Vol. 233 May 15, 2020 Medical Economics: “Smoke and Mirrors”

May 16, 2020

Charges by and payments to your medical care providers are really “smoke and mirrors.”

 

Plan to read the Explanation of Benefits (EOB) you get from your health insurance company or Medicare or Medicaid after your next visit to a provider in an office, clinic, or hospital.  It will have three lists of dollar amounts, Charged, Approved, and Paid. Here is an example of a Medicare EOB a patient got after their major orthopedic surgery:

The surgeon charged $7,724. . . Medicare Approved $1,656.11 and Paid $1,320.21.
The surgery is called by the surgeon, his staff, and the hospital by one name, “Fusion of a joint”. The  surgeon’s charge to Medicare lists 4 procedures, each with its own procedure code, all of which are actual steps in the operation. The charges range from $1,000 to $3,400 each, adding up to the total of $7,724. Medicare lists 4 separate “approved” and “paid” amounts for each of the 4 listed procedures, adding up to the $1,320.21 paid.

The balance between “Approved” and “Paid” is $331.22 and may be billed by the provider directly to the patient in some states (called “balance billing”) , but not in Massachusetts by state law.  Medicare “approved” amounts vary greatly among states based on complex formulas including rural/urban location, average labor costs, transportation costs, past history of Medicare payments, and many other regional factors.

The Certified Registered Nurse Anesthetist (CRNA) charged $1,040. . . Medicare Approved $227.50 and Paid $178.36.
The specially-trained and certified CRNA puts the patient to sleep, monitors the patient during the surgery, and brings the patient up out of the induced coma after the surgery is completed. The CRNA sits besides the patient in the operating room at all times (in this case for four hours). This is the current excellent standard of care.

The Anesthesiologist (MD) charged $2,160. . .Medicare Approved $227.50 and Paid $23.52 (not a typo)
The anesthesiologist MD’s role is to supervise the CRNA, may supervise up to 2 or 3 CRNAs at the same time, is not in any one operating room, but is available to help out should any problems arise. The anesthesiologist may in fact be providing complete anesthesia to another patient assigned to him in another operating room.

The Physician Assistant (PA) charged $676 . . .Medicare Approved $137.69 and Paid $107.95
The PA, in this case an employee of the surgeon’s but could have been a hospital employee, acts as an assistant during the operation. The PA is also certified by the state after post-graduate training and clinical experience that is different than that of a registered nurse.

The Hospital charge for the surgery and a 3 day was not listed . . .Medicare Approved “yes” and Paid $14,172.71
“Maximum Patient May Be Billed” in a State that allows” balance billing” is $1,408. (with 5 footnotes).

Each “Paid” amount is accompanied with four or five different footnotes in the EOB referring to “special payment methods”, “Federal, State, and local rules on deductibles and coinsurance”, “quality reporting adjustments”, and finally “refer all questions about benefits to the private insurer which administers Medicare in your area [BC/BS in Massachusetts]”.

Now think about the last article you read about medical care costs that you thought you understood. What were those figures based on?  Was it provider charges or Medicare “approved allowances” or “actual payments”? In truth none of these “charges” or “payments” are based on actual costs i.e. time duration ( this operation estimated by the surgeon and planned for by the hospital to take 2 – 2 1/2 hours lasted 4 hours), staff support (nurses, techs, cleaning, etc.), supplies, X-rays, etc. Hospitals and governments have spent millions of dollars trying to calculate and track actual costs on which to base reasonable and reliable reimbursements (insurance payments) with variable and controversial results.

Private health insurance “approved” charges are actually set by periodically negotiated contracts between providers and the insurance companies. Hence the rise of Physician Organizations and the merger of hospitals into Health Care Systems to maximize their negotiating power  . . . and hence the increase of billing staff and increasing reliance on computers by providers to keep track of all the codes and the various reimbursement schedules.

As your eyes glaze over by these figures, you may be thinking, “Well OK, but this is for an inpatient procedure, and we have known for a long time that hospital reimbursement is a very complex situation. What about office visits and other outpatient services”?

Established patient pre-op visit by Internist charged $250 . . .Medicare approved $115.11 and Paid $91.24.
Routine EKG taken by Internist charged $144.52 . . .Medicare Approved $144.52 (not a typo) and Paid $53.37.
This visit was for pre-op clearance. A medication was prescribed and a follow-up visit scheduled.

Routine pre-op blood tests ordered by surgeon, lab charged $58.69 . . .Medicare Approved $58.69 and Paid $0.00 (not a typo).
Cardiologist interpretation of EKG charged $21.17. . . Medicare approved $8.94 and Paid $7.02.
Internist follow-up visit 1 week later charged $200 . . . Medicare approved $78.71 and Paid $62.39.
This visit cleared the patient for surgery.
Pre-op office visit with surgeon charged $362 . . . Medicare Approved$115.11 and Paid $91.91.

