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One way to Avoid Obamacare

posted Aug 30, 2017, 6:15 PM by Thomas Stern

The world is watching as the US healthcare system slowly implodes and our elected leaders do nothing to stop it.  The cost of healthcare is climbing while the access to healthcare is declining.  I am not talking about the access to health insurance - I am talking about the access to healthcare.  Most politicians and members of the media do not understand the difference.  Access to health insurance is at an all time high because it is required by law in the United States of America to purchase healthcare from a private company if you do not have an employee sponsored plan and do not qualify for a government sponsored plan.  That concept seems un-American to me.  The result is skyrocketing insurance rates.  You can't print money as fast as someone will take it from you given the opportunity and now private healthcare companies have the opportunity.  Check out the 1st quarter revenues of United Healthcare in 2017.  They were up 9.4%.  I can assure you the revenue in my practice was not up 9.4%.

So what can you do when the law requires you to purchase a product whose costs are out of control?  One option is to not get health insurance and pay a penalty.  I don't like that answer because then you pay money and assume risk for being uninsured. I think I have found a better answer called health care sharing ministries. Wikipedia does a good job describing health care sharing ministry.  There are certain requirements these organizations have to meet one of which is having similar beliefs.  The ties to a religion protects it from the requirements of Obamacare.  The down side is not everyone is eligible and pre-existing conditions and certain behaviors such as smoking and drinking are exclusive.  They function very similarly to traditional insurance companies - you have a card you present for care and claims are paid through traditional clearing houses.  The fees are a fraction of what Obamacare costs.  I have encountered several patients that belong to these organizations and they have spoken positively of them.  I personally do not belong to a health care sharing ministry but it is something you might want to consider if you are struggling to afford health insurance thanks to Obamacare.

The Beginning of an Epidemic

posted Aug 20, 2017, 7:16 AM by Thomas Stern

I am conservative when it comes to prescribing medication as a rule.  I believe in using the least amount of medication necessary for the shortest amount of time to achieve the desired outcome.  I favor non-pharmacological treatments over medicine whenever possible.  As a result I am a sleep physician that does not prescribe "sleep medicines". This may seem odd but the reason is that traditional "sleep" medicines are really sedatives. There is a difference between sedation and sleep as described by this article from the New England Journal of Medicine. These sedatives are associated with several adverse outcomes including motor vehicle accidents, dementia and death.  Sedatives are very effective at what they are designed to do which is make people unconscious. I used them routinely when I worked in the intensive care unit.  Interestingly they are also associated with adverse events in the ICU as well. Patient's who have sleep disorders like sedatives because sedatives makes them unconscious quickly and prevent awareness of poor quality sleep.  Sedatives actually hurt your quality of sleep by suppressing REM sleep and making sleep disordered breathing worse.  Sedatives cause physiologic addiction so people who use them experience withdrawl if they stop abruptly.  Long term use of sedatives will cause tolerance so that a dose that used to work no longer works and the poor sleep quality returns.  The options are to go up on the dose or go through withdrawl.  That is why the FDA has only approved sedatives for short term use - weeks to months in most cases.  Why would anyone prescribe these drugs long term?

The press is full of stories about the opioid epidemic in America right now.  Prescribed opioids are the number one cause of drug overdose death in the country. Prescribed opioids kill more people than heroin and cocaine. Why are opioids being over-prescribed by physicians? I recently read this concise review of the opioid epidemic in Medical Economics. The opioid epidemic started in the mid 1990's when The American Pain Society concluded pain was under-treated.  This lead to pain scales being incorporated into vital signs.  Then a private company called The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) decided that hospitals should not be paid by medicare unless they do a better job treating pain.  When hospitals get threatened with non-payment from medicare what do they do?  They put together committees and care plans to address that issue.  In this case hospitals made a conscious effort to address pain which resulted in physicians writing more prescriptions for opioids.  In the US there were about 80 million opioid prescriptions written in 1991 and in 2011 that grew to 220 million. Over 15,000 Americans are dying annually from prescribed opioids. This epidemic demonstrates a major failure in JCAHO and our federally funded healthcare programs.  If a physician is responsible for one death due to incompetence we get sued and can lose our license.  JCAHO promoted a practice which has influenced hundreds of thousands of deaths and still has a major influence on our healthcare system.  Why aren't regulatory bodies held to the same standard?

