Wednesday, December 26, 2018

Do I need to go to the emergency room?

It is 5 PM on a Thursday and you have had a nagging pain in your cheek all day. You otherwise feel well, and have no obvious fever. You called your family doctor but a few minutes too late and just got the answering service. Now what? Could you have a sinus infection? What you do next has a huge bearing on the costs of the U.S. health care system and quite possibly on your budget as well.
For many of us, the next step is to hop in the car and go to the closest emergency room, where you know someone will see you. Of course, in most communities you had better bring a large book, because odds are you will be sitting in the waiting room, along with crying children and coughing adults for many hours. When you are seen, you may be prescribed an antibiotic you really do not need, because the doctor knows you have been waiting for hours and expect a prescription, and it is easier to do this than to explain why you don’t need it. Chances are that a few weeks later you are going to get a complex set of papers that seem to indicate you are on the hook for $500 of the $1250 bill from the emergency department visit.
In Massachusetts, estimates are that 39% of the annual 2.4 million ER visits were for conditions that could as easily have been cared for in a doctor’s office or urgent care setting. The costs of care in these settings differ dramatically. The average ED visit costs $1220, while the average cost of an office visit is $165, at an urgent care center $172 and in a drugstore retail clinic, $69. This huge disparity in charges has many insurers working hard to keep you out of the ED, and the bluntest tool they have to do this is to impose a huge co-pay on visits that do not result in a hospital admission or even refusing to pay at all.
This attempt to reduce inappropriate ED visits can unfortunately cut needed visits as well. If a patient is worried about the expense, they may avoid an emergency visit for a problem that clearly does need emergency care, such as chest pain or passing out. Since insurers pay based on diagnosis codes that are based on the physician’s final diagnosis after a complete evaluation and patients have symptoms, the insurer may decide your final diagnosis coded as “gastritis” did not warrant the visit when your severe chest pain and nausea clearly did suggest such an urgent visit.
Another potential problem is that even when you visit a hospital that is in your insurer’s “network,” the emergency physician group that staffs the ED may not be contracted with the insurer. A major dispute is on-going between UnitedHealthcare, America’s biggest private health insurer, and Envision Healthcare, one the country’s largest employers of doctors who cover emergency departments around the country. If they cannot find a compromise, patients visiting ED’s staffed by Envision doctors will find themselves getting enormous surprise bills come January 1.
What should you as a patient do? If you are having chest pain or trouble breathing, or if you have suffered a serious injury or have another problem that obviously needs immediate attention, call 911 and get seen. If you have a problem that can wait to be seen in your doctor’s office, it is better for your pocketbook and your health to do just that. If you do not have a family doctor, or if you feel you cannot wait until they are able to see you, try an urgent care center first. In many cases, either the on-call doctor reachable by phone or a nurse advisor paid by your health insurer can help you make this decision.

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Thursday, December 20, 2018

Insulin: The Canary in the Coal Mine?

