Healthcare That You Should Avoid, part 2

A chest X ray. One of many tests you shouldn't have routinely. Credit: Aidan Jones/Wikimedia commons

16% of all spending in the US is on healthcare. About half of that is spent by federal, state, and local governments, and the other half is spent by the private sector. In 1970 about 7% of all spending was for healthcare. Total annual spending on healthcare per person has increased from less than $1,000 in 1970 to about $8,000 now.

Defenders of our current healthcare spending are quick to point out that while we’re spending much more, we’re getting much better healthcare. New technological developments are constantly bringing better treatments to patients, and patients are living longer. The increased expense, they would argue, is worth it. But we shouldn’t believe them. In all other sectors (housing, transportation, food, …) quality improves while prices drop. We spend a smaller fraction of our money on transportation than we did a generation ago despite the fact that cars are safer and more fuel efficient and that commercial airline travel is inexpensive enough to be enjoyed by the middle class. We are right to expect medical care to become both better and cheaper over time.

Why hasn’t it? I believe our current insurance payment system rewards overutilization and drives prices up. (I wrote a series of posts analyzing the issue in 2009.) Because the vast majority of healthcare dollars are not paid by the patients receiving the care, there is little disincentive to provide care that has little or no benefit. In fact there is a great incentive to the doctor to provide as much such care as possible.

Besides high prices, this has resulted in a healthcare culture in which doctors offer and patients have come to expect tests and treatments which have been proven to be entirely without benefit. Last April in an attempt to educate both doctors and patients about interventions that are valueless, the American Board of Internal Medicine Foundation partnered with a number of physician specialty societies and formed an initiative called Choosing Wisely. I wrote about it at the time. The program listed 45 different tests and treatments in nine different specialties that doctors shouldn’t offer and that patients should question.

This week, Choosing Wisely has expanded this list. Many new physician specialty societies have come on board and the list of valueless tests and treatments has grown to 90.

Among the new recommendations are:

  • Don’t perform EEGs for headaches. The American Academy of Neurology finds that EEGs don’t help in diagnosing the cause and do not improve outcomes.
  • Don’t recommend feeding tubes in patients with advanced dementia; instead offer oral assisted feeding. The American Geriatrics Society reviewed the evidence that careful hand-feeding is as safe in patients with severe dementia and that tube feeding leads more frequently to agitation and worsening skin sores.
  • Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium. The American Geriatrics society reminds us of the risks of motor vehicle accidents, falls and hip fractures can more than double in older adults taking sleep medicines.
  • Cough and cold medicines should not be prescribed or recommended for respiratory illnesses in children under four years of age. The American Academy of Pediatrics reminds us that these medicines have little benefit in young children and have potentially serious side effects.

Feel free to browse the list yourself. It is a fascinating gallery of bad medicine. I must confess that I’m guilty of some of the misdeeds myself. I have a handful of older patients who take Ambien (zolpidem). How delighted will they be when I refuse their pharmacy’s request for the next refill and tell them that there are safer alternatives?

Choosing Wisely is a worthwhile effort. It may prevent patient harm and improve care. But I suspect it will not make a dent in costs. As long as doctors have a financial incentive to provide inappropriate care, some of them will. As long as patients have little financial incentive to assure that their care is appropriate, many of them will not.

Learn more:

Medical Waste: 90 More Don’ts For Your Doctor (Shots, NPR’s health blog)
Group Urges Health-Test Curbs (Wall Street Journal)
Doctors list overused medical treatments (Los Angeles Times)
Choosing Wisely

My last post about Choosing Wisely: Healthcare That You Should Avoid

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The Pathogens on Cupid’s Arrow

 

“Love is a burning thing
And it makes a fiery ring”
— Johny Cash

On Valentine’s Day some think of chocolate, or wine, or flowers. Physicians think of sexually transmitted infections (STIs). This week with perfect timing, the Centers for Disease Control and Prevention (CDC) released two studies quantifying the burden of STIs in the U.S. The studies estimated the nationwide burden of eight STIs – chlamydia, gonorrhea, syphilis, genital herpes, human papillomavirus (HPV), hepatitis B, HIV, and trichomoniasis. The results showed that there are about 20 million new cases of these STIs annually, and that the prevalence of STIs, that is the number of new and existing infections at a given time, is 110 million. Over half of the STIs, both in terms of new infections and prevalent infections, are due to HPV, the virus that can cause genital warts and cervical cancer. And most of the infections are in young people between the ages of 15 and 25. How romantic!

