The Lifestyle Chronicles - NGA Healthy America Call to Action

The Healthy America Call to Action seeks to address the declining health status and increasing cost of health care caused by lack of physical activity and poor nutrition. A comprehensive strategy is needed to modify lifestyles throughout the community. This will be accomplished by consistent support of community commitment and personal responsibility. It is a long-term agenda.

"Although there is no single solution to this multi-faceted problem, governors can encourage wellness without becoming heavy-handed regulators. They can help build a culture of physical activity, prevention and wellness. They can promote healthy lifestyles and encourage healthy choices in homes, schools and workplaces. Statewide wellness is not a goal that governors can achieve single-handedly or within one term, one election cycle or even in a ten year period, but they can immediately begin to address it."

Promote Healthy Lifestyles and Personal Responsibility
Corporate health promotion and disease management programs produce a return on investment of $1.49 to $4.91 in benefits for every dollar spent.

Reduce Obesity
Weight loss of 5 to 10% reduces risk for disease, especially cardiovascular disease. A sustained weight loss of 10% accomplished by better nutrition and moderate physical activity can increase life expectancy and reduce an overweight person's medical costs by more than $5,000.

Improve Nutrition
Eating vegetables and fruit can reduce the incidence of cardiovascular disease and cancer. Five servings each day reduces cancer rates by 20%. People who eat eight or more servings daily are 30% less likely to have a heart atteck than those who eat less than 1.5 servings daily.

Increase Physical Acitvity
Overweight people can reduce the risk for developing diabetes by 60% with physical activity such as brisk walking for 30 minutes daily and losing 5 to 10% of body weight. It has been estimated that regular, moderate physical activity by inactive Americans may save as much as $77 billion per year in medical costs.

The information contained in this post is from a report to the Healthy America Forum prepared by Damon Thompson, Vice President, Lipman Hearne Inc., Washington DC and supported by resources from the Robert Wood Johnson Foundation.

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The Lifestyle Chronicles - NGA Healthy America Forum

I returned today from the winter meeting of the National Governors Association. The weekend was devoted to the 2006 Healthy America Forum. Objectives of the forum and the follow-up are to educate, motivate and guide gubernatorial action to improve the wellness of all Americans. The governors, members of their staff and their invitees participated (I was invited by Governor Sanford as a representative of SC).

The two days consisted of sharing best practices for improving wellness where people live, work and learn. Discussions centered on facilitating healthy choices in communities, implementing model programs and policies at public and private worksites and using the public education system to improve child nutrition and physical fitness.

The governors are in a unique position to play a positive role in helping Americans change behaviors and choose healthier lifetyles. Individually and as a group they appear to be commited to this purpose. Listed below are the governors serving as a Task Force to accomplish the objectives.

Mike Huckabee
Governor of Arkansas
NGA Chairman

Janet Napolitano
Governor of Arizona
NGA Vice Chair

Mark Sanford
Governor of South Carolina

Arnold Schwarzenegger
Governor of California

Tom Vilsack
Governor of Iowa

Phil Bredesen
Governor of Tennessee

Over the next week or so, I will be reporting to you about different aspects of the forum. Please share with me any thoughts you have about this effort. Also, contact members of the task force and your governor about thoughts regarding this project, and copy me so I can follow-up (marcusnewberry(at)charter(dot)com). I think the governors have an excellent opportunity to accomplish something and I will do anything possible to assist. It can't be done without your involvement.

Also, I saw Arnold and listened to his presentation from a choice seat in the front row but did not get the chance to meet him.

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The Lifestyle Chronicles - Life Is Short; Art Is Long

During my early years in medicine it never occured to me that health care was a commercial activity. I doubt my classmates or fellow house officers ever gave much thought to the commercial aspects of medicine. Please don't misinterpret that our thoughts and motives were so pure as to exclude money. Believe it or not, medicine had not yet been commercialized.

In those days there was frequent reference to medicine as an art and a science. This is not a reference you hear often today. I would hazard the observation that today medicine is more of a science and a business. You could also say that relative to today medicine then was more art than science.

