Thursday, November 17, 2016

Gluten - It's Not Just The Bread - 2

There are three (possibly more) illnesses caused by gluten - celiac disease, gluten allergy and gluten sensitivity.

There are no medicines or pills to take. Whether it is celiac disease, allergy or gluten sensitivity, the only effective approach is to totally avoid gluten. This is relatively easy to do at home but it can be more complex eating out. Gluten is obviously in products made from wheat flour like bread, pasta, pizza, pretzels, pies and cakes. At home it means getting rid of the obvious - white or whole wheat flour, pancake mix, cake and cookie mixes and many cereals like Wheaties. More difficult to recognize are pantry items that have gluten lurking in them that might surprise you. Cheerios and Corn Flakes include wheat flour. Soy sauce usually is made of both soy and wheat although wheat-free soy sauce is available.  Worcestershire sauce is a problematic item; some brands are gluten-free while others are not. Malt vinegar is made from barley and so is not gluten-free; white vinegar may be not be gluten free whereas balsamic and apple cider vinegar are usually safe. Beer is brewed from wheat and barley. Hard liquors are often made from wheat but are distilled and so are generally gluten free.  Seasonings can be a complex problem; some seasonings may use wheat to stabilize the spice or herbs in it.
Basically, it is a process of reading the labels carefully. Food package labeling has improved immensely in recent years and can be a real blessing in the grocery store. The ingredients label must note if it contains wheat.
If you follow the basic very healthy Mediterranean style diet you can reasonably easily remain gluten free. The Mediterranean diet is fundamentally one based on a fresh vegetables, simply cooked, multiple fruits, legumes such as beans and lentils and modest size quantities of meat, poultry or fish plus olive oil along with nuts and seeds and wine in moderation.

It's easy to prepare food from scratch but in our society we don't tend to do that anymore. Most foods come processed and pre-packaged; often those forms are adulterated with substances that include gluten. That's why the label reading is very important. But far better to start with fresh ingredients from the produce, meat and fish sections and prepare them in a way that doesn’t use gluten.

Eating in a restaurant is more of a challenge. There you're not in control of the ingredients used. As for everyone, ordering meals based on fresh prepared vegetables and fruits along with high quality meats, poultry and fish is best. Then the question is whether the chef used any added gluten-containing ingredient such as in the seasoning or marinade. Gravies are often thickened with flour as are many soups.  Eggs of course are gluten-free so you might expect that an omelet will be gluten-free even if you add veggies such as spinach, tomatoes and perhaps some cheese. But it may not be. Why? It's because some of the commercial prepackaged omelet mixes include a bit of pancake batter to make the omelet a bit smoother and fluffier. Something you would probably never guess. But if you are gluten sensitive, your GI tract will figure it out a short while later with disturbing symptoms.

Even a restaurant meal free of gluten might have been prepared next to a gluten containing meal leading to cross contamination.  So it is critical that the restaurant know your requirements and be prepared to assist.
The food industry has jumped on the gluten free bandwagon in a major way. They see market potential. It is now a multi-billion dollar per year market and growing. Why so much? Many people have started to go gluten free even though they are not sensitive nor have celiac disease. They believe that they do or will feel better by avoiding gluten. Of course this means that there are more and more gluten free products on the grocery shelves now for those that must be gluten free. Unfortunately, the food manufacturers that have produced so much gluten free food are not necessarily manufacturing healthy foods. A food product may be gluten free but processed to contain high levels of salt, fat and sugar – hardly healthy. Once again, read the label, this time for the calorie count, the fat content, the added salt and sugar.
Here is the bottom line. For a sizable portion of the population, gluten is a toxic substance. Celiac disease is very serious. Gluten allergy although uncommon can be devastating. Gluten sensitivity, while not life threatening, can be very life altering in a most negative way. Unfortunately because the symptoms of celiac or sensitivity are not necessarily GI related, the diagnosis is often elusive. For those with gluten-related disease the only treatment is preventative – completely avoid gluten. 

