributed to ACA financial penalties to hospitals with higher than expected readmission rates.
Reduce hospital-acquired conditions – ACA financial penalties to hospitals in the highest quarter of avoidable hospital-acquired conditions may have helped the composite rates for those to drop by 17% from 2010 to 2013.
Pay for Performance – ACA payment incentives to hospitals and physicians to improve their performance on various cost and quality measures: “too early to tell”.
Bundled payments – This departure from fee-for-service reimbursement pays the hospital, the physician, and post-hospital services with a single payment for a procedure or condition. 7000 providers have signed up for it, but it is “too early to tell”.

2. Changes in the Organization of Health Care Delivery:
Accountable Care Organizations (ACOs) – An ACO is an organization of physicians and hospitals formed to improve the integration and coordination of ambulatory, inpatient, and post-acute services for a defined population of Medicare beneficiaries. 405 ACOs are participating in a program that allows them to keep a portion of any cost savings they can generate without degrading quality. Although the pilot program of about a dozen Pioneer ACOs “saved” $385 million in the first two years, it is “too early to tell” if the others will have a postive effect.
Primary Care Transformation – A pilot program to reduce costs and improve quality in primary care has shown a $14 per month cost reduction per Medicare enrollee and less emergency room visits and hospitalizations in the 2.5 million patients participating in its first year, but it is “too early to tell”.

3. Changes in Workforce Policy:
The effects of increased primary care reimbursement for Medicaid patient services, increased National Health Service Crops scholarships for practicing in underserved areas, and establishment of a National Health Care Workforce Commission (but remains to be funded by Congress) are all “too early to tell”.

4. Increase Innovation in Health Care Delivery:
The Center for Medicare and Medicaid Innovation (CMMI) was funded at $1 billion a year for 10 years to undertake a wide variety of experiments in improving quality for patients and reducing the 43% share of national health costs now paid by the government.

  • Commonwealth Fund says: CMMI is perhaps the most promising of the ACA efforts, but “way too early to tell”.
  • The CMMI itself reports it has launched 26 “demonstration models” of cost reduction and quality improvement. The Pioneer ACOs mentioned above is the first model “to meet the statutory criteria for expansion”.(2)
  • A separate report from Weil Cornell Medical College Department of Healthcare Policy and Research states that to date the CMMI has spent only one-third of its $10 billion, that it seems to be slow in distributing data from its experiments to participating organizations, and that it is hampered, as most quality improvement efforts are, by the lack of consensus on what constitutes “ improved quality”. So it is “too early to tell” (2)

Wow, that is definitely more than you may have ever wanted to know about the ACA so far!
It is certainly more than I can remember.
It is clear that Obamacare does have a lifetime before it.
As that lifetime unfolds one can only hope that responsible adults will guide it through its future developmental stages.

Bottom line: carry a small laminated copy of this blog in your pocket or purse to pull out when engaged … embroiled, …immersed, …or even entangled in any discussion about Obamacare, which will continue, even if Hilary renames it.

Remember, Medicare was just as controversial when first passed. One governor that opposed Medicare actually mobilized his state’s National Guard the day Medicare was passed in fear of the hordes of newly insured people that he expected to overwhelm emergency room departments.

1. NEJM June 18, 2015;  The Affordable Care Act at Five Years
2. NEJM May 21, 2015;  Assessing the CMS Innovation Center

Vol. 123 April 15, 2015 What Does “Board Certified Physician” Mean? What Does It Have To Do With The 2016 Presidential Candidates?

April 15, 2015


 “Nowadays, medicine is an open-resource team approach. I get all this information in the room with a patient in seconds, and then I use my experience and my knowledge to pull together a plan”

– Dr. Jonathan Weiss, a triple-board-certified physician explaining why he is against a test every ten years to maintain board certification;
NY Times, April 14, 2015, D3

A “board-certified physician” is one who has voluntarily applied for and passed a test of medical knowledge in one of 24 general specialities or over 30 subspecialties.. A non-profit American Board of Medical Specialties (ABMS) composed of physicians was established in 1933 to administer the tests to physicians who apply for the certification after completing their residency training. Each approved specialty board issues a certificate to successful candidates (It hangs on the wall in your physician’s office). Unlike the bar exam for lawyers, physicians are expected to pass the test the first time, though a second attempt is sometimes necessary in some specialties. Most hospitals and many health insurance companies require board certification as a sign of competence as part of their credentialing. States do NOT require board certification for licensure.

