Op-ed: Medicare payment cuts

I wanted to draw your attention to the New Hampshire Union Leader, which ran an op-ed last week that I wrote concerning the planned cuts in physician Medicare payments:

Cut Medicare payments for doctors, you'll have fewer doctors

Medicare is planning to cut physician payment rates by 10 percent in 2008. These reductions will continue annually, and it is predicted that the total cuts will be about 40 percent by 2016.

The topic of physician compensation generally elicits little public sympathy. After all, the average primary care physician salary in 2006 was about $150,000. Who are we to complain about reimbursement? As you will see, however, cuts in physician Medicare payments affect everyone.

Medical practices today essentially function as small businesses. Physicians are responsible for expenses like rent, payroll, employee health insurance and malpractice insurance. These costs are expected to increase 20 percent in the next nine years. During this same time, physician Medicare payments are faced with cuts of 40 percent. Already, some practices lose money every time a Medicare patient is seen. Some may find the link between medicine and money distasteful, but the hard truth is that it is impossible to practice medicine in a business model that is headed for financial disaster.

At a time when baby boomers are approaching the age of 65, some physicians attuned to this economic reality have simply stopped accepting Medicare patients. According to a recent survey by the American Medical Association, 60 percent reported that they would have to limit the number of new Medicare patients they treat due to next year's cut. Half would reduce their staff. Fourteen percent would "completely get out of patient care." Some seniors are already faced with calling 20 to 30 providers in the desperate hope that someone will accept Medicare.

It is unlikely that the primary care shortage will improve in the near future, as Medicare reimbursement rates continue to be a primary driver of physician salary. In a report by the Center for Studying Health System Change, incomes of primary care physicians fared amongst the worst in keeping pace with inflation between 1995 and 2003, while medical specialists fared the best.

Medical students, already burdened with an average debt in excess of $100,000, are clearly gravitating towards specialties where salaries have better kept pace with inflation. The report concludes that with "the diverging income trends between these specialties and primary care, the result is likely to be an imbalance in the physician workforce and perhaps a future shortage of primary care physicians."

Some may be wondering if this is just a "Medicare problem." Should you care if you have private insurance?

Absolutely. With primary care being the backbone of every health system, patients cannot have their chronic medical issues addressed in a timely fashion with a lack of primary care access. In delaying care, chronic diseases blossom into more serious conditions that are forced to be seen in already overcrowded emergency rooms.

Hospital-based care is often the most expensive and the corresponding rise in health care costs plays a major role in the increase of health insurance premiums. Unfortunately, the government responds to rising health care costs by further reducing physician payments and the cycle continues to spiral out of control.

You will hear physicians rallying against the Medicare fee reductions in the coming year. Think about how this affects you. Contact your government representative and do your part to break this vicious cycle.

Cosmetic and therapeutic laser therapy

We are happy to announce that we will be offering cosmetic and therapeutic laser procedures. These procedures are proven, safe, effective and affordable.

All lasers are FDA-approved. No anesthesia is required. No down time is necessary and normal activities can be resumed immediately. All procedures are performed in the comfort of our office and take on average 15 minutes for each laser procedure.

Here is a sample of what we can treat.

Hair removal


Acne


Acne scars


Skin tightening


Leg veins


Hair removal (dark skin)


Wrinkles


Pigmented lesions


Angiomas


Rosacea


More before and after photos.

Video testimonals.

Frequently asked questions.

Please call us at 603-891-4500 to schedule a pre-procedure consultation, or if you would like further information.

New Information on Bone Density Studies

Whoa! Long-time no blog! There's a lot going on at Nashua Medical Group, too, so I think we'll need to post a few more times to make up for it.

Just a quickie this time, though. I was cruising through a summary of recent research reports on the Medical Economics website when I came across this article:

Little Benefit to Repeat Bone Density Scans in Older Women

Even after eight years, second scan reveals little useful information

Repeating bone mineral density (BMD) scans among postmenopausal women reveals little new information that is helpful in predicting fractures, according to a report in the Jan. 22 issue of the Archives of Internal Medicine.

