Health for life

ACOs and insurers discuss terms

The Disease Management Care Blog likes to think of itself as having achieved "critical mass." Now that its readership has climbed into the thousands (and Twitter is now well beyond 600), medical meeting organizers want to issue press credentials, medical journals are sending it embargoed previews and spammers are working particularly hard at getting maliciously-linked comments posted. The best upside for the DMCB, however, is its email correspondence with smart professionals who have insights that run contrary to the mainstreams confirmation bias.

Heres a gently edited email from one astute observer that the DMCB wanted to share:
 
While policymakers extoll the clinical integration virtues of ACOs and the PCMH, what goes unmentioned is that these vehicles often involve provider consolidation. While coordination of care and wasteful utilization might improve, does this mean that those entities could also amass considerable market leverage or become quasi-monopolies? Could that drive up costs?

I was at an specialty provider conference in early March where it was cited (in an admittedly unscientific member poll) that 25% of institutions surveyed had themselves been part of a consolidation or site of service change, mostly from community private practice to hospital-based setting. If physicians are not being employed outright, theyre entering into professional services agreements (PSAs).  Since this has to increase negotiating clout with insurers, the other locally competing providers are responding with an in-kind physician arms race.

Given this dynamic, what will happen when a system has a become a very efficient ACO and controls primary care with a locally dominant medical home network? Even if they fail to show any cost savings, will their ability to command favorable contracts be the key to economically surviving? Darwin would be proud of these long-beaked birds.

Are our federal and state governments prepared to reconcile the twin needs of integration and competition? I can’t help but think that regulators will be outmaneuvered by these increasingly powerful health care entities and that an unintended consequence of orm will be the increasing price points and the return of sticker-shock health care inflation.

Need an example of what is going on at the local level? Check out St. Lukes in Idaho and their ongoing battle with Trinity. St. Luke’s is a CMS designated ACO (on page 33) and is buying up assets left and right, employing physicians, and doing so in almost a direct anticompetitive way. I think that currently St. Lukes is doing a lot of forward thinking things, but if St. Luke prevails and Trinity does indeed go out of business as they state they will, it will leave a monopoly in that mostly rural state. When that happens, St. Lukes can set the price point.  Will they use that power to coordinate care or maximize revenue?

Believers in ACOs and the PCMH would do well to take a look at the Trinity perspective.

Vincent Scordo is the proprietor of Scordo.com, a fabulous blog about Italian American cooking. Check out his Pasta Challenge, which is more than sufficiently awesome.

As Ive said in the past, eating out/ordering in is a colossal waste of money, and beyond the occasional breakdown or special night out I tend not to reach for the Chinese take out menu or make reservations at our local restaurant. My other rationale for not eating out is that I simply will not get the same quality food at 95 percent of the restaurants in our immediate area (including New York City). Im not a trained Chef, but outside some extraordinary restaurants in New York, Ill take a simple meal prepared at home, with high quality ingredients, over a mediocre restaurant experience. Eating well at home is not rocket science, and moreover, you dont always need to purchase exotic ingredients to make tasty dishes. (The ingredients need to be high quality, but they shouldnt break the bank).

Here are 4 ingredients that can help you eat cheap and well for as long as our recession lasts:


From Flickrs Minimalist Photography


2. Tuna in Olive Oil
I always keep between 3-4 cans of Italian tuna in olive oil stocked in my kitchen. My ideal tuna sandwich consists of one can of tuna (do not discard the oil!) with salt and pepper on toasted whole wheat bread. You can also add some fresh parsley and a few slices of tomatoes if theyre in season. (Try it without the mayonnaise, I swear youll like it.)

3. Pasta and Rice
My pasta and rice arsenal includes: thin linguine, angel hair or capellini, linguine, rigatoni, penne rigate, pastine, soba noodles, arborio rice for risotto, Carolina rice, brown rice, jasmine rice, and whole wheat couscous. Having the aforementioned pasta and rice on hand at all times gives you limitless possibilities, including: linguine with olive oil, parsley, and garlic, baked rigatoni with tomato sauce, mozzarella, and Parmigiano-Reggiano, soba noodles stir fried with green peppers, chicken breast, and onion, brown rice with ginger, cilantro, and cracked black pepper, couscous with feta, red onion, cucumber, and olive oil, etc.

