Happy Hallowe'en!

• Why it's probably okay to let your kids eat lots of Hallowe'en candy 
•  Pictures of people freakin' out in a haunted house.
• .Fourth annual Evil Week on Lifehacker.

Spider Bites

I agree with this article on spider bites, particularly in California.

Happily for us, brown recluse spiders are native to the Southeast US.  For us on the other side of North America, this means a bite from this highly venomous spider is not going to happen unless the spider arrived in some furniture being moved from the South.  Admittedly, this has been known to happen- it's just that this is not normally brown recluse territory.

Black widow spiders have a more powerful venom than other local spiders, but they are not roamers.  They build webs in secluded areas and wait for insects to get caught it the web.  The best way to avoid black widow bites is to avoid putting your hands or feet where you can't see them (such as when you are moving a wood pile, cleaning a shed, remodeling a basement...)  That being said, black widow venom is fairly powerful and can in some cases cause tissue break-down and infection requiring antibiotics.  On the other hand, if you are bitten by one, you're going to notice it!  This is not one of those cases where you just wake up with a tender red bump.

Smaller spiders are just not that venomous around here.  If you happen to roll over one in your sleep, they can bite hard enough to break skin but their venom is not going to cause serious tissue damage.  Mind you, any break in the surface of your skin  can cause infection, but generally keeping the break clean with soap and water, and protected with Neosporin and a bandage is your best means of preventing infection from occurring.

What's an HMO and what's a PPO?

These are both forms of health insurance that are popular in the U.S.  PPO's (preferred provider organizations) have been around the longest.  HMO's (health maintenance organizations) were first developed in the 1980's, went out of favor for a while, and are back on an upswing due to the economic recession.

PPO's are the more traditional insurance which is provided by a company (such as Blue Shield, HealthNet, Anthem/Blue Cross and so on), and it is typically paid for by your employer with costs to you in terms of deductibles and co-payments.  The PPO is made up of doctors and offices and hospitals that are willing to take your insurance and have a contract with your insurance company.  When doctors who accept your insurance see you, they send a claim (or bill) to your insurance.  If your insurance allows it, you may at some point later get a bill from the doctor, lab or hospital for the balance of what they billed but your insurance didn't cover.  Mind you, some insurances do not permit such "balance billing".

In other words, in a PPO your doctor gets reimbursed to treat you and does not get reimbursed to not treat you.  It therefore means that PPO doctors have an incentive to do the most they can to keep you healthy and also happy with the office and your care.  Admittedly, there is an element of trust that when your PPO doctor wants to see you back or get some tests done, it is in your best interest and not because it's profitable.

HMO's were invented in the 1980's as an alternative designed to reduce costs of health insurance.  Insurance companies offer doctors "capitation" contracts.  In such an agreement, instead of a doctor agreeing to accept certain amounts of money for certain services provided, the agreement is to accept a certain amount of money every month for every HMO member who has selected him or her as their primary doctor (PMPM = per member/per month).

HMO's take a variety of forms.  In some, they are almost like socialized medicine insofar as the health insurer directly employs all the doctors and owns all the facilities.  Kaiser is an example of this.  In others, the HMO is a collection of doctors, groups and hospitals willing to accept capitated payment contracts.  Western Health Advantage and Anthem/Blue Cross HMO are examples of this.

In any of these forms, the HMO offers real trade-offs compared to traditional PPO's.  HMO's are usually a bit cheaper in terms of monthly premiums and also in terms of exposure to deductibles and co-payments.  On the other hand, you are required to receive your care from a restricted panel of doctors and hospitals and there is no option to receive care outside the HMO.  To be sure, seeing a doctor not in your PPO costs you more money, but it is an option which is helpful when you need a second opinion or a surgery that is not performed at your local or preferred hospital.

From the doctors' point of view, HMO's are radically different from PPO's.  The actuarial risk; the risk of losing money on sick patients requiring expensive care, is on the insurance company in a PPO.  If they take on a lot of sick people, or pay too much to doctors, or run their business poorly they lose money.  In an HMO, that financial risk is now taken on by the doctor.  If the doctor takes on too few HMO patients, a few HMO patients getting sick can cause the doctor to lose money.  In order to hedge against this, the doctor has to take on a LOT of HMO patients.  Remember, in an HMO the doctor is paid monthly to be your primary doctor even if the two of you have never met!

This shift in who carries  the financial risk has some impacts that are important to the patient.  In an HMO, the element of trust now is that if the doctor does not need to see you, it is in your best interest and not because seeing you causes your doctor to lose money.  Also, it shifts the party who is most concerned about the money from the provider of your health insurance to the provider of your actual health care.  I would not go so far as to say this is immoral, but it does require patients to be aware of and comfortable with this arrangement and its implications.

In short, PPO's are usually more expensive, but optimize choice on the part of the patient as to where they can go.  They also do not require you to go to your primary doctor to get to a specialist, unless you prefer to or the specialist happens to prefer it.

In comparison, HMO's are often cheaper, but you are fully limited to being able to see only the doctors or hospitals in the HMO.  You must see your primary care doctor in order to be referred to a specialist.

In a PPO, the financial risk is on the insurance company.  Since your doctors only gets paid to see you, you are trusting that they are not over-seeing or over-testing you in order to make money.

By contrast, in an HMO, the financial risk is on doctors.  Since your doctor gets paid every month for having you as a patient even if you have never met, you are trusting that your doctors are not under-treating you to save money.

