Drug Advertising and Side-Effect Information

Everyone who watches TV has seen ads for "new" drugs with 10 seconds of why it's the best thing since sliced bread, and 20 seconds of side-effects including-but-not-limited-to death, deathiness and death-like symptoms. Kidding.

This should raise several important questions.

First, why do drug companies keep running these obnoxious ads?  Because they keep working (pdf).  Despite their disagreeable qualities, most patients who see the ads ask for a prescription for the drug and most doctors who are asked to prescribe it will do so.  Why?  Most patients are hopeful that something "new" may help them, and most doctors find it faster and easier to say yes than to explain no.

Also, ads should raise the question of how is this drug "new'?  Depends on how you define it.  Drugs advertised on TV are certainly not generics: they are newly developed and approved drugs that will therefore be expensive.  On the other hand, only 10% of them will be new insofar as being the first ever of their kind, or better than already available drugs that do the same thing (congeners).  The other 90% are what is known in the trade as "me-too" drugs.  They are no better than older generically available drugs, and are being sold in hopes of obtaining market share for the drug company that makes them.

Last and not least, I get the most questions on side-effects.  The questions are basically around what are the side effects, and how bad are they.

Listed side effects are not inevitable.  They are simply a list of possible side effects.  WebMD does a great job in discussing what side effects actually are and how they can occur.

Common side-effects may occur in up to 10% of people who take a medication. This also means that 90% of people who take the medication experience no side effects.  Severe side-effects are far less likely to occur, as the FDA does not permit the sale of medications that are seen to frequently cause severe side-effects.

The tricky bit is trying to find out for yourself what side effects actually can happen with a medication, and also how commonly they actually occur.

The problem is that the information provided by pharmacies or in with the medications is largely provided by lawyers, and not by doctors or pharmacists or nurses.  The PI (Product Insert) is principally designed to prevent class action lawsuits by listing every possible reaction to the medication  to prevent you from being able to sue for failure to disclose ("You didn't tell me that could happen.").

It would be helpful if the PI also told you how often the side effect actually happens, whether it's real or theoretical, whether it happens in humans or only in test animals and whether it happens in patients like you, or only in ICU patients with organ transplants receiving the medication in their iv (not kidding).  Problem is, they don't.  The PI is not written to inform you, it is written to protect drug companies.  The much-vaunted PDR (Physician's Desk Reference) is simply a copy of PI's from all medications.

There is no shortage of information from sites such as drugs.com which do a pretty good job of providing useful information in plain English about medications.  However, I've still never seen one that tells you how common the side effects actually are with numbers.  Sorry, but it matters.  You might be okay with a medication where dizziness occurs in 1 in 10,000 people, but not so much if it were occurring in 10% of people.

Sider 2 is useful in getting that information.  Its A-Z listing shows side effects in color-coded columns from most common to least common and allows you at a glance to see if a side effect is common or rare and also percentage of occurrence by the color coding in the sidebar.

Micromedex is the first (or second) most widely used medication database used by doctors and pharmacists.  It's smartphone app is available for only $2.99/year. It does a superb job in easily presenting drug information including actual occurrence rates of side-effects.  However, it is targeted to doctors and pharmacists.  If you want to use it, you'll need a medical dictionary at your side to translate it.  Sorry, we say rhinorrhea and you say runny nose.

Low FODMAP Diets

Certain types of foods may cause digestive symptoms we commonly associate with Irritable Bowel Syndrome (IBS)  and gluten intolerance.

IBS is a real problem involving heightened sensitivity to digestive system distension or fullness, which can result in abdominal discomfort, nausea, bloating and diarrhea.

Celiac disease (also known as sprue) is a reaction to gluten (a wheat protein) resulting in progressive injury to the absorptive lining of the gut.  Around 1% of people have celiac disease. On the other hand, many more people report chronic abdominal discomfort, bloating or diarrhea which is alleviated by avoidance of gluten, even though they are proved not to have true celiac disease.

