Tag Archives: obesity

On Healthcare Costs

“Monday Musings” for Monday August 19, 2013

Volume III, No. 31/124

healthcare_costs_cropped

Health Care Reform

 By Assad Meymandi, MD, PhD, DLFAPA*

With Obamacare looming to take effect in 2014, and opponents dismembering it limb by limb, we thought another essay on American healthcare is in order. To begin, American healthcare is the costliest in the world, yet quality is patchy and millions are uninsured. Incentives both for patients and suppliers need urgent treatment. The cost of healthcare in one state of Indiana is more than the entire country of India. America spends twice as much per person on health care as Swedes do. Yet there are over 50 million uninsured and many more underinsured. We are spending 16%, soon to be 17% of gross domestic product (GDP) on health care, the most expensive in the world. Literally billions of words have been written since the Truman administration attempted health care reform. Surely, billions more words will be written before we arrive at a satisfactory solution. Meantime, here are some practical and simple suggestions to ward off the current crisis.

1)    Number one money guzzler is obesity. Obesity causes diabetes, cardiovascular disease, hypertension, musculoskeletal problems, back pain, and stroke. The cost of cardiac bypass is $16,000 to $18,000. The cost of back surgery, ninety percent related to obesity, is in the tens of billions of dollars. If we could prevent even a small percentage of people from becoming obese, we could drastically reduce medical expense. We need preventive measures and ought to offer incentives to encourage healthy eating and exercise.

2)    Reimbursement issue: The system encourages oftentimes unneeded procedures and very expensive lab tests and scans. The system does not pay for process and thinking medicine. This flawed system drives the doctors to spend less time with their patients. I do know that with the inflation- adjusted rates, primary care physicians are receiving one-third less pay today than they did 20 years ago.

3)    Government mandated single payer may be the answer. But look at the examples of Canada and England. It takes as long as three years to get elective surgery in their system. That is not consistent with the temperament of freedom seeking Americans.

4)    For-profit driven health care companies should be banned. The middle man and health care insurance companies/venders are poisonous. The dollars that should go to patient care go to pay the salaries, bonuses and backdated stock options of the company’s chief executive officers and their staffs. Convicted William McGuire of United Healthcare and many others like him are examples of these unwelcome middle-man-intruders in medicine.

5)    Waste, repetitious expensive lab work and million dollar work-ups are commonplace in medicine. The primary cause, besides financial incentives of the sinister “more-lab-work-you-do, the-more-fees-you-collect”, is the practice of defensive medicine. We need some comprehensive tort reform to keep physicians from over-ordering. The fear of malpractice litigation does indeed lead the doctors to order tests that may not be necessary to the patient’s care, resulting in billions of dollars of needless expenditure.

6)    There is no question that there are a few bad apples in the barrel. The holy house of medicine does have contaminants. There are a few physicians who go into medicine for anticipated financial rewards, but they are not very many. Remember in the 1970’s, insertion of Swan Ganz catheter in pulmonary arteries was the rage in medicine. Cardiologists were suing their pulmonologist colleagues as to whose practice domain insertion of the catheter belonged. We have had reports of unethical behavior in the ranks of cardiothoracic surgeons scaring patients to submit to procedures such as bypass operation and insertion of stents for which there was no indication. But these unethical doctors are very few. The overwhelming majority of physicians consider medicine a calling and their sacred profession a priesthood. But we do need to keep a closer eye on the few bad apples, thus requiring us to strengthen the States’ Medical Boards.

7)    Finally, in order to reduce cost, we must emphasize and preach the gospel of prevention. Recently in a health related meeting with several people, among them Lanier Cansler, former Secretary, NC Health and Human Services, I asked what percentage of the Department’s budget is spent on prevention. It is an astonishing 5 to 7%. I believe we should approach this issue with thoughtful planning, but a revolutionary attitude. We must effectively combat the unwelcome and dangerous epidemic of obesity. But first, we physicians, nurses and members of healthcare providers, including US Surgeon General, the country’s highest ranking medical doctor, ought to combat obesity.

