Statins: "I heard cholesterol pills are bad for you!"

"Statins" are the most commonly prescribed cholesterol lowering medications, and have been around since the 1980's. The first four are now available generically, and were originally developed based on naturally occurring plant-based compounds. Lipitor was ground-breaking in the mid-1990's because it was more potent ("stronger") and mainly because it was completely synthetic in origin. Crestor followed in the same manner.

They are called "statins" because the chemical names all end in -statin: lovastatin, atorvostatin, pravastatin, etc., etc.

Concerns about rare but severe side-effects in news and magazines fail to make clear the extent of any risks and benefits in taking statins.

Downsides:

• Flatulence (passing gas) is actually the most common side-effect. Not harmful, not associated with diarrhea; just more passing gas. I have, so far, never had anyone stop taking a statin because of this.
• Liver injury. Turns out, increased liver function blood tests turn out to be from the effect that lowering your cholesterol has on allowing solidified fats in your liver to dissolve and return to normal. (so called "fatty liver") This is not a toxic effect on your liver. Unfortunately, warnings that go on drug labels rarely ever go off them.
• Muscle injury. Actual toxic injury to muscle is rare with statins. Rare as in 10-25 times per 10,000,000 (10 million) prescriptions written. That's 1-2.5 in a million. Your chances of being struck dead by lightning are about 1 in 5,000. Please, let's put that in perspective.
• Muscle aching. Here, were talking achiness that is not harmful, and goes away within a few days of stopping the medication. This occurs in about 4% of folks. Mind you, this comes from studies showing 21% of people taking a statin complain of achiness, but 17% of people taking a sugar pill (placebo) do, too. The human mind is a funny thing...

Upsides:

• Reduced risk of heart attack or cardiac arrest by about 31-34%.
• Similarly reduced risk of stroke.
• Reduced risk of Alzheimer's dementia.
• Reduced risk of colon cancer.
• Reduced risk of osteoporosis.

Short story:

• Statins can make you pass gas more often, but can't hurt your liver. Muscle aching is uncommon and actual muscle injury is extremely rare.
• They do reduce you risk of heart attack, stroke, Alzheimer's, colon cancer and osteoporosis.
  

Wal-Mart Pharmacy Changes

As you may know from prior postings on this subject or as a matter of common knowledge, last January Wal-Mart started offering deep discounts on hundreds of commonly used generic prescription medicines at $4/month or $8/3 months.

As of this January, the following changes have been made:

1. 3-month (90-day) prescriptions are $10.
2. New prescriptions have been added at $9/month or $24/90 days:

• Ventolin HFA, the asthma inhaler
• bupropion ER, the equivalent of Zyban for stopping smoking
• alendronate/Fosamax, the osteoporosis weekly pill
• tamoxifen, the breast cancer chemotherapy pill
• several birth control pills

Otherwise, the other medicines are still $4/month.

As previously mentioned, I'm not a big Wally World fan. However, I have to say these prices on hundreds of the most widely used medicines are probably saving lives in a time when lots of folks have to make food/medicines/housing/heating decisions all the time.

The increase from $8 to $10 for 90 days worth is still an unbelievably good deal; particularly with the addition of the aforementioned medicines!

I imagine the reason they continue to offer these discounts is that folks spend an average of $35 whenever they walk in. If you don't want to buy anything else, then don't. But that's a pretty unbeatable deal on medicines if you need them.

Economic Triage

I am borrowing this picture from a newspaper article that talked about something I haven't really seen in print as much as I would expect, which is patients having to not see a doctor because of cost or insurance problems.

Patients canceling, re-scheduling or failing to appear for appointments should not surprise anyone in a full year of the worst economic downturn since the Great Depression with no end in sight.

This article touches on some of the decision-making folks have to face, and also some approaches and resources to stay as healthy as possible.

Certainly, if cost is a problem with medications we are prescribing or tests that we order, do not hesitate to ask. (Believe me, you may find it slightly embarrassing, but you're far from alone.).

If you need to re-schedule a physical or visit due to financial problems, just give us a call in advance. If you are unsure whether this is prudent, it's okay to ask.

We want to see you as often as is in keeping with good preventive health care and treatment of emergencies or with chronic medical conditions. However, the world is presently far from perfect, so let us know if you are having difficulties.

Diabetes control: what if my sugars are too high?

