Critical Condition

IN DEFENSE OF ICONOCLASM -THE DEFENSE OF DR J DOUGLAS BREMNER

2009-09-16T17:39:00.000-07:00

Having read the Open Letter to Dr. J Douglas Bremner of Emory University published on September 12, 2009 by Dr. David Gorski in Science-Based Medicine Blog in defense of Dr. Peter Lipson’s criticism of Dr Bremner I was immediately brought back to three articles all published in the 1999 medical literature.

One was by Dr Elliot Fisher from Dartmouth who was among the very first to dare to ask the basic question about “more possibly being worse” in US bio-medicine in JAMA. The second and third articles were from Dr Larry Dossey who then edited the journal Alternative Therapies in Health and Medicine who wrote eloquently about intolerance among bio-medical scientists toward even considering Alternative Medicine.(Dossey, Larry‘You people’: intolerance and alternative medicine. 1999;5(2):12-17,109-112)

I would ask Drs Gorski and Lipson if an iconoclast like Dr Bremner might be serving a valuable role as gadfly to an entrenched failing status quo in bio-medicine who have made the mistake of deifying science? I would posit that the very essence of science is always and incessantly asking the question- “is it possible that I may be wrong?”. And I strongly support the return of narrative- the patient’s individual story- to the practice of medicine. The incomparable Sir William Osler, one of my heroes in medicine, knew that well.

I believe that of all the determinants of successful US bio-medicine medicine going forward that a strong dose of humility is in very tall order.

To make progress our egos must die first- a basic psychiatric principle. It is much better and much more important to be tolerant and kind than to be right.

I support Dr Doug Bremner’s role as a colorful and passionate iconoclast. We need more just like him.

Dr.Rick Lippin
Southampton,Pa

THE US NEEDS AN IMPROVED CDC-What Went Wrong and What Can Be Done?

2009-04-14T15:25:00.000-07:00

The US Centers for Disease Control(CDC), almost synonymous with US public health, is clearly one of the most important health agencies in our federal government. Comprised of 7coordinating Centers with approx 8,800 total employees and a budget of approx $8.8 billion dollars the CDC is also one of our largest federal health agencies. While both its vision statement and mission statement are commendable, in recent years its seems to have gone “off track” and like, most of our federal agencies, and requires at the very least significant improvements- at best and, what this writer recommends, a major overhaul

This brief essay will explore my personal opinion as to where the CDC went wrong and suggest some solutions.

DOING GOOD MEDICAL SCIENCE IN THE ERA OF DEREGULATION AND INFLUENCE OF RELIGIOUS AGENDAS

First and foremost is the CDC attempting to fulfill its good mission in an almost 30 year period of emphasis on deregulation and excessive emphasis on partnering with the for profit sector. While this pressure has been felt by all of our health agencies it seems to me that since public health efforts do not generally generate profits perhaps this trend may have differentially impacted the CDC? However personally I do not know to what extent the CDC’s programs have been directly affected by this trend other than by anecdote. The US GAO (Government Accountability Office) has published a limited number of reports on the CDC. Then there is The CDC Foundation which describes and applauds the CDC's public/private partnerships in some detail.(note Board of Directors). Now I believe that public/private partnerships are both necessary and desirable as long as strict conflict of interest and disclosure rules with teeth in them are enforced which I suspect has not been the case in recent decades. Also, bio-medical science, generally, in our federal agencies has also been regrettably influenced by unscientific religious agendas especially in President George W Bush’s 8 year administration (2000-2008)

THE FAILURE OF THE EXCESSES OF REDUCTIONISM -SINGLE ORGANISM-SINGLE DISEASE MODEL

Because the CDC history if filled with a remarkable historical legacy of major infectious disease success stories the agency is still very much populated by professionals who are thoroughly wedded to a reductionistic infectious disease paradigm. So we have CDC virologists and bacteriologists who are very “pathogenic organism” oriented by training, experience and temperament. This paradigm has resulted in a series of failures in managing and communicating such risks as West Nile, Lyme Disease, Mad Cow Disease (BSE), SARSs, the Seasonal flu and the Pandemic flu to name a few. More recently we have witnesses the mismanagement of pathogenic organism contaminated foods such as tomatoes, peanut butter products and pistachio nuts. Dr. Marc Siegel in his remarkable and prescient book entitled FALSE ALARM-The Truth About The Epidemic of Fear describes in some detail these failures. Referring to an epidemic of fear he cites the concept of “the bug de jour” which grabs what he calls the media megaphone only to turn out to be a “false or exaggerated alarm” which then dies off to be replaced by yet another needless scare. Also he provides numbers of US cases of these diseases compared to very real and present disease to back up his thesis. One example of this is the methods the CDC reports even seasonal flu deaths (25-30,00 annual deaths) or in the recent Salmonella peanut butter products deaths (less than 10 deaths) failing to advise the public that in both cases these deaths are most often in the frail and elderly who were likely to die from something else shortly. A CDC spokesman, Mr. Curtis Allen told Insight Magazine in 2004, "There are a couple problems with determining the number of deaths related to the flu because most people don't die from influenza - they die from complications of influenza - so the numbers [of deaths] are based on mathematical formulas. We don't know exactly how many people get the flu each year because it's not a reportable disease and most physicians don't do the test [nasal swab] to indicate whether [the symptoms are caused by] influenza." Also the most serious danger of predicting "epidemics that never happen" is what some have called “the boy who cried wolf phenomenon” meaning that if you scare the public enough on issues that never become reality then the public finally becomes desensitized and complacent which in the event of a every real event leaves us very dangerously vulnerable.

THE EMPHASIS ON PREVENTION-THE CDC’s “P” THAT NEVER OCCURRED.

Recognizing the enormous toll that individual health behaviors like smoking, overeating and a sedentary life style has on the health of American’s in 1992 the CDC to its credit changed its name to the Center for Disease Control and Prevention. However for a variety of reasons that emphasis on health promotion, while still recognized as on of its 7 coordinating centers – The Coordinating Center for Health Promotion- has gotten short shrift over the years with limited progress to show for all its efforts. Also the budget for Health Promotion is approx ½ of the budget for infectious diseases within the agency. Even though the name change occurred in 1992 but, by law, the well known three letter acronym CDC was retained. (sort of tells you something about the agencies priorities?)

THE DIVERSION OF RESOURCES AND MISMANAGEMENT OF BIOTERRORISM RISKS AND VACCINE PROGRAMS-CDCs COMPLICITY

Without question bioterrorism needed to be taken seriously by our nation as we became increasing aware of terrorism but most especially after the 9/11 attack and a month later (Oct 2001) the mailing of letter laced with anthrax spores which resulted in the death of 5 US citizens with 17 others sickened but scared most (over 300 million) Americans. The fact is, however, with the exception of a salad bar and coffee creamer contamination with Salmonella by a small disgruntled religious sect in The Dalles, Oregon in 1984 (751 ill – 0 deaths) our nation has never been attacked by a biological weapon from an external enemy in recent times. The 2001 anthrax letters, conversely, were sent by a mentally ill US ARMY scientist. Furthermore the two most important vaccine programs under Operation BioShield signed into law by President Bush in 2004 ($5.6 billion over 10 years) in our war against Bioterrorism –namely Anthrax and Smallpox Vaccines- were grossly mismanaged resulting in failures of both vaccine programs at great cost to the nation. While the CDC should not be solely blamed for these vaccine program failures since the FDA and DoD were involved the CDC was complicit in and contributed to their failures. The fact that the last case of Smallpox in the US occurred in 1949 and the World Health Organization declared Smallpox eradicated in 1976 begs the question of what the Government knows that we citizens don’t.

WHAT CAN BE DONE? –A FIVE POINT PLAN

1)Like all US federal health agencies the CDC rules pertaining to collaborations with the for profit sector must be modified to allow for science driven policies and programs removed from the excesses of the profit motive. Also no CDC programs should be influenced by extreme religious views.

2)A new breed of infectious disease experts who understand a systems (holistic) approach to organism –host –environment interaction must be hired lest the reductionist model continue to fail

3)Much more of CDCs budget must be allocated to its Center for Health Promotion where the most significant public health benefits could accrue. A concerted effort and funding should be allocated to the worthy goals of the CDC’s Healthy People 2010

4)Or perhaps the entire Health Promotion program should be carved out of the CDC to free the CDC it to do what it does best?

5)While bioterrorism is important we must accurately perceive their risks, avoid profiteering off of unwarranted fear,and do much better with successful vaccination or other preparations as is necessary

REGAINING LOST TRUST-PERHAPS THE MOST IMPORTANT TASK

This nation needs a strong, well funded and vibrant CDC. Perhaps the greatest tragedy of the recent CDC, again like other US Health agencies, is that the US public has lost confidence and trust in it. The rebuilding of trust may take years but it must begin in earnest as soon as feasible

Whoever CDC’s new leaders are must recognize the gravity of lost trust and must be committed to addressing that immediately

I am personally confident that our new administration is committed to most of the issues I address in the essay. But I’m not sure they fully understand yet either the reductionism verses systems (holistic) approach to infectious disease management or the gravity of the failed bioterrorism risk perception and risk management programs.

One can only hope that we have enlightened leaders who are leading our nation’s health agencies that are ready for change to meet the very real and pressing public health challenges of the 21st century

Richard A. Lippin MD
April 14, 2009

Your Wallet Versus Your Nation?

2009-03-07T19:30:00.000-08:00

The recent withdrawal of Dr. Sanjay Gupta from the nomination of US Surgeon General raises once more the financial sacrifice that less than independently wealthy individuals may have to make to enter the world of public service.

While Dr.Gupta denied that the huge drop in income was "not at all an issue" in his decision to withdraw his name as Surgeon General I for one suspect it was. We will never know?

Also I don't know what level of income Dr. Gupta generates as a sexy health media reporter for CNN, and it is really none of my business what a person's income is, sufficed to say that I suspect that it may be excessive given the value his "cheerleading style" of health reporting services brings to our nation. I liken it to the inflated value a superstar professional athlete or top movie star brings to the common national good. But as the old cliche goes if the market will bear it -it is we the consumers who "pay for these exorbitant salaries" who are to blame.

This Gupta withdrawal(good for the nation by the way) incident reminded me of a telephone conversation I had in the summer of 2004 with then my own Congressman Jim Greenwood from Bucks County,Pa (PA-8th District) after The Philadelphia Inquirer published a letter I wrote about Greenwood accepting a job with BIO- the trade association for the biotech industry at a base salary of $650,000 dollars per year before up to $250,000 supplemental bonus. What I objected to was Greenwood taking the job with BIO at a time that hearings were being held on possible unsavory practices by the pharmaceutical industry which Greenwood himself was chairing.Greenwood was offered the job of president of the Biotechnology Industry Organization on July 16,just four days before he was to hold a high-profile congressional hearing into antidepressants and child suicide.

Mr. Greenwood,a decent man,told me on the telephone call that he placed to me that he believed his position with BIO was "a continuation of his public service." That characterization seemed disingenuous to me- not because I don’t believe in free enterprise or biotechnology- but I do not believe it is "public service" when generating a profit is the fundamental goal of BIO's member companies. I conveyed this disagreement to Mr. Greenwood. He then complained about his personal financial needs of himself and his family on the "meager salary" of a Congressman.

Now I know that Ivy League University educations don't come cheap these days. Nor do grocery bills for that matter. But please Mr Greenwood or anyone else don't insult my intelligence by confusing a high salaried executive job with a position in public service to the nation.

Most Americans know the difference between serving your wallet and serving your nation.

Presumably people like Sanjay Gupta and "should have been President" Al Gore do know the difference between national public service and other means of generating income but my former Congressman Jim Greenwood and his more sleazy and venal former colleague in Congress Billy Tauzin, who now heads up Big PhRMA after pushing through a Medicare bill highly favorable to Big PhRMA, don't seem to undertand the concept.

Also, as Common Cause and other organizations have tried to propose over many years, do we really want to tolerate the capacity for politicians to accept private sector executive positions in companies or trade associations for which they had political oversight with just a 1 year waiting period before lobbying is permitted? Is this really good for a nation which has been witness to the number and gravity of corporate scandals that we have experienced in recent years? Haven’t we had enough? I think so.

I believe our new President is asking us all to consider more service to our nation and less to our individual wallets which is not really a bad idea for our troubled times

What do you think?

Dr. Rick Lippin
Southampton,Pa

THE HAPPY DEMISE OF "ALTERNATIVE MEDICINE"

2009-03-01T16:20:00.000-08:00

HERE IS MY OPEN LETTER TO SENATOR BARBARA MIKULSKI HAPPILY DECLARING THE END OF THE NEED FOR THE PHRASE "ALTERNATIVE MEDICINE"

Senator Mikulski,

My heartfelt congratulations to you for holding the HELP Senate Hearings this week on the value of Integrative Medicine as we embark on the long overdue process of transforming American Medicine.

If you peruse my website you will note that I have been involved in this effort for over 30 years and am pleased to inform you that I personally know several individuals who provided testimony at your historic hearings this past week.

As for me, I believe that the false dichotomy between Mainstream vs. Integrative Medicine is now over. Going forward we will only have "good" medicine which meets much more rigorous standards of efficacy (does it work?), safety (does it harm?), and affordability.(can we pay for it?)

Most importantly, all medical research and medical practice in the US must be removed from the pathology of the excesses of the influence of powerful vested financial interests which in past decades has placed valuable Integrative Therapies at a distinct and grossly unfair disadvantage

Those days are now over in part to you and other courageous politicians who are helping Americans give voice to a new American Medicine.

Again my personal thanks for the hearings and your leadership.

Be Well,

Dr. Rick Lippin
Southampton,Pa

"CURE FOR CANCER"-MISGUIDED IRRESPONSIBLE PHRASE

2009-03-01T16:00:00.000-08:00

Here is my open letter to Senator Arlen Specter Re "Curing Cancer"

Senator Specter,

Since I heard you make a similar comment I want to express my objection to your and President Obama’s use of the phrase “we need to cure cancer in our lifetime”

This phrase is not consistent with what experts know about the biology of cancer- over 200 different types I might add.

Senator -There is no “cure for cancer”. Just like there is no “cure” for aging. We can cure individual patients with certain types of cancer, thank goodness, but indisputably, the greatest risk factor for most cancers is cellular and bodily aging.

Declaring we “need to cure cancer” is well intentioned but naïve – harkening back to President Richard Nixon’s failed war on cancer from the 1970’s.

We must continue to chip away at the many factors that contribute to cancers but to suggest we will “cure” all is completely unrealistic and is actually irresponsible.

I share your interest in these diseases and applaud your own personal triumphs and political leadership.

Sincerely,

Richard A. Lippin MD
Southampton,Pa
February 25, 2009

DR GEORGE LUNDBERG FOR US SURGEON GENERAL

2009-02-23T19:42:00.000-08:00

PETITION TO PRESIDENT BARACK OBAMA TO APPOINT DR. GEORGE D. LUNDBERG AS OUR NEXT US SURGEON GENERAL

On January 6, 2009 TV news giant CNN announced that Dr. Sanjay Gupta, CNN’s Chief Medical Reporter, had been offered and accepted the offer by then President Elect Barack Obama to become our nation’s next US Surgeon General

Respectfully, the signers of this petition, as both health care professionals and many thinking US citizens from all walks of life believe that the appointment of Dr. Gupta would be both a mistake and a very serious lost opportunity for this historic administration and for our nation. Conversely, we strongly recommend that Dr. George Lundberg would be an ideal appointment to this office in these times of unparalleled challenge.

Perhaps for the first time in recent history we believe that our Surgeon General’s first task is to use the “bully pulpit” of that position to help remoralize American Medicine in the following three areas. These three issues transcend any particular important scientific public-health topic per se like smoking, obesity, mental health, HIV/AIDS and many other worthy topics. But these core issues must be addressed first and foremost before any worthy scientific pubic health issue can be addressed effectively. So we urge our new Surgeon General to address the following upon entering the position.

1) Affordable health Insurance for all American Citizens. Not having health insurance is a major determinant of poor health. It is immoral for the wealthiest nation in the world to have 47 million American (greater than 15%) without some level of basic health services coverage. All the scientific breakthroughs that bio-medicine has to offer will not remove this current moral stain upon our national identity and psyche and reputation in the international community of nations. If we do not act soon this immorality will continue.

2) Rebuilding Trust in our Federal Agencies that are Responsible for our Public Heath. Because of an emphasis on deregulation in recent decades there has been a very serious erosion of public trust in our federal agencies that are legally charged by mandate to protect our public health. Examples of agencies that have failed recently are the FDA (especially protecting us from unsafe medications and unsafe food), the CDC who has presided over a series of failures relating to accurate risk management and communication in infectious diseases, to the EPA who has dangerously weakened standards to ensure clean and healthy air and water, and OSHA who has virtually abandoned its mandate to provide safe and healthy workplace for hardworking American workers. American consumers literally don’t know who or what to believe. This loss of trust in our federal agencies may take years to rebuild but our next Surgeon General must participate in this rebuilding process.

3) Wanton Overuse of Potentially Dangerous Medicines and Medical Technology – While the uninsured don’t receive basic medical care the insured (most of us) receive too many potentially dangerous medical interventions. The most glaring examples of this are excessive use of medication (polypharmacy) among the elderly especially in nursing homes, the out of control use of diagnostic imaging services like MRI and CAT scans, and the continued problem of unnecessary medical procedures and surgeries. All of these are examples of miracle technologies when taken to excess becoming dangerous. The reason we have this phenomenon in American medicine is excessive emphasis on the free market where sellers of these services convince American consumers through doctors and hospitals that they actually need them. Our next US Surgeon General needs to help put the brakes on these dangerous and costly excesses driven by a for profit model that is clearly out of control.

Dr. George Lundberg not only is a consummate public health scientist who knows public health issues, he strongly embraces the above three priorities in words and deeds.

As Editor- in-Chief of the Journal of the American Medical Association’s journal, commonly known as JAMA, between 1982-1999, the most widely read medical journal in the world, Dr. Lundberg earned the respect of a worldwide readership of JAMA. In 1999 he then went onto become(until January 30, 2009) Editor-in-Chief of MEDSCAPE, the leading source of online health information and education for physicians thus establishing himself as genuine pioneer in e-medicine work a trend he recognized very early and began at the AMA. He was dubbed “Online HealthCare’s Medicine Man” by The Industry Standard. He excels in both professional and patient medical education.

Dr. Sanjay Gupta , conversely , trained in neurosurgery,-named in 2003 as one of the sexiest men in America-,shows little to no evidence of embacing the three fundamental priorities outlined above in this petition. Quite to the contrary Dr. Gupta has been a voice for the status quo in our very broken, profiteering based, bloated, bio-medical complex. One medical journalist described Gupta’s reporting as an “unquestioning –almost cheerleading approach to health news” most often reporting on the “the issue, or worse, the breakthrough of the day”. Gupta’s ties to the pharmacutical industry and medical testing industry need to be further investigated in his vetting process. We the signers of this petition demand this. And Gupta’s on–air attack of Michael Moore’s data contained in Moore’s movie Sicko requiring formal retraction by CNN and duly noted by Nobel Laureate Paul Krugman of The New York Times was a disgrace.

At this critical time in nation’s history we need a physician with the gravitas, the in depth experience, the credibility with both the professional and public communities, and most importantly, the moral credentials and authority to effectively utilize the bully pulpit of the US Surgeon General position to speak, not only for good public health science removed from the excesses of financial interests, but also to speak from a platform of core lifelong values. Dr. George Lundberg fits that job description..

Quite frankly, in short, we need a man or woman of gravitas, moral fiber and substance – not a sexy media star, flitting from one opportunistic subject to another, apparently tied to vested interests- for this venerable office of US Surgeon General

PLEASE HELP DR. GEORGE LUNDBERG BECOME OUR NEXT US SURGEON GENERAL BY SIGNING THE PETITION BELOW AND PLEASE PASS THE PETITION ON THE OTHERS OF LIKE MIND.

Click here to sign the petition

Thanks

Dr. Rick Lippin
Southampton,Pa

NOTE UPDATE March 2009- We are now asking you to sign by clicking on this slightly revised petition- Thanks for your continued support!-Rick Lippin

“If I were President Obama’s Health Care Czar- Here is what I would tell him”

2008-11-27T06:16:00.000-08:00

Health care is complex Mr. President- No country on the planet has completely figured it out. But clearly there is something terribly wrong with the Unites States- the wealthiest nation on the planet- having 47 million of its citizens uninsured (>15%), with many millions more underinsured, not having the peace of mind that when they are sick they can access some level of health care. This is not only wrong, Mr. President –it is immoral- an immorality, Mr. President, that betrays the nobility of both the great profession of Medicine and the greatness of our nation.

Yet conversely, Mr. President in my opinion we in organized medicine and those industries that profiteer from it (most notably multinational pharmaceutical companies, diagnostic equipment companies and medical instrumentation companies) are in part to blame for promoting the premise that high technology medicine solves all human problems. We have medicalized all sorts of America’s social problems like joblessness and poverty for which there really is no justifiable medical intervention.

We must, as a profession, convince ourselves and our patients that in medicine “more is not always better”. We must focus, Mr. President, on diagnostic and therapeutic medical interventions that rigorously stand up to the necessary tests of proven efficacy (does it work?) and, more importantly, proven safety (does it harm?). Also, we in the medical profession- recognizing the truly miraculous technologies we have achieved- need a strong dose of humility now to recognize that we cannot cure everything. Certainly “aging and death are not curable medical conditions” Caring must achieve parity along with curing. We are not in fierce battle with disease. We are instead, first and foremost, in a caring profession- a profession that recognizes that just simply “being there” for the patient and their family is perhaps our most fundamental obligation. Mr. President- that is actually the historical root of the phrase “attending physician” which is still a term in common use today.

Many have said, including Dr Elias Zerhouni – immediate past head of our prestigious US National Institute of Health (NIH)- that a high-tech-high-cost treatment driven “disease care system” is just not economically sustainable.

Now I fully realize Mr. President that transforming a $2 trillion dollar plus disease care industry in this nation will be painful for many including possible economic dislocations for many employed in this industry. But we must transform our disease care industry into one that emphasizes and economically incentivizes and rewards both individual (health behaviors) and more importantly institutional (public health) prevention. We must retrain our disease care workers into genuine health care and prevention workers. We must transform high-tech-high-cost, often dangerous, hospitals into great institutions of healing again. The money save by engaging through this necessary transformation will free up necessary funds for those who really do need the best technology that contemporary bio-medicine can offer. Mr. President – we must engage in this necessary transformation incrementally and with great compassion since it is a change of monumental proportions.

Mr. President. I realize that my proposal to you is bold. But our times call for boldness perhaps like never before in our young nation’s history. Mr. President-Tinkering at the edges of a conceptually and fundamentally broken US health care system is not enough.

As your trusted advisor I believe that ultimately we need the kind of dramatic and bold change in health care as we envision and propose to address in dealing with our global environmental crises. Nothing less, Mr. President, will carry the day.

Be Well Mr.President

Dr. Richard Lippin
Southampton, Pa

*Reprinted with permission of Assad Meymandi MD.PhD., Founding Editor-in-Chief of the Wake County Physicians Magazine .Vol. 14, No. 1, January 2009

AMERICAN MEDICINE’S HANDWASHING OBSESSION- Yet another good concept taken to irrational excess.

2008-03-26T16:07:00.000-07:00

Recently US Medical leaders from the hospital sector and the public health community have been imploring hospital employees and the public to spend much more time washing their hands.

I knew we were in trouble however with this concept – essentially a good one when applied rationally – when the Commissioner of Health for my home state of Pennsylvania said at a public meeting that I attended last year that he was considering giving up the practice of shaking hands with people especially during the winter months. Whoaaaa???

And where money can be made an entire "handwashing industry" has sprung up including training modules,educational materials and a variety of handwashing products.

Now in hospitals we have the very real and very tragic problem of increasing number of hospital acquired infections(HAIs)which undoubtedly could be partially mitigated by more handwashing especially by staff so a to avoid cross transmission of pathogenic organisms between patients. But even in this situation hospitals would do well to focus on other underlying reasons for increased hospital based infections such as the overuse of antibiotics and other medications and a variety of patient host resistance factors such as aging, nutritional status, the presence of underlying diseases and immuno-suppressed states.

My basic reasons for positing that we are perhaps overly obsessed with handwashing are twofold-

-Firstly I have believed for decades that infectious disease specialists who tend to populate our public health agencies including our own CDC focus far too much on organisms and their pathogenicity exclusive of considering host resistance or general environmental factors in disease causation. I have always been surprised by this bias toward organism vs. host because I thought that the interaction between the two was a well established principle. As truly remarkable the contributions of Louis Pasteur were in establishing the Germ Theory of Medicine it would not hurt to re- look at two of Pasteur’s contemporaries Claude Bernard and Antoine Bechamp who held a more holistic scientific view of disease causation. Yet because of the miracles of the infectious disease model and the incredible effectiveness of vaccines and antibiotics we ran successfully with this model in my opinion to excess. Now the excess is “biting us back”.

On a personal note in 1991 I wrote a letter about the common cold that was published in a local medical society journal which posited that the adenovirus theory of the common cold wasn’t getting us very far and that we just might want to look at other possible factors. I was in part validated by the work of Dr.Sheldon Cohen of the University of Pittsburg who published rigorous scientific studies on the relationship of stress to the common cold.(and other diseases)

-Secondly I have become intrigued with what has become known as "The Hygiene Hypothesis" first proposed in 1989 by David P Strachan in an article in the British Medical Journal(BMJ)which fundamentally posits that possibly a large number of immunologic disorders such as allergies and asthma might actually be caused by or contributed to by the excesses of a clean environment especially during infancy and childhood. Much more work needs to be done and I am not suggesting that we all "consume a daily portion of dirt" but expert epidemiologists, allergists and immunologists are taking the theory seriously. Perhaps the infectious disease specialty community would benefit from considering this theory in their deliberations about the frequency and intensity of handwashing?

Now I give full credit to Viennese physician Ignaz Semmelweis who in 1857 introduced the simple principle that students and physicians in the Vienna General Hospital must clean their hands with a chlorine solution between patients in the obstetrics clinic and after visiting the hospital morgue thus reducing the deadly disease known as puerperal fever. But ironically Semmelwies’ handwashing recommendation was stimulated by noting that Viennese mothers who gave birth at home attended to by midwives had a much lower rate of this disease.

Anyway we have come a long way since the days of the “Father of Handwashing” Semmelweis and much good information can be gleaned by the CDCs current recommendations for both handwashing in health care settings and
handwashing for the general populations.

I can’t help but think however that washing of ones hands is only a small part of a comprehensive approach to reducing hospital based infections and reducing the spread of common diseases like the flu or the common cold.

Using some poetic license- not very popular at all with bio-medical scientists- I cannot help but wonder that on some unconscious level whether we handwashers are like Shakespeare's Lady Macbeth trying to cleanse way our collective guilt about where we have taken contemporary modern medicine- in part because we take good scientific principles to excess. Handwashing is only one example of this phenomenon of excess.

And the next time I hear a health care leader announcing publically that he/she is giving up on the shaking of hands as a warm greeting to others remind me once more to question authority.

Dr. Rick Lippin
Southampton, Pa

Medical Journalists-You Too-First Do No Harm!

2007-11-25T13:47:00.000-08:00

As a physician, long before the days of the free flow of health information over the Internet, I had always believed in an educated patient as the basis of a more mature relationship with my patients. I rejected the paternalistic “guild” model of medicine with its secretive language and magic potions and magic procedures. I related as much to the model of physician as teacher as to physician as healer. Furthermore, I have always cherished freedom of the press as guaranteed by our constitution as a cornerstone of our democracy.

Yet, in recent years. I have a nagging feeling that the main stream media, in particular, has failed in several ways regarding its responsibilities as professional medical journalists and that some accountability might even be in order for what I call "doing harm".

Putting aside the Internet, which is still the “wild west”, with few if any controls on quality of information there are many reasons for the documented boom in both print and electronic medical journalism in recent decades. These include an extremely competitive “24/7” news business which seeks to enhance advertising revenues through sensationalism as its first goal of survival, a great hunger for health information among the reading, listening and viewing public-especially in an aging population and the dramatic growth in numbers of medical research papers that are published daily by health organizations and institutions all clamoring to be heard above their competitors.

There are four areas where I believe medical journalism in particular must improve

1)Confusing and Conflicting Medical Information. In Woody Allen’s classic movie Sleeper (circa 1973) upon awakening after 200 years of being frozen “everything that was good for you to eat was now bad to eat and vice–verse”. Unfortunately the public experiences these conflicting and confusing reports in a much shorter cycle time in contemporary society. I suppose the quintessential example is the diet issue but regrettably there are many other examples of this phenomena in almost any area of health and medicine. The most detrimental effect of this I that it erodes confidence and trust in the science and health communities-trust which may take decades-if ever-to rebuild.

2)“Disease Mongering” or the medicalization of all human problems.The drug companies in particular but also the medical profession and the hospital industry want you to believe you are much sicker than you actually are. This results in their selling you more of their products and services. A particularly cruel hoax is the medicalization of normal personality traits such as shyness and (no I’m not kidding) sleeping late and the medicalization of aging such as grey hair, baldness and wear and tear arthritis. Last year AlterNet.org did a good review of disease mongering written by Stan Cox.

3)“Fear Mongering”- Reporting legitimate reasons to fear a disease is vitally important medical journalism. Providing accurate and timely information is a great public service. Conversely in recent years for many complex reasons we are unfortunately scaring people unnecessarily thus inducing anxiety and even worse panic. Both needless anxiety and panic over unproven risks actually causes harm physically to individuals and to societies. Furthermore it dangerously diverts limited and precious resources away from greater proven risks. Finally, if exposed to enough “chicken little-the sky is falling” fearmongering stimuli the public eventually becomes apathetic when the feared medical catastrophes don't take place thus rendering us woefully and dangerously unprepared for the real thing. I suppose the most recent classic example of this is the virology world’s obsession with single bird flu virus (H5N1). Dr. Marc Siegel, an internist from New York University, wrote an excellent book entitled False Alarm wherein he lays out many examples of unnecessary scares by the bio-medical community facilitated by the media.

4)"Medical Breakthroughs"- Reporting so called “medical breakthroughs” where none exist is another example of where the media can also cause direct harm. Modern bio-medicine is indeed miraculous but it is generally accepted that the single cause-single cure-"magic bullet" model for diseases like polio are not very applicable to the chronic degenerative diseases on the nervous system like Alzheimer’s and Parkinson’s disease, chronic cardiovascular and pulmonary disease, chronic arthritic disorders and most cancers. Instead it is generally accepted that bio-medical scientists will chip away at these diseases using many different strategies which will not result in dramatic breakthroughs or even cures. We will be living with these disease longer for example or might even die with them- not of them. So for the media to use the term breakthrough is a cruel hoax for those individuals suffering from these diseases proving false at worse – premature at best- hope for these individuals. The recent hype over the stem cell “breakthrough” was a good example of this exaggerated reporting.

What can we do?

Well to begin in March of 1997 – just a decade ago the AHCJ = Association of Health Care Journalists was born. I urge you to explore their website.They published an excellent Statement of Principles of their association which includes sections on Professionalism, Content and Accuracy on Independence, on Integrity and on Responsibility. They have formally endorsed the Code of Ethics from the Society of Professional Journalists. Their dilemma however, as I see it, is that these documents are not legally binding and they, like many bio-medical scientists, are employed by often large for profit-in this case- media companies which has eroded the capacity for these fine people to remain as professional as they would like and need to be.

So we as citizens must continue to be healthy skeptics of journalism and science trapped in for profit enterprises. We must demand a return to a time when journalism and medicine were indeed professions whose core competencies and values were independent of or at least sufficiently distanced directly from the profit motive.

I believe the tide is turning. I believe most scientists, doctors and the medical journalists who report their work hunger deeply for a return to professionalism.

Dr. Rick Lippin
"Blake"

BUSH ABOUT TO MAKE A HUGE DOMESTIC BLUNDER ON CHILDREN'S HEALTH CARE

2007-10-01T16:20:00.000-07:00

Our current president may have made one of the biggest foreign policy blunders in the entire history of US presidential decisions by invading the nation of Iraq for the wrong reasons and then not having a plan to manage a successful war.

Now he is about to make a huge domestic blunder by vetoing the SCHIP (State Childrens Health Plan) renewal legislation.

This is a political nightmare for "W"-the perfect storm. The average American, who doesn't have time or energy to dig into the SCHIP legislative details would see "W" as a cruel and venal person to even imagine not providing health care to US children.

