Interesting Tidbits from the Medical Literature

More on Losing Health Insurance
It is worse than I thought. Up to 14,000 Americans per day may be losing their health benefits during this economic downturn (a nice term for "crisis") according to a report by the Center for American Progress and Health Care for America Now.

"Approximately 2.4 million workers and their families have lost the health insurance their jobs provided since the current recession started in December of 2007, according to an analysis by Nayla Kazzi at the Center for American Progress. "

"More than 51 million Americans under age 65 do not have health insurance as of January 2009, and millions more drift in and out of coverage as their employment and financial situation changes. According to a March 2009 study from Families USA, approximately 87 million Americans under 65 - nearly one in three - went without health insurance for some period in 2007 or 2008."

(See "When You Have No Health Insurance or Money" blog post). More and more people are being qualified for the government's Medicaid program - millions of people are already enrolled and the number is growing. If families try to purchase private insurance, they need to expect rising costs there as well (assuming they are healthy enough to qualify and do not have any pre-existing health problems).

And More on COBRA... It Strikes Employers, Too
The economic stimulus package will subsidize 65% of the COBRA health insurance costs for up to 18 months. Some companies feel that this will be an additional (and costly) burden to companies who have to pay the administrative costs to manage this program for laid-off workers. Personally, I think the minor administrative costs are the least a company can do for these disadvantaged workers. In a way, it was nice for our government to help out.

Get Ready for the Upcoming Epidemics
Most young families have never seen measles or Hib-related diseases, but that may change soon. There have been pockets of Hib and measles cases popping up across the country. There were about 400 cases in the U.S. last year. Unimmunized families may see them first-hand, unfortunately. As more and more families opt not to vaccinate their children due to unfounded fears that they cause autism and other developmental disorders, those diseases will surely return - perhaps with a vengeance. Measles has never left and continues to be among the leading causes of death in children worldwide. I suspect that families without health insurance will also be skipping these important vaccines.

According to the CDC, there were 131 cases of measles in 2008, the most since 1996. Most experts feel that this resurgence of measles is due to the highly vocal anti-vaccine movement.

Swine flu may be less serious than we expected, but expect an unprecedented vaccine campaign in the fall. Not only should a swine flu vaccine be available, but we will still have our usual and customary annual strains that take about 35,000 lives each year. Anticipating the circulating strains is becoming more and more difficult as these ancient viruses mutate and change. The World Health Organization fears that up to two BILLION people could be infected by swine flu if the current outbreak turns into a true, global pandemic

Speaking of Vaccines
The pneumococcal conjugate vaccine, Prevnar, which has been protecting infants and children against seven of the more common streptococcal strains is now going to be even better. A newer, improved vaccine called Prevnar 13 will be adding protection against six additional strains, offering even more protection against pneumonia, meningitis, and yes, even the dreaded middle ear infection.

In the last decade, the insertion of tympanostomy tubes for recurrent ear infections has increased 35%; a whopping 85% increase since 1996. Although there has been an active campaign to reduce the astronomical amounts of antibiotics used in the management of pediatric ear infections, the overall usage has not drastically improved. Many parents feel that tubes are a less-risky alternative to frequent antibiotic use.

Cell Phones May be Contributing to Hospital-Acquired Infections
First they blamed dirty hands, then stethoscopes (rightfully, so). A few years ago, a study proved that our neckties (I stopped wearing them and I have a great collection of medical ones) may be spreading dangerous pathogens. Now, cell phones are being blamed for the spread of MRSA (Methicillin-Resistant Staphyloccoccus auerus) - the superbug in a study of Turkish hospitals. It doesn't surprise me at all. Since I do not carry a cell phone with me during clinic hours, this does not pertain to me. Computer keyboards and other hospital equipment may also be contaminated. Personally, I consider EVERYTHING in the hospital potentially contaminated. I hate touching elevator buttons ("Can you push three from me, please?) and I never touch stairway banisters.

Electronic Medical Records (EMR) "Depersonalize" Medicine
I read a New York Times story about how EMRs are going to transform medicine into a highly-efficient machine, saving billions in healthcare costs. This is not without a big price, however, in the social arena. Not only do medical providers have to spend additional time documenting their medical records (not all medical providers are good typists!), but computers have created yet another depersonalized barrier in the medical relationship.

We have used EMRs for several years in our office, but I rarely use the computers in the exam room during the encounter unless I am just briefly checking lab results, etc. I just do not want a flat screen between me and making eye contact with the patient, I am sorry. I find it terribly disruptive to have a medical provider typing away as a patient is talking. I experienced this as a patient with my own medical provider. As in the past, I still jot down my notes, only to type the later, in the comfort and quiet of my own office.

We get less than 15 minutes allotted for each patient visit. I am not going to waste 12 minutes of that precious time by typing notes.

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When You Don't Have Health Insurance (or Money)

Millions of people in the U.S. do not have health insurance, and more and more are losing their insurance when they lose or change jobs. When you have limited financial resources, priorities rapidly shift to the essentials, like food and shelter. Getting medical care tend to be low on the list. Nearly every day, someone will tell me that this will be their last visit due to insurance or financial constraints.

I tend to be highly sympathetic and do the best that I can to hold down costs, often by putting down a lower billing code and making sure to order only tests that are absolutely essential. When prescribing medications, I will look for samples (becoming increasingly scarce) or only use the less-expensive generics. I am often embarrassed by the costs of medical care. As a salaried employee of a large, health organization, there is little that I can do to

I am definitely less sympathetic when I know my patient has not changed expensive habits, like smoking, drinking expensive coffee, and eating out instead of packing a lunch. When someone asks me to bill them for their small, insurance co-payment and I notice they have a pack of cigarettes sticking out of their purses, I tell them how I feel. I am getting too old to let these "teaching moments" slide.

