Health for life

Study shows clear benefits of a healthy diet, exercise, maintaining normal weight and not smoking

A large, multi-center study led by Johns Hopkins researchers has found a significant link between lifestyle factors and heart health, adding even more evidence in support of regular exercise, eating a Mediterranean-style diet, keeping a normal weight and, most importantly, not smoking.

The researchers found that adopting those four lifestyle behaviors protected against coronary heart disease as well as the early buildup of calcium deposits in heart arteries, and reduced the chance of death from all causes by 80 percent over an eight-year period. Results of the study, "Low-Risk Lifestyle, Coronary Calcium, Cardiovascular Events, and Mortality: Results from the Multi-Ethnic Study of Atherosclerosis," are described in an online article posted June 3, 2013 by the American Journal of Epidemiology.

"To our knowledge, this is the first study to find a protective association between low-risk lifestyle factors and early signs of vascular disease, coronary heart disease and death, in a single longitudinal evaluation," says Haitham Ahmed, M.D., M.P.H., the lead author who is an internal medicine resident with the Ciccarone Center for the Prevention of Heart Disease at Johns Hopkins.

"We evaluated data on more than 6,200 men and women, age 44-84, from white, African-American, Hispanic and Chinese backgrounds. All were followed for an average of 7.6 years. Those who adopted all four healthy behaviors had an 80 percent lower death rate over that time period compared to participants with none of the healthy behaviors," says Ahmed.

Study participants all took part in the ongoing Multi-Ethnic Study of Atherosclerosis (MESA), a prospective examination of the risk factors, prevalence and prevention of cardiovascular disease. MESA participants were recruited from six academic medical centers and did not have a diagnosis of cardiovascular disease when they were enrolled.

All participants had coronary calcium screening using computed tomography (a CT scan) when they were first enrolled in the study to see if there were early signs of calcium deposits in their heart arteries that are known to contribute to heart attack risk. As the study progressed, the researchers also assessed whether the participants had a heart attack, sudden cardiac arrest, chest pain, angioplasty or died due to coronary heart disease or other causes.

The researchers developed a lifestyle score for each of the participants, ranging from 0 (least healthy) to 4 (healthiest), based on their diet, body mass index (BMI), amount of regular moderate-intensity physical activity and smoking status. Only 2 percent, or 129 participants, satisfied all four healthy lifestyle criteria.

"Of all the lifestyle factors, we found that smoking avoidance played the largest role in reducing the risk of coronary heart disease and mortality," says Roger Blumenthal, M.D., a cardiologist and professor of medicine at the Johns Hopkins University School of Medicine, director of the Ciccarone Center and senior author of the study. "In fact, smokers who adopted two or more of the healthy behaviors still had lower survival rates after 7.6 years than did nonsmokers who were sedentary and obese."

Blumenthal, who is also the president of the American Heart Associations Maryland affiliate, says the findings "bolster recent recommendations by the American Heart Association, which call for maintaining a diet rich in vegetables, fruits, nuts, whole grains and fish, keeping a BMI of less than 25, being physically active and not smoking."

The researchers emphasize that their study shows the importance of healthy lifestyle habits not just for reducing the risk of heart disease, but also for preventing mortality from all causes.

"While there are risk factors that people cant control, such as their family history and age," says Ahmed, "these lifestyle measures are things that people can change and consequently make a big difference in their health. Thats why we think this is so important."

The regulators go to work....

Fed up by pharmceutical, biotech and medical device manufacturers vulgar use of "honoraria," "consulting fees" cozy "investment" relationships and other financial sweeteners to buy physician loyalty, Congress included the "Physician Payment Sunshine Act" as part of the Affordable Care Act.

The initial proposed set of regulations appeared in the Federal Register on December 19, 2011.  Comments were invited and CMS reponse i.e., the"Final Rule," has just been released.  It can be found here.  This sample of the mainsteam news media reporting indicates generally positive reviews.

Case closed? 

Not quite.  Thats why you read the Disease Management Care Blog.

As the DMCB understands it, the idea is to notify patients and the public about potential physician conflicts of interest, especially if they are recommending one treatment versus another. The financial relationship data from August through December of this year has to be reported to CMS by March 31, 2014. CMS will, in turn, post the information on the web in September of 2014.