You get the picture, so I won’t list the seven separate charges for a post-surgery office visit with the PA including “application of cast”, “cast supplies”, and “X-rays of the joint” (10 separately coded X-ray views) each of which had its own reimbursement code totaling $886.00 charged, $276.89 Approved, and $218.66 Paid.  Post-surgery Physical Therapy visits, each lisitng 2 separate reimbursement codes, were charged at $193 and paid at $68.38 per visit.

With all these separate reimbursement codes for “unbundling” of procedures and visits, no wonder computers have been bought by both sides (providers and insurance companies/Federal government) to implement EMR (electronic medical records) to keep track of it all to maximize (or minimize and track) reimbursements.

So, next time someone asks this patient, “How much did fixing your joint cost?“, they could say:
“My pre-op services charged $1036.38 and were paid $305.93.
The surgeon and his assistant charged $8,400 and got paid $1,428.06.
The anesthesia charge was $3,200 and was paid $210.88.
I have no idea what the hospital charged, but it was paid $14,172.71.
So, Medicare was charged $26,809.04, Medicare paid $16,117.58 , and it didn’t cost me anything.”

Of course, that is not true either since you have paid for Medicare benefits through payroll and Social Security deductions for decades.
The rest is all smoke and mirrors.

Now imagine that you are a graduate student at the Harvard School of Public Health and your thesis assignment is to design a rational, understandable, and politically acceptable plan for provider reimbursement (payments) for medical services. Ready, get set, GO!

 

 


Vol. 232 May 1, 2020 SARS-CoV-2 is not only NOVEL; It Is WEIRD

May 1, 2020

A few not-so fun facts about the strange behavior of COVID-19 (the disease) caused by SARS-CoV-2 (the virus).

COVID-19 is proving to be so unpredictable with so many variations that it really is weird. Most other coronaviruses merely cause a mild cold. This one can be lethal.

It’s deadliness is presumed to be from a “cytokine storm”, an explosive immune response to the virus within the infected person. This “hyper immune response” causes massive vascular damage in the lungs (and now kidneys and brain and toes.), BUT the people most vulnerable to the virus are those with suppression of their immune system (the elderly, people on chemotherapy, people taking high doses of steroids). You would expect that if your immune system was suppressed you would be less likely to have a “cytokine storm”.

SARS-CoV-2 causes major damage to essential organs, but it can also cause isolated loss of smell and taste, gastro-intestinal upset, headache, aches and pains, and, most mysteriously, just purple bruises on the toes of young adult males.

It is more likely to  kill the elderly and those with chronic diseases like diabetes, high blood pressure, and autoimmune diseases, but it can kill healthy 21 year olds with no other disease. There is some evidence that the amount or “dose” of the virus one receives is the cause of this variability. Young, healthy health care workers caring for Covid-19 patients in ICUs have higher rates of serious illness presumably due to the large amount of virus shed by their patients to which the workers are exposed.

It is highly contagious because one infected person can infect 2 or 3 other people before they have any symptoms. The SARS and MERS epidemics, the two previous lethal coronaviruses we experienced, were not so contagious. Both were spread by people who already knew they were sick, so it was possible to identify infected people, isolate them, and take containment steps. Also SARS and MERS  killed their hosts (patients) so quickly that the spread of the infection to others was much less. In truth, why SARS and MERS disappeared before becoming a wider spread epidemic is not really known. (Maybe that’s where Trump got the idea of “a miracle” saving all of us from economic ruin.)

The higher death rate of infection in blacks and Hispanics has been explained by 1) assumed ethnic/racial differences, 2) the close living of tightly packed urban areas, and now 3) the greater exposure to air pollution from increased tiny particles (PM 2.5 – 2.5 millimeters in size) more prevalent in city air. Maybe all three?

Men are much more likely to die from the virus than women. Studies are now under way  to test whether female hormone administration might protect infected males. We know that women are hardier than men in many diseases, and that it may be genetic rather than hormonal, but who knows?

Originally it was thought to skip children, but recent data from China shows that it can infect and cause serious illness in children, including infants. The virus apparently does not cause infant infection in utereo,  but it is unclear whether infant infection occurs during the birth process or later by contact with the infected mother.

Rational, specific recommendations to meet a pandemic in the U.S. were developed in detail by a 2005 Pandemic Task Force  started by President George Bush after he read an account of the 1918 influenza epidemic while on vacation. It was disbanded by Trump in a cost cutting move, and its report was ignored.

