When you go to lab to get blood tests done and you are asked to sign a paper you are NOT being told that you WILL be billed.
Marshall recently bought new billing computer software that automatically prints out a form called an Advance Beneficiary Notice (ABN) whenever a doctor orders a test that has a limit on how often it might be done or has often been not reimbursed to Marshall.
This form tells you that:
Your doctor feels you need this test.
If your insurance, for some reason, refuses to pay Marshall for doing the test, Marshall may bill you for it.
Problem is, Marshall's billing people are not involved in tell you about this or helping to determine whether or not you actually will get a bill or not. The lab people are just being asked to have you sign the paper whenever the computer prints one out.
You won't get a bill for:
annual screening tests done at least a year after the last one
diabetic glycohemoglobin tests (HbA1c) at any frequency at all for out of control diabetes
tests often ordered for screening but ordered for non-screening purposes, such as a mammogram for an abnormal screening mammogram, or a PSA test for an enlarged prostate.
This article is fascinating (in a real science geek, wonky kind of way) about ongoing study into the genes that different diseases and diagnoses may have in common.
The study itself is interesting, but so are the implications of different, seemingly unrelated illnesses having a common genetic link. The ramifications for future ways of thinking about and treating or preventing disease is profound.
Update: we have, indeed, ordered swine flu vaccines about 2 months ago. We have not yet received them, though are told we may get them within the next few weeks.
News coverage of problems in both production and distribution are not grossly exaggerated.
We have been keeping a list of patients at high risk to call when we receive vaccine.
This group is a non-profit and non-denominational organization, and I gather that the local chapter is a social group with entirely voluntary attendance and participation.
The November calendar shows a couple of Sunday events such as a dance and a cards & games potluck, and also breakfasts or dinners at local restaurants 3-4 days each week.
From what I've been told, support is there for you but the events are generally social affairs and not ongoing grief counseling. For many , this is just "what the doctor ordered".
OK, not your most glamorous topic. It is, however, one I get a lot of questions about.
Constipation refers to bowel movements (BM's) that are dry, pebbly looking and hard to expel. Dehydrated, in a word.
Your BM's are made of undigested plant fibers (roughage), bacteria and bile pigments. The roughage comes from fruits, vegetables and whole grains in your diet. The bacteria are a normal part of the bacterial flora in your digestive system (there are more normal bacteria on/in a human body than actual human tissue cells!). The brown color is from bile which is made by your liver, stored in your gall bladder and secreted into your small intestine to help you to dissolve and absorb essential fats in your diet.
Problem is, your colon and rectum work to re-absorb water from your bowels so you don't lose a lot of water in your BM's and become dehydrated. When your colon can't do that, it's called diarrhea.
Constipation can occur if you don't eat enough fruits and vegetables. This will mean you lack the necessary bulk to fill your rectum. Filling the rectum stretches nerve endings in it which signal your brain that you need to go to the bathroom. As this goes on, too much water gets drawn from the contents of your rectum. The end result is dry, pebbly, hard BM's. Constipation!
Please note that normal does not mean having a BM every day- it means having soft normally formed BM's.
Treatment of constipation starts with increasing dietary fiber.
Eat more fruits and vegetables; five servings every day would be good not only for constipation, but also in reducing many kinds of cancer.
Metamucil, Citrucel, bran or flax seeds taken every morning can also help and is safe.
If this is not sufficient, other medicines can be used daily and will not produce dependency on them.
Stool softeners such as DSS simply make your BM's softer and easier to pass.
Natural cathartic agents gently stimulate a BM, such as Senakot, prunes or prune juice.
If constipation has been going on for a long time, your rectum can become so conditioned to feel full that it can no longer signal an urge to defecate to your brain. This neurogenic bowel problem can get to the point of needing strong laxatives just to have a BM.
In such a case, you may need to do all of the above plus use Milk of Magnesia or a Dulcolax suppository every 2-3 days as needed.
Constipation with fever, abdominal pain or rectal bleeding may represent an emergency for which you should be seen as soon as possible by a doctor.
All the medicines mentioned above are easily available over the counter. Please feel free to see me about constipation. It's a very common and obnoxious problem that can be helped!
