WAKE UP!
Everyone has repeatedly heard that being physically inactive and eating a high fat diet leads to weight gain which sooner or later leads to Type II Diabetes (plus heart disease). But YOU know there are pills you can take for the high sugar and if that does not do the trick, you can take Insulin injections. So, what the heck? Right?
Several recent studies should serve as a WAKE UP call for you.
Avandia-wonder diabetes pill causes a 40% increase in heart attack rates
Actos- wonder diabetes pill causes a 40% increase in heart attack rates
Insulin- wonder injectable causes a 50% increase in cancer risk – mostly G-I, Pancreas or Liver
What will it take for you to take control of your own life and start changing your personal behaviors to achieve a healthy lifestyle?
Guidance is available from a myriad of sources including my book Why Health Insurance does not ensure Health.
Gerald L. Evans, M.D.
Changes in Health Care over time
An article in Saturday’s Boston Globe (8/21/10) recalling the 200th anniversary of two physicians starting the first hospital in the United States evoked many memories of the way changes in health care innovation have evolved since then; many wonderful and some not so wonderful. Great contributions like the development of penicillin by Dr. Fleming in the late 1920s and cardiac catheterization by Dr. Lewis Dexter at the Brigham in the 1960s led to great advances.
Physicians in the 60s and 70s recognized the need for specialized technology to further advance their ideas which led to collaboration with bright engineers like Herb Karsh at MIT’s Lincoln labs which led to the development of an early computer to facilitate physiologic study of the heart.
Paralleling these medical innovations were health insurance programs. Initially there were indemnity programs which set “reasonable” (less than charged) fees. In the 80s HMOs made their appearance with moderately discounted fees which physicians, hospitals and other medical personnel either accepted or were unable to care for patients who joined those HMOs. That was probably the beginning of the end of the strong bond of the physician/patient relationship. Patients from one community could not continue to see specialists from another as they were not in the same circle or network. Significant reductions in reimbursement led physicians to reduce their time spent with patients further eroding that relationship. Independently, technology exploded with bright engineers developing solutions to medical problems before physicians recognized their potential usefulness. Health care costs exploded. HMOs discounted more. Medicare, facing depletion of its trust funds, encouraged patients to shift to HMO Medicare plans which costs the government less than traditional Medicare.
Cost containment became more important than how medical care was delivered. All those payers – government, insurance companies, and HMOs focused all their attention on that goal. Hospitals became more concerned with garnering your insurance information to ensure payment then to addressing your care. Rising care costs have been attributed to variations in care, too great a use of technology, excessive pharmaceutical costs, defensive medicine etc. Each attempt to rein in costs has, not surprisingly, led to rapid escalation in costs. The “system” has not yet figured out then when two parties ( doctor and patient) decide on what is done for a patient AND someone else pays for it (insurance company), there will be excessive spending. Every patient will tell you to spare no expense. “I’ve got insurance”. Go to a cocktail party where there is an open bar and see how much liquor is consumed in comparison to a similar party with a cash bar.
So now we have health care reform which will add 30 – 40 million people to the insured pool and we are told it will save money. How are they going to do it? Standards of care are being developed which stipulate what care is appropriate for a given diagnosis and equally important, what care is inappropriate (unnecessary or redundant). Interestingly, there are few if any physicians in clinical practice developing these standards. The newly enacted Health Care Reform Act has hundreds of parts. Another one of these is mandatory computerized medical records for physicians and hospitals. Using the standards of care and the medical record will make it easy for any insurance company to control the practice of medicine. Just print out the guidelines and pay for those things that are recommended and debit the provider for those not recommended.
We’ve come a long way from those two physicians who started a hospital 200 years ago. Unfortunately it may not be such a good direction.
Gerald L. Evans, M.D.
