The Stalwart

Is A Dime's Worth Of Prevention Only Worth A Dime Of Treatment?

That's not what you usually hear, but it may be so. At least it's worth questioning the standard dogma.

Blood Sugar, Data Centers and MADD

I saw a post today on Art de Vany's blog  about carbs, sugar and insulin resistance which ended with this line:

The really bad part of all this is that there are a lot of high insulin people out there who can "bonk" from low blood sugar if they don't get their carb hit. And then after the hit wears off, they may "bonk" again. They may be driving when this happens and are easily angered and lose concentration. They can be a danger to themselves and others when this happens. I would bet a fair number of auto accidents could be traced to blood glucose/insulin surges.

I thought the last line was interesting. It was literally five minutes later then that I saw this post on Valleywag about the recent outtage at data center RackSpace. Apparently the company's facilities were hit by a truck, whose driver had passet out to... low blood sugar. Interesting.

Perhaps everyone else knew this but me, but apparently this is a common phenomenon, as a quick search of the web will reveal.

Not trying to be glib here, but I wonder why there isn't an organization like MADD encouraging people to be more careful about their sugar intake. Or, in typical MADD fashion, trying to criminalize people with hypoglycemia. Speaking of MADD and neo-prohibitionism, the Reason magazine crowd has been all over them lately.

Also, is it possible that Tony Soprano's issues with blackouts and such were more the result of blood sugar issues than panic attacks? He did have a pretty terrible diet after all. Then again, the creators of the show seemed to make it pretty clear that there was a psychological element rather than anything physiological.

Good News on the Peanut Front?

As one who suffers from severe peanut allergies (I've had it since before it was trendy), it's always good to see some good news.

Seeing of which, does anyone know what's happening on the Xolair front these days?

More Reason To Support Walk-in Clinics

On the overconfidence of doctors:

1316 patients who had no regular source of care and kept their initial primary care appointment were enrolled and randomized with either a nurse practitioner (n = 806) or physician (n = 510). ... No significant differences were found in patients' health status ... at 6 months ... hypertension ... was statistically significantly lower for nurse practitioner patients (82 vs 85 mm Hg; P = .04). No significant differences were found in health services utilization after either 6 months or 1 year. There were no differences in satisfaction ratings following the initial appointment (P = .88 for overall satisfaction). Satisfaction ratings at 6 months differed for 1 of 4 dimensions measured (provider attributes), with physicians rated higher (4.2 vs 4.1 on a scale where 5 = excellent; P = .05).

But docs are taught more medicine than nurses; why are they no better at primary care?  Probably because docs are famously overconfident.  For example, one study found that on average when docs were 88% confident that their patient had pneumonia, in fact only 20% of such patients had pneumonia.   And overconfidence is fatal in primary care.

On Pfizer's New HIV Therapy

Derek Lowe discusses the significance of Marivorac, Pfizer's newly approved HIV therapy:

Pfizer got a tiny bit of good news yesterday when an FDA panel recommended their new HIV drug, Maraviroc, for approval. There are several stories that can be told about this news, so let's try a few: The business story is that this is not going to make a lot of difference for the company, because the drug isn't going to be a first-line therapy. They have to hope that it performs well and can expand its use, because a $25 to $50 million/year drug is a roundoff error on the scale of Pfizer's financial concerns. So much for the money.

...

And the big philosophical story is how the world has changed in the last twenty years. Here's a new HIV medication, one with a new mechanism, and it makes the second business page of the paper if it makes it at all. A completely new drug for a dreaded disease is coming, and no one thinks it'll do all that well, because of all the competition, y'know. It'll be given to people who've failed courses of treatment with all the other HIV drugs out there, and unless you're paying attention it's hard to keep up with all of them.

Is There Something Going Around?

Every time I get the flu or a cough someone says to me, "Yeah, there's something going around, everyone I know is sick."  I've always figured that this was just the result of mental bias.  Maybe they do know one other person who has a cold, or maybe it's just something to say.   

Another problem with these statements is that germ theory is rubbish.  Kidding!

Anyway, a new website aims to answer this question.  Who Is Sick? will attempt to create an online map that documents stuff like headaches, nausea and colds in your neighborhood.  The key will be in getting enough people to actually use the site and regularly remember to enter it in anytime they have some ailment.  I'm not sure what incentives they can offer to get people to do this.  But it would be really cool if it did work, and then if someone tells you that there's something going around, you can tell whether they're actually basing that on something or if they're making time-wasting chit-chat.

The C Word

Cancer has injected itself into the public consciousness a number of times lately, as current or past bouts with hit have struck a surprisingly high number of Presidential candidates.   Obviously, cancer is a pretty scary prospect for anyone facing it, but I've been wondering whether there's a generational gap when it comes to thinking about it.   It seems like the "C Word" might not be as ominous sounding to me as it is to someone 30 or 40 years older.   Fact is, I don't think of it as a death sentence.  I think of it as a serious illness, to be sure, but hearing about it doesn't strike me with the same thud as it might someone who is older .

It's pretty obvious why cancer doesn't seem so scary to me -- it's not as scary of a disease at it used to be Cafe Hayek points to a piece on today's Times on this subject:

News about cancer, it seems, is everywhere. But, as statisticians readily explain, impressions can be misleading. While cancer remains the second-leading killer of Americans, behind heart disease, and while no one would make light of the toll from the disease, cancer deaths are on the wane.

68% of Medicare Spending From Only 23% of Users

Pulled this out of an article in the WSJ regarding medicare reform. This alarming fact is causing a shift in the way the US government reimburses private care providers- it will now try and tempt private care providers to take on very sick patients by compensating them more for doing so.

