California Blue Cross Blue Shield Will Not Deny Benefits Retroactively

I saw this in the Wall Street Journal originally, but the original story is from the LA Times. California Blue Cross had been denying claims on patients; claiming they had filled out their form fraudently. Patients and advocates claimed that the application forms were confusing and designed to cause errors. The State intervened, and fined Blue Cross. Now, there is a settlement, and patients with individual insurance will not have that insurance retroactively denied because of "honest" mistakes on an application form.

Although this does not affect individual policy holders in New York, it is still heartening that there is movement afoot on this front. Individual policy holders already pay twice as much, or more, than group policy holders. And claims are often denied for "pre-existing" conditions. Hopefully, more can be done.

What About Those Discounts??

The front page of The New York Times has an article today describing how certain kidney and cancer specialists receive the drug epogen, which raises red blood cell count, at a volume discount. This discount allows large groups to profit from the use of this drug in their office. The Times quotes several sources showing that groups were able to make a significant percentage of profit based on the sales of this drug. The Times also points out that the US gives higher doses of this drug to more people on a per capita basis, than any other country. It finally points out that recent studies showing that, like chocolate, to much epogen is too much of a good thing.

I don't disagree with the premise that physicians shouldn't be driven by profit any more than I think my lawyer or accountant should be. We all want to pay our professionals to provide necessary service and no more. And it is true that "volume discounts" give providers an extra incentive to given even more drug. But there are several caveats that need to be noted.

First of all, small practices do not benefit from these discounts in the same way. Medicare reimbursement is often slightly lower than the actual "retail" cost of a drug to a physician. Discounts given by manufacturers at this level are in effect just an agreement to not lose money each time you give something in the office. This gives large groups a further competitive advantage over small groups: further eroding small practices in this age of declining reimbursements and increasing expenses. Large practices tend to have non-physician business managers, who, in my experience, are much more aggressive than the average doctor at trying to maximize reimbursements.

As much as people don't like doctors profiting off of potentially unneeded therapies, the opposite effect: poor reimbursements leading to not giving a therapy, is also bad. A perfect example is the new Shingles vaccine recently released. This vaccine is recommended to all adults over the age of 60 who have not had shingles. The drug is not covered under Medicare Part B (doctors office): it needs to be filled at a pharmacy or the patient has to pay cash to us and then seek reimbursement from Medicare, Part D (pharmacy). This is different from other vaccines, such as flu-shots, which are covered in the doctors office. One large commercial insurance company is paying our office 70% of the cost we pay for the vaccine: we lose 45 dollars every time we give that vaccine in the office.

Not surprisingly, patients are not receiving the vaccine in large numbers. We can't afford to stock it for commercial payers: we give people a presrciption for the pharmacy and tell them to get it there or come back. And Medicare patients have not been paying us upfront for the drug: again we give them a script (which theoretically should be covered by part D) and tell them to come back with it. However, for the same reasons we can't afford to stock the drug, I get the feeling pharmacies don't like it, either. So very few people are getting vaccinated.

The final part of the article describes how, as studies showed higher doses of these medications may not be as benign as physicians thought, use has scaled back. At least everyone seems to be following the mantra "first, do no harm" even if they're sort of up to no good.

Avoid That Heart Attack 24/7: Go For 8/5

Weekends can be quiet times at hospitals. Overall staffing is lower, and many areas are closed except in the case of emergencies. Given that a lot of what does occur in hospitals is "routine," the question is, does it make a difference? A recent article in the New England Journal of Medicine states that it might. The article, which looked at the short, medium and one year mortality rates of over 230,00 patients with myocardial infarctions (heart attacks) in NJ over a 15 year period showed that being admitted to the hospital over a weekend increased the absolute risk of death by over 1%. When the researchers looked at the data, there were no significant differences in the health or presentation of patients on weekends versus weekdays.

An interesting editorial in the Journal, by two Canadian physicians, notes that in Canada, hospitals and physicians are paid more when performing invasive cardiology procedures on the weekend, thus making it tenable to gather together the team required to perform these procedures. The editorialists note that this is similar to paying overtime; common in almost all other lines of work.

Obviously, if you have chest pain, don't wait till Monday before going to the Emergency Room! We are happy to note that the cardiologists at NYU (where we admit) always seem willing to come in on weekends.

Throwing Out Drugs

According to an article in todays Wasington Post, you shouldn't just throw those old drugs into the toilet. Its bad for the groundwater, landfills, bacteria in septic systems, etc. Drugs should be put out with the regular trash. You may want to put them in a sealed container so pets or kids don't eat them.

Detecting Chronic HPC Infection in Women Over 30

NPR has posted an excellent article (and podcast) on some changes in screening recommendations for cervical cancer, particularly in women over the age of 30. Although they refer to people over 30 as "older women" I will forgive them! Some important points:

• There is a new test for high risk strains of HPV virus that can detect the virus even when PAP smears are negative.
• Because younger women tend to clear the virus it is not recommended for women under 30.
• Women in monogamous relationships with negative HPV and Pap smears may need to have routine GYN exams less frequently (3 years)

Although you should speak to your gynecologist before changing how you see her/him, this is a very promising development in the field of preventative care.