What should you do? If you are gluten sensitive, then you need to avoid gluten. If you have celiac disease this is especially important, indeed critical. If you are gluten sensitive you'll be most uncomfortable if you eat anything containing gluten.  The degree of discomfort and the length of the discomfort will probably depend upon how much you eat at any given time. So the key is to avoid it. But before you try to diagnose and treat yourself, talk to your doctor; that is essential. Your problem may or may not be gluten; it’s too important to leave to chance.

Gluten - It's Not Just The Bread - 1

Gluten is a mixture of proteins found in wheat, rye, barley, spelt, kamut and a few other grains. Gluten which means glue in Latin is the substance that gives bread its texture and elasticity. It's what gives bread that sticky pull which is so nice when you break a good French baguette; it's what gives a muffin its spongy characteristic and it helps form those little cells in warm bread that soaks up butter.
Gluten is not found in rice, corn, quinoa, amaranth or tiff. Despite its name, buckwheat does not contain gluten. Oats are gluten free but often raised near wheat or processed in mills that also grind wheat so they can be and often are cross contaminated.

There are three (possibly more) illnesses caused by gluten - celiac disease, gluten allergy and gluten sensitivity. Celiac disease is a serious life-modifying and often life-threatening disease. It is an autoimmune disease meaning that gluten sets up a reaction in a predisposed individual such that the body attacks its own cells. Not only can it cause gastrointestinal damage leading to malabsorption but it can lead to problems in multiple other organs in the body. Previously rather uncommon with no more than one person in 300 having the disease, today about 1% of Americans have celiac disease and the incidence appears to be rising still. It occurs in people who have a genetic predisposition, these being about one third of the population. But within that group of predisposed individuals, only some will develop celiac disease for reasons that remain unclear.

Gluten allergy is uncommon, affecting less than 1% of the population. It's an allergy similar to how some people develop G.I. symptoms from, say, shellfish. Usually the reaction comes on quickly after eating, can be quite severe often with abdominal pain, nausea, vomiting and diarrhea. The reaction stops once the offending allergen (gluten) has passed out of the body.

Gluten sensitivity (or gluten intolerance) affects perhaps 10% and possibly more of the population. It ranges from rather mild to quite severe. The most common symptom is abdominal discomfort ("bellyache," nausea, bloating) in two thirds of affected individuals. The next most common symptoms do not relate to the GI tract – eczema, “foggy mind,” headache and fatigue, all occurring in about a third of individuals. One third develop diarrhea when they eat gluten. Other less common symptoms are depression (20%), anemia (20%), numbness in hands or feet (20%), acid reflux and joint pains in about 10%.  The severity of the symptoms seems to depend upon how much gluten is ingested at one time. The more one eats, the worse the symptoms. For some people the symptoms dissipate within just a few hours but, for others, problems such as diarrhea, reflux or even abdominal discomfort can persist for days or even weeks.

In a continuing care retirement community of about 2000 residents where I live, Charlestown probably has about 20 with celiac disease, a few with gluten allergy and 200 or so with gluten intolerance/sensitivity. Many will not be aware of the connection between their symptoms and gluten ingestion. The diagnosis is often missed by physicians because the symptoms can be vague. Many problems cause abdominal discomfort and many of the symptoms of gluten associated disease are not related to the GI tract, such as headaches or rash.

There are no medicines or pills to take. Whether it is celiac disease, allergy or gluten sensitivity, the only effective approach is to totally avoid gluten.


Monday, July 18, 2016

The Octopus As Analogy for Healthcare Innovation


“ 'When an octopus settles on a coral reef, it changes colors to provide protection from predators. But the color changes are not directed centrally … Each cell has the innate capacity to recognize its surroundings and change color to match.

We need that type of decentralized innovation in medicine today – innovation that starts with the provider and the patient.'

"In the last chapter of his landmark book, Fixing the Primary Care Crisis, Stephen C. Schimpff, MD FACP, introduces the above, unusual but striking analogy, for the current healthcare conundrum.
Innovation is ubiquitous in the healthcare community. We have come to expect it from our medical professionals, scientists and pharmaceutical companies. What sets Dr. Schimpff’s cause célèbre apart is his understanding that the healthcare delivery system itself is most in need of innovation.

