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Family Webicine

with Rod Moser, PA, PhD

Stories from behind the examining room door, as told by Rod Moser, PA, a primary care physician assistant with more than 35 years of clinical experience.

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The opinions expressed in WebMD User-generated content areas like communities, reviews, ratings, or blogs are solely those of the User, who may or may not have medical or scientific training. These opinions do not represent the opinions of WebMD. User-generated content areas are not reviewed by a WebMD physician or any member of the WebMD editorial staff for accuracy, balance, objectivity, or any other reason except for compliance with our Terms and Conditions. Some of these opinions may contain information about treatments or uses of drug products that have not been approved by the U.S. Food and Drug Administration. WebMD does not endorse any specific product, service or treatment.

Do not consider WebMD User-generated content as medical advice. Never delay or disregard seeking professional medical advice from your doctor or other qualified healthcare provider because of something you have read on WebMD. You should always speak with your doctor before you start, stop, or change any prescribed part of your care plan or treatment. WebMD understands that reading individual, real-life experiences can be a helpful resource, but it is never a substitute for professional medical advice, diagnosis, or treatment from a qualified health care provider. If you think you may have a medical emergency, call your doctor or dial 911 immediately.

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Monday, November 25, 2013

My Last Post (At Least for Now)

By Rod Moser, PA, PhD

Rod Moser

I have been writing blogs for WebMD for nearly a decade. At first, I had to be talked into doing them, and then it became addicting. Family Webicine – a glimpse behind the exam room door — became an integral part of my clinical life

I wrote seasonal blogs on poison oak/ivy, sunburn, mosquito bites, dog bites, toddler bites, and frostbite. And I tackled controversial subjects like vaccines NOT causing autism.  I also did a few 12-part series, like the Dirty Dozen – The Twelve Dirtiest Places. My 600 or so blogs (lost count) will still be available in the WebMD archives, but at the end of this month, the Family Webicine blog site will be retired. Actually, in a few more years, I hope to retire from full-time clinical practice myself. I don’t plan on retiring from writing, however.

Over the years, people learned a great deal about me as a clinician, a father, a grandfather, a backyard chicken farmer, dog breeder, and as a person. My blog was a way for me to voice my frustration over the cost of medical care and pharmaceuticals. I openly chastised rude medical providers who make patients wait for their appointments, perform cursory examinations, and leave the examination room without addressing the patient’s questions. I complained about patients who always come in late, add “Oh, by the way” issues to their medical visits, and answer their cell phones. Virtually anything that went on behind those closed examining room doors could end up as a blog topic (within good taste, of course).

My blog readers have shared poignant moments in my life, like the joyous birth of at least 3 of my 6 grandchildren, my mother’s dementia, cancer in my friends/relatives, and even some painful deaths. I wrote about my pets, and was especially touched by supportive readers after the tragic death of my favorite dog, Herman. A few years later, those same readers helped me celebrate 6 new puppies born in our bedroom. Two of those puppies still live with us, along with their mother. I see a little bit of Herman in all them; something that has helped heal my broken heart. Since Family Webicine was my only social network, friends and family would read my blogs to find out what was going on in my life.

My blog readers followed me through four of my own surgeries; two for kidney stones and two for a torn rotator cuff.  I am facing a third surgery on my rotator cuff since the first two failed.  I spared no feelings about experiencing medical mistakes that happened during those surgeries. When medical providers become patients, we get to experience our troubled health system first-hand.

For those of you who have taken time to read my blogs and especially those who made comments, I thank you (even if some of those comments were not complimentary). When someone takes the time to write a comment or rebuttal, I knew that I was covering a topic that sparked interest. Those comments helped me become a better person; a better clinician.

I have not given up writing. I have a few books in the computer that need to be finished, and I hope to write a health articles for several newspapers. I will still have an active presence on WebMD as long as they need me. I hope to will remain an active contributor to WebMD Answers. As long as people have questions, and I have the answers, I will post a response.

