Friday, March 25, 2011

Seeking new ways of paying for healthcare in the United States

Few if any people would argue that the healthcare insurance system in the United States works, at least unless they are making political arguments against President Obama’s health care bill. Even those folks, however, I’m sure would privately admit that the system is failing. Americans are paying more for their healthcare every year, yet health outcomes here are average at best. Additionally, with health insurance benefits being steadily cut, many Americans are finding themselves in the situation of having to pay for their healthcare, in addition to paying for their healthcare. Now is the time to begin experimenting with alternative ways to pay for healthcare, and I’ve recently noticed a couple of options that have really caught my imagination. And despite being a ‘crazy naturopath,’ I’m not going to suggest you go out bartering free-range organic quail eggs for your healthcare!

The first interesting trend I’ve noticed is the rise of fee-for-service practices. While NDs and acupuncturists have traditionally operated such practices, an increasing number of MDs and NPs are operating their businesses this way as well. This new wave of providers are offering not only primary care, but urgent care as well. In such an arrangement, you pay for services only when you need them, rather than paying a monthly premium whether or not you use the services. As a result, one of the groups that has gravitated towards these practices are the uninsured looking for lower-cost urgent care visits. Many fee-for-service clinics argue that by not contracting with insurance companies, they are able to offer lower prices to consumers, as much as 40% lower, in fact. For the uninsured, these clinics are often the best option in non-emergencies.

The other group that gravitates towards these types of clinics is the underinsured. This group is increasingly large, and includes everyone from people with high-deductible ‘catastrophic’ plans they have purchased themselves, to those with employer-based plans that also carry high deductibles and offer few services. Fee-for-service clinics often have shorter wait times, and patients find that they are able to get appointments sooner than they would with the doc designated by their insurance plan. Additionally, most of these clinics offer paperwork that can be submitted to insurance companies so that their fees can be applied to deductibles or be reimbursed. The combination of a high-deductible ‘catastrophic’ plan to guard against emergencies, combined with visits to fee-for-service clinics for urgent care and primary care is becoming an increasingly viable option, as it decreases the amount of money spent on unused services, and allows for better patient care and better access to doctors.

The second movement, still in it’s infancy, that’s caught my eye is being pioneered by Qliance in Seattle. This clinic operates as a modified ‘concierge’ practice, in that members pay a monthly fee that guarantees them access to a primary care doctor, covers visit fees and covers the most common lab work. Patients are still responsible for some incidental fees, such as medications and more advanced lab testing, but even so, Qliance offers very affordable services. The practice recommends that patients purchase high-deductible ‘catastrophic’ health insurance plans in addition to their subscription to the clinic, and most patients thus end up in a situation where they pay separately for emergency care (through insurance companies) and primary care (through Qliance). While in most circumstances, purchasing items a la carte increases costs markedly, this arrangement keeps costs low for consumers, and most importantly, provides excellent customer service. Qliance deserves plaudits for taking the ‘concierge’ model and using it to create affordable healthcare at a larger clinic.

Finally, I read recently about a start-up company named Castlight, who are taking it as their mission to ‘cast light’ on healthcare costs, with the goal of allowing patients to do comparison shopping when they purchase health insurance. If you are like me, you’ve tried to do comparison shopping for health insurance and have found it maddeningly impossible. It’s difficult to compare services, it’s difficult to compare what will and won’t be covered, and above all, it’s difficult to compare how much it will all cost you. Castlight seeks to enable consumers to comparison-shop, and understand how their actual health expenses will vary depending on what plan they choose.

While still in a pilot phase that’s being offered only at select employers, Castlight is planning on offering its services more broadly as they expand. This company has been lauded by the Wall Street Journal for applying free-market mechanisms to health care, and I believe that it will likely be a company you’ll hear more about in the future, and one that may inspire competitors offering similar services. I applaud Castlight for working to arm consumers with information; as I wrote in a previous column, I believe that it is important for health care consumers to be knowledgeable about health when they see their doctor, so why shouldn’t they also be informed about the economics of health as well?

The days when physicians were able to maintain something of an ivory tower about health are gone, and it’s time for us doctors to work in co-operative partnerships with our patients, not in benevolent dictatorships, as was done in the past. Patients want high quality care, and they want to be able to afford it. For decades, the American push for low prices has meant a similar trend to low quality, but these fledgling programs are showing that affordability and quality don’t have to be mutually exclusive. Ever skeptical, I can’t fully anticipate whether or not this will be able to expand into a viable option for millions of people, but even as we speak, a growing group of Americans are feeling great and not breaking the bank to do it.

