Pick up the pace!

There's been quite a number of publications looking at exercise benefits for diabetes and obesity.  The evidence points to benefits of a faster pace for a shorter amount of time.  for example, sprinting for 6 seconds followed by a 1 minute rest, repeated 10 times, 5 days a week for 2 weeks,can improve exercise capacity in sedentary people by 10%.  that's only 10 minutes of actual exercise time!

Another study starts with 5 min warm-up; then an 8 second sprint follwed by 12 second rest repeated 60 times; then 5 min cool-down.  Leg muscles get a little bigger and belly fat gets smaller.  Insulin sensitivity improves.  Including the warm-up and cool-down that is 18 minutes of actual exercise and 12 minutes of resting in a half hour.  This exercise schedule is more effective for weight loss and reducing waist measurement than a steady exercise for 45 minutes.

There are a couple things to keep in mind when starting a high-intensity interval program.  First, don't over-exert yourself at the start, especially if you are not exercising much or have been exercising at a leisurely pace.  Take a couple of weeks to build up to the high intensity and complete duration.  Second, don't try this on a treadmill.  The machine isn't designed to speed up and slow down at such a rapid rate.  An eliptical trainer or bicycle can be set at high resistance; you simply speed up and slow down on your own.  Of course you can do this while running/walking.  I suppose that interval body-weight squats or jump-rope would also be suitable.  The key is to use your 'big' muscles, that is your leg muscles.High intensity intervals on a keyboard, joystick or TV remote won't get you the results that have been published.

Check your smart phone store or Ipad app store to download a free app to keep time for you.  Search 'HIIT or 'high intensity intervals' to find the appropriate timer.

Struggling with the insurance approach

I'm frustrated with the mess that the insurance approach to health care makes for both patients and providers.  I have 'contracts' with many insurance companies.  Each has their own approach to determine what they will pay me for an office visit.  Medicare clearly calculates how a price is determined.  It still leaves a huge gap since I am paid by volume as well as time.  I can see twice as many patients and still meet the criteria for a specific payment.  I don't want to herd patients through my office but quality time is reimbursed poorly.

I really don't know how private insurance companies decide the reimbursement rate.  The reimbursement range is wide; the best-paying company reimburses 25% more for an office visit compared to the lowest-paying company, for the same level of care.  the lower-paying insurance companies (and Medicare) say I need to be 'more efficient', which ends up meaning see more patients and spending less time with each patient.

I understand sales and volume discounts for mass-produced items and companies trying to increase business.  I understand that a service-based business may offer a new customer discount or other sales promotion to increase business.  Neither of these conditions apply to my medical practice.  If I refuse to rush patients through my office and the insurance companies (and Medicare) refuse to pay adequately for the time I spend with patients, I have 2 basic choices. First, I drop the contracts that pay poorly.  Those patients either see another physician who is on their plan or they pay me directly.  My second choice is to leave clinical medicine and get a job with a medically-oriented business.  I have spoken to many physicians who have chosen one or the other, and they have been helpful understanding the risks, benefits and compromises of each.  It is a choice that I will ponder leisurely until I am compelled to make a change.

New location for Renown Diabetes Center

The Renown Diabetes Center is at a new address:  850 Mill Street, #100.  All of the excellent staff is working at the new location.  The phone number is the same, (775) 982-5073.  The fax numbers have changed.  The prescription fax line is now (775) 982-3959 and the general fax line is (775) 982-3958. 

The location is easy to find.  Take the Mill Street exit off of US 395 and head west (towards downtown).  The building is one door past the corner of Mill and Kirman, on the left.  If you know where Dish Cafe is, we are right across the street.

Diabetes Conference open for registration

The University of Nevada School of Medicine is hosting the annual continuing medical education program for diabetes care on Friday, September 7.  The theme of the program is "Breaking the Link Between Diabetes and Cardiovascular Disease"
You can view the program brochure here.
You can register at this link.
I look forward to seeing you at the conference.

100 pushups revisited

Three years ago I started a program to eventually perform 100 pushups without interruption. I had to postpone the program due to a bad shoulder. Since then physical therapy, surgery and more physical therapy lead me to try it again.

Many web sites have protocols to build up to 100 pushups. It starts with a test of how many I can do to failure, with good form. I am then referred to a table telling me how many pushups to do and how many sets. This is typically done three times a week. Each workout adds more reps. There are several smart phone apps available. I chose the Rittr Labs app for my Android phone to keep me on track. What I like about this app is that it will adjust the next workout based on my perception of the present workout being too easy, just right or too hard. I also like this app because it uses the same protocol for squats, situps and pullups. No, Rittr doesn't have I-Phone apps. I haven't looked at the Apple app store to see what apps are comparable.

As far as the pushups go, I did my baseline- 18 pushups- and have finished 2 workouts since then. No shoulder pain yet; maybe I will make the 100 pushup goal this time.

