July 8th, 2009 by Dr. Val Jones in Health Policy, True Stories
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My mother-in-law just had a CT scan of her head in the Emergency Department of her local hospital. My husband called me to ask if I could “talk to her about her headache.”
Severe headaches in the elderly are indeed worrisome, and I wondered if she had fallen recently – if she might have a bleed in her brain requiring immediate surgery. Of course, she’d need a CT scan to rule that out… I was prepared for the worst. But what I learned by simply talking to Mrs. Zlotkus was unexpectedly revealing – not only about her diagnosis but about our healthcare system in general.
As it turns out, Mrs. Zlotkus had been having severe headaches for about 3 months. She was taking Vicodin daily to “take the edge off.” When I asked her about the location of the pain, she said that it was “just on one side of my head, from the top of my neck to the top of my head.” I asked her if the pain sometimes traveled to the other side, or if it involved her eye. “Never,” was her quick response. She also told me that she’d been seeing a physical therapist for 2.5 months for neck stretching exercises.
Mrs. Zlotkus told me her CT scan was negative, and that her blood tests didn’t show any “temporary arthritis.” (That’s temporal arteritis, I presume.)
“Well,” I said, “There’s only one thing left that I can think of that will give you a headache in the exact area you’re describing – and that’s shingles. Did you notice any scabs or painful bumps on your scalp when the headaches first started?”
“Why, yes!” Said Mrs. Zlotkus. “About 3 months ago I noticed some very painful, crusty scabs on my scalp. I thought for sure it was because my hairdresser used extra strong chemicals on my hair. I scolded her for it. She told me to put tea tree oil on it.”
Oh, boy. There it was – a diagnosis as plain as the nose on her face.
“Um… Well did you tell the ER docs about the scabs?”
“No. They never asked me about it and I didn’t see what my hairdresser’s chemical burn had to do with my severe headaches.”
My mother-in-law’s work up (ER visit, CT scan, several doctor visits, pain medicines), misdiagnosis (neck muscle stiffness), and mistreatment (physical therapy) for shingles probably cost upwards of $10,000. Worse than that, she did not get anti-viral treatment early enough in her outbreak to prevent a long-lasting pain syndrome (called post-herpetic neuralgia). Now that she has this shingles-related headache, it’s very hard to treat. And taking lots of acetaminophen-rich medications (Vicodin) is the last thing her liver needs right now.
So how did the healthcare system fail Mrs. Zlotkus? In my opinion, this is a great example of the “failure of synthesis” that Evan Falchuk discusses on his See First blog. Somehow, the physicians involved in Mrs. Zlotkus’ care didn’t take the time to think about her symptoms, to ask the right questions, and to put all the puzzle pieces together. Instead, they just ruled out the potential emergency issues (a stroke/hemorrhage, or temporal arteritis) and gave her a follow up appointment with a neurologist (who couldn’t fit her in their schedule for 2 months). They didn’t take a full history – they just dumped her in the most likely diagnostic category (neck stiffness) and let some other specialist follow up. Shameful.
I’ve described more egregious examples of hasty medical care on this blog – consider the case of an elderly woman (the mother of a friend of mine) who was misdiagnosed with “end stage dementia” when she really had acute delirium from an overdose of diuretics… Or the case of my girlfriend who was mistaken in the ER for a drug seeker when she was suffering from a kidney stone.
Sometimes I feel as if I have to keep an eye on all my friends and family before they set foot in a hospital, ER, or doctor’s office. I’m afraid that those providing their care will be so rushed and thoughtless that my loved ones will wind up with a huge bill, the wrong diagnosis, and perhaps even a near-death experience. I am seriously afraid for them.
The bottom line is that we have to stop rewarding providers for volume over quality. We have to value the history and physical exam beyond the CT scan and lab tests. We have to give doctors the chance to think about their patients – rather than turn up the speed dial on the clinical treadmills as a means to reduce costs.
My mother-in-law just spent $10,000 of our tax dollars on a diagnosis that could be made in 5 minutes of thoughtful questioning over the telephone. Multiply that cost by the number of other Medicare beneficiaries who are suffering similar misdiagnoses in this country and we’re talking serious money.
Under-thinking leads to over-testing. Has the CBO taken that into consideration in its scoring of various reform plans? I don’t think so. To me, this is yet another reason why we need physicians at the table in healthcare reform – we see the real cost drivers that others might not think of – even if some of us are too busy to diagnose shingles correctly!
July 8th, 2009 by AlanDappenMD in Primary Care Wednesdays
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We often are asked in our practice, “Why don’t you accept Medicare?” The immediate answer is simple: we cannot afford to. We opted out of Medicare because the service won’t pay for phone consultations, won’t pay for email consultations, barely pays for an office visit, and does not pay nearly enough to cover a house call.
