Vol. 63 March 28, 2012 “Low Back Pain…Oh, NO!”

March 28, 2012

All I said was, “My back pain is a little worse”, in response to the casual “how are ya?”

Suddenly I was engulfed in four other back pain stories. Just try it yourself at the next cocktail party, political rally, or “wherever three or more are gathered”. At least 80% of us Americans have back pain at sometime in our life. Almost 30% of us have it at the same time. (1)

About three years ago I decided to actually do something about mine when I found that I couldn’t complete the short walk from Fenway Park to the MBTA station with my grandson. I suspected that my back pain and stiff, wooden-like, sore thighs were side effects from Lipitor. I stopped taking it, but after no improvement in a month, I went to my primary care doctor. He quickly sent me to a neurosurgeon, passing “lumbar MRI for $1300.”

The neurosurgeon said he could fix my gait by straightening out the “rubber band tangle of spinal nerves” of spinal stenosis by chipping away a little of my backbone. After surgery on L4 and L5 (just in case you are taking detailed notes) my thigh muscles were no longer stiff, wooden, and sore after 100 yards of walking. But, I still had a funny walk, and my low back pain remained. I walked funny because I couldn’t get up on my toes, and my balance was off. The neurosurgeon sent me back to the neurologist saying “I fixed him above the knees, but have no idea what is going on below them.”

The neurologist performed his medieval-torture test called an electromyogram (involves sticking needles into muscles and shocking them with electrical pulses), and sagely announced that I had “diabetic neuropathy”. As diplomatically as I could, I told him that I didn’t have diabetes.  I also blurted out, “ …and I don’t know where the stolen microfilm is hidden.” Several tubes of blood later, the neurologist had ruled out all but two diagnoses, “a peculiar gait” (thanks, but I already knew that) and CIDP (“Chronic Inflammatory Demyelinating Polyneuropathy” or “Chronic Idiopathic Demyelinating Polyneuropathy”). “Idiopathic” is the cover term for “I don’t know”. I am repeatedly impressed by how well we physicians can cover up our ignorance of causation with such lofty sounding terms.

At least CIDP was a diagnosis that had a treatment. Three months after starting monthly intravenous infusions of gamma globulin, I ended up in the hospital in the middle of the night with a pulmonary embolism, a “known but unusual” side effect of the infusions. So I went off the gamma globulin and onto coumadin for a year. I still walked funny and had back pain. By this time my neurologist had joined my children in recommending physical therapy and more exercise, but my children had since moved on to recommending Pilates, Yoga, and meditation.

“I’m an American. Just give me a pill” was my plea to my rheumotologist. He had struggled over 20 years to place me in the correct category of arthritis diagnoses. Whichever one of my three “revolving” diagnoses was the correct one; it had caused both hips to need replacement 10 years before my back pain started. Replacement resolved the hip pain, but one leg ended up an inch shorter than the other.

Many of my friends assumed that my funny walk was from my hips. I grew weary of repeatedly trying to explain things while standing in a bathing suit on the dock, sot that summer I started handing out this card.
.                                 “Yes, I walk funny. My hips are fine. I have some back pain.
.                                   My spinal stenosis was fixed in April. The muscles in my
.                                   lower legs and feet have grown weak because of a rare nerve
.                                   condition, a peripheral neuropathy. No, I am not diabetic.
.                                                         Thank you for caring.”
The card was not entirely true. I have discovered since then that peripheral neuropathy is NOT a rare condition at my age.

My rheumotologist did not think that my back pain had anything to do with my underlying arthritis, whatever that was. He suggested I go back to see the neurosurgeon. Much to my surprise the neurosurgeon said that my repeat MRI looked great, and “he couldn’t see anything else to operate on.” He also said, “You probably should get more exercise.”

Desperate for relief I then turned to Pilates and Yoga, much to the amazement (and joy) of my daughters. Pilates aims to strengthen your core while Yoga seeks to relax it. Both use poses and exercises that mimicked those of physical therapy and the self-help back exercise book one of those afore-mentioned cocktail-party-story-tellers recommended. (2) My flexibility and general well-being improved, but I still woke up with a stiff, sore back that usually resolved by my second cup of coffee, only to return in the evening after walking and standing for the day.