Old clinicians never stop practicing (or writing). I suspect I will have ample opportunities to suture up more of my grandchildren, treat their infections, or cast their broken arms. There will always be family medical questions to answer and more stories to write about. Every person on this planet has their stories but few take the time to write them down. I will always be grateful to WebMD for twisting my arm to write down at least some of my stories. If you have stories, you should be writing them down, too.

I have a retirement countdown calendar in my office: 121 “working weeks” before I finally hang up my stethoscope and turn my lab coat into a car rag, I will have practiced medicine for nearly 44 years. That’s a long time, folks, and I have to say it has been a great run. I will miss my patients, and I will miss my WebMD “patients”, too.

Thank you so very much for sharing a decade of my life and medical career.

I have a patient waiting.

 

Posted by: Rod Moser, PA, PhD at 10:41 am

Monday, September 30, 2013

A Close Call

By Rod Moser, PA, PhD

woman choking

My wife had prepared for this baby shower for weeks. This past Saturday, twenty or so cackling and happy women arrived for the food and festivities: the upcoming birth of our sixth grandchild. I say “grandchild” since the sex of this newest member of our family has not been revealed.

My wife decided to have it catered by a local chef and author of a popular cookbook, but she also assigned me to get up early and make sushi. Since men are traditionally excluded from these events, I was also put in charge of parking and walking people to and from their cars. As it often happens with well-planned events, it was raining cats and dogs – the first major rain of the year.

The food was great (they allowed me to eat), but I was still relegated to the back room with my son, the father of this new baby. My daughter-in-law was having her first baby and was overjoyed by all of the gifts. After a dozen or so squeals of “so cute” or “Isn’t that darling?”, I was glad to be among the outcasts.

At the end of the shower, I was called upon again to retrieve cars and hold umbrellas for the departing guests. Soon, we were down to just a few women, including the other grandmother-to-be who had flown in from Phoenix for the party. I felt it was safe to return to my beloved reclining chair and seek out any of the leftover treats that had not been consumed. She was sitting on the couch about ten feet from me and we were having a pleasant conversation. She was eating.

Surprised by the sudden silence, I glanced in her direction. She had a fearful look on her face and was staring blankly. Her face was ghost-white and she was holding her neck.

“Are you okay?”

She responded by a quick shaking of her head as a no. I sat up.

“Can you breathe?”

Again, she quickly shook her head indicating that she could not. I jumped up.

Much to the horror of the guests that were leaving, I picked her up and gave her two very quick and forceful abdominal thrusts, known as the Heimlich maneuver. Out came a huge bolus of food, followed by some violent coughing and vomiting.

Now that her breathing had commenced again, I notice that her hands were tightly clenched, indicating anoxia (a severe lack of oxygen) had occurred. She continued to cough and hack up food and liquid that was aspirated into her lungs. I got out my stethoscope and heard evidence the she had aspirated a bit into her lungs, but she was breathing fine now.

Since she had a prior heart attack, she spent the next twelve hours in the emergency room being monitored.  By that time, her chest x-ray was clear and her electrocardiogram did not show any changes (the ER was able to call the hospital in Phoenix and her previous ECG was transmitted electronically). She was released to go home. Her only complaint was that her ribs were sore!

I have been a medical provider for over four decades. I have performed CPR many times in the hospital or clinical settings, but never once have I had the opportunity to perform a Heimlich, and certainly not in my home. These events can happen anytime; anywhere, so we all need to be prepared.

My son’s mother-in-law is safely at home in Phoenix again. I am still eating up some of the leftovers from the baby shower, being extra careful to chew. What could have been the worst baby shower yet, ended up just fine. Had this episode occurred when she was in the bathroom or even driving home, the outcome could have been grave (literally).

The next time we host a baby shower, maybe I will be invited.

Posted by: Rod Moser, PA, PhD at 12:22 pm

Monday, September 16, 2013

Does Green Signal Sinus Infection?