First, a word about insulin. Insulin is a hormone produced in the pancreas that has many roles in the body, but most importantly regulation of the way the body uses sugar. Some people develop an “auto-immunity” against the islet cells that produce insulin and stop making it: this is Type 1 diabetes (which used to be called Juvenile diabetes because it is the commonest type in young people). Before the discovery of insulin, patients with Type 1 diabetes all died very soon after the disease developed. Many more people have Type 2 diabetes, in which their islet cells still exist, but are not able to secret enough insulin, and their bodies resist the effects of insulin. Patients with Type 2 diabetes do not usually die of the diabetes itself but develop many complications affecting the heart, kidneys, eyes and blood vessels.
In the early 1920’s, Frederick Banting and Charles Best, working at the University of Toronto, discovered insulin and were able to extract it from the pancreases of animals. For patients with diabetes this was a life-saving miracle and Dr. Banting won a Nobel prize in 1923 for the discovery. For almost 70 years, beef and pork-derived insulin remained the main forms of insulin marketed. Late in the 20th century one of the first medical uses of genetic engineering allowed the production of synthetic insulins from modified yeast and bacteria. These are now the forms used by 99% of patients with diabetes. As I note in Prescription for Bankruptcy, the discoverers felt that insulin should be freely available to all patients who needed it, so they sold the patent to the University of Toronto for $1. If they knew what Big Pharma had done with their discovery, they would be spinning in their graves.
In the book I told about “Jack,” whose diabetes was never well-controlled because he was unable to afford the amount of insulin he needed, despite having employer-paid health insurance. Well, “Jack” was not alone. A survey by the American Diabetes Association early this year found that 27% of patients prescribed insulin were using less than the prescribed dose because of cost. A study published on-line on December 3, 2018 by JAMA Internal Medicine surveyed 199 patients attending the Yale Diabetes Center over the summer of 2017. Of their patients, 25.5% reported cost-related under-use of insulin. This pattern bore no relation to the type of insurance they had but did relate to their incomes. Patients with lower incomes were much more likely to under-use their insulin (except for those at the lowest level, who presumably had Medicaid, which does cover 100% of the cost of insulin).
Why is this so prevalent? Well, between 2007 and 2017, the average wholesale price (AWP) of four of the most popular insulins almost tripled in price. The AWP of Humulin, the most-prescribed insulin, rose from $258 in 2010 to $1100 in 2015. As employers have responded to the skyrocketing cost of health insurance by offering plans with higher deductibles and co-pays, the cost of insulin has put many lower and even middle-income patients in the position of choosing between optimal control of their diabetes and buying new school clothes for their children.
Remember: this soaring cost is not for a “elective” treatment or a convenience; it is for a critical medicine needed to keep people alive. Nor is it to support research; there was no improvement in the products as the price went up 3-4 fold. The price of insulin simply went up to give the manufacturers higher profits.
The “free market” is not working in pharmaceuticals. We must demand change.

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Saturday, December 15, 2018

Will Obamacare be finished? - DON'T PANIC

Millions of people panicked on Friday, Dec 14, when a conservative Texas federal judge declared the Affordable Care Act unconstitutional. First, do not panic! There will be no enforcement of his decision while this decision wends its way through the appeals process. Even the Trump administration, no friend of the ACA, indicated that enrollment would continue for 2019 health plan coverage.
The original attempts to litigate the ACA out of existence were based on the individual mandate, the requirement that everyone had to purchase health insurance or face a fine. This requirement was the only way affordable health insurance policies could be offered. If young healthy people opted to not buy insurance and only older sicker people did, the cost of health insurance would be exorbitant. The original legal challenges were based on the supposed inability of Congress to force people to purchase insurance. The Supreme Court ruled that this was a form of taxation, and that since Congress did have the power to tax, the ACA was constitutional.
Last year the Republican-controlled Congress eliminated the monetary penalty on people who chose to not buy health insurance. The Texas judge ruled that since the individual mandate was key to making the ACA work, the entire law was now invalid. Note that Judge O’Connor did not immediately block enforcement of the ACA, presumably knowing that his decision would be appealed, as it will be. If his decision were to stand, all provisions of the Act would be invalid, including the highly popular features such as allowing children to stay on their family policies until age 26 and the elimination of insurance companies’ ability to exclude “pre-existing conditions” from coverage.
Democratic attorneys general from several states have been defending the ACA since the Trump administration refused to do so, and they will be appealing Judge O’Connor’s decision to the New Orleans-based Fifth U.S. Circuit Court of Appeals. Whatever the Appeals Court rules, you can be sure that the U.S. Supreme Court is the next step.
As I have noted in prior posts, exclusion of coverage for pre-existing conditions is a serious problem for half of all Americans, and there is a growing swell of public opinion that this pernicious practice must not be allowed. Hopefully common sense (and fear of not being re-elected) will allow members of Congress to do the right thing.

