Tag: kaiser permanente

California/General interest/Health/Medicine
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The doctor is in… cyberspace

by Fran Johns

Getting health care — whatever happens with the health care bill — is no longer just a matter of getting to the doctor. Issues of comfort, efficiency and cost control increasingly point to the use of telemedicine, which is coming, ready or not. And one recent report suggested the medical profession isn’t ready. Pauline Chen, M.D. , writing recently in the New York Times, cited resistance by doctors and nurses alike to what some consider long-distance health care.

Telemedicine has the potential to improve quality of care by allowing clinicians in one “control center” to monitor, consult and even care for and perform procedures on patients in multiple locations. A rural primary care practitioner who sees a patient with a rare skin lesion, for example, can get expert consultation from a dermatologist at a center hundreds of miles away. A hospital unable to staff its intensive care unit with a single critical care specialist can have several experts monitoring their patients remotely 24 hours a day.

But despite its promise, telemedicine has failed to take hold in the same way that other, newer, technologies have. Not because of technical challenges, expense or insufficient need. On the contrary, the most daunting obstacle to date has been a deeply entrenched resistance on the part of providers.

Tech industry writer/elder care advocate Laurie Orlov thinks those concerns are a thing of the past. Since data was gathered for the study Dr. Chen cited, Orlov points out in her Aging in Place Technology blog, doctors, patients and technology have come a long way. “Forget the JAMA study”, Orlov says, “here come the virtual visits.”

Medical practices, hospitals, clinics are well aware of a much-changed world and consumer health care costs that can be breathtaking. American Well’s virtual visit platform use is growing, as are other virtual platforms discussed in our 2009 Calibrated Care report. They have read about transformation of self-care and virtual visits in Denmark. Given the geographic distribution of people — and the distance required to get to doctors in some states and rural areas, given the availability of technology that was barely known or completely unknown in 2006, these are going to happen, reimbursement has begun, criteria for the use has emerged, and the JAMA study (and its much-syndicated press coverage) is already irrelevant.

On a technologically lower level is the use of PC programs long in place for Kaiser patients. They haven’t asked for a testimonial, but here’s one, with enthusiasm. The e-mail your doctor program allows doctor-patient communication at the convenience of each (my primary care doc, oncologist and other specialists almost all answer queries within 24 hours or less); test results are posted immediately and can be viewed via charts or graphs to show how you’re doing; drug information or other Q&A’s are immediately accessible through personal accounts. All of the above save time, money and patient angst.

Doctors in cyberspace could be good medicine indeed for U.S. health care.

California/General interest/Health/seniors/Sports/USA/Women
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Skip the cold meds – hit the gym

by Fran Johns

Just in case the cold weather and a few sniffles are luring you toward the couch in front of the TV, you may want to stop and read Wall Street Journal health writer Laura Landro’s article in today’s “Personal Journal” section first.

Regular workouts may help fight off colds and flu, reduce the risk of certain cancers and chronic diseases and slow the process of aging.

Who knew? Well, most of us knew, we just haven’t been convinced. But Landro’s piece is stuffed — no offense to couches or potatoes — with evidence from new research, including data on fitness v the common cold. The fit, it turns out, have fewer and less severe colds, of shorter duration than the afflictions of their less-fit fellow creatures.

No pill or nutritional supplement has the power of near-daily moderate activity in lowering the number of sick days people take,” says David Nieman, director of Appalachian State University’s Human Performance Lab in Kannapolis, N.C. Dr. Nieman has conducted several randomized controlled studies showing that people who walked briskly for 45 minutes, five days a week over 12 to 15 weeks had fewer and less severe upper respiratory tract infections, such as colds and flu. These subjects reduced their number of sick days 25% to 50% compared with sedentary control subjects, he says.

Medical experts say inactivity poses as great a health risk as smoking, contributing to heart disease, diabetes, hypertension, cancer, depression, arthritis and osteoporosis. The Centers for Disease Control and Prevention says 36% of U.S. adults didn’t engage in any leisure-time physical activity in 2008.

Even lean men and women who are inactive are at higher risk of death and disease. So while reducing obesity is an important goal, “the better message would be to get everyone to walk 30 minutes a day” says Robert Sallis, co-director of sports medicine at Fontana Medical Center, a Southern California facility owned by managed-care giant Kaiser Permanente. “We need to refocus the national message on physical activity, which can have a bigger impact on health than losing weight.”

