Heart of the Matter

Health Care Reform Revisited

During the presidential campaign, I wrote about the candidate's health care reform proposals, outlining the disastrous ideas of John McCain as opposed to the sketchy ones of Barak Obama. Now in charge, Obama is, thankfully, beginning to flesh out his ideas and will announce significant dollars to begin the process of improving our health system and making it more affordable to individuals and to the country.

For too long we have ignored these festering problems as the booming economy and the Bush wars distracted our attention and allowed us to ignore the soaring costs and stagnating quality of our system, something that anyone who pays insurance bills or goes to the doctor can attest to. As the president has said, we now have a crisis that provides an opportunity.

There has been an increasing body of research into our health system that has not surfaced in the atmosphere of the prior administration. A great example is provided in an article in this week's New England Journal of Medicine by Elliott Fisher, M.D. and a group from Dartmouth Medical Center for Health Policy Research. The article points out the ridiculously large variation in Medicare spending per recipient in various areas around the country. Some examples: 14 years ago spending per capita in 3 of the nearly 50 regions around the country; Boston, East Long Island  and San Francisco were nearly identical but rates of increase in spending were markedly different, 2.4%per year in San Francisco, 3% in Boston and 4% on Long Island. That relatively unimpressive difference translates into an average per capital spending by 2006 of $2,500 more on Long Island then that in San Francisco.($7,500 vs $10,000) That is a whopping 33% higher! And that translates into an extra $1 Billion dollars for the NY region.  Almost real money. They were careful to show that health care was not any better or worse despite the differences.

An even more egregious example; spending in Miami was proceeding to increase at 5% a year over the same period. Miami region now spends on average more than $13,500 per recipient whereas in Minneapolis spending is LESS THAN HALF as much.

What accounts for these disparities?

The authors go on to point out that physician behavior, their willingness to order tests and referrals for marginal indications accounts for much of the difference. Although there was agreement among doctors in both regions on treatment plans when the indications were strong, the doctors in the high priced areas ordered lots more tests on people who had weaker indications that a given test would help. It is almost that a culture grew up in these medical communities that it was better/easier to reassure patients with more tests than with, well, reassurance (a lot cheaper than a CAT scan). Further, hospitals make money from doing tests and admissions, not by keeping people out and well.

To some extent this situation has been the unintended consequence of Medicare ratcheting down the reimbursement for doctors to talk to patients as opposed to doing something to them, direct marketing to patients (witness the endless Viagra and allergy medicine ads) and the fierce competition in some markets among hospitals trying to attract patients to the latest super duper imaging machine or fancy surgical program.

Fixing this will require a lot of work and a lot of changes (read: "weeping and gnashing of teeth and howls of protest"). But the payoff is considerable. By leveling out these growth rates among regions, the Medicare program which will have a projected deficit of $650 Billion by 2023 could have a $750 Billion SURPLUS! I.e. $1.3 TRILLION savings. Pretty near the cost of the bailout now going on.  Now that is almost real money.

Thomas Sbarra, M.D.

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Fish oil. A ‘natraceutical’. Why it is good for you...

Fish oil has been seen as a biologically active compound for some time. Initially it was noted that societies that eat a lot of fish have less heart disease (Fins, Eskimos, Pacific Islanders, Japanese).  Clearly, except perhaps for the Finnish the lifestyles are a lot different than western societies, which might explain the findings. (When was the last time you went on a seal hunt or paddled a canoe to Tahiti?) Several studies in the last several years, however, have shown the benefits of taking fish oil in certain western populations of people at risk for developing heart disease. Those with high triglycerides and/or low HDL levels derive the most benefit but improved health has been seen in all groups. The reduction in heart disease is modest, on the order of 10-15% (similar to the benefit obtained from aspirin) whereas improvements with statin drugs are in the 30-40% range. But every little bit helps, especially if you are at high risk.

How does it work?

The omega 3 fatty acids in fish oil actually replace some of the molecules in the cell membranes of the lining cells in blood vessels, making them more flexible and resistant to cholesterol deposition. They also provide raw material for the liver to make more HDL and reduce triglycerides by changing how the liver processes dietary fats.

