Choosing Doctors

This is an excellent article, which appeared in Medscape Week in Review on 24 May 2016.  It’s reprinted here in its entirety.  If even doctors are challenged in selecting a doc, how should the consumer feel?

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Choosing Between Two Doctors: One Physician’s Experience

Andrew N. Wilner, MD

|May 19, 2016

Introduction

Recently, a close family member—let’s call her “the patient” —needed a complex elective surgery. Her medical doctor gave us a few surgical referrals. We picked the one at the top of the list.

Luxury of Choice

The ability to choose one’s medical doctor is a luxury. Often, an accident or sudden severe symptom such as syncope or chest pain results in emergency transport to the nearest healthcare facility, where one is greeted by the duly assigned healthcare provider of the day. The relationship is forged on the basis of urgency and need, and both patient and doctor accommodate accordingly.

How to Choose?

But sometimes, one has the luxury of choice. Before entering into the sacrosanct patient-physician relationship, a patient can do due diligence regarding the physician’s training, experience, standing among his or her peers, as well as online reviews such as Yelp, where doctors are rated “like restaurants.” It’s not clear how useful all of this research is except to weed out the few bad apples who failed their boards and consistently receive one-star online reviews. But bad reviews tend to be based on long waiting times and snarky staff, not the doctor’s performance. A doctor’s competence, except in the most flagrant cases, is exceedingly hard to judge. Even a surgeon’s track record of successes and failures will be affected by the age, stage of illness, and comorbidities of the patients. A surgeon who only operates on “easy” cases might have a great track record. A more proficient surgeon who takes all comers would have a much worse record. Most doctors are capable, competent, responsible, and get the job done. But even capable, competent, and responsible doctors are not interchangeable.

Doctor #1

Our trusted doctor’s referral was sufficient endorsement, but I still did a background check that revealed an impressive website that included education materials, a patient portal, patient approbations, and boasted an affiliation with a nationally respected medical center. We made an appointment.

It was all uphill from there.

A few days later, the doctor’s office called requesting that we change the appointment. The secretary explained that she was using new scheduling software and had made a mistake. Could we come the following day instead? We were able to change our busy schedules to accommodate. No harm, no foul.

We were told to register ahead of time on the patient portal. We tried, but the passwords didn’t work. This was frustrating and took days to fix.

The Visit

We faxed records several days ahead of time and even brought hard copies with us. I had already made several calls to the doctor’s office to ensure that we were “in network.” We arrived early, as instructed, completed registration paperwork, consents, record releases, and more, then handed the records to the secretary. The doctor saw us on time, listened intently, and suggested further testing. These results would guide his final decision regarding which procedure to do. Upon review, his recommendations included many of the blood tests we already had. When I pointed this out, he seemed irritated and said that he didn’t have access to these. This was incredulous, as I had faxed them days ago and handed hard copies to his secretary just minutes before. He just shrugged and indicated that the consultation was over.

Who’s On First?

We went to another office where an LPN printed lab slips for the blood tests. I saw that there were new tests as well as some we already had. Perhaps the doctor wanted the same ones repeated? Even though this surgery was outside my realm of expertise, I observed that an entire panel of blood tests had no bearing on the problem at hand. When I pointed this out, the LPN filling out the forms agreed, cheerfully admitting that she had clicked the wrong box on the computer screen.

The blood tests had become a comedy of errors. The doctor had ordered additional tests that needed to be done, which were mixed with orders for blood tests that had already been done, combined with tests the LPN had mistakenly ordered. Sorting out this mess took more than an hour. That extra hour meant that we missed the 3 PM closing time of the blood lab and had to make another trip, resulting in more time off from work, frustration, etc.

A few days later, when we checked the results on the now functioning portal (the office never called), I saw that despite my arduous efforts, the same blood tests had been repeated anyway. In this era of high insurance deductibles that can run into the thousands and, indeed, tens of thousands of dollars, these errors would result in hundreds of dollars of out-of-pocket costs. To make matters worse, one of the original routine tests that had been normal was inexplicably abnormal on the unnecessary repeat testing. A third “tie-breaker” would now be required, inflicting more discomfort on the patient and consuming more time and resources.