Hepatitis A Can Strike in the Nicest Places

Hepatitis A is a food born virus that is spread via the fecal-oral route. Although we usually immunize people when they travel to developing nations, the disease can strike anywhere. This was proven when, recently, an employee of the famous caterer Wolfgang Puck was found to have have the disease. Although no one has gotten sick yet, up to 3500 people were potentially exposed. The original article is here.

For patients who travel or eat out a lot, it may make sense to talk to one of us about vaccination against hepatitis A. The two shots you need may save a lot of hassles down the road.

Woman's Heart Disease Risk Score (The Reynolds Index)

A woman's signs and symptoms for heart disease are different than a man's. Women are less likely to have classic signs of heart disease such as chest pain and more likely to have non-specific symptoms such as generalized fatigue. Although standard procedures such as a stress test or an angiogram work to asess risk in the symptomatic patient, better methods of stratifying which women are at higher risk for developing heart disease in the future are needed.
One promising new development is the Reynold's Risk Score, which allows a clinician to plug in certain numbers, such as age, cholesterol, smoking status and a special blood test called the c-reactive peptide. By entering these numbers into the website, a woman can assess your risk of heart disease over the next 10 years.

We are happy to help you calculate your Reynold's Risk Score. Please realize that many insurance companies do not pay for the c-reactive peptide, and this may be an out of pocket expense (themoney goes to a lab, not to us)

Whats The Evidence (or Why Are You Giving Me That Drug??)

Decisions about what to do given a set of symptoms and signs is one of the most important functions that a physician performs. In recent years, more attention has been given in the medical literature to ways to synthesize the available scientific data and make medical decisions. The formal study of how to determine which decision is right based on the available literature is called Evidence Based Medicine, or EBM. EBM has been used to evaluate many controversial, and formerly controversial issues, including hormone replacement, the use of certain medications in heart disease and diabetes, and cancer prevention. EBM holds out the promise that it will cut the number of unnecessary tests and increase adherence to practices that will actually promote health.

Having said that, EBM can be a double edged sword. As well described in an article in this week's Time Magazine, EBM is often perceived of taking the "art" out of medicine and also making it less humanistic and more mechanistic and impersonal. Also, for ethical or practical reasons, EBM can't answer all the questions doctors would like to answer.

As a physician, it is important to keep up with EBM, and using proprietary software, at Westside Medical we do. Having said that, many of the questions that face the primary care physician, particularly in the area of acute care, are not fully answered and need the art of medicine as well as the science.

Coffee: It Has Fiber, Too

Many people who enjoy a cup of coffee in the morning notice that it has a cathartic effect on the bowels as well. Although this is likely due to its stimulating the colon, a recent study from Spain has shown that coffee contains anywhere from 1.1 grams of soluble fiber (filter) to 1.8 grams (instant). Soluble fiber is helpful in producing non-gassy stool and may have cholesterol decreasing benefits as well. Go Coffee!

Should You Learn the Heimlich Manuever?

I have to admit I was a bit suprised when I read this. But according to Lenore Skenazy in the New York Sun, the American Heart Association is now recommending three ways to help a choking victim. These are (in the order you should try them)

1. A hard back slap right between the shoulder blades. If that doesn't work...
2. The Heimlich Manuever (now just called abdominal thrusts). And if that fails...
3. Chest compressions (as you would do for CPR)

Don't worry if you do Heimlich first (I will still give the man the credit her deserves). The most important thing in the case of choking is to act quickly.

PS: I tried to go to the AHA website to find this new guideline. Its not officially posted, but you can buy it!

Join the Gym! Know the Price!

We encourage a regular exercise program for almost everyone at Westside Med. But joining a gym is confusing: there's always a "special" and you always think you are getting ripped off compared to the next person. The NY Post has an excellent article today showing how prices can literally change day by day. The article also points out that January and May offer the best deals. We encourage joining any gym as long as you go three days a week!

Salmonella Outbreak

There is a sizable Salmonella outbreak throughout the United States, and many cases have been reported in New York State. The source is peanut butter: Peter Pan and Great Value which have a product code located on the lid of the jar that begins with the number "2111." If you find yourself with a diarrheal illness and have had this, please be sure to bring the peanut butter and yourself to the office.

Fake Drugs?

The New York Times published an article describing a study on the growing problem of counterfeit drugs. Although a problem mainly in Asia and Africa, there have been reports of fake drugs for sale in the United States. Most of these were "recreational" drugs such as oxycontin or Viagra, but Tamiflu, used to treat influenza, has also been counterfeited. The level of sophistication of the counterfeiters was scary: drugs were packaged correctly and even had the hologram "seal of authenticity" of the real deal.

Bottom line: Although not a problem in the United States at the moment, care should be taken when getting drugs from certain foreign countries.