4. Whole Chicken
Buying a whole, free range, chicken is the equivalent to getting the deal of a lifetime. A whole chicken gets you two types of meat (dark and white) as well various parts which translate into various types of dishes. I purchase a whole, free range, chicken every other week and butcher the chicken according to my perences. If Im interested in making a whole roasted chicken, Ill simply leave the bird as is and make a rub mixture with lemon zest, salt and pepper, rosemary, and olive oil. If I have a little more time on my hands Ill butcher the bird into nine pieces and freeze the parts for various dishes throughout the week, including: braised chicken thighs with fresh mint, breaded and baked drumsticks and wings, thinly pounded chicken breast with shitake mushrooms and sherry wine, etc.

~~~

If you like this article, check out:

• The 10 Cheapest, Healthiest Foods Money Can Buy
• 10 Ways to Eat Less Meat
• Touch of Class: 10 Thrifty, Healthy Ingredients to Improve the Quality of Your Meals

Men who are overweight or obese when they are diagnosed with prostate cancer are more likely to die from the disease than men who are of healthy weight, according to a Kaiser Permanente study published today in the journal Obesity Research & Clinical Practice. In patients with more aggressive forms of prostate cancer, the researchers also found an even stronger correlation between obesity and mortality.

This study included 751 Kaiser Permanente patients with prostate cancer who underwent radical prostatectomy, an operation that includes removal of the prostate and surrounding tissue. The researchers explored the association between the patients body mass index and prostate cancer mortality, adjusted for tumor aggressiveness and other characteristics.

The researchers found men who died from prostate cancer were 50 percent more likely to be overweight or obese at diagnosis compared to men who did not die from the disease. Men with high Gleason scores, a rating of the aggressiveness of prostate cancer cells, had the highest association between BMI and death, specifically men with Gleason scores of 8 or higher. The Gleason score ranges from 2 to 10, with the highest number representing the greatest likelihood of tumor cells spreading.

"We found among patients undergoing surgical treatment for prostate cancer, weight at time of diagnosis is more strongly correlated with prostate cancer survival than many other factors researchers have studied in the past, including some prostate cancer treatments," said lead author Reina Haque, PhD, a researcher at Kaiser Permanente Southern Californias Department of Research & Evaluation in Pasadena, Calif. "Moving forward, we are hoping future studies will examine the effect of weight loss and other lifestyle modifications on prostate cancer mortality."

Additional studies are needed to determine which lifestyle modifications, such as diet or exercise, could prolong a prostate cancer patients life. Further investigation also is needed to determine if the findings of this study, which looked at men who had prostate cancer surgery, apply to men who received other treatments such as radiation or hormone therapy.

Although the connection between mens weight at prostate cancer diagnosis and likelihood of survival has been examined, many previous studies were limited by self-reported body weight data or it was unclear when the BMI data were obtained. So the link between obesity and prostate cancer mortality remains controversial. However, the methodology of this study was different because the researchers used BMI collected from medical records, instead of self-reported data. The researchers identified men who died of prostate cancer and compared their BMI at time of diagnosis to controls to determine if body weight is related prostate cancer death. The biological relationship between obesity and prostate cancer prognosis is still not understood, and is an active area of research.

Perhaps you bent the wrong way while lifting something heavy. Or youre dealing with a degenerative condition like arthritis. Whatever the cause, once you have low back pain, it can be hard to shake. About one in four Americans say theyve had a recent bout of low back pain. And almost everyone can expect to experience back pain at some point in their lives.

Chill it. Ice is best in the first 24 to 48 hours after an injury because it reduces inflammation, says E. Anne Reicherter, PT, DPT, PhD, associate professor of Physical Therapy at the University of Maryland School of Medicine. "Even though the warmth feels good because it helps cover up the pain and it does help relax the muscles, the heat actually inflames the inflammatory processes," she says. After 48 hours, you can switch to heat if you per. Whether you use heat or ice -- take it off after about 20 minutes to give your skin a rest.
Keep moving. "Our spines are like the rest of our body -- theyre meant to move," says Reicherter. Keep doing your daily activities. Make the beds, go to work, walk the dog. Once youre feeling better, regular aerobic exercises like swimming, bicycling, and walking can keep you -- and your back -- more mobile. Just dont overdo it. Theres no need to run a marathon when your back is sore.
Stay strong. Once your low back pain has receded, you can help avert future episodes of back pain by working the muscles that support your lower back, including the back extensor muscles. "They help you maintain the proper posture and alignment of your spine," Reicherter says. Having strong hip, pelvic, and abdominal muscles also gives you more back support. Avoid abdominal crunches, because they can actually put more strain on your back.
Stretch. Dont sit slumped in your desk chair all day. Get up every 20 minutes or so and stretch the other way. "Because most of us spend a lot of time bending forward in our jobs, its important to stand up and stretch backward throughout the day," Reicherter says. Dont forget to also stretch your legs. Some people find relief from their back pain by doing a regular stretching routine, like yoga.
Think ergonomically. Design your workspace so you dont have to hunch forward to see your computer monitor or reach way out for your mouse. Use a desk chair that supports your lower back and allows you to keep your feet planted firmly on the floor.
Watch your posture. Slumping makes it harder for your back to support your weight. Be especially caul of your posture when lifting heavy objects. Never bend over from the waist. Instead, bend and straighten from the knees.
