30 November 2009

4-Week Decline In Flu-Like Cases

USA Today

Federal health officials reported Monday that cases of flu-like illness in the USA have declined for four weeks in a row, though hospitalization rates remain high, especially for children younger than 4.

The steady decline in the USA and elsewhere prompted the World Health Organization to propose Friday that swine flu may have peaked in North America, the Caribbean and parts of Europe, though the "winter influenza season continues to be intense."

U.S. officials challenged WHO's hopeful assessment, saying it is too soon to declare that swine flu is tapering off.

"We are certainly nowhere near the end," says Daniel Jernigan of the Centers for Disease Control and Prevention, noting that, even after the monthlong decline, "we're still above the peak we had last winter."

Jernigan says there also was a drop in cases at this stage of the 1957 pandemic, which appears to offer the closest parallel to today's outbreak. But flu cases and deaths rebounded after the Christmas and New Year's holidays. "The conditions that influenza likes – winter with people crowding together – haven't even come yet," he says.

Deaths of children continue to mount, the CDC reported, with a record 27 during the week ending Nov. 21. That's the highest one-week total since swine flu, also known as H1N1, was identified in April. Doctors have reported about 200 pediatric swine flu deaths to the CDC, which says many more deaths probably have gone unreported.

As of Monday, 66 million doses of swine flu vaccine were available for states to order, and more were on the way, the CDC's Thomas Skinner says.

U.S. Redoubles Efforts On AIDS / HIV


The United States, which is preparing to lift a ban on visits by foreigners infected with HIV, will host a global AIDS conference in 2012 as a sign of redoubled U.S. commitment to fight the pandemic, U.S. Secretary of State Hillary Clinton said on Tuesday.

"We have to continue to seek a global solution to this global problem," Clinton told a news briefing announcing the 2012 biannual conference would take place in Washington D.C., the first time it has been on U.S. soil since 1990.

The International AIDS Society, which organizes the conference, hailed the change and urged other nations that maintain bans on HIV-positive visitors to follow suit.

"The return of the conference to the United States is the result of years of dedicated advocacy to end a misguided policy based on fear, rather than science," IAS President-elect Elly Katabira said in a statement.

Clinton said the end of the ban on HIV-positive visitors to the United States, enacted 22 years ago, would take effect in early January and would be "vigorously" enforced.

Health and Human Services Secretary Kathleen Sebelius said the end of the ban was an important shift.

"It was a policy that tore apart families, kept people from getting tested, forced others to hide their HIV status and forgo lifesaving medication ... and most of all it didn't reflect America's leadership in fighting the disease around the world," Sebelius told the news conference.

The AIDS virus infects 33 million people globally and around a million in the United States, but more people are living longer due to the availability of drugs, according to a recent United Nations report.

However, more than half of the people who need life-saving drugs are not getting them, according to the 2009 AIDS epidemic update by the World Health Organization and Joint UN Programme on HIV/AIDS.

Cocktails of drugs can control HIV but there is no cure.

While the Obama administration has vowed to continue the President's Emergency Program for AIDS Relief or PEPFAR, launched during the Bush administration, some AIDS activists have voiced concern that the issue may not get as much attention as Washington confronts a raft of other global problems.

Eric Goosby, the new U.S. global AIDS coordinator, told the news conference that a full report plotting the future of PEPFAR would be issued later this week and would show expanded U.S. support for the world battle against HIV/AIDS.

27 November 2009

Using Technology To Improve Health-Care: An Interview With Humana CIO Bruce Goodman

Wall Street Journal

A lot has changed in the way the health-care industry uses technology since Bruce Goodman became Humana Inc.'s chief information officer in 1999. And, he says, there's still a lot of work to be done.

Mr. Goodman, who joined the Louisville, Ky., health-insurance giant amid the Y2K frenzy over the ability of computers to deal with a year ending in 00, sees both technical and creative challenges looming for his industry. His primary goal is to get doctors, patients and insurers fuller information more quickly.

Mr. Goodman recently discussed these challenges and more with The Wall Street Journal. Here are edited excerpts of the conversation:
An Echo of Y2K

THE WALL STREET JOURNAL: Do you think we'll ever see something like Y2K again?

Mr. Goodman:
The health-care industry is going to go through something equivalent to Y2K in a couple of years. There is a new code that the government is promoting around how you describe medical procedures called ICD-10. And that significantly expands the code set when a doctor describes what they have done for a patient.

So the old code said, "broken leg." The new code set gets much more specific as to exactly what part of the leg is broken and why it got broken. Tennis accident, skiing accident; it is really detailed.

You have got to go through all the systems where those kinds of codes are carried and expand those fields and bring in those new code sets. A lot of it can be automated. But it means remediating millions of millions of lines of code across lots of systems—systems hospitals use, we use, doctors' offices use. [When completed] it gives you more capability. You can do much more refined studies in terms of what is going on.

WSJ: How much freedom do you give Humana employees when it comes to using technology?

Mr. Goodman: They have a lot of freedom, but we are in a highly regulated business. We have some very confidential information about our members, and we are very sensitive to the level of security and the devices employees use. Our data center is attacked millions of times a month from the Internet. So we don't have our users using devices that can bring viruses and worms and Trojans and phishing expeditions into the mother ship.

WSJ: How can you tell which ones meet that criteria?

Mr. Goodman: For example, currently the Apple iPhone doesn't. It is not a secure enough platform where we would allow our highly confidential data to move. We tightly control laptops and other things that we give to our people. BlackBerrys, by the way, do satisfy the requirement, and we have those.

WSJ: What's the difference between the iPhone and the BlackBerry?

Mr. Goodman:
The main difference is that if you lose a BlackBerry there are ways of ensuring that if somebody else picks it up, they can't get into the network and access your private data. There is a way of basically shutting it down. It's much more challenging to do that on the Apple devices.
Reforming the System

WSJ: There's a lot of talk now about using technology to reform the health-care system. What have you guys done to date?

Mr. Goodman: You want doctors to use your Web site for self service. The difficulty was that a typical doctor's office has patients from dozens of different health plans. So, each health plan has various degrees of advancement in terms of providing Web capability, right? And then the doctors would have to train their staff, which tends to have a fairly high turnover in the front office, to use all of those different systems. So, we got to a certain point of adoption and we were having a hard time getting beyond that.

We went and had a conversation with a competitor, Blue Cross Blue Shield of Florida, and said, "This is silly. Why don't we come up with a uniform Web portal for doctors?" Now more than 95% of all the doctors' offices in Florida use this capability, and it includes Aetna, UnitedHealth, Cigna, a lot of local plans and ourselves, so that the majority of patients that come into a doctor's office, they can go to that one Web site and get the information they need.

