Sun Primer

Posted on | July 25, 2014 | No Comments

image: NOAA

Mike Magee

The sunny season has arrived, and for many it’s “sunfusion” – sunlight confusion. Is sun exposure good or bad? Let’s start here: Sun Beds (tanning salons) – bad.(1)

But what about everyday natural sun? On the positive side: boosts Vitamin D (may protect against diabetes, heart disease, osteoporosis and other diseases), elevates endorphins, and increases self esteem (in some). On the negative side: cancer, aging, cataracts and more. (2) Quite a divergent set of realities. No wonder we’re confused whether to seek sun or shade.
Let’s look at some basic sun facts. (3,4)

The Rays: UVA – penetrates clouds and glass, penetrates deep into skin layers (epidermis and dermis), creates wrinkles and causes skin aging, featured in tanning booths. UVB – stimulates melanin, varies with site and environment, penetrates upper layer of skin (epidermis), aids vitamin D production, can cause sun burns. (5,6)

A New Threat: Not really. But our focus has increased for good reasons. Sun worshiping and a “healthy” tan are now associated in our culture with health and wealth. We’re living longer (damage and risk are cumulative), beach wear exposes more skin surface, and today tanning parlors are big business. (2)

Reasonable Levels of Exposure: Some feel that over reaction to sun risk has caused an increase in Vitamin D deficiency. For most in US, up to 30 minutes standard exposure 3 times a week takes care of Vitamin D, which is also available through supplements. (2,7)

The Cancers: 90% are directly linked to cumulative UV exposure. This includes basal cell and squamous cell cancers. Basal cell cancers occur mostly on the face and have a low risk of spreading. Squamous cell cancers often occur on ears, lips and temples and are more prone to spread. As for melanomas,experts say about 2/3 are directly related to UV induced genetic mutations. While only 3% of skin cancers are melanomas, they account for 75% of skin cancer deaths and are the most common cause of cancer for adults age 25 to 29. (3,4,6)

Tan Equals Protection: No. Tan equals skin damage. Melanin is sent to the upper layer of the skin to try to block UV rays. Tan does give some blocking equal to 3 SPF sun screen but skin cell DNA damage is the price you pay for this inadequate response. Tan also equals deep collagen damage which means wrinkles and visibly aging skin. (8,9)

Skin Tones: Six types ranging from freckle-faced fair to black skin face varying levels of risk according to the Skin Cancer Foundation. (2) If you are the former like me, SPF 30 should be your constant companion and you need to head for shade whenever possible. Others can get by with SPF 15. Site matters especially beaches and ski slopes. Clearly lying on the beach all day fully exposed doesn’t make sense for anyone.

Sunscreen Confusion: FDA has acknowledge that standards for protection and terminology need upgrading. That’s to be completed by October, 2010. No more use of the terms “sunblock” or “waterproof”.  And SPF ratings over 50 will disappear as the SPF up-coding between competitors abates. The new system will be a simple 1 to 4 rating and include UVB and UVA rays. (8,9,10)

So those are the basic facts. Hopefully that solves some of the “sunfusion”.  Bottom line – moderation, common sense exposure, increased care for the very fair.

For Health Commentary, I’m Mike Magee.

References:

1. Magee M. Dangers of Tanning. Health Politics. 2006.http://www.youtube.com/watch?v=qaMv3xyIvR0&feature=channel_page

2. Beck M. Sun-Kissed or Sunburned? The Wall Street Journal. D1. April 27, 2010.http://online.wsj.com/article/SB10001424052748703465204575208011470022100.html

3. Skin Cancer Foundation. Basic Facts. http://www.skincancer.org/Skin-Cancer-Facts/

4. Skin Cancer Fact Sheet. American Academy of Dermatology.

5. Skin Cancer Foundation. UV Information. http://www.skincancer.org/UV-Information/

6. Landro L. A Shade Seeker Finds New Ways To Block UV Rays. The Wall Street Journal, D1. April 27, 2010

7. Vitamin D Fact Sheet. American Academy of Dermatology.http://www.aad.org/media/background/factsheets/fact_vitamind.htm

8. Skin Cancer Foundation. Sunscreen.http://www.skincancer.org/Sunscreen/

9. Facts About Sunscreens. American Academy of Dermatology.http://www.aad.org/media/background/factsheets/fact_sunscreen.htm

