May Is High Blood Pressure Education Month

The AMA this week featured an article reminding us that we can prevent 1 of 3 deaths from cardiovascular disease, the number one killer in America.

Awareness of hypertension (high blood pressure) is important for reducing mortality from stroke, kidney disease and other vascular events (like heart attack and abdominal aortic rupture). Home blood pressure monitors are very affordable.

Treating or looking at just office or hospital blood pressures can be very misleading. People often show artificially high blood pressures in these settings and can easily get over medicated if that is the only information your doctor or health provider has.

Rather than waiting for a medical evaluation or event to record your blood pressure, I would recommend investing in a good digital arm unit and record your morning blood pressure from time to time. Hypertension is not diagnosed with a single measurement, rather monitoring for trends and averages is how a doctor decides to treat elevated blood pressure. In general resting morning blood pressures should be under 140/90.

The Million Hearts program features an award winning mobile app from the famous Marshfield Clinic that can be downloaded for free to help you monitor and record your blood pressure. Patients in my practice can also download and report their recorded blood pressures using our e-portal access link. As I am often heard counseling my patients- “a chance to measure is a chance to improve”.

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Patents on “reinvented” medications lead to higher insurance premiums

Earlier this week a patient of mine showed me another reformulation of Minocycline- this time for a mouth rinse for periodontal disease. It was going to cost her 240 dollars for one treatment and there was no data to share on effectiveness for the treatment. Her encounter reminded me of this piece I blogged in 2012. It is worth reviewing this information to keep the public informed. We all have choices to make.

The Doctor's Report

This Friday’s Wall Street Journal (June 22,2012) features an article authored by Jonathan D. Rockoff reporting that Abbott Laboratories is contesting a portion of the healthcare law regarding patent protection. Patent protections for the drug industry have a long history. In a prior newsletter I explained to our readers/patients how name brand products and generics work. I would defer interested persons to that article if you wish to have more historical and practical information regarding this.


Abbott is challenging a portion of the healthcare bill that deals specifically with ‘biological medications’  (which by the way is the future for therapeutics).  If their case wins, Abbott will guarantee future profit for their drug, Humira.  Drug companies have a long history with patent law, and use it to maximize profits.  Patent law, patient protection, and the price protecting properties of full dollar insurance work together to increase profits of pharmaceutical companies and…

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It Is Time To Speak Up About The Medicare Payments To Doctors Data Dump


The siege against the doctors continues.  For decades some have been asking the government to report what they have been paying the individual doctors for Medicare services.  Well, they finally did that and the Wall Street Journal was there to report it.  What I find fascinating is that with all these decades to share such information with doctors (perhaps to allow us to peer review and reflect on what the data meant to us as providers) the government chose to dump it onto the public as some sort of “shame on the doctors” tactic. There was no real explanation or education about what this data means, just pages of payments based upon codes submitted for services rendered to Medicare patients by Medicare doctors.

Today I replied to an article from the Marketplace Health Care website. As a Medicare provider and the president of our local physician’s association, the Independent Physicians of Lee County (IPALC), I thought it was time to help my readers and the public understand the nuances and complexities of what they are seeing in the recent data dump regarding physician payments from Medicare. Following is a copy of the comments I recently left on the website.

“There is mention of unconscionably high costs. Costs imply price. It is imperative for the public to understand that the fees paid to physicians are set by the government via CMS. If there is a cost complaint, understand it isn’t the providers setting these fees. When you look at the data of the million plus paid group you will likely learn that these providers are charging for injectable and or infusion therapy. These fees are set by Medicare at a profit margin cap of 3-4% above the price the physician pays to the middleman (usually McKesson or Cardinal distributor companies). What this means is that the physician who billed Medicare for the product they bought passed through all but 3-4% of that fee. With that portion of paid services, 3-4% profit margin remains for the physician who then pays him/herself, staff, benefits, real estate expenses, his/her retirement benefits, etc. It is true that opthalmologist have the best “assembly line” model for care but that translates into high volume and therefore high service units being provided by a very limited number of doctors.

These high “costs” reflect high productivity. In all business models high productivity is what the market wants. A better reflection of whether a physician is “costing” medicare a lot of money is to look at patient visits. If a doctor has a lot of visits relative to his peers he or she may be getting more reimbursement but is more productive. Additionally visits have variable levels of complexity and often due to the pressure of coding requirements and fear of fraud accusations most providers actually undercharge/undercode the complexity of their care.