Kick the habit. Smoking can increase your risk for osteoporosis of the spine and other bone problems. Osteoporosis can lead to compression fractures of the spine. One study found that smokers are about a third more likely to have low back pain compared with nonsmokers.
Watch your weight. Use diet and exercise to keep your weight within a healthy range for your height. Being overweight puts excess stress on your spine.
Try an over-the-counter pain reliever. Anti-inflammatory drugs such as ibuprofen (Advil, Motrin), naproxen (Aleve, Naproxyn), and aspirin can help reduce back pain and swelling. Acetaminophen (Tylenol) is another over-the-counter option for pain management. Be sure to check with your doctor or pharmacist about any interactions over-the-counter pain relievers may have with other medications you are taking. People with a history of certain medical conditions (such as ulcers, kidney disease, and liver disease) should avoid some medicines

Every Saturday, we post a piece from the CHG archives. This one comes from June 2009.

Though it might seem intuitive, determining a recipe’s cost and nutritional value can get pretty complicated, pretty quickly. Ingredient prices can add up before you know it, and a combination of fats, meats, and cheeses will take a toll on your calorie count without even registering on your radar. And sometimes, even the most harmless-looking dishes, like All Recipes’ Greek Pasta Salad with Shrimp, Tomatoes, Zucchini, Peppers, and Feta, can run you $2 and 42 grams of fat per serving.

So, how can you tell if a dish is good for you, just by looking at it? How can you avoid the pitfalls of secretly fatty and financially unsound food? How can you err on the side of caution when it comes to cooking?

Look no further, sweet readers. We’ve got you covered. If your recipe source doesn’t give a nutritional breakdown and you’re unsure of the potential cost, these tips will help you decide whether the money/waistline expenditures are worth the trouble. If you have any suggestions, be sure to include them in the comment section.

DO choose your source wisely. Man, I love Paula Deen. Her food looks stupendous and she’s endlessly entertaining – like Yo Gabba Gabba if it was a charmingly cackley southern woman. That said, her concoctions might not be the best choice for those concerned about weight. If you know you’re looking for healthier recipes, sources like Everyday Food, Cooking Light, and Eating Well will generally be more helpful than the Neelys or the Two Fat Ladies. Likewise, reproducing a dish from Grant Achatz’s Alinea cookbook will probably run you a pretty penny compared to the average Cook’s Illustrated meal. Starting your search with a website, cookbook, or blog aimed at your requirements is half the battle.

DO check the number of servings. Once you have a recipe in mind, before you do anything else, check how many people it’s supposed to sate. Fourteen ounces of flank steak does little damage split among eight eaters, but can destroy diets if it’s meant only for two.

DO read the ingredient list caully. After the serving size, the ingredients are the most important determinant of the cost and nutritional value of a recipe. Scan the rundown, look for a few keywords (many of which are listed below), and be extra aware of extravagant or difficult-to-find foods for your area, which will drive up the price.

DO consider recipes with one or two out-of-the-box ingredients. In small doses, odds are it/they won’t break the bank, and you can incorporate new flavors into your repertoire. Lemongrass? Meyer lemons? Lemon basil? Sure, why not?

DON’T dismiss a long list of ingredients outright. Lighter foods like Bon Appetit’s Turkey Chili with Beans frequently require multiple, inexpensive spices and flavorings to make up for the absence of fat. While their sheer number can seem pretty intimidating, don’t fret. Oftentimes, these foods can be found right in your pantry for minimal cost.

DO count the number of ingredients already in-house. Speaking about that pantry, recipes based on dry goods will usually be cheaper than ones requiring a trip to the supermarket. Look for meals that use rice, beans, pasta, and other staples as jump off points, and go from there.

DO opt for whole food ingredients. If it can be found in the outer aisles of your supermarket, it’s probably a good start to a meal. Fresh fruits, veggies, and lean meats give recipes more bang for the buck, and almost guarantee a healthier overall experience. Fewer preservatives and extra-excellent flavor are just bonuses.

DON’T choose recipes made from processed food. The less ingredients are handled by humans, the better. Why? Well, in general, heavily processed and pre-cut edibles are more expensive and worse for you than the aforementioned whole foods. Semi Homemade-style meals may be convenient, but when you’re sacrificing money, nutrition, and taste, is it worth it?

DO watch out for lots of meat and cheese. In moderation, neither of these is anything to fear. But prices and calories rise when a meal centers on multiple cups of frommage or large cuts of beef or pork. Instead, search for recipes where meat and cheese are add-ons instead of the main event. You’ll save all around.

DO calculate about 12 or 13 grams of fat per tablespoon of butter or oil. When doing a cursory scan of any recipe, I take extra care to check the total cooking fat. If there’s a lot, but it can be easily reduced (like in sautés), I keep going. If there’s a lot, but the amount is set in stone (as in some baking), I move along to the next dish.

DON’T rule out all fatty ingredients. Nuts, olives, avocados and certain oils aren’t low-fat foods, but they’re healthy ones because of the vitamins and minerals they offer. Relatively inexpensive and often pivotal to a dish’s overall flavor, they should be incorporated into any diet in moderation.

DO look for words like: baked, roasted, steamed, grilled, or sautéed. These cooking techniques tend to use less fat than others while still producing flavorful foods. Steaming and boiling are good keywords as well.

DON’T choose recipes with the words: fried, au gratin, cream sauce, bisque, bacon-wrapped, or lard. Each of these terms implies one thing: fat. If you’re serious about watching your weight, there are lighter recipes for certain dishes (Spaghetti Carbonara, etc.), but straight-up lobster bisque will do a number on your numbers.

Confusing? Maybe. Do-able? Definitely. With some practice, these rules will get easier to use. And in the end, you’ll have no problem telling the difference between the recipe you really want and the recipe you thought you wanted.

Readers, fire away in the comment section.

