Sunday, November 22, 2009

Mammograms and USPSTF

Recently, the U.S. Preventive Services Task Force (USPSTF) announced that mammograms should start at age 50 and be every 2 years after that. The American College of Obstetricians and Gynecologists (ACOG) had recommendations for yearly mammograms starting at age 40. ACOG posted their response to the USPSTF recommendations. Some people have talked about the USPSTF being the death panel. I disagree.

USPSTF is a government organization that has been around since 1984. In the past 25 years, they've only issued 126 recommendations. They are extremely conservative in that only strongly proven prevention services would be recommended. They have always been that way. Doctors understand that they must do what the USPSTF recommends AND MORE! The guidelines from USPSTF are just the minimum prevention services a doctor should provide. Most doctors provide much more than what they recommend.

Most professional doctor organizations have their own set of recommendations irrespective of the USPSTF. Most doctors follow their professional organization's recommendations, because that is considered the "standard of care." The "standard of care" is what a doctor faces in court, if there is ever a lawsuit. If every doctor in your county checks the PSA (prostate specific antigen - a prostate cancer test) at age 50, then that is considered the standard of care. However, the USPSTF has always recommended against checking the PSA because it has never been shown to improve lifespan. Doctors do not always follow the USPSTF guidelines.

Another example is the Pap smear. The USPSTF says that Pap smear should start at age 21 and be done every three years. The common practice for many physicians is to start Pap smears when sexual activity starts and continue yearly. I have even heard of one physician that insists on checking every six months. I do not think that physician is practicing the standard of care. Similarly, a physician who checks only every three years for a woman in her 20's is not practicing the standard of care. ACOG recently (this month) issued a recommendation similar to the USPSTF. We'll see how quickly these new guidelines are adopted by the general medical community. I wouldn't be surprised if my gynecologist insists seeing me again this year even though everything was normal last year.

The thing is, doing too many Pap smears and PSA tests result in too many follow up procedures and too many worried patients for no good reason. Most abnormal pap smears will go away within a year. The HPV infection that caused the abnormal pap is usually killed off by the body's own immune system. It is extremely rare that a temporarily abnormal pap smear will eventually result in cervical cancer. Yet, if there are certain changes found on a Pap, we would do a colposcopy, which is a biopsy. And if the biopsy shows more HPV infection and cell changes, then we'll cut off part of the cervix or freeze it off. That can result in scarring that causes a cervix unable to hold in a baby (so it has to be sewn together during pregnancy and mother placed on extended bedrest) or a cervix that cannot deliver a baby (requiring a C-section). We are likely causing more treatments and complications than necessary currently.

As for PSA testing, I generally recommend against it unless the patient insists or believes that it is the right thing to do. If it's positive, then a biopsy may be necessary. Approximately 70% of 70 year old men have prostate cancer cells somewhere in their prostate. So they come back with a diagnosis of prostate cancer and then require surgery, radioactive beads, or some other treatment. The complications from the prostate cancer treatments are extremely unpleasant. Because of the location, some will end up with urinary incontinence. And some men end up having to learn self-catheterization, where they stick in the tube a few times a day to empty their bladder. Some will have rectal problems. Most 70 year old men die of heart disease, stroke, or some other cancer, not prostate cancer. Most prostate cancers are extremely slow growing and do not cause any problems. They do not need always require treatment.

Some of the commonly accepted preventive services look for problems too early. That results in worse health care because we end up doing too many further tests, interventions, and procedures that cause complications. So yes, some preventive services cause more problems than they prevent.

Looking at countries that have better healthcare outcomes than ours, one will see that their standard of care is more similar to the USPSTF than the professional doctor's associations. USPSTF looks at cost benefit ratios and overall outcomes of doing screening tests. The professional doctor's associations may care a bit more about making their doctors more money.

Go back to the mammogram recommendation. Canada and the UK start pap smears and mammograms later and more infrequently. They have better overall outcomes than us. If we change our practices with mammograms and pap smears, we may achieve better outcomes. There is nothing "death panel" about worrying less and having better overall outcomes.

Sunday, September 20, 2009

Insomnia Explained

Here is one of my favorite topics: SLEEP. It's what I would like right now and what most people spend a third of their time doing. This post is about insomnia.

