Shameless Corporation of the Week Award

This weeks Shameless Health Care Corporation is United Healthcare. (For prior winners, scroll down the blog). I have many examples of the shameless and egregious behavior of United over the years, but this story sums up how they treat their policyholders. They treat their contracted physicians even worse.

Marlene is a single stepmom who is raising the two children of her deceased sister. They live in a cramped apartment and stretch a dollar as far as they can. She is extremely responsible about health care for herself and her stepkids. Since I don't contract with United Health Care, she pays me and sends the bill to United for them to reimburse her. Over the last two years, they have reimbursed her ZERO for health visits and illnesses for herself and the teenage kids.

Under the contract with United, they should pay a portion of "out of network" care. United has a pattern of delay and hassle that is repeated over and over. United sends me forms to fill out after each visit, even though they have the information in full on the bill I give her to submit. They want a complete duplicate of the information that they already have. When I resubmit the forms they stall and after 90 days they send a denial, stating they did not receive proper information and allowing me to "appeal" on the patient's behalf. When I send the appeal letter with copies of everything, nothing more happens. This cycle can take about a year to complete. There is no phone number to call on the letters and phone calls to United Health Care corporate puts you on a recording loop.

United Healthcare is truly a shameless corporation. Despite the fact that my patient has insurance that should cover her and her step-children, I provide heavily discounted care because I know she will never be paid a dime by United.

The CEO of United Health Group was paid $3,241,042 last year and has a retirement account of $10,703,229. The prior CEO of United was paid $342 million over 5 years. I don't know what his retirement is.

Shameless!

U.S. Should Focus on Primary Care

A new study conducted by the Commonwealth Fund was published by Health Affairs and it showed that the U.S. lagged behind other nations in some very important ways that affect health and access to quality health care. The study surveryed over 10,000 primary care physicians in Australia, Canada, France, Germany, Italy, the Netherlands, New Zealand, Norway, Sweden, the United Kingdom, and the United States. The study found that:

• The vast majority (69 percent) of U.S. respondents report that their practices have no provisions for after-hours care, leaving their patients no choice but the emergency room. The U.S. was behind every other country surveyed on this finding.

• Fifty-eight percent of U.S. primary care physicians say their patients often have trouble paying for their medications and care, compared to 5- 37 percent in the other ten countries.

• While 99 percent of doctors in the Netherlands and 97 percent of doctors in New Zealand and Norway use electronic medical records (EMRs), only 46 percent of U.S. doctors report EMR use.

• One-third of U.S. physicians report receiving any financial incentives for the quality improvement measures tracked in the survey. By contrast, 89 percent of doctors in the U.K. and sizable majorities of their counterparts in the Netherlands, New Zealand, Italy, and Australia report financial incentives tied to quality.

Primary care forms the foundation of a quality health delivery system, coordinating care and holding down prices.

The authors conclude, "Overall, the survey highlights the lack of national policies focused on U.S. primary care. Unless primary care practices are part of more integrated care systems, they are on their own facing multiple payers with uncoordinated policies. In contrast, other countries with multiple payers seek coherent payment and coverage policies. As the United States looks to develop new primary care models that could work well for patients and physicians, policymakers can learn a great deal from diverse initiatives under way in other countries."

It's Post Secret Day

Check it out every Sunday.

When to Take Tamiflu

With the H1N1 flu season hitting most communities, the question of when to give patients Tamiflu comes up for physicians. Tamiflu is the antiviral medication that can shorten the severity of flu symptoms by...drumroll...one day. To be effective it should be given within the first 48 hours of symptoms.

There are no medical guidelines for who should take Tamiflu. If patients have symptoms severe enough for hospitalization or have a chronic condition or asthma, Tamiflu should definitely be prescribed. Pregnant women and young children are at more risk for severe flu so they should be given Tamiflu when symptoms present, but what about everyone else?

Is shortening the illness by one day worth the $100 Tamiflu costs? Some doctors are concerned about creating resistant strains of influenza if Tamiflu is overused. And giving Tamiflu to "prevent" flu is not recommended because people who live in a household with a flu victim have only a 15-27% chance of catching flu anyway. That said, if a person with high risk factors is exposed to the flu, giving Tamiflu is likely to prevent illness.

As with any medication, adverse events can occur. With Tamiflu adverse event reports were primarily related to unusual neurologic or psychiatric events such as delirium, hallucinations, confusion, abnormal behavior, convulsions, and encephalitis. Most of the reports come from Japan.

I am not prescribing Tamiflu routinely for people with flu symptoms. If they ask for it, and understand how it works and the small risks of taking it, I will write the prescription. Tamiflu is not a substitute for the flu shot.

Who Sues for Malpractice?

There are a lot of myths out there about which patients are most likely to sue a doctor for malpractice. Many doctors think it is "poor patients on welfare." They would be wrong. Evidence shows that low income patients on Medicaid are actually less likely to sue than others. But there are some patients and situations that should raise a red flag for physicians that they could bring a lawsuit.

• Angry patients: A patient who is upset about the doctor-patient relationship, either because something didn't work out or they perceived a lack of caring, is more likely to sue the doctor. Plaintiff attorneys say that the majority of their calls come from patients who had poor rapport with their physicians. What works in a medical error? An explanation of what went wrong and, if appropriate, an apology!

