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Tuesday, April 26, 2011

How can 9 patients run up $3Million in ED visits? It can be done.

Reprinted from story on:

9 patients, 2,678 ED visits, $3 million dollars

Author:  Dr. Kevin

Apparently, 9 patients in Texas, the majority of whom had mental health issues, visited the emergency department nearly 3,000 times during the past 6 years.
Many of those visits were due to non-emergency causes, and it is speculated that these patients’ mental health history played a role, as this physician comments, “They have a variety of complaints, [and] a lot of anxiety manifests as chest pain.”

The proposed solutions, however, are not ground-breaking, and include “referring some frequent users to mental health programs or primary care doctors so they would go there first in the future.”

Mental health and primary care access are scarce resources, and patients who have chest discomfort often cannot wait for an appointment with a primary care doctor, and thus, head straight to the hospital. Combined with the fact that Texas has one of the largest proportion of uninsured patients, it becomes obvious why some choose to use emergency services.

Although these numbers may seem shocking, I’d bet that many doctors aren’t surprised at all.  [for a solution visit this site and this site for interesting low cost solutions to overutilization of EDs for primary care issues]

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Friday, April 22, 2011

Save our Antibiotics for Big Bacterial Infections NOT for use on viruses

Antibiotic Stewardship
by JP Saleeby, MD

To open up, I want to make it perfectly clear the intentions of this article by stating a few facts.  These are facts back up by loads of peer-reviewed publications.  These facts are likewise rational and logical.

Fact:  Antibiotics save lives.
Fact:  Antibiotics reduce morbidity and mortality in severe and life threatening infections.
Fact:  Antibiotics have in the past 20-years been overprescribed.
Fact:  Antibiotics are necessary in the practice of good medicine and new guidelines need to be followed in light of present day resistance.

It is both intuitive and evidence based that appropriate use of antibiotics in modern medicine have saved thousands of lives.  Prior to the discovery of the antibiotics (antimicrobials) infection was a leading cause of death in humans.  Today, many life threatening illnesses such as pneumonia, sepsis, flesh-eating bacterial infections (necrotizing fasciitis), or meningitis are so dangerous, that delay in antibiotic therapy can cost a life.

For those pseudo-healthcare practitioners that are blinded by sheer bias and hatred toward contemporary western medicine (and suffer brain squeeze because their craniums are so far up their rectums), spouting the foolish notions that "you don't need antibiotics" or "antibiotics are never good for you", be warned.  Those reading this article that are experiencing a grave illness due to a microbe should be aware that those advocating the cockamamie notion that all things antibiotic are evil, should run as fast and far away from those practitioners.  Furthermore, they can and should be held culpable for the death of a patient should they intentionally delay people from getting life saving antibiotic therapy.  Intuitive practitioners, some chiropractors and those who favor wave eagle feathers and crystals over folks in an attempt to cure a complex septic patient should put their unsubstantiated opinions and bias' aside and refer their patients to a medical doctor for definitive care.  No need to stain you hands with blood over an idiotic notion unfounded by any empirical evidence.  Enough ranting about unfounded prejudice against antibiotics amongst healers.

While there is no question about the helpfulness of antibiotics, it is also true that since their inception they have been abuse and over prescribed.  Now we realize the ills of haphazard and unbridled use as we see resistant organisms appear more often and on the rise.

According to Dr. J. G Bartlett in a Medscape CME published in November of 2010 entitled "Addressing the Rising Tide of Antimicrobial Resistance" he spells out the rise of the top six microbes that are defying our current regiment of antibiotic therapy.  They are Enterobacter, Staph. aureus, Klebsiella, Acinetobacter, Pseudomonas aeruginosa andEnterococcus.  In the US methicillin-resistant Staphylococcus aureus (MRSA) is on the rise with some 94,360 cases a year and 18,650 deaths reported by Kelevens et. al., in JAMA in 2007.  Those are some fierce numbers for a bacterium that only 10 years ago was only seen in hospital ICUs and nursing homes.  Now greater than 60% of cultures of abscesses in my local region culture positive for MRSA.  The whole penicillin class of drugs (Amoxil, Keflex, etc.) is useless against MRSA.  Clostridium difficile infections are another example with diagnosed cases on the rise and antibiotic resistance mounting as well.  Death by C. difficile infection has taken an exponentially rise since 1999.

Furthering the crisis of antimicrobial resistance and of great concern is that in the last ten-years the development of new antibiotics and antibiotic classes has all but dried up.  A 2004 report by the Infectious Disease Society of America (IDSA) stated that there is“antibiotic discovery stagnation” were we are witnessing bad bugs with no new drugs to fight them.  An example of how slow we are to develop new antimicrobials is seen in a study published in 2009 in theClinical Infectious Disease journal by Dr. H.W. Boucher reporting that between 1983 and 1887 sixteen new antibiotics were developed.  From 1993 - 97 ten antibiotics were developed and this dropped to only five from 2003 - 07 and from 2008 projected until 2012 only one new antibiotic coming to market.  From the 1930's through the 1970's there were eleven new classes of antimicrobials developed by pharmaceutical companies, with only four classes in the 1950, and during the 2000's only two new classes were developed.  The 1980s and 1990's saw a dry spell, with no new antibiotic-class development. These are scary numbers considering the rapid rise in microbial resistant organisms just in the past decade.