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Saturday, December 8, 2018

Conflict of Interest: a growing awareness of the issue

In Prescription for Bankruptcy, I document the many possible conflicts of interest inherent in the relationship of doctors and the pharmaceutical industry. These range from the ubiquitous “free lunches” brought in by the companies’ reps, that have been shown to clearly influence prescribing patterns, to the more pernicious large financial amounts the industry gives to opinion leaders. Many of the “thought leaders” who write guidelines and lecture at medical meetings are heavily subsidized by Big Pharma, either in the form of research support and/or generous speaking fees. In addition, many of the experts who sit on FDA panels deciding whether to approve new drugs for marketing have strong financial links to the pharmaceutical companies.
Well, it turns out that this same issue is a potential problem in the medical device industry. Medical devices range from simple products such as syringes and canes to coronary stents and joint replacement prostheses. The global medical device market was estimated in 2015 to be worth $370 billion, about half the global market for prescription medications, and is growing faster than the pharmaceutical market. In the European Union and the United States, medical devices account for 6-7% of total health expenditures. A study published in the journal Health Affairs in October 2018 found that there is an enormous variation in what is paid for the same device. It will not shock readers of Prescription for Bankruptcy to learn that cardiac implant devices may cost up to six times as much in the U.S. than they do in some European countries. The researchers also found enormous price variation within the same country, based on the bargaining power of the purchaser.
With this background, a study presented at the November 2018 Scientific Sessions of the American Heart Association takes on particular relevance. They analyzed data now made public under the Sunshine Act to review payments made by device manufacturers to cardiologists. Biomedical manufacturers distributed about $520 million to some 30,000 U.S. cardiologist from 2014 to 2016, averaging over $17,000 per cardiologist. This was NOT evenly distributed: 1,067 doctors received over $100,000 during the three-year study period, and they got almost two-thirds of the total payments. The payments were most often for speaker’s fees (54%), consulting fees (18%) and ownership stakes (12%). Based on what we know about the tactics of Big Pharma, we can assume the largesse was focused on the “opinion leaders” who were likely to have outsized influence on device selection. The researchers found that physicians with financial relationships to manufacturers were up to twelve times more likely to use an implantable cardioverter-defibrillator or similar device from that company than from another.
The good news is that there did not appear to be any patient harm from this bias. There was no evidence of increased rates of complications or in-hospital deaths among patients whose doctors had financial ties to industry. The impact on the cost of care is another story.

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Tuesday, December 4, 2018

How many of those have you done?

When your choice of hospitals is limited, there is the inherent problem of any monopoly, with little incentive to provide better service or lower prices, but when there are multiple hospitals in a community, another problem arises. As I note in Prescription for Bankruptcy, when there are several hospitals in a city competing, the temptation is strong for every hospital to provide all services – particularly the high-prestige, high reimbursement services. Every hospital “must” have its own high-tech imaging equipment, even when fewer units would be adequate to serve the community. This is one reason why so many more CT and MRI scans are done in the U.S. compared to Canada – in most cities in the U.S., the tests can be done same-day or the next with no backlog of patients needing the service. While this may be touted as a good feature of the American system, a great many of the tests done are of little value and may even result in over-treatment.
More important from a patient’s perspective is the duplication of surgical and other interventional treatments. As in most fields, the more often a surgeon or hospital does something, the better they get at it. For procedures that are very commonly done, it may be possible for every hospital or surgeon to do them well. I would not worry about the volume of cases that he or she had done when a surgeon suggested an appendectomy. For more complex procedures, however, it does become quite critical to your health. A study reported in the journal Stroke in May 2015 looked at carotid endarterectomy, a procedure in which a surgeon opens a blocked artery in the neck, allowing better blood flow to the brain. They found a definite increased death rate in patients operated on by a surgeon who had done fewer than ten cases in the prior year. Another study, reported in Surgery in 2013, looked at operations on the thyroid for Graves disease, an overactive thyroid. While the impact of hospital volume was less dramatic, there was a significant increase in complications when the surgery was done by less-experienced surgeons. More recently, a study published in JAMA Cardiology on October 31, 2018 looked at outcomes among patients having their aortic valve replaced. By far the lowest 30-day mortality was found in hospitals with the highest number of cases done. Another looked at outcomes and hospital volume in patients having complex repairs of abdominal aortic aneurysms (Annals of Surgery 2018) and found peri-operative death rates correlated with surgical volume: the death rates at low, medium and high-volume centers were 9%, 4.9% and 3.9%.
Even as “bread and butter” a hospital function as labor and delivery shows this phenomenon. A study reported in The American Journal of Obstetrics and Gynecology in December 2012 looked at outcomes among newborns delivered in California hospitals. They only looked at full-term, normal birth weight babies, as most agree that when obstetric complications are anticipated, referral to a specialty center is needed. They looked at asphyxia among newborns, and divided hospitals into four categories based on numbers of deliveries. This life-threatening complication ranged from 9/10,000 births at the highest volume centers to 18 at the lowest.
The bottom line for you: if anyone suggests you need a complex procedure, carefully study how often the surgeon and hospital have done it!
For policy makers, consideration needs to be given to incentivizing hospitals to consolidate complex procedures at fewer hospitals.