10. FDA Aims To Upgrade Sunscreen Labeling.http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm049091.htm

CDC Ranking of Top Ten Least Active States

Posted on | July 17, 2014 | No Comments

CDC now ranks population level activity rates state by state. Here are the top ten least active states with % of inactive population

Mississippi: 36%
Tennessee: 35.1%
West Virginia: 35.1%
Louisiana: 33.8%
Alabama: 32.6%
Oklahoma: 31.2%
Arkansas: 30.9%
Kentucky: 29.3%
Indiana: 29.2%
Missouri: 28.4%

Sex, Coverage and Gender Bias: Being “Hobby-Lobbied”!

Posted on | July 16, 2014 | 2 Comments

David and Barbara Green/Hobby Lobby

Mike Magee

In its 5-4 decision in favor of Evangelical Christian purveyor of all things crafty, Hobby Lobby, the conservative male contingency of the Supreme Court managed to both engage and enrage all sides in the culture wars of a half century past.

With the decision, “closely held” (whatever that means) corporate entities “gained a conscience”, just like individuals, and the right to pick and choose from the menu of 20 forms of contraception required under the Affordable Care Act. Hobby Lobby chose to delete 2 morning after pills and 2 intra-uterine devices (IUD’d) they considered to be abortion inducers.

The Democratic leadership rapidly responded with a proposed Senate Bill (Protect Women’s Health From Corporate Interference Act) that would negate the effect of the Supreme Court decision and immediately drew the support of the 55,000 gynecologists strong American Congress of Obstetricians and Gynecologists which, in a clear slam down stated, “a woman’s boss has no role to play in her personal health care decisions…The value of family planning, including contraception, is clear. It allows women to time and space their pregnancies, leading to more optimal health outcomes for mother and for baby. And it helps to prevent unintended pregnancy; in America, nearly one half of all pregnancies are unintended…It is also essential that when an ob-gyn prescribes the appropriate contraceptive for each individual patient, he or she can trust that the patient will have access to that treatment option. Restrictions to this access are an unnecessary, inappropriate impediment in the patient/physician relationship.”

The last time ACOG came out this strongly on birth control was a half century ago when ACOG’s then director of women’s health issues, Luella Klein, MD, labelled the growing reimbursement for the newly released Viagra in the face of widespread non-coverage of birth control pills a “form of bias against women”. “People say pregnancy is natural, but what woman wants 21 or 25 pregnancies… This insurance exclusion makes no sense. Contraception provides great savings to the health care system, yet it is the individual woman who is shouldering the burden of this cost savings to insurers.”

While the pill had been legal and widely available since 1965 when the ruling in Griswold v. Connecticut struck down state laws banning the sale of birth control, the pill remained largely uncovered as the new millennium approached by insurance companies who said it was not a “medical necessity”. This claim had been under attack for decades, but legislation over the years had been successfully defeated by a coalition of businesses and the United States Conference of Catholic Bishops. This is the same group that pharmaceutical giant Pfizer approached in 1997 to get a Vatican read on whether they would actively oppose Viagra.

As a Catholic commentator explained the nuanced tortured rationale leading to the green light years later, “The Church has not condemned the use of Viagra. Artificial contraception, as you must know, is the intentional prevention of conception or impregnation through the use of various devices, agents, drugs, sexual practices, or surgical procedures before, during, or after a voluntary act of intercourse. Viagra, on the other hand, is a drug that helps males to overcome a pathological condition preventing them from engaging in the conjugal act with their spouses. Destroying or denying a good (conception) is quite different from enhancing or strengthening a good (as by use of Viagra).”

In the first six weeks after Viagra’s approval, the Church stood by it’s word – no opposition expressed to the drug, and tacit affirmation that this was “real medicine for a real disease” that made possible the normal resumption of natural marital relations. The tightrope for Pfizer was attempting to maintain the support of physicians who were becoming increasingly vocal about what they considered to be gender specific reimbursement bias, without triggering a negative reaction to Viagra reimbursement by the formidable Catholic lobby.

