Wellness

Post Punk Vaping Dwarf

Well, it’s official: CVS has stopped selling cigarettes and other tobacco products.

The sales ban will cost the multi-billion dollar pharmacy chain about $2 billion a year in profits.  But the hope is that the move will provide a more consistent health promotion message to consumers (it has changed its corporate name to CVS Health) and lead to new business (for example, through visits to its in-store health clinics).

But will this move have any effect on smoking in the population? It’s difficult to say at this point.

The impact of the ban on overall tobacco sales nationwide will probably be negligible.  Only a very small percentage of consumers buy their tobacco at pharmacies and there are plenty of retail options available beyond the local pharmacy.

CVS is also banning the sale of electronic or e-cigarettes. Advocates from this industry are predictably agitated: “It’s smoking that causes all the health problems, not the smokeless alternatives.” Others argue that e-cigarettes and other smokeless alternatives are effective aids for those wishing to quit-smoking.

Continue reading “CVS Health: Breathing a Little Easier and Holding Our Breath”

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The Future Looks Like a Girl With a Gun Resized

I am a public health professional, educated at the vaunted Johns Hopkins University Bloomberg School of Hygiene and Public Health. I like guns, and I believe the Second Amendment clearly secures the rights of individuals to own firearms.

You read that correctly. I am a public health professional.

And I like guns.

This make me a heretic in American public health, where embracing firearms and the rights of gun owners is a gross violation of orthodoxy.

As a society, our focus on guns and not gun users derives from the shock of mass killings, such as those in Newtown, CT, Aurora, CO, Virginia Tech, and Norway, which has some of the strictest gun control laws on the planet. Mass killings, however tragic, get distorted by saturation media hysterics and 24-hour political grandstanding. What gun opponents refuse to discuss is the precipitous fall in violent crime and deaths by firearms over the past 20 years, and how it coincides with an equally dramatic increase of guns in circulation in the US.

While that isn’t cause and effect, the association is certainly curious.

In 2013, the Institute of Medicine, at the behest of the Centers for Disease Control, produced a report on firearms violence that has been ignored by the mainstream media. The upshot: defensive use of firearms occurs much more frequently than is recognized, “can be an important crime deterrent,” and unauthorized  possession (read: by someone other than the lawful owner) of a firearm is a crucial driver of firearms violence.

That report went away for political reasons. Translation. Nobody wanted to talk about it because it raised more questions than it answered.

Continue reading “Why Public Health Needs a New Gun Doctrine”

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There are minor operations and procedures, but there are no minor anesthetics.  This could turn out to be the one lesson learned from the ongoing investigation into the death of comedian Joan Rivers.

Ms. Rivers’ funeral was held yesterday, September 7.  Like so many of her fans, I appreciated her quick wit as she entertained us for decades, poking fun at herself and skewering the fashion choices of the rich and famous.  She earned her success with hard work and keen intelligence–she was, after all, a Phi Beta Kappa graduate of Barnard College.  Ms. Rivers was still going strong at 81 when she walked into an outpatient center for what should have been a quick procedure.

So when she suffered cardiac arrest on August 28, and died a week later, we all wondered what happened.  I have no access to any inside information, and the only people who know are those who were present at the time.

But the facts as they’ve been reported in the press don’t fully make sense, and they raise a number of questions.

What procedure was done?

Early reports stated that Ms. Rivers underwent a procedure involving her vocal cords.  A close friend, Jay Redack, told reporters at the NY Post, “Her throat was bothering her for a long time. Her voice was getting more raspy, if that was possible.”  In a televised interview, Redack told CNN that Ms. Rivers was scheduled to undergo a procedure “on either her vocal cords or her throat.”

However, the Manhattan clinic where Ms. Rivers was treated, Yorkville Endoscopy, offers only procedures to diagnose problems of the digestive tract.  All the physicians listed on the staff are specialists in gastroenterology.  Any procedure on the vocal cords typically would be done by an otolaryngologist, who specializes in disorders of the ear, nose, and throat.

So it may be that acid reflux was considered as a possible cause of Ms. Rivers’ increasingly raspy voice, and she may have been scheduled for endoscopy at the Yorkville clinic to examine the lining of her esophagus and stomach.  Endoscopy could reveal signs of inflammation and support a diagnosis of acid reflux.

Upper gastrointestinal (GI) endoscopy involves insertion of a large scope through the patient’s mouth into the esophagus, and passage of the scope into the stomach and the beginning of the small intestine.  It’s a simple procedure, but uncomfortable enough that most patients are given sedation or, less commonly, general anesthesia.