[We've since partnered with plans in other states and] we're rolling out in Texas, Illinois, Oklahoma and New Mexico. Not only has it been successful in terms of increasing adoption of the Web, but we have also gone off into clinical transactions, like e-prescribing. The venture has gone from practically no revenue to $70 million in revenue. And it does 600 million transactions a year.

WSJ: Is this the model for how technology can improve health care?

Mr. Goodman: Absolutely. What many people don't realize is that health plans are in a unique position to provide information about the patient.

If a member is seeing more than one doctor or is getting prescriptions from more than one doctor, we see all of that if we insure them. We know when a member didn't refill a prescription, so we can tell a doctor there is a gap in adherence. If doctors are doing e-prescribing using hand-held devices, we can show them lower-cost drug options for their patients at the time of the script writing.

More to Do

WSJ: What parts are missing now?

Mr. Goodman: A number of things. Very few doctors' offices have electronic medical-records systems. And patients don't do a personal health record because a lot of them don't see the value of it. And frankly until you connect all the pieces and crunch it with data analytics, there isn't a lot of value to it. Part of [what will drive] adoption is getting everybody hooked up, and then generating actionable information that is useful to everybody in the system. You could take a lot of money out of the system by doing that.

WSJ: Who has to make this happen?

Mr. Goodman: What's disappointing about what's going on in Washington is that health plans are viewed as the villains, and we're actually in the best position to promote some of these advances because we have the data. We can provide monetary incentives to the doctors and to the [patients] to take advantage of whatever data analytics we do and, therefore, drive the adoption. And with the adoption you improve quality of care and you lower the cost of care.

When you have a not-for-profit organization or a plan, [they just don't have the incentive] to connect the doctors. When you have somebody who's in it for a profit, you have a motivation to root out fraud and abuse and to try to really improve the quality of care, because it costs less if you have good care.

Looking Ahead

WSJ: How will the experience of being a patient be different in the future than it is now?

Mr. Goodman:
To get an appointment at a doctor's office you'd go onto the Web, whether you're using a smart phone or not. And when you show up at the doctor's office, let's say it was your first visit, a lot of information that normally they would ask you for has already been downloaded.

In the exam office, there is a monitor and the doctor has everything in front of him or her. If there is a prescription needed, the doctor can do that electronically and can find out what's the most cost-effective drug for you and make sure you don't have a drug interaction [issue], because you have already had all of your prescription information downloaded.

To pay, you have an ID card, or maybe your cellphone, that immediately connects you, and your claim is adjudicated in real time. There is no paperwork.

WSJ: We started by talking about 10 years ago. Looking ahead 10 years, what happens to IT?

Mr. Goodman:
I think there is always a place for people that really understand technology and can deliver an industrial-strength capability into the business. Maybe everybody will walk around with a contact lens that has 5G capability and an earplug, and you are integrated into the Internet.

I absolutely think [that sort of thing] is going to happen. I don't know if it is in 10 years, but bandwidth is going up. Cost of computers is going down. Size of computers is going down. Cost of storage, size of storage is going down. Those are the key trends. They make everything possible.

You get an embedded chip. Maybe it gets its energy from your stomach. You could burn 100 calories a day to keep your electronically embedded stuff going.

Rising Numbers Requesting Food Aid

Wall Street Journal

The U.S. Agriculture Department said Monday the number of households that reported struggling to buy enough food in 2008 jumped 31% over the previous year.

According to the USDA's annual poll, 17 million U.S. households reported some degree of food insecurity in 2008, up from 13 million households in 2007.

"It is time for America to get very serious about food security and hunger," said Agriculture Secretary Tom Vilsack, who is pressing Congress to expand such programs as food stamps and free school lunches that consume roughly 70% of his department's budget.

Comparable numbers for 2009 aren't available yet. Officials with organizations involved in feeding the hungry say the survey results square with growing demand at food pantries: the number of people seeking help this summer is up an average of 30% from the summer of 2008, according to a recent survey of food banks by Feeding America, a food-bank network.

The 2008 survey results suggest that almost 15% of U.S. households had trouble putting enough food on their tables, up from 11% in 2007; the proportion is the highest detected by the survey since it began in 1995. Put another way, about 49 million people, including about 17 million children, worried last year about getting enough to eat.

Maura Daly, vice president of government relations for Feeding America, said 90% of food banks in the recent survey reported that, according to anecdotal evidence, unemployment is the leading factor for the increased demand.

U.S. consumers in 2008 also saw a sudden acceleration in the cost of food. While the food inflation rate has stalled this year, some economists are worried that the move by many recession-weary farmers to cut production might ignite grocery prices again next year.

The global recession is helping swell the number of hungry people around the world to the highest levels since the early 1970s.

But the way USDA economists measure food worries in the U.S. is far more liberal than their gauge for other nations, where people are labeled food insecure only if they consume fewer than 2,100 calories a day. Few of the U.S. households labeled as food insecure by the USDA have it that tough.

Instead, the USDA's domestic survey tries to quantify the number of households that have difficulty providing enough food at some time during the year. Many of these families are able to avoid hunger by participating in such federal nutrition programs as food stamps, or by having their children participate in a free school-lunch program.

Still, the USDA survey indicates that someone in about one-third of food-insecure households experienced some hunger or came very close to it in 2008. In these households with very low food security, food consumption fell and normal eating patterns were disrupted.

According to the survey, 6.7 million U.S. households had very low food security in 2008, up 43% from 4.7 million households in 2007.

Breast-Screening Advice Upended

Wall Street Journal

For years, women have been taught to perform regular breast self-exams and those 40 and older told to undergo annual mammograms to detect breast cancer, a disease that kills about 40,000 people in the U.S. every year. Now, new guidelines released by an influential government-funded authority on screening offer this message: never mind.

The new U.S. Preventive Services Task Force guidelines, published Monday in the Annals of Internal Medicine, state that routine mammograms aren't necessary for women of average cancer risk in their 40s, and that women between 50 and 74 years old don't need to undergo mammograms more often than every other year. They also recommend that physicians abstain from teaching women how to examine their breasts for signs of cancer because of a lack of evidence that it is of any benefit.

The guidelines were based on a routine review of research published since the last set of recommendations and a new analysis of data. The guidelines were formed by weighing benefits of screening compared with the harms of false positives, such as anxiety and unnecessary additional tests and biopsies, which are expensive and time-consuming, according to Diana Petitti, vice-chairman of the task force.

The task-force recommendations only apply to women without a family risk of breast cancer and who don't have genetic mutations known to be associated with breast cancer, such as the presence of BRCA1 or BRCA2 genes.

