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CLICK HERE for the article showing how Robotic surgery results in more income for hospitals.

Article summary

Hospitals are using robotic assisted surgery even though it costs them $3,000 more per surgery. (cost includes maintenance, training and supplies)
75% of all radical prostate were done by robotic assisted surgeons in 2009 in the US.
Following the money, it turns out that it the hospital makes money this way.
The hospitals typically get a fixed amount of money for a of surgery.
Patients getting robotic assisted surgery get out of the hospital 2 1/2 days earlier, and at $1500 per hospital day, the hospital makes money.
Increase cost = $3,000, Decrease expenses = $3,750; Profit = $750 per surgery
AND, since the this surgery makes fewer errors there are fewer complications from the surgery, so again the hospital saves money.
Guess: net cost savings per surgery >$1,500

Vitamin D ROI may be 1000X better than ROI for robotic surgery

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Details on robotic assisted prostatectomy at wikipedia
One of the robots - da Vinci- is currently used on Bladder Cancer, Colorectal Cancer, Coronary Artery Disease, Endometriosis, Gynecologic Cancer, Heavy Uterine Bleeding, Kidney Disorders, Kidney Cancer, Mitral Valve Prolapse, Obesity, Prostate Cancer, Throat Cancer, Thyroid Cancer, Uterine Fibroids, and Uterine Prolapse

Also from wikipedia: Three major advances aided by surgical robots have been remote surgery, minimally invasive surgery and unmanned surgery. Some major advantages of robotic surgery are precision, miniaturization, smaller incisions, decreased blood loss, less pain, and quicker healing time. Further advantages are articulation beyond normal manipulation and three-dimensional magnification, resulting in improved ergonomics.
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A long term benefit - can allude to it

People notice that HMO clients are healthier - so more join and more continue to stay with the HMO
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WalMart charging more for smokers health insurance Oct 2011

$25 for smokers, $15 for non-smokers (per 2 weeks) = 66% more
That an employee smokes is based on the honor system
Wonder how much employers in the future will reduce health insurance cost to those getting adequate amount of vitamin D
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Total Cost of Medical Care at end of life should decrease with more vitamin D

Stay healthy for longer time, and die quickly.

Vitamin D should reduce medical costs
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There have been many reports of reduced surgery complications when the patients had enough vitamin D (> 50 ng/ml).
A hospital spending a few dollars for vitamin D should see an average payback of hundreds of dollars in reduced complications for some surgeries.
All items After surgery or trauma in VitaminDWiki
There were reports of improved outcomes for bariatric, colon, hip, pancreatic, gastrointestinal, cardiac as well as many other surgeries.
The routine practice of prescribing a single dose of 50,000 IU of vitamin D before surgery could be very beneficial.
Perhaps patients for some surgeries will get 150,000 IU during the weeks before their surgery.

While it would be far better if people would take enough vitamin D so as to not need many surgeries, this at least could be a start.
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HMOs can save money vitamin D by:

1) reducing # of surgeries - which can be implied by many documents in VitaminDWiki, but not directly supported
2) reducing the recovery time from surgery - many studies which document this in VitaminDWiki,
3) reducing returns to the hospital after surgery
4) reducing the number of times a client needs to see the doctor per year, which can be implied by many documents, but not directly supported (future)

  • 2&3 would appear to require the least change to an HMO
  • 2&3 Total cost of the surgery event would be less with vitamin D, but HMO would get the same income from Medicare (see robot above)
  • 1&4 Get same income from employer, but can expect resistance from the HMO employees

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Aetna and Walgreens and United Way Continue Vitamin D Giveaways – May 2010

  • example of Health Insurance company that at least wants the positive publicity

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Encourage with recognition of doctors - say immediate points added to an annual recognition award

  • Encourage with gift certificate to doctors
  • Encourage with gift to charity in name of the doctor and/or patient ( e.g. March of Dimes, Breast Cancer Research ...)
  • Encourage with gift certificate to patients (e.g. local pharmacy)

Phase II

Health Care provider groups should speed-up the vitamin D revolution/evolution

  • Moving to higher percentage of the initial procedures which have been found to result in large ROI
    • (higher fruit on the same tree)
  • Extend the concept to new procedures
    • (low hanging fruit on other trees)
  • And the ultimate goal - extending vitamin D supplementation so as to greatly reduce some of the procedures
    • is this providing nutrients to existing trees or planting new trees?