Was sedation given?

Three types of medication are commonly used for sedation during endoscopy:

1.  Midazolam, diazepam (Valium), or other medications in the benzodiazepine family are often used to help patients relax before the start of the procedure and to produce amnesia.

2.  Narcotics such as Demerol and morphine are often used to provide pain relief and make the procedure less uncomfortable.

3.  Propofol, a potent sedative and hypnotic medication, may be used to induce sleep and prevent awareness.  Many people first heard of propofol as the medication associated with the death of singer Michael Jackson in 2009.

Continue reading “What Killed Joan Rivers? Piecing Together a Medical Mystery”

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Giant Zuckerbergs
In the past few years, the fortunate among us have recognised the hazards of living with an overabundance of food (obesity, diabetes) and have started to change our diets. But most of us do not yet understand that Facebook is to the mind what sugar is to the body. Facebook feed is easy to digest. It has made it easy to consume small bites of trivial matter, tidbits that don’t really concern our lives and don’t require thinking. That’s why we experience almost no saturation. Unlike reading books and long magazine articles (which require thinking), we can swallow limitless quantities of photos and status updates, which are bright-coloured candies for the mind. Sadly, we are still far away from beginning to recognise how toxic Facebook can be.

Continue reading “Facebook Is Bad For You. And Giving Up Using It Will Make You Happier”

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Screen Shot 2014-08-27 at 10.40.39 AMHow much does a colonoscopy cost? Well, that depends.

If you’re uninsured, this is a big question. We’ve learned that cash or self-pay prices can range from $600 to over $5,400, so it pays to ask.

If you’re insured, you may think it doesn’t matter. Routine, preventive screening colonoscopies are to be covered free with no co-insurance or co-payment under the Affordable Care Act.

However, we’re learning that with colonoscopies, as with mammograms, people are being asked to pay sometimes. It’s not clear to us in every case that they should pay, and since we don’t know all the details of these events, we can only offer some general thoughts. We’ve also heard from Medicare enrollees without supplemental Medicare policies that they think they’re responsible for 20 percent of the charged price — so 20 percent of $600 vs. 20 percent of $5,400 is a big deal.

If you’re on a high-deductible plan and the charge to you will be, say, $3,600, you can probably ask around and find a lower rate.

A thorough view of some colonoscopy billing issues is in this article in The New York Times by Libby Rosenthal, who has been covering health costs for the paper. We’ve heard also about in-network providers using out-of-network anesthesiologists, so it pays to pay attention.

Continue reading “How Much Is My Colonoscopy Going to Cost? $600? $5,400?”

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flying cadeuciiLast year, we soundly criticized the American Heart Association (AHA) on this blog for its proposal to lower the thresholds for treating cholesterol and getting larger numbers of Americans to swallow statins. We also exposed wellness vendor StayWell, for its mathematically impossible claims of success in British Petroleum’s wellness program. Proving that great minds aren’t the only ones that think alike, StayWell and the AHA have now joined forces.  Specifically, the AHA invited the CEO of StayWell, Paul Terry, Ph.D., to help write its workplace wellness policy statement, sort of like Enron inviting Bernie Madoff to help design its financial plan. You don’t learn of this fox-in-the-henhouse conflict of interest unless you read the table on the penultimate page of text.

Naturally, Mr. Terry parlayed this windfall to StayWell’s advantage. The statement: “currently available studies indicate that employers can achieve a positive ROI through wellness” is footnoted to two studies authored by:  Paul Terry, along with other Staywell executives.  One wonders how a StayWell executive writing policy for the AHA based partly on StayWell’s own articles passes the AHA’s own test of “making every effort to avoid actual or potential conflicts of interest that may arise as a result of an outside relationship.”

How did this conflict of interest get by the peer reviewers? Look at the list of peer reviewers. Prominent among them is Ron Goetzel. Readers of THCB may recall Mr. Goetzel not just from his central role in the Penn State debacle, but also from the ”The Strange Case of the C. Everett Koop Award,” in which it was documented that his committee gave the ironically named award to a sponsor of the award (without disclosing that conflict), even though that sponsor had admitted lying about saving the lives of 514 cancer victims, who, as luck would have it, didn’t have cancer. (The sponsor, Health Fitness Corporation, a division of the equally ironically named Trustmark, has won the Koop award several times, thus proving the cost-effectiveness of their sponsorship.)

