Health for life

The Disease Management Care Blog is reconsidering the wisdom of agreeing to host the Cavalcade of Risk #140. The links below are a unpleasant reminder that disasters are lurking everywhere and that there is no escape.  Being a contrarian physician-blog that dwells on health care and insurance, your DMCB was confident that it could intellectually digest the topics below.  After writing this Cav of ubiquitous hazards, however, the DMCB now wants to digest some Xanax and PeptoBismol.

Who knew that so much could go so wrong out there?

Ever heard of the "Terrorism Risk Insurance Act" (TRIA) of 2002?  Neither has the DMCB, but readers can learn more about it at the Insurance Regulatory Law Blogs post on Quantifying the Unquantifiable: Some Perspective on Terrorism Risk.  It turns out the U.S. government is providing "reinsurance" (insurers can buy their own insurance) for a host of commercial companies that have to deal with a threat that is hugely expensive, quite rare and non-random, which is the very antithesis what the usual market needs to function well.  And by the way, TRIA is set to expire 2014 and it looks like it may not be renewed.  Seems some sort of budget issue has come up.

If being reminded about terrorism isnt enough to rattle you, how about cyberwar?  Thats tackled by the Risk Management Monitor Blog in this post on how UK Infrastructure Providers Accept an Unexpectedly High Level of Risk of Cyber-Threats, and the National Response Is Fractured and Incoherent.  It appears, lacking a coordinated response by their government, that the Brits businesses and banks have decided to deal with this risk on their own.  Unfortunately, theyre not dealing with it very well.  Not only have some companies been slow off the mark, others have decided to accept the inevitability of an intrusion and plan on simply dealing with it then.  How many other key industries worldwide have adopted the same cavalier attitude, asks the DMCB?

Terrorism, cyber attacks.... its enough to make the DMCB flee to the country and seek sanctuary on a farm and live simply off the land.  But wait, even that isnt safe, because Lynch Ryans Workers Comp Insider Blog points out that the risk of getting trapped, suffocated or crushed in a grain bin is increasing.  In response, the National Grain and Feed Association has a video on one more reason why our nations farmers deserve a lot of respect.  The DMCB thinks it deserves to flee back to the suburbs.

So it might be best to stay safe and stay at home, right?  Well, if you have a mortgage on that home, the canadianfinanceblog warns that your sneaky bank may try to to sell you "mortgage life insurance."  It turns out this may be a lousy deal, since the premium may not change even as the balance on the mortgage declines.  Better to get standard term life policy.  And when youve done that, you can scrutinize the rest of that small print in the mortgage documents that you signed for some other unpleasant surprises.

After you read all that fine print and discover what youve unwittingly agreed to, you may want to think about property losses from hurricanes, floods, tornadoes and earthquakes. Yes, you can buy a specific insurance policy for each of those possibilities, says the Free From Broke Blog.  On the other hand, given how uncommon hurricanes, tornadoes and earthquakes are, it may make more sense to invest in a sump pump and simply stash away an emergency fund.  The DMCB followed that game plan during the recent flooding from Tropical Storm Lee and now needs a basement mold mitigation fund and a get-rid-of-wet-carpets fund.

Plus, you may want to get "home insurance" against the possibility of a loss from a robbery.  Unfortunately, says the My Personal Finance Journal Blog, the cousins across The Pond are grappling with a daily toll of more than $3.5 million in home insurance fraud.  As a result, the DMCB calculates that honest home owners there are unnecessarily having to add a hidden tax of $1 for every $3 in insurance.

While youre putting bars on your home windows and barricading the doors, it may be smart to take that money out from under that mattress and seek some investment income, right?  If thats your plan, you may want to check out this "101" posting on the fundamentals of investment risks posted at The Financial Literates Blog.  How many things can go wrong, you ask?  "Fifteen" says the FLB!

