Vitamin D interventions can quickly benefit the HMO bottom line

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Premise: HMOs will save millions of dollars by adding vitamin D before and after many procedures

Vitamin D improves health.
Health Maintenance Organizations get paid a fixed amount per person per year.
When the person uses the HMO less during a year the HMO effectively earns money (actually does not have to pay money)
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Want the HMO to take baby steps initially

   Something they can try and get instant positive feedback - at low risk

Vitamin D aspects as Low Hanging fruit

Later, after seeing how good the low hanging fruit is, the HMO can become aware of:

1. fruit higher up the same tree,
2. other trees,
3. the benefits of planning ahead (pruning, fertilizer, etc)
4. things the HMO can cultivate which are not trees (Preventive Medicine: Kaiser Permanente==> Kaiser Preventive?)

How vitamin D can initially benefit the HMO:

Helps heal faster (especially bones) - thus fewer days that HMO has to pay for hospital/ physical therapy faster
Reduces complications from pregnancy, surgery- fewer days
Reduces problems with some drugs, chemotherapy, radiation therapy
Improves immune system - reduces secondary problems - Staph. MRSA
Reduces time in ICU/critical care

Contra-indications: when not to take vitamin D

Interaction with drugs
Interaction with chemotherapy - increasing effectiveness perhaps to the point of death
Hypercalcimia

Why add vitamin D now

Lots of recent research supports it (see below)
Inevitable that vitamin will be used before/after some medical procedures - typically surgeries
First organization to have vitamin D intervention will save huge amounts of money, then others will follow.

What are the malpractice considerations?

It might be malpractice to not recommend more vitamin D now - and not get sued until years in the future
Perhaps the risk is highest are to those which do NOT recommend vitamin D.
Probably want to avoid promising the patient any results from taking the vitamin D - reduces the probability of a malpractice suit

A first-cut at ROI

The total costs associated with a procedure = $700
  Specialist's time: 1/2 hour = $170; Staff time 3 hours = $300; Blood Tests = $200; Supplements $30
Rough Estimate of the Benefits to the Bottom line = ROI = 3.3X
IF could save two days for every intervention, then would save $1500 X 2 - $700 (cost of intervention) = $2300
Return On Investment for this example = $2300/700 = 3.3x
Probably the average savings due to reduced healing time and complications across all interventions will be much smaller
  Note: this does not account for the development of the protocol - described below

Actions that an HMO can take to get these savings

Possible medical interventions to choose from: all of which have been significantly helped with vitamin D

What might be the concerns of the HMO upper management?

$$: supplies, personnel, payments from Medicare, advertising, ....
Number of participants leaving, or decreasing number of new participants
The need to expand: additional facilities if no change is made, etc,
Ability to bring in more patients when fee-for-service doctors are reluctant to increase vitamin D
   Vitamin D decreases the income of a fee-for service practice
   Vitamin D keeps the HMO income the same, but decreases the outgo

Portion of comment by Rich B.

The biggest concern to HMO management is that many doctors will consider vitamin D clinical results to be unproven, based on flimsy anecdotal evidence.
The HMO needs to take the approach that:

• The evidence is strong enough,
• The risks are low enough,
• The cost is cheap enough

so that the cost-benefit ratio points in the direction of radical vitamin D supplementation.
If you wait until the supporting evidence is bulletproof, you are going to waste billions of dollars in the interim, and there is even a chance the evidence will never gain the status of irrefutable truth. It is somewhat like the evidence indicating the dangers of smoking, or the evidence of the dangers of not washing hands after doing autopsies and then delivering babies (Semmelweis).

Hopefully the medical community will not delay for decades as it did in the past for other supplements: Iodine, scurvy, rickets

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Clinical Trials for vitamin D interventions near a surgery

Trial Of Vitamin D3 in the Treatment Of Secondary Hyperparathyroidism after Gastric Bypass Surgery
Vitamin D Effects on Prostate Pathology (Dprostate) 40,000 IU daily prior to surgery, Vieth
Doxercalciferol Before Surgery in Treating Localized Prostate Cancer does not say how much]
Vitamin D Replacement After Kidney Transplant 50,000 IU per week after transplant
Vitamin D3 Substitution in Vitamin D Deficient Kidney Transplant Recipients (VITA-D) 6800 IU daily after transplant
Impact of Vitamin D Therapies on Chronic Kidney Disease 50,000 IU twice per week
High-Dose Vitamin D Deficiency in Burn Injury (VitaminD) 50,000 IU weekly
Interventional Trial of Vitamin D Deficiency in the Patients of General Departments 2008? 2 doses of 100,000 IU
VITdAL@ICU - Correction of Vitamin D Deficiency in Critically Ill Patients loading dose of 540,000 IU
Will increasing vitamin D in blood to 100 ng reduce deaths of colon cancer patients- July 2010
Identifying Vitamin D Deficiency in Very Low Birth Weight Infants only 400 IU