All of these services are critical to our medical practice. Medicare would require us to hire too many staff, as well as require us to do too much paper work and administration. I cannot afford to invest in either and still manage to operate in the black. Medicare has too many regulations and rules; we can’t understand a lot of them, and frankly, Medicare doesn’t seem to understand them most of the time either. If I would accepte Medicare, then they have the right to audit our notes and then fine us for non-compliance for infractions that are not readily clear. Their external auditors get paid for every infraction they find which means the temptations for fining doctors are irresistible.
Yet the truest answer as to why we do not accept Medicare is that the service does not focus on what we feel is paramount: practicing effective and efficient medicine in order to ultimately achieve and maintain the good health of our patients. The service’s paltry reimbursement structure coupled with its impossible to-adhere-to regulations doesn’t allow us to offer a complete service to our patients. This complete service includes wellness care as well as the ability to take the time to understand each patient’s unique medical needs and circumstances.
The crux of the issue is that Medicare worries about the forest, in other words, the internal process, money management, reimbursement and policing agreements, data mining, and organizing dozens of internal bureaucracies. These agendas and policing policies help the Medicare service to manage the forest, however these are often in direct conflict with what we feel is key to effective healthcare: taking care of the individual, or each tree.
I do want to make clear that being afraid of audits, punitive actions and the vagaries of no one understanding all the rules is never a reason to leave Medicare — after all, patient care is filled with risk. However, it became clear to me that I, a single doctor voice, dealing with the collective frustration almost all doctors feel when dealing with Medicare (and most insurance companies) had three divergent paths to choose from:
- Do nothing. Ignore the conflicts of interest and the lack of patient-centered care and swallow frustration for a paycheck. Just do your best or what Medicare tells you to do.
- Work towards reforming Medicare from within through involvement in the process and by working with your professional associations.
- Ignore the payers altogether. Work outside the system, returning to the roots of primary care, reforming the business of primary care one person at a time.
Personally, I had to reject Option 1. I was witnessing too many wrongs among my colleagues and for patients. Primary care, a profession I am passionate about and believe in fully, would never have a future under this model. Hoping that things would work out if we just worked harder and harder while blindly submitting to Medicare’s interests and demands meant surrendering my patients’ trust, primary health care’s future, and my soul for a salary. There had to be a better way of making a living.
Working towards Option 2, trying to create reform from within the Medicare system, was nothing but futility on immediate analysis. The ability for me personally to influence the debate for what needs to be done in Medicare for primary care would be a David v. Goliath story without the biblical ending.
In the end I am just one family doctor, that’s what I know, that’s what I’ve spent my life doing and studying. Option 3 chose me. Opting out is financially the riskiest since it requires patients to do something that they have been socialized against for three generations, which is to pay directly for medical services (as they do with nearly everything else in our capitalistic economy). Doctors are well aware that 95% of patients will fire any doctor who refuses to accept Medicare.
This decision meant I might lose my shirt and put my home and small life savings at risk, something thousands of Americans in other professions do everyday. If they could take the risk, then my risk is nothing less than a trivial American story.
The United States was built on this: a country of immigrants fleeing an “old establishment” to build something new. It’s a group of people declaring: “You can’t tax us without representation!” It’s a government that permits us to challenge established norms, challenge power without being jailed or shot. The question today in health care for all of us as patients is will we stampede towards the utopian ideal of “free care” while ignoring the predictable consequences that nothing is free.
The question put to primary care doctors by Medicare is clear at the moment: Will you let us at Medicare regulate care, dictate “best” treatments and control individual health and choices since we know what’s best. Can you, doctor, be our “yes man?”
Eight years ago I cast my vote and opted out of Medicare. Predictably my journey has not been easy but I have never regretted the decision.
Until next week, I remain yours in primary care,
Alan Dappen, MD
July 7th, 2009 by EvanFalchukJD in Better Health Network, Health Policy
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At healthreform.gov, the Department of Health and Human Services publishes data on the “Health Care Status Quo.”
It reads a bit like what would happen if you took the Dartmouth Atlas of Healthcare and buried it in Stephen King’s Pet Sematary.
The front page of healthreform.gov now has a map of the 50 states where you can click and read about the “current status of health care and the need for reform.”
(I should add that DC is included in the map, too. But as of the time of posting the link doesn’t seem to work).
It lists a grab-bag of categories of information on each state. But no matter what the data shows in a state, the HHS report always concludes the same thing. Fifty times out of fifty:
[Insert state name here] families simply can’t afford the status quo and deserve better. President Obama is committed to working with Congress to pass health reform this year that reduces costs for families, businesses and government; protects people’s choice of doctors, hospitals and health plans; and assures affordable, quality health care for all Americans.
