Health for life

Now that 2011 is gone, this is a good time for the Disease Management Care Blog pause and take stock. How is it doing?

It likes to think of itself as a unique ongoing journal club on the organization, delivery and financing of health care.  If the DMCB was soup, thered be three ingredients:

1) reliance, whenever possible, on peer-reviewed and published evidence,

2) a physicians "real world" experience and

3) a ready dash of skeptical humor.

The DMCB must be doing something right.  Despite a narrow mix of medical science, economics, effectiveness and policy, the DMCB has attracted a relatively large and elite readership.  If youre reading this, that means you. 

Sophistication

When it looks at the ISPs of its many return visitors, the DMCB sees dozens of academic institutions, big and small name news media outlets, publishing houses, trade associations, information technology businesses, Congress, CMS, the White House, state government, foundations, commercial insurers, hospitals, health care consulting organizations and population management service providers. Many are household names.

It doesnt stop there. The DMCB has been contacted by and gotten to know folks from all levels in the health care industry.  Based on those conversations, it knows this a smart group.  The author of this blog is a better person for it.

The DMCB knows each regular visitor, twitter follower and Google subscriber has been earned one person at a time. It knows its elite readers are knowledgeable, active or interested in health policy, population health management, the patient centered medical home or primary care. These are not casual readers.

And you have a lot of company:

According to Google Analytics mix of ISP addresses and cookies, DMCB Ver. 2011 had 29,000 unique visitors with 42,000 visits. A third were repeat (defined as more than one) visits.  While there is no definition of a "regular" reader, the number of visitors with more than 50 DMCB "hits" in 2011 numbered 5153. There were 786 visitors with more than 200 hits. 

The DMCB also has 416 Twitter followers.  According to TweetReach, the DMCB regularly reaches almost 1500 persons with its tweets.  Depending on re-Tweets, that number can exceed 7000. 

There are also 466 Google RSS subscribers. 

These 2011 numbers suggest there are thousands of persons that regularly read the DMCB.  Every individual visitor, follower and subscriber returned or opted-in based on the DMCB content and only the DMCB content. There is no marketing, emailing or use of any services to promote the DMCB. It doesnt have the advantage of a sponsoring institution or explicit link to a big-name business. And its readership continues to slowly grow.

The DMCB Web Juggernaut

The DMCB is regularly lected and linked in many prestigious web outlets, include HealthHombre, Health Affairs, KevinMD, Forbes, and many sister blogs. Its also appeared in the web sites of USAToday, Wall Street Journal, the Washington Post, Dartmouth Atlas, Business Week and the National Review. Its also been linked in the intranet web sites of many insurers, provider organizations, and health information tech companies.

And, by the way, according to YouTube, the DMCBs videos to date have had 33,486 views.

As testimony to its growing web presence, the DMCB is on the first page when the term "disease management" is Googled.  The DMCBs growing web traffic has ironically made its "Comments" section a target by spammers with links to its dubious medical web sites.  With only one unobtrusive Google "Ad" that generates pennies per click, it still got a check for $100 (prompting the derision of the DMCB spouse, but thats another post).  The DMCB has also been offered - and used - cash to provide link backs.  It also had one complaint lodged over copyright infringement over an image (the post has since been removed, with apologies).  Simply put, folks are paying attention.

Last but not least, the DMCB is proud of its four 2011 peer reviewed publications in Population Health Management, Self Care and the Journal of Comparative Effectiveness Research.

And a thank you....

... to the readers who have commented or emailed with feedback, comments and insights.  To the readers who use their precious time and keep coming back.

Yesterday, HOTUS and I hosted (HOTUSted?) our first official family holiday, if you don’t count that one time everyone came over and sang karaoke for Arbor Day. We were celebrating Easter, as well as the debut of our wedding dishes ™, a monumental event in any aspiring adult’s life. My sister and her lovely man friend brought us roses, which were promptly made into a cat appetizer (catpetizer?).