Clinical Trials for Vitamin D - 2012 784 Vitamin D Intervention trials as of Dec 2011

Studies

  Cancer - - - - - - - - - -

All items Cancer - After 113 items

Is vitamin D the only supplement which consistently helps cancer survivors – Aug 2010
Vitamin D3 sensitizes breast cancer to radiation treatment - increasing cancer cell death – May 2010
    as with Chemotherapy, vitamin D can greatly reduce the the amount of therapy needed.
    Reminder: must not take vitamin D if some types of chemotherapy can not be reduced
Vitamin D reduces lung damage due to adiotherapy – Oct 2011
Chemotherapy might be amplified by vitamin D
Metastatic Cancer is maybe reduced by vitamin D - 5 articles
Vitamin D appears to both prevent and treat various cancers – Mar 2011
Vitamin D reduces hair loss from chemotherapy etc does not contribute to ROI, includes link to a patent
Better chance to survive colon cancer surgery if have more vitamin D.PDF file

  Bone - - - - - - - - - -

90% reduction of post operative infections for hip surgery with 2,000 IU/day
Vitamin D 2nd most recommended way to prevent next hip fracture – Nov 2010
Is it ethical to NOT give vitamin D in osteoporosis trials– NEJM Sept 2010 liability?
D2 megadose and bone mineral density following biliopancreatic diversion surgery.
Hip surgery followed by 100000 IU then 1000 IU of vitamin D daily – June 2010
Calcium and vitamin D supplements after hip fracture reduced death rate by 25% – Feb 2011
Should stock-up on vitamin D if having surgery due to fragile bones – Jan 2011
Hardly any children had enough vitamin D before bone surgery – April 2011
Osteoporosis medication 7X better when more than 33 ng of vitamin D – June 2011
Low vitamin D before orthopedic surgery – dark skin 5X more likely – Oct 2010
Stop - Read This Before You Have Orthopedic Surgery - Nov 2010
Noticed bones heal faster when more than 60 ng of vitamin D

  Pregnancy - reduce complications before, during, and after birth - - - - - - - - - -

300,000 IU loading dose of vitamin D stopped gestational diabetes in RCT – Oct 2011
5X more likely to be deficient of vitamin D during pregnancy than anything else
70% of pregnant women had complications due to lack of vitamin D - May 2010
7X more likely to have low birth weight babies when mother very low on vitamin D – March 2010
Death rate 2X higher for 37 vs 40 week pregnancy web May 2011
80 percent recent increase in Strokes following pregnancy - July 2011
Severe preeclampsia 4X higher when very vitamin D deficient e.g. 10 ng vs 40 ng blood levels
Preeclampsia and small infants associated with 7 ng less vitamin D – Mar 2011
How to reduce preeclampsia - May 2011
Why vitamin D reduces of premature birth - April 2011 Note: 2X death rate for premature birth
Babies Receive Heart Transplants Instead of Vitamin D Treatment
C-section 4X more likely when vitamin D less than 37 ng – many items suspect C-section is more expensive in many ways
High maternal vitamin D resulted in 30 percent less infant problems with breathing – Nov 2011
  perhaps too long for initial consideration, 12 months. Note this improvement was for < 40 ng of vitamin D
Bacterial vaginosis during pregnancy 3X more likely when low on vitamin D – Sept 2010

  ICU/trauma - - - - - - - - - -

All items After surgery or trauma 352 items

Veterans with enough vitamin D were almost 2X more likely to survive ICU – Oct 2010
Virtually all veterans in ICU had vitamin D less than 32 ng – Jan 2011
ICU time is 2X more likely to be longer than 2 days if vitamin D less than 20 ng – Mar 2011
Critical Care patients with low vitamin D were 85 percent more likely to die – Sept 2011
Critically ill 70 percent more likely to die if vitamin D less than 15 ng – Jan 2011
ICU needs vitamin D - Vitamin D Council Sept 2011
Critical Care patients need vitamin D
Study: 540,000 IU oral to ten patients near death in an ICU as a single dose achieved around 40 ng/ml, but it takes three days to do so
  "I predict that eventually vitamin D will be available as an IV and that the most useful preparation will be intravenous 25(OH)D."

