Archive for the ‘Medical topics by Paul Goldfinger MD on Blogfinger’ Category

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Photo from the LA Times.

Photo from the LA Times.

Bloomberg News (8/17/16,) reports the four largest health insurers in the US have posted hundreds of millions of dollars in losses on their Affordable Care Act exchange businesses. Data show UnitedHealth is predicting a loss of $850 million this year, while Aetna, Anthem, and Humana are each expected to lose about $300 million. As a result of these losses, the insurers are exiting ACA marketplaces.
Meanwhile, the Los Angeles Times (8/17, Petersen, Sisson) reports Aetna’s decision to pull out of the ACA exchanges in 11 of 15 states where it is currently operating, as with other insurers’ moves out of certain markets, “could make this fall’s enrollment period crucial” to the Affordable Care Act. Experts “disagree on whether the latest pullbacks and price hikes, floating in a sea of election-year politics, signal that the nation’s health insurance exchanges have reached a terrible tipping point — or whether they are simply seeking a new state of equilibrium.”

Sarah Collins, the Commonwealth Fund Vice President for Healthcare Coverage and Access, “said she believes the Obamacare markets are maturing rather than dying,” noting that “major carriers including Blue Cross, Blue Shield and Kaiser Permanente have not pulled out of the Obamacare exchanges.”


Bloomberg News:    “While Obamacare can compel individuals to buy insurance—a mandate upheld by the U.S. Supreme Court in 2012—the law has no authority to force insurance companies to offer plans through its exchanges.”

Obamacare advocates had hoped that big government subsidies to consumers would persuade healthy people to sign up for the ACA plans. But the policies have largely been taken out by older, less healthy people who are more expensive to insure. “What we are left with … is a highly subsidized program for relatively low-income people,” says Dan Mendelson, the CEO of consulting firm Avalere Health. “We’re not getting to the broader vision of a robust private market structure that enables a broad swath of Americans to purchase their insurance.”

The fate of the exchanges rides, in part, on the November election. While Donald Trump has said he’ll repeal Obamacare, he hasn’t said exactly what would replace it. Hillary Clinton has backed the creation of a public insurance plan, as well as offering people 55 and older the option of buying Medicare coverage.

Blogfinger Medical Commentary.  Paul Goldfinger, MD.

In 2013 I began to express concern over the real possibility that quality of care would decline in some ways under the Affordable Care Act (ACA).  Some of those concerns are now being borne out, and many of you have been experiencing deterioration in quality. Below is a sample from the Kaiser Health News:

“Kaiser Health News (8/16/16) reports that a new study conducted by researchers at the National Women’s Law Center found that many health plans offered through Affordable Care Act marketplaces include ‘language that allows them to refuse to cover a range of services, many of which disproportionately affect women.’”

I know little about medical economics, but I will continue to follow quality care issues which are presently being studied in many research trials.

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Where's the pink? Public housing in Neptune Township, NJ. Blogfinger photo. May, 2016.

Where’s the pink? Public housing in Neptune Township, NJ. Blogfinger photo. May, 2016.

Blogfinger Medical Commentary.   Paul Goldfinger, MD, FACC

Many of you understand the meaning of the pink ribbons. Those who do probably don’t need to be reminded to get mammograms, but, for those of you who don’t know what the pink ribbons mean, they are supposed to increase breast cancer awareness—especially  the need to keep up with mammogram screenings.   I won’t attempt to speak for Meridian, the mammogram-industrial complex that sponsors the pink campagn, but I can share a few facts about breast cancer,  since it is May.

About 65% of all women over age 40 do  keep up with mammogram screening, but there are many who do not   There are a variety of reasons for that, and the Susan G. Komen website can tell you more on that subject (click link below)

Komen web site

It used to be that black women had a lower percent of mammogram screenings than whites, but that difference no longer exists. But it is still true that black women have higher mortality rates from breast cancer than whites.

From the Susan G. Komen web site. 2016.

From the Susan G. Komen web site. 2016.