These observations might appear judgemental and perhaps I am guilty. Memories are like difficult girlfriends. The further you get away from them, the more romantic they become. No, my purpose is more pragmatic. It is a good time to ask what has been gained and what has been lost. If health care is to be reformed, let it be based upon more than economic principles.

The essence of medical care is the encounter between a patient and a provider. Over the past 50 years this encounter has become surrounded by numerous enterprises and the nature of the encounter has been radically changed. Evaluate that encounter to determine value and quality.

Just so you will know where I am coming from; my spirits are dashed upon the rocks by pharmaceutical advertising, the multiple understandings and misunderstandings of health insurance, imperialistic hospitals, the wasteful aspects of competition, the worship of technology, the lack of emphasis on prevention and the forced march of primary care on the "trail of tears".

(Once upon a time - and they lived happily ever after.)

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The Lifestyle Chronicles - The Children Shall Lead Them

The immunization advisory committee to the Centers for Disease Control and Prevention voted unanimously to vaccinate all children between 6 months and 5 years against influenza. Annual visits to the pediatrician provides an infrastructure to accomplish this task. Young children are significant factors in spreading influenza and they give good immune responses to vaccination.

Influenza vaccination is given to fewer than half of the 185 million Americans who are supposed to receive it. There is probability that the children could save the lives of most of those people.

The Lifestye Chronicles - If You Could See What I See

Marvelous article by Dr. Abigail Zuger that speaks to the difference in perspective and the difficulty with communications between patients and physicians. I wonder which is from Venus and which is from Mars.

The Lifestyle Chronicles - Quality Again

The North Carolina GlaxoSmithKline Foundation has awarded a three year $1.65 million grant jointly to the University of North Carolina at Chapel Hill and Duke University. The purpose is to address quality of health care and patient safety, health disparities, global health with emphasis on HIV/AIDS and mental health care. It is a tall order covering a lot of territory. I wish them well and look forward to their accomplishments. The attention to quality of care is timely and it would be useful if that included healthy lifestyle.

On another front, the American Medical Association has an agreement with Congress to develop approximately 140 physician performance measures covering 34 clinical areas for doctors to report to the federal government in an effort to improve the quality of care. The focus will be on diagnostic tests and treatments known to produce better outcomes for patients. Of course, this will be linked to "pay for performance".

The AMA project, or something like it, was inevitable, and on the surface it sounds good. But, before this is over there will be a lot of grief. The intention is to make health care better and hopefully that will happen. Wouldn't it be marvelous if healthy lifestyle and prevention were the main focus. I shudder to think of the paper work and record keeping that will result. It should stimulate the move to electronic medical records.

How did we ever get so wrapped up in being sick, and the fear of being sick? This may be the greatest example of a self-fulfilled prophesy the world has ever witnessed. That is, if everyone is not too sick to appreciate it.

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The Lifestyle Chronicles - First Comes the Question

The Women's Health Initiative is a large and important project for the study of optimum health and how to achieve it. Three recent studies from the project presented conclusions contrary to accepted practice. As might be expected, this has generated broad interest and concern.

A report in 2002 concluded that hormone treatment for menopause created health risk that could not be justifed by the benefits. There were specific conditions of the study that did not apply to all treatment regimens and subsequent studies have qualified some of the previous conclusions. But, the bottom line is that a different perspective has been established for hormone therapy for menopause.

Recently, a study concluded that low-fat diets did not reduce the incidence of heart disease, stroke or cancer of the breast and colon. Another study demonstrated that supplemental calcium and vitamin D did not prevent bone fractures or colorectal cancer. Needless to say, these results have created confusion and concern. An article in the NY Times asked the question, "So what do women do now?"

People seek the comfort of certainty but certainty is relative at best. These studies are important but they did not cover all aspects of these complex areas. Until future studies clarify and refine the current conclusions, there is benefit to the re-examination of common practices. Keep an open mind, examine all the data, always consider the conditions that apply to a given individual and replace the false comfort of certainty with hope.

