Tis the season for Naughty or Nice - Health Insurers making a List & Checking it Twice

     During the holiday season we hear ”he knows if you’ve been bad or good “ and “be good for goodness sake.” The “he” might be your PPO or HMO insurance company. They monitor prescription refill rates, lab follow-ups and health screenings. The health insurance company sends friendly reports on delinquent patients to their doctors. So when your monthly prescription bottle of 30 pills, lasts you 40 days, it flags you as a non-compliant patient. “ … gonna find out who’s naughty or nice…”

     You might think, “Who cares?” Well, the doctor/ medical group might care when it shows up on the doctor’s quality rating. For example, once anti-depressants are started, they should be taken for a minimum of six months or so. Even if the doctor advised it or prescribed it, it lowers his quality of care rating when his percentage of patients finishing six-month courses of treatment is low. When you look up a doctor on your insurance website, and see how many stars he has on the quality area, this is one criteria. “… he’s making a list and checking it twice…”

     Lab follow-up is important and “quality” doctors do advise it. So if you have high blood pressure, diabetes or other health problems that has a EBM (evidence-based medicine) protocol, then be good and don’t have lapses. Every diabetic should have an A1c test every six months. If you don’t show up for the blood test and no lab billing ever goes to your insurance company, then you are being non-compliant. (With computerized records they will have direct access to tests being done and test results, without just waiting for billings.)

     What about that screening colonoscopy that your doctor has been advising you since you turned 50? So you’re 55 now and both you and your doctor have been showing up on the “naughty or nice” list (n/n list) of the insurance company. Oh, by the way, while you are waiting to schedule, just ask for the home stool test. It is not nearly as accurate in screening for colon cancer (only 5 percent versus 90 percent with colonoscopy). But it helps you and the doctor with being on that n/n list.

    

Now that you know a little bit about how insurance companies rate doctor quality, now let’s look at “efficiency” (think $$$ ).

First you need to know that no matter what the doctor charges, the managed care insurance company has a contracted rate that the doctor must accept in order to be in network.
So how do they rate a doctor for cost? Part of the answer lies in what he orders: if any X-ray, CT or MRI is ordered for an uncomplicated low back pain, then that goes on the naughty list. In treating ear infections, if amoxicillin is not the first antibiotic, then off to the n/n list. If any antibiotic is prescribed in the first four days after an office visit for bronchitis, then n/n list.

     Of course doctors use their clinical judgement and are used to non-clinicians overlooking their art of medicine. So, let’s sing, all together now: “You better watch out, You better not cry, Better not pout I’m telling you why…”  (It’s better than the alternative: “having a blue Christmas without you …”)

Diabetes Awareness Month. Are you aware? Good, now what?

     We are in the midst of Diabetes Awareness Month. Are you aware? Good, now what? It’s easy to miss the forests for the trees: don’t focus on diabetes as a sugar problem; it’s mostly a blood vessel problem.
For those of you who are proud of “not having” diabetes, look hard at whether you are closer than you think. Many overweight, inactive Americans have average glucose readings (A-1-C levels) that are not normal but not quite diabetes. The new normal levels are under 5.7, not 6.0. If your A1c levels are not ideal, then your arteries could be in trouble. Don’t think clogged arteries are just about heart attacks. Yov’ve heard the ED commercials: arteries with fatty plaques can get reduced blood supply to the genitalia.

When the retina gets less flow, then excessive number of small vessels form, which leads to blindness. Other complications of even “borderline” diabetes are kidney damage, strokes, blood clots, poor leg circulation, etc.     Are you aware now? Let’s look at American Diabetes Association (ADA) (Diabetes.org):
-November 14 is the birthday of Sir Frederick Banting, the co-discoverer of insulin.
-2010 slogan is Let’s Take Control of Diabetes.

-an epidemic: 24 million Americans have diabetes now; 57 million more are at risk.
-kills more Americans each year than breast cancer and AIDS combined.
     The ADA makes us aware that symptoms may seem harmless and delay getting diagnosed:
Type 1 diabetics might have an increase in urination, thirst and hunger. There might be weight loss and fatigue,
Type 2 diabetics may have additional symptoms (Used to be called Adult Onset Diabetes, but now there are so many overweight teens getting it). An increase in infections and delay in healing. There may be blurred vision or funny sensations in the extremities.
But maybe the most important symptom the ADA mentions that: “Often people with type 2 diabetes have no symptoms!”

