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At a recent club meeting we were discussing the quality of 3D printed tanks in 28mm scale. There are a lot of freely available print files for 10mm and 15mm scale models which are typically either single piece or small number of pieces but when it comes to larger scales you can't reliably get a decent level of detail without a multi-part kit.
Following their successful Kickstarter campaign, Canadian company 3D Wargaming have now released a range of 3D printable covering a selection of common WWII and modern vehicles as well as some sci-fi and alternate history ones. I've been keen to give What a Tanker a go for a while but don't currently have any suitable models so I thought it was an ideal opportunity to fire up the printer and have a go and printing the icon Panzer IV to see what the quality was like.
The download for this particular model includes 33 individual STL files and there's a simple exploded diagram on the publisher's website but no further instructions so, being in a hurry to set up the print overnight, I just decided to print one of each file which just about fit onto the 20cm x 20cm print bed of my Ultimaker 2+ with a bit of rotating and jiggling around.


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Today was an amazing and highly entertaining show featuring two great guests. First up was Chris Krimitsos, Founder of the Tampa Bay Business Owners Group to discuss his latest project – the launch of StoryJam Theater, a podcast that promotes great stories from the community. Chris told some great stories himself on the show today including the lesson learned at a young age from his Uncle Jimmy about understanding your value and not letting customers that do not value your product or service to control too much of your business. He also told a great story about a young video producer from Orlando that missed a huge opportunity over making an emotional decision stressing the importance to think logically when analyzing business opportunities. Learn more about Chris at http://www.tbbo.org or contact him directly at 813-489-5585 or email at firstname.lastname@example.com. Also, help support his Podcast on iTunes and search for StoryJam Theater!
On the 2nd half of the show was Steve Gavatorta, a business consultant, trainer, and coach and author of the book The Reach Out Approach, A Communication Process for Initiating, Developing and Leveraging Mutually Rewarding Relationships. Steve spoke of the importance of developing trust in relationships and we spoke at great length about the use of DISC profiles which analyze personality traits of people and how they can be used as an effective tool to consult with business owners when dealing with staff, or analyzing business counterparts. Chris contributed some great insight and stories to this segment as well and you can learn more about Steve at his website http://www.gavatorta.com or contact him at 813-908-1343 or email at email@example.com and ask him how he can help you in your business!

subset: commoncrawl


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A couple weeks ago I've waited for forty-five minutes sitting on a couch for a bride who was meeting me to do her first look photographs. I don't mind waiting for people. Things can go wrong and take longer that expected. I'm actually used to it.
At the minute forty-six of my never-ending wait, she showed up. Next to her husband who had already seen her. A while ago.
"Hey! I've been looking for you" I said with a real and honest smile on my face. I truly don't mind waiting for people on their wedding day. I've done this for years. It just happens.
All I heard was "A lot of things happened today".
I called her, sent her messages in the meantime and tried to go to her room instead of having her walking towards the meeting place she set a few days ago.
I explained to her that we only had a few minutes before the ceremony started to get the couple some beautiful photographs by the garden.
"It's too hot" was all I got back after that. We've had about 12 minutes to do a photoshoot in a lobby full of tourists because she didn't care about what I had to say. It was hot. But there are a couple places in the gardens, in the shady area, with a nice breeze.
The wedding is done and the pictures turned out great, but I KNOW that those pictures could look better than that. And it drives me mad. Even today, after hundreds of weddings done.
All I have to say is PLEASE DON'T BE A BRIDEZILLA. You probably laugh at brides acting crazy on movies or online stories, but those stories are real.
Listen to the people that is trying to help you. Pay attention to your options and do what experienced people think it's best.
You can only look good in your pictures if you feel good. If you are enjoying it.
Enjoy your wedding day.
I'd love to be there for you.
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Tuesday, December 14, 2010
Hospitals are Unsafe - There Are Still Plenty of Preventable Medical Errors
The results of a recently published study are therefore concerning. A group lead by Dr Landrigan at Harvard evaluated the number of "harms" which occurred at ten randomly selected North Carolina hospitals. They taught a cadre of reviewers to use "triggers" in the medical record to prompt further analysis for an error that caused harm. The harms were categorized into five groups with E being temporary yet requiring an intervention through, F temporary but requiring initial or prolonged hospitalization, G permanent harm, H as life threatening harm and I causing or contributing to death. They then selected 10 records per quarter for the years 2002 through 2007 from each hospital, at random. The records were then reviewed in a random order by multiple internal and external trained reviewers, both nurses and doctors.
They found 588 harms among the 10,415 patient days or 57 harms/1000 days or 25 harms per 100 admissions. About 63% or 364 of the 588 harms were classified as preventable! These included 13 that caused permanent injury, 35 being life threatening and 9 contributing or leading to death.
Similar to prior studies, the harms occurred most frequently after procedures and medications. Most harms fell into categories E (144) and F (163).
It was disappointing to find that the rates of adverse events did not decline over the study time period. This, despite the fact that in North Carolina has an enviable record of a high level of engagement in patient safety programs and studies.
So there are still plenty of adverse events that occur in a hospital, they are most likely to be related to procedures or medications, most are preventable, and all too many are life threatening or lead to death.
This leads to the question of whether the many and various approaches that hospitals have embarked upon are actually doing what they need to do. It may be time for a reappraisal. Certainly a patient should have the expectation of not being harmed when in the hospital.
Wednesday, December 8, 2010
Two Treatments For Macular Degeneration – At Wildly Divergent Costs
Wednesday, December 1, 2010
Replacing the Aortic Valve Without Open Surgery!
A new approach is called transcatheter aortic value implantation (TAVI.) In this procedure, a catheter is inserted into the large femoral artery in the groin and run up to the heart. From the catheter, the patient's valve is opened wide with an inflatable balloon. Then a bioprosthetic value made from bovine pericardium affixed to a stainless steel support frame is deployed into place via another balloon catheter and secured to patient's own aortic valve base.
A randomized study of 358 patients with aortic stenosis not considered surgical candidates was completed comparing TAVI to standard therapy at 21 medical centers and reported in the New England Journal of Medicine on October 21, 2010. The results were clearly favorable. Standard therapy was noted to not alter the natural history of aortic stenosis with 51% dead in one year. TAVI was superior with improved cardiac symptoms and good hemodynamic performance of the new valve which persisted for at least the first year of follow-up and with 31% dying during that year, a substantial decline in mortality.
But there is never a "free lunch" and TAVI was associated with a 5% risk of serious stroke (compared to 1% in the control group) and multiple vascular complications, the latter apparently related to the requirement for a large catheter placed into the femoral artery. Further MRI studies of patients suggest that many have new perfusion defects of the brain after TAVI suggesting that emboli from the new valve may be rather common.
But all things considered the improvement in symptoms and the reduced death rate (it took only 5 patients treated with TAVI to avoid one death by 1 year) argue that TAVI is now the appropriate therapeutic approach for those with aortic stenosis who cannot otherwise undergo surgery. Hopefully, coming improvements in the device will lead to fewer complications.
The big question – will this become the approach of choice for those who otherwise are candidates for standard surgery for aortic valve replacement?
Sunday, November 14, 2010
Teamwork Improves Surgical Safety and Reduces Mortality
Airlines have proven that teamwork in the cockpit improves safety substantially to the extent that commercial airlines demand and licensing now requires evidence of team competency.
Some hospitals have used the airline team training model – called crew resource management – to improve teamwork in the OR. The Veterans Health Administration (VHA) has 130 hospitals providing surgery and in 2006 mandated team training nationwide. Since it took time to arrange the training for each hospital, a study was instituted to compare surgical mortality between those hospitals which had already undergone training and those which had yet to do so (Journal of the American Medical Association, Oct 20, 2010 – both the article and accompanying editorial.)
The mandatory team training included working as a team, challenging each other as to perceived risks or safety lapses, checklist guidance, and preoperative briefing and post operative debriefing. Team members were also taught various communication strategies, how to step back and reassess, how to communicate during care transitions and basic rules of conduct.
The major measure was surgical mortality which was reduced by 18% in the 74 hospitals that had received the training compared to a 7% reduction in the 34 hospitals yet untrained (the controls.) The risk-adjusted mortality rates dropped from 17 per 1000 patients before training to 14 after training.
The study demonstrated the value of team training in reducing mortality. I would add that, although not studied, it is likely that errors were reduced overall. Surgical teams are often excellent at responding to problems including those resultant from human error. Reducing mortality was obviously important, indeed very important, but reducing preventable errors overall – as I will presume occurred – will have meant a better outcome for many patients.
The concept of team training is relevant not just in the OR but in many hospital settings such as bedside patient care rounds and with procedures done in the cardiac As I have written about before, the more team training is fostered, and indeed mandated, the lower will be the rate of preventable errors.