So, having posted a few days ago on good blood sugar goals, an obvious good question is what about if they are higher than goal?

Pills are used to improve blood sugar control and to prevent eventual and inevitable failure of insulin production by your pancreas.

However, diet and exercise are 2-8 times more effective than pills in maintaining normal blood sugars and body weight. A major reason to use pills is that diet and exercise cannot keep your pancreas from eventually needing insulin, and pills can prevent this.

Insulins are used where your body has simply become unable to make insulin for itself.

If sugars first thing in the morning or before meals are over 125, it usually means the meal before this was high in carbohydrates and or that you were not very physically active (such as sleeping or sitting at a desk all day). If you take fast insulins (such as Humalog) before meals, it may mean that the amount you took was too small.

You can get lower sugars in these settings by eating less, being more active or exercising, or by increasing the dose of pills that help to maintain greater insulin responsiveness (such as metformin). If you use insulins and you fasting morning sugars are under 125, but later pre-meal sugars are higher, then increase your fast insulin dose by 1-2 units for the meal before this. For example if your pre-dinner sugar is 155 and you took 5 units of fast insulin before lunch, next time try 6-7 units before the same kind of lunch.

If you are seeing higher than goal sugars after your meals, then try reducing the size of your meals. You may need to increase the dose on pills that help your pancreas to put out more insulin (such as glimiperide, Glyburide, or Precose) or increase your before meal doses of fast insulins.

If you are using long-acting insulins (such as Lantus), then your fasting morning blood sugars are telling you how well your dose is working out for you. The sugar goals for this time are the same as everyone else's: 80-125 is good to go.

If they run over this for over 3 days in a row, then increase the Lantus dose by 2-3 units every 2-3 days until it falls back into this zone and then stay at that dose.

If they are under 80 for 3 days in a row, then go the other direction. Decrease the Lantus dose by 2-3 units every 2-3 days until your morning sugars come back up into the zone, and then stay at that dose.

Rules of thumb:

• Fasting AM sugars reflect overall steady basal insulin activity which maintains normal baseline sugars.
• Pre-meal sugars show how your body is doing with your last meal and activity level since then.
• After-meal sugars are telling you about how much and what you just ate and how well medicines that help with this are working for you.
• Feel free to call or see me if you are concerned about your blood sugar control, medicines, or what to do next!
  

Diabetic Labs: what are those every 3 month tests for?

Every 3 months, you should have a test done called a glycohemoglobin A1c, or glyco for short.

This is a test that tells us what your average (mean, actually, if you are savvy about statistics) blood sugar has been over the prior 2-3 months.

What it actually is is a measurement of glucose (blood sugar) molecules that have become stuck to hemoglobin molecules in your bloodstream. Hemoglobin is the large molecule in your red blood cells that helps to pick up and deliver oxygen to your organs.

Naturally, the normal number is not zero since you'd have to have no blood sugar or no hemoglobin!

People without diabetes have a glyco between 4.0 and 6.0, where 5.0 is an average blood sugar of 100.

If you have diabetes, this test result would be higher because your blood sugar is higher than it should be.

The glycohemoglobin test is useful because it tells us how well controlled your blood sugars have been over a 2-3 month period around the clock and not just at times you check it or the morning you go to the lab. Here is a table that shows how high your average sugar is depending on your glyco test result. A rule of thumb is add 40 points for every 1.0 above a test result of 5.0.

The American Diabetes Association recommends a glyco of under 7.0, however endocrinologists (specialists in gland disorders, including diabetes) recommend under 6.5.

I recommend this lower goal of under 6.5, too.

Under 7.0 does reduce your chances of diabetes causing damage to small blood vessels and causing blindness, nerve pain, kidney failure, erectile dysfunction (male impotence) and circulation problems to your feet.

However, getting the glyco under 6.5 accomplishes this and also prevents damage to larger blood vessels and thereby reduces your chances of having a cardiac arrest, heart attack or stroke. I think it's worthwhile going for the brass ring here, as long as efforts to do so are not causing problems with hypoglycemia or medication side-effects.

As to that computer print-out you get at the lab, do not worry about it!

• It is not a bill, and signing it does not mean MediCare or your insurance will bill you. (If you don't believe this, read the fine print carefully and think like a contract lawyer while you're doing it.)
  