Health Care Reform’s “Medical Home”
Editor’s Corner
Raymond Carter, Editor, Medical Home News Volume 2, Number 8 August, 2010
I have invited members of the Medical Home News Advisory Board to submit short op ed pieces for inclusion in this space. Other Medical Home News readers are welcome to do so as well. This month, in fact, we feature a piece from a Medical Home News subscriber, Dr. Gerald Evans.
Medical Home Circa 1975 – Bring It Back!
By Gerald L. Evans, MD
The Medical Home Concept is trying to define itself. Is it care coordination? Is it proactive reaching out to patients instead of waiting for them to come to you? Is it physician run, nurse practitioner run, or team run? Could it be specialist run or multidisciplinary? It would appear all options are evolving as examples of the so- called medical home. I have my own bias as to what it should be, but you will figure that out below.
We have certainly seen a very definite trend in the last 20 years away from the private physician supported by a cadre of others (RNs, LPNs, Techs) to teams of health care professionals working as a team without a designated leader. Indeed, medical schools shy away from applicants known for their leadership skills in college as they preferentially want team players. Thus, in this new concept of medical home, it can be run by a physician, a nurse practitioner, or by a coordinator who is responsible for the overall patient interaction to make the parts flow amongst the providers in the group. However, before describing the medical home itself, it would be wise to define the purpose of the medical home. I find very limited descriptions of what it should actually do. Maybe it is not as implicit as the articles on the topic appear to presume. I think this will have great bearing on the structure of the successful medical home of the future.
What are the primary functions of the medical home?
#1. In my practice, I told my patients my primary responsibility was to make sure they took the best care of themselves they possibly could in order to remain free of the need for medical services and to minimize those medical needs when they did develop illnesses. Part of my initial assessment was a focus on personal behaviors, emphasizing daily aerobic exercise (all ages) and healthy low fat nutrition. Smokers were told my practice was smoke free and they had to commit to stopping smoking. I gave them 3 months to achieve that goal and told them I would bust my chops to help them. The success rate was greater than 90% and most of them quit that day. Everything I told them to do was spelled out in detail with reasons supporting its importance. Their behavioral changes were an integral part of their ongoing medical care and revisited at all visits. Laboratory work was done for baseline and to show them how effective their personal efforts were in reducing their disease risks. Avoidance of medications to treat numbers was always a goal. More detailed testing was done as clinically indicated by symptoms or risk stratification in high risk individuals — always with the thought that abnormalities were powerful reinforcement of their need to work hard in their own behalf.
The vast majority of people responded very favorably. (In addition to individual patients, I have done this with corporate, municipal, and union workers in groups at worksites with similar success and much more cost-effectively). I would add that effectiveness in this approach is enhanced by the authority of the physician. In our worksite programs, nurses, exercise physiologists, and nutritionists supported the effort, but the physician impact and leadership was a powerful motivating factor.
continued on page 9
Medical Home Circa 1975 – Bring It Back!…continued
#2. The second part of the medical home is patient care when needed. Preventive care is part and parcel of the above, but patients do get sick and need care. Recognition of when a patient has a significant illness is based on many factors, not the least of which is prior knowledge of the patient. The more experienced practitioner will likely be the better diagnostician. That individual can evaluate the patient quite well without involving specialists early on.
In current practice, the patient who tells his primary care physician that he has a burning discomfort deep in his anterior chest when he walks about after dinner will usually be sent promptly to a cardiologist without initial treatment or further assessment by the primary physician (risk of heart attack more concerning than acid indigestion). That will lead to a major workup starting with a stress test (likely abnormal if a typical 48 year old male with risk factors), which will lead to a cardiac catheterization and an angioplasty. In the medical home concept, that physician would have given the patient an Rx for sublingual nitroglycerin with specific instructions how to take it. The patient would also be told after testing that he should take some Tums for the next episode and then call you. The results would dictate any additional steps that may or may not be indicated.