As if that wasn’t enough to throw a wet blanket on the national mood, this week’s Morbidity and Mortality Weekly Report followed up on a story I first wrote about a year ago – the emerging threat of multi-drug resistant gonorrhea. Gonorrhea remains a serious public health threat in the U.S. with over 300,000 new cases reported in 2011. Peruse my post from a year ago for the detailed history of the gonorrhea bacterium repeatedly overcoming whichever antibiotic we use against it. Since the 1940s gonorrhea has developed resistance to sulfanilamide, penicillins, tetracyclines, and most recently fluoroquinolones. That leaves cephalosporins as the last family of antibiotics uniformly effective against gonorrhea.

This week’s report warns that strains of gonorrhea resistant to cephalosporins have been isolated in Japan, France, and Spain in the last few years. Strains in the U.S. remain sensitive to cephalosporins, but laboratory measures of cephalosporin sensitivity in isolated strains are slowly decreasing. No other effective antibiotic alternative is on the horizon, so the appearance of cephalosporin-resistant gonorrhea may essentially mean the appearance of untreatable gonorrhea. How romantic!

So as we approach the end of the antibiotic century, perhaps we should all try to rediscover the virtues of monogamy. That may sound quaintly retrogressive, but no more so than the notion of having no treatments for common infections.

“You must remember this
A kiss is still a kiss
A sigh is just a sigh
The fundamental things apply
As time goes by”
— Herman Hupfeld

Learn more:

‘Ongoing, severe epidemic’ of STDs in US, report finds (Vitals, NBC News)
CDC Warns of Super-Gonorrhea (ABC News)
‘Severe epidemic’ of sexually-transmitted diseases is sweeping the nation, warns CDC on Valentine’s Day (Daily Mail)
CDC Grand Rounds: The Growing Threat of Multidrug-Resistant Gonorrhea (Morbidity and Mortality Weekly Report)
Incidence, Prevalence, and Cost of Sexually Transmitted Infectious in the United States (CDC Fact Sheet)

My last post about multi-drug resistant gonorrhea: Untreatable Gonorrhea – The Next Infectious Threat

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Newsflash: Smoking is Very Unhealthy

Image credit: Wikimedia commons

I have shocking news. Smoking is very very bad for you.

In 1964 the US Surgeon General issued a report summarizing the known adverse health effects of smoking. At that time about 40% of American adults smoked. A widespread campaign followed informing Americans about the link between smoking and lung cancer, emphysema, stroke, and heart attacks. Federal law required the placement of health warnings on cigarette packages, and school children all learned about the adverse health effects of smoking.

By 2010 the prevalence of smoking decreased to 19% of American adults, mostly because of more people quitting (rather than fewer people starting). But from 2004 to 2010 the prevalence of smoking has changed little. We seem to have reached a steady state, a nadir of smoking despite the now well-known health hazards. And while smokers were much more representative of the general population in the 1960s, they are now disproportionately poor and less educated. Current smokers are also on average younger than non-smokers, since so many smokers quit as they get older.

This week the New England Journal of Medicine (NEJM) published two studies that attempted to quantify the differences in longevity between smokers and non-smokers. The studies followed hundreds of thousands of men and women and compared the information about their smoking status to their longevity and cause of death.

The results were fairly dramatic. On average, those who never smoked live over 10 years longer than those who continue to smoke their whole lives. For those between 25 and 79 years old, the death rate for smokers is three times that of those who never smoked. Those who quit also did much better than those who didn’t. Those who quit between the ages of 25 and 34 lived 10 years longer than those who continued smoking, almost reaching the longevity of those who never smoked. The benefit of quitting decreased with increasing age, but never disappeared. Smokers who quit between the ages of 55 and 64 still lived 4 years longer than those who kept smoking.