• MediCare covers glyco tests every 90 days for stable well-controlled diabetes. When they say 90 days, they mean it so do know when was the last one so you can avoid this problem. Feel free to ask, too.
• If your diabetes is not well-controlled as your doctor defines it, then MediCare will pay for glyco tests more frequently than every 90 days.
• We are very careful to make sure that your lab forms reflect this, so that if we instruct you to get tests done more frequently, this will not result in a billing problem for you.
• Bear in mind that the lab simply generates a form any time they are asked to do any test for any reason where MediCare may have a time limit! THIS IS NOT THE SAME THING AS BEING TOLD YOU WILL BE BILLED. THIS IS COMPUTER-GENERATED PAPERWORK!

End of rant ; . )

Diabetic Blood Sugar Goals: where should my blood sugars be?

If you have diabetes, checking your blood sugar is a great way of being able to instantly tell how your body is responding to your diet, exercise habits and medications (whether pills, insulins, or both).

The latest generation of glucometers (finger-stick blood sugar monitors) are easier to use than older ones as they need such a small amount of blood you can test easy and less painful sites such as the forearm or sides of the fingers.

As for how low your sugars should be, the answer is basically as close to normal as possible without going so low that hypoglycemia (low blood sugar) occurs.

Fasting (first thing in the morning and pre-meal sugars should be low enough to reflect good overall blood sugars. After eating, sugars will of course be higher since your body is breaking down your food and absorbing vital nutrients into your blood for use and storage. This includes glucose, or blood sugar.

Good goals to meet are:

Fasting or pre-meal: 70-130
1 hour after eating: under 280
2 hours after eating: under 180
3 hours after eating: under 150

Notice that these goals may vary somewhat depending on the recommendations of various medical organizations (such as here, and here).

Where these recommendations all agree is that the goal is to keep your sugars as close to normal as is possible and safe, so that your are reducing as much as possible the risks of diabetes harming your body.

More coming up on what to do if your sugars are too high, and what are those every 3 month lab tests for?

Generic medicines: just as good as the brand name

When a drug company researchs, develops and then markets a new drug, the law provides a period of time in which it is illegal for anyone else to copy it and then sell it. This is intended to give drug companies an incentive to research and sell new drugs.

After a period of several years, it becomes legal for other manufactures to copy it and sell it under other brand names or generic labels.

The FDA requires that generic versions are within 5% margin of error of the brand name drug in terms of how it is released into your bloodstream over time. In other words, generics have to be the same chemical as the brand name drug with very similar action in your body.

On the other hand, it is possible for one generic to be 5% "above the curve" and for another to be 5% "below the curve" which means that the two generics might be 10% different in how they get in and out of your system.

For the most part, this difference does not seem to result in clinical differences or outcomes in a variety of medicines including blood pressure, cholesterol and hormonal medicines.

Mind you, it is possible that reactions to inert ingredients that are in one generic but not another may account for side-effects such as rashes or stomach upset.

Serevent and Foradil

Recent news coverage raises concerns on the part of the FDA (Food and Drug Administration) of these two long-acting medicines.

Both are taken twice a day, and both are bronchodilators which work by relaxing your breathing tubes and allowing them to open up.

If you are supposed to use these daily for emphysema, that's perfectly safe to do.

The safety issue on these medicines is around asthma. Asthma involves unusual sensitivity of your lungs to allergens or irritants and needs to be treated with inhaled steroids (such as Advair, Flovent, Beclovent, AzmaCort, etc.) which prevent sensitivity reactions from occurring.

The problem, then, is that if you just use the bronchodilators without the steroids (treatment without prevention), inflammation in your lungs can progressively worsen and cause potentially fatal asthma flare-ups. Using bronchodilators alone is a bit like hiding the smoke without putting out the fire.

We'll be away over the holidays!

The office will be closed on Wednesday the 24th and open as usual on Monday the 29th for the Christmas holidays. Phone calls to the office will connect you to the doctor on call.

Also, we will be out on Thursday and Friday January 1st and 2nd of the New Year to celebrate the New Year holidays. Again, phone calls will put you in touch with the doc on call. We'll be back as usual on Monday the 5th.

Plan if you have specific needs such as prescriptions or other concerns.

Have a wonderful, happy and healthy holiday season!

Keeping away the colds and flus

Colds are certainly going around, and influenza (the flu) has been cropping up in a few states such as Florida and Washington. The flu that has been seen so far is not unusual, and if you have received a flu shot this should help.