One of the founding specialty boards in 1933 was the American Board of Ophthalmology (ABO), which brings us to the 2016 Presidential candidates.

Rand Paul, MD, a recently announced Republican candidate for President, took and passed his ophthalmology boards in 1995.  In 1997 he and 20 other practicing eye doctors protested the ABO’s changing of its certification from “lifetime” to “must be renewed every 10 years.” They argued that this Maintenance of Certification (MOC) test every ten years was “time-consuming for the practitioner, expensive ($1,500-$3,000), and irrelevant to patient care”. They formed a new board, the National Board of Ophthalmology (NBO), that would issue life-time certification for $500. Rand Paul was the lead organizer. He, his non-physician wife Kelley, and his non-physician father-in-law became members of its Board of Directors. NBO was never recognized by the ABMS, was dissolved by the State of Kentucky in 2000, was recreated in 2005 ( that just happened to be 10 years after Rand Paul was initially certified by ABO), and finally was dissolved again in 2011. It certified about 60 physicians in its lifetime.

Rand Paul is not the only critic of the ABMS and the Maintenance Of Certification (MOC) concept. Others have questioned the ABMS certification exams’ ability to evaluate actual clinical decision-making and clinical competence. Others have suggested that the exams’ heavy emphasis on memorized medical facts and pharmaceutical details is irrelevant, when nowadays such details are just a click or two away from the doctor in the exam room via electronic device. In 2013 a prestigious-sounding organization, the Association of American Physicians and Surgeons (AAPS) brought a “restraint of trade” suit against the ABMS for its MOC requirement.

I was impressed by that name, until I Googled it. The AAPS is an ultra-conservative organization established to fend off  “the evils of socialized medicine”. Its positions include “HIV is not the cause of AIDS”, “abortions are associated with breast cancer”, and “childhood vaccinations cause autism”. Rand Paul and his father Ron, also a physician and a past presidential candidate himself, are both members of the AAPS.

“So what” you might think at this point.
Rand Paul’s beliefs and actions indicate to me that he has an excellent ability to create, maintain, and operate within his own reality, one which ignores accepted evidence. Perhaps one could say that very same thing about any politician with whom you disagree, but I don’t disagree with every thing that Rand Paul says.  Physicians are trained to make decisions often using inadequate data. I am surprised that Rand Paul, as a trained physician, can successfully maintain a belief construct that is so at odds with established facts.  Also, he tried, and failed, to develop an alternative governing body of his profession when he disagreed with its policies. It was NOT about trying for better patient care.

These are undesirable attributes in a President of the United States. It also makes Hilary’s real estate shenanigans in Arkansas, her use of more than one email address as Secretary of State, Jeb Bush’s claim to being Hispanic, and Elizabeth Warren’s claim to being Native American look pretty penny ante by comparison.

Vol. 116 December 15, 2014 Obamacare Update

December 16, 2014


“After a year in place, the Affordable Care Act has largely succeeded
in delivering on President Obama’s main promises.”
– NY Times

“Americans would rather see it improved than repealed.”
– Boston  Globe

Today, December 15, is the deadline for new enrollees to sign up for health care insurance under Obamacare ( December 23 in Massachusetts). It seems an appropriate time to take a look at how it is going. The deadline for renewals is February 15.

The recent Jonathan Gruber “revelation” about Obamacare’s “non-transparency” alleged that “ they did not tell the public that young, healthy people must subsidize sick people to make the numbers work.” Well, hello, what about insurance don’t you understand?! Those of us whose house has not burned down are subsidizing (aka “insuring the loss of”) those whose house has burned down!

Since the ACA was passed in 2010 the number of uninsured has fallen by 25%-33% depending on the study. At least 8 million and perhaps 11 million previously uninsured are now covered. Critics of the ACA charge that number is overstated by about 700,000 who merely got dental insurance coverage. More about that later in this blog. The law “is helping the health care industry by providing new paying patients and insurance customers.” It certainly is!  Health insurance companies are looking at a “nearly $2 trillion ( yes, TRILLION) of subsidized coverage through insurance exchanges and Medicaid over the next 10 years,.” Share prices of four of the major health insurance companies – Aetna, Cigna, Humana, and United Health – have more than doubled since March 2010. (1)

ACA subsidies are helping many who could not get health care coverage previously, but deductibles and variable out-of-pocket costs can remain a burden on low- and middle-income Americans. Please note the key word “Americans” here because the law does NOT extend coverage to un-documented immigrants. Undocumented immigrants and adults in 23 states that have not extended their Medicaid coverage as subsidized by the ACA comprise the major portion of uninsured persons. Texas, Florida, and California have the highest proportions of those people.

