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 27, 2019
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 https://www.medicare.gov/nursinghomecompare/search.html 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
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 https://www.medicare.gov/nursinghomecompare/search.html 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 https://www.medicare.gov/coverage/preventive-screening-services. 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
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 https://www.medicare.gov/coverage/preventive-screening-services. 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
Monday, March 25, 2019
My last doctor said I had lupus!
During my time in practice, I had at least eight patients who came to me sure they had systemic lupus erythematosus, also commonly called SLE or lupus. This is an “autoimmune disease,” characterized by joint pain, that can affect almost any organ, including skin, kidneys, brain and heart, and can even be fatal. In every case, they had been given this diagnosis because of a blood test called an ANA, for anti-nuclear antibody. Not one of these women (they were all women) actually had lupus. Why then were they told they did?
All of us, doctors and patients, tend to have too much faith in tests. When something is written on paper with a decimal point, it must be true, right? What is hard to accept is that just as a patient’s story may change with retelling, or a doctor may not hear a murmur they did hear previously, lab tests are far from perfect. If your serum sodium was 137 last time and is 144 this time is that different? Quite possibly not. Plus/minus 3-4 % is normal variation; even if you took a tube of blood and split it in two and sent the samples labelled Smith and Jones, they would be unlikely to have identical results.
Many tests do not have numeric results but are “positive or negative” or “normal or abnormal,” and here is where it gets complicated. Essentially every such test used in medicine, whether it is a strep screen or a cardiac stress test, has false positives and false negatives. That is, you are fine but your test is not (false positive), or you are sick but your test is fine (false negative). A test for which 90% of sick people had an abnormal result and 90% of well people had normal results would be considered a very good test. Thus, any test must be interpreted in the context of the person on whom it is done. If you are a middle-aged smoker with high cholesterol and you have been having chest pain when you take out the trash, then a positive stress test helps to confirm that you have coronary disease. If you are a fit 30-year-old woman whose family all lived to 90 and have a stress test as part of an executive physical, a positive test is most likely to be erroneous, a “false positive.”
So, let’s get back to my patients who were told they had lupus. The most widely used screening test for lupus is the ANA. It is a very useful test, because 99% of people with lupus have a positive ANA, so a negative test makes it very unlikely the person has the disease. The problem is that about 30% of healthy people also have a positive test. There are ways of making the test better, but these are often not done by non-specialists. So, indulge me in some simple math. Lupus is not a common disease, but neither is it really rare. About 1 of every 200 people going to a doctor for joint pain have lupus. As noted, about 30% of all people, sick or well, have a positive ANA. So, if you do an ANA test on all 200, the one who has lupus will have a positive test, and so will 60 people who do not. This means that 60/61, or 98%, of the positive tests will be false positives. If the doctor does not take this into account, it is easy to tell someone that their test says they have lupus as the cause of their joint pain, when they actually have something else and a false positive test.
The bottom line: do not take medical tests as gospel. If you get a new diagnosis, question it. If you are not entirely satisfied with the explanation, consider a second opinion.
Prescription for Bankruptcy. Buy the book on Amazon
All of us, doctors and patients, tend to have too much faith in tests. When something is written on paper with a decimal point, it must be true, right? What is hard to accept is that just as a patient’s story may change with retelling, or a doctor may not hear a murmur they did hear previously, lab tests are far from perfect. If your serum sodium was 137 last time and is 144 this time is that different? Quite possibly not. Plus/minus 3-4 % is normal variation; even if you took a tube of blood and split it in two and sent the samples labelled Smith and Jones, they would be unlikely to have identical results.