The fact that Gloria Feldt, then president of Planned Parenthood had made a very publicized comment about the disparity was of some concern. But when the 39,000 strong American College of Obstetrics and Gynecology issued a statement condemning the lack of coverage in the face of reimbursement of Viagra as a “form of bias against women”, pressure was building. Forced to take a stand, Pfizer quietly voiced support for reimbursement of both Viagra and contraceptives as necessary and medically sound therapies, and added coverage of birth control pills for its own employees for the first time.

With the Hobby Lobby ruling, instigated in part by the prior compromise with the US Conference of Catholic Bishops over coverage of contraception in Catholic organizations including hospitals and universities, the old lines have been reformed. And once again, American women and their doctors are caught in the cross-fire.

For Health Commentary, I’m Mike Magee

Are Doctors Afraid To Touch Patients?

Posted on | July 3, 2014 | 5 Comments

Mike Magee

Where do I begin? When I read the JAMA title last week, “Banning the handshake from the health care setting”, my immediate reaction was, “Seriously, have we gone this far?”

Then I read the dispassionate opening, “The handshake represents a deeply established social custom. In recent years, however, there has been increasing recognition of the importance of hands as vectors for infection, leading to formal recommendations and policies regarding hand hygiene in hospitals and other health care facilities. Such programs have been limited by variable compliance and efficacy. In an attempt to avoid contracting or spreading infection, many individuals have made their own efforts to avoid shaking hands in various settings but, in doing so, may face social, political, and even financial risks.”

And my second reaction was, “Is this really about patient welfare or about institutionally based doctors and their reticence to take the risk to touch a patient”.

Then I read, “Particularly in the current era of health care reform, innovative, practical, and fiscally prudent approaches toward the prevention of disease will assume increasingly important roles.” And my third reaction was, “Do they really want to go there, to justify contact-less caring as cost-effective?”

And in the arena of rare and strange analogies, the authors proclaim, “Although the mortality associated with smoking has been found to be substantially greater than that associated with hospital-acquired infections, some parallels may be drawn between the proposal to remove the handshake from the health care setting and previous efforts to ban smoking from public places.” To which my inner doctor shrank as humanistic care went up in smoke.

Finally I read the very last sentence, and it said, “Given the tremendous social and economic burden of hospital-acquired infections and antimicrobial resistance, and the variable success of current approaches to hand hygiene in the health care environment, it would be a mistake to dismiss, out of hand, such a promising, intuitive, and affordable ban.” And I concluded, “Just one more reason why Americans need to avoid going to the hospital.”

For Health Commentary, I’m Mike Magee

ACA Will Amplify Healthy People 2020′s Early Successes

Posted on | June 27, 2014 | 2 Comments

Mike Magee

We are now in the fourth decade of “Healthy People”, the US Public Health’s strategic road map for both guiding and measuring the success of population wide health initiatives. The scope of the initiative is impressively broad, including 42 different categories and over 1000 touch points.

We’re currently striving to reach goals outlined in Healthy People 2020. In that plan, 26 “leading health indicators” are identified for top priority concentration. A snapshot reveals that, in the first third of this decade, the nation has met or exceeded the goals in 4 areas, and has demonstrated improvement in 14 of the 26.

A recent summary revealed some high points:

1. Age-adjusted homicides have decreased to target amounts.

2. Targets for adult physical activity and muscle strengthening have been met.

3. Childhood exposure to secondhand smoke has declined as hoped for, and environmental efforts have cleansed the air that our children are breathing.

4. Improvement has been shown in the frequency of pre-term births and in infant deaths.

5. Colorectal cancer screening, childhood immunizations, and hypertension control have improved.

6. Adolescent use of drugs and alcohol are down.

7. Adult tobacco use continues to decline.

8. More HIV positive individuals know their serostatus.

9. More kids who reach the 9th grade have gone on to earn a high school diploma.

The summary also revealed 8 areas where no improvement has occurred and 3 areas where we have actually reversed the progressive trend, including:

1. Major depressive episodes and suicides in adolescents.

2. No improvements in the rates of childhood obesity or in the intake of vegetables.

3. A decline in dental visits.

The data reported out precedes the full 2014 implementation of the Affordable Care Act. But recent data has shown that nearly 10 million citizens have gained new access to health insurance, and with it will come higher levels of care coordination and other critical services like dental care and substance abuse treatment. Also built into standard models, and innovative trials occuring throughout the country, are a wide range of health promotion activities whose results will serve to guide future programmatic initiatives. Preventive services at no cost to patients are now available to over 100 million Americans.

