MINNESOTA PROVIDER TAX- PREVIEW

This weekend I want to tell you about a special tax on physicians and dentists and other health care providers. We like to think in Minnesota that we are pretty progressive, we have a special tax to help cover the uninsured, to help make sure everybody in Minnesota has health insurance.- Lots of people in Minnesota do not have health insurance though. It is not new, it has been around for a really long time, since the early 1990's. Most people in Minnesota do not know it exists. Most people in the United States do not know it exists. Lawyers do not have to pay it. Plumbers do not have to pay it. Teachers do not have to pay it. If you are a physician, but don't take care of patients, you don't have to pay it. If you are a physician and you derive income from taking care of patients, you must pay it. If you are a physician and you are salaried by a larger institution, your institution typically picks it up.

It does not exist in other States in the Union....................

PART 2 - the rest of the New York Times blog comment submission-Unpublished

"For any clinician, it is profoundly frustrating not to have more effective meds. Although, until there is essentially a cure for AD the debate of how effective a med truly is will probably wage on. Aricept has been available for almost fifteen years. Last I checked the Federal Employees at the FDA do actually consider study design when reviewing the data. Why would the government whom we trust to take an active role in fixing the broken health care delivery system approve a useless med, or a dangerous med?

The article pays little attention to the inequities of Medicare, in covering Aricept which seems counterintuitive since Medicare has been used as a model and a benchmark for government run health care, or at least much rhetoric has been paid to this in the last three months. The article does simply imply that we need to put our resources elsewhere instead of into cholinesterase inhibitors.

In 1979, my mother at age 62 was diagnosed with AD. My family began to fall down the “rabbit hole” (as the author refers to it) of AD. I was seventeen years old and the Alzheimer’s Association was not even incorporated yet. It was still three years before National Alzheimer’s Awareness week began. AD was not a household word. I do strongly believe that I would have wanted to take the chance even at 20% odds of using one of these medicines to slow the progression of AD. One month or one day or one hour for most families having a more lucid conversation and the sparkle of their loved one present is well worth it. That for some may be a bit too humane and not utilitarian enough.

As a physician I have seen these medications albeit temporarily, improve one’s cognition, not just in Mini Mental status points but by patient and family report. That is significant. Is there utility in this? Yes from a humane standpoint. I have treated many patients, where the side effects are problematic and the medicine is discontinued. Those are simple reasonable facts and follow any standard of care. Is it easy to find families whom are angry because the med did not work? Of course it is, given the nature of the disease and the limitations of current pharmacotherapy. Doctors and meds and by default the giant nefarious drug companies get blamed as much or more as the disease process. This seems to be human nature and roughly parallels the decline of the physician-patient relationship and the uptick of the “consumer-provider” relationship in health care.

These types of articles further detract from the ancient physician healer- patient alliance. They seem to create more apathy towards AD that is already present in many physicians in the medical community, given the ultimate futility in stopping the disease with current treatments.

There really are few clinical scenarios that do not warrant a trial of these medications. The main reason to withhold a trial of these meds is about cost. With that said, we should stop denying our priorities and simply start rationing care. After all AD is fatal anyway.

Does the pharmaceutical industry spend ungodly amounts on marketing and advertising? Absolutely. Perhaps we can simply eliminate this. Perhaps the revenue used in Research and development can be shifted over to the government. Perhaps the government should take over the pharmaceutical industry.

In regard to research, the article did not cover how much the drug industry does spend on R&D. Moreover it did not cover the relatively minimal spending on AD research at the federal level. For example, compare AD to HIV and AIDS related illness. AIDS takes the lives of about 14,000 people a year. AD kills about 72,000 people in the same time period. Federal Funding for Research according to the Kaiser Foundation in 2006 was about 2.6 billion dollars for HIV/AIDS for direct research. Spending on AD research at the level of the NIH is about 659 million. (One quarter of the research dollars while killing five times as many people)

Perhaps we need a more utilitarian approach to rationing care, except it seems like research has already taken that approach. Is it any wonder why we don’t have better meds for AD?

