PEDIATRICIAN Spring 2003 - AAP-CA

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In addition, problem-focused behavior therapy was provided by the program psychologist on an individual basis when referred by a team member. Within these sessions, a particular nutritional or physical activity goal was identified as a primary treatment target. A behavioral program was then developed, using positive reinforcement for meeting the specified goal. Specifics of treatment were adapted according to the patient’s age and developmental stage. DIETARY TREATMENTS One team prescribed a standard balanced, hypoenergetic reduced-fat diet because of research demonstrating improvements in adiposity on this diet when combined with behavioral modification and exercise. 26, 27 The diet followed US Department of Agriculture recommendations for intake of specific food types, as depicted by the Food Guide Pyramid. Particular emphasis was placed on limiting intake of high-fat, high-sugar, and energydense foods, and increasing intake of grain products, vegetables, and fruit. Recommendations were tailored on an individual basis to incorporate an energy restriction of approximately 1042 kJ (250 kcal) to 2084 kj (500 kcal) per day compared with usual energy intake. Specific macronutrient goals were 55% to 60% carbohydrate, 15% to 20% protein, and 25% to 30% fat. The other team prescribed a low-GI diet because of preliminary research suggesting a physiologic mechanism relating GI to body weight regulation. 16,17 The low-GI diet was designed to obtain the lowest glycemic response possible while providing adequate dietary carbohydrates, satisfying all nutritional recommendations for children, and maintaining palatability. This diet differed from the standard diet not just in the GI of the component carbohydrates foods, but also in the macronutrient ratio. Emphasis was placed on food selection, not energy restriction: patients were instructed to eat to satiety and snack when hungry. Specifically, patients were told to combine low-GI carbohydrate, protein, and fat at every meal and snack. A “Low-GI Pyramid,” modeled after the Food Guide Pyramid, was used as a teaching tool. This modified pyramid placed vegetables, legumes, and fruits at the base, lean proteins and dairy products on the second level, whole-grain products on the third level, and refined grain products, potatoes, and concentrated sugars at the top. Specific macronutrient goals were 45% to 50% carbohydrate, 20% to 25% protein, and 30% to 35% fat. Results Characteristics of the cohort are described in Table 1 according to dietary treatment group. Mean age, length of follow-up, number of visits, and sex were similar between the two treatment groups. Baseline BMI and body weight were slightly greater in the reduced-fat group compared with the low-GI group, but the difference was not statistically significant. Ethnicity differed in the study cohort primarily owing to different follow-up rates (of the 190 patients before exclusion for lack of follow-up, white subjects comprised 71% of 118 individuals assigned to the low-GI group vs. 67% of 72 individuals assigned to the reduced fat group). The figure depicts the mean change in BMI from the participant’s first to last clinic visit according to dietary treatment and baseline BMI tertile. For each BMI tertile, the low- GI group had a significantly larger decrease in BMI than the reduced-fat group. Compared with the reduced-fat group, a larger percentage of patients in the low-GI group experienced a decrease in BMI of at least -3 kg/m2 (11 participants [17.2%] vs. one participant [2.3%]. As presented in Table 2, the overall mean change in BMI for the low-GI group was -1.53 kg/m2, compared with -0.06 kg/m2 for the reducedfat group (P
Why California’s MICRA Is Good for the Nation Ron Bangasser, M.D. The National Medical Liability Crisis It is upsetting to watch physicians walk off their jobs to protest the cost of medical liability insurance in New Jersey, Nevada, Mississippi, West Virginia and Florida. But it would be far more upsetting if there were no doctors at all to provide surgery, trauma care, diagnose illnesses and deliver babies. Some of these physicians are being charged up to $200,000 annually for their liability coverage, and like the proverbial canary in the coalmine, these physicians are trying to warn us about a coming national health care crisis. California faced a similar calamity in the 1970s. Malpractice insurance was soaring with some physicians expecting 400% premium increases. Worried that soaring costs would drive physicians from California and leave patients without care, then-Gov. Jerry Brown called a special session of the legislature to solve the medical liability crisis. California’s MICRA The solution then, and now, was the Medical Injury Compensation Reform Act. Before MICRA, California malpractice premiums were among the nation’s highest. But post- MICRA, rates in California stabilized. Take a look at the impact on rates beginning in 1986, the year legal challenges to the law were finally exhausted. From 1986 to 2000, premiums fell 12% in California, while rising 55% nationally (inflation adjusted dollars). During that same period, rates in Florida rose 809%; in Nevada 8375%! Under