Erik L. Goldman

WASHINGTON — Although health savings accounts and other forms of tax-deferred, consumer-driven health care financing options have captured the fancy of policy makers, employers and employees have been reticent about embracing them.

As of June 2007, between 8 million and 9 million Americans were enrolled in a health savings account (HSA) or other tax-deferred plan, with 4.5 million new enrollees in 2007 alone, according to data from Forrester Research Inc., an independent technology and market research company. But consumer awareness of these options remains very low. A recent study by the Visa Corporation indicated that only 35% of all Americans have even heard of HSAs, and only 14% expressed any interest in starting one.

That is likely to change as HSAs prove their worth, Elizabeth Bierbower, vice president of product innovation for Humana Inc., said at a health care congress sponsored by the Wall Street Journal and CNBC. She pointed out that 5 years after the introduction of health maintenance organizations (HMOs), combined enrollment in all existing plans was only 5.5 million. That changed quickly after major employers were convinced that HMOs would save them money. Ms. Bierbower predicted a similar trajectory for HSAs.

Some companies are taking a very proactive role in pushing HSAs, especially for lower and middle-income workers. Ms. Bierbower said Humana has been a strong HSA advocate for its employees. For those making under $50,000 annually, Humana will contribute $6 for every $1 an employee contributes to an HSA. “[The ratio is] lower if your salary is higher, but there's still a big incentive to do this. We try to encourage long-term thinking.”

With copayments, pharmacy costs, and out-of-pocket expenses on the rise, even people with relatively generous health plans are finding that they still come up short. A Kaiser Family Foundation survey in 2006 showed that 29% of families reported that one or more members had difficulty paying medical bills.

Doctors, said Ms. Bierbower, often bear the brunt of Americans' lack of planning for health care expenses. In a Humana survey of consumer attitudes, researchers found that many Americans are quite willing to leave their physicians holding the bag, in the form of unpaid bills.

She said that people are more inclined to ignore a doctor's bills than a hospital's, because hospitals pursue their payments more aggressively and can hurt peoples' credit ratings, something they think doctors don't do.

Advocates of HSAs and other forms of consumer-driven coverage say that one of the primary virtues of these plans is that they push the end-user of health care services to become more cost conscious, and presumably more judicious, in their health care choices. In practice, this seems to be borne out. A McKinsey survey showed that people enrolled in HSAs or other consumer-driven plans were 50% more likely to ask about overall costs of health care services, and 100% more likely to ask about drug costs, compared with people in traditional health care plans.

WASHINGTON — Although health savings accounts and other forms of tax-deferred, consumer-driven health care financing options have captured the fancy of policy makers, employers and employees have been reticent about embracing them.

As of June 2007, between 8 million and 9 million Americans were enrolled in a health savings account (HSA) or other tax-deferred plan, with 4.5 million new enrollees in 2007 alone, according to data from Forrester Research Inc., an independent technology and market research company. But consumer awareness of these options remains very low. A recent study by the Visa Corporation indicated that only 35% of all Americans have even heard of HSAs, and only 14% expressed any interest in starting one.

That is likely to change as HSAs prove their worth, Elizabeth Bierbower, vice president of product innovation for Humana Inc., said at a health care congress sponsored by the Wall Street Journal and CNBC. She pointed out that 5 years after the introduction of health maintenance organizations (HMOs), combined enrollment in all existing plans was only 5.5 million. That changed quickly after major employers were convinced that HMOs would save them money. Ms. Bierbower predicted a similar trajectory for HSAs.

Some companies are taking a very proactive role in pushing HSAs, especially for lower and middle-income workers. Ms. Bierbower said Humana has been a strong HSA advocate for its employees. For those making under $50,000 annually, Humana will contribute $6 for every $1 an employee contributes to an HSA. “[The ratio is] lower if your salary is higher, but there's still a big incentive to do this. We try to encourage long-term thinking.”

With copayments, pharmacy costs, and out-of-pocket expenses on the rise, even people with relatively generous health plans are finding that they still come up short. A Kaiser Family Foundation survey in 2006 showed that 29% of families reported that one or more members had difficulty paying medical bills.

Doctors, said Ms. Bierbower, often bear the brunt of Americans' lack of planning for health care expenses. In a Humana survey of consumer attitudes, researchers found that many Americans are quite willing to leave their physicians holding the bag, in the form of unpaid bills.

She said that people are more inclined to ignore a doctor's bills than a hospital's, because hospitals pursue their payments more aggressively and can hurt peoples' credit ratings, something they think doctors don't do.

Advocates of HSAs and other forms of consumer-driven coverage say that one of the primary virtues of these plans is that they push the end-user of health care services to become more cost conscious, and presumably more judicious, in their health care choices. In practice, this seems to be borne out. A McKinsey survey showed that people enrolled in HSAs or other consumer-driven plans were 50% more likely to ask about overall costs of health care services, and 100% more likely to ask about drug costs, compared with people in traditional health care plans.

WASHINGTON — Although health savings accounts and other forms of tax-deferred, consumer-driven health care financing options have captured the fancy of policy makers, employers and employees have been reticent about embracing them.

As of June 2007, between 8 million and 9 million Americans were enrolled in a health savings account (HSA) or other tax-deferred plan, with 4.5 million new enrollees in 2007 alone, according to data from Forrester Research Inc., an independent technology and market research company. But consumer awareness of these options remains very low. A recent study by the Visa Corporation indicated that only 35% of all Americans have even heard of HSAs, and only 14% expressed any interest in starting one.

That is likely to change as HSAs prove their worth, Elizabeth Bierbower, vice president of product innovation for Humana Inc., said at a health care congress sponsored by the Wall Street Journal and CNBC. She pointed out that 5 years after the introduction of health maintenance organizations (HMOs), combined enrollment in all existing plans was only 5.5 million. That changed quickly after major employers were convinced that HMOs would save them money. Ms. Bierbower predicted a similar trajectory for HSAs.

Some companies are taking a very proactive role in pushing HSAs, especially for lower and middle-income workers. Ms. Bierbower said Humana has been a strong HSA advocate for its employees. For those making under $50,000 annually, Humana will contribute $6 for every $1 an employee contributes to an HSA. “[The ratio is] lower if your salary is higher, but there's still a big incentive to do this. We try to encourage long-term thinking.”

With copayments, pharmacy costs, and out-of-pocket expenses on the rise, even people with relatively generous health plans are finding that they still come up short. A Kaiser Family Foundation survey in 2006 showed that 29% of families reported that one or more members had difficulty paying medical bills.

Doctors, said Ms. Bierbower, often bear the brunt of Americans' lack of planning for health care expenses. In a Humana survey of consumer attitudes, researchers found that many Americans are quite willing to leave their physicians holding the bag, in the form of unpaid bills.

She said that people are more inclined to ignore a doctor's bills than a hospital's, because hospitals pursue their payments more aggressively and can hurt peoples' credit ratings, something they think doctors don't do.

Advocates of HSAs and other forms of consumer-driven coverage say that one of the primary virtues of these plans is that they push the end-user of health care services to become more cost conscious, and presumably more judicious, in their health care choices. In practice, this seems to be borne out. A McKinsey survey showed that people enrolled in HSAs or other consumer-driven plans were 50% more likely to ask about overall costs of health care services, and 100% more likely to ask about drug costs, compared with people in traditional health care plans.

WASHINGTON — The United States has one of the highest diabetes-associated limb amputation rates of any industrialized country, but many of these expensive and debilitating operations could be prevented through more aggressive early treatment of minor wounds, ulcerations, and infections.

Among people with diabetes in the United States, 7/1,000 lose a limb each year, compared with 5.5/1,000 in Germany, 3.5/1,000 in the Netherlands, 2.7/1,000 in the United Kingdom, and 1.2/1,000 in Denmark.

According to the International Working Group on the Diabetic Foot, the prevalence of limb amputation among diabetics ranges between 0.2% and 4% worldwide.

Between 50% and 85% of all lower-extremity amputations could be prevented, said Vickie R. Driver, D.P.M., at a health care congress sponsored by the Wall Street Journal and CNBC. “Eighty-five percent of all amputations are preceded by foot ulcers that have been allowed to progress. Lower-extremity ulcers and infections need to be seen as medical emergencies, and we need to treat them early and aggressively.”

Intensive patient education and a concentrated limb-sparing effort by cross-disciplinary medical teams using a wide range of surgical and medical interventions can greatly reduce amputation rates, according to a retrospective study by Dr. Driver and her colleagues at Madigan Army Medical Center in Tacoma, Wash.

From 1999, when Madigan introduced a comprehensive Limb Preservation Service, to 2003, amputations went from 9.9/1,000 leg ulcer patients to 1.8/1,000, an 82% decrease. This was despite an overall increase in the number of diabetic patients entering the medical center (Diabetes Care 2005;28:248–53).

There is no single “magic bullet” therapy that will spare amputations, emphasized Dr. Driver, who is now director of clinical research in foot care, endovascular, and vascular services at Boston Medical Center. Treatment of advanced nonhealing wounds takes a combination of diligent monitoring of the feet and legs; aggressive treatment of any injury or infection, however minor it may seem at the time; careful debridement for more advanced ulcers; and application of a wide range of state-of-the-art therapies. Patients as well as physicians need to understand that in the context of diabetes, even a relatively insignificant injury can presage severe problems down the road.

Specialized matrix dressings like Promogran and wound-healing gels like Regranex, which contain growth factors to stimulate healing, definitely have a place in the management of diabetic leg ulcers, though neither of these alone is universally effective, Dr. Driver said.

She had high praise for vacuum-assisted closure (VAC), a relatively new form of negative-pressure wound therapy (NPWT) that involves targeted application of subatmospheric pressure to a wound. VAC is used in conjunction with specialized dressings such as GranuFoam.

“This is used for wounds that are very deep. It has three main benefits: It removes fluid from the wound, it pulls the edges of the wound together, and it stimulates new growth,” Dr. Driver said. A 12-week study at 18 U.S. centers randomized 162 patients with severe advanced foot ulcers to treatment with VAC (n = 77) or moist wound therapy (n = 85) using state-of-the-art dressings. After 112 days, 43 of the VAC-treated patients (56%) showed 100% wound closure, compared with 33 of those treated with moist dressings (39%).

There was also a marked decrease in the need for subsequent surgeries or amputations (43 procedures in the VAC patients vs. 120 procedures in the moist wound therapy patients). The average total cost to achieve healing was $25,954 for VAC vs. $38,806 for moist wound care, a difference of $12,852 (Lancet 2005;366:1704-10).

A subsequent study pitted VAC against advanced moist wound therapy (AMWT), which included hydrogels and alginates, in 342 diabetic patients with severe foot ulcers.

At 12 months' follow-up, 73 of the VAC patients (43%) achieved complete wound closure, compared with 48 of the AMWT patients (29%). A total of 105 VAC patients (62%) reached the 75% closure mark, compared with 85 (51%) of the AMWT group (Diabetes Care 2008;31:631-6).

The patients treated with VAC also had fewer amputations (6 vs. 11) and fewer acute care admissions, all of which contributed to a markedly lower total cost of care.

VAC, Regranex, Promogran, and many of the other cutting-edge wound-healing therapies are not cheap, but when properly applied they can greatly reduce the overall cost of caring for diabetes-associated ulcerations. Left unchecked, those costs can be tremendous, and the total price mounts rapidly as ulcers persist. Of total expenditures on leg ulcers—and Medicare spends between $1.5 billion and $2 billion annually—70%–80% is for hospitalizations, not ambulatory care or medications.

According to data from Medicare, the average cost for managing a patient with a noninfected foot or leg ulcer is $775 per month. That increases to $2,048 per month if the patient develops cellulitis. If he or she goes on to develop osteomyelitis, the cost averages $3,798 per month.

In analyzing data from her experience at Madigan Army Medical Center, Dr. Driver said she found that wound depth directly correlates with number of outpatient visits. Patients with ulcers extending down to the tendon or joint capsule had an average of 30 office visits per quarter, compared with 9 per quarter for those with epithelialized wounds. Further, having an extensive and deep leg ulcer carried 40% odds of hospitalization for any and all causes within the next 3 months.

In a seminal but underreported 2004 study, researchers in the Netherlands showed that an optimal foot care program aimed at identifying and treating minor foot/leg injuries, when added to an intensive glycemic control program, could markedly reduce total cost of care per quality-adjusted life-year for people with diabetes. Foot care plus glycemic control programs had a total cost per quality-adjusted life-year of roughly $25,000. Intensive glycemic control alone had an average cost of $32,057 (Diabetes Care 2004;27:901-7).

WASHINGTON — The United States has one of the highest diabetes-associated limb amputation rates of any industrialized country, but many of these expensive and debilitating operations could be prevented through more aggressive early treatment of minor wounds, ulcerations, and infections.

Among people with diabetes in the United States, 7/1,000 lose a limb each year, compared with 5.5/1,000 in Germany, 3.5/1,000 in the Netherlands, 2.7/1,000 in the United Kingdom, and 1.2/1,000 in Denmark.

According to the International Working Group on the Diabetic Foot, the prevalence of limb amputation among diabetics ranges between 0.2% and 4% worldwide.

Between 50% and 85% of all lower-extremity amputations could be prevented, said Vickie R. Driver, D.P.M., at a health care congress sponsored by the Wall Street Journal and CNBC. “Eighty-five percent of all amputations are preceded by foot ulcers that have been allowed to progress. Lower-extremity ulcers and infections need to be seen as medical emergencies, and we need to treat them early and aggressively.”

Intensive patient education and a concentrated limb-sparing effort by cross-disciplinary medical teams using a wide range of surgical and medical interventions can greatly reduce amputation rates, according to a retrospective study by Dr. Driver and her colleagues at Madigan Army Medical Center in Tacoma, Wash.

From 1999, when Madigan introduced a comprehensive Limb Preservation Service, to 2003, amputations went from 9.9/1,000 leg ulcer patients to 1.8/1,000, an 82% decrease. This was despite an overall increase in the number of diabetic patients entering the medical center (Diabetes Care 2005;28:248–53).

There is no single “magic bullet” therapy that will spare amputations, emphasized Dr. Driver, who is now director of clinical research in foot care, endovascular, and vascular services at Boston Medical Center. Treatment of advanced nonhealing wounds takes a combination of diligent monitoring of the feet and legs; aggressive treatment of any injury or infection, however minor it may seem at the time; careful debridement for more advanced ulcers; and application of a wide range of state-of-the-art therapies. Patients as well as physicians need to understand that in the context of diabetes, even a relatively insignificant injury can presage severe problems down the road.

Specialized matrix dressings like Promogran and wound-healing gels like Regranex, which contain growth factors to stimulate healing, definitely have a place in the management of diabetic leg ulcers, though neither of these alone is universally effective, Dr. Driver said.

She had high praise for vacuum-assisted closure (VAC), a relatively new form of negative-pressure wound therapy (NPWT) that involves targeted application of subatmospheric pressure to a wound. VAC is used in conjunction with specialized dressings such as GranuFoam.

“This is used for wounds that are very deep. It has three main benefits: It removes fluid from the wound, it pulls the edges of the wound together, and it stimulates new growth,” Dr. Driver said. A 12-week study at 18 U.S. centers randomized 162 patients with severe advanced foot ulcers to treatment with VAC (n = 77) or moist wound therapy (n = 85) using state-of-the-art dressings. After 112 days, 43 of the VAC-treated patients (56%) showed 100% wound closure, compared with 33 of those treated with moist dressings (39%).

There was also a marked decrease in the need for subsequent surgeries or amputations (43 procedures in the VAC patients vs. 120 procedures in the moist wound therapy patients). The average total cost to achieve healing was $25,954 for VAC vs. $38,806 for moist wound care, a difference of $12,852 (Lancet 2005;366:1704-10).

A subsequent study pitted VAC against advanced moist wound therapy (AMWT), which included hydrogels and alginates, in 342 diabetic patients with severe foot ulcers.

At 12 months' follow-up, 73 of the VAC patients (43%) achieved complete wound closure, compared with 48 of the AMWT patients (29%). A total of 105 VAC patients (62%) reached the 75% closure mark, compared with 85 (51%) of the AMWT group (Diabetes Care 2008;31:631-6).

The patients treated with VAC also had fewer amputations (6 vs. 11) and fewer acute care admissions, all of which contributed to a markedly lower total cost of care.