My regular readers will recognize that these are not randomized studies, and they therefore deserve some skepticism. That’s true. One study was controlled for alcohol use, educational level, and body mass index, but one can easily imagine other confounding factors (poverty, poor access to health care) that may be more prevalent among smokers and independently increase the risk of death. So we can’t be certain that the effect of smoking is as large as the study suggests. Still, the studies add to a mountain of evidence that has already established the risk of smoking. And a randomized study will never be done, so we will never be able to measure the risk exactly.

The bottom line is that smoking is likely to cut your life short. Quitting at any age has benefits. Sooner is better.

The author of an accompanying editorial in the same NEJM issue concludes with this concern.

Because smoking has become a stigmatized behavior concentrated among persons of low social status, it risks becoming invisible to those who set health policies and research priorities. Yet, the need for greater attention to the policies known to reduce the prevalence of smoking remains urgent. As former Australian Health Minister Nicola Roxon has said, “We are killing people by not acting.”

But the increasing “invisibility” and disenfranchisement of smokers seems to me inevitable. For half a century we have very successfully educated people about the risks of smoking. We have waged a campaign that has made it clear that smoking is hazardous and we have tried to make it uncool. We cannot simultaneously applaud our important success while being surprised that those most resistant to the message are those whom information and solid judgment are least likely to reach.

All diseases that are predominantly acquired through behaviors, like HIV or cervical cancer, follow the same pattern over time. As education about prevention of the disease spreads, those who have access to information and value their health will stop contracting the disease. A generation later those who are still engaging in the risky behaviors are very difficult to reach. Few problems are more intractable than people in free societies choosing to harm themselves.

Further progress in decreasing the prevalence of smoking is likely to be incremental and slow. I suspect further attempts at addressing this problem through policy will involve tradeoffs, not solutions.

Learn more:

Smokers Lose 10-Plus Years of Life, Studies Find (Wall Street Journal)
Quitting smoking prolongs life at any age (LA Times)
Putting a Number on Smoking’s Toll (NY Times)
21st-Century Hazards of Smoking and Benefits of Cessation in the United States (NEJM article)
50-Year Trends in Smoking-Related Mortality in the United States (NEJM article)
New Evidence That Cigarette Smoking Remains the Most Important Health Hazard (NEJM editorial)

Tangential Miscellany

Seven years and over 300 posts ago I decided to start writing a weekly health news blog. Since then my posts have been republished in half a dozen publications, started some fascinating debates, and I hope educated and stimulated you. Thank you for reading. I promise to try not to bore you in the next seven years.

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Curing Clostridium difficile with, um, Feces

[This post is grosser than most. You may not want to read it over lunch.]

 

Electron micrograph of C. dif. bacteria. Image credit: CDC PHIL(6260)/Louis S. Wiggs

Last year I warned that Clostridium difficile (C. dif.) infections are becoming more common.

C. dif. is a bacterium that infects the colon causing severe, sometimes life-threatening, diarrhea. C. dif. infection is frequently a complication of antibiotic use. Antibiotics can kill the normal bacteria in the colon and establish an opportunity for C. dif. to proliferate. After a course of antibiotics, a person can remain susceptible for a few months, and subsequent exposure to C. dif., usually in a healthcare setting, can lead to infection.

The mainstay of C. dif. treatment is more antibiotics, typically vancomycin or metronidazole. But these antibiotics don’t always work, and in many cases the C. dif. infection is not eradicated and the diarrhea recurs.

For over 50 years investigators have suspected that restoring normal gut bacteria could treat C. dif. infection. In 1950s the bacterium C. dif. had not yet been isolated, but the severe colon infection that sometimes followed antibiotic use was well known. In 1958, physicians in Denver treated patients with C. dif. colitis with enemas containing feces from healthy people. They reported that their patients rapidly and dramatically improved and urged further study of this treatment.

Since then, antibiotic treatment for C. dif. was discovered, and the idea of curing C. dif. by restoring normal bacteria languished, mostly because the thought of treating a patient by giving him feces is aesthetically so unappealing. Nevertheless as C. dif. became more prevalent in recent years, and as antibiotic treatments became less effective, many gastroenterologists have resorted in desperation to treating these very sick patients with donated feces, either by enema, or through a colonoscope, or through a tube inserted through the nose to the small intestine. Invariably the success rates were extremely high, but this treatment never gained legitimacy, partially because of the lack of a rigorous trial comparing it to accepted antibiotic treatment, and partially because of the enormous yuck factor.