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Saturday, December 1, 2018

Move that body!

Fads come and go in medicine just as they do in fashion. Think back to blood-letting as the cure for most ills. In our own more enlightened era you could think of aspirin. For years, a daily aspirin was widely recommended to prevent heart attacks and even ward off colon cancer. Now we have been taught that unless you have proven coronary disease, daily aspirin is more likely to kill you from bleeding than keep you alive. Digoxin was universally used to treat heart failure until we were told it was pure poison and should never be used, and now we are told that its judicious use in some patients may be helpful. Coffee was bad for us; now it is good.
Is there anything close to a universal truth in medicine? Anything that we will not be told tomorrow is bad for us? There is one: modest or moderate exercise helps just about everyone! Even moderate exercise has been shown to lower blood pressure, ward off heart attacks, improve blood sugar control in diabetics and ward off dementia. It reduces inflammation and improves your immune system.
We are all aware of the obesity epidemic that has swept the world, and evidence shows that obesity contributes to numerous diseases, from diabetes to childhood asthma to breast cancer to osteoarthritis. While dieting in theory should help, very few diets work for long-term weight loss in many people. Weight loss can be induced with surgery, but that is a very dramatic approach to say the least for most of us.
Changing our exercise habits is much more fun than dieting, and it has more sustained benefit. Exercise does not have to mean going to a gym or wearing a leotard. Walking, dancing, gardening or housework all count. The latest advice from the U.S. Public Health Service is that children and adolescents should do 60 minutes of moderate to vigorous exercise daily and that adults should do at least 150 minutes a week of moderate exercise or 75 minutes a week of vigorous exercise. That is NOT that much. Walking the dog for 30 minutes 5 days a week will get you to the moderate goal and if you enjoy the gym, 30 minutes three times a week is all it takes.
How much exercise do we do? Not much. A group of researchers looked at self-reported activities reported in the national Health and Nutrition survey (NHANES) – and fess up, you are more likely to exaggerate your exercise than otherwise, right? They found that 51% of adults were completely inactive and 14% insufficiently active. Only 23% described themselves as highly active.
One of the few controversies around exercise is whether extremes – running marathons or competing in triathlons – is possibly harmful. The evidence is mixed, with an increased risk of atrial fibrillation later in life in endurance athletes. A recently-reported study from the Cleveland Clinic, however, showed that the fitter you are, the longer you live. So, if you are a dedicated runner, go for it!
If we want to live longer and in better health, hide the car keys and walk to the store. Take up ballroom dancing. Dust off that old bike sitting in the garage. Get a dog. Help coach your kid’s soccer team. Also, pressure the local school system to be sure ALL kids get exercise daily and not just the ones who are on a travel team.
News Flash: two articles in the journal Neurology in February 2019 showed that in both younger and older adults, aerobic activity improves cognitive function!