ACA health care insurance premiums were predicted to skyrocket, but in fact they will rise an average of 5% for 2015. “One reason may be that insurers who came in high in 2014 found themselves beaten out for enrollments. 77 new insurance plans will be competing for customers in 2015.” (2)  The online application for new customers is down to 16 screens from the original 76 screens that scuttled the first website application.

A physician from Kentucky in an essay in the NEJM pointed out that the two Kentucky senators remain vehemently opposed to Obamacare despite the fact that 413,000 Kentuckians have gained health insurance coverage under the ACA law. Senate Minority Leader Mitch McConnell (R-Ky) has suggested that Kentucky could keep its health care exchange established by the ACA, Kynect, “even if the ACA is repealed”. (Does “have your cake and eat it too” come to mind here?) “It is unfathomable that they can continue to oppose the law and that geography can determine the adequacy of American’s care.” (3)

Government reports reveal that 1.4 million new enrollees have made selections of plans through December 5 through federal exchanges in 37 states. Reaching the CMS announced target of 9.1 million enrollees by 2015 appears to be imminent. The law’s “penalty” for individuals remaining underinsured started out at $95 (or 1% of income) annually in 2014 will go to $325 (or 2% of income) in 2015.

It is too early in its implementation to evaluate the ACA’s promised improvement of quality. A recent study of Massachusetts mortality rates after ACA implementation suggested that its effect has been positive, but many criticized the study’s conclusions as speculative and premature. Obamacare did create the Medicare Hospital Readmission Reduction Program aimed at reducing readmission within 30 days of hospital discharge; an expensive event supposedly associated with inadequate treatment during the first hospitalization or inadequate follow-up as an outpatient. The national readmission rate for Medicare dropped from 19% in 2007-2011 to 17.5% in 2014, “in part as a result of the ACA”.

An early sign of the success of Obamacare might be the very recent demand to expand its dental insurance benefits for children to adults via a proposed Comprehensive Dental Reform Act of 2013. (4) Look to this concept and the coverage of non-documented immigrants to become issues in the 2016 election. For those of you with a really long-term outlook, expect Hilary’s Affordable Veterinary Office Care (HAVOC) to be a hot issue in 2020.

Even during this very polarized midterm election some perceived a subtle shift on the Republican side from “Obamacare opponents” to “Obamacare critics”. They may be getting the message that a large portion of the citizenry is liking the health insurance coverage that reduces their stress and concern about the potential impact of uninsured illness on their life and pocketbook. Maybe more member of both parties will switch from Obamacare “opponents” to Obamacare “critics”, since we all agree that Obamacare, or whatever Hilary chooses to call it during her first term, can be improved.

1. Bos Globe Nov. 18, 2014; pg A8
2. Cape Cod Times Nov. 1, 2014
3. The Affordable Care Act, 1 Year Later, NEJM 371;21, pg. 1960, Nov. 20 2014
4. Integrating Oral and General Health Care, NEJM 371:24, pg. 2247, Dec. 11, 2014

Vol. 108 August 15, 2014 “Big” Marijuana?

August 15, 2014

hubWhat will be the future impact of marijuana use?

A recent article in the New England Journal of Medicine suggests very plausibly
that the history of tobacco use tells us how the marijuana industry might develop.


“The tobacco industry has provided a detailed road map for marijuana:

  • deny addiction potential,
  • downplay known adverse health effects,
  • create as large a market as possible as quickly as possible,
  • and protect the market through lobbying, campaign contributions, and other advocacy efforts.”

Marijuana (MJ) IS LESS addictive than tobacco. Presently about 9% of MJ users meet the criteria for dependence as compared to 32% for tobacco users. But, recent studies show that heavy MJ use by an adolescent can lead to structural brain changes and subsequent dependency as an adult. All researchers agree that MJ use in those under 21 years can be harmful and should not be permitted. Most agree that MJ is NO more a gateway drug than alcohol and tobacco are.