I CHALLENGE ALL AMERICANS- WHAT COULD MORE EMOTIONAL THAN THAT TOPIC?

Yet Bush in his typical self destructive stubborn style digs in his heels on any legislation that smacks of more government involvement in health care. This -despite the embarrassment of our failed US system against our peer nations.

He loses either way if he vetoes because the nation is ready for more government in health care.

What better place to start than with our children?

The DEMS will destroy "W" on this veto! And many members of his own party are defecting.This president knows no bounds in political self-destructiveness.

See more from CNN

As for me, If you have been reading this blog I am for prevention (individual AND institutional) as the only way out of this whole health care mess in this country and abroad.

Dr. Rick Lippin
"Blake"

EFFICACY(DOES IT WORK???) IS EMERGING AS A KEY ISSUE IN HEALTH CARE REFORM

2007-09-20T14:29:00.000-07:00

If you are a patient in 21st century American Medicine I have some shocking news for you.

A significant portion of your health has NOTHING to do with the enterprise/business of American Medicine. Social factors like poverty and jobs are much more important for example. This has been known for years but paternalistic organized medicine has duped us and infantilized us. (not unlike what most organized religion has done to us!)

Much of what doctors do to/for people has never ben proven to be effective-putting aside that MUCH of what they do is unsafe especially in hospitals! Surgeons are especially culpable.

Please read this provided by Maggie Mahar “When it comes to wasteful healthcare spending, the work done at Dartmouth by Dr. Jack Wennberg and Dr. Elliot Fisher does the best job of exposing how much money we spend on unnecessary, unproven, and sometimes unwanted treatments and hospitalizations."

I would add Dr. Nortin Hadler from University of North Carolina who has also brilliantly explicated how much US health care has been unproven to be effective or even worse safe. Hadler’s book The Last Well Person is a true landmark.

And of course Shannon Brownlee’s new book Overtreated is excellent validation of its own title.

Today Dr. Steven Schroeder published an article- maybe the most important article in on health care reform in a decade in the prestigious New England Journal of Medicine drove home these points and more.

READ THE DARTMOUTH RESEARCH THESE BOOKS I'VE RECOMMENDED AND THIS OUTSTANDING ARTICLE PUBLISHED TODAY.

Wake up America-Grow up America- Retake your health care.

Be Well and-

"See you on the new highground!"

Dr. Rick Lippin
"Blake"

AN OPEN LETTER TO MY YOUNG AND BRAVE US CONGRESSMAN

2007-09-16T06:42:00.000-07:00

14 September 2007

Congressman Patrick J. Murphy
Congress of the United States
House of Representatives
Eight Congressional District, Pa
Washington, DC 20515

Honorable Congressman Murphy;

Thank you for your letter of 6 September 2007 on the matter of US health care reform which in my opinion is the domestic issue that will elect our next president.

I am extremely proud to be a constituent of your district in that, as a freshman Congressman, you took the lead in the most important foreign policy issue of our times – the failed war in Iraq. This took enormous courage on your part and I am very grateful for that.

Now it is time for you to step up to the plate and fight for universal health care.

I must disagree with your statement that “presently a functional and affordable universal single payer system is many years away” as you say in your letter to me. We are in far too much trouble for more incrementalism.

While I admire and thank you for your vote for HR 3162 which will expand health care coverage to our nation’s children under SCHIP, I respectfully offer to you that this is not nearly enough.

Congressman Murphy- You may know that David Walker, head of our Government Accountability Office (GAO) is stating correctly that we are facing an economic “tsunami” in Medicare for example unless we act now.

I have posited for over ten years now that the only way out of our nation’s health care crisis is both individual and institutional prevention, which you did not reference in your letter to me.

Congressman- I urge you to support a variety of introduced legislation whose goals are to pass into law a requirement for more prevention.

For example my colleagues at Health Promotion Advocates have long supported at least two pieces of legislation that enhances prevention at the workplace and increases funding for health promotion research.

Furthermore, there currently exist legislative initiatives for much more prevention in Medicare programs

And we must have institutional prevention like healthy environments, healthy schools and healthy workplaces. (It is not just about individual health behaviors like smoking, inactivity, alcohol and drug and medication abuse etc.)

In 1995 I published my own #8 point health care plan I called “Grow Up America” which I slightly modified after 9/11 and Hurricane Katrina. Then First Lady (now Senator) Hillary Clinton liked my plan. I attach my plan with this letter for your and your staff’s consideration.

Every one of the eight points I recommend either has or could have legislation built around it.

Dr. Elias Zerhouni, head of our nation’s prestigious National Institute of Health (NIH) stated that our high technology expensive US “disease care system” is simply not economically sustainable in our nation (and for that matter in other nations). Dr Zerhouni is correct. We need a true health care system based on prevention.

Congressman-I know you have an interest in stem cell research as I do, but this is not the answer either. The projections for success in this arena, unlike prevention, are indeed decades away if we ever see them at all.

Individual and intuitional prevention can save us from one third to a staggering one half of our #2 trillion dollar plus (17% of GNP) plus US healthcare expenditure which if not managed soon is a direct threat to our nations economy and our national security.

Prevention- fairly and ethically implemented- will save us from economic catastrophe and it will divert dollars to those who suffer from non-preventable diseases.

Congressman- having met a key member of your staff I am very pleased to work with her, other members of your staff, and/or meet with you personally in your Doylestown,Pa or DC office to solicit your support for prevention based legislation.

Please accept my sincere best wishes for continued success and for good health for you and your family

Sincerely,

Dr. Rick Lippin
Southampton, Pa

cc-
David Walker- GAO
Elias Zerhouni- NIH
Sen. Hillary Clinton
Sen. Barack Obama
Sen. Christopher Dodd
Former Sen. John Edwards
Cong. Dennis Kucinich
Sen. Arlen Specter
Sen. Robert Casey
Gov. Ed Rendell
Michael O’Donnell -HPA

Maybe you could write a similiar letter to your Congressperson?

Comments welcome

Rick Lippin
"Blake"

"Healtho"and Sicko-More on Dr. Patch Adams

2007-08-28T19:22:00.000-07:00

I hope by now you have seen Michael Moore's groundbreaking movie SICKO which I have predicted will "lock in" Health Care Reform as the the domestic issue that will elect our next US President See AlterNet story on Michael Moore efforts throughout the summer and AlterNet reader reactions.

If you have seen SICKO give yourself a treat and pull out the movie PATCH ADAMS starring Robin Williams-circa 1998- which didn't have the timely political power that Moore's movie is having but will make you feel good generally and feel even better that people like the real life Dr. Patch Adams, whom I have known for 30 almost years, has been heroically trying to improve and humanize US Medicine since he entered medical school in the 1967.

Moore is the classic muckraker whose latest film on the tragedy of US Health Care is his best. One pundit said while it has its comical moments it is basically not funny given the human suffering and blatant corruption that Moore effectively exposes. Adams, while not shy about his disdain with the US health care system, basically through lifelong actions and projects has demonstrated in the real world what a genuine humanized health care system could be like. Some have called Adams a mere clown which of course he actually is and quite proud to be. Others have said he is an irrelevant side-show?. But now that "sideshow" seems to be prescient by at least 30 years. Last November I promised
in this blog that I would write more about my friend Patch Adams,his work,his Gesundheit Institute and a recent project Patch and his colleague and partner Dr. Susan Parenti have launched about designing healthy and humane health care systems.

If you go to Patch Adam's website known The Gesundheit Institute you will note that Patch's activities have revolved, in the past, around two basic themes.

One is demonstrating the healing power of humor through clowning which Patch has brought to hospitals literally throughout the world by himself and with clowning teams which he has organized. This was long before the so called "mirth response" or laughter had been empirically demonstrated to have physiological benefit.Patch,however, never claimed that clowning could ever take the place or match the power on bio-medicines powerful tools of drugs,surgery or radiation. But he recognized intuitively the value of introducing humor through clown healing work in health care system that was mired only in pathology and power grabbing paternalism as well as intellectual stagnation under the guise of hypocritical "professionalism". Patch's clowning project has resulted in clowns being part of hospital work in every continent on the planet.He now takes clowns to hospitals and other settings about 300 days a year in over 40 countries- most recently in war torn Afghanistan. And Patch has come to realize the movement he began does not need him alone- the ultimate measure of success.

The other major project Patch has been trying to consummate is the building of a model hospital.The
Hospital,projected to be located in the hills of West Virgina-not far from our nation's capital-,would embody all the elements of Patch's views of what a true values based and humanistic healing institute would look and feel like to staff, patients and visitors.

The hospital was to have been a model for a humanistic place of healing which would democratize patient care and incorporate humor and the arts as a healing force.Good health said Patch in a recent essay on the hospital project was about close friendships,meaningful work,a lived spirituality of any kind,an opportunity for loving service and an engaging relationship to nature,the arts, wonder,curiosity,passion and hope. Patch's basic definition of health is having a day to day vitality for life.Of course most of these principles go unmet among most people (especially adults) in today's maddening US consumerist, workaholic, time crunched, US society and certainly in the business of high tech-now dangerous what we hypocritically call hospitals.

Patch states, however, that after 33 years of trying to build his beloved hospital "ground has yet to broken". But he tells his readers and supporters ,of which I count myself as one minor player, that his "journey has been heavenly all along the way.Simply being in a idealistic quest is its own reward. I've never felt I've sacrificed anything, says Adams, or thought is was a hard journey. Hard would have been having to work in corporate medicine and lie to patients and myself everyday."Now that is MY kind of doctor!

Recently Patch through his collaboration with Dr. Susan Parenti has launched yet another project grounded in the philosophy put forth in Dr. Parenti's paper to "Redesign the US Health Care System by "Thinking Universally and Designing Locally" thus introducing what Parenti powerfully refers to as "perturbation" which, sounding gentle, like the proverbial ripple on the pond spreads in all directions and reaches many distant shores.She calls her position a "third position" in the US health care reform debate. "Do it local, do it now, do it small, link with all"-says Parenti.

This coming October Patch is leading a 4 day Health Care Design intensive workshop for changing the health care system in Urbana,Illinois (Oct 11-14) For details click here Among the speakers is Susan Parenti. I encourage you to attend.

Also do me a favor -buy some red round clown noses (See final scenes in movie Patch Adams) and wear one-even once. Do as I once did and give the noses to your best friends and take a group photo which I guarantee will become one of your favorites among your collection.

I call upon Michael Moore to wear a red nose-even once- as a show of support and to honor Dr. Patch Adams.

As the health care reform debate generates momentum we all could do worse than wearing red noses and opening up our hearts and our wallets by writing a $ check to The Gesundheit Institute led by the incomparable Dr. Patch Adams - one of the most remarkable-definitely heroic- people I have had the privilege of knowing.

Thanks

Be Well,

Dr. Rick Lippin
"Blake"

US CORPORATE EAP PROGRAMS-OVERSIGHT, ORWELLIAN OR SOVIET PSYCHIATRY REDUX?

2007-07-31T05:50:00.000-07:00

I have practiced Occupational Medicine(OM) for over 35 years in several settings in the US. Even though I am not a psychiatrist I became very interested in the stress workers would report to me and its impact on employee health,safety,well being, work satisfaction and and productivity. This lead to my chairing the mental health committee of the American College of Occupational and Environmental Medicine (ACOEM) from 1996 to 2001) and by being named as the only physician to a government(NIOSH) team which was defining research priorities in work stress and what NIOSH called Organization of Work(OOW)

But this essay is about a sister profession-namely the corporate Employee Assistance Program or EAPs as they have become to be know. I happened to be at the very beginning of this important profession's birth in the late 1970s and early 1980s which historically grew out of addressing alcoholism at the workplace but since, to its credit, has markedly expanded its scope of practice. The primary worldwide professional organization which now provides a home for most of the professionals in the field is EAPA.

I guess from the very beginning of my observation of how corporate EAPs operated I was struck the good work that they were doing but their failure -even to this day- to adequately and formally address the work stress issue.

In short in reading the EAPA Association Standards I could not locate any portion of the standards that even used the term "work stress". What???? I noted that in the metrics that they tend to utilize the phrase "work adjustment" which really scares me. (soviet psychiatry redux?) The basic definition of EAPs from EAPA I guess tells the story. It says "Employee Assistance Program" or "EAP" is a worksite-based program designed to assist:

(1) work organizations in addressing productivity issues, and

(2) "employee clients" in identifying and resolving personal concerns,including, but not limited to, health, marital, family, financial,alcohol, drug, legal, emotional, stress, or other personal issues that may affect job performance"

This is fine BUT where is the proverbial "arrow going the other way" meaning that the workplace psycho-social environment may very well be the single most important contributor to most of the problems that EAPs seek to address?

We can theorize why this is not addressed by EAPs

1)The word "stress" for years was "fuzzy" -now it is well defined

2)Teasing out work stress from other stressors we all have at home and in our culture is not easy (hence the workers compensation profession doesn't award too many stress claims either)

3)Most importantly and very sadly the EAP professionals are paid as employees or consultants to the corporations in which they work. Would they dare to state that employees of those who hire them are stressed from work?. After all, this is a direct indictment of managements inability to provide a work environment that might be harming people? As an Occupational Physician I understand the EAP professionals dilemma in the US but I refuse to accept it.

Many fine courageous researchers including those from academia and government have unequivocally proven that work stress is a major epidemic and is harming US workers- big time! I cite the US National Institute for Occupational Safety and Health(NIOSH)who published an excellent publication on work stress

Furthermore the empirical evidence for work stress in particular contributing to or causing cardio-vascular(heart)disease (America's number 1 killer) is voluminous and robust..In my opinion no reputable occupational physician, eap professional or cardiologist could deny the rigor and strength of this compelling data.The work the pioneering and new leaders in this field can be fully explored at The Job Stress Network website If you explore this website, believe me, you will get an excellent education!

I would also like to recognize The American Institute of Stress(AIS) and the The American Psychological Association(APA) for assuming leadership roles in this matter of extreme importance to the health of Americans.

I personally have no doubt remaining whatsoever that work stress is both harming and killing employees in many US workplaces.

Here is what I propose

-That the EAPA immediately develop a formal position paper on work stress and incorporate it into their formal standards. To not do so perpetuates the glaring omission at best -the lack of basic professional ethics at worst.ACOEM needs to do so likewise

-That NIOSH (nested in the US CDC) and other independent excellent researchers provide to the OSHA (nested in the US Department of Labor) which is formally charged under law with protecting the health and Safety of US workers the necessary data to begin the process of publishing a formal enforcable OSHA standard on the issue of work stress.

- That education and certification of both occupational physicians and nurses and, most importantly EAP professionals, be dependent on demonstrating competency in recognizing, measuring and mitigating a major killer of American workers- Work Stress

Thank you for your continued interest in this topic and please let me hear from you. Tell me your stories about work stress by posting a comment om this blog.

Be Well

PS-Find and do safe, healthy, meaningful work till the day you die.

Dr. Rick Lippin
"Blake"

Growing Evidence For The Decline of Bio-Medicine's Obsession with Reductionism

2007-06-28T06:03:00.000-07:00

In January of last year (2006) I wrote a piece on this blog suggesting that contemporary bio-medicine was failing in part because it did not recognize the limits of a reductionistic model.In that blog which I called "American Medicine's Denial of the Anatomical Existence of the Neck (scroll down to January 11)"I cited Descartes(1596-1650) fundamental error of splitting mind and soul from body, the rise of "Holistic Medicine" since the late 1960s (actually I still like that term-"Holistic" despite the term's many competitors), my own promotion of what I called a Bio-Psycho-Social-Spiritual (BPSS) model of health care, and the rise of neuroscience and all of its profound implications such as human perception,human choice and intentionality and their impact on human health outcomes, which would render "the medical revolutions" of the human genome project and stem cell research (inflated promises) almost childlike.

Also in 1985 I published a statement I called "Reductionism's Last Hurrah" in my field of Occupational and Environmental Medicine (OEM) stating that the complexity factor alone renders scientific analysis of all exposures unfathomable.

Well since my January essay two important events occurred in my professional life that confirmed my belief that the excesses of a reductionistic model were causing contemporary bio-medicine to fail.

The first was a remarkable paper which was sent to me entitled "Beyond Reductionism-Reinventing The Sacred" by Stuart A. Kauffman,Professor at the University of Calgary, with shared academic appointments between biological sciences, physics and astronomy.(Wow- Talk about a "Neo-Renaissance Man"!).In this remarkable paper Kauffman,(formally from the University of Pennsylvania-my own home state), frames a new scientific world view of emergence and ceaseless creativity, which, he notes, is "awesome in what has come to pass in reality, and God enough for me and many, where God is the creativity of the universe, yielding a global ethics of respect for all life, the planet, awe, wonder and spirituality cut free from a transcendent God." I promise you, this is an essay -published by "EDGE"- worth reading many times.

The other event (less spiritual than the stunning Kuaffman essay but none the less important) in my life was listening to the Keynote Address at the 2007 American Occupational Health Conference(AOHC), my own medical specialty's most important annual conference, this year held during the first week in May in New Orleans, Louisiana. Professor Laura Punnett (Sc.D) from the Department of Work Environment,University of Massachusetts,Lowell- an institution with a long history of outstanding research on the subject of human work with a strong tradition of social conscience and progressive values, delivered the landmark address. I could almost not believe the words I was listening to or the data presented on the slides. It was as if I had waited 30 years to hear this keynote address at a major traditional US allopathic medical specialty conference. For more on Dr. Laura Punnett click here.

In the address Dr. Punnett literally challenged our specialty of Occupational Medicine(OM) to adopt a new research and practice paradigm. While the address revolved around inequitable distribution of workplace risks as it relates to workplace related musculoskeletal disorders-the latter being the largest current challenge in Occupational Medicine-more importantly Dr.Punnett presented a compelling case for socio-economic (SES) variables (e.g- poverty,education, power etc) not being viewed as confounding variables in studying disease and conducting academic research but rather as what she calls effect modifiers. Thus, with this recommended study design protocol change that Punnett recommends, SES variables, for example, become far more important factors than bio-medical researchers would heretofore consider. Dr. Punnett also stressed the importance of what the US National Institute of Occupational Safety and Health (NIOSH) calls Organization of Work (OOW) on which I have personally worked. Punnett refers to an inclusive (Holistic?) Multi-level Exposure Paradigm for Occupational Health which must include ALL of these factors including SES, gendered position, work organization and both physical and psycho-social exposures. I pinched myself for the first time at my conference and applauded the conference planners for inviting Dr. Punnett to be our keynoter.

I guess I consider myself a scientific "cyclist"(not bicycles) but rather I believe scientific and medical practice paradigms are historically cyclical. The ancient healers were holistic for example.The full flourishing of contemporary western reductionism without question produced miraculous results from which we have all benefited. But I submit respectfully the model has been taken to excess and has "run it's course".

Also I do not believe that reductionism is inherently wrong or incorrect. But this I am sure of.In any culture-in any time-REDUCTIONISM IS INCOMPLETE.

So welcome to the new age of holistic medicine (Hospice/Palliative Medicine is an excellent interdisciplinary model).This is the new medical world we will live in for the foreseeable future. It is not anti-science but leverages the best that contemporary reductionistic bio-medicine has to offer thus allowing bio-medicine to achieve its full potential.

Please - Let's here from you.

And Be Well,

Dr. Rick Lippin
"Blake"

The Power of Art- Moore's Movie SICKO Will Change Our Nation

2007-06-20T19:26:00.000-07:00

Call me non-intellectual but I've always believed that the power and intensity of a single piece of Art, properly timed, on rare occasions can transform a nation.

Examples include Harriet Beecher Stowe's novel Uncle Tom's Cabin and it's impact on slavery, Upton Sinclair's muckraking novel The Jungle on slaughterhouse conditions which lead to tighter standards on food and worker safety and the TV special called Harvest of Shame which educated the nation on unjust working conditions of migrant farm workers.(thanks Professor Joe Palermo for the references).Twe more contemporary examples of this phenomenon are the photographic image of planet earth from space which I believe jolted us into global conciousness and "former president elect" Al Gore's oscar winning movie An Inconvenient Truth which undoubtedly advanced worldwide awareness of the treat of global warming. Certainly you-our readers- could think of yet more examples. Post them as comments to this blog.

Michael Moore's movie about our nations severely broken US Health Care System-entitled SICKO-is such a piece of Art.

Due to open broadly in the US next Friday on June 29 this film and activities and "buzz" surrounding the movie will further stimulate an already great hunger for bold and radical change in our US Health Care System. (See my blog immediately below entitled "1993-1994 is NOT 2009-2010"

Amy Goodman, who hosts a nationally syndicated news radio program called Democracy Now, calls what Moore is doing more than just a movie. She calls it a movement. See her piece in AlterNet. She is indeed correct. For more on this movement go to Moore's web sites including a YouTube group or checkout SICKO'S the movie's official website.The websites and Michael Moore invite you to tell your own horror stories about US Health Care.I've told a few myself.

Marilyn Clement, National Coordinator for Healthcare Now ,the nations leading advocacy group for "Single Payer-Medicare for All" has also encouraged citizens to rally around the openning of SICKO. They are even trying to raise $ so people of very limited financial means can view the movie for free!

Another one of my long held beliefs is that there are three essential ingredients to a successful socio-political movement. They are,in order of importance-

- Timing
- Timing
- Timing

:)

Moore's timing on releasing SICKO this month is impeccable and is a testimony to his political intuition or even genius?

This is his best Moore movie yet and this will reinforce the reality that health care reform will indeed be the domestic issue that will elect the next US president.You can take that one to the bank. "Trust me -I'm a doctor":)

If the current White House is stupid enough to even touch Moore for his trip to Cuba they will transform Moore into a martyr which will only generate yet more "buzz" for SICKO and surrounding activities.

Take a break this summer. Go to the movies and see SICKO. It will be good for your own personal health -and the health of our nation.

You will be witnessing first hand the power that art and art alone posseses to capture the hearts and passions of a nation on an issue of profound importance.

Capturing of only our minds, also extremely important, is a job best left to others.

Be Well,

Dr. Rick Lippin
"Blake"
Also founder -International Arts-Medicine Association (IAMA-1985)

_

1993-1994 IS NOT 2009-2010

2007-05-29T17:26:00.000-07:00

Several times on this blog I have posited that, after the war strategy is defined by all accounts this fall, Health Care Reform will be the domestic issue that will elect the next President of the United States of America.

I have been called naive by highly respected experts from government,academia, and the non-profit "think tank" sectors. Even some close intelligent friends said I was dreaming? I have been called naive for "not understanding the political process". (Did I not witness the failure of the Clintons in 1993-1994?)Called naive for "not understanding that not enough of the US middle class is dissatisfied with our current Health Care system?"-an apparent prerequisite for change.Called naive for "not understanding that one cannot mess easily with the $2 trillion dollar plus US disease care sector without major economic dislocations to the US economy". That this MUST be very incremental?

Yet here is my answer. As I say in my blog title 1993-1994 IS NOT 2009-2010. Much has changed in the intervening 15 years- and for the worse-much worse! While the well intentioned but mismanaged Clinton plan failed,the collective rage against Big Insurance and Big PhRMA is growing rapidly as are legal actions against them. Credible polls consistently report Health Care Reform as a priority for most Americans. All the Democratic Presidential candidates have spoken often individually and when assembled in forums or debates on health care.

Furthermore "three stars recently aligned" for me (no-I am not an advocate of astrology) to make me believe that perhaps I just might be correct about the ripeness of this health care issue.

First the head of the US GAO Comptroller General David Walker appeared on 60 Minutes recently predicting an economic "tsunami" if politicians did not act on Medicare "yesterday"!

Secondly a sober and intelligent yet muckraking filmaker Michael Moore appeared on comedic but smart pundit Bill Mahar's popular TV show just last week to talk about his new movie SICKO which just premiered at the Cannes Film Festival a few weeks ago. Mahar who viewed the entire movie said that the it could very well be the tipping point for the Health Care Reform issue after it is released this late June in the US. And get this- Moore said his movie was well received in Cannes by both Democrats and Republican types.(Moore even had some preventive medicine advice for his mid-western type couch potatoe brothers and sisters as it relates to advocating "any mild exercise and discovering fruits and vegetables" which has personally helped Moore himself lose weight)

Finally the too long awaited details of the "electric presidential candidate" Senator Barack Obama's Health Care Reform plan were released today in Iowa City,Iowa as reported by THE NEW YORK TIMES. Obama did not mince words when he laid the blame for our failed US health care system at the feet of Big Insurance and Big PhRMA-deservedly so I would personally add. Obama said that similar efforts to create universal coverage were "crushed under the weight of Washington politics and drug and insurance industry lobbying". Obama then went on to say "This cannot be one of those years" GO BARACK!

But if you disagree with me you can listen to the Republican Presidential candidates who are almost embarassingly and tragically silent on this issue with the exception of former Sec.of HHS Tommy Thomson whose incompetence contributed to the problem in the first place. Or you can listen to those phoney TV ads about the "success" of Medicare part D -enhanced drug coverage for US seniors-which by some other accounts ranks up there as one of the worst pieces of legislation passed by Congress in decades-Passed literally in the middle of the night only after intense -some say unethical- swarms of lobbying by the Pharmaceutical Industry. PhRMA CEO, former Louisiana Congressman, Billy Tauzin (current salary at $2 million/year)gloated and boasted of this venal victory calling it "the way politics works" (some are calling for investigations)

So I ask -Am I naive? or not? Let me know? I need and value your input.

Dr. Rick Lippin
"Blake"

Dems Emphasize Cost Control and Prevention in Debate

2007-04-27T05:05:00.000-07:00

While the first democratic presidential debate last night correctly focused on the war in Iraq, in the middle of the forum, some leading candidates had an opportunity to put forth some ideas about health care reform. Here is the transcript of the debate in case you missed it.

All 4 candidates who had a chance to speak on Health Care emphasized cost control and prevention!

John Edwards,who to his credit,set the mark on health care reform by releasing a detailed plan a few months ago, also spoke about one of my favorite topics-mental health parity-undoubted a re-energized issue after the tragedy at Virgina Tech on Monday a week ago.I wrote about mental health parity last year on this blog -see Tues.April 4, 2006

Barack Obama said straight out and forthright " The second thing,I think,that we're going to have to do is make sure that we control costs" since he notes in U.S. we spend much more and get less!

Hillary Clinton said "we have to control and decrease costs for everyone... We have to cover everybody but we've got to improve quality...We can save money within the existing system. I am not ready to put new money into a system that doesn't work until we've tried to figure out how to get the best outcome through the money we already have" said Hillary- not being afraid to harken back to 93/94 when the insurance companies and pharmmaceutical companies made the american public "nervous" about her and Bill Clinton's plan.

Bill"no new taxes for health care" Richardson said flat out "I would focus on prevention... We need to focus more on deterring these diseases like diabetes that is 30 percent of our Medicare cost"

Now mind-you the phrase "cost-control" scares people because they automatically believe that means less care. It does not! We are at a point on the U.S. bio-medical technology curve where more is not always better! It actually might be harmful. Cost control can mean better-"first do no harm"-care and prevention.

Yet we have the paradox of some segments of our population getting no to minimal basic care? These fellow citizens need basic care now!

The demographic destiny of 77 million U.S. baby boomers beginning to utilize a high tech expensive economically unsustainable "disease care" system and gobbling up more and more expensive medications, many of which are unsafe, is indeed a freightening economic prospect. The head of the U.S. GAO Comptroller General David Walker calls it an "economic tsunami" - especially his Medicare cost projections.

I personally support a modified HR 676 - The Conyers/Kucinich, single payer- "Medicare for all" bill.But not in its present form. The bill must be modified to include a hefty dose of both individual AND institutional prevention! The prevention strategies must be implemented with fairness and compassion

Good for the Dems last night. Some of the leading candidates got it right on Health Care Reform- the domestic issue that could very well elect one of them to the U.S. presidency in November of 2008.

Dr. Rick Lippin
"Blake"

Washington's Dirty (not little) Big Health Care Reform Secret

2007-04-15T16:34:00.000-07:00

On Sunday March 4th 60 MINUTES Steve Kroft interviewed the Comptroller General of the United States -head of the U.S Government Accounting Office (GAO)-David Walker.. Appointed by former President Bill Clinton, Mr. Walker is now on a nationwide crusade to save the nation from what he calls a "fiscal tsunami".

Now mind you accountants by temperament are intelligent,sober people not prone to excesses of emotional rhetoric but if you heard Mr. Walker's interview you need to be scared into action.

This is the man with the data and he did not mince words-How refreshing from within the Federal Government!

"I would argue that the most serious threat to the United States is not someone hiding in a cave in Afghanistan or Pakistan but our own fiscal irresponsibility," Walker told Steve Kroft of 60 MINUTES

We suffer from a fiscal cancer. It is growing within us. And if we do not treat it, it could have catastrophic consequences for our country," Walker stated.

The cancer, Walker says, are massive entitlement programs we can no longer afford, exacerbated by a demographic glitch that began more than 60 years ago-- a dramatic spike in the fertility rate called the "baby boom."

To illustrate their impact, he uses a power point presentation as he travels around the country with his "fiscal wake up tour" to show what would happen in 30 years if the U.S. maintains its current course and fulfills all of the promises politicians have made to the public on things like Social Security and Medicare.

...the real problem is health-care costs. Our health care problem is much more significant than Social Security," he says. By that I mean that the Medicare problem is five times greater than the Social Security problem.The prescription drug bill was probably the most fiscally irresponsible piece of legislation since the 1960s," Walker argues.

This is no wild eyed zealot says CBS News.Yet some say he is a chicken-little overstating the magnitude of the problem.

I do not have the data that Comptroller General Walker has access to, nor do I have his accounting skills, but to me he is performing a great public service by sounding his alarms now. He is demonstrating a rare quality among Washington heads of federal agencies and even more rare among Washington politicians-namely backbone!

I know a bit about health-care economics and to me his message is a legitimate plea for fundamental and dramatic health care reform and what I call compassionate,fair and ethical, yet nevertheless, significant and yes painful,costs reductions.

Tough choices ahead - That's for sure. But not facing them is the worst choice we could possibly make

Dr. Rick Lippin
"Blake"

Health Champions Project

2007-03-31T19:25:00.000-07:00

Getting back to the main sponsor of last Saturday's 3 hour forum for Democratic presidential hopefuls(see my immediate previous post) The Center for American Progressive Action Fund headed by John Podesta has a HEALTH CHAMPIONS PROJECT that may be worth your consideration.

I'm not quite sure from the site how to become a "Health Champion" and collaborate with this group but I like their 4 goals of:

-Providing affordable coverage for all Americans;

-Controlling health care costs;

-Guaranteeing choice of doctors and health plans;

-Making prevention a national priority

As you know from my previous posts on this blog I resonate with #4 the most and probably number #3 the least.

(But we know how obsessed American's are with freedom of choice of doctors and health care plans? Don't we?)

Lets's hear from you on these #4 goals of The Center for American Progressive Action Fund.

By the way the 3 hour forum should have been televised! given the importance of this issue which may very well elect our next president.

So those out there in TV land pick it up!

Dr. Rick Lippin
"Blake"

Democratic Blockbuster Event on Health Care Reform

2007-03-24T12:17:00.000-07:00

The Center for American Progress Action Fund headed by John Podesta sponsored a three hour live forum today on U.S. Health Care Reform for presidential candidates at the University of Nevada-Las Vegas which was video webcasted. (Should have been televised in my opinion)

SEIU - The Service Employees International Union headed by Andy Stern which includes health care workers had a heavy hand in this production for good reasons.

Seven democratic candidates, in my opinion, all of whom had good appearances, agreed this could be the single most important domestic issue of the campaign for President in '08.

I will be writing a lot more on this in days/weeks to come but here is my ranking for today's appearances in order of who impressed this writer and why.

1) Sen. Chris Dodd for stating correctly that the healthcare issue should not be "stovepiped". Jobs and the general economy have more to do with health care than the medical care industry. He is correct! He also used the word "shame" as it relates to our current system.

2) Cong. Dennis Kucinich for showing the most political backbone for making a passionate moral case for single-payer.

3) Sen. Hillary Clinton for showing great knowledge and passion on the health care issue which she wrestled with in 93/94. Hillary hit a home run today!

4) Former Sen.John Edwards who is the ONLY candidate who has put forth a recent very specific plan (The Conyers/Kucinich bill H.R. 676 is many years old)and hence sets a mark for others. He used the term "mandatory prevention"

5) Gov. Bill Richardson who also did well and talked about a portable "Hero's Health Card" for our Veterans to use anywhere geographically in the Health Care system. (bravo!) As a governor Richardson kept referring to shared financial responsibilities between the Federal Government and the States. He, like others, mentioned the worthy idea of school based health clinics. Prevention starts early.

