focus

For the Daily Prompt: cringe.

I took this on the ridge on top of Mount Zion yesterday. Absolutely gorgeous hike, with the rhododendrons floating among the tall trees and tons of wild flowers. Here are little wild strawberries…. we will have to come back in September.

Cringe: I cringe when I hear the discussion on the news being about health INSURANCE  and not health CARE. We need to change the focus.

We HAVE a mandate that anyone in the US can have health CARE. That is, the emergency room cannot legally turn anyone away. But the bills can bankrupt you and take your house away. Not only that, but the emergency room is the most expensive and worst way to take care of people in the world. The emergency room cannot treat cancer, cannot treat hypertension, cannot help a person with depression, cannot do the long term chronic care that I do. Per person in the US we pay twice as much as the next most expensive country and they have universal care. What is the matter with the citizens of the US? We care more for corporations protecting their profits than we do for our citizens health. And I think this will bring our country down….. we will collapse.

I am a physician but I also run my own clinic. I am a small business owner. And I really expect that health INSURANCE will force my clinic to close.

Call Congress. Say we want health CARE not health INSURANCE.

 

Causes of Death in the United States in 2012

When I first started doing annual physicals I sat down and looked at the top causes of death and then organized the counseling part of the physical around them: starting with heart disease and working down the list. I think of the annual physical as my opportunity to “MOM” patients and say “STOP DRINKING LIKE A FISH OR YOU GONNA DIE EARLY,” though perhaps with a little more diplomacy. Sometimes without much diplomacy at all.

The top ten causes of death in the United States in 2012 were heart disease, cancer, chronic lower respiratory diseases, stroke, unintentional injuries, Alzheimer’s disease, diabetes, influenza and pneumonia, kidney disease, and suicide.

http://www.cdc.gov/nchs/data/databriefs/db168.htm#which_population

This is 2,543,279 deaths in 2012.

Let’s take the causes one by one.

Heart disease: This is number one. 599,711 deaths. 23.6% of total deaths all ages both sexes in the US in 2012. So that is where I start when I do the counseling part of a physical.

Let’s review heart disease risk factors:
hypertension
high cholesterol
family history
diabetes
kidney failure
lack of exercise
tobacco
alcohol
smoking other things…
illegal drugs
stress
obeisity
As you might guess, this part of the discussion can use up a lot of the visit….

Cancer: All the cancer deaths together are 22.9% of the 2012 total.
We can screen for a few cancers: lung cancer is now the number one killer for both sexes. A chest xray is useless for screening. There is a certain population of current or former heavy smokers where a screening CT is useful. No, I do not recommend a “screening full body CT”, that is crap. Yes, lung cancers do get picked up randomly when we do a chest film for some other reason.
We can screen for breast cancer, colon cancers, look for skin cancers, the prostate cancer screen is a counseling nightmare and I don’t recommend a PSA but will do one if the person wants and other cancers pretty much we have to watch for symptoms….stop smoking, ok? That’s what causes 70% of the lung cancer and breast cancer used to be number one in women but smoking made lung cancer beat it out….
If you want details about any screening test, go to the US Preventative Task Force site:
http://www.uspreventiveservicestaskforce.org/Page/Name/tools-and-resources-for-better-preventive-care

Chronic lower respiratory diseases at 5.6%: ok, smoking again. Emphysema and chronic obstructive pulmonary disease, AKA COPD. Asthma too. This article is fascinating, that third generation children of smokers in a polluted part of California are worse and have inherited genetic modifications than third generation children of non-smokers who live in a less polluted part of California. Lovely. I grew up in a two pack a day camel household and no wonder my lungs are tricky.

Stroke, also called CVA, cerebrovascular accident, at 5.1% and then there are TIAs, transient ischemic accidents, the stroke warning symptom.

What are the risk factors for stroke?
Oh, smoking of course
hypertension
high cholesterol
stress
lack of exercise
obeisity
blocked carotid arteries
blood clots
atrial fibrillation

Unintentional injuries at 5.3%, also known as accidents.

Deaths from prescription medicines taken correctly outstripped deaths by MVAs, motor vehicle accidents and guns in 2007. The CDC declared an epidemic of overdose deaths, but it’s just starting to creep into newspapers and public consciousness.