People with insomnia often say that they dread bedtime. They hate trying to go to sleep. They know it will be one more night of staring at the clock, thinking about how they have to be upright and working again in 5 hours, 4 hours, 3 hours.... It’s a huge struggle trying to concentrate and not yawn through the next day. And yet, they are so tired and irritated! It’s just that when they lay down to sleep, the brain begins to wake up and the body is wracked with anxiety and exhaustion at the same time. It’s an extremely frustrating experience for anyone who has gone through it.

Over-the-Counter Medications

If the insomniac comes in to see me, then they’ve tried Tylenol PM, Unisom, Simply Sleep, and other over the counter sleeping pills. Hint: Generic Benedryl is probably the cheapest option – they are all made from the same active ingredient, diphenhydramine. Benedryl is known to cause hangover effects and a dry mouth. It often dulls a person the next day, so it is not ideal. Plus, some people have a paradoxical reaction to Benedryl, making them more hyper and unable to sleep. Those people can sometimes have a similar reaction to alcohol. Instead of being slightly sedated like most people who drink alcohol, they become more agitated and excitable. If it works well though, it’s a fine option, and relatively safe, even when used frequently. It says to not use it long-term on the package because sometimes insomnia is caused by or related to other medical problems, so you should see the doctor if you have chronic insomnia.

Some insomniacs have tried the more “natural” melatonin, valerian root, chamomile tea, or warm milk. The problem with herbals is that it is not controlled by the FDA, so there is no guarantee that you are getting what you are buying. The dosage may vary greatly from one pill to the next so the results are inconsistent. Certainly herbal tea and milk can be calming, so it’s worth a try. However, if you are allergic to ragweed, you should avoid chamomile, which is a relative of ragweed. I recommend trying melatonin products to travelers with frequent jet-lag. But for the insomniac, melatonin usually doesn’t work well enough.

Other Problems Caused by Insomnia

Insomnia is dangerous when it makes someone so tired they start falling asleep at the wheel. It also makes people gain weight because the hormones produced during sleep suppress appetite. Plus, the body makes more steroid hormones during the day to keep a tired body awake, and that increases appetite. The steroid hormones can cause metabolic syndrome, making insulin and blood sugars chronically high, leading to diabetes. It is extremely important to get enough sleep for many reasons, but for insomniacs, sleep just seems impossible.

Hope for Insomniacs

When I see a patient suffering from insomnia, I have a few tricks up my sleeves. First, there is the ever-powerful placebo effect. No, I’m not kidding. I tell them that there is hope and that there are many treatments out there that can help. There is one treatment that is bound to work. So there’s no reason to give up hope. Most treatments are quite safe, non-addictive, and effective. Some treatments can be used in combination with each other. Once the insomnia is treated and sleep is finally stabilized, we can wean off any pills. Confidence in being able to fall asleep again is critical for stopping insomnia. The insomniac views the bedroom as a bad place, wrought with frustrations. Just thinking about sleep is anxiety-provoking. Once the bedroom is a friendly inviting place for rest again, insomnia can be cured.

The sleep hygiene rules are a set of guidelines that help with mild sleeping problems. The most important thing is to maintain a regular sleep schedule. Do not eat a dinner that causes heartburn. Avoid exercising or caffeine after dinner. Keep the bedroom cool, dark, and quiet, which means no TV. Avoid long naps during the day. These are great guidelines to help people sleep well in general. However, the tired insomniac may not be able to fight insomnia with those tools alone.

Detailed Guide to Fighting Insomnia

I recommend the following:

1) Decide on a time to wake up in the morning. Let’s say 7am for this example.

2) Count back 10 hours. That would be 9pm.

3) At 9pm, one should not exercise anymore. Do not eat any meals beyond this point. Do not do anything exciting. Taking a relaxing stroll, a candlelight bath, or reading a book would be good activities for this time.

4) At 10pm, one should prepare for going to bed. So changing into sleeping clothes, brushing, flossing, defrosting the next days dinner, preparing the next day’s lunch, or packing one’s bags for the next day are good activities. Making a to do list or a shopping list is okay too, but not if it’s too anxiety-provoking.

5) At 11pm, settle down to sleep. Set the alarm clock, put on SleepPhones, and listen to your favorite sleep track. If you just want nature sounds, we offer those on our CD, Full Night Player, and on free download. Take 10 deep breaths, counting 4 seconds each for the inhale, the exhale, and the time between breaths. If you prefer to be guided into sleep, I recommend self-hypnosis tracks, such as those offered by Dr. Steven Gurgevich.