Pharmaceutical companies don’t like to invest in developing vaccines. It is very expensive, and they make little or no profit. Vaccines are administered once or maybe twice in a lifetime. Big Pharma makes more money out of treating chronic diseases like diabetes, heart disease, and cancer because those patients are on medications for a long time (like the rest of their lives). Even the development of antibiotics is low profit because patients only take them for 7-10 days, and they’re cured. 

We know that three medications in combination suppresses HIV (the “AIDS cocktail”) . That treatment changed AIDS from an acute, lethal disease to a chronic, livable condition. Likewise, it may take several different medications in combination to suppress this virus.

Very rich capitalists (Bill and Melinda Gates) in the absence of  governmental funding have given millions of dollars to support vaccine and medication development for the use of the world-wide population. (“Taking money from the rich to benefit the poor” sounds like Socialism doesn’t it?) Bill Gates sounded a pandemic warning as long ago as 2015, and as recently as this week.(1)

SARS-CoV-2 infection may or may not provide protection from reinfection. Most viruses, like measles, can infect you only once because the infection causes you to produce protective antibodies that persist for years. Unfortunately other coronaviruses studied have shown that their antibodies persist only for a few months, certainly not for over a year. This obviously has implications for administration frequency of any soon-to-be-developed vaccine. 

We don’t know if SARS-CoV-2 will mutate like the flu virus does. If it does, then vaccination frequency will be like that for the flu: every year to protect against our the best guess of the strain that will appear that year.

Scientists are suspicious that this virus may become “seasonal” like influenza, despite it’s appearance world-wide in very different climates. It flourished in our winter and Australia’s summer, in our cold, wet  Northeast and in sunny, dry California.

With the current state of knowledge about this virus it seems to me that we all are enrolled in a giant clinical study while  awaiting the development of a vaccine and effective treatment. We are even dividing ourselves into “experimental groups” like Oklahoma, Iowa, and Florida that are lifting social restrictions and “control groups” like New York and Massachusetts that are not. Unlike the usual clinical study no one asked for our consent. It is just happening.

Clinical studies are very expensive for a variety of good reasons.  It is very clear that this one, though unintentional, is costing all of us a great deal. Let’s hope that some results come soon.

References:
1. New England Journal of Medicine 382;18 April 30, 2020


Vol. 231 April 15, 2020 After The Pandemic – Back To The Future??

April 15, 2020

 

“The transmission of SARS-CoV-2 could resemble
that of pandemic influenza by circulating seasonally
after causing an initial global wave of infection.”

 

 

A recent mathematical simulation study from the Harvard Chan School of Public Health suggests that our current pandemic could follow the path of the 1918 flu pandemic, i.e. recurrent surges of infections after quarantine measures are relaxed.

FACT: SARS-CoV-2 was, and is, NOT containable. Each infected person transmits the virus to 3 other people on average. Most people infected with this virus will have mild cold-like or flu-like symptoms. In fact, two other known coronaviruses are the second most frequent cause of colds. Unfortunately this coronavirus of SARS-CoV-2 can cause severe illness and even death in some per cent of the infected.

FACT: “Flattening the curve” through social distancing and isolation does not decrease the number of infected people. It’s sole purpose is to change the timeline of illness to reduce the peak demand for services for the severely ill (estimated 3% hospitalized). It is hoped that spreading that demand over time for ICU services (estimated about 1%) will reduce the number of deaths due to “lack of available resources”.

FACT: There are really only two ways to stop an pandemic, a vaccine or herd immunity. Immunity develops when individuals get infected, respond by making antibodies, get better, and end up protected from getting the illness again. Herd immunity exists when so many people have developed antibody protection that the few people who don’t have such immunity are surrounded by others who cannot have the disease again, and so can not transmit it to them. (There is a third way an epidemic stops, of course, where most people die before they can pass it on, like Ebola, but this virus is not like that.)

You have heard about herd immunity for children unvaccinated against measles (another very highly contagious virus) when they are surrounded by children who have been vaccinated against measles. Herd immunity works by lowering the risk of anyone being exposed to a person with the infection. I can remember the “last of the chicken pox parties”, another method to expedite herd immunity in a timely fashion, in my old neighborhood in the 80’s.(The chicken pox vaccine became available in 1984). An epidemiological term for herd immunity may be more intuitive, though it sounds a whole lot colder; “depletion of susceptible individuals.” The estimated herd immunity threshold for measles is 95% of the population vaccinated. The ideal is often stated as 98% vaccinated against measles.