MJ’s effect on cognitive functioning IS LESS than alcohol, but it can slow reaction time. Effects of MJ are independent of blood or urine levels. There is no breathalyzer test for MJ. DUI standards for MJ do not exist. (see Buzzfeed video, “Drunk vs. Stoned”)

We now accept that smoking tobacco is a major cause of death. To our knowledge no one has ever died of marijuana. Since it is inhaled it can cause lung damage, but it doesn’t cause cancer. Sensitive to the concern about damage caused by inhaled MJ, sellers are already pushing vaporizers and edible products. A rumored joint venture between a medical MJ vendor and an e-cigarette manufacturer apparently sent stock prices soaring.

MJ is cited often for its useful effects for cancer and AIDS patients, and those benefits are real. There is very little evidence that MJ “reduces anxiety”. Such claims imply that “a little reduction of anxiety” will, of course, make your work and life easier and users will be more successful. Can’t you just envision the ad campaigns for “cool”, “mellow”, and “helpful MJ”?

Cigarettes started out as a “roll your own” process used by a small portion of the population in the 1880’s. By 1950 half of our population used tobacco, mostly cigarette smoking. As the process of making cigarettes was industrialized, 120,000 cigarettes a day were rolled and packaged by machines. Advertising and marketing soon expanded the use of cigarettes to the general population with special targets of women and the young. Cigarettes were made “more mellow” and had additives to speed absorption and “enhance taste”. Increasing the potency of MJ is already well under way and literally has free rein, since there is no standardization of MJ products. Competitive sellers boast of their product’s enhanced potency and use it as a marketing tool.

As the tobacco industry grew, so did the smoking lobbies and corporations that resisted regulation of tobacco products or distribution of the scientific studies of tobacco effects. The National Cannabis Industry Association with 450 business members and offices in Washington, D.C. and Denver already exists.  The strength and power of the tobacco lobby prevented us for 50 years from accepting cigarette smoking as a public health problem. Unlike cigarettes, MJ also has the internet that provides direct, and directed, advertising to the public; a fantastically effective and profitable way to sell a product as proven by our pharmaceutical companies.

Anyone that does not believe that MJ will become a major business need only look at the competitive scramble for permits in states newly allowing medical marijuana dispensing ; a fierce competition despite ambiguity of Federal vs. state law compatibility, as well as hefty application and annual permit fees.

“The free-market approach to tobacco clearly failed to protect the public’s welfare and the common good: in spite of recent federal regulation, tobacco use remains the leading cause of death in the U.S.” The author calls for “collaboration among the FDA, NIH, SAMHSA (Substance Abuse and Mental Health Services Administration) , the National Highway Traffic Safety Administration, and other agencies” to “understand the harms and forecast the effects of industrialization” of MJ. In light of the ineffectiveness of multiple governmental agencies in “collaborating” to ensure proper, transparent food labeling and enhance the public health, one can’t be too optimistic about government’s effectiveness in influencing the manufacture, selling, and use of MJ in the future.

1. NEJM 371:5 July 31, 2014 “Big Marijuana – Lessons From Big Tobacco”, Richter and Levy
2. Institute of Medicine, Marijuana and Health, 1982
3. Institute of Medicine, Marijuana and Medicine – Assessing the Science 1997

Vol. 106 July 1, 2014 Whas’up with Obamacare?

July 1, 2014


My nomination to the
“Understatement Hall of Fame”

“I think that probably no one fully anticipated when you have a law
that phases in over time how much confusion that creates for a lot of people.”

– Health and Human Services Secretary Kathleen Sebelius, April 8, 2013

The news media (and a lot of republicans) have not been ranting or raving about Obamacare lately. They seem to be preoccupied with Immigration laws, Tea Party challengers in Congressional primaries, and Hilary’s uptick in her campaign (aka “book tour”). I thought it might be helpful to look at “where Obamacare is at”.

82 out of 87 provisions are in effect
Of the 87 provisions in the Affordable Care Act signed March 3, 2010 (over 4 years ago!) 82 are in effect in today. Granted there have been some postponements in deadlines for enforcement and some delays in implementation of certain sections, but overall Obamacare is apparently plugging along very well. Only 3 additional provisions are slated to go into effect for 2015 to 2018. Kaiser Foundation has an interactive website to track each provision and its implementation status if you really want to know all the details.