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The Lifestyle Chronicles - Why Do That?

The English (British) Department of Health has proposed creation of a Medical Care Practitioner (MCP) who would not be medically qualified but would be allowed to diagnose patients and write prescriptions. Objections from the British Medical Association are based upon the potential for confusing patients and negative influence upon the quality of care.

Physicians in Britian and the United States are the product of extensive training that makes them exteremly well-qualified to care for people with illness and disease. How many times do we have to beat our heads against the wall trying to short curcuit that process? The health care system does not need additional categories of practitioners or assistants for physicians. The diagnosis and treatment of illness and disease is a complex undertaking that demands highly qualified attention. Lower that standard and you will regret it.

It is time to recognize that providing care for people who suffer with illness and disease is only one part of the health care system. The larger part of health care is the prevention of illness and disease. There is a body of science supported by practical experience that validates preventive health care. Preventive health care will accomplish the task of decreasing the work load for those who care for illness and disease, and at a fraction of the cost in human suffering and money.

If there is need to develop a new category of health care practitioner, let it be a public health care practitioner. And let it be one who can work to develop that aspect of the health care system devoted to achieving and maintaining optimum health. This should be a health care professional highly skilled in communications, education and motivation. Also needed will be the skills, patience and persistence to work with all aspects of the community to promote and reinforce optimum health status for all citizens.

Reorientation of health care priorities is necessary. For example, the Medicare drug benefit is misdirected and wasteful. These are resources better utilized for preventive health care and, when it might become necessary, assisted living and nursing home care. Wake up, Mr. Politician, and look at how today's decisions determine the future. For the life of me, I cannot envision the advantage of an elderly population who are all on drugs.

Individual responsibility and community commitment, please!!!!

The Lifestyle Chronicles - Memories

I have thoroughly enjoyed Grand Rounds posted today by Maria at intueri. She did a great job of presenting things in a new and delightful way. It prompted me to read more completely some of the blogs. Reading the experiences of others has filled the evening with memories. One of the memories seemed fitting to share on this Valentines Day.

It was long ago and far away on a warm summer night about 4am in the emergency room at Parkland Hospital. The night had been busy but now there was a lull in the flow. I was standing at the counter of the nursing station writing a note for the chart. The nurse who had worked with me most every night for the past two weeks was sitting behind the counter doing some chart work of her own. The door to the emergency room was open and there came through it the faint sound of an ambulance siren in the distance. I stopped writing and stared blankly ahead thinking of what might be coming. Gradually, I noticed the nurse had also stopped writing. As I looked at her, she smiled and said, "they are playing our song".

See, Maria, what you have done. It has taken me off focus from my topic. Or, maybe, it is all about my topic. The comradship developed doing difficult work is special and the memories last.
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The Lifestyle Chronicles - One Day At A Time

I worry about studies and reports that focus upon just one aspect of lifestyle for answers to obesity and health status. Obesity and related health problems have always been with us but the incidence began rising in the 1970's and 1980's. There have been numerous efforts to identify the causes(s) but very few of them were well designed or reliable.

Of course, causes and solutions have been proposed. People have rushed to benefit from the "new way" until the "next new way" comes along. It is a breeding ground for cynicism and the continuing rise in the incidence of obesity, diabetes and hypertension speak to the lack of success.

The parable of the blind men and the elephant applies here. Each one is feeling a part of the elephant and extrapolating to describe the whole. There is no single aspect of lifestyle or diet that explains health status but each aspect influences health. Likewise, there is no drug or supplement that corrects the impact of unhealthy lifestyle on health status.

Was it too much, too little and/or the wrong kind of fat, carbohydrate or protein in the diet, too little physical activity, too much stress, too little sleep, too many drugs, change in family habits, eating out and "on the go", too much processed food, altered fats, surplus corn and corn syrup, not eating whole foods, etc. Well, yes, these and probably more.

People live one day at a time and they need the encouragement, discipline and focus to organize each day around a healthy lifestyle. Each day consists of the things that must be done, the things that need to be done and the things that people want to do. With a little planning and organization, these things do not have to be mutually exclusive.

