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.

Tuesday, August 18, 2009

Healthcare Will Bankrupt the Country

The congressional budget office projects that, without changes in law, total spending on healthcare will rise from 16% gross domestic product in 2007 to 25% in 2025 and 49% in 2082. It will bankrupt our country if we do not change. In countries that have better health outcomes, they spend far less of their GDP.
Countrypercentage of gross
domestic product
life expectancy

We are already spending far too much for so-so outcomes. That's why we need reform yesterday.

Andrew Weil wrote his opinion on why healthcare costs so much in our country. I agree with him on all points. His first point is similar to my point #7 from my first post. Call it a death panel or rationing of care, whatever you want, but there is a lot of unnecessary "care" (torture) going on in my opinion, and it needs to be brought out into the light. Don't count on a heart transplant and continue to eat junk food. Or less extreme, don't count on Lipitor to save your life. It will only prolong the life of 1 in 10 persons who take it, costing $90 a month per person. It may help 1 in 5 persons from having a heart attack. Sure, it's worth taking and I prescribe it very frequently. But I have no illusions that most patients who will have a heart attack will still have a heart attack despite taking Lipitor.

Some patient dissatisfaction with the healthcare system stems from an incorrect perception of efficacy. Even doctors are guilty of this fallacy. When I prescribe antibiotics for a bronchitis, I really think that it will work. But in the back of my mind, I know that research shows it doesn't really help most of the time. We try to help you feel better, fix what we can, and ease your anxieties. But we are not magicians with magic pills and potions. Like Weil, I think our medical progress is great, but we should not depend on it.

Monday, August 17, 2009

Public Plan or Co-ops

When the public plan died, I could no longer support the reform. But with co-ops, I guess something is better than nothing.

A public plan would be far more efficient than co-ops. The overhead would be far lower because decisions would only have to be made once, rather than 50 times. There would be only one electronic medical record system, rather than 50 different ones that may or may not talk to each other. Negotiations would occur once, rather than with 50 different groups.

The only benefit I see with co-ops is that the bill just might pass. If the co-op would have some negotiating powers with drug companies, then that might help too. The public plan had acquiesced on drug price negotiations.

Still, a co-op system would be much less efficient and would cost the overall healthcare system much more. All of the cost savings from this plan would have to be recalculated, and I'm sure it would be much less. It may be so much less that it does not fix the system. In that case, the anti-reform people can wag their fingers in a few years in an "I told you so." But there is always the hope that another bill may pass in the future to fix the things we couldn't fix this time.

Here is an interesting blog post from another perspective. says the prize is the universal mandate.

Here is my response to that post. Interesting perspective. No one will vote to take away their own insurance, true.

I'm concerned about the viability of the system as a whole. If it costs so much that it drags down our economy, then it's essentially bankrupting our country.

So if we mandate that everyone is covered without a public option in place, then the insurance companies will make a giant profit and be able to further fund the suppression of a public non-profit option. They will bankrupt the country by concentrating power and wealth in the hand of a few CEOs, taking it away from us, the little people.

I still think that we need a non-profit mandate in the insurance mix to compete with those evil health suppression (insurance) companies. This co-op compromise is my last straw. If they weaken this reform any further, then my liberal vote is gone.

Friday, August 14, 2009

The House Bill, explained in English, plus a rant.

There is a lot of confusion about the current healthcare bill, not just the horrible lies. (Why call them myths when there are clearly politicians lying for political gain?)

Here is my understanding of what’s going on. I am not an expert and welcome corrections if I have misinterpreted anything.

The House has a bill written down that’s over 1000 pages long. I’ve seen it, read parts of it, not the whole thing.
The Senate does not have a bill written down. They are still debating what should be in the bill.
Neither chamber has voted on anything yet. The two chambers mostly agree on the issues, but do differ on some points. That will have to be resolved before a final bill passes both chambers months from now. I expect that the final bill will likely be somewhat close to the current House bill.