One more interesting fact.  The incidence of narcotic overdose is higher in patient's taking sedatives.  Don't worry - I am not going to be pressured into prescribing sedative medications.

More Fake News

posted May 31, 2017, 6:51 PM by Thomas Stern

Politicians are not the only people who have to deal with fake news.  Physicians deal with it on a regular basis as well.  The source is the same - the main stream media and the internet.  If you believed advertisements for supplements, FDA approved drugs and devices there would not be a need for physicians.  One of those 3 things can cure whatever afflicts you - whether it's obesity, insomnia, depression, anxiety, wrinkles or sexual dysfunction. The ads can be convincing.  The problem is they prey on desperate people. After trying years of things that don't work they will stumble in my door.  What greets them is not what they want to hear.  It's called reality.

There are a couple of questions I answer on a daily basis because there is so much misleading information being advertised.  One is alternative treatments to sleep apnea.  I dream of the day there is a comfortable easy to use effective treatment for sleep apnea.  There was a nerve stimulator invented a couple years ago that I really thought was going to replace CPAP.  The problem is it does not work as well as CPAP.  The only results I have seen published were in a group of mostly men that were not very obese (Average BMI of 28) and whose sleep apnea was moderate on average (AHI=29).  The AHI improved to 9 one year after the procedure.  The procedure was associated with serious adverse events and almost 1/3 were considered non-responders.  The device costs $20,000 and the procedure to put it in costs $30,000 to total $50,000.  Oh, and by the way insurance companies are not paying for it.  Still there are advertisements that paint a rosy picture.

The second question I answer frequently is the use of stem cell transplants to treat COPD.  For $7,000 cash there are clinics that will harvest your stem cells and then give them back to you to help with your COPD. Ironically the physicians working in this clinic are not even pulmonologists.  There is not one piece of credible evidence that demonstrate stem cell therapy works for COPD.  If there were - insurance companies would be standing in line to pay for it.  Two years of treatment with the currently available COPD meds costs more than $7,000. If this procedure worked I would learn how to do it myself.  Unfortunately it does not.

It seems fake news is part of our society that is here to stay.  It is bound to be part of society with free speech that values the pursuit of fame and financial gain over the truth.

How do Adverse Childhood Experiences effect my patients?

posted May 7, 2017, 6:19 AM by Thomas Stern

Poor socioeconomic status is blamed for a lot of healthcare disparities.  Poor people are more likely to be sick.  There are many theories as to why this happens.  Poverty is cited as a risk factor for mental health issues, substance abuse, and obesity.  You fix poverty and the rest of the problems will follow.  Seems logical.  What is painfully obvious is that throwing money at the problem does not work. Poverty is certainly not an absolute condemnation for further poverty.  There are so many great American stories of people starting off poor and becoming billionaires. Many of them site their childhood poverty as an inspiration for hard work. Why does poverty impair some and inspire others?

My personal belief has been that the amount of money a family has in the bank does not predict the outcome of a persons life.  I am certain part of this belief comes from the fact that I was raised by a behavioral pediatrician who was heavily influenced by a mentor who was trained by Anna Freud. I had discussions about Freud's theories with my dad as a teenager. Freud believes the unconscious mind influences behavior. He also recognized that early childhood trauma influences adult behavior.  Because of this early influence I believe that if children are neurologically normal and you keep them safe, provide basic needs (shelter, food, clothing) and an emotional connection they will become well adjusted adults. I don't think it matters how much money you have in your bank account. My residency consisted of training in internal medicine and pediatrics.  These concepts were never discussed in my residency.  They were never discussed in my pulmonary or sleep training.  I considered them  opinions.

