Noteworthy: A Salty Problem; Apps to Recommend to Your Patients

A Salty Problem

Nanny-state proponents often justify policies of government supervision as necessary to save lives in a dangerous world. The smoking bans, the seat belt and helmet laws, the excise taxes on everything from booze to sugar - it's all necessary to help people make "better choices" and live healthier lives.

And the science proves it, they say. Rarely do such proposals come without a stack of studies suggesting that if people just did more X or less Y, Y number of lives would be "saved."

But sometimes the science seems to get ahead of these efforts.

Take salt, for example. New York City Mayor Michael Bloomberg is among those proposing policies aimed at reducing people's sodium intake. Salt is the latest enemy of public health advocates, who have waged war in the past against businesses that produce and sell food and other products high in calories, fat, trans fat, saturated fat, cholesterol, various carcinogens, and alcohol. The theory: salt is responsible for high blood pressure and heart disease, so it must be purged from restaurant menus and prepared foods.

But a study of the relationship between sodium intake and blood pressure, as well as deaths from cardiovascular disease, published recently by the Journal of the American Medical Association, is complicating these arguments. The study concluded that "moderate salt intake might be no problem and that for many people, diets very low in salt could be a recipe for trouble," as NPR.org put it, adding: "the increases in salt and diastolic [blood] pressure" among those with higher sodium levels than the control group "were not associated with an increase in deaths from cardiovascular disease, such as heart attacks and strokes. Indeed, people with less salt in their urine were more likely to die from cardiovascular causes." The study in Europe followed about 4,000 people over 25 years.

The study is causing consternation in the nanny state. Many of those committed to salt-reducing public health policies are questioning the findings. The debate will continue.
But perhaps we can just pause a moment to allow the science to catch up with the advocates' declaration of the latest public health crisis and the need for government intervention to correct it.

Apps to Recommend to Your Patients

We hear often from physicians who love the apps that they download to their smart phones. Articles on the best apps for docs are always among our most popular tech-oriented articles. (It's so much more fun than reading about EHRs, isn't it?)

So we've been wondering: How often are physicians recommending mobile apps to their patients as tools for improving their health?

If you're a doctor who hasn't had time to navigate the world of mobile apps, here are some great suggestions for ones that are more than just waiting room time-killers:

• iMedicalapps.com recommends iTriage (for iPhone and iPad) to track symptom- and disease-based medical information. It also allows patients to check out healthcare providers. MGMA also gives this app a thumbs-up.

• MGMA's bloggers also recommend MedsLog, an iPhone app that helps patients remember which medications to take, when to take them, and when to refill prescriptions. Missed a dose? There's an alert for that.

• Another winner for both patients and physicians is Quick MT, a quick medical terminology and abbreviation reference app for iPhones that features a searchable database for medical terms.

Just spending a few minutes browsing the medical apps section of the Apple app store reveals programs to track a baby's growth and vaccination dates, learn the musculoskeletal system, and monitor ovulation and fertility. And it's not just iPhones, anymore. Every web-enabled smart phone comes with an app store and healthcare-related applications are among the most popular for developers to create because everyone wants them. Ontrack, which helps diabetic patients track blood-glucose levels, and Cardiotrainer, which helps ordinary people track their exercise levels, are popular Google Android-based apps.

When patients see a smart phone attached to your belt, don't be surprised to get questions about which apps they should download.

Private-Office Healthcare Jobs

Perhaps politicians looking for a solution to the jobs crisis should look to an industry they've been focusing on changing for the last decade: healthcare. More specifically, they might want to look at office-based physician practices, which supported 4 million jobs in 2009, according to new AMA data.

The association's economic impact analysis, partnering with The Lewin Group, titled "State-Level Economic Impact of Office-Based Physicians," provides information on the economic impact of office-based doctors in all 50 states and the District of Columbia, of which there were 638,661, as of October 2010. Among the findings:

• Private practices contributed $1.4 trillion in total economic activity in 2009, or the equivalent of 28 million people making $50,000 annually.

• Private practices in the median state supported more than 46,400 jobs per state, including clinical and nonclinical jobs. On average each office-based physician supported 6.2 jobs across the nation, including his own.

• Practices paid out $833 billion in wages and benefits. Furthermore, on average, each office-based physician supported $1.3 million in wages and benefits nationwide.
• Let's not forget the taxes paid by these offices - physicians' offices nationwide supported $63 billion in total state and local tax revenues in 2009; that's $100,000 per physician on average.

