Perspective on Health Care

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.

Current H1N1 flu vaccine recommendations by the CDC

I understand through an email update from the California Medical Association, that vaccine for the novel H1N1 flu ("swine flu") is to be available along with the standard seasonal Autumn flu shots.

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.

Novel H1N1 Flu- Update

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.
  

To Grizzly Flats

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.

With love and respect,

Mark Tong, MD

How your pharmacy works

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.

Upcoming Vacation

I will be away from the office catching a bit of beach time from Thursday through Monday!

Cindy will be here, so the office will be staffed to help you.

UFCW patients: yes we take your new insurance!

Effective 9/1/09, UFCW & Employers Benefit Trust (UEBT) and UFCW Northern California and Drug Employers Health and Welfare Trust Fund (Valley Drug Fund) will change from Anthem Blue Cross PPO to Blue Shield of California PPO.

We accept both of these insurances, so this change will not effect your health care at our office. All we ask is that you let us make a copy of your new card whenever we next see you.

The Influence of Health Insurance Companies on Health Care Reform

This is a link to a fascinating interview by Bill Moyer of Wendell Potter. Mr. Potter was employed as a Vice-President of Public Relations for Cigna, which is one of the largest health insurance companies in the US. Was, that is, until a bit of an eye-opener when he was back in Tennessee visiting family.

...we shouldn't fear government involvement in our health care system. That there is an appropriate role for government, and it's been proven in the countries that were in that movie.

You know, we have more people who are uninsured in this country than the entire population of Canada. And that if you include the people who are underinsured, more people than in the United Kingdom. We have huge numbers of people who are also just a lay-off away from joining the ranks of the uninsured, or being purged by their insurance company, and winding up there.

BILL MOYERS: You told Congress that the industry has hijacked our health care system and turned it into a giant ATM for Wall Street. You said, "I saw how they confuse their customers and dump the sick, all so they can satisfy their Wall Street investors." How do they satisfy their Wall Street investors?

WENDELL POTTER: Well, there's a measure of profitability that investors look to, and it's called a medical loss ratio. And it's unique to the health insurance industry. And by medical loss ratio, I mean that it's a measure that tells investors or anyone else how much of a premium dollar is used by the insurance company to actually pay medical claims. And that has been shrinking, over the years, since the industry's been dominated by, or become dominated by for-profit insurance companies. Back in the early '90s, or back during the time that the Clinton plan was being debated, 95 cents out of every dollar was sent, you know, on average was used by the insurance companies to pay claims. Last year, it was down to just slightly above 80 percent.

So, investors want that to keep shrinking. And if they see that an insurance company has not done what they think meets their expectations with the medical loss ratio, they'll punish them. Investors will start leaving in droves.

I've seen a company stock price fall 20 percent in a single day, when it did not meet Wall Street's expectations with this medical loss ratio.

The link is to a video, and also to a viewable and printable full transcript.

Check it out, if you are interested to understand how commercial insurance companies influence the discussion and the political process around the reform of our health care system.

Tylenol, Vicodin and Percocet safety

If you follow the news much, you will be noting that an advisory panel to the Food and Drug Administration (FDA) is expressing concerns about the safety of two commonly prescribed narcotic "pain-killers" Vicodin and Percocet, and also about the safe dosing levels for Tylenol (generically known as acetaminophen).

Just to clarify, the issue is not so much about the maximum safe doses of acetaminophen so much the fact that it's in a number of prescription and over-the-counter medications and that it may be easy for people to accidentally take too much as they may not realize how much they are actually taking.

Acetaminophen is in "non-aspirin pain relievers" over the counter, and in Tylenol as regular,
Extra-Strength and Arthritis. It is also in a large number of generic and Tylenol brand cough and cold formulas, allergy medicines and sleep aids.

In addition to this, it is a component of Vicodin and Percocet which are prescription medicines for pain.