• Money Issues: Now that more patients are paying out of pocket costs, if they feel overcharged they become less tolerant of errors. If patients know the approximate costs up front, they aren't surprised and outraged when that big bill arrives. We all know, however, how hard it is to find out anything about costs in advance. Big problem!

• Doctors Dissing Others: So many lawsuits have been filed because of one doctor or nurse making disparaging remarks about another; "How did such a thing happen to you?" It's easy to be a Monday morning quarterback.

• Lousy Service: Bad service goes along with poor doctor-patient rapport. It is hard for someone to feel respected and cared for, if they get bad service or the rooms are dirty or the phone call isn't returned. If a mistake happens, the doctor must be available to discuss it. An absent doctor or poor service turns patients and family members into "angry patients" (see number 1).

Medical mistakes happen because the human body is complex, treatments are complex and there are no guarantees in life. Most patients don't sue their doctors when a bad outcome occurs. The experts in risk warn us that the relationship is the most important prevention for lawsuits, followed by meticulous documentation in the medical record.

Big J&J Layoff

Johnson and Johnson has announced that they will lay off 7000 employees. That is about 7% of the employees at the company. How can the economy really be improving with such large job eliminations occurring?

J&J is one of the most admired and diversified health conglomerates with a consumer division, diagnostic/devise equipment, pharmaceutical drugs and R&D arm. Johnson and Johnson is present in 57 Countries around the world.

If a company like J&J is cutting back this much, it shows the economic recovery will be long and hard.

Unreal Health Care Costs

I took my son to the ER for a broken thumb. It was a minor injury but the thumb is the most important digit on the hand. The ER care was just fine...a quick look, an Xray and a small splint. We didn't have to wait long and everyone was courteous.

Imagine my surprise to receive the bill from the hospital. Yes, I have insurance. My out of pocket expense was minimal but here is what the insurance company was charged:

• Hospital Misc.- $56.00 (could this be the splint?)
• Diagnostic Xray - $342.00
• Emergency Care- $952.00
• Surgery - $570.00
  Total $1920.00

Take a look...surgery? There was so surgery, no procedure. There was no break in the skin. The doctor component of the visit was about 7 minutes (mainly because I knew the doc and we chatted about politics)

This bill is unreal and is comprised of unreal health care costs. The insurance paid a component of the bill. They have a cap on what they will pay for each element.

I am an informed consumer so I will be calling the hospital billing office to discuss the unreal charges. I doubt that most patients would do that if they had insurance. It would be "somebody else's problem". We need to bring the patient back into the loop to control costs. We all pay in the end anyway.

The Doctor and Radiologist bill will be separate.

A Weeks Worth of Food

Universoul Productions has compiled a fascinating look at what one family from different countries eats during one week. Take a good look at the family size and diet of each country. I found this amazing. Starting at the top:
#1 - Chad, cost $1.23 U.S.
#2- Bhutan, cost $5.03 U.S.
#3- Ecuador, cost $31.55 U.S.
#4- Egypt, cost $68.53 U.S.
#5- Poland, cost $151.27 U.S.
#6- Mexico, cost $189.09 U.S.
#7- United States $341.98 U.S.
#8- Germany, $500.07 U.S.
#9- Italy, $260.11 U.S.

I think the photos and the cost of food speak for themselves. Which country has the best diet?

Fake Hymens For Non-Virginal Women

As a physician, I see a lot of strange things and meet lots of interesting people. I guess I shouldn't be surprised when the oppression of women in many countries across the globe has created a market for fake hymens for non-virginal women. Since virginity is valued above all else in many religions, it was only a matter of time when the artificial hymen would be manufactured and sold. Now with the internet, fathers and mothers in Sudan and Egypt and anywhere else, can order online for their little bride.

For $15-$29.00, a family can obtain a Chinese-made artificial hymen that might (?) fool a groom or at least the groom's family. The "hymen" is a 5X7cm folded piece of albumen covered on one side by dark red ink. Place in the vagina before sex, the plastic hardens slightly and rips upon intercourse. Voila! A few drops of "blood" and everyone is happy.

Why would a product like this be in demand? In Muslim countries a girl who is not a virgin will have hell to play after the wedding. Her husband can divorce her or the family can keep the dowry and disown her. It is such hypocrisy that 50% of the population can be discriminated against. There is no such obsession with the man's virginity.

The whole issue of a woman's virginity is a carry over from ancient times and religious texts. "Then the wedding night sheets were hung over the balconies in the morning, to let the rest of the world know how virginal the bride was, altho rumours of sheep's blood and substitutions have been heard." A visitor to Rome in the mid-20th century remarked on how virginity could be faked.

The "fake hymen" is just a modern day version of ancient misogyny. It goes along with the horrendous practice of marrying off pubescent girls to older men who want "virgins". I guess there is more success in finding a 12 year old virgin. Sick, sick, sick.

Blog Plagiarizing

I was just alerted by a fellow blogger (thanks, Yesmeen) that another site is stealing my posts and posting them as if it is their content. The blogs are completely posted, titles, graphics and all, on this other site that has health advertising also. There is no contact info so I cannot contact the blog administrator.

Blogging is a passion and a hobby for me and I spend a great deal of time researching the information I post to make sure it is accurate and as clearly written as possible. I also try to think of topics that are of interest to a wide variety of readers.