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Thursday, November 29, 2018

US life expectancy falls again

I had planned to tackle a different topic today until I saw the front-page story announcing “U.S. Life Expectancy Falls Further.” The Centers for Disease Control (CDC) released data on Thursday showing that life expectancy in 2017 fell by a tenth of a year, to 78.6 years. While this may not sound like much, it is in stark contrast with what is happening in most of the developed world, where life expectancy is rising. The U.S. has lost three-tenths of a year since 2014, an astonishing reversal for a wealthy nation, and lags even further behind our peer countries. Life expectancy in Japan is 84.1 years and in Switzerland it is 83.7; these are the two OECD nations with the highest life expectancy. Of the 36 OECD nations, the U.S. ranks 29th. So much for the nonsensical claim that changing our current health care system would result in our losing our “best in the world” health care. Somehow “We’re number 29!” just does not have much ring to it, does it?
As I point out in Prescription for Bankruptcy, not all of a nation’s health is due to health care. One could make the argument that the health care system is actually less important than social factors in determining a country’s overall state of health. When John Snow stopped the Broad Street cholera epidemic in London a century and a half ago, he did it not by inventing a new medication but by removing the handle off the water pump that was the source of most of the local cholera. The dramatic fall in cardiac deaths in the U.S. in the past decades has owed less to medical intervention than to the very effective anti-smoking campaigns that have reduced cigarette smoking.
One of the factors behind our depressing fall in life expectancy has been the increased rate of suicide in the U.S. Around the world, increased urbanization and social stability have led to a dramatic 29% drop in suicides since 2000 (see: The Economist, Nov 24/2018), while in the U.S. the suicide rate is up 18%. Rates are highest among those who have suffered job loss and loss of social support, and are highest among those in the most rural areas. The ready availability of firearms means that when a suicidal impulse occurs – and it is by far most often an impulsive action rather than a carefully-planned decision – it is likely to be “successful.” Also playing a role is the opioid epidemic, and the increased availability of very potent opioids such as fentanyl. These deaths play an outsized role in our lower life expectancy because they occur in young adults.
To move up from the bottom of the heap, we need to reduce the easy access to guns, put more effort into fighting the opioid epidemic, and vastly improve our social support network. A $1 million spent on a new gene therapy may save one life. The same $1 million spent on suicide prevention could save hundreds.

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Wednesday, November 21, 2018

If you have a doctor you like and trust, stay with them - you will live longer!

Having been in practice in Framingham, Massachusetts, for over 35 years, I had quite a few elderly patients. One day when I was making hospital rounds, including seeing two patients over 90, a nurse smilingly said "you know, Dr. Hoffer, your patients just don't die!" I responded jokingly that I made them all sign a contract not to die until I permitted it, and thought no more of it. However, as we move away from having lifetime relationships with our physicians, and as medical care becomes more and more fragmented, it turns out we are losing more than a Norman Rockwell moment. Data now very strongly supports the importance of continuity of care in optimal health outcomes.
A study done in South Korea and published in the Annals of Family Medicine (Nov/Dec 2014) looked at a cohort of over 47,000 patients with newly diagnosed hypertension, diabetes and high cholesterol. They followed these patients for five years. They used standard methods of measuring continuity of care and compared outcomes with greater or less continuity. Those with lower indices of continuity of care had 12% higher death rates, 57% more heart attacks and 44% more strokes than those with higher continuity scores. The results make intuitive sense to me, because all of the conditions they studied are known to respond to medication, and both high blood pressure and high cholesterol have no symptoms and it is well-known that many patients stop taking their prescribed medicines. Having a trusting relationship with your doctor, and regular follow-up, makes it more likely you will follow the plan of care prescribed.
Just this year, a very large "meta-analysis" published in BMJ Open (Pereira Gray DJ et al) looked at 22 studies of the impact of continuity of care on health outcomes. They found very strong association of increased continuity of care with decreased mortality.
Not only is life extended, but costs are lower! A study by Andrew Bazemore at al published in the November 2018 issue of the Annals of Family Medicine looked at a sample of 1.45 million Medicare beneficiaries cared for by 6,551 primary care physicians. Comparing patients in the highest and lowest quintiles of continuity scores, they found that odds of hospitalization were 16% lower with good continuity of care and costs per patient were 14% lower (presumably reflecting less hospitalization).

