Thursday, August 27, 2009

FAQs - Fast Facts - What You Need to Know About H1N1 influenza

I've been getting a lot of questions from my patients about the H1N1 influenza virus, which was commonly described as the swine flu earlier this year.

Naturally everyone is fearful, particularly about the unknown.

Do I need the vaccine?
Research has shown that the H1N1 virus, which is similar to that of the 1918 Spanish flu pandemic, was around until about 1958. Since then, other influenza types have pushed out this variety. In other words, individuals born before 1958 seem to have some immunity. Those born since then have less protection.

(Note the New England Journal of Medicine article - Historical Perspective — Emergence of Influenza A (H1N1) Viruses - July 16th, 2009, notes that the H1N1 human virus disappeared in 1957 and reappeared again in 1977. The 2009 pandemic H1N1 virus is created by multiple other influenza virus components which is beautifully diagrammed here in the Perspective piece The Persistent Legacy of the 1918 Influenza Virus related to the NEJM article).

CDC also observed that those most impacted by the novel H1N1 virus were those 25 years and younger. Specifically:

The information analyzed by CDC supports the conclusion that novel H1N1 flu has caused greater disease burden on people younger than 25 years of age than older people...


The number of reported cases per 100,000 population was highest among people in the 5 years to 24 years of age group (26.7 per 100,000). This was followed by those in the 0 to 4 years of age group, whose case rate was 22.9 per 100,000 people. The rate declined further to 6.97 people per 100,000 in the 25 years to 49 years of age group. The rate was 3.9 per 100,000 people in the 50 years to 64 years of age group. At 1.3 people per 100,000, the novel H1N1 flu infection rate was lowest in people 65 years and older.

This epidemiological data supports laboratory serology studies that indicate that older people may have pre-existing immunity to the novel H1N1 flu virus. This age distribution is very different from what is normally seen for seasonal flu, where older people are more heavily impacted.

As a result, unlike seasonal influenza the recommended group is young adults, age 24 years old and younger down to 6 months old, caregivers watching children 6 months and younger, as well as those ages 25 to 65 years old who have chronic illnesses and pregnant women. Naturally healthcare workers should all be vaccinated.

Typically seasonal influenza vaccine is given to people 65 years or older unlike the H1N1 vaccine. Also groups at risk very much similar to the list above should be vaccinated. In the past children 6 months to 59 months were recommended to have the vaccination as well. That has expanded to children and teenagers up to 18 years old.

So indications for the seasonal influenza vaccine are very similar to the H1N1 except that people over 65 years old won't need the latter.

Will I get a vaccine?
The information so far is that the H1N1 vaccine will be available in limited numbers because it has been difficult to produce. All influenza vaccines are grown in eggs, this is why before getting vaccinated patients are often asked if they are allergic to eggs. Unlike other influenza strains, this particular one has been very difficult to culture which has been frustrating.

As currently planned, the H1N1 vaccine will be given in two shots. Clinical trials are currently ongoing in Austrialia.

It will not protect against the seasonal influenza virus. So if you need that vaccine, you will need to get it as well.

Either vaccine takes at least 2 to 3 weeks before becoming effective and providing immunity.

For healthcare providers and doctors like myself, this means we will need three shots this year!

How dangerous is the H1N1 virus?
It doesn't appear to be any more dangerous that the typical seasonal influenza virus. However, the typical flu virus does kill about 36,000 Americans annually, so even the "normal" flu virus can be dangerous.

Nevertheless, because it is believed those born after 1958 may not have any natural immunity that the numbers of deaths could be much higher. Organizations are bracing for a busy flu season.

What are the symptoms?
Flu symptoms are classically, high fever, diffuse muscle / body aches, and dry cough. People often remember what time and where they are when symptoms first develop. It can last about 1 week.

It is not a bad cold and symptoms don't usually come on gradually over a period of days.

Complications of the flu can include pneumonia and death.

Can the H1N1 virus be treated?
If you contact your doctor within 24 to 48 hours of having onset of symptoms, then an anti-viral medication known as TAMIFLU can be very helpful. If you think you have the flu, then call your doctor as soon as you are suspicious.

How can I prevent getting the flu?
The typical preventive measures like handwashing and keeping your hands away from the eyes, nose, and mouth are helpful. Handwashing technique using regular soap is fine. The key is washing hands for an adequate period of time like 20 seconds.

Also avoid sick people as well.

