Wednesday, January 30, 2008

United Health hit with $3.5 million fine

United Health has been hit with a $3.5 million dollar fine by the Department of Managed Health and it couldn't happen to a more deserving company! The department of Insurance investigated the company and found it had violated more than 130,000 claims and improperly denied 30% of claims that were reviewed during the investigation. That is not an accident. Underpaying or denying 130,000 claims is a company culture!

Here's one little example of what they do.

This after noon I received a letter from United Health regarding a patient I saw December 7, 2007. The charge was $115.00, submitted on the usual standard claim form with the proper codes and descriptors. Get this...instead of a payment for services rendered seven weeks ago, they are requesting the Doctor's name (!!!), title (!!!), and medical license number. Yes, I have been seeing United Health patients for years, but they are requesting, from Dr. Toni Brayer, my name. If this isn't the most blatant delay in payment I don't know what is.

David Hansen, regional CEO for United Health told the Wall Street Journal "We have already taken and continue to take aggressive steps to address the issues raised by the departments and to improve our operational performance in California." Gee, I guess someone forgot to tell the claims payment department that.

Tuesday, January 29, 2008

Grand Rounds - don't miss it

If you want to keep up with the medical blogosphere, check out this week's Grand Rounds hosted by Kim at Emergiblog. Check it out!.

Sunday, January 27, 2008

The Law of Unintended Consequences

Health care is filled with the unintended consequences of laws, regulations and poor planning that plague our ability to care for patients. Here are a few, in no particular order. You may have more to add.
  • Lab laws. I used to be able to contract with labs to do tests on my patients. I negotiated a low fee, kept a few dollars for lab draw and my services and everyone won. Enter California Legislature. Now patients have to go to another lab for blood tests. Pap smears cost $55 rather than $7 and a blood panel that was $22 now costs $180. Unintended consequence: Primary care lost a revenue stream, patients get gouged on test costs. (By the way, this law was sponsored by the big laboratories.)
  • Employee break legislation. A wonderful new law says all employees (think nurses) must take a lunch break within 5 hours of starting a shift, even if she is taking care of a patient, in the OR, dieting, or just not hungry. To stagger breaks some nurses will be eating lunch at 9:30 AM. Yes, more nurses will be hired to cover breaks. Unintended consequence: Watch health care costs continue to soar.
  • Stark Laws. Primary care physicians are not allowed to invest in ambulatory care centers or surgi-centers. It's fine for surgeons, anesthesiologists, gastroenterologists and all others to be part of the out-patient trends for patient care and they are partnering with hospitals and other organizations across the U.S. Unintended consequence: More reasons for demise of Primary Care.
  • Discounts Illegal. Medicare and Health insurers have made it illegal for physicians to offer discounts for their share of the co-pay for covered services. I guess they think patients will utilize more service (?) if they don't pay their share. Unintended consequence: Patients pay more even if they need a break.
  • New Triplicate Laws. The State and Feds have made it so difficult to prescribe pain medication with special prescription pads and regulations regarding refills that physicians are hamstrung in prescribing the best medication. Unintended consequence: patients that need pain meds aren't getting them or are getting the wrong (no triplicate needed) med instead.

Saturday, January 26, 2008

IQ - Why do Men Think They are Smarter?

A number of studies have shown that "men" think they are better looking than they really are and "women" often underestimate their good looks, thinking they are less attractive. It should come as no surprise that the same holds true when it comes to intelligence.

Adrian Furnham, a professor of psychology at University College London, reported that men and women have fairly equal IQ's but men think they are smarter than they really are and women underestimate their own brain power. In 30 international studies, the men overstated their intelligence and women underplayed it. This happens in Japan, Argentina, Britain, Zimbabwe and America. What is going on here?

Another interesting fact is that both men and women think their sons are smarter than their daughters. So those perceptions are passed on to the kids and keep the myth going.