My best friend asked, “So, is this what you are going to settle for for the rest of your life?” By chance, I had my annual exam with my primary care physician the next day. I entered the office determined to get relief. He read my lumbar spine MRI report out loud to me. It sounded like a fly over of the Bad Lands or the Grand Canyon. He followed with, “You are not on anything for degenerative arthritis. What has worked in the past?” Restraining myself from punching him in the mouth for calling me a degenerate (back pain can make people cranky) I responded that my rheumotologist had tried several different ones in the distant past and that Indocin helped the most. “Well, let’s try 50mg. a day and see how that goes.”

Two days later I woke up without back pain.   Thank God, I’m an American!

References:
1. Arch Intern Med. 2009 Feb 9;169(3):251-8. The rising prevalence of chronic low back pain. Freburger JK
2. The Egoscue Method of Health through Motion, Pete Egoscue, HarperCollins 1992.

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Vol. 50 August 15, 2011 “Want To Go Dutch?” …or French…or German?

August 15, 2011

Before we learn FROM other countries’ experiences with medical care,

we first need to learn ABOUT them. (1)

Since all other developed countries have universal health care insurance it is a no-brainer that we, the sole remaining developed country without universal health care insurance, should look to other countries’ experiences for help in our incremental struggle towards it. Looking to the United Kingdom’s NHS has been the most frequent step because of our common language. It has also been the most politically risky one because of the potential stigma of being labeled as “soft on Socialism”. All Dr. Berwick had to say was that there were parts of the NHS that he thought were good, and he was immediately barraged by Congressional criticism as the interim head of Medicare.

So, what about France and Germany that have 5% administrative costs as compared to our 20%? (Remember, Capital One Visa card charges about 7-8% to its users.) We spend around 16% of our gross domestic product on healthcare while the French (see SICKO by Michael Moore, 2007) and the Dutch spent around 10-11% in 2007. You are already familiar with peri-natal morality rates and other measures of quality showing that our health status is no better and is sometimes even worse than those countries despite our higher costs.

2007    Infant      Mortality  Life Expectancy
Germany    4.1 79
France    4.2 79.9
Canada    4.6 80.3
U.K.    5 78.7
U.S.    6.4 78

…the DUTCH ? !

The recent proposal from Congressman Paul Ryan (R-WI) to replace traditional Medicare with a voucher system for individuals to purchase private health insurance brought the Dutch universal health care system into our spotlight. Both Ryan’s Plan and the Dutch system rely on regulation of private insurance, so-called “managed competition”. In 2006 the Netherlands switched from a system of mandatory social insurance administered by nonprofit sick funds to mandatory basic insurance that citizens had to buy from private insurance companies.

A recent analysis of the Dutch system (1) indicates that despite the intention to control costs while continuing universal access, the reality of “managed competition” has fallen short in four key areas:

1. the growth of health care spending has NOT slowed and the administrative cost and complexity has increased (600 workers were added to the tax department to verify eligibility and dispense vouchers),

2. the number of Dutch people who have “defaulted” on their premiums and have, therefore, become “uninsured” has increased the number of uninsured from 1.5% to 3%,

3. the value of “consumer choice” has proved to be very small with an average of only 4% per year changing their insurance between the 4 insurance conglomerates that control 90% of the health insurance market,

4. the amount of government regulation did not decrease; price controls, global budgets, and patient cost-sharing remained in effect. (In 2010 payments to specialists were reduced in response to budget overruns)

The Dutch Ministry of Health requires that insurance companies accept all applicants regardless of health status and must charge only community-rated premiums to avoid “cherry picking” of the most healthy portions of the population. Also, risk equalization formulas are used to protect insurance companies from excessive losses incurred by the sicker, higher-risk populations. Insurance companies are expected to compete in price and quality through SELECTIVE contracting with networks of hospitals and physicians. These same policies are shared by many of the health care reform proposals in the U.S., including Ryan’s Plan.

The actual outcomes of this “managed competition” in the Netherlands include:

  • total costs of health insurance for Dutch families has increased by 41% since 2006
  • the country now spends 15% of its gross domestic product on health care rather than 10%
  • more than 40% of Dutch families receive government subsidies to pay their health insurance premiums, and that will increase as the government moves to protect “defaulters” from losing their insurance after six months of non-payment of premiums.
The article ends with this statement:
“The idea that the Dutch reforms provide a successful model for U.S. Medicare is bizarre.”
The Ryan Plan is based on the same principles, but would also gradually reduce governmental contributions so that a 65 year old beneficiary would pay for 2/3 of his or her medical costs. It is obviously no panacea for U.S. health care insurance problems.