Wednesday, November 10, 2010
Leadership In Medicine – New Expectations
Today, a hospital physician CEO might be expected to develop new or improved clinical programs, in part by recruiting the best and the brightest, by building new wings, and by purchasing new technologies. The measure of success would be improved finances as a result of added admissions. A dean might be expected to develop new research programs by building new facilities and recruiting the needed scientists. The success measure would be rising on the NIH rankings of total research dollars awarded. A pharmaceutical company physician leader might be expected to find new drugs that will be "blockbusters." His measure of success will undoubtedly be financial as well. A similar picture extends to the CEO of a health insurer.
Are these the right measures? Are our medical leaders really leading? Or at least leading toward truly valuable goals?
Leadership is all about success in three sequential activities, as outlined by John Kotter at the Harvard Business School. The first is generating a vision for what needs to be done. Perhaps it will be the clinical program, new research activities or a new drug. The second step in leadership is to convince others that the goal is worthy. Aligning everyone involved with the desired outcome can be difficult but without alignment there will be no action. And the third, often overlooked, is to get the needed individuals to actually help to achieve the goal, the vision. These are difficult steps, especially in or university setting where lines of authority are diffuse and responsibilities overlapping or in a community hospital where the physicians are mostly in private practice and not hospital employees.
But the question is what should be the vision and what should be the measure of success in achieving that vision?
An article in the Journal of the American Medical Association by Dr Robert Brook [July 28, 2010, pages 465-6] got me to thinking about this issue.
We know that despite spending more per capita on medical care, we still have far from the best care. We do not lead in infant mortality or total life expectancy. We do poorly at coordinating the care of those with chronic illnesses, such as diabetes and heart failure, and the result is less than adequate care and care that is much more expensive than it needs to be. As a society, we have rampant adverse behaviors such as overeating and lack of exercise plus many of us still smoke, all leading to more chronic illnesses, increasingly occurring at an earlier age.
I would suggest, echoing Dr Brook, that real medical leadership today needs to focus on the important outcomes, not the ones that just improve our organization's financial successes [not withstanding that strong finances are critical in order to accomplish a valuable end – "No money, no mission."] This means that medical leaders must begin to accept the responsibility for aligning the various constituencies and power brokers both within and without of medicine toward real healthcare progress. Unless medical leaders accept this challenge, it will increasingly be done by others, and done without serious input from physicians and others in the field.
What then are the important issues and outcomes?
I would suggest that we must find a way to first markedly improve prevention of illness. Within medical care itself, this means assuring that primary care physicians are trained and have the incentives to do basic screening, administer vaccines, and give sound advice. It means actually advising about diet and exercise for the person with high cholesterol, not just giving out a routine prescription for a statin. And medical leaders need to take the initiative to change government policy regarding food and nutrition. For example, it makes little sense that the beef with the most saturated fat is marked "prime" by government inspectors or that food processors can label a cereal "healthy" because they have added some vitamins to what is manufactured from non whole grains plus sugar and salt.
Second is to develop methods to assure that every patient who has a chronic illness gets intensive care coordination among all of the providers involved. This means the development of multi-disciplinary teams of physicians, nurses, pharmacists and others who actually work collaboratively and with the patient's interest foremost. There can be various models but among them is the creation of "centers" (cancer centers, heart centers, trauma centers) at academic medical centers and at community hospitals, developed with real authority to function effectively. Another is to use bundled payments or "capitation" to reward coordination. And most importantly is to have one physician, usually the primary care physician, serve as the coordinator – the orchestrator.
Third, medical leaders need to address the need for care delivery to be customer focused with the recognition that the customer is the patient and the patient's family. Too often we develop programs or actions that continue the current provider-oriented approach rather than a patient/customer-oriented approach. If medical leaders do not address this now, a rising tide of consumerism will force the issue later. Eventually, patients will hold the physician directly accountable and will expect to pay only if the care is patient-focused.
Having addressed these basics, medical leaders then need to turn to the more global health issues, health not only of the individuals under their care or their institutions' care but the care of the community, the population at large. This is critical if all Americans are to have a healthy life regardless of social or economic status.
To accomplish this will mean that hospital, insurance company and pharmaceutical company boards of directors and university boards of regents will need to give out new, different and clarified directions to their CEOs, presidents and deans, holding them accountable with new measures that reflect realistic progress toward these goals. Otherwise, although there will be various medical breakthroughs of great value for treating disease, American medicine will continue to stumble along, as it has, without making any real progress in what is truly important.
Tuesday, October 26, 2010
New Finding May Aid Alzheimer's Treatment Options
Imatinib (Gleevec, used to treat chronic myelocytic leukemia or CML) does inhibit GSAP and, in laboratory models, reduces beta-amyloid creation. Unfortunately, imatinib does not cross the blood brain barrier so it cannot be used clinically. A search is now on for a compound that acts like imatinib yet can get into the brain. If found, it would be a very exciting discovery.
Tuesday, October 19, 2010
The Implications of Chronic Disease
The Milken Institute quantified some of these issues in a research report a few years ago. They evaluated cancer, diabetes [presumably type 2], hypertension, stroke, heart disease, pulmonary conditions and mental disorders. Here are some of the key findings:
• "More than 109 million Americans report having at least one of the seven diseases, for a total of 162 million cases.
• The total impact of these diseases on the economy is $1.3 trillion annually.
• Of this amount, lost productivity totals $1.1 trillion per year, while another $277 billion is spent annually on treatment.
• On our current path, in 2023 we project a 42 percent increase in cases of the seven chronic diseases.
• $4.2 trillion in treatment costs and lost economic output.
• Under a more optimistic scenario, assuming modest improvements in preventing and treating disease, we find that in 2023 we could avoid 40 million cases of chronic disease.
• We could reduce the economic impact of disease by 27 percent, or $1.1 trillion annually; we could increase the nation's GDP by $905 billion linked to productivity gains; we could also decrease treatment costs by $218 billion per year.
• Lower obesity rates alone could produce productivity gains of $254 billion and avoid $60 billion in treatment expenditures per year."
To me the important point is that "each has been linked to behavioral and/or environmental risk factors that broad-based prevention programs could address." Restated, we as individuals need to take responsibility for our own health. Not every illness is preventable, but a very large percentage are. It is up to us to eat a nutritious diet in moderation, exercise our bodies, seek ways to reduce chronic stress and avoid tobacco. These four steps would make a huge difference in our health and our lives.
Meanwhile, we each need to have a primary care physician and that physician needs to accept the responsibility to assist us with our prevention strategies and to coordinate our care should we develop a chronic illness. This will mean better health and much lower costs.
Friday, October 15, 2010
Encapsulated Pig Islet Cells For Diabetes Type 1 – A Trial
"Intraperitoneal islet transplantation has the potential to ameliorate type 1 diabetes mellitus and avert the long-term consequences of chronic diabetes which cannot be achieved by conventional insulin treatment.
As donor human islets are not available in sufficient numbers, porcine islets are the best alternative source as they are recognised as the most physiologically compatible xenogeneic insulin-producing cells. Although the use of pig-derived cells raises the risk of xenotic infections, this can be minimised by obtaining cells from designated pathogen-free (DPF) animals bred in isolation and monitored to be free of specified pathogens. The worldwide experience to date in more than 200 patients who have received transplants of pig tissue has not demonstrated evidence of transmitted xenotic infections.
As animal-derived tissues have to be protected from immune rejection when transplanted into humans, transplants are usually accompanied by immunosuppressive therapy. However, porcine islets are preferably transplanted without the use of immunosuppressive drugs which cause significant morbidity. To protect them from immune rejection, the islets can be encapsulated in alginate microcapsules which permit the inward passage of nutrients and glucose and the outward passage of insulin. Alginate-encapsulated porcine islets transplanted without immunosuppressive drugs have survived rejection for many months in animal studies, and have been retrieved from a diabetic patient over 9.5 years after intraperitoneal transplantation and shown to contain viable islets that stain positive for insulin.
DIABECELL® comprises neonatal porcine islets encapsulated in alginate microcapsules. DIABECELL® has been safely transplanted in healthy and diabetic mice, rats, rabbits, dogs and non-human primates. Following DIABECELL® transplants, the requirement for daily insulin was significantly reduced in diabetic rats and non-human primates.
The optimal dose and frequency of transplantation of the current DIABECELL® preparation for the treatment of type 1 diabetes in humans can only be determined in clinical trials. The intention of this phase I/IIa clinical trial is to obtain at least 52 weeks safety and preliminary efficacy data in type 1 diabetic patients following transplantation of a single low effective dose of DIABECELL® into the peritoneal cavity."
The results of this study, still a few years off, will be of great interest to those whose diabetes is hard to control with standard insulin approaches.
Monday, September 27, 2010
More on Transplanted Pig Organs – Xenotransplantation
Individuals that develop liver failure often die before a suitable donor can be found or before the damaged liver can heal on its own. There is no artificial liver comparable to the dialysis machine for kidney failure. But using a specially develop pig liver outside the body to cleanse the person's blood of noxious compounds is a possibility. There have been some positive results using a normal or a genetically modified pig liver for such "extracorporeal" perfusion until a donor organ is available or until the patient's liver recovers on its own.