Or if you want to avoid those 15 dreaded errors, how about an "annuity?"  This lengthy post by the Free Money Finance Blog on Why Do We All Hate Annuities explains that the fine print is perplexing, the sellers are a shady lot, their fees are high, the company (like AIG) could go belly-up, you lose control of your money and theyre still a big gamble.  One option is "laddering."  Another option, says the DMCB, is digging a hole and stashing away some precious metals.

While being attacked, hacked, crushed, ripped off or making a bad investment bet is a possibility, at least we Americans have an enlightened government that is helping us buy health insurance, right?  Think again, says Louise of the Colorado Health Insurance Insider.  She points out the feds online "healthcaredotgov" web site can be misleading.  It appears that the site reports blunt pricing underwriting statistics that fail to capture what is really going on.  While Louise makes the point that brokers can help customers navigate this complicated marketplace, the DMCB thinks that the healthcaredotgov website is a telling lection of the unsophistication of Washington DCs health insurance bureaucrats.  Good grief, and these amateurs actually want to be in charge.

Maybe you should take charge, then, and confront the risk that you may come down with a debilitating, crippling and non-curable condition and need long term insurance.  The curiously named High Yield Savings Accounts Blog  offers up a check list of what to look for in such a policy, such as excluded services, maximum lifetime benefit terms, riders and renewable guarantees.

While were struggling with hazards, perils, dangers, disasters, terrorism and disease, Hank Stern over at the Insure Blog suggests there is a way out from all this danger, at least for the fairer sex. Women may want to have a mid-day tipple because another observational study has shown that there is an association between imbibing and well being.  To that, the DMCB says "Cheers!" and points out if you end up in the hospital anyway, your physicians will know what to do.

"Gulp!" says the DMCB.  While it likes the idea of imbibing to support the DMCB spouses continuing good health, it thinks it should also look into buying an electric generator, firearms and a years stash of fresh water and vacuum-packed ready-to-eat meals.  While its doing that, itll be looking forward to Jay Norris of Insurance Shoppers hosting the next edition of the Cav.

When pundits claim that health care spending is out of control, what do they mean?

Does it mean that Massachusetts outlawing of hospitals excessive price increases is a good thing? That rolling back the Affordable Care Act will automatically usher in a new round of price gouging? That when the DMCB generates another medical co-pay, the DMCB spouse is right to wave a copy of the bill around and demand that the DMCB do something now to orm the U.S. health care system?

As the Disease Management Care Blog understands it, what the pundits, Massachusetts legislators, patient advocates and the DMCB spouse mean is that more and more of our nations gross domestic product (GDP) is being spent on health care services.

That assumes wed all be better off if the U.S. were spending its national treasure on stuff like manufacturing, technology, education and innovation. So, instead of committing just under 18% of our output on hospital care, physician services, nursing homes, medical devices and drugs, wed all be better off if we spent it on the production of solar panels, Facebook, public school vouchers and iPhone apps.

That way we wouldnt be struggling with the prospect of another 1% gain on GDP (to 19%) and the looming possibility that well soon be spending a whopping fifth of our economy on health care.

But is the spending on health care really that bad?  As noted here, the DMCB pointed out that non-government-insured health care costs have been moderating for years.  Whats more, recent year-to-year increases in health care spending in the U.S. are actually lower than much of the developed world.

And now theres one more reason to doubt the prevailing wisdom about rising health care costs. Charles Roehrig, Ani Turner, Paul Hughes-Cromwick and George Miller of the curiously name Altarum Institute point out that the normally rising and falling GDP associated with routine economic cycles can make steady health care costs look relatively worse or better than they appear.

To dampen the impact of a cyclic economy on the assessment of health care spending, the authors compared health spending to U.S. "potential GDP." Apparently, this obscure economic metric has been used by economists to portray what GDP would be if the economy were operating at full employment of the current population and without any idle production capacity.  This metric has the advantage of "smoothing out" many of the peaks and valleys of the normally measured GDP.

Using potential GDP as the comparative baseline, the authors found that health care spending growth gained less than 1% of the economy starting in July of 2005, well before the onset of the Great Recession of 2008. In other words, during that time, the health care industry grew pretty much at the same rate as the "potential" GDP. 

