Monday, March 24, 2008

Calculate Your Heart Attack Risk Now!

You can easily calculate your risk of having a heart attack or dying from a heart attack by going to the National Cholesterol Education Program's website. All you need to know is your cholesterol (total and HDL - good cholesterol), your latest blood pressure, and whether you are on medication to control blood pressure. The other information you need you should know already - your age, gender, and whether you smoke.

The number generated is your risk of having a heart attack over the next 10 (TEN) years. If your risk is 5 percent, that means if 100 people with the same risk profile, i.e. same cholesterol, blood pressure, age, gender, etc., were followed over 10 years, five of those individuals would die or suffer from a heart attack over that time. The other 95 individuals would do just fine.

The calculator should not be used for people who have diabetes or who have had a heart attack or heart disease (coronary artery disease) in the past as these individuals are already considered high risk.

While you cannot change risk factors like age or gender, other risk factors for heart disease are modifiable. Blood pressure and cholesterol can be lowered. For one thing, you can decide whether or not to smoke, and whether or not to eat well. If, after taking the test, you discover that your risk is 10 to 20 percent or 20 percent or higher, you should check with your doctor. He may suggest that diet and exercise are enough or if a cholesterol-lowering medication needs to be prescribed to further decrease your risk.

Remember that this is only a tool and is not a substitute for sound medical advice. Even if your number is low, you still need to do the right things to stay healthy. Heart disease is the leading cause of death in this country, but don't ignore the second leading cause of death, cancer, either. You should, however, review your numbers with your doctor at a future visit.

The calculation is based on the information and findings from the famous Framingham Heart Study. This research study initially started in 1948 and followed a group of over five thousand adults, ages thirty to sixty-two, with extensive physical examinations, history taking, and blood work every two years to determine risk factors and patterns for heart disease. In 1971, the study followed a similar number of the original participants’ adult children and their spouses. Though the data was based on thousands of people over a period of years, the calculation may not be entirely accurate for individuals who are non-white (the study was performed on people living in Framingham, Massachusetts, which at the time of the study was predominately Caucasian). Nevertheless, we can thank the study for our current understanding that addressing high blood pressure, high cholesterol, smoking, obesity, diabetes, and physical inactivity decreases the risk for heart disease.

When you use the calculator, you are in fact using evidence-based research to determine your risk of heart disease. See if your doctor uses the same way to determine your risk next time you see him or her.

Wednesday, March 19, 2008

McCain's Healthcare Plan is the Worst - Consumer Driven Healthcare Not the Answer

FORTUNE magazine published an opinion piece in their March 17, 2008, issue titled Why McCain has the best health-care plan. McCain like many of his fellow Republicans believes that giving individuals more responsibility is a way to solve the healthcare crisis.

Frankly, expecting Americans will use tax incentives to find their own healthcare insurance is laughable. Already when tasked to fund their own retirement, the vast majority don't want the responsibility, are inadequately prepared and planning to work longer. This is despite planning for their retirement is in their best interest. Who wants to be forced to work longer if they don't have to? Companies are discovering that although they relinquished their responsibility of helping their employees' retirement by eliminating the pension plans for the cheaper 401k plans, workers are not better off. Many workers even fail to enroll in the 401k plans and many that do are only invested in the money market option, which won't keep up with inflation. Now many employers are stepping in, requiring mandatory 401k enrollment (workers can opt out), and defaulting the funds into a mutual fund that has better returns.

Experts who believe that the consumer will make the right choices when given the important job of finding their own health insurance, funding it, and making best use of it obviously aren't aware of the consumer experience with retirement planning. An entire industry has developed to help people plan for retirement. Will the same occur in healthcare? Who will be the healthcare advisors? Doctors? Insurance agents? A new field of advisors?

If the public approaches the responsibility of healthcare insurance the same way it does with personal retirement planning, our country is in big trouble. Unfortunately unlike postponing retirement, a person can't predict or delay when he will get ill. Relying on the public to shop for healthcare will result in many more being uninsured, others not getting preventive care, and a workforce that will be increasingly unhealthy and unable to compete in a global market. As an insider I know what to do in this new world, but what about the rest of us? Specifically, what about you?

