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 the COBRA Strikes

More and more patients have been presenting to my office for complete physical examination, asking for extensive lab work and refills of medications. Why? They are losing their insurance, often due to losing their jobs. And, even if they do quickly find a job in this troubled economy, there is often a delay of months until a new insurance will be in effect. To make matters worse, the new insurance may be an HMO may not have our office as a preferred provider. This visit may be their last visit to our office. Obviously, continuity of care and provider preferences are not high priorities for insurance companies. Their unwritten goal is to provide an acceptable quality of care for the least amount of money.

It is required by law that employers offer COBRA insurance when an employee leaves or is terminated. The law does not require that the insurance is affordable. Since many companies pay all or at least a significant part of the premiums, the terminated employee, without an income, is required to pay the full amount. In many cases, it can cost a family $1000 a month. I like to call this the bite of the COBRA. As long as people do not eat or pay their housing costs, their unemployment checks may cover COBRA costs.

Companies have group insurance, usually at a discounted rate, and usually from the low-bidder. The insurance company is required to insure all employees (and their family members), even if they have a pre-existing medical condition, such as diabetes or cancer. When the employee loses their jobs, any pre-existing condition would preclude them from getting private insurance from another vendor. So, often, the only option for recently terminated employees is to pay the astronomically-high COBRA premiums.

Obama's Economic Incentives Plan has a provision for the government to pay about 65% of the cost of COBRA for people who have lost their jobs, for up to nine months. This will help, but what will really help is complete health care reform, and some government oversight on what insurance companies can charge. The housing market has taken a huge dive, so it is really time for a substantial adjustment in health care costs, including insurance premiums and drug costs. Health care giants, like oil companies, have taken huge profits in the last few decades. Universal health coverage is in all industrialized countries, except the U.S. About 28 percent of the country is receiving health benefits through the federal government, however, through Medicare, Medicaid, and Veterans services. All in all, 15% of our country's GNP is health-related services, more than any other country. In addition, illegal aliens living in the U.S rack up billions of dollars in charges just using the emergency room for mostly non-emergencies.

Compared to other countries, the cost of medical care in the U.S. is among the most expensive. An American friend of mine, living in Mexico, pays only a few hundred dollars a year for basic health insurance. While the level of technological care in Mexico may not be up to U.S. standards, neither are their standard fees. Granted, I would rather receive medical care in the U.S. if I were ill, but it would really be nice if those fees reflected the cost of doing business. A private doctor that I know once bragged about charging $30 for a lab test that cost him about three CENTS in his office. He laughed all the way to the bank.

While traveling in New Zealand years ago, I saw a posting of charges on a health clinic wall. I was shocked that the same services provided in the U.S. are many times greater. One common antibiotic in the US was nearly sixty dollars; it was on eight dollars in New Zealand. The pharmacist explained to me that the entire country of New Zealand is the collective bargaining unit, so the government negotiated for a lower fee. In the U.S., we pay what the market allows. Walmart is advertising hundred of prescriptions now for just $4.00 and why not? Naprosyn 500mg, for instance, costs a pharmacy about $17 per thousand. They are able to fill over 17 prescriptions of sixty tablets - a one month supply - at $4.00 each, they would still make a 388% profit (not counting the cost for the pharmacist to put it in a smaller bottle, of course).

Basically, insurance premiums are high largely in part because medical charges are high. Medical charges are high for many reasons - high malpractice premiums, high salaries, expensive laboratory tests, expensive imaging (x-ray, CT, MRI) studies, administrative costs, and of course, expensive medications. In the end, the wage-earning consumer (or the federal government) eventually picks up the heavily inflated tab.