Many tests do not have numeric results but are “positive or negative” or “normal or abnormal,” and here is where it gets complicated. Essentially every such test used in medicine, whether it is a strep screen or a cardiac stress test, has false positives and false negatives. That is, you are fine but your test is not (false positive), or you are sick but your test is fine (false negative). A test for which 90% of sick people had an abnormal result and 90% of well people had normal results would be considered a very good test. Thus, any test must be interpreted in the context of the person on whom it is done. If you are a middle-aged smoker with high cholesterol and you have been having chest pain when you take out the trash, then a positive stress test helps to confirm that you have coronary disease. If you are a fit 30-year-old woman whose family all lived to 90 and have a stress test as part of an executive physical, a positive test is most likely to be erroneous, a “false positive.”
So, let’s get back to my patients who were told they had lupus. The most widely used screening test for lupus is the ANA. It is a very useful test, because 99% of people with lupus have a positive ANA, so a negative test makes it very unlikely the person has the disease. The problem is that about 30% of healthy people also have a positive test. There are ways of making the test better, but these are often not done by non-specialists. So, indulge me in some simple math. Lupus is not a common disease, but neither is it really rare. About 1 of every 200 people going to a doctor for joint pain have lupus. As noted, about 30% of all people, sick or well, have a positive ANA. So, if you do an ANA test on all 200, the one who has lupus will have a positive test, and so will 60 people who do not. This means that 60/61, or 98%, of the positive tests will be false positives. If the doctor does not take this into account, it is easy to tell someone that their test says they have lupus as the cause of their joint pain, when they actually have something else and a false positive test.
The bottom line: do not take medical tests as gospel. If you get a new diagnosis, question it. If you are not entirely satisfied with the explanation, consider a second opinion.
Prescription for Bankruptcy. Buy the book on Amazon
Tuesday, March 19, 2019
Will an Apple watch really save your life?
Last year, Apple’s Tim Cook shared widely the story of an 18-year-old Florida girl who claimed that her watch saved her life by alerting her that her pulse was 190, prompting her to go the hospital for evaluation. She was found to have kidney damage of which she was unaware and referred for treatment. My problem with that heart-warming story was that it was hard to believe she was not aware of that rapid a pulse on her own, and that it may have had nothing to do with her kidneys. This week we have been bombarded with news from a study reported at the Annual Meeting of the American College of Cardiology about the watch’s ability to detect previously unknown atrial fibrillation and thereby “save countless lives.”
First, a brief word about atrial fibrillation (AF). AF is a very common heart rhythm disorder that gets much more common with age. While rare in people under 50, it may affect as many as 10% of those over 75. Most people with AF are very aware of the condition because the heart beats very fast as well as erratically. A few have no symptoms, particularly if they are on a medicine for some other reason that slows the rate. AF can be associated with heart failure and, most ominously, it is associated with a greatly increased rate of stroke. The accepted wisdom is that most patients with AF should be on blood thinning drugs to prevent stroke except for the minority who have absolutely no other stroke risk factors beyond the AF.
The study looked at the ability of the watch to use an app to detect AF. Over 400,000 people self-enrolled on an invitation they got when they down-loaded the Heart Study app. A pulse notification was received by 2161 (0.5%) participants. Not surprisingly, notification was highest in those over 65 (3%) and lowest among those under 40 (0.2%). ECG patches were sent to 658 participants and returned by 450. AF was identified in 34% of those who were notified and wore the patch.
So, a few conclusions can be made. First, the watch can pick up some cases of AF. Second, it has many “false positives:” people who did not have AF despite what the watch said. A huge problem is that the study was not designed to detect “false negatives:” we have absolutely no idea how many of the participants did have AF that was not detected by the watch because no one got a patch who did not receive an AF alert. Since Apple watch wearers tend to be younger and healthier than non-wearers, many of the alarms are likely to be false positives, thereby causing anxiety and unwarranted health expenditures to evaluate the alarms.
Another problem with the study is that we really have no idea whether treating younger people who do truly have AF detected by the watch will help or harm them. The evidence that using blood thinners prevents strokes was all obtained back in the 1990s and came from people who had symptomatic AF. These drugs have enormous potential for harm from bleeding, and it is very possible that treating people found via apps may do more harm than good.