~~~

If you liked this article, you might also dig:

• How to Tell if a Recipe is Worth Cooking With Five Easy Questions at Casual Kitchen
• Frugal Food Hacks: 10 Tricks to Simplifying Online Recipe Searches
• The Dos and Don’ts of Buying a Cookbook

This is the first of a series of blog posts in which I will recount my adventures at Stanfords Medicine X, Conference: An experience which has changed my life, and I will not soon forget. :-) 

The Palo Alto Westin Hotel is a small hotel tucked into the Palo Alto scenery, and spitting distance from Stanford University. Warm, and welcoming, employees genuinely seem to care about ones lodging needs. As I checked in (having completed a journey that began 9 hours before, at 2:00 AM, in Ames, Iowa), I gave the attendant $50 of my last $71, for a security deposit. I really hadnt planned on THAT, so I was hoping the rest of the day wouldnt require any more money from me. (I also hadnt planned on everyone, and their mother, requiring a tip from me.)

After settling in, I went about the business of trying to find out what I was supposed to do next. I was a little outside of my comfort zone... Okay, a lot outside my comfort zone. Okay, "The Village" level outside of my comfort zone. I hadnt traveled anywhere in 5 years; heck, I hadnt even left my small town to go anywhere in the nearby vicinity, in 5 years. When you have no car and minimal financial resources, the world sort of closes in on you. Social media, and walking everywhere, are about the few things you have.

I was in the most expensive city in America, where I knew no one, where I had $21 left, where I didnt know how to use my loaned smartphone, and where I had planned to attend a session in 15 minutes in some supposedly nearby street. "Just turn right on University Avenue, up ahead," said the bellhop. Except, there was a train running through it. Yes, a train. Before I had a chance to wonder much farther, two gentlemen who seemed about equally lost -- but who knew how to use their smart phones -- asked me if I was going to the Stanford startup session. "Yes, I said," so I followed them. And follow the leader is what I did... all weekend, pretty much.

What is the Angry Type 2 Diabetic doing in Palo Alto, you ask? Attending Stanford sessions, nonetheless? Well, in case you missed it (which I almost did), last Spring I was selected (among many applicants) for a scholarship to attend Stanfords Medicine X Conference, in Palo Alto, California. I had applied at the suggestion of a friend, and quickly forgotten about it. :-)

At the time I didnt know much about Medicine X... but my curiosity was piqued. I knew the things I believed in: the patient, the patients ability to quantify their experience, and social media to glue it all up together... and now Stanford University, via Medicine X, seemed to want to address all those things. Nothing makes one feel better than when the crazy things one rants about get acknowledged by large institutions.

So, I took them up on their offer. I was, and am, confident that this is the future of medicine. It is, in my mind, one of the only ways to guarantee the patient has a voice. A voice that isnt clouded by the need to see 30 patients or more a day, 6 minute doctor sessions, and clinicians who are hell bent on not deviating from anything they learned back in 1976. A way to circumvent the little treatment and education patients with type 2 diabetes are receiving. A way for patients with limited resources, to make the most of their health situations.

But... after a week of being stranded at home, with the flu, and not being able to work, the little savings I had for this event disappeared in the form of medicines and bills. So I almost didnt make it out there. Almost. I have my family to thank for making this event happen for me. For believing in this little wild adventure on which I was about to embark.

And boy was it an adventure.