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 *The writer is Adjunct Professor of Psychiatry, University of North Carolina School of Medicine at Chapel Hill, Distinguished Life fellow American Psychiatric Association, and Founding Editor and Editor-in-Chief, Wake County Physician Magazine (1995-2012). He serves as a Visiting Scholar and lecturer on Medicine, the Arts and Humanities at his alma mater the George Washington University School of Medicine and Health.

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On the Cost of Healthcare

Monday Musings for Monday April 22, 2013

Volume III, No. 15 /118

(Editor’s Note: Much has been said and written about the 2000 plus pages of ‘Obamacare’ which I have recently finished reading.  It is a boring document written in arcane language with abundant legalese absurdities and bureaucratic banalities. We are devoting two ‘MM’s to bring some clarity to the matter, since 2014 will be the year much of the law will take effect. Today’s column are some thoughts about what will help, and next week Dr.Ted Kunstling, a pulmonologist and Medical Director, Duke Raleigh Hospital, will continue with his reflections).

Health Care Reform (Part I)

By Assad Meymandi, MD, PhD, DLFAPA*

Socratic elenchus and Aristotelian entelechy are elegant, and the prose of Plato, is lyrical and beautiful. All three in their discourse ask ‘Who are you? What do you do?’ ‘Are you and your lives making any difference?’ I apply the same to health care in America. What are we, what do we do? And what we are doing is making any difference? American healthcare is the costliest in the world, yet quality is patchy and millions are uninsured. Incentives both for patients and suppliers need urgent treatment. The cost of healthcare in one state of Indiana is more than the entire country of India. America spends twice as much per person on health care as Swedes do. Yet there are over 50 million uninsured and many more under-insured. We are spending 17%, soon to be 20% of gross domestic product (GDP) on health care, the most expensive in the world. Literally, billions of words have been written since the Truman administration attempted health care reform. Surely, billions more words will be written before we arrive at a satisfactory solution. Meantime, here are some practical and simple suggestions to ward off the current crisis.

1)    Number one money guzzler is obesity. Obesity causes diabetes, cardiovascular disease, hypertension, musculoskeletal problems, back   pain, and stroke.  The cost of cardiac bypass is $18,000 to $20,000. The cost of back surgery, ninety percent related to obesity, is in the tens of billions. If we could prevent even a small percentage of people from becoming obese, we could drastically reduce medical expense. We need preventive measure and offer incentive to healthy eating and exercise.

2)    Reimbursement issue:  The system encourages doing procedures and very expensive lab tests and scans. The system does not pay for process and thinking medicine. This flawed system drives the doctors to spend less time with their patients. I do know that inflation adjusted, primary care physicians are receiving one third less pay today than they did 20 years ago.

3)    Government mandated single payer may be the answer. But look at Canada and England. It takes as long as three years to get elective surgery. That is not consistent with the temperament of freedom seeking Americans.

4)    For-profit driven health care companies should be banned. The middle man and health care insurance companies/venders are poisonous. The dollars that should go to patient care go to pay the salaries, bonuses and backdated stock options of the company’s chief executive officers and their staffs. Convicted Richard Scrushy of Health South and William McGuire of United Healthcare and many others like him are examples of these unwelcome middle-man-intruders in medicine.

5)    Waste, repetitious expensive lab work, million- dollar work- ups are common place in medicine. The primary cause, besides financial incentive of the sinister “more-lab-work-you-do, the-more-fees-you-collect”, is the practice of defensive medicine. We need some comprehensive tort reform to keep physicians from over ordering. The fear of malpractice litigation does indeed lead the doctors to order tests that may not be necessary to the patient’s care, resulting in billions of dollars of needless expenditure.