Alas, we were also commemorating the loss of our Old Lady Cart (2007-2011), a beloved and highly useful member of the family. If you’ve ever been to New York, you’ve seen an old lady cart, probably pushed around by a baby boy. (Just kidding.) The four-wheeled device is kind of like a shopping cart, but smaller, more colorful, and incredibly prone to catching a wheel on sidewalk cracks, which then causes it to pitch forward, which then causes you to fall into it (shins first), which then leaves you with a bruise that lasts longer than the Roosevelt presidency. (Franklin Delano, not Theodore No Middle Name).

Our particular Old Lady Cart bit the dust on Saturday, the victim of overloading after a trip to CostCo. What began as, “I’m just getting a hunk of brie for my parents,” turned into, “Why WOULDN’T we want 90 ounces of Palmolive?” The right front wheel snapped 60 blocks north of my apartment, in the rain, after a nasty bump. It wasn’t pretty. And neither was I, at the end of the journey. Badness.

(Also, if the nice man who helped me lug the disabled cart up three flights of subway stairs happens to read this blog – thank you. And I’m sorry I almost dropped it all those times.)

Anyway, back to Easter. We feasted on many delectable hors d’oeuvres, drank much Gruner Veltliner, and dug into a homemade pie from my Ma and Pa, the finest purveyors of homemade pie in three states (Alaska, South Carolina, and Wyoming). But the centerpiece was Dave Lieberman’s Braised Hoisin Beer Short Ribs with Creamy Mashed Yukons and Sesame Snow Peas. It’s neither cheap nor healthy, but sweet Bea Arthur, was it ever good.

Well, I take some of that back. That last part – the Sesame Snow Peas – fall quite nicely into the parameters of this here blog. Due to a mix-up at the grocery story (meaning: I got mixed up), we used snap peas instead of snow peas. No big whoop. Thing still came out dang fine. Crisp, tender, and just the right counter for extra-heavy potatoes and beef.

If you should make it yourself, feel free to reduce the oil, possibly by quite a lot. We used a nonstick skillet, and didn’t need anywhere near the prescribed amount (3 tablespoons). I think about half would do it.

And that’s it. Hope y’all had a happy (also hoppy) Easter, and that your old lady carts live forever. *sniffle*

~~~

If this looks quite tasty, you will most definitely enjoy:

• Broccoli Almond Stir Fry
• Sautéed Shrimp and Asparagus with Sesame Seeds
• Vegetable Lo Mein

~~~

Sesame Snap Peas
Serves 6
From Dave Lieberman.


1 lb. snap peas, washed and thoroughly dried
2 tablespoons vegetable oil
1 tablespoon dark sesame oil
1 teaspoon sesame seeds, toasted if perred

In a large skillet, heat oils over medium-high heat. Add peas and sauté about 2 or 3 minutes, until they are bright green. Remove to a bowl and sprinkle with sesame seeds.

Approximate Calories, Fat, Fiber, Protein, and Price Per Serving
99 calories, 7.7 g fat, 2 g fiber, 2.2 g protein, $0.46

NOTE: Honestly, you could probably cut the oil in half and still have a really nice dish here. Give it a shot.

Calculations
1 lb. snap peas, washed and thoroughly dried: 191 calories, 0.9 g fat, 11.8 g fiber, 12.7 g protein, $1.99
2 tablespoons vegetable oil: 265 calories, 30 g fat, 0 g fiber, 0 g protein, $0.18
1 tablespoon dark sesame oil: 119 calories, 13.5 g fat, 0 g fiber, 0 g protein, $0.40
1 teaspoon sesame seeds, toasted if perred: 17 calories, 1.5 g fat, 0.4 g fiber, 0.5 g protein, $0.17
TOTALS: 592 calories, 45.9 g fat, 12.2 g fiber, 13.2 g protein, $2.74
PER SERVING (TOTALS/6): 99 calories, 7.7 g fat, 2 g fiber, 2.2 g protein, $0.46

Is it too late to still be wishing happy new years? Well, it’s my first column of 2011, so I hope no one will mind if, two weeks into January, I’m still talking about it.

From Flickrs apocs

Two weeks into January, you say? And how many broken resolutions?