Progress has also been made with genetically modified insulin-producing pancreas islet cells for treating diabetes. One approach is to place the transplanted islet cells into a "capsule" that allows insulin to exit out and nutrients like glucose to enter in yet keeps immune cells that would destroy the islet cells at bay outside the capsule.
Further progress in xenotransplantation is likely but there are significant barriers to success. Genetic modification of the pig is possible but it is not yet clear all of the modifications that will be necessary. Concurrently, work is progressing to develop immune modulation with drugs just as is done to suppress the immune system with human to human organ transplants. Further development of encapsulation may aide the process, especially with islet cell transplantation for diabetes.
Despite all of the progress to date, the barriers to success are very real and only time will tell if xenotransplantation will become a truly viable path to organ replacement
Wednesday, September 22, 2010
Transplanted Organs From A Pig
Today the only option for more organs available for transplant is to encourage more individuals to pre-certify their desire for organ donation should they die in a traffic or other accident.
But another approach, still in the future but gaining traction, is to use organs from an animal – known as xenotransplantation.
Most efforts in xenotransplantation focus on the pig, in part because the organs are near to the same size as humans and the physiology is similar. Very real progress has been made in recent years. The steps required to make this approach effective include genetic modification of the pig so that the human immune system will no longer "reject" the transplanted organ. This has included removing the genes that produce the most important pig carbohydrate antigen that human immune cells recognize. Another step has been to add genes that create certain protective proteins in the complement regulatory system (another part of the body's mechanism to eradicate "foreign" materials like bacteria, viruses or a cancer.) So far, these steps have been major advances but not sufficient so further efforts will be necessary in order for say, a pig heart or kidney to be successfully transplanted into a primate and eventually into a human. But the progress is real, exciting and promising. Stay tuned.
Tuesday, September 14, 2010
Thought Controlled Artificial Limbs
Monday, September 13, 2010
Are Physicians Knights, Knaves or Pawns?
Sunday, August 22, 2010
What should We Eat?
In 1941, following studies that demonstrated that certain vitamin deficiencies caused specific diseases [thiamine and beriberi, niacin and pellagra, vitamin D and rickets, vitamin A and blindness, vitamin C and scurvy and iodine and thyroid disease], the US Department of Agriculture issued dietary guidelines for the minimum requirements for various vitamins along with those for protein, calcium, phosphorus and iron. These recommended dietary allowances, or RDAs, became the standard for nutrient targets to prevent deficiency diseases.
There followed the addition, for example, of vitamin D to milk and various vitamins like thiamine and niacin to prepared cereals in an attempt to avoid nutrient deficiencies. It was a successful approach but it is not adequate in today's time for helping to prevent multiple serious chronic illnesses, many of which are beginning to develop in children and young adults.
An article in the Journal of the American medical Association [JAMA] on August 11, 2010 by Mozaffarian and Ludwig urges that we think in terms of "food" and not in terms of "nutrients." They point our that we know full well that a diet of fresh fruits, vegetables, whole grains and nuts is associated with a lower incidence of chronic illnesses just as certain fish reduce the risk of heart disease.
We also know that processed foods such as lunch meats, fast foods, salty snacks, and sugared beverages increase disease risk. They argue that our "nutrient-based" current approach "may foster dietary practices that defy common sense." For example, many packaged, processed foods substitute refined carbohydrates for fat and market them as fat free or low fat which they are but they are certainly not healthy. Similarly, many packaged foods such as soups are very high in sodium. "Taking the nutrient approach to self serving extremes, the food industry "fortifies" highly processed foods, like refined cereals and sugar-sweetened beverages, with selected micronutrients and re-characterizes them as nutritious."
The authors recommend that we not drop our attention to nutrients levels but that we concurrently lessen the focus on nutrients and emphasize food-based targets such as fruits, vegetables, low fat meats and fish. These foods are inherently healthy, are low in saturated fats, have no trans fats, are low in salt, high in fiber and high in nutrients. This approach would be consistent with scientific data on what is healthful, what is likely to help prevent chronic illnesses, would "mitigate industry manipulation" and help us all to understand what a healthy diet can be.
The Department of Agriculture should take these recommendations and put them into action.
Saturday, July 10, 2010
Time to Rethink How We Pay for Medical Care and Healthcare
If the basic payment system changes to one that:
-Expects us (patients) to pay for routine, basic and preventive care, including medications, up to a maximum of, say, $1000/year, (offset by tax-advantages HSA accounts for all, including those on Medicare, and tax credits for the less well off)
-This creates a "professional services contract" between the patient and the provider (rather than today's contract between the provider and the insurer)
-Insurance pays for everything beyond that.
Then three things would happen:
-We would pay attention to what drugs, tests and procedures are offered or suggested and query our provider in much more detail than we do now – because it is our money that is being spent in a direct manner with the provider.
-Providers would be mindful of the "contract" and be careful to recommend drugs, tests and procedures only if truly needed, appropriate and useful; they would think about our pocketbook.
-Insurance would cost much less.
Possibly a fourth thing would happen:
Because we are paying our provider, especially our primary care physician (PCP) directly, as we do our lawyer, accountant or other professional – and paying a price jointly agreed to be acceptable – our PCP would earn enough to:
-Reduce the total number of patients in his/her practice
All of which would result in:
-More time available per patient
-Time available for true preventive care
-Time available to give good coordination of care to those with complex chronic illnesses.
This would not be a panacea and there are other changes also needed to the payment system, but the effect of these few initiatives would be -- less expensive yet better quality care.
And if this does not come to pass, expect primary care physicians to take matters into their own hands by moving to retainer based practices, charging an annual administrative fee, or just not accepting insurance, especially Medicare, anymore.
Thursday, July 1, 2010
Today's Health Insurance Has Perverse Incentives
Since we have "prepaid" care, we have no incentive nor does our physician to look for ways to reduce the costs. Yes, we may have a co-pay or a small deductible but that does not really get us thinking much about what is being proposed for our care.
Take drugs. Let's say you need an acid suppressor for reflux esophagitis [acid reflux or GERD.] Your doctor could tell you to go to the grocery store and pickup Prilosec for about $30 for a months supply. Or, he or she could give you a prescription for Nexium. It would cost about $150 for a two week supply and is no better than Prilosec. But your insurance will pay for it except for your co-pay of, say, $15. So your doctor will probably suggest Nexium since it will cost you less. But the overall system is paying out a huge amount more than necessary. What a perverse incentive.
Much better if we all had insurance with a high deductible. [In practice this might mean a general insurance policy and a separate medication insurance policy as with Medicare; but each would have its own high deductible.] In that situation we pay less for the insurance and self insure for the deductible, just like car collision insurance. Now we are focused on cost effectiveness. We would purchase the Prilosec at $30 and save $120 off the cost of Nexium. Better still would be having the physician actually spend time with us to talk about preventing the reflux in the first place. Here again, if we were paying out of pocket for our routine primary care, we would expect our physicians to spend the time with us to review the following – don't eat just before going to bed; avoid caffeine before bedtime; cut back on alcohol; avoid spicy foods; and put the head of the bed up on 4 inch blocks. These don't cost anything and generally will solve the problem without the need for any medications. Now that is real cost effectiveness.
Thursday, June 24, 2010
A Disease Industry vs. A Healthcare System
Eventually, as pressures mount, there will be a push for a change to a true healthcare system from the current disease-based system. This will probably take a fair length of time given that Congress did not address the payment system in the healthcare reform legislation. Basically on this point, they left it as just more of the same.
But there could be a breakthrough. Some group, some organization or some jurisdictions might create a model, gain some success and that might lead to wider adoption. Some of the large multidisciplinary "clinics" like Mayo, Geisinger, Dean and others which have contracts for "covered lives" have had success in giving more comprehensive care yet reducing costs. And some insurer/provider combined organizations – such as Kaiser-Permanente – have shown the same beneficial effects. Perhaps others will begin to adopt their examples toward better health care at lower cost.
Thursday, June 10, 2010
Turbulence Ahead in Health Care
But we can be sure that technology advancements will slow for no one. The rate of medical technology advancement now is very fast and the speed will only accelerate. One big problem is that technology advances so fast that there is no time for a purchase – say new CT scanner or diagnostic device in a clinical laboratory – to create any return on the investment before a new or upgraded technology becomes available.
The electronic health record is a case in point. Despite years of work and billions spent, we are essentially still in an early generation of the EHR. It will be years and many more billions before the EHR begins to bring the true value of improved care with increased quality, better safety and reduced costs while improving provider productivity.
America does not have a healthcare system; we have a "disease industry." We focus on disease and pestilence and do a good job of caring for those with acute illnesses and trauma. But we certainly do not address health well and we are not good at caring for chronic illnesses – which are rapidly overtaking acute illnesses as most common and already they consume the bulk of our healthcare dollars.
At some point we must break from our current disease care model and shift to a health promotion and disease prevention model. Until that occurs, the cost of medical care will continue its rapid rise. As a disease industry, the incentives are all based on doing more and more but there is little or no incentive to work on prevention.