Because this is not a prescription drug, it comes in many forms and it is up to you to figure out the multiple issues to get the dose right.  One issue that comes up often is purity and contamination. I don’t believe there is any serious issue with contamination with industrial chemicals, as some manufacturers would have you believe (so that you will buy their more expensive and ‘pure’ product). The purification process is relatively easy and cheap so everyone is pretty much doing it.

You need to take about 1200mg a day of the active ingredients, which are abbreviated as EPA, and DHA (eicosapentanoic acid and dohexaepanoic acid) COMBINED.  These two fatty acids typically are about 200 to 350 mg each per capsule so the combined total is 400-700mg for each pill and you would need to take 2 or 3 a day to get to 1200. So factor the issue of number of pills a day into the cost. In people with very high Triglycerides the dose may need to be up to 3,000 mg a day.

You can get these at pharmacies, natural food stores and health food stores or on line. You should be able to get these for about 10-20 cents a day if you shop around. Once you find a source you can stick with it but it is a pain at first.

You might expect some fishy tasting burping at first but that usually goes away. Taking the pills with food helps avoid that. Freezing the capsules also helps but I have rarely found anyone who needs to do that. You should recheck your fasting lipid profile in 6 weeks or so to see the effect.

Tom Sbarra, M.D., F.A.C.C.
The Cardiovascular Specialists, LLC
www.tcsma.com

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Cholesterol: Part Deux

Link: http://www.cardiacwellnessprogram.com

I my last post we began to talk about cholesterol levels and how low they should be for optimal health. 

Arguably this debate began in 1956 when a famous epidemiologist

(they study populations for health trends) Ancel Keys examined the incidence of heart disease in Japanese men and found a remarkably low incidence, about 10% of the rate in the U.S. he also noted that the cholesterol levels were about ½  of those in America. To sort out whether this was some genetic difference, he cleverly looked at emigrant Japanese populations in Hawaii, California and Wisconsin. He found a stepwise increase in cholesterol levels and heart disease incidence such that the Japanese in Wisconsin had exactly the same levels and rates of heart disease as Caucasian Wisconsinites.

Even though Japanese  in Japan smoked a great deal more than Americans, they still did not develop heart disease even if they had diabetes which, in America is associated with a >70% risk of heart attack.  It appeared that lifelong low cholesterol levels were protective. This was so striking in the 50’s that medical schools in Japan had a deal with Harvard University to send them cadavers for their students to dissect that had evidence of coronary disease because they had none at home! Regrettably, thanks to the intrusion of McDonald’s and KFC into Japan, they now have cholesterol levels that are about ¾ of ours and they now have enough heart disease to provide their own cadavers.

Other evidence abounds that low cholesterol levels are good for you.  Our nearest relatives, chimpanzees have cholesterol levels naturally <40 with largely but not exclusively vegetarian diets and have virtually no coronary disease.  Babies similarly have cholesterol levels <40 and obviously thrive.

If low cholesterol is good, how is this for a health care plan?

Could we mount a national effort to lower cholesterol? We have gotten nearly ½  the smokers to quit. Could we get Americans to lower their cholesterol in the same way? If we could do this, we could save some of the $800 billion we spend on heart disease each year (that is $4,000 per person, almost a 1/3 of your average insurance bill). It would probably be cost effective to pay people to lower their cholesterol levels rather than deal with the heart disease that will inevitably result.

So, when I become president, I would vote to pay people $50 a year to keep their cholesterol level below 150.  It works with your car insurance, why not health insurance? Think about it.

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Cholesterol Series: How low can you / should you go ?

Much has been made, rightfully so, of the dramatic reductions in heart attacks and strokes in patients on statin therapy. In the landmark trials in the 90’s that showed how effective these drugs could be, reductions of LDL cholesterol of 30-50% resulted in a 30% reduction in incidence of ‘events’ (heart attack, stroke and death). A remarkable result for sure but what about the other 70% ???  Well, they went on to have ‘events’ despite treatment. So is this glass 30% full or 70% empty? Statins are the most successful drugs ever used to prevent or treat heart disease but can we do better?

