EBOLA is back in Africa. Is ZIKA next? Are we prepared?

Lesson Learned from recent EBOLA and ZIKA episodes. We need to designate REGIONAL EMERGING VIRUSES REFERRAL CENTERS (REVRCs).

1. There should not be an automatic default to just designating Ebola Centers as REVRCs although there is likely to be significant overlap.

2. REVRCs should be academic medical centers with respected, comprehensive infectious disease diagnostic/ treatment and research capabilities, and rigorous infection control programs. They should also offer robust, comprehensive perinatology, neonatology, and pediatric neurology services, with the most sophisticated imaging capabilities (and emerging viruses “reading” expertise).

3. National leadership in clinical trials.

4. A track record of successful, large scale clinical Rapid Response.

5. Organizational wherewithal to address intensive resource absorption.

REVRC protocols will be templates for are other mosquito borne diseases lurking on the horizon, such as Chikungunya, MERS, and Dengue.

Fast forward to this weekend:  “There have been 17 suspected cases and two confirmed cases of Ebola in Congo’s Bas-Uele province,…. Of the 19, three deaths have been reported. …. health officials were trying to located 125 people believed to be linked to the cases.” (A)

What are we waiting for? DESIGNATE REVRCs NOW!

 

(A)   EBOLA RETURNS: WHAT YOU NEED TO KNOW ABOUT THE OUTBREAK IN CONGO, by BY CONOR GAFFEY, Newsweek, http://www.newsweek.com/democratic-republic-congo-ebola-609143

 

Background posts:

EMERGENCY ROOMS are not all created equal!   http://doctordidyouwashyourhands.com/2016/04/emergency-rooms-are-not-all-created-equal/

We don’t know what we don’t know”  http://doctordidyouwashyourhands.com/2016/04/we-dont-know-what-we-dont-know-about-zika-1-the-challenge-to-emergency-preparedness/

Former hospital prez says: Designate local Zika centers now.   http://doctordidyouwashyourhands.com/2016/06/former-hospital-prez-says-designate-local-zika-centers-now-medical-experts-do-not-know-if-or-where-or-how-much-or-on-what-trajectory-the-zika-virus-may-spread-across-the-united-states/

 “I got Zika. The US health care system had no idea what to do with me…”  http://doctordidyouwashyourhands.com/2016/08/i-got-zika-the-us-health-care-system-had-no-idea-what-to-do-with-me/

 “With little known about Zika virus, hospitals scramble to stay ahead.”  http://doctordidyouwashyourhands.com/2016/08/with-little-known-about-zika-virus-hospitals-scramble-to-stay-ahead/

Hospitals are developing their own Zika preparedness models. Compare the Central Florida and Johns Hopkins approaches! Which template makes more sense?    http://doctordidyouwashyourhands.com/2016/09/hospitals-are-developing-their-own-zika-preparedness-models-compare-the-central-florida-and-johns-hopkins-approaches-which-template-makes-more-sense/

 

 

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The only sure things are death and taxes and PRE-EXISTING CONDITIONS

“PRE-EXISTING CONDITIONS” is a predatory insurance industry term, not a medical term.

“Think it can’t get worse? …..The ACA specifically protected against discrimination for pre-existing conditions that showed up through genetic tests. You might not be sick yet—in technical terms, the illness has not manifested—but if you, for example, test positive for one of the pathogenic variants (a less X-Manly term than “mutation”) in the BRCA gene that predisposes you to breast cancer, you could still get covered. If the House bill becomes law, that protection vanishes. “(A)

Here’s a primer:

“A pre-existing condition is a term insurance companies used before the Affordable Care Act, the healthcare law better known as Obamacare, to classify certain diseases or health problems that could cause a person to be denied coverage or make their coverage more expensive than that of people considered healthy.” (B)

 “So what qualifies as a pre-existing condition under the bill? Nobody knows. The bill lacks any specifications, allowing health insurers a spacious margin for deciding who gets to pay through the nose for coverage.….Each of us is vulnerable to the unchecked exclusionary power that the health care bill would restore to the health insurance sector — a power that insurance providers have wielded before and used to devastating effect.” (C)

“Before Obamacare…..the patchwork of state and insurance regulations allowed each state to define pre-existing condition in its own way….”