6)    There is no question that there are a few bad apples in the barrel. The holy house of medicine does have contaminants. There are a few physicians who go into medicine for anticipated financial rewards, but they are not very many. For most, doctors consider medicine a calling, and their sacred profession, a priesthood. But we do need to keep a closer eye on the few bad apples, thus requiring us to strengthen the NC Medical Board.

7)    Finally, In order to reduce cost, we must emphasize and preach the gospel of prevention. Recently in a health related meeting with several people, among them Lanier Cansler, Secretary, NC Health and Human Services, I asked what percentage of the Department’s budget is spent on prevention. It is an astonishing 5% to 7%. I believe we should approach this issue with thoughtful planning, but a revolutionary attitude. We must effectively combat the unwelcome and dangerous epidemic of obesity.

dad_sig_pic

 *The writer is Adjunct Professor of Psychiatry, University of North Carolina School of Medicine at Chapel Hill, Distinguished Life fellow American Psychiatric Association, and Founding Editor and Editor-in-Chief, Wake County Physician Magazine (1995-2012).He serves as a Visiting Scholar and lecturer on Medicine, the Arts and Humanities at his alma mater the George Washington University School of Medicine and Health.

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On St. Paul, the Birth of Mozart, and Discovery of CETP

Monday Musings
Volume III, No. 3/107
by: Assad Meymandi, MD, PhD, DLFAPA*

dore-conversionofsaul

Conversion of Saul to Saint Paul. The Birth of Mozart. Discovery of CETP.

This week three important events take place. I will elaborate in the order of importance.

Event I

The Feast of the Conversion of Saul to Saint Paul the Apostle:

Many biblical scholars and historians of impeccable credentials including Eusebius of Pamphili, Saint Jerome, Saint Augustine of Hippo, Saint Ambrose who converted Saint Augustine of Hippo form pagan pursuits and Manichean beliefs to Christianity in 386, and baptized him on Easter morning 387, and Pope Gregory, have written and attested that the conversion of Saul to Paul took place on January 25. Among more modern historians, I recommend a comprehensive and magnificent book published in 1747 by Oxford Press written by the most formidable historian of early Christian era, Lloyd George Lyttleton (1708-1773). The book uses earlier references to lay down the cornerstone of this historic event, namely conversion of Saul to Paul on this date. Saul was a Pharisee with a precise/dry life style, demanding, draconian, exact and unforgiving. Every “t” had to be crossed and every “i” had to be dotted. He lived a life of exactitude with no love and no joy. Paul on the other hand brought the message of hope, faith, love, charity and forgiveness. The two people, Saul and Paul, were extremely opposite in orientation and life style. In many Christian churches including the Roman Catholic, Eastern Orthodox, Oriental Orthodox, Anglican and Lutheran churches, January 25, is celebrated recounting the conversion. The feast is at the conclusion of the “Week of Prayer for Christian Unity and International Christian Ecumenism” which began in 1908. The feast is an octave (an eight-day observance, not a musical octave!) spanning from January 18 (observed in Anglican and Lutheran tradition as the Confession of Peter, to January 25.

Here is the collect for the occasion.

“O God, who taught the whole world
through the preaching of the blessed Apostle Paul,
draw us, we pray, nearer to you
through the example of him whose conversion we celebrate today,
and so make us witnesses to your truth in the world.”

Event II

The birth of Johann Chrysostom Wolfgang Amadeus Gottlieb Mozart:

257 years ago, on January 27, 1756: God wanted to show his mere mortal children, like you and me, what He could do with music. He chose a special child, Mozart to demonstrate the complex sublimity and eloquence of music. Mozart composed more than 623 incomparable pieces in all genre of music, from symphony to opera, to chamber music, etc., in his short life of 35 years. We devoted the December 16, Mozart’s mortal anniversary “Monday Musings” to the miracle of Mozart. If you do not have it, please e-mail us and it will be sent to you.