6) Former Sen. Mike Gravel- Promoted a voucher system but correctly pointed out that we should "not trust our leaders" who are bankrupting this nation over the last 50 years. So "let the people decide" says Gravel. He also spoke about 77 million baby boomers who are hitting retirement age over next 5 years and their voice being heard.

7) Sen.Barak Obama was also good but the least impressive candidate today in my opinion because considering his strong polling numbers HE DOES NOT YET HAVE A HEALTH CARE PLAN! Maybe this relates to his short tenure in federal office which could be his general soft underbelly on all issues? (I'm still watching his smoking habit too). His says his plan will be on his website within 4-6 weeks?

I was genuinely impressed with all seven. The Republican candidates were invited to today's forum but none accepted. Nor are any of their plans remotely worth considering except perhaps "Republicrat" Arnold Schwarzeneger, Gov. of California, who is not running (actually cannot run) for U.S President.

Bravo to the DEMS who stepped up to the plate today on Health Care- Y'all done well

But where was my candidate? -Al Gore?

Dr. Rick Lippin
"Blake"

Mental Illness in U.S. Presidents--"Call Me Incompetent But Don't Call Me Crazy"

2007-03-07T14:02:00.000-08:00

This is very serious subject for several reasons-

- We obviously need mentally competent Presidents of the United States

- We need better laws to ensure such mental competency both prior to and while holding such an important office

- We need to ensure that psychiatric evaluation,diagnosis,and treatment of Presidents are as free as possible from any influence whatsoever from partisan politics.

I had planned to write on this topic in the future but was stimulated by a remark that Sen. Dick Durbin (D-Ill and new Senate Majority Whip) made in January of this year that our current Vice-President was "delusional" about Iraq and the daily vitriol that spews forth on a number of mostly progressive liberal blogs about the sanity of our current president and vice-president. Reflecting upon Mr. Reagan's Alzheimers disease while still in office was another stimulus to this piece.

As a physician I go out of my way NOT to tele-longdistance-diagnose anyone as was done by former Sen (Dr.) Bill Frist in now landmark Terri Schiavo case where Frist insisted she was not in a persistant vegitative state.(He then tried to recant saying he was speaking as a Senator not a Doctor?)

But back to the more to the general issue of presidential mental health

About a year ago (Jan 2006) an excellent article which studied biographical source material in 37 presidents from 1776 to 1974 was published in The Journal of Nervous and Mental Diseases on the topic of Mental Illness in U.S. Presidents... and concluded that 18 presidents (49%) met criteria suggesting psychiatric diagnoses and in 10 instances (27%)"a disorder was evident during presidential office, which in most cases probably impaired job performance". Thankfully the authors concluded that no national calamities appeared to have occurred due to presidential mental illness. Here is the abstract for the article. (Sorry folks you must cough up some bucks for a full reprint)

Presidents with mental illness provide opportunities to discuss the stigma of mental illness,the treatment of mental illnes, the possible abuse of psychiatry (see Citizens Commission on Human Rights) and issues surrounding privacy in a public figure whose privacy rights in my opinion need to be subjugated by the public's right to know the health and competency of their President who is also their Commander-in-Chief.

In 1967 the 25th Amendment to the U.S. Constitution was ratified which addresses transfer of power in cases of presidential illness or death precipitated by the tragic assasination of President John Kennedy in 1963.

The prestgious College of Physicians of Philadelphia, of which I am a fellow, under then Executive Director Dr. Marc Micozzi launched several initiatives beginning in 1996 to better understand presidential health and disability with special emphasis on improving the 25th amendment by giving it,in Dr. Micozzi's words, "operational definition by statute or regulation"

Currently,for example, the 25th Amendment does not address who makes the final medical determination that the president is unable to hold office? (That's not good)

An educational exhibit took place at the College between 1996 and 1998 entitled "When the President is Patient" which traced George Washington's thigh carbuncle/abcess to George(Papa)Bush's thyroid condition.(see NY Times Coverage)

Sen. Arlen Specter (R-PA) delivered Opening Remarks (Nov 19, 1997) at a College Forum on Presidential Diability and the 25th Amendment where he closed by stating he was very interested in whether the College "will recommend legislative action to strengthen our current system for providing for the health of The President of the United states".(now that's a positive way of saying it) But Specter also raised the issue of the nation possibly being better served if White House Physician were required to consult with an independent panal of physicians for a mandatory second opinion. ("The panal will see you now-Mr. President")

In it's final report on the College's Presidential Health Task Force chaired by Dr. William Kissick the group concluded that "the current system of providing for the health of the president of the United States has in the past failed to serve effectively the president himself and the public, and has even been exploited as a means of deceiving the public about the state of the president's health.This committee went on to propose that an Act of Congress be passed into law to create a physician panal to provide a second opinion to the White House physician. A draft bill was even prepared by this committee. (Alas, I do not know the current status of this draft legislation?)

Needless to say the College of Physicians of Philadelphia deserves significant credit for these initiatives in the late 1990s. And special thanks to Dr. Marc Micozzi for spearheading these efforts and to Sen. Arlen Specter for assisting the College.

The College did not, to my knowledge, specifically focus on Presidential mental disability in any of its activities and deliberations?

Sufficed to say that psychiatric status is often ommitted from any or most of our own health evaluations. Yet for the President of the United States - past, present and future- I would focus on that first and foremost.

In our increasingly volatile world it seems like a pretty important priority to me?

Don't you agree? Let's hear from you!

Dr. Rick Lippin
"Blake"

John Edwards Health Care Plan "Pastiche"

2007-02-21T15:16:00.000-08:00

A few weeks ago Presidential Candidate John Edwards put forth a health care plan ahead of the other leaders in the U.S. presidential race. At least he set a mark!

John Broder of The New York Times summarized it well

(The brave unelectable candidate Dennis Kucinich is co-sponsoring HR.676-Single payer- Medicare for all)

The trouble with the health care plan mark that Mr. Edwards has set is that it is a true "pastiche-collage-soggy mix and match"(you put in your own metaphor"________________ )multi-component,phased in plan, that still aligns we weary and broke U.S. health consumers with employer based-private insurance industry managed health care which Mr. Edwards himself admits has been a failure.

But to his credit Mr. Edwards says that his plan would create a federal health insurance agency that could someday (when?) become the basis for a single-payer system that would eventually (when?) do away with private health insurance.

Sorry Mr. Edwards, I understand that you can't "steer" a 2 trillion dollar "mega-ship" too quickly or too sharply lest it breaks apart thus producing what many are predicting would be serious dislocations to the US economy. But Mr. Edwards ,the mega-ship you are trying to steer, alas, is the Titanic and we have already hit the proverbial iceberg and sinking fast.

(I'll put aside for now the loss of campaign contributions from the industries that your plan might hurt).

My take is that in recent times we have little reason to trust the health care industries like Big PhRMA or Big BIO, the for profit and "not for profit" high tech Hospital Industry and certainly Big Insurance who feed together,like pigs at the trough, while the patients and even most providers get beaten up and beaten down.

Again in The New York Times Paul Krugman asks the question "is the health insurance business literally a racket?" citing racketeering lawsuits filed by two New York Hospitals against United Health Group.

Anyway we bloggers who attempt to cover this health care issue await the details of the leading other Dems for Prez like Hillary and Obama as well as the leading Pubs for Prez like Rudy Giuliani and Mr. McCain (I'm counting out Mitt Romney because I don't believe anyone who is named after a piece of athletic equipment or clothing can be president)

Anyway, thanks again Mr.Edwards for the kickstart which places increasing pressure on the other candidates to put forth details on their own health care reform plans.

A dear friend of mine believes in incrementalism as you seem to. He calls it "one slice of baloney at a time". Actually I wish he said salami because, so far, most of what I am tasting from the presidential candidates is "baloney" (not the food variety)

Stay tuned folks- When the war plans become clear, health care reform waits in the wings as the issue that will decide the Presidency in 2008

Dr. Rick Lippin
"Blake"

The BIOtech Bubble is Bursting

2007-02-17T19:57:00.000-08:00

Almost a decade ago I believed that the predictions that the humane genome project and more recently stem cell research would revolutionize medicine were overly optimistic both in their capacity to advance human health and to create a new economy in health care.

I know that many progressive, mostly democratic members of the US Congress, and high visibility governors such as Eliot Spitzer of New York and Arnold Schwarzenegger of California have placed their political and financial bets on these technologies and many average American citizens still hope that these technologies will yield cures to many of our most devastating diseases.

But alas- the politicians were duped by an overly optimistic report generated in 2004 by Stanford University health economist Lawrence Baker and Bruce Deal of The Analysis Group in preparation for the run up to a California Ballot initiative.(now known as the Baker-Deal Report)

And the American public has been duped, in my opinion, by probably well meaning mainstream media fed incorrect information by both the scientific community and very powerful for profit BIOtech companies into believing that these technologies were revolutionary. Instead the public should have been told the truth- that these technologies were in their infancy and that there were no guarantees that they would work at all?

For an excellent summary of this issue I commend to you a post by David Hamilton- a free lance writer from San Francisco on Slate.com last week entitled The Biotech Bubble

Am I an anti-biomedical technology Luddite? By all means no- but I do believe, as many do, that we are currently on that part of the biomedical technology curve where real scientific and financial return is much more difficult to achieve for dollars and resources invsested. And since medical school, for me over 35 years ago, it became very apparent that technology in medicine would never solve all of its problems- not by any stretch of my imagination anyway.

Dr. Rick Lippin
"Blake"

Mayor of New York Comes Through For Prevention

2007-02-13T11:59:00.000-08:00

In a landmark speech on health care reform yesterday the Honorable Michael R. Bloomberg, Mayor of the greatest city on the planet, New York, New York , jolted to the front of the pack among politicians by endorsing prevention by stating "we're paying for a disease care system- not a health care system." He also emphasized the role of "prevention-oriented electronic health records"(EHRs)

The good Mayor has a program of 10 preventive health care steps that every person can follow know as "Take Care New York"

Pinch me!

I've waited for a prominent politician to take this leap for at least a decade. Little did I know it would be a Mayor!

I would personally add that an important component of prevention are Institutions and yes, Government, stepping up to the plate as well as individuals regarding healthy environments in the broadest sense of the word. And healthy jobs for all!

Below is once more my own #8 point plan from 1995 (slightly revised after Katrina)

GROW UP AMERICA-A HEALTH CARE PLAN FOR ALL AMERICAN CITIZENS- proposed by Richard. A Lippin MD*

- Stop prolonging death. It’s both expensive and dehumanizing at best, greedy and cruel at worst.

-Empower US citizens to assume increased individual responsibility for health and convince medical consumers that it is in their best interests not to assume the role of helpless, dependent victims/patients.

-Yet also recognize that we have medicalized America’s social problems. So we must provide healthy and safe jobs for all able citizens thereby reducing poverty and all its subsequent health impacts (possibly 1/3rd of Health Care Costs)

-Provide healthy environments including healthy air, water, soil and food.

-Rebuild America’s public health infrastructure to ensure we provide appropriate macro and individual interventions to especially low income citizens such as childhood and adult immunizations and response to man-made and natural catastrophes.

-Face the reality that a very large percentage of illnesses, injuries and hospitalizations are entirely preventable. Subsequently, the elimination of tobacco, alcohol, drug, medication and dietary abuse alone could immediately reduce medical costs by a factor of at least fifty percent.

-Incent and train physicians to maintain the health of patients and populations. Radical changes in provider re-imbursement and medical education strategies are necessary

-Recognize that early childhood preventive medical education can profoundly affect lifelong health behaviors.

*proposed in June of 1995
Revised January 2006/2007

Mayor Bloomberg- I speak for many when I say we are in your debt for telling like it is-and it must be.

Prevention is our ONLY way out of our economically unsustainable disease care system. But please Mr. Mayor- Sick and injured people still need our help too- so please a transition to "Prevention with a heart" is the way to go.

Dr. Rick Lippin
"Blake"

OBAMA ON HEALTH CARE-HALF RIGHT

2007-02-10T10:47:00.000-08:00

Today Barack Obama was electric again and spoke about prevention in health care during his Presidential announcement speech - my personal favorite solution to the "now everyone agrees" genuine crisis in US Health Care.

H.R. 676 (Conyers/Kucinich etc)- Single payer-"Medicare for All", for example, needs more prevention in it.

But Mr. Obama also has a bill in Congress called the Genomics and Personalized Medicine Act which is ill conceived and informed. The Human Genome so called health revolution is a myth

Below is what I wrote in January 1999-

Major advances in modern Neuroscience with all of its profound implications (like the physiology of human perception and the physiology of human intentionality or choice) will significantly dwarf, if not render childlike, all the projections that molecular biology and the human genome project will “revolutionize” Medicine in the 21st century.

(Feedback welcome on my 1999 comments)

But still Obama exudes passion and programs for the growing ranks of the disenfranchised and disillusioned Americans. He's a candidate to be taken seriously-no doubt about it!

Dr. Rick Lippin
"Blake"

It's Efficacy( Does it Work?) -Not Quality That Comes First!- Says Dr. Nortin Hadler

2007-01-30T06:58:00.000-08:00

Last Monday, Jan 22, Dr. Nortin Hadler author of probably the most important book on U.S. Health Care The Last Well Person: How to Stay Well Despite the Health-care(2005)System since Ivan Illich's Medical Nemesis written over 30 years ago(1976),wrote a groundbreaking piece for ABC News.

Now Dr Hadler is writing for ABC News and I urge you to track his latest thinking periodically on ABC NEWS

He gave me permission to reprint the essay below from last Monday. It is worth your reading.(I have bolded some statements that especially resonate with me)

"Curing Health Care Insurance-Examining the Insurance Mess - and Its Unspeakable Remedy"

OPINION By NORTIN HADLER, M.D. ABC NEWS

Jan. 22, 2007-None of us needs to be told. The health care delivery system in America is indefensible. About $2 trillion fuels the system, some 16 percent of our national productivity. If we were all covered, that's more than $6,500 per person.

Despite such a fortune, about 40 percent of us can't afford the care we are told we need, either because we are inadequately insured or out-of-pocket payments would bankrupt us.

Medical bills broke the back of more than 40 percent of us who have declared bankruptcy. Even those who feel adequately insured are bedeviled by difficulties in getting care; those inadequately insured are tormented by them.

Despite outcries, this sorry state continues to deteriorate. Why?

Clearly, the cause is not a lack of money. Every other resource-advantaged country indemnifies its entire population with less than half of what we spend, with better national health statistics to show for it.

The problem must reside in the way the money is spent.

Is the "Best" Medicine the Most Effective Medicine?

The guiding principle of all health care reform in America is the belief that American medicine is the "best" in the world.

Reform would tackle misdistribution and the inconsistencies in the quality of care. Once these are overcome, all of us will be afforded the "best" to prevent us from getting sick, and the best to heal us when prevention fails.

The savings that would result from a decrease in the national burden of illness would be enough to provide for adequate distribution of care.

It follows that the goal of health care reform is to make certain that American medicine is performed expertly so as to provide optimal quality of care.

Serving this agenda are national committees to establish the criteria for expert care for particular diseases, national committees to collect the data on how particular states, hospitals or practice groups approach these standards, and national committees to see if it matters.

Much of this effort has taken heart disease as the target because of the volume of cases, the costliness of treating these diseases, and the consensus as to the best care. Many a program has been implemented to move practice up to these standards.

The quality movement is enjoying its day in the sun. Legislators and potentates in the hospital and health insurance industries are beating the drum. Few are questioning the basic premise of the quality movement.

Does it matter to the patient if practice meets these consensus standards? There is a crying need for such heresy.

A recent analysis of the Medicare experience (JAMA, Dec. 13, 2006) should muffle the drumbeat. The degree to which practice met the accepted standards for Medicare patients admitted for heart disease did not predict who lived and who died.

Even for the poster child of the quality movement, heart disease, something is amiss.

Focusing on Quality Alone Could Compromise Care

Why wouldn't performing up to these standards of care for heart disease, to "high performance," be advantageous to the patient?

Maybe the Medicare analysis could not detect the shortcomings in the way doctors and hospitals meet standards of care.

More likely, though, is that the standards of care are far less important than the committees that formulated them pronounce.

If what we do to you doesn't work, or doesn't work much, than it doesn't matter how well we do it. It also doesn't matter how cheaply these services are provided; if it doesn't work it's worthless at any price.

The quality movement is putting the cart before the horse. The "horse" is efficacy.

The quality movement overcame great odds to gain its current influence. Physicians and surgeons, like other professionals, are not reflexively disposed to "outsiders" questioning their competence. Even peer review is a prickly process.

I applaud the quality movement and admire many of its leaders. However, quality is not the goal. It is the process. Efficacy first, then quality, promotes effectiveness.

There is an "effectiveness movement," bloodied and bent but unbowed. It can muster far more illustrative science than the quality movement.

But the forces that thwart the demand for effectiveness are powerful, wealthy and predictable.

Most of the high-ticket items (procedures and pharmaceuticals) are minimally effective, or ineffective. Many of these are considered standards of care. Many are cash cows touted by vested interests.

Effectiveness Key to Performance

From my perspective as a clinician who has cared for patients and taught students for more than three decades, if I have to treat more than 20 patients to do something really meaningful for one, the treatment is marginal; I do not prescribe or advocate it and would have no problem if it was not covered by health insurance.

If this seems extreme, consider the fact that many new and expensive treatments available today do not meet the threshold of meaningful results for even one out of 50 patients.

Furthermore, designing trials to test whether new or old treatments meet this one in 20 level of effectiveness is not difficult, expensive or time consuming. We would no longer be marketed to prescribe and consume minimally effective treatments, or treatments that offered no important improvement over the tried and true.

If we have effectiveness at the base of our health care insurance system, adding cost-effectiveness and quality would be rational and straight forward. We could well afford such a rational health care delivery system, with most of the $2 trillion to spare. We would be more "high performance" than any other country.

And our unsung, well trained and caring physicians, nurses and allied health professionals could get back to serving patients instead of the health care delivery system.

Dr. Nortin Hadler is professor of medicine and microbiology/immunology at the University of North Carolina at Chapel Hill, and an attending rheumatologist for University of North Carolina Hospitals

Hadler is a brilliant courageous iconoclast who is dedicated to science and is meticulous and thorough with his research homework. He may make you squirm or even possibly your blood boil but I for one take his work to the intellectual "bank"

Thanks Nortin!

Dr. Rick Lippin
"Blake"

The Commonwealth Fund -Rx for Controlling Health Care Costs

2007-01-29T14:58:00.000-08:00

The Commonwealth Fund website is one of my favorite sources of sober and intelligent analyses of solutions to our current U.S. health care crisis.

Today I received an e-mail alert from this highly regarded and generous private foundation, founded in 1918 by a woman philanthropist Anna M. Harkness, with then the "broad charge to enhance the common good". The current mission of The Commonwealth Fund is to promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults.

But my e-mail alert today disappointed me because the #7 point health care expenditure reduction strategy that The Commonwealth Fund published cluster around the following themes and failed to highlight prevention My heart was broken and spirit dashed.

President Karen Davis and her Commonwealth Fund colleagues believe that change can come about by:

-Reshaping market incentives to reward value-driven health care and increase competition

-Generating information on the clinical effectiveness and cost benefit of medical services to support coverage policy and medical decision-making

-Reducing high insurance administrative overhead and promoting competitive pharmaceutical prices

-Reforming provider payment systems to reward efficient and effective care

-Strengthening primary care

-Investing in health information technology

-Investing in insurance reforms to ensure access, affordability, and equity.

Yet this all seems quite admirable!?

If one delves into the report there is reference to prevention as one of "the most desirable strategies" from a public perspective. But prevention seems to get lost in what I can only presume is "Commonwealth" believing that prevention is not yet a politically viable option in the current 2 trillion dollar U.S. "disease care" system-err industry?.

I and others posit that our disease care system is economically unsustainable and that prevention is,in the end,our only real way out of this economic wilderness.

I frankly do not understand why there remains so much resistance to prevention? I personally believe Americans are ready and able to accept it.

But as I have said on this blog a $2 trillion dollar industry doesn't just roll over for those among us who believe so much in prevention and public health. Too many dollars on board for this giant ship to make a sharp turn in choppy waters?

I'd like to hear from you

Be Well,

Dr. Rick Lippin
"Blake"

Presidential Candidates on Health Care Reform?

2007-01-25T14:45:00.000-08:00

I honestly have lost track of how many presidential candidates we have?? And I AM NOT-REPEAT NOT a single issue person- i.e.- Health Care Reform.

But Cervantes and I began this blog in Nov of 2005 because we correctly agreed that U.S."Health" Care was in rapid realtime economic and moral/ethical meltdown.

Now that it is clear to me at least that the US Governors are generally not stepping up to the plate (Cervantes never wavered from endorsing a single payer-universal federal plan) I have personally decided to support those who embrace a single payer-universal health care plan for all US citizens. My only proviso would be there must be an emphasis on prevention

Ida Hellander,MD Executive Director-Physicians for a National Health Program was kind enough-THANKS IDA! to alert me to John Edwards stating in The Washington Post that that he was supporting Universal Health Care

Further more Dr. Hellander directed me to Greg Sargent's blog over at TPM Cafe Blog that Barack(yikes!-he's a smoker!)Obama has made a half hearted attempt to endorse Universal Health Care.

Dr.Hellander of PNHP says Obama's remarks were less than well conceived.There's a lot of talk about "boldness" but Obama's remarks are anything but?

Where is Hillary? The dethroned queen of 92-93 HealthCare reform can rise again! But she must not be shy just because her timing was off by a almost 15 years the first time around and she forgot to invite the providers to the planning table. People can learn a lot in almost 15 years!

Thanks Dennis Kucinich for always being on the progressive forefront on this and other issues

Since Al(he's still my favorite candidate)Gore got an Oscar nomination for his movie on the Environment-An Inconvenient Truth maybe he can do a sequel on health care?

But Michael Moore may beat him to Sundance this time with "Sicko"- a movie in prep about our US "Health" Care System

Stay tuned folks- This is getting real interesting? I'm actually "cautiously optimistic" that Americans might actually see decent health care for all soon?

Dr. Rick Lippin
"Blake"

Very Bad News For Preventive Medicine

2007-01-24T15:11:00.000-08:00

A group of entrepreneurs has hijacked the concept of prevention as a means toward solving the US Health Care System Crisis.

On Wed January 10 U.S. PREVENTIVE MEDICINE - a for profit company- founded by Christopher T Fey,Founder and Chairman and Brian Baum,President and CEO- was launched. A full page ad in The Washington Post followed.

An e-mail I sent to them today appended below(slightly revised) expresses my opinion on this ill conceived venture

Dear Messrs Christopher Fey and Brian Baum;

I cannot bring myself to wish you and your colleagues well with the launching of US Preventive Medicine -a for profit company.

Until state and federal legislation incentivizes the correct model you espouse, which is prevention, and third party payers cover the services you are offering, in my opinion, you are omitting a huge number of uninsured and underinsured Americans- some say as much as 100 million US citizens.

Furthermore most the most highly regarded Preventive Medicine experts in our nation and the world fully and objectively understand the relationship of poverty and other SES=Socio-Economic-Status factors on health outcomes. I do not see that understanding at all in your for profit expensive high tech diagnostic and therapeutic/interventional approach to prevention. Please correct me if I missed it?

What we need in this nation is a citizen demand for single payer health care with an emphasis on prevention

To build for profit prevention centers even before third party carriers are reimbursing for such services is, in my opinion, nothing less than a very cruel hoax perpetrated on the American health consumer- most especially the disenfranchised. Shame on you.

If you believe my fundamental criticism of US PREVENTIVE MEDICINE is not accurate or fair I would be very pleased to hear from you both.

Sincerely

Richard Lippin,MD

PS- I intend to circulate my letter to you above as widely as I can

"Blake"

New NY Gov. Spitzer Wimps Out On Health Care Too

2007-01-23T13:42:00.000-08:00

Putting aside the meaningless tripe King George Bush will spew forth tonight on Health Care on National TV,I thought maybe superstar former Attorney General - now Gov. Eliot Spitzer of the great state of New York would see the light and propose a health care plan that would dare to use the phrase "single payer". Instead like Romney of MASS, Schwarzenegger of CAL, Rendell of PA and probably several others.

Mr Spitzer like these other big state Govs have proposed complex plans that 1) are not fully understood because they are overly complex 2)in some cases require federal and state legislation to implement and 3)take too damn long to achieve desperately needed health care for all in their states now. Mostly however they all seem to buy into continuing their relationships with Big Insurance whose overhead costs and greed are bankrupting the health care system- to put aside Big PhRMA/BIO for the moment.

Spitzer had one of the strongest financial incentives to be bold but, alas he wimped out.

Here is what Gov Spitzer said recently at his state of the state address-from ONE NEW YORK- to his New York constituents (excerpt)

Next, we must fundamentally reform our health care system.
No one can afford health care anymore - not New Yorks working families, not our businesses and not our government.

In just the last 15 years, state spending on Medicaid as a share of the budget's General Fund has increased from 14 percent to 35 percent.These are dollars we have made an affirmative decision not to spend on education, tax cuts, infrastructure or the kind of health care investments that are so desperately needed, like preventive care,workforce retraining and insuring New York's 500,000 uninsured children. And these are dollars we will need to sustain the local cap on Medicaid expenses-a critical tool to lower property taxes and to relieve pressure on localities.

It will take a fundamental restructuring of our health care system to
make health care affordable again and to free up the resources for
other urgent priorities.

This restructuring requires hard choices:

We will be forced to close and consolidate hospitals that have been mainstays of their communities, yet because of excess capacity, have cost taxpayers millions of dollars to support.We must shift spending away from expensive institutional nursing homes toward community and home-based alternatives, so seniors can have the care they want at a price they can afford.

We must use the state's vast bargaining power to reduce the prices we pay to large drug companies and pharmacy chains for expensiveprescription drugs.

And we must aggressively fight Medicaid fraud through a state False Claims Act and a Martin Act for Health Care, which I will propose this year.

The savings from reform will not just be reinvested in other priorities such as education and property tax cuts. Savings will also be spent on the kind of health care investments that make good moral and economic sense.

We will introduce a budget that, in the very first year, guarantees access to health insurance for all of New York's 500,000 uninsured children. And within four years, we will further cut the number ofuninsured. Using a new streamlined enrollment process that guardsagainst fraud, we will enroll the 900,000 uninsured Medicaid-eligible adults.

Expanding access to health care will reduce state spending significantly in the long run, because seeing a primary care doctor costs farless than providing charity care for the same patient in an emergency room and it leads to far better care.

We will also invest in better management of high-cost cases involving patients with multiple chronic illnesses a relatively small number of cases that make up a disproportionately high cost to the system. Better managed care will not just save money for patients and the state,but will lead to better overall care.

In making these hard choices, we will not turn our backs to the millions of New Yorkers who rely on us for their health care. The actions we take will not be arbitrary, but in furtherance of a comprehensive strategy to restructure our health care system".

One of my most intelligent friends calls these approaches "a slice of baloney at a time" and believes in incrementalism in health care reform.

I reject this incrementalism and believe we need a single payer system now

Under Mr. Bush's "reign" health care has dramatically worsened in the US by almost any measure and costs have skyrocketed to unimagined heights. And frankly as a citizen and a doctor in the US I am tired of being ashamed.

As far as I can acertain Dennis Kucinich running for President and Dr.Howard Dean DNC Chair are supporting single payer systems.Who else is? out there?

I am watching Senators Clinton an Obama carefully.

Stay tuned as this unfolds now given that this issue ranks very high among US voters concerns (after the war) say credible polling organizations and "the pols have at last caught on to the polls" and, of course, the stimulus of the Dec.6, 2006 watershed US election is not to be minimized.

The Heathcare Reform Issue is finally with us. I personally hope for moral and ethical reasons as much as financial ones

Dr. Rick Lippin
"Blake"

Bush's Weak Health Care Card Coming Up

2007-01-20T11:15:00.000-08:00

President Bush will be talking about Health Care next Tuesday night during his State of The Union Address(SOTA)

How pathetic.I guess his complete disaster in Iraq leaves him few cards left to play.

Some creative Governors have put forth their own state plans in part because the Feds were doing nothing while the US Health Care System significantly worsened during "W"s six year is office. And now the Dems, finally on the Federal level,- especially none other than Dr.Howard Dean- are planning major Federal overhauls of our broken system in rapid economic meltdown.

Credible polls, by the way, have ranked health care as a major priority for the American public for at least 4 years.

The proposal, according to the Washington Post that Bush will put forth, would give those who buy their own health care coverage the same tax benefits now enjoyed by those with employer-sponsored plans. Bush also will announce steps next week to take some federal money now going to hospitals and institutions and give it to states for programs to get medical coverage for the more than 46 million people without insurance.

Well if there was ever an example of "too little too late" this is it!

I am almost too embarrassed for the President and the Nation to watch

But being a good and forever hopefull US citizen I will tune in and urge you to do so also

Next Tues January 23rd-9 PM EST

Dr.Rick Lippin
"Blake"

Single Payer is Necessary Now

2007-01-19T04:53:00.000-08:00

While I was busy blogging about California's and Pennsylvania's Health Care Proposals just put forth last and this week respectively Guy Saperstein, one of the "100 Most Influential Lawyers in America" (according to the National Law Journal) posted a compelling case for a single payer health care system on AlterNet on Tuesday.

Saperstein correctly points out that by every objective documented measure the US has a second rate health care system which, too boot, is economically unsustainable. Also he states we are paying for a massive,inefficient bureaucracy - namely the private insurance based health care system destined collapse our system.

The reason,he says, however that the Dems are not generally endorsing a single payer system,like Medicare,which already exists for 40 years and does generally work, is that a single payer system will be viewed as "socialized medicine" and therefore is not politically viable. Fear among politicians of the Insurance industry and Big PhRMA/BIO lobbies are very real.

I began asking the question on this blog beginning in a Feb 06, as the Nov 06 elections loomed in Nov "where are the Dems on Health Care?- Where was Democratic leader Dr. Howard Dean?" Hearing silence I turned to writing about creative solutions from Governors and a few ex-governors.(Richard Lamm and John Kitzhaber)

Well apparently Dr. Dean has recently appeared (re-appeared?) on this issue endorsing single-payer at a Democratic Alliance conference in Miami correctly saying that "healthcare is emerging as a top-tier political issue?" Really? I thought every credible poll has been telling us that for at least two years?

Well it's still not to late and I say we rally around Dr.Dean and The Democratic Alliance- A group of Progressive Philanthropists and the American public who is fed up to get this job done now.

My one regret about the Saperstein piece on AlterNet on Tuesday is that it failed to reference even one word about prevention and health promotion- clearly our only way out of the economic meltdown of our high-tech, high cost "disease" care system.

So I again include my own 8 point health care plan from 1995 called "Grow Up America" below which undoubtedly is even less politically viable than a single payer system

GROW UP AMERICA-A HEALTH CARE PLAN FOR ALL AMERICAN CITIZENS- proposed by Richard. A Lippin MD- 1995

- Stop prolonging death. It's both expensive and dehumanizing at best, greedy and cruel at worst.

- Empower US citizens to assume increased individual responsibility for health and convince medical consumers that it is in their best interests not to assume the role of helpless, dependent victims/patients.

- Yet also recognize that we have medicalized AmericaÂs social problems. So we must provide healthy and safe jobs for all able citizens thereby reducing poverty and all its subsequent health impacts (possibly 1/3rd of Health Care Costs)

- Provide healthy environments including healthy air, water, soil and food.

- Rebuild America's public health infrastructure to ensure we provide appropriate macro and individual interventions to especially low income citizens such as childhood and adult immunizations and response to man-made and natural catastrophes.(added 2006)

- Face the reality that a very large percentage of illnesses, injuries and hospitalizations are entirely preventable. Subsequently, the elimination of tobacco, alcohol, drug and medication abuse alone could immediately reduce medical costs by a factor of at least fifty percent.

- Incent and train physicians to maintain the health of patients and populations. Radical changes in provider re-imbursement and medical education strategies are necessary

- Recognize that early childhood preventive medical education can profoundly affect lifelong health behaviors.

I would posit that my plan would cut health care costs anywhere from 1/3rd to 1/2 of our current 2 Billion dollars =16% of our GNP national health expenditures

But, alas, I am a realist? Who wants to grow up? Some patients that I see do but probably not enough to vote for a preventive based health care system?

Anyway Saperstein characterizes the current US health care system as "fast approaching a perfect storm". He is correct and we need to read his article and turn it into federal legislation quickly.