By scrubbing the previous recommendation of annual mammograms for women 40 and older, the new guidelines are likely to be controversial and confusing. They also raise concerns that health insurers will curtail coverage and reimbursements for screenings that fall outside the guidelines, according to doctors and groups including the American Cancer Society.

Phil Evans, a professor of radiology at the University of Texas Southwestern Medical Center and president of the Society for Breast Imaging, says he was "shocked" by the changes. "There's a ton of scientific data in this country and others on screening that shows a significant benefit for women between 40 and 49 to be screened," he says.

The National Comprehensive Cancer Network, the American Cancer Society and the American Medical Association recommend annual mammograms for women starting at age 40, while the American College of Physicians recommends women in their 40s decide for themselves whether to seek annual exams.

USPSTF Breast Cancer Screening Guidelines: Then and Now

2002: Recommended every 1 to 2 years for all women older than 40
2009: Recommends against routine screening for women 40 to 49; recommends mammograms every 2 years for women 50 to 74; insufficient evidence to conclude benefit or harm of mammograms for women 75 and older

Breast Self-Examination

2002: Insufficient evidence to conclude benefit or harm
2009: Recommends against teaching BSE

Digital and MRI Mammography
2002: Not addressed in guidelines
2009: Insufficient evidence to conclude benefit or harm 
Source: U.S. Preventive Services Task Force guidelines published in 2002 and 2009

The task force, which receives funding from the federal Agency for Healthcare Research and Quality but is independent from the government, last issued guidelines for breast cancer in 2002. "The task force isn't saying there isn't a benefit" to screening women in their 40s, but "we're saying the benefit is small," Dr. Petitti said. "The change really is a change between do it routinely and don't do it routinely." Women 40 and older who are free of any symptoms should talk with their doctors and decide with them whether to put off screening for a few years, she said.

Dr. Petitti's advice is less nuanced about the issue of breast self-examinations. "Women should know it doesn't work," she said. Two large studies published since the last guidelines, involving 200,000 women in China and more than 100,000 in Russia, showed no benefits from breast self-examinations, she said.

There is agreement among scientists that mammography saves lives but that it also gives rise to numerous false positives. It reduces cancer death by about 15% in women ages 39 to 59, according to the task force's review of published data.

There are fewer cases of cancer in younger women, which means there are fewer absolute benefits when weighed against risks for women in their 40s. For each case of cancer death prevented among younger women, 1,900 women must be screened, according to the task force's review of published data. That ratio drops to 1 for 1,300 for women 50 to 59 years old, and 1 for 377 for women 60 to 69 years old, according to the task force.

The task force's interpretation of the data overstates the downsides of mammography for women in their 40s and doesn't take into account the fact that saving a younger woman leads to more "life years saved" than for older women, Dr. Evans says.

About $3.3 billion was spent on mammograms in the last 12 months, according to the American College of Radiology.

Whether the new guidelines lead to changes in insurance reimbursement is likely to be a big concern among health providers and patients.

The Centers for Medicare and Medicaid Services, which administers government health benefits for the elderly and the poor, says the new guidelines wouldn't change how it covers mammograms for Medicare patients. But that may not be the case for private insurance. The task force guidelines tend to influence public and private insurers' coverage decisions, though they aren't the only factor, according to John Ayanian, a professor of medicine and health-care policy at Harvard Medical School who published a paper last year on the impact of cost-sharing on mammogram usage rates in the New England Journal of Medicine.

Susan Pisano, spokeswoman for America's Health Insurance Plan, an industry trade group, says she anticipates mammogram coverage will continue even for those who fall outside the new guidelines' target age range. What may change, she says, are insurers' aggressive outreach efforts to get women to get their screening, such as the reminder postcards they used to receive about getting their annual mammogram.

Eric Winer, chief scientific adviser of Susan G. Komen for the Cure, a breast-cancer advocacy foundation, and director of the Breast Oncology Center at Dana-Farber Cancer Institute in Boston, says that "at a minimum, what we can say is that women and their doctors have a right to make a decision about whether they should be screened. If they don't have financial coverage, then they don't have that right."

Covidien Submits Label Change for Optimark Contrast Agent


Covidien, a leading global provider of healthcare products, today announced that it will voluntarily contraindicate the use of its Optimark™ gadoversetamide injection, a gadolinium-based contrast agent (GBCA), in magnetic resonance imaging (MRI) procedures involving patients with severe renal impairment. The Company is modifying the product's label to reflect a contraindication for this small patient population, which constitutes less than 0.5 percent of the U.S. population.

Mallinckrodt Inc., a Covidien company, has submitted this label change to the U.S. Food and Drug Administration (FDA) and is implementing the new label in the U.S. effective immediately. The revised label contraindicates the product's use in patients with acute or chronic severe renal insufficiency (glomerular filtration rate of less than 30 mL/min/1.73m2) or acute renal insufficiency of any severity due to hepato-renal syndrome or in the perioperative liver transplant period.

The Company is implementing this label change in all other countries where Optimark contrast agent has been approved for sale, in accordance with local regulatory requirements. Covidien also will update its educational materials to help physicians make informed decisions regarding the appropriate use of this product.

GBCAs are important tools to aid physicians seeking to diagnose and treat patients. In 2008, more than 9.5 million patients in the U.S. were given GBCAs to help improve the diagnostic quality of MRI scans.

When used as directed in appropriately-screened patients, GBCAs have a favorable safety profile, with the majority of any adverse reactions in this class being mild and usually transitory. A possible relationship, however, has been asserted between the use of GBCAs and nephrogenic systemic fibrosis (NSF) among patients with severe renal impairment. This subset of patients can be easily identified by obtaining patient history and/or laboratory tests.

“We have concluded that Optimark contrast agent should be reserved for the vast majority of the population – more than 99 percent – where the risk/benefit profile is well established,” said Dr. Herbert Neuman, Vice President, Medical Affairs and Chief Medical Officer, Pharmaceuticals, Covidien. “For the small percentage of the U.S. population – less than 0.5 percent – with severe renal impairment, we believe it is prudent to act now, rather than wait for a causal link between GBCAs and NSF to be established. Although the label already advises caution when using GBCAs with these patients, we are voluntarily taking this next step to help ensure this small, at-risk population does not receive administration of a contrast agent that could pose a risk of NSF.”

In 2007, the FDA recommended that use of all GBCAs should be avoided in patients with severe renal impairment unless the diagnostic information is essential and only available with a contrast-enhanced MRI procedure, resulting in a boxed warning for each GBCA. In addition, the FDA will hold a joint Advisory Committees Meeting on December 8 to discuss whether other steps are necessary to ensure the safe use of all GBCAs.

