Blue Cross Blue Shield's Medicare Blue: Another Member of the Insurance Hall of Shame

My patient has had two heart attacks. You would think that his insurance company would try to prevent him from having another one. After all, you might say, heart attacks are expensive, and they wouldn't want to pay for that. You would be wrong on both counts.

Medicare does not pay for outpatient medications. This may have made sense when Medicare was created, since the cost and number of medications for the elderly were relatively low. However, nowadays, it's very tough to pay for the average senior citizen's medications. Hence, the Medicare Part B plans. These were put in place by the Bush Administration to encourage private companies to offer medication insurance for Medicare beneficiaries. Perhaps one problem with these plans is that they have less of an incentive to pay for prevention than traditional plans. After all, why pay for a medication to prevent a heart attack if you don't have to pay for the hospital stay or the bypass surgery? At least, that what I think is happening.

 So, back to my patient. As overused as they may be for other indications, statins prevent heart attacks in patients who have already had one or more heart attacks. (Statins are cholesterol-lowering medications such as atorvastatin, a.k.a. Lipitor.) The American Heart Association and the American College of Cardiology recommend only the two most potent statins, atorvastatin and rosuvastatin, for these patients.

My patient had severe muscle aches on atorvastatin, and it barely touched his cholesterol. He tolerates rosuvastatin, and it is the more potent drug. There is no question that he should be on it. Yes, it's expensive, but he needs it, and it costs less than a bypass. Medicare Blue won't pay for it. I've appealed twice, and the second time, their letter basically said, "we'll cover this when hell freezes over."

Keep it classy, Blue Cross, Blue Shield.

United Healthcare Strikes Again!

As I said in a previous post,*  United Healthcare is the worst in the rogue's gallery of modern health insurers. Last week, I got another confirmation of this fact. One of my patients came in for his history and physical exam and had not gotten his blood drawn in advance. Why? Because United Healthcare will not pay for labs that associated with a history and physical unless they are drawn on the very same day as the visit.

When my patients come in for a History and Physical, I try to have them get their labs drawn before they come in. That way, we can have a face-to-face talk about what diet might lower their cholesterol or why they might be anemic, or whatever. I can also get any follow-up labs drawn on that day. It makes everyone's life easier, and, sometimes, it even saves the insurer money. Some lab results might require a face-to-face discussion instead of a phone call, and, if I don't have the labs on the day of the physical, the patient will have to come in for another visit, which means another bill to insurance.

I don't know why United Healthcare does this. Probably, some deranged actuary has convinced them that it makes financial sense, even though none of their rivals appear to think so. I don't believe that United Healthcare is consciously vindictive, but they sure do good impression of it.

Comment on "How Doctors Choose to Die"

http://forum.facmedicine.com/threads/how-doctors-choose-to-die.17135/

This reminds me of one of my last nights in residency. (Details changed to protect privacy.) As I signed on, I saw that I would be responsible for a very sick, 100-year-old man. I had a sinking feeling that he was going to die that night, and, if he did, I would have to do horrible things in a fruitless attempt to bring him back. He was demented and unable to speak for himself, so I told the family what I thought might happen. I asked their permission to allow him to die if it came to that.

They refused. He was from a foreign country, and his family mistrusted our medical system, since, where they were from, doctors had abused people like them. They weren't about to let a man in a white coat stint on their venerated grandfather. So I went to the call room and tried to sleep, fearing the inevitable beeper interruption.

A few hours later, it came. The 100-year-old man had stopped breathing, and his heart had stopped. Someone had 'called a code.' I came downstairs to find my team around his bed. Looking at each other sheepishly, the interns, nurses, and I stabbed him with a large needle to place a central venous line, pounded his brittle ribs, and shocked his withered heart into a few more beats. As I jammed the endotracheal tube down his throat as gently as I could, his dying eyes glared at me, and his face contorted in a rhythmic, reflexic scowl of brain death. His heart stopped again. Finally, I decided we had played the charade long enough. I pronounced him dead.

I cannot dismiss the effect the family's collective history had on their priorities. Perhaps there was no other way for them, but, to me, this whole effort had been a horrible crime.

Calling a code is not always pointless. Chances of survival are bleak, but a previously vigorous person who makes it through a code has a reasonable chance of walking out of the hospital on their own two feet and in good mental shape. On the other hand, once someone is frail and fatally ill, cardiac resuscitation is practically useless.

Resuscitation for all cardiac arrests is still the default in fact, though not in law (at least in my state). This is for bad and good reasons. Doctors are afraid of lawsuits, and some salvageable lives have been forsaken out of prejudice or base motivations. A family's wishes cannot be dismissed lightly.