VAC, Regranex, Promogran, and many of the other cutting-edge wound-healing therapies are not cheap, but when properly applied they can greatly reduce the overall cost of caring for diabetes-associated ulcerations. Left unchecked, those costs can be tremendous, and the total price mounts rapidly as ulcers persist. Of total expenditures on leg ulcers—and Medicare spends between $1.5 billion and $2 billion annually—70%–80% is for hospitalizations, not ambulatory care or medications.

According to data from Medicare, the average cost for managing a patient with a noninfected foot or leg ulcer is $775 per month. That increases to $2,048 per month if the patient develops cellulitis. If he or she goes on to develop osteomyelitis, the cost averages $3,798 per month.

In analyzing data from her experience at Madigan Army Medical Center, Dr. Driver said she found that wound depth directly correlates with number of outpatient visits. Patients with ulcers extending down to the tendon or joint capsule had an average of 30 office visits per quarter, compared with 9 per quarter for those with epithelialized wounds. Further, having an extensive and deep leg ulcer carried 40% odds of hospitalization for any and all causes within the next 3 months.

In a seminal but underreported 2004 study, researchers in the Netherlands showed that an optimal foot care program aimed at identifying and treating minor foot/leg injuries, when added to an intensive glycemic control program, could markedly reduce total cost of care per quality-adjusted life-year for people with diabetes. Foot care plus glycemic control programs had a total cost per quality-adjusted life-year of roughly $25,000. Intensive glycemic control alone had an average cost of $32,057 (Diabetes Care 2004;27:901-7).

WASHINGTON — The United States has one of the highest diabetes-associated limb amputation rates of any industrialized country, but many of these expensive and debilitating operations could be prevented through more aggressive early treatment of minor wounds, ulcerations, and infections.

Among people with diabetes in the United States, 7/1,000 lose a limb each year, compared with 5.5/1,000 in Germany, 3.5/1,000 in the Netherlands, 2.7/1,000 in the United Kingdom, and 1.2/1,000 in Denmark.

According to the International Working Group on the Diabetic Foot, the prevalence of limb amputation among diabetics ranges between 0.2% and 4% worldwide.

Between 50% and 85% of all lower-extremity amputations could be prevented, said Vickie R. Driver, D.P.M., at a health care congress sponsored by the Wall Street Journal and CNBC. “Eighty-five percent of all amputations are preceded by foot ulcers that have been allowed to progress. Lower-extremity ulcers and infections need to be seen as medical emergencies, and we need to treat them early and aggressively.”

Intensive patient education and a concentrated limb-sparing effort by cross-disciplinary medical teams using a wide range of surgical and medical interventions can greatly reduce amputation rates, according to a retrospective study by Dr. Driver and her colleagues at Madigan Army Medical Center in Tacoma, Wash.

From 1999, when Madigan introduced a comprehensive Limb Preservation Service, to 2003, amputations went from 9.9/1,000 leg ulcer patients to 1.8/1,000, an 82% decrease. This was despite an overall increase in the number of diabetic patients entering the medical center (Diabetes Care 2005;28:248–53).

There is no single “magic bullet” therapy that will spare amputations, emphasized Dr. Driver, who is now director of clinical research in foot care, endovascular, and vascular services at Boston Medical Center. Treatment of advanced nonhealing wounds takes a combination of diligent monitoring of the feet and legs; aggressive treatment of any injury or infection, however minor it may seem at the time; careful debridement for more advanced ulcers; and application of a wide range of state-of-the-art therapies. Patients as well as physicians need to understand that in the context of diabetes, even a relatively insignificant injury can presage severe problems down the road.

Specialized matrix dressings like Promogran and wound-healing gels like Regranex, which contain growth factors to stimulate healing, definitely have a place in the management of diabetic leg ulcers, though neither of these alone is universally effective, Dr. Driver said.

She had high praise for vacuum-assisted closure (VAC), a relatively new form of negative-pressure wound therapy (NPWT) that involves targeted application of subatmospheric pressure to a wound. VAC is used in conjunction with specialized dressings such as GranuFoam.

“This is used for wounds that are very deep. It has three main benefits: It removes fluid from the wound, it pulls the edges of the wound together, and it stimulates new growth,” Dr. Driver said. A 12-week study at 18 U.S. centers randomized 162 patients with severe advanced foot ulcers to treatment with VAC (n = 77) or moist wound therapy (n = 85) using state-of-the-art dressings. After 112 days, 43 of the VAC-treated patients (56%) showed 100% wound closure, compared with 33 of those treated with moist dressings (39%).

There was also a marked decrease in the need for subsequent surgeries or amputations (43 procedures in the VAC patients vs. 120 procedures in the moist wound therapy patients). The average total cost to achieve healing was $25,954 for VAC vs. $38,806 for moist wound care, a difference of $12,852 (Lancet 2005;366:1704-10).

A subsequent study pitted VAC against advanced moist wound therapy (AMWT), which included hydrogels and alginates, in 342 diabetic patients with severe foot ulcers.

At 12 months' follow-up, 73 of the VAC patients (43%) achieved complete wound closure, compared with 48 of the AMWT patients (29%). A total of 105 VAC patients (62%) reached the 75% closure mark, compared with 85 (51%) of the AMWT group (Diabetes Care 2008;31:631-6).

The patients treated with VAC also had fewer amputations (6 vs. 11) and fewer acute care admissions, all of which contributed to a markedly lower total cost of care.

VAC, Regranex, Promogran, and many of the other cutting-edge wound-healing therapies are not cheap, but when properly applied they can greatly reduce the overall cost of caring for diabetes-associated ulcerations. Left unchecked, those costs can be tremendous, and the total price mounts rapidly as ulcers persist. Of total expenditures on leg ulcers—and Medicare spends between $1.5 billion and $2 billion annually—70%–80% is for hospitalizations, not ambulatory care or medications.

According to data from Medicare, the average cost for managing a patient with a noninfected foot or leg ulcer is $775 per month. That increases to $2,048 per month if the patient develops cellulitis. If he or she goes on to develop osteomyelitis, the cost averages $3,798 per month.

In analyzing data from her experience at Madigan Army Medical Center, Dr. Driver said she found that wound depth directly correlates with number of outpatient visits. Patients with ulcers extending down to the tendon or joint capsule had an average of 30 office visits per quarter, compared with 9 per quarter for those with epithelialized wounds. Further, having an extensive and deep leg ulcer carried 40% odds of hospitalization for any and all causes within the next 3 months.

In a seminal but underreported 2004 study, researchers in the Netherlands showed that an optimal foot care program aimed at identifying and treating minor foot/leg injuries, when added to an intensive glycemic control program, could markedly reduce total cost of care per quality-adjusted life-year for people with diabetes. Foot care plus glycemic control programs had a total cost per quality-adjusted life-year of roughly $25,000. Intensive glycemic control alone had an average cost of $32,057 (Diabetes Care 2004;27:901-7).

Two new natural products–one containing olive polyphenols and the other a proprietary combination of whey proteins—can reduce the symptom burden and appearance of mild to moderate psoriasis.

Both products were recently introduced in the United States as oral formulations, filling a void left by drug therapy development for psoriasis over the last decade, which has largely involved oral medications for severe disease. The cost and side-effect profiles for the various biologics make them largely inappropriate for mild disease.

Polyphenols extracted from olives are potent antioxidants. Several years ago, Japanese researchers found that polyphenols can also down-regulate inflammation and improve psoriatic plaques.

Dr. Fujio Numano, a cardiologist at the Tokyo Vascular Disease Institute, observed the antipsoriatic effect while studying the cardiovascular effects of a proprietary olive polyphenol formula called Olivenol. This compound, which comes from water pressed out of organic olives, contains high levels of hydroxytyrosol, a strong, naturally occurring antioxidant.

Dr. Numano, who died in 2005, was one of Japan's leading cardiovascular researchers. Toward the end of his career he became interested in the role of oxidative stress and inflammation in heart disease. Several years before his death, Dr. Numano became aware of Olivenol, which is produced by CreAgri, a Hayward, Calif. nutraceutical company. He decided to test it in the context of heart disease.

He enrolled 35 heart disease patients in an open-label trial of Olivenol, with the object of assessing its impact on patients' lipid profiles, inflammatory markers, and overall cardiovascular health. It turned out that 8 of the 35 had skin disorders, including several with psoriasis. Dr. Numano noticed that most of these patients experienced significant improvement in their skin conditions while taking the olive polyphenols.

Roberto Crea, Ph.D., a biochemist who identified the antioxidant potential of hydroxytyrosol as well as a practical method for extracting it from the water byproduct of olive oil production, recalled in an interview: “Dr. Numano contacted me and said he had a big surprise. He said one of his patients, a 71-year-old with widespread psoriasis who was on heavy immunosuppressive drugs, showed remarkable improvements after several months on the Olivenol. After 2 months, 80% of the lesions had disappeared.”

Cautious about jumping to premature conclusions, Dr. Numano recruited several other people with psoriasis or inflammatory skin disorders like allergic contact dermatitis, erythema nodosum, and seborrheic dermatitis. The Olivenol formula gave measurable, sometimes marked improvement in all of the patients within 8 months, said Dr. Crea, who is chairman of the board and chief scientist for CreAgri.

He was not entirely surprised by the apparent anti-inflammatory effect. In vitro experiments with the polyphenol formula showed that it could inhibit TNF-α, interleukin-1, and lipoxygenase-5.

“We always felt that while the antioxidant properties were very important, they were not the whole story. Olive water also contains components we know next to nothing about. I believe they may be inhibitory factors for enzymatic reactions or signals in the inflammatory cascade,” he said.

Dr. Numano's work is intriguing, but Dr. Crea stressed that it is far too soon to call Olivenol a true therapy for psoriasis: “We certainly don't want to overstate the potential value, and we're far from saying olive polyphenols are a cure. But we think we've got something here that can help a lot of patients.” His company is planning to fund a formal controlled clinical trial of Olivenol in psoriasis patients. The product is currently available as an antioxidant dietary supplement.

The second natural product, whey, a common by-product of dairy food production, is proving to be a cornucopia of anti-inflammatory and immunomodulatory proteins, some of which appear to improve inflammatory diseases like psoriasis.

Dr. Yves Poulin and his colleagues at the Centre de Recherche Dermatologique du Québec Métropolitain have been studying a proprietary formulation of whey proteins, called XP-828L, in patients with mild to moderate disease. The formula was developed by Advitech, a Canadian company focused on developing evidence-based nutraceutical products. Dr. Poulin did not disclose any conflicts of interest, but one of his associates is vice president of research and development for Advitech.

The investigators randomized 84 patients with confirmed mild to moderate psoriasis (27 women, 57 men) to treatment with either a food grade cellulose placebo or 5 g/day of the whey protein powder.

Patients were instructed to take the assigned treatment orally between their morning and evening meals. After 56 days, the placebo-treated patients were switched to 10 g/day of the whey proteins, while those who received treatment from the outset remained on the lower 5-g daily dose.

All patients discontinued all other antipsoriatic therapies at least 28 days prior to beginning the trial. They were assessed by blinded investigators at two different medical centers on day 56 (8 weeks) and day 112 (16 weeks). Investigators used Physician's Global Assessment (PGA) scores, Psoriasis Area and Severity Index (PASI), body surface area measurement, and patient-rated itch severity in their assessments.

In the intent-to-treat analysis, patients receiving the XP-828L formula showed a statistically significant reduction in PGA scores from a mean of 3.05 at baseline to 2.79 after 8 weeks. There was no significant difference in the placebo-treated patients, whose scores went from 3.12 to 3.05. Exclusion of the 15 patients who did not complete the protocol did not change the finding in any way.

There was a trend toward greater improvement in the PASI scores among patients receiving the whey proteins, but the differences between the two groups were not significant (J. Cutan. Med. Surg. 2006;10:241–8).

There were no major differences on any of the assessment scales at 16 weeks, following the period in which placebo-treated patients were switched to the 10-g daily dose of the whey proteins. Their PGA scores improved more or less to the level seen in the patients treated with the lower dose, who generally maintained their improvements but did not obtain any additional benefit after the first 8 weeks.

The investigators concluded that “a period of 56 days of treatment with 5 g/day of XP-828L is sufficient to induce and maintain a clinical improvement of mild to moderate psoriasis.” Though it is clearly no competition for the biologics or other advanced drug therapies, the whey protein formulation can reduce symptoms and severity in many cases.

Moreover, it can do so with minimal risk of adverse effects. There were no clinically apparent side effects from the whey proteins at either the 5-g or 10-g daily dose, and there were no changes in creatinine, total bilirubin, transaminase enzymes or other biochemical markers.

The precise mechanisms underlying the whey protein effects are not entirely clear, but Dr. Poulin noted that whey contains β-lactoglobulin, α-lactalbumin, lactoferrin, immunoglobulins, and growth factors that have immuno- modulatory effects.

In vitro work with XP-828L shows that the compound can inhibit production of Th1 cell cytokines, especially IFN-γ and IL-2, which would presumably have a down-regulatory effect on T-cell-mediated disorders like psoriasis and possibly other chronic inflammatory diseases like irritable bowel syndrome, ulcerative colitis, and atopic dermatitis. The formula also contains high levels of transforming growth factor (TGF)-β₂.

“Additional studies are needed to evaluate the potential of XP-828L to complement traditional treatments for psoriasis. From its safety and efficacy profiles, a natural product such as XP-828L could be a good addition to traditional therapies [for psoriasis,” they wrote.

ELSEVIER GLOBAL MEDICAL NEWS

Two new natural products–one containing olive polyphenols and the other a proprietary combination of whey proteins—can reduce the symptom burden and appearance of mild to moderate psoriasis.

Both products were recently introduced in the United States as oral formulations, filling a void left by drug therapy development for psoriasis over the last decade, which has largely involved oral medications for severe disease. The cost and side-effect profiles for the various biologics make them largely inappropriate for mild disease.

Polyphenols extracted from olives are potent antioxidants. Several years ago, Japanese researchers found that polyphenols can also down-regulate inflammation and improve psoriatic plaques.

Dr. Fujio Numano, a cardiologist at the Tokyo Vascular Disease Institute, observed the antipsoriatic effect while studying the cardiovascular effects of a proprietary olive polyphenol formula called Olivenol. This compound, which comes from water pressed out of organic olives, contains high levels of hydroxytyrosol, a strong, naturally occurring antioxidant.

Dr. Numano, who died in 2005, was one of Japan's leading cardiovascular researchers. Toward the end of his career he became interested in the role of oxidative stress and inflammation in heart disease. Several years before his death, Dr. Numano became aware of Olivenol, which is produced by CreAgri, a Hayward, Calif. nutraceutical company. He decided to test it in the context of heart disease.

He enrolled 35 heart disease patients in an open-label trial of Olivenol, with the object of assessing its impact on patients' lipid profiles, inflammatory markers, and overall cardiovascular health. It turned out that 8 of the 35 had skin disorders, including several with psoriasis. Dr. Numano noticed that most of these patients experienced significant improvement in their skin conditions while taking the olive polyphenols.

Roberto Crea, Ph.D., a biochemist who identified the antioxidant potential of hydroxytyrosol as well as a practical method for extracting it from the water byproduct of olive oil production, recalled in an interview: “Dr. Numano contacted me and said he had a big surprise. He said one of his patients, a 71-year-old with widespread psoriasis who was on heavy immunosuppressive drugs, showed remarkable improvements after several months on the Olivenol. After 2 months, 80% of the lesions had disappeared.”

Cautious about jumping to premature conclusions, Dr. Numano recruited several other people with psoriasis or inflammatory skin disorders like allergic contact dermatitis, erythema nodosum, and seborrheic dermatitis. The Olivenol formula gave measurable, sometimes marked improvement in all of the patients within 8 months, said Dr. Crea, who is chairman of the board and chief scientist for CreAgri.

He was not entirely surprised by the apparent anti-inflammatory effect. In vitro experiments with the polyphenol formula showed that it could inhibit TNF-α, interleukin-1, and lipoxygenase-5.

“We always felt that while the antioxidant properties were very important, they were not the whole story. Olive water also contains components we know next to nothing about. I believe they may be inhibitory factors for enzymatic reactions or signals in the inflammatory cascade,” he said.

Dr. Numano's work is intriguing, but Dr. Crea stressed that it is far too soon to call Olivenol a true therapy for psoriasis: “We certainly don't want to overstate the potential value, and we're far from saying olive polyphenols are a cure. But we think we've got something here that can help a lot of patients.” His company is planning to fund a formal controlled clinical trial of Olivenol in psoriasis patients. The product is currently available as an antioxidant dietary supplement.

