Saturday, April 27, 2019

Is anyone healthy?

A wag once said: “There is no such thing as a healthy person, just one who has not had enough tests.” As we make every minor deviation from the average into a disease, that jest is becoming uncomfortably close to the way our current medical system behaves.
Part of the problem is that many “diseases” represent an arbitrary cut-off of a number. Thus “hypertension” is defined as a blood pressure above a specific threshold. We all have blood pressures, and these pressures vary from minute to minute. Clearly everyone with any medical background would accept that a BP of 220/150 was a very bad thing and should be treated. But how about 142/90? To demonstrate how arbitrary any number is, consider that the diagnosis of hypertension starts at 140/90 according to the European Guidelines, and 130/80 according to the US Guidelines. The US definition was recently changed to a lower cut-off, overnight classifying tens of millions of people as having a disease. Using this definition, almost half of all adults would now carry a diagnosis of hypertension.
Before the discovery of insulin, pregnant women with diabetes all died. Once insulin was introduced, diabetes became a treatable condition, and doctors went looking for it. Since blood sugars also range widely, and reflect when and what we last ate, arbitrary thresholds were set to define gestational diabetes, or diabetes developing during pregnancy. The numbers used were changed in 2008, not because of new knowledge but by consensus among experts. As is virtually always the case, the numbers were set to label many more women as having the disease – and therefore creating many more customers for the physicians treating them and the pharmaceutical industry.
Then there are “diseases” that are only laboratory numbers. Thus “chronic kidney disease” is defined by a serum creatinine above an arbitrary number. The number picked does not take into account that kidney function slowly deteriorates with normal aging. Almost half of older adults are thus labelled as having chronic kidney disease even though most of them will never have any symptoms from their kidneys in their lifetime nor benefit from any treatment.
Proponents of these expanded definitions may well have the best of intentions, but over-diagnosis is not harmless. In many cases, people newly labelled with a disease are put on medications that are of minimal benefit and may do harm. They may become uninsurable or may have to pay higher premiums for life and health insurance.
The “expert panels” that promulgate these definitions almost invariably make changes that expand the pool of patients. They rarely look at the downside of over-treatment, and they tend to be dominated by academics with multiple financial ties to the pharmaceutical industry.
Your best defense against being labelled with one of these “diseases by definition” is to suggest that your doctor give you 6 to 12 months of lifestyle changes before giving you either a label or medication. Perhaps the desire to escape being labelled as hypertensive or pre-diabetic may be just what you need to motivate you to lose that 10 pounds you have always said you would and to start walking at lunch time.

Prescription for Bankruptcy. Buy the book on Amazon

Saturday, April 20, 2019

So, you are going to "rehab"

This is the scenario. You (or your mother) were admitted to the hospital with pneumonia. On the third day a cheery continuing care nurse comes in and says “you don’t have a fever any more and the doctors feel you can be discharged to finish your course of antibiotics but your nurse tells me you are still too weak to go home, so we are going to send you to rehab. Here are three facilities that have a bed for tomorrow. Why don’t you discuss this with your family and tell me which one you prefer.” This happens dozens of times a day in every community.
Several issues immediately arise. The first is that when you ask the continuing care nurse which is best, she tells you she is not allowed to make a recommendation. Another is whether this transfer is really necessary or whether another day or two in hospital would allow you to go home instead. If a rehab stay is necessary, how do you decide on a facility with very little time to research your options?
Remember that hospitals are paid by Medicare based on the admitting diagnosis, not on how long you are hospitalized. For pneumonia, the hospital will get the same payment if you are out in 2 days or spend two weeks. This means that the incentive is to get you discharged ASAP. If you feel you are almost ready to go home, dig in your heels and say you want to stay another day and then go home; they won’t like it, but will usually agree.
Also, critically: Medicare will pay for a rehab stay only if you are admitted to hospital and spend three nights. “Observation” days do not count. As the patient, you have no way to tell an official admission from an observation stay – same room, same bed, same nurses most of the time. ASK!
Most hospitals will not make recommendations about facilities. Hospitals say their reluctance is due to fear about violating a government decree that hospitals may not "specify or otherwise limit" a patient's choice of facilities. But that rule does not prohibit hospitals from sharing information about quality, and a handful of health systems, such as Partners HealthCare in Massachusetts, have created networks of preferred, higher-quality nursing homes while still giving patients all alternatives. Most hospitals simply dump the choice in the lap of the patient and family.
One easy way to get a “first pass” screen of nursing homes is to use the Medicare web site. Go to and enter your zip code. You will see a list of all Medicare-certified nursing homes and their ratings across the results of state health inspections, staffing ratios and “quality measures.” These are listed by distance from the zip code given. Staffing ratios are obvious: the more nurses, aides and therapists per resident the better. The quality measures include such things as how often residents were successfully discharged to community setting, how often they had unplanned ED visits or readmission to hospital, how often antipsychotic medications were started and others.
This information will let you immediately eliminate the poorly-rated nursing homes – and if all the ones on the list with openings are one or two-star (out of five), I would refuse all of them. If one or more are four or five-star, you are probably safe. The next step is to have a friend or family member visit and get a gut feeling. Do not be over-impressed with the newness of a facility or the paintings on the wall. You are, hopefully, not going to be there long, nor is this a hotel. What is crucial to a good recovery is the staff. Look around. Are most of the residents restrained in chairs? Visit the PT department. Ask residents about the food and about how quickly call bells are answered. If the staff seem defensive and uncomfortable answering such questions, this is probably not the facility to choose.
Once you are at a rehab facility, the more family involvement the better. It is human nature for the staff to pay more attention if they know concerned family and friends are around a lot. They are also the best ones to notice if things are not going well and seek remedies. Be sure to eat even if the food is not home cooking: you cannot recover without adequate nourishment. Even if you would rather rest, do your physical therapy. Remember, the more work you put in, the sooner you get out of there.