The House bill proposes universal health care by forcing everyone to buy health insurance. If you don’t buy an approved plan, then you have to pay extra income taxes (2.5% extra). Approved plans must meet these Consumer Protection qualifications:

No Discrimination for Pre-Existing Conditions (Insurance companies will be prohibited from refusing you coverage because of your medical history.)
No Exorbitant Out-of-Pocket Expenses, Deductibles or Co-Pays (Insurance companies will have to abide by yearly caps on how much they can charge for out-of-pocket expenses.)
No Cost-Sharing for Preventive Care (Insurance companies must fully cover, without charge, regular checkups and tests that help you prevent illness, such as mammograms or eye and foot exams for diabetics.)
No Dropping of Coverage for Seriously Ill (Insurance companies will be prohibited from dropping or watering down insurance coverage for those who become seriously ill.)
No Gender Discrimination (Insurance companies will be prohibited from charging you more because of your gender.)
No Annual or Lifetime Caps on Coverage (Insurance companies will be prevented from placing annual or lifetime caps on the coverage you receive.)
Extended Coverage for Young Adults (Children would continue to be eligible for family coverage through the age of 26. )
Guaranteed Insurance Renewal (Insurance companies will be required to renew any policy as long as the policyholder pays their premium in full. Insurance companies won't be allowed to refuse renewal because someone became sick.)

If your current plan does not meet those requirement but you’re still happy with it and do not want to change, that’s okay, you don’t need to change. The plan you have will be “grandfathered” and you can keep it. And if you have a new baby, your baby can have the same plan. But your neighbor can’t buy the same plan after the bill passes because he’s not already grandfathered in the non-approved plan.

If you don’t like your plan, there will be many new options offered by the insurance companies that meet the new government regulations listed above. So you can choose which of those you would like to buy.

To make health insurance more affordable for all, the House is proposing the formation of a new healthcare plan, run by Washington. “Anybody*” can buy into the government plan, which initially will be one size fits all. Over the next few years, there will be more plans offered that provide different levels of coverage for different prices. The * exceptions are as follows:
• If you have Medicare, it will remain the same.
• If you qualify for Medicaid, you will remain in Medicaid.
• If you are military, you will have the military’s healthcare plan.

So in addition to the private insurance company options that are now better and improved with consumer protections, there is the government plan. You can choose any approved plan you like. If you have a non-approved plan and still want to keep it, you can keep it.

Okay. So basically, if you are against this healthcare bill, then you are AGAINST consumer protections. If you are against this bill, then you WANT Aetna, Cigna, United Healthcare, and Blue Cross to continue ripping you off. If you are against this bill, then you WANT the USA to go bankrupt from skyrocketing healthcare costs. That’s frankly Anti-American.

Sarah Palin and other politicians are TERRORIZING their own base for political gain. They want us to fear reform so they can get more money from pharmaceuticals and insurance companies. Terrorism is defined as “the use of violence and threats to intimidate or coerce, esp. for political purposes.” The fringe is terrorizing the rest of America by bring guns to town halls, displaying threatening posters, and disrupting public discourse. It’s rather ironic, is it not?

This healthcare bill WILL save us money in the long-term, and it will keep us healthier and happier.

Wednesday, August 12, 2009

Response to another doctor's blog post

I wrote a response to Dr. Kristie McNealy's blog post. I think it's still awaiting moderation on her blog, so you may not see it there yet.

Here's her original post: ObamaCare: A Physician’s Point of View On The Negative Ramifications of America’s Affordable Health Choices Act of 2009

Here is my response: Thank you for taking the time to read the bill and to post your thoughtful insight. I’m glad for healthy debate. I am a family physician practicing in Pennsylvania, and I disagree with your reasoning.

#1 Opting out and paying for your healthcare elsewhere IS an option, provided you carry an approved plan. If you carry only cheap catastrophic insurance, then you are not trying to stay healthy and therefore costs society more.

#2 I’d be surprised if any significant number of people on Medicaid can afford any other insurance. The supposed lack of choice is just fear-mongering for 99% of Medicaid patients.