Monday, March 21, 2011

In solidarity with doctors around the world

As I write this column, doctors in a number of countries in the Middle East are being attacked, arrested, and otherwise prevented from saving the lives of people injured while demonstrating for the right to have a say in their government. In some countries, far worse is being done.

As a naturopathic physician, I cannot stress enough that I find this unacceptable. Amidst the debate over the No Fly Zone in Libya, and calls for more strident action in other countries, not nearly enough is being done to ensure the protection of doctors, nor enough to guarantee access to medical care. This is something that we can all agree on – humanitarian aid to those in need. I urge you all to contact your representatives in government to make your opinion known. People across the Middle East don’t have governments that respond to the will or desires of the people. We that have that luxury should use it to help those in need.

Friday, March 18, 2011

Food Intolerance and ADHD

Some of you may have heard on NPR about a recently published study that demonstrated that dietary changes can reduce symptoms in about 2/3 of children diagnosed with ADHD, so that they may not need medication. I listened to it myself, as ADD/ADHD is a special interest of mine, and did a little more research to learn more about the proposed diet, and how to implement it. Some of you may also remember my earlier article about ADHD and diet; to be clear, they are proposing something altogether different.

The interview on NPR was a bit vague, and I was left wondering what type of diet they had found was effective. The diet that was found to be successful was a food sensitivity elimination diet, based on elimination of foods found to test high on an IgG blood test. Essentially, the researchers ran blood tests on 50 children diagnosed with ADHD, determined which foods they were having reactions to, and then had those children avoid the foods for five weeks (of course they also had a control group of 50 children who weren’t avoiding any foods). At the end of five weeks, 30 out of 50 children had reduced symptoms of ADHD. For the next four weeks, those children were fed the foods that they had been avoiding for the past five weeks. Of the 30 kids who had had reduced symptoms when they avoided the foods, 19 relapsed when they started eating them again.

This is confirmation of what has been clinically observed by some naturopathic doctors in the past, that reactions to foods are part of the cause behind ADHD for some kids. The exact mechanism is not yet known, but this study indicates that in some cases, ADHD isn’t a disease proper, but rather a symptom caused by an immune response to foods.

There are, however, some factors that prevent this from being implemented immediately. One is the fact that most physicians haven’t been properly trained how to interpret these tests, or implement the necessary dietary changes, a limitation recognized by the authors of the article. Some solace may be taken in the fact that many naturopathic doctors are well-versed in how to deal with food allergies, both in testing for them as well as counseling patients on avoidance. Beyond this, however, is the question of food sensitivity testing technology. As I stated in a previous blog entry, food sensitivity testing is unfortunately not yet at the standard of other testing procedures (such as cholesterol, blood sugar, electrolytes, etc.). Additionally, the study itself doesn’t discuss the testing methods in the detail necessary to implement their methods. I am keenly interested in learning what testing method was used in this study, as it appears to be one that correlates well to clinical outcomes. As I learn more, I’ll keep readers of this blog updated on what I learn.

As always, this information should be considered as just a piece of the puzzle. ADHD is not as simple as a food allergy, it’s not as simple as a behavior problem, it’s often multiple things. Proper treatment of ADHD can include food avoidance, behavioral therapy, coaching, supplements, homeopathy, biofeedback, and even medication. There is unfortunately no magic bullet, but at the same time, the fact that so many of the interventions are lifestyle-based should encourage us, because these things are within our control. There is a lot that we as parents and practitioners can do about ADHD before having to use medications, and I encourage you to explore those options.

*For those seeking the article itself, you can find it here.

Friday, March 11, 2011

Basic Cleanse Program

We’re entering springtime, which for a lot of people means time for a cleanse. What follows is partially a cleanse, and partially a prescription for healthy living that reduces toxic load over the long-term. This program is appropriate for practically everyone, as opposed to some of the more intense programs, which are appropriate only for certain people, under the observation of a trained professional. I generally take a middle-of-the-road course, recommending a whole foods diet and mild herbs as the core of the program. You won’t see strange drinks, algae or powders here, but you may see some unfamiliar veggies. Try to find recipes that appeal to you – you may find some new favorites!