One needs to extract the pass-through revenues that go to the high cost of medication/injections/infusions. Then you have a better idea as to whether that physician is costly or just providing costly medication which is necessarily the price we are paying due to patent protection incentives to get really good therapy.

Folks are going to be barking up the wrong tree if they want to accuse the physicians for those costs- look instead towards the drug industry. Also bear in mind we the people and through our government policies set up these pricing mechanisms and patent incentives to get great medications and innovation. In most instances even though the prices are high, the drug industry costs are more than offset by improved worker productivity, less disability and the avoidance of even more expensive health care costs.”

To read more on issues related to Medicare and the perils of price-fixing in health care consider re-reading some of my prior blogs and a prior newsletter:

Balance Billing Is Key To the Medicare Debate

Patents On Reinvented Medications

From a prior newsletter of mine: Generic Medications

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‘Concierge’ doctors’ contracts give patients choice and savings – 3/12/2011

'Concierge' doctors' contracts give patients choice and savings – 3/12/2011.

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It is Busy Season in Fort Myers Florida

It is Busy Season in Fort Myers Florida.

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It is Busy Season in Fort Myers Florida

As I was winding down my office business today I realized I haven’t blogged for a bit of time. There have been plenty of things to blog about in the recent weeks but I have been “pulling back” as I contemplate the latest events.

Today I went back to my practice website and was reviewing the pricing section of my site. On that page I have an explanation of my philosophy about how I have come to stop contracting with health insurance companies and I feel it is worth posting today for general public consumption and contemplation. Here goes:

Why I’m not contracted with insurance companies

“because I work for you”

“I am passionate that the patient/physician relationship be maintained. This is the primary reason I have been on record repeatedly advocating for more patient choice and less health insurance and government interference with patient management. I serve the patient, not the insurance companies. In this day and age, the ability for the physician to maintain his or her position as the patient advocate is compromised by insurance, government or hospital-employer arrangements. I feel it is important to stay at an arm’s distance from a hospital employer, insurance payer paycheck and the government’s next pay cut if I am going to be able to properly take care of my patients. I don’t contract with private health insurance because over the years I have learned that the insurance companies don’t pass any savings to the patient. The companies also interfere with my care recommendations, from which prescription I can write to which test I can order. This interference paradoxically increases the cost of delivering care which explains a lot of the rising cost of health care in America and also compromises patients’ trust in the system and even in their doctor.”

-Raymond Kordonowy, M.D.

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New Anticoagulants Prove to be Safe and Effective

In the recent February edition of Cardiology today a large data set (meta-analysis) that incorporated over 70,000 people supported the favorable risk-benefit profile for the new anticoagulants compared to warfarin. There were significant reductions in stroke, intracranial hemorrhage (often a life-threatening complication if it occurs) and mortality (that means benefit of total survival) compared to the old standard warfarin (Coumadin) in patients being treated for stroke reduction benefit in atrial fibrillation.

I had written a newsletter/blog on these new agents last year and then suggested these drugs would be game-changers in this common disease situation. This report supports that position. More and more patients are being transitioned to the newer agents; cost being the single major reason that patients and doctors don’t switch to these newer products. These drugs don’t have the drug and food interaction concerns that warfarin does. They also don’t require therapeutic monitoring as they work predictably when dose appropriately. Dropped kidney function does support the decision to use lower dose products and so monitoring of kidney function as well as blood counts still need to be performed but not at the same monthly interval that warfarin monitoring requires. These medications also are more user friendly for dosing before invasive surgeries- requiring much less time off medication (and thus less risk from being off therapy) prior to surgeries, colonoscopies, etc.

Bottom Line: The newer anticoagulants show favorable safety and effectiveness when compared to the former standard of care medication, warfarin for the indication of reducing stroke risk in atrial fibrillation, a heart rhythm condition commonly associated with cardio-embolic strokes. The newer agents currently FDA approved in the United States include: Pradaxa, Xarelto and Eliquis, all name brand, patent- protected pill medications.

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Medical Marijuana Back in the News – This Time For Seizures

This past week or so America is reading about how parents are carting up their kids and moving to Colorado in order to receive “Medical Marijuana” for seizures. I just watched the video on USA today and honestly, the one child who reportedly is having hundreds of seizures a day looked to me like she was just blinking. I don’t know how someone is objectively measuring this child’s reported seizure activity- call me skeptical. Also the father who is constantly clenching his jaw and not looking at the camera seems a bit unconvincing and unconvinced himself.