But, if you don't want this to happen to you, please plan for this. If and when you are fatally ill, make sure everyone in your family understands that you want to go peacefully when it is time. If you don't, some prodigal son might return and demand that everything be done to 'save' mom to assuage his own guilt. Or your spouse, not knowing your wishes, might be unwilling to deny you the 'best' care. Give them permission to let you go.

Misinformed Outrage Over FDA Letter to 23andMe

Tonight, I read an excellent post on the website KevinMD* supporting the FDA's recent action against 23andME. 23andME offers broad genetic testing to the public.** The comments that followed raged that it was ridiculous for the FDA to regulate the tests as a 'device' since the tests are not a device and that the FDA was interfering with patient freedom by outlawing these tests. Not so fast. As a doctor and occasional lawyer, let me explain why the commenters are thoroughly misguided.

First, 23andMe can still market the tests.** They have simply barred the company from making bogus interpretations and unsubstantiated claims about what the tests can do. For why that matters, see the post on KevinMD.*

Second, the tests are a 'device' in this context. Sometimes, lawmakers and regulators use common words as shorthand for specialized concepts. The shorthand is spelled out within a particular law or regulation for use in that context only. Common usage is not relevant. As the FDA says in its letter, and as 23andMe surely knew, "this product is a device within the meaning of section 201(h) of the FD&C Act, 21 U.S.C. 321(h), because it is intended for use in the diagnosis of disease or other conditions or in the cure, mitigation, treatment, or prevention of disease, or is intended to affect the structure or function of the body."***

23andMe claimed that their tests were the ' “first step in prevention” that enables users to “take steps toward mitigating serious diseases” such as diabetes, coronary heart disease, and breast cancer.' The FDA offered them the opportunity to substantiate these claims. They ignored the offer. Theirs is exactly the sort of behavior the FDA was founded to regulate.

So please, disagree with the law if you like, but read before you rage.


[PLEASE MAKE ALL COMMENTS WITHIN THE BLOG. NOT EVERYONE HAS FACEBOOK.]

* (http://www.kevinmd.com/blog/2013/12/23andme-providing-data-physicians-manage.html) 

** (https://www.23andme.com/ancestry-only-notice/?redirect=Od5SRaMng_bubQswwbkFyONDrnQDavEBPlg5nNjo754=) 

***(http://www.fda.gov/iceci/enforcementactions/warningletters/2013/ucm376296.htm)

Too Much Information: Medicine and National Security

This is not a very 'Tumoriffic!' update. My health is fine right now. This is about current events. It is not an exhaustive or radical post, just an analogy that occurred to me as I considered doing a particular test on a patient.

*******************************************************************************

There is such a thing as too much information--too much of the wrong kind of information, or information too dearly bought. This is true in medicine, and I believe it is true in national security.

Beginning in the late 1800's, burgeoning technology granted us more and more power to image and measure the body as never before. The number of screening tests ballooned. One might assume that the that early detection--more information--would automatically lead to fewer deaths and less misery. That is not always the case.

Similarly, technology has granted our government power to monitor private individuals as never before. The advocates for this technology believe that it will automatically lead to fewer deaths and less misery.* I am skeptical. I think it is human nature to overestimate benefits and underestimate risks of new technologies in all fields. National security should learn from medicine.

Sometimes, information can lead us down destructive paths. We used to test every middle-aged man's PSA instead of limiting the test to those at high risk. Unfortunately, most men with a high PSA did not have prostate cancer, most prostate cancers would not grow fast enough to impact lives, and treatments were (an are) risky. For every 1,000 we tested, we terrified over a 100 with a 'positive result.' The resulting biopsies and treatment left 29 of those men impotent and 18 in diapers. They gave two men heart attacks, and one man a blood clot in his lung. One man may have died due to the treatment, and one man might have lived longer. (http://www.cancer.gov/cancertopics/factsheet/detection/PSA) The PSA test gave us more information, but we did not know what to do with it.

In medicine, we gloried over the supposed prostate cancer deaths averted and did not see the harms. In national security, they tout the terrorist plots foiled, but, inevitably, innocents are harmed. (e.g., http://www.portlandcopwatch.org/PPR34/PJTTF34.html, and http://www.humanrightsfirst.org/our-work/refugee-protection/refugees-falsely-accused-of-terrorism/page/2/)

Sometimes, the very act of gathering information is harmful. For at least 70 years after the invention of the x-ray, doctors routinely x-rayed pregnant women to image the fetus and evaluate the pelvis to plan delivery. As first publicized by British physician Alice Stewart in 1958, this could increase the child's risk of cancer by a factor of ten.  The x-ray may have prevented some delivery complications, but it caused millions of cancers. (http://www.ratical.org/radiation/KillingOurOwn/KOO6.html) The NSA's inquiries are showing harms much more quickly. (e.g., http://www.reuters.com/article/2013/11/13/us-usa-security-hearing-idUSBRE9AC0S720131113, http://legalinsurrection.com/2013/11/lavabit-founder-i-had-effectively-lost-the-ability-to-control-my-own-network/, and https://www.aclu.org/blog/national-security/you-may-have-nothing-hide-you-still-have-something-fear)

These are but a few examples. In national security as in medicine, technology has given us powers once only attributed to gods. It is natural to want to use them to try to prevent all of the disease or evil in the world. Sometimes, however, the prevention is worse than the disease.