If this litany were not enough to dismiss the policy statement forthwith, there is small matter of the actual policy itself, a full employment act for wellness vendors and cardiologists alike, advocating more screening of more employees more often, while ignoring more self-evident facts than Sergeant Schultz. Specifically, they cherry-picked the available literature, continuing to cite the old “Harvard study” whose lead author has now walked it back three times. Except that they didn’t call it the “old Harvard study,” but rather a “recent [italics ours] meta-analysis,” despite the fact it was submitted for publication in 2009, and the average year of the analyses in the study was 2004.  Some studies began in the 1990s and were able to use sleight-of-hand to “show savings” despite presumably — in accordance with the conventional wisdom of the era — getting people to eat more carbohydrates and less fat.  No wonder Soeren Mattke of RAND Corporation dismissed the Harvard data as archaic in his interview with CoHealth radio in February 2014.

Continue reading “Circulation: The Nineties Called. They Want Their Wellness Policy Back”

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Recently published statistics show that the top-grossing medication in the U.S. for 2013 was the antipsychotic Abilify (aripiprazole) with over $6 billion in sales, narrowly beating out the previous few years’ winner, Nexium.

The past decade’s dominating pharmaceuticals have been Lipitor (atorvastatin) for high cholesterol and Nexium (esomeprazole) for acid reflux. Nexium was preceded at the top by Prilosec (omeprazole), and before that we had Pepcid (famotidine) and Zantac (ranitidine) somewhere near the top of the sales data.

A country’s medicine cabinets tell us something about its culture and its predominant issues.

From the late 1960′s to the early 1980′s the tranquilizer Valium (diazepam) was the top grossing drug. The 1965 US sales volume of tranquilizers was somewhere around 166 million prescriptions or 14% of all prescriptions filled in this country. Both “uppers” and “downers” were subjects of the 1966 best seller “Valley of the Dolls”. Valium rose to the top after the previous few years’ blockbuster tranquilizer Miltown (meprobamate) proved to have significant toxicity risks.

So, this country has gone from treating nervousness and suppressed emotions to heartburn and high cholesterol, the latter two sometimes self-inflicted through dietary indiscretion, and now back to psychiatric conditions like schizophrenia. True, there are other, “softer” indications for Abilify – bipolar disorder, treatment resistant depression and for chemical restraining of aggressive individuals, even children.

One cannot help but stop and reflect on this pharmaceutical sales phenomenon.

The postwar years, although portrayed in media as a time of health care advances, optimism and prosperity, were years of great anxiety. My own observation is that many of my patients and acquaintances who were children during World War II lack the emotional imperturbability of those whose childhood fell in the 1930′s, born in the early to mid 1920’s.

Continue reading “What’s In Our Medicine Cabinets?”

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flying cadeuciiRube Goldberg was an American cartoonist and inventor, perhaps best known for the extremely complicated contraptions he devised for performing the simplest tasks.  Each year, a national Rube Goldberg Machine Contest is held, challenging competitors to devise bizarre contrivances that can shine a shoe or zip a zipper.  One day while watching a group of children marvel at such a machine in a museum, a thought occurred to one of us: As healthcare becomes more complex, the interactions between patients, physicians, hospitals, payers, and communities increasingly resemble a Rube Goldberg machine.

Consider a recent case.  Ms. Jones was a 50-something year old African American woman with type I diabetes, high blood pressure and end-stage kidney disease requiring peritoneal dialysis, a form of dialysis performed nightly at home.  She was recently admitted to the hospital because of an apartment fire that destroyed everything she owned, including her home dialysis equipment and medications.  Once she was hospitalized, the medical team restarted her dialysis, restored her blood chemistries to normal, corrected her blood sugar, and began to make plans for her discharge.  There was just one problem.  They had no place to send her.

Ms. Jones could not return to her apartment, which had essentially burnt to the ground.  She did not qualify for admission to a nursing home.  And she couldn’t afford to rent a new apartment, at a cost of about $1,500 per month.  She had paid for insurance on the apartment for years, but had recently let the insurance lapse to help finance the purchase of an $8,000 living room suite.  The medical team had heard that social service agencies would provide one month’s rent, but it turned out that she could get only one-time distributions of $100 from the Red Cross and $200 from the Salvation Army – not nearly enough.

