Health Care Policies of the Candidates for President of the United States

 

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Current Health Care Policy

Obama Care, the Patient Protection (protection from getting health care) and Affordable (joke) Care Act

  1. Introduction:
  • ACA is legislation passed on March 23, 2010, designed to fundamentally change the way American healthcare is designed and implemented.
  • It aims to overhaul expansion of coverage, workforce reform, cost control, insurance reform, quality reform, and increase focus on wellness and prevention.
  1. Why did we need PPACA?

Healthcare statistics

      1. Costs of Healthcare today:
        • American healthcare is twice as expensive as the average industrialized country.
        • $2.6 Trillion spent on healthcare in the U.S. annually, 17% GDP
        • $8500 per capita in U.S., in 2012 
          • (China spends $7/capita, India $36)
        • We pay double to triple the costs of other industrialized countries
        • Estimated costs to go to 25% GDP by 2025
        • Medical costs are the #1 cause of bankruptcy in the U.S.
        • Insurance premiums are up 400% in 10 years, wages are up 34%.
        • Starbucks pays more for it’s healthcare than it pays for coffee.
        • An MRI of the brain costs $105 in Japan, $4500 in North Platte.
        • Instead of spending our money on screening, prevention and chronic disease management we spend on procedures, tests, and treatments
        • Medicare population will double in the next 15 years.
      2. Quality of the U.S. Healthcare system
        • Of the 11 industrialized nations, the U.S. ranks 11th in life expectancy.
          • some African countries life expectancy is 43 years
        • We rank 19th out of 19 in mortality amenable to medical care.
        • We have fragmented, non integrated, unaccountable healthcare system
        • As the number of primary care doctors goes up in a community then costs come down, quality and satisfaction are improved. It’s a linear relationship.-1   
        • tests and procedures do not equate to better health
  1. Healthcare philosophy and behavior
      • The fundamental questions is: Is healthcare a right of all citizens or a privilege that has to be paid for?
  • “The U.S. healthcare system is absorbed in treating disease rather than preventing it.”-
  • 40% of deaths are related to obesity, diet, nutrition, lack of exercise, smoking and excessive alcohol, not wearing seat belts, etc.-1
  • There are only two factors shown to decrease healthcare costs; access to insurance and a relationship with a personal, primary care physician.-1
  1. In summary: Good and Bad of ACA

The Bad:

  • High deductible insurance plans, higher premiums demanded by private insurance industry to “cover the cost of the sickly new patients signing up for insurance.”
  • Record profits are being realized by private insurance companies.
  • Subsidized premiums for 70% of Americans
  • Expansion of Medicaid to cover indigents

The Good:

  • Innovative cost and quality programs to increase the value (quality/cost) of health care.
  • It has momentum, in it’s 6th year, billions of dollars and untold hours and energy spent already to implement and innovate changes in US healthcare
  • kids on parents policy up to age 26
  • No pre-existing health conditions can disqualify you from coverage.
  • Motivating doctors and hospitals to improve quality, and measure results.
    • if a patient get’s an avoidable complication in a hospital, it may not be covered by Medicare.
    • If a Medicare patient is readmitted to the hospital in less than 30  days, Medicare will not  cover the cost of the readmission.
      • this has led to innovation to prevent readmissions, whereas before it was a financial windfall for a hospital system to have readmissions, more fees!
  1. Definitions of Health Industry Terms

Medical Industrial Complex– the conglomerate of parties involved in health care that fight change and reform tooth and nail: Hospitals, Insurance companies, Pharmaceutical Manufactures, Medical device manufacturers, Physician Groups like the AMA and other specialty groups.

Universal Health Care

Health insurance for all citizens of all ages provided from a government entity paid for by taxes.  Like we all have police protection, fire protections, military protections from foreign aggressors.

Socialized Medicine

Generally means universal health care for all, paid for by public funds, and employing the health care team to provide that care.  This is what Great Brittan implemented.  Canada has universal care but private health systems to provide that care.