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Low hanging fruit analogy for health care providers

  1. Let them enjoy the low hanging fruit (see benefits of vitamin D to surgery)
  2. Show them fruit on another tree
  3. Show them how to use a ladder to get some higher hanging fruit
  4. Show them how to prune the tree and add nutrients to get more fruit next year
  5. Show them how to plant more trees.

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Provide positive feedback: to the health professionals ( doctor, oncologist, nurse, ....)

Exploiting the experience of the Big Pharma - what actually has been proven to work

Organization can give rewards to the doctors who try the 'drug'

  • dinner
  • gift
  • give the doctor travel money to present a paper describing the pilot test
  • give the doctor and his family a weekend time at a resort

Give recognition

  • Parking space of the month
  • Immediately credit points toward annual recognition reward
  • Award use of vitamin D in areas other than the specific procedures

Other possibilities - some of which may be illegal, some of which Big Pharma could not do.

  • give money
  • give credit that can be applied to buying equipment for the doctor/department
  • Extra day of vacation
  • Give time off to write a paper/study
  • Use of a Smartphone, iPad, electronic stethoscope, or other gadget
  • Give vitamin D for a year
  • Give a gift certificate
  • Give a month of fitness center
  • Give money to charity of Doctor's choice

Can use use another feature developed by Big Pharma: Have a Vitamin D detailer

A vitamin D detailer go around to the doctors to 'talk up' the drug, answer questions, etc.
The detailer could also talk to the patient. The doctor would not have to know so much as to be able to convince his patients.
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Small business operators are starting to have a reason to keep their employees healthy

This might provide a reason to promote vitamin D for their employees

In the past employees in small businesses were not paid for sick leave.
This meant that the waitress or nursing home employee would come to work sick rather than lose wages
Now some cities are starting to require paid sick leave for small businesses
As of Aug 2011: Washington DC, San Francisco, with it being considered in Seattle
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US NEWS Review of US Health Care Plans probably early 2011

  1. 1 Unitedhealth Group
  2. 2 Wellpoint Inc. Group
  3. 3 Kaiser Foundation Group
  4. 4 Aetna Group
  5. 5 Humana Group
  6. 6 HCSC Group
  7. 7 Coventry Corp. Group
  8. 8 Highmark Group
  9. 9 Independence Blue Cross Group
  10. 10 Blue Shield of CA Group
  11. 11 Cigna Health Group
  12. 12 BCBS of MI Group
  13. 13 Health Net of California, Inc.
  14. 14 BCBS of NJ Group
  15. 15 BCBS of FL Group
  16. 16 Regence Group
  17. 17 BCBS of MA Group
  18. 18 Carefirst Inc. Group
  19. 19 Wellcare Group
  20. 20 HIP Ins. Group
  21. 21 Metropolitan Group
  22. 22 Unumprovident Corp. Group
  23. 23 Universal Amer Fin Corp. Group
  24. 24 Lifetime Healthcare Group
  25. 25 BCBS of NC Group

from http://www.pohly.com/companies.html

Health Care Provider Companies (hyperlinks at the above source)
Ardent Health Services - about 27 psych hospitals
Beverly Enterprises Inc. - largest post-acute health provider
Cancer Treatment Centers of America
Community Health Systems - about 32 hospitals
Health Management Associates - about 60 hospitals or so
HCA, Hospital Corporation of America - owns hospitals
HCR Manor Care - owns over 350 nursing centers
Kindred Healthcare - owns about 100 hospitals or so
Life Point Hospitals - about 20 or so rural hospitals
Magellan Healthcare Corporation - owns psychiatric hospitals
Province Healthcare - about 20 rural hospitals
Quorum Health Resources - provides management services to hospitals
Select Medical Corporation - about 79 acute care hospitals
Sun Healthcare Group - about 100 nursing centers and other
SunLink Health Systems - about 8 rural hospitals
Tenet Healthcare Corporation - 2nd largest hospital company
Triad Hospitals, Inc. - has about 54 hospitals
Universal Health Services - owns & manages hositals
Vanguard Health Systems - about 16 acute care
Warm Springs Rehabilitation System - rehab hospitals in Texas

Fix vitamin D prior ?to surgery (love the title)

Delicia Yard, December 23, 2010

Nearly half of persons undergoing orthopedic surgery go into the operating room with deficient vitamin D levels — a condition that should be corrected ahead of time to improve outcomes.?