Women in the workplace talk about this all the time. Men are so confident about their abilities and they think they are capable of anything. They speak forcefully, can dominate the discussion and are often looked to as the experts...even when the women in the room are smarter and have better track records. The most assertive female is often seen as aggressive, yet if you compare styles, she is likely less dominant than the males in the room.

Confidence and self-belief may be what propels men forward. It doesn't hurt to think you are better looking than you really are too.

Friday, January 25, 2008

Handwashing Reduces Diarrhea

Here we are with fantastic technical advances of the 21st century and surprise! A new study shows that hand washing reduces episodes of diarrhea by 30%. Since diarrhea is caused by pathogens (read: germs) that get passed from human to human or human to food to human...hand washing interrupts this cycle.

What was interesting about this report is that hand washing was as effective in preventing diarrhea as is providing clean water to developing countries. The challenge is without clean water, how are people supposed to wash? The World Health Organization reports more than 3 million cases of diarrhea annually and more than 2.2 diarrheal deaths in low and middle-income countries. Access to clean water is something we take for granted but 2.6 billion people do not have access to adequate sanitation and over a billion do not have clean water to drink.

We are lucky to have fresh water. We are blessed to have easy access to sanitation. This study is a reminder of what is still possible, using simple techniques, to reduce illness and death.

Amswer Quiz #4

The answer is #5 Mandibular fracture. This patient was struck on his left lower jaw and suffered a comminuted fracture. The open fracture caused the left half of his mandible to be pushed upward. Surgical wiring of the jaw puts it back in alignment but he'll be drinking from a straw for a good period of time.

Thursday, January 24, 2008

Medical Quiz 2008 #4

How smart are you? What is your Diagnosis? Click on the image to get a better view.
#1. Dental abscess
#2 Neurofibromatosis
#3 Cleft jaw
#4 Hemiatrophy syndrome
#5 Mandibular fracture
Check back tomorrow for the answer!

Wednesday, January 23, 2008

Medical Journal Update

Ultrasounds for aortic aneurysms:
Abdominal aortic aneurysm ruptures occur suddenly and are almost always fatal. They are about 4 times more common in smokers, than in people who have never smoked. The researchers studied 67,770 men ages 65-74 and found that performing an ultrasound to screen for an enlarged aorta significantly reduced death. Aorta's enlarge slowly until they rupture but do not cause any symptoms. The aneurysm can be surgically removed if found in time. This study showed men over age 65, especially if they have ever smoked, should have screening abdominal ultrasounds. (Women who smoke may also benefit but the study didn't look at the gals.)
(Annals Internal Medicine, 2007)

Patients with gastroesophageal reflux disease (GERD) can use PPIs intermittently:
GERD is a chronic condition that needs long-term therapy. Most doctors prescribe proton pump inhibitor (PPI) medication for daily ongoing treatment. Researchers compared people who used PPIs daily with patients who took the medication only when their symptoms were acting up. They found PPIs were more effective than placebo and "on- demand" PPIs were more effective than daily maintenance if there were no ulcers. Since PPIs are expensive, this shows that patients who suffer from GERD can take the pills when they feel they need it and don't need to take it every day.
(Aliment Pharmacol Ther.,2007)

Aspirin reduced the incidence of colorectal cancer:
Colorectal cancer is the 2nd most common cancer in developed countries. This study followed healthy men and patients with mild strokes for 23 years. They found aspirin reduced the incidence of colorectal cancer. the effect was seen only after 10 years of follow-up. Because aspirin can cause stomach ulcers ask your doctor if you should take it. (I almost always recommend it to both women and men for cardiovascular protection. Now we have another reason for this cheap, old-fashioned "wonder-drug")
(Lancet, 2007)

Monday, January 21, 2008

The Shape of a Mother

I just wanted to share this link of a woman who gave birth to triplets (at home no less). She bravely photographed her growing belly and it is awesome to see. For those who are dismayed at the flabby tummy afterward...keep in mind that it takes a year for the post pregnancy abdomen to resolve...although I am sure the loose skin will remain. Who cares? The result was worth it. Check it out.

