Parents concerned about ADHD should not only be attentive to the AMOUNT of sleep their child receives but also to their QUALITY of sleep.
A medical study highlighted in the NY Times revealed that children with sleep breathing disorders were 40 to 100 times more likely to exhibit behavioral problems like ADHD.
Sleep medicine is one of the fastest growing fields in health care today and researchers are discovering new health implications from poor quality sleep in nearly every field of medicine. With recent discoveries into sleeps’ implications, health care providers of all specialties are beginning to view sleep on the same level as nutrition as a component to good health.
In the medical study, one of the study’s lead authors said, “It’s incredible that we don’t screen for sleep problems the way we screen for vision and hearing problems.”
Children with sleep apnea and even milder forms of sleep breathing disorders (SBD) are not likely to “outgrow” their condition as they mature. In fact, it will likely become worse. Poor quality sleep due to sleep breathing disorders has been proven to increase calorie consumption (study) and weight gain which is correlated with increased risk of sleep breathing disorders. The weight of excess tissues around the neck causes the airway to narrow or collapse. The problem begins to spiral out of control in this manner:
Poor sleep –> Increased calorie consumption –> Weight gain –> Occluded airway during sleep (apnea or SBD) –> Poor sleep…….
The article reveals that the drugs used to treat ADHD, like Ritalin, Adderall or Concerta, can cause insomnia. Dr. Vernon Rowe, board certified neurologist and sleep medicine physician Rowe Neurology Institute has long contended that children who snore or experience poor sleep become wired, not tired. “Unfortunately, you can add kids with ADHD to a long list where medical professionals, by using drugs to treat symptoms, may be doing more harm than good because they are not addressing the root cause of the problem.”
As the medical director at the Institute’s Sleep Disorder Center, Dr. Rowe recorded this video message for parents who are concerned with their child’s sleep and or behavior.
Dr. Rowe recorded this video message for parents who are concerned with their child’s sleep and or behavior.
By Elizabeth S. Rowe, Ph.D., M.B.A.
MedPAC finds High Hospital Charges and Costs, NOT Higher Volume, makes US Healthcare more expensive than the rest of the world.
This year’s agenda for MedPAC (The Medicare Payment Advisory Commission, which advises Congress on Medicare Policy) includes an analysis of the high hospital charges and costs in the US compared to other countries, and what policy changes in Medicare can be made to ameliorate these high costs. The presentation by staff at a recent public meeting (MedPAC Presentation)included the results of their research, which showed that American high hospital charges and costs for Medicare are 50% higher than those of the closest comparable country, as a percentage of GDP. Commercial hospital costs are 100% higher in the US. However, the reason was traced to higher costs, NOT greater utilization; in fact the average length of stay and number of admissions per capita are lower in the US.
The analysis only considered hospital costs, and it includes costs of hospital employed physicians. Since private physicians are paid less than hospital employed physicians for comparable services, this data suggests that private practice independent physicians in the US are NOT overpaid compared to these other countries.
The presentation listing of possible actions that could be taken to correct Medicare payment policy include introducing site neutral payments which “removes incentives to move lower priced services to hospitals where overhead is higher.” Site neutral payments policy for hospital employed and private practice physicians was officially recommended last year also (see March 2014 Report, at www.medpac.gov). A second possible action would be to simplify quality reporting, since “complexity” was one of the reasons identified for US hospitals having higher overhead than the compared hospitals.
This meeting is the first of several public meetings where this topic is being discussed by the Commission, and the data details and resulting official positons and recommendations will be presented as a chapter in the March 2015 Report to Congress. The presentations and transcripts of the discussions for all of the MedPAC public meetings are posted online at www.Medpac.gov
By Vernon Rowe, MD
This article takes for granted that you are already aware what a slippery slope spinal surgery for back pain and neck pain can be. Put concisely, one bad thing leads to another. Surgery is not the “final answer” for back and neck pain. Just as injury begets weakness which begets another injury, one spine surgery frequently leads to more spine surgeries. It’s a complex topic, but at RNI we feel very strongly that the fault for this lies in the weak tissues surgery leaves behind, rather than surgery patients having worse conditions to begin with. Click to read a fuller discussion of the risks of back surgery. At RNI we consider it our mission to move you from the slippery slope to solid ground with the most conservative and effective therapy possible.
Why diagnosis by an independent neurologist is crucial in back pain and neck pain
Here are just a few reasons why you need an independent neurologist for your back pain and neck pain, like those at the RNI,–the only independent neurology institute in Kansas City.