By Rod Moser, PA, PhD

boy wiping nose

One of the most frequent concerns in pediatrics (and the least understood) involves the color and significance of nasal mucous. Many parents believe that when the mucous turns green, the child has a bacterial or sinus infection and needs antibiotics. This is “handed-down” information from grandmother to mother; and it is just not true.

Viral respiratory infections (colds) can cause a variety of mucous color changes in the first few days of an illness…green, yellow, orange, brown…just about every disgusting color you can imagine.  If you are a parent that is a “mucous color watcher”, then read on….

  • After sitting stagnant in a congested nose all night, mucous tends to be the worst and grossest in the morning (or after a big sneeze).  This is not unlike a stagnant pond that turns green. There may be some bacteria at play, but this is usually the resident bacteria that flourish in the nose. A green nose in the morning is no cause to take warning.
  • If you are a mucous color watcher, then pay more attention to it in the afternoon or as the cold progresses. If the nasal mucous is consistently green, day and night, for a week to ten days, it is more likely to be medically significant.
  • If a persistent, foul, green mucous is only coming out of one side of a toddler’s nose – a toddler who does not seem to be sick – this is not likely an infection. One of the more common causes is a foreign body in the nose, usually decomposing food. Raisins, beans, and pieces of any food are occasional found in little noses. No one really knows why toddlers do this, but they do.
  • Simple colds tend to last a week if we treat them and seven days if we leave them alone. In children, nasal congestion and cough can last a lot longer, especially children who are constantly exposed to other children. Back-to-back colds can make symptoms last a month or more. When persistent colds are accompanied by fever, rapid respirations, wheezing, or worsening symptoms over time, there is a good chance that a secondary bacterial infection has taken hold. These children need to be seen by a medical provider.

If a child has persistent green mucous, all day long for ten days or more, from both sides of the nose, and these symptoms are accompanied by headache, sore throat, or fever, then it is time to re-evaluate. Although rare, there are incidents where antibiotics may be needed.

Posted by: Rod Moser, PA, PhD at 1:03 pm

Monday, September 9, 2013

Anaphylaxis: The Life-Threatening Allergic Emergency

By Rod Moser, PA, PhD

emergency room

I have had an anaphylactic reaction three times in my life: twice from bee stings when I was a teenager, and once from an antibiotic drug reaction several years ago. I was almost given that same drug by mistake when I was a patient in the hospital. Unless I had inquired what they were putting in my intravenous line, I would have had a fourth anaphylactic reaction.  Even with all of the hospital safeguards, including my allergy listed prominently on my wrist band and chart, the nurse simply ignored it.

I can assure you that I now have a ready supply of epinephrine pens (called an EpiPen) at home, but when I had my last unexpected reaction to the antibiotic, my epinephrine had seriously expired. You would think I would know better. I have enough epinephrine in my house now to treat a small village.

More and more of my patients have serious allergic reactions listed on their chart. Recently, a 13 year old girl who was highly allergic to peanuts mistakenly took a bite of a Rice Crispy treat that had peanut butter in it. Even though she spit it out immediately and took an antihistamine, she developed an anaphylactic reaction. Her airway quickly became compromised and three shots of epinephrine were administered by her physician father. They did all of the right things, but they could not save her life. Sadly, these tragedies are not uncommon.

Anyone can develop a life-threatening allergic response, especially those with known allergies or asthma. For some, the reaction can be totally unpredictable. Even the elderly (now including myself), are at a higher risk from insect venom.  I am among the 3% of adults who have bee sting and other insect allergies.  Food allergies to things like peanuts, tree nuts, shellfish, fish, eggs, and milk are all too common now – 4% of the U.S. population or 12 million people have serious food allergies. Drug allergies are always a concern when I am prescribing them.  Penicillin remains the most common drug allergy, but even ibuprofen can cause serious reactions in those who are allergic. Chemical reactions to latex (gloves, condoms) have also caused life-threatening allergic reactions. Up to 6.5% of the general population is allergic to latex and many do not even know it.