“At Covidien, patient safety is our highest priority,” Dr. Neuman said. “The extensive efforts of the FDA, industry, clinician organizations and thought leaders since 2006 have increased awareness of NSF and its apparent relationship to GBCAs in patients with severely impaired renal function. This increased awareness has had a noticeable impact on the practice of medicine and contributed to a significant reduction in the incidence of the disease. We look forward to additional dialog with the FDA and the joint Advisory Committees on this important topic.”

About Covidien

Covidien is a leading global healthcare products company that creates innovative medical solutions for better patient outcomes and delivers value through clinical leadership and excellence. Covidien manufactures, distributes and services a diverse range of industry-leading product lines in three segments: Medical Devices, Pharmaceuticals and Medical Supplies. With 2008 revenue of $10 billion, Covidien has more than 41,000 employees worldwide in 59 countries, and its products are sold in over 140 countries. Please visit www.covidien.com to learn more about our business.

24 November 2009

Change In Diet, Exercise Can Help Alleviate Arthritis Symptoms

Chicago Tribune

Dr. Sunil John has watched many of his patients with osteoarthritis improve with some simple lifestyle changes like exercising more, eating less and taking over-the-counter pain medications.

That might be a surprise to people who think taking it easy is a better answer to the pain and stiffness in their joints that accompany osteoarthritis –– sometimes known as degenerative joint disease. But exercise and weight loss can be the best medicine for arthritis pain management, according to rheumatologists, who deal with joint, soft tissue and connective tissue problems.

"It's important to be active, and weight reduction is very important because, obviously, with more weight there's more stress on the joints," said John, a rheumatologist at Advocate Medical Group who is affiliated with Advocate South Suburban Hospital in Hazel Crest. "It improves the activities of daily living."

John said physical therapy tailored to the specific joint problem can help ease pain and increase range of motion. He also recommends a low-impact exercise like swimming, which does not put pressure on joints and increases blood flow to ligaments, muscles and tendons. Heat therapy also can help, he said.

In addition to over-the-counter pain relievers, some research has shown that glucosamine medication and chondroitin sulfate, a dietary supplement, may slow the progression of cartilage loss. Some doctors also give cortisone shots to help reduce inflammation and alleviate pain.

Dr. Monica Aloman said she often shows her osteoarthritis patients simple stretching exercises for the thigh, neck, fingers and shoulder rotator cuffs, and refers them for physical therapy.

Aloman, a rheumatologist who works at Advocate Christ Medical Center in Oak Lawn, said she cautions patients about weight-bearing impact exercises that could "further aggravate the cartilage destruction."

"Physical therapy is the mainstay of improving symptoms in the long term, but basically there is no (cure) for this," Aloman said.

Several area hospitals offer seminars on osteoarthritis, which affects roughly 27 million Americans, according to the Centers for Disease Control and Prevention. Advocate Christ Medical Center held a seminar in September on osteoarthritis therapy and medication, and Silver Cross Hospital in Joliet held a program on rheumatoid arthritis –– a chronic inflammatory condition that affects about 1.3 million Americans –– this month. The Arthritis Foundation also sponsors lectures on arthritis and has a "Life Improvement Series," which includes aquatic therapy, exercise and self-help programs to increase mobility and reduce pain and stiffness.

Rheumatoid arthritis mainly affects joints, though the disease also can attack many other organs and sometimes also features high fevers and fatigue. Certain medications can slow progression of the disease and prevent joint deformities, and physical and occupational therapy are also effective rheumatoid arthritis treatments, experts said.

"Osteoarthritis is a localized problem you can get with aging or when you overuse your joints like avid sports people do. ... In other words, a mechanical problem," John said. "Rheumatoid is an autoimmune disease with an overactive immune response or an immune response not working as it should."

Patients with rheumatoid arthritis often are prescribed disease-modifying anti-rheumatic drugs, or DMARDs, which are immunosuppressants that help reduce inflammation and slow disease progression, as well as over-the-counter and prescription pain medications, and calcium and vitamin D to prevent bone loss.

Aloman said inflamed finger joints should be splinted and recommends ultrasound therapy, which uses high-energy sound waves to ease the pain of affected areas.

Before deciding on a treatment regimen for arthritis patients, rheumatologists said, the type of arthritis must be determined.

Aloman said patients with osteoarthritis find their pain aggravated by activity and weight-bearing exercise but relieved with rest, whereas those with rheumatoid arthritis often have high fevers and unexplained fatigue, prolonged morning stiffness and swelling of the hands and fingers. She said rheumatoid arthritis affects mainly women who are older than 40, though it also may strike men.

19 November 2009

He Knows If You've Been Sick Or Not

Mall Santas ask for H1N1 vaccine priority.
St. Petersberg Times

TAMPA — Victoria, an infant in green pajamas, sat in Santa's lap Wednesday at WestShore Plaza representing both the joys and dangers of playing jolly old Saint Nick.

The girl didn't pout and she didn't cry. But when she reached for Santa's Christmas necklace and stuck it in her mouth, an alarmed look crossed Santa's bespectacled eyes.

'Tis the season for swine flu. And the girl, like all children, carries plenty of naughty germs.

"Now don't put that in your mouth," white-bearded Jack McElhinney said gently while pulling the necklace out.

McElhinney is known in his profession as the "Iron Santa." Seven days a week for 16 holiday seasons, the Lutz senior has not missed a day as the WestShore mall Santa. But this year, the H1N1 scare has Santas nationwide shaking in their sooty black boots.

"If the Santas across the country get sick, there's going to be a lot of disappointed kids around the world," McElhinney said. "When you think of it, I get exposed to every illness known to man and then some. I'm in a high-risk category here."

That's why many Santas think they should become a priority group to receive swine flu vaccines, which are in limited supply. Santa America, a national group, even asked an Alabama congressman for legislative help last week.

Around here, the Hillsborough County Health Department plans to stick to the Centers for Disease Control guidelines on who should get the vaccine: pregnant women, students, people with chronic conditions and health care and emergency workers.

Stephen Huard, department spokesman, didn't need to check the list twice. "Santas didn't make the priority list," he said.

Same goes for Pinellas County.

"I can picture Santa saying, 'You've been naughty, where's my shot?' " said Maggie Hall, health department spokeswoman. "Our supplies are so small, I'm sorry, Santa."

Across the nation, Santas are taking their own precautions. The Amalgamated Order of Real Bearded Santas, a trade group, featured a seminar on swine flu at a recent conference in Philadelphia. It urged members to take vitamins and use hand sanitizer.

The 200 or so Saint Nicks who volunteer to visit sick or grieving children through Santa America will be washing their suits daily instead of weekly. And they won't be wearing gloves so they can wash their hands more frequently.

At Tyrone Square Mall, officials didn't allow Santa to be interviewed or photographed. Same at International Plaza. But at both places and WestShore Plaza, hand sanitizer dispensers were in the Santa station lines.