#3 Ditching the healthcare plan with this complaint doesn’t make sense. At least it’s an option, while not perfect, it’s better than what 20% of Americans have now, which is NO coverage for basic healthcare. And in 3 years, it will likely be improved.

#4 That’s because the private insurers are wasteful. Medicare spends 3% on administration. Private insurance spends on average 15% on administration. If they get their act together, stop generating excessive paperwork by denying tests, or paying their CEO $3 million annually + $750 million in stock options, then they will be just as competitive.

#5 Your interpretation is wrong. Note that it says “grandfathered.” In lawyer-speak, that mean if your current health insurance doesn’t meet the provisions in the new laws (like not being able to drop you at a whim, not covering a pre-existing condition, or not cover preventive care like an annual exam), then you can still keep it because it’s “grandfathered.” You can OF COURSE still buy your own private health insurance! You actually have more choices.

#6 I don’t like that the government has excessive power either. But look, the benefits of the bill still outweigh the problems. Perhaps that clause will be stricken or not enforced.

#7 I’m glad they will be looking at cost effectiveness. Our country (its individual citizens and the federal government) need to control our spending in all areas. The government is in debt because WE are in debt. Stop pointing fingers. Do you have your house paid off and all bills settled? I know I don’t. Is your net worth in the red or in the black? It’s been 8 years since I graduated from med school, and I’m still in the red. Unless we change, our government can’t change.

I know you disagree with this, and this is my own opinion. Some very young NICU babies live a horribly disabled life and cause severe anguish for their parents. Some of those NICU babies are from young drug-abusing mothers who could not possibly give them adequate loving care. And if the parents manage to care for them into adulthood, they would will have to place them in a group home when they get too old. If the parent feels guilty or just really wants to save a 24 week old preemie, then they can certainly foot the bill on their own. If my elderly mother had cancer and just wanted to die a natural death rather than live through the torture of multiple ICU stays, I would respect that. Similarly, if I had a 24 week preemie, I know it would lead a tortured life in and out of hospitals, required various surgeries that it would not understand and would suffer through, causing frequent anguish for me and my husband and other kids. I would give it the grace of death, not life at all cost. In my opinion, it’s the humane thing to do.

All of the money in the world can't always relieve suffering. Look at Michael Jackson. I believe in a holistic wellness. Not everything is black and white. Wellness is gray. Patients must be fully informed of the risks and benefits in major decisions. If we as doctors act as god and impose an artificial right or wrong and tell patients they must preserve their life irrespective of their suffering, that's wrong. Patients have a right to choose how much suffering they are willing to endure for preserving life.

If you want to pay the money to save someone denied by the government plan, you have the right to do so. Doctor generally will not refuse treatment (especially if it's life-saving - we LOVE saving lives) if you request it. You would just have to understand that it will go on your tab.

A comment in there said that the Canadians come across for their healthcare, paying out of pocket. Hey, if you’re willing to pay, you’ll be able to find a doctor to take care of you! The Canadians pay for their basic care through taxes. We’ll have basic care through our insurance. If you want to pay more for extra luxury care, you have the right to do that.

Other responders to the post talk about how scared they are. Being afraid is not a good feeling. Take control and become informed. Don't listen to Glenn Beck and get more scared, unless you're masochistic. Change that fear to action - please read the bill. If you don't understand it, discuss it with your friends to figure it out. I think that if you overcome fear and actually learn about the issues, you'll see that having this healthcare reform is better than not acting at all. You know very well that by delaying this bill this time, we won't have it again before Congress for another 4 years. A lot can happen in 4 years. Many Americans will die because they do not have basic coverage in 4 years. Will you stand by and just be scared? Or will you act to save lives? Read the bill.

Sunday, August 9, 2009

Why Health Care Costs So Much - and some proposals to help decrease it


I am a human being, like all humans beings, fragile and sometimes ill. I am also a family doctor. I graduated from the University of Virginia Medical School. After my family practice residency training, I was part of a private practice in Connecticut for two years prior to taking my current position as a University Physician at a major Pennsylvania university. My perspective is from that of a caring family doctor who believes patient care is paramount in the healthcare industry. We cannot afford our current healthcare system because it’s broken. This essay examines the problems I see and provides some tangible solutions. I just want what will work best for my patients and as many Americans as possible.