The most important and effective ways to not get colds and flus are avoidance and hygiene.

• Wash your hands frequently with soap and warm water, or waterless hand cleanser. Anti-bacterial soaps are more expensive, but are not better. It's the scrubbing action that rids your hands of bacteria and viruses. A thorough hand washing should take as long as it takes to sing the Happy Birthday To You song twice (to yourself in your head, if you prefer : .).
• Avoid rubbing your eyes, and touching your nose and mouth. This is how bacteria and viruses enter your body!
• Avoid being around people who are obviously ill. This is tricky with Christmas coming up, but if you or your children are ill it's polite to inform family and other guests in advance.
• Masks are useful in preventing the spread of colds and flus.
• Surgical masks like those worn in operating rooms are disposable and made of thin paper-like material. These are worn by the sick person to prevent coughs and sneezes from throwing cold and flu viruses into the air, where they can float for up to several hours afterwards. They do not keep you from inhaling bacteria and viruses into your mouth and lungs!
  
• N95 respirator masks are reusable and are worn by well persons to filter out bacteria and viruses when you breath. This link shows several places you can buy them. They can often be found in hardware stores (for workers around fine dusts), and in medical supply stores (for allergy sufferers).
• N95 masks are so called because they are certified by NIOSH (National Institute of Occupational Safety and Health) as filtering out 95% of workplace dusts and particles. Because of the material used, they actually filter out 99% of bacteria and viruses including TB, pneumonia, colds and avian flu ("bird flu").
• Get the kind that have a valve for breathing out because they are much more comfortable to wear.

Hopefully, these steps will help you to stay well during the cold and flu season!

Things that should concern you that you may have something more serious could include chest pain, shortness of breath or wheezing. Please feel free to call us to be seen as soon as possible to make sure that you don't have a more serious condition such as asthma or pneumonia.

Nosebleeds

'Tis the season for nosebleeds; the air is drier, indoor heating is in use and colds and flus abound.

Most nosebleeds occur because each nostril has a network of small, delicate blood vessels right at the opening of the nostril (Keiselbach's plexus, for those who like to know these things).

Problem is, this plexus in in reach of your hand meaning that sneezing, rubbing or wiping your nose (or picking your nose) can physically damage them and result in bleeding.

Most remedies for nosebleeds seem like remedies for hiccups- mainly designed for the amusement of bystanders.

Direct pressure stops bleeding in the nose just like it stops bleeding from other places such as a cut on your hand.

So, treat nosebleeds as follows:

1. Press firmly but gently along the side of your nose with your finger.
2. Do not tilt your head back (tasting your own blood is off-putting), do not pack your nose with Kleenex (you remove blood clots are renew the bleeding when you take it out).
3. DO THIS FOR 15 MINUTES WITHOUT LETTING UP THE PRESSSURE!
4. It takes 15 minutes to not only form a blood clot, but for it to be hard enough so that when you let up on the pressure it doesn't just fall apart.
5. This cannot be over-emphasized; 15 minutes is a long time in our hurry, hurry, hurry society. If you need to watch TV and wait through two entire sets of commercial breaks, do it.
6. If necessary, repeat again.
7. If this doesn't work, spray 3-4 puffs of an over-the-counter nasal decongestant spray (Afrin, Neo-Synephrine, 4-Way, etc.) into the bleeding nostril to shrink down the blood vessels and try 15 minutes of direct pressure again.
8. If this still hasn't work, you should call to be seen or go to the emergency department.

Nosebleeds are generally not a sign of high blood pressure. It takes an exceedingly high pressure to cause this to occur, such as 170-240 on your blood pressure cuff. Mind, if your blood pressure is that high you should be seen urgently about this.

Medicare Part D

You still have time to add prescription drug coverage to your Medicare!

Open enrollment ends at the end of this month.

Until then, you can go on-line or call 1-800-MEDICARE to get help adding this to your Medicare Part A and B (these cover hospital and outpatient medical care).

Basically, these are commercial insurance plans that meet or exceed standards set by the federal government. They are used for covering the costs of you medications.

There are lots of choices, and lots of differences in cost. The last time I looked, there were over 50 plans in California and the average premium was about $45/month.

DO. NOT. PANIC.

First of all, if you have very little money (make less than $14,355/year yourself, or less than $19,245/year as a couple at last count) you may be entitled to Plan D at no cost to you at all as long as you pick a plan that does not exceed the average premium cost for California.