Teresa A. Hillier, M.D., of Kaiser Permanente Northwest/Hawaii in Portland, Ore., and colleagues measured the total hip BMD of 4,124 women, average age 72, on two occasions eight years apart and predicted the risk of fracture. Between the two tests, women lost an average of 0.59 percent of BMD a year.

Of the sample, 877 women had an incident non-traumatic non-spine fracture, including 275 hip fractures, and 340 women had a spine fracture. There was no difference between risk of fracture and the BMD measurements taken on the first or the second occasion.

Although repeat testing may be of some value in some sub-groups, such as those with other risk factors for rapid bone loss and younger women who have gone into premature menopause, one test is adequate for most postmenopausal women, the authors conclude.

"For the average healthy older woman 65 years or older, a repeat BMD measurement has little or no value in classifying risk for future fracture -- even for the average older woman who has osteoporosis by initial BMD measure or high BMD loss," they write.

I had previously been repeating bone density studies every 2-3 years to judge progress of bone thinning, but it looks like I'll have to think harder about that policy. What I note about this study, though, is that it doesn't offer advice about when to first screen women. Should you start a year after their last period, when they officially enter menopause and after the initial rapid burst of bone loss begins? Or should you wait until age 60, or 65, or 70 when the cat's out of the bag, so to speak? It also doesn't address the issue of whether you should treat women whose bones are somewhat thin (osteopenia, not full-blown osteoporosis) with low doses of medications like fosamax, or just watch them to see what happens. The women in this study were all in their 70's when the worst of the loss would have already happened. What about preventing that from occuring?

One thing we do know is that regular exercise with moderate impact (like brisk walking), weight training (even using relatively light weights), getting 500 mg of calcium 2 or 3 times daily, and taking in adequate Vitamin D (1200 IU) can help reduce risk. Recent studies also find that people on chronic acid reducing medications like omeprazole (Prilosec), Nexium, Protonix, Prevacid and Aciphex will have more osteoporosis as well. Even medication like ranitidine, cimetidine and famotadine will thin your bones somewhat. Some of this may be due to trouble absorbing calcium from your diet, since you need a low pH to do that properly, but the research scientists feel it might also have to do with messing up the pH in the bone where the calcium is deposited. Seems you need a little acid there, as well, and the acid lowering medications are at work in that area, too.

Guess the best I can say at this time is: Watch this space! Things are bound to keep changing.

We are accepting new patients, and we will see you promptly

It seems that patients in Concord, NH are having trouble finding primary care access. This is going to be a growing problem as the baby boomers age and primary care panels fill up.

This story of a patient looking for primary care is becoming commonplace:

When Casey Garner moved to Concord about a year ago, he started looking for a primary care doctor. It took him a dozen phone calls to find a practice that was accepting new patients. And the one he found was outside the city, in Boscawen.

"We looked around," he said. "Most of them were full practices."

Anyone who's moved to the city in the last year knows that Garner's experience is typical. Eight of nine primary care practices in Concord are closed to new patients. The only one that's taking new patients opened its rollsthis week.

Doctors and hospital administrators say the shortage is due to a number of factors: population growth in the region, a slackening of the doctor supply, space limitations and a series of physicians leaving the area within a short time. But the closures make it difficultfor people moving into the city to find medical care. Many Concord practices said they get calls every day from patients they have to turn away.

An accompanying editorial only highlights the growing crisis.

You will be happy to know that here at Nashua Medical Group, we have available access and there are multiple providers accepting new patients.

Thanks to our open-access scheduling, we can offer same-day appointments under normal circumstances.

So, if you're one of many who are frustrated with physician access and closed practices, give us a call at 603-891-4400 or visit our website.

Thanks,
Kevin Pho, M.D.