If I contract H1N1 earlier in the year, am I immune for the remainder of the year?
Yes. However, it would be far better and presumably less misery if you used the vaccine to have your immune system learn what to watch out for in the future rather than contract the virus.

Note that much like seasonal influenza if you've been exposed that this immunity doesn't carry over to the following year as the strains of influenza virus changes annually. This is the reason that flu vaccines are given annually as the contents of the vaccine need to be changed to match the new viruses, while others like pneumococcal vaccine are given years apart simply as a booster.

Where can I find more information?
Learn more and get updated information at the Centers for Disease Control.

Monday, August 24, 2009

Picking the Best Health Insurance Plan - Open Enrollment. Choose Wisely.

It's that time of year again when many Americans have the opportunity to choose their insurance plan for the year. Open enrollment.

Most of us approach the time with indifference, dread, boredom, and often with a flick of a wrist, sign some papers and move on to more important things.

We would be wrong. All insurance plans are NOT created equal. Some are far better than others in keep you healthy and well even though on the surface they appear the same. Research consistently shows that within the US about 100,000 Americans die prematurely because they didn't have the basic things done like blood pressure, cholesterol control, vaccinations, or cancer screenings like mammograms.

The stunning fact? They all had health insurance.

Had they received care from the health insurance plans rated in the top 10 percent in the nation, they would be alive today.

It wasn't that the top 10 percent had the "best" hospitals or "best" doctors, but that insurance plans used their dollars to ensure that their enrollees got the right care that every medical student knows about during training. People over 65 years old should get a pneumovax vaccine to prevent 23 varieties of bacterial pneumonia. Ideally blood pressure should be controlled to less than 140 / 90 or in some cases even less then 130 / 80.

Somehow, this doesn't occur outside the academic classroom. Studies note that Americans only get a little more than half of the recommended treatments and preventive testing noted by organizations like the American Heart Association, American Cancer Society, and doctor groups like the American Academy of Family Physicians.

Result? People dying sooner than necessary, not because they didn't have access to the latest medication or imaging test, but because they didn't choose a health insurance plan focused on keeping them healthy.

So during open enrollment, make sure you choose wisely. There are plenty of places to research to help guide your decision.

In California, the Office of the Patient Advocate rates all of the HMO plans. Note the wide range of ratings from 2 stars to 4 stars. If you are going to spend a lot of money on health insurance to stay healthy and well, why would you chose a plan that is lower ranked? PPO plan ratings will occur in 2010.

For others, the National Committee for Quality Assurance has an excellent report card system as well ranking Commercial programs (health insurance companies), Medicare, and Medicaid programs. Fortune 500 companies use these reports to determine which plans to offer their employees. So perhaps the decision of offering you the best health insurance plan has been made for you already!

100,000 Americans with health insurance died prematurely because they didn't choose wisely. If you have a choice, then make an educated one so more likely than not you will be here another year to spend with family and friends.

Thursday, August 20, 2009

Is healthcare reform a win or a loss for Americans?

Although the media has been focused on repeating the same town hall meeting shouting matches, one should look carefully at other thoughtful pieces appearing in business magazines like Fortune and Money which claim to have the objective truth about healthcare reform.

Because they have it wrong as well.

Shawn Tulley, editor at large for Money, wrote "You'll lose 5 key freedoms under health care reform" specifically indicating that Americans will lose the ability to have high deductible insurance plans funded by health savings accounts (HSAs) as well as the ability to seek specialty care without first being evaluated by a primary care doctor.

My concern about HSAs is a philosophical one, but important. Do patients understand when they can safely skip and when they need to be seen by a doctor or get the preventive tests they need? Unlike auto insurance, having a dent in the car left unchecked is one thing, but what about one's body? Research shows those most likely enrolled in HSAs are doctors and accountants which makes complete sense. The former know when to seek care and when to safely skip. The latter understand the tax advantage of HSAs. Patients in high deductible insurance plans are generally less satisfied, would prefer to return to comprehensive health insurance if given the opportunity, and typically avoid getting necessary testing or treatment done due to cost.

I've heard the argument that consumer driven healthcare will make people better consumers. Please. We've tried this with retirement planning. Employers jettisoned their pension plans and moved workers to 401k plans where employees would have more responsibility and skin in the game to do the right thing and plan for retirement well.