I'll wait for another decade for Prevention! I am a patient but persistant man.

Be Well all,

Dr. Rick Lippin
"Blake"

PS- Hey Michael Moore - Where is your movie on the US Health Care crisis allegedly entitled SICKO?

"Prescription for Pennsylvania"

2007-01-17T12:59:00.000-08:00

The title of this blog is Governor Ed Rendell's long awaited Health Care Reform Plan for Pennsylvania (this bloggers home state) that he unveiled today in a noontime speech.

Not unlike his counterpart Governor on the other coast, Gov. Arnold Schwarzenegger from California, Gov Rendell offers up an Rx that is a potpourri of initiatives,incentives and assessments(taxes?) to try to address what Rendell correctly states is a situation where "no longer is it a question of whether we can afford to act. The cost of inaction is far greater in terms of individual health consequences and from the increasing burden on taxpayers"

Like Mr. Schwarzenegger's Golden State plan this Keystone state plan will include sacrifices for all- and hopefully benefits for all underinsured and uninsured Pennsylvanians.

Among the positive aspects of the Rendell plan are:

- CAP=Cover all Pennsylvanians- a complicated set of initiatives through the private insurance system to ensure that all Pennsylvanians ultimately have health insurance- But when this blogger asks is ultimately? And thumbs down from me on working the benefits through mostly employers and the private insurance industry.

- Increasing access by enabling nurses, nurse practitioners,midwives,physician assistants and other non-physician health practitioners to practice to to the fullest extent of their training and skills. Even working weekends and nights is incentivized- Good for you Mr. Governor- That took courage! (hopefully you won't need to see a Doctor soon?)

- Improving quality of care with emphasis on patient safety initiatives and chronic disease management programs- GREAT! and long overdue!

- Rewarding wellness programs to reduce paying for avoidable medical services. "The health care costs related to tobacco and adult obesity in Pennsylvania totaled more than $9 Billion says Rendell an enormous economic burden" You got my vote their Mr. Governor- Out go the cheesesteaks

- Keeping Pennsylvanias, especially the poor and uninsured, out of the emergency room- a very expensive way to deliver health care. "Pennsylvanians statistically are more likely than the average American to go to the emergency room" for care. I'm for that one too Mr Governor.

My consternation with the plan is that it is too complex and will take too much time to implement. Several components of the plan will require legislative and federal approval.

Also, in the end. I believe Mr. Rendell "wimped" out on us (and missed his own opportunity) as a leading, hopefully progressive Democrat, by not endorsing Universal Single Payer Health Care for all Pennsylvanians and by example the rest of the nation.

You are definitely correct Mr. Governor- Government cannot and should not solve all the state's problems. But Government, at all levels, needs to engage health care. The business model(US penchant for "the free market solves all problems") applied to health care has been an abysmal failure rendering the US Health Care system an embarrassment in the international community.

Human beings and human flesh are not commodities. It's time we recognize that.

For more on the Rendell Rx visit Governor's Office of HealthCare Reform

Dr. Rick Lippin
"Blake"

Pennsylvania's Fundamental HealthCare Reform Problem

2007-01-16T10:51:00.000-08:00

Almost lame duck Pennsylvania Governor Ed Rendell will be announcing his Health Care Reform plan for the Keystone State's approximately 12 million residents this week. I'll be watching carefully as a Pennsylvanian and a HealthCare Crisis blogger

Unlike other Governor's Mr.Rendell has a special problem. It turns out that Pennsylvania has probably the largest concentration of Health Care and related Industries in the US maybe second only to the New England region?

So once Mr.Rendell announces his plan(s) I'll be providing my comments on it.

But the cheesesteak eating-sports loving- affable Governor- former effective Mayor of Philadelphia (1991-1999) and Chair of the Democratic National Committee=DNC (1999-"Go Al Gore") see Wikipedia has the classical problem of one industry's profits (health care) are another industry's costs.

For more details on exactly how concentrated the Health Care Sector is in and around Philadelphia for example The New England HealthCare Institute, in partnership with the prestigious Milken Institute, published a January 04 report entitled On the Critical List: Health Care Job Vitality in New England-Addendum to The Economic Contributions of the Health Care Industry to the New England Region.An entire section 11 was devoted to A Case Study: The Pennsylvania and Philadelphia Story.

Just one example-Perhaps the most important structural factor in Pennsylvania's "advantage" is its remarkably strong pharmaceutical cluster says the above report. As private funding plays an increasingly important role in the health care industry, Philadelphia's proximity to pharmaceutical company headquarters and research laboratories is a significant advantage in the search for new sources of job growth.Primary U.S. operations and/or major research and manufacturing facilities for most of the world's top 10 pharmaceutical companies ranked according to sales are located in the greater Philadelphia area. Companies with a major presence near Philadelphia include Merck, GlaxoSmithKline, Novartis, Bristol-Myers Squibb, AstraZeneca, Roche, and Wyeth. While many of these companies have operations in New England, particularly specialized research laboratories, the vast majority of their expenditures remain in the greater Philadelphia area.

However other industries in Pennsylvania are "crying uncle" as health care costs -especially drugs- have dramatically soared over the past decade in particular!

What is Governor Rendell to do? Can he pull the rabbit out of the hat? I regret to say I doubt it. Out of sheer destiny of geography Ed Rendell and the citizens of Pennsylvania are right smack in the middle of an economic meltdown of a treatment based "disease" care system which is economically unsustainable.

To Rendell's credit he trying other sectors like renewable energy and of course tourism, but it may be too little too late for the citizens of Pennsylvania. Installing or tilting at windmills is not going to solve Pennsylvania's Health Care dilemma.

More to come on the Rendell plan this week

Dr. Rick Lippin
"Blake"

Arnold "The Governator" Schwarzenegger Kickstarts HealthCare Debate

2007-01-15T05:49:00.000-08:00

The more I thought about the drama that unfolded last Tuesday night when California Governor Arnold Schwarzenegger announced his health care reform plan the more I felt compelled to write again.

Firstly there he was "The Terminator"- Austrian born Republican Governor of the nation's largest state -former 7 time winner of the Mr. Olympia title (in part thanks to anabolic steroids) -standing before a crowd on crutches just recovering from a severe right broken leg- calling for Universal Health Care coverage for his fellow citizens. 6.5 million Californians are uninsured -more than any state in the union.

Billy Shakespeare would have loved it.

The plan, which is another complex "Rube Goldberg" legislative initiative, is designed to please or piss off every special interest group or medical system stakeholder in the Golden State.

While I can't seem to download the multipage legislation per se-the devil being in the details- I found one statement the Governor's office that interested me most. In a press release of January 8th Schwarzenegger shared responsibilities and shared sacrifices

Of course I was particularly interested in the paragraph of the release that dealt with "Encouraging personal responsibility for Health and Wellness by implementing the Governor's Healthy Incentives/Rewards Programs in both the public and private sectors" Here is the language from the press release and I assume the speech.

"Encouraging personal responsibility for health and wellness: Implement "Healthy Action Incentives/Rewards" programs in both the public and private sectors to encourage the adoption of healthy behaviors. Californians, who take personal responsibility to increase healthy practices and behaviors, thereby reducing their risk of chronic medical conditions and the incidence of infectious diseases, will benefit from participation in this groundbreaking program."

I wrote to the Governor's office to provide details since this interested me a great deal. I honestly never thought I would live to see a US Governor use the term "wellness" in my lifetime since the word grew out of the health lexicon of the 1960's counter culture.

Anway I give the hybrid "Republicrat Governator" credit for standing up on crutches just a few days after a serious skiing injury requiring surgery and kickstarting (The Gov. is a motorcycle enthusiast as well) a national dialogue on healthcare.

I fully understand that the Feds have more important issues to cope with right now but US Health Care is too far broken and much too expensive to ignore much longer.

Thanks Arnold!

Dr. Rick Lippin
"Blake"

Two Heavyweight Thinkers on Health Care Weigh In

2007-01-12T08:48:00.000-08:00

I told you I would be keeping an eye on California knowing that the "new" Governor Arnold Schwarzenegger would be announcing his health care plan for The Golden State last Tuesday.

Well, rather than doing my own analysis with the exception of one of my persistent drumbeats, below I refer you to two serious intelligent essays on the California plan

Interestingly both writers come to fairly similar conclusions about lukewarm (it's a start) support of the plan

The first is an excellent blog by Kevin Drum writer of Washington Monthly's-"Political Animal"- http://www.washingtonmonthly.com/ posted on Wednesday January 10 under the title Community Rating.

The second piece is New York Times Senior Columnist Paul Krugman's piece in the New York Time today entitled Golden State Gamble. http://www.nytimes.com/
If you go to the Times today you will be able to read the Editorial without forking over any of your hard earned dollars. But after today you'll need to pay an annual fee for the NY Times Editorials (in my opinion it's worth it!-especially Dowd!)

Anyway my drumbeat referenced above is about the importance of prevention and health promotion which the California plan did not adequately address-Too politically dangerous but ultimately an economic imperative.

So once again I refere you to http://www.wecandobetter.org/and www.healthpromotionadvocates.org

A treatment based "disease care" system (vs. "health care") is simply not economically sustainable.

Dr. Rick Lippin
"Blake"

More Emphasis on States Leading in Health Care Reform

2007-01-08T09:54:00.000-08:00

Today USA Today published a front page story on the evolving role of the states in Health Care Reform stating that 43 out of 50 states have made expanded medical coverage a priority for their state legislatures in 2007. For full article go to http://www.usatoday.com/news/nation/2007-01-07-states-health-coverage_x.htm

Our own blog here has been writing since February of 06 that, for good or for bad, the states would take the lead in Health Care Reform since in this writers opinion the Feds-

- Have other very real and very important pressing priorities even under Pelosi/Reid for 2007

- Still view health care as a potential third rail of politics since witnessing the debacle of the dethroned queen of major US Health Care reform (then First Lady -now Presidential Candidate) Sen. Hillary Clinton mismanage this issue beginning in 1993

- Are busy either announcing or posturing on both sides of the aisle for Presidential runs coming sooner than usual (like warm weather in January)

Below are a few URLS that will help you determine why our Nations' Governors, both Pubs and Dems, are marching down this path now and how they are doing it. One is a brief blurb is from The Kaiser Family Foundation http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=41987

As usual The Commonweath Fund has good research and sound advice for the states in this recent piece http://www.cmwf.org/publications/publications_show.htm?doc_id=437168

Never shy, former Speaker of the House Newt ("Contract with America") Gingrich had launched The Center for Health Transformation in 2003 as a project of the Gingrich Group, a consulting firm founded in 1999 by Gingrich and specializing in "transformational change". The Center is "a collaboration of transformational leaders dedicated to the creation of a 21st century intelligent health system in which knowledge saves lives and saves money for all Americans". The Art of Transformation a book by Newt Gingrich and Nancy Desmond promotes their agenda as does their website http://www.healthtransformation.net/

Many of the states seem to focusing first on covering all children/citizens- hard to argue with that! Except OUCH!- where is the money for 85 year old grandpa's quadruple coronary bypass surgery? Or even worse where is the money for the immoral prolongation of death and dying in many of our nations' hospitals and nursing homes?

But the fundamental dilemma with most of these state plans is that they still are mostly focusing on health care financing and are not getting at what former two term Oregon Governor Dr. John Kitzhaber calls transforming US Medicine from "disease care" to true "health care" See http://wecandobetter.org/

As part of their week-long series on health care, "Prescription for Change," in October of last year ABC News came to Portland to speak with John Kitzhaber. You can read the story
http://abcnews.go.com/Health/PrescriptionForChange/story?id=2580596&page=1. In my opinion he's got it right!

Kizthaber correctly says we have to have the courage to change our entire construct of thinking about medicine and emphasize prevention -working medicine from the front (much less expensive) end. He says almost in disbelief "It's really mind-boggling to think that we continue to cling to this thing, in spite of the fact that it's not working for any of us."

As I have done before I encourage you to visit the website of my friend Dr. Michael P. O'Donnell www.healthpromotionadvocates.org who has advocated for Health Promotion programs and Health Promotion research for over 30 years! Talk about persistence paying off! O'Donnell now has very well crafted legislation at the federal level which the states would do well to explore for incorporation into their ambitious plans for 2007

(As the DGA =Democratic Governors Association said last year-"WE CAN'T WAIT FOR 2008"

Dr. Rick Lippin
"Blake"

2007 IS THE YEAR REAL HEALTHCARE REFORM HAPPENS!

2006-12-26T10:46:00.000-08:00

It was either the November elections with control of both Houses of Congress taken by Dems and 6 "pickups" by Dem Governors and or the realization that the states and the nation are rapidly going broke with the status quo "healthcare" (really disease care) system that makes me believe that finally, after all these decades of bickering, that 2007 will be the year that real healthcare reform will take place in the US. Do we really have a choice?

I last wrote about the key role that US Governors will play in March on this blog citing the Virginia Gov. Tim Kaine and Illinois Gov Rod Blagojevich (say his name bla-GOYA-vich). I also cited our nation's only Hispanic Governor of New Mexico,Bill Richardson, whose DGA tagline then was "Won't Wait for 08".

But most importantly I cited two former Governors whose ideas about Health Care reform are worth very serious re-consideration. Former Gov. of Oregon Dr. John Kitzhaber's program makes the most sense to me. His work can be found on www.archimedesmovement.org and former Gov of Colorado Richard (Dick) Lamm, while focusing less of Health Care issues recently wrote a book in 2003 entitled The Brave New World of Health Care by Richard D. Lamm (Paperback - Aug 2003. These two leaders are not just nibbling around the edges like most others but are going to the heart of what makes US Health Care so moribund and who also offer tangible but tough solutions.

Well in my blog post of March 3, 06 I posed the question where were the powerful mega- states like New York, Pennsylvania. Massachusetts, Texas and California to name a few on Health Care? I didn't hear much then to my surprise and dismay.

Little did I know that the following month (April ,2006) outgoing Massachusetts Gov. Mitt Romney(R) would send shock waves through his own state and the nation by signing a landmark (albeit complex-145 pages) health care bill that would provide nearly every citizen of ,what my blog partner Cervantes calls the Peoples Republic of Massachusetts, with some level of health care.

Building on what was viewed by many other Governors as a master stroke of compromise other states began to move quickly including Vermont, Maine, Minnesota ,Michigan, West Virginia and Kentucky. It seems that every state is jumping on the bandwagon in some form or another. And a year earlier the now notorious Maryland "Wal-Mart" law forcing large employers to contribute some health insurance to its workers- was overturned and now in appeal

A good summary can be found on http://www.stateline.org/live/printable/story?contentId=166268 "States Think Big on Health Care Reform" (Thank Stateline.org)

I've got my own eyes on three key states.

-One is where I and my family live and work. The Commonwealth (not common wealth) of Pennsylvania where healthcare is a huge business. Gov Re-Elect Ed Rendell is being very careful not to embrace a Massachusetts "Universal Health Care model" nor "A Single Payer model"

-I'll be listening carefully to what California Gov. Arnold (leg in a cast) Schwarzenegger will say on Tues January 9 at his upcoming State of the State address where he promises to explain how he will push the Golden State closer to Universal Health Care in the coming year.

- New York Governor Elect Eliot Spitzer has already shown his hand as an aggressive reformer of healthcare. This was not only reflected by his recent relentless pursuit of health care fraud as NY Attorney General but his recent support of the the New York Commission on Health Care Facilities in the 21st Century which called for the closure of 9 hospitals and the restructuring of 48 other institutions- still a drop in the bucket in Gov. Elect Spitzer's whopping $45 billion dollar Medicaid budget(ouch!). Be bold Gov. Spitzer- you cannot afford otherwise.

In the end with all the plans put forth by Governors and Feds alike (Rep Pete Stark D-CA, a staunch Medicare-for-all advocate is expected to be named chairman of the House Health Subcommittee) most are still emphasizing payment mechanisms and cost-shifting which still misses the mark. Pay for Performance, Gain-Sharing and IT- Information technology are getting some long overdue attention but not nearly enough.

Former Governor Kitzhaber says correctly we already have a de facto system of universal healthcare- expensive emergency room medicine. Kitzhaber goes on to say "about 40% of what affects people's health status are behavioral choices and lifestyle decisions. About 30% has to do with your genetics. About 15% are social factors like whether you have a job, a house or a healthy neighborhood. 5% are environmental factors" What all this means is that the $2 trillion dollar plus US health Care Industry has only about a 10% impact on US citizens overall health? What??? Could that possibly be true??? This is clearly unsustainable! Undeniable demographics, says Kitzhaber, is really what is driving us over the edge.

But let's face it a $2 trillion dollar plus industry doesn't roll over easily. Big money -real big money is on the line. Real battles lay ahead. But I am convinced the heyday of greed is over. 2007 is the pivotal year when America chose not to go bankrupt over healthcare anyway.

Dr. Rick Lippin
Southampton, Pa
"Blake"

The Gesundheit Hospital Project- The Incomparable Dr Patch Adams

2006-11-30T06:33:00.000-08:00

As a sequel to my last post on Hospitals, I am planning an article on my dear friend, the heroic Dr. Patch Adams, who has been spreading a healing through humanism, laughter and arts message around the world for over 30 years. See http://www.patchadams.org/. Also Patch (#=his signature is a "patch") has been planning to build a model hospital in West Virginia and says "we enter our 33rd year without having broken ground" but also stating that "simply being in an idealist quest is its own reward". The movie Patch Adams starring Robin Williams www.patchadams.com circa 1998 garnered worldwide attention to the real Patch but did not stimulate the funding to build Patch's beloved humanistic hospital. I believe Patch's time has arrived so as he says "cough it up ($) now"!

(Right now I am fully engaged in a battle to keep probably the best 19th century American Painting -Thomas Eakins' "The Gross Clinic" in Philadelphia. The Philistine healthcare leaders at Thomas Jefferson University and Hospital are attempting to sell it to of all people- Wal-Mart heirs in Bentonville Arkansas for 68 million dollars)

More on Patch Adams and his many projects soon.

Dr. Rick Lippin
"Blake"

What Do You Want From Your Hospital?*

2006-11-22T06:31:00.000-08:00

I've come to the sad conclusion recently that the penultimate US cultural paradox is the "Health"(broadly defined) of US Hospitals and as a subset the health of US health care workers within all strata. In short, the 5000 or so US hospitals are in deep trouble- very deep trouble. They have lost their way and may not be able to find their way back unless they are radically transformed in my opinion.

What evidence do I have to make such a sweeping pessimistic statement? To begin let us start with the fundamental issue of how safe hospitals are? (Seems a rather odd question to pose for institutions whose fundamental purpose is to cure or heal the sick or restore the injured?). But since the release of the landmark NIH report "To Err Is Human: Building a Safer Health System (2000)Institute of Medicine (IOM) on medical errors stating that then medical errors were the 8th leading cause of death in the US in my opinion not much has changed? Although there are a few rays of hope in Institute of Medicine. Preventing Medication Errors. Washington DC: National Academy Press; 2007.

Furthermore some estimate that medication errors are the 4th leading cause of death in the US. Hospital Acquired Infections (HAIs) have alarmingly rise in recent years and now number anywhere from 5-10% of the @35 million Americans admitted to the hospital each year. (see Emerging Infectius Diseases, Vol. 7, No.2, March -April 2001)Violence and crime have increased in hospitals recently especially in emergency room settings in inner city intitutions where paradoxically some of our greatest teaching hospitals reside.

Hospital billing systems are broken with with estimates by some that a whopping 95% of hospital bills having one or more errors. Many hospital Health Information Technology systems, (HITs)while holding great promise, have been poorly implemented leading to negative consequences. http://jama.ama-assn.org/cgi/content/abstract/293/10/1197

Many hospitals are in severe financial crisis and may go the route of bankruptcies not unlike the US Airline Industry (see Health Affairs Vol 25, No 1- Jan/Feb 2006- "Could US Hospitals Go The Way of U.S. Airlines" by Stuart H. Altman, David Shactman, and Efrat Eilat from Brandeis University.)

Perhaps at the core of why hospitals are broken so badly are three critical issues

- Hospitals (even so called non-profits) are driven almost exclusively by a market driven business model which has abysmally failed

- Hospitals cannot plan because they have no planning roadmap given their justifiable requirement to operate under seemingly everchanging government driven oversight, legislation and regulations

- Hospitals have deified technology to an extreme irrational and costly degree. They have grossly failed to recognize that while their patient/customers want good technology- that patients also want and deserve that their social, psychological and spiritual needs be addressed/met. In short technology is good but simply incomplete. I call it the need for "Bio-Medicine Plus"

Technology "bites back" when overused says Edward Tenner from Princeton. Why Things Bite Back: Technology and the Revenge of Unintended Consequences (Vintage) by Edward Tenner And Diana Dutton believes in many cases our medical interventions are "Worse than the Disease": Pitfalls of Medical Progress" by Diana Barbara Dutton. Drs. Elliot Fischer and Gilbert Welch of the White River, VT.,VA hospital published a most compelling and convincing paper in JAMA entitled "Avoiding the Unintended Consequences of Growth in Medical Care: How Might More Be Worse?"( SPECIAL COMMUNICATIONS:Elliott S. Fisher; H. Gilbert Welch-JAMA, Feb 1999; 281: 446-453)

On the brighter side:

- Lives are saved every single day in our nation's hospitals

- Election Day November 2006 Was a Good Day for Health Care? says Karen Davis -President and CEO of The Commonwealth Fund http://www.cmwf.org/aboutus/aboutus_show.htm?doc_id=422964

- Innonvative hospital leaders like those in The Planetree Hospital Movement are not giving up http://www.emediawire.com/releases/2006/11/emw474587.htm

- Western history and other cultures have much too teach us.

My personal take on hospitals as a 61 y/o doctor. Well, in the 1960's and 70's patients could not find a parking space at our best teaching hospitals. Progress has been made on that front.

As a Med student I would routinely get physically lost in the huge academic hospitals where I trained and I wondered how the patients and visitors were faring? That too I am happy to report has improved.

Generally though I am disheartened and disgusted by the state of health of most US Hospital. I am freightened for myself, my family and friends who enter at them own risk and for my colleagues who work therein.

What do you want from your hospital? How can we achieve that. Please let us hear from you?

We have a moral imperative not to give up. As America "greys" we obviously need good healthy hospitals more so than ever.

Dr. Rick Lippin
"Blake"

*PS- This essay was in large part stimulated by the proposed sale of arguably the most important piece of 19th century American Art (The Gross Clinic painted by Thomas Eakins) by Thomas Jefferson University for $68 million dollars to Wal-Mart heirs in Bentonville, Arkansas- representing the ultimate "triumph" of the marketplace over the core of what health care should be all about.-ral

WITH GRATITUDE TO CERVANTES FROM HIS MISSING PARTNER

2006-11-08T17:16:00.000-08:00

As Cervantes noted for both personal and professional reasons I was unable to continue posting on Critical Condition this past summer.

Ironically among the issues that prevented me from continuing was a new HIT= Health Information Technology System that I was instructed to implement in my medical practice. I was told that I must type in the patient encounter information during my interaction with my patients. (I never liked the word "encounter" in medicine)

Being a doctor who actually enjoys and values listening to patients including maintaining eye contact I found this HIT requirement to be just one example as to why Cervantes and I named our blog Critical Condition

Needless to say some personal medical issues cropped up with me which seem to be resolving

My main reason for posting tonight is -

- to apologize to both Cervantes and the readers and contributors to this blog for not communicating sooner- That was wrong on my part

- to thank Cervantes for his posts of 20 July, 14 August and most recently 9 October and his efforts and plans to keep Critical Condition blog viable. And thanks to also those who posted comments over the summer. A few readers thought I had died! Not quite yet!

With Cervantes permission I would like to continue to only occasionally post as a guest and I will reply whenever possible to posts in the comments section of this blog.

If and when I obtain a professional position that allows me to write more I would consider hosting a blog again

I greatly admire bloggers who have the time/ stamina/ creativity to write sometimes daily. I discovered I don't.

And I greatly admire the blogger movement which undoubtedly has changed in a very fundamental and democratic way the capacity to be heard by many without joining the mainstream media. It's quite a remarkable phenomenum.

Yet-As I have said in the past the most creative bloggers out there among which is our own Cervantes will become the mainstream media within 5 years

I was down but now "semi-back". Please keep in touch - Important work in US HealthCare reform is just beginning! We are still in "Critical Condition" and need and appreciate your help.

Be Well,

Dr. Rick Lippin
"Blake"

Welcome Back to CC

2006-10-09T06:52:00.000-07:00

As I announced previously, unfortunately Dr. Rick is currently unable to continue with this project. However, the Critical Condition blog is still here for people who want to contribute. I particularly want to encourage health care providers and healers of whatever description -- physicians, nurses, PAs, therapists, psychologists, technologists, you name it -- to contribute here, but I'm also interested in perspectives from patients and outside observers.

This contribution from ~~Dr.~~Mr. Lewis is in response to a post on Stayin' Alive about medical education, in which I endorsed recommendations to ease up on the basic science in the first two years of medical school, in order to allow more time for learning the basics of clnical practice. ~~Dr.~~ Mr. Lewis adopts a personal, creative approach to healing which I would say is swimming against the current of "evidence based medicine," but it's important to hear the diversity of voices in the field.

Anyone who wishes to post here should send me an e-mail (see the sidebar) and if it fits our very broad criteria, I'll put it up for you. No endorsement by me is implied or necessary -- posts here that are signed by people other than YT are the responsibility of the poster. -- Cervantes.

Quoting Ezekiel Emanuel: "Personally, despite being taught the Krebs cycle (twice during medical school as well as twice in college), I have never used it in my practice or research."

What a terrible shame! The Krebs cycle is so fundamental to... well, to damn near everything, that to ignore it is to ignore a significant portion of the biochemical fundament of healing. I was not taught the Krebs cycle twice. I taught myself the Krebs cycle several times, and have contemplated it for years -- especially in its context as the biochemical mechanism most prominent in mitochondrial function. This is the very basis of cellular health and integrity, EVERY aspect of which depends on the energy compounds generated in the mitochondria (by way of the Krebs cycle). The pertinence of energy to all biological systems and functions can be reflected in mythic terms: "energy is eternal delight" (Blake). That would be apart from eternal adequate cell function, maintenance and repair.

One non-mythic example: a tired, run-down friend of mine was suffering with a high-pressure job and wondering if she was going to be able to cut it. (She is an RN on a trauma unit, by the way, and in this case one of the traumatized was HER.) I suggested a program of what I described, for simplicity's sake, as "mitochondrial nutrients". The basic routine was: a gram or two each of powdered carnitine, ascorbic acid, and potassium bicarb, stirred into water (makes a nice alka-seltzer-like fizzzz) twice daily, combined with a B-50 (B-complex) tablet, and a lipoic acid capsule (100 or 200 mgs). The combination of carnitine and lipoic is known to activate aged or flagging mitochondria (search engine for "bruce ames", "mitochondria", and the compound names); carnitine alone in multi-gram doses often has nice ergogenic/anti-fatigue effects. The potassium is an intracellular essential for all enzyme activity, and I had reason to suspect she was K-depleted. The ascorbic helps correct the generally-universal hypoascorbemia, as well as being a great anti-stress compound (e.g. throwing the switch to send precursors toward DHEA instead of cortisol in the adrenals). It also imparts a pleasant tartness, to counteract the brackish and metallic potassium bicarb. The B-complex was a general measure to ensure full repletion and tissue saturation with the essential coenzymes -- particularly but not exclusively NAD, and others in the coenzyme-hungry mitochondria.

The result was excellent. Her fatigue quickly vanished, and her confidence and general resilience were restored. As she described it (paraphrased): "it is like drinking liquid energy... you can feel it activating all your cells within minutes", or words to that effect. Those were HER words. I had promised nothing of the sort. I told her that the effect, if any, would likely be subtle, developing over several days or weeks, so be patient. As it turned out, happily, she did not have to be patient. (I love it when that happens.) She also noted an improvement in her skin -- less wrinkles, and a fuller, more-hydrated look (less piqued). That's understandable. Potassium depletion and sodium predominance tends to dehydrate, shrink and shrivel things. And taking a big dose of potassium in the evening (best time to replete with potassium) is known in nutritional folklore circles to act as an "overnight face-lift". (Try it. It really does work, often.)

In any case, most people are potassium-depleted at the cellular level even if normokalemic (same with magnesium); most people are also slightly acidotic. Correction of this is absolutely essential to anything properly called healing. The potassium depletion, associated with chronic low-level acidosis, started with the advent of the neolithic: : Eur J Nutr. 2001 Oct;40(5):200-13 : Diet, evolution and aging--the pathophysiologic effects of the : post-agricultural inversion of the potassium-to-sodium and : base-to-chloride ratios in the human diet. : Frassetto L, Morris RC Jr, Sellmeyer DE, Todd K, Sebastian A. : PMID: 11842945 [I could give many more citations on this]

And, regarding the primacy of mitochondrial function, a fellow by the name of Richard Fiddian-Green has had many fascinating things to say -- including that mitochondrial malfunction is the likely undergirding (though perhaps not quite "cause" in the conventional sense) of a range of chronic diseases such as CAD, type 2 diabetes, COPD, hypertension, MS, depression, Alzheimer's, Parkinson's, and many more. He is no doubt correct, provided we understand the concept of terrain, or "the patient that has the disease, rather than the disease the patient has". Further, he suggests that many commonly-used drugs are acting as inhibitors of mitochondrial function -- really an alarming charge, if correct. That would mean that the CURING is going on while the HEALING is actively thwarted! Here are a few snippets from Fiddian-Green's writing: ITEM: : http://bmj.bmjjournals.com/cgi/eletters/325/7370/913 :

"An impairment of mitochondrial oxidative phosphorylation : appears to be the primary cause of organ dysfunctions and : failures including psychiatric disorders in the acutely and : possbily even in the chronically ill (2-17). The commonest : causes of impaired mitcohondrial oxidative phosphorylation are : an impairment of oxygen and/or nutrient delivery and the many : inhibitors or uncouplers of oxidative phosphorylation which : may be contained in recreational drugs, medications prescribed : and/or environmental pollutants. The impairment may on : occasions be due to increasing the demand for energy from ATP : hydrolysis beyond the capacity of mitochondria to replenish : their ATP stores." ITEM: :
>
http://bmj.bmjjournals.com/cgi/eletters/325/7366/701#25874 : "Both acute and chronic psychiatric disorders might be the : products of an energy deficit, that is to say an impairment of : the adequacy of mitochondrial oxidative phosphorylation and : accompanying generation of free radicals (2,3). : Antidepressants cause neuronal cell death (4). Fluoxetine : hydrochloride, protriptyline hydrochloride, amoxapine and : doxemine hydrochloride might do so by interfering with : mitochondrial oxidative phosphorylation and hence promoting : the generation of free radicals (5,6,7,8). These potentially : harmful effects are not limited to antidepressants, : haloperidol having similar effects (9)." : [...snip...] : "Drugs and hormones that exert their actions by stimulating : the release of cAMP do so at the expense of ATP from which : cAMP is derived. In circumstances in which the ability of : mitochondrial oxidation to replenish ATP stores is compromised : these drugs and hormones have, therefore, the potential to : compound the severity of the energy deficit present. As an : impairment of oxidative phosphorylation is accompanied by a : fall in tissue pH, enzyme kinetics are changed potentially : changing not only the efficacy of the drugs but also inducing : the expression of rogue genes." I

TEM: : http://www.chestjournal.org/cgi/content/full/116/6/1839 : "[T]he severity of tissue acidosis in anaerobiosis is related to : the degree of impairment of oxidative phosphorylation... Gastric : pHi [intramucosal pH] is a metabolic signal of tissue hypoxia." : [...snip...] : "[C]ontinued accumulation of protons and later net ATP degradation : compromises essential ATP-dependent functions, such as the sodium : pump, and cells swell and die. ATP degradation allows free : radicals to be generated on resuscitation." : [...snip...] : "[M]easures directed toward preventing a fall in gastric pHi5 : and restoring the gastric pHi to normal in a timely manner in : anaerobiosis are associated with improved outcomes and reduced : ICU and hospital stays and costs.6 7 8 9" MORE, see: http://bmj.bmjjournals.com/cgi/eletters/325/7375/1255

For a moment, consider also the glucose-insulin-potassium (GIK) solutions used for decades in cardiology. The idea is to drive potassium and glucose into the mitochondria-rich cardiac cells, and give them a boost of energy: the glucose as the calorific energy source, and the potassium as enzyme activator. It was a very good idea, based on understanding of cell physiology basics. Of course it would be much more effective if one were to toss in some magnesium, B-complex, lipoic acid, carnitine, coenzyme Q10, taurine and so on. Whatever. For its time, and even still today, it was and is quite good. In this instance, CURATIVE medicine, perhaps inadvertantly, stumbled upon a HEALING technique. Unfortunately, however, the healing aspect was never grasped. (Winnie Churchill's remark springs to mind: "Many people stumble over the truth, but then pick themselves up and hurry off as though nothing had happened.") For decades, GIK has been bound hand and foot, and restricted to the role of CURE for acute MI, etc. -- in which capacity it performs fairly well. This restriction bespeaks a profound lack of vision. It misses the vast potential of what might be called the "mitochondrial/bioenergetic orientation", or simply an awareness of cell physiology basics followed by application of appropriate nutrient/coenzyme arrays; i.e. HEALING at the biochemical and cellular level. That, combined with a focus on the vertical -- i.e. not waiting until the subject is horizontal, on a gurney, with cardiac arrest. But such was not to be, and in the last analysis (if you'll pardon that trite expression) it really ought not be.