References:
1. Managed Competition for Medicare? Sobering Lessons from the Netherlands , NEJM 365:4 , p. 287, July 28, 2011, Okma, Marmor, and Oberlander


Vol. 44 May 1, 2011 Why Can’t Medicare Be Like Visa?

May 1, 2011

Last week I made two purchases on the same day with my Visa card, one for $293 and one for $273, but the two transactions could not have been more different.

I spent $293 for three pieces of metal to repair line cutters on the two propeller shafts of my boat. The $273 was for a shot of the shingles vaccine, Zostavax.

At the marina, I told the parts manager what I thought I needed, and after a brief exchange he went back into the large storage area, brought out what I needed, showed me how to install them, and swiped my Visa card. I left with the parts, the receipt, the confidence that the parts would solve my boat problem, and the certain knowledge that the charge would appear on my Visa statement next month.

At the doctor’s office, I filled out the short registration/information form, was greeted by the nurse who ushered me into a small exam room, gave me the injection, and sent me back out to the front desk to sign out. And that is where all semblance to my other purchase ended. The receptionist began a little speech which sounded well-rehearsed but only because she delivers it 20 times on a vaccine day,

 “If you have Medicare Part D we can not bill your insurance. You may pay today with check, Visa, or Master card, and we will give you written instructions on how to be reimbursed by your insurance carrier. Here is the detailed receipt for today’s service that you will need to send in to your insurance carrier. Also, here is the list of the numbers they will require you to provide; our tax ID number, the physician’s  NPI number, the procedure code, and the National Drug Code number of the vaccine. Please note that there are 6 physician NPI numbers on this list, and we have circled the one you should submit as the supervising physician for today’s injection. You will need to go to your insurance carrier’s website to print out a claim form, complete it, and mail it in for your reimbursement of today’s charges. Don’t forget to include todays’ detailed printout even though you have provided much of the same  information on your carrier’s claim form. Keep copies of everything that you submit. Usually the carrier will reimburse you in about 60 days. Any questions?”

I had two…no, three immediate reactions.
1) what the hell?,
2) what is so special about this service that I need to do this instead of them?,
3) what if once a year all doctor’s offices did this for all their services to all their patients?
Boy, wouldn’t that be an eye-opener for patients!  Talk about transparency! A taste of the reality of what doctors’ offices go through every working day to get paid by multiple insurance carriers with different forms, review procedures, and deadlines might jumpstart a consumer campaign for single-payer health insurance!

But, I kept quiet and handed her my Visa card. She swiped it, had me sign the slip, and gave me a copy along with a detailed encounter printout, a page of instructions, a page with the required numbers, and a wish to “Have a nice day”. I went home printed the claim form on my carrier’s website, completed it (9 digits for practice tax ID#, 10 digits for NDC#, 10 digits for physician’s NPI#, two 5-digit procedure code #, and two 5-digit diagnosis code # ). There was no line to record one of the numbers, so I just wrote it on the bottom of the form. I attached the doctor’s office printout (being careful to follow instructions to NOT staple or paperclip any of the pages together), copied all the pages, and mailed it. The carrier’s website told me to expect them to take at least 30 days to process my claim. There was no note about when I could expect payment.

By the way, $46 of the $273.21 charge that day was for the physician. The rest was for the vaccine.

Why can’t that medical service transaction be as simple as the one for my boat parts?

Medical Services are too complex, and there are so many of them?
Have you ever seen a marina chandlery or more commonly an auto parts store? Shelves stacked with myriad parts, big and small, rising right up to the ceiling and a countertop piled high with catalogs and specification books that make the ICD-9 code books look like magazines. All  sharing space with a computer terminal usually on a swivel to make it easier for the customer to help spot the picture of the one part for the boat or car model he wants. No, complexity of inventory can’t be the barrier. Just think Amazon.com.