People eat food (Where is the nutrition label on broccoli and spinach? Is obesity the result of overeating carrots?). People are physically active; they walk, climb stairs, mow the lawn, rake leaves, move furniture. People are mentally engaged in activities. People have families and social networks.

People need to have a plan and get a life, one day at a time. Today is last month's next month and last year's next year. How about doing it today? If it was easy to do, no one would have a problem but it helps if we all do it together. Personal responsibility and community commitment, please!!!!

The Lifestyle Chronicles - Best Friend

Harry Truman is quoted as saying that "if you want a friend in Washington, get a dog". That was true in his day and it is even more true today. Furthermore, he was usually "giving them hell" while he was walking. It must have been Harry's way of boosting his mood. He was a politician so it would be difficult to know if it was the walking or the talking.

The February issue of the American Journal of Preventive Medicine reported a study by researchers at the University of Victoria in British Columbia. They found that dog owners walked an average of 300 minutes a week compared to 168 minutes a week for the people without dogs. A dog is a buddy you can always count on.

"Dear Lord, please help me be the kind of person my dog thinks I am!"

The Lifestyle Chronicles - What is Quality?

Make no mistake about it, we are going to hear a lot about quality in the near future and it won't be the version used by marketing. This time around quality will be linked with other concepts like outcomes, evidence based medicine and pay for performance. There will be change and some good will come of it, although each of us will disagree as to which parts are good. But, quality is a word ladened with value judgements. Much like beauty, quality is in the eyes of the beholder.

Traditionally, health care has been a process oriented activity. The process of gathering information about a health problem and health status to reach a conclusion or diagnosis is second nature to health care providers. It is a process designed, taught and practiced to avoid, as much as possible, mistakes and oversights. Treatments are based upon the diagnosis plus judgements about the condition of the patient. Adjustments to treatment are based upon the reponse of the patient and any other new information. So far, so good.

Humans beings are complex biological creatures. Even when the diagnosis and treatment are correct the expected outcome may not be achieved. Also, it is not uncommon to achieve the expected outcome based upon valid experience and have that differ from the patient's expected ouitcome. This happens even when there is good communication between the provider and the patient.

A factor often overlooked by the provider and ignored by the patient is that the majority of Americans lead unhealthy lifestyles. Health care is burdened by the perception that years of unhealthy lifestyle can be reversed in a brief period. This is in spite of no change in lifestyle. And, there is the issue of non-compliance by the patient. Where is the quality in this puzzle?

The rapid development and deployment of technology has expanded the scope and range for diagnosis and therapy. The amount and refinement of information is achieved more quickly and with less discomfort to the patient. Diagnosis can be more accurate and therapy more effective. It should not be unexpected that technology has changed the health care system and the perception of quality.

Deployment of technology in health care is a complex and tricky undertaking. Demand to use the newest technology is based upon the opinion that it improves quality. Yet, there is a learning curve for any new technology and the mad rush to utilization may result in a period of less quality for efficiency and effectiveness of care. Additional pressure comes from the business need (business quality?) to recoup the investment in an expensive new technology. Is it any wonder that marketing praises the availability of new technology for competitive advantage? And, providers can generate more income with use of technology whether or not they own it.

Meanwhile, marketing being marketing, competition being competition and human nature being human nature there is pressure to produce the next new technology. It is not surprising the next new thing is a varient of the previous thing and produces the same information and results. True breakthroughs are not common and analysis of paradigm shifts find they have occured in small steps over a long period of time.

Can any of us fault the hope and trust of a cancer patient who choses a clinical trial over an established therapy or flies across the country to a cancer center with more technology? This process can lead to the perception and sometimes the reality of improved quality but most often the outcome is the same. Occassionally, this pursuit can lead to some remote site in the desert receiving injections of extract from who knows what.