The second natural product, whey, a common by-product of dairy food production, is proving to be a cornucopia of anti-inflammatory and immunomodulatory proteins, some of which appear to improve inflammatory diseases like psoriasis.

Dr. Yves Poulin and his colleagues at the Centre de Recherche Dermatologique du Québec Métropolitain have been studying a proprietary formulation of whey proteins, called XP-828L, in patients with mild to moderate disease. The formula was developed by Advitech, a Canadian company focused on developing evidence-based nutraceutical products. Dr. Poulin did not disclose any conflicts of interest, but one of his associates is vice president of research and development for Advitech.

The investigators randomized 84 patients with confirmed mild to moderate psoriasis (27 women, 57 men) to treatment with either a food grade cellulose placebo or 5 g/day of the whey protein powder.

Patients were instructed to take the assigned treatment orally between their morning and evening meals. After 56 days, the placebo-treated patients were switched to 10 g/day of the whey proteins, while those who received treatment from the outset remained on the lower 5-g daily dose.

All patients discontinued all other antipsoriatic therapies at least 28 days prior to beginning the trial. They were assessed by blinded investigators at two different medical centers on day 56 (8 weeks) and day 112 (16 weeks). Investigators used Physician's Global Assessment (PGA) scores, Psoriasis Area and Severity Index (PASI), body surface area measurement, and patient-rated itch severity in their assessments.

In the intent-to-treat analysis, patients receiving the XP-828L formula showed a statistically significant reduction in PGA scores from a mean of 3.05 at baseline to 2.79 after 8 weeks. There was no significant difference in the placebo-treated patients, whose scores went from 3.12 to 3.05. Exclusion of the 15 patients who did not complete the protocol did not change the finding in any way.

There was a trend toward greater improvement in the PASI scores among patients receiving the whey proteins, but the differences between the two groups were not significant (J. Cutan. Med. Surg. 2006;10:241–8).

There were no major differences on any of the assessment scales at 16 weeks, following the period in which placebo-treated patients were switched to the 10-g daily dose of the whey proteins. Their PGA scores improved more or less to the level seen in the patients treated with the lower dose, who generally maintained their improvements but did not obtain any additional benefit after the first 8 weeks.

The investigators concluded that “a period of 56 days of treatment with 5 g/day of XP-828L is sufficient to induce and maintain a clinical improvement of mild to moderate psoriasis.” Though it is clearly no competition for the biologics or other advanced drug therapies, the whey protein formulation can reduce symptoms and severity in many cases.

Moreover, it can do so with minimal risk of adverse effects. There were no clinically apparent side effects from the whey proteins at either the 5-g or 10-g daily dose, and there were no changes in creatinine, total bilirubin, transaminase enzymes or other biochemical markers.

The precise mechanisms underlying the whey protein effects are not entirely clear, but Dr. Poulin noted that whey contains β-lactoglobulin, α-lactalbumin, lactoferrin, immunoglobulins, and growth factors that have immuno- modulatory effects.

In vitro work with XP-828L shows that the compound can inhibit production of Th1 cell cytokines, especially IFN-γ and IL-2, which would presumably have a down-regulatory effect on T-cell-mediated disorders like psoriasis and possibly other chronic inflammatory diseases like irritable bowel syndrome, ulcerative colitis, and atopic dermatitis. The formula also contains high levels of transforming growth factor (TGF)-β₂.

“Additional studies are needed to evaluate the potential of XP-828L to complement traditional treatments for psoriasis. From its safety and efficacy profiles, a natural product such as XP-828L could be a good addition to traditional therapies [for psoriasis,” they wrote.

ELSEVIER GLOBAL MEDICAL NEWS

Two new natural products–one containing olive polyphenols and the other a proprietary combination of whey proteins—can reduce the symptom burden and appearance of mild to moderate psoriasis.

Both products were recently introduced in the United States as oral formulations, filling a void left by drug therapy development for psoriasis over the last decade, which has largely involved oral medications for severe disease. The cost and side-effect profiles for the various biologics make them largely inappropriate for mild disease.

Polyphenols extracted from olives are potent antioxidants. Several years ago, Japanese researchers found that polyphenols can also down-regulate inflammation and improve psoriatic plaques.

Dr. Fujio Numano, a cardiologist at the Tokyo Vascular Disease Institute, observed the antipsoriatic effect while studying the cardiovascular effects of a proprietary olive polyphenol formula called Olivenol. This compound, which comes from water pressed out of organic olives, contains high levels of hydroxytyrosol, a strong, naturally occurring antioxidant.

Dr. Numano, who died in 2005, was one of Japan's leading cardiovascular researchers. Toward the end of his career he became interested in the role of oxidative stress and inflammation in heart disease. Several years before his death, Dr. Numano became aware of Olivenol, which is produced by CreAgri, a Hayward, Calif. nutraceutical company. He decided to test it in the context of heart disease.

He enrolled 35 heart disease patients in an open-label trial of Olivenol, with the object of assessing its impact on patients' lipid profiles, inflammatory markers, and overall cardiovascular health. It turned out that 8 of the 35 had skin disorders, including several with psoriasis. Dr. Numano noticed that most of these patients experienced significant improvement in their skin conditions while taking the olive polyphenols.

Roberto Crea, Ph.D., a biochemist who identified the antioxidant potential of hydroxytyrosol as well as a practical method for extracting it from the water byproduct of olive oil production, recalled in an interview: “Dr. Numano contacted me and said he had a big surprise. He said one of his patients, a 71-year-old with widespread psoriasis who was on heavy immunosuppressive drugs, showed remarkable improvements after several months on the Olivenol. After 2 months, 80% of the lesions had disappeared.”

Cautious about jumping to premature conclusions, Dr. Numano recruited several other people with psoriasis or inflammatory skin disorders like allergic contact dermatitis, erythema nodosum, and seborrheic dermatitis. The Olivenol formula gave measurable, sometimes marked improvement in all of the patients within 8 months, said Dr. Crea, who is chairman of the board and chief scientist for CreAgri.

He was not entirely surprised by the apparent anti-inflammatory effect. In vitro experiments with the polyphenol formula showed that it could inhibit TNF-α, interleukin-1, and lipoxygenase-5.

“We always felt that while the antioxidant properties were very important, they were not the whole story. Olive water also contains components we know next to nothing about. I believe they may be inhibitory factors for enzymatic reactions or signals in the inflammatory cascade,” he said.

Dr. Numano's work is intriguing, but Dr. Crea stressed that it is far too soon to call Olivenol a true therapy for psoriasis: “We certainly don't want to overstate the potential value, and we're far from saying olive polyphenols are a cure. But we think we've got something here that can help a lot of patients.” His company is planning to fund a formal controlled clinical trial of Olivenol in psoriasis patients. The product is currently available as an antioxidant dietary supplement.

The second natural product, whey, a common by-product of dairy food production, is proving to be a cornucopia of anti-inflammatory and immunomodulatory proteins, some of which appear to improve inflammatory diseases like psoriasis.

Dr. Yves Poulin and his colleagues at the Centre de Recherche Dermatologique du Québec Métropolitain have been studying a proprietary formulation of whey proteins, called XP-828L, in patients with mild to moderate disease. The formula was developed by Advitech, a Canadian company focused on developing evidence-based nutraceutical products. Dr. Poulin did not disclose any conflicts of interest, but one of his associates is vice president of research and development for Advitech.

The investigators randomized 84 patients with confirmed mild to moderate psoriasis (27 women, 57 men) to treatment with either a food grade cellulose placebo or 5 g/day of the whey protein powder.

Patients were instructed to take the assigned treatment orally between their morning and evening meals. After 56 days, the placebo-treated patients were switched to 10 g/day of the whey proteins, while those who received treatment from the outset remained on the lower 5-g daily dose.

All patients discontinued all other antipsoriatic therapies at least 28 days prior to beginning the trial. They were assessed by blinded investigators at two different medical centers on day 56 (8 weeks) and day 112 (16 weeks). Investigators used Physician's Global Assessment (PGA) scores, Psoriasis Area and Severity Index (PASI), body surface area measurement, and patient-rated itch severity in their assessments.

In the intent-to-treat analysis, patients receiving the XP-828L formula showed a statistically significant reduction in PGA scores from a mean of 3.05 at baseline to 2.79 after 8 weeks. There was no significant difference in the placebo-treated patients, whose scores went from 3.12 to 3.05. Exclusion of the 15 patients who did not complete the protocol did not change the finding in any way.

There was a trend toward greater improvement in the PASI scores among patients receiving the whey proteins, but the differences between the two groups were not significant (J. Cutan. Med. Surg. 2006;10:241–8).

There were no major differences on any of the assessment scales at 16 weeks, following the period in which placebo-treated patients were switched to the 10-g daily dose of the whey proteins. Their PGA scores improved more or less to the level seen in the patients treated with the lower dose, who generally maintained their improvements but did not obtain any additional benefit after the first 8 weeks.

The investigators concluded that “a period of 56 days of treatment with 5 g/day of XP-828L is sufficient to induce and maintain a clinical improvement of mild to moderate psoriasis.” Though it is clearly no competition for the biologics or other advanced drug therapies, the whey protein formulation can reduce symptoms and severity in many cases.

Moreover, it can do so with minimal risk of adverse effects. There were no clinically apparent side effects from the whey proteins at either the 5-g or 10-g daily dose, and there were no changes in creatinine, total bilirubin, transaminase enzymes or other biochemical markers.

The precise mechanisms underlying the whey protein effects are not entirely clear, but Dr. Poulin noted that whey contains β-lactoglobulin, α-lactalbumin, lactoferrin, immunoglobulins, and growth factors that have immuno- modulatory effects.

In vitro work with XP-828L shows that the compound can inhibit production of Th1 cell cytokines, especially IFN-γ and IL-2, which would presumably have a down-regulatory effect on T-cell-mediated disorders like psoriasis and possibly other chronic inflammatory diseases like irritable bowel syndrome, ulcerative colitis, and atopic dermatitis. The formula also contains high levels of transforming growth factor (TGF)-β₂.

“Additional studies are needed to evaluate the potential of XP-828L to complement traditional treatments for psoriasis. From its safety and efficacy profiles, a natural product such as XP-828L could be a good addition to traditional therapies [for psoriasis,” they wrote.

ELSEVIER GLOBAL MEDICAL NEWS

NEW YORK — Dr. Whitney A. High is into heavy metal and skin, but if you think he's a biker with a leather vest and a Black Sabbath tattoo, you've got it wrong.

Dr. High, of the University of Colorado, Denver, is a clean-cut young dermatopathologist with a soft spot for geology and physics, and his interests in heavy metal involve titanium and vanadium, not Metallica and Megadeath.

His unique set of interests—skin disease, metals, and physics—has landed him in the center of the growing controversy around gadolinium contrast agents and their role in nephrogenic systemic fibrosis.

Dr. High is part of an elite team of investigators trying to determine whether the gadolinium agents in MRI contrast media play a causative role in this devastating, largely untreatable skin disorder. Their answer could have major medicolegal and clinical implications.

Nephrogenic systemic fibrosis (NSF) is characterized by excessive fibrosis in the skin and other soft tissues that leads to disfigurement, tissue constriction, and in some cases, respiratory failure, ocular damage, and cardiac problems. It was first reported as "scleromyxedema-like disease" in renal dialysis patients in 1997. In the last decade, hundreds of cases have emerged worldwide, primarily, if not exclusively in people with end-stage renal disease (ESRD). Other than that, there were few clues as to what caused the distinctive skin and soft tissue changes.

"For a long time, we could not figure out what was going on," Dr. High said at the American Academy of Dermatology's Summer Academy 2007. The first break came in January 2006, when Austrian researchers described nine patients with ESRD, five of whom had developed NSF, with all five having undergone imaging procedures with gadolinium contrast agents. These five patients developed signs and symptoms consistent with the disorder within about 4 weeks of exposure to gadolinium-based contrast used in magnetic angiography.

Further damning evidence emerged late last summer, when Danish investigators reported that 13 of 13 ESRD patients with NSF had received gadodiamide, a commonly used gadolinium contrast agent. There were no other shared risk factors among the 13 cases.

Is there a gadolinium smoking gun in the tissues of NSF patients? That's the question Dr. High is seeking to answer.

"I had previously reported on a granulomatous reaction to titanium alloy in a patient with ear piercings. That's how people knew I was interested in metals and skin disorders, and that's why I got called in on this gadolinium issue," he said.

There are five gadolinium contrast agents currently in use around the world. The two most common are Magnevist (gadopentetate) and Omniscan (gadodiamide). Manufacturers of the products, already reeling from the Food and Drug Administration's recent issuance of a black box warning about the potential risk of NSF, are hoping that gadolinium will be judged an innocent victim of circumstance.

Malpractice lawyers, of course, hope for the opposite.

So far, the findings seem to be favoring the lawyers. Using a technique called energy dispersive spectroscopy (EDS), investigators are able to detect metals such as titanium, vanadium, and gadolinium in human tissues, said Dr. High. He has detected gadolinium in the skin of four of seven NSF patients he has studied (J. Am. Acad. Dermatol. 2007;56:21-6).

He stressed, however, that EDS is "a semiquantitative technique, not a mass-based technique, and it should not be used as such." EDS can tell whether certain metals are present in the tissue, but it cannot be used to determine how much is present, except in a relative type of way.

That type of determination requires a technique like mass spectrometry. This method, too, showed significantly elevated levels of gadolinium in all NSF patients of Dr. High's original series.

Dr. High and his colleagues have used mass spectrometry to analyze a range of different tissues. Infant foreskin samples, predictably, show no gadolinium. Multiple sclerosis patients without renal problems who had undergone semiannual MRIs showed no gadolinium. Tissue samples from Mohs surgery for skin cancer? Also clear, as were skin samples from ESRD patients who have not had gadolinium-based scans. ESRD patients who had undergone imaging with gadolinium contrast, however, did show traces of the metal albeit at much lower levels than the patients with NSF.

Circumstantial? Unlikely. "If you have gadolinium in your tissues, you got it from somewhere. There is no regularly encountered source of gadolinium in this form in nature. So unless you happen to be a gadolinium miner, you got it from a doctor," said Dr. High.

But Dr. High seems reluctant to pin blame for NSF exclusively on gadolinium contrast agents. Bear in mind that nearly all NSF patients have ESRD, meaning that their ability to filter and eliminate toxins such as metals is sorely impaired. "Renal failure patients are a toxic soup of metals—calcium, iron, zinc, copper, aluminum—all sorts of metals," Dr. High said, adding that he believes NSF results from "a collusion of coconspirators. Gadolinium alone may not be the only prerequisite exposure, and other metals may be involved in its deposition or in disease evolution." Only time will tell.

Case in point, the prevailing model for how gadolinium ends up in the skin involves a hypothetical process called "transmetallation," in which other metals, such as iron or calcium present in the tissue, knock the gadolinium off the chelator to which it is normally bound.

"Transmetallation is just a theory at this point. It hasn't yet been irrefutably proven to occur in the body. Electron microscopy cannot detect what a metal is bound to, but a special kind of subatomic particle accelerator can."

To that end, Dr. High will soon be the first dermatopathologist to gain access to such an instrument. By the time this article is published, he will have been engaged in particle accelerator experiments designed to prove whether gadolinium in tissue is no longer bound to its chelators, as the transmetallation theory suggests. "There will likely be other information coming out to show that other metals may contribute to gadolinium deposition and perhaps to NSF itself," he said.

Even if gadolinium is not the only cause of NSF, it certainly appears a strong trigger in susceptible individuals. Estimates indicate that 3%-5% of patients with ESRD may be at risk for NSF. It appears that, in addition to ESRD, predisposition to thrombosis and inflammation may be involved. The risk is also likely proportional to the number of scans a person receives during renal failure.

For those who develop the disorder, there's little physicians can do. "I see about 10-12 patients with NSF at the University of Colorado. We've tried everything—photopheresis, plasmapheresis, renal transplant. No single treatment works uniformly well for all patients. And there are no formal studies comparing modalities."

Dr. High predicted that the current controversy about gadolinium will prompt a surge of interest in "medical geology" and the study of how elemental metals affect human health. Currently, Dr. High is working on a rapid, noninvasive screening device to detect metals such as gadolinium in human tissue.

Gadolinium conglomerations in a fibrohistiocytic cell from the skin of an NSF patient are shown above. Courtesy Dr. Whitney A. High

NEW YORK — Dr. Whitney A. High is into heavy metal and skin, but if you think he's a biker with a leather vest and a Black Sabbath tattoo, you've got it wrong.