While the DMCB agrees with the intent, it also took the time to scroll through the Final Rule and found some interesting information on page 226. 

CMS estimates the manufacturers will each need to hire a compliance officer and bookkeeping personnel.  Based on prevailing hourly salary rates (page 228) for approximately 1,150 companies, the total cost in year 1 of the Sunshine Program will be $193,037,104.  After some systems automation kicks in and start-up costs are eliminated, the cost will decrease to $144,777,828 "annually thereafter" (p. 229).  There will also be "infrastructure costs" to the tune of just over $12 million in year one and just over $1 million for each subsequent year.

The DMCB thinks thats worthy of some sticker shock, especially when were all agreeing that the health care system is already too expensive. Ultimately, it remains to be seen if patients will use the internet as advocate-consumers and blunt their physicians conflicts of interest.  Based on data like these (the impact on consumer behavior) and these (on hospitals) we dont know if patients will vote with their feet or if physicians bad behavior will lessen. 

It could work, but once again, finding out is going to cost American health care consumers hundreds of millions of dollars.

Stay tuned!

While the Disease Management Care Blog has had more than its share of doubts about the Affordable Care Act, it ultimately agreed that the "individual health insurance mandate" may be a necessary - if perilously unconstitutional - requirement.  Conventional wisdom says that unless everyone buys into the system, healthy persons will forgo the expense of insurance. That means only the sick will pay for insurance that ultimately cannot cover the collective cost of their illness. That will lead to a rapidly escalating prices, otherwise known as a "death spiral."

And thats why, now that the mandate has been taken up by the Supreme Court, Obamacares supporters fear that striking the mandate could unravel everything.

Which is why the DMCB found this "dont worry, be happy" analysis by Lewin Groups John Sheils and Randall Haught very interesting. They say Obamacare can still succeed without the mandate.

Based on complicated economic modeling using a mix of inputs, methods and assumptions, they found, in contrast to the widely quoted Congressional Budget Offices mix of inputs, methods and assumptions, that

1) many persons without health insurance would take advantage of the ACAs generous premium subsidies, and

2) an open enrollment window limited to one month a year would blunt the impact of persons "gaming" health insurance by only enrolling when theyre sick. 

While insurance would not be universal, the Lewin authors estimate that between 21 and 24 million Americans who were previously uninsured would become insured.  While premiums could increase by 12.6%, the premium subsidies would help put the word "affordable" in the ACA. 

To further buttress their argument, they point out that in 1993 New York State required its health insurers to accept all applicants regardless of health status.  Despite many dire predictions, there was no spiral and no documented loss of coverage.

What can the DMCB conclude after reading this?  Its easy: no one really knows what is going to happen in 2014 with or without the mandate. 

It looks like there is only way to find out.

"I do what I have to do, so that I can do what I want to do."

Life is not a simple exercise for me. While it just seems to come naturally to some, its just not so, for me. Having a positive state of mind is a continuous choice I have to make, and it is a continuous decision to stop self destructive thoughts in their tracks, and choose to believe the positive mantras that might seem cheesy, or ludicrous to me.

I dont really know why I am like this... and I could psycho-analyze it to death, but Im not sure how helpful that would be. Im pretty sure that some of the hurdles Ive faced (especially in my childhood) have helped me develop a somewhat dim view of the world. Things like childhood obesity, a grim personal appearance (thanks to undiagnosed PCOS), constant exhaustion and mood swings (thanks to undiagnosed Hypothyroidism), uninvested parents and a lack of personal development, etc.

I felt so alone most of my childhood, and so inadequate, that I spent it trying to pursue instant gratification. In my teen years, eating and TV became my sole companions and comforts, while my family was mostly off in their own world. Its still like this today, you know. I dont get social phone calls from family, nor so much as a card on a birthday, or a holiday... and quite frankly, I dont remember the last time I got anything at all in the mail, from them, or even a social phone call. You can see why a child would try to drown itself with love in the form of whatever one came across -- be it food, or TV, or what have you. Pick your poison.