You can start to see where it might be easier than you suppose to get more acetaminophen into you than you thought. This Q&A rather sums it up:

People think that if it’s a safe drug and I have this pain, it works better if I take more,” said Cesar Alaniz, a clinical associate professor at the University of Michigan College of Pharmacy.

How Do Drugs Get Tested?

The recent news about over-the-counter (OTC) Zicam causing a loss of sense of smell in over 300 people raises a few eyebrows. Frankly, Bextra being withdrawn in 2005 for being linked to causing an increase in heart attack risk raised quite a few eyebrows, too.

It's important to make a distinction between pharmaceuticals and supplements.

Pharmaceuticals are regulated and approved by the Food and Drug Administration (FDA) and must be proved to be safe as well as effective in treating the condition for which approval is being sought.

Supplements, herbs and vitamins are marketed as nutritional or dietary supplements and therefore are not required to meet any such standards. Let the buyer beware!

By the time a pharmaceutical has received FDA approval to be sold, it has been researched and extensively tested in labs and then in humans for both safety and effectiveness. The testing in humans usually involves several thousands of folks, half of whom receive the tested drug and the other half a placebo.

This is done in such a way that the doctor giving the drug doesn't know whether the person will receive an active drug or a placebo. This is called randomized, double-blind placebo/control study, and is intended to keep people from reporting or not reporting side-effects because they know beforehand whether they got drug or placebo. Also, it is done this way so the doctor cannot reveal whether they are getting drug or placebo, either.

Granted, this assumes that the drug manufacturer is conducting the research in accordance with standards, and isn't "massaging the data". It also assumes that the directorship of the FDA is aggressively pursuing its mandate on behalf of the public.

In the case of Bextra, the drug company reported 11 months of heart attack data as a full year, thereby under-reporting the incidence of heart attacks related to the drug to the FDA.

Also note that the burden of proof of effectiveness and safety is on the company, and not the FDA. This is as it should be from the point of view that the costs of such proof should be on the company which stands to profit from FDA approval, and should not be upon the consumers and taxpayers.

Also, it is important to realize that if a drug as a rare side-effect and perhaps only occurs in one out of 10,000 or 50,000 people who take it, this is not going to become evident until several million people have taken it. This is neither a failure of the drug company, nor the FDA. This is simply a fact of life, which is why there are processes for reporting potential rare but serious side-effects with medicines. An example of this is the current investigation of psychiatric side-effects with the new smoking cessation drug Chantix.

Bottom Line:

Supplements and herbs differ from pharmaceutical drugs significantly in that they are not required to be proven to be safe or effective, nor to be tested for interactions with medicines or foods, nor for truth in labelling.

This does not mean that they do not work or should never be taken, but it does mean that a reasonable degree of skepticism in the literal sense should be exercised.

A trial period of changes in hospital coverage: and now for something completely different!

Short story:

Starting Monday July 13th, for a trial period through the end of October, my call group will have patients admitted and cared for by the hospital's hospital-based doctors for 3 weeks on and 3 weeks off. We will care for our patients for 3 weeks off and 3 weeks on, alternating with the hospital-based docs.

At the end of this trial period, we'll see how it's been working out for everyone, including our patients to see if we all want to continue on in this 3 weeks on/3weeks off cycle.

Long story:

Physicians used to be on-call for the needs of their patients 24/7/365. Naturally, that gets old pretty quickly since you can never be away from a phone our out of the area.

A few decades ago, a common practice developed where different doctors would agree to share coverage on evenings, weekends and holidays. When you are on-call you're on for the group, but when you're off you're all the way off (as in you can go fishing or skiing, leave town, catch a movie with your kids...).

In the past 5 or so years, a nationwide trend which Marshall adopted is one in which family doctors only see patients in the office, and the hospital hires doctors who only see patients in the hospital (such doctors are referred to as hospitalists). Supposedly, the patients get better care as they are seen by doctors who only ever treat hospitalizably ill people. Also, supposedly this is more profitable for both the family docs and the hospital.

