Tag Archives: health

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Patients or profit?

We can choose single payer, medicare for all, with overhead of 3-4 percent. That means 96-97 cents out of every dollar goes to HEALTH CARE, not PROFIT.

Or we can choose PROFIT:  the current law says that the private insurance companies have to spend 80 cents of every dollar on health care. 20 cents to PROFIT.

The insurance companies’ goal is to earn money, PROFIT, not give health care.  They are posting BILLIONS in profit.

The person on the phone who says your medicine or care is not covered? I think the insurance companies say that is health care. They are paying the person to refuse your care. They send us weekly updates on what has changed in the 1300 different insurance companies and I don’t know how many insurance plans because they all have more than one. You ask me, your doctor, if something is covered and I say, “I have no idea. It was covered last month. It should be covered. I don’t know.” The insurance companies pay people to write an individual website for every insurance company: 1300 websites. Can YOU keep track of 1300 log ons and 1300 passwords? And I think the insurance companies say that the money paid to set up the website is health care. I don’t think it’s health care, do you?

I want my health care dollar to go to HEALTH CARE not PROFIT.

Stop the bill. Stop the insanity. Stop putting INSURANCE COMPANY PROFITS in front of HEALTH CARE. We the people of the United States can decide and can tell Congress what we want.

Medicare for all, one set of rules, 3-4% overhead, we are one nation, under God, indivisible.

And we do not put profit first.

Physicians for a National Health Program: http://www.pnhp.org/

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Health care mandate in the United States

At a health care town hall last year, our representative said that US citizens have not given Congress a mandate for health care.

I raised my hand. “I beg to differ. The mandate is already law. The law says that no person in the US can be refused care at any emergency room. We have the mandate. Unfortunately the emergency room is the most expensive and cruel and last minute care that we could possibly choose.”

Expensive: any ER visit costs more than a whole day of visits to my rural family medicine clinic.

Last minute: the emergency room doesn’t do chronic care. Their purpose is to 1. try to stop someone from dying and 2. decide if the person should be hospitalized or should follow up in clinic. They do not do prenatal care, treat high blood pressure, treat diabetes, depression, high cholesterol, alcoholism. They do not do chronic care and aren’t meant to.

Cruel: you can go to the emergency room to try to keep from dying. Say you go coughing blood. They find a lung cancer. Now, you have a choice: be treated and maybe you will survive or maybe you will die anyhow and your house will be sold to pay for the medical care. Do you choose to go home instead and die so that your family inherits the house?

The United States spends twice as much per person as the next most expensive health care system in the world and they have universal health care and we don’t. We care more for corporate profit then US citizens and visitors health. I cringe when the discussion is about health INSURANCE not health CARE.

I am a physician but I also own my own business. As a small business owner, I think that I will soon have to close. Why? I am in my 50s with a daughter. I think that within two years my HEALTH INSURANCE will cost more than I pay myself. And I will close the clinic.

We need health CARE not health INSURANCE. The Obamacare law said that health insurance companies can ONLY keep 20 cents of every health care dollar they collect, down from 22.5 cents. They have to spend 80 cents on health care. For medicare the overhead is 2-3 cents per dollar.

Medicare for all, single payer. Put 97 cents of every health care dollar to health care instead of only 80 cents. Or shall we continue down the road to small business and local government collapse and citizen health collapse?

Congress, you can’t wheel and deal your way out of this one. We want health care for our dollar not insurance.

For the Daily Prompt: wheel.

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Distant light

I am trying to catch that distant line of light on the horizon as the light recedes….

….I am so grateful that the basic healthcare requirements will not be dismantled, joy!

….and now on the horizon I hope for vision and light and single payer, medicare for all. My Veteran patients this week are afraid, that Veterans Choice will be taken down. I am afraid too….and still, I hope for vision and light.

 

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Alcohol

Let’s talk about alcohol.

I am a family practice physician and I talk to people of all ages about alcohol. The current recommendation is no more than seven drinks a week for women and fourteen drinks a week for men, no saving it up for the weekend. No more than two drinks in one day for women and no more than three for men.

“What?” you say “No way. Come on, that’s ridiculous.”

My patients don’t say “That’s ridiculous.” After all, they are paying me to do a physical exam and a preventative exam. I am supposed to give them advice. But what is the basis for that?