Before Obamacare, along with significant diseases that were considered to be pre-existing like cancer, diabetes and heart disease, there were a variety of fairly minor conditions…other possible situations falling under pre-existing condition clauses are chronic conditions as acne, hemorrhoids, toenail fungus, allergies, tonsillitis, and bunions, hazardous occupations such as police officer, stunt person, test pilot, circus worker, and firefighter, and pregnancy and/or the intention to adopt. (D)(E)

In summary:

“In the pre-Obamacare era, insurers were able to deny coverage outright to people with pre-existing conditions. The Affordable Care Act banned individual states from allowing insurers to charge people with pre-existing conditions at a higher cost.

Under the American Health Care Act, states can opt to allow individual insurers the discretion of deciding what does and not count as a pre-existing condition. While people with those pre-existing condition can’t be denied coverage, they can potentially be charged more.” (F)

 So once again we “don’t know what we don’t know.” But we can speculate that health insurance applicants with pre-existing conditions might be “red-lined” by insurance companies and be quoted higher premiums up to five-times that paid by others, rates coupled with deductibles and co-pays that make policies unaffordable. (G)

aka the UNAFFORDABLE CARE ACT!

 

(A) The House Health Plan Makes Your Genes a Preexisting Condition by Adam Rogers, WIRED, https://www.wired.com/2017/05/house-health-plan-makes-genes-preexisting-condition/

(B) From acne to pregnancy, here’s every ‘preexisting condition’ that could get you denied insurance under Trump’s new healthcare bill, by Lydia Ramsey, Business Insider, http://www.businessinsider.com/what-counts-pre-existing-condition-ahca-trump-obamacare-2017-5

(C) Under The Republican Health Bill, We All Have Pre-Existing Conditions, by Miles Howard, WBUR,  http://www.wbur.org/cognoscenti/2017/05/05/under-the-republican-health-bill-we-all-have-pre-existing-conditions

(D) What Is A Pre-Existing Condition Anyway? by Linda Bergthold, Huffington Post, http://www.huffingtonpost.com/entry/what-is-a-pre-existing-condition-anyway_us_590f60c8e4b046ea176aec7e

(E) What the GOP health care bill really says about pre-existing conditions by Tami Luhby, CNN, http://money.cnn.com/2017/05/01/news/economy/obamacare-trump-pre-existing-conditions/

(F) Pre-existing conditions: How 130 million Americans may be affected by the Obamacare repeal, by Christina Gregg, AOL, https://www.aol.com/article/news/2017/05/05/pre-existing-conditions-american-obamacare-repeal-american-health-care-act/22071483/

(G) The Republican Health Care Plan Is a Nightmare for the Old and Nearly Poor by Jordan Weissmann, Slate, http://www.slate.com/blogs/moneybox/2017/03/13/republican_plans_could_raise_insurance_premiums_by_750_percent_for_some.html

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Repeal and DESTROY Obamacare

“Republicans have promised for seven years to repeal the Affordable Care Act, under which around 20 million Americans gained health coverage. But they had no consensus on how much of the law should be repealed and had great difficulty devising a comprehensive replacement.” (A)

 “Republicans are often right when they point out Obamacare’s shortcomings, like too few insurers on the exchanges in some states. That absolutely ought to be addressed. But snatching coverage from 24 million of our nation’s most vulnerable people to give as much as $1 trillion back to its wealthiest ones doesn’t fix that.” (B)

“The American Health Care Act…. could transform the nation’s health insurance system and create a new slate of winners and losers. (C)

Winners: High-income earners; Upper-middle-class people without pre-existing health conditions; Young, middle-class people without pre-existing health condition; People who wish to go without insurance; People who want less comprehensive health coverage; Large employers; Medical device companies, indoor tanning companies and a few other medical industries

Losers: Poor people: Older Americans, in most states: People with pre-existing health conditions, particularly in some states; State governments; Hospitals; Planned Parenthood

Some key concerns: (D)

          Some of Obamacare’s signature features would be gone immediately, such as the tax on people who don’t purchase health care, known as the “individual mandate.”