When one is swimming in loneliness, illness induced mood swings, life induced anxiety, and self loathing... it is extremely hard to have self control of any kind. Whether it be with your rigerator, or with your checkbook, or whatever brings you immediate release. Whats worse is that when you dont have deadlines or commitments of any kind, you can put off desperately needed changes, for as long as possible and tell yourself that tomorrow, you will start; but when someone tells you that you have NO choice, that its the hour zero and you need to buckle down, or else... your life turns into a shiny, red button. Do not press the shiny red button, they say... You must guard yourself to never press the shiny red button. Everyones anticipating, and policing you. Everyone knows.

History Eraser Button

This is what life is like for many of my fellow type 2 diabetics, right now... A shiny red button. Its easy to understand how one gets to that kind of place, and ever soooo hard to help someone get out of that place, see the light, and understand that although life may be smacking us with its behind (like the announcer guy on this Ren and Stimpy video), that we have a choice. We indeed have a choice, and our lives dont automatically go down the drain... Our destinies are not planned for us. We MAKE our own futures; we write them today.

While the dysfunction of the "fiscal cliff" negotiation crawls along like a slow-motion Titanic movie dubbed in some obscure foreign language, vaguely interested readers may want to check out this PIMCO analysis. PIMCO is a leading global bond trading firm and when its sages talk, people listen.

Bill Gross, PIMCOs CIO, offers a remarkably readable Beatle-esque analysis of the macroeconomic "headwinds" that are bedeviling the U.S. economy. While Mr. Gross observations have important implications for the DMCB readers living on Main Street, they are particularly scary for the insurers on Wall Street (as well as their cousins on Not-For-Profit street).  Thats because insurers rely on investments to supplement income. Sputtering bond returns in the insurers portfolios could ultimately translate into even higher premium costs for their beneficiaries.

According to Mr. Gross:

1. Developed countries like the U.S are reducing their considerable debt and, like it or not, austerity will be part of the solution. In the meantime, there are compelling data that show that when a countrys debt exceeds 90% of gross domestic product, it slows economic growth. The U.S. is now at 100%, which means the likelihood of using tax revenues to fix the debt will be blunted by years of a lackluster economy. Even if President Obama gets his way with the House Republicans, fixing the debt problem will take many years.

2. The fall of the Iron Curtain and the entry of China to the global economy added billions of consumers to the world market.  That impact is now waning.

3. "Technological unemployment" means machines, robotics and software are cheaper than full-time-equivalents (FTEs) on an assembly line. Its possible that that will lead to a "new normal" unemployment equilibrium of 7%

4. Its the 20 to 55 year age group that grows families, buys houses and grows companies. The U.S. population is aging, which means there will be greater savings and less consumption leading to lower economic growth.

The good news is that hydrocarbon energy will be getting cheaper, housing may finally be turning the corner and who knows when the "Next Big Thing" (think handhelds) will hit.

Depressing stuff, eh? The DMCB isnt the only one thats dismayed at all the doom and gloom.  Rather than turn to the Beatles for inspiration, the DMCB wonders if the current situation is being best summed up by the still-rockin Rolling Stones. 




(By the way, the DMCB declines to link the actual music video. Its a horrid, misogynistic and antifeminist display of modern vulgarity that unnecessarily detracts from 1) a nifty chord progression and 2) the miracle that Keith Richards is still alive. Look no further for another window into the war on women.)

What happens when a tricorders batteries go dead

Heads-up displays in cars. Apps that can remotely open garage doors. Cable TV embedded in bathroom mirrors. The techie Disease Management Care Blog lusts after all of them and understands when advances like these cross from being mere conveniences to vital necessities.  While it waits for an unenthusiastic DMCB spouse to catch up, it looks forward to the arrival of other lifestyle enhancements like internet-enabled goggles, ear hair curing nanotechnolgy and Star Trek styled tricorders, perably with lots of blinka blinka diodes.      
      
Good thing that the X-Prize Foundation agrees on the latter, though without the blinka blinka.  According to this web page, it will award $10 million to any outfit that can cram "artificial intelligence, wireless sensing, imaging diagnostics, lab-on-a-chip and molecular biology" in a single home-based "tool" that is safe, weighs no more than five pounds and has internet connectivity. Competitors for this "Qualcomm Tricorder X PRIZE" are expected to make trade-offs between audio, visual displays, imaging technology, portability, bandwidth-use, power requirements, and sensors.

