Health for life

A wealth of research is pointing to an ever increasing problem that is shown to increase our risk of cancer, as well as a host of other genetically influenced illnesses. The problem is with light sources in the bedroom at night when most people are asleep.

As a class, people who dont drink at all have a higher mortality risk than light drinkers. But nondrinkers are a diverse bunch, and the reasons people have for abstaining affects their individual mortality risk, in some cases lowering it on par with the risk for light drinkers, according to a University of Colorado study.

Multiple studies have shown that the likelihood of dying for people who drink increases as they consume more alcohol. Those same studies have shown that a persons mortality risk also increases at the other end of the spectrum — among people who choose not to drink at all — though the risk is still much less than for heavy drinkers.

Some researchers have hypothesized that the increased mortality among nondrinkers could be related to the fact that light alcohol consumption — drinking, on average, less than one drink a day — might actually protect people from disease and reduce their stress levels.

But researchers at the University of Colorado Boulder, working with colleagues at the University of Colorado Denver, decided to examine whether characteristics of different subgroups of nondrinkers could explain the increased mortality risk.

"Among nondrinkers, people have all sorts of background reasons for why they dont drink," said sociology Professor Richard Rogers, director of CU-Boulders Population Program in the Institute of Behavioral Science. "We wanted to tease that out because its not really informative to just assume that nondrinkers are a unified group."

For the new study, published in last months issue of the journal Population Research and Policy Review, Rogers and his colleagues relied on data collected in 1988 by the National Health Interview Survey about the drinking habits of more than 41,000 people from across the United States. The researchers also had access to information about which respondents died between taking the survey and 2006.

During the survey, nondrinkers were asked to provide their reasons for not drinking. Possible answers ranged from "dont socialize very much" to "am an alcoholic" to "religious or moral reasons."

The research team divided nondrinkers into three general categories: "abstainers," or people who have never had more than 12 drinks in their lives; "infrequent drinkers," or people who have fewer than 12 drinks a year; and "former drinkers." Each category was further divided using a statistical technique that grouped people together who gave similar clusters of reasons for not drinking.

The team then calculated the mortality risk for each subgroup compared with the mortality risk for light drinkers, and they found that the risks varied markedly.

Abstainers who chose not to drink for a cluster of reasons that included religious or moral motivations, being brought up not to drink, responsibilities to their family, as well as not liking the taste, had similar mortality risks over the follow-up period to light drinkers.

"So this idea that nondrinkers always have higher mortality than light drinkers isnt true," Rogers said. "You can find some groups of nondrinkers who have similar mortality risks to light drinkers."

The other subgroup of abstainers — whose largest reason for not drinking appeared to be a dislike of the taste and to a lesser degree family responsibilities, religious or moral motivations or upbringing — had a 17 percent higher mortality risk over the follow-up period compared with light drinkers.

The scientists also found that infrequent drinkers generally had a slightly higher mortality risk than light drinkers. Former drinkers, however, had the highest mortality risk of all nondrinkers. Former drinkers whose cluster of reasons for not drinking now included being an alcoholic and problems with drinking, for example, had a 38 percent higher mortality risk than light drinkers over the follow-up period.

By comparison, people who drink between one and two drinks per day, on average, have a 9 percent higher mortality rate than light drinkers, while people who drink between two and three drinks per day have a 49 percent higher mortality. People who consume more than three drinks per day had a 58 percent higher mortality risk over the follow-up period compared with light drinkers.

Despite confirming that some subgroups of nondrinkers have a higher mortality rate than light drinkers, it doesnt necessarily follow that those peoples mortality rates would fall if they began drinking, Rogers said. For example, people who were problem drinkers in the past might increase their mortality risk further by starting to drink again.

Also, people who dont drink at all, as a group, have lower socioeconomic characteristics than light drinkers, which could be one of the underlying causes for the mortality differences, Rogers said. In that case, starting to drink without changing a persons socioeconomic status also would not likely lower mortality rates.