So, take the hype with a grain of salt. Enjoy your watch but do not depend on it to save your life.
Prescription for Bankruptcy. Buy the book on Amazon
First, a brief word about atrial fibrillation (AF). AF is a very common heart rhythm disorder that gets much more common with age. While rare in people under 50, it may affect as many as 10% of those over 75. Most people with AF are very aware of the condition because the heart beats very fast as well as erratically. A few have no symptoms, particularly if they are on a medicine for some other reason that slows the rate. AF can be associated with heart failure and, most ominously, it is associated with a greatly increased rate of stroke. The accepted wisdom is that most patients with AF should be on blood thinning drugs to prevent stroke except for the minority who have absolutely no other stroke risk factors beyond the AF.
The study looked at the ability of the watch to use an app to detect AF. Over 400,000 people self-enrolled on an invitation they got when they down-loaded the Heart Study app. A pulse notification was received by 2161 (0.5%) participants. Not surprisingly, notification was highest in those over 65 (3%) and lowest among those under 40 (0.2%). ECG patches were sent to 658 participants and returned by 450. AF was identified in 34% of those who were notified and wore the patch.
So, a few conclusions can be made. First, the watch can pick up some cases of AF. Second, it has many “false positives:” people who did not have AF despite what the watch said. A huge problem is that the study was not designed to detect “false negatives:” we have absolutely no idea how many of the participants did have AF that was not detected by the watch because no one got a patch who did not receive an AF alert. Since Apple watch wearers tend to be younger and healthier than non-wearers, many of the alarms are likely to be false positives, thereby causing anxiety and unwarranted health expenditures to evaluate the alarms.
Another problem with the study is that we really have no idea whether treating younger people who do truly have AF detected by the watch will help or harm them. The evidence that using blood thinners prevents strokes was all obtained back in the 1990s and came from people who had symptomatic AF. These drugs have enormous potential for harm from bleeding, and it is very possible that treating people found via apps may do more harm than good.
So, take the hype with a grain of salt. Enjoy your watch but do not depend on it to save your life.
Prescription for Bankruptcy. Buy the book on Amazon
Monday, March 11, 2019
Surprise!
Case 1: On March 1, ABC News reported the story of a Florida woman bitten by a stray cat she was trying to help. Having heard about rabies in stray animals, she went to the closest emergency room, where she got her first rabies vaccine and was also given an injection of rabies immune globulin, designed to protect the victim before the vaccine takes hold. She also later got a bill for $48,512, of which $46,422 was for the immune globulin. The product is not in particularly short supply and is available from three manufacturers and the average price paid by hospitals for the dose she got would been about $4334.
Case 2: A posting on Kaiser Health News back in November 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.
Case 3: There is also the story I recount in Prescription for Bankruptcy about a man who was mugged and taken to the emergency department for attention. He was aware (and concerned) enough to check before being transported that the hospital to which he was taken was “in network” for his insurance. He had suffered a broken jaw and was taken to the operating room for repair. Weeks later he got very large bills from the oral surgeon and anesthesiologist who cared for him who were not in his insurer’s network.
These three cases cover most of the causes for surprise medical bills. The Florida cat lover was at the mercy of price-gouging by the hospital she went to for help. The California professor and her insurance paid astronomical prices to the prestigious hospital system that knows it can overcharge because they are in the driver’s seat. It is hard to sell a health insurance package in northern California that does not include the perceived leading hospital in the area. The mugging victim was victimized a second time because even when a hospital has signed a contract with a health insurance company, many of its doctors may not. This practice is particularly common among specialties where the patient does not really have much choice in who sees them: emergency physicians, radiologists, pathologists and anesthesiologists.
Hospitals are now required to post their charges on-line, but to date they have (probably deliberately) done so in the most abstruse manner possible, using obscure terms that most non-medical people find hard to read or search. Hopefully some clever people will soon come up with an app to make the search more user-friendly.