So while antibiotic use is necessary and critical in the very ill, judicious use is necessary to save our "big guns" for those really bad infections.  Most pharangitis infections are viral and despite this fact many GPs would prescribe antibiotics just to appease an anxious patient, and not treat the real root cause.  This practice has to stop.  No one will argue about utilizing a broad spectrum aggressive antibiotic regiment in a septic patient, but we need to look at the evidence of stopping drugs when cultures are negative and using effective shorter courses.  Evidence is mounting that a three day course of antibiotics for community acquired pneumonia (CAP) is as effective as a seven- or ten-day course.  On the other side of the continuum, those that don't advocate the use of antibiotics at all will harm the really sick.  We must reach a happy medium.
JP Saleeby, MD is an emergency room physician who practices integrative medicine in solo practice.  His weltanschauung is practical, pragmatic and not at all crunch or granola.  For more information visit &

© 2010

Tuesday, April 19, 2011

Colorectal Cancer Screening - New biomarkers (ColoVantage)

Colon Cancer Screening:  To scope or not to scope?

By Yusuf M. Saleeby, MD

Colon cancer screening by fiberoptic colonoscopy is recommended by the vast majority of physicians and the American Cancer Society as a screening test for colorectal cancer.  While colonoscopy is the “gold standard” for colon cancer screening, nearly 50% of Americans over the age of 50-years avoid the procedure and ignore the recommendation. There are some obvious and not so obvious complications and risks associated with the procedure and the notions people have with the bowel prep process and undergoing conscious sedation are not at all appealing.  But many avoid the procedure due to expense, discomfort of procedure, and inability to devote the time for the relatively invasive procedure.  A recent study by a British group of researchers published in the peer-reviewed medical journal Lancet calls into question the validity of conventional fiber-optic colonoscopy as a screening tool.

Colorectal cancer is the third most common cancer and the 2nd leading cause of cancer death in the US, Canada and Europe.  There are about 100,000 new colon cancer cases in the US each year and approximately 40,000 new cases of rectal cancer.  Of these, there are about 50,000 deaths annually attributed to colorectal cancer.  What causes colon cancer is a difficult and elusive question that has not been fully explained.  However, epidemiological studies have revealed that dietary constituents are implicated in colorectal carcinogenesis.  Those constituents are a diet high in fat and red meats, considered causative, and a diet low in calcium and fiber as these would be considered protective.  Additionally, there are genetic factors.   For example, researchers have found that certain biomarkers in both animal and human trials affect the dietary factors.  Colon cancer develops by an adenoma-carcinoma sequence in the pre-cancerous or injured cell.  The appearance of colonic polyps has been an end-point in some research trials, however, normal appearing mucosa can still contain very small foci of aberrant crypts (invisible to colonscopy) referred to as micro-adenomas and these will certainly lead to dysplasia.  Researchers are studying these small foci and discovering what diet and chemopreventive agents work best at suppressing their growth.  Omega-6 fatty acids affect lipid peroxidation of DNA and this exposure provides stimulation for precursor tumor cells.  Diets low in calcium apparently inhibit apoptosis (cancer cell death) leading to higher risk as well.  Calcium has also been shown to reduce the recurrence of adenomas in three recent trials.  However, in one of these studies the use of fiber in the diet actually increased recurrence dramatically, counter to what we currently believed about fiber.  Much study is needed to realize the impact of our diet and environment on ur genes and how that interaction produces cancer.

It has been shown through many trials that colon cancer screening, effective follow-up and treatment can reduce risk of colon cancer death by as much as 35% and risk of getting colon cancer by 20% with early detection of precancerous polyps, this according to Dr. Otis Brawley, chief medical officer of the American Cancer Society.  The much used, most efficient, least expensive and practical screening test is the stool occult blood test (aka FOB or Hemoccult®).  With an abnormal finding (positive for occult blood) the next step can be taken.  Most American physicians would opt for a referral for colonoscopy.  But there are alternatives.  There are less expensive and possibly safer alternatives to the more invasive conventional colonoscopy which has been the predominant method for further screening (and now primary screening) for colon cancer.
A 2004 research study performed in England over a 4-month period reviewed the results of some 9223 colonoscopies performed in the traditional flexible colonoscopy fiber-optic method, the majority of which were conducted in teaching hospitals.  To paraphrase the study, it revealed that IV sedation was used in just over 94%, cecal intubation (the ability to run the scope to the end-point which is the cecum) was only 56.9%.  Reasons for failure were attributed to patient discomfort (35%), looping (30%), and poor bowel prep (19%).  Normal results were reported in 42.1%.  Polyps were reported in 22.5% (a pre-cancerous finding) while evidence of carcinoma was only realized in 3.8% of cases.  Rectal bleeding requiring admission was reported in six patients and the overall perforation rate was one in 769 cases.  Colonoscopy was also considered a factor in six deaths occurring immediately following the procedure.  The conclusion of this study revealed a wide variation of sedation guidelines, the studies were often incomplete and does not achieve the targeted 90% cecal intubation rate.  Serious complications were comparative with previous studies and points out that while thousands are done in America, there are inherent risks and short-comings.

