Sunday, April 21, 2024

How much will that cost me? On hospital pricing

Hospital pricing is notoriously difficult to understand. Until very recently, it was also impossible to find out how much a hospital was going to charge you for a test or procedure until you got the bill.

Starting January 1, 2021, each hospital operating in the United States was required to provide clear, accessible pricing information online about the items and services they provide both as a comprehensive machine-readable file with all items and services and in a display of shoppable services in a consumer-friendly format.

Initially this rule was largely disregarded, and those hospitals that did post prices did so in a way that only computer geeks could access. Gradually, more hospitals are complying.

Does this matter to you? If you have good health insurance, it may not matter that much, as your insurance company will have negotiated rates for most hospital services. If you are uninsured (still 10% of the U.S. population) or if you are among the many more with high-deductible plans, it matters a lot.

If you have a high-deductible plan, you may have to pay the entire charge for an MRI of your knee, and so if it is $800 or $2800 matters.

There are two things you need to know before “price shopping” for a test or procedure.

The first is that prices vary wildly, and with little correlation between price and quality. A recent study found that the hospital charge for uncomplicated vaginal childbirth varied from $1183 to $55,221 (that is not a typo!).

The second is that if you call the hospital billing department and ask the price, there will often be a major difference between what you are told and what is posted on the hospital website. In only 15% of hospitals that both posted prices on-line and gave them over the phone were the prices the same, and differences often exceeded 50%.

So…if you are uninsured or underinsured, take the time to price shop when you can – when it is not an emergency. Try the websites for several hospitals near you to get an idea of which are at the high end and which at the low end. Then, try calling the billing departments. If they quote you a lower price than the on-line price, get in in writing by email or post.

Two other cost-conscious suggestions:

When you are well, check which hospitals near you are in your insurance network – when you are ill this will probably not occur to you, and going to an out-of-network hospital can cost you dearly.

Just because your doctor says you need something does not guarantee that it will be covered. Always ask if prior authorization is needed before having the test or procedure.

The money you may save will be yours!

Prescription for Bankruptcy. Buy the book on Amazon

Saturday, April 13, 2024

But I read it on Facebook!

The Internet has led to democratization of information access. Information that was locked away in libraries or simply not readily available to most of us can now be found with a simple search.

Along with that, however, has come a flood of misinformation. When you do a Google search, the leading links may be pure gold or utter dross. How can you tell the difference?

If you were to open your favorite social media site and read that Frigidaire appliances were suddenly bursting into flames, would you immediately put your refrigerator out on the street? I doubt it – you would probably check this out on Consumer Reports or call your appliance store. You would also apply your common sense.

So, why is it that some of my patients would come to a visit and say they had stopped their cholesterol medication because they saw a post that the medicine caused dementia?

Anything can be posted on the Internet. Some flagrantly racist or other hate speech may (or these days may not) be taken down, but grossly misleading health information usually stays on-line.

When you search, the top hits are often sponsored links or sites that have carefully managed their description to get a high ranking, with minimal relation to the quality of the content.

How can you tell if a site is worth visiting? Focus on the messenger before looking at the message. The best place to look for scientifically valid and unbiased information are sites maintained by the National Institutes of Health. These will always have the domain as part of their URL. Another great source of information is the National Library of Medicine, whose URL will contain

If these do not give you what you want, go next to websites maintained by major medical centers such as the Mayo Clinic, Johns Hopkins or Mass General-Brigham. These will obviously lean towards attracting patients to their institution, but still have high quality content.

Avoid celebrity sites and those that are trying to sell products or services.

The quickest way to decide if a link is likely to be useful is to go first to those tagged .gov, then to those tagged .edu and third to those tagged .org.

When seeking health information, caveat emptor!

Prescription for Bankruptcy. Buy the book on Amazon

Monday, April 8, 2024

Bird flu - time to panic?

Spoiler alert: No.