One drink is defined as a regulation 12 oz beer or 6 ounces of wine or two ounces of hard liquor. If it is a high alcohol beer or wine or liquor, the amount is less.

It is NOT the liver doctors that have given us these numbers. It is the cardiologists, the heart doctors. One drink in women or two in men lowers blood pressure and in general, has good effects. Go over that daily and there is a rebound in blood pressure as the alcohol wears off. Alcohol works in the same way as benzodiazepines: it makes people less anxious and more relaxed and lowers inhibitions. Both alcohol and benzodiazepines are addictive for many people. That is, they develop tolerance, it takes more of the substance to have the same effects, more tolerance and then it takes more and more substance to try to feel half way normal.

Cardiologists qualify this recommendation as follows: there is no recommended daily amount of alcohol that is considered heart protective because there are too many alcoholics. The recommended daily amount of alcohol for an alcoholic is none. The recommended daily amount of alcohol for the general population is none.

Alcohol withdrawal can be very very dangerous medically. I think that the three most difficult things to quit are heroin (and all opiates), methamphetamines and cigarettes, but alcohol is more dangerous. In heroin withdrawal all of the pain receptors fire at once, so it is torture, but people don’t die. With serious alcohol withdrawal, the blood pressure skyrockets and the person can have seizures, a stroke, a heart attack, delerium tremens and can die. In the hospital, benzodiazepines are used to slow the withdrawal, replacing alcohol in a controlled manner.

Alcohol does more than affect the blood pressure. Over time, alcohol can damage the heart and lead to congestive heart failure.

Of course, you know that it can damage the liver and lead to cirrhosis. Cirrhosis is sneaky: as long as there are a few functioning liver cells, the lab work can look pretty normal. The liver makes proteins for the blood and makes proteins that allow our blood to clot. Once there aren’t enough healthy cells to make those proteins, alcoholics will bleed quite spectacularly. If the amount of the protein albumin in their blood is low, fluid leaks from the blood into the tissues: so whatever part is “dependent”, that is, lowest, will be swollen. Alcoholics can have legs with swelling where I can push with my finger and there is a two or three cm dimple. Alcohol also can lead to gastritis and ulcers. If someone can’t clot and they are vomiting blood from an ulcer, the doctor gets a tummyache too, from worrying. Ow. The liver is also supposed to filter all of the blood in the body. As the liver gets blocked with dead liver cells, the blood starts to bypass it. The bypass is through blood vessels in the stomach. Remember that person vomiting blood? The swollen vessels in the stomach are called varicies and we don’t like them to bleed. They are big and can bleed really really fast. The person can die. I don’t like transfusing and really don’t like transfusing 12 units of blood. In end stage alcoholism, the liver no longer lowers the blood level of ammonia. Ammonia crosses the blood brain barrier and poisons the brain. We haven’t even discussed the lack of vitamin B12 and thiamine which can cause unraveling of the myelin sheaths on the long fibers in the spinal cord: this means that the person gets permanent asterixis and “walks like a drunk” even when they are sober. I’m sure I haven’t remembered all of the consequences of alcohol, but that will do for now, right?

How much alcohol daily causes the above charming picture? We Don’t Know. Really. And it is not okay to do randomized double blinded clinical trials to find out. Same with pregnant women: we don’t know if there is a safe amount of alcohol during pregnancy and we bloody well can’t test it. It is safer not to drink while you are pregnant.

In clinic, I ask how much people drink. If they say 1-2 drinks daily, I ask what the drink is. Sometimes they look confused. I explain that I have one patient who has two drinks a day: however, it is a 12 ounce glass with a little ice and a lot of whiskey. I asked him to estimate how much whiskey and he said, “6-8 ounces.” That is, each glass is 6-8 ounces. His blood pressure is not under control and so far I feel like a failure as a doctor with him; he is NOT reducing the amount. In medical school, the two jokes were: How much alcohol is too much? More than your doctor drinks. And: How much does the patient drink? Double or triple what they tell us.

The popular word in college used to be that you could drink one drink an hour and still be “okay”. “Okay” to drive and it would wear off. Sorry, nope. Breathalyzers are now pretty cheap; buy one if you are drinking more than the 1-2 per day. And the college students that are binge drinking 6-8 or more drinks on Friday and Saturday: it DOES have long term effects and it IS doing damage.

