- Del Meyer, MD - http://delmeyer.net -

Obesity policies, bottled water hype, a Grimm Medicare tale, new cancer research, active duty and thoughts on rights, privileges and Medicare

Are Obesity Policies Too Thin?

Russell Jackson reports in Southern California Physician: Obesity is an increasingly urgent medical issue. A Journal of the American Medical Association report says that obesity-related deaths – those caused by lousy eating and exercise habits – rose by one-third from 1990 to 2000, to about 400,000 a year. By comparison, smoking-related deaths totaled about 435,000 in 2000.

Indeed, the Rand Corporation, a think tank in Santa Monica, says that in the next 20 years, obesity-related diseases will cancel out advances in technology and treatment. It predicts that by 2020, about 20 percent of health care expenses for people between 50 and 60 will be tied to obesity-related disabilities.

Further, the National Institutes of Health in Bethesda, MD, reports that about two-thirds of American adults are clinically overweight-meaning their body mass index is between 25 and 30. Of them, about one third – or about one in five adults – is actually obese.

All that extra flab has an enormous price tag. “Among the obese, lifetime medical costs related to diabetes, heart disease, high cholesterol, hypertension and stroke are $10,000 higher than among the non-obese,” says Fay Bhattacharya, MD, PhD, Assistant Professor of Medicine at Stanford University. “In year-2000-equivalent dollars, $31 billion was spent in 1996 for adult overweight- and obesity-related cardiovascular disease treatments alone. Among the overweight, lifetime medical costs can be reduced by $2,200 to $5,300 following a 10 percent reduction in body weight.”

So why haven’t insurance companies stepped up to he plate to make obesity “prevention” a priority? Some have. (Seewww.socalphys.com.)

Our Voice: They shouldn’t. Preventive medicine is not an insurance issue. I once ran a cigarette-withdrawal clinic. As in most cases, our success rate was less than sterling. One patient epitomized the attitudes about prevention: If I join your group, I really have to stop smoking. So I’m joining Smoke-Enders because they said I can join them and not have to quit smoking.

Patients will utilize their insurance benefits as well as their preventive medicine benefits and see no connection with the latter changing their behavior in the former unless they are partially responsible for their insurance benefits. We have found that a copayment proportional to the total cost of care is the only way patients learn the connection between habits and health. If all insurance had a copayment for every hospital stay or office visit proportional to the cost,utilization would decrease, health-care effectiveness would increase, quality would improve, and cost of health care would be brought under control without any government or HMO intervention. The army of reviewers could return to the practice of nursing, relieving the nursing shortage.

Despite the Hype, Bottled Water is Neither CLEANER nor GREENER than Tap Water.

Brian Howard, Managing Editor of E Magazine, reports in CSA Bulletin: Message in a Bottle. “You drink tap water? Are you crazy?” asks a 21-year-old radio producer from the Chicago area. “I only drink bottled water.” In a trendy nightclub in New York City, the bartender tells guests they can only be served bottled water, which costs $5 for each tiny half-pint container. One outraged clubber is stopped by the restroom attendant as she tries to refill the bottle from the tap. “You can’t do that,” says the attendant. “New York’s tap water isn’t safe.”

Whether a consumer is shopping in a supermarket or a health food store, working out in a fitness center, eating in a restaurant or grabbing some quick refreshment on the go, he or she will likely be tempted to buy bottled water. The product comes in an ever-growing variety of sizes and shapes, including one bottle that looks like a drop of water with a golden cap. Some fine hotels now offer the services of “water sommeliers” to advise diners on which water to drink with different courses.

A widening spectrum of bottled water types are crowding the market, including spring, mineral, purified, distilled, carbonated, oxygenated, caffeinated, and vitamin-enriched. There are flavors, such as lemon or strawberry, and specific brands aimed at children. Bottled water bars have sprung up in the hipper districts, from Paris to Los Angeles.

The message is clear: Bottled water is “good” water, as opposed to that nasty, unsafe stuff that comes out of the tap. But in most cases, tap water adheres to stricter purity standards than bottled water, whose source–far from a mountain spring–can be wells underneath industrial facilities. Indeed, 40 percent of bottled water began life as, well, tap water.

To read the entire report, go the California Society of Anesthesiologists site atwww.csahq.org/pdf/bulletin/issue_6/water043.pdf.