• Much more likely to die in ICU if vitamin D below 20 ng – Feb 2012

ICU surgical patients with low vitamin D stayed longer and had more sepsis – Dec 2011

• Being vitamin D deficient in the ICU is not good - Feb 2012

  Kidney - - - - - - - - - -

Adding Vitamin decreased kidney deaths by 4x – Dec 2010
  It is amazing that such excellent results were buried in the paper. They were not in the title nor abstract.
  This is the result of about 10 trials with about 5,000 kidney disease patients.
Some form of vitamin D may be the lowest cost treatment for Chronic Kidney Disease Sept 2011 probably just long-term

  Cardiovascular - - - - - - - - - - may be too long-term initially

Overview Cardiovascular and vitamin D
  147 Cardiovascular and vitamin D intervention studies (that is, give vitamin D and see what happens) - as of Feb 2011
Cardiovascular event 56 percent more likely after vascular surgery if low on vitamin D – Oct 2011

  Length of stay in hospital/rehab - - - - - - - - - -

Hospital stay 6 days longer for nursing home residents with low vitamin D – Oct 2011
Rehab patients vitamin D deficient - with chart Nov 2010.pdf file
Higher vitamin D helps regain muscle strength after knee surgery – July 2011

  Hospital problems - - - - - - - - - -

Staph infection reduced 50 percent when have more than 30 ng of vitamin D – Aug 2011
MRSA inpatient cost 2X higher if less than 20 ng vitamin D – June 2011

  Elderly - - - - - - - - - -

Vitamin D deficiency was the best predictor of older patient death in hospital – May 2010
Fraser Health in Canada is using vitamin D intervention to reduce falls – Nov 2011
  Vitamin D interventions for falls result in large ROI - measured over years, not months
  CLICK HERE for many excellent proofs that vitamin D intervention reduces falls]

  Thyroid surgery - - - - - - - - - -

Every Thyroidectomy patient should get vitamin D and Calcium – Nov 2010 2 days longer stay
Patients low on vitamin D stay in hospital longer after thyroid removal – Dec 2010

  Not yet categorized - - - - - - - - - -

• VA found less testing for vitamin D resulted in increased health costs – Jan 2012

Virtually all Bariatric Surgery patients vitamin D deficient – should we routinely supplement – Jan 2011
93% of Spinal cord injury patients were low on vitamin D March 2010 - even more for those with dark skins
burns (will add links in the future)
Stem Cell Transplants consume vitamin D – July 2011
California got 19X Return On Investment by having people quit smoking Sept 2011 Scientific American
   Money saved by decreased medical costs were 19X more than the taxes lost from decreased tobacco use

A possible way to compactly represent the information is a matrix, such as:

There are several advantages to having many HMOs start concurrently

Might avoid the hesitancy of an HMO of being the first to try a new procedure

• A lot of inertia must be overcome by any organization to decide to be the first to try something - especially conservative organizations
• What will my peers (other CEOs) think? Will I be be laughed at?
• Far easier to go along with the crowd/mob = not change, which = no decision

Costs could be amortized over many organizations

• Cost of developing the protocols
• Cost having vitamin D advocates on-call - perhaps 24 hours a day
• Cost of developing educational material for doctors, medical staff, and patients (could be on-line)
• Cost to analyze the results of the interventions
• Cost of updating the protocols, educational materials based on lessons learned/analysis
  • and will learn far more quickly when many organizations are involved:
    • which procedures give the most ROI (Return On Investment)
    • which type of patient provides the best ROI (black, elderly, obese, etc.)

Experiment with different ways to encourage participation by reward/recognition practices

• Suggest many ways and let evolution see which ways actually work (Big Pharma has done this for decades)

Possible phases of each intervention

1. Doctor agrees to try adding vitamin D to this patient/procedure
2. Patient agrees to adding vitamin D: default capsule - option liquid, sublingual, etc.
3. Test patient for possible rare adverse reaction to vitamin D
4. Blood test (reminder, patient may not live near a facility which can test blood): Vitamin D, Magnesium, Calcium, PTH....
5. Test results are analyzed: specialist with decision to go ahead, and establish precise dose regime (daily, weekly, amount)
   Adapt the protocol if the procedure is sooner or later than typical
6. Patient is informed of how much vitamin D and possible co-factors to take - and perhaps reduce Calcium
7. Patient gets the supplements - typically for 1 month before and 1 month after the procedure
8. Blood is again tested one or more times before the hospital procedure
   might need to adjust Vitamin D dosage if tested levels are higher or lower than desired
   the reason for the blood test is primarily to make sure that vitamin D level was raised enough and other factors are in safe range
9. Results of testing is analyzed by specialist as before
10. PROCEDURE/SURGERY
11. Patient is reminded to take the vitamin D for next 30 days - telephone, email, SMS, . . .
12. Possible blood tests at end of the intervention period
13. Possible education of patient of the amount of vitamin D and co-factors for long term (on-going)

Implementation options include:

• Mandate that 10 % of every procedure listed be supplemented with vitamin D
• Suggest that unless the patient, or others... object, that 10% of procedures be supplemented
• Mandate that 10 % of only X procedures by have vitamin D intervention
• Suggest that doctors individually try vitamin D only for those procedures that they think it will help
• Encourage that the doctors ....
• Enable the doctors to try vitamin D as they individually see fit
• Extend to more locations (hospitals)
• Future: use vitamin D proactively so as to decrease need for surgery/sickness/time off