SPECULATION: A team of scientists from Harvard using mathematical model simulations have diagramed how herd immunity might develop for SARS-CoV-2 depending on different durations of social distancing while we wait the 12-18 months necessary for vaccine development and testing. Their study of other coronaviruses (the common cold ones) indicates that a herd immunity threshold of 60% would reverse the epidemic,  BUT that different durations of social distancing could result in a HIGHER number of total cases.

I, as a pediatrician, don’t do math very well, so I’ll let the conclusions of their mathematical model simulations speak for themselves. These estimates assume rigorous social distancing and that about 80% of us will eventually be infected. 

No social distancing – 60% herd immunity reached in October, no peak delay, no “flattening of the curve”.

4 weeks of social distancing (to mid May) – peak is delayed, 60% herd immunity threshold is reached in October, total number of cases are 10% higher than “no social distancing”.

8 weeks of social distancing (to mid June) – peak is delayed, 60% herd immunity is reached in November with 15% higher number of total cases than “no social distancing”.

12 weeks of social isolation (to mid July) – markedly reduced new cases during the summer, 60% herd immunity in January,  and 20% higher number of total cases than “no social distancing”.

20 weeks of social isolation (to late August) – markedly reduced new cases through November, 60% herd immunity in February, and 20% higher number total of cases than “no social distancing.” (1)

The mathematical model predictions represent infections only, not amount of severe illness or death rates.

I know just enough mathematics to appreciate that there are lots of assumptions incorporated into mathematical modeling, just like CFO reports to Boards of Trustees, you know , as in “smoke and mirrors”, but these predictions are sobering.  The researchers suggest that periodic, intermittent relaxation of social distancing might give the best results in the long run, i.e. allow and deal with recurrent surges of infections from relaxation of restrictions until most of the population becomes immune.

“Intermittent social distancing might maintain critical care demand within current thresholds, but widespread surveillance will be required to time the distancing measures correctly and avoid overshooting critical care capacity.”

Thankfully for us mathematically impaired the study stated some conclusions in English :

SARS-CoV-2 can proliferate at any time of year.

The duration of immunity to SARS-CoV-2 is not known. If immunity to SARS-CoV-2 is not permanent, it will likely enter into regular circulation.

High seasonal variation in transmission leads to smaller peak incidence during the initial pandemic wave but larger recurrent wintertime outbreaks.

New therapeutics, vaccines, or other interventions such as aggressive contact tracing and quarantine – impractical now in many places but more practical once case numbers have been reduced and testing scaled up – could alleviate the need for stringent social distancing to maintain control of the epidemic.

Then they blur that bit of hopeful glance into the future with, of course, “virus mutation might give us a new SARS-COV every winter season just like the flu . . . until 2024”!

Enough of these not-so-fun medical facts. Let’s finish with some good news.
The recovery rates from this virus as of today are 78% in the  U.S.
For even more good news (on a variety of subjects) tune into SGN – SOME GOOD NEWS , a brand new weekly YouTube news program by John Krasinski.

References:
1. Boston Globe, April 12, 2020, Ideas Section K; includes excellent graphs of the different social distancing duration scenarios.


Vol. 230 April 1, 2020 Biden Picks His Running Mate

March 31, 2020

Press Conference

Former Vice President

Joe Biden

(Official Transcript   April 1, 2020)

BIDEN: Good morning everyone. I am glad to see all 8 reporters are sitting 6 feet from each other. I know it is burdensome, but we must work together to defeat this awful Zika. . . Rebola. . . flu . . . er, what?,  . . . I mean, you know, the Coroner virus.

Speaking of the current virus crisis . . . boy that has a nice ring to it, doesn’t it? . . . it almost rhymes . . .I would like to announce my pick of a running mate; Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Disease of NIH since 1984. . . almost twenty or . . .  er. . . many years ago.

Now before I start to answer your questions, let me give you some reasons for my choice.

Number 1: Dr. Fauci is smarter than I am, but I am taller and younger than he is.

Number 2: He is very experienced. He has worked with many Presidential administrations since he came to Washington . . . in the 1980’s as I remember. He told Ronald Reagan about the AIDS epidemic, advised two Bushs . . .  one of them gave him the Presidential Medal of Freedom . . . by the way, Ben Carson got his medal during that same ceremony, . . . where was I? Oh, yeh . .  .two Clintons . . .  yes two, remember Hilary’s Health Care Plan?. . . and, of course, an Obama or two. 

Number 3: He gives very good TV interviews, even on Fox News with Sean Hannity trying to mislead the viewers.

Number 4: His medical training has given him that special skill that all physicians must have to succeed  — “Always sound right,  and if you don’t know an answer, make one up.”  But he is more like my famous namesakes on Dragnet . . .  Sgt. Joe Friday . . .”Just the facts, Ma’am.”