Fear of fraud?
By the patient? My doctor’s office staff knows me by sight, but I still have to confirm my date of birth and Medicare number every time I go in. On the very first visit I had to show a picture ID. By the doctor? In 30 days I will “audit” the charges on my Visa bill. I could do it the next day on-line if I wanted to. If I don’t agree or think that something is amiss, an email or a phone call to Visa will put it on hold. If I didn’t challenge or question the charge within 30 days, Visa could let Medicare know and Medicare could transfer the same amount as a credit to my Visa account. I’ll get to see the correctness and timeliness of that credit in my next Visa bill. If several patients reported charging problems with the same physician or office, Visa would be all over them.

If  Visa can call me within 24 hours to verify my purchase of diesel oil at a marina two states away from my home state where I had purchased oil just two days previously, I would expect them to be able to set up programs that would flag potential physician fraud. Certainly the current government and insurance carrier computer programs that have missed millions of dollars of fraudulent charges, in Florida alone, are nothing to brag about.

Too expensive?
The 7%  that Visa charges merchants and retailers for conducting transactions seems like a real bargain to me. If Citizens Bank can make enough profit on the $20 pre-payment “float” of Fast Lane, Visa could probably make an acceptable profit on the “float” from a $50 annual fee for health insurance transactions.

Lack of standard pricing?
Visa seems to be able to handle that quite well now among different airlines, hotels, catalog stores, and everyone else with a weekly special, redeemable coupons, and the like. Of course, a national standard, or at least a regional one, for health services pricing might make everyone’s life a little simpler, and easier to monitor.

Inertia, or fear of changing how we do things now?
Many hospitals, physcians and more than half of consumers currently favor a single-payer system, not because they are social liberals, or muddle-headed do-gooders, but because they are exhausted by and fed up with our current complex, inefficient, and bureaucratic payment system that is so easily manipulated by the insurance companies for their own benefit.

WHADDAYA THINK?    Take this poll to let me know.


Vol. 43 April 15, 2011 “I Told You So”

April 15, 2011

“The [U.K.] proposals draw heavily on market-style incentives to drive improvements in outcomes and increase responsiveness to patients and the public. But they also include new arrangements for accountability, fundamental changes to the structure of the NHS, and a shift in the responsibility for paying for health services to groups of capitated physicians. (1)

Sound familiar?  Those words describing the current British health care reform effort could serve as a description of U.S. health care reform and the creation of Accountable Care Organizations (ACO). I know I bill myself as an “evidence-based” blogger, and therefore distant from the personal ranting, either angry or self-serving, by other bloggers, but this article in the New England Journal of Medicine spurs me to electronically shout out in triumph, “I told you so!”  In my blog (2) and in a paper (3) I wrote in 1967 (when?) I opined that  there seemed to be more similarities than differences between the U.K. and U.S. health care systems.  This well-researched article in the NEJM  agrees with me.

BOTH the U.K. and U.S. reform acts:

Seek to reduce costs by making providers accountable for total per capita health care costs ($32B less for U.K.over 5 yrs. and $100B less for U.S over 5 yrs.)

Seek to strengthen primary care

Remove payment incentives to increase volume of patient visits (Pay for “value” in U.S.;  “fixed budget” in U.K.)

Do NOT require providers to “bear risks” for  catastrophic illness like insurance companies do now (but that is an option for ACOs in U.S.)

Primary Care Physicians (PCP)
While the U.S. pays lip service to strengthening the PCP, the U.K. proposal really means it. U.K. will give the general practitioners CONTROL of over 70% of the NHS budget! The GPs will form primary care groups called GP Consortia. These Consortia will buy additional care for their registered patients from hospitals and specialists competing for contracts. 170 Consortia have already been formed and another 100 are being planned. A physician-run ACO in the U.S. would be similar, but the ACO would include both primary care and specialty physicians like present day multi-specialty groups. No one knows how many ACOs will be developed, and many of them will be formed by hospital systems.

Commentators on both sides of the Atlantic have voiced concerns that physicians will not be able to deal with these new managerial responsibilities successfully; physicians in neither country like to develop budgets, live by budgets, or even value management/administrative skills.

Quality Incentives
In the U.K. the National Institute for Health and Clinical Excellence (NICE) will set care quality standards for the Consortia and the contracts they grant  or “commission”. The Center for Effective Research (CER) established by the U.S. Affordable Care Act will have the same role of issuing standards of care. The practice of setting national targets for care  will be dropped in the U.K. to be replaced with “a system of open reporting of data on performance and clinical outcomes.” This newly available data will allow patients (“the market forces”) to choose high quality care among the “any willing providers” in the absence of national targets and differential prices. As in the U.S. there is little evidence that patients actually use such data when it is available to make decisions about where to seek care.

