5 Steps to prevent Heart Disease

Tuesday, May 31, 2016

Consensus report from ACC/AHA and NLA

Consensus reference JACC 2016




Masters Course at NLA in NOLA taught:

 CAC is the best biomarker to go to to determine further risk.

Risk in non-diabetic

Many people think insulin resistance is main cause of cardio-vascular disease?
Here is risk profile of someone who is insulin sensitive without diabetes.


e


Guidelines have shown benefit with treatment with statins in low risk group of 5-7.5%
Guidelines advise discussing options with patient and to consider CAC to raise or lower risk profile to help decision process. 

Determine Lifetime risk of patient to determine if low dose statin needed

My approach is to
 implement multiplier effect  to treat lifetime risk



e





e
This is a case with high HDLc 60 and CAC zero. 

Subsequently most people would not treat this patient with statins. 

                MESA calculator:
The estimated 10-year risk of a CHD event for a person with this risk factor profile including coronary calcium is 3.9%. The estimated 10-year risk of a CHD event for a person with this risk factor profile if we did not factor in their coronary calcium score would be 8.7%

 Pooled co-hort calculator:

Lifetime risk of atherosclerotic cardiovascular disease Question:
69%
(95% CI 62% to 73%)
Lifetime risk for a 50-year-old with optimal risk factors Question:
5%
(95% CI 0% to 12%)






 
I would want the patient to get an LDLp or apo B and a Lp(a).

Discordance between particles numbers and non-HDLc is possible in a diabetic.

Treatment to Goals over Long term with Low dose Combination treatment:
1-Atorvastain 10 mg/d
2- Wax matrix niacin 1,000 mg/d
3- If still not to goal add one half ezetimibe a day

4- Still not to goal, now is time to go to maximum statin dose. 

My philosophy is to avoid the maximum doses for lifelong treatments to avoid unforeseen side-effects and improve efficacy with multiple actions of multiple drugs at low doses. 

Goals:

LDLp  750 to 1,000

Non-HDL cholesterol  80 to 100


An option is to repeat CAC in 10 years or get CIMT now and serially.
It is generally accepted that lowering LDLp will initially raise CAC calcium score. 

However, in 10 years a complex atheroma may develop which has a residual risk that a high dose statin cannot resolve while early treatment can prevent.

Thus the idea behind the multiplier effect is to prevent the plaque from growing to that complex state which carries a build-in residual risk (30%) that statins have not been able to treat. 

For example:
Treating a 40 year old diabetic man with CAC 50 and his LDLp has been kept around 800. 
However his CIMT shows his atheroma is getting thicker.
This is a good candidate to treat more aggressively and keep his:

LDLp below 750 always.

or

non-HDLc below 80 always.

Naturally, this is assuming his other risk factors are kept under control.






Sunday, May 29, 2016

5 minute video demonstrating proof of regression of plaque on high fat diet

This is how a lipidologist determined if 
Atkins or Low Carb High Fat diet 
 would make his arteries worse. 



Link below

5 min video poster on CIMT response to 7 years Atkins diet

My weight loss success with Qsymia, Victoza, Invokana, Metformin, Ad libitum Atkins (low carb high fat)

I went on a diet in 2-17-06 and lost 80 lbs with The 3 Hour Diet by Jorge Cruise. My lab data

I regained 50 pounds despite 2.5 hours exercise a day. NYT article about Biggest Loser by Kolata

In June 2016 I added Qsymia to Victoza. Nutritional ketosis and Exercise failed at weight loss

I am opening an Obesity Cholesterol Clinic in Topeka next month.  This is a model of treatment I hope to reproduce for my patients. 


Thursday, May 26, 2016

Niacin vs. PCSK9 - why the expensive drug replace the inexpensive drug?

PCSK9 has no outcome trials, yet it is advised over Niacin by Consensus ACC/AHA consensus statement with NLA.  Niacin taken off list despite excellent cost and excellent compliance with wax matrix OTC niacin 1,000 mg.

Zetia only has one positive outcome trial yet it was used for many years before that trial came out.


Niacin's Randomize trials with clinical positive cardiovascular outcomes:
source Table 26.2 C JR Guyton in Contemporary Endocrinology,  Dyslipidemias p 446 Chapter 26.

  AIM-HIGH and HPS2 ended early after 3 yrs.
 Zetia IMPROVE-IT trial was 9 yrs.

 LDLc  lowering matters.

FACT: reduction of 10 mg per deciliter in the LDL cholesterol level in HPS2-THRIVE

Wax matrix niacin review Journal Clinical Lipidology  
Very few flushing side effects with this preparation.  Thus compliance good.
Cost $100 for 1,000 tablets, thus cost is excellent at two 500 mg tablets a day.

PCSK9 IV drug costs $14,000 a year?  

Niacin at the very least should still be an option on the guidelines for Doctors to use with statins even if LDLc is 70.