27 states have decided to expand their Medicaid coverage
The ACA offers federal reimbursement for 100% of the initial years cost to states expanding coverage by raising the income level of eligibility for Medicaid. The federal subsidy to the states who expand coverage will gradually decrease each year, but the maximum cost to the state will be 10% by 2020.Medicaid ACA status by state
Three more states are openly discussing the move and 29 are not moving at all.

Enrollment targets continue to be met.
As of April 2014  13.5 million individuals have been determined to be eligible to enroll (“buy health insurance”) in a “marketplace plan” (either state-created or federally run) 8.5 million individuals or two-thirds of these could be eligible for financial assistance in the form of an advanced tax credit for their health insurance purchase. 8.1 million individuals of the 13.5 million total eligible have actually selected a plan. However, no premiums have actually been billed or paid just yet.

ACOs are blossoming nationwide, particularly in the northeast corridor.
Creation of Accountable Care Organizations (ACOs) which incentivize health care providers (physicians, hospitals, and other members of the health care team) to band together to provide patient care more efficiently (“less costly”) and with improved quality. It is a lynch pin of Obamacare. According to the Levitt Partners (yes, creation of the ACOs legal entities has become another guarantor of lawyers’ retirement funds), a total 626 ACOs covering 20 million patients, or 17% of the U.S. population, now exist. Most of these individuals have purchased commercial health insurance policies (another reminder of the boon of ACA to health insurance companies)  AND most patients don’t even know that they are now in an ACO. About 2/3 of the U.S. population lives in localities with ACOs mostly concentrated in the Northeast, 40% of the general population have access to at least two ACOs, and 10% of Medicare patients are patients of an ACO.

MSSP participating ACOs
As of May 2014 about one-half of the ACOs (338) are participating in the Medicare Shared Savings Program (MSSP) covering 5 million patients in 47 states, DC, and PR. In the MSSP the ACO that “saves money” by reducing costs without compromising defined quality standards gets to keep some of that money for its providers. This is usually called “risk sharing”, and though dismissed initially as “managed care in different clothes”  reluctant providers have clearly jumped on the bandwagon. In May of 2012 the first report  period identified 27 MSSP ACOs. There are different levels of risk to ACO providers so “when you see one ACO you have seen just one ACO”. About 50% of ACOs include hospitals as members. Preliminary data about ACO performance is currently mixed, and credible  data about which models will work the best is still unavailable.

What about the cost of ACA?
Of course, increased access of individuals to effective health insurance is going to cost money. In April of this year the non-partisan Congressional Budget Office (CBO) working with the Joint Committee on Taxation REDUCED their estimate of the cost of ACA in 2014 by $5 billion (from the $36 billion originally estimated). The estimated cost over 2015-2024 wa REDUCED by $104 billion (of $1,400 billion total originally estimated).CBO est. cost of Obamacare


Billions of Dollars, by Fiscal Year graph

 Wrap Up Of  Whas’up with Obamacare
“First, all major parts of the ACA except the individual mandate are popular — including the insurance-market reforms, the subsidies to make insurance affordable, closure of the drug-benefit “doughnut hole,” and the incentives for most employers to provide affordable insurance as a fringe benefit. Second, lawmakers who support repeal will not want to snatch insurance coverage from an estimated 37 million people who will be insured thanks to the ACA in 2017. Third, repeal would cut into the sales and profits of health care providers and suppliers of all stripes.”  (1)

The Supreme Court ruled that the individual mandate penalizing people (via their annual tax return) who don’t purchase some form of health insurance was constitutional because the court considered it  “a tax, not a fine”. Justice Robert’s unexpected vote in favor of the ruling prompted Jay Leno to quip,”The Obamacare ruling makes Roberts the first Republican to favor an insurance law with an individual mandate since, well, Mitt Romney.”

1. “Here to Stay- Beyond the Rough Launch of the ACA”,  HJ Aaron, NEJM, June 12, 2014




Vol. 112 May 1, 2014 Sugar is Bad! Oh no, Not Again.

May 1, 2014


I say “oh, no, not again” because 30 years ago I spent some time in my practice and in the community
defending “bad” sugar against accusations that it caused hyperactivity and attention deficit syndrome.
Research, then and now, has shown that in only about 25% of hyperactive children
eliminating, not the sugar,but the dyes and other additives in sugary foods can reduce their hyperactivity.


