Voices of Medicine

Whether a consumer shops in a supermarket or health food store, works out in a fitness center, eats in a restaurant or grabs a quick refreshment on the go, he or she will likely be tempted to buy bottled water. It comes in an ever-growing variety of sizes and shapes, including a bottle that looks like a drop of water with a golden cap. Some fine hotels now have "water sommeliers" to advise diners on which water to drink with different courses. A widening spectrum of bottled water types are crowding the market, including spring, mineral, purified, distilled, carbonated, oxygenated, caffeinated, and vitamin-enriched. There are flavors, such as lemon or strawberry, and specific brands aimed at children. Bottled water bars have sprung up in the hipper districts, from Paris to Los Angeles.

The message: Bottled water is "good" water, as opposed to that nasty stuff from the tap. But in most cases, tap water adheres to stricter purity standards than bottled water, whose source - far from a mountain spring - can be wells under industrial facilities. Indeed, 40 percent of bottled water began as, well, tap water.

To read the entire report, go to www.csahq.org/pdf/bulletin/issue_6/water043.pdf.

Our Voice: The United States has safe tap water. There is no need to spend three times as much for bottled water as for gasoline, or to pay as much for one Evian bottle of water as for 1000 gallons of tap water.

A Grim, Grimm Tale
Barry B. Sheppard, MD, President of the San Mateo County Medical Society writes in "Of Gypsies and Gaffs":

"When I was a much younger man, the term Gypsy brought to mind romanticized visions of a nomadic people able to tell fortunes and work small magics. And Gaffs were very large and wicked-looking hooks mounted on the ends of poles used to land the sharks my father and I sportfished off the coast of South Carolina. For the past few weeks, however, I have become embroiled in a struggle involving GPCIs and GAFs of a very different nature. To emphasize the point that this is my own, and therefore biased, account of the situation as well as to allow for some blurring of the identities of the players, I have set this tale to paper in the form of a Grimm's fairy tale -the grim part being apropos as well.

"Once upon a time, about seven years ago, a wicked Queen, later to be known as the Centers for Medicare and Medicaid Services, sent out a decree across the fair land of California. The land was to be divided into regions on the basis of similar expenses incurred in providing health care to the people in an effort to adjust for, to some extent, widely varying office rents, employee reimbursement levels, etc. in the various regions of the state. Each resulting Locality would then be assigned a GPCI (Geographic Practice Cost Index), which had the power to transform itself into a GAF (Geographic Adjustment Factor); and each GAF had the power to alter the Medicare gold that funneled through the office en route to physicians. The piles of gold, when touched by the GAFs, would be adjusted heavier or lighter depending on the cost of practicing medicine in each region. Each GAF, however, only had a single spell and thus each pile of gold entering a particular locality was adjusted to the same amount for all the GAFs in that locality. Even though the system was designed to correct inequities of cost incurred by physicians, the amounts of gold were so miserly that no one in the kingdom was happy.

"In setting up the localities, however, the wicked Queen was not diligent in her duty. She began by carefully measuring and sifting through regional differences in cost of practice and established six counties as rightfully having their own locality. She then lumped two similar counties into a seventh locality. Beginning to tire of the tedium of the process, she lumped three counties into one locality, Locality 3, despite a significant cost difference in one county from the other two. Looking at the daunting number of counties still to be apportioned, she threw up her hands in disgust and lumped all 47 of the remaining counties into one locality, Locality 99.

"Soon afterward, four of the 47 in Locality 99 realized that their costs were significantly more than the costs of their fellow counties in that locality. However, try as they might over the ensuing years, they could not escape the locality. One well-conceived plan was stymied by Parliament largely because of opposition from the other 43 counties that benefited from GAF-averaging with the "high cost" counties…"

If you're still with Dr Sheppard's fairy tale, read the entire Grimm story at www.smcma.org/ Bulletin/BulletinIssues/Oct04issue/President.html

The voice of H. R. Greene, of SMCMA's Board of Directors: "We all know that the RBRVS hasn't done what it's supposed to do, accurately build our overhead costs into Medicare reimbursements. If we don't get everything we're entitled to, we pay doubly because the commercial payers peg their reimbursements on Medicare….We have joined with ACCMA and SCCMA to reject the CMA plan."

A Personal Voice: All government programs are variations of a Grimm tale. As physicians, we deal with the medical needs of individual patients. Lumping one patient's needs with another's, even our own, interferes with helping one or both. When government groups millions in one pot, no individual's medical needs can be fully met.

The 'OMICS of the Cancer War
This current issue of the UC Davis Cancer Center SYNTHESIS discusses the battle to defeat cancer. The two most important aspects are patient education and biomedical research. For generations, scientists have worked to understand the cell down to its smallest components. Today, researchers in genomics, proteomics, transcriptomics and metabolomics seek to understand the cell as a whole, in all its complexity.

Elbert Branscomb, associate director of the Biology and Biotechnology Research Program at Lawrence Livermore National Laboratory, likens cells to small cities. "Think of a cell as the whole city of Chicago, at rush hour, busily making another Chicago," says Branscomb, who is also a member of the UC Davis Integrated Cancer Research Program.

The mind spins at the immensity of the challenge: Each human cell has at its disposal about 30,000 genes. These genes can manufacture perhaps 100,000 different proteins to carry out the cell's work, or metabolism. The number of byproducts of metabolism - metabolites - is unknown; a common estimate is 3,000.

For cancer research, the implications are tremendous. "We are moving towards an understanding of cancer that will enable us to tailor-make the optimal treatment for each person," says Hsing-Jien Kung, deputy director of the UC Davis Cancer Center and director of its basic science program. "This university has made a tremendous, multidisciplinary commitment to this revolution, and we are leading the way into the future." The entire article on the exciting research is at www.ucdmc.ucdavis.edu/synthesis.

delmeyer@healthcarecom.net