Health care providers frequently view quality from the perspective of training and credentialing. Where did you go to school? Where did you do your residency? Are you lisenced to practice? Are you certified by a speciality or subspecialty board? It is a reliable process, but we all know the limitations. I have not been involved for some time with the JCAH (Joint Commission for Accrediting Hospitals) but recall a lot of wasted time and effort in the process. This may have been revised since then.

In addition to technology and specialty care, hospitals stress the hotel aspects of their business. Private rooms, parking, carpet, wood paneling, etc. Comfort and marketing are the key ingredients. There is a tendency for the rich to get richer and the level of amenities to rise higher. At some point, and it is lower than many think, the level of amenities have no bearing on the quality of the health care process or outcomes but the perception may be otherwise.

Quality in health care will continue to attract attention. Several references have appeared to a book entitled "Redefining Health Care" written by Michael Porter from Harvard and Elizabeth Olmsted from The Univerity of Virginia. The book is not due out until May but it is reported to argue that the real problem in health care is a lack of good information on quality and outcomes. The government is encouraged to take the lead in measuring health care quality and outcomes by establishing and enforcing standards and risk-adjusted measures. Organ transplantation is used as an example (Wall Street Journal, February 1, 2006).

Undoubtedly, the issue of quality will link up with the pay for performance movement and it will create quite a stir in health care (check out Kate Steadman and Matthew Holt). The long and the short of it is that change is coming but exactly how and when is not yet clear. Meanwhile, I wonder how much we can learn from the experience in the steel, railroad, airline, automobile and newspaper industries where the need to restructure has some momentum. My conclusion is that misery loves company but there will be little sympathy, and change is inevitable but not always controlled.

I was struck by a recent post from Grunt Doc and the comments that lamented the collapse of the house of cards that is health care. Providers and patients are discouraged and they have been discouraged for some time. Although the wish may be for a quick end by decapitation, I fear the change will be more like being run over slowly by a steam roller.

The lessons of history tell us that when change comes it will not be in the form or on the time table that was expected. Patience is not only a virtue, it is necessary. I am confident that Grunt Doc and those who commented on his post have already gotten a good night's sleep and continued the good fight.

The essence of health care is the desire and effort to improve the health of people who seek your expert assistance. As the years pass you will find that your efforts made more of a difference than you could ever realize at the time.

The Lifestyle Chronicles - Goliath and Davids

The proposal to reduce Medicare spending by $35.89 billion over the next five years would reduce hospital payments more than $8 billion and nursing home payments more than $5 billion. Get ready for a vigorous lobbying campaign. Contrary to the methods and styles of lobbying in Washington, most of this will be done at the homes of the lawmakers where hospitals occupy center stage with lots of employees.

Meanwhile, Illinois Attorney General Lisa Madigan believes that not-for-profit hospitals in her state do not give enough service to the needy in return for the financial privilege of being tax-exempt. She has proposed the Tax-Exempt Hospital Responsibilty Act that would require hospitals provide free care to uninsured patients whose family income is no more than 150 percent of the federal poverty limit ($9,570 for a single person and $19,350 for a family of four). Deep price cuts would be given on a sliding scale for uninsured patients with incomes between 150 and 250 percent of the poverty limit. Hospitals would be required to provide charity care equal to at least 8 percent of the operating costs during a fiscal year. Not-for-profit rural and government hospitals would be exempt.

Attorney General Madigan also plans the Fair Hospital Billing & Collection Practices Act to address the common complaints about hospital billing. Complaints range from confusing charges to aggressive collection tactics by hospitals and the collection agencies they use. Looks like some chickens are coming home to roost. Also, sounds like a job for boards of trustees that are responsible to the community.

On another front hospitals are being called to task for the unhealthy food they serve. This would include the fast food franchises that operate within hospitals. Turns out the charge is being led by the America's medical students. The American Medical Student Association has launched the Healthy Foods in Hospitals Campaign. Leave it to the younger crowd to focus upon the basics.