We have tried to capture the value of RNI’s approach by sharing a woman’s story (and video) of going from wheelchair to pain-free walking, and we hope that you will check it out. It’s quite a story, hopefully you find some inspiration in it.
Many Surgeons have an inherent “lean” toward surgery. They do order diagnostic tests like MRIs and x-rays, just like a general or family doctor can. But surgeons can’t help seeing every patient through the lens of their most powerful tool: “Can surgery help this patient?” The problem is, patients don’t want surgery if they can possibly avoid it. Thus, even the best surgeons see your case through a different lens than you see it yourself.
Any neurologist is highly specialized in diagnosing back pain and neck pain, and in assessing risks and treatment options. Every back pain and neck pain patient is unique, with different degrees of problems associated with a bone or disc abnormality. A neurologist is trained to discover the causes of symptoms, as well as using EMG testing to assess the injury to nerves and whether it is reversible in the short and long term. But if a neurologist sees a patient sent by one of his or her surgical friends, and they both work in the same hospital system, then that neurologist is conflicted in his or her assessment. On the one hand he/she has a primary duty to the patient to provide the best care possible. On the other, the neurologist’s salary might be paid by the hospital system, which receives compensation, as does the surgeon, when surgery is done. So we at the RNI believe it’s best for a patient to see an independent neurologist, or at least one in another hospital system, to have a true and unbiased second opinion about whether surgery is necessary. In most non-emergency cases, a conservative approach is both possible and optimal.
You need the most informed and trustworthy referral to a surgeon. An independent neurologist who has seen thousands of cases can find the best surgeon for your case. Unfortunately, some patients can’t be helped by even the best physical therapy. Disc herniation can be too extreme, bone can build up around nerves to the point where they no longer fit through. Neurologists at the RNI know fine surgeons they can rely on if surgery is necessary, no matter which hospital system that surgeon is in, so the RNI can frequently give a patient multiple options should they need surgery. We have a great deal of experience with all major hospital systems in the KC region, though we’re independent from hospitals, so you can trust there’s no financial motive at play.
Neurologists make a long-term connection with patients. Surgeons don’t generally care for patients with back pain and neck pain over the long term. The last time you see a surgeon is likely at a post-op follow-up visit a month or two after surgery, long before you are fully recovered. There are a plethora of cracks to fall through later on, the most important being a return to the same posture and muscle conditioning that led to the injury in the first place.
RNI coordinates all aspects of your treatment, from diagnosis to recovery and prevention of re-injury. We at the RNI are a tightly coordinated team of caregivers, diagnostic equipment, and facilities in order to deliver the best possible outcomes for neurology patients. This includes an imaging center with both MRI and x-ray, and a physical therapy team that gets the majority of back patients better without surgery. These outstanding individuals deserve their own paragraph:
Highly specialized physical therapists who follow your case from your first visit. RNI’s physical therapy team gets the majority of RNI back patients better without surgery, by re-training the muscles of the hip and abdomen to support the back the way they were intended. What these physical therapists accomplish can seem like a miracle to the patients they help.
If a surgeon refers you to physical therapy at all, he’ll leave it up to you to pick a physical therapist off the internet. Not only will the therapist you find be a generalist, they will have little more to go on than a few words about the type of surgery you had.
A good neurologist will support you in the long term. Back injuries are a long-term problem, and to fix them a great deal of commitment is required of the patient. That commitment can keep you healthy and out of surgery, but you can’t do it on your own. RNI nurses, physicians, and physical therapists support you all along the way.
by Vernon Rowe and Aaron Seacat
Healthcare and Baseball are alike in many ways, and this similarity was driven home when the Kansas City Royals, against all odds, won the American League pennant.
Healthcare and Baseball are ponderous institutions, with tremendous inertia doing things the way they have always been done. But occasionally, disruptors can change the way things are done and induce a paradigm shift in the way the game is played for the better.
Jonathan Bush, in his book Where Does It Hurt: An Entrepreneur’s Guide To Health Care, makes this point about healthcare when he says “Health care is starving for efficiency experts, customer service geniuses, retail mavens, people who have created thriving and modern businesses in other industries [disruptors.]”
In the famous Moneyball example in baseball, a paradigm shift occurred when Jonah Hill showed Brad Pitt (as Billy Beane) the most important part about winning was getting on base. In the movie, John W. Henry, of the wealthy Boston Red Sox , tells Billy Beane: “The first one through the wall…is threatening the way that they do things…and every time that happens–whether it is the government, or way of doing business or whatever it is …the people who are holding the reins, have their hands on the switch, they go [expletive deleted] crazy.”