Whats more, in June of 2009, health care cost growth gained an additional 1% of potential GDP, only to fall back below 1% again in May of 2011.  Most of the increases seemed to be accounted for by Medicare Part D spending; if that particular cost is backed out, excess growth would have been 1% or less throughout the measurement period.

The authors can only hypothesize on why health care costs didnt outstrip the U.S. economy. While it could be partially accounted for by the rising numbers of uninsured (who would have avoided going to hospitals or seeing doctors), the authors point out that other trends could have played a role: changing physician practice standards, increasing numbers of salaried physicians, market pressures pushing down on fee schedules, increases in patients out-of-pocket expenses making them less likely to access the care system, new care models (including disease management?), the increasing use of generics, previously expensive drugs going off patent and the drop-off in the number of "blockbuster" pharmaceuticals.

This means when the economy bounces back and/or Obamacare results in more insured Americans, there is no guarantee that underlying health care inflation will return.

A heart-healthy diet helped men at high risk for heart disease reduce their bad cholesterol, regardless of whether they lost weight, in a study presented at the American Heart Association’s Arteriosclerosis, Thrombosis and Vascular Biology 2013 Scientific Sessions.

The 19 24- to 62-year-old men in the study had metabolic syndrome, which ers to three or more significant risk factors for heart disease and stroke. The risk factors included in this study were high waist circumference, high blood pressure, high levels of triglycerides and fasting glucose and low levels of high density lipoprotein or HDL “good” cholesterol.

For five weeks, the men followed a standard North American diet which is high in fats, carbohydrates, ined sugar and red meat. For a second five weeks, they ate a Mediterranean-style diet, which is high in fruits, vegetables and whole grains, and low in red meat. It also includes olive oil and moderate wine drinking.

The men then went on a 20-week weight-loss regime, then another five weeks of Mediterranean eating.

Regardless of whether patients lost weight, following the Mediterranean-style diet resulted in a 9 percent decrease in levels of low density lipoprotein (LDL) known as “bad” cholesterol. Similarly, blood concentrations of the protein part of the lipoprotein, called apolipoproteinB, dropped 9 percent after eating Mediterranean-style. Apolipoprotein plays an important role in lipid transport and metabolism.

“The Mediterranean-style diet, or MedDiet, may be recommended for effective management of the metabolic syndrome and its related risk of cardiovascular disease,” said Caroline Richard, M.Sc., study lead author and a registered dietician and Ph.D. candidate in nutrition.

Smoking, Why do you smoke | Some people who have really addicted to cigarettes will ignore the effects that will result from smoking. Sometimes people say rather not eat than not smoke why. due to narcotic effects of nicotine contained in cigarettes has given a considerable effect on the body condition of people who smoke.

There are many reasons why smoke dangerous for your own health and the health of your family, if you have the habit. The reasons are (bad effect of smoking):

1. Cancer
Smoking increases the risk of cancer in the lungs and lips. The more you smoke, the greater the likelihood you die from cancer. Spare yourself not to get one of these diseases, because if you already have cancer, then the possibility of recovery is less.

2. Bronchitis

Smoking habits also will menyembabkan diseases that are harmful to the lungs including chronic bronchitis and emphysema and can cause death in people who suffer from this condition or suffer from asthma.

3. Gastric ulcers

With the smoking habit, this will also lead to diseases of the stomach (gastric ulcers) or it will aggravate the already suffering from the disease.

4. PNEUMONIA

The children of parents who smoke are more often suffer from pneumonia and other respiratory illnesses compared with children whose parents do not smoke.

5. HEART

The most dangerous smoking is to increase your chances of suffering or dying from heart disease or cerebrovascular disease.

6. Infant Growth

In addition to cause disease in smokers, these habits will affect the babies conceived or born of a mother who has a habit of smoking. Growth of infants born to mothers who smoke will be smaller and will grow more slowly than in infants whose mothers did not smoke.