The American Cancer Society is now recommending the use of Virtual Colonoscopy as an alternative to traditional fiber-optic conventional colonoscopy (CC).  Virtual Colonoscopy is the use of a spiral Computed Tomograph (CT) to visualize the colon.  The trade offs are a little radiation exposure in virtual, but the gain is a better study technically, with no failure to “progress to the cecum” issue, the ability to re-visit the study and finer resolution.  The upside continues as it is non-invasive and thus the risk of perforation, post-operative complications, bleeding and risks of anesthesia are eliminated.  Cost is another factor in favor of VC over conventional fiber-optic method.  The most obvious downside is that if a malignant lesion is noticed there is no way to perform an excisional biopsy for further pathological study; one would have to sit for a conventional colonoscopy.

Virtual colonoscopy as it continues to develop, evolve and become more popular will realize a costs drop.  Patients find it more comfortable, there is no need for procedural sedation, and the risk of penetrating iatrogenic complications are almost nil.  Insufflations of colon with air is the only “invasiveness” and can be mildly uncomfortable, though nothing like the introduction of a scope.  Another benefit is that a day off from work and limiting other activities is not necessary.  By insertion of a short rectal tube, carbon dioxide is used to insufflate or expand the colon lumen for better visualization.  No sedation is required, the spiral CT study only lasts 15-minutes at most and the patient can return to normal activities post study.
Specialized software is used to produce 2D and 3D reconstructions of the colon for radiological interpretation.  Using VC permits assessment of colonic segments that are rendered inaccessible to CC as in the case of an obstructing lesion or patient intolerance.   Additionally, the modality of CT in the performance of a VC allows detection of potentially important extra-intestinal findings (e.g. tumor in another solid organ) that would not be found by any of the other screening techniques.

In a recent clinical study involving 6,283 screening subjects, the diagnostic yield and use of resources for screening purposes compared VC to CC. The study found that VC and CC had similar rates for detecting advanced cancer, but CC had considerably greater complication.  The American College of Radiology Imaging Network trial revealed that CC does have the advantage of being both a screening and therapeutic tool, but VC appears to be a good screening alternative due to its good performance in recent studies, less invasive method, and more efficient use of resources.

Colorectal cancer screening with VC has been endorsed by the three major gastrointestinal societies: the American Gastroenterological Association (AGA), the American Society for Gastrointestinal Endoscopy (AGSE), and the American College of Gastroenterology (ACG).
VC is also indicated after incomplete conventional colonoscopy, as up to 13% of incomplete CC were found to have lesions 6mm and larger.  VC is better than a barium-air contrasted study due to reduction in sensitivity of the contrast.  Because of the nature of the CC exam, and the unwillingness of the population at large to undergo this type of exam, this may explain the reason as to why 50% of eligible adults needing the CC do not get it performed. 

The one main concern with using VC is the radiation exposure.  However, the use of very low dose scanning protocols that reduced radiation exposure can still maintaining image quality.  Even with the use of multi-slice spiral scanners, radiation dose is kept to a minimum by reducing the mili-Amp current used.  In one study researchers found that the absolute life time risk for cancer induction from a normal dose virtual colonoscopy was only 0.14% in a 50 year-old person and about 0.07% in a 70 year-old person.  When you compare the 6% mortality risk from colon cancer against the much smaller cancer risk from VC radiation exposure, the benefits far outweigh the risks.  Risk of perforation with current carbon dioxide pumps is about 0.005%, again far less than with standard CC procedures.

When running a cost analysis, this is what I have found to be the case:  A standard doctor’s office visit for consultation, pre-procedure lasting no more than 5-minutes costs $216.  Estimates for the procedure itself for specialist performing it was around $850.  The estimated cost for anesthesia was somewhere between $300 and $400.  Not figured into this cost was the use of the GI suite/operating room.  That would have been billed separately from the hospital used.  So you are going to walk away with a bill at or over $1400.  That is even before any intervention that may be involved.  If a biopsy is taken, then you have that additional procedure billed and then there are the costs of the cyto-pathology report.  So this becomes a very expensive screening process.  Often too expensive for the vast majority of Americans who don’t have the health care coverage or who are uninsured.  VC typically comes in at about $1200 for the procedure and reading, but that cost will certainly drop it becomes more popular.  That being said, you are paying for convenience, comfort and putting yourself at less risk for untoward outcomes.  More people can be screened with the less expensive VC procedure, thus eliminating the risks associated with CC, the expense and time involved.  When positive findings are found on VC they can be referred to a gastroenterologist for CC and biopsy and further workup, thus lightening the screening burden on this sub-specialist group.  Virtual colonoscopy may not be covered by third-party payers for screening purposes at this time; however that is likely to change in the near future.
But for most patients seeking screening exams there are still far less invasive, less costly and less time consuming options.  The keyword here is medical biomarkers.  Not to be overlooked, and worth mentioning again is the most simple and effective screening method on the first tier; the stool occult blood test (FOB, Guaiac® or Hemoccult® test).  This test can be performed by your doctor or at home by yourself with a simple kit.  The test kit is then developed with a chemical solution to detect microscopic blood in your feces that is typically associated with a pre-cancerous or cancerous lesion.  While a positive test may mean other things besides malignancy (hemorrhoids, fissures, infection, recent intake of undercooked red meat) there are other tests used to back this screening modality up.  This occult blood test can be had for a few dollars. 

