Friday, April 6, 2012

Step Aerobics Tips

How to Use Water Exercises for back pain
Water exercises for back pain relief back pain and too often to strengthen your back. There are a few tips to follow to get more use should be with these exercises.

Calories burned during aerobic phase
Step is a great way to burn calories and how to deal with weight problems. Have you ever thought about how many calories you burn in aerobic steps? Scroll down for the calculation and all the answers.

Aerobic Dance
Aerobics is a great way to stay healthy and wealthy. Read about their strengths and how do you know this form of exercise, alone at home to reach ...

Exercises in warm water
Hot water is a great way to keep track of various forms of exercise because of its advantages. This article guides you through the various benefits that the drills provide hot water, and give you some examples of what these exercises.

Chair Aerobics
Chair aerobics are good for those who can not claim a high load. Here are 10 different types of chair exercises that will help you with your aerobic fitness.

Step aerobics shoes
To learn how to choose the best pair of shoes for step? If yes, then you are exactly right. Read the following article talks about the essential step of shoes ...

Aerobics for seniors
Health is wealth, and it seems especially if you are getting older and your finances closely. Read on for some basic aerobic exercises, the lives of older people to assist with enthusiasm!

Aerobic Shoes for Women
We have some of the best brands of gym shoes for women available. These shoes are designed for maximum comfort for you, while influential movement. Read more ...

List of Aerobics
Explained in the list of aerobic exercises in this article, you can choose from, and start practicing at home. Aerobic exercises are a great way to fit your body, how to improve breathing and cardiovascular health. Read on.


The benefits of aerobic exercise
Aerobic exercise can also almost all the exercises, making the heart pump more oxygen to the muscles. Learn more about the various benefits of aerobic exercise.

List of aerobic
The following article lists some of the most effective aerobic as well as tips on how to select and implement aerobic exercise. Read more ...

Aerobic Fitness
Several aspects of aerobics will present information on the tests, exercises, etc. mode must approach this task, it is also an important thing to consider, is considered.

Low Impact Aerobics
The following article provides some of the most effective exercises with low impact aerobics and how to get the most benefit from them. Read more ...

The best aerobic exercise for weight loss
If you're wondering, this is the best aerobic exercise for weight loss, you have to get on the right side. Scroll down to find that aerobic exercise is best for you, the ideal length of the sessions of aerobics and the best time to do it in order to achieve maximum weight loss.

Water aerobics
Water aerobics is a great way to get fit and tone. Read the following article to understand the basics and learn a few routines.

Water Aerobics Shoe
Steep for water aerobics? Well, you have these specially developed aqua aerobic shoes? Otherwise, you will need to purchase one. Here is more about their services and opportunities that are available for this type of water aerobics shoes.

Water aerobics equipment
Water aerobics, equipment differs from these exercises machines and fitness equipment, most of that water are intended to help inform the organization. Read on to learn to read more about these plants in a water aerobics that help to strengthen muscles and burn some extra calories will.

Water aerobics equipment
Gym equipment in water are useful in the practice of aerobics in the pool. Read on to learn more about the features and benefits of water aerobics that year.

Water aerobics routines
More water aerobic routine that is played are usually made those skilled in the permit, to receive an education that is much cooler and more efficiently. Find a routine simple, but effective here.

Water aerobics workout guide
If you start with aerobic exercise in water, then you should follow the instructions for water aerobics, so enjoy this exercise to avoid injury. The best part of endurance training, the water that may be of almost all age groups.

Aerobic exercises done at home
Aerobic exercises are one of the best exercises to lose weight quickly. However, there are some aerobic exercises to do at home? Some of the best exercises that you can eat at home. Read more ...


Types of aerobic exercises at home
Most types of aerobic exercises at home will help you get fit. It just takes some discipline and determination! Aerobic exercises are a popular form of weight loss workout routine, so many celebrities have their own training videos and won.

Aqua-aerobics
For those who are tired of going to the gym, here is an effective water aerobics workout that keeps you cool, so is any other form of exercise could never do.

Procedures for water aerobics for seniors
The search routine of water aerobics for the elderly? Then you just right. Read more about the benefits of these exercises and routines, and how to insert them in your life.

Aqua Exercise for Weight Loss
One of the newest trends is to do exercises to help the water to lose weight, and there are many fitness enthusiasts who swear by the benefits of this training program.

Water aerobics exercise routine
One way to stay fit is a routine practice of water aerobics that follow the body meets. It is also one of the easiest exercise routines for older people and the possibility of injuries that occur in practice, even very low.

Water aerobics
Water aerobics has become the latest trend in the fitness world, although for a long time. It has become popular is that people can perform in each age group without any problems. Read the details on this form of aerobics.

The flow of water aerobic
Aerobics moves are always popular in gyms and fitness centers. Water aerobics is one of the few exercise routines, where you actually lose are pounds and have fun together.

Types of aerobic exercises
There are different types of aerobic exercises that you can take to stay fit. It is not necessary to visit the gym for a variety of aerobic exercises.


Endurance Training
The following article deals with information on different forms of aerobic exercise. The importance of this training is described in the following paragraphs.

Step Aerobics Moves
Step aerobics is a fun exercise, such as step aerobics movement, in consultation with the class and the teacher, the music at a high level. Here are some basic steps to a level that gives you an idea of ​​what happens in the classroom.

Aerobic moves
You are in the process of weight loss from the body? If so, then this article is very helpful. Learn some aerobic moves.

Step Aerobics Equipment
Do you step aerobics? Details of step aerobics equipment, you can buy and have a great aerobic workout at home.

Aerobic exercise equipment
We see the discussion on the different types of machines aerobic exercises, and benefit from them.

Step Aerobics Workout
Educational choices is a step better than many other exercises to do because of the different movements, which are not only fun but also help you lose weight and tone your body. ..

Step Aerobics
As a step aerobics is an excellent form of exercise especially for those who carry out regular quickest on the track. See how to do step aerobics workout that you enjoy.

Step Up Exercise
You can lose weight, strengthen muscles and give your body a boost to close the regular training and discipline. More information about the increased work and how to do it by reading the following article.

At high impact aerobics
For the very impact aerobics routine is basically a high-intensity, even brisk walking, jogging, aerobics and many other painful exercises. Read on to learn more about the great impact aerobics and learn how they differ from simple aerobics.

Aerobic Steps
Dancing is aerobic exercise, which can not be fun, but also help you burn calories faster. We will see some basic movements of dance aerobics ...

Step aerobics choreography
The introduction of a step in your training program will help you find the strength and tone. Here are some simple aerobic choreography presentation is for you to learn.

Fitness classes
Like any other form of exercise, aerobic strive for a healthy life. You are the best way to get a toned body, and to lose pounds. Read on to learn more about a variety of aerobics for men and women.

Aerobic exercise at home
They are trying to lose weight or stay fit, aerobic exercise is completely at home. Discover the best aerobic exercises at home, which is not only a good source for fitness, but also relieved.

What is aerobic exercise
I do not know what is aerobic exercise? Search for their health benefits? Read the following article for some basic information on aerobic exercise and get their benefits to human health.

Water jogging
Water, water jogging, aqua-jogging or walking is excellent exercise for people with injuries, and for people who want to avoid injuries. Learn about the different exercises to get running water.

Water treatment research work
During this period, health consciousness, it seems that fitness enthusiasts thrive in a wider movement to make. Water exercise therapy research is a new way to keep fit. Want to know how to help aquatic therapeutic exercises? If you want to read you.