7. The Bad Examples

If we as parents, teachers or health workers do not give a bad example to our children, our students and the community by the habit of smoking. With the habit of smoking to our children, our students and the community will see the behavior of people who become teachers or peers and consequently, they will go smoke.

8. Economy

Smoking habits would need money to buy it and the result would be a waste of money for useless things. Apparently the money used to buy cigarettes does not mean, but if the collected amount will be many. In developing countries more money spent on people to buy tobacco. If the money used to buy tobacco used to buy food, then the kids and the whole family will be healthier.

Looking at bad effect of smoking should we as a society that already know the meaning of health, can avoid it, not until we feel regret after getting the effects of the disease that is not good.

Read this post also smoker dont have health insurance

"I  think I need to go back to the hospital....."

The Disease Management Care Blog remembers her very well. She had come to the United States after escaping on foot from post-war Hungary.  She liked to have sliced pears and cognac for lunch. As her health began to fail, her stubbornness began to exceed her self-sufficiency, leading to multiple hospitalizations. One time, despite making sure she had a post-discharge outpatient appointment, a fresh pile of prescriptions and home visiting nurse services, her illness flared and she had to come back to hospital.

She was not only my patient, but she represented one of Medicares dreaded readmission statistics.

By now, DMCB readers know that CMS, buoyed by its value-based purchasing program, has targeted readmissions by reducing payment levels to hospitals that fall outside the expected norm. Threatened by the loss of income, it’s assumed that hospitals will respond by developing higher quality discharge planning and care programs that keep patients from having to come back.

An important part of reducing readmissions is to identify those patients that are at greatest risk. That would help on two levels:

1) if a hospital had more than its fair share of patients at risk, it could argue that an increased number of readmissions is the result of a sicker patient population and not quality of care. As a result, the hospital could be held "harmless;

2) hospitals would be able to focus extra care resources on those patients who are spotted early as likely to come back, thereby reducing the readmission rate.

In other words, patients like the lady from Hungary would not necessarily lead to a cut in hospital payment rates and, for example, she could be proactively given extra care, such as a doctor appointment within 48 hours, a week’s supply of free medications and twice a day home nurse visits.

Which is why this just published JAMA article "Risk Prediction Models for Hospital Readmission" by Devan Kansagara, Honora Englander, Amanda Salanitro David Kagen, Cecelia Theobald, Michele Freeman and Sunil Kripalani is important.  The authors set out to see what the evidence-based published scientific literature had to say about predicting readmissions.   They filtered thousands of erences, reviewed 286 publications found 30 rigorous studies that described 26 models. 

To the DMCBs delight, the authors applied a “c statistic” to the 30 publications to assess a wide variety of retrospective and concurrent prediction methodologies using a host of data inputs such as age, gender and past diagnoses. According to this article, the c (or "concordance") statistic measures how well a test can predict the presence or absence of a "condition" which, in this case, was being readmitted to the hospital.  One way to think of this is the likelihood of correctly identifying a condition when there are two people, one with it and one without it.  If the likelihood is 50%, thats no better than random guessing.  If its 100%, thats perfect.  By the way,if this sounds a lot like the area under the receiver operator curve, youre right.

And what did the all-seeing "c statistic" say?  All of the published models had disappointingly similar levels of performance that ranged between the extremes of .52 to .83 with most in the .50 to .7 range. Whats more, only one study examined the most important question of all: is it possible to find patients with preventable readmissions?

What does the DMCB think?

1) This may be another area where national health policy has gotten out in front of the scientific evidence.  If we cant reliably assess or predict readmissions with sufficient accuracy, there is a distinct likelihood that statistical variation, not quality of care, will lead to some hospitals being victimized by CMS with lower payment rates. Whats more, if hospitals cant tell which patients are likely to come back, how are they supposed to target their expensive care management programs at those who are most likely to benefit?

2) There are undoubtedly some proprietary predictive models that havent been reported in the literature that claim to have higher levels of accuracy.  Yet, without the scrutiny of successful peer-reviewed publication, itd be difficult to believe that theyre really any better than the mainstream published range of .5 to .7.  The next time the DMCB runs into one of these outfits, its going to ask about the "c statistic" and if they havent published their results, why not.

