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Jilted: We No Longer Accept Your Health Insurance

Jilted: We No Longer Accept Your Health Insurance

Dear patients on insurance company X: I am very sorry to give you the bad news: effective immediately, we are no longer providers on your medical insurance plan. I am sorry about this because many of my favorite patients are on your insurance plan. It will miss seeing you. I am also sorry because this makes your already short list of possible doctors even shorter, making it much harder for you to get good care. There is a reason there aren’t many doctors on your plan: it just doesn’t pay enough to be worth it. I suspect that some of you must feel jilted, like you just got an unexpected “Dear John” letter. I hate giving this sudden bad news; I’ve been with many of you for more than 10 years, walking alongside of you through sickness and pain, births and deaths, sadness and joy.  But what I hate the most is that all of this is happening because of money; it makes me feel selfish or petty. Please believe that we did everything we could to avoid this situation. Here are the things that drove us to this hard decision: 1. Your insurance was already paying us significantly less than average, and now wants to pay us even less. 2. Your insurance also requires us to do far more paperwork than most. 3. Their referral process is very complicated and frustrating. As a primary care doctor, I make my living by what I get paid for office visits.  We don’t do a lot of procedures, we don’t see people in the hospital, and we don’t own a lab to make us...
Supreme Court: Health Insurance Mandate Constitutional

Supreme Court: Health Insurance Mandate Constitutional

The Supreme Court ruled today that the individual mandate requiring all Americans to obtain health insurance under the Affordable Care Act is constitutional — what many described as the “heart” of the law. In addition, insurance companies cannot discriminate against those with a pre-existing condition. However, a major provision that would have required expansion of medicaid to cover more of the poor has been struck down. Currently, Medicaid is a joint federal-state program that provides healthcare to certain poor Americans, such as children and the elderly. In 2014, the Affordable Care Act would have opened up Medicaid to anyone with an income under 138% of the federal poverty line — what some argued would place an undue burden on the states. The court agreed that the federal government’s ability to revoke a state’s Medicaid funding is limited. To read the full ruling, click here. Physicians Weekly wants to know… what is your reaction to this...

Reducing Triglyceride Levels in Patients at Risk for CVD

Almost one-third of adults in the United States have elevated triglyceride levels (>150 mg/dL), and these levels are continuing to rise in adults aged 20 to 49 at rates that mirror those of obesity and diabetes diagnoses among the young. Observational and epidemiologic studies have demonstrated that high triglycerides (200-500 mg/dL) are associated with increased risk of cardiovascular disease (CVD), with the highest levels (≥1,000 mg/dL) associated with an increased risk of pancreatitis. “High triglyceride levels indicate that patients have high levels of circulating cholesterol-rich remnants,” explains Michael Miller, MD. “Cholesterol-rich remnants are highly atherogenic.” Dr. Miller chaired an American Heart Association (AHA) writing committee that published a scientific statement on triglycerides and CVD in the April 18, 2011 issue of Circulation. “There has been little consensus in the literature about the role of triglycerides in coronary disease,” he says. “There has been no detailed statement on triglycerides that has systematically reviewed both the pathophysiologic and clinical trial evidence to date. For this reason, the AHA felt it was necessary to educate healthcare providers about the importance of triglycerides as a biomarker of cardiovascular risk.” He adds that the 2011 AHA position statement analyzed more than 500 international studies from the past 30 years. Helpful Strategies in Reducing Triglycerides Dr. Miller says it is well known that dietary and other lifestyle interventions can help patients lose weight and have a strong effect on triglyceride levels. “These improvements also translate into salutary effects on systolic blood pressure and glucose, reduced insulin resistance, and systemic inflammation, thereby resulting in an improved metabolic profile.” According to the guidelines, substituting unsaturated dietary fats...