The advent of biomarkers has made the screening and management of many cancers less invasive in the 21st century.  There are dozens of biomarkers that already exist and many more in development with new tests coming to clinical use each year.  There are biomarkers for the detection of prostate, breast, lung cancers and many more.  For the purpose of this discussion we will limit ourselves to the biomarkers currently available for the potential screening and management of colorectal cancer.  Chief among the markers is Carcinoembryonic Antigen (CEA), it is rather non-specific as it can detect different malignancies that arise under the diaphragm.  Smokers typically have an elevated CEA for starters and this must be realized when using this test as a screening tool.

Another cancer biomarker is CA 19-9.  The CA is shorthand for carbohydrate antigen.  This test is also known as sialylated Lewis (a) antigen and is also a blood test like CEA, but more specific for colon cancer and pancreatic cancer.  The CA 19-9 test was discovered in 1981.  While elevated levels in the blood can be found in non-malignant conditions such as Mirizzi’s syndrome and diseases of the liver and bile ducts it is currently one of the key tests for pancreatic and colon cancer management.  The reluctance of using these tests more widely comes from the guidelines for the American Society of Clinical Oncology and the American Cancer Society which are still discouraging the use of CA 19-9 and other cancer markers as “dedicated screening” tests.  Their reasons are mostly the higher incidence of false positives.  That would be a person with a positive test with no malignancy.  Other reasons may be purely political, as a simple blood tests would “take away” expensive and profitable procedures from those performing flexible sigmoidoscopies and colonoscopies.  The main use of CA 19-9 is with following pancreatic tumors that are being treated with chemo or surgery; by checking for increases in levels that would indicate recurrence or worsening of the disease.  As with any test, there is never a 100% specificity/sensitivity.  In CA 19-9 about 5% of the population does not possess the ability to produce the Lewis antigen because of a deficiency of a fucosyltransferase enzyme and thus no Lewis antigen or CA 19-9 would be produced even with large tumor burden.

There are other markers under investigation that may become more useful in the future.  In 2009 researchers at the University of Cincinnati (UC) published in a genetics journal their findings about a gene called AMACR which regulates cancer development and discovered a polymorphism (mutation) related to colon cancer.  Dr. Xiang Zhang, PhD who was the lead researcher of the UC study explains, "From the colon tissues, we've identified two types of genetic deletions [of the AMACR gene] that may allow us to predict whether people will have a good or bad cancer outcome," Dr. Zhang continued to say, "If a person carries one of the deletions, it may predispose him or her to a more aggressive type of colon cancer."  While not developed as of yet as a screening tool, it will help physicians determine prognosis and treatment protocols for those that have colon cancer.  Yet another cancer biomarker for colon cancer is CA 242.  Elevated levels of CA 242 in colorectal cancer patients had similar rates of being positive as CEA and CA 19-9.  The sensitivities are similar as well, and more so for recurrence and metastatic detection using CA 242.
While there is an increased demand for biomarkers of colorectal cancer (and other cancers for that matter), for early detection, risk assessment, prognosis and follow up post treatment, the perfect, gold-standard test has not yet been realized.  Short comings are: too frequent false positives and false negatives as a stand-alone screening test.  Other biomarkers under the microscope for consideration are APC, p53 and Ki-ras.  These are still in development for use as viable clinical tests.  The detecting of colon cancer in the early stages offers clinical advantages and better outcomes; therefore, the National Cancer Institute has established an Early Detection Research Network to promote more research in this field of study.  The emphasis of the network is on translational research and collaboration among scientists in the field of oncology with the hopeful development of better cancer markers in the near future. 

A rather new and promising colorectal biomarker is the ColoVantage® (methylated DNA from SEPT9 gene marker).  ColoVantage® is the brand name of a test launched in 2010 by Quest Diagnostic Labs and as of March 2011, has gained approval by the New York Health Department as a sanctioned colorectal screening test.  With its reported 70% sensitivity and 89% specificity rating, it is a good first line test for screening large numbers of people less likely to undergo colonoscopy of any type (CC or VC).  The American Cancer Society is also warming up to the idea, but is slower to act as they are advocating more scrutiny.  Quest Diagnostic is offering the ColoVantage at a retail cost of $355.   Direct Access Testing sites such as eStatLabs offer this test direct-to-consumer for $300.