Although it is tempting to blame the current problem on the insurers, the device manufacturers, the drug companies or the providers, the truth rests more in the way we have set up our payment systems for care. Insurers pay for doing "something." This leads to more and more diagnostic and treatment efforts and it encourages the manufacturers to constantly find new approaches. Not bad in and of it self but the incentive is not there to prevent illness and not there to coordinate the care of those with chronic illness. And without this shift in incentives, the cost of care will just keep rising.
Two good steps for the future would be:
Change the Medicare payment code to encourage prevention, coordination, and primary care. With Medicare taking the lead, commercial insurance would likely follow.
Let everyone have a high deductible policy so that each of us will have a real interest in asking about our care and being sure that each and every recommendation for a test, a procedure or a prescription is really the best and really necessary.
Friday, May 14, 2010
Cut Health Care Costs With Prevention
Prevention is the key to both better health and lower health-care costs over the long haul. This is where the nation — and each of us as individuals — needs to put energy and resources. In the long run, it is more important than addressing the high cost of new technologies and drugs or their inappropriate overuse.
Today, the U.S. basically has a medical care system rather than a health care system: We focus on treating illness when it occurs but not on preventing it in advance.
According to a recent New England Journal of Medicine article, there are about 465,000 preventable deaths per year in the U.S. from smoking, 395,000 from high blood pressure, 216,000 from obesity, 191,000 from inactivity, 190,000 from high blood sugar, and 113,000 from high cholesterol.
These are mostly due to our lifestyles: One-third of Americans are overweight, another third are obese, and 20% smoke. We eat too much packaged and prepared food rather than nutritious foods, and we do not exercise. Even children's physical activity now declines with age, from about three hours per day at age nine to less than an hour by age 15.
This helps explain why the U.S. ranks 39th for infant mortality, 43rd for female mortality, 42nd for male mortality, and 36th for life expectancy — but is first for per capita spending on health care.
Clearly, there is something terribly wrong with this picture. And unless we get serious about prevention, there will be a diabetes epidemic and more heart disease, cancer, arthritis and other chronic illnesses. Life spans will shorten rather than lengthen, and the costs will be enormous.
I firmly believe that each of us must each take responsibility for our own preventive health care. That said, other players in society should assist us in the following ways:
Our government should insist that restaurants post calorie counts and fat content and schools restrict the availability of sodas and other non-nutritious foods in cafeterias. In addition, it can provide a food pyramid — recommended diets or eating plans — that is not influenced by vested interests.
Our employers should provide wellness programs like Safeway's, which encourages staff to utilize smoking-cessation, weight-reduction, stress-management, and nutrition counseling at no charge. Those who participate are given a reduction (incentive) of their portion of the health care premium. In a Wall Street Journal op-ed describing the program, CEO Steven A. Burd reported that over four years Safeway's per capita health-care costs (including both the company's and employees' portions) did not rise while those for most American companies had increased 38%. In addition, the company had less absenteeism and higher worker productivity.
Insurance plans should offer subscribers lower premiums for not smoking, for being at reasonable weight, and for exercising.
Physicians, especially primary care physicians, should spend the time necessary to provide good preventive medicine, which includes counseling, screening tests (high blood pressure, weight , cholesterol, cancer), and immunizations.
Prevention is valuable at any age. At the Erickson Retirement Communities, residents can opt for a program that includes health-promotion classes for all (similar to Safeway's) and care coordination for those who do develop a chronic illness. The physicians limit themselves to about 400 patients (compared to about 1,300 to 1,500 for most primary care physicians) and offer same same-day visits and as much time as needed per visit. They use an electronic medical record system, nurses to assist with care coordination, visits to each hospitalized patient, and an automatic office visit within 72 hours of a hospital discharge. The results are striking: fewer hospitalizations, shorter lengths of stay for those who are hospitalized, and a drop in the "bounce rate" (i.e., unplanned readmissions to the hospital in the 30 days after discharge) from the national Medicare average of (an outrageous) 24% to less than 10%. In other words, better health, better care and reduced costs.
In summary, a combination of nudges and incentives can assist us in achieving our responsibilities for health promotion and disease prevention — responsibilities commensurate with the new right of all Americans to have insurance.
This would be a start toward a true health care system and away from a medical care system. What else do you think needs to be done?
Stephen C. Schimpff, MD, is a retired CEO of the University of Maryland Medical Center in Baltimore and is the author of The Future of Medicine — Megatrends in Healthcare. He blogs at this website and can be reached at firstname.lastname@example.com
Tuesday, May 4, 2010
Further Disruptive Trends in Medicine
Retainer Based Practices – Primary care physicians find that their incomes have been flat or reduced, their work hours increased, their time with each patient shortened and their frustrations with insurers heightened dramatically over recent years. Some are just saying "I can't take it any longer" and switching to a different type of practice model. Some simply will not accept Medicare, telling their older patients that they must either pay out of pocket or go elsewhere. Others are converting to "retainer-based" practices. Here the patient pays a flat fee each year, often $1500 to $2000, in return for having their PCP available by cell phone 24/7 and responsive by email. Appointments within 24 hours are guaranteed. The physician will see you in the ER, take care of you in the hospital and do home or nursing home visits as needed at no extra charge. But you still need your insurance in case you have need to see a specialist, have tests or imaging studies or are hospitalized. So the cost to you is extra. This is very disruptive of the standard approach today but I predict it will become very common in just a few years.
Smart Phones – Physicians, especially younger physicians and residents, are becoming very reliant, although not dependent, on these devices. They use them as shortcuts to knowledge, to stay well informed, and to communicate, argue, and debate with one another, which is a excellent form of learning. Smart phones keep being refined and as they are, more and more physicians want them, use them, rely on them and become more effective physicians as a result.
Greater Clarity with Imaging – Today's CT scanners and other devices can produce remarkable images of the body's internal organs, better than those of a medical illustrator. And the clarity of the images increases dramatically each year with engineering refinements. Virtual colonoscopy using a CT scan, for example, can now be done in a manner such that the viewer can see a high resolution magnified image of the inside of the colon, capable of visualizing small details of a polyp, a diverticula or other anomaly. It can be projected on a large TV screen where a group can review it together and jointly consider the situation and make recommendations for care of the patient.
Surgical Robotics – Today the daVinci robot is used primarily for cardiac surgery, prostate cancer surgery and some gynecologic surgery. But soon it will be used by other surgeons in diverse fields. An otolaryngologist for example, might perform surgery on the base of the tongue to remove a cancer while avoiding the critical nerves and blood vessels in the area. The visualization of the site is much better than with conventional surgical approaches, the margin of safety is improved and the patient's outcome is bettered with more effective surgery, more salvage of critical anatomy and faster recovery. These refinements in the use of the robot will likely lead to considerable demand from both patients and physicians.
Image Guidance – We tend to think of "X-rays" as being used for diagnostics and the newer technologies have dramatically improved this ability. But think of the surgeon who "wants no surprises" once inside and operating. The greatly improved ability to visualize organs makes no surprises a near reality. But the imaging can also guide the surgeon to improve on his or her technique during the procedure. Intra-operative CT scanning can be used intermittently and at low dose to assist the surgeon to know the location of critical vessels or nerves. Ultrasound can be used to give real time direction to the placement of radioactive seeds into the prostate to treat cancer. These and similar image guidance techniques improve safety and effectiveness.
Fewer General Surgeons – It has been known for some years that there are too few general surgeons; fewer are entering the field and some areas, especially rural and urban poor areas, have all too few general surgeons today. The reasons for the reduced interest of graduating medical students is not completely clear but the trend is obvious.
Reduced Career Time as a Minimally Invasive Surgeon – Laparoscopic or minimally invasive surgery spread across the country and the world with remarkable speed after its introduction some 20 years ago. The patient has smaller incisions, faster recovery time, less time in the hospital and the costs are lessened as well. Surgeons rapidly learned the techniques and patients demanded it. But there is a price not fully expected. Surgeons are developing a variety of occupational problems from carpel tunnel syndrome, to neck disorders, to low back pain. It is all about ergonomics – "the patient is better off but the surgeon is suffering." Indeed it may well be that their practice lifetimes may be substantially curtailed unless these ergonomics issues are addressed and quickly.
There are many changes coming in medical practice and these are but a few. The ones noted here will have significant and ultimately disruptive effects on the way medicine is practiced today and tomorrow.
Sunday, April 25, 2010
Disruptive Changes Are Coming to the Delivery of Medical Care
We have grown accustomed to scientific research producing major medical advances such as those I wrote about in The Future of Medicine — Megatrends in Healthcare. But there are now some very disruptive changes coming in how medical care will be delivered by your doctor or hospital.
Some examples:
Team-based care for chronic illness. The combination of an aging population and adverse behaviors such as obesity and smoking will create epidemics of diabetes, heart failure, and other diseases that last a lifetime and are difficult to treat. They require team-based, multi-disciplinary care. Team-based care is not the norm today, and the lack of it substantially increases the costs and diminishes the quality of care. The primary care physician must become the team coordinator, be more an orchestrator and less an intervener.