Restaurant Eating

Recently, my patients have been asking me about how to stay on a weight loss diet while eating out at restaurants and traveling. It's an interesting and difficult question, one I've wrestled with myself on many occasions. I thought I'd post a section on food choices at local area restaurants, with a few words about travel.

First, my most extensive experience lies in low carb eating. Some of the foods I mention won't be compatible with low fat diets, if you're on one. Where possible, I'll try to distinguish these. I will also make suggestions related to actual restaurants in the Nashua area.


Mcdonald's

Generally, I try to avoid McDonald's and all other fast food joints, but if you're running to one because of time issues, or the demands of your children, you can still make some good food choices. First, avoid the burgers and french fries. These are needlessly filled with fat and carbohydrates, a deadly combination. McDonald's has some salads available now. The single best is likely the chicken ceasar salad, which has actual grilled chicken, instead of deep fried strips on it. If you're going low carb, ditch the croutons. If you're low-fat, go sparingly with the dressing.


Subway

This can actually be a good choice, no matter what diet you're on. If it's low carb, they have a couple of Atkin's salads, and Atkin's wraps, which use a low carb wrap instead of the usual. These are generally pretty tasty. I usually get the wrap, but have it with tuna. There are also some Weight Watcher's choices and low fat sandwiches there as well. I believe DeAngelo's has some low carb wraps also.


Lilac Blossom

For the low fat eater who wants simple food, there are several steamed entrees on the menu at both locations. For low carb eaters in the early stages of their diets, the best choice would likely be Mu Shu. Just don't use the pancakes and the bean sauce. For later stages, order other entrees so long as there's no breading and deep frying involved, and eat them without the rice. Be careful with the soups--most of them have added corn starch. The teryaki sauces on the beef also have sugar in them.


You You Bistro

If you're eating low fat, check out the cold noodle salad, any of the sushi platters, the udon noodle soup (vegetarian or beef). Avoid tempura vegetables or shrimp. I'd also suggest avoiding the rice bowls if you're on a diet. If you're eating low carb and want sushi, try to get sashimi without the rice. Otherwise, I like the spicy beef salad (you can ask them to make this with chicken) and will order the minced herbed chicken without the rice. Hot Pot Bi Bim Bab is pretty good, too, provided you ask them to make it without the rice. Miso soup and salad are all acceptable to either type of diet. Finally, you can always ask for edemame. These are steamed soy bean pods that arrive salty and hot at your table. You squeeze the beans out into your mouth. The taste is bland, but really satisfying and somewhat addictive.


Bugaboo Creek

This is a low carb friendly place, provided you can bypass the obvious bad choices (like any of the desserts) and ask for vegetables with your steak. I myself have never made it past the blackened salmon ceasar salad (without croutons), which is about the best ceasar salad I've ever had anywhere. There's cob salad and a few other choices for the low fat among us.


Shorty's Mexican Roadhouse

Shorty's has an ever-changing menu. Here's a first important tip: avoid the chips. Just push them away from you at the table. The salads here are pretty good, and you might do ok with the chili. For the low carb, you can order fajitas and just eat the meat (or portabello mushrooms) as is, without the tortillas. They also often have a salmon dish of one sort or another. Avoid the refried or other beans if you're low carb. As for the fajitas and the salads, these are good choices at other Mexican restaurants in the area, like On the Border, Margarita's, and La Carreta.


Italian Restaurants

These include Giorgio's (which some people view as more Greek than Italian), Ya Mamma's, Villa Banca, and Bertucci's. There are others, but the same principles apply. First, avoid the bread and the garlic bread. This is an obvious no-no if you're doing low carb, but even if you're eating low fat, you just don't need that many calories. Most people go to Italian restaurants to enjoy pasta, which comes in giant mounds. Bread is completely wasted in these circumstances. My only personal exception would be Bertucci's, where I would actually pick the rolls over the pasta (If I were to design my heaven, there would be Bertucci's rolls up there waiting for me). If you're eating low carb, check out the appetizers. At Giorgio's, I seldom make it past them. Generally, I order 2 or 3 and that makes up my meal. If you really want one of the main pasta dishes, ask to have the sauce served over vegetables. For low-fat dieters, avoid the Alfredos and carboneras. For low-carb dieters, avoid all pasta and bread, and anything breaded. Generally, steamed mussels are a good choice, and are often available at Italian restaurants.