1) Insurance company profits

To make money, insurance companies charge as much as they can. To save money, they pay for as little as possible. They charge your employer first, who pays a percentage. Then they charge you, deducted from your pay. Then they charge you a co-pay. Then they charge a deductible. Then there’s a maximum spending limit. You pay at every step of the way. It’s only fair that you pay for some of care you receive, but you are paying too much. Then by hiring a secretary to deny your MRI, making your doctor jump through hoops to get it approved for you, they make incrementally more money for the one MRI they successfully deny. Meanwhile, your doctor has to pay another secretary to deal with the insurance company's paperwork. They negotiate deals with your doctor to pay your doctor less when they participate with your insurance. They stop covering some medications. They force you to try generics before paying for a brand name.

Where does the extra money go? It goes to shareholders of the insurance companies, to the managers, and to the employees. If you are covered by United Healthcare, then you are paying them 50% more than necessary. Suppose you spend $100 a month on health insurance. You are giving $22 to the company’s profit. You give $12 to the employees, many of which are paid to deny you coverage and generate paperwork. Almost $1 may go to the CEO as compensation. $65 is actually used to pay for your health care. In contrast, Medicare’s administrative costs are $3, so $97 would go to pay for your healthcare.

The major difference I see between health insurance and car insurance is that the health insurance has evolved to pay for all aspects of our medical care. It’s not a safety net in the traditional sense of being an insurance. It’s a healthcare program that you are buying. In contrast, you still pay for oil changes, tire rotations and other maintenance work on your car. Car insurance doesn’t kick in until you have an accident. With health insurance, the point is not for accident coverage, but for overall health maintenance so you reduce those accidents and catastrophes. A flu shot is an oil change; a complete physical is a tune-up. A heart attack is an accident. Health maintenance is a completely different goal than accident coverage. To allow for some individuals to profit from the denying of health maintenance to someone else is sick.

By taking profit-making out of the equation, most of the money paid into the healthcare system would actually be used to pay for health.

2) The Food Industry AKA Corn Subsidies

Healthcare costs more because unhealthy people cost more. People are less healthy because of the foods they eat. A brand of apple sauce with standard packaging is easy to market. But you can’t market an apple. The fresh food is almost always healthier than any processed packaged version of that food. There is just no substitute for real food, but the food industry is able to spin their packaged food as being healthy or even health-promoting when it’s far from the truth. Their goal is to make money by selling something edible. So they will add vitamins to nutrient poor bleached flour, extract fat but add sugar, or increase salt but not fry to convince you that something bad is somehow now good for you. By promoting the eating of real food (something not from a cardboard package), Americans will be healthier.

Corn is a major problem. Everything from cereal to sausages to cheesecake can contain some form or derivative of corn. Government subsidized corn creates cheap food. But then we pay for it later in medical costs. Corn farm subsidies were started in the 1970’s, and consequently, our incidence of diabetes has increased dramatically, in part due to the cheap availability of calories and sugar from corn. At the current rate, diabetes will eventually be more expensive to treat than heart disease or cancer. To slow that rate down, we need to stop subsidizing these empty meaningless harmful calories. By reducing the corn farm subsidies or redirecting those subsidies to teach farmers to produce other types of food, we’ll have a more balanced nutrition plan for our citizens. It’s not enough to tell people to not eat it when it tastes good and is cheap. If it’s more expensive, people will stop eating it. That will help people be healthier and reduce the increasing costs of the obesity epidemic.

Increasing the costs of corn will also increase the costs of beef, decreasing the demand. That is not only good for the environment by saving water and reducing greenhouse gases from raising cows, it’s also better for the public health. Eating less beef means eating less fat. The beef will be more grass fed and leaner. Perhaps cheaper vegetables and more expensive meats will help to encourage Americans to eat a healthier, leaner, vegetable-based diet. The health benefits from a better dietary profile are limitless.