I’m not a huge fan of New Year’s Resolutions. I think January 1 is an arbitrary start date that might not match up with actual good timing. Take the chestnut of a resolution to eat better and work out more – why not time this with the time of year that’s actually conducive to activity and healthy eating? In the depths of winter our bodies want to store fat, its cold and snowy outside and, at least in the Northern Hemisphere, vegetables are wan and flavorless. You want to lose weight? Talk to me in June.

Waah, but I need to be bikini-ready already by then! Who exactly is telling you you’re not bikini-ready now? That’s another problem with New Year’s Resolutions – the outside pressure. We’re told it’s the time to make commitments, and so we leap in, and then berate ourselves for falling short. But what else should we expect when the drive to change hasn’t come from within ourselves?

Also it’s an easy way for gyms to sell more memberships.

On the other hand, though, sometimes we need an arbitrary impetus for change. Something that says, Hey, evaluate! And change what needs changing! One of my good friends made a resolution two years ago to set aside at least one night every week as a free night – no plans, no commitments. (This friend works in the music industry, where nighttime commitments are rampant, and is a generally popular guy.) Not only did he keep this resolution but it so improved his life that now, years later, the free night is a solid institution.

Don’t make resolutions for resolutions’ sake. But if the swooping tide of reevaluation and reinvention that comes with the new year inspires you, go for it! Just make sure you’re excited and inspired about your plans, and that your goals are not unattainable. Impossible or awful goals – to drop 20 pounds in a month, switching from a McDonalds diet to strict raw foodism – are just a set-up for disappointment and self-flagellation down the line.

In the spirit of positive, attainable change – and the spirit of this column! – I’ve put together what I hope will be a helpful and inspiring list. These aren’t commandments or edicts, just steps you can choose to take. You can choose a couple of items on the list as goals for yourself, or just keep them in mind next time you hit the supermarket (or farmers market). Figure out what’s important to you, what you might want to change, and how you can reasonably reach those goals.

1. Rethink Your Meat.
One of the strongest environmental impacts you can make with your food choices is what meat you eat, and how much. Conventional industrial meat production is, in a word, not-so-good. It’s not-so-good for the environment, it’s not-so-good for workers, and it’s not-so-good for animals. (I don’t think there’s anything morally wrong with killing animals for meat; I do think it’s horrible to make animals live miserable lives of suffering leading up to the slaughter.) And yes, human beings evolved to eat meat. But not miserable chickens that live immobile in cages, pecking out their own feathers, eating nothing but cornmeal and animal byproducts.

From Flickrs stickeresq

Industrial meat also has a markedly different nutritional profile than wild or pastured meat – the balance between Omega-3s and -6s swings way towards the 6s, which is not what your body wants – and animals who eat real food, rather than food-like sludge, taste better, too! Pastured, humanely-raised meat is, yes, more expensive. As it should be! Don’t skimp here. Buy less meat, and choose to spend your money on higher-quality, tastier, more ethical stuff. Dairy and eggs (also from happy-animal farms!) and plant proteins are cheap, good for you, and delicious.

2. Process Food Yourself.
Think about what goes into processing a processed food. All of the ingredients must be collected; any additives, preservatives, flavorings, or nutritional enrichments must be either derived or created themselves. The food is processed – mixed, cooked, prepared – in a factory. The food is packaged – plastic is made, trees are turned into cardboard, paints are applied to the label. The food has to be tested – the recipe was devised in a lab, and nutritional information has to be determined for the label. Odds are the food is marketed – someone designed its package and a marketing campaign; time is bought for television commercials, ad space is purchased in magazines, coupons are sent to you in the mail. Then the food is packed and driven – possibly in a rigerated truck – to a warehouse, and then to your supermarket. Now think about how much of the dollars you spend on that processed food is going toward quality ingredients, and how much of your money is going to… everything else.

There is no question that for a little more time in the kitchen, you get so much more bang for your buck with unprocessed foods. And I mean your literal buck, but also your nutritional buck and whatever metaphorical bucks this is all costing Earth. Unprocessed foods are closer to what our bodies evolved to eat. They are more nutritious, and their nutrients – naturally-occurring rather than added later on – are in better forms for our bodies to absorb. Also, who knows what undiscovered chemicals and compounds are in kale that haven’t been discovered yet and distilled into vitamins?