          States would have the option to get waivers from two of Obamacare’s requirements: that insurers cover “essential health benefits,” and that they charge the same price to everyone regardless of their health history. That would get rid of a key protection for people with preexisting conditions.

          AHCA would end Medicaid expansion in 2020, cut the program by $880 billion

          States could also opt out of Obamacare’s essential health benefits requirement. This is the core set of medical services that the Affordable Care Act requires all insurers to cover.

          The AHCA would fund high-risk pools for those who lose coverage. Experts worry the bill doesn’t have enough money.

          The AHCA allows insurers to charge their oldest enrollees up to five times as much as their youngest ones.

The Senate goes next, all men on the Republican working Group. “Notably missing from the working group are any of the five GOP women senators, particularly Maine’s Susan Collins and Alaska’s Lisa Murkowski, two moderate votes Republicans will need to get a bill passed through the senate.” (E)

 

 

(A)   House Passes Measure to Repeal and Replace the Affordable Care Act, by Thomas Kaplan and Robert Peer, https://www.nytimes.com/2017/05/04/us/politics/health-care-bill-vote.html?rref=collection%2Fbyline%2Frobert-pear&action=click&contentCollection=undefined&region=stream&module=stream_unit&version=latest&contentPlacement=1&pgtype=collection

(B)   New American Health Care Act is snake oil, Newsday, http://www.newsday.com/opinion/editorial/american-health-care-act-problems-1.13567594

(C)   Who Wins and Who Loses in the Latest G.O.P. Health Care Bill, Margot Sanger-Katz, https://www.nytimes.com/2017/05/04/upshot/who-wins-and-who-loses-in-the-latest-gop-health-care-bill.html

(D)   The American Health Care Act: the Obamacare repeal bill the House just passed, explained, by, Sarah Kliff; https://www.vox.com/policy-and-politics/2017/5/3/15531494/american-health-care-act-explained

(E)    Here’s What You Need to Know About the Health Care Bill, by Benjy Sarlin, NBC News, http://www.nbcnews.com/politics/congress/here-s-what-you-need-know-about-health-care-bill-n754611

 

 

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Non-compliance with prescription drugs can lead to clinical complications

The last DOCTOR post was about overmedication with prescription drugs and how to talk to your doctor about “DESCRIBING”. “Describing” is tapering off of drugs no longer needed. *

This post is about a related problem, the non-adherence to prescription drugs and the often severe and adverse consequences of non-compliance.

Non-Adherence refers to those who: Failed to fill or refill a prescription; Missed a dose; Took a lower or higher dose than prescribed; Stopped a prescription early; Took an old medication for a new problem without consulting a doctor; Took someone else’s medicine; or Forgot whether they’d taken a medication. (A)

Physicians should confirm that each patient:
– Understands their medications by reviewing: brand or generic name; function; how, when, and length of time the medication is taken; possible side effects; foods, liquids and activities to avoid while on the medication; refills (if necessary); and medication storage.
– Physicians can ask: “This medication will be an additional expense, how does it fit into your finances?”
– Have family members or caregivers be part of the team to help with administration and provide reminders
– And finish with: “I have given you a lot of information, let’s review your understanding of the prescription(s). (B)

Here are some details on the non-adherence epidemic.

The numbers are staggering. “Studies have consistently shown that 20 percent to 30 percent of medication prescriptions are never filled, and that approximately 50 percent of medications for chronic disease are not taken as prescribed,” ….“This lack of adherence….is estimated to cause approximately 125,000 deaths and at least 10 percent of hospitalizations, and to cost the American health care system between $100 billion and $289 billion a year.” (C)

“Within two years of having a heart attack, nearly 1 in 5 people stop taking lifesaving cholesterol-lowering drugs known as statins, according to a new study. And nearly 2 in 5 end up taking the drugs in lower doses or less often than they should…” (D)