My current recommendations are with what is available to the public today a viable biomarker testing protocol.   It has a two-prong approach:  First, the inexpensive and readily available FOB (Hemoccult®) test.  This is still the mainstay of colorectal screening and probably will be into the foreseeable future.  The second recommendation is not in the realm of CC or even VC, but rather a chemical biomarker.  Cheap by comparison and readily accessible with no risk of untoward affects is the ColoVantage test.  It would be done in combination with the FOB to complete the evaluation.  CA 19-9, CEA or the CA 242 biomarkers would be my second choice in biomarkers for initial testing.  Finally, if both FOB & ColoVantage tests are positive, the algorithm would proceed to a 2nd tier, the virtual colonoscopy or conventional fiber-optic colonoscopy.



Bowles, CJ, Leicester, R., A prospective study of colonoscopy practice in the UK today: are we adequately prepared for national colorectal cancer screening tomorrow? Gut 2004;53:277-283

University of Cincinnati, Potential Colon Cancer Biomarker Revealed Through Study Of Human Tissue. ScienceDaily (2009, January 21).

Owen RW., Biomarkers in colorectal cancer. IARC Sci Publ. 2001;154:101-11.

Sudhir, S. Mukesh, V., Henson, D., Biomarkers for Early Detection of Colon Cancer, Clin Cancer Res May 2001 7; 1118

Koprowski H, Herlyn M, Steplewski Z, Sears HF. Specific antigen in serum of patients with colon carcinoma. Science 212 (4490): 53–5.

M Ugorski, A Laskowska (2002). Sialyl Lewis a: a tumor-associated carbohydrate antigen involved in adhesion and metastatic potential of cancer cells. Acta Biochimica Polonia 49 (2): 303–311.

Robertson A, Davidson B., Mirizzi syndrome complicating an anomalous biliary tract: a novel cause of a hugely elevated CA19-9. Eur. Jour. of Gastroent. & Hepa. 19 (2): 167–9. 
Locker G, Hamilton S, Harris J, Jessup J, Kemeny N, Macdonald J, Somerfield M, Hayes D, Bast R., ASCO 2006 update of recommendations for the use of tumor markers in gastrointestinal cancerJ. Clin. Oncol. 24 (33): 5313–27. 

Spila A, Ferroni P, Comparative analysis of CA 242 and CA 19-9 serum tumor markers in colorectal cancer patients. A longitudinal evaluation. Anticancer Res. 2001 Mar-Apr; 21(2B):1263-70.

Griesenberg D, Nürnberg R, Bahlo M, Klapdor R., CEA, TPS, CA 19-9 and CA 72-4 and the fecal occult blood test in the preoperative diagnosis and follow-up after resective surgery of colorectal cancer. Anticancer Res. 1999 Jul-Aug; 19(4A):2443-50.

Carpelan-Holmström M, Louhimo J, Stenman UH, Alfthan H, Järvinen H, Haglund C.Tumour.,  CEA, CA 242, CA 19-9, CA 72-4 and hCGbeta in the diagnosis of recurrent colorectal cancer.
Biol. 2004 Sep-Dec; 25(5-6):228-34.

Eche N, Pichon MF, Quillien V, Gory-Delabaere G, Riedinger JM, Basuyau JP, Daver A, Buecher B, Conroy T, Dieu L, et al., Standards, options and recommendations for tumor markers in colorectal cancer], Bull Cancer. 2001 Dec; 88(12):1177-206.

American Society of Clinical Oncology 2006 Update of Recommendations for the Use of Tumor Markers in Gastrointestinal Cancer.
Published in Journal of Clinical Oncology, Vol 24, No 33, 2006: pp. 5313-5327

Quest Diagnostic Laboratory web site, Information on ColoVantage.  Acquired 3/25/2011. Acquired 4/12/2011

TeleHealth to the rescue!

Contact the HELP Committee:
Committee on Health, Education, Labor and Pensions
428 Senate Dirksen Office Building
Washington, DC 20510
American States Lag European Nations in Licensure Portability
Created By: Linkous, Jonathan On Wed, Mar 23, 2011 03:14 PM on ATA Site

Allowing physicians the right of free circulation as providers of medical services within the 25-nation European Union is part of a founding EU principle for freedom of circulation of goods, persons and services. The EU lays out minimum training requirements for general practice and specialist physicians and provides for mutual recognition of physicians’ qualifications. It also enforces measures to ensure that the licensing provisions of individual Member states permit the free movement of doctors both to establish themselves and to practice their profession in all Member states. This is currently covered under the EU directive 2005/36/EC.

The 25 independent countries in Europe long ago figured it out. But the fifty states in America are still struggling with how to allow physicians to practice, and citizens to access healthcare across state boundaries. With the help of the Federation of State Medical Boards we are looking to put together a patchwork solution, but that still may be years away.

Shame on us.


Yusuf Saleeby March 29, 2011 2:52 am on ATA Blog
Mr. Linkous, I could not agree with you more. In this era of physician shortages, poor access to PCPs, long lines in the ED, we must petition the government to allow physicians who are licensed in any one state to have reciprocity to treat citizens in other states.