With permission, I allow my material to be re-printed at other credible sites because my goal is to educate and reach even more readers. Those sites attribute my blogs to EverythingHealth.

If anyone knows how to top this practice, I would be grateful to have information.

SSRI Withdrawal Syndrome

Karen is a 38 year old new mother (baby girl 8 months) who came to me with unusual symptoms that were of concern. She began having "episodes" of a buzzing, electrical feeling in her head and neck. It felt like a "shock" in her head. At times she would feel so dizzy and off balance that she had to pull over in the car or sit down. There was no headache but she felt some numb patches on her arms and legs. There was a vague depersonalization that accompanied the spells. It would happen for several days, then disappear for weeks and then come back. The "spells" lasted a few minutes to hours but seemed to be increasing over the past week.

When patients present with strange symptoms like this, a doctor has to start at the beginning with a detailed history. Any new medications? Any over the counter medications? Any drugs or alcohol? Any visual changes or blurry vision? The answer to all of these questions was no.

The work up progressed with blood tests looking for Vit B 12 deficiency, thyroid dysfunction, infection. When these returned normal and the symptoms persisted, more testing was needed.

Unusual symptoms like this in a young woman could be a sign of an autoimmune disease that affects the myelin sheath around nerves, such as Multiple sclerosis. In MS the episodes can wax and wane, just like Karen's did. She felt worse when it was hot and MS episodes can be triggered by heat. I was quite concerned that it could be MS, but we were reassured when an MRI of the head and spine returned normal.

Luckily, the symptoms disappeared again. Imagine my surprise two months later when the mystery was solved. Karen had been prescribed Zoloft, a SSRI medication for post-partum depression. She started on a low dose and when that didn't work, her OB doctor told her to increase it. Instead of getting a new prescription, she just doubled the dose and ran out of the drug after two weeks. She would fill the prescription the next month and run out again and again. She was starting and stopping an SSRI medication, getting no good effect, but triggering classic SSRI withdrawal syndrome each time she stopped.

Zoloft is a short acting SSRI. That means they are cleared from the body quickly when discontinued. If the dose is abruptly discontinued there is a rebound that blocks the neurotransmitter, Acetylcholine. It can also cause an excitability in the brain that is not well understood.

When Karen was asked if she was taking any new medication she honestly said "no" because she had stopped the Zoloft and didn't realize the importance of her "on and off" regimen. That one key clue would have solved the mysterious diagnosis months earlier.

When she started taking the proper dose of Zoloft continually, her depression lifted, her "shock waves" and dizziness resolved and it was a good lesson for both doctor and patient.

What Medical Condition Costs the Most?

What medical condition costs the U.S. Health system the most in disability and overall costs? If you said heart disease or cancer or pulmonary disease you would be wrong! I would have said one of those myself.

The answer...slow drumroll....is musculoskeletal disease. Yes, 50% of the adult population reported having a disabling musculoskeletal condition in 2008. The expenditures for these problems include the costs of preventive care, the cost of direct care, the cost of care in hospitals, by physicians, therapists and other caregivers. It also includes the loss of productivity. In 2004 it was estimated that the cost of care for musculoskeletal problems was $840 billion. (Hey, isn't that about equal to the bank bailout?)

What are musculoskeletal conditions? They include that old nemesis: Low back and neck pain. Spine problems are among the most common problems that bring patients for medical care. That's why the chiropractic industry is booming.

Another leading cause of disability is osteoarthritis, which affects almost 22% of all adults. Osteoarthritis leads to millions of Advil and Tylenol doses and often culminates with total joint replacement (hips and knees). With the influx of baby boomers, the increase in total joints will ensure orthopedic surgeons decades of future employment.

Osteoporosis (bone loss) is another disease of aging that causes hip, spine and humerus fractures in people older than 65. All of those Sally Field commercials for Boniva are aimed at consumers and the expense to diagnose and prevent bone loss adds to the overall cost of treatment.

About 60% of all injuries involve the musculoskeletal system and falls are the most common cause. The emergency department, doctors offices and hospitals all deal with patients with bone and muscle injuries. Patients that are admitted to a hospital spend an average of 5 days in the hospital. Ching, ching!

Despite these facts, the NIH research budget for musculoskeletal conditions has been decreasing with time and they are not in the top 10 conditions that receive funding. In addition, the proportion of orthopedic surgeons to the aging population is not keeping pace. We aren't training enough orthopedic surgeons to keep up with demand and the projected need for 2020 is woefully short.

With declining Medicare payments and rising malpractice insurance costs, physicians are shying away from specialties that take care of "old" people. Rheumatology, geriatrics, primary care and orthopedic surgery are all specialties that are going to be needed, but we have done no workforce planning as a nation to ensure there will be enough to care for the population.

Need Surgery, Travel Abroad

Medical Tourism has been a growing phenomena since the cost of health care is increasing by double digits each year in the United States. The Journal of American Medical Association (JAMA) reports that up to 750,000 U.S. patients have traveled to other Countries for surgery. Patients in other countries like Canada and the U.K. travel even more for surgery and medical care. Some health insurance companies will even pay you to travel because they reap the value of lower cost procedures for the insured. How much value? A patient who needs a spinal fusion would pay $90,000 in the U.S. compared to just $7,000 in Thailand.