Our Voice: The United States has safe tap water. There is no need to spend three times as much for bottled water as for gasoline, or pay as much for one Evian bottle of water as for 1000 gallons of tap water.

The Tale of a Battle That May Be Lost Before You Even Know of its Existence.

Barry B Sheppard, MD, President of the San Mateo County Medical Society, writes in “Of Gypsies and Gaffs”: “When I was a much younger man, the term Gypsy brought to mind romanticized visions of a nomadic people able to tell fortunes and work small magics. And Gaffs were very large and wicked-looking hooks mounted on the ends of poles used to land the sharks my father and I sportfished off the coast of South Carolina. For the past few weeks, however, I have become embroiled in a struggle involving GPCIs and GAFs of a very different nature. To emphasize the point that this is my own, and therefore biased, account of the situation as well as to allow for some blurring of the identities of the players, I have set this tale to paper in the form of a Grimm’s fairy tale—the grim part being apropos as well.

“Once upon a time, about seven years ago, a wicked Queen, later to be known as the Centers for Medicare and Medicaid Services, sent out a decree across the fair land of California. The land was to be divided into regions on the basis of similar expenses incurred in providing health care to the people in an effort to adjust for, to some extent, widely varying office rents, employee reimbursement levels, etc. in the various regions of the state. Each resulting Locality would then be assigned a GPCI (Geographic Practice Cost Index), which had the power to transform itself into a GAF (Geographic Adjustment Factor); and each GAF had the power to alter the Medicare gold that funneled through the office en route to physicians. The piles of gold, when touched by the GAFs, would be adjusted heavier or lighter depending on the cost of practicing medicine in each region. Each GAF, however, only had a single spell and thus each pile of gold entering a particular locality was adjusted to the same amount for all the GAFs in that locality. Even though the system was designed to correct inequities of cost incurred by physicians, the amounts of gold were so miserly that no one in the kingdom was happy.

“In setting up the localities, however, the wicked Queen was not diligent in her duty. She began by carefully measuring and sifting through regional differences in cost of practice and established six counties as rightfully having their own locality. She then lumped two similar counties into a seventh locality. Beginning to tire of the tedium of the process, she lumped three counties into one locality, Locality 3, despite a significant cost difference in one county from the other two. Looking at the daunting number of counties still to be apportioned, she threw up her hands in disgust and lumped all 47 of the remaining counties into one locality, Locality 99.

“Soon afterward, four of the 47 in Locality 99 realized that their costs were significantly more than the costs of their fellow counties in that locality. However, try as they might over the ensuing years, they could not escape the locality. One well-conceived plan was stymied by Parliament largely because of opposition from the other 43 counties that benefited from GAF-averaging with the “high-cost” counties…”

If you’re still with Dr Sheppard’s government fairy tale, feel free to read the entire Grimm story atwww.smcma.org/Bulletin/BulletinIssues/Oct04issue/President.html.

The Voice of H R Greene of SMCMA’s Board of Directors: “We all know that the RBRVS hasn’t done what it’s supposed to do, accurately build our overhead costs into Medicare reimbursements. If we don’t get everything we’re entitle to, we pay doubly because the commercial payers peg their reimbursements on Medicare… . We have joined with ACCMA and SCCMA to reject the CMA plan.”

Our Voice: Actually, there is no need to read the entire Grimm Fairytale. All government programs are variations of a Grimm tale. As physicians, we deal with the medical needs of each individual patient. Any attempt to lump one patient’s needs with another’s, even our own, interferes with helping one or both. When the government groups millions in one pot, no individual’s medical needs can be fully met. The quality of care plummets and a large segment of society is no longer helped. This then begs the validity of the initial government “help” program.

The Battle to Defeat Cancer: Intro to ‘OMICS

This current issue of the UC Davis Cancer Center SYNTHESIS discusses the battle to defeat cancer, which progresses on multiple fronts. The two most important aspects of the battle are patient education and biomedical research.

For generations, scientists have worked to understand the cell down to its smallest components. Today researchers in genomics, proteomics, transcriptomics and metabolomics seek to understand the cell as a whole, in all its complexity.

Elbert Branscomb, associate director of the Biology and Biotechnology Research Program at Lawrence Livermore National Laboratory, likens cells to small cities. “Think of a cell as the whole city of Chicago, at rush hour, busily making another Chicago,” says Branscomb, who is also a member of the UC Davis Integrated Cancer Research Program.