As we see in the Veteran's Administration, physicians with a single state license are able to practice in any of the 50 states, likewise the Indian Health Service provides the same allowances. Why not make state-to-state reciprocity allowable by Federal Law, with a nominal fee ($10) to register in the state in which you wish to practice outside your licensed state. Telehealth will then be unencumbered by borders and costs can be contained with reasonable license fees.

Time to write some letters to the US Senate Committee on Health... (HELP).

Democrats by Rank
Tom Harkin (IA)** Ranking Democrat
Barbara A. Mikulski (MD)
Jeff Bingaman (NM)
Patty Murray (WA)
Bernard Sanders (I) (VT)
Robert P. Casey, Jr. (PA)
Kay R. Hagan (NC)
Jeff Merkley (OR)
Al Franken (MN)
Michael F. Bennet (CO)
Sheldon Whitehouse (RI)
Richard Blumenthal (CT)

Republicans by Rank
Michael B. Enzi (WY)** Ranking Republican
Lamar Alexander (TN)
Richard Burr (NC)
Johnny Isakson (GA)
Rand Paul (KY)
Orrin G. Hatch (UT)
John McCain (AZ)
Pat Roberts (KS)
Lisa Murkowski (AK)
Mark Kirk (IL)

In good health,

Yusuf (JP) Saleeby, MD
Phone: (800) 965-8482
E-fax:   (888) 242-0735

Information contained in this e-mail transmission is privileged and confidential. If you are not the intended recipient, do not read, distribute, or reproduce this transmission. Please call (800) 965-8482, or reply to this e-mail to notify the sender, and delete this message immediately. 

Saturday, April 16, 2011

Access to Health Care

Yusuf (JP) M. Saleeby, MD
Access to healthcare in South Carolina is in need of a large band-aid.  South Carolina happens to be one of the unhealthiest states in theUnion by reports with a ranking of 46 out of 50 in the nation.  This low ranking may be in part to the lifestyle and genetics of the population, but very likely the resident's poor access to quality healthcare is a determining factor.  Poor dietary habits, a diet traditionally rich in fatty and fried foods along with the general lack of exercise by the vast majority contribute to this but can be overcome with proper preventive medicine interventions.  Syndrome X (Metabolic Syndrome) is rampant in the southeast, hitting SC very hard with large populations of those suffering from hypertension (HTN) and diabetes mellitus (DM).  Lack of access to basic healthcare mean hypertension, diabetes and other disorders go unrecognized and thus untreated.  Ramifications of untreated HTN and DM alone can account for great morbidity among the population, leading to heart disease, renal failure, stroke, and blindness to name a few outcomes.  This population of under-treated will eventually consume a greater healthcare dollar as their disease process worsens and sequelae materialize.
Statistics show some 19.4% of those living in South Carolina are uninsured, having no type of health insurance at all.  From a 2002 report, the uninsured residents cost the healthcare system upwards of $1,936 per individual per year.  While 60% of the uninsured are hard working citizens, the vast majority (74%) when asked list "affordability" as the reason for not obtaining or purchasing health insurance.  About half the eligible individuals without health insurance do not enroll in public programs for two chief reasons; firstly, they don’t want to receive government support and secondly, they don’t want government to provide health coverage.
The problem goes beyond the individual residents of the state.  Almost 80% of businesses in SC, excluding self-employed and government workers have fewer than 10 employees and 53% of these “small employers” with a work force less than 10 employees do not offer group-sponsored health insurance to their employees because of cost issues.  Now that the problem has been identified, what is the solution?  Well it is a complex and multi factorial problem to solve.  Should the government step in and cover the cost of supplying healthcare to all individuals at great expense to the taxpayer?  I say no.  A resounding no!  For the most part we see the failures in the system of government sponsored or supplied healthcare with what is currently going on with Medicare and Medicaid.  Another example of mediocre healthcare delivery is with our nation's veterans.  The Veteran Administration (VA) system of healthcare is increasingly slow, impersonal and cumbersome.  Private sector delivery systems can provide an answer as long as they are regulated to eliminate unfair business practices and unscrupulous profiteering.  To allow a system to become successful as a business model, it must keep overhead down, allow current advances in communication technologies to be at its disposal and become free from the blood letting of insurance companies and a legal system with no reforms to place a ceiling on monetary awards for malpractice claims.  One way to solve issues of cost containment for delivery models that will allow savings to be past to consumers is the use of telehealth with self insurance and the passing of legislation for tort reform.  For a mere fraction of the cost of operating a brick-and-mortar typical family practice, telehealth can accomplish almost 70% of what can be conducted in an office setting without the cost prohibitive costs.  End result is the savings passed along to the patient (consumer).  Making routine and basic healthcare one again affordable.  

Exploring this model is the AtroGene Telemedicine group.  This group of clinicians have departed from the typical means of conducting business via a traditional office based practice and is exploring new ways of healthcare delivery via telephone and video-consulting.  The Internet savvy end consumer will most likely embrace this new technology with offers great promise and practicality.  Older patients who are used to office based practice may find the task of trusting the Internet and telemedicine a daunting task.  The younger patient, typically will have minor acute illnesses that have lower acuity and can be managed comfortably by practitioners well versed in telemedicine, knowing the abilities and limitations of the system.  Thousands of healthcare dollars can be saved if this new model is embraced.  This will divert non-emergent or non-urgent patients from burdening our already overcrowded emergency departments and allow for better and more efficient management of higher acuity patients in true need of the ED.