Medical centers in Thailand, India, Singapore, Argentina, Costa Rica, Brazil, Mexico, Hong Kong, the Czech Republic and Hungary are popular worldwide destinations. Need a new dental bridge? It would cost you $5,500 in the U.S. but only $500 in India. A full facelift can be obtained in South Africa for $1,200 compared to $20,000 here.

Many of the surgeons in these centers were trained in the United States (Harvard, Johns Hopkins) and the Medical Centers are spa-like. The hospitals are accredited by a relative of the Joint Commission, the accrediting agency in the U.S. The price may also cover travel and hotel expenses for the patient and a companion. Medical Tourism or Global Health Care has been called "first- world health care at emerging-market prices".

The American College of Surgeons has acknowledged the changing landscape that Surgical Tourism brings. The ACS has issued a statement that offers tips for patients to consider before booking international surgery. The three main concerns are the possibility that the "informed consent" is not up to par with the U.S., the communication with the health care team may not be like the U.S. and the devices used and the procedures may not be up to U.S. standards.

Cover those bases and the gastric bypass for $6,000 in Costa Rica might look more attractive than paying $28,000 in the U.S. With the out of pocket expense for patients who have insurance, these prices can look attractive. For the 46 million U.S. citizens that are uninsured, a vacation coupled with a hip replacement (USA-$43K, Thailand-$10K) might be appealing.

Victorian Health

In the Victorian Era, a doctor could have a carriage trade of just a few wealthy women invalids that he visited every day. It was a status symbol for a wealthy gentleman to have a personal physician come to the house to minister to his wife. Now we know what kind of treatment was being offered!

Shameless Corporation of the Week Award

This weeks Shameless Corporation Award is shared by Horizon Blue Cross Blue Shield of New Jersey and the company it contracts with to manage claims, Magellan Health Services. Magellan is notorious for denying benefits to the Blue Cross patients. In this case, a young woman who was a victim of date rape was unable to receive mental health benefits even though she was insured. Magellan stopped paying for her mental health visits with a psychologist for no reason. They just said "no"and appeals were met with further denial.

Lois Gorwitz is a psychologist who worked for Magellan for two years as a claims reviewer and she said the culture and pressure from supervisors was to deny claims. Gorwitz said the company denied claims because they are in the business to make money. She quit because she was uncomfortable with the pressure to deny valid claims. Magellan is expecting 2009 profits of $210 million, exceeding predictions.

Horizon Blue Cross Blue Shield is the states largest insurer and they posted $5.5 Billion in sales last year. To see more about EverythingHealth's Shameless award recipient, and the college student who was denied benefits, watch this Vid.

Nurses, Lawsuits and H1N1

Only in the United States could a virus like H1N1 bring out the worst in medical politics and greed. We are facing a "pandemic" that requires coordination, communication and the best of medical practice. But what are we getting? Strikes, lawsuits and anything BUT putting patients first!

The strong nursing union, California Nurse Association (CNA), is taking this opportunity to call a strike on three large Catholic hospital chains (including 34 hospitals) throughout California and Nevada. The union bosses say the chief concerns are a lack of protective gear, improper isolation techniques and staffing that requires nurses to work (oh horrors!) 12 hour shifts during the flu crisis.

Although the nurses seem to want to walk out during a pandemic to "protect patients", the nurses in New York and Washington also filed a lawsuit over the idea that they should be required to get the flu vaccine. You can't have it both ways, nurses! You either want protection or you don't.

This is such an obvious smokescreen for contract negotiations, not H1N1 preparedness. Coincidentally, the CNA is in negotiations now with Catholic Healthcare West. How convenient! Since nurses in California already earn more than many physicians, this type of unprofessional bargaining rhetoric is nursing at it's worst!

By the way, most nurses in California hospitals work part time and receive full benefits. At a time when unemployment is at an all time high, nurses are receiving up to 6% pay raises due to union bargaining.

I respect nurses and believe in true collaboration for patient care, but as we prepare for flu season, this type of unprofessional, opportunistic behavior needs to be called out for what it is!

Copperhead Snake Bite

Ever wonder what a copperhead snake bite will do? This patient was bit on his finger 4 days prior. The venom causes local tissue destruction and a secondary infection can set in. Copperhead snake bites are usually not fatal but, as you can see, the damage can be extensive.

(hat tip to copperhead-snake.com)

Too Tired to Blog

Good News for Proton Pump Inhibitors (PPI)

Proton Pump Inhibitor drugs (PPIs) have been used since the 1980s to reduce gastric acid secretion and to treat ulcers and reflux. They are now among the most widely prescribed drugs world wide and Prilosec and others can be obtained over- the- counter. Any time drugs are used long term, we should be re-evaluating their safety. The good news for PPIs, is that they are safe for chronic use.

PPIs do their work on the parietal cells of the stomach. They bind at the "proton pump" and prevent secretion of acid into the stomach. The effect is prolonged (24-48 hours) and the drug is cleared by the liver with very little effect on the kidneys.

The side effects are few so these medications (Prilosec, Aciphex, Prevacid, Protonics) are often prescribed to hospitalized patients and for patients with GERD, gastritis and ulcers. Patients take these medications for years and there have been numerous studies that looked at potential long-term effects of PPI use.

The studies have shown that PPIs are highly effective drugs and they have revolutionized the management of acid-related disorders during the last 2 decades. When was the last time you heard of someone getting surgery for "ulcers"? That was a common treatment just 30 years ago.

