Private Hospitals Encourage ER use, Medicaids seeks to decrease usage

In a bygone era in China, a physician was only paid if he kept his patients healthy. If they fell sick, he would not be paid. This is still the ethos in Chinese Medicine, and, of course, we don't live in anything resembling that world anymore, nor should we. But I bring up that framing of "health care" as a gentle reminder of how far from ideal our for profit system has become. If a fraction of the money spent on procedures, hospitalizations, and ER visits were spent on clinic visits, home visits or even providing decent food our outcomes would be so much better. This story just underlines the difference in the two systems, where Medicaid tries to keep costs at a minimum, yet can barely pay for clinic visits due to the reimbursement structures, where for profit hospitals see huge mark ups on ER visits. You have to wait for an advertisement to read the story. Excerpts below.

Hospitals seek more ER patients even as Medicaid tries to lessen demand
By Phil Galewitz, Published: August 22

Complaining of abdominal discomfort and chronic bronchitis, 22-year-old Toshia Johnson, an unemployed mother on Medicaid, went to a hospital emergency room in Bend, Ore., more than two dozen times in the year that ended in June 2010. She was never admitted to the hospital and used the ER for routine care because, she says, it’s near her home and the care was free.

But in the first six months of this year, after entering a state-funded program designed to reduce unnecessary ER use by Medicaid patients in central Oregon, Johnson has gone to the ER just once, after breaking her tailbone. In the first half of this this year, ER visits by the 400 patients in this program have declined by more than half from the same period last year, saving Medicaid $1 million, officials say.

Efforts to reduce unnecessary ER visits by patients in Medicaid, the joint state-federal health program for the poor and disabled, are proliferating as states search for ways to control the soaring costs of the program. But state officials complain that their efforts are sometimes hampered by hospitals’ aggressive marketing of ERs to increase admissions and profits.

“Many hospitals are actively recruiting people to come to the ER for non-emergency reasons,” said Anthony Keck, South Carolina’s Medicaid director, citing facilities that tout their speedy ER service on highway billboards. “When you are advertising on billboards that your ER wait time is three minutes, you are not advertising to stroke and heart attack victims,” he said.

ER visits totaled 124 million in 2008, an increase of about 31 percent since 1997, according to the Centers for Disease Control and Prevention. The average wait time for treatment is 33 minutes, up from 22 minutes.

...
Dallas-based Tenet Healthcare Corp., a large hospital chain some of whose facilities have seen a surge of patients using the ER for primary care, recently began accepting online appointments to make it easier for patients to use the ER. It’s also promoting average waiting times on the Internet and on billboards. Spokeswoman Carol Britton says that there hasn’t been a “significant increase” in ER visits by Medicaid patients as a result of the promotion.

Medicaid officials in Washington state were so concerned by hospitals’ ER marketing that they issued new rules making it harder for hospitals to qualify for Medicaid bonus payments if they promote their ER for primary care. “They sure don’t help us when we are trying to get word out that the ER is not the place you go for primary-care diseases like treating asthma or diabetes,” said Jeffrey Thompson, chief medical officer for the state Medicaid program.

Sicker than most

States are focusing on Medicaid recipients in part because these patients use ERs three times as much as people with private insurance and twice as much as people with no health insurance, according to federal researchers...

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Recent Research Shows Acupuncture Useful for Kids

There have been a number of recent studies about acupuncture for children. I think the problem comes with the number of visits needed for the conditions they describe below. It's hard enough for adults to keep up with their acupuncture series, harder still for families and children. I'm board certified in Pediatrics and still think that the fit with kids and acupuncture can be tricky. (For more information about my practice, please click here.)

Most of us would say yes to anything that makes our children feel better, and expert evidence is piling up in favor of kiddie acupuncture. Recent research from the New York Eye and Ear Infirmary found that acupuncture was as effective at treating amblyopia, or "lazy eye," as eye patches. Other studies have linked acupuncture with reduced symptoms of ADHD in preschoolers and decreased crying episodes in colicky infants. And, according to a small study from doctors at Rush University Medical Center in Chicago, acupuncture may alleviate pain and nausea in kids with chronic illnesses.

Worried about the ouch factor?
"While no one likes needles, kids are often surprised at how relatively painless and helpful acupuncture can be," says Kathi Kemper, M.D., founding chair of the American Academy of Pediatrics section on complementary and integrative medicine. "The needles are tiny, and they're not hollow, so they don't tear the skin." To find a reputable provider in your area, Kemper recommends asking your child's pediatrician, who can direct you to someone specially licensed in pediatric acupuncture. You can also use the "advanced search" option at acufinder.com to find a local acupuncturist who specializes in treating kids.