[INFORMED]

Researchers are also investigating whether exercise can influence aging in the body. In particular, they are looking at whether exercise lengthens telomeres, the strands of DNA at the tips of chromosomes. When telomeres get too short, cells no longer can divide and they become inactive, a process associated with aging, cancer and a higher risk of death.

A companion article goes further, suggesting that “spurring more exercise out of the half of Americans who are already active is just as important as coaxing the sedentary off the sofa.” The jury on this, however, is still out. For the time being, you could focus on warding off the January chest cold and stretching out the telomeres.

The Hidden Benefits of Exercise – WSJ.com.

California/General interest/Health/Politics & Causes/seniors/USA/Women
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Doctors making house calls? An old idea whose new time has come

by Fran Johns

Could house calls make a comeback? It’s already happening. The University of California at San Francisco, for one success-story example, started the UCSF-Mt. Zion Housecalls Program in 1999 with a philanthropic gift. Its original goal was to teach medical students about home care, but with the exploding need for primary care for homebound elders it has evolved into filling that need throughout San Francisco — while still teaching the new generation about house calls.

In an article in the San Francisco Chronicle, staff writer Victoria Colliver details some of the many advantages that such programs have.

June Hagosian’s brain tumor has made it difficult for the 77-year-old San Francisco woman to leave her house in recent years, keeping her mostly confined to her bed.

For someone like Hagosian whose medical needs require frequent doctor visits, that would usually pose a problem. But because of a program run by UCSF, the doctor comes to her. She has had to leave her bright yellow home in the Richmond District to go to the hospital just three times in the past seven years.

“This program has been so wonderful,” Hagosian said during a recent home visit with her physician, Rebecca Conant, director of UCSF’s Housecalls Program. “I wish everyone could have it.”

Conant, who had just 15 patients when she took over the program in 2001, is one of five part-time UCSF physicians who spend all their clinical time outside the office, traveling from home to home visiting frail and elderly patients. Housecalls currently serves nearly 100 San Francisco residents and has an eight-month waiting list.The Housecalls physicians visit patients whose conditions make it so hard for them to go to the doctor’s office that they might otherwise put off seeking medical care. By then, they would be so sick they would need an ambulance and end up in a hospital emergency room. The program takes patients regardless of whether they have insurance or an ability to pay, which separates it from private practices that offer home visits as a convenience but at an added cost.

UCSF’s 10-year-old Housecalls Program is an old idea that has gained new traction. Both the House and Senate versions of the health reform bills contain proposals to examine whether home-based care improves the health of chronically ill patients and saves the government money by reducing hospitalizations and ER visits.”There’s no question there is both a medical need and substantial cost savings to the Medicare program,” said Constance Row, executive director of the American Academy of Home Care Physicians.

The Department of Veterans Affairs’ Home-Based Primary Care program, which has been operating for more than two decades, has showed a 24 percent reduction in costs for those patients, and some studies suggest savings as high as 40 percent, Row said.

UCSF’s Housecalls Programs operates on an annual budget of $300,000, almost all of which is devoted to physician salaries. That’s an average cost of $3,000 per patient, which does not include the cost of hospital care when needed. Medicare spends a national average of $46,412 per patient over the last two years of life, when patients typically have several chronic illnesses, according to researchers from the Dartmouth Institute for Health Policy and Clinical Practice.

But new technology – the ability to X-ray patients using portable machines, conduct blood tests and provide other services using mobile devices – allows doctors to offer a much higher level of care in the comfort of the patient’s home.

Conant, an associate clinical professor at UCSF, said she uses mobile devices to aid in her patient care, but she finds home visits offer other advantages like allowing her to see patients’ physical environments, meet their caregivers and better understand what kind of care they need.

“Not only does that improve medical care, but it’s based in reality,” she said.

The UCSF program is not the only home-based primary care program in the Bay Area. Kaiser Permanente, for example, serves some 370 members in San Francisco as part of its 13-year-old Community Care Program, which is handled by physicians, nurse practitioners and social workers.

Reinstituting and reinforcing in-home care, considering the significantly improved care for patients and the reduced cost to the taxpayer, would seem a no-brainer. But brains are losing out to politics a lot these days.

via UCSF program shows house calls’ time returning.

General interest/Health
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Leaving Cancer Alone

by Fran Johns

We don’t talk a lot about not treating cancer. But as mentioned recently in this space, leaving it the heck alone is an option that merits consideration, particularly in the case of breast and prostate cancers detected very early on.  Now comes further news, reported by New York Times health writer Gina Kolata, of studies showing that some other cancers might also go away by themselves.