With Steps #1 and #2 you are well on your way to a medical home concept as I see it. Obviously scheduling next steps in the computerized calendar to make sure you call the patient (smokers in particular) or the patient calls you back (results of nitroglycerin/antacid trial) should be part of any good practice. Personally, I always found email extremely useful, especially with patients who traveled a great deal. (Monitoring pro-times all over the world for Coumadin patients was easy via email.) The more medically experienced the practitioner, the less likely the patient will need referral to a specialist and the more likely they will respond to behavioral changes; i.e. the more successful the medical home.
Gerald L. Evans, M.D. is the former chief of cardiology at MetroWest Medical Center in Framingham, MA and the Founder and Director of HeartVentures, LLC in Framingham. He may be reached at evans@heartventures.com. He also maintains a blog at http://blog.heartventures.com.
Published by Health Policy Publishing, LLC ● 209-577-4888 ● www.MedicalHomeNews.com
Potato gets a bad “wrap”
For many good reasons, “white” foods have gotten a bad “rap”. Like white flour, and white rice, they have suffered by being primarily sugar with little or no fiber. Whole grains provide less sugar spikes in your blood stream which have a negative effect on appetite thereby contributing to obesity.
I would like to come to the aid of the poor potato. If you “wrap” it up in a foil jacket and bake it and then eat it with its skin, you are getting plenty of fiber from the skin and it becomes a healthy potato; undeserving of a bad “rap”.
However, if you un-wrap that potato and add butter, sour cream, bacon bits etc, you have converted that healthy high fiber sugar into an unhealthy, high FAT food. Same problem if you mash it with butter, milk, and salt creating a similar high fat, and also, high salt food which predisposes to high blood pressure.
Now, if you find the plain backed potato blah, you could “flavor” it with something healthy like a small amount of a healthy margarine like Benecol® which is made from plants or add a little salsa or whatever healthy low fat condiment you like. Personally, I like the clean taste of a pure baked potato. (You can quickly bake one un-wrapped in the microwave in 4-5 minutes on high.) Bon appétit!
Gerald L. Evans, M.D.
Weight versus Risk
There is a major concern regarding the increase in weight which is becoming pervasive in our society. We now categorize these as Overweight, Obesity, and Morbid Obesity. Millions are on diets – Atkins, South Beach, low carb, high carb, low fat, no sugar and many self designed “starvation” approaches. Programs like weight watchers are having a major resurgence. Several medications are available and more are in the pipeline. Several have been taken off the market for dangerous side effects. Three are in the FDA pipeline; the first of which received a negative recommendation from the review panel.
The problem is, all of these “diets” result in short term weight loss, but none result in long term weight loss. The very reason for that seems obvious when you stop and think about it. Most people diet for a specific short term goal such as looking good at an upcoming special event. Almost by definition, a diet is a short term undertaking to lose a certain number of pounds. When you get to your goal, you end the diet and return to your old eating habits. Guess what? You gain the weight back. No surprise.
Several points need to be made.
#1 You should not make weight loss your goal. Excess weight causes you problems by raising your blood sugar, blood pressure, and cholesterol. These lead to “vascular” disease which affects the arteries in your body producing heart attacks, strokes and other crippling diseases. Diabetes also prevails. Prevention of these diseases by controlling your risk factors should be your primary goal. That is an important focus because:
a. It does take a lot of weight loss to reduce risk factors
b. It is extremely difficult to lose a lot of weight
The way in which you achieve risk factor reduction/normalization is straight forward. It involves TWO things – modification of your current eating habits to make them “heart healthy” AND DAILY aerobic exercise.
For this article, let’s talk about modifying your eating habits. The real culprits are SATURATED and TRANS fat in terms of risk factors. The secondary factors are other types of fat – the many unsaturated or healthy fats. I advise reducing all fats initially because all fats are very calorie dense (9 calories/gram) versus carbohydrates and proteins (4 calories/gram). The combination of these two nutritional changes along with daily exercise will produce dramatic results. When you reach your weight goal, you can liberalize your healthy fats and maintain your new way of eating FOREVER. Why does this work? Because YOU are going to modify YOUR current eating habits to make them heart healthy by removing or substituting the high fat items. And since your modified eating pattern will be similar to how you now eat, it is easy to sustain as opposed to a DIET.