A former patient of mine, a Hiroshima survivor and now a U.S. citizen, was between a rock and hard place. She is entitled to free medical care in Japan, but in the U.S., she has to pay out of pocket. She cannot afford health insurance. Since the atomic bomb dropped on her city, she has been worried about cancer (rightfully so). Every time she had a sore throat, she would think it was throat cancer. When she coughed, it was lung cancer. I spent a great deal of time reassuring her and trying to keep down her costs by charging less (sometimes free). I was on vacation when she ended up at the local emergency room with a cough. Since they were not familiar with her medical history, they ran some very extensive tests. Her total ER bill for a one hour ER visit was about $5000. In tears, she showed me the bill. I spent the better part of one month trying to negotiate a lesser fee for those excessive charges, to no avail. She ended up paying it all from her savings. She told me that it would have been less expensive for her to fly back to Japan for care. More and more Americans are doing just that - they are flying to other countries to get medical care, like hip replacements.

The cobra is one of the most poisonous snakes on this planet. Like its insurance namesake, its bite can kill and certainly disable a victim - medically and financially.

I am in my 36th year of medical practice and I pray for health care reform. I pray for less-expensive insurance and medical services. I pray that Mr. Obama can pull it off. If not, praying may be our ONLY insurance.

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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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"I Do Not Have Health Insurance"

Several times per week, I have a posting on the Ear, Nose, and Throat message board that mentions that the person posting does not have insurance, or does not have the financial resources to pay for a medical visit. With the economic crisis we are all facing at this time in history, I suspect we will see more and more uninsured Americans. One physician in our office stated just today that three of his patients lost their jobs, along with their insurance, and would not be returning for on-going care. This is just the tip of the financial iceberg.

For the most part, medical care in the United States is embarrassingly expensive. Since I am on the inside, I am often in a position to justify many of those charges to my patients. Insurance is equally as expensive and not all people have insurance benefits with their jobs. In most states, automobile insurance is required - it is the law. Health insurance is optional. I find that inconsistent with common sense since a liver transplant is considerably more expensive than fixing your bent bumper. Unless you have unlimited resources, going without health insurance will devastate your family in the event of a medical crisis. The government will end up paying the costs for the uninsured only after your resources have been depleted. The U.S. does not have universal health insurance, so those people without insurance must pay for their medical care.

When I was a child back in the 1950's, we had one general practitioner in our town. I don't believe my parents had any insurance. An office visit was $3.00 (this included medications in most cases), and a house call was $5.00. Even at those prices, adjusted for the 1950's, this was still a pretty good deal. We were a lower income family; so fortunately, I did not have to utilize medical care very often. At age 18, I had appendicitis, but my mother must have had health insurance by that time, otherwise she would have told me how much it cost.

The cost of a routine office visit in my practice is $141.00, or at least this is what is billed to the insurance companies. Insurance companies typically negotiate these fees and will reimburse considerably less. A cash-paying patient will pay about $98. There are some quick-clinics at the local pharmacy that charges about $65. An urgent care clinic will charge about $75. People who have insurance will typically pay a co-payment of $10 - $30 for their entire out-of-pocket expenses.

Like medical care itself, insurance premiums are astronomical. I have many infants and children in my practice, some who were born with special needs. A parent of a 2-year-old child last week told me that her medical bills are over three million dollars (so far). It only takes a few of those for insurance companies to raise their rates on healthy people to make up for it. In Ancient China, doctors were paid a fee to keep people well. If you became sick, the doctor had to pay you!

I have always been very sensitive about charges, but in my current practice, I have no control over fees that are charged by the medical foundation. I am on salary. If I were in private practice, I would have been bankrupt from giving away free or discounted care. The cost of routine medical care has skyrocketed to the point of embarrassment. The cost of using liquid nitrogen to freeze off ONE common wart is about a $150, and one treatment may not do the job.

When I see a patient or perform a procedure, I put down a billing code that represents what I have done, the complexity of the visit, and the time spent. This code is translated into a bill, either sent to the patient or the insurance carrier. I am basically out of the loop.

Medical providers can "down-code". In other words, they can put down a lesser billing code than what was done. Providers can also not charge for certain "simple and quick" procedures, like removing ear wax. The cost of removing earwax in my office is well over a hundred dollars for the procedure alone. If it only takes me a minute or so to clear out that ear canal so that I can properly see the eardrum, then I do not charge extra. However, if I spend a half hour digging out an impacted amount of earwax from some obsessive Q-tip user, I am going to charge extra - about the cost of 30 boxes of Q-tips.