Dr. High, of the University of Colorado, Denver, is a clean-cut young dermatopathologist with a soft spot for geology and physics, and his interests in heavy metal involve titanium and vanadium, not Metallica and Megadeath.

His unique set of interests—skin disease, metals, and physics—has landed him in the center of the growing controversy around gadolinium contrast agents and their role in nephrogenic systemic fibrosis.

Dr. High is part of an elite team of investigators trying to determine whether the gadolinium agents in MRI contrast media play a causative role in this devastating, largely untreatable skin disorder. Their answer could have major medicolegal and clinical implications.

Nephrogenic systemic fibrosis (NSF) is characterized by excessive fibrosis in the skin and other soft tissues that leads to disfigurement, tissue constriction, and in some cases, respiratory failure, ocular damage, and cardiac problems. It was first reported as "scleromyxedema-like disease" in renal dialysis patients in 1997. In the last decade, hundreds of cases have emerged worldwide, primarily, if not exclusively in people with end-stage renal disease (ESRD). Other than that, there were few clues as to what caused the distinctive skin and soft tissue changes.

"For a long time, we could not figure out what was going on," Dr. High said at the American Academy of Dermatology's Summer Academy 2007. The first break came in January 2006, when Austrian researchers described nine patients with ESRD, five of whom had developed NSF, with all five having undergone imaging procedures with gadolinium contrast agents. These five patients developed signs and symptoms consistent with the disorder within about 4 weeks of exposure to gadolinium-based contrast used in magnetic angiography.

Further damning evidence emerged late last summer, when Danish investigators reported that 13 of 13 ESRD patients with NSF had received gadodiamide, a commonly used gadolinium contrast agent. There were no other shared risk factors among the 13 cases.

Is there a gadolinium smoking gun in the tissues of NSF patients? That's the question Dr. High is seeking to answer.

"I had previously reported on a granulomatous reaction to titanium alloy in a patient with ear piercings. That's how people knew I was interested in metals and skin disorders, and that's why I got called in on this gadolinium issue," he said.

There are five gadolinium contrast agents currently in use around the world. The two most common are Magnevist (gadopentetate) and Omniscan (gadodiamide). Manufacturers of the products, already reeling from the Food and Drug Administration's recent issuance of a black box warning about the potential risk of NSF, are hoping that gadolinium will be judged an innocent victim of circumstance.

Malpractice lawyers, of course, hope for the opposite.

So far, the findings seem to be favoring the lawyers. Using a technique called energy dispersive spectroscopy (EDS), investigators are able to detect metals such as titanium, vanadium, and gadolinium in human tissues, said Dr. High. He has detected gadolinium in the skin of four of seven NSF patients he has studied (J. Am. Acad. Dermatol. 2007;56:21-6).

He stressed, however, that EDS is "a semiquantitative technique, not a mass-based technique, and it should not be used as such." EDS can tell whether certain metals are present in the tissue, but it cannot be used to determine how much is present, except in a relative type of way.

That type of determination requires a technique like mass spectrometry. This method, too, showed significantly elevated levels of gadolinium in all NSF patients of Dr. High's original series.

Dr. High and his colleagues have used mass spectrometry to analyze a range of different tissues. Infant foreskin samples, predictably, show no gadolinium. Multiple sclerosis patients without renal problems who had undergone semiannual MRIs showed no gadolinium. Tissue samples from Mohs surgery for skin cancer? Also clear, as were skin samples from ESRD patients who have not had gadolinium-based scans. ESRD patients who had undergone imaging with gadolinium contrast, however, did show traces of the metal albeit at much lower levels than the patients with NSF.

Circumstantial? Unlikely. "If you have gadolinium in your tissues, you got it from somewhere. There is no regularly encountered source of gadolinium in this form in nature. So unless you happen to be a gadolinium miner, you got it from a doctor," said Dr. High.

But Dr. High seems reluctant to pin blame for NSF exclusively on gadolinium contrast agents. Bear in mind that nearly all NSF patients have ESRD, meaning that their ability to filter and eliminate toxins such as metals is sorely impaired. "Renal failure patients are a toxic soup of metals—calcium, iron, zinc, copper, aluminum—all sorts of metals," Dr. High said, adding that he believes NSF results from "a collusion of coconspirators. Gadolinium alone may not be the only prerequisite exposure, and other metals may be involved in its deposition or in disease evolution." Only time will tell.

Case in point, the prevailing model for how gadolinium ends up in the skin involves a hypothetical process called "transmetallation," in which other metals, such as iron or calcium present in the tissue, knock the gadolinium off the chelator to which it is normally bound.

"Transmetallation is just a theory at this point. It hasn't yet been irrefutably proven to occur in the body. Electron microscopy cannot detect what a metal is bound to, but a special kind of subatomic particle accelerator can."

To that end, Dr. High will soon be the first dermatopathologist to gain access to such an instrument. By the time this article is published, he will have been engaged in particle accelerator experiments designed to prove whether gadolinium in tissue is no longer bound to its chelators, as the transmetallation theory suggests. "There will likely be other information coming out to show that other metals may contribute to gadolinium deposition and perhaps to NSF itself," he said.

Even if gadolinium is not the only cause of NSF, it certainly appears a strong trigger in susceptible individuals. Estimates indicate that 3%-5% of patients with ESRD may be at risk for NSF. It appears that, in addition to ESRD, predisposition to thrombosis and inflammation may be involved. The risk is also likely proportional to the number of scans a person receives during renal failure.

For those who develop the disorder, there's little physicians can do. "I see about 10-12 patients with NSF at the University of Colorado. We've tried everything—photopheresis, plasmapheresis, renal transplant. No single treatment works uniformly well for all patients. And there are no formal studies comparing modalities."

Dr. High predicted that the current controversy about gadolinium will prompt a surge of interest in "medical geology" and the study of how elemental metals affect human health. Currently, Dr. High is working on a rapid, noninvasive screening device to detect metals such as gadolinium in human tissue.

Gadolinium conglomerations in a fibrohistiocytic cell from the skin of an NSF patient are shown above. Courtesy Dr. Whitney A. High

NEW YORK — Dr. Whitney A. High is into heavy metal and skin, but if you think he's a biker with a leather vest and a Black Sabbath tattoo, you've got it wrong.

Dr. High, of the University of Colorado, Denver, is a clean-cut young dermatopathologist with a soft spot for geology and physics, and his interests in heavy metal involve titanium and vanadium, not Metallica and Megadeath.

His unique set of interests—skin disease, metals, and physics—has landed him in the center of the growing controversy around gadolinium contrast agents and their role in nephrogenic systemic fibrosis.

Dr. High is part of an elite team of investigators trying to determine whether the gadolinium agents in MRI contrast media play a causative role in this devastating, largely untreatable skin disorder. Their answer could have major medicolegal and clinical implications.

Nephrogenic systemic fibrosis (NSF) is characterized by excessive fibrosis in the skin and other soft tissues that leads to disfigurement, tissue constriction, and in some cases, respiratory failure, ocular damage, and cardiac problems. It was first reported as "scleromyxedema-like disease" in renal dialysis patients in 1997. In the last decade, hundreds of cases have emerged worldwide, primarily, if not exclusively in people with end-stage renal disease (ESRD). Other than that, there were few clues as to what caused the distinctive skin and soft tissue changes.

"For a long time, we could not figure out what was going on," Dr. High said at the American Academy of Dermatology's Summer Academy 2007. The first break came in January 2006, when Austrian researchers described nine patients with ESRD, five of whom had developed NSF, with all five having undergone imaging procedures with gadolinium contrast agents. These five patients developed signs and symptoms consistent with the disorder within about 4 weeks of exposure to gadolinium-based contrast used in magnetic angiography.

Further damning evidence emerged late last summer, when Danish investigators reported that 13 of 13 ESRD patients with NSF had received gadodiamide, a commonly used gadolinium contrast agent. There were no other shared risk factors among the 13 cases.

Is there a gadolinium smoking gun in the tissues of NSF patients? That's the question Dr. High is seeking to answer.

"I had previously reported on a granulomatous reaction to titanium alloy in a patient with ear piercings. That's how people knew I was interested in metals and skin disorders, and that's why I got called in on this gadolinium issue," he said.

There are five gadolinium contrast agents currently in use around the world. The two most common are Magnevist (gadopentetate) and Omniscan (gadodiamide). Manufacturers of the products, already reeling from the Food and Drug Administration's recent issuance of a black box warning about the potential risk of NSF, are hoping that gadolinium will be judged an innocent victim of circumstance.

Malpractice lawyers, of course, hope for the opposite.

So far, the findings seem to be favoring the lawyers. Using a technique called energy dispersive spectroscopy (EDS), investigators are able to detect metals such as titanium, vanadium, and gadolinium in human tissues, said Dr. High. He has detected gadolinium in the skin of four of seven NSF patients he has studied (J. Am. Acad. Dermatol. 2007;56:21-6).

He stressed, however, that EDS is "a semiquantitative technique, not a mass-based technique, and it should not be used as such." EDS can tell whether certain metals are present in the tissue, but it cannot be used to determine how much is present, except in a relative type of way.

That type of determination requires a technique like mass spectrometry. This method, too, showed significantly elevated levels of gadolinium in all NSF patients of Dr. High's original series.

Dr. High and his colleagues have used mass spectrometry to analyze a range of different tissues. Infant foreskin samples, predictably, show no gadolinium. Multiple sclerosis patients without renal problems who had undergone semiannual MRIs showed no gadolinium. Tissue samples from Mohs surgery for skin cancer? Also clear, as were skin samples from ESRD patients who have not had gadolinium-based scans. ESRD patients who had undergone imaging with gadolinium contrast, however, did show traces of the metal albeit at much lower levels than the patients with NSF.

Circumstantial? Unlikely. "If you have gadolinium in your tissues, you got it from somewhere. There is no regularly encountered source of gadolinium in this form in nature. So unless you happen to be a gadolinium miner, you got it from a doctor," said Dr. High.

But Dr. High seems reluctant to pin blame for NSF exclusively on gadolinium contrast agents. Bear in mind that nearly all NSF patients have ESRD, meaning that their ability to filter and eliminate toxins such as metals is sorely impaired. "Renal failure patients are a toxic soup of metals—calcium, iron, zinc, copper, aluminum—all sorts of metals," Dr. High said, adding that he believes NSF results from "a collusion of coconspirators. Gadolinium alone may not be the only prerequisite exposure, and other metals may be involved in its deposition or in disease evolution." Only time will tell.

Case in point, the prevailing model for how gadolinium ends up in the skin involves a hypothetical process called "transmetallation," in which other metals, such as iron or calcium present in the tissue, knock the gadolinium off the chelator to which it is normally bound.

"Transmetallation is just a theory at this point. It hasn't yet been irrefutably proven to occur in the body. Electron microscopy cannot detect what a metal is bound to, but a special kind of subatomic particle accelerator can."

To that end, Dr. High will soon be the first dermatopathologist to gain access to such an instrument. By the time this article is published, he will have been engaged in particle accelerator experiments designed to prove whether gadolinium in tissue is no longer bound to its chelators, as the transmetallation theory suggests. "There will likely be other information coming out to show that other metals may contribute to gadolinium deposition and perhaps to NSF itself," he said.

Even if gadolinium is not the only cause of NSF, it certainly appears a strong trigger in susceptible individuals. Estimates indicate that 3%-5% of patients with ESRD may be at risk for NSF. It appears that, in addition to ESRD, predisposition to thrombosis and inflammation may be involved. The risk is also likely proportional to the number of scans a person receives during renal failure.

For those who develop the disorder, there's little physicians can do. "I see about 10-12 patients with NSF at the University of Colorado. We've tried everything—photopheresis, plasmapheresis, renal transplant. No single treatment works uniformly well for all patients. And there are no formal studies comparing modalities."

Dr. High predicted that the current controversy about gadolinium will prompt a surge of interest in "medical geology" and the study of how elemental metals affect human health. Currently, Dr. High is working on a rapid, noninvasive screening device to detect metals such as gadolinium in human tissue.

Gadolinium conglomerations in a fibrohistiocytic cell from the skin of an NSF patient are shown above. Courtesy Dr. Whitney A. High

Sometimes, a successful treatment depends on matching the right drug or therapeutic approach with the symptom patterns at hand. But in other cases, it takes a little outside-the-box thinking to get results.

With a disorder like asthma, the problem may be as much environmental as individual, and unless you deal with the environmental triggers, the patient may never really get better. And sometimes, getting to the bottom of one patient's problems can benefit an entire community.

Jason Allen, N.D., a naturopathic physician at the Bastyr Center for Natural Health, Seattle, believes that all health care professionals—regardless of their clinical training or subspecialty discipline—need to pay more attention to the environmental drivers of common diseases.

A case in point is the young girl with asthma who came to see him at the Bastyr clinic a few years ago. Her symptoms were obvious enough, and it would have been easy to jump right into a treatment protocol aimed at controlling her attacks and reducing airway inflammation.

But Dr. Allen's naturopathic training and his personal interest in environmental science led him to think about the problem in a broader context. One of his first principles is to find ways to help patients by improving the environments in which they live. “I asked questions and found out that other kids in her family also had asthma,” he said in an interview. “They all went to the same school, and had at one time had the same homeroom.” He visited the school, and discovered the classroom was next to a parking lot where school buses sat idling their engines during the day.

Children in that classroom were exposed to unusually high amounts of vehicle exhaust. It might not have been a problem for most of the children, but the sensitive or asthmatic ones, like Dr. Allen's patient, were having a hard time.

He teamed up with an environmental hygienist who came to the school and made assessments, which eventually led to a districtwide policy change that stopped bus drivers from needlessly idling their engines.

By thinking outside of the conventional disease-treatment box and shifting into a public health mind-set, Dr. Allen not only helped his young patient, but may have prevented or ameliorated asthma and other respiratory problems for many other children as well. And he saved the school district thousands of dollars in wasted fuel.

All it took was a willingness to look beyond the narrow frame of individual diagnosis and treatment.

“Physicians can treat literally millions of people during our careers through environmental health policy,” said Dr. Allen. He and many other environmentally concerned health professionals believe that more doctors need to speak out about environmental issues. Air and water pollution is extremely detrimental to public health, and makes it more difficult for doctors to help people get well or stay healthy.

According to the Clean Air Task Force, air pollution can be linked to an estimated 50,000 early deaths each year, including 3,000 from lung cancer. It is a primary driver of asthma, accounting for 410,000 asthma attacks, Dr. Allen said. It is responsible for 2.4 million lost work days and 14 million restricted activity days, a very heavy burden of morbidity.

Despite significant amounts of data correlating pollution with a host of common, sometimes life-threatening, disorders, the medical community as a whole has been quiet about environmental issues.

In part, this is because modern medicine focuses largely on treatment of the individual, with public health having little bearing on the lives and practices of most doctors unless they are public health or infectious disease specialists. This focus on the individual is as common in holistic and naturopathic practice, he said.

“Mainstream MDs look at a patient and say, 'What pharmaceutical can I use to treat this condition?' Most NDs or holistic doctors will say, 'What herbs or nutrients can I use?' Public health asks: 'Why do all these people have these conditions?' It's about finding underlying causes and treating” people and their environments, he said.

Positive environmental policy change can emerge naturally out of patient care. More than anything else, it takes a shift in thinking, from the narrow focus of individual therapy to the bigger picture of community health, as Dr. Allen's case shows.

Sometimes, a successful treatment depends on matching the right drug or therapeutic approach with the symptom patterns at hand. But in other cases, it takes a little outside-the-box thinking to get results.

With a disorder like asthma, the problem may be as much environmental as individual, and unless you deal with the environmental triggers, the patient may never really get better. And sometimes, getting to the bottom of one patient's problems can benefit an entire community.

Jason Allen, N.D., a naturopathic physician at the Bastyr Center for Natural Health, Seattle, believes that all health care professionals—regardless of their clinical training or subspecialty discipline—need to pay more attention to the environmental drivers of common diseases.

A case in point is the young girl with asthma who came to see him at the Bastyr clinic a few years ago. Her symptoms were obvious enough, and it would have been easy to jump right into a treatment protocol aimed at controlling her attacks and reducing airway inflammation.