Monday, March 17, 2008

Medicare Restricts Reimbursement for Anemia - Better Patient Care?

A recent FDA advisory committee recommended that anemia medications, Procrit, Epogen, and Aranesp be not used in patients with breast cancer, head and neck cancers and used in patients with incurable cancers. These anemia medications are typically used to support cancer patients, who develop anemia, as a result of chemotherapy. This most recent FDA recommendation follows research studies which reported last year that these medications may have caused more deaths and contributed to tumor growth.

From the article:
  • In its efforts to overturn Medicare's new reimbursement policy, Amgen Corp. spent more than $16 million on lobbying last year and nearly $700,000 on campaign contributions, according to the Center for Responsive Politics. Amgen manufactures all three of the anemia drugs involved — Aranesp, Epogen and Procrit. Johnson & Johnson markets Procrit.
  • The aggressive lobbying campaign succeeded in generating numerous letters and speeches from lawmakers denouncing Medicare's actions and in legislation that would have voided the rule if passed.
  • Many doctors and consumer groups joined in the criticism last year when Medicare made its decision to restrict when it would pay for treatments. Amgen and J&J argued again Thursday that the safety problems cited by FDA have been inconsistently reported across dozens of studies. And they pointed out that only studies involving higher-than-recommended dosing levels showed significant safety risks.
  • The two drug companies have asked for more leeway from Medicare to reimburse doctors for maintaining hemoglobin levels up to 12. The Congressional Budget Office estimated that overturning CMS's decision could increase government spending by as much as $5.3 billion over the next decade.
What is fascinating isn't the science behind this, but the outcry from doctors, lawmakers, and the public when Medicare decided last year only to reimburse doctors if the medications were administered to patients with a hemoglobin of 10 or less (hemoglobin is a measure of the amount of red blood cells). A hemoglobin of 10 was derived from the research that suggested patients given these medications with higher hemoglobins did worse. Although the manufacturers argued that perhaps doctors were administering the medications at higher than recommended levels, doctors generally don't change practice behavior based on medication label warnings as quickly as they do when reimbursement is decreased or no longer covered.

Naturally everyone has a financial stake in seeing this ruling overturned. The pharmaceutical companies will see sales of their medications decrease as there are fewer indications (note their consumer-directed ads about these medications). Doctors will have their reimbursement decreased because they also will have fewer patients to give this medication to, even though the science suggests that many of these patients not only shouldn't get this medication but also that they could do harm. Patients, aligned with their doctors, will see this as a takeaway. Lawmakers, focused on getting re-elected would rather be seen on the side of their constituents, patients and doctors, and lobby against the FDA or Medicare as again taking a valuable benefit away.

Yet, when all is said and done, the heroes in the process, those that are protecting patients by altering doctors' behaviors to comply with the latest in research and those that are protecting the taxpayers by assuring that we are paying for the right care, are buried by massive lobbying and public relations campaigns. Perhaps this is why our healthcare system is in crisis because at the end of the day it isn't about the science, but about where the money goes.

Saturday, March 8, 2008

My interview on Positive Living with Patricia Raskin

This past week I was thrilled to speak on the debut show of Positive Living on TalkZone with talk show host Patricia Raskin about my book. She has interviewed other doctors, like Dr. Mehmet Oz (Oprah's doctor) as well as Dr. Dean Ornish.

We spoke about the state of the healthcare system, the differences between brand and generic drugs, the ability to fund healthcare costs with health savings accounts, and what tests you must do to stay healthy. What you don't realize is our healthcare system on average gets the right preventive tests done 55 percent of the time. As a result, 80,000 Americans (twice the number of women who died of breast cancer) died prematurely last year because they didn't get their blood pressure, cholesterol, and / or diabetes controlled levels recommended expert medical committees and / or didn't get screened for colon cancer or breast cancer. Had they accessed a high quality health insurance plan, which may be no more expensive than what they currently have, they would be here today with family and friends.