A good example are the reports for Massachusetts and Texas- two very different states with very different data.
- 25% of Texans are uninsured, while only 2.6% of “Massachusettsans” are.
- Overall “quality of care” in Texas is “Weak,” while in Massachusetts it is “Strong.”
- The percentage of people with employer-based coverage in Texas dropped from 57% to 50% from 2000 to 2007, but held steady at 72% in Massachusetts
- 20% of Texans reported not visiting a doctor due to high costs, but only 7% of Massachusetts residents did, and “this has significantly improved since 2007.”
- Average premiums for health insurance are about 5% cheaper in Texas, even though the market is described as being less competitive than Massachusetts
- 27% of middle income Massachusetts families spend more than 10% of their earnings on health care, compared to 17% in Texas
What’s going on? The HHS doesn’t seem terribly interested in exploring it. It just says it wants some kind of unspecified health care reform, this year.
I suppose this is the way the political process works. Make the case there is a serious problem, and seek support to do something – anything – about it, now. As Secretary Sebelius put it: “we cannot wait to pass reform that protects what’s good about health care and fixes what’s broken.“ I don’t think anyone really knows what this means, but maybe that’s the point.
It’s a strategy for a political victory, but not for real, needed reform of our system.
http://www.healthreform.gov/index.html
*This blog post was originally published at See First Blog*
July 7th, 2009 by Emergiblog in Better Health Network, True Stories
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Why shouldn’t we have to pay for our health care?
Why….we don’t have that sort of money!!! How dare you even suggest that we should pay!!!!
We manage to buy cigarettes. We manage to buy fast food. Often. We manage to get all the channels we want via cable or satellite television. Some of us even have satellite radio in our cars. And GPS. Our cell phones are really nice, but all that texting costs a pretty penny. We drop a few bucks at Starbucks every week without thinking twice.
And then we roll our eyes when we have to pay for….god forbid…..health care!
*****
Think I’m heartless? Think I’m an elitist?
Think I’m talking about the Medicare patients in my ER who bring in a super-sized number 8 from McDonalds for the entire family and hold out their right arm for a BP while they text rapidly with their left hand?
I could be.
But I’m not.
The patient rolling their eyes at having to pay was me.
*****
Yeah.
Me.
Showed up for a colonoscopy yesterday and the receptionist went over what would and would not be covered by my insurance.
My out-of-pocket payment would be $216.
And my first thought was “why the hell am I paying anything out of pocket for this? I have insurance!”
I was ticked.
*****
But why was I ticked?
Why shouldn’t I have to incur out-of-pocket expenses?
I have insurance. Good insurance. Insurance I don’t pay a single penny for. It’s a benefit I get from my employer for working 24 hours a week.
Did I think I was entitled to full coverage because I was insured?
Entitled?
Me?
*****
Isn’t that term used to describe some patients who get their health care for “free” through a public plan?
Well, I get my coverage for “free”, too, and god help me, the emotion I felt in that office yesterday was “entitlement”.
Now I understand.
And I won’t use that term again.
Ever.
*This blog post was originally published at Emergiblog*
July 6th, 2009 by admin in Better Health Network
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Have you noticed that many products on grocery shelves are bragging that they do not have high fructose corn syrup (HFCS)? HFCS has been demonized by many people in the public as well as the medical community in recent years. But how much different is it from just plain old sugar? The answer is up for debate, but I will do my best to present the facts.
HFCS has been used for many years, but the use really became much more common in the 1980’s. Food companies use it because it makes a desirable end product and is fairly cheap. HFCS comes from corn and is refined to get the sweet taste into a syrup. But is it worse than sugar?
Many experts believe it is no different than sugar. Both are high in calories and are considered “empty” calories, meaning they don’t have vitamins, minerals, or other healthy nutrients in significant quantities.
The American Medical Association and other scientists have agreed that both sugar and HFCS both contribute to risks of obesity, diabetes, heart disease, and other illnesses if eaten in large quantities. In other words, there is no proof to date that HFCS is more harmful than sugar.
So why are so many companies eliminating HFCS? It is all consumer perception. Consumers have heard that HFCS bad so companies are spending time and money eliminating it from it’s products? What are they using instead? Sugar.
Is HFCS natural? The Corn Refiners Association says that HFCS is natural. The FDA does not define the term “natural” so we really have no way of seeing whether something is natural on a food label. Food companies can use this word without repercussion from the FDA since they have not defined it.
For more information on HFCS, check out www.sweetsurprise.com
This post, Is High Fructose Corn Syrup Worse Than Sugar?, was originally published on
Healthine.com by Brian Westphal.