As far as direct to consumer advertising, it is a well known and researched fact that most doctors do not approve of this. The debate on DTC advertising is 50 years old and stems from 1962 and the Kefauver-Harris Amendment to the Federal Food, Drug and Cosmetic Act. The issues of false and misleading advertising and fair balance were addressed back then. In the early 80’s the FDA placed a moratorium on DTC later to be lifted in 1985, with slightly more rhetoric in the guidelines. Perhaps the only positive byproduct of DTC advertising is that it has helped increase awareness. Increased awareness at least generates these discussions. Compare AD to Lewy Body Dementia (about as common of a household word as AD was in 1980). There are not a lot of meds in the FDA pipeline developed to treat LewyBody at this time.

The only aspect of the article that is not as misleading as the TV commercials themselves is the fact that the author has never had a close family member affected by the “rabbit-hole” of Alzheimer’s disease.” From that standpoint the tenor of the article makes good sense. My hope is that some day no person or family shall have to suffer through the devastation, havoc and heartache of Alzheimer’s disease. Right now this article proves that in the collective unconscious of America our hearts are not in the right place in moving towards this ideal."

Joseph J. Sivak MD

New York Times Blog comment submission-NOT published (part one)

Here it is, the comment the NYT health blog did not see fit to print. It is kind of lengthy and I am sure that may be one explanation as to why it was not fit to print. As one can see if you read the entire article and posts, my comment clearly takes on a slightly different opinion and perspective. Luckily, the blog comments before my comment are fair and balanced, and their is no hint of of any quashing of any implied views that might not be in keeping with the PHILOSOPHY of the health blog.

PART ONE:

"The article does not really present data, but opinions. Unfortunately the one sided opinions are about as leading and one sided as the Aricept TV commercial. The commercial seems to create visceral reactions in some that may have more to do with ambivalence towards one’s own mother rather than the treatment of Alzheimer’s.

It is well established in the scientific community that Alzheimer’s was discovered 100 years ago, and it is a progressive neurodegenerative disease that destroys neurons in the CNS specifically at the level of the cerebral cortex. The disease process happens to target cholinergic neurons. Acetylcholine has many functions within the nervous system. Memory is one of the many important functions. This is basic physiology and should not be dismissed. What is not understood in the clinical and research world is how and why this happens. Since acetylcholine has various other functions, artificially providing an influence through medicine on this neurotransmitter, can cause positive effects as well as side effects. Just about every pharmacological agent used in allopathic medicine and for that matter naturopathic, has potential benefit and risks (side effects) there are not many physicians who are interested in hurting their patients or causing more suffering through side effects. That is a concept that is instilled in the 15 year indoctrination process of becoming a doctor. It starts well before medical school.

Aricept is one of four cholinesterase inhibitors available to treat AD, Three are commonly used and one is even available generically. They simply work by blocking the enzyme cholinesterase that naturally occurs and is used to breakdown acetylcholine in the normal physiological equilibrium process. AD is not a normal equilibrium so there is a net loss of acetylcholine producing neurons. Using these medications has a net effect of keeping more acetylcholine around for longer. Since it is used in memory it may help with cognitive decline as well as have other potential side effects at many levels outside of the brain. These are the limitations of most modern meds.

Namenda has a different mechanism of action working to regulate the neurotransmitter glutamate at the NDMA receptor, resulting in a slowing of cellular destruction, and hence some preservation of memory for a relatively and varying period of time.

The degenerative process of AD is highly variable from person to person, like many diseases. The medicines do not work for everyone, and it is dogma that they do not stop AD or reverse the progression. In many patients it may slow the dementia process to one degree or another. Patients and families devastated by this disease need and want hope. It is easy to develop false hope through these meds. I have had the discussion with many patients and families over the years presenting the realistic expectations to families and essentially bringing down those unrealistic expectations that families develop about the medicines. Any competent physician that treats AD has been involved in this dynamic of setting expectations realistically."

Censorship?