"I think the idea that drinking could be somewhat beneficial seems like its overstated," Rogers said. "There may be other factors that lower mortality for light drinkers. Its not just the act of drinking."

One of my least favorite words in the English language is “moist.” I don’t like the way it slides off the tongue, stabbing it at the end with a sinister, pointy “t.” The sound squicks me out, like the feel of cheap velvet or foam rubbing against itself. Whats more, “moist” makes even the most harmless utterances seem a little dirty. Lewd, even. I actively rain from using it on a casual basis, especially when describing people. Because, lets face it: theres nothing creepier than, “Hey Bob, you look moist today."

This aversion is unfortunate, partly because it’s a pretty common word, but mostly due to the food blogging thing. “Moist” depicts almost every kind of well-made meal, and there are few-to-no substitutes for it. “Wet" connotes a soaking, “soggy” is too negative, and “humid," well ... lets not even discuss. It’s got to be “moist.” “Moist” means a cake is well made. “Moist” means cookies are chewy, but firm. “Moist” means you might be eating Alex’s Slightly Altered Light Chicken and Mushroom Marsala.

I got this recipe from Smitten Kitchen, who got it from the June 1995 issue of Gourmet. And man oh man, is it ever moist. It’s moist-esque. It’s the hostess with the moistest. The chicken is basically braised in broth and marsala wine, which not only imparts a marvelous flavor to the mushrooms, but y’know … the moist thing.

The original recipe called for skin-on chicken breasts and more butter than I was comfortable with. So, to cut the fat, I:

• Used boneless, skinless chicken breasts.
• Only used oil to sauté the mushrooms and onions, instead of a butter/oil combination.
• Reduced the olive oil by a third.

It came out beautifully and went really well with egg noodles. All told, its a classy, earthy meal-for-four under eight bucks. Not too shabby. And most definitely moist. (*cringe*)

Chicken and Mushroom Marsala
Serves 4
Adapted from Smitten Kitchen.

2 whole boneless, skinless chicken breasts (about 28 oz), halved
2 teaspoons olive oil
1-1/2 tablespoons unsalted butter
2/3 onion, sliced thin
1/2 pound mushrooms, sliced thin
1/3 cup Marsala
2/3 cup chicken broth
1-1/2 tablespoons minced fresh parsley leaves

1) Gently pat chicken dry with paper towels. Sprinkle with salt and pepper. In a large skillet, heat oil over medium-high heat. Add chicken and brown in two separate batches. When finished with each, transfer them to a plate so juices may redistribute throughout meat.

2) Add onion and mushrooms to skillet. Cook a few minutes, until "liquid mushrooms give off is evaporated," stirring occasionally. Add Marsala. Stir. Cook until Marsala is nearly gone. Add broth, chicken, and any chicken juices pooling on plate. Simmer until chicken is fully cooked, around 15 minutes, turning once halfway through. (I had very thick cuts, and this still timed out perfectly.) Move chicken back to plate.

3) Keep the sauce simmering until it reduces to around 1/3 cup. Kill heat. Salt and pepper the sauce to taste. Add butter. Stir sauce until butter is just melted. Serve chicken with sauce. Garnish with parsley.

Approximate Calories, Fat and Price Per Serving
352 calories, 9.75 g fat, $1.63

Calculations
2 whole boneless, skinless chicken breasts (about 28 oz): 875 calories, 9.9 g fat, $3.48
2 teaspoons olive oil: 79 calories, 8.9 g fat, $0.06
1-1/2 tablespoons unsalted butter: 153 calories, 17.3 g fat, $0.15
2/3 onion, sliced thin: 42 calories, 0.1 g fat, $0.32
1/2 pound mushrooms, sliced thin: 50 calories, 0.8 g fat, $1.50
1/3 cup Marsala: 142 calories, 0 g fat, $0.61
2/3 cup chicken broth: 64 calories, 2 g fat, $0.16
1-1/2 tablespoons minced fresh parsley leaves: 2 calories, 0 g fat, $0.25
TOTAL: 1407 calories, 39 g fat, $6.53
PER SERVING (TOTAL/4): 352 calories, 9.75 g fat, $1.63

The Disease Management Care Blog (DMCB) welcomes readers to this edition of the Health Wonk Review. The DMCB is a physician-writer with knowledge and experience in primary care, health insurance, population health and health information technology. Thats why its delighted to host this compendium of recent writings from the best health policy bloggers offering insights you wont find anywhere else. Read this and the DMCB assures your Huff Po addled colleagues will admire you and your USA Today reading opponents will envy you.