If you have a history of allergies, asthma, or serious allergic responses in the past, you must be proactive. Talk to your health care professional and make sure you have the proper medication, and know how to handle an allergic response in yourself or a family member. You need to have an auto-injection epinephrine pen (available generically or as the brand name EpiPen or Auvi-Q) and know how to use it.

Prevention is the key. While it may not always be possible to avoid every allergic trigger (like bees), every effort should be made to avoid the allergens that you do know. If you are allergic to one or two substances, you are likely to be allergic to more. Peanut butter hidden in a Rice Crispy Treat recipe or Chinese food cooked in peanut oil may end up being deadly.  Letting your pharmacist know your drug allergies can be life-saving. For instance, a person who is highly-allergic to penicillin may not know that the antibiotic, Augmentin, contains a large dose of amoxicillin. Even in the best medical facilities, drug mistakes can happen, so an allergic person should always be on high-alert.

Some of the signs and symptoms of anaphylaxis can begin in seconds or even thirty or so minutes after exposure:

  • Sudden wheezing and a compromised airway
  • Hoarseness
  • Itchy hives all over your body or redness
  • Sudden swelling of the face, lips, or other parts of your body
  • Rapid heartbeat or even a weak pulse
  • Feeling anxious and confused
  • Fainting or passing out

What to do in an anaphylactic emergency:

  1. If the person has an EpiPen or if an EpiPen is available, inject it immediately in a thigh muscle. More than one injection may be required. Be prepared for a second injection in about ten minutes if there is no response.
  2. Call 911 if they have not been called.
  3. Make sure the airway is open. If the breathing has stopped, start CPR until the paramedics arrive

 

Time is critical during these unexpected, life-threatening emergencies. The sooner the patient is handed over to the paramedics and on the way to the hospital, the better.

Posted by: Rod Moser, PA, PhD at 2:34 pm

Monday, August 26, 2013

Complacency Can Kill

By Rod Moser, PA, PhD

two people in a waiting room

Medical science has done very well in combating illnesses, but it has yet to tackle the complexities of human behavior, including complacency. When a patient fails to take their illness or medical condition seriously or fails to follow, common-sense safety rules, the outcome can be serious, even fatal.

Here are some examples from my practice:

  1. My patient with diabetes had been insulin-dependent for so long that he didn’t even think about it anymore. He would take his blood sugar test (sometimes) and his usual dose of insulin (if he remembered). He knew what he was supposed to eat, but when he discovered frozen yogurt, he was hooked. He guessed at the amount of insulin to adjust to make up for those frequent, dietary indiscretions. Consequently, his diabetes was out of control most of the time. This led to a partial amputation of his foot from a minor infection, and eventually contributed to his demise.
  2. Driving can be routine, and even boring. Seatbelts are the law, but many people fail to use them consistently.  My patient was not wearing a seatbelt when a large truck rear-ended her vehicle at a traffic light. She sustained some serious neck injuries.
  3. A parent told me that her children had taken swimming lessons so she had stopped supervising them around the pool. Then one day a protective cover came off the drain to the spa, and her son tried to sit on it. When the filter came on, he was stuck at the bottom. Fortunately, another sibling alerted the parent and he was saved from near-drowning by seconds. The parent now supervises pool activities and the broken drain guard was replaced.

 

In order to effectively manage chronic diseases, like diabetes or hypertension, patients must first accept the disease, and then take an active role in management. A medical provider can prescribe a blood pressure pill, but it is up to patients to swallow them every day. When patients actively participate in their care, like taking their blood pressure at home, they are more likely to be in control.  Since diabetes and hypertension can have very subtle symptoms (unless there is a crisis), it is common for patients to become complacent.

The same is true for preventing emergencies and following safety recommendations, wherever we are. Everyone knows that seatbelts help prevent serious injury in an accident, but it is up to us to buckle them every time we get in the car.