Here: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm

The unintentional injury counseling list includes:
wear your seatbelt
don’t drive inebriated
don’t get in the car with inebriated drivers
check your smoke alarms
in the elderly, decrease fall risk. don’t stack stuff on the stairs.
wear a helmet if you bicycle motorcycle ATV rollarblade ski or invent some new way of getting on the Darwin list. Base jump, for example.
don’t take a lot of controlled prescription medicines or combine them with each other or combine them with alcohol: opiates with benzodiazepines with alcohol with ambien or sonata with barbituates and hello, the drug dealer is not your friend and tells lies: they are cutting the methamphetamines here with tricyclic antidepressants and barbituates and my long term cocaine addict patient was getting methamphetamines with benzodiazepines when he was paying for cocaine. Really.

Alzheimer’s at 3%

This is moving up the list. Fast. Everyone dies of something. Alzheimer’s patients live an average of seven years from diagnosis….And the recent article about Human Growth Hormone transmitting not only prions but Alzheimer’s is really interesting, implies an infectious cause.

Here: http://www.nature.com/news/autopsies-reveal-signs-of-alzheimer-s-in-growth-hormone-patients-1.18331

That was HGH from cadavers. I still would not take HGH made in a lab for “anti-aging” either. Nope, nope, nope.

We don’t know how to prevent Alzheimer’s but that is not the only cause of dementia and we’re still naming different kinds. Very frequently a brain CT or MRI says “decreased white matter” or “small vessel disease”, so there is a contribution from all of the heart and stroke risk factors that can do bad things to the brain with the top ones being: tobacco, alcohol, hypertension, high cholesterol, stress, lack of exercise, diabetes, illegal drugs, and so forth. Keep your brain active and busy.

Diabetes at 2.9%
Ok, it can make you more likely to have a heart attack. Also the biggest cause of blindness in US adults and the biggest cause of lower limb, yes, foot or leg amputation and the biggest cause of kidney failure in adults. Also if your legs are numb from uncontrolled diabetes, you don’t feel injuries and are less able to heal infections. And if blood sugar is high, there are lots of bacteria and especially staph and strep that LIKE high sugar.

influenza and pneumonia at 2.1%

Get Your Flu Shot. Really. And if you are 65 or older or you have tricky lungs or you have a tricky heart, get the pneumovax shot. The pneumovax protects against pneumococcal pneumonia ONLY, not all the colds or influenza or hemophilus influenza. And get your Tdap, because that stands for Tetnus, Diptheria, acellular Pertussis. Pertussis is whooping cough. It’s back. We’ve had three outbreaks in our county in five years. It kills babies under six months. They don’t whoop, they just stop breathing, apnea. Other people whoop, but even with antibiotics, they can cough for MONTHS. The flu shot usually gives 80% protection by two weeks after the shot. Only 80%, people say? Well, are you perfect?

Kidney disease at 1.8%

Causes: kidneys get worse as we age, for one thing.
diabetes
supplements and drugs: kidney failure is on the rise! Everything that we absorb and metabolize is metabolized by either the liver or the kidneys. Liver function can be perfect at age 100: that is, if it has not been trashed by alcohol, hepatitis B or C, drugs, supplements, mushrooms, whatever. Kidney function usually drops by age 80 and I am there calculating the function before I choose an antibiotic because you have to use lower doses in the over 80 crowd and the early kidney failure crowd. If you take ANY PILLS you should have a yearly test of your kidneys and liver function.
infection can hurt kidneys
inherited disorders

Suicide at 1.6%
40,600 deaths in the United States in 2013

Risk Factors http://www.cdc.gov/violenceprevention/suicide/riskprotectivefactors.html

Family history of suicide
Family history of child maltreatment
Previous suicide attempt(s)
History of mental disorders, particularly clinical depression
History of alcohol and substance abuse
Feelings of hopelessness
Impulsive or aggressive tendencies
Cultural and religious beliefs (e.g., belief that suicide is noble resolution of a personal dilemma)
Local epidemics of suicide
Isolation, a feeling of being cut off from other people
Barriers to accessing mental health treatment
Loss (relational, social, work, or financial)
Physical illness
Easy access to lethal methods
Unwillingness to seek help because of the stigma attached to mental health and substance abuse disorders or to suicidal thoughts

And for those who want in depth information, 15 leading causes of death by state:
http://www.cdc.gov/nchs/nvss/mortality/lcwk9.htm

Cost comparison of brain MRI

I called Advanced Medical Imaging (AMI) in May 2014 to get a prior authorization for a brain MRI with and without contrast.