But Dr. Allen's naturopathic training and his personal interest in environmental science led him to think about the problem in a broader context. One of his first principles is to find ways to help patients by improving the environments in which they live. “I asked questions and found out that other kids in her family also had asthma,” he said in an interview. “They all went to the same school, and had at one time had the same homeroom.” He visited the school, and discovered the classroom was next to a parking lot where school buses sat idling their engines during the day.

Children in that classroom were exposed to unusually high amounts of vehicle exhaust. It might not have been a problem for most of the children, but the sensitive or asthmatic ones, like Dr. Allen's patient, were having a hard time.

He teamed up with an environmental hygienist who came to the school and made assessments, which eventually led to a districtwide policy change that stopped bus drivers from needlessly idling their engines.

By thinking outside of the conventional disease-treatment box and shifting into a public health mind-set, Dr. Allen not only helped his young patient, but may have prevented or ameliorated asthma and other respiratory problems for many other children as well. And he saved the school district thousands of dollars in wasted fuel.

All it took was a willingness to look beyond the narrow frame of individual diagnosis and treatment.

“Physicians can treat literally millions of people during our careers through environmental health policy,” said Dr. Allen. He and many other environmentally concerned health professionals believe that more doctors need to speak out about environmental issues. Air and water pollution is extremely detrimental to public health, and makes it more difficult for doctors to help people get well or stay healthy.

According to the Clean Air Task Force, air pollution can be linked to an estimated 50,000 early deaths each year, including 3,000 from lung cancer. It is a primary driver of asthma, accounting for 410,000 asthma attacks, Dr. Allen said. It is responsible for 2.4 million lost work days and 14 million restricted activity days, a very heavy burden of morbidity.

Despite significant amounts of data correlating pollution with a host of common, sometimes life-threatening, disorders, the medical community as a whole has been quiet about environmental issues.

In part, this is because modern medicine focuses largely on treatment of the individual, with public health having little bearing on the lives and practices of most doctors unless they are public health or infectious disease specialists. This focus on the individual is as common in holistic and naturopathic practice, he said.

“Mainstream MDs look at a patient and say, 'What pharmaceutical can I use to treat this condition?' Most NDs or holistic doctors will say, 'What herbs or nutrients can I use?' Public health asks: 'Why do all these people have these conditions?' It's about finding underlying causes and treating” people and their environments, he said.

Positive environmental policy change can emerge naturally out of patient care. More than anything else, it takes a shift in thinking, from the narrow focus of individual therapy to the bigger picture of community health, as Dr. Allen's case shows.

Sometimes, a successful treatment depends on matching the right drug or therapeutic approach with the symptom patterns at hand. But in other cases, it takes a little outside-the-box thinking to get results.

With a disorder like asthma, the problem may be as much environmental as individual, and unless you deal with the environmental triggers, the patient may never really get better. And sometimes, getting to the bottom of one patient's problems can benefit an entire community.

Jason Allen, N.D., a naturopathic physician at the Bastyr Center for Natural Health, Seattle, believes that all health care professionals—regardless of their clinical training or subspecialty discipline—need to pay more attention to the environmental drivers of common diseases.

A case in point is the young girl with asthma who came to see him at the Bastyr clinic a few years ago. Her symptoms were obvious enough, and it would have been easy to jump right into a treatment protocol aimed at controlling her attacks and reducing airway inflammation.

But Dr. Allen's naturopathic training and his personal interest in environmental science led him to think about the problem in a broader context. One of his first principles is to find ways to help patients by improving the environments in which they live. “I asked questions and found out that other kids in her family also had asthma,” he said in an interview. “They all went to the same school, and had at one time had the same homeroom.” He visited the school, and discovered the classroom was next to a parking lot where school buses sat idling their engines during the day.

Children in that classroom were exposed to unusually high amounts of vehicle exhaust. It might not have been a problem for most of the children, but the sensitive or asthmatic ones, like Dr. Allen's patient, were having a hard time.

He teamed up with an environmental hygienist who came to the school and made assessments, which eventually led to a districtwide policy change that stopped bus drivers from needlessly idling their engines.

By thinking outside of the conventional disease-treatment box and shifting into a public health mind-set, Dr. Allen not only helped his young patient, but may have prevented or ameliorated asthma and other respiratory problems for many other children as well. And he saved the school district thousands of dollars in wasted fuel.

All it took was a willingness to look beyond the narrow frame of individual diagnosis and treatment.

“Physicians can treat literally millions of people during our careers through environmental health policy,” said Dr. Allen. He and many other environmentally concerned health professionals believe that more doctors need to speak out about environmental issues. Air and water pollution is extremely detrimental to public health, and makes it more difficult for doctors to help people get well or stay healthy.

According to the Clean Air Task Force, air pollution can be linked to an estimated 50,000 early deaths each year, including 3,000 from lung cancer. It is a primary driver of asthma, accounting for 410,000 asthma attacks, Dr. Allen said. It is responsible for 2.4 million lost work days and 14 million restricted activity days, a very heavy burden of morbidity.

Despite significant amounts of data correlating pollution with a host of common, sometimes life-threatening, disorders, the medical community as a whole has been quiet about environmental issues.

In part, this is because modern medicine focuses largely on treatment of the individual, with public health having little bearing on the lives and practices of most doctors unless they are public health or infectious disease specialists. This focus on the individual is as common in holistic and naturopathic practice, he said.

“Mainstream MDs look at a patient and say, 'What pharmaceutical can I use to treat this condition?' Most NDs or holistic doctors will say, 'What herbs or nutrients can I use?' Public health asks: 'Why do all these people have these conditions?' It's about finding underlying causes and treating” people and their environments, he said.

Positive environmental policy change can emerge naturally out of patient care. More than anything else, it takes a shift in thinking, from the narrow focus of individual therapy to the bigger picture of community health, as Dr. Allen's case shows.

NEW YORK — Many primary care physicians are evaluating skin disorders and often relying on general pathologists to make dermatologic diagnoses, which, according to Dr. Clay Cockerell, could be a recipe for disaster.

Non-dermatologists referring skin samples to general pathologists for evaluation is like “the blind leading the blind” and often leads to misdiagnosis and poor patient care, said Dr. Cockerell at the American Academy of Dermatology's Academy 2007 meeting.

Dr. Cockerell, a dermatologist at the University of Texas Southwestern Medical Center, Dallas, said that only 35% of all skin biopsies come from dermatologists. On a day-to-day basis, dermatologists may do a lot more biopsies than their primary care counterparts, but in terms of sheer numbers, primary care physicians are doing vastly more. In addition, economic pressures may be pushing more primary care doctors to work up patients with skin diseases that, in the past, they would have referred to dermatologists.

There also is a shortage of dermatopathologists across the country. Dr. Cockerell said that the majority of young people entering the field are general pathologists looking to specialize.

The problem is that many general pathologists think that all histologic diagnoses are incontrovertible, and that what's on the slide is all that matters, he said. However, one facet of dermatology that makes it different from many other specialties is that histologically, the same disorder can look very different, depending on the anatomic site involved. The skin on certain body parts, like the elbows, knees and breasts, or any acral skin, can look and behave quite differently from skin of the arms, legs, face, or trunk. Lesions in these sites often do not show the classic textbook histology for the given disease. This is the sort of specialized expertise that primary care physicians and general pathologists often lack.

He described two cases in which lack of dermatologic expertise on both sides of the slide led to an incorrect or delayed diagnosis.

The first case involved a 65-year-old woman who came to a family physician with a solitary skin lesion. The physician, thinking it might be a basal cell carcinoma, took a shave biopsy and submitted it to a general pathology lab. The pathologist noted epidermotropism, exocytosis with atypical lymphoid cells, and a “predominance of T cells,” leading to a diagnosis of “probable mycosis fungoides.”

The primary care physician informed the patient about this diagnosis, and she immediately hit the Internet to learn more. Not surprisingly, the information she found was extremely upsetting, and—wisely, as it turns out—she sought out a second opinion. Dr. Cockerell and his colleagues looked at the lesion, which was not at all suggestive of mycosis fungoides, and then reassessed the histology. Their conclusion: benign lichenoid keratosis.

The second case involved a 36-year-old woman who had gone to a local primary care doctor for evaluation of a chronic, unresolving rash. The general pathologist who evaluated the histology came to a diagnosis of cutaneous lymphoma, which prompted a referral to an oncologist.

The woman underwent two courses of chemotherapy, which did seem to resolve the rashes immediately posttreatment. But they recurred shortly after each treatment, which struck the oncologist as atypical. The oncologist sought further intelligence at a skin tumor conference, and ultimately sent the patient to Dr. Cockerell for evaluation.

What he saw were erupted papules with necrotic areas. The histology showed a lot of atypical lymphoid cells, “but clinically, this did not really look like lymphoma. It turned out to be lymphomatoid papulosis.” The patient was promptly treated with PUVA, leading to a complete remission.

While Dr. Alex Krist, of the Virginia Commonwealth University department of family medicine, admits that the cases presented by Dr. Cockrell are concerning, he sees things differently. The management of dermatologic conditions is an integral part of primary care training, said Dr. Krist. Family physician residents have to fulfill many requirements to make sure they are proficient in the management of skin conditions. Part of the training is knowing when you can handle dermatologic conditions on your own, and when they need to be referred out.

In a study conducted by Dr. Krist and his colleagues, it was found that family physicians are just as good at managing skin conditions as dermatologists. The researchers photographed the patients, made a diagnosis and a management plan, and followed the study patients for 4 months. Two dermatologists then reviewed the patient cases (J. Fam. Prac. 2007;56:40-5).

While the study did not focus on skin cancer diagnosis, “I view [primary care physicians] as knowing what they can manage and how to help people find assistance when they need something more. If I have [patients] with melanoma, I will get them in to see a skin specialist. My role is initial diagnosis.”

When it comes to physicians sending biopsies to general pathologists, the issue goes beyond physicians not knowing about dermatopathologists, said Dr. Cockrell. Many insurance companies have specific contracted labs to which samples have to be sent. “I send samples to dermatopathologists when a second review is warranted.”

Also, added Dr. Krist, “Most of my patients have acute skin conditions that need to be dealt with in a couple days.” Referring them to dermatologists could take 4–6 weeks. Even in cities where dermatologists are prevalent, there are not enough of them to handle all the skin conditions that patients present with,” he added.

NEW YORK — Many primary care physicians are evaluating skin disorders and often relying on general pathologists to make dermatologic diagnoses, which, according to Dr. Clay Cockerell, could be a recipe for disaster.

Non-dermatologists referring skin samples to general pathologists for evaluation is like “the blind leading the blind” and often leads to misdiagnosis and poor patient care, said Dr. Cockerell at the American Academy of Dermatology's Academy 2007 meeting.

Dr. Cockerell, a dermatologist at the University of Texas Southwestern Medical Center, Dallas, said that only 35% of all skin biopsies come from dermatologists. On a day-to-day basis, dermatologists may do a lot more biopsies than their primary care counterparts, but in terms of sheer numbers, primary care physicians are doing vastly more. In addition, economic pressures may be pushing more primary care doctors to work up patients with skin diseases that, in the past, they would have referred to dermatologists.

There also is a shortage of dermatopathologists across the country. Dr. Cockerell said that the majority of young people entering the field are general pathologists looking to specialize.

The problem is that many general pathologists think that all histologic diagnoses are incontrovertible, and that what's on the slide is all that matters, he said. However, one facet of dermatology that makes it different from many other specialties is that histologically, the same disorder can look very different, depending on the anatomic site involved. The skin on certain body parts, like the elbows, knees and breasts, or any acral skin, can look and behave quite differently from skin of the arms, legs, face, or trunk. Lesions in these sites often do not show the classic textbook histology for the given disease. This is the sort of specialized expertise that primary care physicians and general pathologists often lack.

He described two cases in which lack of dermatologic expertise on both sides of the slide led to an incorrect or delayed diagnosis.

The first case involved a 65-year-old woman who came to a family physician with a solitary skin lesion. The physician, thinking it might be a basal cell carcinoma, took a shave biopsy and submitted it to a general pathology lab. The pathologist noted epidermotropism, exocytosis with atypical lymphoid cells, and a “predominance of T cells,” leading to a diagnosis of “probable mycosis fungoides.”

The primary care physician informed the patient about this diagnosis, and she immediately hit the Internet to learn more. Not surprisingly, the information she found was extremely upsetting, and—wisely, as it turns out—she sought out a second opinion. Dr. Cockerell and his colleagues looked at the lesion, which was not at all suggestive of mycosis fungoides, and then reassessed the histology. Their conclusion: benign lichenoid keratosis.

The second case involved a 36-year-old woman who had gone to a local primary care doctor for evaluation of a chronic, unresolving rash. The general pathologist who evaluated the histology came to a diagnosis of cutaneous lymphoma, which prompted a referral to an oncologist.

The woman underwent two courses of chemotherapy, which did seem to resolve the rashes immediately posttreatment. But they recurred shortly after each treatment, which struck the oncologist as atypical. The oncologist sought further intelligence at a skin tumor conference, and ultimately sent the patient to Dr. Cockerell for evaluation.

What he saw were erupted papules with necrotic areas. The histology showed a lot of atypical lymphoid cells, “but clinically, this did not really look like lymphoma. It turned out to be lymphomatoid papulosis.” The patient was promptly treated with PUVA, leading to a complete remission.

While Dr. Alex Krist, of the Virginia Commonwealth University department of family medicine, admits that the cases presented by Dr. Cockrell are concerning, he sees things differently. The management of dermatologic conditions is an integral part of primary care training, said Dr. Krist. Family physician residents have to fulfill many requirements to make sure they are proficient in the management of skin conditions. Part of the training is knowing when you can handle dermatologic conditions on your own, and when they need to be referred out.

In a study conducted by Dr. Krist and his colleagues, it was found that family physicians are just as good at managing skin conditions as dermatologists. The researchers photographed the patients, made a diagnosis and a management plan, and followed the study patients for 4 months. Two dermatologists then reviewed the patient cases (J. Fam. Prac. 2007;56:40-5).

While the study did not focus on skin cancer diagnosis, “I view [primary care physicians] as knowing what they can manage and how to help people find assistance when they need something more. If I have [patients] with melanoma, I will get them in to see a skin specialist. My role is initial diagnosis.”

When it comes to physicians sending biopsies to general pathologists, the issue goes beyond physicians not knowing about dermatopathologists, said Dr. Cockrell. Many insurance companies have specific contracted labs to which samples have to be sent. “I send samples to dermatopathologists when a second review is warranted.”

Also, added Dr. Krist, “Most of my patients have acute skin conditions that need to be dealt with in a couple days.” Referring them to dermatologists could take 4–6 weeks. Even in cities where dermatologists are prevalent, there are not enough of them to handle all the skin conditions that patients present with,” he added.

NEW YORK — Many primary care physicians are evaluating skin disorders and often relying on general pathologists to make dermatologic diagnoses, which, according to Dr. Clay Cockerell, could be a recipe for disaster.

Non-dermatologists referring skin samples to general pathologists for evaluation is like “the blind leading the blind” and often leads to misdiagnosis and poor patient care, said Dr. Cockerell at the American Academy of Dermatology's Academy 2007 meeting.

Dr. Cockerell, a dermatologist at the University of Texas Southwestern Medical Center, Dallas, said that only 35% of all skin biopsies come from dermatologists. On a day-to-day basis, dermatologists may do a lot more biopsies than their primary care counterparts, but in terms of sheer numbers, primary care physicians are doing vastly more. In addition, economic pressures may be pushing more primary care doctors to work up patients with skin diseases that, in the past, they would have referred to dermatologists.

There also is a shortage of dermatopathologists across the country. Dr. Cockerell said that the majority of young people entering the field are general pathologists looking to specialize.

The problem is that many general pathologists think that all histologic diagnoses are incontrovertible, and that what's on the slide is all that matters, he said. However, one facet of dermatology that makes it different from many other specialties is that histologically, the same disorder can look very different, depending on the anatomic site involved. The skin on certain body parts, like the elbows, knees and breasts, or any acral skin, can look and behave quite differently from skin of the arms, legs, face, or trunk. Lesions in these sites often do not show the classic textbook histology for the given disease. This is the sort of specialized expertise that primary care physicians and general pathologists often lack.

He described two cases in which lack of dermatologic expertise on both sides of the slide led to an incorrect or delayed diagnosis.

The first case involved a 65-year-old woman who came to a family physician with a solitary skin lesion. The physician, thinking it might be a basal cell carcinoma, took a shave biopsy and submitted it to a general pathology lab. The pathologist noted epidermotropism, exocytosis with atypical lymphoid cells, and a “predominance of T cells,” leading to a diagnosis of “probable mycosis fungoides.”