The Lifestyle Chronicles - Videogames

Physical inactivity is a major aspect of unhealthy lifestyle. Inactivity is associated with a number of things but one often mentioned is the widespread use of videogames by youth. If true, and it probably is, could videogames be used to promote health and healthy lifestyle? Others are creating videogames for useful purposes. I pass these along for what they are worth in hopes that someone might see some use for improving health status.

The military makes widespread use of computers and they are finding use of videogames as a training tool. Turns out that American youth have the prior experience for a runnung start. The United Nations World Food Program developed a videogame called Food Force to teach children something about global hunger. More than three million people have downloaded it (at http://www.food-force.com) and the NFL Players Association has become a promotional partner. It was not cheap, Food Force cost $350,000 to develop.

Might be worth a try for those who know more about this than I do.

The Lifestyle Chronicles - Leadership

Governor Sanford of South Carolina has invited me to attend the National Governors Association Winter Meeting held Feb. 25-28 in Washington, DC. The first two days will be devoted to a national forum on Healthy America: Wellness Where We Live, Work and Learn, which seeks to raise national awareness about the urgent need for everyone to lead healthier, more active lives. This initiative by Arkansas Governor Huckabee, current chairman of the NGA, will highlight the behavioral changes necessary for sustainable, long-term health and work with the policy community to educate, motivate and guide actions to improve the wellness of all Americans.

Governor Huckabee practices what he preaches. He lost over 100 pounds by means of a healthier lifestyle and pulled himself from the clutches of diabetes. This comes at a time of increased attention to the epidemic of Type-2 diabetes mellitus associated with unhealthy lifestyle and obesity.

I look forward to the meeting and I will give you reports on the proceedings.

The Lifestyle Chronicles - Who Pays?

Health insurance is a complicated issue with many facets. The State of the Union address proposed more emphasis on tax deductable health savings accounts (HSAs). Presumably this would put choice and decision making with the consumer who would make better decisions because of the financial risk/reward (consumer driven health care).

I came across this report from researchers at the University of Michigan who have studied the impact of out-of-pocket health costs on American behavior. They advocated that any plan to increase consumers' role in health spending must include provision to get proven preventive care for little or no money of their own. Research shows the more people have to pay out of their pockets for prevention the less likely they are to do it. HSAs would be considered out-of-pocket.

How people view risk and the desire for security are at the core of the health care crisis. There is a strong tendency to overrate risk with severe consequences even though the incidence is low. And, people truly do not fully understand the influence of daily activities on health status. The portion of the personal budget that has the greatest influence upon future health status is not considered by people as health care. It is food, housing, transportation, education, recreation, etc. And, these are dollars that are going to be spend in any case whether there is a health benefit or not.

Preventive maintainence perhaps similar to the airline industry or personal warrenty cards would not be inappropriate concepts. Primary health care should focus upon this area with emphasis upon health risk assessment and risk management. There might be need (opportunity) to develop and train health coaches who could work in primary health care practices and industry and schools.

The Lifestyle Chronicles - Lessons

It has been thirty years since I first read The Lord Of The Rings and many times since then the story has entered my thoughts. The recent movies did a marvelous job of capturing the magic but this is a story that is best digested by reading.

We knew all along that Frodo and Samwise would accomplish their task but not without a lot of difficulty and effort. Frodo was tempted by the ring but in the end succeeds in its destruction with unlikely help from Gollum. The contribution of Gollum is unintended on his part but crucial for completion of the task. Sarumon is a powerful white wizard but gazes too deeply into the crystal and falls under the spell of Sauron, the Dark Lord of Mordor. The loyalty and trust between Frodo and Samwise are tested severly but in the end sustains them.

It is just a story but think about it.

The Lifestyle Chronicles - Balance and Stability

My age is greater than 65 years. By common definition I am a senior citizen, and a senior physician. Most of my colleagues have retired but I feel and function much as I did at age 45 years. Ah, those were the days. So far, I have not joined AARP.