Lastly, sleep and depression. If you are having trouble sleeping, don’t drink. No alcohol at all. Alcohol is a depressant. It helps people to fall asleep. But they do not have “normal sleep architecture” and it works AGAINST them staying asleep. People often wake up as the alcohol wears off. And the blood pressure is having that rebound, remember, and often their heart will race. That is withdrawal. If you are having trouble sleeping or you are depressed, do not take a depressant. It makes it worse.

I saw a nineteen year old in clinic who admitted to “occasional” heroin use. “But I’m not addicted,” she said. I said, “Well, that’s good. But I took care of a bunch of people undergoing heroin withdrawal while I was in residency and it looked like one of the most painful things on the planet. So I would advise you to quit while you are ahead.” I saw her a year later and she said, “When I tried to quit, it WAS hard. I was addicted and didn’t know it. I’m off now and I won’t go back.” So if you tell me, no problem, I can quit alcohol any time, I say more power to you. Show me. And if it’s harder than you think, get help.

 

Originally written in 2009 and updated a little today. The picture is just a little fuzzy…like it might be if I was drinking…..

https://www.drugabuse.gov/about-nida/noras-blog/2015/06/addiction-disease-free-will

https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/what-standard-drink

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Cloudy with a chance of hope

This is for the Daily Prompts: hopeful and year.

I took this from the beach with my zoom lens: fog, clouds, lowering, indistinct. My daughter left for college in September and is home now…. well, sort of, except she is off with friends all over the place, including right now.

It’s been a cloudy and hopeful period, since September. It is the first time in 24 years that I have not had children or teens at home, and the first time in 28 years that I have lived nearly alone…just the cat. The cat is not happy with then young adults leaving. She blames me.

I am worried about the US Medical system, the corporate takeover where more and more physicians are employed and then have no connection to how their patients are billed. They also take no responsibility for people going bankrupt over medical bills. We physicians are as responsible for the mess of US Health Care as the patients are, as Congress is, for letting 1300 insurance companies use 500 billion dollars on administrative costs….And people say I don’t trust government healthcare….but don’t take away my mother’s medicare, the VA benefits, medicaid for the disabled and very poor or the healthcare for our active duty. And yet I see for profit companies like triwest: the government contracts my local VA care to them and I fought Triwest for a year to get them to pay me for my Veterans Choice patients. And they won’t pay me for the time we spent fighting to get paid, nor the interest for waiting on a payment for an entire year. Guess who got that money? The For Profit Contractor Corporation: Triwest. And Noridian, the local medicare contractor, held my payments for 6 months. They said my paperwork was wrong….turned out it had been wrong for six years but they frankly didn’t care until they were getting audited. So who paid the price? I did and you did. In rising costs and confusion and physicians quitting. Again, I did not see a penny for the time on the phone, for the time spent trying to ask Noridian why, after 6 years of payments, they were refusing my renewal…..and meanwhile I saw my patients and went further into debt. And do you think the bank corporation wrote off their profits? No, you laugh at that…..

But, you say, where is the hope? The hope is that I think we are at the point where enough physicians are quitting outright, enough Veterans Choice patients are calling their Congress People, the patients refuse to be patient any longer….and I am seeing more people fight for a single payer system, for a system where the money does not go to profit and administration while people die waiting for prior authorization and insurance corporations change the rules every week and refuse and refuse and refuse care…..I think people: patients and physicians: will wake up and change the system.

And that, Mr. Trump, is what I would do to make the US great again….

 

 

 

 

 

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quit

I’ve quit

again
stop start

stop
quit

I don’t think I’ll go back
it wastes the days
makes me so sick
takes so little for me to overdo

I resent lost time
and suffering

my body doesn’t want it
and tells me so
ferociously

alcohol you say?

that too

but I was talking about men

 

The photograph is my mother’s father’s mother. I have one of the originals. The back is stamped: Battle Creek, Michigan. So she was having a “rest cure” at Dr. Kellogg’s famous health retreat.

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Prior authorization: call for comments

The Washington State Medical Association has called for comments on prior authorization rule making for insurance companies. https://wafp.net/prior-authorization-rulemaking-oic-call-for-comment/

Here is my reply:

I have a small solo family practice clinic. My business plan was arranged to spend more time with patients. I have an office manager and no nurse, no back office.