I posted a comment to a New York Times Blog a couple weeks back. The NYT's decided apparently it was not publishable. It's interesting because there is tremendous variation between blog sites, comments and what apparently gets published on the internet. There are certain guidelines, and obviously certain things can not get published. Posts containing profanity, pornography, etc, would be deleted on most blogs. That makes sense. That is intuitive. However past all that, there is the issue of content that may not agree with the agenda, of the blog or the publisher.
The internet has blown things wide open. It is now considered like the old Wild West. No real clear laws on content etc. Do anarchy and power and money prevail? How ironic in a most politically correct world.
Where do we get our news? TV, newspapers, opinion polls? What I am wondering is if there was ever a time, when a reader got an objective news opinion. Things are slanted to the political right or left, Fox News and CNN and MSNBC fight it out. There is lots of money and power on both sides.
Interestingly enough, since the internet is wide open and someone expresses an opinion that the blog host or publisher might not agree is in keeping with their views, is it ok, to block it, to censor it?
What is the purpose of censorship? -To shape the minds and hearts of the people? What is the purpose of that? To control people like puppets?
Such things as book burnings by the Nazi's rising up come to mind. The Bolshevik revolution in Russia a century ago comes to mind. I think this was censorship. I think this was trying to control people and shape their opinions. In 21st century America in the political battles between the right and left how do we get our news? What does the internet mean? Everybody gets to have an opinion now. It is as simple as point and click.
I visited Communist Russia in 1988, right at the crux of Glasnost and Perestroika, I can tell you that the average citizen in the Soviet Union was not doing well economically, they were pretty beaten down. This is from first hand accounts of talking with Average Citizens. In fact one of the people I met, showed us his apartment, took us to a restaurant. We talked for hours. Ironically this person had been a journalist and lost his job because he was writing unpopular opinions. He had to take a job as a barber, and had his salon at his house, a small 6' by 10' room concrete floor that looked like a cave at his apartment. It was pretty sad. I wonder if good journalists that hint at publishing something not in keeping with the political views of the establishment loose their jobs in America in the 21st century.
Another interesting example is that long before the internet, there was a publication called Mother Jones’s magazine. It was considered to be very left by most readers. From what I got out of it, back in the day the left was considered too be pretty close to pro-communist. Interestingly after the Tiananmen Square uprising in 1989, (remember the Chinese guy standing in front of the tank, blocking it and risking his life) The student uprising was considered to be pretty anti-communist. It seemed like the magazine was all over this in support of the students. Yet this was anti-communism. As a reader it confused me. All I could take from it, was that the politically correct view was to side with the opinion of the oppressed, the underdog, - that seemed ok to me.
How do we get objective news? How do people assert their opinions?
Arguably from an intellectual standpoint, it has always been "cool" to be on the side of the left. It gives the appearance of sophistication, being "well-read" and you look way cooler at cocktail parties. You are thinking out of the box, you are non-conformist; you have intellectually "arrived". Interestingly enough, being non-conformist is simply a way to attract attention to oneself, and after a point nothing more than pathological narcissism. Are intellectual minds shaped and overridden by this? How ironic?
Can we think for ourselves, or are we busy thinking we are standing up for the underdog, so we can hold court with our editors, our students, our colleagues at the cocktail party. Perhaps we are deluding ourselves. Perhaps censorship in America in the 21st century does not exist. Who actually decides the political views of a billion dollar industry or publication? Some rich guys with several big houses? How ironic. Not very politically correct.
In 1988 Soviet Union, still very communist, I found that the "party bosses” had an awful lot of privilege that the average citizen did not have. Ironically we complain about our capitalist society politicians having privilege that the little guy does not.
Right or left: Do money, power, greed and connectedness always prevail? Does pathological narcissism always override?
I will post a link to the blog from the NYT; it was about meds and treatment for Alzheimer's disease. It was to me, more opinionated than objective. It painted a certain picture. I believe my comment that was not published was not in keeping with the painted picture. I will publish that tomorrow. It is all simply opinions, and the New York Times is allowed to do what they want with their blog. Fair enough. It is just kind of sad, because arguably the NYT's is kind of powerful and I would have thought all opinions count. Mine was probably too long.
You can judge for yourself.
Remember it is a link address to a NYT's blog. God forbid: I would never cut and paste anything from their blog. We get into lawyer stuff then.
Tomorrow when I post my comment on this blog, (my comment the NYT's did not see fit to print) remember it is just my views, and at this point in America, I am still allowed to own my own views. Thank God the NYT's is a private sector in the United States in the 21st century and allowed to publish what they want.
Here is the web address from NYT blog -topic Alzheimer's
If you can't get in the post was from Aug 5, 2009. Author is Jane Gross, titled "The New Old Age Hope With a Deductible" (Under Health tab Go to blogs)

http://newoldage.blogs.nytimes.com/2009/08/05/hope-with-a-deductible/