I really wasnt sure what to expect... and thinking Id immediately see many of my fellow diabetes advocates, I had worn my fun-loving shirt "Diabetics Luv Pricks," for my travel day. It really made me an attention magnet, in ways I didnt want to be one. hehe "So what are YOU doing here?," "What exactly are you going to bring to MedX, with what you do?," "Whats your role in MedX?," "I thought this conference was just for startups," etc.

People were really proud of being startups of their own companies (even if it was just a company of 1 or 2), and people were really... PROUD of being in the center of the universe, as it was put to me more than once. And... it was a bit unnerving, to be honest.

Just like I did on my first day of college, I called home, and cried, and begged to leave. And just like on my first day, thank goodness I didnt.   :-) Culture clashes can be rough things.

Its been about a couple of weeks since Ive ranted on anything, and I really apologize for that. The fact is... Ive really been exhausted. Ive been exhausted, and in a lot of pain. Id call it chronic pain, but its only chronic in the sense that other events keep happening, and happening, on top of one another, to not let the affected parts of my body just take some time to heal. Its like this stupid domino effect, of sorts, except, well... every time a stupid domino falls, it hurts, and I feel every bit of my 35 years of age.

Where do I start?

Well, lets see... About two weeks ago, while I was walking to our corner supermarket, I fell hard on some ice. And I mean, I fell REALLY hard. The kind of hard where you sit there, wondering if you broke anything, and unable to get back up after a few minutes. (The driver, passing by at about 20 mph, must have had a really good laugh at my expense.) The fall itself was painful, but then the pain didnt seem that bad after a few hours, and the next day, everything was fine.

Except for day 2, and day 3... which were utter hell. Then I felt 70, instead of 35... and in need of some kind of walker. (With apologies to 70 year-olds, who can probably run laps next to me, right now.) Leave it to me, to fall on some almost non-existent ice, on the mildest Winter weve had in at least 30 years. On the 4th day, I felt distinctly better, though not completely healed... But on the 5th day, I had to work -- and as some of you may know -- I work unloading trucks for a local department store, a few days of the week. Of course, I had to help unload a very atypical, large truck of merchandise, so that on day 6, I was back to feeling like I felt on day 2.

At work, I *also* hurt myself... by smashing my left shin against a flat of merchandise, which is still black and bruised, and throbbing, and overall, my joints just dont seem to be holding up so well. Im having some pain in my left ankle, which actually began BEFORE I fell, the week before, from the constant stiffness of needing to walk on ice, and slippery sidewalks.

Many baths with Epsom Salt, and stretching exercises later, and Im still one very achy feeling "old" lady. I also, still have to work tomorrow... It will be my third day in a row, when we usually have some off days in between.

Carpal Tunnel hasnt exactly been playing nice, either, with my poor wrists and elbows (at least on my left arm) not letting me get a good nights rest. I might yet consider some kind of joint support supplement, before this is all over. I mean, I feel like my warranty expired.  Are you tired of the whining yet??? I am. LOL And I have to live with me!

So... reading through one of my dear friends blogs, I found a great, happy post... to sort of help focus some of my crappy attitude right now. My friend, A Diabetic Ballerina, wrote on adding a touch of "bling" to our diabetic tools. She gave me some inspiration to give it a little of my own twist... I may not be able to change a lot of my circumstances, but I can at least laugh while Im doing some of the stuff I have to do.

So Ive decided... that I cant freak out too much about having off diabetes days, from the pain, or whatever else comes my way... if my meter looks like this:

The Disease Management Care Blog feels your pain. 

You help lead a unique and innovative care coordination initiative.  Your program has some preliminary data that strongly suggests quality has increased while costs have remained neutral or gone down.  Patients are satisfied.  Docs are happy.  You even have a patient anecdote or two.

But somethings missing.

While your institutions marketing department has been supportive, you believe that the customers you want to serve are tired of glossy brochures, breathless press releases and chatty sales reps.  Your customer meetings are fun, but you cant tell if the positive feedback is the result of real insight or that second glass of wine. 

On the other hand, the prospect of publishing your findings in some scientific journal is too dreary to contemplate. 

You know some more meaningful is at stake.  You want to share your good news and get some feedback.

Heres your solution: the Care Continuum Alliance Annual Conference.  Hundreds of individuals just like you - individuals who give a damn about patients, are excited about making a difference and want to make a living doing it - will be available to give feedback.  Who knows, some of them may talk partnerships.  Others will resent your competition, confirming that you are on the right track.

The CCA Call for Proposals can be found here.  You have until March 6 to submit.

How to Overcome Cancer at Children - Cancer at children is something that very afraid for parent, all parent will be scare to deal with it, in spite of the parent really patient. in this condition, parent must always support and give the spirit for their children, in order the children can be strong and always on good condition.