Wednesday, May 25, 2016

Niacin not dead at NLA Master's Course in NOLA 5/16

LDLc was reduced in Niacin trials and if given more time may have improved RRR after seven years as with Zetia (IMPROVE-it)

"By contrast, in the AIM-HIGH trial,8 adding niacin to effective LDL cholesterol–lowering therapy reduced the LDL cholesterol level by only 5 mg per deciliter"
NEJM ref

"On the basis of meta-analyses of statin trials, the reduction of 10 mg per deciliter in the LDL cholesterol level in HPS2-THRIVE would have been expected to produce a 5 to 6% proportional reduction in the risk of major vascular events.1 There is no similar evidence from randomized trials regarding the effects of raising the HDL cholesterol level, but if the inverse association with vascular disease risk in observational studies is causal (which has been questioned)18 and half of it is reversible within a few years (as with LDL cholesterol–lowering therapy1) then the increase of 6 mg per deciliter in the HDL cholesterol level observed in HPS2-THRIVE might have been associated with a reduction in the risk of major vascular events of 4 to 5%.2
Consequently, the combined changes in the lipid levels would have been expected to reduce the risk of major vascular events by approximately 10%, which is slightly larger than the observed result (although still statistically compatible with it)."
NEJM ref



At the Master's conference both Dr. Bays and Dr. Jacobson showed the LDLc results of HPS2 Thrive 

That slide was worth the $750 the course cost me. 




Friday, May 20, 2016

Obesity update needed in Masters Course at National Lipid Association.


PROPOSED EDITORIAL

by Brian Scott Edwards MD
American Board of Obesity certified
NLA board certified
Fellow NLA
Obesity not well covered by NLA
May 2016 New Orleans
I listened to a talk on nutrition  at the National Lipid Association Masters Course.
Unfortunately no distinction is made for insulin resistant  patients who would probably benefit from low carbohydrate high fat diet.  The American Diabetic Association does approve of LCHF as a possible weight loss diet. 

Saturated fat again is said to universally raise LDLc.  No mention of LDLp or apoB effect but they did say don't replace SF's with refined carbohydrates.   They also pointed out that  monkeys don't do well on Olive oil.
My main concern is that this update on Minnesota trial was never discussed.
 Buried files found on Minnesota trial.
Moving on to the coverage of Obesity.
  Any diet to lose weight is fine. 
The challenge is to maintain weight loss. 
 There were slides for this but basically the speaker only said maintaining weight loss is very difficult and then was vague about the reasons. 
I suggest the following needs to be incorporated into the teaching program at the very least for balance. 


Reduced obese failure to maintain weight loss explained here on HBO WEIGHT LOSS NATION 1 min video has been validated in recent New York Times article by Gina Kolata here:

Biggest Loser has 800 calories BMR decrease lower than expected with energy gap

Low Leptin in reduced obese tells brain it is starving.
 This is the salient point of why reduced obese regain despite diet and exercise. 
  Guidelines state 1 hour a day exercise will maintain weight loss.
 The National Weight Control Registry (NWCR) people do this with 1200 to 1500 calorie diet.
It is possible.

However,
 The Great Starvation Experiment by Ancel Keys  drove 32 men crazy with starvation over 24 weeks on 1550 calories/day  and one hour walking a day which  is what guidelines expect reduced obese to do for the rest of their lives just to maintain their weight loss.

Patients are told it's diet and exercise and will power that will maintain their weight loss and the evidence is with the 10,000 people in NCWR who have done it.

Reduced obese have to do Ancel Keys Starvation diet it for the rest of their lives.
NOT possible for most people as in LOOK AHEAD who failed under the best of circumstances.

In LOOK AHEAD trial the difference with control group was 2.5% weight loss. 
50% NWCR people do it completely on their own.  Amazing group of people.
Look how well the Control Group in LOOK AHEAD did without help

Treated group in LOOK AHEAD:
39% maintained greater than 10% weight loss for 8 years. 
Untreated Control Group in LOOK AHEAD:
24% of the control group lost more than 10% of weight after 8 years.

 How to tell the brain it is not starving in the Reduced Obese group. ?
The Chronic Disease of Obesity needs lifelong drugs.
4 new diet medications


My suggestion for future speakers on Nutrition and Obesity at NLA is to read two recent reviews by

Ochner and Greenway 





Tuesday, May 17, 2016

A Doctors Update on Obamacare

I count at least 14 tiers of medical care in this country. 
1-Medicare,
2- Medicaid,
3-Platinum,
4-Gold,
5-Bronze
,6-Catastrophic in some states,
 7-Employer subsidized pool,
8-Gov't employee insurance (the best?)
9 Veteran's hospitals
10-No insurance w tax penalty but free ER care
11-Rich people buy Boutique medical care
12- Don't forget special categories.   Free money under Ryan White (sic) for HIV and the National Dialysis Program.
13-I have no idea what special deals there are for mental and physical disabilities.  The problem is so many people in so many states have no access to these 14-programs.
What happens to all the children who have taken in lead in Flint? 
15- All the states and territories have different plans. 

Buying medicine or getting it free is a whole different discussion.
There are many good generics available.  Walmart sells many of them for $10 a month.
However many more new very good,  very expensive drugs for HIV and Hepatitis C, Psoriasis, Rheumatoid arthritis,  Immunotherapy for cancer. 
Trump says he will take down state lines for insurance.
Sounds like Medicare for everyone to me.
He wants Medicare to negotiate drug prices with drug companies.
Of course he says he is flexible on issues.  :)
Hillary of course will do all those if she gets a democratic congress.
Billy's letter with my purple comment's:

Brian, a good description of the two- tiered Obamacare system.

So you pay $14,000 a year for health insurance?
So Billy, my medications cost more than $1,000 a month retail if I was not in an insurance plan, especially platinum
Invokana 300 mg $700 a month from Canada Pharmacy even higher in USA.
Victoza 1.8 mg  retail for one month supply at Walgreens:
VICTOZA 3-PAK 18 MG/3 ML PEN  9.0 ml package
N/A1
 
$1495.98
(qty:2)
Qysmia 45 mg (I have a coupon for this but I get some credit I think)
Billy I get extensive blood work at least 3 times a year.
I see Internist, endocrinologist in KS and FL. at least 2 times a year each.
I go to opthalmologist once a year.
With abdominal pain last year I had EGD, MRI abdomen.
I have osteopenia so I had another DEXA scan last year.
I get a colonoscopy at least every 5 years.