Companies discovered that people don't do what is in their best interest. Many never enrolled. Others invested simply in cash unaware that they needed to make investment decisions. As a result, employers are requiring new employees to opt-out of the 401k program rather than opt-in and changing the default investment to a target date mutual fund. It isn't that people don't want to do the right thing. They do. But if they can't handle retirement planning, how well do you think they will do with healthcare planning?

Which leads to the next cherished freedom that supposedly will be given up. The freedom to choose your doctors. Certainly having a trusted primary care doctor who can help get you better and help you navigate the healthcare system is critically important much the same way a trusted financial adviser can help people avoid pitfalls and traps. Was it poorly done a decade ago? Yes. No one I know of goes to medical school to become a "gatekeeper". We all train to become doctors. Some of us become primary care doctors - family physicians, internists, pediatricians, obstetricians / gynecologists - while others become specialists.

Mr. Tulley makes the mistake that many patients do in believing that getting the best care means "freedom" to access all tests, hospitals, specialists, and imaging studies. Is that what people really want or do they simply want the right doctor, the right care at the right time?

The supposed freedoms given up would not as be terrible Mr. Tulley claims since they are responsible for allowing the US to have the worse healthcare outcomes of any industrialized country in the world, highest costs per capita, and shut out millions from accessing medical care by being uninsured.

It's this kind of misinformation that is troubling. The quiet thoughtful analysis which is dead wrong.

Thursday, August 13, 2009

What Was Good for Grandma Doesn't Work For You - Get Screened for Cancer!

We all have selective memories enhancing good experiences and downplaying bad ones. This phenomenon is particularly common when counseling patients on what preventive screening tests should be done and the need for blood pressure and cholesterol medication to decrease risk of heart attacks and strokes.

The typical office conversation boils down to this -"My grandmother lived to 95 and never saw a doctor in her life and never took medications for anything". This could be in fact true.

Unfortunately, there are key differences with grandma who lived a generation ago and today. This is quite obvious with a recent report in the NY Times which noted that Hispanics that moved to the US had higher cancer rates. In some cases, the risk of cancer increased by 40 percent!


Researchers speculate that one reason for the increase in cancer risk is that immigrants quickly adopt new, less healthy dietary and lifestyle habits, such as increased alcohol consumption, after moving to the United States. It is also possible that some of the increase may be due to more aggressive diagnostic measures in the United States that result in greater cancer detection compared to other countries.
In other words, our lifestyle, what we eat and drink as well as what we do (or not do in terms of physical activity) impacts our likelihood of developing illness. What is particularly disturbing about this article is the speed in which immigrants begin to develop cancers after moving to the United States. In the past, it appeared it took at least a couple generations before immigrant populations began to have illness similar to their adopted countries.

Research has shown that Japanese immigrants to the United States have the same low risk of heart disease as native Japanese inhabitants. By the fourth generation of Japanese Americans, the risk of heart disease is identical to that found among the general American population. It's not just that the type of foods available vary greatly from the native countries, but that it is far more available, less expensive, and individuals work less at acquiring food than generations ago.

This is particularly apparent after I finished reading (actually listening) to the book by Michael Pollan - The Omnivore's Dilemma. The food industry has made the type of foods we eat, more corn based and more meats, because of use of technology, antibiotics, pesticides, and hormones to boost yields of produce and animal products. Consequently the make up of the food is very different than what grandma ate. Is the flesh of a chicken breed purely for breast meat, confined in a tight space with other chickens, fed a diet of corn the same as a chicken roaming on fields and feeding on the variety of food sources found on a typical farm the same type of meat?

He suggests that the food is different and can increase the risk of illness. So not only is the type of food potentially different than what grandma ate, but also far more plentiful and cheaper. As a result, we are eating far more meats routinely than what used to be a periodic indulgence. Grandma probably spent more time gathering and preparing food than we do now. (My grandparents killed chickens on their farms for dinner. The food was amazing).

For better or worse, we've outsourced this responsibility. Vegetables come triple washed and cut. Meats no longer look like pieces of the animals they are from. What's for lunch or dinner? Microwavable meals. Baked products? Simply add water.

What does this mean for you and me? Since we can eat more than ever because food is cheaper than the past and the amount and types of food we eat has changed, the composition of food may be very different than years ago as the food industry uses technology to boost yields, and we spend less time finding and preparing food, our lifestyle is fundamentally different than our grandparents.

As a consequence, we need to treat our health differently and screen for illnesses. An excerpt from my book on recommended guidelines to discuss with your doctor is found here.

So I suppose the commonly quoted phrase is true - you are what you eat!