The biggest mistake people make is that they think that all health insurance plans, doctors, and hospitals are created equal. They aren't and for you to make sure you are getting what you deserve, you need to research much the same way you do for a car. Incidentally, even if you doctor has great bedside manner it doesn't mean he has made sure you are up to date on the latest preventive screenings. Research shows on average it takes 17 years for a new guideline to be commonly practiced in the country. So if you weren't a doctor or didn't have a friend who was a doctor, how would you know if you were getting the right care?

As a practicing front-line primary care doctor I am extremely concerned about the future of our healthcare system, its current crisis, and how it on average fails you, the patient. Until there is real healthcare reform, it is up to YOU to make the right choices to stay healthy, live longer, and spend wisely. It's not hard. It's up to you.

Wednesday, March 5, 2008

Colonoscopies Miss Colon Cancer

A report in the Journal of the American Medical Association found that flat colon polyps, which are harder to see than raised polyps, were ten times more likely to be cancer. Japanese gastroenterologists found these harder to detect flat polyps by using a dye during colonoscopy. The study also found that having a colonoscopy wasn't enough for adequate screening, but rather how much time and care the doctor took to examine the colon. From the report:

  • The growths tend to be smaller when they are cancerous — the size of a nickel instead of a quarter — and are level with the colon wall or depressed like a pothole. They blend in with the surrounding tissue and are difficult to spot.
  • While knobby polyps were found in four times as many participants, more than half the colon cancers found — 15 of 28 — were in flat and depressed growths. Thirteen were in polyps.
  • Undetected flat growths could explain some mysterious "interval cancers" that show up between screenings in people who have regular colonoscopies, experts said.
Currently the recommended guidelines for colon cancer screening include having a colonoscopy every 10 years starting at the age 50. Recently updated colon cancer screening guidelines from the American Cancer Society now include virtual colonoscopy as well as a stool DNA test. These two newer techniques join screening by using a flexible sigmoidoscopy every 5 years with or without annual stool testing for occult blood or screening via a barium enema. For individuals at average risk (i.e. no family history of colon cancer or no personal history of medical problems like ulcerative colitis that increases an individual's risk of colon cancer greatly), any one of these interventions should begin at age 50.

While I understand the addition of a virtual colonoscopy, which may be more acceptable for the public to accept rather than having a endoscope inserted into the colon for evaluation, I'm not so sure that the radiation exposure related to this screening test is justified. I suspect in the end it was added because:

  • The biggest issue is not which screening a patient should get, but that patients come in for screening. All colon cancer deaths can be averted through screening and early treatment, but only 30 percent of people recommended to get screenings actually do, according to the Cancer Society.
  • "The challenge we have is getting people to participate in screenings," said Jack Mandel, an Emory University epidemiologist who has studied colon cancer screening tests. "We can prevent these deaths."

Monday, March 3, 2008

Obama Rhetoric for Healthcare Reform Plan Is No We Can't

Bill Weir, anchor of Good Morning America Weekend, said this weekend about the healthcare proposals offered by Senator Obama and Senator Clinton in the following way.

Senator Obama's plan is "built on political realism."
Senator Clinton is "sticking to a plan that is built on idealism."

Ironic, isn't it? Senator Obama, who has great vision and inspires many, falls very short on his rhetoric of "Yes, We Can" when it comes to healthcare. Why is that? He promises a brighter future for all of us and says that he is the agent of change. He states that this generation must, like generations before, take charge and bring new hope to a country that badly needs it.

Yet, when it comes to healthcare insurance, which as a doctor I see as a necessity and not a luxury, he with his advisors instead opt for a piecemeal incremental plan rather than a politically risky plan that would mandate all Americans to purchase health insurance. How do you think people felt decades ago when they were told that their wages would be taxed to fund new radical programs called Social Security and Medicare? Was it the right thing to do? Was it politically difficult to have it implemented?

Leadership involves making good choices consistently over a long period of time. Obviously one can't be right all of the time. While Senator Obama argues that his decision against authorizing the use of force against Iraq shows good judgment, time will tell. One good or bad decision doesn't make a good leader but the number of decisions over time as leaders will be tested over and over again. His stance on healthcare reform, particularly for a Democrat, shows that he is very much like all other politicians in looking for political expediency rather than the idealism that he portrays in his public appearances.