Health Care Systems

Large incorporations of health care assets into a single entity.  A system will include hospitals, urgent cares, ER’s, nursing homes, doctor offices and pharmacies and ancillary services like therapies.  Example: CHI, Mayo, Cleveland Clinic, Banner Health, Kaiser Permanente

Healthcare models in other countries

Single Payer-Private providers

Canada, South Korea, Taiwan

U.S.-Medicare, Medicaid, Indian Health, Military Tricare

Single Payer-Government employed Providers

Brittan, Norway, Spain, Italy

Multipayer-Private providers

Germany, Switzerland, Japan, U.S. (2/3 of our healthcare)

Multipayer- Government  or large system Providers(Kaiser, Mayo, Cleveland Clinic)

U.S. is alone

Positions of our candidates for POTUS

Republicans:

Donald Trump:

  • Repeal ACA.
  • Buy insurance across state lines.
    • (Which is silly to think that will cut costs, there are only 3 major insurance carriers.  Fords are not cheaper in KS or CO than in NE and can be sold anywhere to anyone.)
  • Use HSA to pay for bills not covered by insurance.
    • (I’m not sure Donald Trump worries too much about financial issues that the rest of the American’s are concerned with.)
  • No plans to change Medicare.
    • In regards to Medicaid he says he will make a deal with hospitals.

Ted Cruz:

  • Repeal ACA, the CBO estimates it would cost $350B to repeal ACA over 10 years.
    • he spoke for 21 horus on the floor of the US Senate in 2013, reading Green Eggs and Ham, by Dr. Seuss.  At least his book was written by a doctor.  Had he read “Fractured” by Dr. Ted Epperly we might have all learned something.  He was leading a movement to defund the ACA.
  • Expand health savings accounts to cover deductibles and copays
  • Sell health insurance across state lines.
    • (from all 3 companies)
  • Medicare reform:
    • raise the age of eligibility,
    • tiered options: pay more for more complete coverage.
  • Wants to delink insurance from your job, make it portable.
    • (So if the employer is paying for it, how do you do that if the employee is fired, or quits, or wants to retire?  Answer, either the individual starts paying $1500 per month for $5k deductible insurance or the government pays it.)
  • Repeatedly fear mongers on the campaign using the threat of “rationing” if we have universal health care.
    • (We have rationing now, it’s a daily issue.  It’s in the form of denials by insurance for services your doctor orders, formularies, nursing home refusals to accept patients, high costs of care also rations our choices.  Don’t let politicians scare you with the “R” word, rationing is part of life, being done now.  Rationing can mean making informed decisions about treatments and tests that will not benefit our quality of life and may do harm and cause pain and suffering.)

Marco Rubio:

  • Repeal ACA, replace with tax credits to pay for insurance.
  • Purchase insurance across state lines.
  • Speed up the generic medication process,
    • by this he must mean changing patent laws.
  • Privatize Medicare and supplement the policy with a “base rate” and seniors pay extra for the policy they choose.
    • essentially take our most efficient health care delivery system and throw it back to private insurance industry and then supplement it at a base level and make citizens pay for a better plan if they desire.

John Kasich:

  • PCMH model of innovative care delivery, already part of the ACA.
  • this philosophy is more in line the Primary Care physician groups, like the AAFP
  • many of these concepts are already being implemented in the ACA

Democrats:

Hillary Clinton:

  • Supports ACA.
  • Cap spending out of pocket to $250 per month, lower deductibles and copays.  3 visits per year, no deductible applies.  Currently we have one visit for an annual physical that is free.
  • Tax credit or refund if a family spends more than 5% of it’s income on health care, up to $5,000.
  • Push for price transparency at hospitals and offices so people can shop and increase competition.  This is a good thing, just like retail.
  • import drugs from foreign countries with safety standards similar to the FDA.
  • Cut patents on drugs from 13 years to 7.  Thus more generics.
  • Deal with insurance companies through anti-trust to prevent further consolidations.
  • Strengthen state powers to limit insurance premium increases.
  • Save Medicare money by negotiating drug prices.
  • Cut hospital and doctor fees by lumping reimbursements into one payment based on a diagnosis or symptom, instead of fee for service which pays doctors to order more tests and do more procedures.
    • This is good idea as well, and is being done now with ACA.

Bernie Sanders:

  • Universal health care, the only candidate to promote.  The most radical proposal.
    • Medicare for all.  Funded from tax revenues.
  • Private insurance only for supplemental plans.
  • Import drugs from Canada.
  • Require drug companies to disclose the prices they charge in Europe for the same drugs.
  • The federal government will set the fee schedule for doctors and hospitals.
    • Some doctors and hospitals may not accept the rates, thus opting out and creating a black market or 2 tiered system.
      • This is happening in the U.K. now.
  • “We spend 3 times more on health care than U.K., 50% more than Canada for much worse outcomes.. “(paraphrased) – Bernie Sanders

What the various parties involved are thinking

American Public:

  • Current opinion on Obama Care, Affordable Care Act
  • Most Americans approve of the policies and provisions in the ACA,
    • even though they don’t know that is where the policy came from

Doctors:

  • Some doctors like the status quo, it is working nicely for them.
  • Some want to see innovation and quality improvement initiatives.
  • Doctors are frustrated by payment systems that are essentially a gamble for them based on outcomes of health conditions and costs of care that are not in their direct influence.
    • How can a doctor control the lifestyle of a patient.
    • How can a doctor control costs at a hospital he doesn’t own or manage.