Remember Martin Luther King, Jr.

Martin Luther King, Jr. (Jan 15, 1929 -April 4, 1968)

  • "I have a dream that one day this nation will rise up and live out the true meaning of its creed" 'We hold these truths to be self-evident, that all men are created equal."'
  • "I have a dream that my four little children will one day live in a nation where they will not be judged by the color of their skin but by the content of their character."
  • "Now is the time to lift our nation from the quicksand of racial injustice to the solid rock of brotherhood. Now is the time to make justice a reality for all of God's children."
  • "Every man must decide whether he will walk in the light of creative altruism or in the darkness of destructive selfishness."
  • "History will have to record that the greatest tragedy of this period of social transition was not the strident calmor of the bad people, but the appalling silence of the good people."
  • "Injustice anywhere is a threat to justice everywhere."
  • "Never forget that everything Hitler did in Germany was legal."
  • "Nothing in all the world is more dangerous than sincere ignorance and conscientious stupidity."
  • "Our scientific power has outrun our spiritual power. We have guided missiles and misguided men."
  • "We must build dikes of courage to hold back the flood of fear."
  • "I have decided to stick with love. Hate is too great a burden to bear."

Saturday, January 19, 2008

Oatmeal for Cholesterol

The recent news about Vytorin and Zetia not being effective for lowering cholesterol was front page headlines across America and in the medical blogosphere. What didn't get any attention was the new research that shows "oatmeal lowers cholesterol even more than we thought 10 years ago ".

Dr James Anderson looked at new studies and compared them with the original conclusion reached by the FDA 10 years ago. He found, without exception, that oat consumption lowered total cholesterol as well as the "bad" LDL cholesterol. He says "Whole grain products like oatmeal are some of the best foods one can eat to improve cholesterol levels."

Other benefits from eating oatmeal have also been found. It can reduce the risk for hypertension, type 2 diabetes and weight gain. It may supply unique compounds that may reduce early hardening of the arteries.

So what's not to like? Whole Foods sells steel cut Irish oatmeal for under a dollar a pound. Statin drugs can run $30-120/month. Oatmeal causes no side effects (unless you are on a gluten free diet) while statins can often cause muscle pain, liver damage or interact with other drugs. At the very least, oatmeal should be "prescribed" by physicians for everyone whose cholesterol is high.

Gotta oatmeal is bubbling over.

Thursday, January 17, 2008

Medical Quiz #3- Answer (see prior post)

This was a toughy. The answer is #4 Furuncular myiasis. This is a human botfly larvae (Dermatobia hominis) emerging from a nodule on the patient's upper arm. The fly's eggs are carried by mosquitoes after the female fly catches the mosquito and attaches its eggs to the body. The eggs hatch and enter the human body when the mosquito is feeding on it. The larvae develops in the subcutaneous skin and after 8 weeks the larvae emerges (like in the photo) and drops off into the soil. They develop in the soil into small gray botflys.

Believe it or not, the wound doesn't usually become infected because the larvae can only survive for 8 weeks in an uninfected body. It may even secrete an antibiotic. The larvae are difficult to remove but duct tape can cut off their air supply and kill them. Yet another great use for duct tape!!!

This species is found in the New World tropics. Fortunately infection is not common. Just remember to travel with your duct tape.

Wednesday, January 16, 2008

Medical Quiz 2008 #3

This one is really really hard. I missed it myself but I guarantee, when I see it in a patient...I will know what it is. Click on the image for a better view.

What is the diagnosis?
1. Cutaneous leishmanaisis
2. Cutaneous larva migrans
3. Epidermoid cyst
4. Furuncular myiasis
5. Tungiasis

Check back tomorrow for the answer.

Grand Rounds is Here

Grand rounds this week is at Sharp Brains and is posted as a clever message to our next Mr. or Ms. President! Check it out for good medical blogging. Everything Health is mentioned again!