As the government’s Public Health experts have reported, “public health always represents unfinished business.” But to this they add,  “Further analyses to explain the changes noted herein can amplify national discussions about aspirations for a healthier nation.” With the institution of the Affordable Care Act, and the expansion of electronic medical records, as well as the ability to monitor the results of hundreds of competing approaches to advancing health and human potential, we are clearly on the right track.

To declare success, however, we will need to structurally unite around these gains, deflect naysayers, and maintain momentum. As important, we must demonstrate, as part of our success story, that investing in health and prevention can effectively decrease not only the nation’s chronic disease burden, but also its every expanding financial burden as well.

For Health Commentary, I’m Mike Magee.

AHC’s and The “Medical-Industrial Complex” : Re-establishing Appropriate Checks and Balances

Posted on | June 20, 2014 | No Comments

Mike Magee

In this week’s New England Journal of Medicine, there were dueling articles addressing the question whether this nation’s investment in Academic Medical Centers is helping or hurting when it comes to improving the quality and efficiency of our health care system.

In the lead article, Gail Wilensky and her co-authors add up the federal and state subsidies for Graduate Medical Education (GME) in their first paragraph ($9.5B from Medicare, $2B from Federal Medicaid, $4B from State Medicaid, and $4B from the VA and HRSA) for an impressive $19.5B, and challenge conventional wisdom by stating that increased funding will not offset the cost of training physicians, and that indirect funding formulas only serve in “paying institutions more, rather than because they provide higher value”.

The second article, penned by experts from the AAMC, argues that “The cost of GME extends well beyond the costs partially covered by direct GME support. Investments in research and complex clinical activities are critical to the environment for robust, diverse training programs.”

It’s an inside the Beltway battle. But the real elephant in the room is the “medical-industrial complex” whose appetite over the past half century has become every bit as large as the “military-industrial complex” Eisenhower warned about at the end of his second term as President in 1960.

How did we get to this point? First, what is an Academic Health Center? Most consider an AHC to consist of a medical school and one or more other health professional schools (nursing, dentistry, veterinary medicine, pharmacy, public health) existing in tandem with one or more affiliated teaching hospitals, usually under common ownership or at least closely aligned. As vertically and horizontally integrated entities, they have significant market power and expansive programmatic offerings. These generally include a full spectrum of patient care programs, both in-patient and out-patient, the newest and most complex technologies, a rich collection of professional talent in all fields, a high volume of basic medical science and applied medical scientific research, and the full spectrum of residency and fellowship training programs.

Who pays for all this and when did it begin? The origins of the AAMC and coordinated advocacy by AHC’s dates back to the end of the 19th century. At that time a small group of institutions led by Harvard, Yale, Columbia, University of Pennsylvania, Johns Hopkins and others coalesced to explore how best to advance medical education, research and patient care. Medical education, focused originally on undergraduates, and improving the quality of their training (as exposed by the Flexner report in 1910) required a multi-decade concerted effort. Research at the time was a minor source of revenue for institutions who relied on modest foundation grants and the free service of busy clinicians.

As Eli Ginzberg frequently noted, World War II was a watershed moment for the future of AHC’s. In 1942, the AAMC and the AMA created a liaison board to consider the impact of the war on medical students and the provision of services for citizens at home. It would become the Liaison Committee for Medical Education (LCME). This body would concern itself with a range of issues including physician workforce planning.  Before the war ended, fully 40% of all physicians (55,000) were in uniform. As important, the war provided them with a taste for specialization and they liked the flavor of it especially when served up by medical luminaries like Hugh Morgan in Medicine, Michael DeBakey in Surgery and Bill Menninger in Psychiatry.

A sizable portion of these wartime physicians decided to take advantage of the 1944 Servicemen’s Adjustment Act’s (GI Bill) liberal financial support and reimbursement policies and went to AHC’s for specialty training. What they discovered were enterprises that were expanding, slowly at first, with the help of funds from the Hill-Burton Act of 1946 designed to improve patient access to hospitals nationwide, especially those in rural settings and the poor in urban environments. AHC’s took advantage as well of capital markets and linkages to the new Veterans Administration hospitals designed to manage the war casualties.