3) Redundancy and inefficiency in medical records

Have you ever tried to get your medical records? Did your physician keep a paper chart with illegible handwriting? Some medical offices charge patients to get a copy of their chart. Here in Pennsylvania, a doctor’s office can charge you up to $33 plus shipping for 20 pages of a medical chart. When you change doctors, if the new doctor doesn’t have access to a legible organized copy of the major and minor issues regarding your health from your previous doctor, they would have to start from scratch. Your medical history is often quite subtle with many important details of which you may not be aware. I can’t possibly explain to you every little medical tidbit I gleam from your records. Even if you think you know your medical history, the medical chart still contains valuable information. It needs to be easily accessible.

Hospitalizations are especially inefficient. Your cholesterol profile may have just been checked by your family doctor, but when you have chest pain after the doctor’s office closes, the emergency room doctor won’t have access to those numbers and may repeat that test. During the hospitalization, your cholesterol medication switches from your regular Lipitor to generic Zocor, because the hospital pharmacy only carries Zocor. So when you leave, the doctor writing your hospital discharge medication list has you taking Zocor instead of Lipitor. And maybe you don’t know that they do the same thing so you take both when you leave the hospital and overdose on the medications until you follow up with your family doctor. But perhaps your family doctor still hasn’t received a copy of the hospital chart at your follow up appointment, so it’s impossible to tell which little yellow pill you are describing. Eventually, your medications are straightened out.

Now, your EKG looks a little abnormal, but it always looks that way, so it’s really okay. Your doctor might even tell you that, but you don’t know just how abnormal abnormal looks. When you’re out-of-town on a Sunday attending your niece’s graduation, you fall ill and go to a different hospital. There, they do an EKG and it’s abnormal. But your regular doctor’s office is closed, and the hospital won’t release your medical records to the other hospital unless you sign a form, and then maybe they’ll get to it on Monday. Meanwhile, the ER doctor thinks you’re having a heart attack and pulls all of the stops because of the abnormal EKG. Instead of sending you home, you end up staying in the hospital getting unnecessary tests that end up costing $5,000, lots of bruises from needles, and costing sick days for you, your husband, your sister, and her husband to take care of you while you’re in the hospital.

Do you have your immunization records? Unless you got them from your pediatrician, your family doctor probably doesn’t have the complete set. I frequently have to obtain disease titers (like for measles) or give extra vaccines because patients do not know when their last tetanus booster was or if they received their second Hepatitis A shot after their trip to Cancun (Mexico).

Numerous inefficiencies and redundant care can be corrected with easily accessed electronic medical records that talk across all types of health care (clinic, office, hospital, ER, rehab, physical therapy, mental health, specialists, primary care, and pharmacies). Currently, it’s as frustrating for physicians as it is for patients to not have everyone on the same page. I think that patient privacy can still be well protected while easier access is achieved. It involves having a common health record platform. There is no incentive for private industry to create software that communicates well with other software. A government-sponsored software standard is necessary.

4) Drug companies

From a patient’s perspective, I’m glad that there has been reform of the drug industry’s ability to give physicians gifts. From a physician’s perspective, I’m disappointed that I missed out on the paid Caribbean cruises, European chateau vacations, and club seat tickets to professional sporting events. Now I just get pens, notepads, and an occasional in-office lunch. So that’s not a major cost in your prescription drugs anymore.

I don’t even mind the magazine advertising and commercials. The companies need to make money to have the capital to develop more products.

What I’m disappointed with is that private drug companies make more money by selling you a treatment than they do by developing a prevention. For example, if the company gives you a one-time $200 HIV vaccine, then it won’t make $2000 a month selling antiviral drugs to you for 20 years. There is little incentive for them to develop cures either. If they develop stem cells to cure diabetes, then the huge profits from routinely medicating 8% of the entire US population are gone. If the private drug companies had more incentive to develop cures and preventions, then overall healthcare costs would decrease.