Tuesday, August 4, 2009

Are Health Savings Accounts - HSAs - Right for You? The Rules. The Truth.

Increasingly more Americans are being offered health savings accounts (HSAs) either from their employers or when choosing individual insurance plans.

What are they?

What are their advantages?

What are their disadvantages? (There is no free lunch after all).


Definition - Health Savings Accounts were enacted under President George W. Bush and allow individuals to save money tax-free for medical expenses. Unlike previous medical savings accounts, money not used within a particular year can be rolled over. In other words, the "use it or lose it" problem no longer applies.


HSA funds can be invested like retirement accounts into various mutual funds, bonds, savings accounts and those earnings are tax-free.


When the funds are spent on appropropiate medical expenses as defined by the IRS, the transaction is also tax-free.


In other words, HSAs are the only financial vehicle that essentially never gets taxed when done correctly. Set aside money tax-free (like your 401k), invest (if you want to) and earnings are tax-free, and finally spend money tax-free on medical expenses. You aren't obligated to use HSA funds to pay for medical expenses if you have other dollars available. In fact, after age 65, you can take out the money from the HSA, pay some taxes like your 401k, and voila use it like your other retirement accounts. There are NO income restrictions on who can get a HSA.


Sound too good to be true? Is it right for you? Depends.


The catch are at least a couple, not major, but you must know.


First to have a HSA it needs to be paired with a high deductible insurance plan. Unlike health insurance policies that you may have had in the past, you now have to pay a deductible before the insurance policy kicks in. Very similar to your auto insurance policy. Consequently, doctor office visits won't be the small copay, but potentially a hundred or two hundred dollars. The same may apply to prescription drug coverage.

Despite a higher cost when you use healthcare services, you still may have more take home pay. A high deductible insurance plan typically has lower monthly premiums. If you set aside money for your HSA you have less taxable income. Just be prepared for a little sticker shock. Of course, you can use the money you set aside in the HSA to pay for these expenses.


The second, which is far more important, is will you know when to seek medical care and when to safely skip? Unlike your car which many of us will defer repairs for damages in fender benders, will you know when you must spend money?

Research already shows that patients often skip important needed preventive care, medications, and doctor visits when copays go up. Should you pay for the colonoscopy, which is easily a few hundred dollars, to screen for colon cancer at age 50 even if you feel perfectly well and have no family history (Yes). Finding cancer early is far less expensive than waiting and needing abdominal surgery as well as chemotherapy, which costs tens of thousands of dollars and not only drains whatever other savings you have, but will be unlikely to extend your life. If only you had done the right thing.


HSAs favor those who will be proactive in taking care of themselves and knowing when to go seek medical care, when to invest money to stay healthy, and not "wing" it. Perhaps it isn't surprising then that doctors and accountants are people most commonly enrolled in HSAs. The former know when to get medical care and when to safely skip. The latter know all about the major tax savings as well as the ability to use a HSA as a retirement account.

For the rest of us, this is why I wrote my book - Stay Healthy, Live Longer, Spend Wisely - Making Intelligent Choices in America's Healthcare System - which gives you all the information you need to know to use the HSA wisely.

  • How to make the most out of your office visit (after all each visit will cost more).
  • The truth about prescription drugs (is the marketing really worth the hype?)
  • What tests you must have to stay healthy and well (saving money by being uninformed will cost more in the end don't be ignorant).
  • Assembling the right team of doctors.
  • How to pick a health insurance plan and hospital.
  • Websites that are free and excellent references (far better than simply Googling).
  • Body scans, herbal dietary supplements (buyer beware).
  • Much more and all for less than a price of a copay or a date to the movies! Your health is worth far more. What you don't know might kill you sooner!

Are HSAs good for you? As a doctor and someone who studied accounting at business school, I would have no problem enrolling. If I wasn't a doctor, I would always have some uncertainty about whether I was doing the right thing.

No need to worry, my book is written in an easy to read language that anyone can pick up. It's an insider guide just for you and your friends who will now have the knowledge I give my loved ones all the time.

So go ahead and save some money on healthcare, but make the right choices, be informed, be educated, and be empowered. Save money and stay healthy.

Monday, August 3, 2009

Nurse Practitioners NOT the Answer for the Primary Care Crisis

Time recent article titled, "If a Health-Care Bill Passes, Nurse Practitioners Could Be Key" bothered me not because I see nurse practitioners as competitors. It disturbed me because the article had elements of truth to it and yet reached the wrong conclusion.