Step aerobics routine
Step routines are the most recent version of the traditional aerobics are ideal for toning your body and burn calories. To learn more about step aerobics routine.

Aerobic exercises
Aerobic exercises are the most popular forms of exercise for many years. Check out some of the benefits of aerobic exercise and the discussion below.

Water aerobics: procedures for water aerobics
Water aerobics routine is not very different from the aerobic soil. More than once, the aerobics instructors have a variety of aerobic exercises in the routine aerobic groundwater. Scroll down to learn more about water aerobics routines.

Fitness classes for women
Fitness classes for women will help you lose weight, not only, but also tone. Aerobic exercises "Words are interchangeable with used cardiovascular exercises," "heart and respiratory exercise," or simply "cardio". Read about some aerobics for women to know.

Aerobic Exercise for Weight Loss
This article is a guide to aerobic exercise in order to pay the excess calories. This is what explains the different types of aerobic activity, which may lead to a lean and fit. Read on to learn more ...

Fitness classes for beginners
Fitness classes for beginners, the idea is for those who want to start fitness regimen. If you are in a position to carry out relatively simple, you can add weight to their training.

Aerobic vs Anaerobic Exercise
Join us as we venture into the world of competitive fitness in order to find the answer in the aerobic vs. anaerobic long-awaited. Both have their pros and cons, so read on who has priority over the other ...

Aerobic exercise at home
Aerobic exercise helps improve home oxygen in the body. Contribute to weight loss and maintain shape. We hope to make the best aerobic workout at home.

Water aerobics: burn calories with water aerobics
Aerobic exercise may be using groundwater. Calories burned during a session of water aerobics may vary. Water aerobics is a simulation of the earth and gym exercises performed in water. We read to know more about calories burned on aerobics.

Water aerobics certification
Water aerobics certification is very important when they occur, or increase the chances of you in education, such as fitness. Can help water aerobics certification deserves a lot of money and good life if you can give good service to people. Read on to learn more about Water aerobics certification.

Aerobic exercise equipment
Or losing weight or maintaining a slim and equipment, aerobic exercises are the most popular choice. Knowing what are the benefits of aerobic equipment and a few of them in this article.

Examples of aerobic exercise
These exercises require a lot of oxygen when they did, and also increases the amount of oxygen in our body are aerobic exercises. Throughout the world, fitness experts recommend a series of aerobic exercise to lose weight and your body, because that's what burns extra fat. Then look at the article below are examples of aerobic exercise.

Certified Aerobics Instructor
With changes in lifestyle that have occurred, it has become important because you have time to exercise. Aerobic exercise for 46-60 minutes a day of great help in developing the muscle groups do. Aerobics class is best with someone who is a certified aerobics instructor under his belt.

Aerobic exercise routine
Aerobic exercise routine consists of three phases. It begins with heating, then goes through a difficult phase of the movement. The last step is a step cooling. Aerobic exercises, when performed in the usual way, to increase the oxygen in the body. This is crucial to stay healthy and fit.

Water aerobics shoes
Water shoes and aqua aerobics shoes are a must for people, it is known that aerobic exercise. These shoes look, but others are very useful against damage and scratches.

Water aerobics routine
Aerobics in water is fast emerging as an effective way of training. It consists of several exercises that are officially classified as a water aerobics routine, which are known. It examines the various water aerobics routines and their benefits in the next article.

Aerobic Dance Shoes
Aerobic shoes are shoes for athletes. Tors shoes are designed for endurance sports like running, cycling, cardio-boxing, etc. If you designed the collection in the same article.

Benefits of Water Aerobics
Water aerobics is one of the best types of exercise are among the summer. These water exercises are an effective way to lose weight and still beat the summer heat. To learn more about the benefits of water aerobics in this article.

Aerobics at home
Aerobic exercise refers to exercises that increase oxygen in the blood and thus oxygen in our body. In fact, the word aerobics "with oxygen". Read about all the exercises that fall under the category of aerobic exercise to discover the home.

The benefits of aerobic exercise
Aerobic exercises are based on routines that help to improve blood flow and oxygen to the body. There are many advantages of these routine exercises, credited as the increased metabolic activity and tonic muscle groups.

Water aerobics exercises
A great way to burn unwanted calories is to attend to water aerobics club. Aerobic exercise in water are the most desirable form of exercise in the sweltering summer months. To learn more about water aerobics exercises ... More

Aerobic Exercise
Aerobics is a form of exercise that can be a fun activity. Read on to learn more about aerobic exercise and how it may be beneficial in several ways.

Exercises in water - water treatment
Water research, as well as water exercises or water aerobics is known to be an effective way to stay fit and recover from injuries, not to make your workout. Learn more here.

Aquafit - aerobics water
Water aerobics or pool exercises, is a good way to get fit without the usual risks of injury and pain that get associated with traditional aerobic exercise takes place on land or in the gym.

Step and benefits
Step Aerobics brings you one step closer to the optimum condition. And also with an incredible performance.

What is aerobics?
Aerobic and cardio are very effective if done methodically. Calculation of aerobic heart rate is a matter of minutes.

The best aerobic exercises
Aerobic means "with oxygen" and regular exercise is rhythmic large muscle groups. Aerobics improves overall health and well-being, gradually burns fat and improves cardiac function.

To determine your heart rate
Set the heart rate for aerobic exercise

The best automatic bike

In general, you'll notice that most people who want to learn to ride a bike in the first place, would be concerned with the task of moving. If you have solved one of them, the bikes with automatic transmissions, which will be a problem. As the name suggests, automatic transmission motorcycles are the ones who do not understand, the default installation of the gearbox and clutch tools. These engines are not the best choice for those who need to learn to drive, or those who do not want to worry about shifting, intended to drive. The next part of this article will help you get the best automatic transmission motorcycle market.

The best automatic bike


Honda DN-01


Honda DN-01 is a cruiser with Honda, which has been available for commercial use, manufactured in 2009. This is one of the best features of an automatic transmission fitted as on the street. It has a liquid cooled 680 cc V-twin 8 valve with a power of 43.3 bhp. It reached a speed of 60 miles per hour in 7.4 seconds and a top speed of 113.1 kilometers per hour. E ', equipped with a continuously variable automatic transmission revolutionary transmission (CVT), which is a manufacturer as "Human Friendly Transmission" is defined. Last recorded price is around $ 15,600. With a total capacity of 4.0 liters tank, about 42.3 MPG.

Aprilia Mana 850 GT ABS



Aprilia Mana 850 GT ABS is roadsters Mon Aprilia, the Italian motorcycle manufacturing giant. It was formed with 839.3 cc V-twin four-stroke engine with an 76 km welcomed. This vehicle is equipped with three driving parameters, such as sports, hiking, and rain. If you ride bike "Sport" mode, it is given full power and torque, with a maximum engine braking. For "Touring" mode, all parameters with a high capacity down to those who are in turn contribute to improving fuel efficiency. If set to rain, "This will be a share of 25 percent. Driver can also switch to manual transmission and transfer control to the pedals or steering wheel. Tank Aprilia Mana 850 is 16 liters.