Echelons of care for acute illness. Advances in the care of as heart attacks and strokes also demand a different model of care. The role model is trauma — people with minor injuries are sent to a local ER, more severely injured to a regional trauma center, and the most severe to a Level 1 dedicated trauma center. This approach is accepted for trauma but not yet for heart attacks and stroke. Today the standard of care for a heart attack is immediate angioplasty with stent placement to stop the heart attack in progress and reduce heart muscle damage. The patient brought to a small community hospital should be referred on to a larger center equipped with trained interventional cardiologists, an expert staff, and the needed equipment — all available 24/7. This will result in higher-quality care but will disrupt the economics of many doctors and hospitals.
More high-tech hospitals. More serious illnesses means there will be a need for more hospitals, more beds (especially ICU beds), and more operating rooms with highly sophisticated technologies. This marks a departure from recent decades, when the mantra has been "too many hospitals and too many beds." Since smaller hospitals will have difficulty accessing the credit markets to finance expensive technology and facilities, we can expect to see a wave of hospital mergers and fewer stand-alone hospitals.
Patient-centric medicine. There is an emergence of consumerism in health care. ("The patient will no longer be patient.") So, our current provider-oriented culture will have to change to a patient-oriented culture. Patients will insist on prompt service, improved safety and quality, greater respect, much more convenience, and a closure of the current information gap between doctor and patient. Absent satisfaction, patients will go elsewhere. These are very disruptive changes indeed from the present provider-centric approach to care delivery.
Delegation of care. Shortages of physicians will mean more reliance on others to deliver care — e.g., nurse practioneers and physician's assistants for primary care, social workers and psychologists for mental health care, and optometrists for vision care. Physicians will need to change their attitudes toward these providers by involving them and embracing their value.
A new value proposition for technology. We think of new technologies as being of value if they improve diagnosis, treatment, or prevention while providing a decent return on investment. (See my earlier post on this topic.) But in the future, we will also expect a new technology to help health care professionals compensate for shortages of certain kinds of care providers, enhance their responsiveness to more demanding patients, control rather than exacerbate costs, and enhance safety and quality — very different from today's value proposition.
Employee physicians. Professionals' expectations are changing as much as those of patients. While most physicians in the U.S. today are in private practice, a growing number — especially younger ones — want to be employed. They want to spend less time on administrative tasks and want more time for family activities. Women are now 50% of graduates from medical school; many will want time off for child-rearing, further exacerbating the shortage of doctors..
E-health. The internet and digital medical information will have a major disruptive effect on the practice of medicine. Many physicians eschew these technologies today — often because insurers don't reimburse them for the time involved. But they will be expected by their patients to use e-mails, telemedicine and telediagnosis, ePrescriptions, and an electronic medical record. If doctors want to keep their patients, they'll have to change.
These are some of the major changes I see coming down the pike. Do you agree that they will transform the delivery of care? Are there others you would add to the list?
What are the challenges that health care organizations and professionals must overcome to make the transition to this new age? Will there be strong resistance or will change come about smoothly?
Monday, April 19, 2010
Is Technology a Cost Driver or a Cost Saver in Health Care?
Pharmaceutical, biotechnology, and medical-device and equipment companies have been extremely effective at producing innovations that have created major benefits for medical care. But the cost of new patented drugs and devices (pacemakers, defibrillators, stents, ventricular assist devices, insulin pumps, laparoscopic surgical instruments, etc.) are high. As a result, many argue that these advances are driving up the costs of health care. This is a distorted view.
In many cases, the cause of rising health-care costs are not the technologies per se; it is a flawed payment system.
Here is an example.
Stomach ulcers are common, mostly caused by a bacterium called Helicobacter pylori, or H. pylori. Discovered about 30 years ago, it lives in the stomach with all of its acid and invades the wall of the stomach. Now we can cure ulcers with antibiotics. A common therapy is clarithromycin and amoxicillin combined with a proton pump inhibitor (i.e., acid suppressor) like Prilosec, Nexium, Protonix, or Prevacid. It is essential to take the three drugs twice a day without fail for 14 days; anything less and the cure rate goes down substantially.
So the makers of Prevacid have come out with a nicely designed package called Prevpac, which contains the two antibiotics and the proton pump inhibitor and clearly labels the morning and evening doses. Frankly, it is a good idea. It cost about $350 at the pharmacy. Not an unreasonable price to pay to eliminate a disease that in the past had been chronic and impossible to cure, a disease that often reduced quality of life and frequently necessitated surgery, right?
Here's the catch: Until recently, Prevacid, one of the drugs in the Prevpac package, was on patent and its price was very high. If one bought the three drugs individually, the price was about $250. (Go figure.) And if one substituted Prilosec (about $30 over the counter) for the Prevacid along with the clarithromycin and amoxicillin, it would bring the price down to under $100. Multiply this by the number of individuals who are found to have stomach ulcerations caused by H. Pylori and you would save some big money nationally.
But that is not the way it works. Your insurance probably has a $15 deductible. So you only pay $15 of the $350, a good bargain for you. If you go the route of buying the three drugs separately for $250, you have to pay $45 ($15 X 3). And if you opt for the Prilosec substitution, the price to you is $60 ($15 X 2 plus $30.)
The point is that our insurance system is full of perverse incentives. So you will choose the Prevpac or your doctor will do so for you to help you save some money. It would be much better if we paid, say, the first $1,000 of our medical bills out of pocket each year and then had insurance kick in. Insurance would be much cheaper and we would become aware of the cost implications, ask our doctor for assistance, and go with the cheaper yet equally effective approach.
The U.S. payment system also impedes the adoption of innovative technologies that could reduce the cost of health care.
For example, distance medicine like telemedicine, teleconsults, telediagnosis, and simple e-mails can reduce the need for visiting the doctor's office and emergency rooms and can prevent unnecessary hospitalizations. These all will obviously reduce overall costs, but currently there is no reimbursement for telemedicine, teleconsults, and the time it takes for physicians to do e-mails. Similarly, there is no reimbursement for tele-diagnostic devices such as the electronic home scale that reports daily weight to the physician's office.
Reimbursement will be necessary if these valuable, cost-saving techniques are to become widely utilized. Or, if you had a high deductible policy, you would save real money by e-mailing your doctor and paying a minimal fee rather than coming into the office.
We can also harness technologies that reduce expenditures by improving safety and quality. Prescribing drugs via e-mail in the office or via the hospital computer (known as computer physician order entry or CPOE) can eliminate illegible handwriting, prevent prescribing to someone who is allergic to a drug, avoid adverse drug interactions, and assist the physician in prescribing the correct dose, number of doses per day, and route of administration (e.g., oral, intravenous, intramuscular injection, rectal, etc).
Other important technologies that can help reduce costs are simulators, robots, and identification devices. Indeed, simulation will profoundly impact the safety and quality of operative procedures, cardiac catheterization, colonoscopy, and many other procedures and, in turn, drastically affect cost management. It can shorten the time it takes to become proficient thereby reducing training time and costs.
These are but a few of the ways technology can actually lead to lower costs.
Questions we need to consider are:
How can we maximize the value of technologies to reduce costs while improving quality and safety?
How can we advance the needed evidence to assure that we only select truly useful technologies?
How can we stimulate physicians to only recommend cost-effective drugs or devices for their patients?
How can we encourage individuals to select high-deductible health plans and then take an active role in making medical decisions?
Tuesday, April 13, 2010
Teamwork Can Help Avert the Pending Cost Crisis in Health Care
Most health care money in the United States goes largely for the care of people with complex chronic illnesses such as diabetes, heart failure, cancer, lung disease, and the like. We will soon see many more individuals with these illnesses because of two factors: the population is aging ("old parts wear out") and adverse behaviors such as poor nutrition, overeating, lack of exercise, and smoking. This will cause costs to soar, which will force the U.S. to revamp how we care for this population.
Such a revamp is long overdue.
The traditional American approach to medicine is for one physician to take care of the patient's illness. (Think here of the internist treating pneumonia with an antibiotic or the surgeon treating an inflamed appendix with a scalpel.)
But chronic illnesses require a multi-disciplinary team approach to care. The diabetic patient, for example, needs an internist, an endocrinologist, a podiatrist, an ophthalmologist, a nutritionist, an exercise physiologist, and many others to assure comprehensive care of high quality.
The key is to have one person who coordinates all of the various providers to be sure they have the right information, are all working together, and are all following an agreed-to care plan. They need not all be physicians. Indeed other providers are equally important to the team-based approach and they add less costs.
Mostly, this just does not happen today. In part, it is because of the medical culture which needs to change; "it's the way we do it" (and have done it for over a century).
But perhaps the biggest culprit is the lack of a fee structure that encourages the primary care physician to coordinate the care properly. Coordinating the care of a patient with a complicated illness that lasts a lifetime takes a lot of time, but this time is not now compensated by most insurance. Since most primary care physicians are very busy already, and since they are not accustomed to coordinating care, this is a new requirement that, absent a payment structure as incentive, they will just not accept readily.