Internal-medicine specialists cleared 723 patients for elective orthopedic surgery to repair such conditions as distal radial or ulnar fracture of the hand, vertebral compression fracture, and knee or hip replacement. However, a retrospective chart review revealed that although 57% of the patients had normal vitamin D levels (?32 ng/mL), 28% had insufficient levels (<32 ng/mL) and the remaining ?15% were vitamin D-deficient (<20 ng/mL). ?

"Nearly half of the patients who were considered 'healthy' enough for surgery had significantly low levels of vitamin D, placing them at risk for poor bone healing, osteomalacia, or even secondary hyperparathyroidism in the most severe cases," observed the authors in a statement describing the findings.

The statement also noted that putting people on 2,000 to 4,000 mg of vitamin D (depending on their deficient value) could usually correct levels in four to six weeks. Very aggressive treatment right before surgery also can bring deficient vitamin D levels into the normal range.?

Which sources of endorsements would best support our case?

Endorsements by vitamin D researchers
Endorsements by doctors who are pro-vitamin D
Endorsements by vitamin D research organizations (not just individuals)
Endorsements by vitamin D authors (some of whom are medical doctors)
Endorsements by researchers who have published articles on vitamin D and the specific procedure
Endorsements by doctors in the target organization (KP for example, now that we have found at at least KP doctor)

Form of the endorsement (want it to be easily stated - not require a lot of reading)

Fully supported by: 15 KP doctors, 5 vitamin D groups, 50 US doctors, 70 doctors outside of the US,....
Support, with reservations by - - - - - - - - -
allow individuals to add reservations, different set of procedures
Reject - with comments by - - - - - - - -

It is my feeling that "KP doctors" will provide a more important endorsement than "vitamin D groups", etc.
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This is the initial draft (Dec 2010) of an e-mail which will eventually go to vitamin D experts

Vitamin D should provide a HMOs a virtually instant 1000% return on investment

At VitaminDWiki we have been looking for a way to get vitamin D into widespread use.
We looked for those groups/organizations which can see immediately benefit from the use of vitamin D.

It appears that large health care providers have the most to gain,
so we are assembling a proposal to be given to a series of large health care providers.
Will probably start with Kaiser Permanente, in the US.

Have the HMO experience the economic benefits of vitamin D

Start perhaps with just 1 out of every 10 of perhaps 5 different medical procedures.

Supplement/Replete with vitamin D for 1 month before and 1 month after.

Permit opting-out by: doctor, patient, member of family, oncologist, anesthesiologist, …
of vitamin D supplementation of the procedure for any reason.

Significant immediate benefit

Most people and organizations will only believe something after they can see it

We have an initial list of 'low hanging fruit' medical procedures
which appear to provide at least one of the following economic benefits:
- Reduce by at least 1/2 hospital day on average
- Reduce by at least 1 rehabilitation/therapy days on average
- Reduce number of complications by 30%

Not Rock the Boat

Will suggest that the HMO initially try dosage levels which are
compatible with current protocols and standards so as to not upset the medical staff:
- Repletion: frequent doses of 50,000 IU of vitamin D
- On-going 4,000 IU daily (pregnancy)
Will need your help with the initial list of procedures
We would like experts, such as yourself, to augment/refine/prioritize the initial list:

bariatric surgery, pregnancy, prostate surgery, thyroid surgery, kidney transplant,
bone procedures (back, broken bones, knee replacement, hip replacement), burns,
cancer (being careful to not have enhance the chemotherapy),

Concerns to be addressed

Risks: such as patient law suits, doctor pushback.
There must be so little risk, so few concerns, that the proposal can easily understood by the gatekeepers, managers, and the board of directors.

Rewards: Return on Investment, retain current customers, gain new customers, stay ahead of the competition

The Future

We feel that after an HMO experiences the economic benefits of vitamin D
that it will want to expand the trial to more of the same procedures and perhaps to other procedures as well.