Second, use the available resources to narrow your search:

• You live in California. Only look for plans offered in California.
• Most generic drugs are not a real issue. The ones that aren't generic are the ones that will cost you (such as Actos and Avandia for diabetes, brand name insulins like Lantus and Humalog and ARB's for blood pressure and heart failure like Diovan, Cozaar and Atacand). Generate a list of your expensive drugs, and then look for plans that cover them.
• If you already have Part D and always end up having to pay full cost on you pills before the end of the calendar year, this does not mean that your insurance no longer covers it! This means you've hit the "donut hole" for the year.
• This means Part D has covered $2,250 for the year and that you are on the hook for the next $2,850. If you go past that for the year, then Part D picks up for the rest of the year.
• If this keeps happening to you, pay a bit more for a plan with "donut hole" coverage!

This link shows all the plans available for 2009 in El Dorado county in nice neat columns showing what they are called, how much they cost, whether they are free to low income folks and whether they have gap (donut hole) coverage or not.

It also provides links to the plans so you can see all the details, and toll-free numbers for folks who prefer telephoning.

Use it or lose it!

Diabetes control: low blood sugars

Having addressed blood sugar goals, and treatment of high sugars, what about lows?

Developing low blood sugar (hypoglycemia) can be frightening, since most people find that they suddenly feel very shakey, weak "like someone just pulled the plug on me". If your blood sugar reading is under 70 (which means a lab would find that it is under 55- 60) or has dropped quickly over a short period of time to low-normal levels, then you may find your self feeling this way all of a sudden. If you do, DO. NOT. PANIC.

If it is convenient and safe to do so, go ahead and check your blood sugar. Certainly, if your were in a hospital or ER and said this was how you felt, we'd stick your finger immediately and find out if that was the trouble.

If it is indeed low, then have something to eat or drink. Orange juice is fine, but really anything with a few carbs is okay. A piece of bread, a few crackers a piece of candy, a piece of fruit will do just fine. You should feel back to normal in a few minutes. If you don't, then re-check your blood sugar.

It is generally not necessary to eat large amounts of food or drink over the few minutes until the hypoglycemic symptoms resolve. This can result in weight gain and very high blood sugars for hours afterwards.

The goal is to get low sugars back up into a normal range of less than 125 quickly and safely without feeling compelled to over-do it.

Certainly, frequent episodes of low sugars are something we should discuss to determine whether any of your medications doses are too high.

Low sugars that don't respond to eating, keep dropping back or are causing fainting or near-fainting are a serious emergency for which you should call 911 or be taken to an emergency department.

Presidential Candidate Health Care Reform Proposals

The New England Journal of Medicine in its October 16th issue provides a review of Senator McCain and Senator Obama's proposals for improving health care in our country.

This journal is one of the most widely read, well-researched and respected professional medical journals in the world and these reviews are presented for an audience of physicians and other medical professionals.

They are well worth reading as they are understandable to a broader audience which would include anyone with an interest in the opinion of one of the most prestigious medical journals in the country.

To summarize,

Early in his campaign, Obama recognized that the success of health care reform rests on the plan's ability to slow spending growth and make health care affordable for everyone. His plan would reorganize the health-insurance market — but not change the basic financial incentives in the system that drive up spending. Although the plan would significantly increase the number of Americans with health insurance, it remains to be seen whether that would come at a price Americans would be willing to pay.

The choice facing health care professionals, like all Americans, is basic: Who deserves to be trusted with the stewardship of America's health care system? The McCain proposal violates the bedrock principle that major health policy reforms should first do no harm. It would risk the viability of employer-sponsored insurance and the welfare of chronically ill Americans in pell-mell pursuit of a radical vision of consumer-driven health care. Senator McCain's plan does not demonstrate the kind of judgment needed in a potential commander in chief of our health care system.

Alli- over the counter weight loss medication

Alli (R) is the over-the-counter equivalent of prescription Xenical (R), and is approved as safe and effective in weight reduction by the Food and Drug Administration.

It is safe to take with other medicines except for Coumadin (R) or warfarin the prescription blood-thinner, and organ transplant medicines.

When taken with meals, it keeps about 20% of the fat in the meal from being absorbed into your bloodstream and then being deposited into fat cells. This 20% then is excreted in your bowel movements, which may make them oily looking.