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Current Hip Fracture recovery time (probably will be shorter with Vitamin D)

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Perhaps emphasize those interventions which result in higher average ROI

Patients at high risk of being vitamin D deficient:

• dark skin
• diabetic Note: 117 Clinical Trials for Diabetes and Vitamin D as of Sept 2011
• senior
• MS
• pregnant
• obese
• using drugs which consume vitamin D
• Have a condition which Prevents Adsorption in the gut
• Have a condition which Prevents Conversion to active vitamin D such as HIV
• Patients living far from the equator or in cloudy regions ( such as Washington State, Scotland)

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An idea for a long-term additional method for a HMO to discover the benefits of vitamin D intervention

Similar to Fraser Health, or Finland decades ago, offer say 4,000 IU of vitamin D daily to a subset of the HMO clients
   Say to clients which doctor is willing to go-along with the intervention
Benefits will be seen over many months, years
ROI might actually be higher than mentioned above due to the far lower costs
A Random Controlled Trial would be nice to get proof, but would be unethical and could increase liability
Could alternately track the reduced health needs at one hospital with intervention vs another without intervention
Provide vitamin D in a variety of forms (capsule, liquid, sub-lingual, Vegan, Kosher, ...)
To increase compliance - might suggest 50,000 IU capsules to be taken once every 2 weeks (mark-off calendar when taken so as to not forget)
Provide variety of patient education modes for vitamin D and co-factors (web, class, printed, ...)
Less than 4,000 IU if person is already taking some vitamin D or is younger than 9 years old
Initial benefits should be first noticed by the HMO in about 2 months (colds, flu, aches, pains, ...)
Blood tests: recommended by optional 3 months after starting the intervention - primarily testing for things other than vitamin D (PTH, Magnesium, . . . )
Substantial benefits will be well documented in about a year

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At some point want to suggest to the group getting the cost savings that 10% of documented net savings be given to vitamin D non-profits

- - - -so as to expand awareness, and bring even more people (and doctors?) into the HMO
Non-profits such as Vitamin D Wiki, Vitamin D Council, Vitamin D Association (UK)

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Cost of Health Care about $10,000 per year: HMO or otherwise

New York Times, Nov, 2010

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HMO types: Staff, Group, Network

from WikiPedia - June 2013
HMOs operate in a variety of forms. Most HMOs today do not fit neatly into one form; they can have multiple divisions, each operating under a different model, or blend two or more models together.

In the staff model, physicians are salaried and have offices in HMO buildings. In this case, physicians are direct employees of the HMOs. This model is an example of a closed-panel HMO, meaning that contracted physicians may only see HMO patients. Previously this type of HMO was common, although currently it is nearly inactive.[5]

In the group model, the HMO does not employ the physicians directly, but contracts with a multi-specialty physician group practice. Individual physicians are employed by the group practice, rather than by the HMO. The group practice may be established by the HMO and only serve HMO members ("captive group model"). Kaiser Permanente is an example of a captive group model HMO rather than a staff model HMO, as is commonly believed. An HMO may also contract with an existing, independent group practice ("independent group model"), which will generally continue to treat non-HMO patients. Group model HMOs are also considered closed-panel, because doctors must be part of the group practice to participate in the HMO - the HMO panel is closed to other physicians in the community.[6]

If not already part of a group medical practice, physicians may contract with an independent practice association (IPA), which in turn contracts with the HMO.
This model is an example of an open-panel HMO, where a physician may maintain their own office and may see non-HMO members.

In the network model, an HMO will contract with any combination of groups, IPAs (Independent Practice Associations), and individual physicians.
Since 1990, most HMOs run by managed care organizations with other lines of business (such as PPO, POS and indemnity) use the network model.

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See also VitaminDWiki

• HMO Data collection and analysis
• HMO extra
• Coloradans paid by Kaiser to lose weight – Dec 2011
• HMO - Kaiser information
• BUPA is an HMO in the UK which can also benefit from vitamin D interventions
• All items in Cost savings due to Vitamin D 158 items
• How companies and individuals can benefit from vitamin D
     People want to return from sick leave ASAP now
     From Knowledge at Warton Sept, 2011
• How Health Insurance could profit from vitamin D
• Reduce Chronic Pain which has the following
    Survey found vitamin D to be #1 supplement - across ALL problems
• HMO forum Started Nov 2011
• Overview of Vitamin D Wiki for Fraser Health - Nov 2011 They started giving 20,000 IU weekly to their clients in senior homes - 2012.
  Overview has a good summary of vitamin D benefits to seniors, hospitals, Canadians, Northern Europe, etc.
• HMO Benefit and risk