Yes, such ideas could be awkwardly retro-fitted onto cure-based conventional medicine -- calling it "mitochondrial/bioenergetic medicine" or "Krebs-cycle-based medicine". But that would take decades, and would rely on the ridiculous delivery system (a cluster-fuck of impossibly-expensive institutions, bloated salaries, armies of lawyers, and all the rest) that turns a 1.2-cent aspirin tablet into a $10.95 aspirin tablet. Forget it! Let cure-based conventional medicine be cure-based conventional medicine. Meanwhile, practice health and healing, cheaply, yourself and for/with friends. The total cost of treatment for my RN friend was perhaps 15 cents per day, which includes my consulting fee of $00.00. The same kind of consulting (albeit without quite my depth of knowledge of this stuff) could be performed by any reasonably-intelligent person after several hours of study. It is not rocket science, though it CAN be if you insist on digging deep (unnecessary for daily practice). We don't need more doctors and Phds; we need more conscientious and fairly-knowledgeable caring friends. Besides, names such as "Krebs-cycle-based medicine" are too narrow. We're talking about a whole-terrain orientation, not focussed sheerly on mitochondria and Krebs cycles, however important they are.

SO, to return to the good doctor's remark -- "I have never used [the Krebs cycle] in my practice or research" -- all I can say is that he has missed-out on something at the core of healing, and fundamental to it, though he may continue to be very good at curing. And that is appropriate. Let medicine go on curing, curing, curing, but let us never confuse that with healing and health. The "health care" system must be renamed the "disease care" system, for proper perspective. Curing is a good thing and I am not opposed to it. I just want it to be placed in proper perspective. It is good, but very limited in terms of enduring benefits and true quality of life, plus it gets ruinously expensive in short order. And three cheers for the Krebs Cycle! May it long inform the work of healers, and restore the health of billions -- one educated individual at a time. Alan Lewis [aelewis AT provide DOT net]

Right Questions, Questionable Answers

2006-08-14T11:35:00.000-07:00

Alastair Wood in NEJM has some correct diagnoses for the ailing drug approval process. (Free full text on this one -- NEJM has started making some of their content of broad public interest accessible, but I'm gonna keep hammering on them until they open up the whole thing.) However, I'm not buying his prescription.

Presenting problems:

For most approved drugs, we don't have adequate long-term safety data. Sometimes we find out the hard way that widely prescribed drugs can be dangerous; no doubt many of them are and we don't even know it, because the data necessary to find that out aren't being collected.
Sometimes drugs are approved with the requirement that the manufacturers do so-called "Phase 4" studies, i.e. longer term follow-up on safety and/or effectiveness, but these requirements are weakly enforced, at best.
Many drugs haven't been tested head-to-head against others. To get approval, all you need is to beat placebo, or perhaps an alternative that's known to be sub-optimal. So we don't necessarily know which drug is really best.
Drug companies have a disincentive to develop drugs for long-term prevention, because it would take so long for them to get back their investment. For diseases associated with aging, such as Alzheimers and osteoarthritis, such drugs would be a great boon.
Drug companies have a strong incentive to concentrate on developing "me too" drugs -- slightly different versions of established drugs -- because there is little risk of hitting a dry hole, i.e. spending billions and never getting a commercial product. That steers investments away from true clinical breakthroughs, which are riskier to pursue. (He pays less attention to this, but they also invest in "evergreening" - slightly new formulations of their own drugs, and new combinations of old drugs, so they can keep exclusive marketing rights.)

Now, real clinical innovations are almost always based on publicly funded research, which the drug companies build on to develop commercial products. Obviously, we could just drive the public investment deeper toward clinically useful products, which would solve a lot of the problem. But Wood is dismissive of this idea, basically on the grounds that "it ain't gonna happen." (Smacks of creeping socialism and all that.)

As for safety, we could simply enforce existing requirements for Phase 4 studies, but Wood seems to assume that's asking too much. We could also develop improved surveillance and reporting systems for adverse events, and maybe piggyback some data collection on existing large-scale cohort studies to get better information. But Wood doesn't even consider these options. Similarly, we could just change the approval process to require head-to-head comparisons with existing standard treatments, or at least require more Phase 4 studies to do that, but again, it never seems to occur to Wood.

Nope. His solution to everything is to grant drug companies longer periods of marketing exclusivity if they will just do the right thing in each of these areas. That way, they can make more billions, just the motivation they need.

A significant problem with this idea, which Dr. Wood does not mention, is that it means the drugs will cost far more, for a longer period of time. Which means millions of people won't have access to them, the cost of health care will continue to rise, and inequalities will persist and widen. That would seem to be a downside.

So why does he focus exclusively on exclusive marketing rights and guaranteed return to investors, and ignore other solutions? Does this help to explain it?

Dr. Wood reports having received consulting or lecture fees during the past two years from Scirex, Sapphire Therapeutics, Abbott Laboratories, Elan Pharmaceuticals, NicOx, Medco, Novartis, and Eli Lilly; having acted as an adviser to various reinsurance companies regarding pharmaceutical matters; and serving as a director of Antigenics, chairman of the clinical advisory council and an investor in Symphony Capital, and a director of Symphony Neurodevelopment and Symphony Evolution. On September 1, 2006, Dr. Wood will become managing director of Symphony Capital. No other potential conflict of interest relevant to this article was reported.

Was there no-one else on the planet who could have written on this subject?

(Cross-posted from Stayin' Alive)

Announcement and some content

2006-07-20T06:58:00.000-07:00

Blake, Dr. Rick, has been forced to suspend his participation in this blog due to various circumstances. I'm really sorry about that because he was off to a great start. I'm going to try to keep this site warm by cross-posting from Stayin' Alive, and maybe doing one or two things that are special to this blog. As always, others are invited to submit posts -- check my e-mail on the sidebar. Now here's today's entry from Stayin' Alive. -- C

Before I get to more of that brown shoe insurance stuff, I was meaning to write about the National Institutes of Health (NIH) peer review process. Assuming the U.S. still has enough resources 10 years from now to continue to fund health-related research, this does matter. This post will consist of exposition -- not the most exciting part of the movie. After a brief intermission, we'll start moving the plot.

There is a fairly bewildering tangle of institutes and funding mechanisms, which are served by a wide variety of review panels. Some panels only meet once, to consider one-time invitations for proposals called Requests for Applications. Other standing panels meet at intervals to consider proposals in one or another general field. Most of these are not associated with a single institute, but consider proposals directed at various institutes. Program Announcements, which are open invitations for proposals that may persist for 3 years or more, with quarterly deadlines, and some RFAs, may be issued by multiple institutes or single institutes.

Then, for RFAs and PAs alike, there are multiple funding mechanisms. For example, the R03 mechanism funds small scale, preliminary studies. The R21 mechanism is for slightly larger scale "exploratory and developmental" studies intended to lead directly to the big enchilada, the R01, which is funding for a large-scale research project of $500,000 a year or more and up to 5 years. There are mechanisms to fund research programs consisting of three or more linked studies with shared infrastructure; research center grants that focus even more on infrastructure development; grants for mentoring and professional development of investigators; and others.

All of these may be written in such a way as to shape the broad directions of research, with general shaping by Congress and more specific shaping by NIH staff, but for so-called extramural research - paid for by NIH but done independently - the applicants develop the specific research aims, questions or hypotheses, and study designs. Then they get a score from the peer review panel.

Typically, in one meeting, a panel may review some 40 proposals. Three panel members will be assigned as reviewers of each proposal, and each member will get about six proposals to review. If you do the math you'll see that there are about 20 members on a panel. All the panelists have access to all of the proposals, although only the assigned reviewers have access to the appendices, such as previously published research by the investigators, draft questionnaires, detailed protocols, etc., that may go with them. However, panelists are not required, or even particularly encouraged, to read proposals not assigned to them ahead of the meeting.

So, the assigned reviewers, ahead of the meeting, write critiques of their proposals. There used to be a lot of mail that flew around the country prior to the meeting, but now they post their essays on a special Internet site where the reviewers assigned to a given proposal can read each other's critiques. A federal travel agency gets everybody a flight and a hotel room, most likely in a strip mall wasteland in the Washington, D.C. suburbs, and the action begins.

[Curtain on Act One]

What Do You Really Want from your Doctor?

2006-06-15T13:07:00.000-07:00

A physician friend once said to me you can either “get love or attention from your doctor or the best technical skills available but rarely both”

Over the years as a practicing physician it seems to me that often many intelligent patients equate the quality of, at least their outpatient physician interactions, with the amount of time the physician provides to them.

(If you need a highly technical skill of a specialist or sub-specialist especially in the areas of invasive diagnostic procedures or highly technical surgery this essay is not really that relevant. In that case find the best technician you can locate who has a track record of many successful procedures to assist you)

But much has been written on the topic of time spent with patients in the outpatient office as an indicator of patient satisfaction. See http://www.aamc.org/newsroom/reporter/april01/physiciansvisit.htm for example. In the era of managed care with shrinking allotment of time provided to each patient this often leads to frustration in both the patient and the physician. Frustration may also aggravated it seems by requirements for physicians to be required to directly input patient data into a computerized Health Information Technology Systems- so called “HITS” while with the patient!

The intelligent educated patient while being empowered by democratized health information on the internet is perhaps further frustrated by their physician’s inability to answer all the questions that this often voluminous information stimulates. The access to health information by patients has caused nothing short of a seismic shift in the doctor-patient relationship with some estimates that there are now over 100,000 health related websites on the internet today with anywhere from 40-80% of all adult Americans accessing them for health information.(see http://ibscrohns.about.com/cs/activismandibd/a/aa051903_p.htm) for some guidlines who how to use the internet effectively.

Often, in my opinion, for example if a patient has a rare disease and a modicum of intelligence it is even likely that the patient, after a thorough computer search, may know more about recent developments about their own particular conditions than their primary care doctor. This takes a mature physician to cope with that shift in heretofore traditional information driven power dynamics.

Dr George Lundberg, former Editor of the Journal of the American Medical Association (JAMA), has said that the Internet is one of the three biggest advances in medical science in the last 500 years.

Anyway this got me thinking about possible new emerging roles for especially primary care physicians like family doctors and internists besides the traditional valid roles of diagnostician and interveners- usually with prescribing medications, ordering routine diagnostic tests and perhaps some very limited counseling on health behavioral changes

These new possible emerging roles for primary care physicians in the new 21st century medicine might include:

-Information sorters, guides and interpreters
-Decision specialists/coaches in an emerging co-decision model
-Teachers of health care topics
-Motivators of Behavioral Change
-Integrating patient’s deepest values into health care decisions and practice
-Spiritual guides especially during major life transformational events like death and dying
-Care coordinators (“quarterbacking”)
-Patient advocates against unjust medical practices
-Providers of emotional support (simply being there or “attending to”)
-Others?

Let me here from you on what you expect from your doctor or what you really want from your outpatient doctors? It's worth thinking about?

Many scholars believe, as I suspect, that this is highly variable and should be individualized always in the context of, at the very least, mutual respect between two human beings.

As for me the best healing occurs when both the doctor and patient recognize that a mutual meaningful connection has been made and growth occurs in both the physician and the patient.

Dr. Rick Lippin
(“Blake”)

BIOTERRORISM- Don't Trust A Wealthy Heart Surgeon

2006-05-27T20:56:00.000-07:00

I began by writing a book review of Senator-Doctor Bill Frist’s 2002 book
"When Every Moment Counts- What You Need to Know about BIOTERRORISM from the Senate's Only Doctor"- Published by Rowman & Littlefield Publishers-Lanham, MD -$14.95. But I found myself drifting from the traditional book review format to comment on the credibility of the author himself. Since I am trained and hold board certification in the medical specialty of Preventive Medicine I felt some latitude in doing so.

First- A few pre-review comments. Personally I do not believe it is ethical or wise for a sitting Senator to write a for profit book about a topic over which he/she has legislative involvement and oversight. Secondly Dr. Frist is a well-trained cardio-thoracic surgeon who to my knowledge has no formal training in Public Health or Preventive Medicine. Thirdly gratis copies of the book are presumably being distributed by Sanofi -Pasteur, a multinational vaccine production company, who stands to directly benefit financially from this book's recommendations and implications.

Written in 2002 I apologize for this late review but I received the book @ 1 month ago. The book is endorsed by former US Surgeon General C. Everett Koop, Senator Edward Kennedy and former Senator Sam Nunn. The book must be reviewed in the context of the horrific post “9/11” 2001 terrorist events and the shortly thereafter (only three weeks later) anthrax mailings in US in October 2001 as well as wide press coverage of pronouncements made about pre- Iraqi war intelligence regarding the "obvious imminent threat" of bio-weapons of mass destruction.

The book begins with the "Anthrax in the Capital" (Chapter 1) the dramatic day-by-day account of the unfolding story beginning in our nation's capital on October 15, 2001- the very day an anthrax laced letter was opened in the offices of US Senator Tom Daschle. And my guess is that this book was hastily written by Sen. Frist as a result of that very real tragic incident and the role that Dr. First, personally played in “managing” that event as the then Senate’s only “trust me I am a (albeit heart surgeon) doctor.”(There is now a second doctor-senator) Fortunately deaths were limited and we presumably learned a lot. Of course the perpetrator of that dastardly deed which ultimately infected 22 people and killed 5 fellow Americans in other locations is still at large today. (I might add that 33,000 were given preventive antibiotics- really necessary in retrospect?)

The only other know "bio-terrorism attack" in recent US history was the purposeful contamination of food using Salmonella bacteria at a salad bar in Oregon by the followers of guru Bhagwan Shree Rajneesh in September of 1984 who were trying to sicken enough people to swing a local election ballot initiative their way. A total of 751 people became ill with zero deaths.

So the remainder of the book represents hypothetical risks of bio-terrorism with also one chapter on Chemical Weapons another chapter on The Threat to Our Food and Water Supply. Finally a final chapter on how we can prepare as a nation individually at the state and Federal level and through legislation. The book, to its credit, is written mostly in a Q&A format and at a language level that makes for easy reading by the general public. Chapter 2 is dedicated to "Safe at Home- A Family Survival Guide" which had some good tips in it which including psychological prep of children and how to stay generally healthy. I liked this chapter.

Following are specific chapters on specific threats;

-Anthrax
-Smallpox
-Plague
-Botulism
-Tularemia
-Ebola and Other Viral Hemorrhagic fevers
-Chemical Weapons
-The Threat to Our Food and Water Supply.

These chapters seemed generally scientifically accurate given the mega-proviso that terrorists can and will likely successfully utilize these organisms and methodologies?

The book closes with a Chapter 11 - "A Nation Prepared - Safeguarding Our Future". It references Senator Frist's political work that led to the passage of The Public Health Threats and Emergencies Act of 2000 co-sponsored by Sen. Ted Kennedy. It also references The Bioterrorism Preparedness Act of 2001 proposed post anthrax incident and according to Dr Frist "also addresses the areas of food safety and agroterror that have been sorely neglected in the past." The chapter calls improved intelligence gathering, improved collaboration with the US Department of Defense (DOD), more oversight by the FDA to protect our nation’s food supply and there is a special emphasis on the need for coordinated communications.(hah!)

Of course Republican Frist calls more public-private partnerships regarding drug and vaccine development and antitrust relief to drug companies and vaccine makers as well as increased liability protections. Dr. Frist had the honesty and accuracy to state then in 2002 in this book that the nation was not yet prepared “Clearly America is not yet ready to meet this deadly threat" says the good Doctor Frist.

But here we are four years later in May of 2006 and we have the following:

1) Not a single bioterrorist event occurred in the US since the Oct 2001 Anthrax letters.

2) Re: Intelligence- the perpetrator of the sent Anthrax laced letters remains at large.

3) No Weapons of Mass Destruction including Bio-Weapons were found in Iraq before or during the war as of the writing of this essay.

4) "Coordinated Communications" during the very real (non-bio event) Hurricane Katrina (summer 2005) proved to be absolutely abysmal.

5) The US experienced a very real and dangerous extreme shortage of "regular flu" vaccine in winter flu season 04/05 because of our financial ties to a single flu vaccine plant in Great Britain that had quality control problems.

6) The US attempt at Smallpox vaccination program initially geared toward first responders and health care providers (2003-present) was/is a medico-legal fiasco especially in the private sector.

7) The US attempt at Anthrax vaccination in the military was moderately successful but also experienced very difficult medico-legal problems as well.

8) We are currently spending perhaps billions on a potential pandemic flu plan (admittedly not bioterrorist) which some experts are stating was at least initially ill conceived because of its focus on a single organism (bird-flu variety H5N1) and a failure to allocate pandemic flu dollars where they could be most effectively utilized. See http://www.thenation.com/doc/20060605/siegel

Senator-Doctor Bill Frist presided over the US Senate in the powerful position of majority leader since Dec 23, 2002 during which most of the problems I note above (1-through 8) occurred.

Perhaps I'm being unfair in what started as a book review also when I state that Senator Doctor Bill Frist's family wealth was derived from the largest for profit Hospital Chains in the US called Hospital Corporation of America (HCA) subject of a decade long federal investigation on Medicare, Medicaid, and Tricare fraud charges resulting in a payment of $1.7 billion dollars in fines -the largest health fraud settlement in US history. And Dr. Frist's mishandling of the Terri Schiavo landmark death and dying case where the good doctor-senator Frist engaged in "long distance video neuro-diagnosing" under pressure from the fundamentalist Christian right to unsuccessfully prevent Terri Schiavo from being removed from her "life" supporting technology despite her neuro-vegetative state. But I add this here since the very credibility of the author of this book both as a doctor and a political leader are strained by these events.

In summary, the Frist book on bioterrorism itself is not a bad handbook for those who believe a bioterrorist event is indeed likely or even imminent. Actually this writer honestly does not know what the true risk really is? Some of the data is necessarily top secret. Just this month UN Secretary-General Kofi Annan urged the 191 UN member states to agree on a global strategy to combat terrorism with “a top priority to come up with new ideas to prevent terrorists from using biological weapons” See http://www.wtop.com/?nid=251&sid=779748

What I do believe is, that if the risk is indeed real, I would not place my personal confidence in, nor urge my fellow American Citizens to place their confidence in, a very wealthy heart surgeon turned politician whose leadership and self- professed expertise in this important arena of bioterrorism and related health issues has proven to be at least so far an embarrassing and dangerous failure- perhaps placing our nation at even greater risk than before his book was ever written.

Rick Lippin MD, (“Blake”)

The US Workplace-"The Forgotten Environment"

2006-05-14T17:38:00.000-07:00

The 91st Annual American Occupational Health Conference, my own medical specialty’s most well attended annual conference held last week, brought me back to Los Angeles,California which I hadn’t visited in over a decade. Well, the City of Angels still impresses me as a unique but quirky American City. Their addiction to automobiles with soaring gasoline prices has got to scare them soon I hope into much more mass transit and their glitz, glamour, and botox party Hollywood/Beverly Hills “scenes” seems hopelessly out of sorts with the gravity of our nation’s current numerous crises. One irritant (actually quite dangerous especially for the elderly) demonstrating how pedestrian unfriendly this city is was the amount of time the walk sign provides you, the lowly pedestrian, after you press a button to allegedly halt the constant stream of high speed traffic to “allow” you to walk across a 4-6 lane high speed highway. I promise you, Mayor Villaraigosa and Governor Schwarzenegger the time provided requires literally running for any age group. Maybe this is the good Mayor’s or Governor’s civic wellness program for Los Angelinos?

Well more importantly is the state of the specialty of Occupational Medicine, as I perceived it through the conference and in the hallways or over coffee with my colleagues. The biggest shift in the field is a sea change in the American College of Occupational and Environmental Medicine (ACOEM) www.acoem.org membership demographics from company and government employed occupational doctors in the 1970s (over 80 % of the membership) who actually collaborated with Safety, Industrial Hygiene, Toxicologists and Epidemiologists to seek to understand and mitigate workplace safety and health hazard to most Occupational Docs now working in for profit clinics (over 80%) mostly attempting to “manage” (i.e. reduce) workers compensation costs for mostly musculoskeletal "injury" cases. Hence, Dr. Joseph LaDou, an academic leader in Occupational Medicine from California himself, has written about “The Rise and Fall of Occupational Medicine in the United States ” and calls for radical reform including a public health model of Occupational Medicine and the dismantling of the US workers compensation system as two means to save the profession

Beginning with Clinton admin and accelerated by the Bush admin the enabling law and regulatory agency for Occupational Medicine –OSHA- has almost been completely gutted giving corporate America little incentive to retain or hire occupational health professionals. Instead companies are “encouraged” to engage in voluntary partnerships with OSHA -reminding me of faith based volunteerism that Mr. Bush believes should replace other government funded or regulated social safety net programs in other fields.

Alas published data reveals that recent trends in workplace related injuries and illnesses are not good (see http://www.hillnews.com/thehill/export/TheHill/Comment/OpEd/092105.html).
And I for one believe that work stress and depression remain at epidemic proportions due to either layoffs-“you cant have occupational heath without an occupation” and the fear of layoffs re downsizing and outsourcing trends. Although I must admit things seem a bit brighter in recent months regarding these trends. I wrote a piece in 2004 on US worker use of antidepressants in www.medicationsense.com which I still believe remains excessive.

In 2004 I also wrote a review of sociologist Elaine Draper’s book called The Company Doctor: Risk, Responsibility, And Corporate Professionalism wherein I basically agreed with Draper that the US must adopt an independent tripartite model of Occupational Medicine funded by Industry, Government and labor which is the working model in many European nations. This model might save US Occupational Medicine?

A few bright spots of the conference were the opening key-note address by Dr. Paul Brandt-Rauf from Columbia University and Editor of ACOEM’s journal JOEM who urged occupational doctors to sign up now for work in environmental medicine in third world nations like Bangladesh where Brandt-Rauf and his colleagues from Columbia are doing quite remarkable work on lowering arsenic in drinking water which is a huge environmental health problem in many countries including parts of the US. My professional association to its credit had the vision to add Environmental Medicine to its worker health field in 1992 recognizing the magnitude and the importance of the global environmental moment yet not long after prompting organized labor to correctly call the workplace “the forgotten environment” hence the title of this blog piece.

Also a seed of social conscience has become manifest in ACOEM called the Section on Underserved Populations was founded just two years ago. This small section is correctly focusing on preparing migrant clinic based primary care docs in occupational medicine basics who will absorb the estimated 11-12 million soon to be legalized workers who are now working “undercover” on farms, in landscaping, hotels, garment factories, construction etc. These workers don’t currently dare call any attention to themselves by reporting an occupational injury or illness less they be arrested and deported for illegal immigrant status. Go to www.migrantclinician.org

Finally, if progressive dems or independents win US congressional elections in November of this year and capture the White House in 08 look for a long overdue stronger OSHA and increased activities in Occupational Health no matter what delivery model prevails.

I have practiced Occupational Medicine for over 30 years and it always occurred to me that the term “worker health” was inherently a liberal concept where workers might be viewed as assets and not expendable costs on the balance sheet despite the inherent power dominion that empoyers have over employees and the classical business definition of efficiency.

But I have always been a dreamer- I know of no other way to live?

My view of Occupational Medicine romantically goes beyond the avoidance of work related pathology which I would die very happy to see come to pass. My view is that work, being so central to human existence, is actually a prerequisite to good heath. I hold the view that job satisfaction is grossly understudied and under appreciated as a determinant of human health. One of my mentors Dr. Lennart Levi from the Karolinska Institute in Stockholm, Sweden said it well many years ago when he said-

“Work should be designed by man for man. Work should serve human needs- not vice versa. Good and healthy work should give meaning to life. This is not what work looks like to millions of workers all over the globe. Work should become man’s servant-not his master”

Dr. Rick Lippin ("Blake")

Ignore This Post

2006-05-10T11:29:00.000-07:00

You probably don't know that Board-Certified Homevideoneurodiagnostician Bill Frist has declared this to be "Health Week" in the Congress, because the corporate media, to their credit, have largely ignored it. The basic idea seems to be for the Republicans to move outrageous proposals that they know won't pass, in order to score points with some of their base constituencies. I was committed to joining in the mass movement to completely ignore this, but then I decided it might be instructive with respect to some recent topics to take a quick look.

The first thing they tried was to cap jury awards in malpractice suits. That didn't get the 60 votes it needed to break a Democratic filibuster. (And let's acknowledge the resurrection of the minority from the dead.) The malpractice system definitely has flaws, but excessive compensation to horribly injured people is not one of them. (Okay then, malpractice is now on the to-do list here.)

Now they have an even more nefarious proposal. Under cover of a bill to allow small businesses to form purchasing cooperatives across state lines, they want to override state regulations requiring that health insurance be comprehensive. The plans could be lower in cost because they wouldn't have to cover things like mammograms, well-child care, or even chronic disease care.

If you've been reading Stayin' Alive, you already know that one of the most pernicious consequences of our fragmented health insurance system is that insurers don't have an incentive to keep you healthy, because by the time you get sick, you probably won't be their problem any more. Therefore, while it saves society money to provide services like cancer screenings and immunizations, preventive care represents a cost to insurers that they might not recoup. That is why state regulations require that plans offer certain basic services. But now "Dr." Bill Frist wants to kill you, so that businesses can save money, and give some of it to Republican candidates.

You can read all about Sickness Week in Forbes. Or you can ignore it, which is what I recommend.

(Cross-posted on Stayin' Alive)

A Legal Culture of Drug Pushing-"Bitter Pill" Awards Announced Yesterday

2006-04-27T02:47:00.000-07:00

As a follow up to my last post and to Cervantes post on Stayin Alive I had the pleasure of participating in a nationwide conference call yesterday during which PAL=The Prescription Access Litigation Project announced the 2006 "Bitter Pill" awards.

This year Bitter Pill Awards were presented in four categories to drug companies engaging in over-zealous and questionable marketing practices. The drug industry’s national lobbying group, PhRMA, received two awards, and the remaining three awards were shared among makers of five of the nation’s most well-known drugs: Lunesta, Ambien/AmbienCR, Lipitor, Crestor and Strattera.

PAL uses highly creative humor as an effective weapon. For example awards included "The While You Were Sleeping Award" (the dangerous boom in insomnia meds sales), "The Got Cholesterol Award"(excessive and dangerous statin meds use),"The Driven to Distraction Award" (for overdiagnosing ADD and hawking ADD drugs to dangerous excess), and two awards to the Drug Industry's own extremely wealthy and powerful lobbying group= PhRMA-"The Fox Guarding the Henhouse Award" (for pushing voluntary rather than mandatory drug advertising standards), and "The Truth is Stranger Than Fiction Award" (for scaring Americans about the trumped up dangers of Canadian Drugs)

I was surprised to learn during the conference call that, of all people, Sen Dr. Bill ("how to otherwise destroy US Health Care") Frist actually supports much stronger legislation to reign in overzealous unscrupulous drug company marketing. Live and learn about strange bedfellows?

Also one pet peeve (err- rage?) of mine not addressed by this oustanding PAL effort -they can't/shouldn't do everything- is the depiction of smiley people on TV ads literally pushing over-the-counter (OTC) drugs onto neighbors, friends, co-workers and family members by saying "here try this" for your pain, etc. Hey, as PAL says, drugs ain't exactly recommending a good restaurant or digital cameras.

Anyway this outstanding organization, now only in its second year of presenting awards, is to be resoundingly commended for using humorous and creative methodologies as well as serious legal and educational actions to tackle a truly pernicious practice almost unique to American Culture. Most other countries have banned direct to consumer (DTC) advertising of prescription medications. But the good Ole US of A can't seem to break its sick addiction to "the free market solves all human problems" approach to almost everything.

About the Prescription Access Litigation Project (PAL)
Prescription Access Litigation Project (PAL) (www.prescriptionaccess.org) is a project of Boston-based Community Catalyst. PAL is a nationwide coalition of 118 state, local, and national senior, labor and consumer health advocacy groups in 35 states fighting to make prescription drugs affordable. The organizations in the PAL coalition have a combined membership of over 13 million people. PAL works to end illegal drug industry practices that increase the price of prescription drugs beyond the reach of the American consumer, using class action litigation and public education. Since 2001, PAL members have filed 26 sets of lawsuits targeting such practices.

Note: A complete electronic press kit, containing graphics, is available at www.bitterpillawards.org.

Dr. Rick Lippin (Blake)

Drug Coupons = Legalized Drug Pushing-Pure and Simple

2006-04-17T13:34:00.000-07:00

Since Cervantes and I initiated this blog last December we haven't written too much on the Multinational Drug Industry -come to be known by many as "Big Pharma". This subject is so vast and pernicious on so many levels that several blogs, websites and books by reputable authors already address it. Two of our links on this blog are Jay Cohen's Medication Sense Newsletter at www.medicationsense.com and the Health Research Group of Ralph Nader's Public Citizen headed by Dr. Sidney Wolfe.

Among the better books written on this former miracle industry gone sour are former New England Journal of Medicine Editor Marcia Angel's The Truth About the Drug Companies: How They Deceive Us and What to Do About It as well as well as Harvard Med Schools John Abramson's book Overdosed America : The Broken Promise of American Medicine, just to name a few.

Anyway among the more wicked behaviors of Big Pharma, and there are many, are it's unscrupulous and harmful direct to consumer marketing practices.

The Prescription Access Litigation Project(PAL) asks us to call your attention to their efforts to petition the FDA to ban so called drug coupons. PAL says:

Consumer Advocates Call on FDA to
Ban Prescription Drugs Coupons

Today, April 6, 2006 the Prescription Access Litigation Project (PAL)-a project of Community Catalyst-joined with 22 other consumer advocacy groups in calling for the Food and Drug Administration (FDA) to ban pharmaceutical companies from using so-called drug coupons in their vast direct-to-consumer advertising promotions. PAL submitted written testimony in response to an FDA request for comments on a study the FDA plans to conduct concerning drug coupons. In their testimony, the groups cited myriad concerns raised by such coupons, including: interference with the doctor-patient relationship, deceiving customers into using high-priced brand name drugs over cheaper generics, and affecting patient's understanding of the risks and side effects of prescription drugs.

"Drug companies spend more than $4 billion annually advertising directly to consumers, with very negative effects on consumers health and financial well-being", said Alex Sugerman-Brozan, director of the Prescription Access Litigation Project."Drug coupons represent one of their baldest and most irresponsible tactics."

Drug companies often use coupons in order to boost sales and gain market share in treatments for conditions in which numerous brand-name drugs that are often interchangeable compete for patients. Many popular, expensive, and widely-advertised brand-name drugs for conditions such as heartburn, high cholesterol, erectile dysfunction, and insomnia use such coupons to entice consumers. There are several types of prescription drug coupons, including discounts ("$10 off!"). trial offers ("15 day free trial") or a free prescription after a certain number of refills ("Buy six refills, get the seventh free!"). Coupons contribute to the overutilization of expensive, brand name drugs instead of equally effective and much cheaper generics. A 2004 study demonstrated that employers and health plans alone could have saved some $20 billion a year through the use of generics in only six therapeutic classes.

"Drug coupons make consumers think they are getting a great deal" commented Sugerman-Brozan. "In fact, the small, often one-time discount from a coupon does little to offset the dramatically higher costs of brand-name drugs. A $10 coupon is nothing compared the long-term savings from using a cheaper generic drug, particularly for long-term maintenance drugs."

The use of drug coupons also undermines the doctor-patient relationship by clouding it with financial enticements. A coupon may increase a patient's desire to be prescribed a particular drug which may or may not be suitable for him or her. Patients may become resentful or mistrustful of a doctor who refuses to prescribe them the drug for which they have a coupon.