Read more: http://www.sfgate.com/cgi-bin/article.cgi?f=/g/a/2011/07/26/hearstmagfamily5631726.DTL#ixzz1Vo2l8aRu

Effect of Specific Magnetic Polarity on Heart Meridian on EEG

File this under "The Things We Don't Know." I really don't know what to make of these kinds of studies, but am fascinated by them because of all the implications if they prove to be reproducible. Could magnets be used, as many suggest, as an adjunct for acupuncture? Could this be a way to study meridians, ie, changing polarity and seeing what happens? What about other meridians? What about those magnetic bracelets, they're close to all the arm meridians, could they be studied? Could magnetic fields account for the ancient studies of the different astrological effects of acupuncture? I have to admit, I've never given much credence to any of the above questions, but maybe I shouldn't be so close minded.

Electroencephalogram activity induced by magnetic stimulation on heart meridian.
Jo HG, Jo GH.

Institute of Health and Environment, Kongju National University, SinKwan-dong 182, Kongju 314-701, Republic of Korea.Neurosci Lett. 2011 May 16;495(2):107-9. Epub 2011 Apr 1.

Many studies on the effects of acupuncture on brain activity have been concerned with the stimulation of specific acu-points. However, research on brain activity with the stimulation of the body-meridian line is still quite novel. The hypothesis of the present study is that heart meridian stimulations with different directions of line-magnet poles would elicit different effects on EEG activity. Twenty-three healthy young adults between the age of 19 and 22 years old participated in the experiment. Two tiny NEO line-magnets were applied to stimulate the heart meridian. EEG activities were changed significantly between different treatments on the heart meridian using line-magnet with different directions of magnetic poles (p<0.05). The present study shows that the stimulation of the heart meridian with the line-magnets has an effect on brain activity associated with the direction of the line-magnet pole.

Treating High Blood Pressure in the Acupuncture Clini

This is the latest data on the patient we've been following on this blog here and here. He is maintaining control of his blood pressure very nicely in spite of the fact that he hasn't been able to exercise as much as I recommend, nor has he taken the excess weight off. But he has followed through with his monthly acupuncture and takes his herbs religiously.
I did HRV monitoring on him when he came in on Wednesday and his LFR/HFR decreased from .68 to .57.
His SD1/Sd2 went down from .39 to .29 (not a positive result)
But his Sample Entropy went from 1.11 to 1.48 which, in my opinion is the most sensitive marker.
(Brief primer: LFR/HFR stands for Low Frequency/High Frequency HRV. If this decreases, it is interpreted to mean that the stress response in decreased. So decrease in LFR/HFR=decreased stress. The other measure SD1/Sd2, is a nonlinear method, if this ratio increases =decreased stress.)
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Follow up on patient with Severe Thoracic Spine Pain

This is the follow up on a patient I posted on earlier here.
When the patient came in for a follow up visit, his pain was at a 5 level (5 out of 10.) He had had another episode of severe spasm the day before requiring Dilaudid. But it had resolved on its own. He thinks that the acupuncture is helping to quell the severe spasms.
I tried doing cupping on his back since it can be helpful when muscle tightness is involved, but it ended up aggravating after about 10 minutes. So the cups came off.
His readings, again, showed a decrease in the stress response( values follow.) The whole idea is to be able to "balance" his system, reduce his stress there by increase his pain threshold. From there we can reduce his medications and get him moving again with a gentle stretching and exercise plan.
His reading for 60 to 360 seconds, and 360 to 660 seconds.
LFR/HFR- .76 and .24
SD1/SD2- .52 and .56 (not much change, granted)
Sample entropy 1.67 and 1.88

(Brief primer: LFR/HFR stands for Low Frequency/High Frequency HRV. If this decreases, it is interpreted to mean that the stress response in decreased. So decrease in LFR/HFR=decreased stress. The other measure SD1/Sd2, is a nonlinear method, if this ratio increases =decreased stress.)
(For more info on my practice, please click here, for information about stress and acupuncture please click here.)