For example, this HWR has a conservative who actually likes health insurance exchanges and a progressive who is disappointed with a key aspect of the Affordable Care Act. Theres also a unique description of an important collaboration among competing commercial health insurers and a thoughtful discussion of the downsides of preventing HIV infection.  Youll also find a detailed report on how the evening news blew the coverage of an important cancer screening guideline update.

And dont be put off by the wide ranging number of posts.  Read what captures your interest, follow the links and come back as often as you like.   The DMCB will leave the light on for ya.

HOSPITALS

Hospital Quality

Most readers of this Health Wonk Review are undoubtedly sophisticated and dispassionate experts on hospital quality, consumerism, patient satisfaction and outcomes.  Well, Neil Versel of the Meaningful Health IT News blog shows us how that learning contrasts with watching a terminally ill loved one with Multiple System Atrophy struggle with distant physicians, medication errors, incomplete care planning, lack of basic health services, ignored advance directives and occasional Keystone Kops style encounters with health workers who should know better.  And we wonder why Americans are so fed up with the U.S. health care (non) system?  Egads, says the DMCB.

A Medicare Hospital Measure Called "MSPB"

Speaking of hospitals and quality, CMS has started to publicly report peri-hospitalization health care costs using a metric called the Medicare Spending Per Beneficiary (MSPB). According to Jason Shafrin of the Healthcare Economist Blog in this post titled "Measuring Hospital Efficiency," Medicare is now reporting a roll-up of all payments made to docs and the facility three days prior, during and 30 days after a hospital stay. Non-surprisingly, some areas of the country have much higher MSPBs than others. Yet, despite its merits, Jason reports that the measure is not without controversy because we dont know enough about the link between the MSPB and outcomes (does more spending result in high quality?) or if reported higher costs were the the result of waste (for example, unnecessary or redundant testing) versus additional necessary care (perhaps extra days in a rehab facility after discharge were worth it).   The one thing the DMCB does know is how necessary it will be to use the acronym "MSPB" the next time it steps up to a microphone at a health policy confab.  It cant wait.

"Observational Status"

When is an admission to the hospital not an admission?  Thats the conundrum tackled by Dr. Brad Flansbaum of The Hospitalist Leader blog, who helps the reader understand how hospitals use their inpatient facilities to treat outpatients. The key distinguishing factor is a limited 24-48 hour course of care that is aimed at returning the patient home.  Unfortunately, outpatient care is covered with an outpatient insurance benefit that can include significant out-of-pocket expenses.  Medicare has policies that require providers to inform beneficiaries of the financial impact of being in "observation status" but as the line that separates inpatient and outpatient care continues to be blurred, its likely well have to wait for global payments or shared risk arrangements to reconcile patient coverage expectations and billing systems.  Until that happens, Brad has quotes a Medicare official who assures us that CMS is "considering caully how to simplify the rules in a way that best meets the needs of patients and providers without increasing costs to the system."  Right.

HEALTH SYSTEMS

Accountable Care Organizations

While the mainstream focuses on Medicares ACOs (for example), Blue Shield of California, CalPERS, Hill Physicians Medical Group and Dignity Health quietly partnered back in 2007 on a shared savings program that apparently resulted in a noisy $20 million in savings.  Glenn Melnick and Lois Gree over that the Health Affairs Blog have authored an interesting interview-narrative about this initiative that is full of interesting lessons. These lessons include the importance of physician buy-in and participation, a system-wide working familiarity with old-fashioned capitation, a supportive pre-existing provider culture, an emphasis on reducing readmissions, using wellness to reduce use of pricey bariatric surgery services, data liquidity, increasing use of evidence-based guidelines at the point of care, patient "repatriation" from non-participating care settings, data dashboards and empowering non-physicians to engage patients in self-care.  The California HealthCare Foundation has committed to completing a full evaluation of the outcomes next year. The DMCB commits to using some new health policy jargon it discovered in reading this post: "actualize" and "head in a bed."