Prescription for Bankruptcy. Buy the book on Amazon

Saturday, April 13, 2019

When is a check-up not a check-up?

Kaiser Health News told the story of a 69 year old woman who went to a new doctor for her annual check-up, assuming it was covered by Medicare, and was happy with the visit until she got a $400 bill.
Most Americans believe in “annual check-ups,” at which your doctor reviews your medical history, gives you a thorough physical and orders lab tests. The actual value of such visits has been questioned, but they are ingrained in our psyche. Such “well visits” are helpful for children, where preventive care, including counselling and immunizations, adds value. It is not of nearly as much value in adults, and the vaunted “executive physical,” with its extensive battery of tests has been largely discarded. Yet, most of us still have gotten used to seeing our doctor once a year even if we are feeling fine.
When Medicare was first established, it was specifically geared to treating illness, and preventive care was excluded from coverage. Over the years a variety of preventive measures have been added as covered services, including screening tests and immunizations. A full list of these can be found at The newest addition to this list is the “Annual wellness visit,” which is fully covered under Part B. For those who are used to seeing their doctor for an annual check-up, this sure sounds like the same thing, and it does to many doctors as well. Unfortunately, if your doctor conducts this visit in the same way, with a review of your history, a physical and lab tests, you are likely to get an unexpected bill.
The Medicare Annual Wellness Visit is a very limited and specifically described set of services. At this visit your height, weight and blood pressure are to be measured, but no other physical exam is to be performed. The doctor is supposed to assess your risk of falling, your ability to bath and dress yourself and whether you are safe at home. You are to be screened for depression and dementia. Medications should be reviewed. A schedule of preventive services should be provided. If you have seen this doctor regularly, these may sound like a waste of time, and they may well be. I rarely did such visits. If at his last visit a patient had told me he had chopped too much wood and was willing to sell me a cord cheap, I would have felt like an idiot “assessing his fall risk.” What the doctor cannot do at such exams is check your blood pressure, tell you it is a bit higher than ideal and adjust your medication; if he or she does this, it is outside the parameters of the Wellness Visit and not covered. Because of the limited nature of the visit, over half of medical practices surveyed a few years ago did not offer these visits, and only 19% of Medicare beneficiaries received one.
What makes it even more confusing is that some (but not all!) Medicare Advantage plans WILL cover an old-style Annual Check-up.
So, bottom line: if you have standard Medicare, do not schedule an “annual physical” unless you are prepared to pay for it. Assuming you, like most of us over 65, have some chronic conditions being monitored, you should be able to get a longer visit at which all of these are addressed and the doctor has enough time to throw in a little more preventive care.

Prescription for Bankruptcy. Buy the book on Amazon