The complacency equation has two sides. I have seen medical professional become complacent as well. They spend little time with their patients, often skipping the exam (I have experienced this several times when I was in the patient role). They may fail to notice critical health maintenance recommendations, like cholesterol tests, pap smears, or mammograms.

Medical care is a team effort, and the most important member of that team is not the doctor, but the patient. Patients cannot afford to become complacent, and they can’t allow their medical provider to do the same.

 

 

Posted by: Rod Moser, PA, PhD at 3:28 pm

Monday, August 19, 2013

The Waiting Room

By Rod Moser, PA, PhD

two people in a waiting room

Of all of the complaints that patients post about their medical care, waiting time is very high on the list.

A recent poll by Fierce Practice Management shows that medical practices still have a way to go in patient satisfaction when it comes to waiting time.  According to the online poll,

  • 65% of the respondents reported waiting an hour or more to see their provider
  • 37% say that when they have waited a long time, they are often rushed and less likely to ask the provider questions
  • 70% weren’t informed that their provider was “running late”
  • 55% say they did not receive an apology for the delay

Patients should always be informed if the medical provider is “running late”. Our group has tried many things, from constantly posting wait times on a white board in the waiting room, to a high-tech, moving display that updates the wait time like the stock market prices. Apparently, this last method did not work out well, because I no longer see it in the family practice waiting room. As a matter of fact, the white board is also gone. A simple knock on the exam room door to let the next patient know that there will be a delay is only common courtesy.

There are some medical providers who are constantly late (we have one of those providers in our group), and after a while, some patients learn to accept those delays. A local pediatric urologist (now retired) would make his patients wait up to four hours! The parents, knowing this, would bring food and entertainment for the kids being seen.

Speaking from experience, I can tell you that staying on time can be difficult for several reasons, but the most common is that a large percentage of patients often come in with a hidden agenda or extra item that they would like handled during the set visit time. These can range from the “Oh by the way, can you freeze this wart?” to I need a sports physical completed.  While I can’t blame the patient for trying to get as much done during a medical visit as possible, each additional item takes time away from the next patient. By the end of the day, a provider could definitely be running late.

And there are a many other possible reasons for delay: The person just before your visit could have had a crisis or a serious medical issue that took longer, or the doctor may have been called to the hospital or had a family emergency, or it could be another unforeseeable issue entirely.  A few years ago, while teaching a young mother how to insert a rectal suppository on her two-year old child, I had a major crisis. The child suddenly pooped all over me, and I had to go home, shower, change clothes and come back.  About two hours of my patients had to be rescheduled. When I explained my reasons, parents understood completely.

Poop happens.

 

 

Posted by: Rod Moser, PA, PhD at 11:11 am

Tuesday, August 13, 2013

Are You Ready for an Emergency?

By Rod Moser, PA, PhD

cpr

Why should anyone take the time and effort to learn CPR (cardiopulmonary resuscitation)?  If you have a cell phone, all you need to do is call 9-1-1 and the paramedics will be there in a flash. Besides, someone else may be able to start CPR. Right?

Our little patient was just 11 years old and taking weekly swimming classes.  His past medical history was unremarkable and he passed every physical exam with flying colors. Suddenly, without warning, his heart basically stopped (ventricular fibrillation), and he fell into the water. Someone pulled him out and noticed that he was not breathing and he had no pulse.

Emergency medical services were called and arrived in about 10 minutes. In the meantime, a bystander started CPR. Using a defibrillator, his heart was zapped four times as he was rushed to the emergency room. Once he began to stabilize, he was transferred to a pediatric intensive care unit where he underwent therapeutic hypothermia – rapidly cooling the body down to save the brain and neurological function.  A week or so later, he was brought out of his hypothermic state. He woke up in the hospital and complained about the show that was playing on the TV. The cause of his cardiac arrest was said to be a rare, congenital time bomb that no one knew was ticking.