Thus all prior authorizations are done by me, with the patient in the room. Often patients have talked to their insurance company the day before and have been told “your doctor’s office needs to call us”. More than half the time, when I call, we are told that the patient’s insurance company does not cover that service. The patient says, “But I talked to your company yesterday.” The insurance representative responds: “I only talk to physician’s offices, that is another part of the company that speaks to patients.”

This is triangulation, where in the “standard” office, the patient has called their insurance. They call the doctor’s office as instructed by the insurance. The doctor’s office requests prior authorization. The insurance says it is not covered. The doctor’s office notifies the patient, who then assumes that the doctor’s office did something wrong, not that it’s not covered.

This is unacceptable.

I have stopped telling insurance companies that I am face to face with the patient, because some representatives say “I am not allowed to talk to patients, take me off speaker phone.” I document the name of the insurance person in the chart, the length of time for the phone call and I bill for time: counseling and coordination of care. Review by coders say that this is legal.

I suggest that every WSMA physician pick one day to call a prior authorization themselves with the patient present. This would reduce the insurance company triangulation.

I think that insurance companies should be required to tell a patient if a service is not covered, and not be allowed to say, “have your doctor’s office call us” for a service that is not covered.

Feel free to send YOUR comments to the WSMA! https://www.insurance.wa.gov/secure-forms/rules-coordinator/

I like slugs better than health insurance companies.

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Dear Mr. Donald Trump

Two weeks ago I sent this letter to Mr. Trump and all of the presidential candidates. To date I have gotten a form letter from Mrs. Hilary Clinton.

Dear Mr. Donald Trump and all Presidential candidates:

Mr. Trump, I am a rural family practice physician, a woman, who owns and runs my own medical clinic. I take care of patients from age zero to 104. Currently my oldest is 98. I take medicare and most insurances, but not medicaid.

I am running into legal immorality across the board from health insurance corporations that are maximizing profits at the expense of my health care dollar, our taxes and my patients. I would like your advice.

For example, the Veterans Hospital contacted me in May of 2015 and asked me to accept Veterans Choice patients, veterans who live more than 40 miles from the nearest VA Hospital. I accepted. I have 6 veteran patients, who are very complicated. To date I have not been paid for one visit. Now, before you say this is the fault of our government, it isn’t. It is the private for profit government contractor Triwest who is not paying me. They have my notes and we have followed their instructions on how to submit bills. Would you advise me to drop these patients?

For example, my father died in 2014. I called the oxygen company to pick up 6 tanks of oxygen. Then I found 8 more. I gently inquired why he had 14 tanks. The company said that his medical orders said that he should wear it continuously, so they delivered it. “Medicare paid for it.” they said. Ah. Well, I kept the other 8 tanks, because it is my and my father’s oxygen in those tanks: the company can have the tanks back when they are empty.

For example, the head of the sleep apnea supply company came to see me. He said, “You are getting in the way of your patients getting needed equipment.” I said, “Really? How?” “You only allowed a refill of one of the 8 necessary pieces of CPAP tubing instead of signing off on the whole group so we can fill as needed.” “Ah.” I said, “Actually my patients are tired of you mailing them 8 pieces of plastic that are filling up their closets and they don’t want extra plastic crap.” He mails it at the interval allowed by medicare, never mind whether the patient wants or needs it.

For example, I called a patient’s insurance to get a prior authorization last week for a limited sinus CT. They no longer do prior authorizations. They will decide whether to cover the CT scan once they read my notes. I asked if there was ANY way to see if it would be approved. They offered to let me send a letter to a PO Box in Wisconsin. My patient was sick, Mr. Trump. What do you suggest the patient and I do?

This is all legal. But it is not moral. So, Mr. Trump, where do you stand? Is our country’s highest value free enterprise and profit at any cost, no matter how many of our seniors are legally ripped off? Or do we have morals that health care and our elderly are important and need to be protected from legal but predatory businesses.

Please let me know, Mr. Trump. I would rather stick with my small clinic in the United States. At this point I would be financially and emotionally better off working as a temporary doctor internationally. I am sure that there is immorality internationally, but I will be less ashamed when it is not MY country.

Thank you.