As the Royals won the American League pennant and gave Royals fans their first postseason appearance since 1985, they did something never before done in the history of the game—8 straight wins to begin the postseason. They did this with a small market payroll uniquely void of high priced sluggers. In an era where home runs are a valued (and expensive) resource, the Royals success has introduced another paradigm shift in thinking to MLB: the ability to run and disrupt the rhythm of the game can be as important as hitting.
As in the baseball industry prior to Billy Beane, and now the Kansas City Royals, our hospital-centered healthcare system is ponderous, overly expensive, and obsolete. Like the automobile industry of the 1970’s, with its cars gulping gas at the rate of 7 miles per gallon, the healthcare system will need to be re-engineered. The industry itself is sorely in need of disruption.
Most health care is outpatient care, yet most of our healthcare dollar is spent on hospitals–far more than the rest of the world, due to higher rates, not higher volume. MedPAC Study
Independent outpatient centers, like the Rowe Neurology Institute, can be designed to deliver high quality, cost effective care at a fraction of the cost of hospital-based care.
These centers are light on their feet and fast, without facility fee overcharging and the weighty infrastructure of overbuilt hospitals dragging them down. They can eliminate long waits and overpricing. Their only loyalty is to their patients. They are disruptors, and in this sense, are game changers and paradigm shifters.
Outpatient centers like these are perfectly poised to disrupt the healthcare system for the better. Just as the ability to steal bases and disrupt the rhythm of the game of baseball, can be a major addition to the arsenal of hitting and pitching. In the now famous words of Jarrod Dyson, a player for the Royals, “That’s what speed do.”
The Whirlybird Anthology of Kansas City Writers
Edited by: Vernon Rowe, Maryfrances Wagner, David Ray, Judy Ray
Cover Photograph by Elizabeth Rowe
The Whirlybird Anthology of Kansas City Writers presents poems, stories, and memoir selections from 95 writers who have lived or worked in the Kansas City area, many of whom have earned widespread recognition in this country and internationally.
“In some of the selections Kansas City itself is subject or backdrop, for example when Richard Rhodes and Hilary Masters recall specifics of their childhood, or when David Owen returns to explore remembered odors, or when poets respond to the influences of jazz. But also found in these pages are subjects and styles as varied as can be imagined—and imagination is not bound by place.” – from the Preface to the Anthology
Other regional collections have been published in previous years. This work stands on their shoulders, highlighting some of the finest examples of widely published authors, but also introducing new voices to the Midwest medley. In addition to a note of biographical information, many of the authors also provide a personal sound-bite observation about Kansas City.
The Anthology will be launched at a celebratory Reading on November 30, 2012 at 7 p.m. at The Writers Place, 3607 Pennsylvania, Kansas City, MO 64111. 816-753-1090
Dr. Vernon Rowe answers a reader's question about sleep disorders:
Question: I am looking for information for a friend who snores loud and stops breathing in their sleep. How should they even start getting their treatment? I don't even know where to begin.
Answer: Your question is a very important one and your friend is very lucky to have someone like you watching out for them. What your friend needs to understand is that snoring is NEVER normal. There can be different reasons why people snore and some reasons are more serious than others but you have clarified that your friend snores loud and stops breathing which is a hallmark sign of sleep apnea.
Of course the only way to truly know is to have a sleep study at a sleep lab (at this time I don’t recommend "at home sleep testing" because of the equipment deficiencies; mainly reduced sensitivity that can result in a false negative polysomnogram). You can find an accredited sleep center near you by entering your zip code at this link.
Schedule a new patient visit with a physician who is board-certified in sleep medicine. While any physician can write an order for a sleep evaluation, a physician board certified in sleep medicine is much more intimately familiar with how various sleep disorders are identified and treated. At the initial visit, a short evaluation will ask many questions about the patient’s sleep habits, medical history and symptoms that may indicate if a sleep disorder is present. If deemed necessary, a polysomnogram (sleep study) will be ordered.
If scheduling at Rowe Neurology Institute's Sleep Center: Our schedulers will verify insurance coverage for the sleep study and review the details with your friend. Once the sleep study has been completed, a board certified sleep medicine physician will review and interpret the data, make a diagnosis and discuss with your friend what the next steps should be. PAP therapy is the most common treatment for sleep apnea (because it is simple and it works) but there are other options that can be discussed as well. The important thing you can do now is not let your friend continue to go undiagnosed and untreated.
Sleep apnea is a real health risk with links to heart disease, stroke, diabetes and other serious health problems. The good news is that sleep apnea is treatable and your friend will wish he/she had done something sooner. Good luck.