3) Last but not least, while the hospital payment rates are being held hostage by CMS, its the doctors that are making the call on readmissions based on the best interest of their patient.  The c statistic suggests that that will be the most important determinant in the readmission rate.

Investigators who studied a group of recreational marathon runners have established that strenuous exercise such as running a marathon can damage the heart muscle. Although they found the effect is temporary and reversible, they warn that these effects are more widespread in less fit distance runners and that recreational distance runners should prepare properly before marathons. Their findings are published in the October issue of the Canadian Journal of Cardiology.

Previous reports have established that a significant percentage of sports competitors show signs of heart muscle injury and cardiac abnormalities after prolonged exercise. In a new study designed to evaluate what kind of stress running a marathon puts on the heart, and whether this might cause permanent damage, investigators evaluated 20 recreational distance runners aged between 18 and 60 who were scheduled to take part in the Quebec City Marathon and who had no known cardiovascular disease or drug treatment. The participants were all amateur runners. Those who had run another marathon less than two months before recruitment or during the study period were excluded.

The runners were extensively observed and tested six to eight weeks before the marathon and on the day itself. They were tested again within 48 hours after completing the marathon, including a second MRI study and final blood sampling. This timeframe guaranteed adequate rehydration (assessed according to hemoglobin level) and a return to baseline hemodynamic state (assessed according to heart rate and blood pressure) after the race, but was short enough to observe any significant myocardial changes before recovery. All runners with decreased left ventricular ejection fraction (LVEF), a measure of cardiac pumping efficiency, after the race compared with baseline underwent a third MRI study after three months of rest to check whether it had reversed.

Investigators noted that the race induced a decrease in left and right ventricular function in half of the amateur distance runners. When a lot of the heart was affected, the heart also showed swelling and reduced blood flow. "We first established that marathon related segmental function decrease – observed in more than half of all segments – is associated with a decrease in resting perfusion and increase in myocardial edema," observes senior author Eric Larose, DVM, MD, FRCPC, FAHA, of the Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Canada. "We also found that heart muscle changes were more common and widespread in runners with lower fitness and less training. Finally, we observed that these changes were transient," he continues.

The investigators do not believe these temporary changes are a cause for concern. "Segmental function decrease is associated with poor prognosis in the presence of CAD or cardiomyopathy. Segmental dysfunction also indicates a poor prognosis in adults without cardiovascular disease. Although we dont know whether such changes mean that recreational runners are at risk, the attendant edema, and reduced perfusion suggest transient injury," says Larose.

"The changes are more widespread among those with lower fitness levels and less training," observes Larose, who is professor of medicine at Université Laval and a cardiologist and clinical researcher at IUCPQ. "Although no permanent injury was observed in this group of runners, the findings suggest that there may be a minimum fitness level needed beyond which the heart can bounce back from the strain of training and running a long race. Furthermore, these results emphasize the need for proper preparation before recreational distance runners engage in a marathon race," he concludes.

Applying the brake in the name of patient care?

The Disease Management Care Blog poses a simple question: knowing that, despite the best of care, things can occasionally go wrong following surgery (for example, inpatient MRSA infections can still happen and readmission rates will never go to zero), do you really want your doctor or hospital to not be paid for the additional care that you may require?

Go to the websites of organizations like Robert Wood Johnson or The Brookings Institution and youll find impressive expert papers that extol a variety of "payment orms" designed to "align incentives," "reduce waste" and "achieve cost savings."  Dig into these orms and readers will encounter admiration for payment approaches like "prospective payment," case-based," "bundling," and "shared savings."  Youll also find a deep disdain for "fee-for-service" (FFS). 

Prospective good, FFS bad, right? 

"Not always," replies the DMCB. It depends on your point of view. Like, if youre a patient.

The DMCB explains.

The DMCB learned long ago to simplistically think of provider payments in terms of "gas" and "brake" pedals.  FFS applies gas and accelerates provider services; thats because each time a "service" is provided it subsequently generates a "fee." 