Event III

A New Discovery in Health Care. A Plug for Prevention:

Like any other human endeavor, in medicine, we have hype, hyperbole, hysteria and high drama. Charlatans from every corner claim to use their powder on food to make you burn calories and lose weight. Full page ads for miracle treatment of back pain in both skinny and fat people. It should be known to all obese people who suffer from back pain that taking off one pound of body fat takes five pound off the aching back. Incidentally, in my view, doctors advertising in news media, both print and electronic, violate Oslerian ethical mandate of medicine. It is very distasteful. It is more than distasteful. It is really disgraceful. Medicine is not a commodity. Medicine is not a business. Medicine is a calling. Medicine is a priesthood, and we, as doctors, are privileged to be handpicked servants to help our patients (not clients, not heath consumers) for which we should be grateful.

However, there are some medical discoveries reported in peer reviewed journals that are époque making and worthy of note. The recent discovery of Cholesteryl Ester Transfer Protein (CETP) or Evacetrapid is one. A bit of explanation is in order. In America, cardiovascular diseases are the biggest killers followed by cancer. For over a half of century scientists have implicated excess circulating cholesterol, especially low density cholesterol or “bad” cholesterol is responsible for occlusion of coronary arteries, leading to heart attack. We have produced a class of drugs call Statins that lower the bad cholesterol and increase the good. However, Statins have undesirable side effects. The side effects include muscle and joint pain and muscle damage. In some cases Statins have been known to cause lysis or eating away of muscles called rhabdomyolysis. Other side effects of Statins are liver damage, kidney failure and fatigue/depression. Liver damage caused by Statins occurs by increasing production of digestive enzymes. Other serious side effects may be low libido and pancreatitis. I see quite a few patients with neurological side effects, such as memory loss, depression and sometimes more serious neurologic conditions.

Back to CETP: A very important paper published in Journal of American Medical Association (JAMA) describes a new chemical that assists cholesterol lowering drugs or Statins to become more effective and biologically efficient. the name of the agent is Cholesteryl Ester Transfer Protein (CETP) Inhibitor. It is potentially capable of replacing use of Statins altogether doing away with Statins’ side effects. But the best life style is prevention, proper diet; exercise and discipline of what one puts in one’s mouth are the ultimate answer to good health. Medicine does have its genuine miracles. In America, a pill taking culture, we have been brain washed that for every ill there is a pill. A pill to sleep, a pill to stay awake, a pill to focus and concentrate, a pill to cure erectile dysfunction, a pill to cure irregularity, a pill to regulate too much regularity. A pill to cure depressed mood, a pill to tone down elevated mood. Aram Khachaturian or Leonard Bernstein could have done well to compose a piece of music like Saber Dance or Candid to express our ominous pill taking culture. I submit that we should pay more attention to prevention. With 80% Americans ranging from fat to very obese and morbidly obese, no wonder we have so many cardiovascular deaths, diabetes, musculoskeletal, that is back and joint problems. I believe we must invest in prevention and have a major national program of awareness to seriously address health issues most caused by fatness. One of the things that I think is most discouraging is to see so many doctors and nurses (health care providers) who are obese. This is truly an ugly and unacceptable site. Instead of putting something in our mouths, we must learn to take something away from our mouths..

Surely, here we are celebrating the discovery a chemical that will potentially help millions. But the main message is to celebrate prevention. We have had luminous achievements in this field. Salk vaccine against polio is a good example. 2011 was the first year no polio was reported in India with a population of one billion. Malaria is on its way to extinction, same as some 25 other infectious diseases including the big killer small pox. To take responsibility for one’s health is not only a civic, but a moral responsibility. Tobacco, alcohol and obesity kill without discrimination.

*The writer is a Distinguished Life Fellow American Psychiatric Association, Adjunct Professor of Psychiatry, University of North Carolina School of Medicine at Chapel Hill. He is the Founding Editor and Editor in chief, Wake County Physician Magazine(1995-2012)

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