It's that time of the year again! From now through 12/31/09 you can change your Part D plan, which covers your prescriptions. If you haven't been happy with coverage or the donut hole, now's the time to choose something better. If you have been happy with it, now's the time to make sure no changes are going to be made for next year that you wouldn't like.
The Centers for Medicare and Medicaid Services (CMS) has a website for open enrollment.
Here is a table summarizing the 60 different plans available for El Dorado County.
This is a pdf file that you can print off as a worksheet to help you sort out your options on-line or with an insurance broker.
Things to keep in mind:
Relax. You've got to the end of the year!
Focus on looking for plans that specifically cover your expensive medications. The inexpensive ones will be covered by any plan.
Think about whether you might be better off paying more in monthly premiums for donut hole coverage than not being able to afford your medications by the end of the Summer.
Don't be fooled into picking a plan where you make MediCare your secondary insurance! This does not turn out to save you money and seriously limits your heath care!
There has been a great deal in the news just in the past month about new studies and recommendations regarding cancer screening. This is all very interesting, but also pretty complicated.
First off, these stories are based on findings of the New England Journal of Medicine, the U.S. Preventive Services Task Force, and the American College of Obstetrics and Gynecology. The have yet not been widely adopted by other organizations such as the American Cancer Society and medical insurance companies or MediCare. Also, the are not related to present Congressional legislation on health care reform and addressed clinical effectiveness not cost. In other words, it's about the outcomes not the money.
Also, these findings related to people at average risk for cancer, and not to persons at high risk due to family history or other factors.
First, the study in the New England Journal pointed out that screening for breast and prostate cancer was associated with an increase in early detection of localized cancers, but not with a decrease in more advanced cancer.
This is concerning because the idea of screening is to find cancer early, before they have a chance to spread. If that is what is actually happening with breast and prostate cancer screening then we should be seeing a rise in early cancers and a resulting decrease in later stage ones. Which we're not.
What this seems to mean is that there are two types of such cancers. One kind is very slow growing and it may be that a wait and see approach may be as reasonable as biopsies and surgery. The other kind is so aggressive that it may become detectable between screening test intervals.
The thrust of this article is that we need to do more research in tumor biology so that we can identify which tumors should be aggressively treated, and which can be watched over time.
Coming hard on the heels of this, the U.S. Preventive Services Task Force (which has been around for decades) is recommending that breast cancer screening not be started until 50, the to be performed by breast examination and mammography every other year until 70-75 and then discontinued. They have also found that monthly breast self-examination is not generally helpful.
Much of the concern is over the naturally fibrous nature of female breast tissue up to age 50, and therefore the potential of self-examination and mammography to both miss cancers and also to over-call benign nodules and cysts.
The same recommendation stresses that individual patients may wish to proceed with screening between 40-50 based on personal preference, and that the recommendation does not apply to high risk patients such as those with family members with breast or ovarian cancer or positive genetic testing of BRCA mutation which increases risk of developing breast cancer.
The American Cancer Society has strongly disputed this recommendation.
Just this morning, the American College of OB/G announced a recommendation that cervical cancer screening (Pap smears) should not start until 21 years of age regardless of sexual activity prior that age due to the very low rates of cervical cancer in such young women. Further they recommend Pap smears every other year up to 30, then every third year to 70. This assumes no abnormal Pap smears are found.
This is probably based on the already established observation that it takes about 10 years to go from normal Pap smear to cancer and is a best effort at conservative screening without over-kill.
So, there you go: all the news on cancer screening! For now, anyways.
Many patients use nasal saline to irrigate their nasal purposes for allergy problems, chronic sinus inflammation and for relief of cold and flu symptoms.
If you make up the solution for yourself, it's important that the finished solution is exactly the same degree of saltiness (salinity) as your bloodstream. Otherwise, this can make irrigation painful and counter-productive.
The recipe is:
4 cups of clean tap water
2 teaspoons of regular table salt
Use real kitchen measuring cups and spoons, and discard the solution after 2 days.
Patients have been asking me what I think of the government's efforts at reforming our health care system.
I've posted once or twice in this before covering the general principles and how US health care stacks up in terms of cost, administration and quality compared world-wide.