Demand after the war exceeded supply of both hospital beds and physicians, in part due to uneven distribution of doctors. Soldiers returning, 15 million strong, had been exposed to medical discoveries in surgery, blood products, antibiotics and barbiturates, and trauma care. Add to this, that as a result of the War Labor Board’s action declaring expenditures by employers as tax deductible business expenses not restricted by war time wage freezes, and the IRS’s subsequent decision to make health care expenses tax deductible, private health insurance coverage was rapidly becoming the norm for those with corporate employment.

As 1950 arrived, there was enormous public support for more health services and more medical research. To manage the former, it was felt, the country needed more doctors and more hospital beds. The federal and state governments addressed this at first with modest contributions for both medical education and medical school brick and mortar construction. To augment the numbers of physicians, immigration reform permitted a rapid influx of foreign trained physicians. As for the research, federal funding for Research and Development went from 3 million in 1940 to 70 million in 1950, with over 75% dedicated to the specialty dominated AHC’s.

With the influx of funding, bed capacity expanded and 11 new medical schools were added between 1946 and 1963 resulting in 1500 additional student slots, a 25% boost in graduates annually. In 1965, their were 10 additional schools being build, and federal and state “improvement grants” were at work in many others. And then Medicare and Medicaid were passed. This provided cost plus financing of large numbers of patients who in the past had been unable to pay for services. It also provided liberal direct and indirect cost reimbursement for GME programs. As a direct consequence of this, combined with the expansion of employer based plans, 3rd party payments of hospital bills rose from 77% of costs to 91%. In 1960, the total revenue of medical  schools in the US was  $436 M, with 40% or $176M federally funded. By 1976, the schools received $2.4B  with 51% or $1.2B  attributable to federal financing. Between 1960 and 1988, the number of physicians per 100,000 increased from 140 to 233, and total health costs rose tenfold to $497B, 11.2% of the GNP.

AHC’s which had been constrained by financial and physician resources, and managed with controls established by universities, independent local boards and philanthropists, now – flush with cash and driven by specialized departmental chairmen responsible for dollars from research grants, GME funds and patient services – expanded full bore into new technology, hospital facilities, research labs, faculty and GME programs of every shape and size.  And with the additional partnering funds of pharmaceutical and medical device companies whose reps were by now essentially “in-house”, top AHC leaders now had assistance in staffing clinical research, writing papers for publication, receiving invites to serve on journal peer review panels and governmental scientific bodies, and making presentations at prestigious meetings. The “medical-industrial complex” was now fully unencumbered and moving forward with an impressive head of entrepreneurial steam.

By 1983, the institution of prospective payment for hospitalizations combined with the growing excess of both hospital beds and academic physicians, signaled to all that the nation’s “caring capacity” had lost any reasonable linkage to actual need and was riddled with high variability, broad disparities, and unsustainable inefficiencies. Those who thought competition equaled cost containment were sadly disappointed in the years that followed. Rather the forces at work yielded a wide range of conflicts of interest, boundary pushing in advertising and marketing, widespread duplication of services, expansion of the uninsured, and widespread over consumption of services.

The bottom line is that continued advances in efficient and effective health delivery do require responsible national investment in both medical education and medical research. But as we move forward with reforms in the health delivery system as part of the Affordable Care Act, we would be well served to re-institute deliberate checks and balances on the “medical-industrial complex”, rather than enabling further expansion of the very entities that have been so instrumental in creating the complex set of challenges we are currently attempting to address.

For Health Commentary, I’m Mike Magee

Eli Ginzberg in 1990: What Will Physicians Need To Function In The Future?

Posted on | June 13, 2014 | No Comments

“They will need to hone problem solving abilities and understand the role of uncertainty in medical decision making; to gain access to, and to use effectively, the ever larger pool of medical information, which means acquiring computer literacy; to talk to patients and even more important, learn to listen; to develop a greater understanding of the role of the physician in today’s society; to be sensitive to the moral and ethical issues that affect responsibilities toward the medical system; to have the technical competence to practice medicine; and to continue training to keep abreast of the expanding knowledge base and the technology of medicine.”

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