Studies that looked at PPIs and their effect on Vit B12 absorption, iron loss, colon cancer, gastric cancer and calcium deficiency found no definite link. There may be an association in hospitalized patients who are on PPIs and the incidence of Clostridium difficile infection. No association was seen in non-hospitalized patients.

As with all medications, PPIs should be used for appropriate indications only as long as needed. If you or a friend have been taking PPIs for a long time, you may wish to talk with your doctor about a "drug holiday" to see if it is still needed. I review chronic medications with my patients at least every year with the goal of eliminating any that are not absolutely needed.

The Water Giver

EverythingHealth strongly recommends a wonderful new book called "The Water Giver" and I predict you will not be able to put it down. Author Joan Ryan is a remarkable writer who takes the reader on a journey she lived when her son, Ryan, sustained a near -fatal severe head and brain injury on a skateboard. It is both a medical drama and a meditation on motherhood.

The book begins with Joan's description of her son's learning difficulties and years of psychological and developmental testing. Her style as a mother was to intellectualize, do research and try to fix what was "wrong" with her son. The years went by with family stress and teachers conferences and medical consultations but it wasn't until the day he fell, that Joan realized some things are too big to be studied and fixed.

The nightmare began when he was 16 and went skateboarding without a helmet. The fall on a hill near their home caused a huge brain bleed that obliterated much of his brain tissue. He remained in a coma for weeks and underwent multiple surgeries to relieve pressure. The book chronicles months of near death events in the Intensive Care Unit that nearly drove his parents insane with worry. I will let you read it to find out how it turns out.

"The Water Giver" is more than a medical story and more than an account of a child's medical crisis. Joan Ryan used this harrowing time to look deep within herself and understand, finally, what her relationship with this remarkable child was all about. It was a time of sadness, fear and anger, but also a time of self-reflection. It was a time for Joan to realize that sometimes, the best you can do for someone you love is to be the water giver and sooth their thirst. Through Ryan's accident, she discovered what was at her core.

This book is interesting on so many levels. The medical story is riveting and each page is turned to find out what will happen next. It is also terrifying because we know how close each of our children can be to an accident that could change their lives forever.

But the wonder of "The Water Giver" is the deep emotion it evokes as we read about the personal transformation that Joan Ryan underwent when she experienced the most terrifying time of her life. And it is a transformation we can identify with and be thankful that she was brave enough to put it down in writing.

All You Need To Know About Scabies

While playing tennis last weekend, one of my partners whispered, "Hey you should blog about scabies. There is an epidemic going around." I don't know about a scabies epidemic, but catching scabies is common and it can crop up just about anywhere. People don't like to talk about parasite infections, so here is all you need to know.

Scabies are tiny borrowing skin mites with a scientific name of Sarcoptes scabiei. The little female mite burrows just beneath the skin and deposits eggs that mature in about 10 days. New mites hatch and spread to other areas of skin or other people. Symptoms appear 4-6 weeks after infection unless a person has had scabies before. Then the symptoms appear right away.

Scabies are contagious and spread through close physical contact in families, schools or nursing homes. The victim has severe itching, usually worse at night and sometimes you can see little burrow tracks or tiny blisters on the skin. The itching is not caused by the mite but is the body's allergic reaction to the mite. Any part of the body can be infected but they like to go toward the folds of skin...around the waist, wrists, between fingers, breasts, buttocks.

Scabies can be diagnosed by the physician looking under a microscope at small scrapings. Prescription topical creams and lotions eliminate the infestation but the itching can continue for several weeks. (Since it is an allergic reaction). Usually close family contacts are also treated even if they are not showing symptoms.

To prevent re-infestation all clothes and linen need to be washed and dried with high heat. The scabies mite can also be starved by putting items that can't be washed in a sealed plastic bag for a couple of weeks. Mites die if they are starved for a week. Fumigation of the living area is not needed.

Scabies can be dangerous and hard to treat in people that are immune suppressed. For others, the prescription lotions will kill the infection readily.

Shameless Corporation of the Week Award

This weeks Shameless Health Insurer Award goes to American Community Mutual Company. The saga of 17 year old Brianna Rice starts in the summer of 2008. Her dad lost his job as a business consultant and also lost his group insurance. Continuing coverage with COBRA was too expensive so they took out a new policy with American Community Mutual in Illinois. Because the 17 year old was healthy, the monthly premium was only $130.00

In February, 2009, Brianna was diagnosed with celiac disease. On May 12 the insurance company rescinded her insurance and said it was a pre-existing condition and they would not cover any of the doctor or lab bills. Doctor visits from the distant past had mentioned dizziness, high cholesterol (a lab error), fatigue and a cough. They attributed those mentions to celiac disease and said they would not pay for treatment. A physical exam performed on July 2, 2008 showed no major health concerns.

Celiac disease is a digestive disorder and is treatable by eliminating wheat products from the diet. It does not cause cough, dizziness or high cholesterol. Some patients do experience fatigue.

If insurance companies can collect premiums and then cancel a policy when a patient gets sick, the insurance is virtually worthless. Brianna's father has called several other insurers in Illinois but they will not insure her based on the February diagnosis. She qualifies for the Illinois Comprehensive Health Insurance Plan (CHIP) which is designed to help people who cannot get insurance through the conventional market. The average premium is $7,666 to a high of $16,000.