Health officials say if Santas want the vaccine, they should check with their private physicians.

That's what McElhinney did.

"I told my doctor, 'Look, I am in a high-risk category,' and he said, 'You sure are,' " said McElhinney, 76, "And I went to the head of the list."

Beside the swine flu shot, the WestShore Santa has been taking Amantadine, used to prevent and treat the flu, and a daily regimen of multivitamins, plus extra vitamin C, D3, E, and B-complex, and Omega 3, as well as garlic, liquid glucosamine and cinnamon for his blood sugar.

He hopes it's enough.

McElhinney hears the wishes of as many as 300 children a day. They pull beards and spill drinks. Some have tender stomachs.

"Babies. Babies are always erupting on me," he said.

For all this, Santa wonders why health officials won't put old Saint Nick at the top of the H1N1 vaccine priority list.

"We represent one of the most important things in a young kid's life," McElhinney said.

Health officials don't disagree. But for Santa to get his wish, he needs to grant theirs:

Stick giant batches of vaccine for everyone under the Christmas trees.

Acupuncture For Pets

San Jose Mercury News

Squirmy cats may not seem like the ideal acupuncture patients, but Los Gatos veterinarian Dr. Hilary Wheeler knows just how to get them settled down — the first needle goes midway between the cat's eyes and ears. It's a calming point that is known as "yin tang."

"It causes endorphin release and it relaxes them," Wheeler said. "Surprisingly, cats do very well with acupuncture. Some fall asleep and some just become very relaxed."

She said dogs also respond well to acupuncture.

"Usually when I do acupuncture on dogs, they lie on the floor on cushions and their owner is with them so they're comfortable, too."

Wheeler just opened a new clinic in town called the Whole Pet Vet at 325 Los Gatos-Saratoga Road, near the Massol Avenue intersection.

"We're the first fully integrated practice in town," Wheeler said. "My whole perspective in this is there's been a shift from disease treatment to disease prevention, and we're learning that many of the diseases in animals are directly related to exercise, diet and stress."

Wheeler says her main message is wellness.

"We are trying to find options that are less invasive and less toxic than traditional treatments." In addition to acupuncture, Wheeler uses herbal remedies to treat cats and dogs. "Some will still need medicine, but you can decrease the dose," she said. "The majority of my acupuncture patients come in for pain control — arthritis, back pain and hip dysplasia. I also treat a lot of animals for allergies, inflammatory conditions and autoimmune disorders. With acupuncture and herbs a lot of those conditions can be managed without side effects."

Wheeler has been giving acupuncture treatments to a 9-year-old Newfoundland named Dewey for about five months now. It may be combined, if necessary, with a program of pet glucosamine.

"He has degenerative arthritis in his hips and spine," owner Joyce Taylor said. "I know it absolutely, positively works. After his first treatment he could move better and walk better. He could get up a lot easier, and he went from limping to trotting around the yard."

In the beginning, Dewey received four acupuncture treatments in four weeks. Now he gets them as needed, usually every six weeks or so.

Wheeler begins the treatment by rubbing her hand all over Dewey's coat, which helps bring the blood flowing to his body's surface. It relaxes him, too. The rubbing also helps her determine if he has any hot spots, which is an indication of sore muscles. "Damaged muscles may be cold," Wheeler said.

One area Wheeler focuses on is Dewey's legs because he has tremors. Other needles go into his back. In all, Wheeler usually uses 10, 1-inch needles on Dewey.

The initial treatment is $175 and includes a complete physical exam and medical history. Follow-up treatments are $95. Wheeler plans to offer packages to customers' whose pets receive regular acupuncture treatments.

Although Taylor calls Dewey "a child in a fur suit," he was well behaved and after a few minutes settled his big head on his big paws and appeared content.

Taylor, who grooms Newfoundlands, has also had Wheeler treat two other of her Newfoundland dogs. "Arthritis is more common in giant breeds," Taylor said.

Wheeler is also giving Dewey herbs for his allergies.

She said the herbal remedies she offers are mostly based on Chinese formulas, but the herbs are grown in the United States for quality control purposes. Other options include dog glucosamine.

Wheeler contracts with an herbal specialist who can recommend specific formulas based on test outcomes. "If I see a diabetic cat I can consult with my specialist in New York, who recommends a formula," she said.

Wheeler started using holistic treatments at the South County Animal Hospital in Morgan Hill. Later she moved to the Central Animal Hospital in Campbell.

Her new clinic has three exam rooms, a separate nontraditional treatment room where the acupuncture is performed, plus a garden area with artificial turf so dogs can get some exercise.

A state-of-the-art digital X-ray machine uses about 25 percent less radiation and develops pictures much more quickly than traditional X-ray machines.

"It's a much greener way to go, and it's less stressful on the patients," Wheeler said.

Wheeler can also process lab tests in house and performs surgery. There's even a temperature- controlled isolation unit to house animals with contagious diseases such as parvovirus, which affects dogs.

Wheeler is certified by the International Veterinary Acupuncture Society.

She has a part-time assistant, Dr. Kirsten Krick, who is certified in acupuncture. In addition, Krick specializes in treating small animals such as guinea pigs, rabbits and chinchillas.

Holistic medicine for animals is an emerging field, and Wheeler says that there are only a couple of other vets in the Bay Area whose practice includes acupuncture and herbal treatments.

Flu Shot Clinics Draw Crowds

Minneapolis-St. Paul Star Tribune

The flu pandemic may be on its way out for now, but that didn't stop thousands of kids from showing up for H1N1 immunizations Wednesday at vaccination clinics in Anoka and Hennepin counties.

Several thousand people lined up around the Schwan Center in Blaine 
for vaccinations at the flu vaccination clinic, which was 
administered by the Anoka County Health Department

 The flu pandemic may be on its way out for now, but that didn't stop thousands of kids from showing up for H1N1 immunizations Wednesday at vaccination clinics in Anoka and Hennepin counties.

Parents with children in tow began lining up at 1 p.m. for the 2:30 clinic sponsored by Anoka county at the National Sports Center in Blaine. Throughout the afternoon the line meandered through the vast parking lot before entering the Schwan Center where the parents and kids were directed to the appropriate tables for their vaccines.

The county provided sidewalk chalk for the kids to use while they waited outside.

"As a parent what I loved was the abundance of sidewalk chalk drawing outside the entrance," said Martha Weaver, spokesperson for Anoka County. "That was an indicator that we had the audience we wanted."

The clinic was scheduled to run until 8:30 p.m. or until the vaccine ran out. In Hennepin County, two clinics were scheduled to run until 7:30 and 8:30.