6) Wake up at the time that you should wake up and open the curtains or turn on the lights to get some morning light. Having exposure to some light upon awakening is helpful to train your brain. Whether or not you drink any caffeine in the morning is up to you. I do not recommend any more than 1-2 small cups of coffee a day. 3-4 cups of a light tea is fine. Red Bull, Monster, and other such “energy” drinks are strongly discouraged. They contain excessive caffeine and sugar.

7) Stay active during the day, taking the stairs instead of the elevator. Take a short walk during lunch hour. Try to walk 10,000 steps a day. If you do that, there is no need to spend money on a gym membership.

8) Eat at least 3 times a day. Healthy snacks between healthy meals is fine. Eat slowly, savoring each bite, and relax.

9) One alcoholic drink a day is fine, but no more than that. Studies show that drinking more than two drinks a day causes more sleep disruptions.

10) Around 9pm, begin to relax again.

After trying the above method for 3 days, if it is starting to work, then continue. If it has not helped at all, then start a prescription sleeping pill and change the sleep track. Take the prescription sleeping pill about 15 minutes before going to bed. Continue to use the SleepPhones. That way, weaning off of the sleeping pills will be easier if you are already in the habit of falling asleep with your favorite SleepPhones sleep track. If you travel a lot, be sure to bring your SleepPhones along! SleepPhones can be like a security blanket sometimes because it’s soft and relaxing.

Prescription Sleeping Medicines

As for prescription sleeping pills, there is a wide variety of them. The main ones are in these categories.
1) Sedative-hypotics (the Z-drugs) – Ambien, Sonata, Lunesta
2) Anxiolytics (benzodiazepines) – Xanax, Valium, Klonopin, Ativan
3) Antidepressants – Trazadone, Elavil
4) Synthetic melatonin – Rozerem

The anxiolytics are the classic sleeping pills, with the bad reputation of being addictive. They work well, but I prefer to start with the Z-drugs. These are the newer sleeping pills with the main effect of bringing on sleep. They are not physically addictive, so the dosing would never need to be increased. Stopping them abruptly would not cause physical withdrawl problems. Ambien is the oldest of the group and is well known for its effectiveness. These Z-drugs work for most people, but sometimes, one works better than another, so it is worth trying another Z-drug if the first one didn’t work. The biggest side effect I watch for is sleep walking. I never prescribe it to a sleep walker, since it makes the problem worse. Only one person has ever complained of eating more in the middle of the night to me, and it was not exactly sleep eating. None of my patients have had sleep driving. A sleep walker is at increased risk for sleep eating (binging on random things, including inedible objects like paper plates smothered in ketschup) or sleep driving, which is obviously very bad. Other that that, the Z-drugs are quite effective and safe for insomnia. The biggest drawback for most people is the cost. They are at least a few dollar a pill, so a month of pills cost far more than SleepPhones.

The anxiolytics are good medications for calming people down. They are addictive though, especially when used inappropriately. Short-term use or steady long-term use are possibilities as long as the dosing does not need to be continually increased. Because they are scheduled substances, the drug enforcement administration watches the doctors writing these prescriptions with severe penalties for over-prescribing, so some doctors are very reluctant to prescribe these.

The antidepressants Trazadone and Elavil are probably more effective for sleep than they are for depression. They are very old medications and therefore very cheap. The main drawback is a dry mouth, potential for hangovers, and drug interactions. They are safe for long-term use and are not addictive. But one should taper off of them rather than stopping abruptly.

Rozerem is completely not addictive. It is a synthetic melatonin that is supposed to work only on the brain’s melatonin receptors controlling sleep. It is still a relatively new drug, with unknown long-term effects and very expensive. It works for some people and not for others. The effectiveness is not as consistent as with the Z-drugs in my experience. I would like to see a few more years of experience with this medication before prescribing it more regularly.

A Holistic Approach

There are many things that can impact sleep. Sometimes it is work or school stressors. Going through a divorce is one of the most stressful events in a person’s life. Even marriage, moving, or starting a new job can be extremely stressful. Recognizing the stress that started the insomnia can be helpful. Sometimes the fear of a bad night or anxiety associated with trying to sleep can perpetuate the insomnia beyond the stressor. For example, staying up late studying for a big exam then worrying about the results afterward can start an episode of insomnia. But then the lack of sleep and messy sleep schedule spiral out of control, leading to prolonged insomnia, long after the exam is over. Looking within and figuring out what started the insomnia and what’s causing it to perpetuate helps one understand the disease. Sometimes one can prioritize a fix to the stressor if one recognizes its full impact.

