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From the Townsend Letter
November 2013

briefed by Jule Klotter
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Titanium Implants
For seven years, actor Dick Van Dyke suffered with pounding headaches, chronic fatigue, insomnia, and neurological symptoms. Doctors were at a loss; an MRI, a spinal tap, and other tests were all normal. Van Dyke finally resorted to a plea on Twitter: "‘Anyone got any ideas?'" It turned out that dental implants that replaced missing teeth were causing his symptoms. The roots of the implants were titanium, a metal that is biocompatible for most people.

Most metals in dental alloys and medical devices readily bind to cellular enzymes and cells, according to Vera Stejskal and colleagues. Stejskal et al. theorize that T-cells attack "metal-modified cells," producing inflammation and, eventually, autoimmune disease in susceptible people. Replacing metal implants with ceramic and composite implants usually, but not always, resolves symptoms – provided that the removal is done very carefully. "[Removal of incompatible dental material] has to be done with extreme caution," they write, "and according to standard working protocol" in order to avoid exposing the patient further.

Exposure to metal allergens – whether via implants, medical devices, or food – can produce chronic fatigue syndrome and fibromyalgia-type symptoms. The most common metal allergen is nickel, followed by inorganic mercury, gold, phenyl mercury, lead, cadmium, and titanium.

Hubbard SB. Dick Van Dyke traces mystery illness to dental implants [online article]. NewsmaxHealth. June 3, 2013. Available at Accessed June 27, 2013.

Stejskal V, Hudecek R, Stejskal J, Sterzl I. Diagnosis and treatment of metal-induced side-effects. Neuro Endocrinol Lett. 2006:27(Suppl 1):7–16. Available at Accessed August 11, 2013.

Medical Cost Transparency
For the past four years, the Surgery Center of Oklahoma (Oklahoma City, OK), an ambulatory surgical center, has been posting its all-inclusive prices for numerous procedures online. The center charges $3975 for laparoscopic hernia repair and $3200 to remove a gallbladder, according to New York Times writer Tina Rosenberg. In comparison, some Oklahoma City hospitals charge $17,200 for hernia repair and $24,000 for gallbladder removal – well above the Medicare break-even price. The center has attracted consumers from Canada and elsewhere in the US. "‘Patients are holding plane tickets to Oklahoma City and printing out our prices, and leveraging better deals in their local markets,'" Keith Smith, cofounder of the center, told Rosenberg. "‘… several other medical facilities in Oklahoma are now posting their prices as well'" – and lowering their prices.

Medical cost transparency is particularly important as more people turn to high-deductible medical insurance plans. These plans are less expensive, but subscribers have to cover more medical expenses themselves. Having to pay out-of-pocket is encouraging people to comparison shop – just as they would for any major purchase. In response, medical clinics and urgent care facilities and some hospitals are posting their fees online. "‘Providers are increasingly aware they need to have a cash or self-pay price,'" Jeanne Pinder told Rosenberg. Pinder, a former New York Times reporter, founded, a site that posts medical procedure costs for New York City, Los Angeles, San Francisco, Houston, Dallas, San Antonio, and northern New Jersey. New Choice Health is another website for medical cost comparison. More sites are sure to follow.

Large hospital chains, not insurance companies, keep medical costs high, says Rosenberg. These chains have the upper hand during negotiations with insurers. They know that preferred provider organization (PPO) insurers are willing to bow to hospital demands for higher prices, secrecy, and bans on challenging prices in order to have access to popular providers. When insurance companies negotiate deductions, the starting point is a hospital's chargemaster price list. Chargemaster prices are set by individual hospitals. The charges are usually set at about three times the Medicare price, but the recent trend toward transparency has revealed that some hospitals have fixed their prices at 10 or 20 times the Medicare price. (And, no, price does not reliably predict quality of care.) Insurers pass the higher costs to their clients in the form of premium increases.

Rosenberg found that some large companies are bypassing insurance companies and ever-rising premiums. In "The Cure for the $1000 Toothbrush," Rosenberg recounts the experience of Dallas company Texas811 with its 200-odd employees. After receiving notice that Blue Cross PPO premiums were going to rise 68%, Texas811 sought other options. The company eventually signed on with GPA, a Dallas-based company that administers claims for over 200 workplaces. GPA works with ELAP (Philadelphia, PA) to advise self-funded employer groups and help control health care costs. Instead of seeking deductions from a hospital's chargemaster list, GPA negotiates from the bottom up, starting with the break-even Medicare cost. Unlike chargemaster lists, the Medicare algorithm is totally transparent and based on real costs.

Following GPA's advice, Texas811 saved an unbelievable amount of money. Under Blue Cross, dialysis cost the company $10,000 per visit; with GPA, dialysis cost $975 per visit. Because of the savings, the company was able to add free dental and vision coverage and free life insurance, and set up a free primary-care clinic for employees and their dependents. ELAP says that clients typically see a 15% to 20% reduction in costs in the first year after leaving a PPO – more if employees have high hospital costs. Unlike PPO insurers, ELAP and companies like them audit every bill for unreasonable charges, double-billing, and errors.

The secrecy between hospitals and insurers contributes to escalating medical costs. Transparency can help consumers regain some control.

Reinhardt UE. How Medicare sets hospital prices: a primer. New York Times. November 26, 2010. Available at Accessed August 30, 2013.

Rosenberg T. The cure for the $1000 toothbrush. New York Times. August 13, 2013. Available at Accessed August 28, 2013.

——— Revealing a health care secret: the price. New York Times. July 31, 2013. Available at Accessed August 11, 2013.

Sinaiko AD, Rosenthal MB. Increased price transparency in health care – challenges and potential effects. N Engl J Med. March 10, 2011:364(10):891–894.

Sleep Disorders and Vitamin D Deficiency
Is vitamin D deficiency the underlying cause of sleep disorders? S. C. Gominak and W. E. Stumpf argue that it is in their 2012 article for Medical Hypotheses. Vitamin D receptors are located in the same brain areas associated with sleep initiation and maintenance, particularly in the hypothalamus and brainstem. "Vitamin D is now commonly accepted to be … a steroid hormone," they write. "It is the hormonal link that coordinates our metabolism, and the digestive, cardio-vascular, immune, endocrine, and reproductive systems to the sun. …" People now spend less time outdoors, which means less exposure to sunlight, the primary source for vitamin D.

Over a two-year period, the two researchers observed 1500 patients with diverse sleep disorders (obstructive sleep apnea, REM related apnea, absent or reduced REM or slow wave sleep, insomnia) and headache upon waking. Patients, most of whom were vitamin D deficient, slept normally when their vitamin D blood levels stayed between 60 ng/ml and 80 ng/ml with the help of D3 supplementation. If blood levels dropped below 50 ng/ml or rose above 80 ng/ml, the patient's original sleep problem returned. Supplementation with vitamin D2 (ergocalciferol) actually prevented normal sleep in most patients. "As with other hormones such as thyroid, it is the 25(OH) vitamin D blood level, not the dose, that must be stabilized to observe a clinical effect," say the authors.

"Our hypothesis, that vitamin D deficiency may be a primary cause of sleep disorders," say Gominak and Stumpf, "should prompt clinical trials for patients suffering from several sleep disorders that have historically been very difficult to treat: primary insomnia, patients unable to tolerate CPAP, patients inexplicably tired on awakening."

Gominak SC, Stumpf WE. The world epidemic of sleep disorders is linked to vitamin D deficiency. Medical Hypotheses. 2012;79:132–135. Available at Accessed August 15, 2013.

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Jule Klotter


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