Hospitals:

  • They like the status quo.
  • They are nervous about change because they are slow to adapt.
  • They are spending a lot of time and money to negotiate on their own behalf to maintain a profit and market share.
  • They are stressed by employing expensive doctors, and buying expensive technology and accommodating endless rules and regulations of the federal and state government.
  • The ACA has been an incredible stress to them to change and adapt.

Summary and Opinion:

Current reality

We have nearly the worst healthcare system in the world.  We finish near the bottom in almost every category.  We spend the most of any nation, by a factor of 2 or more.  If we continue the innovations of ACA we will improve the quality of care in the U.S., and decrease it’s cost.  We can have the best health care in the world but it won’t come from doing more of the same policies we have done to date.  You can’t go from worst to first without radical change.  Elections are the opportunity to change the direction of our health care delivery system in the U.S.

Career choices and bankruptcy

Our workers are staying in jobs they don’t like or don’t need, just for the health insurance.  Privately insured individuals, like me, can spend up to $1500 or more for coverage that has $12,000 in deductibles before any payments are made on health care bills.  That is $30,000 out of pocket in any given year.  Medical costs are the number one cause of bankruptcy in the U.S., even among insured individuals.

Retirement and employment for younger workers

If we had universal health care that followed us from birth to death and independent of employment then our economy would change dramatically.  Employers would not have to incur the expense, they would hire more workers.  Workers could be more mobile, even start a small business and not worry about their family being uninsured.  Older workers could retire if they have the ability and not worry about spending $1500 per month for insurance.  This would open up jobs for younger workers that need them.  Medicaid could go away, eliminating the number one cost to every state government in our country, and shrink government. Everyone could afford to go the doctor for necessary preventive care to further decrease costs in the long term.  With one universal payer, i.e. Medicare, doctors and hospitals wouldn’t spend millions of dollars negotiating with middle men, hiring lawyers to negotiate contracts, forming defensive organizations, like ACO’s and PHO’s, to combat insurance companies.  We could make national decisions on what we are willing to spend money on, and what we are not.  We can have one formulary to prescribe medications, putting pressure on the drug companies to develop and price products affordably.  If a medication were not on the formulary, people can purchase it privately at fair, market driven competitive prices.

Universal Health Care

Universal health care doesn’t mean all citizens are going to pay the same for their health care or insurance.  Many candidates are already talking about Medicare reform to include paying for choices in coverage.  We can have an insurance rate tiered to our income, just like our income tax.  Cap it at 10% of income, but then refund some money the next year if we are healthy and meet criteria on costs and health parameters.  Keep the deductibles affordable and limit copays or have escalating copays for each visit after 3 per year.  Encourage and legalize innovation in health care delivery, like telehealth.  Cut doctor’s costs through liability reform, cut licensing and credentials hassles to make physicians and nurses more mobile and flexible so we can go practice anywhere in the country and fill in the underserved areas.  Hospitals spend double the salary for locums workers due to the middlemen involved getting licensure and credentialing. Reform physician Residency training programs to design a health care work force that will meet the needs of our aging nation, not pander to the lifestyle choices of 25 year old medical students whom we have invested a million dollars educating and then let them become sub specialists and fleece us with fee for service health care.

Motivation

Universal health care coverage would have another benefit, motivation  for prevention.  Currently we have one insurance up to age 65 and then are turned over to Medicare.  So, the private insurance industry lacks the motivation to emphasize prevention.  Prevention pays off as we get older, and put on Medicare.  So neglecting prevention when we are on private insurance costs our public insurance, Medicare, billions of dollars to treat diseases that we should have prevented for pennies on the dollar.  It will be easier for a government based Universal health care system to financially reward good health behavior and prevention through our tax system.  If you are working to stay healthy, and your costs are lower, you are meeting health parameters that we establish then your taxes are lower, or you earn an income tax credit.  Private insurance could do it as well but they would have to be forced by law to offer refunds if parameters are met and costs are contained.

Eliminate Middlemen

Universal care would eliminate so many middle men in the industry it would be mind boggling.  Billions of dollars could be saved.  If profit were removed from the health care industry by eliminating private insurance companies, all their agents, the lawyers writing the contracts, the expense to the doctors to negotiate with several different companies, the management of hospitals, the PBM industry that plays with formularies, etc.  Between eliminating all this waste, and incentivizing healthy lifestyles through tax policy we may be able to cut our medical spending in half!  That is $1 trillion in savings per year.  It could almost balance the budget for the federal government.