"[Nurse practitioners - NPs] can often treat and diagnose patients, as well as prescribe medication. And they can do these things at a lower cost than doctors — Medicare, for example, reimburses nurse practitioners 80% of what is paid to doctors for the same services."

This is true. Problem? The issue isn't about how much the primary care provider makes but rather how many tests, imaging studies, and medications are ordered that drives overall healthcare costs (as noted recently in Atul Gawande's New Yorker piece).

While there is no question that NPs generally are far better than doctors with bedside manner, good bedside manner and focus on prevention isn't going to stop healthcare costs from rising.

In my experience, these primary care providers, which Congress includes NPs and physician assistants (PAs), are very skilled when part of a team of specialty care, like orthopedics, hospice, oncology, neurosurgery, etc. Their depth of knowledge is typically far more than a primary care doctor has, which makes sense.

However, I've noticed that when it comes to the field of primary care these alternative primary care providers don't do particularly well unless the diagnosis is very straight forward.

Why?

The challenge in primary care (and often why many colleagues of mine wonder why I find primary care so interesting) is the level of uncertainty that exists with every patient encounter. When someone walks in the door, you haven't the foggiest idea what you are dealing with. What Clay Christensen calls "intuitive medicine" relies heavily on the doctor's cognitive and deductive reasoning skills. As medical students know, 90 percent of getting the right diagnosis is from the patient history and the physical exam. At this point, a doctor has a list of working hypotheses or what is known as a differential diagnosis of the possible causes of a patient's symptoms. If lab work and imaging studies are needed, then they are done to help clarify the diagnosis in situations where there are at least two plausible causes and the treatments vary drastically enough that knowing precisely what is wrong matters.

As the TIME article notes, "Nurse practitioners may have less medical education than full-fledged doctors, but they have far more training in less measurable skills like bedside manner and counseling."

When it comes to primary care, less medical education, in my experience for NPs and PAs while many be less expensive per provider in terms of salary are usually more expensive in testing, lab work, and medication. I don't fault them any more than I fault my colleagues going into specialty medicine. Primary care is a really tough field.

Perhaps that is the real issue. Primary care is often seen as easier and hence replaceable by other less expensive providers when it should be looked at as a very cognitive specialty that deserves the same level of respect as others. No one talks about cardiology NPs or oncology NPs being the primary care providers in those specialties.

The crisis in primary care is real. If healthcare reform was serious about increasing the number of primary care doctors now, there are many doctors in training in the pipeline now in medical schools and interns. Immediately wipe out their medical student loans, give them a stipend, and a short commitment in underserved areas so they all have incentive to commit to primary care rather than think about fellowship training in a specialty field. (Because of the shortage of primary care doctors in Massachusetts after universal coverage, I suppose working in that state should count). Add bonus payments to the second and third year internal medicine residents so that they seriously think about dropping their fellowships.

There is no question that doctors must improve our bedside manner and our focus on prevention. NPs and PAs do have a role. It isn't in "intuitive medicine" but rather "precision medicine" where clear rules and treatments apply. Strep throat and bladder infections (known in medicine at UTI - urinary tract infections) can be done by these providers as well as allowing them to counsel and focus on wellness and prevention. No doubt this is why they were chosen to run the walk-in retail clinics found at Target and Wal-mart.

But, don't equate their skills to be comparable to a well-trained primary care doctor when it comes to figuring out what is wrong with you. In my experience they tend to order more tests, more medications, and more imaging, which then begets more tests, more medications, and more imaging. The cost per provider may be cheaper, but the cost to the entire healthcare system is more expensive.

Sunday, August 2, 2009

Healthcare Debate - Common Misconceptions and the Truth

Associated Press released an excellent article - "FACT CHECK: Distortions rife in health care debate" which unfortunately won't be taken as seriously as 30 second soundbites that sadly distort the truth significantly.

As a doctor who is trained in scientific thinking and bases diagnoses and treatments on research, watching the robust discussion and the spin occurring is not only disappointing, but disheartening.

It's too easy to say single payer, malpractice reform, "evil" pharmaceutical and insurance companies, and "greedy" doctors, when the entire healthcare system needs overhaul. Frankly that is why the debate is so difficult. Perhaps as a result, we should be optimistic that with enough people engaged in the dialogue that the right set of answers and solutions will occur. That will only occur, however, after a painful but important conversation we must all have to advance our country forward.

The entire Associate Press article follows.