Overuse of Proton Pump Inhibitors is Expensive & Dangerous

Let’s talk about proton pump inhibitors (PPIs). These drugs, successors to the innovative H2 blockers, have revolutionized the treatment of gastro-esophageal reflux disease (GERD) and peptic ulcers. But like all good things, too much can be a problem, and that’s where we are today. A new study shows that of 90 patients who were tested and found NOT to have GERD, 38 (42%) continued to take PPIs that had been prescribed prior to the testing. Some, apparently, were not always told to stop the medication, and others continued it because they remained symptomatic. Ambulatory patients are not the only ones overusing PPIs. According to UpToDate, the indications for stress ulcer prophylaxis in hospitalized patients are as follows: Mechanical ventilation for more than 48 hours, coagulopathy, GI ulceration or bleeding within the past year, traumatic brain injury, traumatic spinal cord injury, severe burns, or two or more minor risk factors, including sepsis, ICU admission lasting >1 week, occult GI bleeding lasting ≥6 days, or high-dose glucocorticoid therapy. But in most hospitals, intravenous PPIs are routinely ordered for any patient who is NPO (not taking food or drink by mouth). There is not one shred of evidence that PPIs are indicated in this setting. I am old enough to remember the days before PPIs and H2 blockers existed. I assure you that millions of patients were NPO and did not develop gastritis or ulcers. Of course, PPIs are available over the counter (OTC) now, and although they are meant to be taken for only 3 weeks at a time and for no more than 3 such courses per year, there is...

Acute Pain Management in the ED

Pain has been identified as the most common reason for patients seeking care in emergency rooms. Considering the substantial impact that pain has on patients, ED physicians need to be well versed in its management, particularly in acute pain situations. Unfortunately, research has shown that ED physicians often fail to provide adequate analgesia to their patients. There are also challenges in meeting patients’ expectations in treating pain and in changing prescribing patterns of opioid analgesics. The Effects of “Oligoanalgesia” We have more than 25 years of research on acute pain management as well as multiple guidelines on the topic. Despite this information, the phenomenon of “oligoanalgesia”— the undertreatment of pain—continues to persist in EDs. The following are major causes of oligoanalgesia in the ED: Lack of basic knowledge and formal education on acute pain management. Prejudice toward and irrational fear of using opioids in the ED. Lack of adherence to acute pain management guidelines and clinical pathways. Underuse of analgesics titration protocols. Barriers preclude ED physicians from proper acute pain management that include ethnic, racial, and age bias as well as ED environment and culture. Wanted: More Formal Pain Management Training The lack of formal teaching of acute pain management in medical schools has had a profound effect on the gap in emergency physicians’ clinical knowledge on the subject. There may also be a reluctance to change practice patterns or a prejudice toward using opioid analgesics in the ED. Pain management is a subject that is not taught within most medical school programs. Research has shown, however, that utilizing pain management educational programs can lead to substantial improvements (see...

American Society of Hypertension 2012

New research was presented at the American Society of Hypertension’s 2012 Annual Scientific Meeting & Exposition from May 19-22, 2012 in New York City. The features below highlight just some of the studies that emerged from the conference. Exploring Clinical Inertia in Hypertension Control The Particulars: Therapeutic goals are unmet in many patients with hypertension. Previous research suggests that clinical inertia—failure to adjust medication regimens after uncontrolled hypertension is identified—may play an important role in this problem. Data Breakdown: Researchers analyzed 5 years of data to assess the association of patient and physician characteristics with clinical inertia incidence and continued uncontrolled hypertension. Among the 59% of patients who experienced clinical inertia, less than 2% of the variance in clinical inertia was attributable to physician characteristics. In patients, clinical inertia was associated with increased age, Hispanic/Latino ethnicity, obesity, and higher systolic and diastolic blood pressure. Take Home Pearls: Rates of clinical inertia in the treatment of hypertension appear to be high. Important patient characteristics are associated with clinical inertia and may be targets for future interventions. Gender Affects Hypertension Thresholds  The Particulars: Current ambulatory blood pressure (BP) thresholds for diagnosing hypertension do not differ between genders. However, women tend to have lower ambulatory BPs than men. Data Breakdown: In a study, investigators assessed the role of gender on the diagnostic thresholds for awake and asleep BP averages based on cardiovascular disease (CVD) outcomes. The maximum combined sensitivity and specificity corresponded to threshold cutoff values of 135/85 mm Hg for awake BP and 120/70 mm Hg for asleep BP for men. In terms of CVD risk, the corresponding values in women...

Evaluating Pediatric Syncope

A University of Cincinnati study suggests that ECG imaging should be used more often to screen for underlying cardiac abnormalities when evaluating pediatric patients who present with syncope. Of more than 625,000 ED visits for syncope that were analyzed, CT or MRI scans were used in 26.5% of cases, while ECG was used in 58.1% of cases. The study team feels that use of MRI and CT imaging in this patient population should be tempered. Abstract: Journal of Emergency Medicine, March 14, 2012 (online)....