"Charismatic Leaders"

Roy Poses of Health Care Renewal continues to expose the folly running rampant in the U.S. health care system, this time by looking at the "CEO as False Messiah." Dr. Poses cautions readers to pause any time they run into local or national leaders who are uncritically hailed as "visionary."  Its far more likely that their fawning admirers have been seduced by a toxic level of charisma that often leads to catastrophe.  Get real, advises Roy, and admire such folks for being smart while keeping a skeptical eye on their ability to produce results.

PROVIDERS

The Doctor-Patient Relationship

David Williams of the Health Business Blog uses a Health Affairs article on "shared decision making" to lect on the upsides of being labelled a "difficult patient."  Researchers found that an important barrier to forming a doctor-patient relationship is the fear among health care consumers that expressing a perence will annoy their doctor.  David argues thats not such a bad thing, especially since modern consumers now have the option of seeking a second opinion, getting another doctor and ultimately using a questionable treatment. The DMCB really agrees with Davids perspective because it wants to be liked by him.

DRUGS

HIV Prevention Is Good News, Right?

 Nate Ogden of the InsureBlog walks readers through a fascinating exercise on the costs and ethics surrounding the FDAs approval of HIV-prevention drug called "Travuda." While readers may initially want to hail this medical breakthrough, Nate suggests its not so simple: 1) the retail cost of the drug is $11,000 a year, which a) contrasts with the $30 a month cost of equally effective condoms and b) would be enough to treat 20 HIV positive patients, 2) persons taking the drug may misuse their new found protection and paradoxically engage in increased risk-taking sexual behaviors and 3) coverage may be mandated as an insurance benefit, which means therell be one more driver of health care costs for all of us.  Another silk purse turned into a sows ear, says the DMCB.

Would You Like Some Drug Monitoring Along With That Refill?

Never at a loss for words, Joe Paduda of Managed Care Matters takes umbrage with Missouri State Senator Robert Schaafs opposition to the states "Prescription Drug Monitoring Program Act." Joe argues that the act would reduce the incidence of drug-drug interactions and lessen prescription drug abuse through doctor shopping.  Without passage of the bill, says Joe, kids will lose their moms, Scout troops will have to meet without their den mothers and schools will have teacherless classrooms.Dr. Schaff, who by the way is a family physician and leads a prominent physician liability insurance carrier, has a different perspective. The DMCB predicts the Senator will not find Joes disapproval very compelling.

HEALTH INFORMATION ANALYTICS

Health Insurer Data Mining

If its one thing that Medicare has done better than the commercial insurers, its making its claims data available to health services researchers.  The DMCB suspects that the commercial insurers have been reluctant to do so because of the considerable effort involved, concerns about inadvertently running afoul of HIPAAs unwieldy confidentiality provisions, giving their competition otherwise confidential information about payment rates and the lack any relevant value propositions. According to Martin Gaynor at the curiously named Wing of Zock Blog, those barriers have finally been overcome. Aetna, Human, Kaiser and United have all agreed to ship billions of lines of claims data to the not-for-profit Health Care Cost Institute which will make the deidentified data available to researchers.  The DMCB agrees that this is a significant development that will allow researchers to mine insights that, thanks to relatively low numbers of patients, non-generalizable health care settings and limited imagination, have been out of reach. The DMCB hopes the data will be made democratically available on as close to an "open source" basis as possible.