My intention of bringing this topic up again is not to bash parents who are desperately seeking to make their children seizure free but rather to point out the irony of average citizens making brazen claims that marijuana has therapeutic efficacy for seizures.  The examples used in the video are certainly pretty mild conditions. Not all involuntary muscle contractions represent seizures either.  Did the editors of USA today bother to test what was in that bottle the parents claim contains special street marijuana?  For all we know it is a liquefied version of their therapeutic seizure medication.

In the US we have an agency called the FDA which is responsible for overseeing the approval of medications/drugs for indicated medical conditions.  How in the world did this country get to where we are legalizing medical marijuana before the professionals have debated the topic?  To this point the doctor community has never suggested in any substantive number that marijuana bought in the streets has any true medicinal value. Additionally how is it regular folks are out there informing the rest of us that there is a new indication for dope, namely childhood seizures?  What’s astounding is that the media is so stupid they would publicize such claims as if gospel, suggesting doctors and the pharmaceutical industry are so stupid they never figured this out before marijuana was legalized in a few states.  This really smells fishy. 

A couple of years back I took a very honest and thorough review of the history of marijuana as well as the evidence (or rather lack of) regarding medical reasons to use marijuana.  I will remind folks that this whole thing about using the herb of choice for everything from immune system health to seizures just flat lacks scientific evidence.  Given its often desirable side effects, of course America wants to consume marijuana. As far as I am concerned that that is a topic of public debate but please don’t drag your doctor into this. Also, if there really is an opportunity to find an indication then lets by all means scientifically pursue this. Does anyone doubt Johnson and Johnson, for instance,  wouldn’t jump on the opportunity to purify, test and seek FDA approval for selling whatever might be active in the concoction those parents are giving these anecdotal cases?  I don’t.

Florida’s own John Morgan of Morgan and Morgan wants to set the democratic platform up for the medical marijuana topic, I say go ahead and seek legalization, just not for medical reasons.

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The Benefits of Omega-3 Fatty Acids

Omega -3 fatty acids are in the news a lot lately. This recent posting indicates brain atrophy with aging is linked to low measured omega-3 fatty acid levels in the body. Recently I was made aware of a small study showing that krill oil appears to have superior absorption for the omega-3 fatty acids based upon using the omega-3 index measurement.


In my practice I use various tests to assess nutritional status of my patients. For the past year in select patients I have customized a deep cardiovascular risk assessment lab profile from a company called Health Diagnostics Labs in Virginia. This reference lab panel includes measuring the omega-3 index which measures your body’s levels of essential fatty acids. The above mentioned article indicates that knowing and improving this in our bodies translates to a more preserved brain mass with aging. Whether this translates to improved memory is unknown at this time.

If readers are interested in having a nutritional assessment and to consider dietary and/or supplementation considerations to optimize their nutrition, I encourage you to make a service request with my office. Remember I have a registered dietitian on staff to assist in nutritional and weight loss counseling as well.

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Maryland Experiments With Capping Hospital Spending


The Centers for Medicare and Medicaid recently offered a waiver to Maryland in order to try to pursue their hospital payment model as a possible scenario for the rest of the nation.  It is based upon their current model which has been in place since the 70’s. Reportedly in Maryland, hospital prices are the same regardless of insurance status. This makes sense and is how our office prices its services (click here to see Internal Medicine of Southwest Florida prices). The price is the same regardless of insurance status with the exception of Medicare. Medicare sets its prices and we don’t have any say in that program.   The problem I see with setting an entire state’s hospital prices is that health care is a cottage industry. Local patient populations, local overhead costs vary and so having a price for an entire state is not efficient nor necessarily going to be market-based, but the concept of a fair and similar price for the overall buyers is the proper way  to conduct business. It allows honest market disclosure and the same opportunity to access the system, as long as the buyer is agreeable to paying.

I view hospitals like the power grid, bridges, and roads- necessary infrastructure.  Hospitals are a horse and buggy industry due to the movement of better outpatient capabilities ,but they will never be completely obsolete. I think following more of a utility model of payment for hospitals makes sense.  In our present utility industry we have both regulated and private utility services. There is no region in this nation that doesn’t have reliable power. Even in the catacombs of my low population home state of North Dakota, every farm has power and heat. The utility model made that possible and it is still followed.  This is why considering a different paying model for their maintenance and services makes sense. Maryland apparently has been ahead of the curve by 4 decades with their concept. Fee for service is still the best way to pay for things in health care. The reason is it maximizes productivity. All other convoluted models, such as the recent Accountability Care Organization model, result in far too much regulatory modeling with low efficiency and low output delivery of services.

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