ACA

If we continue to tweak ACA initiatives to improve quality and decrease cost then we save even more.  With the right leadership we could be on our way to the best health care system in the world, instead of the worst.  Donald Trump is right about one thing, our politicians are bought and paid for by special interests.  No bigger interest group exists than the Medical Industrial Complex.  They fight change by bribing our politicians with campaign support, and likely many other under the table benefits.  We the people can take back our government by getting involved and writing our leaders and holding them accountable.  Many of the representatives blindly take a party line position on reform, not even thinking independently about how to solve these tough issues.

The ACA has brought us a long way down the path of reform.  There is a long way to go from being worst to being first.  Throwing out the ACA and all the innovations that have been implemented would be a crying shame and set us back a decade.  The CBO estimates a cost of $300 billion to repeal the ACA.  Our system is still broken and more reform is necessary.  Let our politicians know that health care reform is important to you and your children and grandchildren.  Tell them you want a leader that will keep innovating, keep changing, and keep improving our health care delivery system.  Don’t be swayed by the drama of Obama hating and fear mongering about repeal.  Realize that 70% of Americans like the provisions in the ACA.

Personal responsibility

If you want to help America be healthier, then take some personal responsibility in the matter of your health.  Adopt healthy lifestyle habits: don’t smoke, eat healthy, exercise, and maintain an ideal body weight, wear a seat belt and a helmet if you ride bicycles or motor cycles.  Forty percent of our health care costs are caused by our bad habits.  Write your representative about your views on health care reform.

References:

WebMD

NY Times

Candidates Web Sites

“Fractured”, Dr. Ted Epperly-1

Obesity

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 Definition

Body Mass Index is a term used to define obesity.  It is ratio of weight to height.  Calculated as Wt.(kg)/Ht.(m^2)

BMI over 25 is overweight, BMI of 30 is obese

Height:                              overweight wt.:                                         obese wt.:

5’4”:                                       145                                                         174

5-6:                                        155                                                         186

5-8:                                        164                                                         197

5-10:                                      174                                                         209

6’:                                          184                                                          221

6-2”:                                       194                                                         233

6-4”:                                       205                                                         246

Body Fat method:

May be used as an addendum, especially for muscular builds from weight training.  Various techniques to measure.

  • Fit women 21-24%
  • Fit men 14-17%, a six pack abdominals is 8%.

Obesity:

  • Women:32%
  • Men:25%

Body Fat charts and pictures, 

http://www.builtlean.com/2012/09/24/body-fat-percentage-men-women/

Prevalence

Adult

  • 1/3 of U.S. adults are obese, 78.6 million people

Childhood

  • 17%, 13 million children and adolescents
  • Increased 3 to 6 fold (600%) since the 1970’s.
    • associated with head of household educational levels and socioeconomic status

by State and Country

  • highest Arkansa, Mississippi, West Virginia
  • Lowest: Colorado, California

by Race

  • Blacks: 48 %
  • Hispanics: 43 %
  • Whites: 33 %
  • Asians: 11 %

by Age

  • highest age 40-59 (39.5%)

Causes:

Genetic

  • drive to eat,
  • sedentary nature,
  • metabolism, minimal differences in most people
  • fat burning capacity or increased tendency to store fat.

Psychological

  • Overeating and eating “comfort foods”
  • can be associated with stress and depression.

Social/Cultural

  • Our social events can be centered around food,
  • often high fat and carbohydrate items
    • When the last time you had your family over to meet at the park or recreation center and go for a walk or swim or bike ride.

Behavioral

  • Habits of eating are developed over time.
  • Family habits from childhood are reflected in adult habits.
  • Lack of education on nutritional principles can be perpetuated in families.
  • Lack of motivation for long term health consequences of our behavior and lifestyle

Associated Medical Conditions:

  • Diabestes
  • Heart and VascularDisease
    • Coronary Artery Disease, Atrial Fibrillation, Congestive Heart Failure, Stroke, Hypertension, blood clots
  • Obstructive Sleep Apnea
  • Cancer
    • virtually every organ and type of cancer is associated with obesity
      • obesity can increase breast cancer risk by 30%
  • Arthritis
    • every pound of body weight contributes 7 psi to joint surface pressure
    • an extra 50 pounds contributes 350 psi on back and hips and knees
  • Infertility
    • Polycystic Ovarian Syndrome
    • increased incidence of labor and delivery consequences, like c/sections
  • Hormones
    • low testosterone
    • elevated estrogens in men and women
      • “man boobs” and female hormone related cancers
  • Psychological health
    • depression
  • Sleep pathology, Obstructive Sleep Apnea

