I am sick. Where should I go?

In the “old days,” say the 1950’s and 60’s, getting sick was much simpler. If you did not feel well, you called your doctor and either went to his (and 90%+ were male) office or he made a house call. Now, the set of choices is overwhelming – but where you decide to go can have a major impact on your health and your wallet. Your choices include:

The Emergency Department (ED). Pros: always open, prepared to handle just about anything acute that you may have. Cons: usually no idea who you are or your underlying health issues; very expensive – even if you have good insurance, there is usually a high co-pay; little continuity of care, and, unless you are critically ill, a long wait, often a very long wait.

Urgent care center. Pros: extended hours including weekends; can handle most minor emergencies; usually have X-ray and lab; less expensive than ED. Cons: Not 24/7, so be sure to check if they are open; no continuity of care; moderately expensive.

Pharmacy-based drop-in clinics, usually nurse-staffed. Pros: weekend hours; can handle most “minor” illnesses well; usually less expensive that the prior two. Cons: limited diseases that can be handled; little continuity; limited lab or X-ray available.

Your doctor’s office: Pros: they know you and can generally avoid over-testing; continuity of care automatic; least expensive. Cons: limited hours; may not be able to see you quickly.

So, what should you do?

As the ubiquitous phone message says, if you are having a medical emergency, hang up and dial 911. If you are experiencing chest pain, sudden shortness of breath, severe abdominal pain or are bleeding profusely, you belong in the ED. Calling 911 will get you there more safely than driving and will assure you are seen more promptly. Ambulance patients are almost always seen before those who drive themselves or are driven. Most insurance covers emergency ambulance transport (but not “convenience” rides).

If you need urgent attention but are not severely ill – think foreign object in your eye, a deep cut that will need suturing or a red swollen arm on a Saturday – the closest Urgent Care Center is probably your best bet.

For the myriad other “minor emergencies” that need prompt attention such as a bad sore throat, an earache, a possible urinary infection or a very itchy rash, try your doctor’s office first. If they are unable to see you, a convenience clinic at the local pharmacy will probably be able to help you at lowest cost and least waiting. These are the kinds of problems that do NOT belong in the ED.



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Medical Bills and how to fight them

Years ago, when I would visit with my in-laws, after the initial pleasantries, my mother-in-law would bring out a shoebox full of paper and say “Edward, do I owe anyone any money?” In the box were dozens of undecipherable pieces of paper, many of which were marked “This is Not a Bill,” even though they looked like bills. Things have not gotten better.

Medical billing is notorious for being very hard to understand and full of errors. The average person, faced with a gigantic bill, is likely to throw up their hands and pay it, but do not be in too much of a hurry to do so.

The first step is to request an itemized bill, to which you are entitled. This will list all the things the doctor or hospital is charging you for. While the bill should list the items, sometimes you will just get a listing of CPT (Current Procedural Terminology) codes – 5-digit numbers that are medical shorthand for the things done. It is very easy to use Google to get the English translation of, say, 99285 into “Emergency Visit, high complexity.” Very often you will see things listed that were simply not done, and a call or letter should ask to have these removed.

You should also use your common sense to evaluate how well the service for which you are billed matches the service you received. Using the same example, if you are being charged $800 for a 99285 and you went to the Emergency Department with a swollen ankle that was wrapped in an elastic bandage, you should insist the charge be reduced. A high complexity visit is meant to cover caring for a victim of a major auto accident or a patient in coma, not a 10-minute visit for a simple problem.

If the billing department will not reduce the charge, demand a copy of your visit. If the notes reflect a simple visit, repeat your demand and threaten to take the issue to your insurance company or the state department of consumer affairs.

Finally, it is always worth asking for a discount. Uninsured patients are usually charged the “list price” for a service while Medicare, Medicaid and every commercial insurance company gets a substantial discount off these prices. You will very often get a discount of 25% or more just by asking.

It is your money. Don’t part with it without a fight.



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Time to sign up!

All Medicare recipients, and most people enrolled in health plans through their employers or the Affordable Care Act, have the opportunity to sign up and/or change plans during the annual Open Enrollment Period. For Medicare, this is Oct 15 through December 7, 2023.

While I am sure you have many things you would rather do than review your health insurance options, PLEASE set aside time for this critically important task.

Why is it important? Once you choose a plan, you are generally locked in for a year. If you find in March that you have a condition you want treated by “Dr. X,” but Dr. X is not in your health plan, you are out of luck. The fall open enrollment period is your chance to ensure that your needs are best met in 2024.

In the early days of Medicare, there was very little choice and life was much simpler. Now you have the major option of “classic” Medicare or Medicare Advantage (MA). In addition, if you opt for classic Medicare, there are options for the “fill-in” plans that cover Medicare’s deductibles.