After weeks of shortages, the vaccine is finally becoming more widely available -- just as the flu pandemic continued to wane for the third week in a row, according to new numbers reported Wednesday by state health officials. But state officials warned that it doesn't mean you can stop washing your hands.

December is just around the corner, and that's when the first seasonal flu cases start popping up, said Dr. Ruth Lynfield, state epidemiologist for the Minnesota Department of Health. Also, if past pandemics are any guide, there could be a third wave of H1N1 flu in January or February.

"I don't want people to let up," Lynfield said.

17 November 2009

Less Pain At The Office: Ergonomics

Florida Times-Union

The jokes about work being a pain and making you sick are as abundant as the leftover Halloween candy in your pantry.

But for millions of people who consider themselves lucky enough to still be employed these days, the rigors of a demanding job day in, day out can be the precursor to increased muscle aches, pains and strains. And it's anything but a joke.

Whether you work at a desk in front of a computer, stock shelves or ring up items on a register, you may be susceptible to work-related injuries that run the gamut from a stiff neck to nerve damage just from doing your job every day.

Repetitive motion injuries or work-related musculoskeletal disorders are caused by the frequent use of muscles, tendons, nerves and other joints either by maintaining a single position or concentrating on the same task for long periods of time. Over time the pain and injuries can lead to long-term disability.

"Repetitive motion injuries can result from long periods at the computer," said occupational health physician Joseph Czerkawski, medical director of Baptist Occupational Health Southside. "Tendinopathy is the overuse or a repetitive motion type pain of the hand, wrist and forearm. Neck and shoulder problems can occur as well."

One of the best ways to reduce or eliminate workplace injuries, according to the American Academy of Physical Medicine and Rehabilitation, is to make your office work for you. It's the science of molding yourself to your working environment, popularly known as ergonomics.

In 2002, then-Secretary of Labor Elaine L. Chao, unveiled a comprehensive approach to ergonomics designed to address musculoskeletal disorders in the workplace. The four-pronged strategy addresses industry and task-specific guidelines, outreach, enforcement, and research. Since launching the strategy, the Occupational Safety and Health Administration reports significant progress in reducing ergonomic injuries.

Creating healthful environments not only means less occupational injury and illness, but more productivity as well. A 2008 Liberty Mutual Workplace Safety Index report found workers' compensation costs for workplace injuries and illnesses in 2006, were $48.6 billion, with overexertion, slips and falls being the top culprits.

How your office is designed, and how you complete your work, may contribute to work-related injuries. Most offices and cubicles include a computer and a telephone and possibly commercial cabinets. But if they are not used properly or are not ergonomic friendly, it can cost you.

"There is no question that an ergonomic evaluation and proper position at a workstation, along with proper ergonomic equipment is well worth the investment," said Czerkawski. "Companies realize that this is the one area that the return on investment is worth a lot less lost days [from work] for employees."

Wayne Beck, manager of Baptist Executive Health's Baptist@Work Program agreed with Czerkawski. He said making small changes can show big results.

"There is phone-specific ergonomics equipment that an employer may purchase that can drastically reduce shoulder/neck injuries," said Beck. "For example, replacing a regular hand-held phone receiver with a head-set will eliminate awkward body positioning for those who utilize a phone for long periods of time. This, along with proper workstation ergonomics and taking mini breaks from repetitive work tasks, helps to reduce your exposure to work-related injuries. Whether you're someone who sits at a computer and types all day long or you perform assembly line-type tasks, you can reduce your risk for repetitive motion injury, simply by stretching out your at-risk body parts once every hour."

Some of the most common workplace injuries experienced by employees include carpel tunnel syndrome, back and neck pain from long-term static posture, visual fatigue or blurred vision, headaches and nerve and joint pain.

"Positioning your computer monitor to your eye level and using a wrist pad at the bottom of your keyboard to help keep the wrist in a neutral position are just two examples of how ergonomics can be implemented in a workstation," Czerkawski said. "Also, a footrest to support your feet will help reduce pressure on the lower back."

Beck said maintaining a healthful lifestyle not only makes good sense for overall health but can help if you are injured. He recommends a healthful diet along with 30 to 45 minutes of daily exercise. That way, your body will be better trained to properly and quickly recover from the injury.

"Take advantage of resources available to you at work, and have your ergonomic lift tables or workstation assessed to meet the ergonomics guidelines, " said Beck. "If you start to feel minor aches and pains, that's your body's way of warning you that injury is on the way."

Virtual Office Visits A Great Boon To Seniors

Washington Post

Above, Juanita Wood transmits her blood pressure readings to a clinic at her retirement community. where she lives. Her husband, Arthur, seen in the mirror, uses a similar device, though he also keeps a written tally.

Every morning at 10 a.m. sharp, Juanita Wood, 87, taps "okay" on a screen to start up a device that takes her blood pressure and transmits the information to her medical clinic. At 10:30 a.m., her husband, Arthur, 91, touch-starts his own device, neatly lined up next to hers. The machine calculates his blood pressure and weight and sends them off, along with a blood sugar count that he enters by hand.

The Woods, of Catonsville, Md., are participants in one of several pilot projects that home health-care providers, retirement communities and others are conducting to see if high-tech but simple devices can help doctors closely monitor aging patients at home in a way that will help control problems before they escalate and cut back on the need for costly long-term care and hospital admissions -- especially repeat hospital visits for chronic conditions.

Although proponents of health-care reform tout its potential for improving efficiency, often missing from the national debate are specific examples of how changes in the system might improve patient outcomes and reduce costs. These pilot projects are exploring some easy-to-use technology that might make a difference to patients and doctors.

"This helps us detect harbingers of a bad event for patients," said William Russell, vice president and regional medical director for Baltimore County-based Erickson Retirement Communities, which is running the pilot program in which the Woods are participating. "Early detection systems are important because more often than not, elderly patients do not come out of hospital stays with a better outcome."

Preventing problems

Seniors and others with chronic health problems such as diabetes, congestive heart failure and high blood pressure often wind up in hospital emergency rooms after forgetting to take their medication or when their condition deteriorates at home without anyone noticing. When that deterioration is severe enough, patients can be forced to move out of their homes into assisted living or nursing facilities, a costly and emotionally wrenching transition. The hope is that by closely monitoring patients at home, some of these events can be avoided or managed better.

Medicare spends more than $12 billion a year on "potentially preventable" repeat hospital admissions, according to the Medicare Payment Advisory Commission, an independent agency that advises Congress. And that number, according to the commission, is likely to grow, given that the Census Bureau projects that by 2025 there will be nearly 64 million Americans older than age 65, an increase of more than a third over today's total.