Congratulations to American Community Mutual Insurance for winning this weeks "Shameless Corporation Award."

How to Make Health Reform Work

It is still uncertain what we will get from the Congress and Senate for Health Care Reform this year but I see some major problems with the bill as it is currently being discussed. They say something is better than nothing but I am not so sure. Politics, partisanship, big money and industry influence are all playing a role that is not good for the American public.

Here are the problems with the current legislation that must be fixed if we are to win:

• It still leaves 25 million Americans uninsured. 100% coverage is a must and if other countries can do it, so can we.
• Insurers are allowed to charge older customers 5X more than younger. If you are in your 50s you may pay $10,000/year. Is that affordable for anyone?
• Insurers can maintain any profit margin they want. $6.5 billion in "insurance fees" (to help make it financially palatable) will be passed on to consumers in higher rates.
• There are no cost controls on what insurers can charge.
• There are no restrictions on denial of care.
• There is no challenge on monopolies (In some areas there are only 1 or 2 insurers).
• There are no controls on drug prices and no government leverage to negotiate rates.
• There is no definition of covered benefits.
• Most of the reforms don't even start until 2013!
• Medicare rates are below inflation and there is a 25% Medicare cut in physician fees.
• There is nothing to benefit primary care and nothing about coordinated care.
  
• There is no change in the flawed Medicare Sustainable Growth Rate (SGR) formula which is totally unworkable with cuts every year that get "reversed" by congress after physicians and AARP go wild.
• There is no public option.
• There is no liability reform.

So what do we have? The plan is a corporate welfare boon for Insurance companies (instant customers, high prices) and big Pharma (instant customers, high prices). Most of the pieces that would benefit the public are delayed for 4 years. There is nothing to control rising costs and, in fact, costs will skyrocket without changes in how we pay doctors and hospitals. It continues to pay for "more" care, rather than coordinated care. It continues to pay for getting sick rather than staying well.

EverythingHealth supports true Health Care Reform. We deserve a better bill.

Where Would A Doctor Like to Practice?

Medscape has a physician portal and they asked the question: "Where would you like to practice medicine?" The responses from physicians were varied with lots of complaining and joking like "Dubai", but this reply from a family medicine doctor got my attention. I think he speaks for many physicians.

• I would like to work in a fantasy world.


• One where I didn't have to worry about someones economic status.


• Where I could diagnosis and treat and feel confident the patient would actually follow my advice. Where their education level allowed them to be able to read a Rx bottle. And remotely comprehend what I take so long to explain, over and over to them.


• Where we worked to benefit people as best we could, while not being burnt out or abused.


• Where we didn't have to work for a life time to pay off overwhelming school debts.


• Where 3rd party payers, in business to make a profit not provide health care, were a myth.


• Where the legal profession spent time trying to help people, and not as leeches on society, sucking cash out of patient care at any opportunity, often creating the opportunities themselves.


• Where I had the chance to continuously learn rather then spend endless days of clinic drone drudgery. Education limited to reading after a bone weary long day, or compressed into 1 week a year.


• Where all my fellow physicians, worked together for the common good, patients and ours. Advancing medical care, rather than focus on their niche or profits.


• Finally a land where what I did was appreciated. Where my days were not spent in an adversarial relationship with just about everyone, in my struggles to make a difference in a world that just doesn't seem to care if the difference is made or not.

Signs of Ovarian Cancer

Ovarian cancer has the worst prognosis of all gynecological cancers and it accounts for 4% of all cancers in women. Ovarian cancer has been called the "silent killer" because it was thought to have few symptoms and it is difficult to diagnosis in early stages. There are no good screening tests for ovarian cancer, including Ca125. The Ca125 test is not recommended as a screen for ovarian cancer and is mainly used to look for recurrence in previously treated cancer.

Several recent studies have shown that we were wrong to think ovarian cancer is "silent". There are seven symptoms that have been found to be associated with ovarian cancer and they are often overlooked by physicians and patients. Since only 30% of women are diagnosed in early stage of cancer, these symptoms, especially in combination, can be a clue.

• Abdominal distension (an increase in abdominal girth)
  
• Abdominal pain
• Increased urinary frequency
• Loss of appetite
• Postmenopausal bleeding
• Abdominal bloating
• Rectal bleeding

The symptoms can be caused by a number of things and are not specific to ovarian cancer. But any woman with a combination of these symptoms should at least be considered for further work-up and diagnosis.

Rules for Eating Well

After reading about the "10 Most Dangerous Foods" (sloppy journalism) and the E. coli hamburger gross-out, it is refreshing to read some simple tips from my food hero, Michael Pollen. Michael's readers sent in rules for eating well and some were quite thought provoking. Check it out, but here are EverythingHealth's faves:

• If you are not hungry enough to eat an apple, then you are not hungry
• Avoid snack foods with the "OH" sounds: Doritos, Fritos, cheetos, Tostitos, Ho Hos, etc
• It's better to pay the grocer than the doctor
• Never eat something that is pretending to be something else; fake meat, fake butter, low fat sour cream, chocolate-flavor sauce
• Make and take your own lunch to work

Do you have any rules for eating well ?