Two researchers at Monash University in Australia since 1999 (a dietician and a gastroenterologist) have found that certain types of foods may be fermented and/or poorly absorbed and could be responsible for these sort of non-specific, hard-to-pin-down symptoms.  The term FODMAP is now becoming more widely known as a result of their work.

FODMAP is acronymic for:

• Fermentable
• Oligosaccharides,
• Disaccharides,
• Monosaccharides
• And
• Polyols.

This handout (pdf) from the Canadian Digestive Health Foundation breaks this down, and further describes what these chemicals are very nicely.

Basically, some naturally occurring carbohydrates such as lactose (milk sugar), fructose (fruit sugar), the fructans in onion, garlic and wheat and galactans in beans can be fermented during digestion leading to discomfort, nausea and bloating. 

Additionally, some of these are not readily absorbed and can lead to water being drawn in to the colon before elimination resulting in diarrhea.  This latter is particularly true of synthetic sweetening polyols such as sorbitol or xylitol which are used to artificially sweeten foods, chewing gum and other products.

Mind you, we're talking about naturally-occurring constituents of common foods.  Some foods contain more of these than others.  For example, fructans are more abundant in wheat and rye than in rice or oats.  Similarly, apples and mangos contain more fructose than bananas or berries.

This pamphlet (pdf) from Stanford University Medical Center nicely shows within the FODMAP's, which foods to limit and which are okay.

If you feel that your digestive symptoms may be affected by dietary FODMAP's you can systematically limit dietary FODMAP's one group at a time for a few weeks to determine which group or groups you may wish to limit long-term.

Alternatively, you can limit all six groups at once.  If you notice improvement, you can then de-limit one group at a time to identify culprit groups.

Please note this is quite effective with limiting intake of culpable types of FODMAP's.  Absolute avoidance is not generally necessary.

(Also, we are just discussing food substances resulting in fermentation and poor absorption. 

Other digestive symptoms such as fever, weight loss, appetite loss, stringy bowel movements, blood or mucus in your bowel movements are warning signs of much more significant problems such as infections or cancers.  Please see me for such symptoms as soon as possible, and do not try to treat them with a reduced FODMAP diet.)

Interesting Perspectives on the Changes in Medical Practice and Ethics

Unless you are a close student of history or of a certain age (*cough*), you probably don't fully realize how much the current practice of medicine really dates from the civil rights movements of the 1960's and 1970's, and how different this is from previously.

Until quite recently, the ethical principle of benificence (or paternalism, as it is also known) was the standard.  This meant that the  doctor was understood to be a professional with a deep understanding of a complex body of knowledge whose duty was to make complex decisions for patients with the best interests of the patient in mind.  Please note that the "decider" is the doctor and that the doctor also determined what was in the patient's interests. 

This article by James Hamblin in The Atlantic is an interview with Barron Lerner, whose father was an infectious disease specialist in the 1950's.  The interview is in the setting of a book written by him on the evolution of medical ethics from the reflections of he and his father, both of whom are doctors.

A part of the civil rights and free speech movements was the development of ethical autonomy, in which the doctor and the patient are understood to be shared decision-makers.  The physician is there to provide expert knowledge and experience, and to provide and describe a full range of options to allow the patient to be as fully informed as possible and to be able to decide for him/herself what is the best course of action.

Hamblin's article nicely addresses the intersection of autonomy with real concerns like time and differences of goals or opinions.  I'm sure every doctor has had cases where they have felt that the patient was making a truly bad decision, and I'm equally sure every patient has had visits or encounters where they've simply wished the doctor would just get to the point and tell them what needed to be done.  And time certainly is a factor.  Fully investigating the medical concerns at hand, performing a physical examination (yes, a good directed physical examination is still valuable and helpful in arriving at a diagnosis, but it does take time) and then fully describing the range of diagnostic and treatment options, their upside and downside risks and fully answering all questions and concerns is pretty near impossible to do in fifteen minutes in all but the most straightforward problems or concerns.  This is of course coupled with patient focus-grouping which reveals the importance of completeness and length of time with the doctor.  And also promptness. Doh!  Hello, quality-control triangle!