HEALTH INSURANCE

 Group and Individual Insurance Markets

Need a quick lesson on the fundamental differences between group and individual health insurance policies?  Louise over at Colorado Health Insider has a terrific "101" on health insurance guaranteed issue, mandates, underwriting, the role of high risk pools and the impact of Affordable Care Act. The DMCB recommends that everyone - except the White House - bookmark this page just in case were forced by the Supreme Court into a health insurance orm do-over. The White House is being given a pass by the DMCB because if that happens, no one will really care what they think.

Speaking of the Individual Market....

In case you think all progressives uncritically support the Affordable Care Act, Maggie Mahar at the healthinsurance blog inconveniently points out that a big part of the individual health insurance market will remain broken come 2014. Maggies post offers up some compelling statistics that demonstrate that many middle aged boomers (yikes, including the DMCB) who are between ages 50 and 64 years wont meet income thresholds for subsidies.  As a result, theyre looking at the prospect that health insurance premiums could reach an unaffordable average of $7500 a year. Combine that with a lackluster job market, declining incomes and substantial out-of-pocket costs and it is clear that health orm will remain a contentious, time-consuming and difficult work in progress for years to come. In the meantime, the DMCB will wonder about the affordability of essential benefits, the merits of value-based insurance designs, how population health-based care management can help blunt the impact of chronic illness and the wisdom of  using limits on age rating to shift costs to the DMCB spawn.

STATES

One States Perspective on Federal Health Reform

While Californias budget slides into the sea thanks to an unending budgetary earthquake, every dollar counts. Thats why Anthony Wright of the Health Access Blog points out that in addition to the patently obvious merits of assuring access, lowering costs and protecting consumers, the Affordable Care Act is also a windfall for the Golden State.  He quotes and links a California-based Bay Area Council Economic Institute report that calculates that the ACA will add close to a 100,000 new California-based jobs and $4.4 billion in additional state output.  Alas, says the DMCB, between the U.S. Supreme Court and less-than-expected taxable income from the disappointing Facebook IPO, it looks like fixing Sacramentos budget woes may need a Plan C.

How Should States Respond to Health Insurance Exchanges?

Conservatives hate those ACA-mandate insurance exchanges, while progressives love them, right?  And any Republican Governor that sets up an exchange under the terms of the ACA is a hypocritical closet-supporter of Obamacare? Is that so?  John Goodmans Health Policy Blog point-counterpoint posting teaches us that its not so simple.  It turns out that states 1) may fare better with or without the ACA if they maintain control over exchanges, 2) could use the flexibility that comes with control to make insurance exchanges more effective and fair, and 3) with that control will also have a say over the commercial insurance subsidies that will add up to gazillions of dollars.  Just in case you think Johns post is just a lot of hot air, check out this telling Pennsylvania-based Op-Ed.

WORKERS COMP

Links Between Workers Comp and Health Promotion

Many health care providers regard "workers comp" as something as a policy sideshow, but Workers Comp Insider Jon Coppelman shows us that this multi-billion dollar industry is not only a big deal but also not immune to the growing costs of our sedentary lifestyle. When a 50 year old fat ambulance workers stroke was blamed on a lower extremity paradoxical embolism resulting from hours of sitting, the lifelong care costs were ruled "compensible." Next stops are the diabetes-causing donuts on our way to work and the hypertension from those generously salted fries in the company cafeteria. Mr. Coppleman recommends early adjuster involvement in the claims adjudication. The DMCB wonders if the Workers Comp insurance industry should think about being more proactive, including using risk stratification and advocating for common sense health promotion.

WELNESS AND HEALTH PROMOTION

Wellness!  Gotta Have It!

No Health Wonk Review would be complete without one enthusiastic endorsement of all things wellness. Kat Haselkorn of Corporate Wellness Insights steps into that role with copious praise of all the benefits of health promotion, including positive culture change, huge returns on investment, enriched social networks and accelerating employee productivity.  Kat suggests that if just one person buys into wellness, the effect can ripple through the company faster than spandex-clad yuppies swarming at an after-work Zumba class.