For the first time this week I learned of the Adverse Childhood Experiences Study  .  This study was first published in 1998 and proves that adverse childhood events such as abuse, neglect or mental illness in the home when you are a child dramatically increase the risk for chronic health problems as an adult including smoking, sleep disturbances, obesity and substance abuse. You can calculate an ACE score here. Reading this study triggered a mix of emotions in me.  It was satisfying to learn my own conclusions were accurate.  I felt even more thankful for growing up with my parents.  I felt hopeful that I may be able to have more of an impact on my patients who are not able to quit smoking or have chronic insomnia.  I am absolutely terrified because there are very few medical providers who are adequately trained to deal with these issues.  I am heartbroken to think that this many people in our society suffered as children. I feel guilty because I have blamed people with some of these health conditions for their predicament because I did not know how to help them.

I strongly encourage everyone to read the article on addictiion on this web page. The physician who is interviewed suggests addiction shouldn’t be called “addiction”. It should be called “ritualized compulsive comfort-seeking” because these people are seeking comfort to help them deal from their past experiences.  He is not referring just to illegal drugs.  He treats all addictions including addictions to drugs, food, gambling and sex but most of his patients are addicted to drugs.  Over 90% of his patients addicted to opioids have an ACE score of 3 or higher.  Over 90% of patients in an eating disorders clinic in which he works suffered sexual trauma.  How differently would our society treat drug addiction if we approached the patients as terrified victims rather than blame them for what they do?

Healthcare reform

posted Mar 26, 2017, 8:13 AM by Thomas Stern

This past week our congress once again failed to fix our broken healthcare system.  The current system - referred to as Obamacare - has been described by both democrats and republicans as fatally flawed. Despite this our "leaders" can't put together a plan that will provide affordable healthcare.  Instead we all get very expensive health insurance which makes it more difficult than necessary for people to get healthcare. Sadly, our "leaders" in congress don't even realize the difference between healthcare and health insurance.  The reality is the American healthcare system is perfectly designed to do what it is doing - make certain interests a lot of money. People who have a lot of money have great influence over our "leaders".  Fixing the healthcare system is not an intellectually complicated problem. Getting our "leaders" to fix healthcare has proven to be impossible. In order to do this our "leaders" are going to have to prioritize the American people over the wealthy special interests.  

When I was working in the US Senate it did not take me long to figure out there is only one thing that matters to most of our elected officials - and that is to be re-elected. The number one thing that influences voting in our congress is the impact it will have on the next election.  The focus of our "leaders" is not to lead.  Leaders need to make tough decisions.  The last thing our "leaders" want to do is tackle a tough problem.  They would rather kick the can down the road. Our current system promotes indecision.  The healthcare system is a prime example.  The American healthcare system has been identified as a problem for more than 25 years but all that has been done is to perpetuate the system.  Our national debt has been identified as a problem for a long time too and all our leaders do is stand by and watch it grow.

The system solution is pretty straight forward - it is term limits for our "leaders".  Our founding fathers had the foresight to limit the term of president because they identified the potential for corruption.  If only they would have foreseen the same for congress. We will be waiting a long time for our healthcare fix and I predict it will come from employers - not our "leaders". I am not sure it will be in my lifetime.  I am afraid term limits are even farther away.