"Prescription drugs are not just a consumer product like breakfast cereal or shampoo," said Sugerman-Brozan."But using coupons to sell drugs treats them like they are. Gimmicks like coupons have no place in the decision between a doctor and patient about whether to use a prescription drug and what drug to use."

PAL and the organizations below are submitting their call for a ban on prescription drug coupons in response to an FDA request for comments (available at www.fda.gov/ohrms/dockets/dockets/06n0029/06n-0029-n000001.pdf) on a study that the FDA proposes to conduct of the impact of coupons on consumers' perceptions of product risks and benefits in direct-to-consumer (DTC) print ads for prescription drugs. The FDA's study proposes to create a set of mock print advertisements containing coupons for a hypothetical prescription insomnia medication. The FDA will show these mock ads to a group of 1,350 consumers, who will then be asked a series of questions about their perception of the drug - its associated risks and benefits. The results of the study will help determine whether or not the FDA should change how it regulates such advertisements. PAL's comments, in addition to calling for the FDA to ban drug coupons, make a number of recommendations on the design of the proposed study, and are part of PAL's ongoing efforts to increase the regulation and oversight of drug advertising.

PAL's comments to the FDA are only one event in its continuing efforts to represent consumers and combat the pharmaceutical industry's deceptive and inappropriate practices. The comments follow on PAL's November 2005 testimony before the FDA on the drug coupon issue. On Wednesday 26 April at 2 p.m. Eastern, PAL will present its second annual Bitter Pill Awards .

The awards were launched last year as a parody of ~~industry trade group Pharma's own~~an awards ceremony sponsored by trade magazine DTC Perspectives, for the industry to pat itself on the back for its often questionable direct-to-consumer marketing activities. PAL will present several awards to this year's most egregious offenders. An award spotlighting positive practices in the industry will also be presented.

PAL is joined in its call for a ban on Rx drug coupons by:
· Action Alliance for Senior Citizens (Philadelphia, PA)
· American Federation of State, County and Municipal Employees (AFSCME) (Washington, DC)
· The Annie Appleseed Project (Delray Beach, FL)
· Connecticut Citizens Action Group (Hartford, CT)
· Congress of California Seniors (Sacramento, CA)
· Consumers for Affordable Health Care Coalition (Augusta, ME)
· Consumers Union (Washington, DC)
· Gray Panthers California (Sacramento, CA)
· Health Care for All (Boston, MA)
· JPAC for Older Adults (New York, NY)
· Long Island Health Access Monitoring Project (Great Neck, NY)
· Massachusetts Breast Cancer Coalition (Quincy, MA)
· MassPIRG (Boston, MA)
· Massachusetts Senior Action Coalition
· Metro New York Health Care for All Campaign (New York, NY)
· Minnesota Senior Federation (St. Paul, MN)
· New York Statewide Senior Action Council (Albany, NY)
· Tennessee Health Care Campaign (Nashville, TN)
· United Senior Action of Indiana (Indianapolis, IN)
· Utica/Central New York Citizens in Action (Utica, NY)
· U.S. PIRG (Washington, DC)
· Wisconsin Citizen Action (Madison, WI)

PAL's testimony to the FDA is available at www.prescriptionaccess.org

I'll just add that in July of 2002 your's truly (Blake) circulated my anonymous 9 point forecast about major trouble ahead for Big Pharma in which I stated that current marketing practices had transformed Drug companies into legal drug pushers - pure and simple- perhaps worse than the street corner pusher because Big Pharma has the power and $ to be responsible.

Please support PAL in getting drug coupons banned by the FDA. This is long overdue and is one of many good initiatives attempting to rectify one of contemporary western medicine's greatest tragedies- the excesses of the multinational drug companies born out of unbridled greed.

Stayed tuned from Cervantes and myself on Big Pharma issues both here and atStayin Alive.

Guest Post from Tor Dahl

2006-04-13T09:50:00.000-07:00

We're pleased to offer this astute critique of market fundamentalism in the health care policy debate from economist Tor Dahl, President of Tor Dahl and Associates. Dr. Dahl extends and improves upon some ideas I offered here earlier in my post Lost in Space. It's very important that we all get this because most of the people who pass for journalists these days don't, and the politicians either don't get it, or want to fool us.

This is an edited version of a longer article originally published in Dr. Dahl's newsletter, and we thank him for permission to repost it here.

-- Cervantes

The fact is that markets don't work in health care. And it is not only because some people cannot afford it. Here is why:

1. Where there is demand for something for which there is no supply, markets don't work.

The classic example is that of a lighthouse. It cannot collect from those it serves, and would not exist unless and until some entity were to finance the expense of building it.

People living in a geographic area that is under-served by health care are a bit like ships in need of a lighthouse, aren't they?

2. Where there is a supply of something for which there is no demand, markets don't work.

The classic example here is that of pollution. Pollution also directly affects our health and, potentially, our survival as a species.

3. Where there is a monopoly, markets don't work.

The monopolist controls supply of a good or a service and, hence, is free to set price, there being no countervailing power. Examples abound in health: Patent protection for drugs, the scarcity of certain medical sub-specialists, quotas for students entering medical school. In a sense, every nearby health care facility enjoys some monopoly power if no other facility is available in an emergency.

4. Where there is monopsony (one buyer and many sellers), markets don't work.

A national health care system, where a government agency has the sole right to buy drugs for its clients, is an effective monopsony. In the U.S., the Veterans Administration has the power to buy drugs for all veterans and can, thus, negotiate effectively with pharmaceutical companies that have monopoly power. Medicare does not yet have this right, but will likely receive it if costs of drugs continue to rise at the same pace as in recent years.

5. When there are externalities, markets do not work.

In this case, the classical example has to do with the benefits that derive from vaccinations. They extend well beyond those who receive them, since the likelihood for all to be exposed to contagious disease is diminished by the actions of some. This is a positive externality. The spread of bird flu is an example of a negative externality when vital food distribution channels can turn deadly.

There are even more reasons why market forces don't work in health care. Markets only work where there is competition, and effective competition requires perfect information, many small sellers and buyers, no transportation costs, and perfect knowledge. None of these conditions exist in health care delivery. Hence, competition and free markets cannot exist in health care, except in a very limited and narrow sense. That does not mean that we cannot use markets as a distribution mechanism where they can be made to work, e.g. in the sale of over-the-counter drugs and in other cases when people have the funds to pay for their healthcare needs.

But when markets break down, we have to find other ways of supplying health care. Each of these has a cost. To find the least cost solution with the highest benefit seems to be the best way. We are beginning to understand how we can make this happen.

Productivity and quality are key tools in that picture. The chance of ending up with high-cost/high-mortality care once cancer is detected is about equal to the chance of ending up with a low-cost/low-mortality care, says Dr. William McGuire, CEO of the United HealthCare Group. We must solve this problem! The information tools now available would go far in helping the health sector improve the quality of care and perform better. They will allow us to find these islands of excellence within the system, steer patients towards them, and point the way for necessary improvements throughout the health sector.

Mental Health Insurance Parity- An Imperative

2006-04-04T08:27:00.000-07:00

I know all the studies don't justify complete insurance parity for mental health services but a recent post by Cervantes in Stayin Alive Blog "A slightly puzzling result..." (April 3, 2006) http://healthvsmedicine.blogspot.com reminded me that I wanted to put forth a few of my views on this topic. For disclosure purposes I am not a trained Psychiatrist although my only honors in med school were in my Psychiatry rotation. I capitalized on my passion for mental health issues by becoming a leader in my chosen field of Occupational Medicine in the areas of work stress and what NIOSH (the research arm of Occupational Medicine) calls Organization of Work (OOW) . I was the only physician who consulted to NIOSH on it's OOW research team.

Well-"Enuf braggin". But as a practicing physician it became very apparent to me very early on that the prevalence of mental health issues was grossly underdiagnosed and went grossly un or undertreated in part because of lack of coverage by insurance companies.

I came up with two simple questions that I personally petitioned JCAHO that would require that every primary care physician be required to ask of patients during their very brief time with patients under our failed managed care system. The questions are "How are things at work?" and "How are things at home?". Patients could respond on a 1-10 Likert scale and be treated or referred if an emotional disorder was apparent. But alas JCAHO does not certify out-patient facilities yet.

The incidence of depression, anxiety and other mental health related conditions is well documented and is likely rising due to many reasons I won't go into today (please stay tuned)

Kudos to President Clinton for requiring mental health parity coverage for federal workers in 1999. President Bush has promised he would push for parity legislation. Don't hold your breath though folks. Instead he and Dr. Frist are putting the final nails in the coffin of our dying US Health Care System.

For some enlightened views on the imperative for mental health parity insurance coverage I refer you to the Progressive Policy Institute at www.ppionline.org
and The Commonwealth Fund at www.cmwf.org. Both of these progressive organizations are responsibly trying to lead us into a better US Health Care System. Read them and support them!

If you want material on work stress my favorite site is www.workhealth.org which has many good studies and links.

Also I would be very pleased to forward to any reader my work with NIOSH on Organization of Work (OOW) since not only are there very clear biological causes for serious mental health conditions- without any doubt there are psycho-social causes and contributions- believe me-big time. Just e-mail me at ralippin@aol.com

Thanks for your interest in Mental Health Insurance Coverage Parity. Its comin for all. We have no choice!

Dr. Rick Lippin ("Blake")

Vox Populi

2006-03-29T06:49:00.000-08:00

The new Gallup poll says it all.

What's the number one concern of American voters? Is it the War on Terra? Is it saving the blastocysts, or the brain dead? Is it keeping homosexuals in the closet? Is it illegal immigration, or crime, or drugs, or even social security? Nope. It's

The availability and affordability of healthcare

68% of respondent say they worry about that "a great deal," up from 60% last year, and leading the list of voter worries not by a little, but a lot. Social security comes in second, at 51%. And guess what? Democrats worry about it the most, but it is the leading concern of Republicans and independents as well.

So then, who should win the November election? If we can avoid getting drawn into a lengthy discussion about The 10 Commandments, flag burning, the homosexual agenda, and who eats brie, I think the answer is obvious.

But then, if the Democrats reclaim Congress, will they stop listening to the voters, and just listen to the lobbyists? Watch this space.

Cross posted from Stayin' Alive

Inequality and Health Care

2006-03-23T06:10:00.000-08:00

Our second guest post is from Systemdoc. Thanks for sending it in, and we're always looking for more good information and analysis like this. I've done a little light editing and made a couple of enhancements to make this blog-friendly -- that's a free service you get here, and only here. I hope Systemdoc doesn't mind. My interpolation in italics.

-- Cervantes

Starting points in the daily media stream of information about the “health care industry” - comments on the integration of the US health care system into the global financial system – i.e. the “dis-linkage” of health care transactions from any human interaction that has local, community-based accountability.

First, this from AMA Medical News. It's subscription only, but AMA members can read this here.

March 6, 2006
Health plans make more, spend less in 2005
By Jonathan G. Bethely

If physicians needed any more indication of tightening reimbursement, how about this - not only did profits for the biggest health plans go up last year, but those plans also continued to cut the percentage of revenue they spend on care.

The medical-cost ratio - also called the medical-loss ratio or medical-care ratio - is the key number for health plans in terms of their level of profitability. That ratio, simply, is the percentage of dollars the companies spend on health care.

Whereas 10 years ago many plans had medical-cost ratios in the high 80s or 90s, now the highest percentage among large, publicly traded health insurers is Health Net, at 83.9%. Aetna, which had a medical-cost ratio well into the 90s when CEO John Rowe, MD, took over in 2000, recorded a ratio of 76.9% in 2005, Dr. Rowe's final full year before his retirement. That was the lowest medical-cost ratio for the nation's largest publicly traded plans.

Medical-loss ratios for 2005 (Source: Company 10-K, year-end filings with the Securities and Exchange Commission):

76.9% - Aetna
82.3% - Cigna
83.9% - Health Net
83.2% - Humana
78.6% - UnitedHealth Group
80.6% - WellPoint

And this tidbit taken from Don McCane’s daily internet report from Physicians for national health insurance points to the accelerating nature of the financial concentration of dollars/capital in the private portion of the US health care system:

[O]f course, it is estimated that about 60% of the actual health care dollars are provided by public payors, e.g. Medicare. (source: Woolhander and Himmelstein: Paying for National Health Insurance- And Not Getting It – Health Affairs: July/August 2002 pp 88-96)

So we have an example of how the publicly provided dollars/resources are taken up by for profit entities, with the services to the population restricted. With all this consolidation, the “non-profit” sector has been pushed my economic forces to emulate the for-profit sector.

The Center for Health Systems Change (funded by the RWJ Foundation, and is affiliated with Mathematica Policy Research) conducted a review of hospital billing practices -this review had been triggered by the public scrutiny of non-profit hospitals’ billing and collection practices, which, reportedly, had included putting liens on the homes of patients who had not been able to pay their hospital bills.

This report presents the sympathetic view toward the hospitals, that they had restricted some of their more aggressive collection practices, in response to the public outcry/scrutiny, but does make it clear that the public policy/political economy environment is driving them to try to collect unpaid billings from the uninsured. My own sense is that this progressive inequality in the larger US political economy is generating pressures on the health care “system” that lead to increasingly unjust practices – which, eventually, will lead to political unrest.

However, it may be that the ecological pattern of “punctuated equilibrium” will take over, with a period of outright chaos in the us health care sector, with the likely occurrence of the bankrupting of many community-based institutions such as hospitals and medical practices.

The collapse will have to take down some of this institutions before real health care reform, or the return of the "Hippocratic" physician - there is simply too much inequality in the health care political economy, with the "non-profit" hospitals, which even include the catholic church-owned hospitals, going after the meager assets of poor people, who, in fact, are charged higher prices than patients covered by the for-profit insurers. Certainly, in 10 years time, the academics will be writing about how unstable this current set of arrangements turned out to be.

Post by Systemdoc

How Much of Our Health Do We Really Control?

2006-03-19T05:53:00.000-08:00

The topic of how much of our health that we really control is, for me, probably one of the most difficult concepts that I will ever write about on this blog. Since Medical School in the late sixties up to the present I struggle with this central issue. I have concluded there are no easy answers now or likely ever? So I invite lots of dialogue on this from you.

I became interested in this issue because of my interest in psychiatry (never became a psychiatrist) , mind-body medicine , and more recently consumerism in medicine. Issues surrounding patient dependency on "MDieties" and the evils of excessive paternalism always intrigued me. Yet to this day, I remain plagued-almost haunted- by the notion that, as a doctor, my first moral principle was beneficence- to actively do good for my patients- to intervene on their behalf using my technical skill and knowledge that they could never hope to possess?

I scoured the medical literature for evidence on what % of illness was self induced through individual or collective human behaviors verses the roles of genetics.?I became interested in the psychology/sociology of accidents - still believing today that most are avoidable. I became interested in issues surrounding the environment and workplace (my chosen specialty) and how much control especially the disenfranchised really had over this?

This led to my interest in the fundamental dilemma of self- determination verses fatalism or pre-ordination and its association with belief in God verses existential self.

On a more practical note I studied the concept of Health Locus of Control (HLOC) a theory developed in @ 1976 which sought to quantify how much an individual believed health was under their own control (see http://hsc.usf.edu/~kmbrown/Locus_of_Control_Overview.htm)

I read the late Susan Sontag's book Illness as a Metaphor (1978) where she chastised the mind- body movement accusing it of "affirming the primacy of secular spirit over matter" and inducing guilt in those who contracted cancer for example- the disease which ultimately took her life too soon! Yet I personally think Sontag was wrong in her indictment of mind-body.

Now we have consumerism in medicine which is encouraging patients to become educated, to ask questions of their doctors (see Cervantes Stayin Alive blog-Tues March 14-"Don't Be Afraid to Ask Questions") and to become co-decision makers with their doctors. This latter point is a huge tectonic shift in the heretofore paternalistic doctor-patient relationship.

Here is where I personally stand today. I like the model of the doctor as a the teacher. To me the best medicine of all is "helping people become themselves". I loathe the concept of victimhood. Yet, in the end, genetics is real, viruses and bacteria are real, environmental and workplace biological insults are real, natural and man-made catastrophies are real , some accidents I suppose just "happen", and certainly social injustice is VERY real.

When I consider the above external realities my ideas about helping my patients achieve "the gift of themselves" yields to my sense of moral obligation as a physician to offer the hand of benevolent paternalistic intervention to my patients to the best of my abilities with the knowledge and skills that contemporary western medical education and my years of practice have afforded me.

Please let me hear from you. I really need your input, your stories, your hopes your fears on this topic of importance to all of us.Thanks

NIH Director Calls Curative Model of Medical Practice Unsustainable

2006-03-09T13:58:00.000-08:00

Surely I must be dreaming- please someone pinch me!

Because in a remarkable interview by Barbara Culliton , Deputy Editor of Health Affairs of the Director of the US National Institutes of Health (NIH) Elias Zerhouni, MD said that the current curative model of US Medical practice is unsustainable. Published today on the Health Affairs website http://content.healthaffairs.org/cgi/content/full/hlthaff.25.w94/DC1 .Zerhouni sees his job at NIH , probably the most prestigious voice for bio- medical research worldwide, as one of "provocateur, not a manager of the status quo". He also emphasizes, as I have been, that the future of medicine be much more interdisciplinary although, unlike my own emphasis on fully integrating and leveraging bio-medicine with sociology, psychology, and theology (see www.ricklippin.com ), Zerhouni references the need for bio-medicine to shake hands with nanotechnology, sytems biology, and- get this folks- "openness to radical ideas" with the hope that NIH dollars will be spent more wisely and have a cumulative effect on population heath. Yes, you heard me- population health!

While he sees value in electronic medical records technology and even national health insurance , Dr. Zerhouni says these could help reduce medical costs but only at the margins. Zerhouni believes rather that the practice of medicine needs to be fundamentally altered.

This remarkable interview of an obviously creative and couragoeus bio-medical leader is very good news for those of us who believe that more incrementalism in US Health Care System reform is a recipe for failure and also for those of us who believe in the imperative for early disease detection, chronic disease management and best of all primary disease prevention.

My personal Rx for american citizens from a Doc like me is perhaps even more radical?- Meaningful, safe and healthy jobs for all American citizens who are able to contribute and compassionate healthcare for those fellow citizens who are unable to engage in work.

Back to my opening comment on this post. Please e-pinch me. I need to validate that I read this interview while not dreaming. Be well all - better days-they are a'comin! Maybe sooner than we think?

Governors Meeting Theme in DC - Health Care???

2006-03-03T02:41:00.000-08:00

From last Saturday Feb 25 to this Tuesday Feb 28 our nation's Governors (28 Pubs/22 Dems) descended on Washington DC to hold their winter NGA=National Governors Association meeting. Chaired by Mike Huckabee -Rep from Arkansas, who was even interviewed by Sesame Street characters Elmo and Rosita, believe it or not the meeting's theme was Healthy America? Yet competing legitimate interests like the war, homeland security , katrina, the general economy and a lot of back room/hallway corridor worry-chatter from Republicans about losing in this November elections unless they rapidly bail on a failed presidency, still seemed to dominate the headlines.

Needless to say much was said about health care at least at the fringes of our nation's health care crisis. Gov. Huckabee ,to his credit, is promoting wellness in his home state of Arkansas and, as Chairman of the NGA, set the Healthy America theme for the conference. In his home state Huckabee, a young Republican, has created ARKids which provides greater healthcare access to tens of thousands of Arkansas kids and is leading a ballot initiative to devote all of Arkansas' tobacco settlement money to improve the health of all Arkansans

The opening plenary session, "Creating Healthy States," featured a keynote address by U.S. Secretary of Health and Human Services Michael O. Leavitt. Also Dr. David Katz, Yale School of Public Health, also spoke at the Saturday afternoon session."Nearly 129 million adults in the United States are overweight; of these, more than 60 million are obese and 9 million are severely obese. Excess weight is an indicator of poor health habits- such as poor nutrition and lack of physical activity- known to cause or worsen chronic conditions such as diabetes and heart disease. When combined with tobacco use, these health habits are the leading cause of preventable death in the United States," said Gov. Huckabee. "These trends threaten the health of individual Americans and the American economy. We already pay more for health care than people in other Western nations. If we continue to tax our health care systems with chronic conditions, the system will worsen." Wow you would think they might have even been listening to my friend Dr Michael O'Donnell, our nation's leading advocate of Health Promotion or reading his political advocacy website, at www.healthpromotionadvocates.org .The plenary session on Sunday afternoon, "A Culture of Wellness: Healthy Messages" opened with a keynote address by Lee Scott, president and CEO of Wal-Mart Stores, Inc. (ouch! to that hypocrisy!) Following the address, CNN's Dr. Sanjay Gupta moderated a panel discussion focused on delivering healthy messages. Panelists Judy Harris, president and CEO of Channel One; Jennifer Kotler, director of research at Sesame Workshop; and Marva Smalls, executive vice president of public affairs and chief of staff for Nickelodeon Networks shared their experience with evidence-based messages that have proven compelling to the public-particularly those messages directed toward children, youth and their parents

Even former fast food eating-post coronary artery bypass surgery(Sept 04)- former President Bill Clinton spoke on the merits of a better health habits warning the governors that failure to change the nations eating habits will weaken the economy and threaten the lives of its children. Bubba said "We have a huge cultural problem and unless we change it our children may grow up to be the first generation with shorter lifespans than we had!"

Meanwhile head of the DGA= Democratic Governors Association Gov. Bill Richardson from New Mexico, our nations only Hispanic Governor, under the DGA tagline "Won't Wait for 08" is taking some good shots at the President and Dr. Frist for the botched Medicare prescription drug plan and draconian and cruel Medicaid cuts to the states. (more on that topic in my next post)

My question is this? - Where are the powerful Governors from big and powerful states from NewYork, Massachusetts, Pennsylvania, Florida, Michigan, Texas and California on Health Care Reform? With their campaign funding a pockets lined with Big Pharma, Big Hospitals, the AMA and Big Insurance industry $ I think I know? Alas they are not talkin too much about health care reform lest they anger their vested interest funders?

In my recent previous posts on this blog I highlight two former Governors who have the right stuff and right ideas on Health Care. They understand it is far too late for incrementalism. Namely former Governors Richard Lamm of Colorado and John Kitzhaber of Oregon. (see previous posts)

Ok -all 50 state Governors - you talked good game on health care at your fancy meeting. Now get some serious legislation through your states and through bottom up pressure influence the national agenda. The DEM Govs are painfully correct- We "can't wait for 08"

Our President Mr. Bush, Dr. Frist and friends are in "critical condition" on this issue of great importance to all Americans-embarassingly and tragically so.

Health Care Cuts- More Governors Hurt the Poor

2006-02-21T10:04:00.000-08:00

My last 2 posts have dealt with my belief that the US Governors and a few former Governors need to lead with health care reform from "the bottom up" since the current Bush administration including Dr. Frist has no intention of doing anything meaningful and the Dems at the federal level, with some notable exceptions like US Rep. Jim McDermott (D-Wash) and Sen. Tom Harkins (D-Iowa) , are not yet stepping up to the plate despite the upcoming mid-term elections. Why? Where is Dr. Dean? when I need him?

In my previous posts I reference Gov Rob Blagojevich (say his name bla-GOYA-vich) from Illinois, Gov Tim Caine of Virginia, and former Governors Dr. John Kitzhaber (Oregon) and Richard Lamm from Colorodo as shining lights in an otherwise dark environment.

There is cause for some hope but my partners blog on Stayin Alive last Thursday set my optimism back as did an article I read from the Miami Herald on Sunday. My partner Cervantes reported in his post entitled "Department of How could I have missed this?" that after the vicious cuts last year in Missouri's Medicaid program by Governor Matt Blunt who, as a devout Christian, cited the cuts as "morally correct" based on his belief that taxes should not be raised. Also Cervantes learned that the Missouri legislature under Gov Blunt's leadership also voted to eliminate Medicaid entirely by 2008! What!!!! The "show me state" sure showed us how cruel a Governor could be.

Then I learned on Sunday that in the great state of Tennessee, faced with a $650 million shortfall to pay for his state's Medicaid program, Gov. Phil Bredesen cuts 191,000 low-income people from the struggling health plan.That action and other cost-saving measures outraged advocates nationwide, who accused the Democratic governor and former healthcare executive of endangering the well-being of the state's poorest residents.
Similar criticism has greeted Bredesen's latest move, which is unmatched anywhere in the country: Tennessee is the only state that won't pay to cover a widely used class of anti-seizure medications for 560,000 poor adult Medicaid enrollees. In addition, Tennessee is the only state that won't cover these people for eight other types of drugs -- including fertility and weight-loss medications -- that the federal government allows states to purchase under Medicaid.''This is a public health crisis as far as I'm concerned,'' said Beth Coleman, executive director of the Epilepsy Foundation of Southeast Tennessee in Chattanooga.

Also vulnerable under the coverage ban are poor, mental-health patients who use the drugs to treat depression, anxiety, panic disorders, insomnia and tremors. Benzodiazepines also help control muscle spasms in cerebral palsy sufferers.

Meanwhile back to positive news , former federal Secretary of Health and Human Sevices (HHS) Tommy Thompson made some bold proposals last week in my home town of Philadelphia. "Many businesses provide health benefits, but if businesses want to put a brake on escalating costs, they should advocate for health-care coverage for the uninsured" Thomson told area business leaders at a seminar last week organized by the Deloitte Center for Health Solutions.

Thompson's proposal: Just as states require automobile insurance, states should require all people to have health insurance, organizing those not covered at work into a group. The state would request bids for a low-cost, no-frills package and then use some earned-income tax credits to bring the cost to an affordable level, subsidizing where necessary.
Finally, the federal government should pass a reinsurance program that would cover bigger losses than usual in a small business' health plan. Minimizing risk would encourage small companies to provide health insurance to their employees, Thompson said.

Well, it seems that former governors and former cabinet members have the luxury of speaking some sense andshowing some much needed compassion on solutions to the health care crises that is denied all but the most courageous sitting pols. I wonder why?

Lamm (former Governor) is a Lion on Health Care Reform

2006-02-17T10:17:00.000-08:00

I failed to reference in my blog post of Feb 15 on Governors and Health Care an extremely important pioneer again, another former Governor, Richard Lamm of the great Centennial State of Colorado-also called the “Highest State” (mountains not pot)

Gov. Lamm is former three-term governor of Colorado (1975-1987) and now serves as Co-Director of the Institute for Public Policy Studies at the University of Denver www.du.edu/ipps where he maintains a vigorous teaching and speaking schedule. A real maverick Lamm is a lawyer, accountant, and novelist (“1988”). Lamm demonstrated rare courage-and controversy- while as Governor in 1984 he spoke up about physician assisted suicide. He also probably was the first public figure to use the “R” word = Rationing of Health Care required by the realities of US demographics.

In 2003 Richard Lamm’s book on US Health Care was published The Brave New World of Health Care which reinforced his reputation as a recognized expert on US Health Care policy. In the book using extremely colorful but accurate language Lamm correctly concludes as many now have that our current US Health care system is unsustainable, unaffordable and inequitable. Lamm defines the problem for us including what he calls “living on the banks of the river -denial” such as huge unfunded liabilities we are leaving to future generations, and among other cogent observations the dilemma of what physicians want for their patient verses what society at large can possibly afford.(the individual good verses the common good-or "physicians serve their patients by spending other peoples money") An interesting section is “The Tale of Two Governors” where Lamm contrasts former Gov of Virginia James Gilmore who tried to intervene by requiring that a husband agree to re-insert a feeding tube to a wife in a vegetative state (Dr. Frist’s shameful game plan in the recent Schiavo case which received much national attention) verses the progressive policies of then president of Oregon’s state Senate Dr. John Kitzhaber who, in contrast to Gov. Gilmore, led the fight not to pay for excessive organ transplants under Oregon’s Medicaid law but instead use the dollars to maximize the coverage for medically indigent Oregonians.

Lamm’s Proposed solutions’ “Rebuilding the House of Health Care”

- Public Policy should pay for the statistically probable but not the clinically possible

- Managed competition geared toward correct the lack of purchaser power when individuals access the system empowering demand instead of supply side medicine

- Reducing individual expectations-overrating ourselves at the expense of others (the common good).

- Providing basic health care to all US citizens as good social policy through the legislature not through the courts as a “right”

-Expanding Health Care's Moral Universe-the imperative of rationing-tough choices between good and good

- Rethinking The Institutions of an Aging Society including rethinking entitlements, redrawing the ethics map, and controlling health care costs.

Richard Lamm closes his book by stating that the foundation of the house of health care is individual responsibility! (One would say almost a “republican sentiment”) He talks about ethics and duties of the doctor-patient relationship, the ethics and duties of the health insurance plan and the ethics and duties of the state and nation . And he makes the strong case that we do not necessarily maximize health by maximizing health care.

In my view Richard Lamm’s greatest contribution to this growing national debate was his early recognition of the imperative of rationing, intergenerational competition for health care resources, and the need for the nation to confront death and dying. In short, Lamm demonstrated enormous courage sometimes at great personal and political expense. Some call it backbone-I call it sheer courage- that of a lion!

Where are the DONKEYS on Health Care Reform?

2006-02-15T19:14:00.000-08:00

We know where the Pubs are –no where-lost in time and space- But where are the Dems on Health Care reform? I recognize there is a lot of competition for the Health Care reform issue to get on the proverbial radar screen but it seems to me that progressive Democrats and Independents had better move without delay. We have only 9 months till the 06 elections and if these incumbent pols and hopefuls are reading the same polls I am the mainstream Dems are not saying enough about this issue either alone or as a minority party poised to become a majority.

One highly regarded health issues polling organization updated monthly-The Kaiser Family Foundation continues to report that, only after the war and the general economy, Americans say that health care is the most important problem for the Government to address. So why is it that the Dems aren’t yet feasting on this low hanging fruit?

Ironically the Dem party (DNC) is currently headed by a physician (Dr. Howard Dean) who is married to a physician who, when Governor of Vermont, made some tangible progress on Health care for Vermonters. That the kind of state where innovation can happen and Howard did it. Why we don’t hear much from him now on health care is a mystery?

The dethroned queen of US Health Care Reform Sen. Hillary Clinton (D-NY) mismanaged her first lady assignment in 1993 and since then has been like so many once burned an incrementalist rather than an advocate of bold reform.

I came to realize over the past few years that the creative players in this arena were not national politicians from any party but rather governors, former governors and in one case a former state senator who happens to be my friend.

Anyway while we wait for the formal Democratic position on Health Care from Dr. Dean and company let me commend you to the following.

Just inaugurated Virginia Governor Tim Kaine who delivered the less than energizing Democratic response to the recent Bush State of the Union Address (SOTA) referenced his own efforts, as Lieutenant Governor in Virginia, to provide health care for nearly 140,000 children who were not covered 4 years ago. In the SOTA response Gov. Kaine referenced a fellow Democratic Governor’s work on Health Care. It seems that Gov. Rod Blagojevich (D-Illinois)(say his name bla-GOYA-vich) believes that Health Care is a basic fundamental right and was successful in getting signed into law his landmark –first state in the nation- All KIDS plan that will provide every uninsured child in Illinois with affordable comprehensive health care coverage. In stark contrast to neighboring states this innovative Governor has also increased access to health care to not only children but Illinoisan Seniors through his “No Senior Left Behind” program and “I –Save Rx plan” the latter allowing Illinoisans to purchase american made pharmaceuticals from other countries for a fraction of the costs they would have to pay in the good ole US of A. Go Rod!

I proudly disclose that my favorite politician and friend is former State Senator from California John Vasconcellos who just retired from a legendary 38 year career in California state politics where he earned the title “Dean of the California State Legislature”. Perhaps known best nationally for his coverage by Gary Trudeau in the Doonesbury cartoon series because I guess his idea to promote legislation based on the concept of self-esteem seemed funny in the 1980s Well I wasn’t laughing then and I sure am not laughing now. John was and still is of course correct. A healthy self-esteem is indeed the basis for a healthy and vibrant society. After retirement last year John has launched a radical new vision of government know as his Politics of Trust Initiative which can be visited and explored on www.politicsoftrust.net .While all the details of the Health component of this initiative are not yet constructed John assures me that Holistic Health will be it’s centralizing principle. John says, that “each of us arrives with an inherent capacity for wellness and self healing with support from Holistic Health modalities as needed. I’m personally helping John and invite you to also.