“Studies have shown that type 2 diabetes can be prevented or delayed. Thirty minutes a day, five days a week, of moderate physical activity (such as brisk walking) and a 7% reduction in body weight (or about 15 pounds if you weigh 200 pounds) can help lower your risk for type 2 diabetes,” commented Mayer-Davis. “In addition, many diabetes complications, whether you have type 1 or type 2, can be prevented or delayed with exercise and healthy eating.”
      ADA might borrow a slogan from breast cancer awareness: you’re at risk if you’re female and getting older… A crude slogan for diabetes awareness could be:
     If you’re breathing, overweight and inactive (like most Americans), get tested for pre-diabetes and diabetes. And don’t forget the extra risk if it runs in your family.
If you have symptoms, or no symptoms, and you have some risk factors, get tested.
     Ask about your A1c levels. And while you‘re there, ask about advanced cholesterol testing. Controlling cholesterol goes hand in hand with complications of diabetes control.
     There are good medicines for diabetes, but it is better to prevent this disease that never goes away, only controlled. Don’t be a victim to statistics that show that over a decade. 60 % of pre-diabetics become diabetics. Be a victor with brisk walks, a little weight loss and whole grains. Those who do it reduce their risk down to only 25% chance of getting diabetes.

     Do you consider yourself aware now, or just confused about diabetes? Talk it over with your primary care provider and get regular follow-ups.

And now for Great news about health reform.

Here is a list of what they promise:
- Guarantee to be able to keep or get insurance no matter what. Not just if you never got insurance when you could have. But not getting thrown off insurance when you or your partner gets health problems that forces the loss of a job.
- No more high deductibles and copays: sure the colonoscopy is covered but only after you meet your $1000 deductible on some plans now. People often elect to keep down their premiums by choosing a high deductible. Then something comes up and they lose so much: out of pocket can often be $5000 a year for several years
- Everyone gets coverage. How often do we see government funds being used for hospital care for the uninsured?
- Prevention is covered without any out of pocket money. Often expensive heart attack hospitalizations or colon cancer surgery could have been prevented. Again we all pay when our private insurance goes up or more tax money is used for those without insurance.
- The youth are covered under their parent’s group coverage until age 26. now many plans do not allow this unless they are students.
- Less job lock: many people are tied down because of their benefits that their employer gives. There could be more entrepreneurs who go into business for themselves if they are assured of getting the same group benefits and guarantee of coverage.
- No limits of coverage. One could do everything right and be responsible, ready for catastrophe and then a lifelong health problem hits. That million dollar limit, just ten years of 100,000 annual costs can come quickly, and then off to bankruptcy.

The hope of health reform gives all Americans

 the promise of

incredible health and medical care from infancy

till death.

Good News about Health Reform - Sort Of. by Anthony Russo MD in the Pflugerville Newspaper

     Every American, etc. gets coverage for preventive health care... as long as the test has been deemed to have a Grade A or B rating by the U.S. Preventive Services Task Force. (Remember their controversy last year - not recommending mammograms or even women to do self breast exams.) The "Patient Protection" and "Affordable" Care Act(quotes added) mandates that all insurance plans cover certain preventive care services without any co-pays or deductibles. That sounds good ... maybe: preventing problems may end up costing less… maybe).     Let's look in detail at one preventive service. You might ask yourself; do I need to know what my cholesterol is? That depends, according to USPSTF (let's shorten it to TF - here referred to as “the force” ) If you are the right gender and age and have been deemed by TF to have the right degree of risk factors, then yes.