The Foundation antcipates that the device will enable consumers to "incoporate health knowledge and decision-making into their daily lives." The ultimate goal is to allow end-user "direct care" for "15 diseases" that trumps "science" over the "art of medicine," bypasses the monopolistic "bottleneck" created by the traditional doctor, clinic or hospital and places diagnosis and measurement under the control of the patient.

Gosh. It wasnt too long ago that credentialled physicians totally owned the health care space. Thanks to their brute force learning, a rigorous apprenticeship and 10,000 hours worth of experiential heuristics, patient-consumers could be be highly confident of getting a correct diagnosis and treatment.

While thats still true, that space is changing: networked e-Patient communities can harness the wisdom of crowds, IBMs "Watson" can strip-mine the worlds medical knowledge to answer a single question for anyone anytime, computers are aiding the interpretation of imaging studies, non-physician clinicans can monitor as well as coach personalized self-care for thousands of consumers from afar and elite surgeons can remotely project their expertise worldwide with stereotaxic robotics.  While skeptics may doubt the short-term prognosis for this particular X-PRIZE, there can be no doubt that the concept is ultimately sound.

Big changes are in store for medical practice.

The impact will be greatest for care for persons with chronic conditions.  This not only represents another threat to the viability of primary care but undercuts a major value proposition for ACOs.

Providers and health insurers that adapt will survive; those that adopt or co-opt will thrive.
 
Depite the vision of a fully self-sufficent health care consumer, the DMCB doubts physicians will go extinct. They will  adopt and co-opt because high tech plus high touch trumps high tech with low touch.  The sum of a tricorder plus a provider will be far more than the sum of its parts. 

Even the Enterprise needed a Dr. McCoy on board.

If you lead a horse to water, will it drink?  If it drinks, does that cause it to be a horse?  Who says being a horse is good? Do horses cure thirst?

Those were the silly Disease Management Care Blog questions prompted by a paper trail of articles and letters about the Patient Centered Medical Home (PCMH) that recently appeared in the Archives of Internal Medicine.  That being said, the series was a telling example of the assumptions underlying PCMH research and the lack of of buy-in from community-based physicians

To wit:

Primary Care Is Good: The first article was this October 2011 published research that retrospectively mined the Surveillance, Epidemiology and End-Result (SEER)-Medicare-linked database.  The authors found that for Medicare fee-for-service beneficiaries aged 67 to 85 years, more colorectal cancer screening, earlier cancer diagnosis and lower cancer mortality were all associated with an increased number of past primary care visits. While the study could not rule out the possibility that other factors were involved in the association between primary care and cancer screening (Katy Courics campaign, for example, could have prompted patients to see their PCPs), this study indicated that that access to primary care is a good thing.

If Primary Care Is Good, So Is The Patient Centered Medical Home: The second article was this "Decisive Moment" editorial appearing in the same issue of the Archives, authored by Boston academics Asaf Bitton and Joseph Frolkis.  They reviewed the SEER article, which never even mentioned the PCMH.  That didnt stop the editorialists from bringing it up in an opening paragraph as an "innovative model of care delivery." The article then went on to describe the virtues of generic primary care and the need to increase PCPs in the physician workforce. It then saluted the PCMH as "offer[ing] promising early results [with] a pathway to weld some of the best incremental practice change initiatives onto a chassis of sustainable, term based care."

Who Says the PCMH Is So Good? The third was this Editors Correspondence letter that appeared six months later in the March 26 2012 issue of the Archives. Arguing that many PCPs already provide medical home-like services, private practitioner Edward Volpintesta of Connecticut didnt share Drs. Bitton and Frolkis "optimism" over the PCMH  He observed that 100% of any additional fees generated by the PCMH would have to go toward funding its excess costs and never go toward rewarding the physician.

We Say Its Good: Drs Bitton and Frolkis disagreed in a Editors Correspondence reply. Depending on your definition of a medical home, they argued that most PCPs do not offer that kind of care and that their research shows that the added income from the PCMH can be considerable. 

While the article-editorial-correspondence virtual paper trail is a classic exercise in academic repartee filled with the usual medical jargon, tangential policy nostrums, assumptions and quoting the literature out of context, the real lesson here is that there is some real skepticism about the PCMH among otherwise seasoned primary care physicians. While the mainstream peer-reviewed medical journals have articles that are extrapolating the virtues of primary care onto the PCMH, docs like Dr. Volpintesta arent necessarily buying it.