Costs:

  • 190 Billion Dollars annually in the U.S. in direct and indirect costs are related to obesity
  • 21% of all health care spending in the U.S.
  • Obese individuals have medical costs estimated to be 30% greater than normal weight peers
    • $3,000 per obese individual per year

Treatments:

Lifestyle

  • Losing weight is not achieved by going on a diet or starting a fitness program.
  • Losing and maintaining a healthy weight requires a lifestyle change.
  • Lifestyle is defined by components involving nutrition, activity level, hobbies, and habits.

Nutritional Principles:

  • 3 meals and 3 snacks, with good eating habits:
    • eat slowly, put fork down after each bite
    • put your food on a plate, don’t graze around a buffet
    • environment:
      • don’t eat in front of TV, it’s distracting and leads to overeating.
      • drink plenty of water with your meal, have a glass of water before the meal
  • low added sugars (10% of calories from added sugars)
  • low in saturated fats(10% of calories),
  • Mediterranean dietary principles
    • fish, lean meats, legumes, fruits, vegetables, nuts, whole grain breads, plant based fats- canola and olive oil).
  • See the new guidelines: http://health.gov/dietaryguidelines/

Exercise: 

  • 30 min/day most days of the week,
  • 2 resistance weight training sessions per week.

        Adults exercise recommendations:

  • 150 minutes per week of moderate aerobics and 2 or more sessions of resistance weight training for all major muscle groups.

        Children exercise recommendations:

  • 60 minutes of physical activity every day, including at least 3 sessions of muscle building activities and 3 sessions of more intense aerobic activity like running.

Worksite Physical Activity

  • park and walk,
  • take the stairs,
  • stand up at work station,
  • use breaks to walk,
  • short walk after lunch.
  • Wellness programs:
    • motivate employees to attain health goals,
    • pay for fitness memberships,
    • give discounts on health insurance,
    • office contests to promote healthy goals.
    • Work station design:
      • stand up desks.
      • treadmill desks.

Medications:

  • Meds can reduce weight by 10-20% while taking.
  • May not result in persistent weight loss if stopped unless significant lifestyle changes are adopted.

Available Medications: 24 drugs on the market for obesity

Phentermine, generic

  • formerly part of infamous Phen/Phen combination
  • stimulant, acts to inhibit apetite

Orlistat, called Xenical

  • blocks absorption of some of the fats we eat
  • GI side effects are poorly tolerated

SGLT-2 inhibitors (Farxiga, Invoking, Jardiance)

  • Diabetes drugs, very expensive

GLP-1 agonists (Byetta, Victoza, Bydureon, Tanzeum, Trulicity)

  • Diabetes meds, very expensive, injections

Buproprion/Naloxone, called called Contrave

  • can be poorly tolerated with GI side effects

Topiramate/Phentermine, called Qsymia

  • can be poorly tolerated

Lorcaserin, called Belviq

  • 5 HT 2 serotoninergic receptor agonist

Surgery for obesity:

Restrictive procedures, shrink the stomach capacity:

  • Gastric Band
  • Gastric Sleeve
    • most popular modern procedure

Malabsorption surgeries, to prevent the digestion of calories:

  • Gastric Bypass
    • may have increased mortality and complications in some centers

Results of surgical procedures :

  • surgery can reduce all cause mortality by 50% in 5-7 years
  • surgery can reduce incidence of diabetes by 80% in 5 years

Summary/Call to action:

     Obesity is a common American malady.  Obesity has dramatic and expensive adverse affects on our health.  There are several successful strategies and treatments for obesity.  There is plenty of research showing the positive affects of losing weight.  Set a goal for your weight, develop a strategy to achieve your goal.  Measure your progress.  If not achieving your goals then seek help from friends, family, obesity support groups, or see your doctor for assistance in achieving this important goal.

References:

USPSTF

Up To Date

AAFP

CDC, http://www.cdc.gov/healthyweight/index.html

Dementia

Dementia

Dementia is our most-feared illness…Dr. David Perlmutter

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Definition:

Dementia is a common term used to describe a collection of symptoms, it is not a diagnosis.  The DSM, diagnostic and statistical manual for medical diagnosis uses the following definition.