our forward-thinking law, injured patients are entitled to unlimited medical and economic compensation, which often amount to millions of dollars to cover true damages, such as lost wages, medical expenses, rehabilitation, psychotherapy and long-term care costs. Physicians support such full compensation of injured patients. And under MICRA, patients can also recover an additional quarter of a million dollars in non-economic or “pain and suffering” awards. The law also limits contingency legal fees so that seriously injured patients get more (and their attorneys correspondingly less) of the award. Regardless, the law remains under siege from trial lawyers. But the number of medical malpractice suits has remained stable and From 1986 to 2000, premiums fell 12% in California, while rising 55% nationally (inflation adjusted dollars). During that same period, rates in Florida rose 809%; in Nevada 8375%! awards have risen far faster than inflation since 1986, indicating injured patients retain their access to the courts and fair recovery. And in California, injured patients are compensated more quickly than in all states but Minnesota. The real reason personal injury lawyers hate MICRA is that it limits the money they make from patient misfortune. Trial lawyers are not an endangered species. But physicians, emergency rooms and safety-net programs for the uninsured are truly threatened, and everyone’s access to care is endangered without reform. Stabilizing insurance premiums is particularly essential for the poor, who get their health care from economically fragile medical clinics and health centers. It’s MICRA, NOT Proposition 103 The suggestion that Prop 103 forced medical liability rates down in California is clever but lacks any foundation in fact. MICRA was enacted in 1975 but was immediately challenged in the courts. Until the legal challenges were resolved and the courts and lawyers got comfortable with the application of its various provisions, there were no savings from MICRA. After the lead case of Fein v. Kaiser Permanente was decided in 1985 it took several years for the judgments and settlements to show a downward trend. When Prop 103 was passed in 1989, the California medical liability insurers were already returning MICRA savings to physicians in the form of policyholder dividends. Several had filed for rate reductions but found the California Department of Insurance reluctant to even approve rate reductions until the legal status of PROP 103 was resolved. To break the logjam, the physician owned companies met with Commissioner John Garamendi shortly after he was elected. The commissioner examined the medical liability rates and found them appropriate. No rollbacks were required and the policyholder dividends that the companies were paying were accepted in lieu of a rollback refund. Commissioner Garamendi and his staff did not interfere in any way with the medical liability rates. Not a single medical liability rate filing has been denied in California since Prop 103 was enacted. In addition to rate reductions voluntarily undertaken by physician owned medical liability insurers in California since 1989, the physician owned companies have voluntarily returned to California physicians over half a billion dollars in policyholder dividends in the 1990s in response to savings realized through application of MICRA. Since Prop 103 does not affect policyholder dividends, these reductions cannot be attributed to Prop 103. MICRA has kept premiums in California fair and predictable, not Proposition 103. This is a clever trick by the trial lawyers, but has no basis in fact. When Prop. 103 was passed in 1989, the California medical liability insurers were already returning MICRA savings to physicians in the form of policyholder dividends. Before MICRA, California physicians paid the highest malpractice premiums in the country. Today they pay a fair share — 11 % of the total premiums across the country for a state that has about 12 percent of the national physician population. Furthermore, using real dollars, the cost of California premiums has gone down 51.9% since 1976, compared to a crisis state like Nevada who has seen the average premium cost per person go from $4.05 in CONTINUED ON PAGE 30 12 / CALIFORNIA PEDIATRICIAN — SPRING 2003
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Page 3 and 4: TABLE OF CONTENTS continued Distric
Page 5 and 6: in and of itself, but I think you t
Page 7 and 8: CMA House of Delegates Report Paul
Page 9 and 10: Adolescent Idiopathic Scoliosis Whi
Page 11: A Low-Glycemic Index Diet in the Tr
Page 15 and 16: The Tao of Pediatrics and Chinese M
Page 17 and 18: Chronic Pain in Children: A Multidi
Page 19 and 20: LUNG TRANSPLANTATION CONTINUED FROM
Page 21 and 22: Childcare Health Linkages Program:
Page 23 and 24: Annual Las Vegas Seminars — 25 Ye
Page 25 and 26: Early Hearing Detection and Interve
Page 27 and 28: THE TAO OF PEDIATRICS AND CHINESE M
Page 29 and 30: A LOW-GLYCEMIC INDEX DIET IN THE TR
Page 31 and 32: I write in late March, as American
Page 33 and 34: Nikta Forghani, M.D. Weighing the R
Page 35 and 36: COUNCIL ON CHILD HEALTH CHAPTER 1 B
Page 37: CALENDAR May 14, 2003 Los Angeles P

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