Medical Problems

Some medical diseases can cause or worsen insomnia. These problems are often intertwined. Mental illnesses such as depression and anxiety frequently disturb sleep. Even diabetes, allergies, arthritis, heart disease, or high blood pressure can affect sleep. In fact, most medical problems affect sleep, which is why older people tend to sleep poorly due to accumulating medical conditions. If allergies are causing lots of snoring or coughing at night, then treating it may be more beneficial than not. If pain from arthritis is preventing sleep, then taking some plain Tylenol at night might help. Getting a good night sleep is so important to feeling good the next day and preventing other illnesses that it may be worth treating an otherwise minor problem.

Seeing the Doctor

This article is to help you understand more about sleep from my perspective. It is not intended to diagnose, treat, or advise you about your own medical situation. Please consult your doctor for your insomnia.

There are many treatment options for insomnia. Some will work better than others, and lifestyle changes can always be used in conjunction with medications or SleepPhones. It may take some time, but you can fight insomnia with the help of your doctor!

Disclaimer: I am one of the owners of SleepPhones. I am friends with Dr. Steven Gurgevich.

Swine flu season

There are over 40,000 students at our University. There are 4 teams of clinicians taking care of these students. Next week, our team of 6 primary care clinicians will be in charge of seeing as many feverish students as we can. It will be interesting how many have H1N1. Meanwhile, we have all been working at least 1 more hour than usual every day for the past 2 weeks.

Friday, September 4, 2009

Behind the Scenes of an Insurance Denial

I have a college student with a half year of abdominal pains in the liver area. It's an annoying condition and occasionally prevents him from going out with his friends. It is getting worse and it's becoming more and more pronounced, but still not debilitating. He's very worried about it, thinking it might be cancer or something. I'm less worried, but I can't come up with a plausible explanation for his pain. We checked the routine abdominal related blood work and everything is normal. We checked the urine, and that's fine. We ruled out hernias, and his pain is too high for that anyway. His liver ultrasound came back normal, and I can't find anything wrong on exam. Still, his pain is worsening. He's not the type to see the doctor when he gets sick, so I know that when he comes in to see me for a second visit, something's wrong. So now, I'm more worried about a growth of some sort in his abdomen. I order a CT scan to get a better look and make sure we're not missing something.

I know that his insurance company will need a good reason to pay for the CT scan. The only reason I can give is increasing abdominal pain over a period of months. He's not throwing up, having bloody diarrhea, or losing weight. If he had any of those, I would have put that down as a diagnosis in an instant, because I know they would pay for a CT then. But I couldn't lie on the referral for a CT scan, so I wrote down increasing pain. They denied it, predictably. My referral receptionist spent about 20 minutes on the phone initially to call the insurance company to speak to someone. Then because the simple diagnosis didn't trigger the right buttons, the insurance company clerk asked my referral receptionist for more reasons. She came to find me, had to wait for me to finish with a patient, and ask me for more justifications. I'm a terrible liar, so I didn't lie. My receptionist then went back to the phone to finish talking to the insurance company clerk who said that she would ask the medical director for the approval. My receptionist has now spent 40 minutes of her time working on this referral.

A few days later, both the student and I get a denial letter in the mail. I also get the same letter by fax. It says that I can appeal the decision. I would just have to call the 1-800 number. When I call, I am on hold for about 10 minutes to talk to the insurance company's medical director. (I can't call after work hours because they only work from 9-5, so I have to run late for an appointment to wait on hold.) The medical director asks me why we need a CT scan. I tell him that the ultrasound and blood tests are negative, but the patient continues to have pain, so I want to do more testing. The medical director then tells me that since the previous testing was normal, we probably don't need a CT scan. He said that the patients symptoms did not justify a CT scan. I tell him more about the patient. He says that he can't give medical advice but that he can't authorize the CT.

By denying requests, the insurance company saves a lot of money. It costs them perhaps 30 minutes of administrative time to deny one request, which might save them a $1000 CT scan. The insurance company pays a secretary and a doctor to do that denial, spending about $300. Hey, they just made $700 with one denial! Hire more denial specialists!