“Medications are dispensed with the expectation that they will be taken exactly as prescribed. However, most patients do not follow their doctors’ orders. Excuses take many forms: “The medication was too expensive,” “If 1 pill is good, then 2 pills should be twice as good,” or “I didn’t understand the directions on the label.”” (E)

“… Patients may be no adherent during different stages of their treatment. They may decide not to fill their prescriptions in the pharmacy and not start their treatment at all. Patients may use more or less than the prescribed treatment or use their medication at the wrong time. They may also discontinue treatment prematurely.” (F)

* “DEPRESCRIBING” – Is there an epidemic of prescription medicine overtreatment? Start CHOOSING WISELY http://doctordidyouwashyourhands.com/2017/04/deprescribing-is-there-an-epidemic-of-prescription-medicine-overtreatment-start-choosing-wisely/

(A) Medication Adherence in America:2013, http://www.ncpa.co/adherence/AdherenceReportCard_Abridged.pdf
(B) Teaching Patients about their Medications: The Keys to Decreasing Non-Compliance, https://healthcarecommunication.wordpress.com/2009/02/06/teaching-patients-about-their-medications-the-keys-to-decreasing-non-compliance/
(C) The Cost of Not Taking Your Medicine, by Jane Brody, New York Times, https://www.nytimes.com/2017/04/17/well/the-cost-of-not-taking-your-medicine.html?smprod=nytcore-ipad&smid=nytcore-ipad-share&_r=0
(D) Many people stop taking life-saving drugs after heart attacks, by Andrew M. Seaman, Washington Post, https://www.washingtonpost.com/national/health-science/many-people-stop-taking-lifesaving-drugs-after-heart-attacks/2017/04/21/705a28e8-253e-11e7-a1b3-faff0034e2de_story.html?utm_term=.14225b93cfe6
(E) Medication Nonadherence: Finding Solutions to a Costly Medical Problem, by Harold Gottlieb, Medscape, http://www.medscape.com/viewarticle/409940
(F) Definitions, variants, and causes of nonadherence with medication: a challenge for tailored interventions, by Jacqueline G Hugtenburg et al, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3711878/

 

Note: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.

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DEPRESCRIBING – Is there an epidemic of prescription medicine overtreatment? Start CHOOSING WISELY

It is up to you to ask your physician if you, or a family member, are on too many medications.

“If a patient were to hear something to the effect of ‘let’s get some lab tests,’ I would ask the clinician: How many and why?” …. “Once you order six or seven individual lab tests, the odds of one of them being a false positive already is about 20 percent. Just statistically. So if there are a lot of vials of blood being drawn [ask] ‘Why are we doing this? Why are each of these lab tests needed to help in my care?'” (A)

Too many meds may be caused by defensive medicine, different physicians prescribing without considering what the patient is already taking, and patient failure to remember all prescriptions.

Here’s what you can do.
(1) Start by carrying a list of your prescription with you and show it to every physician every time, as well as others who prescribe like dentists and podiatrists. Include on the list over-the-counter supplements such as allergy medicine, probiotics, and pain relievers.
(2) Next, there are many drug on line interaction checkers to use e.g. WebMD http://www.webmd.com/interaction-checker/default.htm RxList http://www.rxlist.com/drug-interaction-checker.htm Medscape http://reference.medscape.com/drug-interactionchecker
(3) Then go to CHOOSING WISELY http://www.choosingwisely.org which seek to reduce overtreatment, and incorporate these recommendations into practice guidelines, local best practices, and decision support systems.
And, most importantly, tell your primary care practitioner every time you get a new prescription from another doctor or start a new over-the counter product.

NOW read the rest of this post to understand why this is so important!