It’s Up to You

When we returned for consultation, the doctor gave us the low down on the surgery. There were several options, all with varied degrees of success and risk, including death. He seemed loathe to make a recommendation. He insisted that it was up to us. This position was infuriating. Of course it was up to us. But it was up to him to make a recommendation. After I insisted, he reluctantly chose one procedure and said that if it was his family member, that’s what he would do. Based on the patient’s age, history, comorbidities, and testing, he estimated that there was only a 75% chance of success. I asked what we could do to improve the odds. He said, “nothing, it’s just luck.” When I added that as a physician it was very difficult for me to be on this side of the desk, he just smiled and nodded. He offered no words of encouragement or advice.

No More Questions

Immediately after we left the consultation room, I remembered an important question and tried to stop the doctor as he strode down the hall. He glared at me as if I should know that the consultation was officially over. Now, it appeared, I was invading his personal space and time. Perhaps I was, but I didn’t appreciate the glare.

Safety or Convenience?

The office assistant explained that the procedure would be done at the outpatient surgicenter at the nearby hospital, although often the doctor did the same procedure in his office. When I asked why we needed to go to the hospital, yet another foreign facility we would have to navigate, she explained that the doctor preferred operating there because they “turned over the room quickly.” (The answer I was hoping for was that the hospital setting provided better facilities and proximity to emergency services, should they be required, but that didn’t seem to be the doctor’s priority.)

Another Opinion? Really?

In the big picture, these were all small injustices; a change in appointment, a defective patient portal, some blood test errors, a receptionist’s perhaps mistaken perception of the doctor’s priorities, and my hassling perhaps an overhassled physician.

But I wasn’t happy and told our family doctor. What if the surgery didn’t go well? This doctor didn’t seem to care one way or another. Our doctor recommended another surgeon for us to try. Faced with the possibility of having to repeat tests, fill out more forms, register on another patient portal, and check benefits with our insurance company, the patient, who had been pretty tolerant of all of the above, wasn’t keen on getting another opinion. Wasn’t one opinion enough? What if the opinion was different? Would we need a third? She had a point. Nonetheless, I insisted.

Doctor #2

The second doctor had no opening in her schedule for months. However, out of professional courtesy, she would see us after normal office hours. I wasn’t enthusiastic about getting a complex consultation at the end of a physician’s busy day, but I appreciated the gesture. (A word of advice: If ever you need an appointment with me, first thing in the morning is best.)

The Doctor Did Her Homework

A few days before our appointment, the office called to say that the doctor couldn’t read a few of the many fax pages we had sent. I was impressed. Not only had Doctor #2 reviewed the records, she wanted to ensure that they were complete.

A Clear Recommendation

The day of the appointment, we arrived early as usual and filled out paperwork. We were told that the doctor was running behind. She didn’t see us until almost 6 PM. We were happy to wait, but I was concerned that the late hour might mute her interest in our case. Not in the least. Our consultation lasted until 7 PM. She patiently listened and reviewed the now voluminous records and blood tests. Nothing needed to be repeated. She acknowledged that there were several options but, without hesitation, made a clear recommendation. She would do the procedure in her office where she had everything arranged as she wanted it, including an anesthesiologist on site. It was true that there was risk for injury and death, but she had never seen these rare complications. She positively glowed as she advised that 3 out of 4 patients with this problem would do well.

Conclusions

The relationship between doctor and patient (and family) is intensely personal. Doctor #1’s office was disorganized with poorly trained staff who made many small mistakes. This did not inspire confidence. Nor did the doctor. He was professional but cold and dismissive. On the other hand, perhaps his technical skills, arguably a surgeon’s most important attribute, were superior to Doctor #2. We had no way of knowing. When it came down to it, the recommended procedure, risk for complications, and chance of success were the same with either doctor. No doubt Doctor #1 was correct—it would all come down to luck. But if we didn’t have luck, I knew which doctor I’d rather have at the bedside. Thank you, Doctor #2.

Note: Minor alterations in the details of the above true story have been made to protect privacy.

Drug Price Reform — When, Not If

Brand name drugs are expensive.  They’re more expensive in the US than elsewhere, but they’re still expensive, regardless.

Prices are based on a number of factors, including what manufacturers think they can get insurance companies and governments to accept.  List prices are paid by consumers without health insurance.  Insurers and government programs pay negotiated rates often substantially below list.