So today what happens is a lack of coordination and an excessive number of tests, X-rays, procedures, and occasionally hospitalizations. The result is much lower quality care than could or should be provided and much higher costs than necessary.
Consider the retired individual who called me saying he was on 23 medications, some multiple times per day. He stated he was not feeling well despite all the meds. And despite his Medicare, Medigap, and Part D plans, he was spending huge sums of money. The 23 included drugs for diabetes and heart failure. So he clearly had serious underlying diseases.
The prescriptions also included three medications for a problem that probably did not require any medication. But those meds, given by four different physicians and adjusted independently by each of the four, led to a side effect for which another physician prescribed yet another medication. This new drug in turn caused yet another problem that led to a serious infection, hospitalization, and a stay in the intensive care unit. The result was less-than-stellar care (to put it politely) at an incredible expense.
But once he found a primary care physician who took the time to understand what was needed, it was only two months until he was down to seven medications, feeling better, and spending a lot less money (as were his insurers).
The diagnosis is clear. Good care coordination means better quality and less expense. Lack of care coordination for those with complex chronic illnesses means poorer quality and a lot more expense
The treatment is equally clear. Physicians, especially primary care physicians, need to be incented — with money — to provide the care coordination are that patients with chronic illnesses need. This treatment could and should begin now.
It is also important to remember that prevention is always better than having to deal with an illness later. Most of these chronic illnesses are the result of our own adverse lifestyle and behaviors; they do not have to occur. Physicians should therefore be encouraged (again with monetary incentives) to spend the time necessary to offer realistic preventive services to their patients.
The moral of the story is that improving quality will not only mean better health care, it will also substantially reduce the costs. An excellent return on investment.
Sunday, February 28, 2010
King Tut and Genomics
Many of us enjoy genealogy as a hobby and to learn about our ancestors. Genomics can been used to study our own genealogy – where did we come from and when? At a recent conference the lady sitting next to me told the group that she and her husband had just had their ancient genealogy studied by DNA analysis. In brief, her ancestors began in the north east of Africa, crossed over to the Middle East, then up into the north of the European continent and finally moved westward to Ireland and then to America. Her husband's ancestors came from Egypt thousands of years ago, moved into the Middle East, then into central Asia and finally to southeastern Europe before immigrating to America. They and their children really appreciated and enjoyed learning about these origins and migrations over the millennia. And it was possible all because of the development of genomic analyses.
Now a group of Egyptologists has used genomic information along with CT scanning to study the ancestry and diseases found in King Tutankhamun and his family. King Tut, as he is often called, lived during the 18th Dynasty of the New Kingdom and died in about 1324 BC after a nine year reign. He followed his father, Akhenaten, who was controversial for his efforts to make major religious change in Egyptian society.
The researchers were able to construct a five generation pedigree. Among the findings – his parents were brother and sister children of Amenhotep III. It was possible to determine which mummy was his grandmother, Nefertiti, and which his father, Akhenaten. Thus these and other previously unidentified mummies can now be given their known names.
King Tut and his father pharaoh Akhenaten were often depicted as markedly feminized in statues and drawings. Did that mean that they had gynecomastia or some other feminizing disease? The genomic and CT skeletal results ruled out many such diseases such as Marfans or Antley-Bixler syndrome. Presumably this was an artistic presentation related to the new religious reforms started by Akhenaten. Other findings on CT scans of the mummies were that King Tut had cleft palate, a mild clubfoot, left foot bone necrosis and a leg fracture. His foot abnormalities on the left forced him to put more weight on the right and probably he had to use a cane. Others in his family tree had cleft palate, scoliosis, club feet and many had dental caries. One mummy had suggestion of metastatic cancer and a few had evidence of trauma – arrow wound to chest, traumatized face and skull. The biopsied materials studied by genomic analysis also identified malaria in King Tut and other mummies, representing the earliest proof of malaria infection to date, some 3300 years ago.
The authors of the article [JAMA, Feb 17, 2010, p638-646 and also a recent program on the Discovery Channel] suggest that a new scientific discipline may be emerging – molecular Egyptology, combining many fields of study including natural and life sciences, humanities, and medicine. For me it is another example of the incredible opportunities developing as we learn more about the use of genomic analyses.
Wednesday, February 24, 2010
"Front of Package Food Labels – Public Health or Propaganda"
But what about claims that a food package is "low salt" or "low cholesterol" or "low fat?" Usually this represents a relative statement. If a soup is low salt but if one eats multiple servings per meal, then low salt becomes a lot of salt. If low sugar means just a small bite of the chocolate bar, that is true but who eats just a small bite?
The article noted that the San Francisco city attorney was able to force Kellogg to stop using the statement that sweetened breakfast cereals "help support your child's immunity." There was no evidence to support this claim and furthermore, sugared foods raise many other health issues.
Manufacturers naturally want to use health claims; it helps sell the product. But these claims can confuse the shopper and may well suggest to the buyer that the government has somehow endorsed the statement when in fact it has not. Indeed, few claims can be verified because no unbiased evaluation has been done to accept or refute them. Stating that a food is fortified with a vitamin does not mean that it is a healthy food; just that it has had the vitamin added. The important question is whether the food, say a cereal, is made of whole grains and has little or not sugars, salt or fat added.
The authors conclude by recommending that the FDA strictly regulate front-of-package labeling based on sound studies. Seems like a very good idea to me.
Sunday, February 21, 2010
We Have Become An Obese Nation
Obesity is a predisposing factor to a broad range of chronic illnesses, among them cancer, heart disease, diabetes, chronic lung disease, and stroke. They make arthritis worse and diabetes very difficult to treat. These are lifelong and expensive to treat. Some estimates suggest that 10% of all healthcare costs relate to obesity and others would suggest even much higher amounts. These are chronic illnesses that reduce lifespan and decrease quality of life.
We are witnessing an increasing epidemic of type 2 diabetes largely related to being overweight and it is estimated that coronary artery disease, declining in recent decades, will once again be on the rise as a result of our sedentary life style combined with a non-nutritious, high calorie diet.
The time is here for a concerted national effort on both the population level and the individual level to correct this serious imbalance. Governments need to mandate nutritious foods in schools while eliminating inappropriate foods from vending machines and the cafeteria. Posting calorie counts in fast food restaurants will at lest help individuals realize the implications of the decisions they make. Schools can teach more about healthy lifestyles. The work of the First Lady, Michelle Obama, to foster good eating habits along with healthy food choices and personal gardening are to be strongly commended.
At the individual level, parents need to teach good eating habits beginning in early childhood. All of us need to appreciate the implications of non-nutritious foods and the perils of being overweight. Physicians need to appreciate the power of their influence on patients and take the time to counsel their patients on the importance of a lifestyle that incorporates good food [fresh vegetables and fruit, more fish than meat, whole grains like whole wheat and brown rice, and the avoidance of prepared/packaged foods,] the right amount of food calories per meal and per day, along with adequate exercise and stress management.
In the end, we cannot blame anyone but ourselves for our sedentary habits and obesity but at the same time we can recognize that the "fix" is very difficult and so we must all help each other to lead a healthier lifestyle. Group support whether it is in the family, among friends, at school or at work can be very helpful to each of us to maintain our effort to reach worthy goals.
Wednesday, January 27, 2010
Watching TV is Bad for Your Health But Sitting Still is the Culprit
Our forefathers and foremothers spent most of their days in some sort of physical activity - farming, cooking, and hunting. But we hop in our car and drive to work; walk a short distance to our office and sit down again; get up to get lunch and then sit back down before our computer. Then we sit to drive home and sit to eat dinner and sit to watch TV. It turns out that our bodies were designed to move. Not only do moving our muscle burn energy but moving our muscles affects many critical body regulatory mechanisms – such as blood sugar balance. Prolonged sitting disrupts these processes.
The moral of the study is that we need to move around. Watching TV may be OK but not if we are sitting still. And going to the gym for 45 minutes a few times per week cannot make up for all that sitting. What we all need to do is move around. Just a few steps every so often makes a difference. Walk up a few flights at work; park further from the building; make trips to the water cooler which is kept at a distance from your office. Stretch in place and do muscle contractions regularly during the course of the day. Don't let your day be sedentary; move more, more, more.
Thursday, January 14, 2010
Misconception - Primary care physicians do not deal with the expensive aspects of medical care so they can have little impact on reducing medical expenditures.
About 5% of all healthcare expenditures go to PCPs but they can have a major impact on the other 95%, especially with good care coordination of chronic illness and with a focus on prevention. To fix this, PCPs need to be incented [paid] to deliver care coordination for the chronically ill and good preventive care to all of their patients. This could have a very high return on investment and a huge impact on total costs. It is a logical place to begin to address the high costs of medical care in America.