“The point of prescription drugs is to help us get or feel well. Yet so many Americans take multiple medications that doctors are being encouraged to pause before prescribing and think about “deprescribing” as well.
The idea of dropping unnecessary medications started cropping up in the medical literature a decade ago. In recent years, evidence has mounted about the dangers of taking multiple, perhaps unnecessary, medications.” (B)

Here are some examples:
“When it comes to treating seniors with diabetes, new research suggests that doctors often don’t cut back on medications, even when treatment goals are surpassed.
The study found that when people had potentially dangerous low blood sugar levels, just 27 percent had their medicines decreased. And when blood pressure treatments lowered blood pressure levels too much, just 19 percent saw a reduction in their medications.” (C)

“….efforts to curb excessive antibiotic use toward outpatient and long term care settings. As many as 70% of nursing home residents receive at least one course of antibiotics each year, but up to 75% of those prescriptions are unnecessary, or the wrong drug, dose or duration of treatment is given, according to the CDC. UTIs are a commonly over-diagnosed in seniors, relying on vague symptoms of confusion or bacteria in the urine, leading to antibiotic overuse. “(D)

“The study…, found that in older adults aged 70 or older, taking blood pressure medication was linked to a higher risk of serious falls. (Serious falls as in, falls that caused an ER visit for a fracture, a dislocated joint, or a brain bleed. Serious stuff indeed!)” (E)

WHAT YOU SHOULD DO:
“Avoiding overdiagnosis and overtreatment also means letting go of some longstanding notions, such as the doctor always knows best; more treatment is better; and that improved technology and early screening will definitely lead to better outcomes..”
“How can we decrease overtreatment? Reducing the use of screening or diagnostic testing that relays more information than requested, increasing the use of surveillance or watchful waiting when small or lower-risk abnormalities are detected, and performing studies to determine the extent of benefit (if any) of treating abnormalities…(F)

(A) Signs of Overtreatment: How to Avoid Unnecessary Care .What to know before saying “yes” to more tests, procedures or prescriptions, by Michael O. Schroeder, http://health.usnews.com/health-news/patient-advice/articles/2015/08/18/signs-of-overtreatment-how-to-avoid-unnecessary-care
(B) How Many Pills Are Too Many? by Austin Frakt, New York Times https://www.nytimes.com/2017/04/10/upshot/how-many-pills-are-too-many.html?smprod=nytcore-ipad&smid=nytcore-ipad-share
(C) Too Many Seniors With Diabetes Are Overtreated by Serena Gordon, http://www.webmd.com/diabetes/news/20151029/too-many-seniors-with-diabetes-are-overtreated-study-suggests#1
(D) CDC warns of overdiagnosis and overtreatment of UTIs in seniors, https://www.univadis.com/viewarticle/cdc-warns-of-overdiagnosis-and-overtreatment-of-utis-in-seniors-316988?s1=news
(E) Blood pressure medications linked to serious falls: What you can do, by Leslie Kernisan, http://betterhealthwhileaging.net/falls-blood-pressure-medications-elderly/
(F) Improving Quality by Doing Less: Overtreatment, by Jessica Herzstein and Mark Ebell, http://www.aafp.org/afp/2015/0301/p289.html

Note: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.

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LET’S MAKE AMERICA ALTRUISTIC AGAIN! National Volunteer Week – April 21-29.

As our economy takes off, there are still many left behind or in need of a helping hand – including veterans with disabilities, those with behavioral health and addiction challenges, the undocumented without access to health services, refugees seeking a new start, and many, many more.

Not-for-profit health and social service agencies are often the only source of case management services for these people are major contributors to our communities. They always need our support but perhaps more so now than ever with the “soft” program cuts proposed in the Trump administration budget to pay for increased military spending.

“If you are not part of the solution, you are part of the problem.” And part of the solution is to volunteer.

We celebrate the selfless individuals around our country who channel their civic virtues through volunteerism… devoted to a cause bigger than themselves….. ~Barack Obama

“Volunteering offers vital help to people in need, worthwhile causes, and the community, but the benefits can be even greater for you, the volunteer. Volunteering and helping others can help you reduce stress, combat depression, keep you mentally stimulated, and provide a sense of purpose. (A)

The smallest act of kindness is worth more than the grandest intention. ~Oscar Wilde

Don’t expect someone to come knocking on your door asking you to volunteer. You have to do it yourself.