Prices are supported by patent and exclusivity laws that protect original manufacturers.(2)  The US is the leader in this, to the point that drug companies will discard work on promising medicines if they believe they cannot obtain patents for them.(1)  For US consumers, it means they pay higher prices than people in other countries for the same drugs from the same manufacturers.  Congress has also made it illegal for US consumers to buy drugs elsewhere and bring them into the US.

“The current model for cancer drug pricing is not sustainable and harms patients and families as well as our health care system.” (5)

“Americans with cancer pay 50 percent to 100 percent more for the same patented drug than patients in other countries. As oncologists we have a moral obligation to advocate for affordable cancer drugs for our patients.”(6)

Take GSK’s Advair inhaler as an example.  The cash price of the 500/50 version of the inhaler for a consumer without insurance in the US is between $560 and $600 for a one-month supply.(3)  The price for the same product in Canada is $84.00.(4)  Some US consumers with insurance will pay a higher copay than the cash price in Canada.  With Horizon Omnia, I was quoted a price of over $300 for this drug by the pharmacy department at Wegman’s.

Prices are becoming detached from research costs.  The price for insulin for the treatment of diabetes has tripled in the last decade, despite the fact that the product has been largely unchanged for decades.(7)  (Synthetic insulin was introduced in the US in 1982, following development in India.)

More increases apparently are pending.(9)

Some people are angry about pricing, and one country is finally taking action.  Colombia has ordered Novartis to lower the price of its leukemia drug, Gleevec.  If the company does not comply, Colombia has threatened to break the patent and issue licenses for production of a generic version of the product.  According to Fox News, members of the US Congress are involved in lobbying the Colombian government to protect the drug company.  US Senator Orin Hatch of Utah is one of the people named in the news report as having close ties to the pharmaceutical industry.(8)

Whether Colombia breaks the current pricing model, or it happens elsewhere, it’s just a question of time.  Current prices are artificial and based on government intervention in the markets, and not on free market economics.

However, that’s the paradox that some conservative politicians like to ignore:  one is against government controls unless the controls lead to higher profits for your friends.

 

 


Sources:

(1) Frakt, Austin. “How Patent Law Can Block Even Lifesaving Drugs,” The New York Times.  28 Sept. 2015.  http://www.nytimes.com/2015/09/29/upshot/how-patent-law-can-block-even-lifesaving-drugs.html?_r=0

(2)  “Frequently Asked Questions on Patents and Exclusivity.”  US Health and Human Services, Food and Drug Administration.  http://www.fda.gov/Drugs/DevelopmentApprovalProcess/ucm079031.htm#How%20many%20years%20is%20a%20patent%20granted%20for?

(3) GoodRX.com.  http://www.goodrx.com/advair-diskus?form=inhaler&dosage=500mcg-50mcg&quantity=1&days_supply=&label_override=Advair%20Diskus

(4) Canada Pharmacy Online.  http://www.canadapharmacyonline.com/DrugInfo.aspx?name=Advair+0042

(5) Fred Hutchinson Cancer Research Center. “Expert opinion on how to address the skyrocketing prices of cancer drugs,” Science Daily.  12 February 2016.

(6) Mayo Clinic.  “Oncologists reveal reasons for high cost of cancer drugs in U.S.”  Science Daily.  16 March 2015.

(7) University of Michigan Health System,  “Sugar shock: Insulin costs tripled in 10 years, study finds,”  Science Daily.  5 April 2016.  https://www.sciencedaily.com/releases/2016/04/160405122030.htm

(8) “Colombia battles world’s biggest drugmaker over cancer drug,” Fox News Health.  18 May 2016.  http://www.foxnews.com/health/2016/05/18/colombia-battles-worlds-biggest-drugmaker-over-cancer-drug.html

(9) Frellick, Marcia.  “17 Essential Drugs at Risk for Price Boost, Analysts Say,” Medscape. 19 May 2016.  http://www.medscape.com/viewarticle/863544?src=wnl_mdplsnews_160520_mscpedit_wir&uac=153634BV&impID=1103558&faf=1

C-Section Cons and Pros

TheVCphoto2 C-Section rate is an important criteria in selecting an obstetrician.  Neither the decision to do the procedure nor the choice of doctor are trivial, but they are related.