Thus I am saving money with my Platinum no deductible plan.
I go on Medicare next year.  I don't know what my premiums will be.
People have told me it is the best insurance they have ever had.
The more income you make the higher your premium is. 
Ginger has a very high medicare premium.  Add the secondary coverage and it adds up especially if there is a deductible?

There are very many that cannot even come close to spending $14,000 a year on Obamacare health insurance.
This is why there are choices.  People determine the best deal for them.  If they have diabetes or some other chronic disease with many medications and hospital visits they need to pay up front. 
If they are healthy and don't take meds and figure they will not need to pay the deductible they can gamble and get the bronze.
My son was offered an even lower level of coverage as a student, Catastrophic.  Less coverage, higher deductible. But unlimited lifeline amount. New with ACA

So instead, they pay for a plan they can “afford” and then find out that they have to pay $6,000 out of pocket before their Obamacare insurance kicks in.

Not correct! The deductible is paid in increments.  That is how the medicine deductible is done with me.  As for a hospitalization, two days in the hospital usually eats up the deductible immediately and what is owed can be paid in increments.  Many different plans with office visits mostly paid for with a small office visit payment.  Billy you can't make this broad statement:    "that they have to pay $6,000 out of pocket before their Obamacare insurance kicks in. "  There may be stories on the internet about it that are not reliable.  I need better documentation of it's veracity.
I am amazed GOP is concerned about deductibles?  That means it's not free medical care.  People have skin in the game.  This is a good GOP principle.  I think people thought Obamacare was supposed to be free? 
What’s the point of paying for insurance you cannot use?
The problem was people had JUNK insurance.  It was cheap with low deductibles but if they got cancer there were lifetime limits on coverage. 
People are paying their monthly premiums, but their insurance doesn’t cover anything until they spend $6,000 of their own money first?

Billy, you clearly have not visited the ACA insurance exchanges and seen the dozens of plans.
First of all ACA now provides many FREE preventive serivces.
Second no policy asks what you medical history is.
I only pay a few hundred dollars a month more to get all the bells and whistles that I want on my plan and I benefit financially from wise shopping.  Lower tiers can do the same .  You are making a broad statement that is not true universally to all plans.' until they spend $6,000 of their own money first?"

And then, unlike you, who can afford to pay $14,000 a year for Obamacare, and a $10,000 deductible, these poor people cannot go to a doctor near them,  (out of network) or the doctor they have been seeing (“If you like your doctor you can keep your doctor.”) simply because they, unlike you, they cannot afford - there’s that pesky misleading word again, afford - the Platinum plan.

Billy, you fail to mention the SUBSIDY PROGRAM which allows working poor to afford insurance after they pay a certain amount of the premium which is what the GOP plan was all about. It's not free.  The working poor have skin in the game.  Ginger and I have paid 4% more federal income tax since two years before Obamacare was started in order to pay for this subsidy.  It's a good thing.

Since about 1979 when Kaiser and HIP plans stared (HMO networks) people made choices for cheaper care in more narrow networks.
People still have the same choices.  Platinum vs. Bronze with HMO vs. PPO. with out of network deductible as I did.

Poor people have always have limited choices.  Reagen said we could not refuse them ER care so the ER became the insurance plan they could afford.
With subsidies and medicaid expansion we can get the poor real insurance and dignity. 

For years in Topeka in Family Practice offices, their patients had to find a new Doctor when they went on Medicare.  They lost their choice and their Doctor.  Most were not willing to pay the market difference.

They are relegated to that second tier.

No the poor were relegated to waiting in the Emergency Room before Obamacare.

So the “Affordable” Care Act is something most people - unlike you - can’t afford and can’t, in practice, use - but are forced to buy, or be penalized, nevertheless.
So Billy I am forced to pay for free emergency care for people who refuse to buy medical insurance?
Billy, people thought ACA was going to be free. 
It's not. 
Surprise!
It pays for itself with 17 taxes.
Insurance companies drop out but a small number and it's probably a good thing.  The forces of the market.

The better EMPLOYER INSURANCE POLICIES are supposed to have a Cadillac tax.  However, lobbies have put that tax off for 18 months. 
Thus the tax payer is subsidizing those better policies as well.
There was supposed to be TRANSPARENCY in Hospital Prices.  I don't know what happened to that?


And yet, the Obamacare pushers can rightfully claim more people have insurance. What the pushers leave out is, it’s insurance the second tier cannot use.

Just not true at all.  Other than internet anecdotes you have no proof, Billy.  Not even counting the added millions on Medicaid.

And what is the Obamacare pusher’s solution to the problem? Spend more money on a system that doesn’t work - Obamacare.

The system works much better that the broken system before Obama. 
1- Everyone with prior illness can get insurance.  This alone is wonderful.
2- Subsides for working poor.
3- Increased Medicaid eligibility
4- Closing dounut on Part D for medicine for Medicare
5-Seventeen taxes to pay for the plan.

We’ve been told, “Insanity is doing the same thing over and over again and expecting different results.”

Tell me, rather than make a new health care plan, how many times did GOP vote to repeal Obamacare?

So, Obamacare - the Affordable Care Act - is not only not affordable, it is insane.
As a physician and a patient I have found it to be a great first step toward single payer insurance.

Except for those who can afford the Platinum plan, and a $10,000 deductible.