In contrast to FFS, case payment, bundling and capitation apply the brakes, because providers receive the payments up-front. Since the money is in hand, providers have an economic incentive to preserve it and withhold services.  The DMCB thinks of "shared savings" in terms of brakes because the up-front payment is essentially held in escrow until the savings (versus a targeted level of utilization) are achieved.

The simplest example of how this can be applied is to hospitalization.  If hospitals are paid for each day that the patient is in a hospital, thats FFS (otherwise known in the industry as "per diem"). 

Instead of per diems, most hospitals are paid with a different payment mechanism based on "diagnosis related groups" (DRGs). Every time a patient is admitted, that generates a payment (similar to FFS).  That payment, however, is not pegged to the number of days the patient stays in the hospital. Instead, the payment is bundled to pay for the entire hospitalization.  Thats why hospitals are always willing to admit patients (the gas) and then in a hurry to discharge them (the brakes).

Under the payment orms championed by Robert Wood Johnson or The Brookings Institution, the inpatient payment bundling would be expanded to pay for the entire case after discharge from the hospital.  Under this system, if the case had to be readmitted, the hospital and providers are SOL.  After all, why should they be rewarded for shoddy care?

Unless, of course, youre the patient.  The DMCB worries that a one-size-fits all approach to payment policy could have unintended consequences. Patients battling unanticipated outcomes would likely per that their providers be incented to give additional care.  They want to be back in the hospital.

The payment policy may be good from the point of view of health orm, but it can be bad for patient care. 

The DMCB asks if we are on the verge of another round of unintended health care consequences.

Well know soon enough when anecdotes of patients being inappropriately denied readmission begin to appear.

Drinking a couple of glasses of wine each day has generally been considered a good way to promote cardiovascular and brain health. But a new Rutgers University study indicates that there is a fine line between moderate and binge drinking -- a risky behavior that can decrease the making of adult brain cells by as much as 40 percent.

In a study posted online and scheduled to be published in the journal Neuroscience on November 8, lead author Megan Anderson, a graduate student working with Tracey J. Shors, Professor II in Behavioral and Systems Neuroscience in the Department of Psychology, reported that moderate to binge drinking -- drinking less during the week and more on the weekends -- significantly reduces the structural integrity of the adult brain.

"Moderate drinking can become binge drinking without the person realizing it," said Anderson."In the short term there may not be any noticeable motor skills or overall functioning problems, but in the long term this type of behavior could have an adverse effect on learning and memory."

Shors and Anderson worked with postdoctoral fellow Miriam Nokia from the University of Jyvaskyla in Finland to model moderate to heavy drinking in humans using rodents that reached a blood alcohol level of 0.08 percent -- the legal driving limit in the United States and many other countries -- and found that brain cell production was affected negatively.

The researchers discovered that at this level of intoxication in rats -- comparable to about 3-4 drinks for women and five drinks for men -- the number of nerve cells in the hippocampus of the brain were reduced by nearly 40 percent compared to those in the abstinent group of rodents. The hippocampus is a part of the brain where the new neurons are made and is also known to be necessary for some types of new learning.

This level of alcohol intake was not enough to impair the motor skills of either male or female rats or prevent them from associative learning in the short-term. Still, Anderson said, th

is substantial decrease in brain cell numbers over time could have profound effects on the structural plasticity of the adult brain because these new cells communicate with other neurons to regulate brain health.

"If this area of your brain was affected every day over many months and years, eventually you might not be able to learn how to get somewhere new or to learn something new about your life," said Anderson, a graduate fellow in the Department of Neuroscience and Cell Biology. "Its something that you might not even be aware is occurring."

According to the National Institute of Alcohol Abuse and Alcoholism, men who drink 14 drinks a week and women who drink seven are considered at-risk drinkers. Although college students commonly binge drink, according to the institute, 70 percent of binge drinking episodes involved adults age 26 and older.

"This research indicates that social or daily drinking may be more harmful to brain health than what is now believed by the general public," she said.