Laxative Abuse and The Colon

The New England Journal of Medicine showed this appearance of the inside walls of a colon found on colonoscopy. The answer to the image challenge, of course, is laxative use. (click on the photo to see up close). The 2nd image shows the appearance of a normal colon. Note the pink skin and the normal folds which are quite different in appearance than the first image.

Laxative abuse causes a condition called Melanosis coli. It causes a dark brown pigmentation that occurs with laxatives containing anthraquinone, such as senna. After a few months of use it is seen and it will disappear when the laxative is discontinued.

Laxatives should only be used for short periods of time. Chronic constipation is a problem for many people. After a visit to the doctor to rule out motility disorder, thyroid disorder or other medical problems, most constipation can be resolved with increased fiber, fluids and exercise. Abdominal massage and relaxation techniques also help to restore good bowel health.

Colonics are never needed for the bowel, which does not build up "toxins" nor are powerful enemas needed for good health.

Health Email Scams

The people who send fraudulent scams and viruses are sinking to a new low. I got a message today on my email network that has super firewalls. Despite that, the email from Mrs. Lauren Smith arrived and was titled "Please Read Carefully".
The message, directed to Dr. Brayer, caught my attention. It read:

"Hi,
My name is Mrs. Lauren Smith, a 66 year old lady, and I have been diagnosed with lung cancer and the doctor said that it is a disease of uncontrolled cell growth in tissues of the lung. This growth has lead to the invasion of adjacent tissue and infiltration beyond my lungs. The doctor has told me that I would not last for long due to my condition. Having to know my present condition, I have willed and given most of my property and assets to my immediate and extended family members as well as a few close friends.

I have now decided to give away my personal jewelry box for a non profit cause. I was a collector of gold jewelry for the past 30 years. I am willing to give this to a non profit group. Let me know how this would benefit your cause.

Best Regards,
Lauren Smith"

I suppose had I clicked on the attachment or hit reply I would have crashed my computer or infected a virus.

Another email also arrived from a Dr. Jennifer Allen and this one wanted to donate veterinary equipment (1 ultrasound and 1 autoclave) to "my work".

Can't wait to see what kind of wacky emails I get tomorrow.

A good site that talks about email scams is here.

Shameless Corporation of the Week Award

This weeks Shameless Health Care Corporation is Cigna. This story involves two identical twin girls who developed cancer at age 4. They were treated with total body radiation and chemotherapy which damaged the hypothalamus and pituitary gland. Those glands are responsible for growth and their endocrinologists determined that they needed growth hormone at age 7 when the damage was evident. Growth hormone is only needed until the bone endplates have developed.

During this time, their dad's employer switched insurance carriers from Aetna to Cigna. Cigna did a medical review and determined that the girls simply had "idiopathic short stature" and did not need growth hormone. Despite letters and "peer to peer" consults with their endocrine specialists, Cigna would not budge and refused to pay for the drug they were receiving.

According to the girls mother, the proactive physicians are very used to dealing with insurance companies and managed to get the drugs free from the manufacturer as a "bridge" because stopping growth hormone stops growth.

Cigna even denied that there was a 2nd twin and they have denied that the parents have appealed the decision.

Cigna certainly wins our award this week for its reckless, shameless behavior as a health insurance company.

Shocking- Ground Beef is Not Safe

It takes a lot to shock me, but the article in today's New York Times about E. coli in ground beef is truly eye opening. I want you to read the entire article but here are some scary highlights and facts that show our meat sources are not safe for consumption:

• A single portion of hamburger meat bought at most supermarkets is not from meat run through a grinder. It is an amalgam of various grades of meat from different parts of many cows and even from different slaughterhouses.
• There is no federal requirement for grinders to test their ingredients for E. coli pathogen.
• Hamburger meat might be labeled "Angus Beef" but it can be made up of low grade ingredients cut from areas of the cow that have contact with feces, which carries E. coli.
• Many big slaughterhouses will only sell to grinders who agree not to test their shipments for E. coli because they fear that discovery will set off a recall of ingredients they sold to others.
• Meat grinders buy trimmings of fatty edges sliced from better cuts of meat and mix them with other fatty meat products that have been centrifuged and treated with ammonia to kill E. coli. One company, Beef Products Inc, produces seven million pounds a week that is sold to grocers and fast-food restaurants and served in the federal school lunch programs.
• The Agriculture Department regulations allow hamburger meat labeled ground chuck or ground sirloin to contain trimmings from those parts of the cow.
• Bacterial testing of ground beef is not required because the industry says the cost would unfairly burden small producers.
• Costco tests trimmings for E. coli before grinding.
• E. coli gastroenteritis is usually a mild disease. Five to 10% can be serious and cause hemolytic uremic syndrome and kidney failure.
• There is no question that the U.S.D.A. does not protect consumers from contaminated meat.
• Hamburger meat is not safe unless you have a butcher grind up a full cut of beef.

I will not be buying hamburger meat ever again. I just threw out some frozen meat from my freezer. The article disgusted me and the description of the slaughterhouses reads like the turn of the century book, The Jungle, by Upton Sinclair , which eventually led to the Meat Inspection Act.

We have learned that we cannot count on the government to protect our finances and we should not count on the government to protect our food. It is up to each of us to learn about and support safe, small organic farming, eating from food sources that are close to home and certainly avoiding ground meat that comes from the grocer.