This is described in great detail in the Nutrition chapters of my book.
Gerald L. Evans, M.D.
Is BIG Better?
I’m not convinced that BIG MEDICINE is better than small medicine. I grew up in a family that owned a paint and wallpaper store. Customer service was a large part of what they sold. Over the years, we have seen “mom and pop” operations bought out and replaced by chains who offered somewhat lower prices. The remaining “mom and pops” could not compete and went out of business. The chain prices rose, but the service component was lost forever.
Big Medicine is heading that way. Physicians who were solo practitioners have had so many external requirements placed on them by government, insurers, HMOs and other entities, that they would have no time to see patients unless they formed groups and hired management to deal with the bureaucracies, Many or most computerized the business side of the office, but now the government has mandated that medical records be computerized. This is not to improve the care of patients, but rather provide data to those external groups who pay for health care and want to find ways to pay less.
Other creative ways to control costs are included in the Health Care Reform bill. Accountable Care Organizations (ACOs) will be created. These are large entities made up of many thousands of patients who will get their entire care from the ACO. The payers, especially Medicare to start, will pay so many dollars per year for your care. The ACO will have to decide how much each member gets paid from that money – a monumental challenge. Is the cardiac surgeon worth more than the chief financial officer? Is the emergency room nurse worth more than the nurse practitioner on the cardiac floor? Is a gastroenterologist who does hundreds of endoscopies worth more than a hematologist who does few procedures? In fact, the gastroenterologist may argue that his/her services generate a lot of charges, so is therefore worth more. The hospital may counter that the income is now fixed in the ACO and all you are doing is spending the profits!
Part of the theory of ACOs is good. Spend more time at the primary care level talking to patients and sorting out the issues rather than sending them quickly for a lot of tests and procedures. That presupposes that the primary care physician is well suited to that task. Certainly the senior ones who trained in the 60’s and 70’s are, but I’m not so confident that the younger primary care physicians have that breadth of clinical knowledge. The medical profession has been pushing for standards of care for the past 20 years. Guidelines, generated from “Evidence Based” clinical research studies have medicine much more cookbook in nature. They do not translate to direct patient care in a clinical setting very easily. Physicians are currently, at least in part, paid on the basis of measurable performance standards like asthma Rx, or ordering certain blood tests to follow a diabetic patient. These are computer measurements, easily extracted from a computerized medical record. Hence, we see the logic of the government’s approach. These measures do not translate to the quality of care the physician is really giving the patient.
We’ll talk more about what quality of care really means in an upcoming blog.
Gerald L. Evans, M.D.
Exercise is Crucial!
In my book, “Why Health Insurance Does Not Ensure Health”, there is a lengthy chapter on the critical need for exercise. A summary of the specifics of what you need to do are outlined here:
FREQUENCY: Plan to exercise every day. The goal is to exercise six or seven days per week. There will be days, often unanticipated, in which something comes up and you just do not have a chance to exercise. Do not plan a day off; rather let it occur naturally. You need to schedule your exercise time into your daily schedule. Do not leave it unplanned with the thought of fitting it in. It will not work. Exercise has to be as important to you as your other activities, both work and leisure.
DURATION: You need to do a minimum of 30 minutes, NON-STOP, aerobic exercise at a pace that makes you “comfortably” short of breath. The 30-minute non-stop requirement is critical to achieving what is called the “training effect”. It relates to the blood pressure and cardio-protective aspects of exercise. Two 15 minute periods do not make 30 minutes NON-STOP!