Yes, that's right. No meal is absolutely zero fat. A fifth of the fat in your meals isn't going to your belly or thighs, but is excreted out of your body. That's the point!

Alli is capable of working as well as any other medication, assuming that you change how you eat in order to minimize this side-effect rather than not taking the pills when you plan to eat pizza or ice cream.

The oily bowel movements are not intended to be punishment; it's probably better than all the fat in meals being fully absorbed and deposited in your fat cells. However it can lead to improved eating habits, too.

This mechanism of action of this medicine is particularly of interest to folks at risk for diabetes, since the growth of abdominal fat cells is what ultimately causes diabetes in the first place!

Disclaimer: I have no financial or other interest in Alli, Xenical or its manufacturers. I am only interested in helping my patients to lose weight safely and effectively.

Weight Loss Recipes

Successful and sustained weight loss requires all three of the following:

1. Reduction in total calorie (fuel) intake: eating less, reducing size of portions, avoiding snacks.
2. Reducing calorie density (richness): not buying or eating foods over 30% calories from fat (the upper left corner of any nutritional fact label), such as "junk" foods, "fast" foods, sweets and so forth.
3. Increasing calorie expenditure (exercise): walking, bicycling, sports, swimming, treadmill, elliptical trainer...

The problem is that human physiology is fantastic for surviving starvation. This is great if the food runs out, but not so great if food is abundant.

I get a lot of questions about healthy food choices and specifically suggestions or recipes, so here are some useful links to healthy recipes that range from simple to complex, basic to elegant:

New York Times: Recipes for Health
Recipe Source: Diabetic Recipes
All Recipes: Healthy Cooking Recipes
Epicurious: Healthy Food Recipes

Bon appetit!

Causes of Death: a bit of perspective

Here's an interesting graphic from National Geographic, which handily illustrates likelihood of causes of death in US citizens.

By all means, look over these and draw your own conclusions. Please note the enormous risks of dying of heart disease, cancer and stroke compared to everything else and consider how much can be done to reduce their risk of occurring: not smoking, taking a baby aspirin a day, improving your weight, blood pressure or cholesterol without "waiting until my body tells me something is wrong". (Your body telling you something is wrong is you having a heart attack, stroke or cancer.)

Also, consider that risks of seriously harmful side-effects often discussed in papers or on TV (bone disease with Fosamax, muscle toxicity with cholesterol pills...) may be as low as 1 in 10,000 to 1 in a million: that is about the likelihood of you dying by accidental electrocution to 3 times less likely than dying through a fireworks accident.

Should kind of make you go Hmmm....

Change in our Immunization ("shots") policy

Sorry to say it, but due to the increasing cost of buying immunizations, the poor reimbursement from insurance companies and their short shelf-life we can no longer afford to give many rountine immunizations. In many cases, we are actually losing $50-100 apiece on shots.

Happily, the Public Health department administers all routine shots at low cost on an appointment basis.

We are more than happy to continue to see you or your family for:

• Well Child check-ups
• Female and Male annual physicals
• DMV exams
• employment physicals
• injuries
• consultations about travel

We still give shots for:

• Adult tetanus
• Adult Hepatitis A, Hepatitis B
• Pneumonia vaccine
  

Sixth Grade Immunizations ("Shots")

The county department of public health is doing their IZ Xtreme program again at middle schools this October. This is available to all 6th graders, and also any 7th and 8th graders who have not received this immunizations.

The immunizations are the standard ones for this age group, and prevent tetanus, pertussis, meningitis, influenza and genital warts virus.

If you believe in preventing fatal or crippling infections in our children and our community, this is a fantastic program that provides over $56o in immunizations to each child free of charge at their school.

IMHO, one of the best uses of taxpayer money I've ever seen!

Health Care Reform

So, I'm going to break team here a little and post on a directly political issue (as opposed to clinical or regulatory/insurance concerns).

This is not intended to be a personal soap box on politics in general; I am simply getting a lot of questions on this lately, and I presume it is due to the national-level debate in the setting of the upcoming Presidential elections in November.

What is Health Care Reform?

That being said, let's clarify some terms. Part of the problem is the overuse, misuse or misunderstanding of some words used in public debate on health care in our country.