Some cancer that usually suffered by children are leukemia, limfoma, retinoblastoma (eye cancer)and bone cancer, where this is the common one that suffered by them.

According to Erwin, excessive protection will encourage the psychological and emotional condition of a child to become unstable. So rather than cure, but it will generate a cancer cell.

"If the mood is not comfortable it will encourage the cancer cells in the body become more active," he added.

In addition to providing support and freedom, one thing is no less important is being honest about the childs illness. "Children who are not informed about the disease would imagine something totally untrue," he said.

For example, a child may be thinking that his cancer illness is a punishment for him due to a delinquency or a specific error.

"It was agreed with that by telling, would make the child become less stressed and feel guilty. Children are entitled to know about his illness. Regardless of age, "he explained.

In a yesterdays post, the Disease Management Care Blog used Edie Weiners video presentation on digitization and commoditization to launch into its own version of health care futurism.  While it struggled with notions of "opportunity costs," it concluded that a) highly evolved patient data bases, b) biometric monitoring systems, c) artifical intelligence-based decision support and d) growing consumer acceptance of informatics will make the need for many traditional outpatient visits obsolete.

Thanks to inspiration from the movie Moneyball, the DMCB explains why.  The movie chronicles the decision of the Oakland As General Manager (or "GM" played by Brad Pitt) to apply a more scientific approach to recruiting players. Eschewing the largely subjective evaluation process used by his veteran scouts, the GM decides to focus on a few key player statistics.  As a result, he recruits players with high "on base" metrics and comparatively low salary demands. Success follows, and not only does he build a championship team, but he is offered a job with the legendary Red Sox. There is a telling scene filmed at Fenway Park in which the Sox owner salutes the new revolutionary approach to baseball by giving a small solilloquy on the merits of adapting or dying. Building a winning team is no longer a highly tailored and subjective approach to individual players, but data, information and insights.

Lesson learned.

The DMCB suggests outpatient primary care may be at a similar Moneyball moment.  Patients can digitize and transport their health care information from afar and, thanks to decision support paired that can be managed by non-physicians or patients themselves, use a data driven approach to get the advice and treatment options they need without having to step into a doctors office.

What are the implications?  The DMCB can think of seven.  There are probably more:

1.   While this isnt happening tomorrow, its a lot closer than most persons suspect.  The DMCB thinks its a threat to all those 5 year business plans.

2. Primary care office visits remain the most vulnerable because, even with the support of government with extra payments and medical home support, a higher proportion of its common "bread and butter" acute and chronic medical issues are particularly amenable to digitalization.

3. Not all primary care office visits will go away. Patients needing a diagnosis that defies the usual algorithms will still need to be seen. That means doctors will need to ocus on being diagnosticians and caring for patients that fall outside the algorithms.  Its the usual "treat and street" clinic visits for routine follow-up of common problems will decrease considerably.

4.  This will erode not only primary care offices, but be an important hit to the business model of "urgent care" clinics.  The architects of these clinics will be well advised to start building remote access capabilities.

5. Think that that special something that can only be achieved in a one-on-one relationship with a physician who really really knows you will be lost?  Think again because its availability will still be a function of data, not doctors, chips not one-on-one care.  That being said, there will still be a market for personalized physician attention: its called concierge practices.

6. Given the willingness of political opponents to quote from writings without accounting for context, the DMCB, thanks to its posts on the commoditization of health care, will never become President of the American Medical Association.

7.  While most of the digitization-commoditization threatens the business model of primary care, dont think that physicians that offer invasive procedures or surgery are immune from what is going on.  Patients are increasingly willing to transport themselves longer distances in exchange for value (across the state or, in the case of medical tourism, overseas), but a far more fascinating application of the digitization and easy transport of patient information is robotic telesurgery.

Image from Wikipedia

An echocardiogram of the heart

The shortness of breath just wasnt going away.

After years of being treated for persistent asthma, Dr. Smith (name changed) found his usual mix of inhalers and pills was no longer working.  Unable to comfortably sleep at night and finding he couldnt hustle as quickly up and down his clinics hallways, he decided it was time to see the Disease Management Care Blog.  After a quick look and a listen to his heart and lungs, the DMCB tapped its heuristics and made a shortcut bet that this wasnt asthma.  The echocardiogram that was obtained that afternoon proved that it was right: Dr. Smith had heart failure.

Heart failure is the leading cause of hospitalizations in the elderly and is a huge cost to the U.S. health care system.  Theore, if docs like the DMCB on an individual basis - or the U.S. on a health care policy basis - could prevent heart failure, that would be a big deal.

"Natriuretic Peptide–Based Screening and Collaborative Care for Heart Failure - The STOP-HF Randomized Trial" that was just reported in JAMA may be a step in that direction.