Setting reasonable priorities is not something that all people know how to do. And not all people are proactive and resourceful when it comes to trimming their personal budgets or finding affordable care.

Things you CAN do

1. Unless you have a true emergency (life-threatening) condition, stay out of the emergency room. If you have a primary care problem, like a sore throat or earache, this would be the most expensive way to get treatment. Call a few urgent care facilities (aka "Doc in the Boxes") for prices. They are certainly less-expensive than the ER.


2. Check your area for free clinics, or clinics that charge a sliding scale. There are fewer and fewer of these around, but sometimes you will be lucky.


3. Many counties have Public Health Departments that offer free or discounted medical services, especially immunizations.


4. Many uninsured and non-working people qualify for state-run insurances like Medicaid but never bother to check their eligibility. Children, especially, will benefit from this.


5. Find a good primary care provider or solo practitioner. Medical professionals who work for themselves set their own charges and have the ability to charge less or nothing at all. You will be surprised how many dedicated professionals will find a way to help you out during these tough economic times.


6. Ask for samples. Although pharmaceutical samples are also becoming increasingly scarce, even a few days of medication to get you started will reduce your overall health costs.


7. Ask for a generic prescription or for an alternative choice of medications known to be less expensive. Although medical providers often do not know what prescriptions cost at the various pharmacies, most will have a good idea if they are giving you an expensive one or a reasonably-priced alternative. Generics are just as good for a fraction of the cost. If your doctor wrote for a brand name, your pharmacist can substitute a generic equivalent in most instances.


8. Don't be shy about shopping around for a better price on your prescriptions. Call the pharmacy, read your prescription to them (if the writing is legible!), and ask how much it will be. Many large, chain pharmacies have huge medication discounts for certain commonly-used prescriptions. A prescription that costs $60 in one pharmacy may only be $18 at another.


9. Ask for a discount. A $75 office visit may only be reimbursed by insurance companies for a fraction of that cost. So, why should you pay more simply because you do not have health insurance? Even fees vary among private medical practitioners, so call around.


10. Be creative in your available resources. I am often surprised that people can afford to buy beer or cigarettes, but they don't seem to have money left for their own medical care. A one pack per day person would save over $150 in a month - a savings less-costly than of an average office visit.


11. If you have a credit card, most medical offices will charge your visit to the card, giving you up to a month to come up with the cash.


12. If feels good when you help someone, so if you are in serious need, it is okay to ask family or friends to help you out. Remember, you are asking for help to get medical care, not to buy a new toy. By helping you, they will feel better.


13. If you are a member of a church or synagogue, many will help the less-fortunate with reasonable, but unexpected medical costs. It doesn't hurt to ask for help. I have seen local churches buy glasses for children, or provide medical appliances for the elderly. Don't forget to thank others who help you, including God.


14. Practice medical self-care. The first-step in staying healthy is taking care of your self and practice healthy habits. Don't smoke. Don't take recreational drugs. Don't drink and drive. Always wear seat belts. Exercise and maintain a healthy weight. These things do not cost a dime.


15. If you have lost your job and are looking for a new one, try and find employment that will offer health benefits for you and your family.

Ten Things you should NEVER do

1. You should never ignore potentially-serious symptoms simply because you do not have the resources. Not only can your condition become worse (and more expensive to treat), you are potentially putting your life in jeopardy. If you feel you need medical care, find a way. You really can't die now and pay later.


2. Don't ignore preventative care, like mammograms and pap smears for women or prostate exams and PSA tests for men. And, keep up with your preventative dental visits.


3. You should never take someone else's medication. Every person and every disease is different.


4. You should never take expired or suboptimal (sub-therapeutic) dosages of leftover medications from prior prescriptions unless specifically instructed to do so by your medical provider. For instance, by not having a complete course of antibiotics - about ten days worth - it may not be possible to eradicate an infection. You may also create a resistant bacterial strain that is more difficult to treat.


5. Many people resort solely on alternative medicines, such as homeopathic remedies, vitamins, or herbs. Most are not scientifically proven by clinical trial, and any response may be merely anecdotal. It is okay to try them, but if you are not improving, you may need traditional medical intervention.


6. You should never smoke. Smokers have considerably more cancer-fears than other people. People who smoke worry that sore throats, lymph node enlargement, or chronic cough may be something serious. Sometimes, they are right - all the more reason NOT to ignore long-standing symptoms.


7. Don't rely solely on online health information sites (including WebMD) in an attempt to diagnose (and treat) yourself. Online health experts have no way of examining you, reviewing your medical history, or treating you based solely on your posting.


8. The same goes for being diagnosed (or treated) by your non-medical friends and relatives...don't do it. Just because people have similar symptoms or experiences, in no way implies that it is applicable to your case.


9. Don't rely solely on phone advice by your doctor or advice nurses. They can only make medical decisions based on what you have told them. Most advice will most likely be conservative. Don't expect to be definitively diagnosed and treated on the phone.


10. Never use the ER as your primary care medical facility. The ER is for life-threatening situations or medical conditions that cannot wait until your regular medical office is available. ER medicine is the most expensive care you can receive. Find a good family practitioner.

As an optimist, I know things will get better. We need to take care of ourselves...our families...and find time to help others. Together, we will get through this economic crisis.

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