Now I’ll take your questions.

[Sounds of shouting, general loud babbling, a baby crying, a chair falls over]

REPORTER:  “ Mr. Biden have you moved away from your promise to pick a female running mate?”

BIDEN: Did I say that?  When was that? . . . Oh, it was during one of those debates? . . . I wouldn’t call it a debate, and I wouldn’t call it a promise. It was a statement from which I am now socially distancing myself, and its a very timely question.  .  . .This social distancing is for the pits. I haven’t smelled somebody’s hair in weeks. . . for the record, my test was negative . . . and I will ensure that women’s voices will be heard in my administration by appointing several to my cabinet. Elizabeth Warren naturally will be Secretary of the Treasury. Kamala Harris as an experienced prosecutor would be an excellent head of the Department of Justice . . . I think she is Latino too, isn’t she?. . . I am not sure about Senator Amy Kolbuchucker from Minnesota, but she has great hair. Marianne Williamson, . . . remember her, the physic healer. . . could serve as Chief of Alternate Universes  . . .excuse me, Alternate Therapies within HHS.  Adding Senator Gillibrand to the cabinet would weigh the group too heavily towards New York, since Dr. Fauci is from Brooklyn.  I will, of course,  appoint Tulsi Gabbard as Ambassador to America Samoa.

REPORTER: “Do you have any concerns about any regrettable incidents in Dr. Fauci’s past?”

BIDEN: Not really. My staff has vetted him very thoroughly. The only whiff of scandal we found was his medical school yearbook picture where he was being lifted by two of his taller classmates so as to appear even taller than they. None of them were in black face.

 Also some people may have difficulty knowing how to pronounce his name correctly. It is pronounced as “Fow-chi” with the soft  “chi” sound common to many Italian names, . . .  and as the Senator from Nevada I wish to say that I have many Italian-American friends who are hard-working, decent citizens, but I must excuse myself from this Corleone hearing for another important committee meeting . . . oh, sorry . . . was I channeling the Godfather again?. . .  a great movie.

There is another small concern, since he is from New York City and his name ends in a vowel people may think he is associated with Rudy Giuliani. . . . but  we know that he is taller than Mike.

We have completely debunked the New Yorker Magazine stories that Dr. Fauci has recommended internal alcohol to kill the coronavirus since external alcohol really doesn’t work. In fact, he only recommended it as an antidote to the daily briefings of the White House Coronavirus Task Force. Dr. Fauci also noted that internal alcohol effects may be briefer than the briefings, so viewers may repeat a dose “PRN” (as necessary). 

REPORTER: “ Is it true that as noted in your background Press Release you just handed out that Dr. Fauci was born on Christmas Eve, and are you concerned about any back lash from Trump supporters who regard Trump as the “Second Coming.”

BIDEN: Dr. Fauci is an American. Even though he was born in Brooklyn, as I remember, there is no question about his eligibility for this office. I think that a resurgence of the Birther Movement which was so viscously directed at my close friend and mentor, Barrack Obama, . . .  there I finally got his name out there. . .  would be very unfortunate. Next question.

REPORTER: “Has Dr. Fauci made any significant contributions in fields other than virology and infectious diseases.”

BIDEN: Well let me tell you a down-to-earth, fascinating story of one of Dr. Fauci’s most recent contributions. It will be a short story, I promise. Since the Coroner virus pandemic has taken over all the headlines, editorial pages, social media memes, political cartoons, TV shows, graphic artist shops, and a lot of other things which has displaced our awareness of the Opioid Death epidemic, Dr. Fauci has developed a new attention-getting graphic to replace the familiar 1-10 faces of pain;  the 1-4 faces of Pandemic Panic levels.

REPORTER: “But face 4 is the same as face 2. Isn’t that a confusing message.”

BIDEN: Exactly

“Thank you Mr. Biden, and Happy April Fools Day.

 


Vol. 229 March 15, 2020 Beware the Ides of March

March 14, 2020

In Shakespeare’s play Julius Caesar, a soothsayer attracts Caesar’s attention and tells him:
            “Beware the ides of March.”
Caesar demands:

            “What man is that? Set him before me, let me see his face.”
When the soothsayer repeats his warning, Caesar dismisses him, saying:

            “He is a dreamer; let us leave him. Pass.”

When I started writing this blog a couple of days ago I was going to call it “A Politically Incorrect View of the Coronavirus” because I wanted to say that the virus will not be contained, that it will very shortly be community-wide,  and that we should marshall our efforts at monitoring, protecting, and treating the high risk people. But today, that is no longer “politically incorrect.” Many of our civic leaders and our leading medical scientists (Anthony Fauci, MD is my most famous medical school classmate, Class of ’66 Cornell Medical College) are now labeling COVID-19 as “community spread” , i.e. not containable through contact tracing since the sources are so numerous that we can not pinpoint a source, like the common cold and the flu.  We are now “mitigating” COVID-19, not “containing” it; just trying to “blunt the peak” on the graph of numbers of infected people.