Patient Preferences in Discharge Care Plans

Results of a survey of inpatient adults suggest that patients highly value verbal communication on discharge care plans. The study also found that information about recommended lifestyle changes and personal communication between their inpatient and outpatient providers were highly valued. Most patients (64.5%) preferred verbal discharge instructions, and just 10.5% requested written instructions. All patients indicated that information on when to contact their primary care physician and on medications they should continue was essential. All patients also wanted “a lot of information” about their condition and test results, but only 39% reported wanting “a lot of information” about their medications. Abstract: Journal of Hospital Medicine, March 23,...

Physician Triage in the ED

Having physicians conduct triage in the ED appears to lead to earlier evaluations, physicians orders, and disposition decisions when compared with non-physician triage. A 2-year before-and- after analysis found statistically significant, average time decreases in the following domains: Disposition decision (6 minutes). Physician evaluation (16 minutes). Analgesia (70 minutes). Antiemetic administration (66 minutes). Antibiotic administration (36 minutes). Radiology orders (16 minutes). Abstract: Journal of Emergency Medicine, March 26, 2012...

Self-Expanding Stent System Approved

The FDA has approved a self-expanding peripheral stent system (EverFlex, ev3) for use in re-opening stenotic regions in the superficial femoral and proximal popliteal arteries. The stent system is designed to restore blood flow to the legs of patients with atherosclerosis. Source:...

Adding Surgery to Medication Benefits Temporal Lobe Epilepsy

When compared with antiepileptic drug (AED) therapy alone, using respective surgery plus AED therapy appears to result in a lower probability of seizures after 2 years follow-up in patients with newly intractable, disabling mesial temporal lobe epilepsy. Results from a small study indicated that 73% of patients who received AED therapy plus surgery were seizure free at 2 years, compared with a 0% rate for patients who received only AED therapy. Abstract: JAMA, March 7,...

A Novel Approach to Reporting Surgery Outcomes

An evaluation of reliability adjustment—a novel technique designed to quantify and remove statistical “noise” from quality rankings—suggests that the approach appears to reduce variation and accurately estimate risk-adjusted hospital outcomes. A six-fold variation in risk-adjusted mortality was found before using reliability adjustment, compared with less than a two-fold variation after using it. Abstract: Annals of Surgery, April...

Trends in Anesthesia Use During Gastroenterology Procedures

In the United States, use of anesthesia during gastrointestinal endoscopies and colonoscopies appears to have increased substantially from 2003 to 2009, according to a retrospective analysis of claims data during this study period. The proportion of procedures that used anesthesia services increased from about 14% in 2003 to more than 30% in 2009. Researchers noted that more than 65% of services were delivered to low-risk patients. Use ranged from 13% in the western part of the U.S. to 59% in the northeastern Abstract: JAMA, March 21,...

Comparing Appendectomy Methods

Researchers in Tennessee have found that early appendectomy for children with perforated appendicitis appears to be associated with significantly lower hospital charges and costs when compared with interval appendectomy. Average total hospital costs were $17,450 and $22,518 for patients treated with early and interval appendectomy, respectively, according to the findings. Costs were significantly increased with unplanned readmissions and adverse events, but these occurred more frequently among patients randomized to interval appendectomy. Abstract: Journal of the American College of Surgeons, April...
Obesity Among Adolescents

Obesity Among Adolescents

Findings from the CDC’s National Health and Nutrition Examination Survey suggest that nearly one in five adolescents in the United States is obese. Below is a breakdown of obesity prevalence in adolescents by race, ethnicity, and gender:...
New Guidelines on Osteoporosis in Men

New Guidelines on Osteoporosis in Men

This week, the Endocrine Society issued guidelines on managing osteoporosis in men. Published in the June 1, 2012 issue of Journal of Clinical Endocrinology & Metabolism, the guidelines recommend the following: Men at increased risk for osteoporosis should be tested by measurement of bone mineral density (BMD). Men at high risk for osteoporosis should be screened with dual-energy x-ray absorptiometry (DXA). This includes those aged 70 and older and younger men with risk factors. Risk factors for osteoporosis in younger men (aged 50-69) include: – History of fracture after age 50 – low body weight – Diseases such as delayed puberty, hypogonadism, hyperparathyroidism, hyperthyroidism, or COPD – Drugs such as glucocorticoids or GnRH agonists – Life choices such as alcohol abuse or smoking Measure forearm DXA (1/3 or 33% radius) when spine or hip BMD cannot be interpreted and for men with hyperparathyroidism or receiving androgen-deprivation therapy for prostate cancer. FRAX, Garvan, or other fracture risk calculators can improve the assessment of fracture risk and the selection of patients for treatment. Men with low levels of vitamin D (less than 30 ng/mL) should take vitamin D supplements. Those with or at risk for osteoporosis should consume 1,000 to 1,200 mg of calcium every day, ideally from dietary sources. Men aged 50 and older with prior spine or hip fracture, low bone mineral density, or other clinical risk factors (eg, those receiving long-term glucocorticoid therapy in pharmacological doses) should receive drug therapy. Those receiving treatment should have their bone mineral density assessed by DXA at the spine and hip every 1 to 2 years. Pharmacological therapy is recommended for all...