More recent patient inquiries were more along the lines of how I, as a doctor, feel about the specific proposals and how I see it affecting me and my patients. Up to now, there hasn't been much I could specifically say since the reform bill before the US House of Representatives was a work in progress. That is, until last night when it passed the House. Reform must now be approved by the US Senate, so it's quite likely that it will be different than the present House Bill before it is presented to the President of the United States for signature into law.
At present, HR 3962:
Would take effect by 2013
Would require Americans to purchase medical insurance or pay a penalty of 2.5% of income, subject to exemption due to hardship
Would expand Medicaid/MediCal to be able to cover about 30 million Americans who currently are too poor to buy private insurance, but too "rich" to be eligible for Medicaid or MediCal (MediCal is the California version of Medicaid, which is a Federal program providing insurance to people close to the poverty line)
Would close MediCare's "donut hole" in Part D drug coverage, and change incentives in the currently scandal-prone MediCare Advantage insurance products
Would lift the exemption of health insurance companies from anti-trust laws, which up to now have kept them from being investigated for their practices
Would forbid insurance companies from denying insurance based on gender or pre-existing medical conditions
Would forbid insurance companies from the practice of rescission, in which they investigate you background upon receiving expensive claims to find ways to retroactively deny your coverage
Would create a governmentally sponsored "public option" for those who choose it over privately available insurance.
Would forbid covering the cost of abortions except in cases of rape, incest or threat to the health of the pregnant woman using Federal funds rendered to insurance products
Would, according to the Congressional Budget Office, be cost neutral
Would be partially funded through a 5.4% income surtax on couples filing jointly over $1Million in income, or individuals filing over $500,000 in income
Would also be funded by changes in the existing MediCare and Medicaid programs, details of which are unclear at the time of this writing (the bill is about 2,000 pages long)
Would help to fund continuing medical education for doctors and nurses
Personal politics aside, I think this is a step in a good direction. I cannot see a problem with a cost-neutral program that would make affordable health insurance available to over 96% of our fellow Americans.
Requiring everyone to have health insurance is common sense. Otherwise, healthy people skip insurance leaving sick people as the main insurance participants which results in continually increasing costs. This gets passed on as increasing premiums in a system that still has to fully and publicly absorb the costs of the healthy uninsureds when the get ill or injured. It makes as much sense as requiring auto insurance, which protects every driver against the possibility of having to pay out of your own insurance even though the other driver was at fault but has no insurance.
As to the carve-out of Federal funds to public and private insurances in the coverage of abortion, from a purely pragmatic point of view that's going to be a real accounting nightmare. From an ethical point of view, I think it's pretty silly since everyone pays taxes that pay for things that one may not use or like. That's just the nature of taxation, government and shared resources in a democratic (as opposed to theocratic or dictatorial) society.
I do hope that some provisions for enforcement are made; it's one thing to illegalize price-fixing and rescission by insurance companies, and quite another to enforce it.
I still remember receiving my settlement checks from several major insurance companies a few years ago in which the were sued in class action filings under RICO statutes and chose to settle rather than undergo a public trial during the heydays of the HMO's. It's not good when every single one of the country's biggest health insurance companies are basically willing to admit that their business practices are indistinguishable from the Mafia.
I also look forward to the day that I don't lose patients from my practice because of a change in their employment or their boss's choice of insurance.
Frankly, I also look to the possibility of lower insurance costs without lower insurance quality for my practice.
I don't know how this will effect my bottom line, though if the "public option" were to reimburse at MediCare rates plus 5%, that would be just fine. The days are long gone when insurances paid much above flat MediCare rates unless you were the biggest fish in the pond. MediCare+5 along with MediCare (independently of the Reform Bill) considering lowering reimbursement of expensive procedures in order to increase payments to primary care services would be mighty welcome to little guys in the trenches like me!
It's not surprising to me that patients often relate problems sleeping.
Lots of things can help with getting a handle on better sleep, bearing in mind that persistent problems with sleep may represent bigger issues that merit further evaluation and discussion.
First, avoid things that can make it harder to fall asleep or stay asleep.
Avoid exercise, caffeine or alcohol within two hours of bedtime.
Avoid leaving unresolved problems or tasks. Keep a "To Do" list next to the bedside so you can jot down a quick note rather than stay up trying not to forget it.
Avoid using your bedroom as an office or for watching TV.