Two Big Differences
The U.S. ACO incentivizes coordination of care between primary care, hospitals, and specialist physicians. The U.K. Consortia will control the money and issue contracts for hospital and specialist services. This could increase competition and hinder collaboration in the U.K.

U.K. patients will still have to register with one GP though they will have more freedom of choice of GP, i.e. patients will no longer be restricted to registering with the closest GP to their home.  ACO patients will be assigned based on “previous patterns of care” though there will be incentives to use “participating providers”.

What are the take home messages?
We are not the only country muddling through a major health care reform while walking the line between regulations and market forces.

Everyone seems to be seeking the goals of higher quality and lower costs through electronic information upgrades.

Given the similarities between the U.S. and U.K. systems,  the charge that Dr. Don Berwick, Head of CMS and a pediatrician, “likes the NHS too much” seems a bit ridiculous.

References:

1. NEJM 364:14, April 7,2011, p.1360-66
2. http://www.hubslist.org, Feb. 1, 2011
3.Mathewson, H.O.. “General Thoughts About General Practice: a medical student’s view of the future of general practice in the United Kingdom.”  J Med Educ. 1968, Jan;43(1):36-41.


Volume 4 September 1, 2009 Obesity

September 1, 2009
OBESITY:  EPIDEMIC, EFFERVESCENCE, or EVOLUTION?

Per cent of Americans considered overweight in 1960: 24
Per cent of Americans considered overweight in 1980: 33
Average pounds heavier American men and women are now compared    to 1980 respectively: 17, 19
Increase proportion of overweight American children and adolescents since 1980: x2 , x3
Estimated annual cost of fuel to fly extra weight of overweight Americans: $250 million
Estimated cost to U.S. healthcare for overweight and obesity alone: $79 billion
Per cent of that cost borne by Medicare or Medicaid: 50
Normal Body Mass Index (BMI) and that of obese person respectively: < 25, > 30
How do you calculate your BMI: www.nhibisupport.com/bmi


World-wide increase in obesity (BMI >30) in last 10 years: 10-40%
Year World Health Organization first used the term “global epidemic of obesity”: 2005
Rank of U.S.
of 28 countries and per cent obese in 2005 respectively: 1 , 31%
Average per cent obese among the 28 countries: 14%
Number of countries with above average per cent obese: 11 of 28
Number of calories in an Oreo Chocolate Sundae Shake at Burger King: 1,010
Number of calories in a tablespoon of ketchup, sugar, or mayo respectively: 15, 45, 90
Number of teaspoons of sugar equivalent to a 20 oz. soft drink: 17
Per cent of all liquids consumed that were soft drinks (both regular and diet) in 1998: 30
Increase in per cent of daily calories from sugary drinks between 1975-2000: +30
Per cent of all consumed calories in the U.S. represented by soft drinks: 7%
Rank of soft drinks in the list of all foods consumed in the U.S: 1
Amount of annual revenue projected for a penny an ounce tax on soft drinks In New York
State: $ 1.2 billion
Estimated reduction in soft drink consumption by same tax: 13%
Estimated annual weight loss in average person by that reduction in consumption: 2 lbs
Chances that switching to artificially sweetened drinks will avoid weight gain:
maybe / maybe not (study results are mixed)
Number of teaspoons of sugar equivalent to a 12 oz. class of orange juice: 10
Chances that a person will eat more when presented with a larger portion: 53-73%
Calorie content of a normal bagel in 1990 and 2009 respectively: 140 , 350
Number of inches average person in the world is taller than in 1900: 1.9
Number of inches world champion swimmer is taller than average in 1900: 4.5
Number of inches that fastest world champion runner is taller than average in 1900: 6.4

References listed in New Yorker article (July 20, 2009) cited above:
The Fattening of America, Finkelstein and Zuckerman (Wiley)
The End of Overeating, David Kessler (Rodale)
Fat Land, Critser, 2003
Mindless Eating, Wansink, 2006
Globesity, Delpeuch et al. (Earthscan)
The Evolution of Obesity, Powers and Schulkin (Johns Hopkins Press)

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