The pilot projects are not designed to have doctors diagnose illnesses remotely or to substitute for hands-on care. Instead, they are intended to allow elderly or infirm patients to get ahead of changes in their chronic conditions that could tip them into a medical emergency.

Juanita Wood, a retired secretary, had some fainting incidents possibly related to blood pressure problems. She hopes that keeping track of her blood pressure and transmitting the readings to her clinic in real time will help her avoid future episodes.

So every morning she straps on a blood pressure cuff attached to her monitoring machine, presses a button to start it up and waits for the cuff to inflate. Her pressure is recorded and then transmitted to the clinic at Erickson's Charlestown community, where the Woods live.

Arthur Wood, a retired architect, takes his blood pressure and weighs himself. Because he is a diabetic, he also is learning how to register his blood sugar levels, using a separate finger-prick device and then manually entering those numbers into his touch-screen unit. The Woods send in their info every morning, and employees at their clinic monitor the readings and alert them if something seems amiss, hopefully before anything major goes wrong.

The monitors that the Woods use are only one of the devices being tested in the pilot programs. Others are simple scales, to monitor sudden weight gain, which is a warning sign for those with congestive heart failure. There are also motion sensors placed under a bed, to make sure a person has gotten up in the morning, and wall sensors that can tell whether a person is moving around the house normally.

The Woods' devices feature a smallish computer screen that comes awake when a patient taps it, displaying his or her personal information. The device is set to blink with a blue light at the same time every morning to prompt patients to do their monitoring. There's no log-in or complex system for the device, and each machine is programmed to deal with one patient's specific medical issues.

The devices are built by Intel, which has been working to develop technology to bolster home health-care services. Last spring Intel and General Electric Healthcare announced they would jointly commit $250 million to develop wireless products to connect the patient to the physician.

The companies are focusing on such products because of research showing that "more than 80 percent of health-care spending focuses on patients with one or more chronic diseases," according to Louis Burns, vice president and general manager of the Intel Digital Health Group.

A matter of money

Right now, the biggest impediment to high-tech monitoring is that Medicare and private insurers generally do not reimburse for it. And the devices can be expensive. As part of a pilot project, Juanita and Arthur Wood get their devices for free; normally patients of a Raleigh retirement community, for example, would have to pay about $100 a month to rent them.

Also, insurance plans typically do not reimburse doctors for treating patients based on data sent remotely, only for face-to-face care. Some patient advocates also worry that electronically conveyed data might be substituted for direct medical care, which the organizers of the pilot projects say is not the goal.

Instead, they say, the devices will allow doctors to accumulate data on a patient over time; this information can then be used in a face-to-face visit with the patient.

This approach allows the doctor to "spend more time with patients so they are able to plumb the depth of the patient's problem," Russell said.

And if the digitally sent data show that something may be going wrong, medical professionals can step in immediately rather than wait for the patient's next routine appointment. "We set up thresholds, and anything above or below that, then the doctors get notified," explained Kelley Gurley, project manager for the Erickson study. "If the blood sugar is low, the patient would receive a call [from the clinic] that says, 'Please call your doctor,' " she said.

The device itself also is programmed to remind patients, in a friendly computer voice, about their  arthritis medication and food consumption if a reading falls outside the parameters set by their doctors. In addition, a "Learn More" prompt on the touch-screen is linked to informational videos related to the data he or she has transmitted. If, for example, a blood pressure reading is high, the machine offers the patient the option of watching a short video in which a doctor explains how to bring the pressure down, such as by sitting down and relaxing for 30 minutes.

The device that the Woods use is known as the Intel Health Guide. Other companies, including General Electric, have their own home health monitoring systems. GE QuietCare is a sensor system most often used in assisted living and similar facilities to track patient activity.

Eric Dishman, general manager of Intel's Research and Innovation Group, said these devices perform an increasingly important function: "You just can't crank out enough medical students to solve our personnel shortage in this country. You need to rely on other means, especially technology, to bridge that gap." There is a productive future in store for students seeking  a bachelor's degree in medical technology.

At their home one recent morning, Arthur and Juanita Wood were reminded by the flashing lights on their machines to start their monitoring process. The prompts were delivered by a female voice, which Arthur Wood noted was "sweet," but added, jokingly, "But I love it when she says goodbye." Because then it means he's done for the day.

Best Buy Offers Tech Support To Children's Hospital

Minneapolis-St.Paul Business Journal

Best Buy Co. Inc. has opened a Geek Squad location at the Minneapolis campus of Children’s Hospitals and Clinics of Minnesota, the first time the retailer has put one of its tech-support operations at a hospital.

Best Buy, an electronics retailer based in Richfield, said that the site, which opened Monday, will provide free tech support to children and families at the Minneapolis campus.

An initial staff of three Geek Squad personnel will support all non-medical technology for patients and family members, including room entertainment systems, laptops, and cell phones. The precinct will be open every day until 7 p.m.

Best Buy is also providing tech-consulting services for Children's ongoing renovations to patient rooms, set to be completed next year. It is not known at this time if the company will implement the tech-support program at other U.S. children's hospitals.

A New Battle Front For Cardiologists: The Doctor's Office

Wall Street Journal

Two major cardiology organizations are targeting a new front in the battle to improve the quality and efficiency of heart care: the physician's office.

The American Heart Association and the American College of Cardiology are aiming to reduce the toll of cardiovascular disease and increase adherence to long-established prevention guidelines by collecting data from doctors that document their encounters with patients during regular office visits.

The initiatives aim to bring to outpatients some of the improvements that hospitals have achieved in the care of patients who have suffered heart attacks or strokes or who have been admitted with congestive heart failure. The heart association's decade-old "Get With the Guidelines" program for hospitals has significantly increased the odds that heart attack patients will be discharged with prescriptions for recommended heart drugs. The ACC's hospital program, the National Cardiovascular Data Registry, has spurred life-saving reductions in the time needed to treat patients suffering a heart attack as they reach the hospital.

But the focus on hospitals misses much of what matters in preventing cardiovascular illness. "Only 5% to 10% of a person's health-care life happens in the hospital," says Vincent Bufalino, a cardiologist and president of Midwest Heart Specialists, a large, suburban Chicago practice. Efforts to capture data on what happens after the hospital—and what doctors do in everyday care to avoid hospital admission in the first place—are scant.

Dr. Bufalino is leading the expansion of the AHA program announced last week. Meanwhile, the cardiology college, whose outpatient effort is called the Pinnacle registry, says it has signed up more than 180 cardiology practices since it launched last month. Both rely on clinical data, not insurance claims, as most previous efforts have done.

The opportunity for improvement is huge, say Wayne County Heart Doctors. Nearly 17 million Americans have been diagnosed with coronary artery disease, according to the heart association; millions more are at high risk. Each year, about 900,000 people suffer a heart attack, and an additional 800,000 have a stroke.