The stakes are higher for COVID-19 (the name of the disease) then for the seasonal flu because it is more deadly to certain segments of our population. The name of the actual virus that causes COVID-19 is SARS-cov-2, and that is a real clue as to the nature of this virus given our experience with previous coronaviruses.

The good news is that the death rate is not expected to be as high as the past two coronavirus epidemics SARS (10% death rate) and MERS (35% death rate). SARS originated in Southeast Asia bats and civets (small, cat-like mammals) . MERS originated in Middle Eastern camels. SARS-cov 2 has been attributed at various times to be transmitted from bats, snakes, and now, pangolins (anteater-like reptiles with scales); all animals available in Southeast Asian “wet markets” of live animals. There is no evidence that implicates domestic dogs and cats as vectors for the virus. There is also no confirmed evidence that a mother can transmit it to her newborn during delivery.

As the number of identified cases increases (the denominator) we were hoping that the calculated death rate would decrease since the actual calculation =  #of deaths/#of cases. It appears now that the death rate could be between 1.6% (University of Bern, Switzerland estimate based on China’s CDC data) to 3.4% (WHO’s estimate from selected outbreaks), clearly at least 10 times the death rate for seasonal flu (0.1%). However, South Korea has the largest number of tested cases with cold symptoms (140,000) and their death rate is 0.6%. Of even more interest, of those 140,000 South Koreans with cold symptoms who were tested, only 4% were positive for SARS-cov-2, i.e. 96% of those with symptoms were infected with the flu virus or some other non-coronavirus.

The bad news is that about half of those in high risk populations who develop significant symptoms will require hospitalization.  80% of those hospitalized will be so sick that they will require ICU care for a number of days. The people at highest risk of requiring hospital-based medical care are those with underlying chronic diseases, called co-morbidities, like congestive heart failure, hypertension, diabetes, chronic obstructive pulmonary disease (COPD), chronic kidney disease, and those over 80 years old (a stage of life, NOT a co-morbidity thank you!).

Nearly 90% of COVID-19 cases have been in people between 30-79 years old. Less than 1% were in children under 9 years. Despite this fact that children are not the primary vector for this virus (unlike influenza), we are closing many elementary schools. In the swine flu epidemic of 2009 we closed 1300 schools for 7-14 days because of evidence that children were primary vectors for its spread. Despite the run on toilet paper resulting in empty market shelves, diarrhea is not a common symptom of the disease.

If COVID-19 is going to be as common as a cold or the flu, but has a lethal potential for select groups of people, how do we triage the people who think they have it while we wait for the coronavirus nasal swab test to become widely available?
The simplest triage diagram has just three branches in the decision tree:

  1.  If you have cold symptoms (but remember a runny nose is not a common symptom of COVID-19) — treat it like a cold with rest, fluids, and decongestants and try not to spread it to other people. (YOU wear the mask, not everybody else)
  2. If you have a fever over 101 and a cough — go see your primary care provider.
  3. If you have the above and feel weak or tired and are short of breath — the PCP may send you to the hospital.

How do people with COVID-19 die?  In the severe stage of the disease (called ARDS- Adult Respiratory Distress Syndrome) respirator machine support (a ventilator) in an ICU is usually needed. Another cause can be an overwhelming secondary bacterial pneumonia and sepsis later in the disease (similar to deaths caused by the flu) and, unexpectedly, some deaths have occurred without pneumonia or severe lung inflammation, particularly in patients with very high blood pressure or those on kidney dialysis.

Watch out for advertisements of fraudulent cures or “protections” from COVID-19. The FDA has formally warned 7 companies, including the Jim Baker Show, that their advertisements for “silver solutions” to kill the virus must stop. There is no evidence that solutions of colloidal silver can kill the virus. Vitamin C is no help either. If Purell with alcohol can kill the virus some people think that alcohol by mouth could kill it. Unfortunately alcohol does not kill the virus. Soap and water or bleach does. Do NOT gargle bleach.

The AMA has responded quickly to the epidemic and filed a request for a rush approval of a CPT code for COVID-19 testing (necessary for insurance reimbursement, hence maybe the urgency of the request). AMA President Patrice A. Harris, M.D., M.A. has said,  “By streamlining the flow of information on novel coronavirus testing, a new CPT code facilitates the reporting, measuring, analyzing, researching, and benchmarking that is necessary to help guide the nation’s response to the public health emergency.” Also as I said, health insurance companies will be asked to pay for the test.