Eat real food and your body will thank you. You’ll notice a difference in your wallet, too. Even something as simple as shredding your own cheese rather than buying a bag already done – it’s cheaper per ounce and you skip the weird powdery coating that stops shredded cheese from sticking – makes a difference on every count.

3. Cook
So what do you do without processed food, just a pile of raw ingredients in your kitchen? Cook! There’s no better way to control what you eat than to cook your food yourself. Don’t trust the folks at Lean Cuisine to do it for you. Not only will you save money by starting with raw ingredients, but you’ll have way more control over exactly what you put in your body. Do you feel best eating a high-fat, grain-free diet? (Lots of people do!) Then pour on the coconut oil and enjoy! Would you rather focus on fresh fruits and vegetables? Bust out the blender and skip the Jamba Juice smoothies. You can decide if your home is powered with wind energy – no promises for the restaurant down the street. And how much salt did they put in your soup? When restaurants serve us giant portions, we’re inclined to finish them. Take responsibility here by taking control. And then have the satisfaction of knowing that you can make your own food.

From Flickrs Nataliemaynor

4. Eat with the Seasons.
I love shopping at the farmers market, but it’s not for everyone – it takes time, can be crowded, and seasonal eating can be limiting. (I’ll sing the greenmarket’s praises in August, but let’s talk about the onions, apples, and potatoes we’ll be seeing all winter.) Luckily, this is not an all-or-nothing deal. You can eat seasonally with supermarket produce and still do good for your bank account, body, and tastebuds. Compare a January tomato with one in July – even at ShopRite there’s a huge difference. And that taste (and color!) is indicative of more nutrients, too. If there’s no local food this time of year for you, consider just eating food from within your country, or your own hemisphere. Food’s cheaper and tastier in its proper season, and when it comes from closer by as well.

5. Enjoy!
Its frightfully easy to get so caught up in worrying if our food is healthy, cheap, and good for the planet that we forget what else food is supposed to be: delicious! A meal is more than calories and nutrients, more than a grocery store receipt. A meal is a sensory pleasure, and a social one as well. If your approach to cooking is pure drudgery, itll never last, and youll find yourself at the drive-through before you know it.

Figure out how to incorporate what makes you happy into your healthy eating plan. Once in a while, round out your healthy protein and veggies with some Doritos. Give yourself permission to enjoy that occasional Chinese food delivery, or splurge on a delicious meal out. Buy an avocado even if its come from halfway around the world.