This week the New England Journal of Medicine published online a study that should convince the skeptics, if not the squeamish. Researchers in the Netherlands randomized patients with C. dif. infection who had already failed one course of antibiotic treatment. The patients were randomized into three groups. One group received the standard antibiotic treatment of vancomycin for 14 days. A second group received vancomycin for 14 days followed by a solution that flushes out the intestines by causing diarrhea (similar to a colonoscopy preparation). The third group received vancomycin for 4 days, the solution that flushes out the intestines, and then an infusion of feces through a tube inserted through their nose into the small intestine.

The research protocol made many strides in minimizing the unpleasantness of the stool infusion, and patients tolerated it very well. The infused “material” was provided by anonymous donors who were screened for infectious diseases. I’ll spare you the details of how the donated material was prepared, but the very curious can read the NY Times article about this study. Suffice it to say that the patients don’t see the infused solution. They only experience a plastic tube in their nose.

The results were quite dramatic. In fact, the study was stopped early because the differences between groups were so great. 81% of the patients receiving the feces infusion were cured after the first infusion, and most of the rest were cured with a second. In the antibiotic group about a third were cured, and in the group receiving vancomycin followed by the intestinal flushing solution, only about a quarter were cured. Many of the patients receiving antibiotics requested the feces infusion after the trial ended.

This should convince physicians and patients that if a first course of antibiotic treatment has failed, fecal infusion is a rational next step. It is hoped that eventually researchers will find and culture the bacteria that are responsible for inhibiting the growth of C. dif. so that eventually patients can swallow capsules of live cultured bacteria, eliminating the need to deal with human waste.

Learn more:

When Pills Fail, This, er, Option Provides a Cure (NY Times)
Faecal transplants succeed in clinical trial (Nature)
Duodenal Infusion of Donor Feces for Recurrent Clostridium difficile (NEJM Original Article)
Fecal Microbiota Transplantation — An Old Therapy Comes of Age (NEJM Editorial)
My previous posts about C. dif.:

Clostridium difficile Infections on the Increase
A New Treatment for Clostridium difficile

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This Year’s Flu Season Isn’t Mild

Photo credit: CDC

The last two years have graced us with atypically mild flu seasons. This year we’re not so lucky. The flu season seems to have started early, and at least on the East Coast is quite severe. This week Boston has declared a public health emergency as their emergency departments became swamped with flu cases. In Pennsylvania, a hospital erected a tent outside its emergency department for the increasing number of flu patients. The number of flu cases is increasing in California too, though we may be a week or two behind the wave of illness that has struck the East.

What should we all do to avoid getting sick?

  • Everyone over 6 months (except for a few exceptions) should get the flu vaccine.
  • If you get sick, stay home except to get medical care.
  • While sick, limit your contact with others as much as possible.
  • Wash your hands frequently with soap and water or with hand disinfectant, and avoid touching your eyes, nose, and mouth.

There are antiviral medicines that can decrease the duration of the flu. They are only recommended for people who are likely to have serious complications from the flu – pregnant women, older people, or people with chronic illnesses. If you are in those categories, contact your doctor at the first sign of flu symptoms. Antiviral medications are more effective the earlier they are started.

The season hasn’t peaked yet, and may turn out to be just moderate. We’ll know in a few weeks. In the meantime I recommend a little social distancing until the worst is behind us. Stay a couple of feet away from people. Say hi with a friendly wave instead of a handshake. Write an IOU to be redeemed in the spring for the hug and kiss with which you usually greet a friend. She’ll thank you if it turns out either of you is about to get sick.

And get your flu shot.

Learn more:

Flu Season Strikes Early And, In Some Places, Hard (Associated Press)
As Cases Spike, Flu Season May Be Peaking In Boston (Shots, NPR health news)
Number of NYC flu cases higher than in past years (Wall Street Journal)
Google Flu Trends for Los Angeles
Seasonal Influenza: Flu Basics (Centers for Disease Control and Prevention)
Key Facts About Seasonal Flu Vaccine (Centers for Disease Control and Prevention)
Hospital Opens Emergency Tent in Midst of Increasing Flu Cases (NBC Phiiladelphia)

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Many Women Who Don’t Need Them Are Still Getting Pap Tests

Cervical cells collected in Pap tests: normal cells on the left, precancerous cells on the right. Ed Uthman/Wikimedia Commons

My regular readers know that I frequently bemoan the fact that we have no effective way to test for most cancers, and that in many cancers early diagnosis does not improve survival. Cervical cancer is one of the few exceptions. Since Georgios Papanikolau developed the test named after him, the Pap test has dramatically reduced the incidence and mortality of cervical cancer.