...a well-known challenge facing Medicare: 83% of its beneficiaries have at least one chronic condition. Most significantly, 23% of beneficiaries have five or more chronic conditions, and they account for 68% of Medicare spending, according to an article published last year in the New England Journal of Medicine by Gerard F. Anderson, a professor in the department of health policy and management at the Johns Hopkins Bloomberg School of Public Health. ...

As the government tries to encourage more beneficiaries to shift out of traditional Medicare and into plans run by private insurers, officials are trying out a new method of paying those insurers. Plans now receive higher payments when they attract sicker people. They get extra money for enrolling certain low-income people, too. ...

It's easy to see why insurers would be attracted to the new payment model. On top of the set amount a plan receives per patient in the managed-care arm of Medicare, known as Medicare Advantage, under the new model, additional payments are tacked on for each health problem the patient has -- a technique known as "risk adjustment." ...

Before risk adjustment, Medicare would have paid a health plan about $8,145 per year to take care of a 70-year-old woman with high blood pressure and osteoporosis, under an example formulated by XLHealth. The amount would have been the same regardless of the severity of her health conditions; only the age and sex of patients was taken into account. Under the new model, Medicare would pay widely varying amounts of money for the same patient, depending on how sick she was.

If her health problems were not severe, the insurer would receive about $4,075 for the year -- much less than under the old model. But if the woman had diabetes, the amount would jump to $6,197. If the diabetes had led to circulatory problems, the insurer would receive $12,182 -- much more than under the old model. If the patient also had emphysema, congestive heart failure and depression, the insurer would receive $30,126 for the year. ...

Seems sort of strange that this logical method hasn't existed before. Nevertheless, it looks as though such a change is seen as good news by health insurance companies such as United Health Group, (NYSE:UNH) as mentioned in this WSJ article. We note though that this company is having internal problems related to options back-dating.

Big health-insurance companies like UnitedHealth Group Inc. view the sector as an opportunity. UnitedHealth has long offered special-needs plans geared toward patients in nursing homes through an experimental Medicare program. Next year, the company plans to begin offering chronic-disease plans too.

The Coming Healthcare War

Matthew Holt discusses a theme we've been touching on a lot in a post called "Why diagnostic radiologists won't make $400K a year forever":

One of the smartest observers of the medical scene, UCSF's Bob Wachter had an interesting article in the NEJM on The Implications of Medical Outsourcing. Here's the key point:

By severing the connection between the "assay" and its interpretation, digitization allows the assay to be performed by a lower-wage technician at the patient's bedside and the more cognitively complex interpretation to be performed by a physician who no longer needs to be in the building — or the country.

Of course they'll be lots of resistance to this -- and if anything Wachter understates the extent of the war that's about to happen (think specialty hospitals) (emphasis added). But eventually collaboration software (as being plugged by Microsoft and Nortel) will remove the need for much direct physical connection between patient and physician, and skilled technicians and lower-paid clinicians will mediate between them.

Eventually, the barriers to entry that have kept incomes so high in the healthcare profession will have to come down, and as Holt says, yes, it will probably be a war, as various interest groups fight tooth and nail (well, lobby) to keep various artificial protections in place. 

If only US factory workers could have claimed "consumer safety" as a reason to prevent outsourcing...

Job Security in Healthcare

We've argued before that the labor-conflicts of the future won't involve the traditional workers in areas like manufacturing or mining, but will involve professional workers, like lawyers and doctors,.  The threats to them aren't 'management', and we don't think of them being unionized (though they are), but both groups organize in a manner to increase barriers of entry and thwart innovation and outsourcing, to make their skills more scarce, and drive up profits.  And arguably, because these groups are more well-heeled, their unions (AMA, ABA) are  more powerful than the trade or manufacturing unions were, in gaining protections.

We received an interesting email from a reader yesterday on the subject of MinuteClinic and the changing nature of healthcare.

I just ran across your website and wanted to let you know I enjoyed your posts.  Regarding healthcare costs I agree that solutions such as Minute Clinic are on to something.  What was once called the Patient-Physician relationship is now the Patient-Provider relationship.  As Providers,Nurse Practitioners (NP) and Physician Assistants (PA) can now fill this role at a reduced cost due to lower training costs, malpractice insurance and salaries.  There is another side to this as well and that is in the proprietary software utilized by Minute Clinic to "guide" medical decision making in their clinics. While the selection of medical problems they currently treat is limited I suspect in time as the programs develop this will be greatly expanded to cover the majority of primary care problems encountered in a Family Practice Clinic.  Who knows, if much of the relatively minor medical decision making is being guided by the a software it will only be a matter of time before the NP's and PA's will be replaced by Providers functioning in virtual reality.  If you think medical decision making can't be made without a physical exam see this weeks article in Forbes (2/27/06) titled Dial-A-Doc by Amanda Ernst.  It's just a thought but there sure seems to be a steady drum beat in healthcare to lower cost, improve access, and with any hope continue to improve quality.  In case your wondering, I work in healthcare as a Trauma Surgeon.  I used to consider Trauma a field with guaranteed job security but not anymore. 

There's no doubt that if surgeons, en masse, really start feeling that their jobs aren't secure, there's going to be a major effort to stem whatever trends are causing that.  It'll be the same for lawfirms who bill their para-legal's hours at $100/hour, when firms in India can do the same paper-pushing for $25.

Back to the subject of healthcare, the main problems facing the industry are the spiraling cost, as well as the swelling ranks of the uninsured.  It's actually the same problem, since, if costs were lower, insurance would be more available.