Likewise access to direct access testing (DAT) will allow astute consumers/patients direct access to lab and blood testing.  By passing the traditional avenues to obtaining routine annual labs, they can once again drastically reduce their expenditures on the basic routine aspects of health and wellness.  With only minor interventions and guidance by healthcare providers the vast majority of the public can obtain affordable healthcare tests they would have otherwise ignored or put off for lack of ability to pay a higher price tag.  Affordable and easily accessible telehealth may very well be the panacea to save the majority of uninsured clients in our state.
Source: some statistical information gained from
Other interesting facts:

A 2010 Press Ganey Pulse Report (survey) demonstrated the national average emergency room wait time was 4-hours and 7-minutes long.
There are 123-million emergency room visits in America each year.  The vast majority are considered non-emergent.
There are an estimated 312,000 Primary Care Physicians (PCP) today, but the current need requires about 13,000 more.
65-million Americans live in areas without enough Primary Care Physician coverage.
Wait times of about 2-months are routinely being reported for patients to see their physicians (PCPs).  (Another article crying out for help, proposes some solutions)
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Health Care 2009

A Lifeline for Primary Care

Thomas Bodenheimer, M.D., Kevin Grumbach, M.D., and Robert A. Berenson, M.D.
N Engl J Med 2009; 360:2693-2696June 25, 2009
Primary care in the United States needs a lifeline. In 2009, for the 12th straight year, the number of graduating U.S. medical students choosing primary care residencies reached dismally low levels.1 Overloaded primary care practices, whose doctors are aptly compared to hamsters on a treadmill, struggle to provide prompt access and high-quality care. Three major factors contribute to this crisis. First, primary care physicians earn far lower incomes than procedural specialists, reducing career attractiveness for medical students with high debt burdens. Second, the work-related stresses felt by primary care physicians tags primary care as the career with more work at less pay. Third, medical education favors training in non–primary care fields. Rescuing primary care requires national policies that address all three issues.
Growing clamor that primary care's plight may undermine important goals of health care reform has Washington policymakers concerned. Primary care has featured prominently in recent hearings held by Senate and House committees, and the New York Times has quoted President Barack Obama as saying that “we're not producing enough primary care physicians.” The administration and Congress understand that after Massachusetts expanded health insurance in 2006, many newly insured adults were unable to find a primary care physician, raising the specter of theoretically universal access to care but no primary care to which to have access. Policymakers are also familiar with studies showing that health systems anchored in primary care have lower costs and better quality.2
A bold federal initiative to revitalize primary care is urgently needed as part of health care reform legislation. This initiative must be comprehensive, simultaneously addressing three interrelated issues: physician payment, practice infrastructure and organization, and the training pipeline (see tableRevitalizing Primary Care.).
For the first of these, physician payment, Medicare and most private insurers currently use the resource-based relative value scale, which was purportedly designed to reduce the payment gap between primary care physicians and procedural specialists. That gap, however, continues to widen. Under Medicare's sustainable-growth-rate approach to containing expenditures, spending on physicians' services remains a zero-sum game: if expenditures for all physicians' services exceed a congressionally set target, physicians' fees are supposed to decline. Because of disproportionately large increases in spending growth for advanced imaging, tests, and minor procedures, physicians whose income depends on evaluation and management (cognitive) services, especially primary care physicians, have seen a relative reduction in Medicare revenues.3 And commercial health plans frequently amplify this gap between primary care and specialty payment.
Congress is considering options for reducing the Medicare payment gap. For the short term, the Medicare Payment Advisory Commission (MedPAC) has recommended that Medicare primary care evaluation and management services receive an increase of 5 to 10% next year.4 Congress is exploring such an increase, perhaps also for additional years. To close the income gap, annual increases of this magnitude would need to compound for several years, and private payers would have to follow suit. Medicare would also have to split physicians' services into separate buckets so that primary care payments would not be reduced as a result of rapid growth in expenditures for procedures and imaging.
An additional strategy to make primary care financially attractive would be providing more relief from medical education debt for clinicians entering primary care. The stimulus package — the American Recovery and Reinvestment Act of 2009 (ARRA) — included expanded funding for the National Health Service Corps, which provides debt-relief opportunities for primary care physicians. Congress is considering further growth of the corps.
For the longer term, Congress is weighing alternatives to fee-for-service compensation of physicians. Currently, reimbursement for office visits does not capture many activities that primary care practices must perform for their patients, especially those with chronic conditions. Under the Medicare Patient-Centered Medical Home demonstration, additional payments would be made to qualifying practices for care-coordination activities, including communication with patients and families by telephone and secure e-mail. Even more ambitiously, Congress may expand the modestly successful Physician Group Practice Demonstration for primary care–oriented integrated care systems, such as the Geisinger Health System and Kaiser Permanente. Under this approach, groups would be rewarded for improved performance on quality measures and assessments of patients' experience by being allowed to share in the savings if costs for their Medicare patients were lower than projected. Under both of these approaches, primary care physicians should receive higher incomes. Moreover, these models provide resources and incentives for enhanced practice capabilities and team orientation to make primary care practice more satisfying and manageable.