     So a 35 year old man has the right to be tested. However, TF says it is only necessary to do the total cholesterol and the good HDL cholesterol. The Force has evidence that there is no need to find out levels for: LDL (bad cholesterol), Triglycerides, etc. This young man could actually have found out his cholesterol at age 21 if he had one of these risk factors:

- diabetes (not borderline diabetes, even if his doctor thinks it is important)
- obesity (the BMI must be 30; if you put your weight in your belly, a big risk for diabetes, but you are not quite obese, then not deemed a risk factor.
- smoking
- high blood pressure
- heart disease
- family history of heart disease only if the male relative was under 50 y.o.(or female under 60)
     What about screening women for cholesterol. The Task Force does not give a grade A or B rating for women, unless they have one of the above risk factors. They recommend women never knowing their cholesterol level unless at risk, NEVER, EVER! What if your doctor ( I mean “health care prescriber” ) wants to do this simple $5 blood test because of multiple borderline factors. Let’s look at this person:
-a 60 y.o. woman who never had a cholesterol check in her life
     She could have the combination of borderline risk factors for heart disease: her glucose A1c level is 6.4 (not quite 6.5 level of diabetes), she is almost obese with a BMI of 29 (not 30), her parents had cardiovascular disease but not within the guidelines, father’s heart attack was at 51 y.o. (over 50) and mother’s stroke was at 61 y.o. (not 60). She heard that high cholesterol and diabetes runs in the family.
     The health reform plan would not cover it since the Task Force does not give her case a Grade of A or B.     Hopefully there will be even more “protection” when it comes to lab charges. Now, the lab sends the full charge of about $100 for cholesterol; when the insurance plan approves of the test, the lab accepts the discounted payment of about $5 as fully paid. Once insurance does not allow it, the lab is obligated to bill the patient the full $100!     Hopefully, insurance plans allow doctors to do tests they feel are necessary. Not everybody is a “Straight A” patient

Pflugerville Newspaper - Intro to my Health Series

By Dr. Anthony Russo /Special to the Pflag
     Welcome to my new series of articles on health and medicine. As a medical doctor with years of experience, I will try to share interesting news and my perspectives of medicine. I am impressed with what the Pflag is doing, including their online version.  When I spoke with the staff at the Pflag, they were interested in exploring various topics from the perspective of a M.D. in our community. Here are some topics to explore, but I will want to see what readers’ concerns are about maintaining health and medical care. Remember the comments section of the Pflag at pflugervillepflag.com.
• Cardiologists tell us that 80 percent of all heart attacks are preventable. Clogging arteries is developing in the majority of Americans, most of whom are unaware.
• News reporters constantly speak of how overweight we are and that pre-diabetes may develop. However, do we understand how much damage can be occurring and how certain meds and activities can help?
• TV and radio bombard us with ads about supplements, diets, gadgets, etc., that have no more proof of effectiveness than a hocus pocus ceremony. Yet how many Americans really understand the scientific method to evaluate if something really works? Be honest, one success story from a person’s mouth convinces us more than a billion-dollar medical study.
     The Pflag is interested in exploring various aspects of health. Let’s explore.
I may bring up more questions than answers. These days with Internet searches, the knowledge base is out there; to get the right answer you need to know the right questions to explore. In addition, my blog has an anonymous comment section. After personally reviewing them, I will post some. Let’s see what Pflugervillians (or is it Pflugervillites!) are interested in when it comes to health and medicine.

• PvilleHealth.blogspot.com
• No questions about any person’s individual medical concerns! No diagnosis or treatment will be offered.
     Everyone should have a doctor-patient relationship, someone to be there for the questions (and sometimes the answers) when it comes to your health. Salud!
          Anthony Russo has been a primary care physician in Pflugerville since 1988.

Health Reform - the Good and the Bad

Any thoughts on the recent articles in the Pflugerville Pflag on health reform?

Statin with that Burger? ...

Since cholesterol lowering "statin" meds are over-the-counter in England, they proposed selling them at fast food places. ( published August 15th, 2010 in the American Journal of Cardiology, "Dr Darrel Francis and colleagues calculate that the reduction in cardiovascular risk offered by a statin is enough to offset the increase in heart attack risk from eating a cheeseburger and a milkshake")
What do you think about this.

In The News...

New reports say
...Diabetics should get Hepatits B vaccines and checked for levels of protection 2 months later.

...African Americans should get initial screening Colonoscopy at 45 y.o. instead of the usual 50.

Gulf oil spill : what evidence is there of bad health effects of disspersants? What part-per-million levels?

What's new in Health?

Any interesting new topics in the news?

Welcome to P Ville Health

Follow this blog for interactive communications about Pflugerville ("P" Ville) Health. What is and what isn't "health" anyway?