5) Malpractice

Well, there are actually many aspects to this. First, there is the actual cost of buying malpractice insurance for doctors, who then pass on this cost to their patients. Second, there are the frivolous malpractice cases, which tax the entire system. Tort reform probably benefits the insurance companies the most – not patients in general. Lastly, but most importantly, all doctors practice defensive medicine to prevent lawsuits. This is from personal experience, and it’s the real cost of malpractice. With proper reform, overall costs can be decreased.

Doctors can’t practice medicine without malpractice insurance. It’s like you’re not supposed to drive without car insurance. Well, hospitals and clinics won’t take doctors without insurance. So doctors must buy malpractice insurance to practice medicine. Malpractice insurers are private companies trying to make money for their shareholders, employees, and managers. They, like healthcare insurers, try to minimize the insurance payouts in all the ways they can, and maximize their charges.

I’m extremely low risk. I’ve never been sued before, I don’t see a ridiculous number of patients a day, and I don’t do surgery or deliver babies. It cost me over $20,000 dollars to buy “tail” insurance when I left my previous practice where I was for 2 years so that I would be covered if someone were to sue me. The irony was, while I was practicing there, the office had already paid $10,000 a year for my malpractice insurance. But it only covers the years I worked there. To be covered for those patients, I had to buy my own “tail” coverage. My new job’s malpractice carrier cannot cover me for those patients. “Nose” coverage exists, but is extremely rare. These costs are ridiculously high because they know we can’t practice without it, and there are no standards regulating their profit margins. Some doctors have had their policies increase in price by 50% a year, which makes it unaffordable. Many areas of the country lack obstetricians because of malpractice insurance problems. That’s dangerous for patients who are unable to get the routine prenatal care they need and to reach a hospital in time for a delivery by an obstetrician. By regulating the malpractice insurance industry, both physicians and patients will benefit.

Tort reform was pushed a few years ago as a solution to the malpractice problem. It certainly does not benefit patients who have been subject to egregious malpractice. It doesn’t even reduce the number of frivolous lawsuits physicians and the legal system may face. I think tort reform mostly just benefits the malpractice insurance companies who would not have to pay extraordinary sums of money. The solution lies in screening out the frivolous cases and reviewing the ambulance-chasing attorneys.

But that’s not the real problem with malpractice either. It’s the common practice of defensive medicine. That’s when your doctor is afraid you’ll sue him so he orders extra tests and gives you extra medicines.

“Well, I really don’t think you have cancer because you’ve been coughing for 2 weeks. But since you are so worried about it, let’s do a chest X-ray just to be sure. Plus, I really don’t think you need that $120 antibiotic course for that cough, but because your father died of pneumonia and you’re worried about it, we’ll treat you just in case.”

If the doctor can have more confidence that the patient will follow up if the cough doesn’t improve, then the doctor would not have to go overboard with testing and treatment. A patient whose health insurance policy covers these routine visits will be much more likely to return in follow up. If the doctor has more confidence that the patient won’t sue him for being diagnosed with cancer 1 month later, then he would not have to order a chest x-ray for the other 999 people who have a 2 week cough and don’t have cancer. By reducing frivolous lawsuits, the practice of defensive medicine will decrease. Overall health costs will also decrease.

6) Physician Pay

I’m a family physician, a primary care specialist. I have not yet made a six-figure income as a doctor, so I’m not that golf-playing social elite. I had to attend and pay for college and medical school. I’m still paying back my student loans. An average medical student graduates $155,000 in debt. They have not been making any money from age 18-age 26. Then they go into residency training making about $50,000 a year having to pay back loans, work 80-100 hours a week, and try to maintain their humanity. That’s from age 26-29 for a primary care doctor (family doctor, internist, or pediatrician), or from age 26-31 for a general surgeon or cardiologist. Okay. Let’s do the math.

Family Doctor at age 40:
8 years x $0 + 3 years x $50,000 + 11 years x $100,000 = $1,250,000 = lifetime pay
With monthly investments of 10% of salary at 8% interest, the doctor would have $216,080 in investments saved up.
But then the student loan costs $1110 a month for 20 years at 6% interest = $266,400.

