Accountants are sometimes disparagingly called “bean counters,” but the truth is that counting beans is much like counting money. Body weight is the result of calories consumed minus calories burned just as net income is revenue less expenses. The calories we put in our mouth are used up by both our basal metabolism and physical activity. Any excess gets stored as fat while a deficit burns up the stores, resulting in weight loss. The bottom line is that 3,500 calories equals 1 pound. Accountants and health care providers will argue that it’s not so simple. Fair enough; consider this a “bare bones” explanation.

To employ a lifestyle that ensures a healthy weight, it is essential to drill down and understand the details of a caloric profit and loss statement. Countless patients complain to their health care providers that they watch what they eat and get plenty of exercise but can’t seem to take off the extra pounds. Once the provider determines through laboratory testing that there is no medical reason for weight gain, such as an underactive thyroid, the therapeutic relationship can reach an uncomfortable impasse.

Failure to lose excess weight in the face of a reasonably healthy diet and regular exercise often comes from overestimating how many calories are burned by physical activity and underestimating how many calories are in those little tasty rewards for good behavior. To lose 1 pound per week, one simply needs to reduce their steady-state intake by 500 calories per day. Here are some foods that can be left off the table to get there: two Spam musubi (506 calories), 1 cup of macaroni/ potato salad (509 calories), 1 cup of oxtail soup (458 calories), one lau lau (414 calories) or one Big Mac (550 calories).

In contrast, calories burned during a given activity depend on one’s current weight, height, age, gender and other individual characteristics. Still, the average person burns about the same amount of energy while watching television as when sleeping and only slightly more when sitting at a desk. Roughly 500 calories are burned during a decent night’s sleep. On the other end of the spectrum, scuba diving can burn as much as 900 calories per hour depending on how cold the water is, while moving along on a stand-up paddleboard will average roughly 500 per hour. Swimming draws roughly the same as does mountain biking or a strong-paced hike up Koko Head. Yoga can also burn up to 500 calories per hour when practiced full tilt.

While diet and physical activity are both essential to maintaining a healthy weight, to pay for one slip of the tongue can take a huge physical effort. Unless you are fully ready to hustle up Koko Head right after lunch, don’t eat that second lau lau. Let it slide only a few times and be ready to carry around an extra pound next time you take the hike. Call my CPA if you don’t believe me.

Happy Thanksgiving!

Wealth of Health, Money Section

Honolulu Star AdvertiserSaturday, October 6, 2018

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Future of US Healthcare Highly Uncertain

The road ahead for US healthcare remains highly uncertain. The Affordable Care Act (ACA), also known as Obamacare, quickly covered approximately half of those who were previously uninsured. However, while fine-tuning to deliver its central aims of access to quality care at  reasonable cost, all three branches of government have posed troublesome challenges. Multiple efforts to repeal and replace the ACA have failed, and instead, its foundation has been actively weakened. What next? While the majority of the public is opposed to a repeal of the ACA, intense uncertainty has spawned a range of competing initiatives for the future of US healthcare.

Medicare-for-all: Under this scheme, the US would move toward a government-run, national healthcare system more consistent with that of the majority of modern nations. Of note, during the recent democratic primary elections, the majority of the candidates who prevailed are moderate-leaning and their support of Medicare-for-all is far from assured.

The benefit of Medicare-for-all is that legal residents and citizens would all have access to care, something the ACA has not yet fully achieved. With greater government oversight, costs may also go down, possibly bringing the US more in line with all other national health systems which spend considerably less per capita.  The downside is that care would become more homogenized and access to expensive new and life-saving treatments is sure to be more limited. The transition to such a system would be tumultuous.

Repeal and Replace, or just continue to erode:  Multiple attempts by Congress during the past two years to quit the ACA have failed. It remains unclear what would replace it. While full repeal is now unlikely, continued efforts to erode the current system may continue. Examples include the elimination of the “healthcare mandate.” That is, the unworried well can opt out of insurance participation without tax effect. This increases premiums because those who do participate, represent a higher risk population. Medicaid block grants to states shifts costs and the burden of responsibility away from the federal government. “Skinny Plans”, one more blow to the ACA enables participants to reduce premiums by reducing the menu of coverage.

Improve the Affordable Care Act: In contrast, another real possibility is that the country will get back to the work of refining and improving the ACA in a manner that continues to increase access to quality care, and reduces cost while improving efficiency.  Efforts must be directed to stabilize insurance markets and bring premiums under control.