If you stop and think about it, when you exercise, you are not training your heart. Your heart exercises all the time. In fact, you exercise to reduce the amount of work your heart does. Your heart beats all the time. It beats slower when you rest or sleep and faster when you exercise. The fitter you are, the slower it beats – not just with exercise, but at rest as well. Are you aware that fit individuals have very slow resting heart rates? Marathoners and fit tennis players run resting heart rates in the 30s and 40s. They develop those slowed rates by intense aerobic training, virtually always by running. Playing tennis is a stop and go sport. Running, jogging, and walking are aerobic activities. A sustained aerobic activity (age and health appropriate), is what you want to do.
When you engage in sustained aerobic exercise (30+ minutes non-stop), you are training the arm and leg muscles to be more efficient. You might think of it as your muscles getting better gas mileage. The fuel your muscles use is oxygen which is carried in your blood. Your heart is pumping that blood to your muscles. If you make those muscles more fuel efficient, they will need less oxygen-containing blood to nourish them and thus the heart will not have to work as hard pumping that blood to them. This efficiency is called the training effect. It reduces the workload on the heart both at rest and at exercise. It takes sustained aerobic exercise to achieve it and thus the 30 minutes non-stop exercise prescription. The training effect reduces both resting heart rate and resting blood pressure which also reduces the body’s oxygen needs at rest and exercise. This is one of the ways that fitness reduces the work of the heart at rest and exercise. Since for most of us, the majority of our day is spent fairly sedentary, this is very important. Similarly, the rise in blood pressure and heart rate with exercise will be attenuated which is also of major importance. So that is why you are going to exercise every day and why you are going to exercise at least 30 minutes non-stop each time.
Please go to the full text for much additional detail.
Gerald L. Evans, M.D.
Fantasyland – are we living in it?
Having just returned from Disney with kids and grandkids, it clearly is a fantasyland for the little ones. It also seemed to be a Mecca for the obese who motored around in scooters designed for the handicapped. We see that reality, an enlarging population, everywhere. I wonder when our government is going to figure out that what they are seeing is a marker for high blood pressure, high cholesterol, heart disease, diabetes, kidney disease, orthopedic problems and stroke. Those are the things that drive health care costs and are bankrupting our economy.
But our federal government must live in fantasyland also. They think health care reform is merely to provide health care coverage to those who do not have it. That is called insurance; not reform. And since covering those un-insured will increase health care costs, and the president insists any plan they devise be budget neutral, they will achieve that goal by a variety of NON-reform measures: further discounting of providers, tax on the wealthy, and an excise (actually sounds more like a luxury) tax on those employers who provide too expensive an insurance plan. Interestingly, the unions are opposed to this as many of their members have the highest cost plans in the country.
Everyone agrees that there is waste and over-utilization in health care. No one wishes to address it. The more and more insurance coverage we offer our citizens, the less responsible they feel for their own health status. “If I have a heart attack, I can get an angioplasty or a bypass and be cured” is a common comment I hear. Nothing could be further from the truth. But it is easier for us to live in fantasyland than take better care of ourselves.
Fantasy: An angioplasty prolongs life. With few exceptions (during an acute heart attack), that is false.
Fantasy: Coronary artery surgery prolongs life. Again, with few exceptions, that is false.
Fantasy: Hospitals and doctors can now do wonderful things if a have a heart attack. Since close to one-third of all heart attacks result in sudden death (before you get to a hospital), I would not bank on the quality of care at the hospital.
Fantasy: Taking cholesterol lowering medicine and blood pressure medicine and diabetes medicine will prevent the problem. There certainly is some truth to that statement, but in the relative scheme of things, I would not count on that either. Cholesterol reduction results in about a 25% reduction in heart attack risk. Most individuals with high blood pressure do not take enough medication to normalize their blood pressure. It is rarely achieved with one med and many need three different meds to achieve control. Controlling blood sugars is helpful to the diabetic, but the disease in the blood vessels is not stopped and heart attacks and other vascular disease are common.