Plumber at age 40:
22 yrs x $40,000 = 880,000 = lifetime pay
With monthly investments of 10% of salary at 8% interest, the plumber would have $238,926 in investments.

At age 40, the doctor is only about $80,000 richer than the plumber. And believe me, the doctor works harder. Most doctors work 60-80 hours a week. A plumber works 40 hours a week. Both take calls at night for emergencies.

But wait, aren’t I arguing that physicians pay is too much rather than too little? Well, the primary care doctor is paid too little. Specialists are paid too much. That’s why the more financially conscious medical students may choose dermatology or allergy rather than pediatrics, for example. There is a shortage of primary care specialists, especially in rural areas. With the proper incentives, more medical students will choose primary care and better serve the preventive medicine needs of communities.

How is physician pay determined? In large part, it’s because of CPT coding. If you’ve ever looked closely at your medical bills, there would a code for your visit to the doctor and codes for any procedures. A visit to the doctor is expensive, but it’s the least of your worries. It’s the labs, the wart that was frozen off, and the X-rays that really adds to the costs. The pay rate is heavily skewed for procedures. Here’s a scenario. At age 50, your family doctor refers you to the gastroenterologist for a routine screening colonoscopy. He has the physician assistant see you for the initial visit to schedule the colonoscopy. Meanwhile, he’s busy doing colonoscopies. He makes a lot more per hour doing your colonoscopy than he does by seeing you in the office. That’s why he has his assistant see you instead. Primary care doctors do much fewer procedures than specialists. They mostly just see you in an office, which doesn’t pay well.

Who writes the CPT codes? The AMA publishes these codes every year. That’s actually how they make their money. The governance in the AMA is skewed, predictably, to the specialties. Percentage-wise, specialties have more representation than primary care. So the code book they publish with the standard reimbursement rates tends to pay specialists much more. Why aren’t family doctors trying to change that? Some are, but 70% of physicians are not part of the AMA. The membership in the AMA is largely old, white, and male. As a medical student, I went to a national conference in Chicago to see if I can change the organization from the inside by joining. They treated me as if I was an affirmative action baby. I was disgusted with the good old boys fraternity that alienates anyone who’s not a country club white male. I don’t trust them. The AMA protects the interests of doctors, not the public. They don’t emphasize prevention because treatment of diseases makes most doctors more money. For example, it was only in the past few years that physicians could bill for smoking cessation counseling. Medicare was the first the pay for that code. The insurance industry reluctantly followed. If doctors are paid for helping someone quit smoking, then perhaps doctors would spend the time to do so. To direct emphasis to prevention, the reimbursement schedule needs to be adjusted to reward patient education and prevention in any government plans.

7) Patient demands

26% of Medicare dollars are spent on the elderly in their last year of life. 78% of that is spent in the last month. Much of the time, the elderly doesn’t have a living will to tell their family that they don’t want everything done, so their family request for the ICU physicians to do everything for their 90 year old grandmother when she really would not have wanted all of that torture anyway.

If you’ve never been in an ICU, you’ve never seen the torture and lack of patient dignity. That’s not a critique of the people working in an ICU. It’s just the reality of the necessary medical care in the ICU to keep people in critical condition alive. It’s an unnatural process, and the environment and treatment is thus highly unnatural. Most patients are purposefully sedated to keep them calm through the entire stay in the ICU because it’s so traumatic. Imagine a loud machine next to your uncomfortable bed blowing air into your lungs every 6 seconds 24 hours a day. After you defecate into your bed, the nurses come to turn you sideways so they can wipe your bottom and clean the sheets. It often happens a few times a day because your stomach can’t handle the 3 different IV antibiotics you’re getting. You have a tube inserted into your penis or urethra to collect your urine. You have a thick IV tube sutured into the skin of your neck giving you up to 3 medications at once directly to the heart. Sometimes it’s used to feed you if your bowels aren’t working. If your bowels are working, then you have a long tube going down from your nose to your stomach delivering liquid nutrition. Sometimes that tube gets clogged, your stomach gets too full, or your have bad acid reflux. That food accidentally gets into your lungs and you develop a bad pneumonia from that. Because you aren’t moving, you’re at risk for blood clots. So you have these leg pumps that inflate and deflate every few minutes to help blood circulate in your legs. Within 1 week of an ICU stay, you lose 15% of muscle mass and will likely need physical therapy especially if you are older. If you have a heart condition or are simply older, your brain will not be as sharp afterwards. You will likely have suffered tiny strokes from lack of oxygen to the brain at some point during your ICU stay. It’s a pretty horrible way to go. And if you make it, then you’ll have permanent bodily scars of your stay there. Ask any doctor or nurse, and more than 90% will tell you that they’d rather not be revived when they are elderly and dying anyway.

