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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