The patient came in today to ask about his denial letter. It took my receptionist about 5 minutes to explain the situation to the patient and another 5 minutes to come tell me about it. I've spent 30 minutes on this problem, and my receptionist has spent 40 minutes on this problem. That's a cost of at least $300 for our office, which our patients have to pay for.

Meanwhile, the patient won't be getting a CT scan. I hate to leave him hanging, since I can't figure out what's wrong with him. So my only other option is to refer him to see a gastroenterologist. I'm pretty sure that's a waste of time and money because he'll see the physician's assistant at the GI doctor's office who won't have any better ideas than I do. The insurance company will then pay for the GI doctor ($500) to repeat my blood tests ($300) and a likely endoscopy ($1000) when a simple CT scan would have answered all of everyone's anxieties. But perhaps the insurance company will try to deny payment for some of those services too. I'm still not sure what to do next with him.

In all of my dealings with Medicare (a government-run plan), they have never denied a test. I've never had to talk to a Medicare denial specialist because they don't exist. I know that if I order a test, it will be covered. There is no waste in this denial nonsense.

I get so frustrated with the amount of insurance paperwork. In private practice, it added an hour to my day. A full hour of frustration: changing medications to suit a new formulary, filling out the form for a 3 month supply of medications, justifying why a prescription medication is needed over an over-the-counter type, and dealing with denials. It's fraud if I stretch the truth so something would be covered. I want to help my patients as much as possible, but I don't want to be accused of fraud either. It's a difficult position for me, and I hate being caught in the middle of it.

Thursday, August 27, 2009

FAQ Novel H1N1 (Swine) Flu

School is back in session, and the weather will soon get colder. The perfect conditions for a flu outbreak are arriving. We're still a few months away from a vaccine (late October for high risk groups). What can we expect with the Swine flu?

Since it has spread mostly in school age children and young adults, it's going to cause a lot of disruption. That's the main reason the public health community is making such a big deal about it. Students will be absent, teachers will be sick, and the work force will be home taking care of sick people. It's an economic concern for the country. It is far less deadly than the typical seasonal flu. The only thing unusual about it is that it's hitting an atypical age group. But the characteristic of impacting young adults is typical of pandemic flu. We've actually been waiting for a flu pandemic for a while now. From a historical perspective, we're overdue. But compared to previous pandemics, this one has been far less deadly.

Frequently Asked Questions

1) How do you recognize the flu?
I've seen a handful of confirmed swine flu cases early this summer. It strongly resembles the typical flu.
Within 24 hours, you go from not feeling quite right to fevers of 101-103 and coughing. The coughing causes a mild sore throat, but it doesn't hurt to swallow like strep throat. You may have very mild nasal symptoms like congestion and runny nose, but not nearly as much as with a typical cold. Plus, with a cold, the coughing doesn't start until a few days in, after the runny nose starts. The coughing with the flu is usually a dry cough. There would not be as much mucus as with bronchitis or a sinus infection. With fevers, most people will have a loss of appetite, body aches, and mild headaches. You can recognize a fever when you have problems with body temperature regulation. For example, you'll be freezing and piling on the blankets shivering but then throw off the covers 5 minutes later, sweating. To summarize, rapid onset of fever (>100f/38C) with cough and mild sore throat are the cardinal symptoms.

2) Should I take Tylenol for the fever?
If you have a fever and are very uncomfortable, then take some Tylenol. Ibuprofen works fine too. Do not take Aspirin. If you have a fever but are not uncomfortable, then there is no need to take fever-reducing medications like Tylenol. A fever is your body's natural way to kill viruses, so if you can let it do its job, a fever is a good thing. If the fever's not coming down with Tylenol, don't worry about it. It doesn't mean that something's terribly wrong. If your fever is more than 104, then consider a cool water bath to bring down the body temperature a bit. If your fever is more than 105, then consider going to the emergency room. Some people insist that they normally run a temperature of 96 and that 99 is a fever for them. I find that the flu will still cause a fever of well over 100 in those people.

3) Should I take a cough syrup?
Sure, if you want to. It's no longer recommended for kids because it's been shown to not work for them, but if you still want to, that's fine. Delsym is a pure cough suppressant, nothing else added. If there's mucus in the coughing, Mucinex DM is good. Cough drops are soothing but do contain a lot of sugar.