This article by Brandon Cohen in Medscape talks about the elephant in the exam room.  Can ethical autonomy go to the extreme of consumerism?  Is medicine another service in which customer satisfaction trumps the actual quality of the service?  Are HealthGrades reviews of doctors just like Yelp reviews of restaurants (read closely how many negative restaurant reviews relate to dissatisfaction with wait service and not so much the actual quality of the food which is what restaurants provide)?  Which is more important: that patients get the best care and have the best health, or that they are personally satisfied?  When are these goals mutually exclusive and when are they not?

If it sounds like I have more questions on this than answers, that's because it's true.  I do know that it's not unusual for Canadians to come to the U.S. for knee replacement because it takes longer in Canada to get MRI's or surgery for chronic conditions.  I also know that Canadians live longer than Americans, and can get timely tests and treatment for serious problems.  I know that most patients complain about TV ads for medicines, but I also know that the ads still run because they work.  I know that a bad rating of a hospital may mean the hospital is really bad, but it also may mean they treat a lot of complicated patients with rare conditions that no one else can treat.

Sunscreens: Summer is definitely here!

If you follow the weather reports (or just step outside) you've noticed Summer is definitely on!

The liberal application of sunscreen every two hours can help to prevent sunburn, skin cancer and wrinkling of the skin.  This is especially important in children, since one single blistering sunburn can double the lifetime risk of melanoma.

Melinda Moyer at Slate Magazine covers (no pun) the topic quite nicely.  Briefly;

• Organic sunscreens are called this because they are carbon-based, and absorb UVA which causes cancer, and UVB which causes sunburn.  
• Mineral sunscreens accomplish this by reflecting UVA and UVB.
• SPF 30 blocks 97% of UVB, SPF 50 blocks 98%.  It's probably not necessary to get anything stronger than that.
• Spray-on, or wipe-on sunscreen may not cover your skin as well as lotions.
• Using combined sunscreen + insect repellent may increase the absorption of the chemicals into your bloodstream, which may not be a good idea.

Environmental Working Group (a non-profit organization) has a great website that provides plenty of information and recommendations on sunscreens and their ingredients, safety, quality and cost.

Their iPhone and Android apps, Skin Deep also makes this information accessible on sunscreens and also  cosmetics in a mobile platform.  You can browse by entering sunscreen as a search word, or barcode scan products at the store.

More on the Topic of the Affordable Care Act ("ObamaCare"): The Stealthy, Ugly Growth of Corporatized Medicine

Yves Smith at Naked Capitalism pretty much sums up how the ACA incentivizes corporatization of medical care and presents an existential threat to small practices.

As previously stated, I think some problems can be improved upon by centralization and technology.  However, I don't think medical care is one of them, and I don't think centralization and technology should be the default approach for all complex problems.

Here in our small local pond, I see:

• Marshall Medical buying out so many medical practices it's becoming the company store in the company town.  They are organizing the doctors into a Foundation in the hopes that it will improve "productivity".  The doctors are unhappy with this as it in all likelihood will translate to more work and less pay.  Such is life when you sell your autonomy.
• Hospitals and "healthcare systems" everywhere are cutting costs by replacing receptionists with automated phone systems.  I don't think that's a good idea in what is ultimately a service, but that's where it's going.  I personally hate being on hold, and I definitely don't want it when I'm trying to call my doctor, or my daughter's doctor.  IMHO, the receptionist in my office is the voice on my phone and the first and last person you meet when you come to see me.  I do not regard or compensate this as a rookie position, and have no inclination to replace Carolyn with a robot.  How would my "productivity" improve by making me harder to contact?
• Computerization of medical records takes time away from nurses and doctors: the time it takes to enter notes or orders is time and eye contact not spent with patients.  Additionally, sharing records and keeping medications up to date is worse than ever since those responsibilities are often given to the newest entry-level employees.  The reason I haven't adopted electronic records is because I've used or beta-tested half a dozen of them and use the hospital's system for hospital patients.  At the end of the day, medical care is all about time and eye contact with patients.
• Medical supply vendors like Robinson's are no longer available to us.  Instead, patients have to go into Sacramento to whatever vendor submits the lowest competitive bid to have a virtual monopoly on medical supplies for the greater Sacramento region.  Since when has taking the low-ball bid ever been a smart move?  How are people in Placerville or Somerset or Grizzly better served by getting crutches or a wheelchair in Sacramento?
• Large employers got a reprieve from ACA insurance until next year, but not small businesses.  I guess the best investment a corporation can make is in a US representative.  I have no issue whatsoever with tax credits being available to folks based on their  annual income. It's also good that you enjoy that break in premiums every month if you bought your own insurance.  However, if you're a small business providing insurance to your employees you have to pay the full monte all year and take the tax credit as an end-of-tax-year deduction.  This does not give small business any reason to provide insurance to employees, and over 40% of employees in this country are from small businesses.  I don't think small business owners had much say in this part of the ACA, unless I missed the memo.

As a matter of history or disclaimer, I am a traditionalist.  I am in a family practice by myself, my wife is a registered nurse who works in the office and I take care of my patients in the ER, the ICU and the hospital and in hospice.  I admit I stopped delivering babies after the 500-600th one, because I was never getting any sleep.

At this point in time, remaining a traditionalist requires a level of canniness and responsiveness.  However, I see no reason to stop practicing medicine the way it has been practiced for the last several hundred years just because everyone  is deciding that they can get more sleep and be more "productive" by becoming an employed cog in a corporate machine.  So far so good, and long may it last.  We'll see if it continues to be better to fight on your feet than live on your knees.

For Your Reading Pleasure

The author of this essay turns his thoughts from review of political events to Spring and the protection of young life.  The writing is a sheer joy to read.

Despite the banality of the thought, we have all found it uplifting to see this small confirmation that despite every natural and human challenge and unkindness, life has waged a battle that it has never lost.

John McAfee: crazy? crazy like a FOX? Great Ask-Me-Anything, especially if you are inclined to dodgy business practices in Central and South America.

Remember: 50% of the police who stop you in most Third World countries can’t read. This is a powerful piece of information for the wise.

On Being an Aging Parent

Oh, it's so true!

Slate carried a great piece today written from the perspective of being (rather than caring for) an aging parent.  I had a fit laughing about "the look" when you forget a name or a date.

Don't get me wrong here: I don't think dementia is funny.  I am simply aware that forgetting the names of things is in the Top Five ist of things people see a doctor for, where there is nothing seriously wrong with them.

At the same time, I am sort of surprised that the risk at 85 years of age or older of developing Alzheimer's disease is 50%.  To me, I guess that sounds pretty good considering (1) the average life expectancy is 78-82, and (2) that means there's a 50% chance at that age and older of NOT developing Alzheimer's disease!  I guess I'm more of a glass half-full kind of guy than I thought.

Do remember (no joke intended) that it has been shown that folks at 85 and older who maintain normal short-term memory tend to regularly exercise, socialize and get out of the house.

The Importance of Sleep

The Big Picture linked to a couple of good articles this weekend on sleep.

While we generally feel like missing some sleep here and there is not a big deal, it's turning out that it is a big deal after all.

The New York Times describes some of the current research on sleep's role in not just consoldating memory and maintaining functional neuronal connections, but also in clearing the brain of accumulated metabolic waste products.

The Boston Globe lists some of the adverse effects noted of sleep deprivation on physical and mental health and longevity.

Interesting Reading

Aeon Magazine has a fascinating article on a town in Belgium that has a long history of taking in people from out of town who have psychiatric or learning disabilities.  Apparently, the improvement in their quality of life and function has been a source of interest in the European psychiatric community since the 19th Century.