We hope, in the long term, that the HMO will have their clients take vitamin D on a regular basis,
which will eliminate some of the procedures, rather than just make them somewhat less costly.

Notes from Dec 2010

After an HMO becomes vitamin D pro-active
1) People become healthier, so fewer procedures
2) Fewer doctors needed if HMO were to keep the same # of subscribers
3) However, more subscribers (people notice that people belonging to pro-active HMO are healthier)

HMO will have to have carefully timed marketing to keep number of health professionals balanced

Can share the (future) HMO/KP pitch for others to use

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Notes of Phone conversation Dect 2010
CEO's first concern is for risks, and then, if the risks are minimal, he can consider rewards
Risks: patient law suits, doctor pushback
Reward: Money to be saved, retain current customers, gain new customers, perhaps gain medical professionals

Propose a very small experiment: supplement with vitamin D before and after say 10% of just 5 types of surgeries.
Propose 50,000 IU of vitamin D3 twice per week for a month before and after the procedure/surgery

I have already compiled a list of 12 medical procedures which should be 'low hanging fruit' for KP
We should be able to have this proposed list reviewed by many vitamin D experts/doctors and narrow it down to say 5 procedures
Criteria: Expect to see a significant reduction in cost to KP by at least 1/2 of the surgeries

Significant = any of the following
- Reduce by one the number of days in the hospital for at least 50% of the procedures
- Reduce by at least 2 days any rehabilitation/therapy for at least 50% of the procedures
- Reduce number of procedures with complications by 30%

(Would like to have more than 14,000 IU per day (= 2 doses of 50,000 per week), but this amount = standard protocol)

The CEO must be give an a very easy case to present to his board of doctors.
There must be so little risk, so few concerns, that he can easily get it passed.

Most CEO's have gatekeepers - and at the size of KP there may be two levels of gatekeepers.

The gatekeeper's goal is to eliminate virtually all of the trash, and answer all of the easy questions.
As with the CEO, the gatekeeper must be able to understand what is being proposed in about 1 minute,
and be be given enough knowledge in 5 minutes to decided that KP needs to investigate this issue.

They can continue to test for vitamin D (The results of the test will rarely make any difference, but, aain there is no reason to upset them by changing policy)
I suggest that KP add-on testing for co-factors of vitamin D - to make sure that the patient remains balanced.
Co-factors: Calcium, Magnesium, Vitamin K, and perhaps Vitamin A and Boron.
I will need to get doctors/researchers to endorse the need for vitamin D before and after procedures, and also test for co-factors.

This KP proposal can readily be presented to many hospital/HMOs/National Health Services around the world. (Blue Shield, Group Health, BUPA,.....)
They virtually always provide medical procedures at a fixed cost.
(It is a very rare medical provider which is allowed to bill, or can even understand how to bill, their real costs for each procedure.)

Additional possible CEO question: Why now. Answer - to get ahead of the competition

Big money
Normally the big ROI is for Big Pharma
(From the book White Coat, Black Hat - my notes are attached
In the US there is 1 drug detailer for every 2.5 doctors
The Return on Investment to Big Pharma for having drug detailers is 10X)

We are proposing that ROI can/should also go to the Health Provider

ROI = 3X estimate is based on:
- No change of income per procedure (for a decade at least
- Average cost of supplementing with vitamin D - including tests for vitamin D and co-factors $1,000
- Average savings per procedure: $4,000, so net ROI = net savings/cost = ($4,000 savings - $1,000 cost)/$1,000 investment = 3X

To put this ROI in perspective:
US hospitals have mostly gone to having robotic-assisted prostate surgery even though it costs them $3,000 MORE per surgery
Because: the hospitals end up earning an extra $750 per surgery
ROI = 0.25X = $750net savings /$3000
Thus, vitamin D will give them 12X larger ROI

Other notes during phone conversation:
Standard Magnesium (Magnesium Oxide) is only 5% bio-available - I have just ordered for some Magnesium which is about 4X better
I have several PhD dissertations in Nutrition and Public Health which shine a very positive light on vitamin D.
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Notes Dec 2010
Why should I want to read this?
Saving billions of dollars is not a reason
I need to have some reason to believe what you say
which can also be given to others - such as the Board of Directors, my doctors, etc.