So far, no one including Marshall can demonstrate a difference in hospitalist versus family doctor care in terms of the complexity of the patients, how well they do and how long they have to stay in the hospital.

Unfortunately, one outcome of this is that there are only 7 primary care docs in Western El Dorado County who still see patients in the office and also in the ER and in the hospital. Marshall's own doctors backed out of the hospital about 5 years ago and can't come back.

I share call with Drs. Keith Boston, Leanne Camisa and Dave Ramos. This means if you have to be in the hospital after hours, one of us will be admitting you and I will see you first thing in the morning (or on Monday AM, if it's a weekend).

Thing is, Camisa and Ramos are married and have two young children. As you can imagine, they are finding it increasingly difficult for one or the other of them to be on-call literally half of their lives.

Bottom Line:

For my call group to continue to function, we needed to come up with some form of relief.

We still feel the best care you are going to get if you get really sick is going to come from a doctor who already knows you well.

We think the hospital docs are excellent docs, but would prefer to take care of our own patients because it's important to us.

However, the times are changing around us and there aren't many of us left doing the full range of practice.

So, we want to try out a system where we're each on-call every fourth night and weekend for 3 weeks in a row, and then 3 weeks off.

During this 3-week off period, the hospital docs will be informed as to your medical history, surgeries and your medications.

Please let me know how you feel about this, and please let me know if you are in the hospital but feel that you would rather that I was seeing you there.

Again, this is a trial period from mid-July for about 3 months. At the end of it, we'll be seeing how it's working out for everyone involved especially our patients.

Happy July 4th!

Have a happy holiday celebrating our nation's independence with your friends and family.

In case it interests you, this link comments on a plain English contemporary reading of the Declaration of Independence. This link is a how-to on photographing fireworks displays.

Remember, that long stick coming out of the rocket is for staking it into the ground; it's not a handle... :-)

Samsung Jitterbug- nice idea for older folks who live alone

A patient who is in her 80's and lives alone, while her son lives nearby in town showed me this last week. (Sorry, tried to upload a photo of it- drat this Blogger!)

Basically, it's a cell phone that you can get through the usual cell phone vendors that is well designed and intended for older folks (especially ones living alone).

It's large and soft enough to be held easily, but is only slightly larger than most cell phones. It opens like a clamshell phone, so the keyboard is protected from damage or accidental activation.

The keys and display are large enough to read and to use easily, even by folks with less than 20/20 vision or "arthur-itis".

A special model of this has three keys colored green, yellow and red. One calls Operator, one calls Help (such as a friend, relative or neighbor) and one calls 911.

My patient liked this over the usual LifeLine pendant ("Help! I've fallen and I can't get up!"), because it works outside the home, and she can also call her son instead of every distress call resulting in an EMT/fire department response.

Working With Your Hands

This is a really nicely written article by a guy with a Ph.D. in political philosophy who is very happily and fully self-employed repairing motorcycles.

The trades suffer from low prestige, and I believe this is based on a simple mistake. Because the work is dirty, many people assume it is also stupid. This is not my experience. I have a small business as a motorcycle mechanic in Richmond, Va., which I started in 2002. I work on Japanese and European motorcycles, mostly older bikes with some “vintage” cachet that makes people willing to spend money on them. I have found the satisfactions of the work to be very much bound up with the intellectual challenges it presents. And yet my decision to go into this line of work is a choice that seems to perplex many people.

I was very impressed by the kind of thinking that goes into how this guy solves problems.

In fixing motorcycles you come up with several imagined trains of cause and effect for manifest symptoms, and you judge their likelihood before tearing anything down. This imagining relies on a mental library that you develop. An internal combustion engine can work in any number of ways, and different manufacturers have tried different approaches. Each has its own proclivities for failure. You also develop a library of sounds and smells and feels. For example, the backfire of a too-lean fuel mixture is subtly different from an ignition backfire.

Hmmm. Sounds like a day in my life...