The C-Section is the most common surgery performed in the US.  The primary factor determining whether this procedure is performed is the doctor and hospital the woman chooses, and not medical need.(7)  The rate of Cesarean births was 4.5% when first measured in 1965; it was over 32% in 2014.  As of 2014, Louisiana and New Jersey led the US in the highest rate of C-Sections — over 38%.(7)

The increase in C-Sections hasn’t made childbirth safer for either pregnant women or the newborn.  The rate of maternal death in childbirth has doubled since 1985, from 7.4 to 17.8 per 100,000 births.(9)  However, there is a question about how much of this increase is real or do to changes in government reporting.(6)

The rate of newborn mortality in the US is slightly worse than the rate in Bosnia.  According to the CIA World Factbook, the US rate is 5.87 per 1,000 births (2015 estimate).  There are more than 50 countries with lower rates of newborn mortality, including Canada, all European countries, all Commonwealth countries, Singapore, Taiwan and South Korea.

A survey of new mothers in 2011-12 found several reasons for the increased use of C-Sections, including

  • Physician or hospital unwillingness to inform the patient about options
  • Hospital and doctor efficiency
  • Limited awareness of surgical risk
  • Blind faith in medical professionals
  • Doctors’ unwillingness to attend births in the middle of the night (4).

However, unnecessary C-Sections are expensive for insurers, resulting is a push not to do them.

In one case part of which I witnessed, a physician decided to delay a C-Section in the hope of a vaginal birth on a woman with a previous history of miscarriage.  That decision was catastrophic.  The placenta tore, the fetus died and the mother almost bled out.

Ultimately, the decision to do a C-Section should be based on medical prudence, and not on insurance, the doctor’s quality of life or hospital income.

What does birth cost?

Cost estimates vary wildly, depending on whether they focus on out-of-pocket expenses for the new parents or the total charge including what insurance pays, as well as by state.  (2)

How much the new parents pay depends on the kind of health insurance they have as well as any supplemental insurance.

What you can do?

If you are a loved one are involved in selecting an obstetrician, you need to quiz the doctor on how he/she makes decisions about doing these procedures.  If the doctor shows a clear preference for surgery in most cases, or expresses concern about insurance and costs, you need to find a different doctor.  The guiding consideration needs to be the woman’s medical condition and history, period.

Any “automatic” decision is probably wrong.  Even a carefully considered decision could be wrong.  There’s nothing trivial about these choices.

____

Sources:

(1) Almendrala, Anna.  “U.S. C-Section Rate Is Double What WHO Recommends,” Huffpost Parents.  http://www.huffingtonpost.com/2015/04/14/c-section-rate-recommendation_n_7058954.html

(2)”Average Charges for Giving Birth: State Charts.”  Transforming Maternity Care.  http://transform.childbirthconnection.org/resources/datacenter/chargeschart/statecharges/

(3)  CDC. “Births — Method of Delivery.”  http://www.cdc.gov/nchs/fastats/delivery.htm

(4) ChildbirthConnection.org.  “Cesarean Section.”  http://www.childbirthconnection.org/article.asp?ck=10456

(5) Haelle, Tara. “Your Biggest C-Section Risk May Be Your Hospital,” Consumer Reports. 13 April 2016.  http://www.consumerreports.org/doctors-hospitals/your-biggest-c-section-risk-may-be-your-hospital/

(6) Maron, Dina.  “Has Maternal Mortality Really Doubled in the U.S.?”  Scientific American.  8 June 2015.  http://www.scientificamerican.com/article/has-maternal-mortality-really-doubled-in-the-u-s/

(7) “10 states with the highest C-section rates,”  Fox News.  9 July 2014.  http://www.foxnews.com/health/2014/07/09/10-states-with-highest-c-section-rates.html

(8) Rappleye, Emily.  “The most common surgery in the world is often unnecessary — and this physician is out to fix it,” Becker’s Hospital Review.  16 May, 2016.  http://www.beckershospitalreview.com/hospital-management-administration/the-most-common-surgery-in-the-world-is-often-unnecessary-and-this-physician-is-out-to-fix-it.html

(9) Wallace, Kelly. “Why is the maternal mortality rate going up in the United States?” CNN.  11 Dec. 2015.  http://www.cnn.com/2015/12/01/health/maternal-mortality-rate-u-s-increasing-why/

 

 

 

 

Microcephaly and Politicians

Zika has hit the US.  According to the CDC, there are now 279 pregnant women on US soil with Zika (3).  That number is likely to skyrocket this summer.  Mosquitoes will bite infected women and spread the disease to others.  Others will visit infected areas, especially with the Brazilzika2.png Olympics this summer, and return with the disease.  Sexual activity may spread the disease.