4) What makes it worse for some people?
People with asthma, smokers, pregnant women, diabetics, and people with chronic illnesses would be at higher risk for complications. The most common complication is pneumonia. That would usually result in more mucus and continued high fevers beyond the 5th day.

5) How contagious is it?
It's pretty contagious. A mask doesn't do much to prevent spread. The virus can live on surfaces for hours, so washing hands is very important. You're contagious one day before symptoms start. So if you come down with symptoms on Tuesday, you were already contagious on Monday and should just let people at school or work know. If you are sick, stay home. Do not return until the fever is gone for 24 hours (without taking Tylenol). If your aren't sure if you're sick, just stay home for a day to see how you feel. By the end of 24 hours, you'll know for sure because you'll start running a high fever if you have it.

6) I'm having severe vomiting and diarrhea. Do I have the stomach flu?
No. There is no such thing a stomach influenza. It's a misnomer. Having said that, what's commonly referred to as the stomach flu is just a stomach virus. Most stomach viruses don't cause a high fever but can cause you to spend many hours in the bathroom. The virus that causes the stomach symptoms is not influenza. Influenza is a very specific virus with very detailed specifications that causes the Flu (a respiratory illness). Still, some people have a more sensitive digestive system. If previous fevers and illnesses easily cause vomiting and diarrhea, then it's possible to have some mild digestive symptoms with the influenza.

7) Should I take Tamiflu?
If you are sick and are able to get to the doctor within 48 hours, then Tamiflu may be able to help a little bit, at a cost of about $100 for the course. It typically decreases the severity by about 20% and shortens the duration by about a day. So instead of running a fever of 103, it may be only 102. Instead of being really sick for 5-7 days, it may be more like 4-6 days. I think it's important for people at higher risk to take it, but it's certainly not mandatory for an otherwise young healthy person. It is not like an antibiotic where you often feel better within 1-2 days. The flu will still have to take its course even with Tamiflu. Tamiflu doesn't work as well if you start it after 48 hours of illness, so it's usually not recommended under those circumstances.

8) How long will I be sick?
Most people will run a fever of 101-104 for about 3 days. By the fourth to fifth day, the fever is about 100-101. The coughing will last 7-10 days. Most people feel at least 80% better by the tenth day.

I still remember my bout with the 2003-2004 flu. I was a resident at the time. The flu vaccine had the wrong strain, so despite getting the shot in November, I still got sick in January, at the height of flu season. The day I got sick, I started feeling not quite right in the morning, but I continued to work. I figured I was just sleep deprived. I went to the nursing home in the afternoon to see my patients there. But since my throat was starting to feel more raw and I had a slight cough, I decided to wear a face mask just in case. I went home early that afternoon and took a nap. I woke up sweating and achy around 7pm. My doctor's office had late hours until 8pm, so I called and drove down immediately. My fever was 103.5, and my doctor told me I didn't have the flu. I was pretty darn sure of what I had, so I insisted that she write an order for a flu swab. The office didn't have the rapid flu test there so I had to get it the next day at the hospital. One of my fellow residents stuck the long flexible metal cotton swab down my nose into my throat for the nasopharyngeal rapid flu test. That hurt my throat more than the flu ever did. I continued to work around the hospital that day until I was paged to report immediately to the infection control nurse. Apparently I was "strongly" positive for the flu. I took Tamiflu for 5 days and was prohibited from working those 5 days.

The CDC has extensive and up-to-date information about the flu as well.

This information is not meant to replace personal medical attention or advice. It is provided only as an opinion based on my experiences. If you are sick, please go about your medical care as you normally would.

Addendum: There is speculation that the swine flu started in Mexico at a gigantic filthy pig factory. That giant pig company is one of the largest pork distributors in the US. If you have access to local organic meat, I strongly recommend paying extra for it. You can't catch swine flu from eating name brand pig products, but you would be giving the big companies money to pollute and spread disease. I get my bacon from Musser Farm Market in Bellefonte. Good local organic stuff.

Saturday, August 22, 2009

$13,020 Medical Waste Discovered Yesterday

This is a true story of a student I saw yesterday. No names with a few changes in specifics because of patient confidentiality rules.