Evidence from the history and clinical assessment that indicates significant cognitive impairment in at least one of the following cognitive domains:

  • Learning and memory
  • Language
  • Executive function
  • Complex attention
  • Perceptual-motor function
  • Social cognition

Furthermore, these conditions must be met:

  • The impairment must be acquired and represent a significant decline from a previous level of functioning
  • The cognitive deficits must interfere with independence in everyday activities
  • In the case of neurodegenerative dementias such as Alzheimer disease, the disturbances are of insidious onset and are progressive, based on evidence from the history or serial mental-status examinations
  • The disturbances are not occurring exclusively during the course of delirium (such as during an acute illness or intoxication)
  • The disturbances are not better accounted for by another mental disorder (eg, major depressive disorder, schizophrenia)

Manifesting as difficulty with one or more of the following:

  • Retaining new information (eg, trouble remembering events)
  • Handling complex tasks (eg, balancing a checkbook)
  • Reasoning (eg, unable to cope with unexpected events)
  • Spatial ability and orientation (eg, getting lost in familiar places)
  • Language (eg, word finding)
  • Behavior

Incidence/Prevalence/Costs:

  • 5.3 million Americans have dementia in 2015
    • Estimates for 2025 are 7.1 million
      • Nebraska has 33,000 cases
  • 5% of population in their 70’s have dementia
  • 25% of population in 80’s
  • 6th leading cause of death
  • 1 in 3 Americans have a demential condition at the time of their death
    • less than 1/2 of patients are aware they have a diagnosable dementia
  • most victims are over 65,
  • women have higher incidence at a ratio of 2:1.
  • higher incidence in hispanics and Black races.
  • Costs U.S. $226 billion in 2015.
  • Medicare costs are 300% higher for a senior with dementia than one without.

Types of Dementia:

Alzheimers Dementia, called AD

  • AD is responsible for 60-80% of dementia.

Vascular Dementia

  • Vascular disease is the second leading cause.

Dementia of Lewey Body, called DLB

  • manifests with hallucinations (visual and dramatic),
  • trouble walking,
  • tremor (like Parkinsonism)

Frontotemporal, FTD

  • manifest more as behavioral variant of dementia
    • change in personality,
    • lack of inhibition,
    • OCD behaviors,
    • apathy

Parkinson’s Disease with Dementia, PDD 

  • 30-40% of PD patients get dementia over course of their disease

 Cause:

 

Reversible: Minority of cases of dementia are from reversible causes (1%)

  • Thyroid disease
  • Vitamin Deficiencies
  • Hydrocephalus
  • CNS tumor
  • Depression
  • Alcohol or Drug abuse
  • Medications side effects:
    • pain pills,
    • sleeping pills,
    • sedatives,
    • anxiety meds,
    • depression meds,
    • anticholinergics (IBS, OAB meds),
    • antihistamines, benedryl, Tylenol PM
    • some Blood Pressure meds,
    • antipsychotics,
    • seizure meds.
    • Stress

Irreversible:

  • AD-protein tangles in the brain, Tau protein
  • LBD-amyloid proteins deposited in the brain, similar to AD
  • Creutzfeldt Jacob Disease, CJD
    • Prion infection in the brain, like Mad Cow Disease in cattle
  • Stroke, or combination of many mini-strokes over time
  • Parkinsons Disease, PD
  • Infections:
    • HIV,
    • Hepatitis
    • Meningitis/encephalitis(WNV, Syphilis)

Symptoms, differentiating dementia from forgetfulness or aging:

Dementia is characterized by:

  • Difficulty remembering recent events, familiar people.
  • Having to be told over and over.
  • Forgetting major events even happened, like a vacation.
  • Difficulty planning
  • Difficulty with following directions, like a recipe you’ve made several times.
  • Getting lost in familiar areas.
  • Difficulty balancing a check book.
  • The person doesn’t notice the issues, others do.
  • Become anxious, irritable with minor events or changes in routine.

Forgetfulness, or normal aging is more characterized by:

Diagnosis/Evaluation:

Your doctor can use several tools to determine if you have dementia.

  • MiniCog testing, can be given at home by family member or caregiver:
    • recall 3 familiar objects after 1 minute of time.
    • Draw a clock face with numbers and hands to display the correct time.
    • If fail MiniCog, further testing is needed.
  • MME: 30 point exam done at doctor’s office

Treatment:

There are treatments available for dementia.  First and foremost is to determine if there is a reversible cause.  Several non-medical strategies can be helpful for dementia.  Modification of vascular risk factors has a favorable outcome in slowing the progression of dementia.

  • Diet,
    • Heart healthy, Mediterranean diet
  • Exercise
  • Social engagement.
    • socializing with friends and relatives
    • games
    • reading
    • learning new skills
    • formal education
    • active hobbies
    • volunteerism

There are medical therapies available to help with dementia.