As we look at needed reforms in our system, it is critical that this data be kept in mind.

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Sunday, November 18, 2018

Lies, damn lies and statistics

The Wall Street Journal published an Op-ed piece on November 12 titled "The False Promise of 'Medicare for All'" by Scott Atlas of the Hoover Institution, promising death and financial ruin should we adopt this approach. I believe that Atlas cherry picked his facts and reached the wrong conclusion. He starts his piece with the frightening thought that Medicare for all would cost $32 trillion over the next decade, an estimate that The Tax Policy Center had previously published. What he fails to mention is that under our current "non-system," the cost projection is much worse. In 2017, US health care expenditures were $3.5 trillion - about twice as much per capita as in comparable Western democracies. If we assume a (very) conservative inflation factor of 5%, the projected cost over the next decade would be over $46 trillion - thus making Medicare for All a veritable bargain! He claims that nationalized programs have failed to provide high quality care compared to the US system, based on largely anecdotal data. As to quality, it is clearly true that wait times in the US are shorter than in most other countries, but what matters more than wait times is the health outcomes. The average life expectancy in the United States is 78.6, while it is over 80 in at least 29 other countries, including Japan and most of Europe. Maternal death rates in the US are dramatically worse than in other OECD nations. Rates of death per 100,000 live births range from 6.4 in Japan to 9 in Germany, while in the US it is 26.4. Our death rates for infants and children are much higher than are those in other OECD nations. A very revealing study found that when looking at treatment of patients with advanced colon cancer treated in neighboring Washington state and the Canadian province of British Columbia, the cost of care in Canada was half that in the United States and that the Canadian patients lived longer! For more details, see my book Prescription for Bankruptcy.

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Tuesday, November 13, 2018

Guns DO kill people

The National Rifle Association recently condemned doctors who are against gun violence, telling us to "stay in our own lane," and complaining we had not checked with outside experts (i.e., them). Last that I heard, reducing preventable deaths was exactly the main lane for doctors. Quite appropriately, this stance has led to a major reaction by doctors, one of whom, a trauma surgeon, posted a picture of herself and the operating team with a young patient who had just succumbed to his bullet wounds despite their attempts. The Centers for Disease Control and Prevention (CDC) recently released a report on firearm homicides and suicides, in MMWR 67(44):1233-7, dated November 9, 2018. They, in an understated way, said that "firearm homicides and suicides represent a continuing public health concern in the United States." During 2015-2016, the US experienced 27,394 homicides, including 3224 among persons 10-19, using guns. In the same period there were 44,955 firearm suicides, including 2,118 among youngsters 10-19. We are so much worse than any other Western democracy that comparisons are meaningless. As I point out in my new book, Prescription for Bankruptcy, people can attempt suicide by many means, but no other means is nearly as "successful" as suicide by gun. Many measures have been proven successful, and none of these would infringe on the legitimate use of firearms by hunters. If every state in the country had similar laws to those in Massachusetts, and a similar death rate from guns, tens of thousands of American lives would be saved. We supposedly live in a country in which the majority rules, respecting the rights of minorities. A clear majority of Americans want better gun control. We MUST stand up to the NRA and tell our elected officials they will not be re-elected if they do not grow spines.

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Monday, November 12, 2018

Don't throw out out those old pills!