Look, let’s be realistic. Quality of life versus quantity of life – which would you prefer? Let your loved ones know so they can help choose treatments when you are unable to speak for yourself.

Medicine is not magic. Sometimes the miracle of an easy appendectomy or the cure of a strep throat with antibiotics may make it seem like anything is possible. But a full body MRI scan will likely not improve your health overall. Neither will an expensive heart catheterization. An experimental cancer treatment is just that – experimental. Some costs are well worth the benefits like fixing a heart in a baby or transfusing 10 units of blood and doing emergency surgeries on a young mother in a car accident. But doing CPR and subsequent ICU care on an 80-year-old frail cancer patient is probably not going to benefit anyone. That is very much a judgment call and subject to religious recommendations. That should be respected, but a well-developed public education campaign of standards in routine medical care is helpful to dispel myths learned from TV shows.

8) Healthcare for the uninsured

If you have a sore throat and think you may have strep throat, you should see a doctor to get an antibiotic. When you call a doctor’s office to make an appointment, they will ask you for your health insurance information. If you don’t have insurance, they may not give you an appointment. That’s the reality of private practice. If you go to the emergency room, they are required by law to see you, regardless of your insurance status. So instead of going to the doctor who costs $100, you go to the hospital that charges $500 for the same treatment. Hospital and emergency room care costs much more than a doctor’s office because they are specially equipped and prepared to handle emergencies. They have the room set up for doing CPR and heart monitors. It’s really unnecessary for a simple strep throat. Whether or not you are able to pay that money back, you have cost the healthcare system $400 more than necessary. That’s part of the out-of-control expenses.

Well, you know you can’t afford the emergency room, and the doctor won’t see you. So you just tough it out. A month later, you continue to run fevers and now you’re feeling so weak you can’t work. So finally you go to the emergency room and you find out that now you have rheumatic fever, where the strep has permanently damaged your heart valves. You have to take antibiotics for years and you have to see the heart specialist regularly. Or perhaps you have diabetes and you can’t afford to see a doctor. So you don’t take medications and show up at the emergency room with a rotting foot that needs to be cut off. Not only does your health suffer from not having regular medical care, it also costs the healthcare system many times more. Preventative, routine, and regular healthcare costs less than emergency last-minute care. Without adequate health insurance, patients do not receive the care they deserve.

In conclusion, I think healthcare reform is mandatory. The currently system is unsustainable and will end up worsening the health of everyone if it does not change. The Health Insurance Consumer Protections in the current plan are a helpful first step. I want the changes made now and in the future to always be in the interest of patients. Hopefully this analysis contributes positively to the reform.

Major points are as follows:

1) Healthcare insurance companies should be non-profit organizations with the goal of providing excellent healthcare, not making a profit.
2) Change the government incentives from cheap corn production to a more balanced variety of vegetables to feed the nation.
3) Standardize medical record software across all platforms to enhance communication and record keeping.
4) Give drug companies incentives to develop cures and preventions rather than treatments.
5) Regulate the malpractice insurance industry. Free market for malpractice insurance is not working.
6) Raise primary care physician pay rates while reducing the specialist pay rates to compensate. This will place more emphasis on prevention and less on treatment.
7) Encourage living wills and promote more realistic patient expectations.
8) Provide cheap easy access to routine healthcare for all.