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The Headache Center at Rowe Neurology Institute has said over and over that there is no single cure for migraine, because every patient is unique and must be evaluated and treated individually. However, there is a pattern developing of satisfied (former) migraine sufferers that all seem to be singing from the same hymnal. In recording their testimonials, like the one below, a common migraine story is developing.
• Had regular or daily headaches
• Currently on or tried multiple medications with little improvement or bad side effects
• Evaluated at Rowe Neurology Institute
• Found previously undiagnosed sleep disorder (like sleep apnea or RLS)
• Usually a side-sleeper or sleeps on their stomach
• Pinched nerves in the neck (possibly triggering migraines)
After a comprehensive neurological evaluation these migraine sufferers receive an individualized treatment plan developed to fix the root cause(s) of their migraine. Patients are most appreciative that they are not simply getting another drug to treat their symptoms. The common treatment “formula” that has emerged.
- Physical therapy to correct the mechanics of the neck and shoulder complex and to strengthen weaker muscle components to correct movement patterns
- Sleep study to diagnose and properly treat the sleep disorder
- Learning to sleep in a “neutral spine” position that was previously difficult or impossible due to undiagnosed/untreated sleep disorder
- Unparalleled expertise in medication management to eliminate or pare down medications to a bare minimum
This model of care at Rowe Neurology Institute (RNI) is unique in that the care provided from RNI's accredited sleep center, the clinical neurologists, electrophysiologist, neuro-radiologists and physical therapist are all coordinated together. Communication happens seemlessly and easily between the different departments so that ultimately, the patient experiences the most effecitive and cost-efficient care possible.
This weekend you moved your clocks back one hour and, if you listened to the public service announcements, replaced the batteries in your smoke detectors. Hopefully, you slept well knowing you had fresh batteries in the smoke detectors and your alarm went off at the right time and you made it into work and ready for a productive week.
But what if you still feel tired and don’t feel refreshed when the alarm rings. Or your focus and concentration is “off” at work. Maybe you lightly doze off at the red light waiting for it to turn green.
Daylight savings is a good time for a self-evaluation of your sleep. Sleep disorders are one of the most common undiagnosed health problems in our society and the consequences of untreated sleep disorders can be costly. Long term, untreated sleep disorders lead to health problems such as cancer, heart disease, memory loss, depression, and diabetes. Short term, untreated sleep disorders can be deadly on an individual basis or in large scale disasters.
Screening for a sleep disorder can be simple.
One test that physicians use is the Epworth Sleepiness Scale (ESS) which can be self-administered by clicking on the following link. Online EPWORTH SLEEPINESS SCALE test.
What was your score?
If you scored 10 or higher, please consult your physician about your sleep or schedule an appointment to visit a sleep specialist in your area. Don’t expect your family physician to address your sleep during routine check-ups unless you specifically ask.
Find a board certified sleep medicine specialist in your area and schedule an appointment.
If you are in or near the Kansas city area, you can request an appointment online at the Rowe Neurology Institute's Sleep Center.
Don't forget to forward this test to someone you know that snores or is chronically tired... and remind them to change their batteries.
Senior Advisor at Rowe Neurology Institute, Elizabeth S. Rowe, PhD, MBA recently traveled to Washington, DC to participate in MedPAC’s hearings on payment policy. Dr. Rowe’s comments follow:
Comments for: The context for Medicare payment policy 090612
Omitted from last year’s Report is a key cause of the increase of cost of Medicare expenditures: the effect on rising costs of the shift of physicians to hospital employment was not included in the 2012 Report. It is now clear that it is the single most important cause of rising costs that can be easily remedied. Payment policies must be changed to incentivize the low cost providers, and keep them from going out of business.
Outpatient medical services payments should be the same regardless of setting, including both physicians and ancillary testing facilities.
The level of these payments should be sufficient to incentivize the continued existence of low cost physician private practices and low cost free standing facilities for imaging, sleep studies, and all other outpatient testing and services that do not require hospitalization.
- Physicians are rapidly being recruited away from private practice and into hospital employment (in the hospital outpatient department or HOPD).
- The disparate payments for the same services in different settings are driving up costs for both Medicare and beneficiaries with no clinical benefits.
- If this trend continues the result will be a system of self-referring high cost HOPD monopolies for services that could better be provided in the lower cost private practice outpatient setting.
The massive shift of physicians from private practice to hospital employment, coupled with the disparate payment schedules, has several serious aspects and consequences.
- Payments to hospital OPD’s for office visits are 80% higher than for identical visits to privately owned physician offices (MedPAC March 2012 report). These higher payments by CMS also lead to higher co-pays by beneficiaries.