Luckily, when this little boy’s time bomb went off, there was a bystander around who knew how to administer CPR AND use a defibrillator. Defibrillators are now commonly located in public areas like offices, malls, airports, and recreation areas. Take some time to become familiar with how they operate (a step-by-step guide is available here), and take note of where they are located in the areas you frequent. They are designed for people with no medical training, so they are fairly easy to use. And they can make the difference between life and death when someone’s heart stops. Here are a few other basic ways you can prepare yourself for emergencies:

  1. Have your cell phone charged and ready. Quick emergency response can save lives.
  2. People should take a First Aid and CPR class. You never know when you may need those skills, not only for your own family, but for a stranger. Be sure to have a well-stocked first-aid kit at home and in your car.
  3. Create a Family Emergency Response Plan.  Try and anticipate possible emergency situations that may involve any of your family members. Teach younger children how to call 9-1-1 when needed.
  4. If you have a child that has a serious allergy, you should always have fresh epinephrine pens readily at hand, both at home and at school. Make sure the school/camp and your child knows what to do during an allergic emergency. Remember that bee stings and other insects could cause allergic reactions as well.
  5. People with serious allergies and medical conditions should wear an identifying bracelet or necklace to alert others.

 

Posted by: Rod Moser, PA, PhD at 11:30 am

Monday, August 5, 2013

Cancer Touches Everyone

By Rod Moser, PA, PhD

group of people

Cancer has a way of reaching out and touching just about everyone; some harder than others. Depending on your age, you may have been personally touched already, and survived. You may have friends or relatives that have not, or are currently battling this common killer.

Cancer first touched my life when I was only six years old, with the death of my father from lung cancer. He was a smoker and an asbestos worker in the shipyards (a huge factor in lung cancer). When he died in 1957, medical science had not even linked either one as a cause. I recently found a medical book about lung cancer published in 1957 that had only three sentences about the inconclusive relationship to smoking. Treatment was limited to drastic surgery and radiation; none of which were very successful.

In the next few years, I heard about lung cancer several more times when my grandfather and three uncles died of this scourge in our tiny, coal mining community. We considered it our “family disease”.

When I started my medical training in 1969, I worked in the hospital to pay for my tuition. Nearly all of my elderly hospital patients had some type of cancer: lung cancer, colon cancer, breast cancer, kidney cancer, uterine/cervical cancer, brain cancer, or prostate cancer. Just the word “cancer” would strike fear in the hearts of patients and their families. For many, the Big C was a death sentence. Doctors would often give the proverbial “six weeks or six months” to live speech without really knowing the final outcome. When you were told you had cancer, you started to put your life in order for your family.

In the last few years, I have lost dear friends to pancreatic cancer, lung cancer, brain cancer, and breast cancer. Many of my close friends and relatives have been diagnosed with various forms of this dreaded affliction. Three of my close male friends now have prostate cancer. Most will do well with modern treatment modalities. When this lightning strikes so close to home, a person cannot wonder when the Big C is going to knock on their own door.

For each person who is diagnosed with cancer, several more lives may be saved. Why? Because cancer motivates loved ones to get tested themselves, or to make lifestyle changes to reduce their own risks. I just finished my own colon cancer screening test and have made an appointment for my annual physical exam to get the ol’ prostate checked. After my brother was diagnosed with a tiny melanoma, I can assure you that I had a thorough skin survey by a dermatologist. Cancer can definitely frighten people into healthier habits, but you really have to practice those habits  consistently. You don’t just wear seat belts when you think you are going to be in a car accident, and you don’t just practice cancer prevention when one of your friends or relatives gets it.