This year, for the first time, over half of Medicare enrollees are in MA plans. These plans, run by commercial health insurance companies and heavily marketed, offer benefits not covered by traditional Medicare, such as payment towards hearing aids and eyeglasses, and even gym memberships. Their major downside is limited choice of doctors and hospitals. There have also been allegations that some plans have denied or delayed needed care. There is no free lunch, and plans that lure you in with lower out-of-pocket costs (and are run by profit-making companies) need to cut costs somewhere.

Suggestions:

1.Even if you are happy with your current MA plan, read the plan information carefully to see what has changed. Plans can and do change what they cover each year. Be sure you know what medications will be covered if your plan provides drug coverage, and what your medicines will cost you. Check if any doctors you are seeing will no longer be covered. Ditto a hospital you prefer to use.

2.Double check with your doctors’ offices to be sure what plans they will be accepting. MA information is often out of date with their list of participating doctors.

3.Be sure your plan and your health needs are a good fit. A plan that covers your fitness club membership may have been inviting when you felt healthy but may no longer be the best fit if you have a new serious illness and the best doctors and hospitals for this condition are “out of network.”

4.Take the time to look at alternatives. Since both plans and your health needs change, there may be a plan that is a better fit. Check the plan ratings on medicare.gov.

5.Ignore the hype and read the fine print. You will be barraged with advertising and sales pitches. Regard these with the same skepticism as you would any other advertising.

Finally, maintain good health habits. Do not smoke or drink; exercise and eat a health plant-focused diet. The healthier you are, the less you will need to worry about what services your plan covers



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RSV - should I get vaccinated?

Respiratory syncytial virus (RSV) has traditionally been thought of as a disease of infants. As many as 80,000 babies under 5 are hospitalized annually in the U.S. with RSV, mostly in the winter, and some 300 die. Until very recently there was little that could be done to prevent RSV.

A monoclonal antibody has recently been approved that was 80% effective at reducing hospitalizations in infants, but it costs $495/dose.

Also new are two RSV vaccines for adults that were shown quite effective, and this availability has focused attention on RSV in older adults.

The “usual” winter respiratory virus about which we have worried for years is influenza. There is quite a bit of variability in influenza from year to year, with estimates of 140,000 to 700,000 flu hospitalizations and 12,000 to 52,000 deaths annually over the past decade. Flu vaccine efficacy has been quite variable but vaccination is universally recommended.

For the past 3 years, Covid has pushed flu out of the headlines, and it is unfortunately still with us.

Estimates for RSV for the same 10-year period are that 60,000 to 160,000 older adults are hospitalized each winter with RSV and 6,000-10,000 die. A CDC analysis of a large sample of adults over 60 found that while RSV was much less common as a cause of hospitalization than flu or COVID, patients with RSV tended to be sicker.

The two recently approved vaccines both reduced the rate of RSV illness requiring medical attention by about 85%. The advisory committee recommended the vaccine for pregnant women to protect their newborns and for adults 60 and older.

Like all new vaccines, there are unanswered questions. There seemed to be a small but real increase in neurologic side effects (notably Guillain-Barré, a temporary paralysis) in vaccine recipients and possibly a small increase in atrial fibrillation. For the frail elderly, the benefits clearly outweigh the risks. For healthier seniors it is less clear.

Cost may be an issue. The vaccine costs $200-$300. It is covered under Part D of Medicare, not Part B like flu or Covid shots. Not all private insurances cover it.

If you are older with heart or lung disease, I would definitely recommend it. If your general health is excellent, the decision is a personal weighing of risks and benefits.

By the way – masks reduce the spread of all respiratory illnesses. And if you are sick and coughing, do everyone a favor and stay home until you are better!



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Big Pharma Cries Wolf

Over the last few weeks, as the administration has begun to implement that portion of the Inflation Reduction Act that allows Medicare to negotiate prices on 10 high-cost drugs, you have heard loud cries from the pharmaceutical industry.

They and their allies on the right claim that allowing Medicare to cut into their profits will harm consumers by reducing their incentive to develop new drugs. Does this argument have merit?

The claim that the industry should be allowed to gouge the U.S. consumer has numerous problems.

First, why should U.S. consumers be the ones to support pharmaceutical company research when their products are sold world-wide? They should establish a defensible price that covers developmental costs and a fair profit and use this in all advanced countries. Lowering prices on product sold in less-developed countries can be a humanitarian offer.

Second, and more important, the major pharmaceutical companies spend more on marketing than they do on research and could easily shift money from marketing to research should they choose to do so.

Third, they consistently exaggerate the money actually spent on research [see: JAMA Internal Medicine 2017;177(11):1575]. They also fail to credit the NIH (i.e. the U.S. taxpayer)-funded basic research that often precedes their own.

While Big Pharma does spend the lion’s share of the money needed for clinical trials, these are only done on products expected to generate big sales and profits. The basic research that is behind most truly new drugs is usually done by academic researchers with government funding or by start-ups that are bought by a major pharmaceutical company after they develop a novel product.