What can you do about these nasty surprises? For diseases – like rabies – with obvious public health importance, you may be able to get treated at your local public health department for free. DO NOT POSTPONE TREATMENT to save money. If your problem occurs on a Saturday, go to the ED.
You must get in the habit of asking the doctors assigned to you if they take your insurance. Do not assume that they do because they are affiliated with a hospital that does. If you get an obviously-inflated charge compared to what others charge, you are entitled to, and should ask for, an itemized bill to see why the total is so high. First take your complaint to the hospital administration and offer to pay a more comparable charge. If that is rejected, and you have employer-paid insurance, take the bill to your HR department and ask them to intercede. If that does get an acceptable result, go to your local newspaper or television station. It gives them material for a human-interest story and just may get the hospital to offer a lower charge. Use social media to try to shame the over-charger.
Prescription for Bankruptcy. Buy the book on Amazon
Case 2: A posting on Kaiser Health News back in November 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.
Case 3: There is also the story I recount in Prescription for Bankruptcy about a man who was mugged and taken to the emergency department for attention. He was aware (and concerned) enough to check before being transported that the hospital to which he was taken was “in network” for his insurance. He had suffered a broken jaw and was taken to the operating room for repair. Weeks later he got very large bills from the oral surgeon and anesthesiologist who cared for him who were not in his insurer’s network.
These three cases cover most of the causes for surprise medical bills. The Florida cat lover was at the mercy of price-gouging by the hospital she went to for help. The California professor and her insurance paid astronomical prices to the prestigious hospital system that knows it can overcharge because they are in the driver’s seat. It is hard to sell a health insurance package in northern California that does not include the perceived leading hospital in the area. The mugging victim was victimized a second time because even when a hospital has signed a contract with a health insurance company, many of its doctors may not. This practice is particularly common among specialties where the patient does not really have much choice in who sees them: emergency physicians, radiologists, pathologists and anesthesiologists.
Hospitals are now required to post their charges on-line, but to date they have (probably deliberately) done so in the most abstruse manner possible, using obscure terms that most non-medical people find hard to read or search. Hopefully some clever people will soon come up with an app to make the search more user-friendly.
What can you do about these nasty surprises? For diseases – like rabies – with obvious public health importance, you may be able to get treated at your local public health department for free. DO NOT POSTPONE TREATMENT to save money. If your problem occurs on a Saturday, go to the ED.
You must get in the habit of asking the doctors assigned to you if they take your insurance. Do not assume that they do because they are affiliated with a hospital that does. If you get an obviously-inflated charge compared to what others charge, you are entitled to, and should ask for, an itemized bill to see why the total is so high. First take your complaint to the hospital administration and offer to pay a more comparable charge. If that is rejected, and you have employer-paid insurance, take the bill to your HR department and ask them to intercede. If that does get an acceptable result, go to your local newspaper or television station. It gives them material for a human-interest story and just may get the hospital to offer a lower charge. Use social media to try to shame the over-charger.
Prescription for Bankruptcy. Buy the book on Amazon
Thursday, March 7, 2019
Do I really need all these pills?
A prior post discussed the importance of taking medication as prescribed, focusing on medications that were intended to prevent things like strokes, heart attacks and fractured hips. There is another side to the coin.
Doctors are increasingly aware of the problem of “polypharmacy:” taking a lot of pills. Almost 60% of all Americans take at least one prescription medicine and a third of Americans over 65 take five or more medications daily. Add to these various supplements and over-the-counter (OTC) pills and that can add up to quite a handful. At times this may be appropriate and beneficial. If you have diabetes, hypertension and congestive heart failure, most of your pills may be needed. However, in many cases pills have been added by one doctor unaware of what another doctor prescribed.
Your primary care doctor (if you are fortunate enough to have one) may not even be aware of everything you are taking. Many medications interact in ways that may be harmful. Some may have been intended only for short-term use but were never stopped. Some may have been appropriate when you were younger but have more side effects as you age.