This quote is from the  Komen web site:     “Overall, breast cancer incidence (rate of new cases) is slightly lower among African-American women than among white women.  However, breast cancer mortality (death) is higher in African-American women.

“For example, in 2013 (most recent data available), breast cancer mortality was 39 percent higher in African-American women than in white women.”

In view of that, you would think that the breast cancer pink program at Meridian would reach out to black neighborhoods with their pink ribbons and an all-out publicized education effort.

But if you drive by the public housing “projects,” as I did,  in Asbury Park and Neptune, there are no pink ribbons to be seen. This is not the first time I have pointed that out.

Meridian should be engaged in an outreach program for African-American communities in Monmouth County.  So how about some  pink ribbons and pamphlets over there?  Actually they should send a group of women, armed with facts and pamphlets, to knock on doors and set up booths in those places.  Better awareness in African-American populations could likely improve those mortality stats.

The statistics regarding the latest controversies about mammogram screenings can be found on BF by typing “breast cancer” or “mammograms”  into our search box on the top right of this page.

Paul Goldfinger, MD



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The CBS Evening News (5/3) reported that research indicates that “medical errors are now the third largest cause of death behind heart disease and cancer.”

USA Today (5/3, O’Donnell) reports that the study authors “wrote that strategies to reduce death from medical care should include making errors ‘more visible’ when they occur, having remedies available to ‘rescue patients,’ and making errors less frequent by following principles that take ‘human limitations’ into account.”


According to the Washington Post (5/3, Cha), “In 1999, an Institute of Medicine report calling preventable medical errors an ‘epidemic’ shocked the medical establishment and led to significant debate about what could be done.” The institute, “based on one study, estimated deaths because of medical errors as high as 98,000” annually. The new research, published in the British Medical Journal, “involves a more comprehensive analysis of four large studies…that took place between 2000 to 2008.”


The New York Times (5/3, Bakalar) “Well” blog reports that the researchers “estimated that an average of 251,454 deaths per year in the United States are caused by medical error.”


Blogfinger Medical Commentary  by Paul Goldfinger, MD, FACC:

It’s been known for about thirty years that there are nearly 100,000 deaths per year due to medical errors, with most reports coming from hospitals. Newer tabulations have been used to generate the latest number (above) of  about 250,000. The Department of Health and Human Services reported that 180,000 Medicare recipients die each year from medical errors.  Some might quarrel with the numbers, but certainly it is clear that a huge number of patients are dying due to medical errors.

The U.S.  has a national network of medical schools that tend to be of high quality, and the admissions are so competitive that only smart people get in, so I don’t think that dumb doctors are the cause of these findings.

The numbers that we are discussing tend to be  due to errors of omission or of commission, and such errors often begin with poor communication, carelessness, wrong diagnoses, poor training of personnel, and ineffective monitoring routines.  Errors may involve nursing or support personnel as well as physicians. Sometimes a sequence of mistakes results in a death, so culpability may be spread around in a particular case.

And then there are the inadequate designs of medical practices including a lack of sufficient safety nets in healthcare facilities of all kinds. In the new healthcare system, there are challenges due to huge numbers of patients, assembly line procedures to augment profits, and corporate management with no knowledge of patient care.

Since stupid doctors are not usually the problem, I have found that the main malfunctions are  wrong incentives—especially financial, inattention to detail, ethical lapses, rushing to meet deadlines, sloppiness in procedures and care, and, today, a breakdown in the time-tested details of care.  Doctors have become employees.  They used to determine the procedures that govern care in hospitals and offices, but now managers who don’t understand how medical care is supposed to work have taken charge.

The safeguards that protect patients are seriously deficient across the country. There are no comprehensive mechanisms to investigate mistakes, and there are no reliable reporting procedures to identify errors and evaluate them.  Even in malpractice suits, when evidence of mistakes are often disclosed, legal gag orders prevent the information from getting out.

When I started in practice, my background was at first-rate training institutions where I rarely saw errors.  The same was true in the large military hospital where I worked, but things were much different out in the real world of private practice where, as a consultant,  I saw mistakes on a daily basis. In US hospitals, over the years, many programs were instituted to identify errors such as establishing intensive care monitoring committees to round in the ICU/CCU to look for quality issues, and we found plenty of questionable care.