I was there when Medicare and then Medicaid were launched. I was there when D.A. Henderson went from the CDC to WHO to direct the eradication of smallpox. I was there when the NIH budget was in its early phase of expanding rapidly every year and new specialized institutes were created. I was there when medical and surgical subspecialities were proliferating and establishing themselves. I was there when medical schools expanded class size and new medical schools associated with the VA were established. I was there when hospitals became large corporate entities, created CEOs, started marketing and advertising campaigns and later began purchasing medical practices.

I have seen explosive growth in the number and size of health insurance companies, pharmaceutical companies and medical device companies. I have witnessed the escalation of advertising directly to the consumer by these companies. I have seen all manner of financial relationships between the companies and physicians. I have seen physicians establish commercial enterprises to deliver high tech medical support services.

I have watched the growth of public demand for medical services and the proliferation of new diagnostic designations to cover a variety of symptoms. I have watched the health care system become a medical system oriented to aggressive diagnosis and therapy. I have watched as more and more resources have been dedicated to senior citizens. I have watched reforms and even aborted reforms create unintended consequences.

Someone tell President Bush that competition is not lacking in medical care. There is competition everywhere there are resources to pay for it. To the contrary, competition is a major force creating instability in the balance between health care and medical care and between those with and without resources. You get what you pay for. When you pay for sickness, you will get sickness.

Many bridges have been crossed to arrive at the current situation. It has not been a simple journey and there will be no going back. But, I fear for the future of my medical colleagues. The health care system is out of balance creating instability that directly impacts their professional future.

Many feel the situation is beyond the control of physicians. I would hasten to add that physicians can change the system more quickly and effectively than any government reform effort. Physicians can get other health professionals and health entities to join them. Physicians can begin to devote more attention to primary prevention and the lifestyles of their patients plus the community. Physicians can regularly review the medications a patient is taking with the intention to decrease or eliminate those that are no longer necessary.

Primary care practioners are poorly compensated for the amount of work they do. I have never been able to find the justification for the difference in compensation between primary care and speciality care. Some have advocated reforms to correct this imbalance. Don't hold your breath and don't expect the resurrection of the "gate keeper" role. Let us create something of value that will change the system.

Primary care providers can reinvent themselves to address some of the major problems and take advantage of future trends in health care. Converting from "sick call" to health risk management and expanding the scope of attention to include institutions and organizations in the community will add value to the health care system. And, it will establish primary care in a leadership role.

Primary care providers need to sharpen their education and public speaking skills. Teaching patients and the public how to achieve and maintain optimum health is far, far more valuable than prescribing medications. Universities and programs that educate health professionals need to focus on this matter. More research is needed on health behavior, and where and how intervention is most effective. This brave new world of communications provides opportunity to be more effective at a lower cost and primary care providers should become experts and innovators.

Obviously, this will take time to have an impact and it will require innovative financing mechanisms. The money is there and it can be redirected to something of value. If the President and Congress have any sense at all, they could start the process by reallocating Medicare Part D funds to prevention. Don't be afraid of the old folks, they don't like Part D and they will probably vote for you anyway. I am not so sure about the AARP. My recent post on Part D that Barbados Butterfly so kindly included in Grand Rounds wasn't very popular but hope springs eternal.

Healthy People 2010 lays out an ambitious agenda that begs to be implemented. Governor Huckabee has started the ball rolling in Arkansas and Governor Sanford has followed suit in South Carolina. The National Governors Association is currently chaired by Governor Huckabee and he has set the topic of Healthy America for the NGA Forum in Washington DC later this month. CardioVision 2020 is a health promotion project for Olmsted County, MN and there is an informal health challenge with Healthy Greenville in Greenville County, SC. There is a Healthy Dekalb County and the Centers for Disease Control and Prevention is a resource.

There will always be sickness, disease and trauma. That is the orientation of the current medical care system and primary care knows too well its role in sick care. I may be an older fart but I am a very lively older fart who is not interested in being sick. I want you to focus on keeping me well. Come on, let's get going before the hospitals decide to build another addition dedicated to perpetuating disease.

It is said that all politics is local. Perhaps the same is true of health. Personal responsibility and community commitment to optimum health should be led by the health professionals that people know and trust. Count me in.

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