Some specifics: many drugs to treat bladder problems cause dry mouth in everyone but also constipation, confusion and falls in the elderly. Young patients with diabetes with good home support benefit from having their blood sugar tightly controlled; it prevents later eye, kidney and vascular problems. Older patients benefit less and are much more at risk of low blood sugar (hypoglycemia) which can be a serious threat, even fatal, if they are over-medicated.
Some patients whose blood pressure has been well-controlled can lower or stop their medications and maintain good pressure for extended periods or indefinitely.
Anti-anxiety medications and many sleeping pills have been repeatedly linked to falls in older patients who take them. Digoxin has been used for a century to treat heart failure but more recently has been found to increase death rates in people who take just a bit too much.
What can you do? First, be sure to carry with you a list of every pill you are taking. This may be life-saving should you end up in an emergency department, but it should also be shown to any doctor you see. Periodically it is useful to ask your primary care doctor to review what each of the pills is for, and to ask whether there are any that might be safely stopped.
I would always ask my patients once a year to make a “brown bag visit,” bringing in every pill they had at home and we would often be able to cull many that were duplicating each other. It was amazing to find that people were often taking the same medication twice, because the pills in the different bottles looked different because of different manufacturers and may have even had different names – one branded, one generic. It may be appropriate to ask if lifestyle changes could take the place of some of your pills. If you are willing to put in the effort, this is often possible.
The same review may be able to identify expensive pills that have an equally good and cheaper alternative.
Prescription for Bankruptcy. Buy the book on Amazon
Doctors are increasingly aware of the problem of “polypharmacy:” taking a lot of pills. Almost 60% of all Americans take at least one prescription medicine and a third of Americans over 65 take five or more medications daily. Add to these various supplements and over-the-counter (OTC) pills and that can add up to quite a handful. At times this may be appropriate and beneficial. If you have diabetes, hypertension and congestive heart failure, most of your pills may be needed. However, in many cases pills have been added by one doctor unaware of what another doctor prescribed.
Your primary care doctor (if you are fortunate enough to have one) may not even be aware of everything you are taking. Many medications interact in ways that may be harmful. Some may have been intended only for short-term use but were never stopped. Some may have been appropriate when you were younger but have more side effects as you age.
Some specifics: many drugs to treat bladder problems cause dry mouth in everyone but also constipation, confusion and falls in the elderly. Young patients with diabetes with good home support benefit from having their blood sugar tightly controlled; it prevents later eye, kidney and vascular problems. Older patients benefit less and are much more at risk of low blood sugar (hypoglycemia) which can be a serious threat, even fatal, if they are over-medicated.
Some patients whose blood pressure has been well-controlled can lower or stop their medications and maintain good pressure for extended periods or indefinitely.
Anti-anxiety medications and many sleeping pills have been repeatedly linked to falls in older patients who take them. Digoxin has been used for a century to treat heart failure but more recently has been found to increase death rates in people who take just a bit too much.
What can you do? First, be sure to carry with you a list of every pill you are taking. This may be life-saving should you end up in an emergency department, but it should also be shown to any doctor you see. Periodically it is useful to ask your primary care doctor to review what each of the pills is for, and to ask whether there are any that might be safely stopped.
I would always ask my patients once a year to make a “brown bag visit,” bringing in every pill they had at home and we would often be able to cull many that were duplicating each other. It was amazing to find that people were often taking the same medication twice, because the pills in the different bottles looked different because of different manufacturers and may have even had different names – one branded, one generic. It may be appropriate to ask if lifestyle changes could take the place of some of your pills. If you are willing to put in the effort, this is often possible.
The same review may be able to identify expensive pills that have an equally good and cheaper alternative.
Prescription for Bankruptcy. Buy the book on Amazon
Subscribe to:
Posts (Atom)