As ICU/CCU chairman of our new committee,  I recall going to the medical staff to inform them of our rounding plans. The President of the staff, an arrogant surgeon, reacted by saying, “Nobody is gaining access to my patients’ charts.”  But we won that battle and were empowered to intervene when necessary.  We also were enablers for our highly trained nurses to be able to question the orders and plans coming from the doctors.

Other procedures to prevent errors have been devised, but obviously, not enough is being done.

The surgeon from Johns Hopkins who was the lead author of the study above pointed out that our society spends fortunes on cancer and heart disease care, but very little on the third leading cause of death——medical errors.  This problem has not been widely recognized, and it is an issue around the world.  It is likely that many of the errors are preventable if only funds were available to tackle the issue.

I might add that a huge arena which has not been analyzed at all is that of the private medical office practice. Most doctors are trained in hospitals. Then they open offices where there are many quality challenges.  Some doctors have been very good at following the standards of good medicine, while other office practices are awful, dangerous places. Today, with corporate incompetents  in charge of offices, I find that it is rare for me to interact with an office practice and not find something worrisome going on.

What to do?  The first thing is for organized medicine to reclaim the traditional doctor-patient relationships and then get strict with doctors regarding their priorities  (“Always place the patient first” is a traditional primary value of the medical profession.)  And the government needs to finance innovative approaches to saving lives threatened by errors.


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The Wall Street Journal (2/29 ) reports that there is increasing evidence that over-the-counter nutritional supplements may interfere with a host of prescription drugs for a variety of common conditions.

“The National Center for Complementary and Integrative Health, part of the National Institutes of Health, is funding a number of programs around the country to study potential adverse interactions that can occur between so-called natural products and prescription drugs, over-the-counter drugs such as aspirin and even small molecules in food. The risks are especially high for cancer and surgery patients and those on heart and blood-thinner medications, which have what’s known as a “narrow therapeutic range,” or small differences between beneficial and toxic doses.”   (WSJ excerpt)

Blogfinger Medical Commentary.  Paul Goldfinger, MD, FACC

This revelation is not surprising.  There is too little known about the supplements that so many people use.  The complimentary gurus often quote “research” which is of poor quality. The FDA doesn’t deal with such over-the-counter supplements, so nobody is watching for evidence of benefit or toxicity that may result from such treatments.

When doctors take a medical history they usually ask about prescription drugs, but they rarely inquire about supplements.  Before you take a supplement, especially if you are on prescription drugs, do some research online to look for possible interactions.  You can ask your doctor, but he probably knows nothing about it.

I think most supplements that make people feel better either have mild pharmacological effects or they work because of the placebo effect, a powerful force that makes phony doctors rich.  And don’t forget that supplements which are supposed to have no side effects  (“Try it, it can’t hurt”) may actually be dangerous under certain conditions as described in the  article above.

There is a very interesting book, Do You Believe in Magic–an easy read–written by a physician  (Paul A. Offitt. MD) regarding over-the-counter supplements.   Subtitle:   “The sense and nonsense of alternative medicine.”

THE HIT CREW:  (This is about a totally natural remedy which helps keep a doctor in bed at night)


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Good Morning Dr. Paul Goldfinger. Here are today's top stories.Friday, January 22, 2016

Good Morning Dr. Paul Goldfinger. Here are today’s top stories. Friday, January 22, 2016

Fasting blood sugar chart

Fasting blood sugar chart

CBS News reports on a public service ad campaign to encourage people to be checked for prediabetes launched by the American Medical Association, the American Diabetes Association, the Centers for Disease Control and Prevention, and the Ad Council.

HealthDay (1/21,)  reports the message of the campaign is “no one is excused from diabetes.” It also includes “a short online test at DoIHavePrediabetes.org.” that “can also be taken through texts and interactive TV and radio announcements.” The CDC issued a news release announcing the campaign, in which AMA President-Elect Dr. Andrew W. Gurman, MD, said, “As soon as someone discovers they may be at risk of prediabetes, they should talk with their physician about further testing to confirm their diagnosis and discuss the necessary lifestyle changes needed to help prevent type 2 diabetes.”