Honda VFR1200F DCT

This is a sport bike with Honda, which can be used for travel. Production began in October 2009. It comes with a 1237 cc V4 DOHC engine that produces 170 horsepower extraordinary. Transfer of technology, which uses an automatic double-clutch transmission (DCT). There are three driving modes, such as "D", "S" and "Manual". Way "D" of wheel-set maximum energy efficiency, while the "S" mode is automatically accelerated at higher speeds. In addition, as a "hand" is the driver to change gears using paddles on the steering wheel. Impress others with their anti-lock braking (ABS) and dual brake system (CBS), which acts on the front and rear brakes simultaneously for effective braking. Mileage is estimated at about 44 MPG.

Ridley Motorcycle Company
http://3.bp.blogspot.com/_LbFB-mIBjYI/S3YhXbjlX2I/AAAAAAAAAtY/21OWeaRDvLI/s400/2009-Ridley-Auto-Glide-Limited-Edition-Front-Light-View-588x393.jpg
In addition to these major brands of bicycles, motorcycles can be equipped with automatic transmissions are also found to be not so well known, but there are good companies, such as Ridley Motorcycle Company. This is a private limited company which is specialized in manufacturing motorcycles with automatic transmissions, with headquarters in Oklahoma City, OK. Models of this company Speedster, Auto-Glide Chopper, Auto-Glide Sport, Auto-Glide Trike, and Auto-Glide TT.

Tuesday, March 27, 2012

Knowing High Quality Sport Lockers Provider

Hello, today i want to write some about sports need equipment such as sports lockers and cabinet. If you like sport or athlete, then you should be with sports equipment which can storing this sport equipment. In this case, then certainly you do not care about your property. Need a special place for the protection and safety lockers give you this answer. The cabinets are specially designed to keep your heavy and expensive sports accessories. Metal cabinets with sports equipment, but do you also to relieve tension on the safety. The safety is first. Use most reliable metal sports lockers.

Would you really know where we can use the cabinet or locker as effective? Then the answer would be the best athlete in the locker room. Athletes who do a lot of exercise and practice. You sweat a lot. After practice, they had only their clothing and equipment in the corners. To avoid the foul smell and used these things, sports lockers can be useful. Thesis cabinets are diamond perforated doors and sides of its ability to draw up and smell. This is because the air is circulated through the safe and easily allows no odor to continue.

Sports lockers are manufactured in different designs suitable for saving space in your room and give the room a pleasant sight. These are designed specifically for sports such as hockey, golf, cricket, badminton, etc. Bearing in mind the length and breadth of the equipment, built in rack is suitable forms. Also there are some planning such a large staff to maintain all equipment. Special designs are created with a mix of bright colors for children's sports lockers. This is done to amuse them with energy and filled with attractive colors.

Besides sports, the cabinets are designed for personal development and keep them in your home. Lockers for personal use to be a little less space to make professional use for a single person. Lockers are available in the system in two or three levels to keep enough space. You can find them in various sizes from small size, medium and large. If you are bored of their projects then you can decorate with balloons and tables. The cabinets are made of steel or durable plastic to withstand the heavy load of accessories for the sport. Do not worry about safety, because the green is reliable and easy to charge things to your favorite sports.

Locker rooms in some of the companies in the world have started their online services. You can visit their websites and get some brochures, and your choice of lockers and the selection order. They will be made as soon as possible. With this tool you can take advantage of superior quality at affordable prices available anywhere in the world without visiting the place personally. But in the online booking increases your responsibility as decisions must be made with proper research on their products because they do not personally visit the place. Introducing a most leading of lockers provider that is MoreLockers which was founded in 2004. Enjoy all the convenience of shopping and found the various needs of your profiles of lockers on the official site at MoreLockers.com. Please browse item for more than 30,000 types of sports lockers and athletic lockers with the best quality here. One of the company benefits they are the most low price shipping cost. The price offered by them was very affordable when compared with similar companies. While it may seem a little price, but always go for the long term the best quality for you to have benefits for longer. Keep things in order and good sports.

So the above discussion, we know where we can effectively use the lockers. We would also suggest for cabinets to choose the sports they are still involved in sport. You can make your choice between different designs and colors suitable for your decorations in the sport room. Thank you..

Monday, March 26, 2012

Type of Computer Viruses

A computer virus is a malicious program written intentionally to enter a computer without your consent or knowledge. It has the ability to repeat, which continues to spread. Some viruses are not small, but again, others can cause serious injury or damage to software and system management. The virus is harmless and should never be left in the system. The most common types of viruses which are listed below:


How many types of computer viruses

There are several types of viruses, which can be based on their origin, equipment, files with the disease, where they are hiding, what kind of damage they cause, type of operating system or platform, etc. Let's look some of them.

Resident Virus
This type of virus consistently, he lives in RAM. Because they can overcome and interrupt all system functions. It can destroy files and programs open, closed, copy, rename, etc.

Example: Randex, and CMJ MrKlunky Neve.

The immediate effects of the virus
The main objective of this virus to replicate and to act in the implementation phase. When certain conditions are met, the virus infected files in the directory or folder and run it in the path specified in the AUTOEXEC.BAT file. This batch file is located in the root directory is always difficult, and perform certain operations when the computer starts.

Example: The Vienna virus.

Type of virus
The virus is that it removes the information in the files, infect it makes them partially or totally useless once infected. The only way to clean the infected files overwrite deleted files, losing the original content.

Examples: roads, Trivial.88.D Trj.Reboot.

Boot sector viruses
This virus affects the boot sector or hard disk. This is a fundamental part of the disk, where information is stored on disk with the program can be started (start) a computer disk. The best way to avoid viruses is to ensure that the boot-sector disks are read-only and not your computer boots from the floppy drive into the unknown.

Example: Polyboot.B, AntiExe.

Macro viruses
Macro viruses infect files that are created with specific applications or applications that contain macros. These programs to automate the mini-series of operations performed as an action so you have one.

Example: link, Melissa.A the Bablas to O97M/Y2K.

Directory of virus
The directory viruses alter the location of the file. When you run the file extension of the program. EXE or. COM, a virus, a virus, run unconsciously virus program, and the original file and the program moved to the virus. Once infected, it becomes impossible for the original file.

Examples: land 2 viruses.

Polymorphic Virus
Polymorphic viruses encrypt or encode themselves in different ways (different algorithms and encryption keys) every time the infected system. It can not "find their antivirus signatures or search using the string (because they are different in each encryption). The virus then creates a large number of copies.

Example: Elkern, Marburg, Satan Bug, and Tuareg.

File infector Virus
This type of virus-infected programs or files executable (EXE or COM extension Baili ..). When you run these programs, directly or indirectly, the virus is activated, produces dangerous is being organized to perform. The majority of existing viruses belong to this category, and can be classified based on the measure.

Example: Cleevix and Cascade.

Virus Company
Virus companies can be considered a type of file infecting viruses types of shares as residents or directly. They are known as companion viruses because once they see the files "that are already active. In other words, in the order sequence of infection, the companion virus waiting for memory" as the program is running (virus dwellings) or act immediately after receiving copies of itself (live virus).

Examples include: stator and Asimov.1539 Terrax.1069

FAT Virus
File Allocation Table or FAT is a part of the disc used to store all the information about where the file space, space that can not be used, virus attack etc. FAT FAT in the forum, and damage to important information. This can be especially dangerous because it interferes with some parts of the disk where important files are stored. Damage can cause loss of information on individual files or entire directories.

Example:

Multi Virus
These viruses can be spread in many ways. This may vary depending on the measure, if the operating system installed, and the presence of specific files.