Personally, I have trained or worked in both HMO's and PPO's, and I have had both kinds as my insurance.  I definitely prefer PPO's for their focus on choices provided to me and my family. 

I mistrust HMO's because I know that the doctors who work in them are under an enormous amount or pressure to take on large numbers of patients to make the HMO arrangement financially viable to them.

Long story short, you get what you pay for with health insurance!

MediCare Open Enrollment is now until 12/7/13

As many of you recollect, the opportunity to shop for or consider changing MediCare Part D coverage is every year at this time, from mid-October until December 7th.

For those of you who are new to MediCare, a bit of back story.

MediCare is a federal entitlement program written into legislation by the Johnson ("LBJ") adminstration, in response to commercial insurance companies dropping coverage of seniors due to their likelihood of needing medical care or treatment.  Part A covers hospital based (inpatient) expenses such as surgery and hospitalization.  Part B covers office  based (outpatient) care such as doctor visits, labs or XRays.

Part D was enacted during the George W. Bush administration to help to provide MediCare coverage of prescription drugs: until then, it was cash-and-carry unless you had pension benefits that provided such coverage.  Part of the Affordable Care Act under the Obama administration involves reducing the so-called "donut hole".  This is an amount of money you have to pony up if you spend a lot of money on medications before the end of the calendar year.  The donut hole will gradually close to zero over the next decade.

This Medicare Plan Finder link allows you to start comparison shopping Part D plans starting with your zip code so that you are only looking at plans offered where you live.  You can also (if you want to) search out plans that cover the medicines you take by entering each medicine by name.  If you want, you can also narrow the search to specific amounts you want for premiums, by strength of patient reviews and a number of other factors.  :You can then examine all the plans that fit your selection criteria and check them out further if you like.  You can also enroll from this site.

All in all, selecting a Part D plan or deciding whether you want to change yours or not is made pretty straightforward and the format is not much different than shopping on Amazon.

A few tips:

• Medicare has nothing to do with Covered California which is an online insurance market under the Affordable Care Act for California for people not on Medicare.
• If a medicine you take doesn't seem to be covered, see if other medicines that are in the same class are.  Medicines in the same class work the same way, and can generally be substituted without any problems.
• Most drugs are generically available.  Only 10% of new drugs are really a new kind, or superior to older less expensive drugs of the same class.  Don't let cost get in the way without asking us if you have lower cost options to choose from.
• These tips are especially important if you use inhalers or injectable medicines since they are often very expensive.

Secure Horizons HMO Part D plan has gotten much smoother to work with over the last two years, so we are accepting it as a Part D plan.  Specialist offices have also gotten a lot smoother at working with them which makes this a much better option than when it first rolled out.

Please don't hesitate to ask if we can help you!

Effects of the Government Shutdown on Medical Care

In the event you were wondering what effect the "government shutdown" has on US medical care, the New England Journal of Medicine (not known as a hotbed of knee-jerk hysteria) informs us that at this time:

Regular inspections and lab research by the FDA (Food and Drug Administration) are on hold.  Emergency work involving human safety (high-risk drug recalls and law enforcement) are ongoing.

CDC (Centers for Disease Control)  tracking of infectious diseases including flu is on hold.

CDC publication of a weekly bulletin advising doctors of medical and infectious disease trends or developments (Morbidity and Mortality Weekly Report) is on hold.

NIH (National Institutes of Health) enrollment of new patients for ongoing clinical trials is on hold.  Yes, this includes children in pediatric cancer studies.

Federally administered health insurance marketplaces under the Affordable Care Act are not affected, as they rely on different funding sources.  The reason some of them appeared to be unresponsive was due to the large numbers of people using them.

California Affordable Care Act insurance marketplace is up and running on schedule!

As of this morning, websites for state-based health insurance comparison shopping are operational.

The Patient Protection and Affordable Care Act, ACA for short, (or "Obamacare" or "Romneycare version 2.0" if you wish) to date has:
-made it illegal for your health insurance to refuse to continue to insure you if you become ill
-required your health insurance to allow you to keep your children on your policy until they are 26
-made it illegal for insurance companies to refuse to cover you because of pre-existing medical       conditions
-provided rebates to employers who already provide health plans
-has reduced the Part D drug coverage "donut hole"(this will be gradually reduced to zero by 2020)

Regardless of one's political leanings, I have yet to talk with a patient who didn't think these were good ideas.  And hey, Congress passed the ACA and it was signed into law by the President.

The next stage has involved states (or the Federal government, if a state declines providing patients and small businesses (50 or fewer employees) with a single website that allows them to compare coverage and pricing for more affordable health insurance with coverage of outpatient care, hospital care, surgery, preventive care, and healthcare of pregnancy, newborns and children.

And now, it's here.  In California, the program is called Covered California.  Check it out for yourself.  Even if you already have insurance through work, it's nice to comparison shop.  I'm already pleasantly surprised that the cost of insuring my family through Covered California with Blue Shield compares very favorably to the Blue Shield I provide at my office.  My next step will be to see whether I can come up with a small business plan for my office that's better than what I currently have.

Mind you, if you already have insurance you are perfectly happy with, "Obamacare" doesn't affect you.  On the other hand, if you have no insurance or aren't happy with what you've got this may be the solution to your problem.

We are contracted with Covered California Blue Cross and Blue Shield.

We are optimistic about the potential for this program to keep people with no insurance or really high deductible plans from falling through the cracks.