End-Around by Private Sector: Recently, JP Morgan, Berkshire Hathaway and Amazon announced that they would collaborate to build a separate healthcare system for their employees.  Remember however, that the responsibility of a publicly traded company is to its stockholders, not its patients. While a new private system might offer lower prescription drug costs, greater efficiencies and more technological solutions to access, diagnostics and treatment, would this work toward the best interests of those who are sick?  Increasingly, our personal data is hijacked as we access search engines, communicate via social networks, and buy online. If we are opposed to subterranean influences on our behavior when we purchase breakfast cereal or sportswear, we shouldn’t be surprised by who might now influence our healthcare decisions and to what end?

Hawaii Buffered: While Hawaii is not immune to any of the above initiatives, it is somewhat buffered. The Prepaid Healthcare Act ensures that employees who work 20hrs per week for 4 consecutive weeks are offered health insurance by their employer. Quest, a unique insurance product that combines Federal and State dollars, has for years optimized the number of covered lives in Hawaii. The late Senator Inouye ensured that Hawaii would not be made to accept any provisions of the ACA if they were less favorable than what already exists. Finally, the Hawaii State Legislature has signaled its determination to create a backstop to the prospect of a repeal of Obamacare.

Uncertainty about the future of American healthcare is uncomfortable for all including patients, providers, payers and governments. It is comparable to the downward pressure of uncertainty in the stock market. We live in interesting times.

Ira “Kawika” Zunin, MD, MPH, MBA, is a practicing physician. He is medical director of Manakai O Malama Integrative Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. His column appears the first Saturday of every month. Please submit your questions to info@manakaiomalama.com or for more information go to: https://www.manakaiomalama.com/

Ira Zunin, M.D., M.P.H., M.B.A
Medical director of Manakai O Malama

Today’s society has an abundance of quality professionals you can trust. They are well trained, highly experienced, caring and good at what they do, capable people upon whom you can rely … with one exception. Little gets done on time. Despite the best of intentions, execution is routinely delayed and, without repeated reminders, might never happen. This impairment in the conduct of business and personal relationships has reached epidemic proportions. I call it integrity diffusion. Tragically, it is the new normal.

In the era of online and mobile communications, we have the ability to maintain a plethora of personal and professional relationships — far more than ever before. So many that we fail to do them justice. Because the majority of these relationships are neither real time nor face to face, we often feel less obligated to honor our commitments and follow through on what we have agreed to.
In the old days a job application required a resume and a cover letter in a stamped envelope. Now, using Craigslist, with a few key strokes one can apply for countless jobs even if unqualified. “Yes, I’ll be there at 10 a.m. tomorrow to interview.” But then another call comes in, for a position slightly closer to home. “No problem, I’ll be there at 9:45 a.m.” Yet there is no sense of responsibility to cancel the first appointment. Result: another no-show.

A teacher of mine once said that every time we honor  commitment, it brings us power. When we fail to deliver, our human connections weaken, our personal credibility dissipates and we suffer from integrity diffusion. It not only erodes the local community. It also affects society in a pervasive manner, reducing productivity and efficiency.
It is the product of the GPS mind in which our focus jumps from one random input to another, stretching thin our relationship to self and ohana, leaving us with little sense of place.

No one is automatically immune to integrity diffusion. Not lawyers, accountants, builders, PV installers, politicians or health care facilities. “I’ll have it to you by the end of business today.” Yet in the interim a hundred other inputs touch us, and, unaware, we drift away from our commitment. It happens so often to each of us that we have come to consider it a nonissue. “Whatever, I’ll get to it in the morning.” But when we awake the next day, there is a whole new set of texts, missed calls, emails, Twitter, Facebook, Instagram, Viber, WeChat and other messages.

What to do? At Manakai o Malama we train staff to use a technique we call “Close the ticket.” When staff are asked by a patient, supervisor or colleague to complete a task, one first acknowledges the request, and a projected time to completion is agreed. This opens a ticket. The ticket is not closed until two things happen: First, the task must be completed; next, confirmation is sent to the one who made the request. If there is a delay or an unexpected challenge, possibly related to execution by a third party, that must be communicated. “I thought this would get done by lunch time, but I need another 24 hours.” The key is to remain accountable until completion and to communicate.

No one is perfect, but understanding that we live amid an epidemic of integrity diffusion is the first step toward healing this modern disease. Setting one’s intention to live a life of integrity and accountability is the next step. The third step involves maintaining awareness and focus. Step four involves active and responsible communication. Eventually, it becomes second nature. Actually, integrity is our true nature and key to being pono. Guard against integrity diffusion. Doing so will strengthen personal relationships, enhance business success and make the world a healthier place.