Foods to emphasize while cleansing and why:
Cruciferous vegetables – This category includes broccoli, cabbage, cauliflower, brussel sprouts, kale, collard greens, bok choi, and broccoli rabe. These vegetables are the core of a good cleanse, as they supply fiber that helps in eliminating toxins, and contain compounds that promote healthy liver function.
Beets – Much like the crucifers, beets provide fiber and compounds that promote healthy liver function.
Leafy vegetables – This list includes arugula, spinach, chard, frisee, lettuce, raddichio, etc. Try to focus on bitter-tasting greens, as they encourage your liver to secrete bile, which improves digestion and rids your body of waste.
Fruits – While fruits contain sugar, they also contains a lot of fiber, so consume moderate amounts of fruit while cleansing to help with clearing out toxins.
Nuts and seeds – Included in this category are almonds, walnuts, sunflower seeds, hazelnuts, pecans, pumpkin seeds and others. These are important to eat throughout the day, but especially in the morning, when they will be most helpful in keeping your blood sugar steady. Additionally, these also provide your body with all-important fiber.
Beans and legumes - Beans and other legumes (such as lentils) provide more of the fiber that is so crucial during a cleanse, do so in a form that is tasty, and bring a lot of protein along to help maintain a steady blood sugar throughout the day. 
Whole grains – This list includes brown rice, whole wheat, quinoa, oats, and corn. Higher in fiber than their processed counterparts, these grains can help to round out meals while cleansing.
Water – Boring old water is crucial for a cleanse. What your body doesn’t eliminate in the stool, it eliminates in the urine. To help that along, try to get about 2-3 liters of water per day.
Green or white tea – Tea is a healthy drink whether you are cleansing or not. It provides antioxidants that are crucial to daily functioning and toxin metabolism, and contrary to popular opinion, tea can aid hydration when consumed in moderation.

As with any cleanse, there are going to be a few restrictions. The basic rule for food avoidance during a cleanse is not to be counterproductive – avoid foods that tax the liver.

Foods and substances to avoid and why:
Coffee – Coffee stresses your adrenal glands, throws off your blood sugar, and disrupts healthy elimination patterns. Coffee causes your body extra work when you want it to be busy detoxing.
Alcohol – Alcohol taxes the liver and disrupts healthy elimination patterns. Count this one out while cleansing.
Refined sugar – While there are sugars in nearly all foods, refined white sugar should be avoided while cleansing as it stresses your body without offering protective compounds.
Tobacco – A massive source of metabolic stress, tobacco generates toxic compounds in the body and interferes with the body’s ability to rid itself of them.
Dairy – While most of us consume dairy regularly, try to moderate dairy while cleansing. It’s hard to digest and forces the liver to contend with saturated fats.
Fried foods – Again, your liver does the bulk of the work when processing fats, and these are no exception. Pair that with a low nutrient value and it’s on the avoidance list.
Recreational drugs – No judgment here, just a recommendation for healthy living. Like coffee, alcohol, sugar, etc., recreational drugs increase your body’s burden when you are trying to detox, so avoid them as you would avoid everything else on this list.

Note that there are a number of commonly consumed foods that are not on either list, such as potatoes, tomatoes, yams or other vegetables. Enjoy these moderately, for though they are not detrimental to a cleanse, they don’t particularly augment a cleanse either.

What about meat, you ask? Many cleanses restrict meat if not forbid it entirely. I don’t forbid it, but encourage moderate consumption and smart choices. Meats provide protein, iron and vitamin B12, among other vital nutrients, but do not provide fiber or nutrients that promote optimal liver function. Likewise, look for lean cuts of meat that provide nutrients without as much saturated fat. Consider eating organic if possible, as conventionally-raised meats are often high in compounds that require a lot of work to eliminate. During a cleanse, take time to think about why you are eating meat; think about the nutrition and benefit you hope to gain from eating meat, and let that be a part of your decision-making process.

Herbs for cleansing:
Milk Thistle – Milk thistle is a well-studied, well-known liver-protective herb. While you are cleansing, Milk Thistle can protect your liver from all the baddies your body is clearing out.
Turmeric – Turmeric is becoming well-known for everything from cancer to joint pain. One of its main actions in the liver is as an antioxidant, where it too protects the liver from toxic substances.
Burdock – Burdock is traditionally used to clean the blood and to enhance liver function. It’s known in herbal medicine as an ‘alterative’ which means that it has a broad cleansing action in the body.
Yellow dock – Yellow dock is used for the same reasons as Burdock, but has the additional benefit of stronger action on the liver.
Flax seeds – If you do want to supplement with fiber while cleansing, my recommendation is to use flax seed meal, as it is milder than psyllium and supplies some nutrients as well.