Two surveys released this week show that the Corona beer brand is suffering from a negative buzz. A 5W Public Relations poll of 737 beer drinkers in the U.S. showed that 38% of them wouldn’t buy Corona “under any circumstances”, and another 14% said they wouldn’t order a Corona in public.  However, Corona beer and seltzer sales actually increased in February.

 


Vol. 228 March 1, 2020 Physician Speeders, Roundup Off One Hook, and Don’t Shoot the Cows

March 1, 2020

“Many people believe medical specialty choices are associated with certain personalities
leading to driving behaviors, such as fast driving, luxury car ownership . . .
and leniency by police officers.”

 


“Do As I Say, Not As I Do” –  the physician’s mantra

A study of 14,560 speeding tickets issued to 5372 physicians in all specialities between 2004 – 2017 in Florida revealed that the average speed of the ticket receivers was 15-16 mph above the speed limit. The 25% of  MD tickets issued for speeding 20 mph over the limit were labeled “extreme speed” in this study; about the same percentage as in the general population of non-MD drivers.  “Extreme speeding” was most common among psychiatrists (31%), but otherwise similar (22-25%) across specialties. Among physicians who received a ticket for speeding, cardiologists were more likely to be driving luxury cars (41%), while emergency physicians, family physicians, and pediatricians (of course) were less likely to be driving a luxury car (20%). 11% of non- physician speeders drove luxury cars. Leniency by officers (“writing a ticket with a lower fine”) towards physicians pulled over for speeding was common, but did not vary by specialty, and was similar between physicians and non-physicians. Police tended to be more lenient to Ob-Gyn physicians, older, and female drivers.

The speediest driver was a general internist clocked at 70 mph.

Quite frankly, I am surprised by the low speeds of the ticket receivers, but not much else in this study. I am certain that the ticketed speed levels would be way higher on Route 3 to Boston any morning of the week. The authors did conclude their paper, I assume with tongues firmly planted in cheeks, with “the connection between the driving behavior of physicians and patient outcomes remains unknown.” (1)

Roundup May Be Off One Hook, At Least
A sharp decline in Monarch butterflies was noted around 2005 and in a 2012 paper the idea that milkweed loss in  Midwestern U.S. corn fields was the cause. The caterpillar stage of the butterfly requires the milkweed to develop. Each year Monarch caterpillars grow up on the milkweed between those rows of corn, and then the butterflies migrate all the way down to a specific forest in Mexico for the winter.  Our corn crops, genetically modified to resist Roundup, were thriving, but the Roundup was killing the milkweed. Hence, the story went, the Monarchs are declining due to Roundup. The evil and perils of Monsanto’s Roundup became a familiar story to us.

Further studies in 2017-2019 using satellite imagery, analysis of chemicals in butterfly bodies , and more accurate counts revealed that only 2 out of 5 Monarchs came from those cornfields and that butterfly counts were stable in the Midwest summer but were declining in the Mexican winter forest. That suggested strongly that something was killing the butterflies en route. Maybe it wasn’t just the Roundup in the corn fields. Even the original “milkweed-loss” proponent backed off a bit. Currently a major study by 120 people monitoring 235 sites along the migratory route is underway to identify what is now considered the multi-factorial causes of Monarch decline. Meanwhile, the federally preserved wildlife area in the U.S. has been reduced by nearly half since 2007, and the Mexican winter-home forest has been reduced by surrounding logging operations and climate change to the size of a soccer field. Science, if not the Monarch butterfly, marches on. (2)

Don’t Shoot the Cows . . . Just Reduce Their Antibiotics.
Carl Sagan was probably the first to point out that methane gas in our atmosphere was really the only sign of true life on earth to any observer from space. We later were told that the chief source of methane on earth were cow farts, and that methane was a greenhouse gas (“bad”) enhancing climate warming. Of course, we all know that manure is an excellent fertilizer. It helps a lot of good green things to grow; good plants that grab carbon dioxide (another “bad” greenhouse gas) out of the air and trap it in organic matter. Soil stores twice as much carbon dioxide as the atmosphere can. Another plus for cows and their solid output.

A curious, enterprising,  and probably not-so-social graduate student measured the amount of carbon dioxide released into the air by different mounds of cow manure over several months. It was a sophisticated, but understandably messy, project whose methodological details are not important here. He found that the manure from cows that had not been given antibiotics released less carbon dioxide into the air, and had an overwhelming positive effect on plant growth. The manure from cows treated with antibiotics released much more carbon dioxide, and resulted in soil much less beneficial for plant growth. In fact, the type of antibiotic given to the cows made a big difference; up to a two-fold increase of carbon dioxide release by one type of antibiotic. Since U.S. livestock contributes 13 million kilograms of antibiotics a year to the environment, it is not exactly a moot point. Picking a different antibiotic might enhance the carbon-capture benefits of manure fertilizer which could help mitigate some climate change. (3) For another unintended consequence of antibiotics on wildlife check out the story of diclofenac and declining vultures in India.