Call it the arrow of cancer. Like the arrow of time, it was supposed to point in one direction. Cancers grew and worsened.

But as a paper in The Journal of the American Medical Association noted last week, data from more than two decades of screening for breast and prostate cancer call that view into question. Besides finding tumors that would be lethal if left untreated, screening appears to be finding many small tumors that would not be a problem if they were left alone, undiscovered by screening. They were destined to stop growing on their own or shrink, or even, at least in the case of some breast cancers, disappear.

The Times article cites studies of testicular, cervical, kidney and other cancers that suggest some, left untreated, might simply go away; the trick now is to begin identifying which these would be.

I don’t know anyone who would opt out of treatment when it is likely to offer restored health. But especially for older populations, the choice of not treating a small cancer could be more frequently and seriously discussed.

Cancer cells and precancerous cells are so common that nearly everyone by middle age or old age is riddled with them, said Thea Tlsty, a professor of pathology at the University of California, San Francisco. That was discovered in autopsy studies of people who died of other causes, with no idea that they had cancer cells or precancerous cells. They did not have large tumors or symptoms of cancer. “The really interesting question,” Dr. Tlsty said, “is not so much why do we get cancer as why don’t we get cancer?”The earlier a cell is in its path toward an aggressive cancer, researchers say, the more likely it is to reverse course. So, for example, cells that are early precursors of cervical cancer are likely to revert. One study found that 60 percent of precancerous cervical cells, found with Pap tests, revert to normal within a year; 90 percent revert within three years.

And the dynamic process of cancer development appears to be the reason that screening for breast cancer or prostate cancer finds huge numbers of early cancers without a corresponding decline in late stage cancers.

If every one of those early cancers were destined to turn into an advanced cancer, then the total number of cancers should be the same after screening is introduced, but the increase in early cancers should be balanced by a decrease in advanced cancers.

That has not happened with screening for breast and prostate cancer. So the hypothesis is that many early cancers go nowhere. And, with breast cancer, there is indirect evidence that some actually disappear.

A sister who is six years older than I was diagnosed with breast cancer at 72, had a mastectomy and is cancer free. Six years later I was diagnosed with breast cancer, had a mastectomy and am cancer free. Last week I visited a college classmate who had been diagnosed two weeks ago with breast cancer; she had a mastectomy and is cancer free. Cancer free is good. But what if — just what if — one of those cancers might have disappeared without major surgery?

Disappearing tumors are well known in testicular cancer. Dr. Jonathan Epstein at Johns Hopkins says it does not happen often, but it happens.

It is harder to document disappearing prostate cancers; researchers say they doubt it happens. Instead, they say, it seems as if many cancers start to grow then stop or grow very slowly, as has been shown in studies like one now being done at Johns Hopkins. When men have small tumors with cells that do not look terribly deranged, doctors at Johns Hopkins offer them an option of “active surveillance.” They can forgo having their prostates removed or destroyed and be followed with biopsies. If their cancer progresses, they can then have their prostates removed.

Almost no one agrees to such a plan. “Most men want it out,” Dr. Epstein said. But, still, the researchers have found about 450 men in the past four or five years who chose active surveillance. By contrast, 1,000 a year have their prostates removed at Johns Hopkins. From following those men who chose not to be treated, the investigators discovered that only about 20 percent to 30 percent of those small tumors progressed. And many that did progress still did not look particularly dangerous, although once the cancers started to grow the men had their prostates removed.

In Canada, researchers are doing a similar study with small kidney cancers, among the few cancers that are reported to regress occasionally, even when far advanced.

One of the things we post-mastectomy women were talking about last week was how we might handle a recurrence. The reality is, as we have all already proved: you live long enough, you get stuff. Maybe someone at Johns Hopkins (or elsewhere; Kaiser San Francisco would suit me fine) will undertake a study in which older women with small breast cancers can opt for “active surveillance” rather than major surgery. Should I qualify, I would enroll. To this admittedly untrained and unscientific survivor it seems a study whose time has come.

Cancers Can Vanish Without Treatment, but How? – NYTimes.com.