As I mention in my book, Prescription for Bankruptcy, one of the many ways big pharma soaks the consumer is by putting arbitrary expiration dates on their pill bottles. Nursing homes and hospitals regularly throw out perfectly good medicines because they are "outdated" and cannot be given to patients. Many patients do the same, trusting the dates stamped on the bottles. This behavior is despite multiple studies both old and new showing that pills are perfectly good well past the date on the bottle. I have always tried to advise my patients to use up all of the pills unless they were obviously crumbling, but I had made an exception for nitroglycerine pills. These are used to treat angina attacks (temporary heart pain brought on by exertion), and are meant to dissolve under the tongue. This compound seemed unstable enough that I advised my patients to store their reserve supply in the fridge and replace the pills every 3-6 months. Well, it turns out I was mistaken, and even this seemingly unstable compound lasts a lot longer than I thought. A study soon to be published in The American Journal of Cardiology looked at nitroglycerine tablets carried in pocket or purse. The 25-count bottles carried in a pocket maintained their potency for 2 years, while those carried in a purse were good beyond 2 years whether in 25- or 100-count bottles. Only the 100-count bottles carried in a pocket fell below acceptable limits at 12 months.

Sunday, November 11, 2018

Women should not die from childbirth in the United States!

Despite spending dramatically more on health care than any other county in the world, the US does not lead the world in health outcomes. Most sadly, the rate of maternal mortality in this country is triple that of other western democracies. As documented in my book, Prescription for Bankruptcy, countries such as Canada, Germany and France in 2015 had maternal mortality rates ranging from 6 to 9/100,000 births while in the US over 26 women died per 100,000 births. The maternal death rate is particularly bad for African-American women. We could do better if we applied well-known principles. As outlined in a position paper in the New England Journal of Medicine dated 11/1/18, there are several published bundles of best practices that would drop the maternal death rate dramatically if adopted by all hospitals. Since many of the pregnancy-related deaths occur after delivery, good follow-up care is essential. Unfortunately the US is one of the few Western democracies that does not mandate paid maternity leave, and as a result, only one postpartum visit is usually scheduled, and half of these visits are skipped. Could we do better? Yes. Will we? Time will tell. Read my book. Put pressure on our elected officials.

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Saturday, November 10, 2018

Are the foxes watching the henhouse?

Increasingly, doctors are expected to follow published guidelines on how to evaluate and treat patients. In many cases, payment is predicated on following these guidelines and in other circumstances, payment for "quality" is geared to compliance with them. There are now literally thousands of such guidelines, often conflicting with each other.
Many professional organizations convene panels of "experts" to issue guidelines on how doctors should evaluate and treat patients. These have the aura of being the last word on the subject, and are used both to guide the practice patterns of individual physicians and often what insurance companies will pay for. It would be wonderful to believe that the panel experts were both knowledgeable and unbiased, but growing evidence says that the panel members all too often have serious conflicts of interest. Some of these are inherent to being in the specialty; if you are a diabetes expert, it is wonderful to lower the threshold at which diabetes is diagnosed and instantly have millions of more diabetics needing your care. Others are financial. Two recent studies published online on JAMA Internal Medicine (on October 29, 2018) looked at this. One showed that over half of the authors of clinical practice guidelines in the field of gastroenterology had financial ties to industry, and that many of these ties were not publicly revealed. Another looked at the authors of guidelines related to very high-cost medications. They identified 18 sets of guidelines covering the use of ten very high cost medications. Out of 160 US-based physicians, half declared receipt of payments from industry and an additional 25% HAD received such payments but not disclosed them. The process of developing practice guidelines needs a hard look and revision to be sure these are based on what is truly best and not what is simply good and also expensive. Guidelines should be developed by neutral experts, and should include patients, primary care providers and experts on statistics as well as specialist with expertise in the field. Read more about this in my new book, Prescription for Bankruptcy.