Finally, much of their research budgets are spent not on truly novel life-changing drugs but on "me too" copycat drugs. When a truly new drug is developed, the other companies turn their research efforts to tweaking the molecule to develop their own similar product on which they then spend money marketing it as better, with no real clinical benefit to patients. [If they sold their product at a lower price, this would be a useful addition, but this is rarely/never done. Instead, they charge a similar or higher price and bombard doctors with marketing.]

The sky will not fall if Americans do not pay 3 times what the Swiss, Germans or French do for pharmaceuticals. Write your representatives in Congress and tell them not to cave to the pharmaceutical industry.

(In the meantime, try to lower your own costs of drugs by checking out Mark Cuban’s Cost Plus pharmacy or by using websites such as GoodRx for medicines you take regularly.



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Covid update - behind the headlines

While most of us want to put Covid behind us, recent news headlines make that hard to do. What should you know? What should you do?

The most important fact is that, like it or not, Covid is probably here to stay. While the worst of the pandemic is thankfully behind us, Covid will join influenza as a prevalent virus against which we must take measures. Recent data shows that infections are trending up, though death rates are much lower than they were 2-3 years ago.

Second, there will be variants! Most viruses mutate, and Covid seems particularly adept at this. Mutations may make the virus more easily transmissible, more (or less) dangerous and/or better able to evade our immune response.

The recently headlined EG.5 and BA.2.86 variants have enough mutations in the spike protein that lets the virus attach to our respiratory cells that they can infect people who have been immunized and/or had prior infection. They do not seem more virulent – hence the rise in infections is steeper than the rise in hospitalizations or deaths.

We have two levels of immune defense. The antibodies produced by vaccination or prior infection are the first line of defense, and the cellular immunity the second. Even if a mutation seems able to escape our antibodies, the cellular response is often still effective.

What should you do? While vaccination is a good idea for most people, if you are older, have underlying medical conditions or are immune-suppressed, I would definitely get a Covid booster. Wait until the newer vaccine is available in late September/early October because it is targeted at mutations that more closely resemble the currently circulating variants and another shot of the old vaccine is unlikely to offer much additional protection.

What about masks? While clearly not a panacea, masks do seem to reduce transmission of most respiratory viruses, including Covid, flu and the common cold. There is little reason to use a mask outdoors or in large well-ventilated spaces, but I would encourage you to use one when in confined indoor spaces such as theatres.

Finally – please stay home when sick. We teach our children to share, but sharing your respiratory virus is not a virtue.



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Where are my meds? How safe are they?

Some 90% of the medications we take are generic. Generic drugs are dramatically less expensive than their branded equivalents and generally similar to the branded products in all but price. Unfortunately, generally does not mean always. Two large healthcare systems tested all the generics sold through their pharmacies and found that 10% had potential quality issues.

A major source of medications sold in this country and elsewhere are manufactured in India and China. The $50 Billion pharmaceutical industry is a leading source of exports and foreign earnings for India. While most Indian pharmaceutical plants are of good quality, many, especially the smaller ones, are not.

The FDA tries to inspect overseas plants whose products are imported to the U.S. In 2019, the FDA reported to Congress that India had the lowest percentage of acceptable inspections of any country. 17% of the plants it inspected had major failings. And, due to the pandemic, the number of inspections the FDA conducted fell dramatically for 2020-22.

You may recall the news stories of children in Gambia and Uzbekistan dying in 2022 due to contaminated cough syrups from Indian manufacturers. This was only the tip of the iceberg. Less dramatic but important are issues of contamination, uneven content of pills and capsules and poor formulation causing poor absorption of medication. These will not kill you, but may well make the medication less effective.

The Department of Defense is sufficiently concerned that they have contracted with an independent testing lab to test the drugs it purchases for our military and evaluate the manufacturers. Kaiser Permanente has been doing the same thing for the past three years.

What can you do? If you look at the prescription label, in small print you will find the name of the manufacturer. You can do an Internet search on the company and see where they are located and also get an idea of how ”legitimate” they seem. If you find that your medication was made by an obscure Asian company, you can ask your doctor to contact the pharmacy about changing to another manufacturer. You can also make your elected representatives aware of this issue.

A seemingly unrelated problem that has been recently making headlines is shortages of important medications. A recent survey of hospital pharmacists found that virtually all reported some drug shortages, and that 83% were rationing some medications. Key shortages have been notable in generic cancer drugs that are the mainstay of many chemotherapy regimens.

Why is this? Do you remember the baby formula crisis last year? The issue is similar: concentration in a small number of manufacturers and a convoluted supply chain. As of mid-August, 48% of the injectable medications made by Pfizer were in short supply. The generic cancer drugs are low-profit and so do not get priority when companies are deciding on what products to manufacture.

The solution here is not in our hands as individuals – it demands that the federal government strongly encourage in-sourcing manufacture of key medications. Just as we cannot depend on Asia to make crucial electronic components and ship them half-way around the world, we cannot outsource the manufacturing of crucial medications.



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