The current guidelines that tell doctors how much of what drug to use and what target LDL levels should be in various circumstances, are produced by the National Institutes of Health and the American Heart Association and are updated every few years.  They are, of necessity, a compromise between what the science tells us, and what the government thinks we can afford (because Medicare patients use lots of these drugs, lower targets would use more drug and cost more). For instance, currently the guidelines suggest target LDL levels of 100-130 depending on risk of heart disease. There is an ‘option’ to use a target of 70 in patients at ‘very high risk’ such as those with diabetes who just had a heart attack.

This begs the question; if 70 is good for those at very high risk and we are allowing 70% of people to keep having heart attacks who are at just high risk, why isn’t 70 good for everyone? Why not lower still?

In fact, data exists that show that you can cause regression (shrinking) of cholesterol deposits in patients with LDL levels of 70 but it is very small, on the order of <1% a year. On the other hand, in a few small studies in humans and in a lot of animal studies in which cholesterol levels are lowered to less than 40, complete resolution of blockages can be seen in 18 months !!

So, is too low dangerous in any way? There is a lot of indirect information that says emphatically NO. for instance, there is a group of people who have genetically very low LDL levels of <15 mg/dl, have very little heart disease that live into their 90’s. Children have levels <40 and they seem to grow just fine. Some studies are underway to test this hypothesis using high dose statins and combination therapies.

I predict that the guidelines will always lag behind the science but will move toward more aggressive treatment. Look for the update in 2009. In the meantime, if you are at risk because of known heart disease, diabetes, a strong family history, or prematurely thickened carotid artery walls (CIMT) you should discuss this with your doctor.

See next weeks article on how low cholesterol levels translate into low heart attack risk in other cultures and the following week on how to determine YOUR risk.

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Trick or Treat? Healthcare Reform

 "Medical Home" a new old model of medical care

 As opposed to the medical reforms suggested by the two presidential candidates, the policy wonks in Washington continue to believe that they have THE answer to the medical care mess , that changing the model of medical care will cure the well recognized ills of the US medical system- high cost, fragmented care, poor long term health benefits. No argument with the problems; we have the highest cost health care system, there is waste and redundancy because different doctors don't know or care what each other is doing to a given patient and we rank in the bottom 20% of almost every category from neonatal death rate to heart attack rate to longevity among western countries.  I do, however, differ with the proposed solutions.

The Medical Home solution includes primary care doctors as gatekeepers, collecting doctors into large multispecialty groups and ramping up ‘payment for performance', measured as success in keeping people out of the hospital. Part of this plan is the current holy grail of an electronic medical system which everyone in Washington, including the candidates see as important enough to subsidize to the tune of hundreds of million dollars. (not much by banking crisis standards but almost real money nonetheless).

I have a newsflash for them, this has been tried before. 10 years ago, primary care doctor gatekeepers were going to save American medicine by ‘coordinating care' through a referral process which amounted to denying visits to specialists and reduced testing. This inevitably pitted primary care doctors and specialists at opposite ends of a tug of war. The primary  docs were acting like any other working person to maximize their income which was tied to less expenditures and the specialists did the same by doing every thing to everyone they did eventually get their hands on.  The result was unhappy patients (recall the headlines of patients who were denied some form of care they felt was important), doctors fighting and little or no savings. The public and the market fought back and discredited most of this policy but vestiges remain. Have you gotten your referral for this appointment? It is now a bit of a rubber stamp and a cumbersome annoyance to everyone in the equation, patients, primary doctors and specialists alike.  And these guys want to revive it!

The difference this time, the mantra goes , would be "more robust reimbursement for better outcomes", a nice free market concept that still denies the fundamental laws of economics (that everyone will try to maximize their income) and that specialists are vital to the system to figure out and manage difficult problems even if they do spend a lot of money to do so. They believe that they can accomplish this slight of hand by convincing doctors to do what they have not done for 200 years, join other doctors in large groups to make care more coordinated, including electronic recordkeeping with mutual shared goals of saving money for the system.  Sorry, I don't see doctors giving up their personal income for the good of the whole.  That is un- American if I ever heard it.

These new/old ideas are just a diversion from the task we must face. We have to move toward a complete, painful and disruptive overhaul of the system, Obama's ideas are at least a start in the right direction. Whether he can get consensus to move in this polarized and chaotic economic atmosphere is a very big question.

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