Scientific American has an excellent examination of the high cost of medications (hint: difficult science is expensive).

The New York Times carries an interesting story of what happens when doctors "Google" their patients.  The author claims just about every doctor does this: I confess the thought had never crossed my mind.

Happy New Year!

Thanks to Medscape for posting this article that really speaks to the root of the doctor-patient relationship, and to Slate for this discussion of the importance of exercise!

Merry Christmas, Happy Holidays and a great New Year for all!

My Christmas wish list to Santa:

• Global energy independence from fossil fuels and nuclear energy over the next 20 years using existing capital, real estate and technologies.  Sounds like a great public works project that would employ a lot of laborers, construction workers and engineers.
• The tech sector should start realizing their job is often to put other people out of jobs.
• National legalization of marijuana: tax and regulate it, and spend the money we spend on criminalizing it on something more useful.  Like Pat Robertson says.
• An end of poverty: a universal basic income equivalent to poverty line income, no strings attached, funded by a combination of a household carbon tax of no more than $100/year and   de-funding organizations helping those in poverty (because no one would techinically qualify anymore).  See reasoned discussions from those flaming commies at Business Insider and Forbes Magazine.

For all of us who's celebration no longer includes family or friends who are no longer with us, may you please find love and hope this season and be consoled that they are not forgotten.

So, what do you think about "Obamacare"?

I got asked this a lot when the Affordable Care Act (a/k/a "Obamacare") got passed, and I'm asked that a lot with the rollout of insurance markets.  I gotta say, my viewpoints on this are complicated.  

For one thing, I have from the beginning been in entire agreement with former Secretary of State Colin Powell that we should have a single-payer health insurance like all the other industrialized countries in the G20.  Yes, that means taxpayer money is spent on providing a basic health insurance from cradle to grave for all US citizens: MediCare for All, if you will. I'd certainly prefer this over a series of "tweaks" that fully involved drug companies and insurance companies in the decision making.  I don't see any of those monied interests allowing a solution that would impact their revenue stream.

Is this a real departure from the status quo? Yes. Why do it?  Because all the other industrialized countries are successfully doing so, with longer life expectancies than the US, lower medical error rates, and at 1/3 of what we pay per capita. (Feel free to see earlier posts for links on these figures.)  I happen to like Germany's system as a model.  The German government provides a basic insurance from birth.  If you want and can afford more extensive insurance, you can buy all you want from the very active and competitive private insurance companies.  If you don't want to, you don't have to but at least you're not a hospitalization or accident away from personal bankruptcy. 

What keeps the insurance companies in line is  that annual increases in premiums of over 6% per annum are not permitted unless the insurance company can prove to the government that it is necessary due to medical costs incurred and not just profit motive. 

What keeps doctors and hospitals in line is that the government routinely does comparison tests head-to-head of medicines, surgeries and devices and then publicizes the results so everyone involved knows what works and what doesn't.

Sounds good to me: I've never heard anyone characterize the German government as being soft-headed or given to wild over-spending.

Otherwise, I have to admit that Covered California (California's insurance website) is pretty impressive.  It runs smoothly and the rates offered look very attractive and the tax credits for individuals or small businesses are generous and not just for the wealthiest or most impoverished but really benefit middle class individuals and businesses with fewer than 25 employees.

I agree with requiring health insurance of all citizens.  Just simple math here: insurance risk pools fail if "healthy" people can opt out but everyone still has to pay if they get sick or hurt.  Arguing that you shouldn't have to carry insurance because you won't get sick is like saying you won't wear seat belts because you've never been in an accident.

On the other hand, my biggest concern with "Obamacare" is its underlying assumption that bigger and more centralized has to be better.  This is my principle objection to other trends in government, services and business.  The ability to shop Amazon from your smartphone and receive your goods two days later at prices lower than in your town is all very well and good (unless you have a small business in your town), but applying this model and philosophy to everything as a default model to every complex system is flawed.