My final recommendation to you comes from the Beaver state of Oregon whose state invitation motto is “we like dreamers”. In a bold move former Governor Dr. John Kitzhaber, who having served as Oregon’s Governor between 1995 -2003, announced just last month that he would not make a re-run at the Oregon governorship but instead chose to devote his life to his passion- Health Care Reform. Launching The Archimedes Movement (“give me a lever and a place to stand and I can move the earth”) Another physician-politician, Dr. Kitzhaber made significant progress on Health Care while in office but his current rhetoric and plans are much bolder and visionary in scope and reflect a genuine sense of urgency. He calls health broadly defined as “the first rung on the ladder of opportunity –the cornerstone of a democratic society allowing people to fully participate to be productive and to take advantage of the opportunities of upward mobility that lie at the very heart of the American Dream”.

These are not just platitudes. Dr Kitzhaber presents solid plans based on sobering social,economic and political realities.For example he projects a shocking $65 trillion dollar unfunded Medicare entitlement when the baby boomers retire while our congress is preoccupied with a 5 trillion dollar Social Security gap. He correctly states that Health care is the fastest growing cost for individual families and businesses eroding wages thus posing a significant barrier to economic stability and growth. He predicts freightening implications for the stability of the US currency since health care is rapidly becoming the single major driver behind our exploding national debt. Unlike many others, Kitzhaber is not an incrementalist but rather, recognizing we are rapidly running out of time, is calling for a Revolution “not of violence but of vision, not of arms but of ideas”. “This is a pending crisis of huge proportions",he says, "that demands immediate serious and bipartisan attention of the United Stated Congress”. He offers Oregon as bottom up pressure on the nation on this issue now.

Here are Dr Kitzhaber’s #3 specific objectives

-to strip down our current system to its bare bones so that we all can see and understand its contradictions and inequities=illumination

-to offer a straightforward vision of what our system should look like. Among the issues Dr. Kitzhaber is interested in is the expensive technology dedicated unnecessarily to inevitable consequences of aging. The failure of the free enterprise model of US health care which is based on "categorical eligibility" rather than universal coverage. While he is not endorsing a Canadian style single payer system he is proposing more “public” Medicine like public education as a social good.

-to describe a direct action plans to spark the kind of national debate we so desperately need

I strongly urge you to visit his new website at www.archimedesmovement.org for more details about this remarkable man and his vision.

I’ll close by saying “Go forth pols of all stripes. Your country is calling you right now. Affordable quality health care is important to all of us and our children and our grandchildren. We’re watching and waiting. Don’t even think of letting us down. That would simply be unacceptable" -ral

Mr.President-STOP CUTTING HEALTH CARE NOW

2006-02-09T09:02:00.000-08:00

Mr President- I am a Doctor but more importantly I am a citizen of a country that I love .I feel it is my patriotic duty, Mr. President, to insist that you cease your and Doctor Frist's cruel and draconian cuts in health care immediately.

Mr. President in your State of the Union Address (SOTA) just 9 days ago you stated and I quote "Our government has a responsibility to help provide health care for the poor and elderly and we are meeting that responsibility" Mr. President -Your actions this week strongly belie your words.

The Seattle Times reported yesterday that you signed a measure yesterday that trims Medicaid and Medicare spending over five years, but you said Congress must make bigger changes as baby boomers retire.The bill you signed aims to trim $39 billion out the of budget over five years, partly through small cuts to Medicaid, Medicare and student-loan subsidies.In addition, the budget proposal that you submitted to Congress on Monday for the budget year that begins Oct. 1 seeks to trim Medicare spending by $35.9 billion over five years.

The Washington Post reported on Tuesday that even the usually favored National Institutes of Health(NIH)-the nation's lead agency in the hunt for the causes, treatments and ways to prevent diseases -didn't get a raise, receiving flat funding of $28.6 billion. Account for inflation, and that's really a cut, argued Dr. Robert Eckel, president of the American Heart Association. In inflation-adjusted terms, Bush's budget would cause a nearly 10 percent drop in spending in medical research since 2003.Some NIH divisions will lose money: $40 million from the National Cancer Institute, and $11 million from the diabetes institute, at a time when Type 2 diabetes is skyrocketing. The NIH this year will spend $8 per American researching heart disease, the nation's leading killer, an amount the heart association decried even before spotting a planned $21 million cut for the National Heart, Lung and Blood Institute.

Some programs you proposed for elimination are those that families have intensely lobbied Congress to enact:
-Universal newborn hearing screening, a $10 million program that helps states provide those tests for poor families, usually administering them before babies leave the hospital. Detecting hearing loss early helps ensure that babies get appropriate services so they learn and develop properly.
-The largest study of U.S. children ever performed. In January, mothers-to-be were to begin enrolling in the National Children's Study to track 100,000 children from mothers' wombs to age 21 to see how the environment _ everything from mother's diet to toddler TV to pollution influences child health. Scientists hoped the first births in the study would point toward some preventable causes of such problems as premature birth, asthma and autism. Ordered by Congress and supported by both medical groups and the chemical industry, scientists already have spent $60 million in tax dollars preparing the study, with waiting lists of families hoping to participate.But NIH budget documents direct researchers instead to close the program down by year's end.

"This is an affront to America's children. It will really hurt children today and for decades to come," said Dr. Alan Fleischman of the New York Academy of Medicine, who chairs the study's federal advisory committee.

Mr President-The late Rev. Martin Luther King Jr. (whose wife's funeral you attended this week) said "Of all the forms of inequality,injustice in health care is the most shocking and inhumane"

Mr. President and Dr. Frist- I know we do not have unlimited resources to spend on health care but you are harming your fellow citizens right now with your actions despite your SOTA speech rhetoric. Most despicable of all are your actions against our nation's innocent children. Yet, Mr. President, I stand ready to help.

Waste not, want not . . .

2006-02-07T10:48:00.000-08:00

This report in Health Affairs by Jonathan Skinner, Douglas Staiger, and Elliott Fisher is a pretty hard slog and won't help you wake up in the morning, so read it at your own risk, but it's definitely instructive.

They took a second look at some earlier analyses that had found that, while the average cost for treating Medicare beneficiaries after acute myocardial infarctions (that's AMIs, basically heart attacks in English) increased by $10,000 from 1984 to 1998, average survival increased by one year. So it looks as though the increased expenditure on new medical technologies is worth it. Most people would pay 10 grand for a year of life. However, it turns out that the relationship between spending in different regions of the country, and outcomes, is negative, i.e. the more spending on people with AMI in a given region of the country, the sooner they die. What gives?

I'll skip the complex analysis and cut to the chase: the improvements in life expectancy, which largely ended in 1996 anyway, are mostly due to inexpensive interventions: aspirin (yup, my old friend acetylsalycilic acid, known to the ancients) and drugs such as beta blockers and ACE inhibitors which are now available as generics. Immediate ways of restoring blood flow to the heart, using drugs or angioplasty, can also help where indicated.* But regions where the tendency is to spend the most had worse survival. One reason seems to be that in those parts of the country, people tend to see many different specialists, who aren't necessarily communicating with each other very well, so people get confused, contradictory, and uncoordinated care. The important takeaway lessons, in my view, which seem to be more or less those of the authors although they are less direct, are two:

We can get as good, or better results than we do now by doing less, and spending less money, but we need to do things right;
Just putting cost constraints on top of the present non-system won't work, because it won't necessarily lead to a more effective allocation of resources. We need a much better coordinated system, in which care is coordinated by doctors who know their patients and can keep track of their needs and the services they get; and standards for effective, appropriately conservative care based on evidence can be promulgated and followed.

The best context in which to accomplish those goals is universal, comprehensive, single payer national health care. That's what I say, anyway.

*Of course, heart attacks can be prevented by eliminating tobacco use, proper diet, exercise, emotional tranquillity, and all that good stuff, but that's for another day.

FREEDOM IS A HEALTH ISSUE

2006-02-05T08:02:00.000-08:00

As a doctor I have always believed that freedom was literally a health issue. By that I mean that people(s) who are free psychologically and politically literally breathe freer and deeper. Emma Lazarus's poem at base of The Statue of Liberty "yearning to breathe free" got me thinking about the topic many years ago. I haven't done exhaustive research on this topic but I am hoping among our readers you might point me to some studies. Anyway our freedoms are under attack right now. And many progressive bloggers for example fear being shut down or shut out economically. That is why I reposting Jill's post from her blog today on http://brilliantatbreakfast.blogspot.com. "Jill" raises questions about corporatiztion of the internet and the freedom of speech of bloggers. Here it is-
If you believe that blogs like this one are going to be allowed to continue forever, guess again. Because the internet is just another government-created program that conservatives and their corporate masters are looking to privatize. And once that happens, companies like Yahoo! and Google and AOL/Time Warner will decide what you see. It will no longer be up to you.Here's their first step:
Companies will soon have to buy the electronic equivalent of a postage stamp if they want to be certain that their e-mail will be delivered to many of their customers.America Online and Yahoo, two of the world's largest providers of e-mail accounts, are about to start using a system that gives preferential treatment to messages from companies that pay from 1/4 of a cent to a penny each to have them delivered. The senders must promise to contact only people who have agreed to receive their messages, or risk being blocked entirely.The Internet companies say that this will help them identify legitimate mail and cut down on junk e-mail, identity-theft scams and other scourges that plague users of their services. Thy also stand to earn millions of dollars a year from the system if it is widely adopted.AOL and Yahoo will still accept e-mail from senders who have not paid, but the paid messages will be given special treatment. On AOL, for example, they will go straight to users' main mailboxes, and will not have to pass the gantlet of spam filters that could divert them to a junk-mail folder or strip them of images and Web links. As is the case now, mail arriving from addresses that users have added to their AOL address books will not be treated as spam. Yahoo and AOL say the new system is a way to restore some order to e-mail, which, because of spam and worries about online scams, has become an increasingly unreliable way for companies to reach their customers, even as online transactions are becoming a crucial part of their businesses."The last time I checked, the postal service has a very similar system to provide different options," said Nicholas Graham, an AOL spokesman. He pointed to services like certified mail, "where you really do get assurance that if what you send is important to you, it will be delivered, and delivered in a way that is different from other mail."But critics of the plan say that the two companies risk alienating both their users and the companies that send e-mail. The system will apply not only to mass mailings but also to individual commercial messages like order confirmations from online stores and customized low-fare notices from airlines. "AOL users will become dissatisfied when they don't receive the e-mail that they want, and when they complain to the senders, they'll be told, 'it's AOL's fault,' " said Richi Jennings, an analyst at Ferris Research, which specializes in e-mail.As for companies that send e-mail, "some will pay, but others will object to being held to ransom," he said. "A big danger is that one of them will be big enough to encourage AOL users to use a different e-mail service."In a broader sense, the move to create what is essentially a preferred class of e-mail is a major change in the economics of the Internet. Until now, senders and recipients of e-mail — and, for that matter, Web pages and other information — each covered their own costs of using the network, with no money changing hands. That model is different from, say, the telephone system, in which the company whose customer places a call pays a fee to the company whose customer receives it. The prospect of a multitiered Internet has received a lot of attention recently after executives of several large telecommunications companies, including BellSouth and AT& T, suggested that they should be paid not only by the subscribers to their Internet services but also by companies that send large files to those subscribers, including music and video clips. Those files would then be given priority over other data, a change from the Internet's basic architecture which treats all data in the same way.This Tuesday the Senate Commerce Committee will hold a hearing to consider legislation for what has been called Net neutrality — effectively banning Internet access companies from giving preferred status to certain providers of content. The concern is that companies that do not pay could find it hard to reach customers or attract new ones, threatening the openness of the Internet.You can bet that these telecommunications companies will be shoveling huge amounts of cash into the campaign coffers of the Senate Commerce committee.

Bush Lays a Health Care Egg in SOTU speech

2006-02-01T05:46:00.000-08:00

Our President ,as I suspected he would, laid a huge egg on health care issues last night in his State of the Union Address. If the democrats don't make an omelet and feast on this one they really are missing a huge oppotunity.

Mr Bush outright lied about advancing health care for the poor and uninsured. And he briefly rushed through a few issues like electronic medical records, health savings accounts and health insurance portability for those who switch jobs. (Later on in the speech the president did mention HIV and medical malpractice reform)

But Mr. Bush failed to address possibly the #1 issue that concern americans. Having Dr. Frist by his side all night just added to irony of the tragedy of failing to propose meaningful reform.

Remember. Our US Health Care System is rapid real-time meltdown.

My Pre-Emptive Response to BUSH Health Proposals

2006-01-30T06:10:00.000-08:00

I recognize fully the arrogance of responding to a speech that hasn't been given. But our times call for boldness. So I decided to be bold. Our US Health Care System is in rapid real-time meltdown which was the reason why Cervantes and I created this blog.

Tommorrow night our President will spend considerable time during his State of the Union Address (SOTUA) on his and Dr. Frist's Health Care Initiatives. He will not be bold. He will extol the virtues of what he calls a "consumer based approach to health care emphasizing tax incentives". I promise you these approaches are destined to fail. "We the People" will continue to pay more for health care and get less than any other western nation peer country. Mr. Bush and Dr. Frist's health care policies and proposals, like other aspects of his ownership society programs, will benefit the rich. The poor as Cervantes says will be "owned"in this ownership society. Below is my #8 point health care "plan" I proposed first in 1995. I have revised it almost ten years later for 2006 world.

GROW UP AMERICA-A HEALTH CARE PLAN FOR ALL AMERICAN CITIZENS

- Stop prolonging death. It’s both expensive and dehumanizing at best, greedy and cruel at worst.

- Empower US citizens to assume increased individual responsibility for health and convince medical consumers that it is in their best interests not to assume the role of helpless, dependent victims/patients.

- Yet also recognize that we have medicalized America’s social problems. So we must provide healthy and safe jobs for all able citizens thereby reducing poverty and all its subsequent health impacts (possibly 1/3rd of Health Care Costs)

- Provide healthy environments including healthy air, water, soil and food.

- Rebuild America’s public health infrastructure to ensure we provide appropriate macro and individual interventions to especially low income citizens such as childhood and adult immunizations and response to man-made and natural catastrophes.

- Face the reality that a very large percentage of illnesses, injuries and hospitalizations are entirely preventable. Subsequently, the elimination of tobacco, alcohol, drug and medication abuse alone could immediately reduce medical costs by a factor of at least fifty percent.

- Incent and train physicians to maintain the health of patients and populations. Radical changes in provider re-imbursement and medical education strategies are necessary

- Recognize that early childhood preventive medical education can profoundly affect lifelong health behaviors.

proposed by
"Blake"
June, 1995
Revised 2006

State of Union Speech. Watch your Wallets-Watch your Souls

2006-01-26T05:16:00.000-08:00

The President “shall from time to time give to the Congress Information on the State of the Union, and recommend to their Consideration such measures as he shall judge necessary and expedient.” Article II, Section 3, Clause 1. US Constitution

This Tuesday night 31 January 9PM (ET) our President will exercise this option. Early reports indicate our President will address Health Care for Americans which Cervantes and I have addressed on this blog at length. Cervantes and I believe our US Health Care system is in real-time meltdown. The upcoming speech discussions are hard to hear over the din of the triple AAAs of Alito, Abramoff and the Axis of Evil. But the mainstream media and bloggers are beginning to ask what will the President say on Health Care?

Well, if the recently implemented Medicare Drug Benefit debacle hasn't caused our President's speechwriters to workovertime to explain that mess and put forth some bold initiatives, I believe the President is setting himself and Dr. Frist and company up for a big fall. And a feast for smart and bold Dems who REALLY CARE about Health Care for our fellow citizens!

Most importantly- Please tune is but please also-

-Watch your wallets
-Much more importantly -watch your souls

Both are in very grave danger or perhaps "Critical Condition"

Prevention – Let’s Give Ben Franklin A Belated Birthday Present

2006-01-23T15:33:00.000-08:00

Founding Father Benjamin Franklin, whose 300 birthday we currently are celebrating, said “An ounce of prevention is worth a pound of cure” (Hmm –was that statistically means tested?). Yet 230 years later America still spends only @2% of its 1.9 trillion dollar Disease Care Industry bill on Prevention. Why in God’s name, I ask, if Father Ben was right so long ago? Let me try to explode (whoops "explore") some myths about Preventive Medicine- a field of medicine that I have attempted to practice my entire 30 year plus medical career. See 5th point on my ETIOLOGY post of 3 Jan

Prevention doesn’t work? - Otherwise highly regarded physicians have tried to convince me for decades that “most of their patients” can’t or won’t change their unhealthy behaviors? Well there is a growing body of scientific evidence that with proper support like health coaches and financial and other incentives people do indeed change unhealthy behaviors from smoking, to diet, to exercise etc. Significant advances in behavioral science like
stages of change theories and tracking of expenditures made by American citizens - usually out of pocket- on preventative strategies from gym memberships to purchases of vitamins and food supplements is a very real testimony to change capacity.

Prevention doesn’t pay? – Alas- Definitely true in today’s Disease Care system. Incentives for payers rarely exist except at the margins. Assuming you are lucky enough to have health insurance have you ever tried to get reimbursement from your insurance company or payer for wellness programs for example?- Or perhaps for often cheaper and safer alternative medicines?- Or the vitamins and diet supplements you are spending @4 billion dollars a year on? How’ bout getting your doctor to spend time with you to talk about health- Sorry folks-not now- Doctors don’t get paid much for so called cognitive services. Docs have to do something to you in order to get paid like write you a script, order a procedure, or send you to a surgeon. Also the economic returns for the largest purchasers of disease care-namely corporations and the federal government’s don’t realize fast enough financial returns from prevention to satisfy their constituents like stockholders and powerful lobbyists for the disease care industry who rig the election of our politicians. Finally immoral/amoral anti-prevention health economists argue, even publicly that “we can’t afford prevention” since people might live longer? OUCH! That one always hurt me personally. Well, perhaps we have such a crisis in health care that prevention is now an economic imperative since we as a nation spend almost twice per capita what our major peers/competitors on the global market spend on health care and, to add insult to injury, get less!

Prevention makes patients feel blame, guilt, and/or abandonment? Well- I suppose in part asking patients to take some responsibility for their individual health behaviors is, to some, controversial? After all who wants to grow up? Conversely, however, without decent jobs or decent wages the poor or working poor often turn to unhealthy pleasures to cope with what an unfair society has thrown at them. Also much of prevention is NOT in fact the responsibility of the individual patient. There is institutional prevention such as clean air, water, soil and foods. There is providing all able Americans decent jobs with decent wages. And there are many diseases and conditions that have almost nothing to do with individual health behaviors and choices such as genetic conditions, environmental assaults to our bodies, and acts of fate or god such as natural catastrophes or accidents and crime often leaving little choice or control by its victims. And of course viruses and bacteria are indeed real and are indeed contagious- in some cases highly contagious.

Prevention is anti-technology? Well who ever said that 21st behavioral sciences were not based on technology? It may be different types of technology like sophisticated computer software but it still is nonetheless technology or increasingly sophisticated neuroscience which can unravel for example be the basis for perception, lifelong beliefs and attitudes and other cognitive processes ultimately leading to many health behaviors. And, while we are on the subject of technology, when in April of 2003 the human genome consortium (a private-public partnership) revealed it had unraveled the full sequence of the human genome(30-40 thousand separate human genes) I and others predicted its application to prevention would be far greater than its application to gene therapy misadventures. Now most prominent leaders in medical genetics seem to agree that detecting genetic traits in individuals for let’s say heart disease and cancer holds the best promise of the human genome project. That surely is technology in the service of prevention.

What can we do? In addition to adopting good personal health attitudes and behaviors I strongly recommend that you visit
Health Promotion Advocates headed by my friend Dr. Michael O’Donnell (PhD) who are making slow yet steady progress on advancing legislation through the US Congress on the value of Health Promotion. You can help! Practicing physicians need to be given economic incentives to help patients change their health behaviors or talk to patients about home life, school or work. Also we all need to become involved in ensuring that much more of our disease care system money is re-allocated to prevention programs. The American Public Health Association has many ways you can become involved in issues on a wide range of prevention topic like childhood nutrition, smoking bans, environmental degradation and many others

Finally a word about my personal views on this topic of Prevention. Prevention and Disease Management (known as tertiary prevention) will no doubt dominate 21st century US Medicine- There simply is no choice on this one. Also, our planet earth is in deep trouble. We are all going down soon if we don’t reverse the poisoning of the bio-sphere to which all human health is inextricably linked. I also personally believe that there is growing evidence that lifelong prevention begins from conception to age 4 or 5. So that is where I would put my health care dollars. I would protect and promote the health of nation’s infants and very young children. That is where real prevention begins and perhaps ends? Feedback very welcome.

The Secret Santa

2006-01-23T13:11:00.000-08:00

Once again, sadly, it's subscription only (I almost wrote prescription only), but the new Health Affairs theme issue on hospitals does an excellent job of telling the same important story 8 different ways. I'll depend mostly on Stuart Altman's version since I am a Heller School alum, with an assist from Alan Dobson and colleagues. (Links take you to the abstracts.)

First Dobson. Americans, we are told, don't like to pay taxes, even to pay for stuff they actually need and use. Or at least the people who make the largest campaign contributions make sure they keep their own taxes low. So, one way to keep taxes low is for government to underpay for the stuff it buys. Specifically, in 2002, Medicare payments to hospitals paid 95 cents on the dollar for the cost of hospital services, and Medicaid, on average, paid 92 cents. So-called "free care," schemes by which states reimburse hospitals for care of the uninsured and indigent, paid less than 20% of those costs. Hospitals aren't allowed to print money, so where does all that free money come from? It comes from overcharging private payers, mostly insurers. They paid 122% of the cost of the services they paid for in 2002, and that subsidized Medicare, Medicaid and free care. So one thing that will happen as Congress continues to tighten the screws on Medicare and Medicaid is that hospitals will either have to jack up their prices for private payers, or cut back on services.

Enter Stuart. In the name of spreading freedom and democracy to the United States, we are about to hear in the State of the Union address that we're going to have consumer directed health care. Yes, we've already worked that over pretty well here. But Dr. Altman et al point up another little problem with it. Part of the idea is that hospitals will have to post their prices for everything, and since "consumers" (that what we'll be, instead of patients) will be paying for a big chunk of hospital services out of their own pockets (from big deductibles, co-payments, and whatever is in their finite Health Savings Accounts), they'll presumably go shopping around for the cheapest hospitals.

The classic version of a hospital in the U.S. is a non-profit charitable institution that provides a broad range of services and has a social mission, such that it tries to take care of everybody in need and provide benefits to the community. That's why all that cost-shifting happens in the first place -- it's the only way for hospitals to fulfill their social mission. Otherwise they'd have to refuse all Medicare and Medicaid beneficiaries, and uninsured patients. But there are already growing number of specialty hospitals, usually for-profit, that don't have emergency departments and that only provide particularly profitable services. They'll easily beat out general hospitals for the cherry picked customers in a brave new world of price transparency and comparison shopping by consumers. Meanwhile, in trying to compete with each other, the charitable general hospitals will have to drive down their own prices.

Stuart predicts that the hospital industry could end up like the airline industry -- highly cost-efficient specialty hospitals will drive the classic hospitals into bankruptcy, just as carriers that service limited, highly profitable routes with scanty amenities have sent the big airlines that used to fly everywhere the way of the dinosaur. Write the Brandeis Jeremiahs:

Downsizing, service reduction and salary cuts are not the only eventualities that could occur. It is also likely that the hospital industry could become tiered -- one system with modern up-to-date facilities, some focused and specialized, that serve the privately insured, and one poorer, underfunded and possibly publicly supported system that serves everyone else (Medicare and Medicaid patients, the poor, the uninsured, and many of the chronically ill); one system that dominates suburban areas with high income, high employment, and extensive insurance coverage, and one that serves the inner city, poor rural areas, and retirement communities.

And I'll just add, if those latter constituencies get served at all. Welcome to The Ownership Society, and the Culture of Life, backing into the future, over a cliff.

[Cross-posted at Stayin' Alive.]

A US Free Market Based Health Care System- Time to Admit This Cruel US Experiment has Abysmally Failed

2006-01-19T04:46:00.000-08:00

My 4th cause for our moribund health care system (see once more my January 3 Blog on the etiology of the crisis) was the US’ peculiar obsession with only free markets as the basis for our health care system. In retrospect I was sorry that I used the word “peculiar”- rather I should have used the word “cruel”.

Instead of expounding exhaustively on this topic I believe that what my blog partner and co-editor, Cervantes, posted on this blog on Jan 12 entitled Lost in Space pretty much summarizes my own view. Cervantes wrote this essay a while back with a physician colleague Anthony Schlaff. The basic summary of this essay was that 1) there is no truly free market in health care nor should there be 2) A free market approach to health care blatantly ignores the reality that universal health care coverage serves the public good over the few who are wealthy. (“we don’t trade in human flesh”) 3) The current proposals put forth by the White House and the majority Republican party leaders in Congress are like Health Savings Accounts (HSAs) and free market “competition” approaches to Medicare Benefit expansions (like the new Drug benefit) are real-time failing now or doomed to fail.

There are many fine values-based experts who have written on this topic. Among my favorites is Noam Chomsky perhaps the US’ greatest living intellectual. In a recent interview posted on January 14th of this year on AlterNet.com Chomsky in simple language says this “…..say for example health care. Probably the major domestic problem for people. A large majority of the population is in favor of a national health care system of some kind. And that's been true for a long time. But whenever that comes up -- it's occasionally mentioned in the press -- it's called politically impossible, or "lacking political support," which is a way of saying that the insurance industry doesn't want it, the pharmaceutical corporations don't want it, and so on. Okay, so a large majority of the population wants it, but who cares about them? Well, Democrats are the same. Clinton came up with some cockamamie scheme which was so complicated you couldn't figure it out, and it collapsed.” (I, Blake, would add perhaps not as complicated as the recently implemented new Drug benefit under Medicare)
Chomsky goes on to say “Kerry in the last election, the last debate in the election, October 28 I think it was, the debate was supposed to be on domestic issues. And the New York Times had a good report of it the next day. They pointed out, correctly, that Kerry never brought up any possible government involvement in the health system because it "lacks political support." It's their way of saying, and Kerry's way of understanding, that political support means support from the wealthy and the powerful. Well, that doesn't have to be what the Democrats are. You can imagine an opposition party that's based on popular interests and concerns”

Let me recommend another extremely important piece written by Malcolm Gladwell of the New Yorker Magazine on August 29th of this year entitled “The Moral-Hazard Myth- The bad idea behind our failed health-care system”. In this piece, Gladwell explains the concept of moral hazard (an Insurance Industry term) and how this pervasive concept is intellectually and itself morally bankrupt. Critical Care readers –you need to understand this counter-intuitive concept of moral-hazard in order to understand how the Republicans are trying, once more, to redistribute health and wealth to the rich. Gladwell tells us that six-times in the past century, beginning during the First World War, efforts have been made to introduce some kind of universal health insurance and six times we as a nation have failed. Gladwell calls this one of the greatest mysteries of political life in the United States? I attribute it to the immaturity of a 230 year old country which took the good concept of free enterprise in business and made a huge and cruel error of applying it to Health Care which, as Cervantes says, ignores the public good of a healthy US citizenry. We all must act now to stop the very life threatening hemorrhaging of our fatally wounded US Health Care system lest we are forced to administer last rites.

PS- BREAKING NEWS- Upcoming Presidential State of the Union Address will primarily deal with Health Care-

Readers and fellow Americans
- Watch your wallet!
- Watch your souls!

Bio-Medical Technology- Label Should Read- “Only Miraculous if Used Properly”

2006-01-17T16:33:00.000-08:00

“Symptom” four in my six-point diagnosis of why our US Health Care system is collapsing as put forth on my Jan 3 blog that refers to the
“Etiology” of our Health Care crisis is America’s love affair with technology. Let me begin with an important-very important-disclaimer. I am not nor ever will be an anti-technology Neo-Luddite. Modern bio-medical technology is truly nothing short of miraculous in that suffering is relieved and lives are saved every single day. But as Cervantes, my partner on this blog, has pointed out any technology is simply “tools” and tools alone need humans to be used properly and tools alas are value neutral. Who could possible argue with the benefits of the discovery of penicillin, the smallpox vaccine, the discovery of insulin and the first x-ray and EKG machine just to name a few among hundreds of breakthrough technologies over the past 200 years let’s say. In more recent times one can cite kidney dialysis, in- utero fetal surgery, in vitro fertilization and anti-viral drugs for AIDS patients. Pretty impressive on its merits by anyone’s standards.

Well- here’s the rub. It’s good ole “US of A” excess and greed that causes technology to “bite back” if you will. (Edward Tenner’s phrase in Why Things Bite Back : Technology and the Revenge of Unintended Consequences (Vintage) (1996). Well folks, what do you expect from an adolescent culture that only @ 230 years old? I guess I first learned of the “revenge of technology” (another Tenner Phrase) first from Mary Shelly’s Frankenstein (movie c1931) and Stanley Kubrick’s rogue computer HAL who made a power grab on its human keepers in his movie 2001:A Space Odyssey (c1968) But my real education came in bio-technology from going to medical school in the late 1960’s in Philadelphia. Something didn’t quite compute in my brain as I witnessed the ravages of ghetto life on patients in 95% plus black north Philadelphia only to go home for my evening meal to watch the body count figures from Vietnam coming through the TV. Yet neither of these dominant cultural factors were mentioned by my distinguished and, I’m sure well meaning, Professors of Medicine and Surgery as they spewed forth on the latest technological advances in their give specialties. Hmmmm? I thought “something ain’t right here?” Then a medical student friend of similar cognitive dissonance several years later introduced to Ivan Illich’s groundbreaking work called Limits to Medicine: Medical Nemesis, the Expropriation of Health (1977). Tenner’s book on the revenge of technology which had two chapters on medical technology lead me too Diana Dutton’s book Worse than the Disease : Pitfalls of Medical Progress (1992). These books, in addition to partially validating my sanity in the insane world of US medical education the late 1960s, provided evidence that excess unbridled technology in medicine could and indeed does in fact cause harm. In 1999 I came across a paper in JAMA by Drs Elliot Fisher and H Gilbert Welch from Vermont (Dartmouth and VA Medical Center in White River Junction, VT). In that paper (Avoiding the Unintended consequences of Growth in Medical Care-(JAMA Vol. 282-No 5 Feb 3,1999) these authors put forth the radical proposition that in medicine more might actually be worse? Sounding somewhat similar to part of an oath I took on the first day of medical school written by a guy named Hippocrates that “first I was to do no harm” (actually in oath-“abstain from whatever is harmful or mischievous”) I was intrigued. These two authors put forth the compelling hypothesis that the law of diminishing returns might indeed apply to medical technology and at some point on the medical supply curve additional technology might in fact leads to harm! Ouch! That’s anti-American to believe that technology might not be the only answer to our woes and that the frontiers of bio-medical science might actually reach an l end point.

But we are a can do US culture with infinite limits I thought? Well fast forward the 21st century to the race for new pharmaceuticals that work better and safer than old ones and the hyperbolic promises of the Biotech Industry which, in my humble opinion, provide more very expensive hype than hope. Could it be that “can do” Americans might actually suffer from an excess of hubris? Furthermore, we all know that bio-medical technology ain’t exactly cheap with expenditures attributed to technology accounting for perhaps as much as one-half to two-thirds of cost increases above general inflation of our 1.9 trillion dollar Health Care (whoops Diseases Care) price tag.

Let me provide just one example where biomedical-technology has gone awry. Have you ever had an MRI or Medical Resonance Imaging test for perhaps a pain in your back? (You know that’s the one where you are slid into a hole in a huge clanking noisy metal magnet that surrounds your body) Well if you are an American adult citizen above the age of 40 years of age you are among the thousands perhaps millions who have had an MRI test at 3 to 6 hundred dollars a pop (conventional vs. rapid MRI). That’s a whopping MRI bill we ALL pay for. At a projected $100 billion annually, diagnostic imaging is one of the fastest growing cost areas in American health care. Outpatient imaging procedures increased 44% between 1999 and 2001and spending is expected to continue to grow at an annual rate of 20% or higher.(To get the best numbers for 2004 you have to fork over $7,750 dollars for a well researched marketing report) Maybe you have had several MRIs?. Now mind you MRI technology is good- but it is actually “too good”. In scientific terms this test is too sensitive producing what we call “false positives”. Fully 90% plus of MRIs in patients above the age of 40 have “positive findings” on MRIs and many patients get treated for these findings. Wouldn’t it be cheaper to ask the patient what year they were born and prescribe the same treatments? Or even better to allow for spontaneous healing to occur? My point being this diagnostic technology is diagnosing “getting older” But the diagnosis of “getting older” doesn’t pay much by insurance carriers or other third party reimbursers. So we medicalize the aging process. Many MRI positive patients, especially older back patients go on to have failed surgeries leaving them often more disabled and in more pain than had they been smart enough to not bother to get their MRI in the first place. This is just one instructive example of the how excesses of technology can backfire from health outcomes, human suffering, and economic perspectives. We all bear the dollar and human costs of these diagnostic and therapeutic misadventures. (The truly abusive application of excessive technology applied to the dying deserves a stand alone essay)

In my Holistic Model of Health Care noted in my recent blog on Reductionism I state and deeply believe that a high technology based health care system while not inherently bad is also, to put it simply, incomplete. Integrating the input of competent and values based colleagues from the behavioral and social sciences as well as ethicists, theologians and economists will ensure that our miraculous technology is leveraged to achieve the greatest good for the most US citizens. And that is what I call “Technology Plus” medicine”. This is the medicine we needed yesterday and beginning tomorrow before rigor mortis sets in on our truly moribund disease care system, which by then will surely be too little to late.