Severe Thoracic Spine Pain in a New Patient

I was off last week, trying to squeeze in a few vacation days, but ended up seeing an emergency patient who was desperate for some alternatives. He is a young man, 25, with chronic back pain on Methadone, Vicodin and Valium. He is able to work at his desk job in spite of the pain and medications, but landed in the Emergency Room on 8.8.11 at 2:00 a.m. due to out of control, severe, 10 out of 10 thoracic back pain. They gave him some Dilaudid and he made it home, but called me "in extremis" and so I agreed to see him.
(Brief primer: LFR/HFR stands for Low Frequency/High Frequency HRV. If this decreases, it is interpreted to mean that the stress response in decreased. So decrease in LFR/HFR=decreased stress. The other measure SD1/Sd2, is a nonlinear method, if this ratio increases =decreased stress.)
He was tearful and shakey , and was extremely tender to the touch in a swath 8" wide from T9 to L1. He appeared to have some muscle spasm from inspection and light palpation. I did an acupuncture treatment that was aimed at general pain reduction and to decrease his stress response. I also treated the spine above the level of the pain, since that can sometimes affect the lower area without aggravation. I did some moxa on the affected area. I also monitored his HSoRV after needle placement. The initial trend is pictured above. The LFR/HFR from the 60-360 second versus the 360 to 660 segment were .96 to 1.18, which does not show a stress response reduction. But his nonlinear analysis shows an increase in his SD1/SD2 from .23 to .41, which is significant and his Sample Entropy increased from 1.23 to 1.63 which is definitely positive and suggestive of a decrease in his stress response.
When he returned to clinic on 8.11.11 his pain level was a 5 out of 10 and had been able to sleep, finally, after his treatment on the 8th.
This is how his LFR/HFR looked on 8.11.11. A more dramatic decline than on the previous run, but similar. His numbers were
LFR/HFR .23 for the 60 to 360 segment, and .16 for the 360 to 660 segment. SD1/SD2 were .5 to .65 respectively. Sample entropy unchanged 1.59 to 1.62. So we'll how he did clinically when I see him today.

Heart Rate Variability in the Acupuncture Clinic

Hi all.
Here is my abstract I'm submitting for an Acupuncture Research Conference in the fall. I hope they accept it. If so, I'll have a poster presentation, the lowest rung of a research presentation, but they're fun to do. Wish me luck! (Other research, on same topic of course, here.)

Heart Rate Variability Analysis in the Acupuncture Clinic: Correlation with Clinical Outcomes

Kristen Sparrow, MD

Private Practice

San Francisco, California

Background: Heart Rate Variability (HRV) analysis is a non-invasive method of assessing autonomic tone and has been studied in conjunction with acupuncture in a number of contexts. Poor health outcomes such as impaired immunity, lowered pain thresholds, mood disorders, and even accelerated aging accompany chronic stress. Acupuncture has been shown to lower sympathetic tone and enhance vagal activity, i.e decrease the stress reponse.

In contrast to the research setting, there are time and efficiency constraints in the private acupuncture practice. In addition there can be monitoring artifacts which make frequency and time domain HRV analysis impractical and unreliable. The author hypothesizes that analysis using nonlinear analysis in addition to the aforementioned analysis methods will give a more sensitive and dependable evaluation of the patients’ autonomic state and show a more consistent correlation with clinical outcomes.

Objectives:

1. Assess the feasibility of evaluating HRV across time, frequency and nonlinear domains in the acupuncture clinic setting.

2. To compare intra-treatment HRV response in patients who have positive treatment outcomes to those who do not.

Design, Setting, and Patients: Case study of 20 patients presenting to a private acupuncture clinic, representing 80 treatment sessions.

Intervention: All patients received body acupuncture prescribed by the tenets of Traditional Chinese Medicine. HRV data was collected after needle placement for 20 minutes using J and J Engineering I 330 2 Biofeedback Device. . HRV data were analyzed after each treatment.

Main Outcome Measure: Patients were assessed by symptom resolution. Their HRV data were compared for the time frames “a” (60 sec to 360 sec) and “b” (360 sec to 660 sec) using Kubios shareware for the following:

1. Time series: pnn50 %

2. Frequency Domain: FFT (LFR/HFR) ratios and HFR%

3. Nonlinear results: Poincaré Plots (SD1/SD2) and Sample entropy

Results:

Patients who responded to their acupuncture treatment tended to exhibit a decrease in LFR/HFR in the segment “a,” compared to “b” by at least 30% and/or an increase from “a” to “b” in the nonlinear measurement SD1/SD2 by at least 20%.

Non-responders, or patients who were aggravated by a particular treatment tended to show no change or an increase in their LFR/HFR from “a” to “b” and a decrease in their SD1/SD2 from “a” to “b.”

Conclusions: In this study the correlation between increased HRV suggesting vagal enhancement during acupuncture treatment and positive response to acupuncture was supported. Use of nonlinear analysis in addition to frequency domain measures added to the sensitivity of HRV outcome measures.