Make sure your bedroom is dark and quiet; use ear plugs and a sleep mask if you need to.
If you can't fall asleep, don't make it harder.
Go to bed and get up at the same times, no matter how poorly you've slept, every day of the week.
If you're having trouble sleeping, go to another room to read or listen to some music. Don't watch TV or use your computer; the light can cause you to become more awake!
Avoid naps, or at least don't nap for over 20-30 minutes.
As far as sleep aids go,
You shouldn't have persistent trouble sleeping for over two weeks. This may be a sign of other problems such as untreated pain, asthma, heart failure, restless legs syndrome, sleep apnea or depression and should be managed as such.
Herbs such as valerian and chamomile can help.
Warm milk does help, due to the serotonin release that it can produce.
Melatonin is safe and effective; just realize that it has to be taken about an hour and a half before lights-out to work!
Benadryl can be used for sleep, as long as it doesn't make you feel groggy when you wake up.
Prescription medicines such as Ambien/CR and Lunesta should be regarded with great caution. They may not be as safe and non-habit forming as believed.
So, since the last discussion of this back in June, the number of primary care doctors in our community who are available to see patients in the ER and in the hospital is no longer 7. It's down to 2. That's right, two.
I will continue in my arrangement with the hospital doctors to be available most, but not all of the time. It is simply not possible for me to be on call 24/7/365.
If you call the office after hours, you can leave a message. Naturally, if you feel you may be having a medical emergency, you should call 911. Otherwise, we will continue to return any phone messages early on the next business day.
Sorry, but I think I'm suffering Garrido overload.
As a dad, I wonder how likely it is that my daughter could be kidnapped by a complete stranger . I certainly remember my own childhood in which we all walked to and from school, got together afterwards to play ball, or went hunting for snakes and crayfish in the woods. I'm sad to see that few kids are allowed to have this sort of independence anymore, and wonder how dangerous coming home from school by yourself really is.
Well...
115 number of children in the U.S. kidnapped in a single year
71,900,000 number of children in the U.S. in that same year
The year in question is 1999, the most recent nationwide statistic I could find on the number of U.S. children who were abducted by strangers (not family members) with intent to keep, harm or hold them for ransom. I'm not sure where the 40 million U.S. children figure comes from in that same source link. The 40 million link goes to a demographic display on Nation Master. The link I have provided is much more specific and accurate.
Note that this figure includes all children under 18 years of age, not just 6-17 year olds.
So, doing the math...
1 in 625,217 Odds of a child in the U.S. being abducted by a stranger
1 in 340,733 Odds of being killed in a fireworks accident
So, it looks like my daughter's twice as unlikely to be kidnapped by a stranger as being killed in a freak fireworks accident. Maybe the Free Range Kids people are on to something here!
Disclaimer: I am not advocating doing clearly ill-advised or criminal things, such as leaving your children at home alone while you go on a vacation. Only you can ultimately decide what seems good for your children.
Here is a link to flu shot clinics for our county. It also includes a list of frequently asked questions such as who should get them and how much they cost.
Regular seasonal flu shots are available, and I have not heard of any supply problems or shortages.
Safeway stores are already giving them.
The Public Health Department also has a Flu Hotline that you can call to find other locations for flu shots. The number is 621-6188.
Actually, the best time to get a flu shot is between Hallowe'en and Thanksgiving. This results in your immune system response to flu to be at its highest at the time we normally start to see flu which is December through February.
This link is to a well written op-ed from the Washington Post and is worth a read. It's fairly brief, to the point and quickly summarizes the similarities and differences in structure, cost and quality of health care in various industrialized nations compared to the U.S.
It certainly reflects the data on the subject, and also my experience of health care in other countries as experience by me, my family or as related by my patients.
Realize that the H1H1 vaccine is separate from this, and is likely to require two shots in series.
The word is that access and supply are not going to be a problem, but in the event that it is, the CDC is recommending that certain groups get first access. Mind you, other sources such as WebMD had news coverage less than a week ago of production delays. It is important to remember that researching, developing and producing vaccines and other biologicals is extremely difficult. The flu vaccines are matured on chicken embryos for gosh sakes!