Meanwhile, the Oklahoma legislature creates a bill that removes any discretion in bringing infected babies to term.

Regardless of the intent in becoming pregnant, no one intends to bring a baby to term who will live for only 4-5 years and cost a fortune in terms of heartache and cash.  That’s not why someone becomes pregnant.

Women understand this.  The Zika outbreak is increasing demand for abortions in the countries that have been affected seriously thus far. (6)

However, because there is no lethal risk to the mother, under the Oklahoma law, a woman has no choice in bringing the baby to term.  The state will incur a mountain of costs in caring for these children, as most families cannot bear the load.

Even the Pope has expressed openness to the use of artificial contraception to deal with Zika.  (2)

Arguably, having a functioning brain should be a requirement for public office.

American writers have been quick to criticize Brazilian politicians for a slow response to the Zika outbreak.  However, as with the Michigan water crisis, this is evidence that American politicians can be just as oblivious.  The US Congress has been no better than Brazil’s in taking preventive action. (1)  The US is quite unprepared for the expected medical costs Zika will create. (5)

What actions can you take?

(a)  Adjust vacation plans.  The mosquito that carries Zika is prevalent in the US south, especially in the Gulf Coast region.

(b) Wear mosquito repellant.

(c)  If you or someone about which you care is pregnant, make sure they have access to good prenatal care and use it.  This is not a surprise you want.

(d) More controversially, lobby your local government for mosquito control measures.  That can affect other wildlife, but that may be a necessary sacrifice until this is past.  Hopefully, Zika won’t become a permanent part of our ecosystem.


Sources:

(1) Branswell, Helen.  “Congress is blocking key efforts to fight Zika, top health officials say,”  STAT News, 10 March 2016.  https://www.statnews.com/2016/03/10/zika-emergency-funding-anxiety/

(2) Burke, Dan and Cohen, Elizabeth. “Pope suggests contraceptives could be used to slow spread of Zika,” CNN.com, 16 February 2016.  http://www.cnn.com/2016/02/18/health/zika-pope-francis-contraceptives/index.html

(3) Cohen, Elizabeth.  “Number of pregnant women with Zika virus in U.S. triples, CDC says.”  CNN.  10:21 AM ET, Fri May 20, 2016.  http://www.cnn.com/2016/05/20/health/zika-cdc-numbers/index.html

(4)  “Oklahoma lawmakers OK bill criminalizing performing abortion.”  Associated Press. 19 May 2016.  http://www.msn.com/en-us/news/us/oklahoma-lawmakers-ok-bill-criminalizing-performing-abortion/ar-BBtfoqO?ocid=ansmsnnews11

(5) “Public Health Experts Warn U.S. Unprepared for Zika Outbreak,”  Insurance Journal, 13 April 2016.  http://www.insurancejournal.com/news/national/2016/04/13/404972.htm

(6) Simmons, Ann.  “Zika fears increase demand for abortions in countries where it’s illegal to have one,”  Los Angeles Times,  9 March 2016.

 

Radiation and cell phones

Cell phone radiation is a problem, although there is disagreement about the level of radiation that should be considered unsafe.

Critics see the following issues with this radiation:

  • Low levels of this radiation can cause a breakdown in the shield between blood and brain, allowing pathogens to seep into the brain.
  • Common levels of this radiation are above the level required to kill neurons.
  • Animal studies have shown that heating of brain cells from cell phone radiation can cause behavioral changes (ADHD-type behavior).
  • FCC standards allow little margin for error, and are based on adults, not children.  There are no separate safety guidelines for children.

Researchers have in fact raised questions about a broad number of health issues associated with cell phone radiation.  However, there is no conclusive findings on any of these items to date.  The issues raised in addition to those listed above include reduced mental quickness and focus, sleep disturbance and low sperm count.