Reality check: What more proof does one need that Obamacare, the Affordable Care Act, was never about affordable health insurance, or healthcare?

It’s always been about the federal government controlling one-sixth of the economy; Obamacare, a wolf in sheep’s clothing, socialism.
It's sad when GOP disowns its American Heritage idea that started in form of Romneycare.  That's insane. :)

Venezuela, anyone?


“This is criminal that we can sit in a country with this much oil, and people are dying for lack of antibiotics,” says Oneida Guaipe, a lawmaker and former hospital union leader.”

"Mr. Maduro, who succeeded Hugo Chávez, went on television and rejected the effort, describing the move as a bid to undermine him and privatize the hospital system.”



 

The articles below are the context that lead to the letter above.
 
 
On Mon, May 16, 2016 at 10:36 PM, William Stevens <wstevens@aol.com> wrote:
Brian, a good description of the two- tiered Obamacare system.

So you pay $14,000 a year for health insurance?

There are very many that cannot even come close to spending $14,000 a year on Obamacare health insurance.

So instead, they pay for a plan they can “afford” and then find out that they have to pay $6,000 out of pocket before their Obamacare insurance kicks in. 

What’s the point of paying for insurance you cannot use? People are paying their monthly premiums, but their insurance doesn’t cover anything until they spend $6,000 of their own money first?

And then, unlike you, who can afford to pay $14,000 a year for Obamacare, and a $10,000 deductible, these poor people cannot go to a doctor near them,  (out of network) or the doctor they have been seeing (“If you like your doctor you can keep your doctor.”) simply because they, unlike you, they cannot afford - there’s that pesky misleading word again, afford - the Platinum plan.

They are relegated to that second tier.

So the “Affordable” Care Act is something most people - unlike you - can’t afford and can’t, in practice, use - but are forced to buy, or be penalized, nevertheless.

And yet, the Obamacare pushers can rightfully claim more people have insurance. What the pushers leave out is, it’s insurance the second tier cannot use.

And what is the Obamacare pusher’s solution to the problem? Spend more money on a system that doesn’t work - Obamacare.

We’ve been told, “Insanity is doing the same thing over and over again and expecting different results.”

So, Obamacare - the Affordable Care Act - is not only not affordable, it is insane.

Except for those who can afford the Platinum plan, and a $10,000 deductible.

Reality check: What more proof does one need that Obamacare, the Affordable Care Act, was never about affordable health insurance, or healthcare?

It’s always been about the federal government controlling one-sixth of the economy; Obamacare, a wolf in sheep’s clothing, socialism. 

Venezuela, anyone?


“This is criminal that we can sit in a country with this much oil, and people are dying for lack of antibiotics,” says Oneida Guaipe, a lawmaker and former hospital union leader.”

"Mr. Maduro, who succeeded Hugo Chávez, went on television and rejected the effort, describing the move as a bid to undermine him and privatize the hospital system.”

The New York Times
Dying Infants and No Medicine: Inside Venezuela’s Failing Hospitals
By NICHOLAS CASEYMAY 15, 2016

BARCELONA, Venezuela — By morning, three newborns were already dead.

The day had begun with the usual hazards: chronic shortages of antibiotics, intravenous solutions, even food. Then a blackout swept over the city, shutting down the respirators in the maternity ward.

Doctors kept ailing infants alive by pumping air into their lungs by hand for hours. By nightfall, four more newborns had died.

“The death of a baby is our daily bread,” said Dr. Osleidy Camejo, a surgeon in the nation’s capital, Caracas, referring to the toll from Venezuela’s collapsing hospitals.

The economic crisis in this country has exploded into a public health emergency, claiming the lives of untold numbers of Venezuelans. It is just part of a larger unraveling here that has become so severe it has prompted President Nicolás Maduro to impose a state of emergency and has raised fears of a government collapse.

Hospital wards have become crucibles where the forces tearing Venezuela apart have converged. Gloves and soap have vanished from some hospitals. Often, cancer medicines are found only on the black market. There is so little electricity that the government works only two days a week to save what energy is left.

At the University of the Andes Hospital in the mountain city of Mérida, there was not enough water to wash blood from the operating table. Doctors preparing for surgery cleaned their hands with bottles of seltzer water.

“It is like something from the 19th century,” said Dr. Christian Pino, a surgeon at the hospital.

The figures are devastating. The rate of death among babies under a month old increased more than a hundredfold in public hospitals run by the Health Ministry, to just over 2 percent in 2015 from 0.02 percent in 2012, according to a government report provided by lawmakers.

The rate of death among new mothers in those hospitals increased by almost five times in the same period, according to the report.

Here in the Caribbean port town of Barcelona, two premature infants died recently on the way to the main public clinic because the ambulance had no oxygen tanks. The hospital has no fully functioning X-ray or kidney dialysis machines because they broke long ago. And because there are no open beds, some patients lie on the floor in pools of their blood.

It is a battlefield clinic in a country where there is no war.

“Some come here healthy, and they leave dead,” Dr. Leandro Pérez said, standing in the emergency room of Luis Razetti Hospital, which serves the town.

This nation has the largest oil reserves in the world, yet the government saved little money for hard times when oil prices were high. Now that prices have collapsed — they are around a third what they were in 2014 — the consequences are casting a destructive shadow across the country. Lines for food, long a feature of life in Venezuela, now erupt into looting. The bolívar, the country’s currency, is nearly worthless.

The crisis is aggravated by a political feud between Venezuela’s leftists, who control the presidency, and their rivals in congress. The president’s opponents declared a humanitarian crisis in January, and this month passed a law that would allow Venezuela to accept international aid to prop up the health care system.