Ten things you can do:

  1. Know your family medical history. Some cancers run in families
  2. Don’t use ANY form of tobacco….ever. If you do, stop now. Today.
  3. Eat a healthy diet like your life depends on it (because it does). If you are overweight, lose those extra pounds.
  4. Stay physically active. Don’t just sit there…do something! Get up and walk around until you think of something physical that you might enjoy.
  5. Get Immunized: HPV, Hepatitis B
  6. Stay out of the sun or at least be proactive to prevent skin cancers (sunscreens, hats, protective clothing)
  7. Practice safe sex. Enough said.
  8. Get regular medical care. Let a medical professional do their job.
  9. Do the recommended cancer-screening tests: pap smears, colonoscopies, mammograms, etc.
  10. Be an evangelical friend. Support those how have cancer and spread the word about the importance of all of these cancer-prevention steps.

 

 

Posted by: Rod Moser, PA, PhD at 11:06 am

Monday, July 22, 2013

Don’t Take ‘No’ for an Answer

By Rod Moser, PA, PhD

woman on phone

Her name was Helen and she had breast cancer. Because of the advanced state of her disease, it was recommended that she undergo a course of treatment that involved a bone marrow transplant. At the time, this expensive procedure was considered experimental so her insurance company refused to approve it. Knowing that an appeal process could take months or even a year or more – time that she may not have – she took matters in her own hands. They mortgaged their home and paid for the treatment in cash (over $100,000). This quick and financially-painful decision did save her life.

She then got a good attorney, did her research, and took the insurance company to court. She won. Not only was she reimbursed for her treatment expenses, she was awarded additional damages.

My teenage patient going to Scout Camp. He reluctantly told me that he was still wetting the bed; wearing pull-ups at night. He did not know how he was going to manage this and keep his secret during his one week camping trip. The answer was a medication called desmopressin – a hormone that could quickly control this nighttime wetting. His insurance company refused. It took me about an hour or so on the phone arguing with the medical director, but in the end, I was able to get this medication approved in time for his trip. The medicine miraculously worked and he was dry for the first time in his life. There are many things in life (most things, in fact) more important than money. His self-esteem was one of them.

If you are denied coverage, there are steps you can take with your insurance company to appeal the decision. Say you go to the pharmacy, pick up your prescription and are informed that the drug prescribed is “not covered” by your insurance, so you will have to pay out-of-pocket.  You are told the price and nearly faint in disbelief.  What are your options?

  1. You can get out your credit card and pay for it.
  2. You can choose not to get it filled.
  3. You can call your doctor’s office and complain; hoping there is a less-expensive alternative medicine that can be prescribed
  4. You can call your insurance company to complain.

 

Calling your insurance company may be frustrating and is often futile. The first level of people that you may get on the phone are just following algorithm instructions on the computer screen. No matter what argument that you present, the answer is:

“No, this medication is not covered. Please call your doctor.”

Most insurance companies will have a formal appeals process that can be equally as frustrating, but those carefully written benefit policies are often iron-clad. If your insurance company does not cover “X”, there may be little recourse, or at least, it may be a long, bumpy road to fight the denial – independent review, arbitration or even court. If a person needs an expensive cancer drug, this will be worth it. For an expensive antibiotic, where there may have an alternative choice, it is unlikely that patients will climb the “appeals ladder”.

The pharmacy may fax us a TAR – or “Treatment Authorization Request”. The medical provider must answer a series of questions to justify our decision to use a particular drug that was not in their preferred formulary (usually a cheaper alternative). The form is faxed to the company to be reviewed by someone; often a pharmacist or medical director. They may or may not approve it. All the while, the patient is going without the recommended prescription.

Granted, there are less-expensive alternatives in many cases that your medical provider could have chosen, but sometimes, there are no other choices. Your medical provider may simply ignore the TAR or not fill it out correctly. Many will even refuse to modify their prescription or treatment plan and will leave you in a quandary.  You are caught in the middle between a cost-containing insurance company, and expensive pharmacy, and a medical provider that refuses to bend and play the game.

Pick your battles. If you choose to fight a health care claim denial, you will need to be very organized and persistent. Read your insurance policy like an attorney. Unless you know what cards you hold in your hands, you cannot possibly win the game.