Actively managing your child's sleep

posted Jan 10, 2017, 11:54 AM by Thomas Stern

My children enjoy Christmas break.  As they grow up, sleeping in is one of the luxuries days off provide.  At the end of break, getting up early again for school is a struggle.  The natural predilection of staying up late and sleeping in late is called delayed sleep phase syndrome.  Delayed sleep phase syndrome is considered normal in adolescence and young adulthood.  Therefore I would argue that delayed sleep phase syndrome is not really a medical problem but describes a normal variation in sleep patterns.  It becomes a psychosocial problem when waking up for school or work is difficult.  When the holidays are winding down and the return to school is getting closer I start to wake my children up earlier than their brains are telling them to wake up.  My oldest is 11years.  He has entered adolescence.  If he does not have a reason to get out of bed he will sleep until noon.  When he sleeps until noon he will not go to bed until after midnight.  I frequently remind him to go to bed at a reasonable hour.  That does not work too well.  Humans are very bad at making other humans go to sleep earlier.  I can sedate people but sleep and sedation are two very different things.  One thing I am very good at is waking people up.  Just ask my 11 year old.  When Christmas break was winding down, I started waking him up earlier.  10AM for a couple days and then 9AM.  It made the transition to school easier.  When my oldest was an infant I did the same thing.  When we first brought him home he slept more during the day than at night.  I would get up with him at night in an effort to let my wife sleep.  She would let him sleep during the day at the insistence of other family members who declared it a mortal sin to wake a sleeping baby. Then she would struggle to get him to sleep and keep him asleep at night.  Putting the baby to sleep became very stressful for her. Over a weekend I started actively manage my sons sleep.  I limited his napping during the day.  I would gently wake him and expose him to indirect sunlight.  Needless to say I was not very popular.  I am not very popular when I wake children early over the last several days of break. I wake them up by opening their curtains and singing to them.   But it works. In a couple of days my son was sleeping more at night.  At the end of break my children fall asleep early.  There are 2 points I want you to remember: 1) Some times you have to actively manage your child's sleep. 2) When changing sleeping patterns in your child focus on when they are awake - do not try to force them to sleep.  

7 years later

posted Dec 26, 2016, 6:31 AM by Thomas Stern

I was very stressed 7 years ago at this time.  I was giving up a job in a medical system with great pay and benefits to go into private practice.  I had 3 children under 5 years old to support and I needed my wife's help to run the practice - so now she had work duties in addition to full time mom duties.  I was assured by many people that a solo private practice simply cannot work.  I didn't have much of a choice though - I had a 2 year non-compete that prevented me from working with other healthcare systems in the area and extended family had just relocated to Charlotte to be near to us. My plan was to stick it out for 2 years and then reassess.  I am still re-assessing 7 years later.  Running a solo practice is certainly not easy although it has become easier as we have assembled a good team around us. There are still days I question what I am doing, but there are many more days I am happy with my independence.  The days I am in question I console myself by remembering that regardless of what I am struggling with I have the ability to improve my situation.  Of course I also have the ability to screw it up even more. I am very lucky that I have a supporting cast of extended family to turn to with expertise in medicine, law, accounting, business, insurance and IT. While decision making has certainly not been perfect it has been enough to keep the practice viable. Will my practice last another year? I think so, but there are no guarantees. How ironic would it be that I survived the arrival of Obamacare just to fail the dissolution of Obamacare? One thing is for certain - I have learned not to stress about things that are beyond my control. This may be due to age.  This may be due to experience. This may be due to fatigue or stupidity.  One thing is for sure - it is definitely not because I planned it 7 years ago! 2017 here we come!

The Passing of a Hero

posted Dec 11, 2016, 8:11 PM by Thomas Stern

John Glenn died last week and I lost a hero.  I learned about John Glenn when I was in school as a child.  The "race to space" and the "cold war" were still hot topics when I was a child growing up in Cleveland, Ohio.  Ohioans were very proud John Glenn was the first American to orbit the earth.  He was also a war hero and a senator.  I was lucky enough to meet John Glenn when I worked in the senate.  I went to college in Washington DC.  Most of my school mates took advantage of that opportunity at some point during our four year stay to take a closer look at how our government operated.  I worked as an intern in the office of Senator Dale Bumpers in the summer of 1991.  I learned more than I wanted to know about our government during that experience and was able to meet some interesting people.  At the beginning of my internship I was being introduced to the senate document room where all interns were expected to go pick things up.  One of Senator Bumpers staff was showing me around.  We rounded the corner of one of the stacks and there stood John Glenn.  The staffer I was with knew Senator Glenn and introduced me. He shook my hand as I quickly blurted out "I am from Ohio".  I wanted to bond with him.  I wanted him to know I understood what a big deal he was. I can't remember what was said after that but he left me mesmerized.  I didn't appreciate it at the time since it was the beginning of my internship but most senators did not shake hands with interns.  I also never ran into another senator in the document room. John Glenn was humble.  John Glenn left the senate years later and returned to space at the age of 77. This week he started on the ultimate adventure and I can assure you that there are some boys from Ohio that miss him. 

