Raymond Kordonowy comments on a recent article in Forbes concerning the shortage of primary care physicians stemming from the pay disparity between specialists and primary care, "The Best- And Worst-Paying Jobs For Doctors",

"On physician payment. The system of payment for physicians has become pegged to the Medicare fee schedule. In appx 1993 Medicare’s program stopped allowing physicians to bill above the allowed fee schedule for covered services (virtually everything is codified). When the RVU system was designed, office evaluations were assigned some of the lowest reimbursements. High tech stuff and procedures got paid more generously (and most likely they should have). The disparity in physician pay is a result of nearly 2 decades of price fixing which now involves all payers. Office evaluation has gotten much more complex and burdensome but the RVU system hasn’t made the proper accounting. Furthermore the demand side of this equation (magnified immensely due to minimal out of pocket per visit costs) has outstripped the supply side (primary physician availability and new trainees is at all time low). As long as we don’t allow a true pricing mechanism for health care services we will continue to see very lopsided earning potentials,unsatisfied customers and dissatisfied providers (in some cases). Overpayment of some fixed prices will drive overuse and underpayment will result in loss of services. Low pay will translate to a loss of that type of provider. This is very poor economics applied real world in the good ole US of A. It is no surprise to me as a provider that the country continues to be choking over what it is paying for health care- the model of payment is predictably flawed. The latest nonsense of ACO’s and shared cost risk will make it even worse."

High blood pressure patients: A recent study confirms that monitoring your blood pressure at home is important for best outcomes and prescribing decisions.  IMSWF physicians for many years now have recommended this approach. Patients documenting home blood pressures and reviewing that information in the office helps the doctor to make better decisions about whether more or less medication is needed to treat your blood pressure.  
http://www.annals.org/content/154/12/I-23.full

I recently read a book titled "Two Days That Ruined Your Healthcare." In its 96 easy-to-read pages, Dr. Waters explains the start of our healthcare problem and the fallacy of false economics that is promoting it.  I couldn't have said it better and I congratulate him on his precise book.  One particular excerpt from chapter 8 titled: Gresham's Law Strikes Health Care poignantly supports the comments I made in the guest opinion piece  I penned earlier this year. 

He states "Gresham's Law holds that bad money drives the good out of circulation. It appears that the law is now at work in U.S. medicine... Confusing ambivalence aside, equal pricing in our society will surely sooner or later lead to equal services. True, the physicians with embedded patterns of excellence may live out their time because they can't bring themselves to jettison superior habit patterns in favor of the new order. Some stalwart hospitals will also naively refuse change-until they declare bankruptcy or are purchased by a larger, more "economically enlightened" system. Patients affiliated with these "vestigial remnant" doctors and institutions be well advised to stick with them as long as they last. They are after all the venerable coin of the realm. Indeed, it might be postulated that the healthcare standards in the U. S. dangle even now by these fragile threads... the "mediocrity lag phase"- the gap between outmoded excellence on the one hand and the practical economics on the other."

What the above information is saying is that because our system has set the prices for services (the bad money), we can eventually expect the differences in quality to go away and we will get what we pay for.  The idea of excellence (the good money/currency of high quality services) will be eventually brought down to the common denominator that is determined by the fixed price.  We are witnessing this happen as we speak - I stated before that  the system doesn't distinguish between a specialist, physician, board certification, or PA for physician (supervised) services- in the eyes of Medicare (and also the insurance payers) it is all paid equally.  This is why your specialist and physicians are placing extenders in their place. Sooner or later even the old dinosaurs like myself who have been holding out will have to either fall to the wayside or provide the same equal product that the fixed prices are creating.  I have been becoming painfully aware of these forces coming to bear especially in the past few years. 

I highly recommend you read Dr. Water's book and get a much more clear understanding as to why all the rhetoric about equating health care to health insurance is missing the point.  Health care starts with competent physicians, nurses, hospitals and extended care facilities, not a health insurance policy. That is the fallacious starting premise that our politicians make and the public is being duped into believing.  We need free market forces in health care. It works for all other services and it will work for health care as well.

Recent cancer report shows cancer death rates are declining signficantly in the United States.  See the following link to read further. http://www.cancer.org/Cancer/news/News/annualreport-u.s-cancer-death-rates-decline-but-disparities-remain

Feel free to visit the April/May IMSWF newsletter on our website to learn more about: What an internist is, alcohol and caffeine, the new "Patient Portal" otherwise known as Online Patient Access, and a delicious recipe for Chicken Vegetable Soup from from Better Homes and Gardens New Cookbook.

The FDA has approved Zostavax for patients 50 and older
(http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm248390.htm).   

Prior to this the vaccine was available for patients 60 and older. 