The Grand Buffet

This is one of my guilty pleasures. In order to eat here, however, you have to have a clear understanding of what's allowed on your diet and the fortitude to stick to it. I would strongly recommend against it if you are on a calorie restricted diet. Generally, eating at buffets can be dangerous. At restaurants, you eat at a more leisurely pace and have the time to notice you're getting full before you hit critical. If you're a low carb dieter and have sufficient willpower, a trip here on a weekend can be a pleasure, however. That's when they serve up the King Crab legs, steamed and served hot or cold. There's also a lot of cold shrimp, a large baked salmon, and a Mongolian grill, as well as roast beef. The salad bar is fine, though also filled with temptations you might want to avoid. Steer clear of the dessert area, and don't bother with the Italian stuff. You'll get better at an Italian restaurant.


India Palace and Mehmaan

Indian restaurants can be a bit difficult for the unwary. As a rule, I would suggest avoiding the breads entirely. Many of the appetizers are deep fried or otherwise coated in batter, and while tasty, they're just too full of calories. I would suggest chicken saagwala, chicken jalfrezi, tandoori chicken any of the kebabs and Palak Paneer. Many of the vegetarian dishes are fine as well, so long as you avoid anything deep fried. If you're eating low carb, watch out for potatoes and skip the rice. That will rule out, sadly, the vindaloos, which otherwise are a treat. Also avoid the lassi's. Spiced tea is ok, provided you can add your own sweetener and don't mind the caffeine. I often ask for a bowl of yogurt to go with my meal (soothes the fire). For those that can tolerate cilantro, raita is terrific.


Giant of Siam

Once again, if you tolerate cilantro, the warm salads are a great choice. Otherwise, I particularly like the ginger dishes without rice, or the chili paste dishes. You can choose your meat. Avoid the Pad Thai. It is one of the best dishes there, but terrible for either kind of diet. Tom Yum soup is very tasty and also goes well with either diet type.


Thon Kao

Another Thai restaurant. The dishes are a bit different here. This is the one Thai restaurant locally that serves sticky rice. If you're a low fat dieter, please try it. It's a real treat. Sadly, if you're eating low carb, you have to give this a skip. Don't worry, I'm in the same boat as you. This restaurant has a real gai krapow, which is minced chicken with basil. In its native form, it's really spicy, but you can ask for it milder if you wish. As with Giant, avoid the deep fried foods. The curries also tend to be pretty rich. If you're doing low-carb, steer clear of the rice. Tom yum soup is fine here, as well. Chiang Mai is excellent as well. Just follow the rules above, especially the one about pad thai.


Here's some general rules for dieting and eating out:

1. Don't be afraid to ask them to prepare the dish in a way that makes it more compatible with your diet. The chef can substitute vegetables for various starchy side dishes, keep those pesky croutons off your salad, and serve your dressing on the side. You're also allowed to ask questions about what's in the dish.

2. If you're with another dieter that has the same tastes you do, split an entree. Some restaurants are kind enough to even the divide the portion between two plates!

3. If you only want half the food and have no one to share, take the rest home! It will make a tasty lunch at work the next day, and one you won't have to spend a lot of time preparing yourself.

4. Consider ordering just an appetizer and a salad, or a couple of appetizers. The portions are smaller, and yet the food is often as good or better than the actual entrees. The waiters are generally very accomodating and will often ask if you want your appetizer served along with everyone else's main course.