* Note that I am not going into questions of motives. Instead, I am taking as a given that most in the medical profession want to heal, and most in national security want to protect.

A Non-Heroic Act

This is from a comment I originally posted on at http://www.kevinmd.com/blog/2013/06/ehrs-talk-work.html.

Recently, a patient who was away on vacation paged me with very worrying symptoms. I told her to go immediately to the nearest emergency room. I then printed out and faxed an automatic face sheet containing her diagnoses, medications, adverse drug reactions, and most recent vitals and labs. Next, I called the emergency room to which she was headed and briefed the attending physician. This physician later informed my patient that my 'remarkable' handoff was part of what saved her life.

This should not have been a 'remarkable' handoff. My electronic medical record system should have sent most of the relevant information automatically and instantaneously even had I not been near a fax machine and had not had immediate access to the medical record and a printer.

In every other aspect of society, your privacy is for sale to anyone who wants to violate it. Only in medicine, where effective information exchange done in your own interest can save your life, is privacy protected so jealously. Medical information 'siloing' (maintaining medical record systems that do not talk to each other) creates endless administrative costs, delays, redundancies, and avoidable errors. This means everything from visit notes to radiology, current and previous med lists, adverse drug reactions, diagnoses, other providers' contact information, patient contact information and next of kin. Don't think communication of this information is important? How well do you think a hospital would work if, every time a new doctor walked into your room, they had to gather and record all of your information from scratch? How much extra time and money would they burn gathering old facts? How much more likely would you be to die? If it makes no sense within a hospital, it makes no sense between hospitals.

Sophisticated patients can mitigate this somewhat by keeping their own copy of important health history, but if you have had a serious illness, your history quickly becomes immensely complicated. It is hard for even a medical professional to always know what parts will be important. This is nothing compared to the challenge for patients who are just not sophisticated in the ways of medicine or computers or for the people who tend to be the sickest--those who are demented or otherwise intellectually or psychiatrically impaired.

Getting my patient's information to that ER physician was no heroic act. It was doable because I happened to be in a location where the information was easily accessible, and I had the time and means to transmit it. But, unfortunately, such handoffs are not common. They should be.

Childhood Flashback 4: Staging

On the day of his admission, the boy's parents drove him an hour up Route 95 to Baltimore and its depressed inner city of red brick public housing developments. Johns Hopkins Hospital in 1981 was a warren of long, windowless, flourescently lit hallways with rust-colored carpets and walls. Rushing crowds of doctors, administrators, patients, and families filled them, each intent on their separate destination.

After check-in, his parents took him to the 8th floor of the pediatrics building which had rows of rooms on either side of a nurses' station. In the boys memory, it would later seem as if everything in ward--the walls, the floors, even the lights--were pale shade of green in never-ending nighttime.

The first step of the process was staging. They knew the nature of the tumor. They did not know its extent. Had it spread to local lymph nodes and to other organs? To the bone marrow? That would determine the boy's chances of survival and his treatment.

Over days, the boy had scans and blood tests. The only tests he would remember years later was the spinal tap the bone marrow biopsy. Paul did them. Both of them were done to his back, where he could not see, and with him curled up on his side like a fetus.

The initial spinal tap was to look for any sign that the tumor had broken the barrier that separated the brain and spinal cord from the rest of the body. The idea of a spinal tap is more painful than it's execution. The spinal cord is bathed in cerebro-spinal fluid contained in the thecal sack. Low in the back, the spinal cord dwindles to a horsetail of separated nerve roots and a tether that anchors it to the base of the spine. There, where there is no longer a risk of impaling the cord itself, a needle can be slipped between the bones of the spine to puncture the thecal sack and draw out a few drops of the fluid. Even with his limited knowledge of anatomy and with Paul's gentle touch the boy quailed at the idea of a needle in such a place, but it was relatively painless as it would be the dozens of times it would be repeated over the next two years to inject chemotherapy.

The bone marrow biopsy is conceptually simpler. The marrow that fills most of the bones of the body is another critical area where cancer may spread. The hip bone is relatively thin and close to the surface. The needle and syringe for the procedure are enormous. When Paul inserted the needle and pulled, the boy felt the horrible suction in his bone, but luckily, his memory was dulled by sedation.

The cerebrospinal fluid and the marrow showed no tumor cells. The only new finding was suspicious mass in the boy's left shoulder