- Payments to hospital outpatient departments for imaging, sleep studies, and other services are 2-5 times higher than to privately owned free standing facilities. For cardiology example see Same Doctor Visit Double the Cost, WSJ Aug 27, 2012.
- Private practitioners and free standing outpatient testing and imaging centers are being driven out of business by low payments.
- Captive hospital employed physicians refer their patients to their high cost employers’ hospital owned testing centers, facilities and specialties, in a self-referral cycle in which physician salaries are linked to “production”.
- The existing “market” in which patients have choice of primary care physicians, and in which their primary care physicians have a choice for further referrals, based on their professional judgment, is rapidly being destroyed because of the lack of choice of hospital employed primary care physicians in their referral behavior. Once the shift of primary care physicians in an area reaches a critical mass, the free standing private practice “market” will be gone. Patients will no longer have a lower cost physician or facility to choose from.
- This monopolization of outpatient care by HOPD’s also creates a quality of care issue because patients will no longer be referred to the best available care in their areas, but instead to whatever specialist their HOPD system happens to have onboard. And if the trend toward concierge medicine continues, the best physicians will be the ones who are not part of these monopolies run by administrators and will not be available to Medicare beneficiaries.
REASONS FOR THE SHIFT OF PHYSICIANS INTO HOSPITAL EMPLOYMENT:
- Hospitals are clearly incentivized to employ physicians because of all of the above; especially the capture of the physicians’ downstream referrals.
- Physicians are incentivized to accept hospital employment because of the lowering payments in private practice to the point that private practice is untenable.
- Physicians are also incentivized by the salary premiums that hospitals can offer due to 1, 2 and 3 above.
- Physicians may not want to deal with the business aspects of being in private practice, which has been made increasingly burdensome and with ACA is expected to become worse. Costs are skyrocketing while reimbursements are literally shrinking.
- Specialists are forced into hospital employment when their referral base is eroded due to the change to hospital employment of their referring physicians. They are incentivized to go into hospital employment by both reduced payments and reduced referral base.
WHAT CAN BE DONE TO CHANGE THIS ADVERSE TREND?
- Equalize payments for ALL outpatient services to make them independent of setting, as has already been recommended for office visits.
- Set the new equal payments to be sufficient for private practicing physicians so they have a choice, and can stay in or go back to private practice if they prefer. Increase payments
for all outpatient services including imaging, sleep, and other testing for free standing outpatient facilities so that they can also stay in business.
- Immediately include hospital HOPD’s in Stark rules that require patients to be told about available alternative facilities and specialists whenever they are being self-referred by the hospital employed physician.
- Increase payments to hospitals for those services that they are uniquely required to provide, and which are now being subsidized by the overpaid outpatient services. Pay them the real cost of what we really need them to provide: trauma, intensive care, etc.
A recent article in the New England Journal of Medicine disects how “market friendly” ACA or Obamacare and its impact on the US healthcare system. The entire NEJM article can be read here.
Dr. Vernon Rowe, founder and medical director of The Rowe Neurlogy Institute, felt compelled to respond to this article in the NEJM to shed light on the ACA’s implications for patients as well as outpatient physicians:
This is a profound article. It strikes at the heart of the main reasons for escalating health care cost, the main one of which is our institutional and hospital-based system of care. This system is growing ever stronger by the day with the legal purchase of primary care practices, stifling any possibility of market forces operating in healthcare.
“…but they fundamentally misunderstand what it takes to be market-friendly… What is needed are reforms that create clear financial incentives that promote value over volume, with active engagement by both consumers and the health care sector. Market-friendly reforms require empowering individuals, armed with good information and nondistorting subsidies, to choose the type of Medicare delivery system they want.”
Fortunately, this has not escaped the attention of MedPAC, the body which advises congress. It is now obvious to the people on this panel that hospital-owned care (even for the same procedure in the same office) is vastly more expensive than "real" outpatient care for the same diagnosis.
"Unless these institutions find ways to reduce costs, lower Medicare reimbursements will force providers to bargain for higher payments from private insurers. And eventually, seniors' access to services will be threatened."
So keep the hospitals out of the outpatient care market. When physicians employed by hospitals recommend testing or surgery, require that those physicians make patients aware of lower cost options in the non-institutionalized sector. Make Medicare and Medicaid beneficiaries aware that there are lower-cost options available for the limited healthcare dollars (voucher or otherwise) that they spend. And fund the Public Health Departments for preventive medical care for the poor. It's really pretty simple.