The widespread application of computers, robots and out-sourcing has, in my opinion, resulted in a massive and tacitly accepted exchange of more expensive but higher quality for cheaper and good-enough.  Remember when you could buy a tool or appliance that you'd hand down to your kids?  Bought anything that good lately?

Many aspects of the Affordable Care Act incentivize doctors and hospitals to coalesce into larger more centralized organizations under the assumption that this will reduce costs and improve the quality of medical care.  In my experience, sometimes this helps, and other times it doesn't.

However, to seek to change the great majority of medical care in the US to a smaller number of much larger and centrally controlled organizations is to risk losing its personal qualities.  What do people like about Kaiser?  Everything under one roof: see mid-level, draw blood, pick up medications all in one visit to one place.  What do people not like about Kaiser?  Never see same doctor, doctors rushing to see patients in 8 minutes, hard to get to see specialists.

I happen to believe that the practice of medicine has a deeply and inherently personal quality to it.  It takes time to ask enough questions to arrive at a correct diagnosis.  It takes time to build a trusting, respectful relationship that is mutual between patient and doctor.  I think and see that it does matter that the doctor who sees you in the hospital already knows you well as a patient and as a person.

So, I guess what I think about "Obamacare" is that it is at least a reasoned and good-faith effort to fix something that is really in need of improving.  However, the long term impact is going to make medicine more like corporate businesses: bigger with more "economies of scale" (uck) that will provide medical care in a way that is less expensive, possibly more efficient (depending on how that's defined) but increasingly impersonal and detached.

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.

Not All Medicines Are Created Equal

When doctors refer to a "class" of medications or drugs, we are referring to a group of drugs that are chemically similar (but not identical), that are used to treat the same conditions, and work the same way (so-called mechanism of action).

Often, medical studies showing some benefit or risk of a single drug are understood to mean that this benefit or risk may or may not accrue to every other drug in its class.

As more study and research occurs, we are coming to realize that in some cases different drugs in the same class can vary significantly in terms of their effectiveness or safety.

For example, Avandia (a diabetes drug) was taken off the market by the FDA several years ago due to heart disease risks with the drug.  Actos (in the same drug class) was not.

Just a few years ago, head-to-head tests showed that two of the SSRI's (serotonin-specific re-uptake inhibitors, commonly used in the treatment of depression and anxiety) were both more effective and lower in side-effects than the others.  Those two are Zoloft/sertraline and Lexapro/escitalopram.

More recently, we find that while the statins are all effective in lowering cholesterol and preventing heart attacks and strokes, two of them are particularly lower in side-effects and drug reactions.  These two are Pravachol/pravastatin and Zocor/simvastatin (in doses of 40 mg a day, or less).

On the positive side, the so-called ACE inhibitors (a class of blood pressure lowering drugs that are particularly beneficial in diabetics) are known to prevent heart attacks and strokes.  Additionally, several are also seen to reduce your risk of memory loss and Alzheimer's dementia due to there ability to positively affect circulation in the brain.  These are Altace/ramapril, Tarka/trandolapril, Capoten/captopril, fosinopril, and Zestril/lisinopril.

Immunizations (or, shots)

Retail pharmacies are already providing annual flu shots.  There is no shortage, so no need to hurry.  Getting a flu shot before late November can help to prevent getting the flu, or giving it to others.

Many retailers also offer pneumonia immunizations.  These are covered once in your life under MediCare and prevent the one kind of bacterial pneumonia that is the most common single kind and also the most deadly.  It doesn't keep you from getting colds or every possible kind of pneumonia, but it does protect you against the worst one!

Shingles shots are also once in your lifetime and covered by MediCare.  Shingles comes about from having had chicken pox as a child.  I think ads on TV make shingles out to far more severe than it is for most folks, but on the other hand it's not something you'd like to get if you could avoid it.  If you've never had chicken pox, then you should definitely get the shingles shot since it will act as immunization against getting chicken pox as an adult, which is a very serious and unpleasant problem.