"Socialized Medicine"

Right off the bat, no one is proposing "socialized" medicine. Period. If we accept the definition of socialism here as advocating government ownership and administration of the means of providing medical services, then you may notice that no one in our debate is suggesting that the federal government should outright own all the hospitals and medical practices and that all doctors should be employees of the federal government. This would approximate the National Health Service in the U.K.

So: throw away "socialized medicine". No one. Repeat, no one is suggesting this. The motives of politicians using this term to stifle debate, or arouse anxiety or anger should be questioned.

"Universal Health Care"

"Universal health care" is a nebulous catch-all phrase that has no specific definition, save that it is meant to mean all things to all people. Generally, the term is used where improving the availability of health insurance and decreasing the number of people in our country who have no insurance is intended.

While no one could reasonably object to any genuine effort to make health insurance more available to more people, you may notice that any such proposal typically includes specific actions like tax credits for purchasing medical insurance, negotiating with health insurance companies at the table, or offering more incentives to HMO's.

Unfortunately, none of these ideas really addresses the underlying causes of our problems with insurance costs or health care costs. Certainly, including insurance companies as equal partners in any planning is like including the foxes in round-table discussions concerning the security of the chicken coop.

The insurance companies are the only interested party who is satisfied with the status quo, because they are the only interested party who is making serious profits at this, and are the only ones who are distinctly for-profit only in their fullest intent and by definition. (Yes, doctors make a profit. We do have bills to pay, kids to put through college and such. However, the ethical and professional mission of the doctor or hospital or clinic is to provide the best possible medical care for its patients.) Patients, doctors, hospitals and politicians all want substantial change.

So: IMHO, any "universal coverage" plan that includes the insurance companies as equal partners and tries to keep their role as close to the status quo as possible without upsetting their apple cart is doomed from the outset to represent little to nothing in the way or substantial and meaningful improvement and change.

"Single Payer"

"Single-payer insurance" or "national health insurance", or "MediCare for all" is advocated by many (disclaimer: including me- more on that later). This would approximate France or Germany's (or. to a lesser extent Canada's) style of health care. Actually, it would approximate the way health care is administered in virtually every developed nation on the planet except ours.

This would mean that all citizens are entitled by right (and not by bought privilege) to a basic level of health insurance from birth to death. This would typically be through a single large insurance pool composed of all citizens and administered by a single large insurer, which is usually the federal government. The State of Oregon has a roughly similar State administered health plan.

"MediCare for all" is a term used to mean the same thing, but in a way that may convey more meaning than the technically accurate but confusing "single payer". Let's face it, the only folks who use the term "payer" here are medical professionals, insurance people and policy wonks. Average folks think "insurance company". MediCare provides for doctor visits, annual exams, cancer screening, care of acute and chronic medical problems, labs, tests, ER, hospitalization and surgery. If you want and can afford more coverage, then you are free to buy it from whoever you choose. Thus, "MediCare for all" is meant to convey the idea of such insurance being extended by the federal government to all citizens, and not just those who are over 65 or disabled.

As is already practiced in many of the other developed countries of the world, the federal government could administer a publicly funded or supported health insurance that would cover the same things that MediCare covers (as described above) and extended to such care appropriate for children, as well. Insurance companies (through employer-based means or otherwise) would fill the niche in the marketplace for those who want to buy more coverage such as improved drug, durable medical equipment or long-term care coverage, or perhaps as specific riders in the same way you can buy homeowners insurance riders on your cameras or jewelry or computers if their value exceeds the basic plan coverage.

So, what do you think about health care reform?

Again, I get asked this a lot by patients in my office, hence this post. I have tried to define all terms as accurately as possible though I'm sure it's evident that I feel the best plan would be for our government to adopt a single-payer model that mirrors every other developed country in the world.

I see no sense in doing so just because everyone else is doing it. I feel we should do so because of the following facts (repeat, facts: not opinions, facts):

• We do not have the world's best medical system, we have the world's 37th best medical system.
• We do moderately well in terms of measurable health quality (24th best), but
• we do very poorly in terms of being able to care for all our people (55th best), though
• we excel (1st best) in emergency care.
• We spend twice as much money per person for this level of performance.
• Unfortunately, one must wonder whether this translates as follows: we have the best emergency care in the world because we have to, since so many people have no other way to get medical care they go to the ER for it or wait until they're crashing and burning to show up, and thus our overall levels of infant death, lifespan and disease occurrence and care suffer for it.
• Economic models prove that having health insurance where you split the pool of people who are insured as we do will lead to exactly the problems we face where people often find that no one will insure them, or they cannot afford available insurance. (Harford, T. 2006. The Undercover Economist, Oxford University Press, pp. 109-110, 113-16, 119-23.)