Examples: Invader, turned and Tequila

The web Script virus
The site contains a lot of complex code to create powerful and interactive content. This code is often used for undesirable behavior.

WormsThe virus is a program that is very similar to the virus, the ability to replicate and cause adverse effects on the system. But it can be detected and eliminated by antivirus software.

Examples of worms are: PSWBugbear.B, Lovgate.F, Trile.C, Sobig.D, Mapson.

Trojan or Trojan horse
Trojan, Trojan horse or other nasty breed of malicious code, which unlike viruses do not reproduce by infecting other files, as well as local self-government similar to the worms. In fact, this is a program masquerading as tools or application.

Logic bombs
They are not like viruses because they are not repeated. They also function as separate programs, but camouflaged parts of other programs. They can only be implemented when certain conditions are met. Their goal is to destroy data on your computer when certain conditions are met. Logic bombs go undetected until launched, and the result can be devastating.
For further information due computer and software management, please visit the G8 Summit Computer Development

Written by The Committe Of Cygnet editorial team.

Sunday, March 4, 2012

Photofunia

Photo editing is not a pleasant thing for most people, including me ... Because the applications that I use is the application that I had never learned, hehehe ....
But I never discouraged to look for the easiest way to edit photos, and downloading it for free. Once upon a time I tried the application's Picjoke.Net. This application is named PhotoFunia. Initially I was confused what I should do, but because there are a lot of frames, then I tried to click. And the results are quite interesting. Then I save edits photofunia and present to my facebook page. Yes, it is not difficult and it is easy for me to use. Wide variety photofunia effects are present every day, so do not let you not try a free photo effects.
Here is a photo I've ever edited using photo funia .. Check it out ...


Funny Pictures
Funny Pictures

Sunday, February 26, 2012

Basic Principles for the poker and blackjack

The following paragraphs summarize the work of online poker and blackjack experts who are completely familiar with all the aspects of online poker and blackjack. Heed their advice to avoid any online poker and blackjack surprises.

The best time to learn about online poker and blackjack is before you're in the thick of things. Wise readers will keep reading to earn some valuable online poker and blackjack as online gambling experience while it's still free.

For the name, now I will give that as a basis for poker, so we can add the chips. In the past, a poker directly opposite each other. However, in the current era of technological things you can do online or play a board game online casino. The number of games that can be played online gambling as smart may force us to find the best casino before you buy a certain number of points. Yes, sometimes you are too hasty in making decisions that lead to errors. Below is a list of online games was provided onlinecasinospotlight.com. There is nothing wrong with the big casino, we see the next prize in the first place. Try these recipes online gambling, you can do if you think he was an expert in the game. The poker game is expected to defeat their opponents, even if you belong to beginners. The confidence we have sown, and imagine playing in a casino in Las Vegas as a luxury. If you have any doubts, look at the video poker games and defeat our opponents.
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Blackjack Ace player a peak (ie, Black Spade) and spade Jack, and the first card will be charged separately, and the player makes the name easy to remember.

The aim of this game is close, without excess in the number 21 ("bust").

Play a game:
Smoke Mamasang players in a circle in Paris. Dealer gives two cards to each player and himself a person and a person.

Blackjack is a game of double loop, which means you can play three hands at once. Enter Paris in a circle next to the central square, if you want to play a better grip. This makes the game more interesting and increase your chances of winning.

There are many online games I can not give a more detailed review, but not discouraged, because the next time I'll try to find information about craps, roulette, etc.

Is there really any information about online poker and blackjack that is nonessential? We all see things from different angles, so something relatively insignificant to one may be crucial to another.

Sunday, February 19, 2012

Juniper Berry Benefits For Human Healths

If you're seriously interested in knowing about juniper berry for health, you need to think beyond the basics. This informative article takes a closer look at things you need to know about juniper berry for health.
It's really a good idea to probe a little deeper into the subject of benefits juniper berry for health. What you learn may give you the confidence you need to venture into new areas.
Juniper Berry For Health

Juniper Berry renal
Juniper berries have properties that act as diuretics. This means that these berries help increase the rate of urine, in the person consuming it. The beach can also break free and uric acid in the body, helps the person to urinate. It also helps to dissolve kidney stones. People with problems like water retention can also communicate with juniper berries, because they help to alleviate the problem through urine. The urinary tract is deleted, then the kidneys to perform their functions properly. However, note that the juniper berries should be used cautiously. The excessive and wasteful consumption of the berries can cause serious kidney damage and render them useless.

Juniper berries for skin
Juniper berry and its extracts have been shown to be effective in helping skin problems too. Acne, athlete's foot, dandruff and psoriasis are some of the skin problems most commonly encountered. If you want to get rid of these problems, all you do is to prepare local demand by simply pressing the berries and use the diluted juice as an ointment on the affected area. It was also said to use the juice on the surface acts as an anti-aging remedy. You may feel a sensation of heat and irritation when applied to the skin. You can mix the mixture until it bites and then when you feel comfortable, you can increase the level of concentration of the extract.


Juniper Berry for Diabetes
Juniper berries are a wealth of natural insulin. This can be very useful for people with diabetes. However, again, extreme caution should be exercised in consumption of juniper berry extract. This is usually done as a tea. Diabetics should be careful because excessive consumption can lead to excess glucose in the body.
Juniper Berry For Health
Juniper Berry digestion
Juniper has a highly volatile oils which they can increase the level of digestive acids in the stomach. As we all know, these digestive acids are an integral part of our digestive system and are necessary for digestion. Then eat the fruits can help speed up the digestion process and makes it safe. Moreover, it also helps to relieve gas system, to help people cope with problems and swelling.

Juniper Berry for menstrual problems
The next time you have those who torture menstrual cramps, you may want to meet a few of these berries taste bitter to help relieve pain and provide some relief of discomfort. Furthermore, extracts of juniper was able to help tone the uterus and help follow-up period of a woman if she has problems of periods of delay.


Other benefits of juniper berries
In addition to those mentioned above, juniper were also used for other purposes. Some of them are listed below.

Cough, select and chests resulting congestion can delete extract of juniper berries.
Juniper berries, and choose whether to help weight loss, detoxification capacity because they have to help cleanse the body.
Beaches, choose coated were used in ancient times to avoid hunger pangs.
They also have anti-bacterial and anti-inflammatory that helps the body fight infections inside and outside.
, Choose disorders such as rheumatoid arthritis, joint pain, nerve and muscle tension, etc., can be treated using juniper berries. The application beaches or local consumption, both of these treatments help.

When word gets around about your command of juniper berry for health facts, others who need to know about juniper berry for health will start to actively seek you out.

Sunday, February 12, 2012

The high cost of drugs: treating cancer and cholesterol while building profit


The cost of drugs can be enormous, as anyone who is on many of them, or even one expensive one, can tell you. For most people with good health insurance, the amount that they pay is only a portion of the cost (as with much of health care); still, the co-payments for some drugs, particularly non-generics, can be high enough to be significant for even upper-middle-class people. Lower income people may have to choose between medication and other frivolities – like food. For very high cost drugs, like many of those made artificially by “recombinant DNA” that are used for conditions including cancers, autoimmune diseases like rheumatoid arthritis, neurologic conditions like multiple sclerosis, and inflammatory bowel disease like Crohn’s, the cost is enormous.