References:
1. British Medical Journal, “The Need for Speed; Observational Study of Physician Driving Habits”, Harvard Medical School, Dec. 18, 2019
2. Scientific American, What’s Happening to the Monarchs, March 2020
3. Scientific American, Manure Problems, March 2020


Vol. 227 February 15, 2020 Milk is NOT Good For You?!

February 15, 2020

“Is nothing  sacred to
scientists?!”

 

 

Two Harvard scientists noting that the current U.S. recommendation is that adults consume three 8 oz. servings of milk products a day while we only consume an average of about half of that (1.6 servings per day), they decided that “the role of dairy consumption in human nutrition and disease prevention warrants careful assessment.” They just published their analysis of 121 peer-reviewed articles on “milk and health” and concluded that ” the health benefit of a high intake of milk products has not been established, and concerns exist about the risks of possible adverse health outcomes.” (1) That’s not what my mom said, but both these guys are nutritional experts . . . one of them is even a pediatrician! Wha-a-a-a?

The one clear benefit of milk is that milk “augments longitudinal growth and attained height”, i.e. infants and children with adequate nutrition who drink adequate milk are taller than those who don’t. There are lots of specific ingredients in milk that may have that growth-promoting effect, but there is no scientific consensus of which one it is, i.e. no one really knows. These two guys (Walter and David may be scientists but they put on their pants one leg at  time just like the rest of us) even tempered that positive comment by adding that “tall stature is associated with higher risks of many cancers, hip fractures, and pulmonary emboli”. Jeez louise !

Here are some of the surprising points of their analysis:

1. The current U.S. recommendation for daily consumption of milk products is based on only a short study (2-3 weeks) of just 155 adults.

2. Recommendations for daily calcium intake vary among countries by 100%. (U.S. 1000 mg; U.K. 700 mg.; WHO 500 mg.)

3. Countries with the highest intake of milk and calcium tend to have the highest rate of hip fractures.

4. There is no evidence that high intake of calcium as infants, children, or adolescents improve adult bone density or prevent later hip fractures. The concept of building up a “calcium bank” early in life for benefits in later life is not correct.

5. The consumption of either whole milk or low-fat milk or cheese has no association with weight change. However, yogurt consumption was associated with less weight gain. “Yogurt and other sources of probiotics in Western diets may protect against obesity through its effect on the gut microbiome or yogurt consumption may just be marker for a more healthy lifestyle”, i.e. nobody really knows.

6. In one study of three groups of young children those that consumed whole milk or 2% fat milk had lower BMIs or lower risk of obesity than those who drank low-fat or skim milk. This and other studies contradicts the U.S. Department of Agriculture (USDA) advice to choose reduced-fat dairy products.

7. Neither whole milk nor low-fat milk consumption has been clearly associated with the incidence of mortality from heart disease or stroke. Those rates appear to be dependent on the companion (or comparison) foods of dairy; ie. red meat, fish, or nuts.

8. Milk consumption is most consistently associated only with a higher risk of prostate cancer. Studies of the association of dairy consumption with colorectal, endometrial, and breast cancer show mixed and non-significant results.

9. The overall mortality based on other protein sources when compared to that of milk is higher for processed meat (+56%), eggs (+15%), and unprocessed meat (+a 5%), about the same for fish and poultry sources , and 10% lower for plant sources.

10. The environmental impact of dairy production is 5 to 10 times greater per unit of protein than the environmental effects of soy, legume, and grain production. “Limiting dairy production could make a major contribution toward reaching international greenhouse-gas targets.”

According to Walt and Dave the ideal “guidelines for adequate milk consumption should be 0 to 2 servings per day for adults, deemphasize reduced-fat milk as preferable to whole milk, and discourage consumption of sugar-sweetened dairy foods in populations with high rates of overweight and obesity.”

Of course, they added “pending additional research”.

According to MY mom, ice cream was non-fattening because its exact number of calories was burned in raising your stomach temperature back to normal after it had been chilled by the ice cream. . . . additional research is probably needed.

References:
1. NEJM 382:7, Feb 13, 2020, pg. 644-654
2. for the other side of the coin – “Benefits of Milk”, Dec. 2017,  https://www.medicalnewstoday.com/articles/273451


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