Super Glue Eyelid

This little girl accidentally got Super Glue onto her eyelid. She came to the doctor without pain and she was able to move the eyeball under the lid but could not open it.

Her doctor in Decatur, Ala gently irrigated the eye area with normal saline and applied antibiotic ointment and a gauze patch over the eye area but the lid remained stuck together. The next day he was able to gently pull the lid open.

If you should ever glue parts of your body together with Super Glue (cyanoacrylate), the treatment is easy. Acetone, the ingredient found in nail polish remover will dissolve Super Glue. A Q-tip with acetone, gently applied to the area, will dissolve the bond without damaging the skin. Don't pull the skin apart, but gently roll or peel it.

If Super Glue gets in the eyeball, the eye protein will disassociate from it over time. A warm sodium bicarbonate solution eyewash will help remove the adhesive.

Photo/story credit: Consultant

In the Patient's Interest

I spent the entire day in meetings today. One would think that is a boring or unproductive way for a physician to spend time, however these meetings made me proud to be a doctor and proud of my colleagues in medicine.

The morning was spent with nurses, respiratory therapists and quality experts who came together to celebrate success with patient safety and quality initiatives that have saved at least 151 patient lives. These caregivers from a number of different hospitals, have worked together for 3 years on on reducing deep venous thrombosis, ventilator acquired pneumonia, skin ulcers and sepsis.

Medicine is a team sport and it is only when the team is humming and everyone is working together that patients can have good outcomes. Hospital errors, medication errors, poor communication between doctors and nurses are prevented by adherence to protocols that everyone follows. It takes laser focus, measuring outcomes and a great deal of hard work to ensure everyone is pulling together in a hospital. The fact that these bedside nurses take the time to work on error reduction and patient safety is really amazing. Have you seen how hard nurses work? My hat is off to these dedicated care-givers.

Tonight I met with physician leaders who are spending their precious "after work" time to discuss how to improve patient care in their communities. We discussed how to seamlessly transfer patients from one hospital to another and how to make sure physicians get continuing medical education to keep their skills on the cutting edge.

We talked about the decline in primary care physicians in most communities and how to help them survive in hostile practice environments when it seems none of the "health care reform" ideas will address the shortage.

While health care reform is being discussed in Washington, doctors and nurses are quietly going about their business providing the best health care we can. I am proud to be associated with these care-givers who are spending enormous amounts of time and energy to improve the system and make the patient the first concern.

Shameless Corporation of the Week Award

Each week EverythingHealth will bestow its "Shameless Corporation of the Week Award" to a deserving health insurance company. Somehow I do not think it will be hard to find a recipient each week.

Today's award goes to: Blue Shield of California HMO.

When Rosalinda Miran-Ramirez awoke with bleeding from her left breast nipple she awakened her husband and had him drive her to the local emergency department. The doctors found a tumor that they thought was breast cancer but a biopsy later proved it to be benign.

Blue Shield denied the emergency room visit and she received the total charge from the emergency visit: $2791.00. Blue Shield reviewed the case and determined that Miran-Ramirez "reasonably should have known that an emergency did not exist." When she appealed, she was denied again and told she was not in "any acute distress."

The Shameless Award for this week goes to Blue Shield of California. Since when isn't a blood soaked shirt and a bleeding breast cause for insurance coverage?

Fertility Clinic Mistake Ends Up Good

It made me feel good to read that a mistake by a fertility clinic in Michigan ended with a happy ending. The biologic parents created an in-vitro embryo that was accidentally implanted into another woman at the clinic. A few days later the clinic notified Carolyn Savage that she was carrying Paul and Shannon Morell's embryo. She never considered terminating the pregnancy or trying to fight for custody.

A 5lb 3oz healthy baby boy was born Thursday to Carolyn Savave and the Morells now have a new baby. They call Carolyn Savage their "guardian angel." This is how you turn a lemon into lemonade. If we can keep the lawyers away...this is an example how how to go with the flow and live life to the fullest.

Congratulations to to very cool families.

Spanking Linked to Lower I.Q.

A new study funded by the National Institute of Mental Health has found that children who are spanked end up with a lower I.Q. than children who are not spanked. The researchers looked at 32 nations (including the U.S.) that used corporal punishment and compared the I.Q. between children.

They found that the children who were spanked the most fell behind I.Q. development scores. But even children who were spanked a "little" were behind those who did not receive corporal punishment.

"The longitudinal part of our study showed that children who were spanked the most fell behind the average IQ development curve, and those who were never spanked advanced ahead of the average", said Dr. Murray Straus, study lead.

The IQs of children aged 2 to 4 years who were not spanked were 5 points higher 4 years later than the IQs of those who were spanked. The IQs of children aged 5 to 9 years who were not spanked were 2.8 points higher 4 years later than the IQs of children the same age who were spanked.

The analysis showed a lower national average IQ in nations where spanking was more prevalent. Dr. Straus said that the strongest link between corporal punishment and IQ was for those whose parents continued to use corporal punishment even when subjects were teenagers.

Spanking is stressful for a child and frequent spanking leads to chronic stress and even post-traumatic stress syndrome. These symptoms can lead to lower I.Q. Is it a cause-effect relationship? No-one knows for sure, but health educators have shown the ineffectiveness of corporal punishment before, so educating parents in positive and non-punitive forms of behavior modification look like the answer.