Current levels of radiation are considered safe under US guidelines.  However, UK, France, Russia and Zambia ban the use of cell phones by children.  Radiation regulations also exist in Poland, Slovenia, Sweden, The Netherlands, Lithuania, Italy, Belgium, Bulgaria and Denmark.  Australian guidelines include using cell phones only in areas of very good signal strength and reducing the length of calls.

Most of these countries also regulate exposure to high voltage overhead power lines.  There have been successful lawsuits in the US regarding these lines in the absence of regulation.

The International Agency for Research on Cancer, a program of the World Health Organization, has classified cell phones as “possibly carcinogenic to humans” based on current research (Category 2B).  The US National Cancer Institute finds the research results mixed and inconclusive.  There are further studies in programs.

Bluetooth and Google Glass devices emit this radiation.  Category 2 and 3 Bluetooth devices emit lower levels of radiation than cell phones, but even these levels may be dangerous.

The charts below are courtesy of the IEEE.  They show radiation penetration into the skull that results from holding a cell phone to your ear.

exposure_heads_png_7ca4e6f7-f908-47e9-bc0e-d4a215ba7859_1024x1024.png

What can you do?

Actions to reduce risk are simple and cheap, so there is no real excuse not to protect yourself.  Radiation dissipates with the square of distance between you and the phone, so keep it away from your skin.

(1)  Use the speaker function on your phone where practical.  Texting is good.

(2) Keep the phone on a belt clip, in a purse or in a briefcase rather than in a pocket or (worse yet) bra.  (Yes, I have seen people do this.)

(3)  Use a corded headset where practical.

Opinion:  There’s still a lot we need to learn about how major illnesses including cancer work.  As we learn, we will find we need to measure things that we are not considering now, and we will find relationships between products or drugs and illnesses that we aren’t even considering now.  We finally established the risk of cigarettes way too late for millions of users.  That may very well happen again with radiation.  When the cost of  being prudent is so low, why not?

____

Sources:

CNET. “Cell phones with the highest radiation levels”.  http://www.cnet.com/pictures/highest-cell-phone-radiation/

German, Kent.  “Why CNET compiles cell phone radiation charts”, CNET. http://www.cnet.com/news/cell-phone-radiation/

Ludwig, Ben.  “10 Phones and Headsets to Keep You Away from Radiation,”   PC Magazine.  17 June 2010.  http://www.pcmag.com/article2/0,2817,2365224,00.asp

National Cancer Institute.  “Cell Phones and Cancer Risk.”  http://www.cancer.gov/about-cancer/causes-prevention/risk/radiation/cell-phones-fact-sheet#q4

RFSafe Corporation.  “Is Bluetooth Radiation as Dangerous as Cell Phone Radiation?” https://www.rfsafe.com/bluetooth-radiation-dangerous-cell-phone-radiation/

RFSafe Corporation. “Specific Absorption Rate, or SAR – FCC Cell Phone Radiation Exposure Limits”.  https://www.rfsafe.com/specific-absorption-rate-sar-fcc-cell-phone-radiation-exposure-limits/

Shipper, David.  “Does Cell-Phone Radiation Cause Cancer?”  Consumer Reports.  28 September 2015.  http://www.consumerreports.org/cro/smartphones/cell-phone-radiation

Stam, Rianne.  “Comparison of international policies on electromagnetic fields”.  National Institute for Public Health and the Environment, Ministry of Health, Welfare and Sport, The Netherlands.  May 2011.

Wikipedia.  “Mobile phone radiation and health”.  https://en.wikipedia.org/wiki/Mobile_phone_radiation_and_health.

Warning regarding Wellness Plans that offer “tax free” incentives to participants

Quoting from a statement issued by Aflac, 9 May 2016:

“Aflac has been approached by companies such as Cypress, Inspired, Traverse, and Bene-Fit regarding wellness programs that claim to provide tax-free payments to employees who participate in the wellness program. The core elements of the wellness program involve a two-step process:

(1) A salary reduction election by employees through a Code Section 125 cafeteria plan, as payment for the cost of the wellness plan.
(2) A payment from the wellness plan, sometimes through a “benefit bank,” to employees which purportedly is on a tax-free basis.