The importance of exercise can't be over overstated. No matter if you're cleansing or not, exercise should be part of your routine. From it's benefits in cardiovascular disease, to weight loss, to stress and anxiety, and on down to cleansing, exercise is vital to a healthy lifestyle.
When cleansing, many people are too tired or too weak to exercise, but this is an unfortunate effect of low-calorie cleanses such as juice fasting or "The Master Cleanse". Sweat is an underutilized route of elimination, and one that will rid your body of toxins just as well as others. It's important, therefore, to make sure you are eating healthily and making smart food choices during cleanses.
During a cleanse, I recommend exercising to the point of sweating for 30 minutes at least once a day. Sweat can help carry out a variety of compounds, including heavy metals, so get that sweat flowing! Make sure that you're staying properly hydrated before, during, and after exercise; remember that water is a primary component of a cleanse, so don't fall behind in water intake.

While cleansing is important, it’s equally important to maintain healthy habits after a cleanse to continue to support your body’s natural detoxification mechanisms. Make note of recipes you liked while doing your cleanse and try to add them to your life. Likewise, observe moderation in consuming foods you avoided during the cleanse. You don’t have to get rid of them entirely, but keep them to a minimum. Think of it this way: A spring clean will clean out your house, but takes a lot of time and work. Regular sweeping keeps it clean, and makes your spring cleaning easier.

Friday, March 4, 2011

Internet research and the Doctor-Patient relationship Part 2

Having discussed some of the reasons why patients use the Internet to learn about their health, I’d like to discuss one of the most contentious issues regarding Internet-usage: self-diagnosis. This again is a source of friction between doctors and patients, and part of the reason that some docs don’t want patients using the Internet. Indeed, I admit that I’ve had some difficulty with this as well, which I’ll presently explain, but I’ve come up with some solutions to this challenging issue that I’d like to share. I want to make clear at the outset that I intend to grapple with this as a fact of our modern existence, not try to fight with it to make it go away – whether or not we doctors like it, this is something patients are doing, and this article is intended to educate both doctors and patients on how to work with this fruitfully.

As a naturopathic doctor, I sometimes see patients whose chief complaints are diagnoses they have found on the Internet. In my clinical experience, one of the primary issues around self-diagnoses is that they can negatively affect patient reporting, making patient outcomes poorer. Here’s what I mean: as a doctor, it’s my job to make a diagnosis based on signs, symptoms and other information gathered from a patient, and then to formulate a treatment plan based on that diagnosis. The part of this process that is most frequently disrupted by self-diagnosis is the patient’s symptom reporting. Self-diagnosis based on Internet research can result in patients being less attuned to their symptoms. In all honesty, diagnoses given by trained medical professionals can have the same result. In both cases, instead of reporting symptoms, patients report the ‘diagnosis’. When I have patients whose primary complaint is a diagnosed problem, I consider that as a primary possibility, but also want to explore other possibilities, just in case. When the patient has either found or received a diagnosis, the situation I sometimes run into is one where patients are able to speak at length about a given disease, but have a dearth of symptoms to report.*

The point for this section is this: If you are going to use the Internet to explore self-diagnosis, don’t lose sight of those symptoms that lead you to ask questions in the first place, and keep an eye out for new symptoms that emerge along the way. Bring all possible information to the doctor’s visit. Bring your hypothetical diagnosis, but make sure you bring your symptoms too. This will help you and your doctor come to the most accurate diagnosis possible, as well as aid the both of you to understand how you as an individual are manifesting your illness. The diagnosis is not the be-all-and-end-all. Your experience of life is the most important factor in seeking health. Your doctor can throw on all sorts of treatments that are shown to be effective for your diagnosis, but unless you are happy and healthy, your doc hasn’t done their job.

As doctors, I think we need to recognize that this is a phenomenon that is happening, and that we should learn to work with, rather than dismiss. When patients come in with self-diagnosis, we shouldn’t be irritated by it, but rather take it as another piece of information. Even if it does not turn out to be the correct diagnosis, there are almost certainly very real reasons why the patient came to the conclusion that it was the diagnosis. These should be clues for us to follow – we can only gain information from them.

Hopefully this has been informative for both professionals and consumers. This is certainly a contentious issue, but it doesn’t have to be one that divides us or causes opposition in the doctor’s office. Patient education is one of the primary callings of the physician, and this topic provides plenty of opportunity for that. As stated in part one of this series, our goal should always be to strengthen the doctor-patient relationship, through education and honest communication.

*A note on under-reporting symptoms: In situations like this, it is frequently challenging to help, as there is little to go on. Without know what this patient’s symptoms are, it’s hard to know what body systems to target, how physiology has been altered, or what to follow up with. All of that information is gathered in the reporting of symptoms. Most naturopathic doctors would agree that a diagnosis alone is not enough, for we individualize treatment based on the unique ways that a patient is manifesting their illness.