By CHARLES BABINGTON, Associated Press Writer Charles Babington, Associated Press Writer – Sun Aug 2, 12:58 pm ET

WASHINGTON – Confusing claims and outright distortions have animated the national debate over changes in the health care system. Opponents of proposals by President Barack Obama and congressional Democrats falsely claim that government agents will force elderly people to discuss end-of-life wishes. Obama has played down the possibility that a health care overhaul would cause large numbers of people to change doctors and insurers.

To complicate matters, there is no clear-cut "Obama plan" or "Democratic plan." Obama has listed several goals, but he has drawn few lines in the sand.

The Senate is considering two bills that differ significantly. The House is waiting for yet another bill approved in committee.

A look at some claims being made about health care proposals:

CLAIM: The House bill "may start us down a treacherous path toward government-encouraged euthanasia," House Republican Leader John Boehner of Ohio said July 23.

Former New York Lt. Gov. Betsy McCaughey said in a July 17 article: "One troubling provision of the House bill compels seniors to submit to a counseling session every five years ... about alternatives for end-of-life care."

THE FACTS: The bill would require Medicare to pay for advance directive consultations with health care professionals. But it would not require anyone to use the benefit.

Advance directives lay out a patient's wishes for life-extending measures under various scenarios involving terminal illness, severe brain damage and situations. Patients and their families would consult with health professionals, not government agents, if they used the proposed benefit.

CLAIM: Health care revisions would lead to government-funded abortions.

Tony Perkins of the Family Research Council says in a video, "Unless Congress states otherwise, under a government takeover of health care, taxpayers will be forced to fund abortions for the first time in over three decades."

THE FACTS: The proposed bills would not undo the Hyde Amendment, which bars paying for abortions through Medicaid, the government insurance program for the poor. But a health care overhaul could create a government-run insurance program, or insurance "exchanges," that would not involve Medicaid and whose abortion guidelines are not yet clear.

Obama recently told CBS that the nation should continue a tradition of "not financing abortions as part of government-funded health care."

The House Energy and Commerce Committee amended the House bill Thursday to state that health insurance plans have the option of covering abortion, but no public money can be used to fund abortions. The bill says health plans in a new purchasing exchange would not be required to cover abortion but that each region of the country should have at least one plan that does.

Congressional action this fall will determine whether such language is in the final bill.

CLAIM: Americans won't have to change doctors or insurance companies.

"If you like your plan and you like your doctor, you won't have to do a thing," Obama said on June 23. "You keep your plan; you keep your doctor."

THE FACTS: The proposed legislation would not require people to drop their doctor or insurer. But some tax provisions, depending on how they are written, might make it cheaper for some employers to pay a fee to end their health coverage. Their workers presumably would move to a public insurance plan that might not include their current doctors.

CLAIM: The Democrats' plans will lead to rationing, or the government determining which medical procedures a patient can have.

"Expanding government health programs will hasten the day that government rations medical care to seniors," conservative writer Michael Cannon said in the Washington Times.

THE FACTS: Millions of Americans already face rationing, as insurance companies rule on procedures they will cover.

Denying coverage for certain procedures might increase under proposals to have a government-appointed agency identify medicines and procedures best suited for various conditions.

Obama says the goal is to identify the most effective and efficient medical practices, and to steer patients and providers to them. He recently told a forum: "We don't want to ration by dictating to somebody, 'OK, you know what? We don't think that this senior should get a hip replacement.' What we do want to be able to do is to provide information to that senior and to her doctor about, you know, this is the thing that is going to be most helpful to you in dealing with your condition."

CLAIM: Overhauling health care will not expand the federal deficit over the long term.

Obama has pledged that "health insurance reform will not add to our deficit over the next decade, and I mean it."

THE FACTS: Obama's pledge does not apply to proposed spending of about $245 billion over the next decade to increase Medicare fees for doctors. The White House says the extra payment, designed to prevent a scheduled cut of about 21 percent in doctor fees, already was part of the administration's policy.

Beyond that, the nonpartisan Congressional Budget Office said the House bill lacks mechanisms to bring health care costs under control. In response, the White House and Democratic lawmakers are talking about creating a powerful new board to root out waste in government health programs. But it's unclear how that would work.

Budget experts also warn of accounting gimmicks that can mask true burdens on the deficit. The bipartisan Committee for a Responsible Federal Budget says they include back-loading the heaviest costs at the end of the 10-year period and beyond.

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