California/General interest/Health/Politics & Causes
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Cancer Gurus, CDC – Whom can you trust?

by Fran Johns

In the news of the past several days are reports that the American Cancer Society is about to concede that screenings for breast and prostate cancer — long touted as the holy grail of preventive medicine — have instead led to a great deal of over-treatment, and worse. Plus admission by the Centers for Disease Control and Prevention that their pooh-poohing of Chronic Fatigue Syndrome has left a lot of folks suffering, perhpas needlessly, for decades.

Who in the world is there left to trust?

I do trust my physicians at Kaiser, and continue to hope the crafters of our elusive health reform bills are looking in Kaiser’s direction. My breast cancer was detected through a regular mammogram. How frequent these screenings should be is still a matter of debate, but in my case early detection led to a quick mastectomy, a small price to pay for living happily a few more years after. (The ever-after business is not a principal to which I subscribe.) On the other hand, small as my tumor was, who’s to say it might have sat there harmlessly a few more years untreated? Please don’t get me wrong; I would not have opted for waiting to see. Just wondering.

I’m not so sure about prostate cancer screening. But since what seems nearly every man I know over 65 has been diagnosed with prostate cancer after a routine screening, it’s possible to wonder about this too. An October 21 New York Times article cites a new analysis by Dr. Laura Esserman, a professor of surgery and radiology at the University of California, San Francisco and director of the Carol Frank Buck Breast Cancer Center and Dr. Ian Thompson, professor and chairman of the department of urology at the University of Texas Health Science Center, San Antonio that “runs counter to everything people have been told about cancer: They are finding cancers that do not need to be found because they would never spread and kill or even be noticed if left alone.” We the healthcare consumers aren’t getting any breaks. Here’s a whole new dilemma to mull over and decide upon: to screen or not to screen, to treat or not to treat. In one group of gentlemen friends I know, others newly diagnosed with prostate cancer are invited to hang out for an hour or so and listen to the pros and cons of the various treatment options — because within the group are men who have gone down at least 4 or 5 different paths.

Another re-evaluation, this one a little more sinister, centers around the dismissive attitude long held by the venerable Centers for Disease Control and Prevention, guardian of our national health and welfare where things like viruses and other causes of infectious disease are concerned. In a Times op ed piece titled ‘A Case of Chronic Denial‘, Hillary Johnson reports on a recent study in the journal Science about a virus found in prostate cancers which will be referred to here by its shorter name, XRMV. It now turns out that there may be a link between XRMV and Chronic Fatigue Syndrome, more commonly referred to these days as CFIDS, and the work now going on in this area of research could be significant in treatment of the latter. Having had a number of friends and family members suffering from CFIDS, I admit to being among those who occasionally thought it might be partly in one’s head, but also aware of the degree of misery and disability CFIDS can bring.

This space is not a health authority. It is, rather aimed at those of us 50-somethings and over, many of whom have trusted many of the above. Trust is good. Open-mindedness is better. Questioning might be best of all.

General interest/Health/Money/Politics & Causes/USA
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Pelosi Reaffirms Public Option, Insurance Reform; Healthcare "A Moral Imperative"

by Fran Johns

House Speaker Nancy Pelosi, addressing a Chamber of Commerce-sponsored Health Summit in San Francisco this morning about Obama’s health reform, stressed elements of the three House bills that might seem palatable to her audience: cost containment, IT design and integration with existing systems to create universal access to care. But she did not back down on a few other consistent statements such as the assertion that no bill will pass the House without a public option.

“We will invest in medical research and technology,” Pelosi said; and will incorporate elements such as electronic medical records for individuals to speed care.

It was clear there were mixed levels of support for reform in her audience. California Pacific Medical Center CEO Warren Browner MD, MPH drew muted chuckles and no boos with a throw-away comment that President Obama had “spent more time on choosing a dog” than on crafting a health policy. CPMC, a Sutter Health Affiliate, was presenting sponsor of the event.

Speaker Pelosi, though, hammered away at the primary intentions of reform: “improve quality, expand coverage and contain costs” while providing universal access to quality healthcare. “We will,” she said, focus on “quality, not quantity; wellness of the person not utilization (of facilities and technologies); value, not volume; and a commitment to prevention and wellness.”