Where to begin? “We live in a world where technology can connect us with new opportunities in almost every area of life, from who to date to what to have delivered for lunch. And while these choices can enhance and enrich our lives, people with time, skills and a desire to do good are also looking to technology to help them make a difference in the lives of others.” (B)

Here are some links to get started: web sites that match organizations looking for volunteers with folks look for nearby volunteer opportunities.
Catchafire https://www.catchafire.org/
VolunteerMatch https://www.volunteermatch.org/
boardnetUSA™ http://boardnetusa.org/public/home.asp
Create the Good http://createthegood.org/
Idealist https://www.idealist.org/en/?type=VOLOP
AllForGood http://www.allforgood.org/
Do Something https://www.dosomething.org/us/about/who-we-are

Even if it’s a little thing, do something for those who have need of a man’s help, something for which you get no pay but the privilege of doing it. For, remember, you don’t live in a world all your own. Your brothers are here too. ~Albert Schweitzer

(A) https://www.helpguide.org/articles/work-career/volunteering-and-its-surprising-benefits.htm
(B) http://www.huffingtonpost.com/2014/01/13/volunteering-websites_n_4551665.html

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I CAN’T DECIPHER MY EOBs. It is rocket science to unravel the complexity.

I usually toss my Explanation of Benefits (EOBs) into a basket, then later throw them out without any review.
I have Medicare with secondary coverage from United, and I get sequential Explanations of Benefits (EOBS) from each.
Here are some of the reasons I can’t figure out whether or not my claims have been processed correctly.
– The Medicare and United EOBs are different and it is difficult to try to link them
– Each has a separate deductible and it’s hard to track
– Some secondary insurers “outsource” certain categories of service such as rehab/chiropractic generating additional EOBs
– I also get a periodic Medicare Part D report, for the Prescription Drug benefit
– If Medicare doesn’t pay then United won’t either even if United would pay if it was primary. For a given provider the secondary co-pay is different depending on whether or not the provider is in or out of network, no matter that Medicare pays
– Every provider codes claims differently so similar service at two providers may be coded and billed differently.
– When I got PT in two different places one charged me $20 per visit, the other calculated a co-pay for each visit.
– I am going to a chiropractor who accepts Medicare and is out-of-network for United so I will not know my out-of-pocket costs until I get both EOBs.
– Medicare and United have different appeal procedures. If I can’t link the EOBs it’s impossible to know where to appeal

Here’s a personal frustrating example:
In early December I received a bill and paid $205 for a lab test done at a reference laboratory. No insurance claims had been processed.
After I followed up, in March I got an email: “I contacted XXX and spoke with ZZZ. Per ZZZ Medicare processed and made payment on one of the charges but denied the other (processed the $82.00 charge denied the $123.00 charge). He is confirming the reason for the denial for the second charge and will work with Medicare regarding processing it for payment. Currently you have a credit of $73.38 however Empire has not processed and paid for the $8.62 coinsurance applied by Medicare. ZZZ will submit that as well.”
As of April 9th, still not resolved.

We are “collateral damage” in a war between hospitals and insurance companies. *
The obvious but unlikely solution is universal coding/ claims/ EOB by all providers, integrated to simplify tracking of a claim through primary and secondary insurers.

to learn more about EOBs you might look at:
What is an EOB? http://www.medicalbillingandcodingu.org/what-is-an-eob/
Understanding Your Explanation of Benefits http://www.patientadvocate.org/index.php?p=441
Understanding Your Explanation of Benefits (EOB) – How to Decipher Your Explanation of Benefits https://www.verywell.com/understanding-your-eob-1738641

Two “must read” articles:
Markups On Care Can Fatten Hospital Budgets — Even If Few Patients Foot The Full Bill, by Chad Terhune. Kaiser Health News. http://khn.org/news/markups-on-care-can-fatten-hospital-budgets-even-if-few-patients-foot-the-full-bill/
Those Indecipherable Medical Bills? New York Times. by Elisabeth Rosenthal. https://www.nytimes.com/2017/03/29/magazine/those-indecipherable-medical-bills-theyre-one-reason-health-care-costs-so-much.html

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