“This is criminal that we can sit in a country with this much oil, and people are dying for lack of antibiotics,” says Oneida Guaipe, a lawmaker and former hospital union leader.

But Mr. Maduro, who succeeded Hugo Chávez, went on television and rejected the effort, describing the move as a bid to undermine him and privatize the hospital system.

“I doubt that anywhere in the world, except in Cuba, there exists a better health system than this one,” Mr. Maduro said.

Late last fall, the aging pumps that supplied water to the University of the Andes Hospital exploded. They were not repaired for months.

So without water, gloves, soap or antibiotics, a group of surgeons prepared to remove an appendix that was about to burst, even though the operating room was still covered in another patient’s blood.

Even in the capital, only two of nine operating rooms are functioning at the J. M. de los Ríos Children’s Hospital.

“There are people dying for lack of medicine, children dying of malnutrition and others dying because there are no medical personnel,” said Dr. Yamila Battaglini, a surgeon at the hospital.

Yet even among Venezuela’s failing hospitals, Luis Razetti Hospital in Barcelona has become one of the most notorious.

In April, the authorities arrested its director, Aquiles Martínez, and removed him from his post. Local news reports said he was accused of stealing equipment meant for the hospital, including machines to treat people with respiratory illnesses, as well as intravenous solutions and 127 boxes of medicine.

Around 10 one recent night, Dr. Freddy Díaz walked down a hall there that had become an impromptu ward for patients who had no beds. Some clutched blood-soaked bandages and called from the floor for help. One, brought in by the police, was handcuffed to a gurney. In a supply room, cockroaches fled as the door swung open.

Dr. Díaz logged a patient’s medical data on the back of a bank statement someone had thrown in the trash.

“We have run out of paper here,” he said.

On the fourth floor, one of his patients, Rosa Parucho, 68, was one of the few who had managed to get a bed, though the rotting mattress had left her back covered in sores.

But those were the least of her problems: Ms. Parucho, a diabetic, was unable to receive kidney dialysis because the machines were broken. An infection had spread to her feet, which were black that night. She was going into septic shock.

Ms. Parucho needed oxygen, but none was available. Her hands twitched and her eyes rolled into the back of her head.

“The bacteria aren’t dying; they’re growing,” Dr. Díaz said, noting that three of the antibiotics Ms. Parucho needed had been unavailable for months.

He paused. “We will have to remove her feet.”

Three relatives sat reading the Old Testament before an unconscious woman. She had arrived six days before, but because a scanning machine had broken, it was days before anyone discovered the tumor occupying a quarter of her frontal lobe.

Samuel Castillo, 21, arrived in the emergency room needing blood. But supplies had run out. A holiday had been declared by the government to save electricity, and the blood bank took donations only on workdays. Mr. Castillo died that night.

For the past two and a half months, the hospital has not had a way to print X-rays. So patients must use a smartphone to take a picture of their scans and take them to the proper doctor.

“It looks like tuberculosis,” said an emergency room doctor looking at the scan of a lung on a cellphone. “But I can’t tell. The quality is bad.”

Finding medicine is perhaps the hardest challenge.

The pharmacy here has bare shelves because of a shortage of imports, which the government can no longer afford. When patients need treatment, the doctors hand relatives a list of medicines, solutions and other items needed to stabilize the patients or to perform surgery. Loved ones are then sent back the way they came to find black-market sellers who have the goods.

The same applies to just about everything else one might need here.

“You must bring her diapers now,” a nurse told Alejandro Ruiz, whose mother had been taken to the emergency room.

“What else?” he asked, clutching large trash bags he had brought filled with blankets, sheets, pillows and toilet paper.

Nicolás Espinosa sat next to his tiny daughter, who has spent two of her five years with cancer. He was running out of money to pay for her intravenous solutions. Inflation had increased the price by 16 times what he paid a year ago.

He flipped through a list of medicines he was trying to find here in Barcelona and in a neighboring city. Some of the drugs are meant to protect the body during chemotherapy, yet the girl’s treatments ended when the oncology department ran out of the necessary drugs a month and a half ago.

Near him, a handwritten sign read, “We sell antibiotics — negotiable.” A black-market seller’s number was listed.

Biceña Pérez, 36, scanned the halls looking for anyone who would listen to her.

“Can someone help my father?” she asked.

Her father, José Calvo, 61, had contracted Chagas’ disease, a sickness caused by a parasite. But the medication Mr. Calvo had been prescribed ran out in his part of Venezuela that year, and he began to suffer heart failure.

Six hours after Ms. Pérez’s plea, a scream was heard in the emergency room. It was Mr. Calvo’s sister: “My darling, my darling,” she moaned. Mr. Calvo was dead.

His daughter paced the hall alone, not knowing what to do. Her hands covered her face, and then clenched into fists.

“Why did the director of this hospital steal that equipment?” was all she could say. “Tell me whose fault is this?”

The ninth floor of the hospital is the maternity ward, where the seven babies had died the day before. A room at the end of the hall was filled with broken incubators.

The glass on one was smashed. Red, yellow and blue wires dangled from another.

“Don’t use — nonfunctional,” said a sign dated last November.

Dr. Amalia Rodríguez stood in the hallway.

“I had a patient just now who needed artificial respiration, and I had none available,” Dr. Rodríguez said. “A baby. What can we do?”

The day of the power blackout, Dr. Rodríguez said, the hospital staff tried turning on the generator, but it did not work.