As the days rolled by, the medical team caring for Ms. Jones began feeling escalating pressure from hospital administration to discharge her.  Her medical problems had been taken care of, and there was no medical need for her to remain in a hospital bed at a cost of $1,500 per day.  The team arranged to get her dialysis supplies delivered to her sister’s house, hoping that she could stay there until she found a place of her own.  But it turned out that too many people were already living there.  Attempts to find temporary housing through friends and her church dead-ended.  Hotels she contacted were all too expensive.  Going to a homeless shelter was not a viable option; it would give her a place to sleep, but she couldn’t perform her dialysis there.  She volunteered that she could live out of her car, for which she reportedly used some of the $300 to buy gas, but it later turned out that she did not have one.

As pressure to discharge Ms. Jones mounted, team members became increasingly frustrated.  Each new hope was thwarted by an opposing reality.  The team had provided their patient with the best available medical care, marshaling the impressive resources of a major academic medical center to solve her acute medical problems as effectively and efficiently as possible.  But now they had run up against a barrier for which they lacked the necessary training and resources – not a medical problem so much as a social one.  Treating acute illness was doable, but looking out for their patient as a whole person with a real life outside the hospital was proving quite another matter.

Continue reading “Health Care’s Rube Goldberg Machine. Who Is Responsible?”

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Hospitals are environments where emotions can run high. These emotions cross all boundaries and can affect physicians, hospital staff, patients and their families. Dealing with an “angry” patient is a common challenge that physicians face.

The first step for a physician encountering an angry patient is to remain calm and allow the patient to express his or her concerns. In my experience, “angry” patients can be viewed as falling into several different categories. By understanding and thinking about these categories, physicians can begin to identify the root of the anger and take measures to address it. This exercise might seem simplistic at first. However, you’ll be amazed by how powerful the results can be.

Why do patients become angry? What are the common “root” causes?

1. Pain

Medical illness is often accompanied by pain, so much so that pain is often considered the fifth vital sign. Assessment and treatment of pain is an important factor for all medically ill patients. Anger is a common emotion in patients with pain, especially chronic pain. It is thought that the presence of significant anger may in fact further aggravate the feeling of pain. Physicians must not only be able to assess pain, but also to weigh the benefits and the risks in prescribing analgesics. When any patient appears to be “angry,” the presence of pain, especially untreated/undertreated pain, must be considered and rectified as a matter of urgency.

2. Fear and worry

Being medically ill, especially if one is hospitalized, can be an intensely destabilizing experience for both the patient and his or her caregivers. In some cases, an unknown prognosis, the occurrence of complications or the impact of the illness on their independence, can make patients fearful about the future. This worry can manifest as anger, and since patients cannot direct their worry or anger toward their illness, this anger may be displaced onto people around them, including hospital workers. Attempting to recognize, and where possible alleviate, their worries is often very helpful.

3. Feeling unheard or uninvolved 

Any patient who displays anger in a hospital setting is guaranteed to attract attention. For some patients the expression of anger may actually suggest that they feel “unheard” in the medical setting. They may feel that they do not have enough information about their condition or their concerns have not been addressed. The question then arises, how do we make them feel heard? Do they understand why they are in the hospital? Do they understand what their treatment options are? Do they feel they have been part of the decision-making process? Ensuring that patients feel they are involved in their care can reduce the anger that can arise out of being “unheard” in a hospital.

Continue reading “The Angry Patient: A Primer For Physicians.”

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cheeseburger

Consider that for the last year or so, we have been treated a deluge of entreaties to reduce our salt intake, with the American Heart Association going so far as to claim that daily sodium intake should not exceed 1,500 mg. This puts it at odds with the Institute of Medicine, and now European researchers whose data indicates that the healthy range for sodium intake appears to be much higher.

Our conversation about  sodium, much like advice about purportedly evil saturated fats and supposedly beneficial polyunsaturated fats, exemplifies a national obsession with believing eating more or less of a one or a small number of nutrients is the path to nutritional nirvana.

A few weeks back, an international team of scientists did their level best to feed this sensationalistic beast by producing what’s become known since then as the meat-and-cheese study, because it damned consumption of animal proteins.

Continue reading “Cheeseburger Please, and Make It a Double”

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FROM THE VAULT

The Power of Small Why Doctors Shouldn't Be Healers Big Data in Healthcare. Good or Evil? Depends on the Dollars. California's Proposition 46 Narrow Networking

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Munia Mitra, MD
Chief Medical Officer

Vikram Khanna
Editor-At-Large, Wellness

Joe Flower
Contributing Editor

Michael Millenson
Contributing Editor

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