Tuesday, January 15, 2008

Clorox Goes Green

I love the green movement because it helps people think about the environment. The first step to any change is conscious thought. We can't change what we don't know.

Now The Clorox Co., the Oakland firm that introduced bleach to America a century ago, is marketing natural, biodegradable household cleaners called "Green Works". More than 99% of the ingredients in "Green Works" are natural and nonpetrochemical. They break down within 28 days and do not harm the environment. And they are not tested on animals. What's not to like?

Think about it. We are closed ecosystem. Nothing goes anywhere except back to the earth or it's atmosphere. Conventional cleaning products are made from petrochemicals that do not biodegrade. They get into our groundwater and watersheds. If you have to wear gloves to use them, that is a tip you don't want them in the soil.

Most of us don't have the time, extra money or inclination to drive (using gas) to a special "green " store to get our overpriced green detergent. It is great that a large company is going "green" and these products will be mainstream in Walmart. I don't care if it is a niche for their bottom line profits. Go ahead, make a profit on doing something good for a change.

It is reassuring to me that the Sierra Club has endorsed the new Clorox products. Carl Pope, the brilliant executive director of The Sierra Club said "We hope we are transforming the marketplace by doing this. These products are clean, they're green, they're not going to hurt you, and they're not going to hurt the environment."

I hope Clorox posts record profits this year.

Sunday, January 13, 2008

Emergency Room Call-Another Doctor Shortage

Across the United States, and certainly in Northern California...hospitals are facing increasing difficulty with the availability of certain specialties to cover emergency rooms. In the past, if a patient is seen in a community hospital by the emergency physician, she can call on a panel of specialists to come in when needed to see the patient. Physicians in Neurosurgery, Orthopedics, Psychiatry, OB, Oral Surgery and even General Surgery are saying "no-more" and these hospitals now either need to transfer the patient out, or pay the doctors to be on call. (If they can even find the doctors)

There are numerous reasons why physicians have little interest in taking call. Hospitals are required to treat everyone, regardless of their ability to pay. With the increasing ranks of uninsured patients, the doctor is also treating for free. There is a perceived higher-risk of malpractice litigation if things don't go well. Since a good "relationship"is the best way to "not" get sued...a new patient might be more litigious. The time taken away from the office (now at high cost) just isn't worth coming in, and there are less hungry young doctors in many communities that are trying to build a practice by taking ER call. Additionally, the days of the "gentleman" physician are long gone. Most doctors have a crushing work schedule and carrying the "2 ton beeper" on nights and weekends is no longer part of the deal.

What is the solution to this problem that is NOT GOING AWAY? At the present, hospitals are ponying up the $$$$ to pay doctors to be on call. This amounts to millions of dollars a year for just one hospital and probably billions across the country. You can count that in to the invisible but real rising cost of health care. I see this increasing as time goes on.

States should be proactive about enacting legislation that protects on-call doctors from lawsuits when they see uncompensated patients...extend the "Good Samaritan Laws" to cover E.R's. The United States needs to really look at how health care is delivered and reimbursed. There truly is a physician shortage in certain specialties that is becoming obvious as our population ages. Patients expect the high tech care they read about but it is worthless if there isn't an available doctor to deliver it at 1:00 AM.

This is a national problem that needs national solutions. I've not heard anything about health care reform that would solve this dilemma. How about a commission to look at the problem and make recommendations that are taken seriously by policymakers. I don't want to arrive in an ER with a stroke or a major trauma and be told "The doctor is not in".

Thursday, January 10, 2008

Do You Wonder Why Americans Are Fat?

I am happy to link you to the most amazing array of bad food choices you will ever see.
Reading this is enough to scare anyone into healthy, low cal eating (I hope). Can you believe those calories?
(hat tip to kevinmd)

Answer 2008 Quiz #1

The answer is #1 - Leukemia.
Gingival (gum) infiltration in a patient with fever, fatigue and weight loss is consistent with acute leukemia. This condition resolved after treatment.