To the DMCB, this spells significant challenges for the dissemination of the medical home outside the academic community and their early adopter allies. 

Some mainstream doctors remain unconvinced.

Small business points at its competitor

It wasnt until the Disease Management Care Blog had read this Jan. 30 Wall Street Journal opinion piece that it realized that its "nano" corporate" status was packed with such futuristic potential. According to the editorialist, American companies should follow the DMCBs lead and be "protean" by dropping old fashioned W-2 employees and substituting 1099 contract relationships.  That way, everyone - including a single person "nano" - can enjoy the upsides of being a corporation and stay below Obamacares 50 employee pay-or-play $2000 penalty threshold.

Since the DMCB formed its own corporation more than 5 years ago, it has certainly participated in "protean" business relationships. Once things get underway, the DMCB often discovers that of the many prominent organizations that it does business with really consist of a small core office populated by a few owner-founders, a single administrative aide and one or two payroll folks who oversee the outsourcing of everything else.  While the term "protean" is certainly novel, the DMCB thinks distributed, adaptable and organic business networks have been around for years.

But the WSJ editorial opens a window into an underappreciated consequence of Obamacare and the underlying assumptions of the central planners who run Washington DC.  The DMCB doesnt necessarily think its bad, but it sure is interesting.

Read on.

While the Affordable Care Act (ACA) was intended to link employment and health insurance, what it has really done is handed many small nimble interlocked businesses another leg-up against their large traditional mainframe competitors. For example, one colleague pointed out to the DMCB that "new" pharma companies are really marketing departments that outsource manufacturing that, in turn, outsources supply management that outsources I.T. that outsources its cloud services. Its the only way they can compete. 

The new economics of health insurance will only accelerate similar trends in other manufacturing and service sectors of the economy.  Toss in the ability of people and capital to move and work across borders and the picture becomes even more dynamic. And in the meantime, Washington DC continues to implement the ACA with a legacy of large companies buying comprehensive health insurance for its employees.

Little did anyone anticipate that the ACA would hamper the success of American big business.

Image from Wikipedia

While the Governors Mansion in Pennsylvania is currently under the control of the Republicans, the Disease Management Care Blog knows the states Insurance Department is relatively apolitical. Thats why this September statement by Pennsylvania Commissioner Consedine before the U.S. House Ways and Means Subcommittee on Health is quite telling. 

In it, Mr. Consedine describes how the Keystone state is encountering difficulties implementing an health insurance exchange. As DMCB readers will recall, exchanges are a key feature of the Affordable Care Act, because theyll provide an online market that will enable individuals to obtain coverage.

According to Mr Consedine, CMS is failing to support a good law with the many regulatory details that turn a vague idea into a functioning reality. These failings include:

1. "Interim," not "final" rules on eligibility, tax credit calculations, cost sharing and the role of brokers

2. Little formal guidance on the determination of the essential health benefit.

3. Delays in issuance of regulations on how states and Uncle Sam will split or mutually indemnify the myriad costs of the exchange and the Federal Data Hub.

4. Delays in the issuance of regulations on how states can exit a federally run exchange to set up one of their own.

5. Lack of clarification of CMS impact on insurance markets operating outside the exchanges.

6. Little understanding of whos in charge of consumer protection statutes.

7. Confusion over reconciliation of multiple states insurance laws and regulations in multi-state exchanges.

8. No guidance on how to roll long-extablished and well functioning state-subsidized insurance programs into the exchanges.

9. Concern that funding of the information technology could be clawed back if Medicaid eligibility does not meet CMS criteria.

10. Little guidance on whether exchanges will need to provide consumers with a list of providers who are accepting new patients.

The concerns are also damning in the context of the the normal tug of war between the states and Washington DC. Thats because in his testimony, Mr. Consedine states he wrote to HHS weeks ago and has not received a reply.  While its not unusual for the Feds to stiff politically inconvenient inquiries, the Disease Management Care Blog is fearful that the reason why HHS seems unwilling to provide a timely reply is because it doesnt know the answers.

If Pennsylvanias experience is typical, that means the roll out of the exchanges could be significantly delayed.

You read it here first.

9/26/12 Update: Senator Hatch agrees with the DMCB