Dont beat yourself up for failing to meet some lofty goal. Recognize and celebrate the ways youre good to yourself – do you nourish yourself with healthy food, are you conscious of spending, do you take responsibility for how your choices impact the environment? Awesome. Now make sure youre enjoying yourself – and your food – as you go.

~~~

If you liked this piece, youll surely dig:

• Food Money Matters: Why Healthy Eating Doesnt Have to Be Expensive
• Spend Less, Eat Healthier: The Five Most Important Things You Can Do
• Vintage Cookbook Hoedown: The Quick Cook Book (1961)

If youre interested in learning more about the latest U.S. health care cost trends, everything you need to know is in this article in the January 2013 issue of Health Affairs.

Or you could rely on the Disease Management Care Blog to point out the articles 7 most important points.  Use them to impress your colleagues and stymie your foes:

1) The data only go up to 2011; well have to wait another year before well know about 2012.

2) 2011 health care spending, as a percent of gross domestic product, remained at 17.9%.  The overall economy was slow and that took its toll on the health care sector.

3) That comes out to $2.7 trillion or $8,680 in health care spending per person.

4) While the percent remained stable, the economy experienced modest growth in 2011. The health care sector, thanks to an overall growth rate of 3.9%, kept pace. Prices for services grew less than the demand for services.  As we grow older, demand is likely to grow.

5) Medicare and private insurance grew faster than the economy, which was offset by Medicaid cost cutting by the states.

6) If the past is any guide, when the U. S. economy rebounds, health care spending is likely to accelerate and resume its march toward becoming 20% of GDP.

7) The relative stabilization of 2011 health care costs is independent of the Affordable Care Act.  Many of its important provisions (such as the mandate) dont kick in until 2014.

In the beginning of 2011, the Disease Management Care Blog amazed, astounded and impressed itself with a series of health care system and industry predictions.  Unlike those lesser blogs that post predictions and conveniently neglect to report back to its readers, the DMCBs commitment to being transparently outcomes-based prompted it to pose the awkward questions that few in the blogsphere are brave enough to ask:  how did its prognostications perform? What accuracy did its augury attain? How did its foretelling function?
Here are the DMCB hunches and brutal self assessments:

1. CMS will delay the January 1 start date for the CMS Shared Savings Program.  The DMCB got that one right.  The usual bureaucratic inertia plus having to respond to the consternation over the initial proposed rule pushed the start date back to April 1.  By the way, this is only one of many missed Affordable Care Act deadlines, so this wasnt all that hard.

2. Despite its luster, adoption of social media in health care settings will not attain a tipping point:  The DMCB got that one right. It knew that front line administrators in clinics and hospitals dont see a financial return on investment for social media and remain notoriously paranoid over HIPAA.

3. Berwick will be confirmed as CMS Administrator.  The DMCB blew this one but should have known that too few U.S. Senators and their staffers regularly read Disease Management Care Blog.  With time, that should change.

4. Naive enthusiasm over the electronic health record and PCMH will bump into painful reality: The DMCB will call this one a draw because use of the EHR has been boosted by the CMS "meaningful use" bribes payments.  Without them, the EHR business case would have to be based solely on spotty quality and phantom claims of cost savings. The PCMH, still lacking any consistent and statistically significant proof that it reduces costs, is still very much alive because of its growing link to ACOs. Thats appropriate, because ACOs likewise lack any proof that they reduce costs.

5. Despite the advent of a new health care era courtesy of Mr. Obama and the ACA, health care costs will depressingly continue to go up.  Bingo says the DMCB.  According to this report on how things are looking for 2011, medical costs are expected to hit 9%.  Thats less than 2010 but still far outstripping the general rate of inflation and evidence that more and more of our GDP is being gobbled up by health care.

6. The population health management industry will continue to thrive:  The DMCB got this right too.  The Care Continuum Alliance is as big as ever and there has been no abandonment by commercial insurers of their commitment to patient coaching and support. 

7. The term "disease management" will use to die.  To the many experts and consultants the DMCB interacts with, purchasers and buyers know that a rose by any other name still smells as sweet.  Call it "care management" or "population health" or "disease management" and no one really seems to care. because they know "disease management" has matured.

8. The political stalemate will continue.  Talk about a no-brainer but even the DMCB underestimated Mr. Obamas reliance on his liberal progressive roots to the detriment of bipartisan compromise.  Yes, theres plenty of blame to share on both sides of the aisle and while it may not be the Presidents fault, the DMCB thinks hes still responsible.

9. Greater interconnectedness will make us more vulnerable and unpredictable "black swan" events will preoccupy Washington DC: while there were no unexpected health care events, who would have foreseen the Arab Spring, the near death of the Euro, the impact of the Tea Partiers and the downgrade of U.S. debt?

10 The DMCB will reach a critical mass - more on that in a future post but its 2011 annual report suggests the DMCB juggernaut is well on its way.

The CDC just released their State Map for Prevalence of Overweight and Obesity:



Stats:

• More than one-third of US adults (35.7%) are obese.
• Obesity-related conditions include heart disease, stroke, type 2 diabetes and certain types of cancer.
• The medical costs paid by third-party payers for people who are obese were $1,429 higher than those of normal weight.
• Non-Hispanic blacks have the highest age-adjusted rates of obesity (49.5%) compared with Mexican Americans (40.4%), all Hispanics (39.1%) and non-Hispanic whites (34.3%)
• No state had a prevalence of obesity less than 20%.
• The South had the highest prevalence of obesity (29.5%), followed by the Midwest (29.0%), the Northeast (25.3%) and the West (24.3%).

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