Read the following link which summarizes the study that helped in this decision:   http://www.internalmedicinenews.com/index.php?id=495&cHash=071010&tx_ttnews[tt_news]=53263

Internal Medicine of Southwest Florida will be offering free protein shakes at our office next Thursday, April 14th at 2PM. 

Dr. Kordonowy's March, 2011 newsletter featured successful weight management in his second article.  He has personally found benefit using Pureweight premeal beverage.  He has recommended it for several patients and it has resulted in successful dietary weight loss- naturally.  We would welcome more people to consider this option to assist in managing their weight and appetite.  This taste session is an opportunity to taste this product as well as the full line of meal replacement/protein supplement products from the Pure Encapsulation line. 

Marcy Russo, registered dietitian will be starting this session and Dr. Kordonowy will come in to answer any questions folks may have about the product line as well as dieting in general.  There will be a brief talk and/or video on protein and the diet.  This is a chance to taste these products without spending any money.  We will raffle unused product and so you may become a winner and chose your favorite product to take home.  We will limit this session to the first 15 people but will plan further sessions if there is more interest than this.  You may reserve your space by calling the office and speaking to Sarah to be place on the list ( 275-0040 ext 209) or you may register on your computer.

The event will include a raffle for free Pure Encapsulations Protein Supplements!  Also, as a perk for attending the event you can get a 25% discount on the protein products!

This is an opinion piece I wrote to the Fort Myers News-Press concerning an article they recently wrote titled, "Patients hit with add-on charges," by Frank Gluck, The News-Press, Jan. 23.

"Drs. Douglas Henricks and Rob Simmons are my practicing partners. Frank Gluck's article suggested their recent patient contract offers were violating health insurance companies' contractual "rules." I wish to clarify to the public that our group does not have contracts with private health insurance companies, and thus their rules do not apply.The contracts recently offered to patients by my partners are voluntary and not new to the local market. Such payment offers are widely used in Naples and have been for several years. Many patients have been asking for such concierge service and thus there is consumer market pressure to offer this. Several years ago, we canceled private health insurance contracts because of inadequate reimbursement and ever-expanding controls/regulation being place upon our work. Presently, the system is setting physician fee schedules, not distinguishing quality and at the same time increasing the workload of patient care. Denial of physician-ordered care results in more office and physician time (through exception requests and other authorization processes) which is not covered by the current fee schedules. Cost savings to the insurance companies that result from denials have yet to materialize in the form of less expensive premiums.

In my 18 years of practice, I haven't seen premiums go down one single time.

At the heart of the matter is that Medicare is setting the fee schedule for physician evaluation and management. Medicare does not negotiate fees with physicians; it mandates them. Medicare does not distinguish whether the care is provided by a sub specialist, board certified physician, physician assistant or a nurse practitioner - the payment is the same. There is no incentive to provide quality. These policies started in the mid-1990s and are resulting in a slow fall to the bottom for U.S. health care.

Private health insurance plans use Medicare's fee schedule as the benchmark for their contract negotiations. They actually are paying physicians even less in Lee County. Private insurers figure that if the doctors will work for the Medicare fee schedule, they need not pay any more than Medicare does.

Physicians do not need to apologize for expecting to be reasonably compensated for their time and expertise. The system's pay caps with ever rising demands and work lists is untenable. The latest health care law adds further regulation (longer work lists). I am concerned the system is going to fall apart.Mr. Gluck's article does serve to highlight that things are at a tipping point. Physicians should be allowed to set their own fees but Medicare should only subsidize patients what its budget allows. Patients would only pay for services that they personally use, rather than some of the patient group paying annual lump sums to subsidize the rest (basically what current concierge contracts accomplish).

I hope this commentary serves to awaken the public to start taking charge of how their dollars are being deployed. We should be offered properly priced insurance contracts which place the patients in the driver's seat for consumption. This means more "pay as you use services" options with a true catastrophic insurance policy as an option. This would keep unnecessary wasted resources from being used up and it would mean your insurance company would only enter the picture when you really had a significant health care cost.

We all pay for the maintenance of our cars and homes and only call on our insurance policies when there has been a wreck, flood or fire. It doesn't need to be any different for health care services."

A recent Italian study indicates a strange combination of melatonin, magnesium and zinc resulted in significant sleep outcomes in the elderly. This study was conducted in an institutional setting. Its small population size, foreign country study site, and weird combination makes this report a bit suspect.  I can't tell but this likely is a particular product likely being sold over the counter in the health food market. 

In other news...

A recent NIH study confirms that intense sugar control in the hospital is not helpful and may in fact increase low sugar episodes.  Combine this information with the increased cost, time and personel distraction that such protocols cause and patients at Lee Memorial Hospital System should question having sliding scale insulin protocols followed when they are admitted for acute illness and happen to have type 2 diabetes.

A recent Mayo study indicates that shingles recurs far more than physicians believed in the past.  There is a vaccine for shingles approved for age 60 and up.