Additionally, I myself have moral and ethical qualms with the status quo.

• I think it is wrong to have to change doctors because of your insurance or your job.
  
• I think it's stupid to put the entire choice of your insurance in the hands of your boss (not because your boss is necessarily mean, but because your boss has the most incentive of any player in the game to keep the cost as low as possible).
• I think it's wrong for 47 million fellow Americans to have no health insurance. That's 16% of our entire country! That's 1 of every 6 men, women and children! Note that this doesn't even count people who are on MedicAid or MediCal which has so few doctors who will accept it you may as well be uninsured in many respects (these folks are referred to as "under-insured").
• I think it's wrong for the most common cause of personal bankruptcy in our country to be unpayable medical bills. Half of all personal BK's are because of this, and 76% of these BK's involved households that already had medical insurance at the time of the illness.
• I think it makes bad business sense to not significantly change a business model that costs twice as much as other businesses in the marketplace, and in which you are the 37th best producer. Personally, I aim to be the best and not settle for Top 40. Let's stop saying "Thank goodness for Slovenia (#38)!" No offense to Slovenia, I just expect better for the amount of money we're spending.
  
• I think adequate medical care should be a right, and not a privilege that you have to purchase. I do not believe that it is acceptable for those of us who are less wealthy to be left to die younger. ("[i]nasmuch as you did it to one of the least of these My brethren, you did it to Me", if I may make so bold.)
  
• Yes, I put my money where my mouth is. MediCare, TriCARE, MediCal, Workers' Comp and union commercial insurers typically pay quite poorly. However, I have patients on all these insurances because I think you should have a doctor and get medical care regardless of whether or not you are old, a veteran, poor, injured on the job, or are a labor union member. (Mea culpa. If I were a baseball fan, I guess I wouldn't be a Yankees fan. Besides, I'm from Pittsburgh. I still remember Roberto Clemente!)

So, frankly I hope to eventually see a single health insurance in our country that covers all our citizens from cradle to grave and still has doctors and hospitals in the private sector where competition will still create incentives to do the best possible job of providing professional medical care.

Even though some of my previous posts reflect some apprehension on my part with the federal government administering the insurance, it really makes the most sense for them to do so. At least, it makes as much sense as calling the police and the police responding as an arm of the state, and not as the result of several calls to local and competing privately owned security companies.

Even if a 10% increase in income taxes had to occur to fund this (tax is to government as income is to your household), would you still be ahead? Certainly, I would. Given the cost to me of insuring my family and my employees I'd still be cash ahead. That doesn't even begin to include the other costs and savings in not having to pay a billing service and freeing up my registered nurse to work with patients and not dicker with their insurances.

Mind you, some proposals suggest this level of tax increase. Others propose that the costs of providing a national health insurance would be more than offset by savings in doing so (The Physicians' Working Group for Single-Payer National Health Insurance, 2003. Proposal of the Physicians' Working Group for Single-Payer National Health Insurance, Journal of the American Medical Association, 200 (6). 798.).

What about you? Run the numbers, do the math. Compare an increase in 10% on your income tax against the costs of your health insurance premiums or deductions from your pay for this, the amount you spend on deductibles and co-pays. Heck, add in the lost income and vehicle maintenance and fuel costs of going to Folsom or Sac for this if you have Kaiser or some HMO. If those costs are higher than a 10% income tax increase for you, let me know.

But, also add in other factors and hidden costs.

What if...

• Every neighborhood had an after hours clinic that would even do house calls?
• You got pregnant and didn't get refused health insurance because your pregancy is a pre-existing medical condition? Hey, what if actually your insurance included more maternity and paternity leave and home care after the delivery?
• What if when you were diagnosed with a really serious disease like cancer, it meant that your insurance stepped up and covered more of the costs when you most needed it?
• What if everyone had insurance, but it didn't affect your choice?
  
• Would it mean maybe we could do better at preventing deaths that are preventable with good medical care? That would be nice, since right now we are 19th best in this out of all 19 major industrialized countries.
• Hey, for that matter, what if better coverage didn't come with higher taxes?

Just sayin'...