Wednesday, January 9, 2008

Medical Quiz 2008 - #2

Here is your 2nd medical diagnosis challenge of 2008. This patient has fatigue, fever, anorexia and weight loss and this appearance of her gums. What is the diagnosis? Click on the image for a better view:
1. Leukemia
2. Scurvy (Vit C deficiency)
3. Acquired Immunodeficiency syndrome (HIV)
4. Sarcoidosis
5. Pellagra (Vit B3-niacin-deficiency)

Check back tomorrow to see if you are correct.

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Monday, January 7, 2008

Doctors and Sexual Misconduct

The Ventura County Star reports some alarming statistics from the California Medical Board about prosecution of doctors who engage in sexual misconduct with patients. They looked at reports over the past 6 years and found only 1 in 7 cases had any action taken at all. Of 680 reports of bad sexual behavior, only 123 doctors received any sanction.

As a physician, I pay $805 as a licensing fee to the Medical Board and that is to support them in their oversight role. We want them to make sure physicians live up to the ethical standards of the profession. Along with that, it is important for doctors to have due process against unwarranted complaints. Some patients might not realize that touching in a physical exam is not sexual in nature. Of course these reports need to be ferreted out.

A study was done in 2004 that showed only one analyst at the Medical Board covered all complaints of sexual, alcohol and drugs reported by patients or others against a physician, podiatrist or physician assistant. Can you imagine the backlog of one person trying to handle all of those reports? After the report came out, the Medical Board assigned two analysts to review them. Given the types of complaints that the Board receives, I am not sure 2 is enough.

The Medical Board of California assures that they will prosecute all legit complaints. They have a new executive director. Oversight of impaired physicians is essential for the comfort, confidence and safety of patients and the Medical Board needs to be diligent in investigating every single complaint. If the doctor is found guilty, swift revocation or suspension of the license is needed.

Saturday, January 5, 2008

Childbirth Classes - Not Too Popular

I remember the "60's" and one of the off shoots from the women's movement was women getting in touch with their bodies and reproduction. It is hard to imagine now, when Brittany is flashing her bare crotch to photographers and soft porn is on family time TV, but back then women actually came together in "feminist" groups to learn about their bodies. An entire industry of prenatal "Childbirth Classes" sprang up to prepare moms and dads for giving birth.

When I had my daughter in the late 1960's we had no such prenatal education. I don't remember ever being told about childbirth classes so I presume they weren't mainstream, if offered at all. Questions I asked my OB about childbirth were waved off with the admonition "We'll see about that when the time comes". Anyone who has had a baby knows that during labor is not the time to ask questions or get any reliable education. It's like learning the basics of atmospheric pressure during a hurricane. Or learning oceanography as a tsunami is approaching.

So I found it interesting to read a report in the New York Times, that pregnant women aren't attending childbirth classes anymore. What? giving birth for the first time and not wanting to learn about labor, epidurals, breathing and how the coach should give a back rub? No more practice panting? How did everyone get so well informed?

It might be that women are working right up to the time of labor and just don't have time. It might be that they expect an epidural when the first "ouch" hits and so the other techniques aren't important. It might be that the ultrasounds showing the baby waving and that cute cleft in the chin have just taken the mystery away. Or maybe, women have seen childbirth so many times on the Discovery Channel , that they know exactly what to expect.

I was excited to have the opportunity to attend a childbirth class for my 2nd baby. Even though by this time I was an experienced doctor and had delivered babies myself, I wanted the experience of being in a room with my husband and a group of other budging belly couples and hearing what the instructor had to say. But like the article points out...I was too busy and skipped the lesson on "C-sections" thinking "Oh, I know all about that". That is the lesson I should have attended.

Thursday, January 3, 2008

Do Doctors Make Too Much Money - Volume II

I am truly amazed that the #1 most read post I have ever written was (read the link after!) "Do Doctors Make too Much Money?". Thousands of people from around the world have "googled" that phrase and found EverythingHealth. Every day there are several visits to that one old piece. I am amazed because I wouldn't have thought there was that much interest in Doctor's incomes. Apparently there is A LOT of interest and many have strong opinions if you read the comments.