More recent advances have shown that cervical cancer is caused by human papilloma virus (HPV), a sexually transmitted infection. Specific testing for HPV is now frequently performed in addition to the Pap test, and a vaccine against the most dangerous strains of HPV is likely to further decrease cervical cancer incidence.

We also now understand that the changes that HPV cause are detectable years before cervical cancer occurs, so the interval between tests can be quite long. Current recommendations are for all women between the ages of 21 and 65 to have a Pap test every three years. If HPV testing is also used, women over 30 can be safely tested every 5 years.

Women over 65 who have been previously tested and have had normal test results are unlikely to benefit from further testing. Also women who have had a total hysterectomy (surgery in which both the uterus and cervix are removed) do not need further Pap tests, because they don’t have a cervix. (An important exception is women who have had a hysterectomy because of cervical cancer or pre-cancerous changes.)

This week brings us evidence of too much of a good thing. The current issue of Morbidity and Mortality Weekly Report (MMWR) published a survey of women over 65 and women who have had hysterectomies. It asked them if they had a recent Pap test. Two thirds of women over 65 answered affirmatively as did 59% of women who have had hysterectomies. I found that as surprising as if 59% of bald men were still going to their barber regularly. It’s hard to know what’s behind this behavior. These women can’t benefit from the tests they’re undergoing. Perhaps this is a manifestation of long-established habits for both the doctors and the patients. Another possible explanation is that some of the women surveyed are simply wrong. The study didn’t actually check medical records, and some of the women may have thought that they had been tested when they hadn’t. Obviously, the most pernicious possibility is that many doctors are still recommending useless testing to patients who trust them. (If Medicare paid for haircuts one wonders how many bald men would still go to their barbers, just for the attention and social interaction, and how many barbers would sent reminder postcards to their bald patients.)

So if you’re between 30 and 65 and are having both Pap tests and HPV testing and your results have been normal, give yourself 5 years between tests. And if you’re over 65 and your tests have been normal, or you no longer have a cervix, congratulate yourself for permanently escaping cervical cancer and feel free to forego further testing.

Learn more:

Pap Tests For Cervical Cancer Are Often Wasted (Shots, NPR health news)
CDC: Women with hysterectomies getting unneeded Paps (USA Today)
Cervical Cancer Screening Among Women by Hysterectomy Status and Among Women Aged ≥65 Years — United States, 2000–2010 (MMWR)
Announcement: Cervical Cancer Awareness Month — January 2013 (MMWR)
US Preventive Services Task Force recommendations for cervical cancer screening
My post in 2009 summarizing the recommendations for Pap tests: Should You Have a Pap Smear?

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On the Passage of Time

The sun will come up tomorrow.
— Little Orphan Annie

But in a trillion tomorrows the sun will become
a red giant and extinguish all life on earth.
— astronomers

If you’re reading this, you’ve completed another loop around the sun. Congratulations.

Marking space is easy. Walls, fences, lane dividers, buoys, flags, are all ways of communicating that the space over there is different than this space over here. Marking time is harder. We need holidays, calendars, events to remember that what comes after is different than what came before. While we can revisit places, we can’t revisit times.

So as the rightmost digit on the calendar is about to be incremented, it’s a good time to reflect on the successes and the setbacks of 2012 and to make realistic goals for 2013. The only thing about 2013 about which I am certain is that we’ll only get to do it once.

I wish us all a prosperous, healthy, and joyous 2013!

