Monday, October 28, 2013

Honey, They Shrank The Network

Repeatedly, President Obama reassured us that "if you like your doctor, you can keep your doctor. Now, we learn the President may have pulled a fast one.

... Elderly New Yorkers are in a panic after getting notices that insurance companies are booting their doctors from the Medicare Advantage program as a result of the shifting medical landscape.

That leaves patients with unenviable choices: keep the same insurance plan and find another doctor, pay out of pocket or look for another plan where their physician is a member.

New York State Medical Society President Sam Unterricht is demanding a congressional probe after learning that one health carrier alone, UnitedHealthcare, is terminating contracts with up to 2,100 doctors serving 8,000 Medicare Advantage patients in the New York metro region.

While other carriers are similarly cutting doctors from their provider lists, United seems clearly head and shoulders above the rest.

Curiously, United is now involved with another aspect of Obamacare - the Obamacare website fix.

The government on Friday named a UnitedHealthGroup Inc. subsidiary as “general contractor” to oversee the troubled federal website designed to sign up Americans for health insurance under national health care reform.
When QSSI was awarded the contract to build the Obamacare Data Hub, questions of conflict of interest arose. In fact, when the QSSI purchase flew under the SEC radar, Sen. Orin Hatch raised the issue.
... He asked Health and Human Services (HHS) Secretary Kathleen Sebelius in an Oct. 19 letter for a full account of contractors hired to set up the national exchange and a list of administration officials who signed off on those awards.

“I am seeking more information about the contracts associated with the entities selected to build the federally facilitated exchange (FFE) and the federal data services hub that will support the FFE,” he wrote.

Hatch wants to know whether HHS reviewed UnitedHealth Group’s purchase of QSSI to determine whether it creates conflicts. 

Make no mistake, the insurers are using the highly popular Medicare Advantage Plans as a test case. If they can successfully eliminate doctors and products which they feel are too costly for them, their efforts will soon expand to all their insurance plans and networks. People have to be on high alert and call their friends, employers and both local and federal representatives.

They told me that if I voted for Mitt Romney, corporate entities would soon control all aspects of healthcare in the US ... and they were right.

Monday, October 21, 2013

Smart Health Insurance Shopping

So you've seen those ads on TV and want to buy individual health insurance on the Exchange/Marketplace. You need to do some homework before you shop. The first thing you need to do is that if you have a doctor or doctors, you should make a list. It's important to know whether your physician will be participating in any of the plans you intend to buy. Remember the part in the President's speech about how you could keep your doctor? Well, that isn't necessarily so. 

If your doctor is not a plan participant, then you will have to consider the plan's Out of Network benefit. Some plans have better coverage than others. Also, many of the newer networks will have fewer, not more, physicians so Out of Network could end up being a major expense depending on your coverage.

You need to know is that the premium will not be the only cost associated with health insurance. The lower the premium usually means the higher the copayment and deductibles. This may not mean that much if you're young and without chronic illness, but if you find yourself seeing multiple physicians on a regular basis, these costs can add up quickly. The true cost of health insurance is much like the true cost of owning a car. The monthly payments are only a part of the story. 

Fortunately, you don't have to rush out and buy health insurance today. You have until mid-December to buy a policy whose coverage won't start until January 1. Ask questions. If you don't like what you're hearing, ask more questions. Make lists. Do your homework. To paraphrase the old Sy Syms commercial, an educated consumer is the best health insurance customer.

Monday, October 14, 2013

Autism - Much Heat But Little Light

Just a mention of the word Autism to an expectant mom is enough to cause terror. In today's parlance, autism is not one disorder but a spectrum of disease - ranging from the savant of Rain Man to those afflicted with Asperberger's Syndrome. Merriam Webster  defines autism thusly:

 a developmental disorder that appears by age three and that is variable in expression but is recognized and diagnosed by impairment of the ability to form normal social relationships, by impairment of the ability to communicate with others, and by stereotyped behavior patterns especially as exhibited by a preoccupation with repetitive activities of restricted focus rather than with flexible and imaginative ones.

The recently developed DSM V criteria for outlining the diagnosis of autism may be found here.

But what causes autism? The truth is that by and large, the cause is unknown. This is not for lack of theorizing, however, as there is quite a laundry list of usual suspects and some unusual, including:

prenatal ultrasound
rainy climate
valproic acid during pregnancy
nail polish
air pollution
household chemicals
labor induction
birth spacing
antibody proteins
low levels of glutathione
intestinal flora

All of these putative causes have their proponents, some with great celebrity, but as of yet, the cause remains elusive. That's the real sticky part. Humans can obviously handle good news. Humans can also handle bad news if given time to fully digest. The one thing we handle poorly is the unknown. And that is truly what makes autism so frightening. A good deal learned recently from the human genome project suggests that there are genetic variations which may either directly cause or predispose to much of the autism spectrum. But this is not the whole story, There are undoubtedly sporadic cases which arise out of the blue, without any warning from family historical data. Many groups of investigators are working to piece together the puzzle that is autism. One such group (in which I have no part) has begun the Earli Study.

EARLI is a network of research sites that will enroll and follow a large group of mothers of children with autism at the start of another pregnancy and document the newborn child’s development through three years of age. The EARLI Study will examine possible environmental risk factors for autism and study whether there is any interplay between environmental factors and genetic susceptibility.