Back to reality – we are the problem, not the health care system. With our personal behaviors, we are developing the diseases that have us flooding doctors’ offices and hospitals demanding everything possible be done to deal with the consequences. Doctors have less time to spend with you due to the volume and the government wants to: a) increase the number of insured and b) pay the doctor less for each visit. This will not work.
The solution to this problem lies not in the health care system, but in the much larger community. I often ask people what they would do differently if they did not have health insurance and had to pay the exorbitant costs for all they care they currently demand because someone else is paying for it. That is like asking how much you would drink at a cocktail party if you were paying for it versus someone else paying for it. (The answer to that turns out to be you drink twice as much when someone else is paying for it.)
Time for the community at large to recognize that living an unhealthy lifestyle and getting bailed out by a very sophisticated and expense health care system when you get into trouble is not in its best interest. Everyone acknowledges that PREVENTION is better than treatment, but we don’t all agree as to what prevention is. To me it is simple and straightforward. It is all of us eating healthy and aerobically exercising every day for at least 30 minutes without stopping. It is NOT dieting. Weight loss is not the focus of prevention. Major sustained weight loss is very difficult to achieve. Eating healthy foods (avoiding saturated and trans-fats) and exercise is very doable by virtually everyone except those with severe musculoskeletal problems in the lower extremities. And unlike the 25% reduction in risk with medications, you get 75-85% reduction of those same risks with proper lifestyle change. The impact of behavioral changes on health care costs would be dramatic; far greater than we will achieve with medications and procedures.
Let’s spend our health care budget on teaching people how to do this properly. It is far cheaper than how we now spend our money and far more effective. And let’s not support a near trillion dollar health care reform bill until it has major plans and funding in it to achieve these goals. We seem to be rushing to pass a bill that does not do what we need it to do. The Senate version is being released now – several thousand pages – and Mr. Reid is looking for a vote on it in the next 72 hours. Do we really want our senators to vote on something they have never seen or read that will have a huge economic impact on all our futures?
Gerald L. Evans, M.D.
Is Health Care an Entitlement?
Many feel that health care is an ENTITLEMENT (def: A guarantee of access to benefits because of rights-moral or social-or by agreement through law.) This has unfortunately led to an abdication of personal responsibility and reliance on the health care system to provide for your health irrespective of your behaviors. Medicine promises more than it offers. Lowering blood pressure, blood sugar, or cholesterol by pills has far less benefit than lowering those parameters by behavior change. The comment, by your physician, that “YOU are CURED” after he opens a narrowed coronary artery by angioplasty, stent or bypass surgery is far from reality.
Many view health care costs as something someone else pays. If health care costs had not been rising significantly year after year, how much might your hourly rate have risen over the past 10 years?
What are the DRIVERS of this increasing cost?
1 Medications – Using the newest “best” ones out there – bloody expensive and potentially hazardous to your health.
2 Getting a CT scan or an MRI for every ache and pain – Very expensive and Hazardous (radiation exposure)
3 Physicians’ role in approaching things via tests, referrals et al is an easy way out. How long does it take to convince you that you don’t need that costly Rx or costly test?
4 Greater use of services – does Entitlement become Demand?
I want everything possible done – I’ve got insurance
I want to see a specialist for this
I want to go to Brigham and Womens for my tests / surgery etc. Do you think the community hospital cardiologist was able to do a cardiac catheterization better when in training at B&W then when doing them in a community hospital with 20 years of experience? What makes you think more expensive is better?
5 Why are you seeing the doctor in the first place?
Cholesterol high at a screening
Blood Pressure running too high
Blood sugar now indicates you have diabetes
Hip hurts
Could these reflect your weight gain, eating the wrong foods, and lack of exercise? Do you eat out often? Are you eating healthy foods? Are you doing daily aerobic exercise? Are you smoking or drinking too much? Are you your own worst enemy?
The data begs for lifestyle change to address these issues; not pills and procedures.
The three modalities that should be targeted are:
1 Activity / Exercise
2 Healthy Nutrition
3 Smoking Cessation
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