This is for a woman under 65 who is having short term memory problems. We are looking for treatable causes of short term memory loss. The blood work is negative. Next is the MRI.

Her MRI is already scheduled at the local hospital where I worked for nine years. It is the only hospital because we are a small county.

The AMI representative suggested that the patient get the MRI in Everett.

“The cost there is $917.00. It would be cheaper. It is only 29 miles away.”

“Yes, but Everett is across the sound. She’d have to drive around or take a ferry. What is the cost in Bremerton?” I asked. “At the radiology providers there?”

“The cost there is $967.00.”

“And where she is scheduled?” My local hospital has a “Rural Hospital” designation. Medicare will pay them more than other hospitals.

“$4585.00.”

I squeaked. “For the same MRI?”

“Yes.”

“Um. You should tell the patient.” Except that, is the patient willing to drive to Bremerton? And is the cost to the patient the same? And do they care?

“Do you want the prior authorization for that site.”

“Can it be changed if I talk to the patient?”

“Yes, she can call us.”

The prior authorizations are now site specific. That is, I’m getting approval for the MRI at a specific place. I have no idea why.* Seems stupid. Seems like just another hoop to remember to jump through and if we get it wrong the insurance can say, “Oh, ha, ha, ha, we don’t have to pay for that. You do.” Chalk up some more profit for the investors. Mission accomplished, money made.

I called the woman and explained. She was willing to go to Bremerton and said that she would call AMI. I asked her to call us back if she had any trouble.

The cost really matters to my medicare patients and any patient that has to pay a percentage of the cost. If they only have medicare part B, with no secondary, they pay 20% of the bill. 20% of 4500.00 is a lot more than 20% of $900. But some of my frailest most elderly most confused don’t really have a choice. Going 29 miles might as well be going to the moon.

And this is a woman with memory loss, remember? She wrote down the instructions and repeated them back to me three times.

Every phone call to insurance is like this, and makes me wonder about our culture.

* Actually, the authorizations are site specific because some places are “out of network” and the insurance won’t cover anything done there. Though I think the whole point of health insurance in the US is to try to remove money from people and avoid paying for care.

This was first posted at everything2 on Friday May 9, 2014. The woman died last month.

Comparison of cost of abdominal CT with and without contrast

I keep reading that the US Health System should be a “free market” with competition.

To have an free market, one needs to be able to check the prices. I want to compare price tags. I have a patient who needs a CT scan of the abdomen and pelvis with and without contrast. So can I, as a doctor, find out the price?

I start making phone calls:

I call AIM Specialty Health, a procedure clearing house hired by many insurers here, to get prior authorization for the CT of the abdomen and pelvis with and without contrast. They ask for the usual identifying information: my name, tax id, NPI number, patient name, insurance number, check my address, phone number, fax number. They ask for theICD-9 codes — codes for the diagnosis. I know those. They ask for the CPT code, which is the procedure code for the test. I have to scramble to find the book and look it up: 74178. With the brain MRI the other day they volunteered site specific charges. Not this time. The representative said they didn’t know. I asked for prior authorization in Poulsbo, since that was most reasonable for the brain MRI. I asked what the patient’s copay is: AIM does not know.

Call to Premara Blue Cross, which is the patient’s insurance company. They can tell me that the patient has a $10,500 deductible each year. She will have to pay that much before the insurance pays anything. I ask them what it will cost at different sites. They say they can’t give me that information.

Next I call 5 different sites to get the price for that CPT code/proceedure.
Call to my local hospital: Charged amount is $4200.00
Call to a free standing radiology clinic in Poulsbo: Charged amount $1416.00
Call to the hospital in Bremerton, south of us: $8958.00.
Call to a free standing radiology clinic further south in Silverdale:$1526.00 + $20.00 for contrast.
Call to the hospital in Port Angeles, north of us: $ 3101.70 for the facility fee. Gave me Radia’s number for the physician fee.
Call to Radia and left message.
Left message with patient.

Radia called back and the fee is $346.80, so that would be added to the $3101.70 at Olympic Medical Center.

Now I know the amount BILLED at five sites. However, that is not the amount my patient will PAY.