I wish all groups godspeed and good luck in their hunt to unmask the culprits underlying these disorders.

Faster please.

Friday, October 11, 2013

Think Your Doctor Is In A Funk? Your Doctor Would Agree With You

While most doctors are satisfied with their job, most agree the stress levels have increased in recent years, with one out of five admitting to feeling just plain burnt out. In an AMA commissioned study, doctors offered that the EMR was the number one negative factor impacting doctors' morale.

  • "What we've created is a monster, when really what we were shooting for was good patient care," said a physician about the government's program to promote "meaningful use" of EHRs with bonuses and penalties. The extra time spent "working the chart" to satisfy meaningful use requirements, the physician said, takes away from face time with the patient.
  • "I am not a clerk," added a cardiologist who complained how the technology increased data entry responsibilities. Sixty-one percent of physicians surveyed are like-minded, saying that EHRs require them to perform tasks others could handle.
  • "The EHR is not just a one-time investment," said a physician with practice management duties. "It's a hugely expensive, ongoing, every-freaking-day investment."
Other complaints including information's being lost in a maze of data, confusing dropdown menus, and lack of a standard for interoperability. Doctors' offices still rely on faxing hard copy and then having to scan information back into the record.

The electronic record isn't the only stressor. Having to jump over multiple and ever-increasing regulatory hurdles compounds the difficulties doctors face. Struggling to meet government's "Meaningful Use" requirements may be the most prominent hurdle. While striving to provide better patient care by adhering to regulation, office visits take longer. Struggling to keep to the schedule shortens the time actually spent with the patient. Not only does this result in a less than satisfactory doctor-patient relationship but increases the likelihood that an error may occur, potentially, a serious error.

Additionally, some large groups base pay incentives on "productivity." This also impacts adversely on the time spent with the patient and the quality of that time. Finally, in an era of declining payment from third party payors, doctors feel it's not about profitability anymore - it's about viability.

So next time you think your doctor is stressed and rushing, he is. Why not take his hand and offer some encouragement? He'll thank you for it.

You can read the study here.

Monday, October 7, 2013

Universal Noninvasive Prenatal Testing for Down's Syndrome?

Today's NY Times returns us to Noninvasive Prenatal Testing for Down's Syndrome. 

... The newest screening test, highly accurate and noninvasive, relies on fetal genetic fragments found in the mother’s blood. Available commercially from four companies, this test is so accurate in detecting Down syndrome that few, if any, affected fetuses are missed, and far fewer women need an invasive procedure to confirm or refute the presence of Down, according to studies in several countries.

The new test, done late in the first trimester of pregnancy, can also detect other genetic diseases, like extra copies of chromosomes 13 and 18, and a missing sex chromosome. It is not yet approved by the Food and Drug Administration, however, and the American College of Obstetrics and Gynecology currently recommends it only for women at high risk for having a baby with a chromosomal abnormality.
The author then cites Tufts' Dr. Diana Bianchi as claiming that a "low risk" woman can get this test done if she's willing to pay for it. Actually, that may not always be true. NY State still tightly regulates laboratories' offering these tests and has been restricting the use of this technology to those at highest risk - age, history, or finding on ultrasound.
There are some drawbacks to these tests. 
... In a recent article in The New England Journal of Medicine, however, Stephanie Morain, a doctoral candidate at Harvard who studies medical ethics, and her co-authors said the fetal DNA tests have some disadvantages. They miss some chromosomal abnormalities detected by standard screening techniques, and they are “not widely covered by insurance.” Prices for the tests range from about $800 to more than $2,000, although some companies offer “introductory pricing” specials at about $200.
The high variation in pricing suggests that as the technology is offered to those women at lower risk, the price should come down to the lower range. It's my belief that insurance coverage may actually serve to keep prices higher rather than lower, but that's for another day.
While the article goes on to say the  tests are only  valid only in singleton pregnancies, some labs are performing the test for women who are carrying twins.
Some caveats - the first being that these tests presently only test for specific chromosomes so that a normal result does not mean a normal baby. In fact, there is no normal baby test. Conversely, an abnormal test result should be confirmed by an invasive test before making any final decisions. Having personally witnessed a mistaken result, I cannot emphasize this enough at the present time.
Finally, I agree with Dr. Bianchi  that the recent research findings in mice give hope that the day that Down's Syndrome can be ameliorated by prenatal therapy may be sooner rather than later. 
Faster Please.

Tuesday, October 1, 2013

Flu Shots For The Expectant Mom?

It's that time of year again and the drug store chains are all advertising flu shots. But for expectant moms, safety is a prime consideration. So what about flu shots in pregnancy? Are there any special risks during pregnancy? And are these vaccinations safe for mom and baby?

The CDC has a great deal of useful information on Flu Shots in Pregnancy.

Influenza is more likely to cause severe illness in pregnant women than in women who are not pregnant. Changes in the immune system, heart, and lungs during pregnancy make pregnant women more prone to severe illness from influenza as well as hospitalizations and even death. Pregnant women with influenza also have a greater chance for serious problems for their unborn babies, including premature labor and delivery.

But are they safe? Again, the CDC has the answer

Yes. The seasonal flu shot has been g.iven safely to millions of pregnant women over many years. Flu shots have not been shown to cause harm to pregnant women or their babies.

There is one caveat - the nasal spray vaccine is not recommended for use during pregnancy.

The CDC has more at the link.  Read the whole thing.