Doctors tried everything they could to keep the babies breathing, pumping air by hand until the employees were so exhausted they could barely see straight, she said. How many babies died because of the blackout was impossible to say, given all of the other deficiencies at the hospital.

“What can we do here?” Dr. Rodríguez said. “Every day I pass an incubator that doesn’t heat up, that is cold, that is broken.”


From: Brian Edwards [mailto:brianedwardsmd@gmail.com]
Sent: May 16, 2016 at 9:17:12 PM EDT
To: William Stevens
Cc: Kevin Banonis; George Webb; Bruce MacCullough; leaton@midwest-health.com; Lynn Thompson; Ray Connin; Rod Taylor
Subject: Re: OK looking to accept Obamacare: So much for the death spiral.

This article says nothing new.
I have Obamacare.
I have written you all about this 2 years ago.
I choose Platinum over gold or Bronze because as a Diabetic I knew I needed health care and I paid high premiums up front with zero deductibles.
People with good health can choose to gamble that they will not get sick and take the Bronze plan with low Premiums but high deductibles.
Why any GOP complains about this business plan is a mystery to me.  Medical care is not given away in Obamacare.  Patients pay for it.
I chose the PPO network rather than the HMO network.  I pay a higher premium but I knew I wanted to go to any hospital in the country especially in Kansas and Florida since I live in both states.  The author acts surprised about this economic pricing of better plans.  Again nothing is given away.
I also knew I might get a rare cancer and want to go to a University Center not in the Blue Cross network.  Thus I purchased a plan with an out-of-network deductible maximum of $10,000.  This way I could go to Sloan Kettering in NYC.
The article Billy shows us is technically correct but there is nothing there to be surprised about. 
The medical market is still a market.
Better insurance products cost more.
I pay $1200 premiums but I get it back in my coverage for my multiple expensive medications.  I have 4 expensive medications that  had  to be pre-authorized and were without difficulty.  I was very pleased.
Without Obamacare I probably could not get insurance because of my pre-existing condition of diabetes.

I have no doubt Hillary or Trump will improve Obamacare and allow everyone to buy Medicare if they want or some other single payer option.








On Mon, May 16, 2016 at 6:03 PM, William Stevens <wstevens@aol.com> wrote:
Spending more money and expecting different results, irrational? No, insanity!

http://www.nytimes.com/2016/05/15/sunday-review/sorry-we-dont-take-obamacare.html?emc=edit_tnt_20160515&nlid=99788&tntemail0=y

Sorry, We Don’t
Take Obamacare
The growing pains of the health care act are frustrating patients.

By ELISABETH ROSENTHAL MAY 14, 2016

AMY MOSES and her circle of self-employed small-business owners were supporters of President Obama and the Affordable Care Act. They bought policies on the newly created New York State exchange. But when they called doctors and hospitals in Manhattan to schedule appointments, they were dismayed to be turned away again and again with a common refrain: “We don’t take Obamacare,” the umbrella epithet for the hundreds of plans offered through the president’s signature health legislation.

“Anyone who is on these plans knows it’s a two-tiered system,” said Ms. Moses, describing the emotional sting of those words to a successful entrepreneur.

“Anytime one of us needs a doctor,” she continued, “we send out an alert: ‘Does anyone have anyone on an exchange plan that does mammography or colonoscopy? Who takes our insurance?’ It’s really a problem.”

The goal of the Affordable Care Act, which took effect in 2013, was to provide insurance to tens of millions of uninsured or under-insured Americans, through online state and federal marketplaces offering an array of policies. By many measures, the law has been a success: The number of uninsured Americans has dropped by about half, with 20 million more people gaining coverage. It has also created a host of new policies for self-employed people like Ms. Moses, who previously had insurance but whose old plans were no longer offered.

Yet even as many beneficiaries acknowledge that they might not have insurance today without the law, there remains a strong undercurrent of discontent. Though their insurance cards look the same as everyone else’s — with names like Liberty and Freedom from insurers like Anthem or United Health — the plans are often very different from those provided to most Americans by their employers. Many say they feel as if they have become second-class patients.

This disappointment is fueling renewed interest in a “public option” that would supplement current offerings. That idea found support from both Senator Bernie Sanders and Hillary Clinton as the Affordable Care Act was making its way through Congress. It was taken up again last week by Mrs. Clinton, when she suggested allowing people 55 and over to buy into Medicare, the government-run insurance for people 65 and over, which is accepted by virtually all hospitals.

Some early studies of the impact of the Affordable Care Act plans are proving patients’ grumbling justified: Compared with the insurance that companies offer their employees, plans provide less coverage away from patients’ home states, require higher patient outlays for medicines and include a more limited number of doctors and hospitals, referred to as a narrow network policy. And while employers tend to offer their workers at least one plan that allows them coverage to visit doctors not in their network, patients buying insurance through A.C.A. exchanges in some states do not have that option, even if they’re willing to pay higher premiums.

Many of the problems may well be the growing pains of a young, evolving system, which established only broad standards for A.C.A. plans and allowed insurers — a large majority of them for-profit — considerable leeway in designing their exact offerings. The specific requirements and policing mechanisms vary by state, and are still works in progress.

Daniel Polsky, executive director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania, is among the researchers who have been studying the law’s effects on patients’ access to care. “We hear lots of complaints, but we really don’t know the extent of the problem because there’s still very little data,” he said.