MedPage Today (1/21, ) reports that Dr. Gurman explained the reason for the campaign: “There are 86 million people in this country who have prediabetes, and 90% don’t know it,” adding, “we need to do something to make people aware of this condition and its risk.” The AMA is also seeking to raise awareness among physicians, “because they may have lots of people coming into their office and saying, ‘I just took the prediabetes test and I think I have it,’” said Gurman.

Blogfinger medical commentary:  By Paul Goldfinger, MD, FACC.

This public service ad campaign is about “prediabetes,” the latest medical issue to strike fear into the hearts of the public. Above, a doctor calls this a “diagnosis.”  Another calls it a “condition.”  But they are all careful not to call prediabetes a “disease.”  It actually is a state of awareness where early detection can result in a prevention program to reduce the risk of  type II diabetes.     In fact, 15-30% of prediabetics eventually get type II diabetes.

Prediabetes  is a name given to a borderline abnormal blood test coupled with the threat that the abnormality will give rise to overt diabetes and to heart disease.Those who are at highest risk of having prediabetes are obese, sedentary, hypertensive males, age 40-60, with a positive family history of diabetes.   The PR buildup will include a massive barrage of ads on TV, internet, doctors offices and elsewhere which will scare people with what amounts to a real concern, but it is not actually a disease, making this PR campaign somewhat unusual.   Maybe it is like the campaign to take BP readings in dental offices or shoe stores.  That way you can identify those with borderline high blood pressure readings who are not quite hypertensive—-ie prehypertensive.

In fact prediabetes has no symptoms, no physical findings, no medicines to take,  and no clear endpoint for therapeutic success except for a normalization of blood sugar levels.  It is really an idea about preventing a disease, diabetes, which can cause death and disability.  Prediabetes, a circumstance that can be found in millions of people,  is certainly a situation worth your attention.  So let’s put it into perspective.

There is type I  diabetes (insulin dependent) and the much more common, but less serious,  type II  (non-insulin dependent or “maturity onset” diabetes.)    The main worry with diabetes is generally not the elevated blood sugar levels (although that could become a problem; ) it is the risk of vascular complications including heart attack, kidney failure, stroke, blindness or amputation. Treating prediabetes is supposed to reduce the risk of clinical diabetes–type II.

The diagnosis of prediabetes is made with blood tests that measure blood sugar levels in a few different ways.  The best test is the A1C  (aka glycohemoglobin test) which averages blood sugar levels over time instead of in a snapshot as occurs with the fasting blood sugar test.  Normal A1C is less than 5.7%; prediabetes is 5.7-6.4% and diabetes is over 6.5%.

If you are said to have “prediabetes,” the usual recommendations include preventive measures which you  would want to do anyhow.  Number one is weight reduction.   Then comes exercise and specific dietary advice.  Control of all cardiac risk factors would be advisable also including BP control, stop smoking, cholesterol treatment, stress reduction, etc.

The Joslin Diabetes Center ( www.joslin.org/info/what_is_pre_diabetes.html  )   at Harvard Med. School says that weight reduction is the most important preventive measure.  They say that calorie reduction is more important than sugar intake. Below is their simple dietary advice if you have prediabetes, but it is good advice for anyone:

—-eating more foods that are broiled and fewer foods that are fried.

—-cutting back on the amount of butter you use in cooking.

—-eating fish and chicken more, and only lean cuts of beef.

—-eating more meatless meals, or re-orienting your meals so that your dinner plate has more vegetables, fruit and starches on it, and less meat.

This is what they say at Joslin, “The solution isn’t “avoid foods with sugar in them.” Rather, you need to lose weight if you are overweight, cut back on portion sizes, and plan for those occasions when you eat a small piece of cake or pie.”

So the latest celebrity disease is upon us, and the treatment is the same as what prevention minded docs have been advocating right along, but another dose of awareness and education could wake up a lot of future diabetics.


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