Learn more about time:

Dave Brubeck, one of the greatest Jazz composers ever, died in 2012. Here is a link to his best known song, from the album Time Out, which was a collection of experiments with different time signatures.
Dave Brubeck Quartet – Take Five (5 minutes)

How is it that the past is so different from the future? Why can we remember 2012 but not 2013 (at least yet)? Why can’t you uncook an egg or unburn a match? Those with a background in science know that the answer relates to the Second Law of Thermodynamics. I’ve seen no better discussion of this fascinating question targeted to a general audience than the following lecture by Richard Feynman.
Richard Feynman – The Character of Physical Law -Lecture 5 -The Distinction of Past and Future (46 min)

Lucius Annaeus Seneca: On the Shortness of Life

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Niacin: Ineffective, and Now with Fewer Side Effects!

Photo credit: Wikimedia commons

I haven’t written about niacin for over a year, and like a misunderstanding of the Mayan calendar that won’t go away, niacin is in the news again this week.

You can catch up on the old news by reading my previous posts (links below) but here’s the story in a nutshell. People with high levels of a cholesterol molecule called LDL tend to have more strokes and heart attacks than people with normal LDL levels. People with low levels of a cholesterol molecule called HDL tend to have more strokes and heart attacks than people with normal HDL levels. (Does that mean that LDL causes strokes and heart attacks or that HDL prevents strokes and heart attacks? Nobody knows.) We’ve long known that taking niacin raises HDL and lowers LDL. That should be good, right? And in fact a study called the Coronary Drug Project in the 60s and 70s showed that in patients with a previous heart attack, taking niacin modestly reduced the risk of another heart attack.

More recently, many other medications have been proven to prevent strokes and heart attacks – aspirin, statins (a family of cholesterol reducing medicines), and beta blockers (a family of blood pressure medicines). These medicines are now in widespread use. Statins especially have very solid evidence that they greatly decrease the frequency of strokes and heart attacks, and now that some of them are available generically they are used extensively. Last year, the AIM-HIGH trial tried to discover whether patients with a history of cardiovascular disease and low HDL had better outcomes by taking niacin with a statin than by taking a statin alone. They didn’t  The rates of strokes and heart attacks were the same in both groups, strongly suggesting that in the age of statins, niacin has no additional benefit.

Now, when faced with a medication that has no benefit, I typically decide not to prescribe it, but not the folks at Merck. They were thinking “How can we decrease the side effects?” Why it would be valuable to decrease the side effects of a medicine without benefit is a mystery that only Mayan astronomers are likely to solve. In any case, the most common and bothersome side effect of niacin is facial flushing, so Merck came up with a tablet in which they combined niacin and a second drug, laropiprant, which prevents the flushing. This combination medicine, called Tredaptive, has been in use in Europe since 2007.

A large trial designed to win FDA approval for Tredaptive ended this week. The results won’t be formally published for some time, but Merck has already released some important tidbits. The study randomized over 25,000 patients to Tredaptive and simvastatin or to simvastatin alone. The patients were monitored for over four years. There were no differences in rates of strokes or heart attacks between the groups, but the Tredaptive group had an increase of a “serious adverse event” the details of which Merck has yet to release. In an unusual move, Merck has asked European physicians not to start new patients on Tredaptive.

This new finding should throw a wet blanket on the few remaining niacin enthusiasts. Niacin use has declined since the AIM-HIGH study and now should decline further. It has no benefit in the vast majority of patients who can tolerate statins.

Learn more:

Why Merck’s Niacin Failure Will Scare Drug Researchers (Forbes)
Merck Says Niacin Drug Has Failed Large Trial (New York Times)
Merck: Niacin Drug Mix Fails To Prevent Heart Attacks, Strokes (NPR Shots)

My previous posts about niacin:
Niacin Much Less Helpful in the Age of Statins
Niacin Does Not Prevent Strokes or Heart Attacks

Tangential Miscellany

To all celebrating, Merry Christmas! May your days be merry and bright.

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Flu Season Hits Earlier than in Recent Years

flu incidence by week (CDC)

This year’s flu season seems to be starting earlier than usual and is getting more intense by the week. The Centers for Disease Control (CDC) reports in its weekly summary of flu surveillance that flu cases are increasing across the country. California still is showing only sporadic flu activity, but 8 other states report widespread activity and 15 others report regional activity.

The CDC reminds us that it’s not too late to protect yourself and those around you by getting a flu shot. The vaccine is recommended for everyone over 6 months of age. And the CDC also has other helpful suggestions for preventing flu transmission. If you’re sick, stay home and limit contact with others. Avoid touching your eyes, nose, and mouth. Cover your coughs and sneezes with a tissue. And wash your hands frequently.