5. Avoid the desserts. If you're in a really fine restaurant and are eating low carb, you can order the after-dinner cheese plate. Just watch out for those cheeses with lots of carb-laden dried fruit strewn through them.


Finally, here's the secret for airplane travel and dieting: Chicken Ceasar Salad! About the only risk here is that you'll get tired of eating it. I have yet to land in an airport in the United States that didn't reliably have this somewhere in one of their food outlets. It's generally portable as well, so you can purchase it and take it on the plane if it's not mealtime at your layover.

Good eating and good luck with the weight.

Another aspect of rising medical costs

Not a day goes by in this country when there isn't a big new story somewhere about the rising cost of medicine. Many of the stories focus on the increasing numbers of uninsured patients, some on businesses, which have funded much of the insurance that is out there, and how difficult it is for those businesses to deal with the ever-rising costs.

The question remains: why are health care costs rising? Kevin has touched on the issue of unnecessary testing and healthcare, but as someone who has been in practice since 1980, I can tell you that these things are hardly new. In fact, over the recent decade HMO insurance plans have worked to trim the number of unnecessary tests and quality organizations have arisen that study just how effective our treatments and interventions are, so that we can send our health dollars in the right direction. With the decline of capitation and managed care, some of the focus on avoiding doing too much has decreased, but we aren't back to where we were in the late 70's and early 80's. (Oh, the stories I could tell!)

One of the driving factors of increased costs has been the rise in the prices of drugs and the explosion in new technology. New drugs are under patent protection, and their manufacturers have a monopoly on their production. They are very happy to charge as much as the market will put up with. Given that many patients have prescription coverage and don't ever see the true cost of the medication, it can put up with a lot. New technologies are incredibly expensive, too. In every other country in the world, the government regulates access to those technologies, except for the very wealthy. Not so in the United States.

In fact, there seems to be a technology race going on between hospitals. In order to remain competitive, they have to buy the latest technology. Once they have made the purchase, they have to keep their technology busy and generating income. As a result, we have better and better tests and treatments, or at least newer and newer ones. But do these things help save lives?

Each new technology brings with it potential benefits and potential harms. It's sometimes difficult to tell if the benefits outweigh the harms in the short-term. People live a very long time. Given the rapid increase in technology, it's unlikely we're willing to take 10 years to determine how well a new treatment is going to work. And ten years is only about 1/8 of an average American's lifespan.

One of the professors at the Wharton School of Business has recently published a new book on this very topic. For those of you who listen to podcasts, you can hear him interviewed on Knowledge@Wharton Audio Articles May 17, 2006 podcast, available on Itunes. Check it out. He has a very interesting take on one of the causes of rising costs.

Unnecessary medical care

A recent article in JAMA looked at the differences in health outcomes among Medicare patients in states that spend a lot or a little on healthcare. Surprisingly, outcomes were better in states where expenditures were less! Kevin's previous blog covered the topic of unnecessary medical tests. We all know these are expensive, but they can also harm people.

How is that?

Unecessary tests will often lead to further unnecessary tests. These cost money, and some of them can be painful and run the risk of causing harm all by themselves. For instance, suppose you have a positive result on a stress test but have no actual heart disease. This is known in medicine as having a false positive result. So, you go on to have a cardiac catheterization. A certain small percent of people undergoing this test can have kidney damage, large blood collections in their groin, damage to arteries or damage to the heart. Individually, your chances of doing well after the test are good, but if you do enough of them on enough people, you will eventually cause some unnecessary disease and damage to go along with your unnecessary test.

As far as stress tests go, your chances of getting a false positive are a great deal higher if the test is done on people who don't have any symptoms to suggest heart disease.

Here is a link to the Dartmouth Atlas project, which is looking at where our health dollars are going and what the outcomes are: http://www.dartmouthatlas.org/

Kevin has included an excellent list of proven, effective tests. Please look them over and discuss them with your doctor. Between the two of you, you will be able to work out the best plan for your health!