Wednesday, January 6, 2010
Misconception– Health care is or should be a right – not a privilege and not a responsibility
We are the only developed country that does not assure all of its citizens basic medical care insurance access – shame on us. We spend more per capita for medical care than any other developed country yet our outcomes are not the best – shame on us. We mostly use price controls to try to slow rapidly escalating costs. They not only don't work but leave patients with less than adequate care and huge bureaucratic frustrations – not logical. All too many individuals find that they are denied coverage because of a preexisting condition when they move from one job to another or find themselves unemployed - unacceptable. As a population we have all too many adverse behaviors such obesity, lack of exercise and smoking that are leading to expensive, lifelong chronic illnesses like diabetes and heart failure – killing ourselves. And primary care physicians find that they do not have time to offer good preventive care nor care coordination to those with chronic illnesses because insurance does not pay for these essential activities, thereby resulting in more visits to specialists, more expensive prescriptions when life style changes could have been effective, more procedures and tests - all of which lead to higher total costs of care.
Howard County, Maryland has instituted a program that offers the uninsured access to primary care for a minimal fee along with specialist care given pro-bono and hospital care for no charge. But in return, each patient works with a health coach to develop a set of goals for the year such as weight control, smoking cessation, exercise enhancement or stress reduction. Patients also are expected to receive appropriate vaccines and obtain basic screening such as checks for high blood pressure. The health coach assists the patient to overcome barriers to success such as helping to find a free smoking cessation program or an inexpensive gym. Patients have been pleased with the program and responded well to the responsibility element. It is a model worth emulating.
Congress is rightly seeking to assure all of access to care regardless of ability to pay. It is not inappropriate for the tax payer to expect the individual in return to lead a reasonably healthy lifestyle as a means to not only maintain and improve health but to lessen the cost of care. Congress also plans to ban the practice of insurers excluding individuals with predisposing conditions. A reasonable expectation [responsibility] in return is that everyone participates in insurance so as to keep the risk pool large and the costs down. In another pairing of rights with responsibilities, commercial insurers and Medicare should be able to incent patients to hold down costs with premium reductions for those who do have an appropriate weight, do exercise, do not smoke, do get their vaccinations and do have screenings done.
Primary care physicians should be able to have a reasonable income without a huge patient load nor the necessity of short visit times but in return the insurer/payer should be able to expect excellent preventive services and good coordination of the care of those patients with chronic illnesses. In this model, both doctor and insurer each have their rights and each their responsibilities, resulting in better care, healthier patients and reduced total costs to the system. Government, and therefore the taxpayer, in accepting the responsibility of universal coverage for those who cannot afford it should have the right in return of a reasonably healthy lifestyle by those covered. The result is better health with lower costs over the long term.
This combination of rights and responsibilities can assure that everyone has access to care and incentives to better health. Yet, it will reduce expenditures through improved quality and eliminate many of the current frustrations with the "system." It satisfies the legitimate arguments of those who insist that medical care is a right with the equally important argument that we all have to accept a meaningful level of responsibility for our health and its costs.
Monday, January 4, 2010
Healthcare Reform Misconception - Giving patients more control of their healthcare expenditures will lead to lower costs
The biggest drivers of costs are related to the lack of preventive care for many of us and the lack of good care coordination for those of us with complex chronic illnesses (e.g., heart failure, diabetes with complications) as discussed in the previous post. These will not be affected much if at all by patients having more "skin in the game."
But the more we know about our medical care costs and the more we ask our providers why a test, a drug or a procedure is necessary then the more likely it becomes that there will be a reduction in total costs. Being more directly invested in the costs of our care will ultimately have a market effect. This is particularly important when told to get a test, X-ray or drug. Ask your physician if the test is really important or is just being done to "be complete" (i.e., avoid malpractice litigation.) Will the results really effect what the doctor decides to do next? And as for drugs, is a drug what is needed or is it a life style change such as Lipitor versus a change in diet and exercise? Or is a generic available? Or another drug that is equally as effective as the branded drug? It is our money so it is important to have these discussions. Unfortunately, as patients we still have an information gap relative to our provider and we tend to accept advice without questioning – this needs to change and being directly responsible for dollars spent may just provoke that change.
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).


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Florence, SC Plumbing Company
Since 1979, we've been your Florence, SC plumbers.
When looking for a plumber in Florence, you have many choices — some better than others. Jordan & Sons Plumbing is a second-generation plumbing company. Though we have offices in other locations throughout South Carolina, Florence is still our home. At Jordan & Sons, we know that growth of a company comes with repeat customers. But, the only way to achieve this is to provide consistent and satisfying service. That is why we strive so hard to deliver the best possible plumbing service in the Florence, SC area.
For several generations — thirty-four years to be exact — we have offered unparalleled plumbing services to our Florence customer base. In some families, for example, we are now servicing the children of the children of the parents we used to serve.
Offering a professional and well-managed team are some of the things that sets us apart from our competitors. In addition to this factor, we are prompt, neat, professional, offer our customers up-front pricing, and provide great warranties — just to name a few.
We believe — in fact, we know — that we give our best effort to exhibit these qualities in hopes of pleasing each and every one of our customers.
Everything we do, and everything we own, is top-notch, state-of-the-art at Jordan & Sons Plumbing. We cut no corners and spare no expense when it comes to products and performance. This is why we feel confident that our plumbing services are the best in Florence, SC. If you need a plumbing service, then our plumbing company is the premiere place to call in Florence, South Carolina.
In addition to Florence, we also serve the surrounding areas. From Darlington, to Hartsville, to Marion, to Dillon, and everywhere in between, we are ready to serve.
So, if you're looking for a local plumber, call us at 843-669-4505.
Florence, SC Address: 2200 W. Jody Road Florence, SC 29501


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LAS CRUCES SUN-NEWS / SEARCH: 5245 Central Road Las Cruces, NM 88012
- 4 beds
- 2 baths
- $99,500 price
- 1901012 mls id
- Square Feet: 2,653 sqft
- Year Built: 2001
- Lot Size: 1.24 acres
- Neighborhood: 213 Peachtree
- Status: Active
A large fixer upper home with approx. 2653 sq. ft.. Home has 4 bedrooms, living/dining room, large kitchen with a multi-split floor 2-story. Home has no heating and cooling and is in need of many repairs. Land is approx. 1.22 acres and it has city utilities but not connected to home. This home might require special financing and/or Rehab financing. Also cash or Seller Financing. Sold ''As-Is'' condition.
- Site Link
- Property SubType Single Family Detached
Courtesy of: Coldwell Banker Legacy
Office Phone: (575) 521-1000
Listing Agent: Patricia Preciado
Updated: 4th April, 2020 8:49 AM.
5245 Central Road Las Cruces, NM
Real Estate | Las Cruces Sun-News Powered by Placester


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D-DAY A photographic journey in the landscapes of landing
Seventy years after the Normandy Landings, the flocks of tourists who come to visit the D-Day sites find it hard to believe that such violent and intense combat took place here. They tend to forget the 100,000 deaths - a figure that has gone down in history totalising the toll of the military operations in Normandy during the summer of 1944, not forgetting the 20,000 Norman civilians who also paid the ultimate price... By the end of the battle, Normandy was devastated. With around 50 panoramic photographs, Christophe Daguet invites us on a journey through time, via total immersion within the historic landscapes of the D-Day Landings and the Battle of Normandy.<br /> These magnificent photographs have the novelistic power of transporting us into the heart of the action.
thématiques : histoire > seconde guerre mondiale | versions étrangères
catégorie : livre
|du même auteur :
|de même thématique :
25,00 €
25,00 €
15,50 €
© OREP 2010 - 2017 mentions légales plan du site droits étrangers contact


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ABOUT Kylie Rose
Hello guys! Welcome to Kylie Rose Fashions.
I sketch, I design and I create original, custom, one-of-a-kind quality fashion garments,created in small quantities to ensure exclusivity. I always knew I had a gift for creating but I didn't quite know what to do with it until that became my preoccupation, finding a name and an outlet for my passion.
'Kylie' is my daughter's name and 'Rosie', my nick-name given by my grandmother. This is how the name Kylie Rose was created.
Favorite Quote:
"It's a new era in fashion - there are no rules. It's all about the individual and personal style, wearing high-end, low-end, classic labels, and up-and-coming designers all together".


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|Reviews for Late Night Baking
| R5mindedgirl chapter 1 . 7/29/2014
loved the end!
| i'd sink us to swim chapter 1 . 2/8/2012
Sweet, great job. Keep writing.
| ChrisCriss chapter 1 . 8/18/2011
very very cute.
i am, of course n love with jeff. he is my back-up Free Pass now, so loved it.
My boyfriend doesn't mind though, well...
are you gonna do more?
| boredandhomealone chapter 1 . 8/14/2011
That was hot but the end had me in stitches! Loved it!
| proudtobegleek chapter 1 . 8/13/2011
Haha, I looooved this!
I love Neff, I love the story, it was cute and hot at the same time, perect mixture :D awesome! :)
| Narwhal92648 chapter 1 . 8/10/2011
Ohmygod I laughed out loud at the last part!