What is bird flu? It is an influenza virus, related to the seasonal flu viruses that plague us every winter but one which predominantly spreads among birds. The specifics are that is an H5N1 form of influenza. (Those letters and numbers describe certain proteins on the virus surface and vary quite a bit from year to year, epidemic to epidemic.)

This particular virus has reached pandemic status among birds – it has been found on every continent but Australia and has killed millions of birds. It seems to be spread by migrating wild birds but has been lethal to domestic fowl, leading to the culling of many flocks in Europe and America. The price of foie gras may go up.

The reason for the recent interest is that the virus can spread from birds to mammals. Foxes, cats, seals, dolphins and bears have been infected. Most recently, outbreaks of bird flu have occurred in dairy cattle in the U.S. Herds in at least five states have been infected.

Last week, the virus was confirmed to have infected a human: a farmworker in Texas. This is not new; scientists have known for some time that people who have direct contact with sick birds or mammals can be infected. To date, there have been no known cases of human-to-human spread.

The virus has been found in the milk from infected cows and eggs of infected chickens, but the virus is killed by pasteurization or cooking. It could potentially be spread by consuming raw milk or using uncooked eggs.

To become a serious threat to human health, the virus would have to undergo major mutations to allow human-to-human spread. Not impossible, but unlikely.

Also in our favor is that the few people proven to be infected with H5N1 have had very mild illness. The man in Texas had only conjunctivitis (“Pink eye”).

Finally, the antiviral drugs like oseltamivir (Tamiflu) work well to reduce symptoms, and are readily available.

So… stay away from raw milk for now, be sure to cook your eggs, and, most important, do not pick up or examine dead birds or animals, and warn your children not to do so. A veterinarian called to a north shore beach found that the dead birds were all infected. Let the pros handle it.

Prescription for Bankruptcy. Buy the book on Amazon

Sunday, March 31, 2024

Colon cancer - find it early!

Cancer of the colon and rectum is very common. Colorectal cancer will occur in over 150,000 Americans this year. It is the third-leading cause of death in men and the 4th in women. Because it is an “equal opportunity” scourge, it is the second-leading cause of death when combining men and women (just behind lung cancer).

Very troubling is the increasing incidence in younger people, a phenomenon that doctors cannot yet explain. We used to think that it was very rare in people under 50 unless you had an uncommon genetic risk, but colorectal cancer is being increasingly diagnosed in people in their 40’s or even 30’s.

When caught early, it is very curable. The secret is early detection.

The controversy is how best to detect it early and when to start looking.

Most cancers begin as polyps, some of which slowly develop into cancer. The hallmark of such pre-cancerous polyps is “atypia,” which can only be proven with microscopic examination. If all polyps are removed, the likelihood of ever developing cancer is minimal.

Clearly the ‘gold standard’ of early curable cancer detection is colonoscopy. After a good clean-out, allowing the gastroenterologist to see well, any polyps present can be removed and sent for examination. Ideally, everyone over 40 should have a colonoscopy (5 years ago I would have said over 50). If it is entirely normal, your next one can be in 8-10 years. If polyps are removed, that timetable will be shortened.

The problem is that no one LIKES having a colonoscopy. It is really not that bad. When you finish this post, Google “Dave Barry colonoscopy.”

No matter how much I or your primary care doctor urge it, not everyone will consent. There are other ways to detect colorectal cancer before symptoms develop, when it is often advanced.

The commonest test is to check for hidden bleeding in the bowel, which can herald polyps. Of the available tests for this, the current standard is the FIT (fecal immunochemical test), which has only about a 25% predictive value for cancer and advanced polyps when positive. A negative test does NOT guarantee you are in the clear, and to be useful the test must be done annually.

Another option is a stool DNA test, which is much more specific for advanced polyps and early cancers. On the horizon are blood tests that are fairly accurate.

Key to properly using any stool or blood test is to follow a positive test with a colonoscopy – sadly only half of people with such positive tests get one in a timely manner.