Medications:

1. Acetylcholinesterase inhibitors (Exelon, Aricept)

  • Can be used in all causes of dementia, score of 26 or less in MMSE.
  • First line treatment in early dementia.

2. Memantine (Namenda)

  • NMDA receptor antagonist, may be protective of neurons.  May have modest benefit in moderate to severe dementia.
  • Used in combination with AcetylCoA inhibitors for moderate to severe dementia.

 3. Vitamin E, 2000 U per day

  • May have some benefit in Dementia,
  • should not be used in combination with Memantine.

Prevention:

Several strategies have been found to delay the onset or slow the progression of dementia.

  • At the Alzheimer’s Association International Conference® 2014, a two-year clinical trial of older adults at risk for cognitive impairment showed that a combination of physical activity, nutritional guidance, cognitive training, social activities and management of heart health risk factors slowed cognitive decline.-1
  • Onion Model of cognitive decline:
    • Aging affects the brain like pealing the layers of an onion.
    • The more layers we build up over our lifetime the longer it takes to peal.
    • The core of the onion is equated to our ability to live independently with quality of life.
  • Learn a new skill (bilingualism delays the onset of dementia by 4 years), engage in formal education.  Stay socially engaged, volunteerism.  Active hobbies that require planning, thinking.
  • Practice Vascular health:
    • Good diet
      • Mediterranean diet:
        • fish, nuts, whole grains, fruits and veggies, olive oil, low in saturated fats (red meat, butter, cheese, sour cream, processed foods),
    • control weight, 
    • exercise, 
    • treat high blood pressure, 
    • control your cholesterol through diet, exercise and medications if necesary, 
    • aspirin may be appropriate 
      • (age > 65 with other vascular risk factors)
    • Don’t smoke,
    • get enough sleep,
    • manage stress (circle of influence vs circle of concern).
  • Avoid excess alcohol, 
  • evaluate and treat depression.

Research:

  • NIH spends $6B on cancer research,
  • $4B on heart disease research,
  • $3B on HIV,
  • but only $480M on AD.
  • Future research is focusing on the protein tangles in the brain and inflammation.
    • Immunizations
    • Antibodies against the proteins
    • Anti-Inflammatories

Conclusion/Call to Action:

Dementia is unfortunately very common.  As we live longer we will have increased incidences of health conditions related to aging.  Our actions, or lack thereof, when we are younger can influence the development and severity of dementia.  Be proactive about your health through preventive and protective habits.   Take action when you are healthy to diminish the impact of conditions associated with aging such as dementia, heart disease and cancer.

Resources:

An Unintended Journey, A Caregivers Guide to Dementia

Bible Verses-Alzheimer’s/Dementia/Memory Loss Activity Book for Patients and Caregivers

Shadowbox Press activity books for Dementia patients

http://www.alz.org

References:

1. Alzheimer’s Association,

2. Web MD

3.Up To Date

4.American Academy of Family Physicians

Telehealth: Access to Healthcare Using New Technology

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The advent of technologies for face to face video conferencing have led to exciting new possibilities to revolutionize medical care.  With apparent shortages of physicians predicted in the future, our patients need another method of obtaining necessary healthcare.  The trend to high deductible, high copay insurance plans have left many patients reluctant to seek care in expensive traditional settings like ER’s, Urgent Cares, and doctors offices.  Now, for $40-$50, patients can see their doctor for minor medical conditions, or chronic medical disease management through telehealth.  Convenient, cost effective medical care delivered to their own homes or offices without traveling or waiting in a office, ER or UC.  Many companies and the health care industry in general are adapting and reacting to this new technology.  Many insurance plans now cover telehealth visits for nominal $10-$15 copays, saving patients hundreds of dollars.  Employers appreciate the cost savings to their insurance plans and patients appreciate the low cost, and convenience of telehealth.

You can schedule a Telehealth appointment with me if you are in Nebraska, where I am licensed.  I am usually only available on the site by appointment so you must call my office number, or email my office to schedule the visit so I can be logged in and waiting to see you.  You must select me from the available physicians after you have logged in and registered.  You must download the App from your App store or register on line at Amwell.com to use your desktop or laptop computer.

Steps:

  1. Be located in Nebraska, where I am licensed.
  2. Install the Amwell App on your phone or iPad through your App store.
  3. Input you medical, insurance, and demographic information on their secure site.
  4. or Register for Amwell on their website, Amwell site
  5. Notify my scheduler that you would like a Telehealth visit, call (308)534-8383 or email us at statesfamilypractice@yahoo.com
  6. Log in to the Amwell site or App at the scheduled time and select me as your provider.