Other HMOs
Latest IoM
At least - other doctor

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BUPA grant award

Professor Lesley Rhodes (School of Translational Medicine, University of Manchester), Grant £153,065: Sunlight exposure and vitamin D status on children in the UK

Aim: Vitamin D is essential for children's bone health and may also protect against disease in later life. The aim of this project is to examine the proportion of UK schoolchildren with sufficient and optimal vitamin D status and see how this relates to their seasonal sunlight exposure levels and oral vitamin D intake.

Findings: Professor Rhodes' team will investigate how much sun exposure modern schoolchildren (aged between 12 and 14) are actually getting and how skin and dietary sources of vitamin D contribute to vitamin D status throughout the year. The children's vitamin D status will be assessed each season by taking blood samples. The children will also personally measure their ultraviolet radiation exposure using a specialised tool known as a dosimeter. Oral vitamin D intake will be recorded with questionnaires. The findings will inform the re-evaluation of current national guidelines related to recommended vitamin D levels, exposure to sunlight and vitamin D intake in children.

Patient benefit: The findings from this research will help to provide more informed advice on measures to be taken to increase the benefits of vitamin D in children, whilst minimising risks of skin cancer.
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As the winter solstice approaches, the shortest day of the year signals the start of winter when sunlight hours fall to an average of just two a day.1 Bupa, the UK's leading healthcare company is urging people to take Vitamin D to reduce their risk of cancer as day-time no longer means sun-time.

Vitamin D helps protect against certain cancers such as breast, bowel, prostate and colon. For people to obtain enough Vitamin D naturally, they need either to expose their skin to lots of summer sun or eat large quantities of oily fish. Bupa's assistant medical director, Dr Virginia Warren said: "Natural ways to get enough vitamin D aren't realistic because our skin cannot make vitamin D from winter sunlight in the UK as it is too weak. In the summer, people are rightly concerned about risks of skin cancer. And nobody wants to eat four tins of mackerel every day to get their vitamin D from oily fish."

Now, after analysing years of independent research,2 Bupa says the only alternative is to take Vitamin D supplements to reduce the chance of developing cancer by 26 percent.3 People need to take at least 1,500 - 2000 international units (IU) a day, which equates to 3-4 high strength capsules (12.5 micrograms/capsule).

Dr Warren continues: "People have to act now to take preventative measures against cancer for their future long-term health. The old-fashioned view was to take a low daily dose of Vitamin D for healthy bones. Cancer is today's biggest killer and we need to protect our bodies from it as much as we can. Taking Vitamin D supplements are an effective, inexpensive and easy way of doing that."

For more information please contact: Michelle Gibb, Bupa Corporate Affairs, Tel: +44 (0) 20 7656 2667, michelle.gibb at bupa.com

About Bupa

Bupa is a leading international healthcare company. Established in 1947, it has over ten million customers in more than 190 countries and employs over 52,000 people around the world. Its main interests are health insurance, care homes for young disabled and older people, workplace health services, health assessments and chronic disease management services, including health coaching and healthcare services in the home.

While Bupa's largest and original business is in the UK, it has significant operations around the world including Sanitas in Spain, MBF, HBA, Mutual Community in Australia, IHI in Denmark and Health Dialog in the US. Bupa also has businesses in Hong Kong, Thailand, Saudi Arabia, India, China and Latin America. In addition, Bupa Care Services owns care homes in Spain, Australia and New Zealand.

Bupa has no shareholders. We reinvest our money to provide better healthcare for our customers, helping them to live longer, happier, healthier lives.
Bupa Foundation board

Dr Virginia Warren

Virginia Warren is an assistant medical director at Bupa. She works in the Group Medical team on health technology assessment and the routine monitoring of outcomes of care to maintain and improve quality. In a wider context she is interested in the interaction between genetics and insurance.
Virginia trained at Oxford and Addenbrooke's. Research into food intolerance and gut disease followed (MD 1987), then training in Public Health Medicine on the East Anglian scheme (MFPHM 1993). Her last attachment as a trainee was to the Faculty of Public Health Medicine where she was the co-ordinator for the Conference of Colleges' (now Academy of Medical Royal Colleges) Purchasing Development Project which used IHD and diabetes as exemplar conditions.

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