My return

posted Dec 6, 2016, 7:31 PM by Thomas Stern

It has been over a year and a half since I last posted to this site.  That is certainly not a way to keep an audience.  I have been contemplating my return to posting for several months now.  The chaos of the healthcare system these days leaves plenty to write about and I think the roller coaster ride is just beginning. I knew Obamacare would implode eventually but I did not expect it this soon.  I knew Obamacare would fail because it does not do enough to control costs. The cost of a hospitalization is still unaffordable for most Americans.  The cost of a lot of pharmaceuticals are still unaffordable for most Americans.  The cost of a lot of medical equipment is still unaffordable for most Americans.  I also knew Obamacare would fail because the majority of people ended up with high deductible health insurance.  Many Americans have learned the hard way that there is a major difference between health insurance and healthcare.  Right now a lot of Americans are paying for health insurance so that they can pay the first several thousand dollars for health care too.  That is not a good formula for American families.

Health insurance is different from other forms of insurance.  Home insurance is affordable for a lot of Americans. Car insurance is affordable for a lot of Americans.  I am not an insurance expert but one of the reasons I suspect health insurance is different is that the "loss" you are insuring against is destined to happen in healthcare.  Everybody dies.  Before people die they tend to consume a lot of healthcare.  I watched 3 grandparents die and the healthcare dollars spent at the end of their respective lives was easily hundreds of thousands of dollars.  None of my grandparents had a house burn down.  I don't think any of them were ever in a major car accident.  While they were covered for catastrophic events in both cases they never had a catastrophic expense. How much would home insurance be if all insurance companies had to cover the cost of one of the homes every policy holder lived in? How much would home insurance cost if it covered all of the maintenance and upkeep for every house?  I don't have an answer but I am guessing it would also be unaffordable. 

Air pollution

posted Apr 7, 2015, 7:42 PM by Thomas Stern

Air pollution is frequently the topic of political debate.  The democratic party uses it to justify increasing regulatory requirements for industry citing global warming as the most serious consequence. Republicans  oppose stricter standards because it makes it harder for US companies to compete globally.  Both sides have significant arguments.  I see flaws in both sides as well.  When I was in elementary and middle schools I learned about periods when the earth was cold referred to as ice ages.  The ice ages were separated by periods with warmer temperature.  I was never taught that temperatures on earth stayed constant.   My conclusion is that global warming and cooling is the norm - not the exception. Is it happening faster than it did?  Well I was not around 3 million years ago - during the last ice age.  I am not aware there are daily temperature logs from that time either.  There are ways to deal with environmentally unfriendly countries from sending cheaper goods into the US to undercut US companies.  Again these are political arguments which I do not like to waste time on.  I was also taught the best form of government is a benevolent monarchy - in which case there would not be political argument. That sounds attractive...

My personal opinion is that air pollution is the most under-appreciated healthcare problem in the world.  In the past 20 years hundreds of articles have been published showing the adverse health effects of air pollution and the positive effects of improving health quality.  Everyone should read the Harvard 6 cities study.  It showed significant health effects of fine particulate matter air pollution at levels one tenth of that in some Chinese cities.  It also showed that when the air quality improved - the adverse health effects improved. Air pollution has been linked to cardiovascular events and cancer - the 2 biggest killers in the US.

If that data is not enough for you to realize the importance of clean air a recent New England Journal article should.  This recent article demonstrated that air pollution caused decreases in the rate of development of lung function in children - and when the pollution improved - children's lungs developed at a more rapid pace.  These studies were done at a level of air pollution that is seen in most of China's provinces. Beijing currently has a level of air pollution 5 times this high.

Dirty water is a public health topic that gets a lot of attention.  Every year close to millions of people globally die due to polluted water.  The thought of exposing millions of people to a polluted water supply and not taking drastic measures to correct it would be considered close to criminal.  If global air pollution continues unabated in the next 100 years air pollution will receive similar notoriety and attention.  

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