The legislation created four tiers of insurance — bronze, silver, gold and platinum. The different levels represent the amount of medical costs a patient could expect their insurance to contribute: 60, 70, 80 or 90 percent. But within each tier there are dozens of plan designs that give buyers the choice of different premiums, deductibles and networks of doctors, among other things. And the options are different in each state. The A.C.A.’s target audience included both low-earning Americans — those too wealthy to qualify for Medicaid but too poor to afford commercial insurance — and those who could not buy insurance through an employer, either because they were self-employed or because their jobs for small companies didn’t offer coverage.

The research thus far suggests that the differences between plans offered through the A.C.A. and those offered by employers may be quite significant. A study in the policy journal Health Affairs found that out-of-pocket prescription costs were twice as high in a typical silver plan — the most popular choice — as they were in the average employer offering. In research conducted with the Robert Wood Johnson Foundation, Dr. Polsky found that 41 percent of silver plans offered a “narrow or very narrow” selection of doctors, meaning at best 25 percent of physicians in an area were included. The consulting firm Avalere Health found that exchange plans had 42 percent fewer cancer and cardiac specialists, compared with employer-provided coverage.

Some of the problems may have been predictable. When designing the new plans, for-profit insurers naturally tended to exclude high-cost, high-end hospitals with whom they had little clout to negotiate discounts. That means, for example, that as of late last year none of the plans available in New York had Memorial Sloan Kettering Cancer Center in their network — an absence that would be unacceptable to many New York-based employers buying policies for their employees. Another issue is out-of-state coverage, which many A.C.A. plans don’t offer aside from emergencies, and which is routinely offered in policies from companies — especially large ones — with workers in more than one state.

As a result, many parents who were excited that they would be able to keep their children on their policies until age 26 have discovered that this promise has gone unfulfilled. When Sara Hamilton of New York was shopping on the exchange for a plan to cover her and her two young-adult children — who live in distant states — she discovered that none of the plans covered doctor visits in those places.

And when Simon F. Haeder of the University of Wisconsin and his colleagues studied the plans sold on the California exchange, they found that they included 34 percent fewer hospitals than those sold on the open market and tended to exclude the priciest medical centers, like Cedars Sinai, a highly regarded hospital that runs the largest heart-transplant program in the country.

Plan size, of course, is not the only consideration. The research also showed that those limitations might not matter so much for patients’ health: The distance traveled and the quality of the providers was similar under both types of policies. He acknowledged, however, that California’s exchange, called Covered California, has higher standards for plans than others do, and those results may not be typical.

For certain patients, narrower networks can be attractive because they tend to have lower premiums. A recent analysis by the management consulting firm McKinsey & Company found that premiums were 22 percent higher for plans with broad, as opposed to narrow, networks.

Meanwhile, as researchers continue to evaluate the pros and cons of new exchange plans, patients are discovering the pitfalls.

In 2013, Angie Purtell of Tega Cay, S.C., bought a gold plan offered by Coventry Health Care. When notified that the plan would double its monthly premium the following year, to nearly $1,000, she went shopping again on the state exchange and chose a Blue Cross silver plan for $500. It was branded “Choice.”

But when she tried to visit her longtime doctor using the new plan, she found she could not. The doctor’s practice, while in South Carolina, was not covered because it is affiliated with the Carolina Medical Center, a few miles over the border in Charlotte, N.C.

In order to make smart choices, patients need far clearer and more accurate information about the plans’ restrictions as well as which doctors and hospitals are in the network. Yet such information is rarely available, and early research suggests that only a fraction of the doctors listed in some directories are available to see new patients.

“Now that you have the A.C.A., we really need to talk about what is an adequate network,” Mr. Haeder said. “But we can’t really talk about that until we know that the listings are accurate, and they’re not.”

ACROSS the country, lawmakers and regulators are refining the plans’ requirements to make sure they work better. And regulators are trying to mandate better information, provided in a more consumer-friendly format.

As of this year, the government requires all the plans listed on the national online exchange — used by 38 states — to provide accurate, up-to-date directories. But such directories are often hundreds of pages long, and there is little enforcement. Even the government advises consumers to double-check with their insurers.

The Centers for Medicare and Medicaid Services recently proposed that states develop quantitative requirements for adequate networks — how many specialists of a certain type, for example, are necessary in a specific geographic area. But after protests from insurers and some states, the agency settled — for now — on a more limited fix that allows states and insurers more time to address the problem.

Next year, the government will begin requiring insurers to label plans “standard” (an average number of doctors for an exchange plan) versus “broad” or “basic” for those offering more or less choice. A few states are enacting their own laws.

But health and consumer advocates say progress is too slow, often leaving patients in the dark as they struggle to buy and use the new plans. Even as conservatives in Congress and the presumptive Republican presidential nominee, Donald J. Trump, have vowed to repeal the A.C.A., many consumers just want the system to work better.

“I’m putting my energy into improving transparency and information,” Dr. Polsky said. “Otherwise, we’re headed to a poorly implemented strategy that just ticks people off.”

Elisabeth Rosenthal (@nytrosenthal) is a New York Times correspondent who is writing a book about the health care system. A continuing conversation about health care costs and pricing in the United States is on the Facebook group page Paying Till It Hurts.


From: Brian Edwards [mailto:brianedwardsmd@gmail.com]
Sent: May 16, 2016 at 6:47:08 PM EDT
To: Kevin Banonis; William Stevens; George Webb; Brian Edwards; Bruce MacCullough; leaton@midwest-health.com; Lynn Thompson; Ray Connin; Rod Taylor
Subject: OK looking to accept Obamacare: So much for the death spiral.