The high cost of cancer drugs, in particular, is the foundation of several industries. The most obvious, of course, are the drug companies who manufacture them, and make great profits. The markup price that health insurers (including Medicare) pay for the administration of these drugs, however, is a major source of revenue for hospitals and the doctors who supervise their administration. The staggering growth of “cancer centers” in almost every hospital that can put one together is testimony to this. Most hospitals pursue certain “product lines” (sorry if it offends you to be a widget in a product line) that they see as the most profitable. Yes, medical need is one component; there has to be demand. Clearly cancer, and heart disease are very common and very serious for the people who have them, as well as being high-profit product lines. If less common, diseases that can be treated by neurosurgery are also serious. Indeed, even some neurological conditions that have not been historically treated by surgery, such as stroke, are becoming profit centers when procedural intervention (by, “interventional radiologists”) can be used to treat them. But there are lots of conditions which are also common and serious and are not among the “product lines” hospitals often develop because they are not “profit lines”; obstetrics and psychiatry and pediatrics come to mind (although neonatal intensive care and pediatric cancer treatment, as well as certain types of high-intervention obstetrics, are exceptions).

It is that cancer-drug markup that makes treating cancer profitable. Anecdote: a relatively high-income colleague received the bill for her first set of breast cancer chemotherapy. $30,000. Her husband hid it for several months. (“That’s not so bad,” she was told by a staff member, “we recently had an uninsured woman get a bill for $45,000.” Didn’t make her feel a lot better.) After that initial event, her copayments for treatment were on the order of $600 a month. Because she had good insurance. And she could afford it. Not without some pain, you understand, but much more than someone in one of the lower income groups. Or who is uninsured. Sure, she is happy her cancer could be treated. The point is that hospitals invest in – and advertise their expertise in -- treatment for this kind of disease, and not that kind of disease based on the profitability of it, not the seriousness of the disease.

In addition to the hospitals and the pharmaceutical manufacturers, scientists and the universities that they often work for depend on deals with drug manufacturers to bring their discoveries to market. This can be very lucrative for the universities who employ these scientists, as well as (often) the scientists themselves. It is big business. Bad? Not necessarily. Only a small percentage of the compounds being researched lead to profitable drugs, which is one of the main arguments that pharmaceutical companies use for their high prices and profits (they are consistently, and by far, the most profitable industries in the world if we include only those industries that produce something; the financial industry is something else). Of course, by the way, most of the initial research that produces these new drugs is supported by the National Institutes of Health (NIH) -- which would be you, the taxpayer. So most of those compounds are developed and studied at public expense; then only the most promising are bought by drug companies. Yes, many of these don’t become marketable, not to mention blockbuster profit centers, but the yield is much greater than it was before all the publicly-funded research culled them out. Oh, by the way, even though you funded that research, you don’t get a discount on the drugs that finally come to market. Sorry.

Sometimes, of course, there are drugs that are “blockbusters”, and they are not always the most expensive cancer drugs. They are big because they treat (or sometimes are thought to treat) conditions that are very common, so that there are millions of users. These are not as likely to support the development of new hospital product lines (where the profit-per-user has to be very high) but make a lot of money for the manufacturers. In the past these have included anti-anxiety drugs of the benzodiazepine class (eg., Valium ®, Librium ®), non-steroidal anti-inflammatory drugs (NSAIDs) for arthritis pain (including a few taken off the market for major side effects like Vioxx ®), and most recently “statin” drugs that reduce cholesterol. These drugs not only work for that purpose, they seem to have other beneficial effects in prevention of heart disease, the reasons for which are not entirely understood, so they are very popular. While selling such heavily-used drugs is always profitable, the greatest profit comes in the first decade (or so) when it is under patent and there are no generic competitors.

In a recent Perspective, “Generic atorvastatin and health care costs”,  in the New England Journal of Medicine, Jackevicius and colleagues look at the impact of the costs of statin drugs on health care costs by examining the projected savings on atorvastatin, initially sold as Lipitor®, which became generic this last November.[1] They used the data on the gradual price reduction that followed simvastatin (Zocor®) becoming generic in 2006. There are some differences; atorvastatin is more potent than simvastatin and less likely to cause muscle pain (myopathy), so it may be preferable to many. When neither was generic, Lipitor® had by far the biggest share of the market, but when simvastatin became generic in 2006, it became the biggest seller, with Lipitor® dropping precipitously and brand name Zocor® almost disappearing. Because of its two advantages (greater potency, less myopathy) generic atorvastatin should become the number one statin in the near future. The savings are projected to be enormous: “The overall cost savings from the availability of generic atorvastatin are projected to reach $4.5 billion annually by 2014, equivalent to 23% of total expenditures on statins in that year.”

That’s a lot of money. It is good to be saving it. However, that “saving” means that we have been spending it for the last decade or more. Yes, drug companies deserve to make a profit. Yes, there are investments made that need to be recouped. But this – like, if perhaps not quite so egregious as what we have seen lately in the financial sector – seems to be excessive.

We should not use drugs that harm us or are unnecessary. The question is can we, as individuals or a society, afford to pay so much for the drugs we need in order for their profits to be so high?



[1] Jackevicius CA, Chou MM, Ross JS, Shah ND, Krumholz HM, “Generic atorvastatin and health care costs”, NEJM 19Jan2012;366(3):201-3.

Friday, February 3, 2012

Komen and Planned Parenthood: The politics of abortion meet the politics of breast cancer


As of this posting it appears that Komen has restored its funding for Planned Parenthood. I thought I would run this post anyway. I think it makes some important points.

As reported in the New York Times on February 1, 2012, “Cancer group halts financing to Planned Parenthood”, the Susan G. Komen Foundation will abruptly end a program that gave about $700,000 to 19 Planned Parenthood (PP) affiliates to fund breast mammograms and ultrasounds for women who cannot afford them. Just to be clear, the Komen Foundation, the world’s largest breast cancer foundation which is famous for its pink ribbons and “Run for the Cure” races, has not changed its position on screening for breast cancer. It just doesn’t want to fund this screeining through Planned Parenthood, which will present a problem for the three-quarters of a million women who have had their mammograms through that organization.

Why? There has been a very long standing relationship between these two organizations committed to women’s health, and this decision seems to be very sudden. According to the Times, “A spokeswoman for the Komen foundation, Leslie Aun, told The Associated Press that the main factor in the decision was a new rule adopted by Komen that prohibits grants to organizations being investigated by local, state or federal authorities. Ms. Aun told The A.P. that Planned Parenthood was therefore disqualified from financing because of an inquiry being conducted by Representative Cliff Stearns, Republican of Florida, who is looking at how Planned Parenthood spends and reports its money.”

On the face of it, this is absurd; any state legislator can do an investigation into any organization for any reason, and they do. Unlike investigations by law enforcement bodies, in which presumably there is at least a reasonable suspicion of illegal activity. It can only be inferred that this “new rule” was specifically instituted to remove funding for PP. And Komen didn’t have to wait for Rep. Stearns; my state of Kansas has been regularly investigating our Planned Parenthood, starting under former Attorney General Phill Kline, who illegally kept subpoenaed records after he left office. When it finally went to trial after several years, the case was decided by a jury in less than 30 minutes, for PP. More recently, the current administration (also, coincidentally, Republican) has tried promulgating new health department rules regulating abortion providers that were absurdly picky, such as the size of janitorial closets. This has also been discarded.