Swine Flu- Update

Yes, there has been a confirmed case of H1N1 ("swine") flu in a student at Camino School. The school has decided to close for a week to diminish the chances for spread within our community. The virus is known to be contagious for 7 days after the onset of illness.

The good news is that the virus shows none of the markers for severe disease, and is not resulting in illness any more severe than a usual seasonal flu!

Swine Flu- An Historical Perspective

Most folks have heard that the Spanish Flu pandemic at the close of World War I killed millions of people, and was a shocking illness that left memories of it for generations afterwards. This is certainly true.

However, in the context of the current early stages of this influenza outbreak, it is useful to look back at the Big One in a more statistical light.

As many as 2.5% of people who got the flu died.

This does not mean that 2.5% of the world's people died, it means that 2.5% of those who got the flu died.

In fact, only 28% of the world's entire population got the flu at all. 97.5% of them survived.

In other words, in the world's worst flu pandemic in history to date your odds of not getting the flu at all were 7 out of 10, and if you did get it your chances of survival were better than 9 to 1.

And this was before advanced emergency medical care, advanced hospital care and before antiviral and antibiotic medicines.

Swine Flu

DO NOT PANIC, PLEASE!

Swine flu is a flu virus (Type A H1N1) which has been identified in Mexico where it caused 20 deaths, and also in the US, Canada, and possibly New Zealand and Spain where it has caused no deaths.

The reason that the federal government declared a national public health emergency in the face of a new strain of flu is to be able to rapidly move flu medicines from a national stockpile to places it is needed as quickly as possible.

With the exceptions of the deaths in Mexico, Swine Flu is like having the flu: fever, aches, congestion, cough and sometimes vomiting and diarrhea.

It should be treated like the flu:

• stay home
• cover your mouth when you cough or sneeze, discard the tissues in the gargage.
• use Tylenol for fever or aches
• use medicines such as Coracedin, NyQuil or Robitussin DM for cough and congestion
• use Benadryl for nausea or vomiting
• use Imodium/AD for diarrhea

Seeking emergency medical attention is reasonable for unusual symptoms such as:

• chest pain
• difficulty breathing
• unremitting vomiting

To avoid getting the flu,

• Wash your hands frequently with regular soap or waterless hand cleaner.
• Avoid touching your eyes, nose or mouth.
• Avoid visiting ill people, if possible.
• Consider using an N95 respirator mask. These filter out viruses and bacteria from the air you breathe, and can be bought at hardware stores where they are used for sawing and grinding work. These are fiber and semi-disposable, not the big rubber ones with large filter cartridges!

Hearing Aids

Hearing aids, technology and the Baby Boom have finally come together in a "perfect storm" with the happy outcome of really good hearing aids for not much more than the older funkier ones.

The technology around small audio devices, high fidelity, good micro-circuits and batteries has been around for a few years, but the demand has not. Not until recently, that is. With the Baby Boomers finally hitting AARP and MediCare age, there are millions of potential customers for hearing aids that "ain't your fathers hearing aids".

Especially for folks with the most common kind of high-tone hearing loss (more loss at pitches around human speech than at lower pitches), the newer "open-ear" devices are a perfect fit. They are nearly invisible, work well, and don't squeal with feedback even when you use a phone, wear ear protectors, or use a helmet or a hat.

These often cost around $4,000 a pair which is not much above the older clunkier ones. MediCare may cover up to about $500 of this. Make sure the vendor has a reputation for seeing you after the sale for any further fittings and fine adjustments.

I am very impressed that I have had several patients in the past few months absolutely ecstatic over their new hearing aids and the quality of service from their vendors. In fifteen years, I have never heard anyone go on about how happy they were with their hearing aids!

The patients in question had obtained them at All American Hearing in Cameron Park, and the Costco in Folsom. As a disclaimer, I have absolutely no financial ties to either organization and receive no compensation or "kick-backs" from them. (I am, however, a Costco member and am impressed by the quality of the meat and produce selections.)