Oklahoma can no longer afford irrational Obamacare hatred

05/16/16 12:30 PMUpdated 05/16/16 01:07 PM
In recent years, as the Affordable Care Act has taken root, there are a series of great anecdotes about Americans who thought they hated the reform law, right up until they really needed it. At that point, these consumers tended to effectively say, “Maybe blind hatred for Obamacare wasn’t such a good idea after all.”
 
As it turns out, a similar situation has unfolded in many state capitols, where Republican policymakers are certain they want to reject every possible aspect of the ACA, until it dawns on them this posture ends up hurting their state for no reason. The Associated Press turned the spotlight on Oklahoma today:
Despite bitter resistance in Oklahoma for years to President Barack Obama’s health care overhaul, Republican leaders in this conservative state are now confronting something that alarms them even more: a huge $1.3 billion hole in the budget that threatens to do widespread damage to the state’s health care system.
 
So, in what would be the grandest about-face among rightward leaning states, Oklahoma is now moving toward a plan to expand its Medicaid program to bring in billions of federal dollars from President Obama’s new health care system.
This shift has been predicted for years, though it’s taking longer than health care advocates had hoped. Just how long can a state like Oklahoma spite itself, on purpose, because it doesn’t like the president? What would it take for officials in the Sooner State to succumb to arithmetic?
 
In this case, Oklahoma’s big budget shortfall, and the prospect of closing state-subsidized nursing homes, was enough to start changing Republicans’ minds.
 
Craig Jones, the president of the Oklahoma Hospital Association, told the AP, “We are nearing a colossal collapse of our health care system in Oklahoma. We have doctors turning away patients. We have people with mental illnesses who are going without treatment. Hospitals are closing, and this is only going to get worse this summer if the Legislature does not act immediately to turn this around.”
 
Warnings like these appear to have raised eyebrows, even among far-right policymakers.
 
The AP report added, “Despite furious opposition by conservative groups, Republican Gov. Mary Fallin and some GOP legislative leaders are pushing the plan, and support appears to be growing in the overwhelmingly Republican Legislature.”
 
The blueprint is still coming together, but Oklahoma will reportedly pursue a model based on Indiana’s compromise with the Obama administration, which isn’t quite as good as the Medicaid expansion policy as it was originally designed, but it will allow red states like Oklahoma to adopt the policy while saving face (and enjoying the much needed benefits).
 
Fallin has reportedly begun referring to the shift as “Medicaid rebalancing,” as a way to avoid references to the president’s name.
 
For those keeping score, 31 states have adopted Medicaid expansion through the ACA, and Oklahoma would be the 32nd if the state proceeds on its current course. South Dakota, Wyoming, Alabama, and Idaho are among the remaining holdouts eyeing a similar change in direction.

Sunday, May 15, 2016

Why are medical insurance premiums so high?


Part one:

Original idea?
 Use premiums to pay for medicine

This is why medical insurance premiums are so high.
Science is not applied to the problem of Obesity.

Lifestyle changes have not been shown to maintain significant weight loss when compared to a control in largest and longest trial that was negative in it’s primary outcome. LOOK AHEAD trial

Kaiser should not spend 50 million dollars from medical premiums to programs that will not help those people that pay the premiums.  The patients that pay the premiums should have coverage for the four new diet medications now available for lifelong treatment.

Instead there is a strategy for bariatric surgery.  Possibly this provides more profit?
After 10 years, 30% of all bariatric surgery patients gain all their weight back.
Unfortunately when the surgery fails rather than start multiple diet drugs, a new more aggressive surgery is advised.

The science of Obesity is available:


Part 2: 
Expensive effort to Rx obesity leaves out medicine


ConscienHealth article:

The Challenge of Systematic Obesity Care

           
“If you want some insight into the challenges of gearing up to deliver systematic obesity care, a new publication in Current Obesity Reports is well worth reading. For a full understanding, you will have to read carefully between the lines.
Adam Tsai and colleagues give a very thorough description of how Kaiser Permanente invests in delivering obesity care in the most positive terms possible. They describe a “whole systems” approach to obesity at Kaiser that starts at the community level, investing $50 million in healthy eating and active living programs in an effort to reduce the impact of obesity that is straining their systems for delivering healthcare.
As a key learning from these community health initiatives the authors cite the importance of delivering an adequate “dose” of an intervention to achieve an effect. They do not, however, cite evidence that they have found the right dose to deliver a change in health outcomes. The effort is noble, but it might be guided by conviction more than evidence.
In the realm of evidence-based interventions, Tsai describes an impressive investment in high-intensity lifestyle programs and medically supervised diets. The commitment to these interventions is truly systematic.

At the other end of the spectrum, the authors describe system-wide access to bariatric surgery.
But in the middle, one comes away with the impression of a significant gap.
For many patients, lifestyle modification is not adequate and surgery seems undesirable.

Yet coverage for intensive medical management of obesity, using FDA approved pharmacotherapy, is hardly systematic. Only two of seven regions will reimburse patients for obesity medications and only if their physicians certify that it is medically necessary.

Tsai cites
1-misperceptions about the biological basis of obesity,
2- misunderstandings about obesity drugs,
3-and a conviction that obesity “should not require pharmacotherapy”
as reasons for the low utilization of obesity medications.

Kaiser is a unique healthcare delivery system, sometimes described as a model for high-quality healthcare. Yet the problems that interfere with delivering a high standard of obesity care are not so different from the problems seen in other parts of the healthcare system.

Delivering systematic obesity care remains a challenge. A long tradition of systematically excluding obesity from medical care stands in the way. The bias against caring for people with obesity is a luxury that has become unaffordable.
Leaving obesity untreated has created a crushing burden of chronic diseases that result from obesity.”