Buck up – listen to Dave Barry and just do it. The life you save will be your own.

Prescription for Bankruptcy. Buy the book on Amazon

Tuesday, March 26, 2024

Kidney from a pig - is it really a big deal?

Your kidneys are critically important organs that clear toxic substances from the body and regulate your fluid balance. Kidney disease is very common, affecting millions of Americans. So-called “end-stage” kidney disease is kidney disease so advanced that without treatment, death is imminent. Presently, over 800,000 Americans are affected by this advanced stage of the disease.

It is very rare that kidney disease can be cured surgically or medically. Instead, you must either get a new kidney from a donor or go on dialysis. Dialysis is a technique in which the blood is filtered by a complex machine that tries to do what the kidneys are no long capable of doing. The technique was developed in the 1940’s but only became widely used in the 1970’s.

Dialysis, to be blunt, is no fun. You have to be connected to the machine 3 times a week and stay at the center for 3 to 4 hours each visit. About 1 in 7 dialysis patients, who have good home support, can do the procedure at home. While it is life-saving, patients on dialysis rarely feel really well.

A breakthrough in the treatment of kidney failure came in 1954 with the first transplantation of a kidney from a human donor to a patient with end-stage kidney disease. This was done by Dr. Joe Murray at the Brigham, and the donor was the recipient’s identical twin. The first transplant from an unrelated donor came 8 years later, in 1962.

Any time an organ is transplanted from anyone but an identical twin, the body recognizes the transplanted organ as foreign, and tries to eliminate it, the way it tries to eliminate bacteria. To prevent rejection of the new kidney, the body’s immune system must be suppressed, leaving the recipient at higher risk of infection.

When transplantation is successful, the recipient of the new kidney feels much better, physically and emotionally, as they can now lead a normal life rather than being tied to a dialysis center.

Why don’t all patients with end-stage kidney disease get a transplant? Simple: there are not enough organs available. Of the 800,000 with the condition, over 2/3 are on dialysis and fewer than 1 in 3 have had a transplant.

If the recent transplant, from a pig that was genetically engineered to have kidneys that were closer to human genes, is successful, the huge bottleneck that is availability of kidneys for transplant would be removed.

Can we declare success? Not yet. The two men who had pig hearts transplanted both died soon after the surgery. We hope the Boston man who got the recent transplant does well, but only time will tell. There are too many unknowns to predict the outcome. In addition to the problem of rejection of the new organ, pigs carry many viruses that humans do not, and one or more of these may cause problems.

If this volunteer is alive and with a functioning kidney in several years, a giant step will have been achieved.

The number one cause of chronic kidney failure is poorly controlled high blood pressure, so if you have hypertension, be sure to have it controlled with medication.

Prescription for Bankruptcy. Buy the book on Amazon

Monday, March 18, 2024

Ultra-processed foods: what are they? Why should you care?

About half the calories consumed by people in high income countries such as the United States and Canada come from ultra-processed foods, and such a high consumption of these “Franken-foods” contributes to many health problems.

What are ultra-processed foods?

Most of our food is processed to some degree, if only with preservatives, and not all processing is bad. Pasteurized milk is “processed,” and is generally safer than unpasteurized milk. Iodine added to salt gives health benefits.

There are many ways to classify how foods are processed, but the most widely used system is NOVA, developed by academic food scientists in Brazil.

NOVA Group 1 includes unprocessed or minimally processed foods. The latter includes removal of inedible parts, drying, roasting, freezing, etc., with no additives.

Group 2 includes processed ingredients such as salt, sugar and oils that are used as additives.

Group 3 includes foods where the Group 2 ingredients are added to Group 1 food to increase their durability and enhance their flavor.

Group 4 foods are those that are ultra-processed, foods that are manufactured, often in several steps. Natural food products are fractionated into sugars, protein, oil and fats, starches and fiber. These component parts are then chemically treated, most often by hydrolysis or hydrogenation. The final food product is then assembled with various industrial techniques and colors, flavors and preservatives are added.