I’ve seen no randomized studies suggesting that lighting candles, singing songs, or eating latkes decreases transmission of flu, but I recommend it anyway. Happy Hanukkah!

Learn more:

Unusually Early Flu Season Intensifies (NPR Health)
Situation Update: Summary of Weekly FluView (CDC)
Google Flu Trends for Los Angeles
Key Facts About Seasonal Flu Vaccine (CDC)
CDC Says “Take 3” Actions To Fight The Flu (CDC)

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When it Catches on They Won’t Call it Concierge Medicine

The idea that patients are better off paying their doctor directly and using their insurance only for unaffordable catastrophes is gaining some traction. With implementation of the Affordable Care Act looming in 2014 many patients are looking at their doctor’s already crowded waiting room and wondering how their care will be impacted when their doctor is responsible for even more patients. And doctors who even now are swamped and frustrated with insurance bureaucracy are wondering how much worse things will get when they have less time for more patients.

Yesterday Bloomberg Businessweek published an article which asks “Is Concierge Medicine the Future of Health Care?” The headline lifted my spirits because of its happy presumption that healthcare has a future. The article interviews several concierge doctors. It makes the important point that practices in which patients pay doctors directly are now thriving at many different prices. From practices charging tens of thousands of dollars a year targeted to the very affluent to practices charging $50 per month for blue collar workers, doctors have found that they can take better care of patients by caring for fewer of them and by concentrating on practicing medicine the way they were trained, not by focusing on what’s covered by a policy.

The article brings up some very common criticisms of concierge medicine that deserve to be answered.

One objection is that concierge medicine leads to a two tiered system in which the affluent get attentive care and everyone else doesn’t  That’s nonsense. The whole point of the article is that direct-pay care is working at many different prices and that some of the practices are targeted to middle class patients. There are already many more than two tiers of healthcare – the County system and Medicaid for indigent patients, private HMO insurance, staff model HMOs, PPOs, direct-pay practices, etc. How many tiers are there in other marketplaces, like food, housing, or clothing? A practically uncountable number. One characteristic of robust marketplaces is that they offer goods at widely varying prices. That means that those who need to save can still afford some access to the marketplace but those who can afford more can get better comfort, or better quality, or more reliability. I can get across town for the price of a bus ticket or the price of a BMW. (I ride my bike.) How many tiers is that?

Another objection is that by shrinking their practices to only those who can afford them, doctors who switch to the concierge model are exacerbating the coming primary care physician shortage. Of course the opposite is true. The physician shortage in primary care is fueled by the fact that people aren’t choosing to go into primary care. Nothing will attract more students into primary care than examples of happy doctors who are making a living practicing in a way that is both ethical and enjoyable. Concierge doctors are not the cause of the shortage; we’re the fix. What would the critics prefer? That we stay in the insurance model and tell medical students how miserable a career in primary care is? That we drop out of medicine all together?

I think the main barrier to even faster growth of concierge medicine is the name. Another problem is that the insurance model is so entrenched in our understanding that we now think of getting routine care through insurance as the “regular” way it works. We don’t have a name for it anymore. If someone says “I saw my doctor” we just assume that someone else paid for it. If she says “I saw my concierge doctor” we understand that she paid herself. But it should be the other way around. We don’t have a word for an accountant or a plumber or a lawyer who gets paid directly by his clients. They’re not concierge accountants or concierge plumbers or concierge lawyers. We need to get to the point that paying a doctor directly doesn’t deserve an adjective before the noun “medicine”. Paying your doctor is just medicine. Having someone else pay for you is insurance medicine.

The Buisnessweek article quotes Josh Umbehr, a concierge doctor in Whichita.

“Health insurance should work more like car insurance,” says Umbehr. “We have car insurance for all the big stuff, but we pay for gas, tires, and oil changes ourselves.”

He’s right. I wish I’d thought of that.

Learn more:

Is Concierge Medicine the Future of Health Care? (Business Week)
Dealing With Doctors Who Take Only Cash (NY Times)
Dollars to doughnuts diagnosis (My 2008 op-ed in the LA Times that explains why I got out of the insurance model)

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