The DMCB explains.

First off, there is a hormone that is made by a stressed heart (yes, the human heart secretes hormones) called "naturetic peptide" (or NP) that signals the kidneys to excrete more salt and water. "BNP" is one type of naturetic peptide that can be detected using a simple blood test.

The STOP-HF trial set out to examine whether BNP levels could identify otherwise well-appearing persons with stressed hearts who were at future risk for the development of clinically evident heart failure.  By catching these persons early and getting them into treatment, the hope was that these patients wouldnt turn out like Dr. Smith.

39 practices in the catchment area of Dublin Irelands St Vincents Hospital erred patients who were older than 40 years and had one of the following cardiovascular risk factors: high blood pressure, high cholesterol, an obese body mass index, documented (by an angiogram or a known heart attack) coronary artery disease, history of stroke, peripheral vascular disease, diabetes, arrythmia or heart valve disease.  Persons with known heart failure were excluded from the study.

After entry into the study, patients had a BNP level drawn and were then erred to either a "control" (observation only) group or to an intervention group.

In the intervention group, patients with an elevated BNP level of 50 pg/ml or more were erred to a cardiology service and had a cardiac function study using echocardiography. In addition, any of the cardiovascular risk factors were aggressively managed with medications and a specialist nurse-coach.

In the control group, physicians and patient were not told about the BNP level and were cared for on a routine basis.  Patients were not erred for any cardiology care unless another reason supervened.

1374 patients were randomized, 697 in the intervention groups and 677 in the control group. High blood pressure was the most prevalent risk factor and most patients had two risk factors. 263 (38%) and 235 (35%), in the two groups respectively, had BNP levels greater than 50 pg/ml.  Average follow-up was 4.2 years and all patients eventually had an echocardiogram to assess their heart function

During follow-up, 8.9% of the control group patients and 5.3% of the intervention patients developed heart failure as determined by echocardiography.  That difference was statistically significant and was due to a higher level of treatment with drugs that help control risk factors and prevent heart failure. When the DMCB uses a number needed to treat analysis, the works out to 28 patients needing to be screened and treated for an elevated BNP to avoid one case of heart failure.  Thats not bad, even if you compare it to aspirin and heart attacks.  There were also fewer emergency room visits and hospitalizations in the intervention group.

The DMCBs take:

1. This is classic population health management: This study was not only about using BNP to find patients at risk for heart failure, it was about relying on nurse coaches to manage the underlying clinical drivers, such as high blood pressure or underlying coronary artery disease.  If the DMCB suggests a better title for this article would have been "Population Health Management to Screen and Treat Patients with Elevated BNP at Risk for Heart Failure."

2. An appealing value proposition with a return on investment: Given a NNT of 28 and the future costs of heart failure, combined with statistically significant reductions in emergency room use and hospitalizations, the DMCB expects population health management service providers as well as medical homes to use BNP and non-physicians to screen and treat patients to prevent heart failure.

3. Still imperfect: Despite aggressive management by a specialized team, 5% of patients in the intervention groups went on to develop disease.  We have a ways to go. 

Image from Wikipedia

Ladies and gentlemen, we have completed our survey of the Best Deals at Trader Joes! Thanks to everyone who wrote in. There were 58 total commenters participating – 54 from the blog, 2 from Facebook, and 2 via email. And? Looking at the top ten vote-getters, this is going to be one hell of a party.

To review the process from last week: Every product mention got one vote. (So, if three different commenters wrote "butter," it got three votes.) Some things, like honey, elicited one clear vote and were easy to tally. Others, like cheese, were much more varied, producing several similar-but-not-exactly-alike answers. In those cases, I tallied the category as a whole, and then elaborated on individual responses within parentheses. (Um … if that makes sense, which it only kind of does. But youll see.)

Some overall observations:

• On the whole, frozen, organic, and restricted-diet (gluten-free, etc.) goods did very, very well, as did TJs house brand products, especially: Roasted red pepper boxed soup, Joe-Joes, Three-Buck Chuck, and Greek yogurt. 
• Overall, it appeared as if you dont necessarily shop at TJs for the basic necessities, but rather, for beloved extras - chocolate, wine, edamame, etc. 
• Almost half of you voted for some kind of cheese. Yowza.
• Votes for bread were split. A few liked TJ breads a LOT, while others mentioned it wasnt quite up to snuff.
• I loved how many people wrote WINE in all caps. Vino lovers, unite!

Without further ado, here are your answers. Print this thing out and take it with you on your next trip to TJs.