I think some doctors are probably paid too much. But the other 99.99% deserve what they get or, if they are primary care physicians...they deserve A LOT more. The doctor group I know the most about is primary care and general Internal Medicine. I can tell you that, on average, these doctors are underpaid and overworked. Now don't write back and compare it to a teacher or a fireman and tell me how underpaid they are too. This is not a is a fact.

If you have been reading EverythingHealth or any number of other health blogs, you know that we are facing a huge primary care crisis in the U.S. because less than 15% of all doctors in training will chose this specialty due to low reimbursement and heavy workloads. Why should you care?

You should care because your body is complex and there is no textbook or computer that can replace the thinking, intuition and training of a doctor. You should care because you are getting older along with everyone else, and the body is less forgiving with age. The Happy Hospitalist an Internist who practices in a hospital setting, describes just another decision making day at the office.
It isn't worth much, unless it is you, or your mother or wife.

You should care about primary care because your average specialist (cardiologist, transplant surgeon, gynecologist, dermatologist, ophthalmologist, pathologist, ENT, orthopedic surgeon and on and on) is not going to concern themselve with the complexities of multi organ disease and granny's alzheimers. They are not going to follow up on that abnormal mammogram or care about your cholesterol level. They are not going to care if you can't sleep, pee or poop...unless it involves an expensive test or procedure. Specialists are trained to deal with one part of your body. That is what they are interested in and that is where their expertise resides.

A primary care Internist has broad knowledge about every organ you own. They think in a comprehensive way and form differential diagnoses that let them process information to come up with the best diagnosis, testing and plan. Some are gifted healers and bring even more to the table.

Many people who follow health care policy believe it may already be too late to save primary care medicine. At the very least we will have two tiers of medicine. Retainer or concierge practices that cater to the wealthy and nurse practitioners who deal with routine health matters. Emergency rooms will be filled with everyone else. Patients will shuffle from specialist to specialist with no coordination, and costs will soar. Then we will see if we paid them too much back in the "good ole' days".

Wednesday, January 2, 2008

Answer 2008 Quiz #1

The answer is #1-Rhinophyma.
This condition enlarges and distorts the nose with prominent pores and thickened skin. The nose becomes larger and irregular due to hyperplasia of the sebaceous glands. The cause is unknown and it was previously thought to be related to alcohol abuse, but that has been debunked. It is most common in males and once the deformity occurs the only treatment is plastic surgery or laser treatment.

Good job, players!

Tuesday, January 1, 2008

Medical Quiz 2008 - How Smart Are You?

This common condition was seen in the oldie actor and comic, W.C. Fields. Can you pick the right diagnosis? Click on the image for a closer view. The answer will be posted tomorrow.

Imagine 2008- It's not hard to do

Happy New Year across planet Earth. My wish is for a world of compassion, peace and abundance for everyone.

John Lennon

Imagine there's no heaven
It's easy if you try
No hell below us
Above us only sky
Imagine all the people
Living for today...

Imagine there's no countries
It isn't hard to do
Nothing to kill or die for
And no religion too
Imagine all the people
Living life in peace...

You may say I'm a dreamer
But I'm not the only one
I hope someday you'll join us
And the world will be as one

Imagine no possessions
I wonder if you can
No need for greed or hunger
A brotherhood of man
Imagine all the people
Sharing all the world...

You may say I'm a dreamer
But I'm not the only one
I hope someday you'll join us
And the world will be as one

Grand Rounds: For great Medical blogging and beautiful photos check out this weeks Grand Rounds from South African doctor Bongi. He made a mention of EverythingHealth, which is always appreciated!

When to Use Urgent Care

We all know that Emergency Departments are over-crowded with long waits and exorbitant fees.  Free standing Urgent Care is a great solu...