The primary care physician informed the patient about this diagnosis, and she immediately hit the Internet to learn more. Not surprisingly, the information she found was extremely upsetting, and—wisely, as it turns out—she sought out a second opinion. Dr. Cockerell and his colleagues looked at the lesion, which was not at all suggestive of mycosis fungoides, and then reassessed the histology. Their conclusion: benign lichenoid keratosis.

The second case involved a 36-year-old woman who had gone to a local primary care doctor for evaluation of a chronic, unresolving rash. The general pathologist who evaluated the histology came to a diagnosis of cutaneous lymphoma, which prompted a referral to an oncologist.

The woman underwent two courses of chemotherapy, which did seem to resolve the rashes immediately posttreatment. But they recurred shortly after each treatment, which struck the oncologist as atypical. The oncologist sought further intelligence at a skin tumor conference, and ultimately sent the patient to Dr. Cockerell for evaluation.

What he saw were erupted papules with necrotic areas. The histology showed a lot of atypical lymphoid cells, “but clinically, this did not really look like lymphoma. It turned out to be lymphomatoid papulosis.” The patient was promptly treated with PUVA, leading to a complete remission.

While Dr. Alex Krist, of the Virginia Commonwealth University department of family medicine, admits that the cases presented by Dr. Cockrell are concerning, he sees things differently. The management of dermatologic conditions is an integral part of primary care training, said Dr. Krist. Family physician residents have to fulfill many requirements to make sure they are proficient in the management of skin conditions. Part of the training is knowing when you can handle dermatologic conditions on your own, and when they need to be referred out.

In a study conducted by Dr. Krist and his colleagues, it was found that family physicians are just as good at managing skin conditions as dermatologists. The researchers photographed the patients, made a diagnosis and a management plan, and followed the study patients for 4 months. Two dermatologists then reviewed the patient cases (J. Fam. Prac. 2007;56:40-5).

While the study did not focus on skin cancer diagnosis, “I view [primary care physicians] as knowing what they can manage and how to help people find assistance when they need something more. If I have [patients] with melanoma, I will get them in to see a skin specialist. My role is initial diagnosis.”

When it comes to physicians sending biopsies to general pathologists, the issue goes beyond physicians not knowing about dermatopathologists, said Dr. Cockrell. Many insurance companies have specific contracted labs to which samples have to be sent. “I send samples to dermatopathologists when a second review is warranted.”

Also, added Dr. Krist, “Most of my patients have acute skin conditions that need to be dealt with in a couple days.” Referring them to dermatologists could take 4–6 weeks. Even in cities where dermatologists are prevalent, there are not enough of them to handle all the skin conditions that patients present with,” he added.

WASHINGTON – With the introduction of the Healthy Americans Act last January, Oregon Sen. Ron Wyden (D) became the first major political player to launch a proposal for significant health care reform since the early days of the Clinton administration.

Sen. Wyden's plan calls for federally mandated, federally subsidized, portable health insurance coverage for all Americans. The plan is designed to break the nation's reliance on employer-funded health insurance, a dependence Sen. Wyden believes has become detrimental to the well-being of many American citizens and crippling to American businesses.

Speaking at the fourth annual World Health Care Congress, a conference sponsored by the Wall Street Journal and CNBC, Sen. Wyden outlined his vision for reform, emphasizing that he is most definitely “trying to upset the applecart.”

The Healthy Americans Act (S. 334) would guarantee all Americans access to private-sector health plans that provide benefits equal to those currently provided to members of Congress. It would do so without increasing corporate or individual income taxes, and–more importantly–do so without obliging employers to pay any more than 25% of health care costs for their employees. The bill would create incentives for both individuals and health care insurers to bolster disease prevention and wellness programs, Sen. Wyden emphasized at the meeting. He said that he believes this is attainable in a fiscally responsible way that would not require any spending beyond the $2.2 trillion currently spent on health care in America; he projected that his plan would save the government roughly $1.48 trillion over a 10-year period, and that these savings would be reinvested in new prevention-oriented initiatives.

“We're currently spending enough on health care that we could have a doctor for every seven families in the U.S., and pay them $200,000 per year. We're spending more than enough money; we're just not spending it in the right place,” the senator said.

Under the Wyden plan, which has support from a diverse group of corporate, labor, and health care leaders, uninsured individuals would choose health insurance coverage from a variety of plans in their states. Federally funded but state-specific Health Help Agencies (HHA) would be created to provide citizens with meaningful comparisons among the various competing plans and to guide them through the enrollment process. The HHAs would also be able to negotiate sliding scale premium reductions to ensure that monthly costs are reasonable and within the reach of working families. HHAs would also provide financial assistance for low-income individuals and families who would not otherwise be able to afford coverage. People who have employer-financed health insurance through their jobs would undergo a 2-year transition during which their employers would “cash-out” the annual total of the individual's health insurance premiums and pass this on to employees as real wages, which, of course, would be tax sheltered once applied to individual or family health insurance policies.

After the 2-year transition, employers would begin to make shared responsibility payments–meaning they would pay up to 25% of the average premium for essential care–but they would no longer be burdened with having to find and manage health care plans for their employees.

Giving employers an honest exit from the health care arena is fundamental to Sen. Wyden's vision. “There's a general awareness that employer-based health care is already melting like a popsicle on a summer sidewalk. A lot of people in their 50s are just hanging on by their fingernails, hoping that their employers will cover them until they're Medicare eligible. My bill is the first and only bill to cut the line between coverage and employment. Back in the 1940s, we as a nation made the decision to put everything on employers. But that doesn't make sense in 2007.”

The aging of the population, the increased burden of chronic diseases, and the emergence of global competition have made employer-based health care increasingly problematic, both for individuals and for the employers themselves.

The other central tenet of Sen. Wyden's vision is to realign the value placed on medical services to support meaningful preventive medicine, disease management, and individual wellness programs.

To this end, the Wyden plan would eliminate individual copayments for all preventive health care services as well as ongoing disease management programs for people with chronic disorders. His plan would encourage insurers to offer financial incentives for participation in wellness programs, nutrition counseling, tobacco cessation, and exercise.

He believes current payment structures unduly favor procedure-based acute care at the expense of primary care, an inequality he hopes to reverse. Under the Healthy Americans Act, primary care physicians would be reimbursed for time-intensive preventive medicine and chronic disease management. The regional HHAs would rate competing health plans, in part based on how well their disease prevention and disease management programs perform.

“Insurance companies will ultimately be competing to keep Americans healthy,” the senator said.

Sen. Wyden contends that the savings obtained by reducing administrative overhead, unnecessary procedures, and costly acute care will more than adequately cover the costs of insuring all uninsured Americans. And at bottom, the Wyden plan is all about universal coverage. He said that he strongly believes universal coverage would free American businesses from the tremendous fiscal ball and chain that health care has become, while protecting individuals from the loss or change of benefits, as often happens with employer-sponsored coverage.

WASHINGTON – With the introduction of the Healthy Americans Act last January, Oregon Sen. Ron Wyden (D) became the first major political player to launch a proposal for significant health care reform since the early days of the Clinton administration.

Sen. Wyden's plan calls for federally mandated, federally subsidized, portable health insurance coverage for all Americans. The plan is designed to break the nation's reliance on employer-funded health insurance, a dependence Sen. Wyden believes has become detrimental to the well-being of many American citizens and crippling to American businesses.

Speaking at the fourth annual World Health Care Congress, a conference sponsored by the Wall Street Journal and CNBC, Sen. Wyden outlined his vision for reform, emphasizing that he is most definitely “trying to upset the applecart.”

The Healthy Americans Act (S. 334) would guarantee all Americans access to private-sector health plans that provide benefits equal to those currently provided to members of Congress. It would do so without increasing corporate or individual income taxes, and–more importantly–do so without obliging employers to pay any more than 25% of health care costs for their employees. The bill would create incentives for both individuals and health care insurers to bolster disease prevention and wellness programs, Sen. Wyden emphasized at the meeting. He said that he believes this is attainable in a fiscally responsible way that would not require any spending beyond the $2.2 trillion currently spent on health care in America; he projected that his plan would save the government roughly $1.48 trillion over a 10-year period, and that these savings would be reinvested in new prevention-oriented initiatives.

“We're currently spending enough on health care that we could have a doctor for every seven families in the U.S., and pay them $200,000 per year. We're spending more than enough money; we're just not spending it in the right place,” the senator said.

Under the Wyden plan, which has support from a diverse group of corporate, labor, and health care leaders, uninsured individuals would choose health insurance coverage from a variety of plans in their states. Federally funded but state-specific Health Help Agencies (HHA) would be created to provide citizens with meaningful comparisons among the various competing plans and to guide them through the enrollment process. The HHAs would also be able to negotiate sliding scale premium reductions to ensure that monthly costs are reasonable and within the reach of working families. HHAs would also provide financial assistance for low-income individuals and families who would not otherwise be able to afford coverage. People who have employer-financed health insurance through their jobs would undergo a 2-year transition during which their employers would “cash-out” the annual total of the individual's health insurance premiums and pass this on to employees as real wages, which, of course, would be tax sheltered once applied to individual or family health insurance policies.

After the 2-year transition, employers would begin to make shared responsibility payments–meaning they would pay up to 25% of the average premium for essential care–but they would no longer be burdened with having to find and manage health care plans for their employees.

Giving employers an honest exit from the health care arena is fundamental to Sen. Wyden's vision. “There's a general awareness that employer-based health care is already melting like a popsicle on a summer sidewalk. A lot of people in their 50s are just hanging on by their fingernails, hoping that their employers will cover them until they're Medicare eligible. My bill is the first and only bill to cut the line between coverage and employment. Back in the 1940s, we as a nation made the decision to put everything on employers. But that doesn't make sense in 2007.”

The aging of the population, the increased burden of chronic diseases, and the emergence of global competition have made employer-based health care increasingly problematic, both for individuals and for the employers themselves.

The other central tenet of Sen. Wyden's vision is to realign the value placed on medical services to support meaningful preventive medicine, disease management, and individual wellness programs.

To this end, the Wyden plan would eliminate individual copayments for all preventive health care services as well as ongoing disease management programs for people with chronic disorders. His plan would encourage insurers to offer financial incentives for participation in wellness programs, nutrition counseling, tobacco cessation, and exercise.

He believes current payment structures unduly favor procedure-based acute care at the expense of primary care, an inequality he hopes to reverse. Under the Healthy Americans Act, primary care physicians would be reimbursed for time-intensive preventive medicine and chronic disease management. The regional HHAs would rate competing health plans, in part based on how well their disease prevention and disease management programs perform.

“Insurance companies will ultimately be competing to keep Americans healthy,” the senator said.

Sen. Wyden contends that the savings obtained by reducing administrative overhead, unnecessary procedures, and costly acute care will more than adequately cover the costs of insuring all uninsured Americans. And at bottom, the Wyden plan is all about universal coverage. He said that he strongly believes universal coverage would free American businesses from the tremendous fiscal ball and chain that health care has become, while protecting individuals from the loss or change of benefits, as often happens with employer-sponsored coverage.

WASHINGTON – With the introduction of the Healthy Americans Act last January, Oregon Sen. Ron Wyden (D) became the first major political player to launch a proposal for significant health care reform since the early days of the Clinton administration.

Sen. Wyden's plan calls for federally mandated, federally subsidized, portable health insurance coverage for all Americans. The plan is designed to break the nation's reliance on employer-funded health insurance, a dependence Sen. Wyden believes has become detrimental to the well-being of many American citizens and crippling to American businesses.

Speaking at the fourth annual World Health Care Congress, a conference sponsored by the Wall Street Journal and CNBC, Sen. Wyden outlined his vision for reform, emphasizing that he is most definitely “trying to upset the applecart.”

The Healthy Americans Act (S. 334) would guarantee all Americans access to private-sector health plans that provide benefits equal to those currently provided to members of Congress. It would do so without increasing corporate or individual income taxes, and–more importantly–do so without obliging employers to pay any more than 25% of health care costs for their employees. The bill would create incentives for both individuals and health care insurers to bolster disease prevention and wellness programs, Sen. Wyden emphasized at the meeting. He said that he believes this is attainable in a fiscally responsible way that would not require any spending beyond the $2.2 trillion currently spent on health care in America; he projected that his plan would save the government roughly $1.48 trillion over a 10-year period, and that these savings would be reinvested in new prevention-oriented initiatives.

“We're currently spending enough on health care that we could have a doctor for every seven families in the U.S., and pay them $200,000 per year. We're spending more than enough money; we're just not spending it in the right place,” the senator said.

Under the Wyden plan, which has support from a diverse group of corporate, labor, and health care leaders, uninsured individuals would choose health insurance coverage from a variety of plans in their states. Federally funded but state-specific Health Help Agencies (HHA) would be created to provide citizens with meaningful comparisons among the various competing plans and to guide them through the enrollment process. The HHAs would also be able to negotiate sliding scale premium reductions to ensure that monthly costs are reasonable and within the reach of working families. HHAs would also provide financial assistance for low-income individuals and families who would not otherwise be able to afford coverage. People who have employer-financed health insurance through their jobs would undergo a 2-year transition during which their employers would “cash-out” the annual total of the individual's health insurance premiums and pass this on to employees as real wages, which, of course, would be tax sheltered once applied to individual or family health insurance policies.

After the 2-year transition, employers would begin to make shared responsibility payments–meaning they would pay up to 25% of the average premium for essential care–but they would no longer be burdened with having to find and manage health care plans for their employees.

Giving employers an honest exit from the health care arena is fundamental to Sen. Wyden's vision. “There's a general awareness that employer-based health care is already melting like a popsicle on a summer sidewalk. A lot of people in their 50s are just hanging on by their fingernails, hoping that their employers will cover them until they're Medicare eligible. My bill is the first and only bill to cut the line between coverage and employment. Back in the 1940s, we as a nation made the decision to put everything on employers. But that doesn't make sense in 2007.”

The aging of the population, the increased burden of chronic diseases, and the emergence of global competition have made employer-based health care increasingly problematic, both for individuals and for the employers themselves.

The other central tenet of Sen. Wyden's vision is to realign the value placed on medical services to support meaningful preventive medicine, disease management, and individual wellness programs.

To this end, the Wyden plan would eliminate individual copayments for all preventive health care services as well as ongoing disease management programs for people with chronic disorders. His plan would encourage insurers to offer financial incentives for participation in wellness programs, nutrition counseling, tobacco cessation, and exercise.

He believes current payment structures unduly favor procedure-based acute care at the expense of primary care, an inequality he hopes to reverse. Under the Healthy Americans Act, primary care physicians would be reimbursed for time-intensive preventive medicine and chronic disease management. The regional HHAs would rate competing health plans, in part based on how well their disease prevention and disease management programs perform.

“Insurance companies will ultimately be competing to keep Americans healthy,” the senator said.

Sen. Wyden contends that the savings obtained by reducing administrative overhead, unnecessary procedures, and costly acute care will more than adequately cover the costs of insuring all uninsured Americans. And at bottom, the Wyden plan is all about universal coverage. He said that he strongly believes universal coverage would free American businesses from the tremendous fiscal ball and chain that health care has become, while protecting individuals from the loss or change of benefits, as often happens with employer-sponsored coverage.

WASHINGTON — With the introduction of the Healthy Americans Act last January, Oregon Sen. Ron Wyden (D) became the first major political player to launch a proposal for significant health care reform since the early days of the Clinton administration.

Sen. Wyden's plan calls for federally mandated, federally subsidized, portable health insurance coverage for all Americans. The plan is designed to break the nation's reliance on employer-funded health insurance, a dependence that Sen. Wyden believes has become detrimental to the well-being of many American citizens and crippling to American businesses.

Speaking at the fourth annual World Health Care Congress, a conference sponsored by the Wall Street Journal and CNBC, Sen. Wyden outlined his vision for reform, emphasizing that he is most definitely “trying to upset the applecart.”

The Healthy Americans Act (S. 334) would guarantee all Americans access to private-sector health plans that provide benefits equal to those currently provided to members of Congress. It would do so without increasing corporate or individual income taxes, and—more importantly—do so without obliging employers to pay any more than 25% of health care costs for employees.