Wait, Planned Parenthood does abortions? Could that be part of the reason? Why yes. Some, but not all, PP affiliates perform abortions. PP provides comprehensive women’s health services, including contraception and education, as well as breast cancer screening. The Times article notes that many have suggested that it is pressure from right-wing anti-abortion groups that has caused this action. For example, “…in December, LifeWay Christian Resources, which is owned by the Southern Baptist Convention, said it was recalling a pink Bible it was selling at Walmart and other stores because a dollar per copy was going to the Komen foundation and the foundation supported Planned Parenthood.” Of course, this is not really a different reason; the reason that Rep. Stearns and AG Kline and others have for investigating PP is because they do abortions.

In further “explanation” (since the original one was so nonsensical), the Komen “…foundation issued a statement saying it was seeking to ‘strengthen our grants program’ and had ‘implemented more stringent eligibility and performance criteria….While it is regrettable when changes in priorities and policies affect any of our grantees, such as a longstanding partner like Planned Parenthood, we must continue to evolve to best meet the needs of the women we serve and most fully advance our mission.” I had to include this last sentence so that I can recommend that you copy it and save it for a time when you need a piece of corporate double-speak jargon that says nothing except “We’re lying here.”

Planned Parenthood affiliates who do offer abortion services see them as part of the continuum of women’s health care. They offer sex education and contraception, but sometimes this fails – or hasn’t been used -- and women seek an abortion, which may be their first contact with PP. And they may then avail themselves of PP’s other services so they do not have another unwanted pregnancy.  Of course, there are many people who are opposed to abortion who support these other missions (contraception and sex education, as well as breast cancer screening). Therefore, PP usually segregates its funds so that only donations that are unrestricted or specifically intended to support abortion services are used for that purpose. However, there are many others, particularly organized “right-to-life” groups, who are not only opposed to abortion, but to the other missions as well.

A rational, data-driven approach would note that the only things that have ever been shown to reduce the abortion rate are comprehensive sex education and easy availability of contraception. This is why the abortion rate in many countries where abortion is legal is lower than in others where it is not – because those same countries provide sex education and contraception. And, of course, they also provide safe abortions so that the women who receive them are much less likely to develop infections, become sterile, or die.

The only way to understand the opposition to contraception and sex education is to recognize that it is really about being opposed to sex. If you hold the view that sex should only occur in marriage, and then only for the purpose of procreation (thus, only heterosexual marriage), and should not be for fun (and maybe should not ever be fun) this starts to make sense. In a bizarre way. Of course, this excepts the many religious and anti-abortion leaders who are involved in active and extramarital sex. They seem to have no problem telling women what to do with their lives, while living their own lives in total hypocrisy. Of course, but these are mostly men, so what do you expect? They don’t get pregnant.

In another big news item in the same issue of the Times, we are informed that rates of second surgery after lumpectomy for breast cancer vary widely by surgeon, from 0% - 70%. (Breast Cancer Surgery Rules Are Called Unclear by Denise Grady reports on Variability in Reexcision Following Breast Conservation Surgery by Lawrence McCahill and colleagues, published in JAMA, February 1, 2012. In doing lumpectomy for breast cancer, there is a cosmetic reason for taking only the least amount of tissue necessary to remove all the cancer. After all, this is the reason that lumpectomy was developed to replace mastectomy. Sometimes, on pathological examination, the “margins” are not “clear”; that is, cancer cells are found microscopically up to or past the border of the excision, and an additional surgery is required to get the rest. The question is whether there are surgeons who regularly seem to do this more often, that is take too little tissue, rather than random variation; the answer seems to be “yes”.

However, the study shows that there seem to be many more surgeons who often do a second surgery even though the margins are clear than there are surgeons who regularly take too little and need to repeat the surgery. This also means that many surgeons who have the former practice may often take too much tissue the first time to avoid the repeat surgery. This is because they believe that there need to be larger margins of normal tissue, of 2-5mm, between the cancer the edge of the excision. Comments by McCahill and other expert breast surgeons indicate that there is no data showing the larger margins provide any lower rate of recurrence than smaller ones.

What is clear, however, is that cancers found earlier and smaller are more likely to require less invasive surgery and have a greater chance of recovery. While the age of starting and the frequency of screening may be controversial (see my perspective on October 30, 2010, Breast cancer screening: conflicting evidence? what are the important questions for health?), it is hard to argue that having making it more difficult to obtain that screening for 750,000 women who use Planned Parenthood is good policy if your goal is to identify and treat breast cancer as early as possible.

Which, of course, is supposed to be the Komen Foundation’s mission.


 The “Lede” story on the Komen Foundation’s reversal, Cancer Group Backs Down on Cutting Off Planned Parenthood quotes Komen’s Twitter post (@komenforthecure): “We want to apologize for recent decisions that cast doubt upon our commitment to our mission of saving women’s lives.”


And for thinking that they could just do this and not ignite a firestorm of protest. Good to see some life in the reproductive rights movement! The anti-abortion-people-who-talk-only-to-themselves-so-much-they-think-everyone-agrees-with-them were unsuccessful in this attempt. Hopefully the women’s health and pro-choice community can remember that these rights are not guaranteed by anything but the willingness of the people to fight for them.

Saturday, January 28, 2012

"Abandoning ship": is debunking ineffective screening and therapy removing hope or just removing risk?

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Sometimes I think I sound like a real medical nihilist, since many of my blogs have been about purported treatments that are ineffective, dangerous, done too often, and cost a lot of money (Cardiac stents and profit-driven corruption: do anti-fraud rules address the problem?, December 24, 2010; Greed, corruption and medical procedures: ignoring or suppressing the evidence?, August 12, 2011; Men’s Health? Women’s Health? Valid screening opportunities or “Hallmark Holidays”?, March 15, 2011).  It is a somewhat distressing feeling. I am a doctor; I want to help people, to relieve their suffering, to help facilitate the cure of their diseases. More than that, I am a family doctor, and have a strong preference for prevention, for early detection of disease when it is still treatable rather than waiting for it to be too far gone for treatment to be effective. In addition, I have regularly criticized our health non-system for leaving out too many people, creating financial disincentives for them to seek care early. This leads to their waiting until their diseases become so uncontrolled that they present to the emergency room, then require admission and costly care, making it worse for them (most important) and more expensive for everyone. So I think prevention and early intervention is a really good thing, and it would be great to have tests that could identify disease early in its course so that we can change its trajectory.

But because I want these things to be true doesn’t make them true, as I discuss in the recent post Avastin®, Plan B®, and Magical Thinking, December 31, 2011. Because we can screen you for something doesn’t mean that we should; because a test can be done doesn’t mean that it is a good test. "A good test", in my opinion, is one that has sufficient sensitivity (rate of being positive when a condition is present) or specificity (rate of being negative when a condition is absent) to tell us whether a you have a disease, or if it matters. Because it can be done also doesn’t mean that it is cost-effective. Because a treatment exists doesn’t mean it is a good treatment, a safe treatment, an effective treatment. And, as with most things being sold, the greater the publicity and advertising around it, the more it means someone will be making money on it, which does not exclude its being of benefit, but is certainly not the same thing.