A girl was between insurances this summer. (Once a student graduates from college, they are automatically off of the parents' insurance plan.) While hiking about a month ago, she stepped into a hole and rolled her ankle. She felt a crack as she came down on her foot and ankle. Her uncle the orthopedic surgeon examined her and determined that she probably broke a bone in her foot. She didn't have insurance, so he decided to forego the X-ray to confirm a fracture (cost approximately $80). He bought her a cast from a medical supply store and off she goes.

For a month, she was in a below the knee cast walking around, healing, doing well. Then she moved to Pennsylvania to start graduate school. She had to drive across the country for 3 days. She takes a birth control pill. After arriving in town, she started to experience calf pain. Since she's still walking funny, she really didn't think anything of it.

She finally qualified for her graduate student insurance yesterday. Her uncle told her to come in for her calf pain and to change from her short leg cast to a special shoe. Because of the calf pain, the cross country driving, leg immobilization, and taking of birth control, we decided to check for a blood clot in the leg. It turns out the prolonged immobilization did cause a blood clot. We also decided to get an X-ray to make sure the bone healed well before taking her out of the cast. Ironically, we found out it was never broken. So she's been immobilized in a cast for no good reason. And that no good reason caused her a blood clot in her leg. If she had known that she did not have a fracture, she would not have been immobilized in a cast. She could have avoided this blood clot if she had a simple X-ray. Was it her fault for not paying for the X-ray? Was it her uncle's fault for skipping the X-ray? I think the answer is immaterial because it has happened, and pointing fingers won't solve the problem at hand.

She is now in the hospital getting anticoagulated. She will likely remain there for 4-5 days with IV heparin and becoming stabilized on Coumadin (rat poison to thin her blood). I predict the hospitalization will cost about $10,000. She will need to have a blood test every 6 hours to make sure her blood is thin enough but not too thin ($1000). She will have a CT scan of her chest to make sure she did not have a blood clot travel to her lungs ($1000). She will have an EKG ($200). She will be visited by a hematologist ($1000). She will have have a slew of expensive blood tests to make sure she does not have a blood clotting disorder ($800). She will have a heart monitor and frequent nurse checks due to the anticoagluation ($1500/day on the telemetry hospital wing). She will never be able to take a normal birth control pill again. She may develop chronic leg and foot swelling on that side that will be annoying and predisposed her to getting foot infections for the rest of her life. When she becomes pregnant, she will require extra attention from the obstetrician to make sure she does not develop another blood clot.

After being discharged from the hospital, she will see me at least weekly for six to nine months to check on her Coumadin level. She will have a restricted diet with a strict portion of green leafy vegetables that must be consistent from day to day. She will bruise easier and may have a hard time stopping bleeding if she injures herself. She must not become pregnant during these months because the Coumadin will cause fatal birth defects (which is why it's an effective rat poison). For her 6 months of outpatient care, she will cost the healthcare system about $4000.

To summarize, she did not have insurance so she did not get an $80 X-ray. Now, she will cost student insurance $14,000. Plus, she will have life-long consequences from this avoidable problem. We all end up paying one way or another when there is waste and inefficiency in the medical system. Everyone will end up paying for this episode. And it all boils down to being temporarily uninsured.

Why does our healthcare system cost so much person in the US? In part, it's due to scenarios like this. See my post Healthcare will Bankrupt the Country to see that we spend 2-3 times as much as other countries for worse results. Anyone who tells you we have the best healthcare system in the world is lying to you. She is now worse off for the rest of her life because the healthcare system was not there for her when she needed it.

Again, this is a true story. She was my patient yesterday.

Thursday, August 20, 2009

Gap Between Insurance Coverage

It's the end of the summer. Many graduate students have graduated and their student insurance is expiring. Some have a job lined up for September. Some are still searching. They finally have some free time after working hard in graduate school. So they come in at the last minute for a full physical to get STD and cholesterol checks, as many refills on their prescriptions as they can get, a quick referral to a specialist, or rid of a nagging problem they've had for the past 2 years. But I have to finish treating them in 1 week because they don't have insurance after that. Oh but wait, maybe we should hold off on too many tests because it would find a pre-existing condition before they got their new insurance. Plus, there are those 2 weeks between their current insurance and their new job insurance. They are not allowed to get sick in those 2 weeks so maybe I can give them some Tamiflu, just in case.

I'm just tired because three of my patients today fell into that category and I ended up far too long with each, putting me an hour behind. I'm usually not behind.