Opioid Prescription Low Among Elderly Patients With Cancer

The proportion of patients older than age 65 with cancer who have an opioid prescription appears to be low, according to Canadian investigators. About 33% of elderly patients did not have an opioid prescription in the analysis, but the proportion of patients with an opioid prescription increased as pain score severity increased.  Abstract: Journal of Clinical Oncology, April 1,...

New Guidelines for Assessing Adiposity

The rate of obesity in the United States has reached the epidemic level despite efforts by healthcare providers and patients to improve health-related behaviors and increased efforts to better understand its pathophysiology. “Assessment for excess adiposity is of critical importance,” says Marc-Andre Cornier, MD. To address the issue of assessing adiposity, the American Heart Association (AHA) released a scientific statement to help clinicians. The statement, which was published in the November 1, 2011 issue of Circulation, provides practical guidance for clinical researchers who seek to identify precise measurements for their patients. It also provides recommendations for clinicians who care for patients whose excess weight is a clinical problem. “Before clinicians can recommend treatment options or talk to patients about obesity prevention, they need to know whether a patient is obese,” says Dr. Cornier, who was the lead author of the AHA scientific statement. He adds that there are also new Medicare guidelines for covering obesity treatment that require clinicians to identify whether or not patients are obese. Medicare will cover provider visits for weight loss counseling in patients who screen “positive” for obesity. Reviewing the Methodologies for Assessing Adiposity Healthcare providers and systems are not regularly assessing for excess adiposity with even the simplest, least costly methods, says Dr. Cornier. “Most methods for assessing excess adiposity are not ready for routine clinical use,” he says. “Measuring BMI and waist circumference is currently best to assess adiposity. These are strategies all clinicians should be practicing on a regular basis for patients. Other newer, complex, and more expensive tools are currently available, but physicians need to do a better job utilizing...

Keys to Transradial Access for Percutaneous Revascularization

Although the adoption of radial coronary angiography and radial PCI in the United States lags behind that of other countries, particularly those in Europe and Asia, transradial coronary intervention has seen an 8% to 10% increased utilization in the U.S., a trend that is expected to continue. The Society for Cardiovascular Angiography and Interventions (SCAI) published an executive summary on transradial access (TRA) for coronary and peripheral procedures in the November 2011 issue of Catheterization and Cardiovascular Interventions. The overview examined utility, utilization, and training aspects to consider when performing angioplasty via the radial artery. “Historically, the traditional route to access blocked coronary arteries has been through the larger femoral artery,” says Ronald P. Caputo, MD, FACC, FSCAI, lead author of the SCAI paper. “TRA is advantageous to transfemoral access because it’s less invasive and has been shown to decrease the risk of access site complications and bleeding.” TRA also is preferred by the vast majority of patients because, unlike the transfemoral approach, it causes less discomfort and allows them to stand up and ambulate immediately following the procedure. In addition, some patients undergoing TRA procedures can be discharged the same day. “These advantages ultimately can decrease length of stay and reduce hospitalization costs while still improving clinical outcomes,” adds Dr. Caputo. Avoiding Complications in Transradial Access Appropriate patient selection for TRA is the first important step in a successful procedure, says Dr. Caputo. Ideal patients for TRA include those with a palpably large radial artery with a strong pulse and a normal Allen’s test with no history of an ipsilateral brachial procedure. Contraindications include abnormal Allen’s test, a...

High Variation in Colon Cancer Treatment

According to MD Anderson Cancer Center researchers, colon cancer treatment appears to vary significantly in the United States. Guideline-based treatment was most likely to be provided to patients with stage I disease (96%), when compared with patients with stage II (low risk, 66%; high risk, 36%), stage III (71%), or stage IV (73%) disease. Across all stages, factors associated with guideline adherence included: Age. Comorbidities. Later year of diagnosis. Insurance Status. The study authors noted that the impact of non-adherence to guidelines on patient outcomes requires further research. Abstract: Journal of Clinical Oncology, March  20,...
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