Sometimes, when evidence is discovered that a test or treatment is not of benefit, eventually we stop doing it. "Eventually", however, may be a lot longer than you might think. In a recent “Viewpoint” in JAMA, Prasad, Cifu, and Ionannidis address “Reversals of established medical practice: evidence to abandon ship[1]. They note that while “Ideally, good medical practices are replaced by better ones, based on robust comparative trials in which new interventions outperform older ones and establish new standards of care. Often, however, established standards must be abandoned not because a better replacement has been identified but simply because what was thought to be beneficial was not.” They go on to discuss a number of treatments that have been “standard of care” but were shown by good, randomized controlled trials, to be ineffective or even dangerous (not to say expensive). These include stenting of coronary arteries for stable coronary artery disease (CAD), postmenopausal hormone therapy to prevent CAD, vertebroplasty for osteoporotic fractures, bevucizamab for breast cancer.

Scarily, but unsurprisingly, “true believers” continued to defend these interventions even after the evidence was clear (their livelihoods depend upon it), and in many cases these treatments continue to be offered and performed. “There are thousands of clinical trials, but most deal with trivialities or efforts to buttress the sales of specific products,” and it is only “Rarely [that]…some investigators find the courage to test established ‘truths’ with large, rigorous randomized trials”. Prasad and colleagues have done many of these latter trials; indeed John Ioannidis is the “guru” of debunking treatments with poor evidence (see David H. Freedman’s article in the November 2011 AtlanticLies, damned lies, and medical science.”) The authors have some suggestions, including limiting the role of manufacturers (of drugs, devices, tests) from conducting the trials on them, although they should pay for them: “Large trials of new innovations should be designed and conducted by investigators without conflicts of interest, under the auspices of nonconflicted scientific bodies. Instead of designing, controlling, and conducting the trials, manufacturers may offer the respective budget to a centralized public pool of funding, keeping the trial design and conduct independent.”

Prevention and screening are also subject to the lure of magical-thinking-compounded-by-the-greed-of-the sellers. Screening for prostate cancer with the use of prostate-specific antigen (PSA) testing is a good recent example about which I have written (while the lack of effectiveness of treatments for prostate cancer is would be included in the group of ineffective therapies that Prasad and colleagues have written about). Pap smears are pretty good screening tests for cervical cancer, but most other cancer screening tests (even mammograms and colon cancer screening, probably the next best) are not nearly as good. Every time there is a recommendation to decrease the frequency of screening (Pap smears, mammography) or not do them at all (PSAs or pelvic exams) there is an outcry from people who think that something has been taken from them. In a scientific sense, what has been taken is unnecessary testing that doesn’t lower their risk of bad outcomes, costs money, and can have significant morbidity when positive screens need additional, more invasive tests, to follow up. But, in a more metaphysical sense, what has been taken is hope, the idea that there is something that they can do that will prevent something bad from happening to them. Something that, while perhaps a little risky (if you understand or believe it), is relatively easy. And also, frankly, something someone else, rather than you, can do. Not like, say, dieting or giving up smoking or exercising. And this false concept is encouraged by half-truths promulgated by passionate advocates of interventions with limited proven benefit, whether traditional allopathic or “alternative”.
Even public health advocates sometimes get so passionate about the health benefits of what they are advocating that they may miss other issues. For example, consider a recent discussion on a progressive public health listserve about “portion control” (limiting the amount eaten at one sitting). This is an important and effective method of addressing obesity, which is in fact a major health problem in this country, but the discussion raised many other issues. These included concerns about “blaming the victim” -- expecting self-control (difficult enough) from people who had historically not had that control in the face of major initiatives by fast-food purveyors to push large portions. Another was the economics involved in asking poor people to pay “more for less” while corporations continue to make huge profits from them. It can, and often is, as difficult for public health advocates to recognize problems arising from their positions and passions as it is for providers or manufacturers to back off from theirs.

The difference, of course, is that the former are really invested in the health of the public, while the latter are invested mostly in, well, their investments.


[1] Prasad V, Cifu A, Ioannidis JPA, Reversals of established medical practices: evidence to abandon ship”, JAMA 4Jan2012;307(1):37-8.


Saturday, January 21, 2012

One thing to NOT worry about: paying for health care -- in France

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I recently saw the film Le Havre, a film set in that French city and made, in French, by Finnish director Aki Kaurismäki. It was a very good film, generally well-reviewed (here is the New York Times review), and part of its appeal for me is its unabashed portrayal of working-class people as the central characters. One of the plots involves the illness of the female lead, Arletty, who suffers severe abdominal pain, is brought to the hospital, and is told that it will be terminal (although, the doctor observes, “miracles do happen”.) I don’t need to share any more of the plot, because what I found striking was really incidental to it.

Kaurismäki goes to some length to depict both the poverty and dignity of his characters. It is an imaginable working class poverty -- this is not the Mumbai of Slumdog Millionaire – but it is certainly poverty. Arletty’s husband is a shoeshine man; they live on an alley off a small street in a house that evokes the apartment of Ralph and Alice Kramden on The Honeymooners. When he sees his wife in such pain, her husband’s main concern is how he will get her to the hospital. He goes to the street to ask a shopkeeper if he can use her phone (they don’t have one), and she offers to drive them.

What is not a concern is whether they can afford her medical care. As I am used to being in the US, to caring for people of limited means, of seeing people in the free clinic who cannot afford to go to the doctor or people admitted to the hospital when they finally show up in the emergency room with disease that is far gone because they haven’t sought care, I found this a bit jarring. I was waiting for Arletty to protest that it was “nothing” (she has been in some denial already), for fear that they couldn’t afford medical care. But she doesn’t, and he says nothing about it, and goes off to find transportation. We could see the same thing in an American movie, and we would expect the same thing in our own lives – when your wife is really sick, you take her to the hospital, you worry about the bills later.

Except that wasn’t why. They weren’t worried about the bills. Because it was France. With a national health insurance system, where everyone, even the wife of a self-employed shoeshine guy living in a tiny house off an alley, has health coverage. In the film, Arletty is in the hospital for several weeks, but of all the issues that occur, how the couple will pay for it never comes up. Not at all. It is not even a thought in their minds. But it is a thought in mine, and I keep having to remind myself that it is not part of the plot because it is not an issue that French people have to concern themselves with. The illness, yes. Whether she will survive, yes. Whether he will earn enough money each day to buy dinner, yes. But not how to pay for several weeks of hospitalization. Amazing.

There was another aspect of the healthcare portrayed in the film that struck me. The hospital was simple and unostentatious. It looked a little dated, old-fashioned, like the houses and the shops and the working-class lives of the characters, even though the film and its theme are contemporary. Maybe this is also something about France. The hospital is clean, freshly-painted, with clean linen, and private rooms, and IV poles and doctors and nurses. But it is simple. The ceilings are not high, there is not expensive art on the walls, or carpets, or hallways twice as wide as they need to be. It is functional. It is not third-world, but it is basic. It is pretty unlike my hospital, or most of the hospitals that we see in the US (except some of the oldest public institutions). If someone with private health insurance saw this hospital in, say, Kansas City, they would be unimpressed. They might rather, next time, seek one that was “nicer”. Fancier. With really good hotel accommodations. This is what we look for in the US, what we expect. Surely this is what they lose in such national-health-insurance countries as France.