You should also try to be nice, regardless of the reasons not to be. You should always be assertive, but not hostile. Taking it out on those minimum-wage, first-tier people that answer the phone does little to achieve your goal.

Write down everything during phone conversations, especially names or employee numbers of your contacts. Enlist the help of your doctor or medical provider to support your case.

You may win some. You may lose some, but that doesn’t mean you should just take NO for the answer.

Posted by: Rod Moser, PA, PhD at 3:54 pm

Monday, July 15, 2013

Convenient Care

By Rod Moser, PA, PhD

doctor

When the first free-standing Urgent Care facility first opened up in a shopping center near me, between a bagel shop and a flower store, I thought the concept would never fly. As the years progressed, more and more clinics opened, and people embraced the idea that there is a need for convenient, fast care – just like there appears to be a need for fast-food establishments.

Ten years later, I found myself working part-time in one, called the Immediate Care Medical Clinic (now closed). Two providers staffed this well-run facility, and we could see up to 90 patients a day in a 12-hour shift. We were open seven days a week and provided full-service care to people of all ages. We were conveniently located between a large super market and a pharmacy. The clinic closed after twenty years, became a Blockbuster Video, and is now a hair salon.

Many free-standing convenient-care medical facilities are staffed by NPs and PAs; or with physicians working full or part-time. These are usually the same people you might see if you made a standard, medical appointment in a regular doctor’s office. The level of care should be the same. Convenient care does not imply inferior care, although one may reluctantly experience inferior medical care just about anywhere.

The need for fast, efficient, affordable care for minor medical issues certainly exists. Busy people want to walk in the door, sign their name, be examined, diagnosed, and treated in a half-hour or less.  The patient or their insurance company is willing to pay a fair price for this convenient medical service, too, knowing that an ER would be much, much more costly.

There are really four types of medical visits:  The well or worried well, the mildly ill or injured, the more seriously ill or injured, and the life-threatening emergencies. Life-threatening emergencies like cardiac chest pain, major lacerations, concussions, and motor vehicle injuries are best handled by a full-service emergency room at the hospital.

Well patients often need physical examinations for work, school, camp, or because routine physical exams are important.  The “worried well” patient generally does not have anything wrong with them, but the patient wants to be sure. They want confirmation that their headache is not a brain tumor, their bellyache is not appendicitis, or their burning on urination isn’t a sexually-transmitted disease.

Mildly ill patients fill the bulk of most practice appointments. Things such as colds, earaches, sore throats, pink eye, diarrhea, vomiting, back aches, or undiagnosed rashes are the most common. Mild injuries include such things as burns (including sunburns), cuts, puncture wounds, or stubbed toes/fingers. Most of these things can be easily seen in urgent care facilities.

More serious illnesses or injuries include uncontrolled asthma, pneumonia, acute abdominal/pelvic pain, foreign bodies that have found their way into unusual places, lacerations needing sutures, or various fractures needing casts.  Only the largest and well-equipped urgent care facilities can handle these; certainly not the little module kiosks located in the corner of a pharmacy.

Standard medical facilities have “continuity of care”. In other words, you will see the same provider year after year; someone who knows you and your medical history, and someone who you learn to like and trust. Any time that you go to an urgent care facility, you may see someone different and you don’t have much control over who you see — they may be an excellent clinician or one that should not be practicing medicine. It can be hit or miss when you go through those urgent care doors. In a standard medical practice, you can just change to a different clinician if the one you are seeing does not meet your needs.

Urgent care facilities are here to stay, and more and more will be offering comprehensive care and expanded services. Find one that you like and use them when it is convenient. It is still wise to establish your care with a regular medical provider; someone who will take the time to get to know you as a person, not just a quick-fix illness.

There is certainly room in the medical world for both.

Posted by: Rod Moser, PA, PhD at 2:02 pm

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