At any rate, the current recommendations for novel H1N1 flu vaccination in the event of inadequate supply is as follows:
First:
Pregnant women
Children 6 months to 4 years old
Children 5 to 18 years old with chronic medical conditions
health care workers with direct patient contact
people living with or caring for children under 6 months old
Second:
19-24 year olds
25-64 year olds with chronic illnesses
Third:
25-64 year olds without chronic illnesses
Last:
all persons 65 and older
Note that the reason for "seniors" to get H1N1 vaccine last is because they are at very low risk to even get the swine flu. This probably means that if you are 65 or older, you got a flu back when you were younger that was similar and gives you partial immunity to the swine flu. Younger folks don't have this response because they weren't around yet!
Remember, this is different than the usual annual flu shots. Those are available and plentiful and should be received between Hallowe'en and Thanksgiving for best effect.
The novel H1N1 influenza ("swine flu") is still being seen, including the unfortunate death of a local 52 year-old woman who apparently had chronic medical conditions as well.
Folks who are at higher risk for severe infection are those with chronic conditions (such as chronic lung disease) and also morbid obesity with a Body Mass Index over 35. The reason for this latter is not clear. Body Mass Index is calculated as follows: Weight/Height x Height and then multiply by 703.
Unfortunately, swab tests for detecting flu are not very accurate, and may detect flu only 50% of the time!
Otherwise, the H1N1 flu is similar to usual winter-time flu insofar as:
Symptoms are different than a common cold, since body aching and sense of weakness and illness is more severe.
Medications for treating this flu are the same, and should be started within the first 2-3 days to be effective.
You should cover your mouth when you cough, or wear a mask.
Wash your hands frequently.
You may return to work or school 24 hours after the fever has gone.
The death of two neighbors and friends in a single day is a deep loss and sorrow. Patient privacy forbids me to name them, but we know who we're talking about here.
I've known and doctored both fellows for years, and their deaths are painful to me as the loss of two patients whom I've known, liked and respected for a long time.
For your community, I'm sure this sadness runs very deep. I have always, and will continue to be truly impressed by the genuine sense of mutual support and real neighborliness in your community.
Much of what happens when you have a prescription occurs behind the scenes.
When you bring in a prescription, or if we call or fax it for you, the medication is labeled, placed in a secure bottle and checked against other medicines you obtain through that pharmacy to be sure that it is safe with your other medicines. The pharmacy also provides verbal and written instructions and precautions about the medicine.
When you need a refill, they provide this by phone and in many cases on-line through a dedicated website.
Even when the bottle says that there are no further refills, a call to the pharmacy will take care of this.
What happens is that they will fax me a request to okay any refills. We respond by faxing them back within 4 hours or less of receiving the request.
Mind you, we may also contact you if we notice that you are overdue for an annual physical or a follow-up appointment for a chronic medical condition. We may also wish to see you first if you are requesting a refill on a medicine that was prescribed a long time ago (such as a pain pill for a condition that went away a few years ago).
Because of the contracts that pharmacies have with commercial insurances (such as Blue Shield, Anthem, United, etc.) they can only fill prescriptions for 30 days at a time. I'm sure they'd be happy to be able to fill more at once, but if they do the insurance won't pay them for the medicines.
The reason for this is that the insurance companies have out-sourced discount contracts for medicines to Pharmacy Benefit Managers (PBM's) or "the mail order pharmacies" such as MedCo and Express Scrips. These companies are contracted with your insurance to contract with drug companies to provide discounted prices for large-volume buyers. In other words, your insurance saves money on medication costs by getting discount rates and requiring you to use them if you want to get more than a month's supply of medicines at a time.
You may use your insurances PBM by looking through the materials they send you every year, or by calling them at the toll-free number on your insurance card. They will provide you with any necessary paperwork. We can provide a 90 day prescription with up to a year's worth of refills if you ask. When this is sent in, they will mail 90 days at a time for up to a year to your address.
Do realize that you probably should not use the 90 day option for a new pill or a change in the dose, until we know it's working well and not causing you any problems.
Also, be aware that the military (CHAMPUS, TriCARE) operates differently. If you have no insurance, WalMart will fill many prescriptions for $4/month or $10/90 days. Just let us know which one you need when asking for a prescription.
When you go to lab to get blood tests done and you are asked to sign a paper you are NOT being told that you WILL be billed.