I checked this with a friend, who is from Canada. He said that this is the way hospitals in Canada are; clean, and functional, but not fancy. He told me he was shocked when his wife had a baby in Kansas City and there were hardwood floors. What for, he wondered? Of course, we know what they are for. They are to help to provide a competitive advantage, to make people choose one hospital over another. For the same reason that hospitals buy new MRI scanners when the hospital down the street has one that is underutilized. Why they have fundraisers to be able to support their cancer center, to attract people with cancer (and, of course, insurance!) to them, rather than to the perfectly good cancer center across town. Why, as depicted in a recent New York Times “Opinionator” by Ezekiel Emanuel and Stephen D. Pearson (“It costs more, but is it worth more?”), hospitals such as Mayo Clinic are building their own billion-dollar proton-beam accelerators to treat cancer when there are more than enough in the country to treat the relatively small number of people who require this kind of cancer therapy.

Because, in the US, healthcare provision functions much more as a business than as a social good. The “product” is healthcare for people, but the product is only of value when it can be sold to those who can pay. We have hospitals that compete for some of our people, while there are others who can barely get care. This competition model can work, just as it works for other products – vendors compete for those who can afford it and ignore those who cannot. If we want healthcare to be an industry, a business, rather than health care.

Le Havre is a very good film, and it does not shy away from social issues. In fact, it addresses many of them. But access to health care is not one, it is not Sicko! The themes I discuss here are just in the background of the film,and I imagine they are not even noticed by French audiences. Or Finnish ones. Being able to afford medical care is not an issue in those places.

Which is as it should be.


Saturday, January 14, 2012

It’s definitely not about the bike – but is it even about ACOs?



One of the major features of the Affordable Care Act (ACA) is the idea of Accountable Care Organizations (ACOs). The final regulations from Medicare were issued in October, 2011, so the creation of ACOs seems to be moving forward. ACOs will be groups of primary care doctors, specialists, hospitals, and possible other providers who act together to provide comprehensive care, and receive either more money from Medicare (and probably, eventually, other payers) or, at least, smaller reductions in payments. The only thing that is definitely required to form an ACO is a group of primary care doctors, but since groups of primary care doctors rarely have sufficient capital to fund the necessary infrastructure, so it is likely that almost all will include at least one hospital.

The stated purpose behind encouraging ACOs is to increase quality. It is easy enough to see how quality could be improved in our non-system of health. Because the bar is so low, there are tremendous opportunities that come from lack of organization and coordination of care. Hospitals get paid for caring for people who are admitted. Thus, up to a point (the point at which payments do not exceed costs), they want admissions. Patients prefer to stay healthy, or at least healthy enough to not have to be admitted to the hospital, and hopefully their primary care doctors support this goal. Hospitals have already started being financially penalized by not receiving reimbursement from Medicare for readmissions for the same problem they were discharged for, or complications of that problem. Managing this issue will require the ACO to have not only financial relationships with primary care doctors, but often with long-term care facilities as this is where patients are discharged to – and return to the hospital from.

Fisher, McClellan, and Safran, in their New England Journal of Medicine article “Building the Path to Accountable Care”  (December 29, 2011; may require subscription)[1], identify five “challenges” to implementing ACOs with suggestions for how to overcome them. The challenges are providing timely and useful data, overcoming transition costs, gaining consumer support, learning what works and using that knowledge to inform policy and practice, and clarifying the path forward. Their suggested approaches to solving them are largely based upon what is being done in existing integrated health systems (such as Kaiser and Geisinger). This makes sense, as these systems were the model for ACOs and are often relatively cost effective, but it will require major restructuring for other such systems to develop in ways that can work as well. The authors do not address a major challenge for ACOs, which is that every patient will be identified with a particular ACO (based on the physician from whom they receive the majority of their primary care) and that ACO will be held financially responsible for that patient’s costs, but that the patient will be free to receive service from outside that ACO. This is a political decision, intended to avoid the criticism that the ACO program is just “managed care” in new clothes by ensuring that the program will not “restrict” people. Of course, it is a huge flaw. If a patient is not happy with the care they receive from members of their “identified” ACO, whether that is for “good” reasons (denying unnecessary, excess, risky procedures, hospitalizations, etc.) or “bad” reasons (less than the best quality), the patient can go elsewhere and receive that service from someone else. And if Medicare deems it unnecessary or excessive, it is the “identified” ACO that will receive the financial penalty, not those providing the service.

The authors’ final challenge, the vaguely worded “clarifying the path forward”, is about future changes, including (from their table) “Create meaningful alternatives to fee for service for all providers.” This is a good idea, and not a new one. It means that rather than have the provider (hospital or doctor) paid for each particular service, the payment is tied to something else. Most simply, it could be a global fee for providing care to a patient, as the capitated payments in traditional HMOs. This allows practices to budget their resources, and also allows patients to get care in the way they need it. If a doctor is being paid a set amount in advance, there is no financial incentive for them to require a person to have to take off from work, travel, park, and wait to be seen when that person has a question that can be answered by phone or email. You would only have to be seen in person if either you or the doctor thought that there was a reason to do so. The disincentive under the current fee-for-service system is that the doctor doesn’t get paid unless you are seen in person. In addition, the ACA law envisions paying more for higher quality (or less for lower quality). So why were these “meaningful alternatives” not included in ACA? Again, political, and the question is “what will change the politics in the future?”

In another NEJM “Perspective”, “Achieving accountable care – “it’s not about the bike” (published online on December 28, 2011), Walker and McKethan argue that it is the skills and competencies of providers, rather than the structure of the systems, that will determine the success of ACOs. Their metaphor is from Lance Armstrong’s memoir, in which Armstrong acknowledges the importance of having a great bike but says that “Although advanced equipment is very important, winning depends more on athletes' riding skills, physical conditioning, and race-day effort.” Cute, but obvious; any athlete with enough money (and all top cyclists have backers with enough money) can buy the best bike, but it is his or her skill and dedication that leads to victory – or not. Is it, however, a good metaphor for medical care? “If an ACO were a bicycle,” Walker and McKethan write, “its wheels, spokes, and gears would be the criteria used by payers such as Medicare to determine providers' eligibility, the methods used to assign patients to a given ACO, and the manner in which financial bonuses are calculated.” They then go on to discuss at some length what ACOs will need to do to “…compel and equip the athletes riding them…” (meaning providers) to do what is necessary, for “…accountable care will depend on a care team's identification of and action on the specific needs and preferences of the individual patient, deploying the most relevant, tailored interventions and supportive services to address patients' specific needs, circumstances, and preferences.”

Sound good? It is an appropriate metaphor in that structure alone will not guarantee success, but it loses strength after that. ACOs are not bicycles, and providers are not athletes. Most important, “success” in the arena of healthcare should not be about “winning”, about “beating” the other “competitors”, but about development structures, methods, practices, and reimbursement procedures in which everyone receives the best, most appropriate care. In which we all win.

And that is going to be one of the big challenges, because neither of these commentaries addresses the fact that not everyone in our country is going to be part of an ACO, and not everyone in our country has health coverage. Those people who do have coverage have found their premiums, co-pays, and deductibles increasing and their benefits diminishing.  ACOs are (at least initially) a program for Medicare recipients, but all we hear from Congress and pundits is that “Medicare costs too much” and that these costs need to be scaled back, so unquestionably the emphasis of programs like ACOs will be on reducing cost.

I have often noted that much of the excess cost in this country is from providing unnecessary, or even harmful, care, and so there is not necessarily a conflict between saving money and increasing quality. But people are different, with different diseases and needs and wants, so there will need to be flexibility. And those who are most disenfranchised will remain outside the pale.



[1]Fisher ES, McClellan MB, Safran DG, “Building a path to accountable care”, N Engl J Med 29Dec2011;365:2445-2447