"It is impossible to disagree with Dr. Schimpff’s compelling argument: The solution to the American healthcare conundrum should be decentralized and begin at the bottom!

"Innovation From the Bottom Up”

Quoted from Michael R H Stewart founder of Crowdfunding For Good and available  in its entirety at this link: 

Wednesday, March 9, 2016

A New Way To Improve Primary Care Yet Reduce Total Costs

PCPs in the current reimbursement model are obliged for business reasons to see too many patients per day which of course means less time per patient. PCPs are frustrated and patients are less satisfied. With less time it is hard to build a strong doctor – patient relationship and without it there is less opportunity to build trust. Readers of my posts know that I am a strong advocate for primary care and for granting the PCP added time per patient but doing so with no decrement in income. Here is an innovative experiment by an insurer to incent PCPs to offer more time to those patients with chronic illnesses while enhancing preventive care to all. 

Added time and good care coordination will improve the quality of care for the individual patient with a chronic illness and yet will reduce costs by eliminating excess specialists visits, tests, procedures and, by improving care quality, it will reduce the need for hospitalizations. That was the assumption underlying a program by a large not for profit BlueCross/Blue Shield plan - CareFirst. Fundamentally the plan incents PCPs with opportunities for increased income in return for giving added time and good care coordination to those with chronic illnesses along with enhanced preventive care to all patients. 

The insurer calculated that about 80% of their medical expenditures went towards the care of just 15% of patients. These were patients with complex chronic illnesses. Knowing that primary care physicians receive about 5% of total healthcare expenditures it was hypothesized that they are in a position to strongly impact much of the other 95%. The insurer also wanted to raise awareness of healthy lifestyles to assist all of their enrollees to remain healthy. So the agenda was to create incentives for PCPs to have an impact to reduce the total cost for those with chronic conditions while improving the care and concurrently maintain the health of the remaining enrollees. 

Oversimplified, the new program works like this. PCPs form into actual or virtual groups or panels of 5 to 10 and enter into an agreement with the insurer which then increases their reimbursement by 12% for each visit. The insurer also agrees to pay the physician within one business day, reducing the doctor’s need for working capital.  

An actuarial analysis of the PCP group’s patients is done using claims data from the prior year to create an anticipated “global budget” for the coming year.  The 15% or so of patients that need chronic illness care coordination are “flagged.” The PCP’s obligation is to give those patients whatever added time is needed per visit, to create a complete care plan and to post it in an electronic medical record (for which the PCP gets an additional $200). This serves as automatic preauthorization; no further calls will be needed for tests, procedures, etc. – a major time saver for the PCP and the office staff. The concept also anticipated that with extra time per patient, the PCP would be able to handle most issues including those of patients with complex chronic illnesses, reducing the need for specialist referrals. Finally, the insurer makes available a nurse “care coordinator” at its expense  to call the patient as often as necessary to check on medication use, medication side effects, weight gain or whatever else the PCP has built into the care plan. The expectation starting out was that this approach of incentives for giving the patient with a chronic illness the intensive primary care and the care coordination needed would enhance quality yet reduce the overall expenditures for that patient.  

If, at the end of the year, the PCP groups’ total claims came in under the projected global budget, the members of the virtual group would get back a portion of the savings. With these incentives, it was anticipated that the PCP would be sure to carefully coordinate care so that there were no excess specialist visits, no unneeded tests or procedures and, with better care overall, less ER visits and less hospitalizations. The end result, it was hoped from the start, would be higher quality care, lower total expenditures for that care, enhanced income for the PCPs and a more satisfying practice. It could be a win for everyone. Now three years in, the plan seems to be working. The physicians are pleased with the added income and the insurer is pleased that total costs have dropped. 