The report, and the AMA's Economic Impact Study website, also provide summaries for each state and D.C., indicating number of physicians, economic output, jobs, wages and benefits, and taxes per area.

The report does not, however, discuss the possible impact of the Affordable Care Act, including initiatives such as accountable care organizations (ACOs) and medical homes, which some see as spelling the end of smaller office-based physician offices.

Hungry Judge, Hangin' Judge

Next time you decide to fight a speeding ticket, try to have your case heard first thing in the morning or right after lunch. Or just bring the judge a snack. A study of 1,000 parole decisions by a group of Columbia University students found that the hungrier the judge, the tougher he tended to be on defendants. The students observed courtroom proceedings for 50 days and found a consistent correlation between time since the judge's (presumed) last meal and the judge's stinginess with parole decisions. In the late morning and late afternoon, as the munchies crept in, judges were less likely to grant parole and were more likely to insist on tougher parole restrictions.

Your ACO Future?

In the months since CMS released its prosaic ACO proposal, questions have run the gamut from how the shared-savings program will work to what kind of technology private practices will need to participate in an ACO.

But to get some insight as to what the future really holds, one may not have to look further than the hospital(s) down the street. After all, hospitals will be at the center of just about every ACO.

"Hospitals are going to want partners who have good outcomes and who are efficient in their use of resources," said Christina Thielst, a freelance hospital administrator and consultant based in Santa Barbara, Calif. "They're going to look at their internal data, as well as others'' external data, so they can identify good partners."

That said, many hospitals - while interested in buying practices, perhaps - have not yet embraced the idea of forming the kind of ACO that CMS describes in its proposal. Many hospitals see barriers that are still a bit steep, says American Medical Group Association President Don Fisher, whose association mostly represents providers in larger healthcare organizations.

Lisa Grabert, the American Hospital Association's senior associate director for policy, noted that one of the big concerns her organization has is the ACO proposal's lack of a "partial capitation" payment plan, which "would allow you to receive some money upfront, which is a big concern for everyone," said Grabert. "It isn't in there."

One suggestion: "There needs to be a way for physicians in small and solo practices to come together with other providers to form the entity required to contract with the Medicare shared savings program," the AHA says in a letter to CMS. "The historical approach to creating such an entity is the formation of a physician hospital organization that combines providers without physicians having to become employees of hospitals, but there are other more contemporary models, such as health networks, that could be viable."

Roach Motel

During a routine colonoscopy at the Albert Einstein Medical Center in Philadelphia last year, a cockroach was discovered in the patient's transverse colon, according to a recent article in the journal Endoscopy, which also reported while other, smaller, insects had been found in patients' colons over the years, this was the first cockroach.

Trouble Among Surgeons

The publication Surgery News, which bills itself as the "official monthly newspaper of the American College of Surgeons," replaced its editor and retracted its entire February edition after the publication of an editorial that many saw as chauvinistic if not downright misogynistic.

When people who are not funny try to be funny, bad things often happen. But when amateur comedians - especially those with regular day jobs, real influence, and important reputations to uphold - dabble in "controversial" humor, well, that's how raging controversies are born. Such were the errors of Lazar J. Greenfield, who, as editor of Surgery News, wrote a breathtakingly foolish "Valentine's Day" editorial that touts the mood-enhancing effects of unprotected sex on women. Greenfield, of the University of Michigan, attributes these supposed benefits to the chemical properties of semen, adding "now we know there's a better gift for [Valentine's] day than chocolates."

Ugh. Greenfield apologized. But apologies were not enough and he resigned his editorship, as well as his post as the College's president-elect. Still, even these steps were not enough for some female surgeons, who told the New York Times that Greenfield's editorial merely underscores a macho culture within the surgical professions. Colleen Brophy, a professor of surgery at Vanderbilt University, told the times that "the way the college is set up right now is for the sake of the leadership instead of patients."

Quotable

"As consumers, we pick up on a lot. We see body language, mannerisms, a raised eyebrow, a shrugged shoulder; things the provider doesn't see and may not know he or she is doing."

Leonard Berry, business professor

Stat

13 %: The percentage of patients who changed doctors in the last year.

71 %: The percentage of doctor-switching patients whose decision was based on something other than economics, such as their relationship with their physician.

Source: 2010 U.S. Survey of Health Care Consumers by the Deloitte Center for Health Solutions

This article originally appeared in the June 2011 issue of Physicians Practice.