Yet, according to the heart association, only about one-third of patients being treated for high LDL cholesterol—the bad form of blood fat—achieve their goal; and only about 45% of people with high blood pressure have it controlled to levels below 140/90, as recommended. In addition, just 50% of Americans regularly get at least 30 minutes of exercise five days a week and more than one in five adults smoke. Meanwhile, two big culprits on the path toward heart attacks and strokes—diabetes and obesity—are on the rise.

"In the outpatient area, there is very little data about the level of quality of care and how it varies across practices," says Gregg Fonarow, a cardiologist at the University of California at Los Angeles and a leader of the heart association's guidelines programs.

The registries' purpose is to gather information from participating doctors on such matters as the advice they give cardiovascular patients and how effectively it helps patients achieve recommended targets.

Patient lab results and pertinent information on age, gender and diagnoses also are supplied to the registry, detached from the patients' names. For example, in the case of a patient with atrial fibrillation, a heartbeat irregularity, the registry would pick up data on whether doctors prescribed the blood thinner warfarin to reduce stroke risk. Doctors will get quarterly reports comparing their own performance with that of colleagues in their practice, as well as with regional and national averages.

The hope is that with feedback, doctors will be more vigilant about prescribing proven strategies and medications that reduce risk of heart attack, stroke and other life-threatening cardiovascular problems, and encouraging patients to comply, say Westland Cardiologists.

Most doctors believe they have the vast majority of their patients' risk factors under control, Dr. Bufalino says. Yet when his practice, which now includes 54 heart specialists, adopted a computerized medical record system a few years ago, many physicians were surprised to find that when their performance was measured across a variety of important and well-known targets such as their patients' cholesterol levels, only about 70% of patients were at their goals, in some cases.

"These are cardiologists, and these guys have never been a 70 in their lives," Dr. Bufalino says. "We found out, wow, there were some areas where we needed some work." Within a few quarters and with the help of Michigan health insurance, the group had nearly all of its numbers above 90%, he says.

Physician practices "need data that isn't just inpatient," says Jack Lewin, chief executive officer of the ACC. "They need the outpatient data too." Systems such as dicom data migration can help.

Wyandotte Heart Doctors say the initiatives will persuade more physician practices to forgo paper charts in favor of electronic medical records, which will make data collection easy—and help improve their numbers at the same time.

"The registry forms make us more cognizant of the guidelines and the [evidence-]supported practices that we have," says David May, a cardiologist and president of Cardiovascular Specialists, Dallas, which is working with the Pinnacle registry.

The electronic form acts as a prompt to help doctors remember to check if a patient has diabetes or to ask whether he or she has quit smoking. Completed forms become part of the patient's record and can be submitted to the database without extra work. Dr. May says he thinks the sheer number of outpatient visits will lead to a rapid accumulation of data that will quickly become useful—not just in tracking care but also in shedding light on which treatment strategies work best. With enough participation, from cardiologists and also from internists, neurologists and primary care doctors, each registry could easily register 1 million outpatients a year, officials say.

Some 1,500 hospitals, roughly a third of the nation's total, are providing data to the Get With the Guidelines program. Essentially all of them have made strides in complying with recommended treatment strategies. For instance, 94% of heart patients admitted to 417 hospitals during the 12 months ended in June were discharged with a prescription for a beta blocker, compared with an average of 78% before the program started. Among more than 1,000 hospitals participating in the ACC's heart attack effort, more than 85% now get patients from the emergency room door to effective treatment within 90 minutes, up from 40% six years ago.

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15 November 2009

On The Coming Doctor Shortage

Wall Street Journal

None of the health-care reform proposals advancing in Congress address a fundamental problem that will soon face this country: a critical shortage of doctors. There were reform ideas put forward in Congress that would have addressed this problem. Most notably, Rep. Joseph Crowley (D., N.Y) and Sen. Bill Nelson (D., Fla.) have proposed training an additional 4,000 new physicians to add to the 25,000 entering the profession each year. But their proposals haven't made it into the bills on which congressional leaders hope to vote.

If the doctor shortage is not addressed and health-care reform is signed into law, millions of Americans will likely find themselves able to obtain insurance for the first time—but may be unable to find a doctor without a long delay. Why? Because expanding the number of insured patients but not the number of doctors will only increase the demand for services that already must meet the demands of an aging population. We must make sure there are enough health professionals to meet those new demands.

Even in the absence of health-care reform, according to the American Association of Medical Colleges, the U.S. will face a shortage of at least 125,000 physicians by 2025. We have about 700,000 active physicians today. One factor driving this shortage is that the baby-boomer generation is getting older and will require more care. By 2025 the number of people over 65 will have increased by about 75% of what it is today—to 64 million from 37 million today.

Doctors are also aging. By 2020, as many as one-third of the physicians currently practicing will likely retire. If health-care reform adds millions of people to the health-care market, the shortage of doctors will be even greater than it is projected to be now.

It is important to note that the shortage the country will soon face isn't just of primary-care physicians. It is true that there aren't enough primary-care doctors and nurse practitioners. But it is also true that we need more cardiologists, neurologists, general surgeons, pediatric subspecialists, urologists and other highly trained specialists.

Nonetheless, the few ideas to address the coming doctor shortages that were briefly considered in Washington treated the problem merely as a shortfall of primary-care doctors. One idea is to shift unused federal training funds to hospitals that need more positions, but only if those funds are used for primary care. Another is to move primary-care physician training out of hospitals and into federally qualified health centers. A third idea is to take training dollars away from doctors and instead use it to train nurses and other professionals.

None of these ideas would actually increase the number of doctors. At most the first two ideas would increase the number of primary-care doctors at the expense of the number of specialists.

But that's not likely to happen either. The fundamental reason why medical students are not entering primary care on their own is that they can't afford it. Medical-school tuition can cost a student as much as $50,000 a year. Some doctors start out owing hundreds of thousands of dollars before they are even able to open a practice. Going to medical school is a little like taking out a mortgage, only without getting a house in return.

Once doctors do start treating patients, they are squeezed between what they earn from government programs and insurance companies on one side and escalating malpractice insurance rates on the other. Meanwhile, specialists can often charge more and pay less in other costs than primary-care doctors. The reality is that many physicians cannot afford to go into primary care.

To address the shortage of doctors and the incentives that compel young doctors to eschew primary care, Congress needs to think about how to increase doctor pay, institute malpractice reform, and provide subsidies to reduce the amount of debt doctors have to take on. Residency caps should also be raised so teaching hospitals can train more doctors. Without these actions new doctors would be foolish to enter primary care, and thankfully our medical schools do not recruit foolish people.