Dutch Study: Patients whose GP knows Complementary Medicine Have Lower Costs and Live Longer

To be filed in the "First, Do No Harm" category...
Eur J Health Econ. 2011 Jun 22.
Patients whose GP knows complementary medicine tend to have lower costs and live longer.
Kooreman P, Baars EW
Department of Economics, Tilburg University, Warandelaan 2, 5037 AB, Tilburg, The Netherlands, p.kooreman@uvt.nl.
Abstract
BACKGROUND:

Health economists have largely ignored complementary and alternative medicine (CAM) as an area of research, although both clinical experiences and several empirical studies suggest cost-effectiveness of CAM.
OBJECTIVE:

To explore the cost-effectiveness of CAM compared with conventional medicine.
METHODS:

A dataset from a Dutch health insurer was used containing quarterly information on healthcare costs (care by general practitioner (GP), hospital care, pharmaceutical care, and paramedic care), dates of birth and death, gender and 6-digit postcode of all approximately 150,000 insurees, for the years 2006-2009. Data from 1913 conventional GPs were compared with data from 79 GPs with additional CAM training in acupuncture (25), homeopathy (28), and anthroposophic medicine (26).
RESULTS:

Patients whose GP has additional CAM training have 0-30% lower healthcare costs and mortality rates, depending on age groups and type of CAM. The lower costs result from fewer hospital stays and fewer prescription drugs.
DISCUSSION:

Since the differences are obtained while controlling for confounders including neighborhood specific fixed effects at a highly detailed level, the lower costs and longer lives are unlikely to be related to differences in socioeconomic status. Possible explanations include selection (e.g. people with a low taste for medical interventions might be more likely to choose CAM) and better practices (e.g. less overtreatment, more focus on preventive and curative health promotion) by GPs with knowledge of complementary medicine. ...

Houston Lawyer Suing over Faulty Hip Prostheses

Per my previous post about the Medical Device Industry trying to quash new regulations, there is this story.
A Houston Lawyer is suing a subsidiary of Johnson and Johnson over hip replacement prosthetic devices that were supposed to last 15 years, but resulted in metal on metal friction that could lead to bone and tissue deterioration. That deterioration, if not caught early enough, could make it much more difficult to successfully replace the faulty hip.
Of course, we also know that there has been a decades long push by corporations to do away with this sort of mass action litigation with something called "tort reform." (See the movie Hot Coffee.) So between trying to do away with regulation, and simultaneously doing away with being able to have your day in court, I guess we'll all just be on our own. (info on my practice here.)

HRV in Post Stroke Patients Teleacupuncture Analysis

This study is from the same group I've linked to and discussed here, here and here. This is Part 1, so I'll be looking forward to their further studies coming up. There is the added advantage that you can view the entire journal article online.
What they found is that using acupuncture on one single point, pericardium 5, on one side lowered increased HRV. (For further information about my practice and research .)

Results. Acupuncture does not change heart rate in the post-stroke patients; however, total HRV increased significantly (P < .05) during and 5–10 minutes after acupuncture. In addition, balance between sympathetic and parasympathetic activity (low frequency/high frequency HRV ratio) changes markedly during treatment. Conclusions. Based on innovative HRV analysis, it could be demonstrated that teleacupuncture between China/Harbin and Austria/Graz over a distance of about 8,500 km is no longer a future vision; it has become reality."

Why it's always "Little" Old Ladies

I was dismayed to read the results of this study since I'm 5'10" tall, and my girls are both 5'9". That would make us at a 30% higher cancer risk.

Risks: Women’s Cancer Risk Increases With Height, Study Finds
By NICHOLAS BAKALAR

The taller a woman is, the greater her risk for cancer, a large study has found.

Researchers at the University of Oxford in England analyzed data on more than 1.2 million British women followed for an average of 9.4 years. There were more than 97,000 cases of cancer among the women. The researchers found that for each four-inch increase in height over 5 feet 1 inch, the risk that a woman would develop cancer increased by about 16 percent.

On the other hand, we all have allergies, link here, so maybe we're not doomed to die prematurely after all. (Studies suggest that people with allergies have an over active immune system, which is a nuisance resulting in hay fever, rashes and the like, but is protective against certain cancers.) Also on the positive side I also only gave the kids organic milk from very early on because I was worried about the hormones in the milk, and now growth hormone does look to be implicated. AND I try to keep my intake of animal protein to a minimum, and one of my daughters is a strict vegan, which should help also. I always wondered why the term was "little" old ladies, and assumed it was because of general shrinkage with the years, but maybe there's more to it??