Common ultra-processed foods we may consume daily include carbonated soft drinks, packaged snacks, ice cream, flavored breakfast cereals, prepared pies, pasta dishes and pizzas, “nuggets,” hot dogs, sausages and powdered instant soups and desserts. Note that some of these may be labelled “all-natural” or organic.

Why should you care? High consumption of ultra-processed foods has been linked to such health problems as obesity, diabetes, high blood pressure, cancer and many gastrointestinal disorders.

Recent studies have shown that ultra-processed foods, usually high in both sugar and fat, trigger a similar brain response as do addictive substances like nicotine and alcohol.

What should you do? First, realize that U-P foods are not arsenic. Having a scoop of ice cream or some fries once in a while will not kill you. In moderation, they can be part of a healthy diet. The goal is to keep U-P foods to less than 25% of your daily calories.

Eat fresh or stewed fruit in place of store-bought pies and cakes. For breakfast, have oatmeal or minimally processed granola with fruit rather than sugary cereals. Cook more: bake chicken or fish rather than heating up prepared frozen dinners.

Look at labels. If a product contains 4 or more ingredients, some of which you cannot pronounce, put it back. If it is obvious where the food came from (eggs come from hens, apples from trees) it is generally OK. If the origin is unclear, try something different.

Don’t fall for hype – an “organic natural” packaged cookie might still be ultra-processed.

Prescription for Bankruptcy. Buy the book on Amazon

Sunday, March 10, 2024

Why do so many American women die from childbirth?

For most of human history, pregnancy and childbirth was the cause of many women’s deaths. In the modern era, this should be an extremely rare event, and in most of the developed world it is.

About 800 women in the U.S. die every year during pregnancy, delivery or the 6 weeks that follow delivery. Our maternal mortality statistics are our shame. Maternal mortality per 100,000 live births is 4.4 in Sweden, 8.0 in France, 9.2 in the United Kingdom and 7.3 in Canada, while in the U.S. it is 26.4.

Globally, maternal mortality has been steadily falling while in the U.S. it has been rising.

There is a clear racial disparity, with deaths from pregnancy much higher among Black and Native American women than among white, Asian and Hispanic women. For Black women, poorer care compounds their tendency to more of the hypertensive disorders of pregnancy. However, even white women die at a higher rate in the U.S. than in any of our peer developed countries.

Why is this? Doctors here are often too slow to recognize the importance of even mild high blood pressure in a pregnant woman and fail to treat it, leading to the dangerous condition called eclampsia. Because severe complications of pregnancy at any given hospital are rare, most hospitals do not have an organized plan to deal with severe hemorrhage after delivery or embolism of the amniotic fluid (large bubbles of amniotic fluid entering the mother’s circulation).

Experts who study maternal deaths estimate that about 70% of the deaths due to hemorrhage, infection or cardiovascular conditions are preventable. California adopted a comprehensive plan to lower maternal deaths, with “best practice” guidelines widely distributed to every hospital and obstetrician, and was able to cut its death rate in half between 2006 and 2013.

Additionally, many women die from treatable mental health problems, notably depression and suicide, that are missed, often because the new mother is not seen after delivery. While most women bring their infants in for a well-baby visit, many skip their own post-partum check, often because they do not want to take time off from work.

Most western countries provide ample paid time off for new mothers, no matter their occupation, while in the U.S. this tends to be a “luxury” afforded only to highly paid professionals. We should be advocating for 3 months paid maternity leave for ALL women.

Ask your local hospital if it has systems in place to deal with the infrequent but lethal emergencies that occur during pregnancy and delivery. Make sure any friends and relatives who deliver have adequate support. Offer to take them for post-partum checks.

We should be emulating Sweden and Canada, not Afghanistan and Swaziland.

Prescription for Bankruptcy. Buy the book on Amazon