The mind spins at the immensity of the challenge: Each human cell has at its disposal about 30,000 genes, the sum of the human genome. Together these genes are capable of producing, via a manufacturing process known as transcription, perhaps 100,000 different proteins. It’s the proteins that carry out the cell’s work, or metabolism. How many byproducts of metabolism there are – the metabolites – is unknown; a common estimate is 3,000.

For cancer research, the implications are tremendous. “We are moving towards an understanding of cancer that will enable us to tailor-make the optimal treatment for each person,” says Hsing-Jien Kung, deputy director of the UC Davis Cancer Center and director of its basic science program. “This university has made a tremendous, multidisciplinary commitment to this revolution, and we are leading the way into the future.”

Read the entire article on the exciting research at our own UCD Medical Center at www.ucdmc.ucdavis.edu/synthesis/.

The Secretary of the Navy wants YOU on ACTIVE DUTY In Washington, D.C.

Richard Deaner, MD, in a Guest Editorial in the Kern County Medical Bulletin, reports recently that in February 2004, he received an official looking letter from the Navy Department. He opened it with foreboding as if opening a letter from the IRS. But these were official orders 25 years after his Navy retirement in 1979. He pulled his Navy dress blues out of mothballs and found they didn’t come close to fitting. He then reread the entire set of orders, more calmly this time. “Don’t wear a uniform,” they said. “I would be on active duty for only 10 to 14 days, unless they decided they needed me in Iraq.”

Dr Deaner was being asked to serve on the Secretary of the Navy’s Retiree Affairs Committee–the only MD among the 24 retired Navy and Marine Corp members comprising the committee. In the subsequent email exchange, “Why Me?” was answered “We want to pick your brain about Medicare, VA benefits, medical benefits, retiree pharmacy benefits–cool stuff like that.”

Dr Deaner states he really enjoyed this ego trip at age 72, flashing a military ID, snappy salutes of the Marine guards, a stay at the Marriott with a view of the Pentagon while his wife enjoyed shopping, visiting old friends, touring the monuments and memorials. Dr Deaner said working from 7-5 daily sure beat being retired.

When asked what else did the committee discuss? He replied classified stuff sometimes. As in Mission Impossible, “I could tell you–but then I’d have to kill you.” You gotta love it, he concludes. This editorial is not posted at their site:www.kms.org.

Thoughts on Rights, Privileges, and Medicare

Merwyn G Scholten, Executive Director, in his Mert’s Musing column, thinks health care is a privilege and not a constitutionally guaranteed “right,” as some seem to believe. As a fiscal conservative, I worry about the ultimate cost of things. Unfortunately, there are too many who tend to take health care expenditures for granted. We’ve been isolated from actual costs of medical care since the post WWII days when health insurance became a fringe benefit of employment for literally millions of Americans. Individual responsibility was lost in favor of letting someone else pay the cost.

And when Medicare and Medicaid became law in 1965, millions more Americans took the coverage offered and were mostly immune to the costs of providing the care beyond small copays for Medicare and a few dollars withheld. from Social Security checks.

Now, we are reaping the end result mode where everyone is questioning every cost and trying to find solutions. We’re seeing employee unrest at increasing co-pays and premium cost-sharing which is cutting into their take-home pay. Unfortunately for medicine, the solutions are too often found in simply paying the provider of the service less for each service rendered in an effort to save dollars to provide care for more eligible citizens.

Meanwhile, government continues to add benefits. Currently it is the prescription drug benefit which is being added (at some ultimate cost yet to be determined). I continue to question the arguments for adopting the program. It was always made to sound like every Medicare recipient is a poor, downtrodden street person or a lonely widow who can barely afford to buy food or find shelter yet alone buy expensive needed drugs. The reality is that a relatively small percentage of Medicare recipients really need (or desire) drug coverage. Many of our elderly live very happy, healthy lives taking nothing more an occasional aspirin while others do require maintenance drugs for their diabetes, heart conditions, etc.

Let’s not forget that our current Medicare population is also worth a collective trillion dollars plus according to estate planners and others who talk frequently about what the current generation is going to have passed on to them over the next 10 to 20 years. They are not all street people; they have dignity and fiscal ability to be responsible for themselves.

I, for one, am not looking forward to having to enroll in Medicare in the next couple of months; I’m not excited about a “one size fits all” program that begins to limit my choices and options and whose aim is to make me dependent on the federal government to make my health care decisions.