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Friday, November 9, 2018

We MUST keep coverage for pre-existing conditions

Despite the Republican party's efforts to "repeal and replace" the Affordable Care Act, "Obama Care" is still with us. Most of the American public have come to realize that a crucial safety feature of the ACA is its mandate that all health insurers cover pre-existing conditions, and that repealing it would take us back to the dark ages when you could find yourself without insurance when you needed it. How widespread are "pre-existing conditions?" An analysis by Avalere health looked at the subject in depth. They found that of the 204 million people who were not in Medicare or Medicaid, fully half: 102,000,000, had one or more so-called pre-existing conditions, including hypertension, diabetes, chronic lung disease, cancer, mental health problems and others. A December 2018 report by CNN also found that roughly 50% of all Americans had some condition or illness that would be considered a pre-existing condition by health insurers, and that a whopping 86% of Americans aged 55 to 64 have one or more such conditions.
In descending order of frequency, the conditions that would not be covered were: acne (>50 million), anxiety (39 million), diabetes (30 million), asthma (25 million), sleep apnea (25 million), depression (20 million), extreme obesity (18 million), chronic lung disease (16 million), coronary disease (16 million) and cancer (15 million)
Since most employer-based health insurance covers families, this means that almost every person is potentially subject to this problem. In the bad old days, you could find that if you switched jobs, your new employer's health plan would not cover you for any illnesses you had. Your choices were then to remain as an indentured servant to your current plan or switch jobs and keep your fingers crossed. However we go, whether towards Single Payer or by improving our current system, maintaining coverage for all medical problems must be a bedrock principle. Read more in my book, Prescription for Bankruptcy.

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Thursday, November 8, 2018

Don't rely on Dr. Google

I have a wonderful cartoon on my desk that is appreciated these days by most doctors. A patient is sitting on an exam table, saying to the doctor: "I already diagnosed myself on the internet. I am just here for a second opinion." While the internet is a wonderful source of ideas, it is like an oriental bazaar, with trash and treasure intermingled and often indistinguishable. Nineteenth century America had travelling snake oil salesmen and 21st century America has the Internet. The biggest problem with using search engines to suggest what you have and what to do about it, which most people forget or never knew, is that placement on the page of "hits" is NOT by goodness of fit. Sites pay directly for high placement, and clever consultants teach you how to get high placement for your site by fine-tuning the descriptors. The best answer to your question may be half way down the second page, and you may never look that far. I tried to convince my patients to always start at the NIH PubMed site, which has a wealth of reliable, vetted and unbiased material. If you do not find what you want there, the next place to look is on sites maintained by large hospital systems such as the Mayo Clinic, that offer validated facts and opinions. The commonly used patient symptom checkers are used by millions, and can be helpful but can be very wrong. Part of the problem is their limited databases. Researchers from McMaster University's ophthalmology department entered 42 scenarios of patients with known eye diseases into the WebMD Symptom Checker and found that while the correct diagnosis did appear in the top three 40% of the time, it was not listed at all 43% of the time! Someone has to pay for these "free" services, and it is usually pharmaceutical companies that want you to use their products. The internet symptom checkers thus give priority to conditions for which there are linked ads. is OK to start with "Dr. Google," but caveat emptor: let the buyer beware. For more see my new book, Prescription for Bankruptcy.

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Wednesday, November 7, 2018

The $48,000 allergy test

A recent posting on Kaiser Health News epitomized much of what is wrong with health care in today's America. An English professor in the California state university system went to Stanford University's outpatient clinic for help with a rash that she thought might be due to a cream she had been prescribed. She had 119 tiny plastic containers taped to her back and ultimately learned that she was allergic to a variety of things, including the ingredient in her cream. All well and good until she saw that Stanford had billed her insurance company for $48,329! This included $848 for the time she spent with the doctor and $399 for each of the 119 small samples taped to her skin. The "usual and customary" charge in the San Francisco Bay area for this is $35 per sample. Why so much? Stanford, as a prestigious institution, has a lot of clout when it comes to negotiating with insurers. They know that many companies want access to "the best" and so drive a harder bargain than smaller hospitals. The insurer paid Stanford at their negotiated rate of $11,376 - still 3-4 times what they would have paid an allergist in private practice for the same service. We need single payer, where the payer and not the provider are in the driver's seat. Read more in my book, Prescription for Bankruptcy.

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