This was so awesome. xD


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Review: The Story of Rachel
Reviewed by ShellyWhen I saw the blurb for this story, I was pleasantly intrigued. I was even more titillated when I started reading. This is the debut story by McLean and after reading her blogsit,e I found the answers for some of the little nagging questions I had. One of course was – it there such a place called Pandora? I knew what the answer was going to be, but there's always a 50/50 chance, right?
Rachel Collin's story starts off with a bang, there's no downtime or pondering of 'what shall I do'? She's a go-getter (not aggressively so, thank goodness) and knew what she didn't want in a man (especially after the disaster that her marriage turned into.) It was just a matter of time before she found what she did want. After trying the online dating sites and the occasional blind date, Rachel finally meets her man -- out of all the popular pick up places, it certainly wasn't where I would ever think the magic would strike.
Like Rachel, Michael Evans is a writer. He's a tad bit older than her, but he's well preserved and pulls off the rower's body quite well. After their initial get together, the conversation gets turned up with phrases like BDSM. I had many moments of laughing out loud reading Rachel's response. If some dude, no matter how nice, smart or good looking, who I just met, brought that up to me, I would like to think that my reactions would have been similar to Rachel's.
Michael is completely and totally attracted to Rachel – but he's convinced that she's only going to last three months, just like his past relationship have. It's amazing how people pray and wish for a thing and when they get it, some will subconsciously sabotage it. To me that was the big difference between Rachel and Michael -- both of them got what they most desired/wanted/prayed for but the way they separately handled it was really well done.
I kinda sorta felt bad for Michael because I just knew that he had more to give and I could see him really putting forth the effort by giving and doing for Rachel without expecting any reciprocity. But like a lot of people, when they're given what they want, they tend to freak out. To his credit, other than Rachel, he's got some things burning on the fire – writing a book, interviewing with the NY Times – he's hoping to be in the movers and shakers crowd.
Together these two had tons of chemistry, even outside of the bedroom. Now that doesn't mean that their sexy times were anything tame, because that would be so wrong. Michael knows how to turn it up and on for Rachel. And I loved, loved that Rachel was so willing to try new things – first because that would make Michael happy and then because it made her happy. Isn't that how we find out what we like, by trial and error?
When Rachel gets to Club Pandora there are some interesting characters there -- if there wasn't, I would've been so disappointed because, really, it's a sex club! Because I just couldn't help myself, I found out from McLean's site that a couple of the characters will have their own stories in the series. I eagerly await Annik's story – that should be an interesting tale of redemption.
In the end, I liked both Michael and Rachel and wished a happily ever after for them. Maybe they'll be some of the upcoming stories in the 'Tales of Pandora' series. Good stuff so far.
Happy Reading folks!
Rating: B+
*ARC provided by author for review
Click to purchase: Amazon
The Story of Rachelby KD McLeanRelease Date: January 15, 2013


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Personalized children's books are becoming all the rage for Hollywood kids these days! Celebrities including Tiffani Theissen, Jennie Garth, Garcelle Beauvais, Beverely Mitchell, Christie Lynn Smith and The Guncles are all fans of these amazing personalized books and are now sharing them with their own little ones!
I See Me books take a child imagination into world's they could only dream of before. Children can take their own journey into the world of make-believe and beyond. Titles available include My Very Own World Adventure, Snuggle Bunny, ABC-What Can I Be, My Very Own Fairy Tale, My Very Own Pirate Adventure and many others.
We are giving away a $215 gift certificate (a total of 5 books) at I See Me.com to 1 lucky reader!
Also exclusive to our readers is a 20% discount at I See Me. All you have to do is enter coupon code SCOOP at checkout (expires 7/1/13).
One Easy Way to Enter:
Leave a comment here with a valid email address (will not be published). Please state your favorite book at I See Me in the comments. One winner will be chosen at random at the end of the contest. One entry per person, per day.
This contest ends Friday, April 19 at 7:00 pm EST. This contest is open to US residents only! Good luck!
*contest rules*
Congratulations to the winner of our Max Daniel Baby giveaway: Simone!


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The Political Affairs Ministry of St. Andrew the Apostle Parish is most active before and during election time. The political affairs ministers have been involved in voter's education and in poll watching, in cooperation with the national body, the Parish Pastoral Council for Responsible Voting (PPCRV).
Political Affairs
- Super User
- Hits: 3453


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Tax Due Dates:
Tangible Property Expensing Threshold Increase
Small businesses benefit in expensing tangible property up to $2,500 and not be audited by the IRS. The action is proactive to tax years
prior to 2015.
Affordable Care Act
All Americans must declare having health insurance for the entire year or possibly be fined by the IRS. Expats must file Form 8965-Health Coverage Exemptions to declare their exemption. Expats are only exempted however if they pass the Bona-fide Residence or Physical Presence
tests. All Americans residing in the U.S. must declare their coverage for the year or face penalties. Many will receive a Form 1095 (A, B, or C) depending on the kind of health coverage. Some purchasing health coverage through a healthcare government website may receive a credit, or a penalty. If this is confusing, it is and Mir Taxes will assist your concerns.
E-File Security Requirements
In order to provide additional security to taxpayers, e-file software may require additional identification,
such as state driver's license number and expiration information.
ABLE Savings Accounts
Beginning in 2015, states are allowed to create "Achieving a Better Life Experience" (ABLE) accounts for disability-related expenses. There is no federal taxation on these accounts.
PATH Act of 2015
The Protecting American from Tax Hikes Act of 2015 was passed by Congress to extend several tax breaks. These include child tax credit, American Opportunity Education tax credit, Earned Income Tax Credit, Educator credit, deduction of state and local general sales taxes, tax-free distributions of IRA plans for charity, and increase expensing limitations. An additional credit extended through 2019 is the bonus depreciation credit. Extensions of tax credits through 2016 include qualified tuition expenses credit, mortgage insurance premiums and credit for nonbusiness property.
Same Sex Marriage
All states must recognize marriages between two people of the same sex for tax filing. Same sex married couples can now file their tax returns for federal and states with a filing status of either married filing joint or married filing separately.
Contact Mir Taxes at email@example.com.
Sponsored by Dunhill Financial and Mir Taxes
Doors open at 6:00 p.m.; seminar starts promptly at 6:30 p.m.
As Americans, all of us are required to file annual tax returns regardless where you live in the world. There will be a presentation by Carl Mir of Mir Enterprises who will discuss "US tax issues and the US expats".
Complementary beverages will be served.
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If you are an expat living and working in Europe, chances are that you are enrolled in one of the
many European health insurances known as mutualities. .......
Avoid paying hundreds—if not thousands—of Euros when converting cash into your Belgian account. To ease the financial pain that hefty transfer fees
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Questions are frequently asked about dependents, such as if an adult child out of college can be classified on as a dependent on the parent's' tax return.


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Monthly Archives: July 2018
Hugtto! PreCure Episode 26: The Queen's Kitchen
Remember Saaya? She hasn't really had a lot to do in recent episodes of Hugtto! PreCure, but episode 26 shines the spotlight on her – and it is well deserved. Saaya's mother also plays a prominent role in this episode.
Cells at Work! Episode 4: Eosinophil
If you are not careful about what you eat, you might end up with food poisoning. This is exactly what the cells have to contend with in the fourth episode of Cells at Work!, which also introduces a new cell.
Harukana Receive Episode 4: Minsa Pattern
With a tournament coming up, Haruka and Kanata get some training in order to prepare. They'll also need matching swimsuits, so a little shopping trip is in order.
Thoughts on Mushroom Girls in Love
Well, my plan to try and get through my backlog of manga and light novels I have built up didn't go exactly as I hoped – I blame a combination of this heatwave we're having here in the UK and … Continue reading
Hugtto! PreCure Episode 25: Secret Revealed
In this episode of Hugtto PreCure!, the girls go to a summer festival. There, a secret that Harry has been keeping is revealed.
Cells at Work! Episode 3: Naive Cell
The third episode of Cells at Work! shows us what the cells have to contend with when an influenza virus invades the body.
Harukana Receive Episode 3: Éclair Sisters
Episode 3 of Harukana Receive introduces a couple of new characters, who Haruka is very eager to play beach volleyball against. Kanata doesn't seem to be entirely thrilled about the prospect, though.


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I finally went out and did something about my want to be a photographer. I volunteered to be the event photographer for Keep Denton Beautiful with their annual Tree- GiveAway event for Denton County Residents.
The organization is a local nonprofit affiliated with Keep America Beautiful, priding itself with making Denton a "more beautiful place to live." The give away is to raise the percentage of foliage coverage in the community by providing 1,000 species of tree native to Texas.
So I wanted to showcase my first, real-life, O-em-gee moment I had this past weekend, and explain what is going on behind the camera. The cliché "A story through pictures."
I can't explain how much fun I had. After copious amounts of coffee, aimlessly wandering around the landfill and second guessing my choice to wake this early for my FIRST shoot, I got into the swing of things and enjoyed being the photographer.
To see more of my shots you can check me out on my online portfolio, right here!