I have heard every objection to getting hearing aids that there is. Think about it in the same way you would think about LASIK vision correction or a remodel on your home. If the money involved would be worth it in terms of quality (hearing really, really well in this case), then the time to spend that money is when you will be able to enjoy it for a long time. This may also mean while you are still relatively young and still working, since you are still bringing in a paycheck. This is easier than after you retire and are living on a fixed income, and certainly better than waiting until you are so old that you may not get to enjoy them for long.

Hearing what's going on around you, not feeling irritated by having to ask people to repeat themselves and being able to fully enjoy a conversation, a party, music or a dance are not at all over-rated!

EMR- Electronic Medical Records

20%
Percentage of doctor
offices using EMR


70%
Percentage of doctor offices dropping EMR
within 2 years of buying one


$65 Billion
Amount of money
being budgeted
towards national
implementation of EMR

I guess I'm not too hot on the concept of electronic medical records.

As a preamble, let me say that I own several computers, have installed my own wireless networks, enjoy using computers, have tried voice recognition software, and have beta-tested several EMR systems.

Bottom line, they do not save me time or make me more money. In fact, they can cost up to $40,000 to implement and take me longer to document what I do. They do not pay for themselves, and they do not help me to render better medical care than simply keeping and paying attention to a well-organized paper record. Plus, the paper record can still be used even if the power goes out, or the scheduling computer doesn't work.

I also note, that the EMR produced notes from many of my specialist colleagues that are often up to 4-5 pages of not much more useful information than I can get out of one page of well-organized well-written manuscripted notes.

As EMR systems become for comprehensive, they can actually start to make the job harder: for example, not permitting me to list a strong family history of breast cancer on the master Problem List. Like many other features of medical care, a system created by non-doctors and non-nurses may not be particularly effective or easy to use by doctors and nurses.

Also, there is no agreed upon code standards, so none of these expensive systems is capable of interfacing with other systems.

Believe me, I would enthusiastically embrace a system that allowed me to do my work faster, better and more efficiently that was affordable and as universally used as Microsoft Windows. I doesn't yet exist.

Sleeping Pills

A word about sleeping and sleeping pills.

Ambien was a hot new drug for sleep back in the early 1990's, and went generic as zolipedem in the last year or so. If you watch TV or read magazines you would have noticed because you have been blitzed with ads for the competion: Ambien CR, Lunesta, Sonata and Rozerem all sound like the greatest thing since sliced bread. At least, they do on TV.

Granted, older sedatives often taken for sleep (such as Valium, Ativan, Restoril, Serax, etc.) create problems because they render you unconscious, not asleep. This is crucially different, since you are losing up to half of the really deep, restorative sleep and dream sleep when you take these. When this happens for over three nights in a row, daytime problems will follow; such as forgetfulness, irritability, tiredness, depression, moodiness or difficulty concentrating.

When Ambien first came out, it seemed to be the best of both worlds: helping people to sleep, but without the loss of deep sleep and dream sleep.

Unfortunately, it may be that Ambien and the other newer sleeping pills may not help you sleep any better, they may just keep you from remembering your sleep. This may be why some people who take it have been seen to cook, eat or even drive at night without remembering doing so.

Basically, people get needed sleep. Insomnia is often a symptom of another problem such as stress, depression, sleep apnea, pain,urinary problems, drinking or long-established bad sleep habits. The treatment then is to treat the underlying problem, not to be drugged into unconsciousness every night.

To make it easier to sleep well,

• Go to bed and get up at the same time every day, including weekends, vacations and holidays.
• Don't eat or have alcohol or exercise within two hours of bedtime.
• Don't watch TV in your bedroom.
• If you can't sleep, go to another room and read or listen to some music. Do not watch TV or use your computer! The light from the screens stimulates your brain and wakes you up.
• Try taking 2-3 mg of over-the-counter melatonin about 1-2 hours before your bedtime.
• Tylenol PM is OK to use for sleep, unless you find that it causes side-effects or makes you feel groggy in the morning.