The bill would create incentives for both individuals and health care insurers to bolster disease prevention and wellness programs, Sen. Wyden emphasized at the meeting. He said that he believes this is attainable in a fiscally responsible way that would not require any spending beyond the $2.2 trillion currently spent on health care in America; he projected that his plan would save the government roughly $1.48 trillion over a 10-year period, and that these savings would be reinvested in new prevention-oriented initiatives.

“We're currently spending enough on health care that we could have a doctor for every seven families in the U.S., and pay them $200,000 per year. We're spending more than enough money; we're just not spending it in the right place,” the senator said.

Under the Wyden plan, which has support from a diverse group of corporate, labor, and health care leaders, uninsured individuals would choose health insurance coverage from a variety of plans in their states. Federally funded but state-specific Health Help Agencies (HHA) would be created to provide citizens with meaningful comparisons among the various competing plans and to guide them through the enrollment process. The HHAs would also be able to negotiate sliding scale premium reductions to ensure that monthly costs are reasonable and within the reach of working families. HHAs would also provide financial assistance for low-income individuals and families who would not otherwise be able to afford coverage.

People who have employer-financed health insurance through their jobs would undergo a 2-year transition during which their employers would “cash-out” the annual total of the individual's health insurance premiums and pass this on to employees as real wages, which would be tax sheltered once applied to individual or family health insurance policies. After the 2-year transition, employers would begin to make “shared responsibility” payments—meaning they would pay up to 25% of the average premium for essential care—but they would no longer be burdened with having to find and manage health care plans for their employees.

Giving employers an honest exit from the health care arena is fundamental to Sen. Wyden's vision. “There's a general awareness that employer-based health care is already melting like a popsicle on a summer sidewalk. A lot of people in their 50s are just hanging on by their fingernails, hoping that their employers will cover them until they're Medicare eligible. My bill is the first and only bill to cut the line between coverage and employment. Back in the 1940s, we as a nation made the decision to put everything on employers. But that doesn't make sense in 2007.”

The aging of the population, the increased burden of chronic diseases, and the emergence of global competition have made employer-based health care increasingly problematic, both for individuals and for the employers themselves.

The other central tenet of Sen. Wyden's vision is to realign the value placed on medical services to support meaningful preventive medicine, disease management, and individual wellness programs.

To this end, the Wyden plan would eliminate individual copayments for all preventive health care services as well as ongoing disease management programs for people with chronic disorders. His plan would encourage insurers to offer financial incentives for participation in wellness programs, nutrition counseling, tobacco cessation, and exercise.

He believes current payment structures unduly favor procedure-based acute care at the expense of primary care, an inequality he hopes to reverse. Under the Healthy Americans Act, primary care physicians would be reimbursed for time-intensive preventive medicine and chronic disease management. The regional HHAs would rate competing health plans, in part based on how well their disease prevention and disease management programs perform.

“Insurance companies will ultimately be competing to keep Americans healthy,” the senator said.

WASHINGTON — With the introduction of the Healthy Americans Act last January, Oregon Sen. Ron Wyden (D) became the first major political player to launch a proposal for significant health care reform since the early days of the Clinton administration.

Sen. Wyden's plan calls for federally mandated, federally subsidized, portable health insurance coverage for all Americans. The plan is designed to break the nation's reliance on employer-funded health insurance, a dependence that Sen. Wyden believes has become detrimental to the well-being of many American citizens and crippling to American businesses.

Speaking at the fourth annual World Health Care Congress, a conference sponsored by the Wall Street Journal and CNBC, Sen. Wyden outlined his vision for reform, emphasizing that he is most definitely “trying to upset the applecart.”

The Healthy Americans Act (S. 334) would guarantee all Americans access to private-sector health plans that provide benefits equal to those currently provided to members of Congress. It would do so without increasing corporate or individual income taxes, and—more importantly—do so without obliging employers to pay any more than 25% of health care costs for employees.

The bill would create incentives for both individuals and health care insurers to bolster disease prevention and wellness programs, Sen. Wyden emphasized at the meeting. He said that he believes this is attainable in a fiscally responsible way that would not require any spending beyond the $2.2 trillion currently spent on health care in America; he projected that his plan would save the government roughly $1.48 trillion over a 10-year period, and that these savings would be reinvested in new prevention-oriented initiatives.

“We're currently spending enough on health care that we could have a doctor for every seven families in the U.S., and pay them $200,000 per year. We're spending more than enough money; we're just not spending it in the right place,” the senator said.

Under the Wyden plan, which has support from a diverse group of corporate, labor, and health care leaders, uninsured individuals would choose health insurance coverage from a variety of plans in their states. Federally funded but state-specific Health Help Agencies (HHA) would be created to provide citizens with meaningful comparisons among the various competing plans and to guide them through the enrollment process. The HHAs would also be able to negotiate sliding scale premium reductions to ensure that monthly costs are reasonable and within the reach of working families. HHAs would also provide financial assistance for low-income individuals and families who would not otherwise be able to afford coverage.

People who have employer-financed health insurance through their jobs would undergo a 2-year transition during which their employers would “cash-out” the annual total of the individual's health insurance premiums and pass this on to employees as real wages, which would be tax sheltered once applied to individual or family health insurance policies. After the 2-year transition, employers would begin to make “shared responsibility” payments—meaning they would pay up to 25% of the average premium for essential care—but they would no longer be burdened with having to find and manage health care plans for their employees.

Giving employers an honest exit from the health care arena is fundamental to Sen. Wyden's vision. “There's a general awareness that employer-based health care is already melting like a popsicle on a summer sidewalk. A lot of people in their 50s are just hanging on by their fingernails, hoping that their employers will cover them until they're Medicare eligible. My bill is the first and only bill to cut the line between coverage and employment. Back in the 1940s, we as a nation made the decision to put everything on employers. But that doesn't make sense in 2007.”

The aging of the population, the increased burden of chronic diseases, and the emergence of global competition have made employer-based health care increasingly problematic, both for individuals and for the employers themselves.

The other central tenet of Sen. Wyden's vision is to realign the value placed on medical services to support meaningful preventive medicine, disease management, and individual wellness programs.

To this end, the Wyden plan would eliminate individual copayments for all preventive health care services as well as ongoing disease management programs for people with chronic disorders. His plan would encourage insurers to offer financial incentives for participation in wellness programs, nutrition counseling, tobacco cessation, and exercise.

He believes current payment structures unduly favor procedure-based acute care at the expense of primary care, an inequality he hopes to reverse. Under the Healthy Americans Act, primary care physicians would be reimbursed for time-intensive preventive medicine and chronic disease management. The regional HHAs would rate competing health plans, in part based on how well their disease prevention and disease management programs perform.

“Insurance companies will ultimately be competing to keep Americans healthy,” the senator said.

WASHINGTON — With the introduction of the Healthy Americans Act last January, Oregon Sen. Ron Wyden (D) became the first major political player to launch a proposal for significant health care reform since the early days of the Clinton administration.

Sen. Wyden's plan calls for federally mandated, federally subsidized, portable health insurance coverage for all Americans. The plan is designed to break the nation's reliance on employer-funded health insurance, a dependence that Sen. Wyden believes has become detrimental to the well-being of many American citizens and crippling to American businesses.

Speaking at the fourth annual World Health Care Congress, a conference sponsored by the Wall Street Journal and CNBC, Sen. Wyden outlined his vision for reform, emphasizing that he is most definitely “trying to upset the applecart.”

The Healthy Americans Act (S. 334) would guarantee all Americans access to private-sector health plans that provide benefits equal to those currently provided to members of Congress. It would do so without increasing corporate or individual income taxes, and—more importantly—do so without obliging employers to pay any more than 25% of health care costs for employees.

The bill would create incentives for both individuals and health care insurers to bolster disease prevention and wellness programs, Sen. Wyden emphasized at the meeting. He said that he believes this is attainable in a fiscally responsible way that would not require any spending beyond the $2.2 trillion currently spent on health care in America; he projected that his plan would save the government roughly $1.48 trillion over a 10-year period, and that these savings would be reinvested in new prevention-oriented initiatives.

“We're currently spending enough on health care that we could have a doctor for every seven families in the U.S., and pay them $200,000 per year. We're spending more than enough money; we're just not spending it in the right place,” the senator said.

Under the Wyden plan, which has support from a diverse group of corporate, labor, and health care leaders, uninsured individuals would choose health insurance coverage from a variety of plans in their states. Federally funded but state-specific Health Help Agencies (HHA) would be created to provide citizens with meaningful comparisons among the various competing plans and to guide them through the enrollment process. The HHAs would also be able to negotiate sliding scale premium reductions to ensure that monthly costs are reasonable and within the reach of working families. HHAs would also provide financial assistance for low-income individuals and families who would not otherwise be able to afford coverage.

People who have employer-financed health insurance through their jobs would undergo a 2-year transition during which their employers would “cash-out” the annual total of the individual's health insurance premiums and pass this on to employees as real wages, which would be tax sheltered once applied to individual or family health insurance policies. After the 2-year transition, employers would begin to make “shared responsibility” payments—meaning they would pay up to 25% of the average premium for essential care—but they would no longer be burdened with having to find and manage health care plans for their employees.

Giving employers an honest exit from the health care arena is fundamental to Sen. Wyden's vision. “There's a general awareness that employer-based health care is already melting like a popsicle on a summer sidewalk. A lot of people in their 50s are just hanging on by their fingernails, hoping that their employers will cover them until they're Medicare eligible. My bill is the first and only bill to cut the line between coverage and employment. Back in the 1940s, we as a nation made the decision to put everything on employers. But that doesn't make sense in 2007.”

The aging of the population, the increased burden of chronic diseases, and the emergence of global competition have made employer-based health care increasingly problematic, both for individuals and for the employers themselves.

The other central tenet of Sen. Wyden's vision is to realign the value placed on medical services to support meaningful preventive medicine, disease management, and individual wellness programs.

To this end, the Wyden plan would eliminate individual copayments for all preventive health care services as well as ongoing disease management programs for people with chronic disorders. His plan would encourage insurers to offer financial incentives for participation in wellness programs, nutrition counseling, tobacco cessation, and exercise.

He believes current payment structures unduly favor procedure-based acute care at the expense of primary care, an inequality he hopes to reverse. Under the Healthy Americans Act, primary care physicians would be reimbursed for time-intensive preventive medicine and chronic disease management. The regional HHAs would rate competing health plans, in part based on how well their disease prevention and disease management programs perform.

“Insurance companies will ultimately be competing to keep Americans healthy,” the senator said.

WASHINGTON — With the introduction of the Healthy Americans Act earlier this year, Oregon Sen. Ron Wyden (D) became the first major political player to propose significant health care reform since the Clinton administration.

Sen. Wyden's plan calls for federally mandated, federally subsidized, portable health insurance coverage for all Americans. The plan is designed to break the nation's reliance on employer-funded health insurance, a dependence Sen. Wyden believes has become detrimental to the well-being of many American citizens and crippling to American businesses.

Speaking at the fourth annual World Health Care Congress, a conference sponsored by the Wall Street Journal and CNBC, Sen. Wyden outlined his vision for reform, emphasizing that he is most definitely "trying to upset the apple cart."

The Healthy Americans Act (S. 334) would guarantee all Americans access to private-sector health plans that provide benefits equal to those currently provided to members of Congress. It would do so without increasing taxes, and—more importantly—without obliging employers to pay more than 25% of health care costs for their employees. The bill would create incentives for both individuals and insurers to bolster disease-prevention and wellness programs, Sen. Wyden emphasized.

He said that he believes this is attainable in a fiscally responsible way that would not require any spending beyond the $2.2 trillion currently spent on health care. His plan would save the government roughly $1.48 trillion over 10 years, and these savings would be reinvested in new prevention-oriented initiatives.

"We're currently spending enough on health care that we could have a doctor for every seven families in the U.S., and pay them $200,000 per year. We're spending more than enough money; we're just not spending it in the right place," he said.

Under the Wyden plan, uninsured individuals would choose health insurance coverage from a variety of plans in their states. Federally funded but state-specific Health Help Agencies (HHA) would be created to provide citizens with meaningful comparisons among the various competing plans and to guide them through the enrollment process. The HHAs would also be able to negotiate sliding-scale premium reductions to ensure that monthly costs are within the reach of working families. HHAs would also provide financial assistance for low-income individuals and families.

People who have health insurance through their jobs would undergo a 2-year transition during which their employers would "cash-out" the annual total of the individual's health insurance premiums and pass this on to employees as real wages, which, of course, would be tax sheltered once applied to individual or family policies. After the 2-year transition, employers would begin to make shared responsibility payments—meaning they would pay up to 25% of the average premium for essential care—but they would no longer be burdened with having to find and manage health care plans.

Giving employers an honest exit from the health care arena is fundamental to Sen. Wyden's vision. "There's a general awareness that employer-based health care is already melting like a popsicle on a summer sidewalk," he said.

The other central tenet of Sen. Wyden's vision is to realign the value placed on medical services to support meaningful preventive medicine, disease management, and individual wellness programs.

To this end, the Wyden plan would eliminate individual copayments for all preventive health care services as well as ongoing disease-management programs for people with chronic disorders. His plan would encourage insurers to offer financial incentives for participation in wellness programs, nutrition counseling, tobacco cessation, and exercise.

He believes current payment structures unduly favor procedure-based acute care at the expense of primary care, an inequality he hopes to reverse. Under the Healthy Americans Act, primary care physicians would be reimbursed for time-intensive preventive medicine and chronic disease management. The regional HHAs would rate competing health plans, in part based on how well their disease prevention and disease management programs perform.

"Insurance companies will ultimately be competing to keep Americans healthy," the senator said.

WASHINGTON — With the introduction of the Healthy Americans Act earlier this year, Oregon Sen. Ron Wyden (D) became the first major political player to propose significant health care reform since the Clinton administration.

Sen. Wyden's plan calls for federally mandated, federally subsidized, portable health insurance coverage for all Americans. The plan is designed to break the nation's reliance on employer-funded health insurance, a dependence Sen. Wyden believes has become detrimental to the well-being of many American citizens and crippling to American businesses.

Speaking at the fourth annual World Health Care Congress, a conference sponsored by the Wall Street Journal and CNBC, Sen. Wyden outlined his vision for reform, emphasizing that he is most definitely "trying to upset the apple cart."

The Healthy Americans Act (S. 334) would guarantee all Americans access to private-sector health plans that provide benefits equal to those currently provided to members of Congress. It would do so without increasing taxes, and—more importantly—without obliging employers to pay more than 25% of health care costs for their employees. The bill would create incentives for both individuals and insurers to bolster disease-prevention and wellness programs, Sen. Wyden emphasized.

He said that he believes this is attainable in a fiscally responsible way that would not require any spending beyond the $2.2 trillion currently spent on health care. His plan would save the government roughly $1.48 trillion over 10 years, and these savings would be reinvested in new prevention-oriented initiatives.

"We're currently spending enough on health care that we could have a doctor for every seven families in the U.S., and pay them $200,000 per year. We're spending more than enough money; we're just not spending it in the right place," he said.

Under the Wyden plan, uninsured individuals would choose health insurance coverage from a variety of plans in their states. Federally funded but state-specific Health Help Agencies (HHA) would be created to provide citizens with meaningful comparisons among the various competing plans and to guide them through the enrollment process. The HHAs would also be able to negotiate sliding-scale premium reductions to ensure that monthly costs are within the reach of working families. HHAs would also provide financial assistance for low-income individuals and families.

People who have health insurance through their jobs would undergo a 2-year transition during which their employers would "cash-out" the annual total of the individual's health insurance premiums and pass this on to employees as real wages, which, of course, would be tax sheltered once applied to individual or family policies. After the 2-year transition, employers would begin to make shared responsibility payments—meaning they would pay up to 25% of the average premium for essential care—but they would no longer be burdened with having to find and manage health care plans.

Giving employers an honest exit from the health care arena is fundamental to Sen. Wyden's vision. "There's a general awareness that employer-based health care is already melting like a popsicle on a summer sidewalk," he said.

The other central tenet of Sen. Wyden's vision is to realign the value placed on medical services to support meaningful preventive medicine, disease management, and individual wellness programs.

To this end, the Wyden plan would eliminate individual copayments for all preventive health care services as well as ongoing disease-management programs for people with chronic disorders. His plan would encourage insurers to offer financial incentives for participation in wellness programs, nutrition counseling, tobacco cessation, and exercise.

He believes current payment structures unduly favor procedure-based acute care at the expense of primary care, an inequality he hopes to reverse. Under the Healthy Americans Act, primary care physicians would be reimbursed for time-intensive preventive medicine and chronic disease management. The regional HHAs would rate competing health plans, in part based on how well their disease prevention and disease management programs perform.