When I know that a patient is private-pay (paying with cash or credit card), I tend to down-code or cut them a break if I can. If I have samples, I tend to give it to them. There is nothing like paying for an expensive office visit, only to be dinged again at the pharmacy. Medication costs have skyrocketed, too.

When the antibiotic Augmentin first came out, it was expensive compared to plain 'ol amoxicillin. A full-course to treat a middle ear infection in a child could be $65 to $80 or more; amoxicillin was only about $10 or $15. My wife and I were traveling in New Zealand years ago, so I compared some of those prices with a Kiwi pharmacist (chemist). Augmentin in New Zealand only cost about $8.00 and was from the same pharmaceutical company. Why? According to the chemist, the entire country of New Zealand negotiated a lower price - and the cost is not increased to the consumer. In the U.S., we pay top dollar for the same medication. Of course, Augmentin is generic now, and the price has dropped (sort of).

The Veterans Administration and some large HMOs do negotiate for cheaper medications for their patients. When I worked for the VA years ago, it would drive me crazy. I would get someone controlled on one blood pressure medication, only to discover that it was now not available. I would have to change it to another one. Six months later, I would be told that that medication is not available, and I would have to go back to the original one that is now suddenly available again, now at a cheaper cost the government, of course.

The cost of medications has driven many Americans across the border to Canada or Mexico looking for deals. This practice is highly discouraged by our government, and is really illegal in some respects. People on fixed incomes who are paying more than half of their monthly income for medications for cholesterol, blood pressure, or diabetes are desperately looking for ways to reduce their costs. Smuggling medications across the border happens every day. I have personally witnessed people being hassled over a bottle of blood pressure medications they bought in Mexico, while tons of cocaine and marijuana seem to make it across okay.

Our government sites safety as their primary concern. Fake medications made in China are showing up everywhere, even in the U.S. Look-alike medications are being sold by the ton in Mexico to tourists. When someone shells out some cold hard cash for a bottle of Viagra before the cruise ship leaves, there is little recourse when those little blue pills fail to work. Maybe you get the real Viagra, but maybe your little blue pill is just that - a little blue placebo from China. Personally, I would not have any problem buying medication in Canada, but I would be a bit leery of some of those Mexican pharmacies along the border.

When it comes to buying food or buying gasoline, someone without health insurance tends to set priorities. Food comes first, followed by rent or mortgage. Then comes automobile costs. The lowest on the list tends to be routine medical and preventative health care. Emergency medical care tends to get attention, even in the worst of economies. When you have an arrow sticking out of your head, you don't typically wait a few days to see if it goes away on its own. A guy in a neighboring community was shooting arrows into the air. Not understanding gravity, he inadvertently hit himself in the head with one of those falling arrows. He hesitated going to the ER because he did not have insurance. I am surprised that the arrow didn't go all the way through since there appeared to be nothing inside his skull.

If you don't have auto insurance, you are screwed if you wreck your car. If you blow your engine because you can't afford routine maintenance and oil changes, you are screwed because auto insurance does not pay for repairs. If you do not have health insurance, and choose to ignore your crushing chest pain, you may not need health insurance anymore - you so need life insurance for your family. If you do not go to the doctor because you have a cold, you will probably be fine. Colds are self-limiting and you don't really need a doctor to tell you that again and again. Of course, if your cold seems to be turning into pneumonia, you are going to have to make a big decision. Should I take the chance of dying, or use my credit card or hard-earned cash to get some medical care? Get the care. Borrow some money or worry about paying the credit card later.

My auto mechanic charges $90 per hour (even if he fixes my car in five minutes). He is a high school graduate and makes more than my own hourly rate in my clinic. Is it fair? Probably; he can fix my car - I cannot. Of course, when he cuts open his head when he slips on some grease, I am not going to reduce his cost by down-coding him. I am going to get even.

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