If the site is “in network” then the site has a contract with Premara Blue Cross, which states the amount that Premara is going to pay. The patient will get an EOB, an explanation of benefits, from the insurance. “Benefits” is an interesting choice of words. The patient has paid for the insurance so that they will cover the bills. Is that a “benefit”?

On the EOB, it will state the amount that was billed for the service. Next it will state the amount “allowed”. “Allowed” is misleading. To me it implies that the insurance has held the cost down. But the insurance “allowed” the site to be “in network” because the doctor/site signed a contract. So this is a contracted price or agreed upon price.

I want to know the allowed/contracted/agreed upon price.

Call to the WA State Office of the Insurance Commissioner. The office says that the patient should be able to request the allowed cost for a specific site. Each site has a separate contract with the health insurance, so the allowed cost could be different at each site.

Call to Premara Blue Cross. This time they say that it’s not that they refused the information, it’s that it was not available. Now the representative says that they need the “units or minutes billed.” I don’t know what that is, but I will find out. I ask if that is the only other thing that I need. They say yes, but I cannot contact the same rep directly. I have to go through the rigamarole each time: my name, my tax id, patient’s name, patient’s insurance identification number, my clinic address, fax number, phone number, sometimes the patient phone number. Usually I have to punch 4 or five of these into the automated system and then have to repeat it all when I reach a human being.

Call to Poulsbo. The units refer to 100 units of contrast. Some patients will need more, up to 200 units.

Call to Premara Blue Cross again. I go over everything with representative Hailey, who then wants to know the amount that Poulsbo is billing. Explained that I was told only the units were needed. She put me on hold and checked with Poulsbo. She is quoted the same price.

Continuing with call to Premara Blue Cross. Hailey has entered everything and doesn’t get a result. She says she doesn’t know. I explain that they have a contract with Poulsbo that names an actual amount. She transfers me to another department after 25 minutes. The representative there says that she can give the allowed amount information to the provider doing the test, that is, to Poulsbo. I explained that the WA State Office of the Insurance Commissioner says that a patient can indeed request that information. I asked if they are refusing it to the patient. Rep repeats that she can give it to that provider but not me. I offer to have the patient in for a visit and get them on speaker phone and again request the information. Without the information, I will strongly consider filing a complaint with the state insurance commission. She decides to transfer me. That’s at 30 min and I am again put on hold.

The call to Premara Blue Cross ended after 45 min and 37 seconds and the third representative in the provider relations department states that if they get a call from Poulsbo that they could tell THEM the contracted allowable amount. Again stated that the insurance commissioner’s office says that the patient can request the amount. Are they and will they refuse it to the patient? Representative Whitney says that she has access only to provider accounts and that the contract with Poulsbo is proprietary information*. I say that I think health insurance is also a contract between the patient and the insurance and surely the patient can ask what it will cost in advance. I stated that I would be calling the patient and the state insurance commissioner’s office again.

I talk to the patient. She will now call the insurance and ask the “allowed” amount for this site. I give her the diagnosis code, CPT code and units billed.

She calls back. Premara says “around $600.00”.

I call Poulsbo and ask if they will check the contracted amount. They call Premara. They call me back.

If she only has 100 units of contrast, the CT of the abdomen and pelvis with and without contrast will cost her $641.00, as the “allowed” amount by contract between her insurance and the radiology site.

I still do not know the “allowed”/contracted amount for the other four sites, so I have failed in my attempt at comparing price tags. I only know the amount the sites would bill. The “allowed”/contracted amount for each site could be different. The hospitals bill more because they have a “facility” fee. I think this means that they are allowed to factor in various hospital costs. Even so, it seems outrageous that one hospital bills twice as much as the other two and more than six times as much as the least expensive site, but the allowed amount might be lower then the billed amount.

I don’t think this is a free market. I think it is an obscured market. And this is just one procedure and one single charge. Think of a hospital stay.
AIM Specialty Health http://aimspecialtyhealth.com/about-aim/guidelines
Washington State Office of the Insurance Commissioner is at http://www.insurance.wa.gov/
Premara Blue Cross https://www.premera.com/wa/visitor/

* When I called about the head MRI, why wasn’t the information about what is billed at different sites proprietary then?

This was initially posted on everything2 on Friday, May 16, 2014.