Wiki Commons Sprew

25 VOTES
Cheese (2 votes brie and goat, 1 vote each for cheddar/stilton, smoked gouda, shredded mexican, fontina)

21 VOTES
Nuts (3 votes almonds, 1 vote pistachios)

16 VOTES
Yogurt (12 votes Greek yogurt)

13 VOTES
Wine (1 vote organic, 2 votes Three-Buck Chuck)

12 VOTES
Dried fruit (3 votes mango, 2 vote bananas, 1 vote strawberries and cherries)
Olive oil

10 VOTES
Frozen veggies (2 votes green beans and corn, 1 vote each bell peppers and asparagus)

9 VOTES
Frozen edamame

8 VOTES
Cereal (1 vote Barbaras Bakery, 1 vote Honey-Os)
Chocolate (4 votes 1-lb. bars, 1 vote white chocolate)
Hummus
Marinara/Pasta sauces (1 vote organic)

7 VOTES
Bananas (1 vote organic)
Cookies (1 vote Maple Leaf, 1 vote Oatmeal Cranberry Dunkers, 4 votes Joe-Joes)
Eggs (1 vote organic)
Pasta (3 votes whole-wheat)
Peanut butter

6 VOTES
Boxed soups (3 votes roasted red pepper, 2 votes tomato, 1 vote black bean)
Bread ( 1 vote Cinnamon Swirl Bread, 1 vote pain au chocolat)
Canned beans (3 votes black)
Coffee
Jams (1 vote blueberry, 1 vote raspberry)

5 VOTES
Frozen Fruit (2 votes berries)
Ice cream (2 votes coffee-flavored, 1 vote Coconut milk)
Pizza Dough (generally frozen)

4 VOTES
Almond, rice, and soy milks
Apples (2 votes organic)
Bars (1 vote cereal, 1 vote Luna/Clif, 1 vote Fiberful, 1 vote Walks Into Bars)
Frozen pizza
Frozen prepared meals (1 vote veggie lasagna)
Milk
Salsa (1 vote Serrano)
Stock/Broth
Tortillas (1 vote organic, 1 vote whole wheat)

3 VOTES
Butter
Canned artichokes
Dairy (1 vote RBST-free)
Flat breads (1 vote Feta & Jalapeno, 1 vote Mediterranean)
Flour
Olives (1 vote canned)
Potstickers
Spinach
Tortilla chips
Trail Mix
Vitamins

2 VOTES
Almond butter
Beer
Frozen pre-cooked brown rice
Frozen veggie burgers (1 vote Morningstar Farms)
Gluten-free rice pasta
Ground beef
Organic whole chicken
Quinoa
Seltzer
Tofu

1 VOTE
Avocados, Bacon, Baby arugula, Balsamic vinegar, Balsamic vinegar dressing, Basmati and jasmine rice, Boxed Indian meals, Broth concentrate, Buttermilk, Canned crab, Capers, Cat food, Cilantro and yogurt dip, Clementine oranges, Coffee filters, Cottage cheese, Cranberry juice, Cream, Dog treats, Doggy glucosamine condroitin, English muffins, Facial cleansing pads w/tea tree oil, Flowers, Fresh produce, Frozen basil cubes, Frozen chile relleno, Frozen croissants, Frozen fish, Frozen hash browns, Frozen pie crust, Frozen shrimp, Gorgonzola gnocchi, Gorgozola crackers, Granola, Ground flaxseed meal, Gyoza, Hatch Green Chiles, Honey, Hot dogs, Individual Mac and cheese, International foods, Jarred hearts of palm, Kashis TLC crackers, Kefir, Kosher chicken/turkey, Laundry detergent, Lemons, Limes, Marinated mushrooms, Mayo (sorry Kris), Meat, Multi-grain pancake mix, Nitrate free meats, Olive tapenade, Organic carrots, Organic sugar, Pesto, Pineapples, Roasted red peppers, Romaine hearts, Pre-cooked lentils, Sausages, Shiitake mushrooms, Smoked salmon, Soy (fake) chorizo, Soy creamer (TJs brand), Special-diet foods, Steel-cut oats (McCanns) , Sun-dried tomatoes, Sushi platters, Sweet potato chips, Tabouli, Tamales, Taquitos, Tempeh, TJs chicken nuggets, TJs spaghetti-os, TJs peanut butter cups, Tomatoes, Tuna, Tuna meals, Veggie sticks

Sweet readers, is there anything youd like to add to this? Maybe something we missed, or another suggestion for a specific store survey? Thanks again for all your replies - this was really fun. (*runs off to buy cheese*)

~~~

If you enjoyed this, youll surely like:

• The Best Deals at Big Box Stores: A Cheat Sheet
• Food, Frugality, and Fighting Brand Loyalty
• Lighten Any Meal: 10 Easy, Inexpensive Steps to Healthier Recipes