The whole concept was to coordinate the care that the patient receives with the expectation that the patient will be better served, the providers will be more satisfied and the total costs will be reduced. It is a transformational change in how the PCP functions. It is an equally huge transformational change for the insurer –a change that accepts that extensive primary care with care coordination costs extra money but recognizes that the end result is better quality at a lower total cost.  

After two years, it was reported that it saved $136 million with the 297 panels of 3,600 PCPs that had joined the program caring for about one million individuals. All of the PCPs enjoyed the added income in their reimbursements and two thirds received end of year incentive payments as a result of the savings. Overall the average PCP in the program received about 29% more than they otherwise would have under the standard fee schedule.  

At the end of three years and with enough data to be actuarially credible, there have been quite definite improvements in ten measures such as costs per member per month, number of emergency visits, admissions per 1000 members, length of stay, cost per admission, and readmissions within 30 days after discharge, etc. while maintaining or improving quality measures. Not all panels of PCPs were as successful as others and those that were tended to be successful in each of the three years in the program. At the end of the third year, about 60% of the panels were granted an incentive award for beating their projected global budget. The successful panels tended to be those in small private practices and, interestingly, had sicker patients under care yet they maintained higher quality scores. Another important finding was that some specialists tended to much higher utilization (and therefore costs) than others despite similar patient problems. PCPs who tended to refer to high utilization specialists were much less likely to achieve an end of year incentive payment. 

Of course, there are some questions to raise. If the PCP is spending more time with these patients but still has the same total size practice, then where is the time coming from? Does it mean less time for other patients? PCPs have now learned which specialists expend more dollars per patient than others. Will their referrals gravitate to these specialists regardless of known or perceived quality? Patients will likely in the future be offered incentives for choosing the PCPs that are most effective with this program; is that appropriate? And what about those PCPs who have converted their practices to direct primary care? They are actually saving the insurer considerably, probably much more than the incented PCPs in this program. The insurer should consider paying all or part of the DPC fee for their insureds since the insurer is benefiting substantially yet at no cost to itself. 

Perhaps the most important outcome, from my perspective, is the recognition by a major insurer that it is possible to create a new incentive-based approach to reimbursement – in this case within the old fee-for-service model – which actually costs more for primary care (up from about 5% of total costs to about 7-8% of total costs) yet significantly reduced those total costs of care while improving quality. 

Note: I talked to CareFirst's CEO, the former chairman of the board and a vice president about the program but I have no financial relationship; this program is used for illustrative purposes only and is not meant to be an endorsement.

Praise for Dr Schimpff

The craft of science writing requires skills that are arguably the most underestimated and misunderstood in the media world. Dumbing down all too often gets mistaken for clarity. Showmanship frequently masks a poor presentation of scientific issues. Factoids are paraded in lieu of ideas. Answers are marketed at the expense of searching questions. By contrast, Steve Schimpff provides a fine combination of enlightenment and reading satisfaction. As a medical scientist he brings his readers encyclopedic knowledge of his subject. As a teacher and as a medical ambassador to other disciplines he's learned how to explain medical breakthroughs without unnecessary jargon. As an advisor to policymakers he's acquired the knack of cutting directly to the practical effects, showing how advances in medical science affect the big lifestyle and economic questions that concern us all. But Schimpff's greatest strength as a writer is that he's a physician through and through, caring above all for the person. His engaging conversational style, insights and fascinating treasury of cutting-edge information leave both lay readers and medical professionals turning his pages. In his hands the impact of new medical technologies and discoveries becomes an engrossing story about what lies ahead for us in the 21st century: as healthy people, as patients of all ages, as children, as parents, as taxpayers, as both consumers and providers of health services. There can be few greater stories than the adventure of what awaits our minds, bodies, budgets, lifespans and societies as new technologies change our world. Schimpff tells it with passion, vision, sweep, intelligence and an urgency that none of us can ignore.

-- N.J. Slabbert, science writer, co-author of Innovation, The Key to Prosperity: Technology & America's Role in the 21st Century Global Economy (with Aris Melissaratos, director of technology enterprise at the John Hopkins University).