Payment reform is a necessary but not sufficient measure for revitalizing primary care, which also requires a modernization program for the second piece of the puzzle — practice infrastructure and organization — akin to federal infrastructure investments to shore up aging bridges and outmoded electrical grids. Most primary care physicians practice in small offices and clinics and cannot afford major capital improvements.
The most pressing infrastructure need is health information technology (HIT). Governments in several European countries equip all primary care practices with interoperable, ambulatory care–focused electronic health records that allow information to flow across settings to enhance the continuity and coordination of care. The ARRA included $19 billion for HIT but did not specify how these funds should be apportioned; it is essential that a substantial share be channeled toward primary care electronic health records.
Yet primary care needs more than computer chips and keyboards. Primary care clinicians require technical assistance to reorganize their practices into modernized medical homes, which will entail the formation of teams to assist physicians in providing proactive preventive and chronic care, the institution of same-day appointment scheduling, the substitution of e-mail and telephone encounters for face-to-face visits when clinically appropriate, and improvement of the coordination of care with specialists, hospitals, and other service providers. Recognizing these needs, Congress included a section in the ARRA calling for the creation of HIT regional extension centers to assist practices and hospitals in implementing HIT. This model draws from the Department of Agriculture's Cooperative Extension Service, a collaboration among federal and state governments, agricultural experts at land-grant universities, and farmers. Extension field agents in every county provide technical assistance to local farmers, spreading agricultural innovations. Believing that what worked for family farmers may also work for family doctors, Congress is considering broadening the scope of a health-oriented extension program beyond HIT to facilitate more profound reorganization of primary care.
The final area requiring action is federal funding of medical education. Medicare spends $8.8 billion annually on graduate medical education (GME), almost all of which flows to hospitals rather than directly to residency programs. Appreciating that this payment mechanism inhibits training in nonhospital ambulatory care settings, which is critical for the development of primary care skills, MedPAC and the Council on Graduate Medical Education are calling for more flexible approaches to Medicare GME payment.5 Advocacy groups for family medicine have gone further and proposed that Medicare GME funding for primary care residency training be wrested from hospital control and paid directly to residency programs, raising the politically charged question of whether GME funding should fundamentally be payment for medical education or a subsidy to hospitals.
The federal government also administers smaller but strategically important programs supporting primary care education under the Public Health Service Act: Title VII (for physicians, physician assistants, and dentists) and Title VIII (for nurses). Despite research documenting these programs' effectiveness, Title VII training funds were reduced from $88.8 million in 2005 to $41.3 million in 2006. The ARRA provided $200 million in one-time funding for Title VII and Title VIII programs, and Congress may increase the base level of funding in the 2010 appropriations bill. Far-reaching medical-education reform would redirect a substantial portion of Medicare's GME billions to strengthening primary care residencies and preparing residents to lead the implementation of innovative models of primary care.
This triad of reforms to primary care policy would result in a comprehensive and interlocking solution to the causes of distress in primary care. Reducing the payment gap would help to refill the pipeline of physicians going into primary care, as would reform of training programs. Changes in reimbursement would pave the way for practice reorganization and be symbiotic with a technical-assistance program. Practice reorganization, in turn, would improve the satisfaction, performance, and productivity of the primary care workforce.
As it writes health care reform legislation, Congress is deliberating over measures that would offer a three-stranded lifeline to rescue primary care. Successfully weaving these strands together is a political challenge, particularly if shifting resources to primary care is viewed by specialists and teaching hospitals as coming at their expense. But for health care reform to succeed in improving access, quality, and affordability, Congress and the Obama administration must make the primary care lifeline strong; otherwise, they risk watching primary care go under.
No potential conflict of interest relevant to this article was reported.
Dr. Bodenheimer is a professor at the Center for Excellence in Primary Care in the Department of Family and Community Medicine, and Dr. Grumbach a professor and chair of the Department of Family and Community Medicine at the University of California, San Francisco, School of Medicine, San Francisco. Dr. Berenson is an institute fellow at the Urban Institute, Washington, DC.
  1. 1
    National Resident Matching Program. Advance data tables: 2009 main residency match. (Accessed June 4, 2009, at
  2. 2
    Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health.Milbank Q 2005;83:457-502
    CrossRef | Web of Science | Medline
  3. 3
    Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med 2007;146:301-306
    Web of Science | Medline
  4. 4
    Report to the Congress. Medicare payment policy. Section 2B. Washington DC: Medicare Payment Advisory Commission, March, 2009:77-128. (Accessed June 4, 2009, at
  5. 5
    Nineteenth report: enhancing flexibility in graduate medical education. Rockville, MD: Council on Graduate Medical Education, September 2007. (Accessed June 4, 2009, at

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