The program claims the tax savings generated from the wellness plan may then be used to purchase additional benefits, such as the supplemental health benefits offered by Aflac. The Internal Revenue Service (IRS) has indicated the claimed tax advantages aren’t available under the Internal Revenue Code. These programs have also been reviewed by Aflac’s Legal Division and its outside counsel. Federal tax law doesn’t provide an exclusion from taxable income that would permit a tax free reimbursement under the wellness program. Aflac also believes these programs pose compliance problems under the Affordable Care Act, the Employee Retirement Income Security Act of 1974 (ERISA), and other federal laws.”

In other words, Federal tax incentives to encourage people to be healthy don’t exist yet.  There are salespeople promising tax breaks that may not be real.

What happened to Burlington County?

The good news is that New Jerseyans have access to remarkably good health care.  With the close proximity to medical centers in New York City and Philadelphia (and even Boston and Baltimore) the care available to citizens of The Garden State far surpasses what’s available to most Americans.

The bad news is that four of the 21 counties in NJ are cancer hot spots.  The worse news is that the hot spots are changing.

The enduring hot spot is scenic Cape May.  With a legacy of industrial pollution and being downwind from Delaware chemical factories, it has had problems and continues to do so.

The list used to include Ocean, Salem and Gloucester Counties.  Cancer incidence seems to have subsided in some of these areas.

The new entrant to the list is Burlington County.  Further research is required to see if there is a clustering around Ft. Dix and McGuire AFB or if the problem is more generally distributed.

Current incidence of cancer in NJ is shown in the chart below.  The chart is based on all cancer types/site for both males and females and all age groups.

Remarkably, the old industrial cities of NJ report relatively low cancer rates.  Of course, that could be attributed in part due to other environmental issues in those areas that can cause death before cancer develops.

As I find more interesting findings, they will be reported in subsequent blogs.

NJStateCancerProfilesMap

 

New Reasons Why You Need a Second Opinion

Ownership interest in dealers of medical devices can encourage doctors to recommend surgeries that are not medically necessary.

Most consumers view their doctor as a professional who will treat their illness in an objective and unbiased manner.  Unfortunately, some doctors have conflicts of interest of which their patients may be unaware.

doctor-clip-art-doctor-clip-art-4

The Wall Street Journal reports a new study that shows that  some doctors invest in dealers or distributors of medical devices used in surgery.  The doctor profits on sales of surgical products.  The profit motive may cause the doctor to refer patients for surgery more often than is medically necessary.(1)

The idea of medical conflict of interest isn’t new, but has traditionally focused on the relationship between doctors and drug companies.  The American Medical Association set for guidelines for doctors to follow regarding conflicts in 2009.(2)  However, there is no measure of how well doctors are following those rules.

A “conflict of interest” is a situation in which  someone who has to make a decision in an official capacity stands to profit personally from the decision”.(3)  Regardless of legality, anyone who makes a  decision when there is a conflict of interest is acting in an unethical fashion.  Judges are expected to recuse themselves (reassign a case to a different judge) when a conflict arises.  Ethically, that’s what every public official or business executive should do.  In practice, most don’t.

At the very least, officials should disclose possible conflicts and let the consumer or patient decide how to deal with them.  Licensed financial advisors are required to do this.  Others should be, but are not.

You don’t want your health to be compromised by a conflict of interest.  Even a successful surgery can have a lasting impact on your quality of life.  That means getting a second opinion on a diagnosis and recommended course of treatment, preferably from someone in an entirely separate medical practice.  If the doctors disagree, you may need a third opinion.

If your doc has a conflict of interest and doesn’t  disclose it to you, you need a new doc.  Integrity matters.


Sources:

(1)  Armour, Stephanie.  “Doctor-Device Deals Need Scrutiny, Report Says,”  The Wall Street Journal.  May 10, 2016.  P. A3.  (Yes, some of us still use printed versions of newspapers.)

(2) Institute on Medicine as a Profession.  “Conflict of Interest Overview”. http://imapny.org/conflicts-of-interest/conflicts-of-interest-overview/

American Medical Association, “American Medical Association Conflict of Interest Principles – Councils, Committees, and Task Forces.”  http://www.ama-assn.org/ama/pub/about-ama/our-people/ama-councils/conflict-interest-principles.page?