250 squats are next on my list. Tenative start date is April 10.

A different concept in insulin delivery

Insulin was discovered 80 years ago and was administered by injection. 80 years later, insulin is still delivered by injection. Insulin pens have made injections easier. Insulin pumps can administer complex insulin delivery schedules. One option missing in the injection world is the convenience of a pump with the simplicity of a pen.

A company new to the diabetes market, Valeritas, has come up with a device that meets this need. The V-Go simplifies insulin delivery for people with type 2 diabetes who need meal time insulin as well as night time long acting insulin. The device is used for 1 day then replaced. It delivers background (basal) insulin with a constant slow delivery of short acting insulin. This replaces the Lantus or Levemir. This delivery is automatic and pre-set. Meal time doses are delivered by pushing a button. There are no batteries, no programming, no tubes. You will never see the needle.

I wore one for a day (without insulin) to see how it 'feels'. I felt a pinprick when the needle went in and the sensation was gone in a few seconds. Within the hour I forgot it was there. When I woke up in the morning I forgot it was there until I saw it. After a 20 mile bike ride there was no discomfort or any annoyance at all.

If you are interested in taking your insulin with this delivery system then first read the web site. Second, watch the how-to video on the web site. Third, please contact me. Most commercial insurance plans will cover this prescription and with a copay reduction card should cost about $25. It is NOT covered by Medicare part D plans yet.

Who Needs Health Insurance Companies?

By George Lundberg, MD, Editor-at-Large, MedPage Today

Published: March 19, 2012

Transcript:

Hello and welcome. I'm Dr. George Lundberg and this is At Large at MedPage Today.

Imagine an America with no health insurance companies.

What do health insurance companies do?

They take as much money as possible from people who want health insurance coverage. They pay out as little money as possible -- so-called medical loss -- to settle claims from creditors for health services and products that have been delivered.

They keep as much money as possible for the incomes of their executives and other employees, and to enhance share value for their owners.

They do try to attract enough premium money from customers -- so-called covered lives -- so that they can spread the risk of a few high-cost customers across the premiums of many low-cost customers.

They try as much as they legally can to cover as many low-cost customers as possible, and to keep as many high-cost customers out of their plans in order to maximize revenues and minimize expense.

They do employ a lot of people, all "following the money" -- sort of a jobs program.

Why do we need them? There must be a better way.

It is true that health insurance companies use market clout to attempt to "keep costs low."

And they are motivated to try to keep their own costs low by limiting use of expensive procedures.

But, by any fair, rational, national, international, and outcome measure, health insurance companies have failed to keep utilization low and failed to keep costs low.

But they have succeeded splendidly at growing their workforces, paying their execs highly, and rewarding their shareholders handsomely.

The for-profit American health insurance industry -- and many of those not-for-profit lookalikes -- is a poster child for the triumph of poorly-regulated and misplaced capitalism in a historically fundamental service profession.

Why does the United States need health insurance companies at all?

The answer is we don't, at least not in their current forms. They cause more harm than they do good.

There must be better way to use our national and personal resources more effectively and efficiently to keep our people healthy and manage their illnesses when they get sick.

Let's create it.

Having abolished health insurance companies in this fantasy, how would you start over?

I would grandfather in Medicare, but insist that it be greatly improved before implementation.

I would expect most ambulatory care to be paid out of pocket up to a means-based annual deductible.

And I would insist on means-based "catastrophic coverage" for ALL Americans.

I would expect the government to pay for preventive services for all that had been proven to be safe and effective, considering them to be public health.

I would take the profit motive out of the health insurance market.

What do you think about these ideas? What would you do? Let our readers know.

That's my opinion. I'm Dr. George Lundberg, At Large for MedPage Toda

Great deal on test strips

Abbott Diabetes care is starting a new program for Freestyle lite test strips. they will provide them at the SAME COPAY as the lowest-cost test strip on your insurance plan. For example, you get a 90 day supply of brand 'X' test strips for $40 with your current plan, but your insurance charges you $150 for Freestyle Lite test strips. Abbott will arrange for you to get a 90 day supply of Freestyle Lite test strips for $40. This works in the same fashion if your copay is for a 30 day supply. You can choose whatever local or mail order pharmacy you normally use. This is available on a limited basis presently through my practice and Dr Eckert in northern Nevada. It is not applicable for Medicare or Medicaid. It will be available through all physician offices some time in March. Please contact me if you are interested in this program.

No more Avandia

Local pharmacies are no longer stocking it. For me to continue to prescribe it the FDA requires me to register with the company as an official prescriber. The benefits of my registration do not outweigh the risks. I will not be signing up with the Avandia physician registry. Please make an appointment to discuss alternative treatments. I will not be changing medications by phone call or e-mail.