Quick update

2006-01-13T08:23:00.000-08:00

Thanks to KEO for digging out the link to the historical national health expenditure data at CMS. It's not quite as user-friendly as the subscription only Health Affairs article because it doesn't come with much interpretation, but if you're interested in seeing the numbers and reading the highlights, it's all right here.

Recycle your bits, as well as your atoms

2006-01-12T10:29:00.000-08:00

This is something I posted a while back on Stayin' Alive. I think it will help establish the foundation that Blake is building here.

Here's a little essay I wrote with my colleague Anthony Schlaff, MD, MPH. (He asked me to tell you that the MPH is the important part.) We couldn't get it published anywhere respectable, so you'll just have to put up with it here.

Lost in Space

Imagine you are on a scientific team planning a trip to Mars. NASA tells you to prepare based on the following assumptions:

1) There is a breathable atmosphere on Mars

2) There is drinkable water on Mars

3) The temperature on Mars averages 60^o Fahrenheit.

4) You can travel faster than light

Edgar Rice Burroughs did exactly that. But would you sign up for the trip?

Those who claim we can solve the problems of health care access and cost through the “free market” are thinking like Edgar Rice Burroughs. If you ever took an economics course, your teacher probably introduced you to the key assumptions of market systems. They include:

1. Perfect information – Buyers know everything, or at least enough, about products offered for sale and the possible alternatives to make a “rational” decision.

2. Consumers generate demand, all transactions are voluntary – Buyers decide what they want, and when to buy it.

3. Balance of market power – There are many sellers and many buyers for every product, who freely compete.

4. No externalities – All of the costs and benefits to society that result from a transaction are felt by the buyer and seller.

5. Adequate circumstances and justice.

Do any of these apply to health care delivery? Not a one!

Information: Fundamentally, what we buy from our health care providers is expertise. Because we usually can’t assess their competence ourselves, doctors, nurses and therapists have to go through legally approved training and be licensed by the state.

Demand: Imagine if Ford and GM could decide when we needed to buy a car – that doesn’t sound much like anybody’s idea of the free market. But doctors tell us we need surgery. That’s called provider-induced demand. While doctors try to be responsible and objective in their decisions, it has been shown that the way in which they are compensated does affect the amount and kind of medical services that they prescribe.

And our consumption of medical services is frequently not voluntary at all. If we have a dissected aorta, you could argue that in some abstract sense we could choose whether or not to have surgery, but common sense tells us we are compelled. We could even go into the Emergency Department unconscious, and only find out later what services we had received.

Market power: We can go to the supermarket and pick from a dozen brands of toothpaste, and most of us can also choose where to shop. But outside of the major cities, most regions are served by only a single hospital. Hospitals are very expensive to build, equip and operate, so it would be wasteful to have more, but that means our choices are limited. There are also structural reasons why most of us have at most two or three insurance companies to choose from, and of course many drugs are patented.

Externalities: Although we are most familiar with so-called negative externalities, such as air pollution from automobiles, medicine actually has many positive externalities. Treating and preventing infections benefits people who would otherwise catch the disease. People who can’t work due to preventable or treatable disease and disability contribute less than they could to the economic support of their families, the net economic production of society, and non-monetized but socially important activities such as child rearing, homemaking, etc. And there are what might be called moral externalities. Most of us would be troubled by large numbers of people with treatable illnesses in our midst, and even more distressed if those included people we knew and cared about.

Justice: We never know when we or our loved ones might suffer from a serious disease or an injury. Most people cannot possibly save enough money to pay for their care if they are badly injured in a car crash, or their child is diagnosed with leukemia. Such events can bankrupt people and destroy their lives. That is why we have insurance – to spread risk, so that everyone pays an amount they can afford, and those of us who suffer misfortune are taken care of.

Last year, our old friend William Frist, M.D. (of the long distance diagnostic powers), in a lecture at the Massachusetts Medical Society, said, “We must agree on a guiding principle: all Americans deserve the security of lifelong, affordable access to high-quality health care." It's nice to have a principle that says people deserve it, but it's even nicer to have a plan that will give it to them. This Senator Frist does not have. His system of "consumer driven health care" is driven by consumers in the sense that they pay for it, out of their own pockets. People who earn more than $40,000 per year "should be encouraged, through changes in the tax policies, to buy themselves and their children high-deductible catastrophic insurance coverage." They would then pay for routine care through tax-free Health Savings Accounts (HSAs). Frist also wants to eliminate the tax policies that encourage employers to provide insurance. He says that the system of employer-provided health care "has been universally blamed by economists for inflating health care costs." However, the reference he gives says no such thing, and the assertion is false.

The truth is that economists blame our fragmented system for our high costs, but Frist's solution is to make it even more fragmented. The other wealthy countries spend much less on health care than we do, and get better results, because they have concentrated market power on the purchasing side, either single payer systems or multiple payers who work within budgets established by governments (e.g., Germany). By driving a bargain, they get lower prices for drugs, medical devices, etc. Also, in our complex system, each provider needs systems for billing dozens of different payers, while the payers have their own overhead and marketing expenses. A quarter of total U.S. health care spending is on administrative costs. Note that in our public insurance programs -- Medicare and Medicaid -- administrative costs are far less.

In the real world, the people who establish HSAs will mostly be healthy and wealthy. These people will no longer be in the pool for comprehensive insurance, the price of which will then rise. Although Frist appears to believe that insurance will be more "affordable" because of competition among providers and health plans, the fact is, they already compete in a market with many large, powerful corporate buyers. By phasing out employer-provided insurance, leaving individuals try to buy insurance on their own, this concentrated purchasing power will disappear. Frist's world is a jungle in which the fortunate will be rewarded and the rest of us will be unable to pay for health care.

Medicine is not just a private good, it is also a public good, like park land, national defense, or law enforcement. It is in fact a mixed good, like education, benefiting both the individual and society. Hence, if we leave it up to the consumer to decide when and what to buy, the public good represented by medicine will be underproduced. Imagine if the "Ownership Society" included the elimination of public education -- the logic is the same.

Champions of market reform in health care have been getting away with proposing fiction as reality for far too long. Both theoretically and empirically, the key market assumptions described above have clearly been shown not to apply to health care. Let’s come back to earth and stop pretending that they do.

American Medicine's Denial of the Anatomical Existence of the Neck?

2006-01-11T04:13:00.000-08:00

Ok folks. In my "Etiology" post of 3 Jan I wrote about six reasons why our US HealthCare system is real-time failing before our very eyes (and bodies). Last week, on Jan 6, I covered Paternalism which I hope was helpful? Today I am writing about the current limitations of what we call Reductionism especially as applied to the chronic diseases that we Americans now suffer and die from. Our health care (whoops-disease care) system, from bio-medical research to clinical practice, to reimbursement mechanisms is dominated by reductionism which in short attempts to isolate a single cause for a single disease or single health outcome. It all started with a "power of personality" 17th century French Philosopher- Rene Descartes (1596-1650) who struck a “deal” with the church that Docs would take care of the body but the mind and soul were to be excluded from the province of scientific medicine (that is not-mind you- a geographic Province in France) Well Descartes model actually worked well for a 3 centuries -give or take -because infectious diseases were killing so many global citizens. (They still kill people in "un" and underdeveloped countries) One you could say that the single cause model worked almost to a miraculous degree especially here in the good ole US of A. Smallpox has been eradicated -we are getting closer to worldwide polio eradication and so many heretofore lethal infectious diseases like tuberculosis and scarlet fever have been treated successfully with antibiotics. We'll as they say no good deed, medical model, or medical paradigm goes unpunished. By the 1950s in the US scientists began to notice that our fellow citizens were dying much more from chronic diseases such as heart attack, stroke and cancer than infectious disease. After billions were pumped into "finding the cause" of these modern killers (see Nixon’s failed reductionistic "War on Cancer"http://training.seer.cancer.gov/module_cancer_disease/unit5_war_on_cancer.html) it became apparent that these chronic disease were indeed multicausal. So we now know that these chronic diseases are contributed to by genetics, diet, environment, lifestyle, and yes, even stress. Well in regard to especially the latter, poor Descarte began turning over in his grave -(See Descartes' Error : Emotion, Reason, and the Human Brain -- by Antonio R. Damasio 1998) and contemporary reductionists began to panic, but a new Bio-Psycho-Social-Spiritual (BPSS) model was being born. Some call it a holistic model. (see www.holisticmedicine.org) A debt of gratitude must be paid to pioneer Dr George Engel, an internist and psychoanalyst, (1913-1999) who mostly in the 1960's and 70s at the University of Rochester tried to advanced his Biopsychosocial model (he didn't dare touch spirituality leaving alone the work of the late great Carl Jung-too mystical for science). But alas Engel’s then was largely lateralized by both Bio-Medicine and Psychiatry because of resistance to change and perceived loss of power and money on both sides-often the curse of the pioneer. I began to use the phrase "Reductionism's last hurrah" in 1985 is essays I wrote and speeches I delivered. Now, please don't get angry, I am no anti-technology Luddite but bio-medicine alone is simply incomplete! Rather a BPSS model leverages the miracles of modern bio-medical technology by fully integrating contemporary psychology, sociology, and theology. Also, once one accepts that the Central Nervous System (CNS) or mind influences all health outcomes it must follow that anything in the universe from objective stimuli to anything perceived or even thought or imagined can and does impact our physiology and health outcomes. (Viruses, alas, still trump hope or prayer) So for 300 years plus the anatomical existence of the human neck which serves to attach the head to the body was denied by medical science despite the fact that everyone that I have ever met or every patient that I have examined seems to have one? (fyi-my collar -or noose?- size is 17 inches) Cervantes has also brought your attention in this blog and Stayin Alive the need for Sociology and to be fully integrated with modern bio-medicine. How can we afford economically, ethically and morally to continue to medicalize America's social problems like poverty, cultural xenophobia or outright bigotry. In short we can't! There is no pill for not having a job or no surgery for people of color not having access to basic health care. From a practical perspective I have personally lobbied JCAHO to require that physicians ask two simple questions to all patients- "How are things at work or school?" and "How are things at home?" Those two simple questions might get this model off to a good start? And patients, of course know this being way ahead of their providers. We could use the famous JCAHO "fifth vital sign" of pain on a 1-10 Likert scale that JCAHO requires be asked by providers to hospitalized patients as our model. (After all folks, hospitals do need that JCAHO certification for big Medicare dollars). But alas, however, JCAHO does not yet certify outpatient practices. Here are my five practical actions to advance the BPSS model.

#5 Practical Actions to Advance a Bio-Psycho-Social- Spiritual (BPSS) Model of Health Care

1) Support Mental Health Insurance Parity Laws. Encourage
patients to seek counseling or psychotherapy during any
illness/injury

2) Switch your primary care Doctor if he/she doesn’t ask you “how are things at work or home?” during every office visit (see Lippin-Simple Mandatory questions”)

3) Be certain that your Doctor(s) and other health care providers are aware of your religious and/or spiritual needs especially during major life transitions, crises, and at end-of life.

4) Try to find meaningful, safe and healthy lifelong work. Support job creation legislation and healthy workplace legislation/regulations. Encourage more research on meaningful work as a health outcomes issue.

5) If you are unable to find a meaningful daily job- find a
meaningful passion and integrate it into your life. Advance
research into this area as well.

This new model is also driven by stunning recent advances in neuroscience and will make the inflated promises of the "genomics revolution" (more reductionism) look like childs play. Is reductionism dead? Not quite yet. But it is very "Critical Condition" and is a major contributor to our moribund Disease Care system. For two very fine books in this area I highly recommend Manifesto for A New Medicine by James Gordon (1996) and the incomparable Larry Dossey book Reinventing Medicine (1999) My personal website at www.ricklippin.com (whoops I revealed myself) explores this BPSS model

Trillions and Trillions

2006-01-10T10:55:00.000-08:00

The Centers for Medicare and Medicaid Services (CMS) actuaries have released their annual report on national health care spending. First, I have bad news. This work, which was paid for by you, the taxpayers, and conducted by federal employees on behalf of your federal government, is not available for you to read unless you happen to subscribe to the journal Health Affairs, which costs $122 a year. CMS issued a press release about this, and then directed people to Health Affairs if they want to read it. So you rabble, wretched refuse, and little people can read the abstract only, here. But you'll have to depend on me to tell you what it actually says.

Oh, and now I suppose you were expecting the good news? Well, the article title, and all of the news coverage that depends on transcription of the CMS press release, emphasizes that spending "slowed" from 2003 to 2004. Actually, it increased by more than the overall growth of the economy, as it always does, but just not by much as it has in the past couple of years.*

Specifically, what they call National Health Expenditures (NHE -- which doesn't include public health, not that it would matter because it's so little) constituted 7.2% of GDP in 1970, 9.1% in 1980, 13.8% from 1993 to 2000 (the era of managed care, which temporarily restrained spending), and 16% in 2004. That's called "slowing" because it's only a .1% increase from 2003. The reason for the "slowing" (by which they actually mean reduced acceleration) is mostly that insurers are trying to steer patients and doctors to more generic and fewer brand name drugs; and the collapse of the market for expensive Cox-2 inhibitors. Otherwise, however, spending on hospitals and physician services just kept on rising without stopping for breath. By the way, it's just a number, but the total NHE in 2004 was $1,877,600,000,000. Yup, that's almost $2 trillion, which we should easily have hit in 2005.

Of this, the share spent by government at all levels was $847,300,000,000, or a somewhat less than half. However, the rate of government spending increased by more -- 8.2% -- than the increase in private spending -- 7.6%. But this 8.2% was a composite of the increase in Medicare spending (8.9%) federal Medicaid spending (6.6%) other federal (9.1% -- which includes the Supplemental Children's Health Insurance Program, VA and military, federal employees, etc.), state Medicaid (10%) and other state and local (6.1%), so as you can see the share of health care borne by various programs and units of government is shifting.

As for where the money is being spent, as I said, growth in spending on drugs slowed a bit, while spending on hospital care accelerated, to an 8.6% increase, and spending on physician service also acclerated, to a 9% increase. This is mostly because people are using more services, and more costly services. And by the way, spending on nursing home care grew much more slowly, at 4.3%, which helped contain what would have otherwise been a larger increase in overall Medicaid spending. (Medicaid pays for about 40% of all Skilled Nursing Facility costs.)

So the aging of the population contributes only a small amount to these inexorable increases. The main reasons? New medical treatments -- once they're available, everybody (with insurance) has to have them; rising prices; and increasing utilization. The reasons for the latter aren't entirely clear but the growing chronic disease burden -- of diabetes and heart disease, in particular -- probably has something to do with it.

As insurance premiums rise, more and more workers are forced off the roles of the insured. States have responded to the increasing burden of Medicaid by restricting eligibility and services as well. So the more we spend, the more inequality we create. Fewer and fewer people are the beneficiaries (or the victims, in some cases) of more and more spending. It has to end somewhere, but that end is not yet in sight.

*They aren't terribly specific about their data sources, but IMHO these estimates are pretty accurate.

Addendum: Here's a good link from our friend Keeping Eyes Open, which discusses the growth of health care spending in context, along with some recommendations for what to do about it.

Is the genie all powerful?

2006-01-09T07:53:00.000-08:00

George Anstadt, in a comment on Blake's post on the etiology of crisis, draws attention to the potential benefits of new forms of information technology in health care, which he calls the "digital Genie." This seemingly very wonkish field is one that we should all try to learn something about, as health care consumers and as citizens.

Health Affairs recently published a theme issue on this subject. (Unfortunately, non-subscribers have access only to abstracts of most articles.) The more conventional term is Health Information Technology, which incorporates Electronic Medical Records (EMR) and Computerized Physician Order Entry (CPOE). These are linked, in that the physician's orders automatically enter the medical record, and information in the medical record can theoretically alert the physician if it affects the appropriateness of an order (e.g., a drug allergy or other counterindication).

People hold out great promise for HIT. If all, or at least most provider institutions used the same data format, medical records could be easily exchanged between doctors and hospitals. Consumers could, in principle, truly own their own records because all the records from all providers could be aggregated on a single server. (Did you know that legally, you already own your own records? You can ask to see them, and get copies. But hardly anyone does.) The record system could be programmed with "process of care standards," so that if someone was due a vaccination, or a screening test, the physician would be automatically alerted. They would also provide comprehensive databases of patient medical and treatment histories so that statistical analyses could be readily done establishing the compliance with quality standards of individual practitioners, hospitals, and health networks. CPOEs could be programmed to reduce prescribing errors and adverse events. The systems could automatically send reminders to people with chronic conditions about self-care. And so on.

This all sounds good although as Dr. Anstadt points out, it won't do anything directly about financial and other barriers to access. But as excited as many people are by the promise of such systems, there is a long road to travel before reality can be even close to the vision, and many potential pitfalls. Famous curmudgeonly critics David Himmelstein and Steffi Woolhandler, in the Health Affairs issue, run down the down side.

First, there's been talk of this digital revolution in HIT for decades, but progress has never come close to the hype. Many hospitals have installed computerized systems that they have ultimately abandoned; and while HIT has indeed gradually been installed in more hospitals, the much-touted safety and quality improvement capabilities are often lacking, and don't always work.

A major problem is that electronic systems don't do anything by themselves. They have to be integrated with human work processes and individual human behaviors. This is extremely difficult to achieve. It is also far from straightforward to determine what really constitutes quality of care. While numerous so-called "process indicators" have been developed -- e.g., what tests should be performed under what circumstances, what drugs should be prescribed, etc. -- there is little evidence linking any of these to better outcomes, and many physicians resist them on the grounds that all cases are individual and their judgment may override the one-size-fits-all recommendation. There is also no particular reason to think that patients will generally comply with the reminders and recommendations the systems generate for them.

Economics are also a problem. These may be good investments for large hospitals, but probably won't repay the investment for small and mid-size physician practices and community clinics. (They might repay the investment from a social perspective, but that won't motivate, or even enable, the individual practices to invest.) There would have to be a substantial government subsidy. They also require technical expertise to install, operate and maintain which doesn't currently exist. And inter-operability -- the single standard so that records will really be portable and exchangeable -- is a huge task that will require a major government investment and mandate, which will be accompanied by massive controversy. There is little discussion in Health Affairs of the privacy issues but they are obviously huge.

So HIT is a tool. Like any tool, it has to be wielded by a skilled user, or in this case, millions of skilled users, all working in concert, within systems of work that function effectively with the technology. A hammer and saw won't build a house, that takes a carpenter. We may be able to use HIT to make health care better, but the basic issues diagnosed by Blake will only be solved by people.

Paternalism-It's All About Power-Maybe?

2006-01-06T05:12:00.000-08:00

In my "Etiology" post on this blog on Jan 3 I put forth, for your consideration, my six causes for the current crisis in US organized medicine. The first I noted was paternalism. In today's essay I will explore this complex controversial issue to be followed by future essays on my other five causes of our real-time current US medical meltdown. Paternalism has always been associated with healing from historic physician-priests, shamans, to contemporary white-coated "MDieties" who deign to receive the supplicant patient so that magical, mysterious and most importantly secretive cures can be administered to the eternally grateful patients. Not only are the cures known only to the healers but a secret specialized language is developed among the healing fraternity. Unfortunately this paternalistic model is based on power dynamics that infantalizes patients keeping them forever dependent on their doctors. I once published perhaps an extreme statement that "the best medicine is simply helping people to become themselves". Now mind you, if you have the misfortune of being born with a huge hole in your heart, or a truck driving 60 miles per hour hits your body broadside, or you develop a life threatening disease like cancer or a stroke you need a highly skilled technical physician pronto!- or stat! as they say in medicine. At that moment in time "becoming yourself" is a silly issue. But a large proportion of medical encounters (>70%) are not that at all. Most rather relate to physical symptoms and diseases that are attitude, behavior and lifestyle related or for example having a "toxic boss". Well, anyway, paternalistic systems (another example being organized religion) begin to fail when two related things happen-when patients become educated and when they become mature. They henceforth expect or even demand that their doctors relate to them as adults who can actually think. Regarding the neo-educated mature patient the internet has dramatically and profoundly changed the doctor-patent relationship. At least 88.5 million US adults will use the internet for health information over the next five years accessing no less than a whopping and growing- 20,000 health related websites. In some cases especially intelligent, persistant or sometimes desperate, computer literate patients will know more about current science and options for diagnosis and treatment for their disease than their doctors. This is a very painful transition for paternalistic docs who don't have the maturity to work with a educated patients. So the era of co-decision is now upon which also places more responsibility on patients some of whom fear that "burden" or even worse "abandonment". In addition to the internet the free market which I will write about in a future essay -if it is truly free-(currently it is not e.g.- largely a physician monopoly and AMA restriction of trade) allows patients to choose all sorts of providers who they can relate to as adults. US organized medicine is trying. For example to see what the AMA says about paternalism you check out this site.http://www.ama-assn.org/ama/pub/category/12037.html .But I remain convinced that this rhetoric is not matched by the AMA's or its members' real practices. After all there is a lot of power and big money at stake which is perpetuated by paternalism and dependent patients. But I recognize it ain't easy for any of us to grow up. Let's hear from you on this difficult but necessary transition for all of us. For any excellent essay on "deconstructing paternalism" I highly recommend http://www.sma.org.sg/smj/4303/4303sf2.pdf from of all places Singapore:)

Yes, we take requests . . .

2006-01-05T07:55:00.000-08:00

A reader inquires about the process of new drug development and approval. A vast subject indeed. First, I definitely recommend as a good critical introduction Marcial Angell's piece in the New York Review of Books (yes, yes, effete east-coast pointy-headed intellectual elitism) from 2004.

Without trying to do it justice, I'll summarize one of her main points by saying that the profit motive leads drug companies to direct their efforts toward maintaining monopolies on drugs that they can sell a lot of, at a high price. Once they lose their time-limited exclusive rights to sell a drug, it's far less profitable for them. They have concluded that the best way to maintain profitability is not to try to develop novel treatments (and most of the creative energy that does lead to new therapies comes out of publicy-funded research anyway), but rather to develop slightly different versions of old drugs that they can get new patents on. Then, when their old drugs lose patent protection, they can use their enormous marketing budgets (considerably higher than their R&D budgets) to convince doctors to prescribe the new, still very expensive patented drugs instead of the now cheap generics, even though the new drugs aren't really any better, at least not for most patients. (Viz., Cox-2 inhibitors vs. NSAIDS; nexium vs. prilosec and even, for many folks, Tums. Etc.)

There are many other problems. Since the drug companies fund and control most of the clinical trials themselves, they can produce both subtle and unsubtle pressure to get favorable results and suppress evidence of harm. In particular, they don't have to test their new compounds against existing treatments, but only against placebos, or they can test them against sub-optimum versions of existing treatments (such as insufficient doses). So a new drug can be approved even if it isn't any better than existing drugs, or is actually worse. Also, the companies aren't particularly interested in finding adverse effects, obviously. It wouldn't be possible to find all the risks and side effects of new drugs prior to approval and marketing, for various reasons, but we could do much better, and all you need to be convinced is one word, Vioxx.

I could go on and on, but in answer to the reader's specific question, about drug companies selling rights, the key is that there are actually two kinds of exclusivity that they get: a patent on the compound, and marketing rights from the FDA. Once a compound is approved for one use, doctors can legally prescribe it even for unapproved, so-called "off-label" uses, but the companies aren't allowed to market it for those uses. So, in order to get marketing rights, they need to do a clinical trial to show (at least ostensibly) that it is effective for a given condition. A company might decide to sell the rights to conduct such a trial and market a drug on which it holds a patent for some new purpose, which is what appears to have happened in the case of Pfizer selling rights to a drug to be marketed as a treatment for stuttering. I have found that there is anecdotal evidence that drugs for anxiety -- such as Xanax -- may help some stutterers, since stuttering is compounded by the social anxiety that it causes for some people. Presumably Pfizer didn't think the stuttering market corresonded to their vastness, so they sold the rights to a smaller company to try to get a drug approved for the purpose.

This isn't necessarily a bad thing per se, but the standards for getting already licensed drugs approved for new indications are ridiculously low. This is often done with very perfunctory, small trials. That's why you see SSRIs now advertised heavily on television for everything from shyness to compulsiveness. It's very doubtful that they really help very many people with those problems. Of course, they don't do a whole lot for depression either.

See my post on Stayin' Alive about Bidil, for a particularly egregious example.

Our first guest post . . .

2006-01-04T13:46:00.000-08:00

And it's a good one, from our friend Barry Levy:

Damaged Care:
The Musical Comedy about Health Care in America

Damaged Care: The Musical Comedy about Health Care in America is a 45-minute show that highlights issues of great concern to health professionals and health care consumers. Written and performed by two physicians, Greg LaGana and Barry Levy, the show features a number of issues including the excesses of managed care and cost containment, the inadequate attention to prevention, the success of “superbugs,” and the time pressures and isolation experienced by many health professionals and health care consumers. Damaged Care encourages health professionals and health care consumers to play leadership roles in improving health care.

The show, now in its 10th year, has been presented in 26 states to many different types of organizations and institutions, including hospitals and state medical associations, medical societies and public health associations, medical specialty societies and nursing organizations, educational institutions, and pharmaceutical industry organizations. Damaged Care has also been performed Off Off Broadway in New York, on Capitol Hill, at five conferences of the Estes Park Institute, and conferences of other organizations ranging from the General Assembly of the Presbyterian Church to Families USA to the Federal Reserve Bank of Boston.

Damaged Care has been featured in The New York Times, and on CNN Headline News, ABC Nightline, PBS HealthWeek, the Joey Reynolds Show on WOR Radio nationwide, the front pages of the Boston Globe and the AMA's American Medical News, and elsewhere.

Damaged Care and its creators are featured in the current issue of Lifestyles Magazine. The article can be accessed at:Lifestyles, or at the Damaged Care website.

Thanks Dr. Levy, sounds like our kind of show.

Roots of US Health Care Crisis ("Etiology")

2006-01-03T12:16:00.000-08:00

Assuming you agree the US is in a multidimensional health care crisis- some would say rapid meltdown- let me put forth for your consideration and, please input, the six factors that I believe have led us to this crisis stage. Each will be explored in future postings by yours truly. They are –1) A paternalistic model which attempts to perpetuate an ignorant and infantilized patient population 2) Excesses of reductionism (single cause for single disease) in bio-medicine which for chronic diseases is failing 3) The US love affair with expensive technological solutions for all human problems 4) The US peculiar obsession with only free markets and the private sector to deliver health care 5) The failure to prevent disease and promote health 6) The excesses of the legal profession’s influence on health care delivery(emphasis on the word excesses please)

Now let’s be realistic - $1.8 trillion dollars worth of entrenched vested “industrial” interests are not exactly ready to roll over easily but several dynamics favor change- yesterday. Public opinion polls increasingly demonstrate the political importance of health care and health care costs to American voters. Some say, after the general economy and the war in Iraq it is the number #3 political issue in 2006. Politicians like to get elected and re-elected. They are listening despite obscene funding and relentless lobbying by the “Disease Care” Industry. Secondly we simply cannot as a nation afford to spend close to 15 % of our GNP on health care and significantly more on a per-capita basis per US citizen (@$5300 dollars per person -almost two and a half times the industrialized world’ median of @ $2,200 dollars) than any peer industrialized nation and expect to maintain the US quality of life we have come to enjoy “duh”.Yet, despite these excessive expenditures, quality of health care as measured by a host of objective measurements is declining? What’s wrong with that picture? “double duh” Finally, being a country founded on Judea-Christian ethics, the ethical and moral depravity that the US health care industry now manifests is incompatible with our nation even pretending to exhibit moral leadership as “a beacon to other nations”. The US remains the only nation among nations in the developed world (except for South Africa) that does not provide some level of health care for all its citizens. These three dynamics make change both inevitable and imminent! The question I keep asking myself is do we need a total system meltdown and collapse before a new US health care system arises? Or in other words “I never underestimate the self-destructiveness of institutions entrenched in the status quo”. On this latter observation I sincerely hope I am wrong.

Welcome!

2005-12-30T07:32:00.000-08:00

Blake explains below the inspiration for this blog. Now I will discuss some of our goals, and the ground rules. We want to encourage and facilitate dialogue about this issues. This isn't going to be a conventional blog with a single voice or a main point of view. Blake and I will post regularly, at least at first, to keep it going. (Mostly Blake, I hope, since I have to take care of Stayin' Alive), but we want this to be a community project.

That means you too can post on this blog, so long as your posts are consistent with our mission statement (see top of the page). Just e-mail your proposed post to one of us (not both, please, that will just cause confusion). The editor will either post it for you as-is, ask for (or suggest) revisions, or tell you in a kind way why it isn't suitable but give you suitable encouragement. (Or, conceivably, if you deserve it, tell you something else.) Regular contributors who prove their mettle will get the keys to the kingdom and have the privilege of posting on their own.

Meanwhile, the comments are unmoderated and we invite everyone to comment. Disagreeing with the poster or with our mission statement doesn't make you a troll, but disagreement must be civil and based on facts and/or reason. Gratuitous insults (and that includes calling people ignorant), inappropriate language, and data free analysis are not welcome here. (We do reserve the right to delete truly offensive comments.)

But the more comments the better! Don't be shy! Let's hear from you. Personal stories are definitely okay -- we care about how the crisis in health care affects people, including you and the people you care about. Contributors don't have to be experts on anything more than their own lives. Experts on policy, social science and medicine are also more than welcome, but keep it accessible. This is about democracy.

So, boldly we go. Let's make it work, together.

Critical Condition-Introduction

2005-12-23T10:31:00.000-08:00

Is US Organized Medicine Doomed?

Organized American Medicine as we know it remains in possible irreversible crisis. Former (canned) editor of the prestigious medical journal The Journal of the American Medical Association JAMA-George P, Lundberg MD use term “crisis” many years ago. See Severed Trust: Why American Medicine Hasn't Been Fixed by George D. Lundberg with James Stacey, 371 pp, ISBN 0-465-04291-0, New York, NY, Basic Books, 2000. The crisis is on many levels but none so indolent as the moral crisis of the profession. What once was profession embodying the most noble of human traits has now, because of greed, and intellectual stagnation has become a quintessential cultural paradox, which may actually be harming more people that it helps? Hospitals have become dangerous places as per the landmark IOM report of November 1999 “To Err is Human” http://www.iom.edu/report.asp?id=5575. Unnecessary surgery, procedures and testing abounds and yet a large and growing % of Americans experience no improvement in health outcomes or have no health insurance at all?

Nothing embodies this moral crisis in US Organized Medicine more than the recent revelations about the US or Multinational Pharmaceutical Industry, which has finally been both broadly chastised and had significant legal actions taken against it. This former miracle industry has “gone sour” through greed, excess, amoral behaviors and intellectual stagnation. They push pills for a variety of human social problems like unemployment, create markets for diseases that don’t exist (shyness, etc) and utilize unscrupulous marketing techniques such as physician “educational” dinners in very fancy restaurants, utilizing cheerleaders with possible sexual favors as sales “reps” and financially subsidizing “independent” research and presentations at highly visible medical conferences. Most egregious and paradoxical of all many of their products are not safe!

I worry about the end game. Vested interests are not changing fast enough. Yet bright, brave and moral leaders scientists and physicians from academia, The FDA, and pharmaceutical companies are beginning to step forward often at significant personal risk to their employability. We are very close to collapse and rebirth -not more failed incrementalism. Optimism remains a moral imperative.

For more physicians who are solution oriented go to Common Sense Medicine at http://www.commonsensemedicine.org/ and the Institute for Healthcare Improvement at http://www.ihi.org/ihi Health Promotion Advocates www.healthpromotionadvocates.org
Also highly recommend Dr. Nortin Hadler’s book The Last Well Person (2004)