(3) http://www.dictionary.com/browse/conflict-of-interest

Assertiveness and Healthcare

Someone has to speak up on behalf of the patient.  Most of the time, that may fall on the patient to do that.  If that can’t or won’t happen, someone else has to do it.

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Consider the following:

  1. Medical care is increasingly complex.
  2. Doctors are human, and fill the complete range from awesome to incompetent.  Some are highly skilled and fully current with developments in their field.  Some let their skills rust years ago, and a few never had them.  I don’t envy them.  Keeping current can require hours of reading every day and travel to medical conferences.
  3. The patient is the first person to know if treatment is or is not working, or if something is going wrong.
  4. As researchers at Johns Hopkins iterated this week, medical errors are the 3rd leading cause of death among Americans.  Estimates of the number of deaths from medical errors annually range from 250,000 to 440,000 Americans.
  5. Medication errors at hospital discharge are a major issue, and one cannot count on medical or home health care providers catching the mistakes.

I’ve seen some of these errors.  My wife has an iodine allergy, and virtually every nurse with whom she has had contact has tried to swab her with iodine at least once.  In her case, any contact with iodine causes anaphylactic shock and she stops breathing.

Breathing is something we tend to take for granted, but it really is a nice thing to be able to do, best understood by those who have had problems doing it.

I’ve had to step in as her advocate.  I make sure admissions and staff know about her allergy and look at the color of substances being applied to her skin.  She isn’t bashful about speaking up, but sometimes she can’t see where the nurse if working.  What she can’t do, I can.

Which brings me to two key concepts: the second opinion and the healthcare power of attorney.

(A)  Second opinions.  Often, medical mistakes have to do with errors in diagnosis, and the wrong diagnosis can delay treatment past the point when treatment can be effective.  Second opinions are also valuable regarding the preferred course of treatment.  As in the case of a friend, one doctor may recommend immediate surgery when another doctor has three or four options that should be tried first.  Because surgery itself can have lasting side effects, it often should be considered as a last resort and not the initial course of treatment.

The second opinion should come from a physician in a different practice and preferably affiliated with a different hospital.  You don’t want personal relationships or conflicts of interest mucking up diagnosis or treatment recommendations.

If doctors disagree, it may be necessary to seek a third opinion.  That’s OK, too.   Your life matters.

(B) The healthcare power of attorney.  Someone needs to speak on the patient’s behalf if the patient cannot or is too timid to do so.  This representative must be someone who is trusted, who knows the patient well, will listen to the patient, will be present to observe the patient’s condition and issues, who will respect the patient’s decisions regarding directives and living wills, and has the willingness to “kick ass” when needed.

Whether in a relationship or not, everyone needs someone in this role.  Regardless of your current health, bad things happen to good people.  On average, each American can expect to cede 9 years of life to illness or injury.  If nothing has happened yet, be thankful.  However, to expect that nothing will is sheer arrogance — if you’re that lucky, how many winning lottery tickets have you purchased?

What do you call someone who won’t speak up for him/herself or have someone else do it?  Deceased.

I don’t want you to go that way.

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Sources:

American Association for Justice.  “Medical Errors.”  https://www.justice.org/what-we-do/advocate-civil-justice-system/issue-advocacy/medical-errors

Hospital Safety Score.org.  “Hospital Errors are the Third Leading Cause of Death in U.S., and New Hospital Safety Scores Show Improvements Are Too Slow.”  23 Oct. 2013.  http://www.hospitalsafetyscore.org/newsroom/display/hospitalerrors-thirdleading-causeofdeathinus-improvementstooslow

McCann, Erin.  “Deaths by medical mistakes hit records,”  Healthcare IT News.  18 July 2014.  http://www.healthcareitnews.com/news/deaths-by-medical-mistakes-hit-records

Johns Hopkins Medicine.  “Medical errors now third leading cause of death in United States,” Science Daily.  4 May 2016.  https://www.sciencedaily.com/releases/2016/05/160504085309.htm

Commission on Law and Aging, American Bar Association. “Giving Someone a Power of Attorney For Your Health Care.”  2011.

Rau, Jonathan. “Hospital Discharge: One of the Most Dangerous Times for Patients,” Science Daily. 2 May 2016.  http://www.medscape.com/viewarticle/862715?src=wnl_mdplsnews_160506_mscpedit_wir&uac=153634BV&impID=1087319&faf=1