Wellness!  Gotta Keep Funding It!

New blogger Tracey Moorhead of the Care Continuum Alliance writes in the Voice On Population Health Blog about the ill-advised willingness of the U.S. House to steal from the ACAs Prevention and Public Health Fund to extend coverage of student load interest subsidies. Tracey passionately argues the fund has already led to important behavioral health screenings, data infrastructure development and expansion of wellness services in multiple states. Whoa, says the DMCB, which isnt surprised at the Care Continuum Alliances advocacy on behalf of prevention and population health.  Good for them.

And Heres An Added Benefit of Being Fit?

Michael Gavin of the Evidence-Based blog notes that a recently published article in the medical journal Pain shows that athletes have a higher pain threshold.  From his point of view, this is why exercise should not only be promoted as an alternative to using dangerous drugs to control pain but as an added overall benefit from achieving maximum fitness.  The contrarian DMCB took a look at the abstract and wonders if persons who are naturally blessed with higher pain thresholds are attracted to exercise (or at the very least, find it less unpleasant).  While readers are figuring out which is cause and which is effect, they can also show their health knowledge chops by not only erring to exercise related "endorpins" but "endocannabinoids" as the basis for the runners "high."

SPECIAL POPULATIONS

Prisoners

Talk about a disenfranchised population. Suffering with highly prevalent rates of Hepatitis C, HIV and mental illness, huge numbers of released prisoners were being left to fend on their own. Harold Pollack, also of the healthinsurance blog describes how thanks to recently passed federal legislation, hundreds of thousands of these individuals will be able to qualify for Medicaid, obtain tax credits that can defray the cost of private insurance and access basic community-based health care services. While health orm is all about the single mom waitress with two kids, the middle America steel worker and the kid with end stage cancer, Dr. Pollack says we all benefit when ex-prisoners are also staying away from crowded emergency rooms, avoiding unnecessary hospitalizations and not burdening over-stretched safety net programs.

Geriatrics

IF you believe geriatric care is important, THEN you should read this post BECAUSE youll get to learn about the "ACOVE" framework. Thats the message the DMCB got after reading Chris Langstons post on the Quality of Geriatric Care over at the John A Hartford Foundation. It turns out that the Assessing Care of Vulnerable Elders is a handy IF-THEN-BECAUSE tool that identifies the specific health issues afflicting the elderly and targets geriatriccare planning. Chris argues wider use of ACOVE would increase quality of care in geriatrics and clarify the important differences between general medical versus geriatric conditions.

CODING

Hate ICD-10?

Heres another anti-ICD-10 rant, courtesy of a post by TBD Consultings Jonena Relth at the Healthcare Talent Transformation Blog.  She argues that veteran front-line health care workers are deeply skeptical about the ultimate value of the insurance billing systems astonishingly complicated specificity and detail. Jonena is concerned that the new coding will paradoxically lead to billing errors and enable greater health insurer mischief. Too bad there wasnt any credit given to the AMA for CMS decision to delay implementation of ICD-10 as well as the organizations continuing advocacy on the issue. As for the health insurers, the DMCB thinks that given the circumstances of a very hostile Administration and the luster of an ACA-driven enrollment windfall, they quietly came as close as they could to expressing concerns over the wisdom of ICD-10.

and last but not least.....THE NEWS DISAPPOINTS...AGAIN

Prostate Cancer Screening and the News Media

As risks, benefits and alternatives to cancer screening move into the public square, Gary Schwitzers HealthNewsReview blog offers up this balanced scientific review on the merits of prostate cancer screening by Richard Hoffman and this insightful description on how the mainstream news media made a mess of things. It turns out that the U.S. Preventive Task Forces recommendations werent really all that new, that a substantial number of physicians have been PSA skeptics for years and that early detection of prostate cancer - whatever its merits - is hugely remunerative to providers. As testimony to the news elites  selective inattention, ask yourself if you should thank Diane Sawyer et al for avoiding this new wrinkle on the topic of lung cancer screening.

Image from Wikipedia