This past weekend I was fortune enough to hear General Colin Powell speak about leadership. Although he didn't mention who he supported for the presidential nomination, he did note that the American public wanted a leader who had vision and who was experienced. He reflected on how Jimmy Carter, Bill Clinton, and the current George W. Bush, didn't have worldly experience prior to entering the White House. General Powell, however, had praise for George H.W. Bush, the 41st president, who was ambassador to China and also head of the CIA previous to inhabiting 1600 Pennsylvania Avenue. The elder Bush had world experience and a deep understanding on what can be done and what needs to be done. It is this kind of wisdom one hopes the American public will value as the next president.

How does this get back to healthcare? We need leadership in this country for both foreign and domestic issues. Healthcare reform will only occur if true leaders step forward and take risks because it is the right thing to do. Besides hearing General Powell, I also heard Professor Uwe Reinhart, healthcare economics expert at Princeton speak. As he noted in the ABC Good Morning Weekend video is regards to American politicians is that "they just don't have the guts. They are gutless wonders when it comes to healthcare." I hope he is wrong.

Sunday, March 2, 2008

Republican Healthcare Proposal Is Not Universal Coverage

The Republican candidates' proposal for healthcare reform does not provide universal coverage and is far more radical than those offered by the Democrats. Unlike Senator Clinton and Senator Obama, who would create a new government agency or system to offer the insurance plans available to members of Congress for those individuals who are unable to get coverage through their employers, the Republicans instead propose to give individuals and families tax credits to buy insurance. They want individuals to have the ability to buy insurance from other states where they currently reside. They would remove the states ability to regulate insurance companies arguing that individuals from one state should be free to purchase another plan offered at another state if it is cheaper. Currently insurers have to abide by state law, so if one state requires insurers to provide certain benefits, the cost may be significantly higher than another state which does not have those requirements. It is hoped that with the tax credits and allowing competition of insurance plans from different states that health insurance will be more affordable. Republicans believe quite strongly in consumer driven healthcare.

By changing the tax code and asking individuals now to shop more for health insurance, rather than employers, in many ways is very different than how the majority of Americans get health insurance. Currently, large employers are working directly with insurers and doctors demanding that they deliver high quality healthcare so workers simply need to choose from available plans during open enrollment. They don't need to worry about tax credits or taking the time to research what health insurance plan is best for them. Frankly, research shows that Americans don't want the responsibility of researching health insurance plans because it is so confusing.

What they propose mirrors what occurred with employers regarding retirement plans. In the past companies provided employees a pension plan. When they became too expensive to administer, most shifted from providing pensions to 401k plans, where individuals were simply given money to invest. Since everyone plans to retire, one would have thought individuals with the new responsibility would have taken an active role and invested wisely. What research has shown is in fact that they often don't enroll in 401k plans, and if they do enroll they don't actively manage their money or don't know how to invest, so that now many can't retire. Companies are now changing their policies and requiring employees to opt-out if not interested and are investing the money in a mutual fund with a retirement target date on behalf of their employees.

I expect the same behavior to occur when it comes to health insurance. It would seem that individuals would take charge of their health because they have more "skin" in the game. They might change their behaviors of smoking, overeating, alcohol use, and adopting a sedentary lifestyle and replace it with a healthier one. Perhaps, but from the retirement savings example, I doubt it. If you don't mandate people to do something they won't. The stakes are far higher than that of retirement planning. At least you can always make more money if you are healthy. If you are sick, you can't necessarily buy yourself good health. Too many of us take our health for granted. It is so precious and precarious that even the most healthy and unassuming children, who haven't had the chance to abuse their bodies can get very ill from cancers and other illnesses.

My biggest difficulty accepting the Republican plan is that I think health insurance is not a luxury or an optional purchase but a necessary requirement for individuals to stay well and if one gets ill, it prevents someone from going bankrupt as he tries to get better. This plan doesn't seem focused on providing universal coverage even though the American Cancer Society estimates that 1 in 2 men and 1 in 3 women during their lifetimes will develop cancer, the second leading cause of death. Note this statistic does not include skin cancer, which is extremely common or the leading cause of death, heart disease. This means we all can expect a medical problem sometime during our lives. What isn't clear is when.

Time will tell if this is the right plan for our country.


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