"Insurance companies will ultimately be competing to keep Americans healthy," the senator said.

WASHINGTON — With the introduction of the Healthy Americans Act earlier this year, Oregon Sen. Ron Wyden (D) became the first major political player to propose significant health care reform since the Clinton administration.

Sen. Wyden's plan calls for federally mandated, federally subsidized, portable health insurance coverage for all Americans. The plan is designed to break the nation's reliance on employer-funded health insurance, a dependence Sen. Wyden believes has become detrimental to the well-being of many American citizens and crippling to American businesses.

Speaking at the fourth annual World Health Care Congress, a conference sponsored by the Wall Street Journal and CNBC, Sen. Wyden outlined his vision for reform, emphasizing that he is most definitely "trying to upset the apple cart."

The Healthy Americans Act (S. 334) would guarantee all Americans access to private-sector health plans that provide benefits equal to those currently provided to members of Congress. It would do so without increasing taxes, and—more importantly—without obliging employers to pay more than 25% of health care costs for their employees. The bill would create incentives for both individuals and insurers to bolster disease-prevention and wellness programs, Sen. Wyden emphasized.

He said that he believes this is attainable in a fiscally responsible way that would not require any spending beyond the $2.2 trillion currently spent on health care. His plan would save the government roughly $1.48 trillion over 10 years, and these savings would be reinvested in new prevention-oriented initiatives.

"We're currently spending enough on health care that we could have a doctor for every seven families in the U.S., and pay them $200,000 per year. We're spending more than enough money; we're just not spending it in the right place," he said.

Under the Wyden plan, uninsured individuals would choose health insurance coverage from a variety of plans in their states. Federally funded but state-specific Health Help Agencies (HHA) would be created to provide citizens with meaningful comparisons among the various competing plans and to guide them through the enrollment process. The HHAs would also be able to negotiate sliding-scale premium reductions to ensure that monthly costs are within the reach of working families. HHAs would also provide financial assistance for low-income individuals and families.

People who have health insurance through their jobs would undergo a 2-year transition during which their employers would "cash-out" the annual total of the individual's health insurance premiums and pass this on to employees as real wages, which, of course, would be tax sheltered once applied to individual or family policies. After the 2-year transition, employers would begin to make shared responsibility payments—meaning they would pay up to 25% of the average premium for essential care—but they would no longer be burdened with having to find and manage health care plans.

Giving employers an honest exit from the health care arena is fundamental to Sen. Wyden's vision. "There's a general awareness that employer-based health care is already melting like a popsicle on a summer sidewalk," he said.

The other central tenet of Sen. Wyden's vision is to realign the value placed on medical services to support meaningful preventive medicine, disease management, and individual wellness programs.

To this end, the Wyden plan would eliminate individual copayments for all preventive health care services as well as ongoing disease-management programs for people with chronic disorders. His plan would encourage insurers to offer financial incentives for participation in wellness programs, nutrition counseling, tobacco cessation, and exercise.

He believes current payment structures unduly favor procedure-based acute care at the expense of primary care, an inequality he hopes to reverse. Under the Healthy Americans Act, primary care physicians would be reimbursed for time-intensive preventive medicine and chronic disease management. The regional HHAs would rate competing health plans, in part based on how well their disease prevention and disease management programs perform.

"Insurance companies will ultimately be competing to keep Americans healthy," the senator said.

WASHINGTON — The globalization of health care is creating challenges for health care systems worldwide. Though the systems themselves may be very different in terms of financing and administration, the problems they must address—aging populations, increasing chronic disease, shrinking budgets, extreme mobility of both patients and health care professionals—are very similar.

Health care analysts, administrators, and providers compared notes on these challenges at the fourth annual World Health Care Congress, sponsored by the Wall Street Journal and CNBC.

"Despite the fact that health care may be organized and financed very differently in different countries, and there may be cultural differences, there are … a lot of common themes, and shared objectives for high-performing health care systems, innovation, and sustainability," said Robin Osborn, director of the International Program in Health Policy and Practice at the Commonwealth Fund.

Simon Stevens, who served as a health care advisor in U.K. Prime Minister Tony Blair's cabinet, said the United States is not alone in confronting a major health care crisis. Single-payer national health systems of the sort found in the United Kingdom and all over Europe make the dynamics a bit different, but they certainly do not avert the crises.

"Despite differences in financing mechanisms, the challenges are similar across all industrialized nations. Tobacco, bad diet, lack of exercise are driving the conditions that result in the greatest consumption of health care resources, and tensions are erupting across [health care] systems due to changes in financing. The U.S. is not the only country debating these issues. The challenges are the same regardless of how you choose to finance the health care," said Mr. Stevens, now the CEO of UnitedHealth Group's Ovations, a health plan for individuals over age 50.

Aging populations are the juggernauts straining health care systems in nearly all industrialized countries. Over the next 30 years, the dependency ratio, an expression of the number of elderly nonworking dependents versus younger working people, "will grow rapidly in the U.S., Western Europe, Japan, and China. And this will radically change how health care is financed," Mr. Stevens said.

He added that while American corporate leaders have been screaming the loudest, the issues around employer-funded health care are not uniquely American.

In a number of European countries, private corporations are footing the bill for significant chunks of health care spending. "In the U.K., 52% of spending is private sector spending, despite the fact that the delivery systems are government funded."

Across the globe, health care is increasingly a transnational endeavor, with immigration, relocation, medical travel, and multinational business blurring borders. The establishment of the European Economic Community, the paragon of economic boundary breaking, has created an interesting health care quandary, said Mr. Stevens.

"In the earlier days of the [European Union], many had hopes that the confederation would lead to harmonization of health care benefits. Not so. Per capita spending on health care in Eastern and Western Europe is fourfold different. Western Europe spends way more. It is implausible to have a set of uniform benefits that are acceptable in Germany but unaffordable in Slovakia."

Migration also has an impact. Whether for employment opportunity or in pursuit of leisure, more people are living outside their countries of origin, and this makes for some peculiar health care dilemmas.

Mr. Stevens noted that in many parts of the world, national borders are blurred. "In California, for example, we know there are 8 million Hispanics living in border counties. Many have dependents across the border in Mexico. How do we handle that? Can we mandate that dependents of U.S. employees only be treated in clinics in Mexico?"

At the other end of the socioeconomic spectrum, there are thousands of retired U.S. citizens living in Mexico, Costa Rica, Panama, and other Central American countries. They're eligible for Medicare, but unable to get coverage for medical services or drugs they obtain where they live. "Does this mean these people must fly back to the U.S. every time they need medical care?"

Physicians, nurses, and other medical personnel also have become highly mobile, often moving far from their countries of origin to countries of perceived opportunity.

Citing only one example, Mr. Stevens said there are more Filipino nurses, born and trained in the Philippines, working in the United States than there are in the Philippines. In the European Union, there are significant migratory flows of health care professionals from east to west.

This can result in shortages of qualified professionals in many countries, hindering the growth and development of their medical systems.

Ironically, it is the influx of international patients seeking lower-cost health care that will be an important driver for the development of hospitals and the retaining of health professionals in nations such as Thailand, India, Hungary, and many Latin American countries.

Health plan administrators are struggling to figure out ways to do business without borders. The challenges are daunting, said UnitedHealth Group's Ori Karev. Speaking specifically of coverage for Americans obtaining care outside the United States, he noted, "There are a lot of complicated issues involved in this: transportation issues, authorization issues, tax issues in terms of the ways in which the IRS will treat medical travel expenses."

As countries such as India, Thailand, China, Brazil, and others become more affluent, their health care spending will increase, as will the number of risk-sharing plans. UnitedHealth Group is already a major health insurance player in India, with an employer-funded plan now covering 300,000 members via a large provider network.

WASHINGTON — The globalization of health care is creating challenges for health care systems worldwide. Though the systems themselves may be very different in terms of financing and administration, the problems they must address—aging populations, increasing chronic disease, shrinking budgets, extreme mobility of both patients and health care professionals—are very similar.

Health care analysts, administrators, and providers compared notes on these challenges at the fourth annual World Health Care Congress, sponsored by the Wall Street Journal and CNBC.

"Despite the fact that health care may be organized and financed very differently in different countries, and there may be cultural differences, there are … a lot of common themes, and shared objectives for high-performing health care systems, innovation, and sustainability," said Robin Osborn, director of the International Program in Health Policy and Practice at the Commonwealth Fund.

Simon Stevens, who served as a health care advisor in U.K. Prime Minister Tony Blair's cabinet, said the United States is not alone in confronting a major health care crisis. Single-payer national health systems of the sort found in the United Kingdom and all over Europe make the dynamics a bit different, but they certainly do not avert the crises.

"Despite differences in financing mechanisms, the challenges are similar across all industrialized nations. Tobacco, bad diet, lack of exercise are driving the conditions that result in the greatest consumption of health care resources, and tensions are erupting across [health care] systems due to changes in financing. The U.S. is not the only country debating these issues. The challenges are the same regardless of how you choose to finance the health care," said Mr. Stevens, now the CEO of UnitedHealth Group's Ovations, a health plan for individuals over age 50.

Aging populations are the juggernauts straining health care systems in nearly all industrialized countries. Over the next 30 years, the dependency ratio, an expression of the number of elderly nonworking dependents versus younger working people, "will grow rapidly in the U.S., Western Europe, Japan, and China. And this will radically change how health care is financed," Mr. Stevens said.

He added that while American corporate leaders have been screaming the loudest, the issues around employer-funded health care are not uniquely American.

In a number of European countries, private corporations are footing the bill for significant chunks of health care spending. "In the U.K., 52% of spending is private sector spending, despite the fact that the delivery systems are government funded."

Across the globe, health care is increasingly a transnational endeavor, with immigration, relocation, medical travel, and multinational business blurring borders. The establishment of the European Economic Community, the paragon of economic boundary breaking, has created an interesting health care quandary, said Mr. Stevens.

"In the earlier days of the [European Union], many had hopes that the confederation would lead to harmonization of health care benefits. Not so. Per capita spending on health care in Eastern and Western Europe is fourfold different. Western Europe spends way more. It is implausible to have a set of uniform benefits that are acceptable in Germany but unaffordable in Slovakia."

Migration also has an impact. Whether for employment opportunity or in pursuit of leisure, more people are living outside their countries of origin, and this makes for some peculiar health care dilemmas.

Mr. Stevens noted that in many parts of the world, national borders are blurred. "In California, for example, we know there are 8 million Hispanics living in border counties. Many have dependents across the border in Mexico. How do we handle that? Can we mandate that dependents of U.S. employees only be treated in clinics in Mexico?"

At the other end of the socioeconomic spectrum, there are thousands of retired U.S. citizens living in Mexico, Costa Rica, Panama, and other Central American countries. They're eligible for Medicare, but unable to get coverage for medical services or drugs they obtain where they live. "Does this mean these people must fly back to the U.S. every time they need medical care?"

Physicians, nurses, and other medical personnel also have become highly mobile, often moving far from their countries of origin to countries of perceived opportunity.

Citing only one example, Mr. Stevens said there are more Filipino nurses, born and trained in the Philippines, working in the United States than there are in the Philippines. In the European Union, there are significant migratory flows of health care professionals from east to west.

This can result in shortages of qualified professionals in many countries, hindering the growth and development of their medical systems.

Ironically, it is the influx of international patients seeking lower-cost health care that will be an important driver for the development of hospitals and the retaining of health professionals in nations such as Thailand, India, Hungary, and many Latin American countries.

Health plan administrators are struggling to figure out ways to do business without borders. The challenges are daunting, said UnitedHealth Group's Ori Karev. Speaking specifically of coverage for Americans obtaining care outside the United States, he noted, "There are a lot of complicated issues involved in this: transportation issues, authorization issues, tax issues in terms of the ways in which the IRS will treat medical travel expenses."

As countries such as India, Thailand, China, Brazil, and others become more affluent, their health care spending will increase, as will the number of risk-sharing plans. UnitedHealth Group is already a major health insurance player in India, with an employer-funded plan now covering 300,000 members via a large provider network.

WASHINGTON — The globalization of health care is creating challenges for health care systems worldwide. Though the systems themselves may be very different in terms of financing and administration, the problems they must address—aging populations, increasing chronic disease, shrinking budgets, extreme mobility of both patients and health care professionals—are very similar.

Health care analysts, administrators, and providers compared notes on these challenges at the fourth annual World Health Care Congress, sponsored by the Wall Street Journal and CNBC.

"Despite the fact that health care may be organized and financed very differently in different countries, and there may be cultural differences, there are … a lot of common themes, and shared objectives for high-performing health care systems, innovation, and sustainability," said Robin Osborn, director of the International Program in Health Policy and Practice at the Commonwealth Fund.

Simon Stevens, who served as a health care advisor in U.K. Prime Minister Tony Blair's cabinet, said the United States is not alone in confronting a major health care crisis. Single-payer national health systems of the sort found in the United Kingdom and all over Europe make the dynamics a bit different, but they certainly do not avert the crises.

"Despite differences in financing mechanisms, the challenges are similar across all industrialized nations. Tobacco, bad diet, lack of exercise are driving the conditions that result in the greatest consumption of health care resources, and tensions are erupting across [health care] systems due to changes in financing. The U.S. is not the only country debating these issues. The challenges are the same regardless of how you choose to finance the health care," said Mr. Stevens, now the CEO of UnitedHealth Group's Ovations, a health plan for individuals over age 50.

Aging populations are the juggernauts straining health care systems in nearly all industrialized countries. Over the next 30 years, the dependency ratio, an expression of the number of elderly nonworking dependents versus younger working people, "will grow rapidly in the U.S., Western Europe, Japan, and China. And this will radically change how health care is financed," Mr. Stevens said.

He added that while American corporate leaders have been screaming the loudest, the issues around employer-funded health care are not uniquely American.

In a number of European countries, private corporations are footing the bill for significant chunks of health care spending. "In the U.K., 52% of spending is private sector spending, despite the fact that the delivery systems are government funded."

Across the globe, health care is increasingly a transnational endeavor, with immigration, relocation, medical travel, and multinational business blurring borders. The establishment of the European Economic Community, the paragon of economic boundary breaking, has created an interesting health care quandary, said Mr. Stevens.

"In the earlier days of the [European Union], many had hopes that the confederation would lead to harmonization of health care benefits. Not so. Per capita spending on health care in Eastern and Western Europe is fourfold different. Western Europe spends way more. It is implausible to have a set of uniform benefits that are acceptable in Germany but unaffordable in Slovakia."

Migration also has an impact. Whether for employment opportunity or in pursuit of leisure, more people are living outside their countries of origin, and this makes for some peculiar health care dilemmas.

Mr. Stevens noted that in many parts of the world, national borders are blurred. "In California, for example, we know there are 8 million Hispanics living in border counties. Many have dependents across the border in Mexico. How do we handle that? Can we mandate that dependents of U.S. employees only be treated in clinics in Mexico?"

At the other end of the socioeconomic spectrum, there are thousands of retired U.S. citizens living in Mexico, Costa Rica, Panama, and other Central American countries. They're eligible for Medicare, but unable to get coverage for medical services or drugs they obtain where they live. "Does this mean these people must fly back to the U.S. every time they need medical care?"

Physicians, nurses, and other medical personnel also have become highly mobile, often moving far from their countries of origin to countries of perceived opportunity.

Citing only one example, Mr. Stevens said there are more Filipino nurses, born and trained in the Philippines, working in the United States than there are in the Philippines. In the European Union, there are significant migratory flows of health care professionals from east to west.

This can result in shortages of qualified professionals in many countries, hindering the growth and development of their medical systems.

Ironically, it is the influx of international patients seeking lower-cost health care that will be an important driver for the development of hospitals and the retaining of health professionals in nations such as Thailand, India, Hungary, and many Latin American countries.

Health plan administrators are struggling to figure out ways to do business without borders. The challenges are daunting, said UnitedHealth Group's Ori Karev. Speaking specifically of coverage for Americans obtaining care outside the United States, he noted, "There are a lot of complicated issues involved in this: transportation issues, authorization issues, tax issues in terms of the ways in which the IRS will treat medical travel expenses."

As countries such as India, Thailand, China, Brazil, and others become more affluent, their health care spending will increase, as will the number of risk-sharing plans. UnitedHealth Group is already a major health insurance player in India, with an employer-funded plan now covering 300,000 members via a large provider network.