History of Telehealth:

Q: How long has this type of service been available and who’s using it?

  • Rural community hospitals and mental health facilities have been using telehealth for years to expand access to specialists and psychiatrists in underserved areas.  Care had to be received at a medical office though.
  • The government’s VA system has been using telehealth to care for veterans, again they must be at a facility.
    • Recently they have introduced in home services.
    • Called Banner iCare, must have at least 5 chronic conditions.
    • They have shown 45% reduction in hospitalizations, 32% reduction in care costs.
  • In Alaska it was estimated that telehealth saved the state $8.5 M in one year in Medicaid related travel expenses.

Q: What type of care can be obtained?

  • Primary care mostly but consultation with specialists are becoming available.
  • Psychological services like counseling
  • Dietary and Nutritional services with a dietician
  • Health coaching is available as well.

Current State of Telehealth:

Q: How does it work?  How does a patient seek medical care using telehealth?

  • The newest innovations are called mhealth, for mobile health.
    • These products utilize smartphones and tablets, as well as desktop and laptop comuters.
    • Patients download an  App, then register and log on.
      • Input their health history: medical conditions, medications, allergies, pharmacy and current symptoms.
      • They can input their vital signs.
      • Then they activate a visit and the doctor is usually available in in 1-2 minutes unless with another patient.

Q: How does it work from the doctors side of the visit?

Doctors are credentialed with the various products and trained to use them.  If a doctor makes himself available to see telehealth patients he is notified when a patient requests a visit.  The doctor then utilizes the physician App and initiates a visit with patient after reviewing the health information input by the patient.  The doctor can see and talk to the patient and then come to a diagnosis and treatment plan.  The App then can be used to send in a prescription and document and bill the visit.  Patient follow up can be accomplished through the App for quality control.

Q: What kind of gadgets are required?

  • Really not much, commonly available devices.
    • Computer, iPad, smartphones
  • Kiosks are available in malls and pharmacies, like a phone booth
    • High Def video, BP cuffs, thermometers, ear scopes, heart monitors, glucometers.
  • Devices are being developed to measure patient data and transmit it to the provider.
    • even EKG’s at home and wearables (smart watches)

Q: Which insurance companies in NE cover telehealth?

  • I found that BCBS of NE covers telehealth.
    • using Amwell product
  • Aetna/Coventry did not.
  • My daughter’s company in Lincoln is now offering telehealth services, Cigna?
    • through MD Live.
  • Medicare and Medicaid still have some restrictions but these are rapidly changing.
  • CMS just released, last week, a statement of “Next Generation ACO model” which will reportedly cover telehealth services to medicare and medicaid patients.
    • ACO product, like SERPA ACO here in Nebraska.

Q: What type of visits are possible in telehealth?

  • Respiratory infections
  • Injuries
  • rashes
  • fevers
  • chronic medical condition management
    • Diabetes
    • Hypertension
    • Obesity
  • NOT: pain pills, or chest pain in older adults, emergencies.

Q: Who are the big players in developing the technologies?

  • American Well, Amwell https://amwell.com
    • this is the product I use.
    • many brand names of products offered under various titles through insurance companies and major employers.
  • Dr On Demand www.doctorondemand.com
  • MD Live https://www.mdlive.com
  • SnapMD
    • lets a provider or network set up their own branded product, can interface with existing EHR
  • John Sculley, former CEO of Apple is involved in the industry as a capital venturist.

Future of Telehealth:

Q: What are the projections for growth in the industry?

  • In 2013 there were 250,000 patient visits.
  • By 2018 it is projected to be 3.2 million.
  • Amwell’s study:
    • 64% of Americans are willing to use video conferencing for health care.
      • Average wait time nationally to see doctor, 18.5 days.  Telehealth < 3 minutes
    • 57% of doctors are willing to use telehealth to care of patients.

Q: What web sites or Apps are available today to allow people to utilize telehealth?

  • Amwell, this is the site I utilize.

  • MD Live
  • Dr On Demand
  • May be coming to your doctor’s office in the future through a self branded product.

Conclusion:

We are seeing a paradigm shift in health care delivery.  Keep an open mind about changes in medical care.  Ask your doctor’s office if they are planning to implement telehealth services.   Check with your insurer or employer to see if telehealth is a covered benefit or plans to become one.  Download an App and become familiar with it.  Then, if the need arises for convenient, cost effective access to medical care you may just find yourself using this new technology.