San Francisco Mayor Gavin Newsom addressed the gathering earlier, touting the success of his “Healthy San Francisco” universal coverage program now in its second year. An independent Kaiser Family Foundation poll recently showed Healthy San Francisco to have a 94% approval record, prompting City/County Department of Public Health Director Mitch Katz, MD to ask when any program of any sort had ever gotten a 94% approval record. Citing the need for protection of such elements as in-home services in an aging population, Newsom said the program’s success was attributable largely to partnerships with local hospitals, clinics and medical facilities (CPMC is one), specifically singling out Kaiser Permanente, which signed on in July. The program does not offer a national model, Newsom said, but has many elements a national plan could adopt. Healthy San Francisco includes things that might not get into a national bill but are favorites with wellness proponents: community organic gardens, city-funded salad bars in schools and an ad featuring a soda-equipped young boy admitting to “a drinking problem.” Another key to the program’s success, Newsom said, is its ultra-simple one-page enrollment form.

Pelosi insisted that the final bill will include “insurance reform: no refusal based on pre-existing conditions, no co-pay for prevention, no cut-offs.”

And the major themes were reiterated: “As President Obama has said, universal healthcare is a moral imperative,” she said; “we are the only country in the developed world without it. I say to those who would have us do a little bit, and another little bit, and another little bit — Lyndon Johnson settled for half a loaf; this is the other half of the loaf.”

General interest/Health/Money/Politics & Causes/USA
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Health Policy: Is Altruism Dead?

by Fran Johns

Recently in this space the me-first word was brought up. (It does not abbreviate well.) Might as well say it out loud: health reform could surely be sunk by the Me-Firsters, those who would put personal desires above the greater good, whether those desires are for better pharmaceutical or insurance industry bottom lines or for some corner of personal coverage, senior or otherwise, that might be sacrificed in the future.

I am not above having those desires. My husband and I actually have a tiny bit of stock in a drug company thanks to some mergers and buyouts I do not pretend to understand (I also don’t mess with the family stock portfolio) and thus a decline could cost household income we can ill afford. Plus, I would hate having the excellent care I get from Kaiser (thank you, Medicare) curtailed and would be seriously bummed if suddenly stuck with paying 100% of my post-cancer meds. But if that, or something equally draconian, is what it will take to get health coverage for my currently-uninsured friends, I would like to go on record as supporting whatever we must do to get access for all. This is not noble, just minimally humane.

There are noble people out there, however. They sign up for Teach for America, they volunteer in nursing homes and day care centers and hospice programs, put in long hours at food banks or take to the streets in other, similarly un-chic endeavors.

Re the current health reform brouhaha, there are also noble people, or at the very least altruistic people, all over the country; you just don’t hear a lot about them. On August 19, for example, President Obama urged supporters of health reform to “speak facts and truth” in what he said was a “contest between hope and fear,” and tried once again to refute some of the misrepresentations still widely circulating. His comments were themselves fairly widely circulated. But unless you happened to run across them in this space you would not have known they were made to 140,000 members of faith communities and/or supporters of community-organizing nonprofits. The people of Sojourners, Faith in Action, PICO and other groups that put together the 40 Days for Health Reform conference call are not in it for personal gain; they happen to believe everyone in this country should have access to health care. The next day, Nancy Pelosi held a press conference reiterating her determination to keep a public option in the final health bill. But again, unless you happened to see it here you would not have known the event was sponsored by the San Francisco Interfaith Council with a lot of help from its friends in the San Francisco Organizing Project.

When the religious right goes on a tear against abortion or end-of-life choice (or for that matter, when the religious left goes head-to-head with its ideologically-opposed brothers and sisters) it makes news. When community organizers stage high-profile protests, the same thing happens. What does not make news is the enormous effort made by people of good will just to promote the common good — most recently, health reform.

Some opponents of Obama and his reform bills even have an altruistic bone or two. The reportedly calm, if badly misinformed, Bob Collier, featured in a front page New York Times article August 25, allowed that “we’ve got to do something about those people who can’t get insurance.” He qualified that later: “There has to be a safety net there. But I don’t want that safety net to catch too many people.” Somehow, Mr. Collier wants to separate out the “truly needy” from the “lazy and irresponsible people who play the system” and wouldn’t we all. The Times said that Mr. Collier gets his information from Fox News, Rush Limbaugh and Matt Drudge, none of whom I see as particularly altruistic. I would surely welcome him to True/Slant.

But the people cited above, people in faith communities (including many I disagree with and some I can’t pronounce), progressive nonprofits, community organizing groups and others just roaming the streets being kind, these people seek access to health care for everyone without worrying about who deserves it and who does not. A great many of them worked hard to put Obama in office, and are now working hard for health reform for no reason other than it is the right thing to do for someone else. Might be unrealistic but they keep at it.

My money is still on those people.

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