The film “FED UP” which I just saw in advance of its general release on May 9 makes a compelling argument that the amount of “unaccompanied” sugar (the American Heart Association calls it “added” sugar) that we eat is causing our obesity epidemic. It is narrated by Katie Couric and produced by the producer of “An Inconvenient Truth”.

The film simplifies complex nutritional and biochemistry processes with an easily understood cartoon diagram showing sugar ingested without accompanying fiber or protein being absorbed quickly, traveling directly to the liver where it ignites a burst of insulin that converts the sugar directly into fat. If fiber or protein is ingested along with the sugar this absorption is slowed, less insulin is released, and less fat tissue results. Hence the campaign against super-size sodas in New York City and efforts to ban soda vending machines from our schools. The film points out how detractors try to reframe the soda discussions into terms of “individual liberty vs. an over-reaching government”, rather than that of a serious health issue.

“FED UP” explicitly demands that we demonize sugar the way we have demonized tobacco. “Both are extreme health hazards”.

The average daily consumption of sugar in the U.S. is 84 grams. The American Heart Association recommends 36 grams a day of added sugar. “Processed food” with its high sugar content gets the black mark here as compared to “real food”, which if it has sugar, also has fiber which delays its immediate conversion into fat. The film’s examples of the success, power, and money of the “sugar lobby” and big food corporations are particularly provocative. The film removes all blame from the fat individual and places it squarely on the persistently clever, seductive advertising (particularly to young children) of food processors and distributors. The film’s revelations of the ability of the food and sugar lobbies to resist truthful, transparent labeling and to continue to outmaneuver an amorphous front of three different federal regulatory agencies is compelling .

Fun facts presented by “FED UP” include:

  • When President Reagan cut the school lunch federal subsidy in the 80’s many schools outsourced lunch preparation to fast food suppliers and closed their school kitchen to lower costs. Today 80% of schools in U.S. have their school lunches provided this way (pizza, french fries, cheeseburgers, and sodas – Pizza Hut, MacDonald’s, etc.) Do you know where your schools get their lunches?
  • Promoting student choice of healthy alternatives is an easy, obvious answer to outsourced vendor lunches, but in a school where a healthy alternative is offered a cafeteria worker reports that “only about 25 out of 350 students actually choose it”.
  • Multiple sugar products are often hidden on ingredient labels by use of unfamiliar names.
  • All the fat taken out of milk and other dairy products during the 1980’s rush toward “fat-free” food has been successfully re-marketed as increased cheese products. Many food manufacturers added even more sugar to restore the taste of “reduced fat” foods.
  • Sugar is the ONLY ingredient on the ingredients list that is NOT accompanied with a “percentage of daily requirement” number. This “% number” has been kept off the labels by the sugar lobby. If it were added, we could quickly see that we often exceed our “daily requirement of sugar” about half way through lunch. The film depicts a bowl of corn flakes as actually a bowl of sugar.

A couple of reservations about the film:
1. The film touches only briefly on the genetic contribution to obesity. It explains the two, clearly thin brothers running around in the background of one of the featured fat families, as TOFI (Thin Outside Fat Inside), a recent concept which depends on specialized total body MRI imaging to identify.

2. Its explanation of why the rest of the world is also getting fat is “that we are so good at exporting our ads and processed food to the rest of the world”. I think that is too weak to explain the rise of obesity in countries like Spain, Switzerland, and Korea.

Internatl obesity rates
“FED UP” closes with some specific recommendations and challenges:

  • Reduce sugar intake by 50% by cooking “real” food.
  • Any food with more than 12 listed ingredients is a processed food not a “real” food.
  • Eat fresh, buy local
  • GO SUGAR FREE FOR 10 DAYS. A difficult thing to do because of all the hidden sugar in soups, sauces, catsup, yogurt, and canned foods. A family in the film did do it for 10 days, liked it, extended it, and lost dozens of pounds.
  • Ask your legislators to pass laws requiring the inclusion of “% of daily requirement” for sugar on all labels, just like all the other listed ingredients.

Dare I close with the tag line that this thoughtful, polemic film provides us (U.S.) with “much food for thought”?
.                                     Look for “FED UP” after May 9.

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