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Advantage Insurance Companies

IMG_0675Well, its been two years since I posted here and fortunately no one has read a damn thing I’ve written, which may be just as well.

Our little private solo practice is breaking even but mainly just enough to make it better than working as a greeter at Walmart, so we continue to provide the best quality of care we can to a limited and sometimes grateful population.

I did fire one guy today.  He had a 40 minute follow up appointment scheduled after a short hospital stay, caused by the resurgence of his diabetes which had been doing fairly well, as least as far as I can tell, because he had not returned for scheduled follow up due in May until a day before the hospital admission when he showed up upset because he had peed his bed.  He refused to go to the ER when I saw how sick he was, so I did the best I could with limited resources, it didn’t work and he ended up getting dragged to the ER for an overnight observation the next day for uncontrolled diabetes associated with a urinary tract infection.  He didn’t want to pay his Medicare Advantage required $30 co-pay for this follow up visit, because it was all my fault he had to see me again so soon, or so he opined.  As we refused to defray this contracted payment (we are not allowed to defray co-pays according to his insurer), he walked out, claiming he felt fine anyway and would see us for his annual in April.  I sent him a certified letter telling him he was only going to get emergency series for the next 30 days and he needed to find someone else to blame for his non-compliance and its consequences.

This pretty much sums up the kind of frustration we experience daily from folks suffering from entitlement syndrome and their chosen insurance programs that promise cheaper or free premiums and deliver cheaper care or deny essential care with devious prior authorization requirements.

Well, I also pre-terminated a guy who called the answering service at 5:55 AM to cancel his new patient appointment for the third time in 6 months.  He was surprised when I called him back at 5:59AM to let him know if he didn’t show up for his 8:20 AM appointment he was not going to get another.  As each early AM appointment had been cancelled on short notice so I was not able to fill that time with other patients,  he had cost me over a thousand dollars so far this year in patient revenue.  He didn’t understand the problem.  So I’m not going to waste my time trying to understand his.

I guess I should stop drinking from my Black Rifle Coffee Company mug.




What is Cancer?

Cancer is a label we use to describe many different diseases that maim and destroy people.  A cancer, or a malignant proliferation of transformed cells, starts out as what appears to be a normal cell in one’s body.  Perhaps some external effect: ionizing radiation, chemicals, infection as examples, or perhaps some innate and pre-programmed abnormality in nuclear DNA  or mitochondrial nucleic acids activates to initiate the process.  Cells that normally know what to do and do it, that respond to the external environment to conform to their assignment without interfering with the structure and function of other cells within the organism, stop being part of that system, feed off that system, and continue to multiply and spread throughout the organism until ultimately this interference fatally destroys the victim either directly or weakens it so much it succumbs to some other force and dies.

What are Progressivism, Marxism, Socialism, and Left-Wing Democratic Politics?

See above.

Why does Cancer grow and spread?

A myriad of processes keep our normal cells coordinated and productive.  Cancer cells are deaf to these –  they have their metaphorical fingers in their ears and are shouting “Lah, Lah, Lah” as loud as they can.  They have their own objective that is destructive and counters the objective of the body from which they have arisen.  Their nature and actions hides them from many of the normal protective mechanisms of the body until their numbers are great enough to overcome these protections.  They grow without concern for the normal cells around them, and spread by any means possible, often finding places to grow that are harder for the body’s protective mechanisms to access, like the brain.  They recruit normal body parts, like blood vessels, to proliferate within them to help feed their growth and spread by using the normal messengers the body uses to stimulate and fool the normal body processes into supporting the cancer.  When they suck significant energy and material from the body, the body innocently speeds up production of the energy and building block substances, often at the cost and neglect of normal body processes, to feed the cancer.  Sometimes this process is so effective that it alone leads to wasting and death without involvement of a vital organ.

Why does Progressivism, Marxism, Socialism, and Left-Wing Democratic Politics Grow and Spread?

See above.

How do you fight Cancer?

The best way to fight cancer is to prevent it.  Be vigilant and avoid exposure to things that promote its growth, and also keep normal cells strong and vibrant.  One does not deny that cancer exists, does not shirk from one’s responsibility by believing that there is a magic pill, diet, mantra or crystal that will prevent it from happening, but accepts that it is a possibility and regularly searches for signs or symptoms of its appearance so that the cancer can be terminated early.  You have to accept that any fight against many active cancers is more likely to lose than win.  So it is better not to have to start the fight at all.

Once a cancer is established, it begins sending seeds through the lymph and blood to establish new colonies throughout the body.  A strong body may be able to extinguish these colonies before they grow, or at least try to contain them and prevent further spread.  Once they are established, however, it is difficult but not impossible to cure the disease.  In some cases you can cut the metastatic disease out as well as the primary cancer, and the body will take care of mopping up the detritus, but this is rare. The primary cancer must be removed or destroyed, and the colonies destroyed by some process.  Commonly we use chemicals that the colonies are very sensitive to, but the normal body is also hurt by the treatment, and sometimes it dies in the attempt to cure the process.  Attempts to find chemicals that either turn off the malignant process within the cancer cells themselves, or stimulate the body’s defense mechanism to overcome the cancer’s defense mechanisms and destroy them are attractive approaches that have seen few successes so far.

How do you fight Progressivism, Marxism, Socialism, and Left-Wing Democratic Politics?

See above.

Next topic:  Is Islam a Cancer?

A Picture is worth a Thousand Waivers

Which one is lame?


Tread on Obama!

Nobamacare DTOM icon_white

Protect the Staff of Asclepius

Give this one FAME!

Side B of ‘Something Better’ According to Faithful

Sister Sebelius


Here I sit at my Computer Screen

Tell me, Sister Sebelius, when are you coming round again?

Oh, I don’t think I can wait that long

Oh, you see that I’m not that strong

The whine of the POTUS is sounding in my ears

Tell me, Sister Sebelius, how long have I been sitting here?

Why did your promises about-face?

Why is my doctor not in place?

Oh, your site crawls across the screen

Ah, can’t you see, Sister Sebelius, I need more caffeine?

Well it just goes to show

Things are not what O shares

Fees, Sister Sebelius, turn my dreams into nightmares

Oh, can’t you see I’m losing faith

And the ACA is just a wraith?

Sweet Cousin Carney, lay your cool cool schtick on our dread

Ah, come on, Sister Sebelius, we’ll take you to the woodshed

‘Cause you know and I know we’ll be tweeting what you said

Yeah, and we can sit around, yeah and you can watch all the

Old Blue States turn red.

Sequester and Cancer Treatment: Time for Change

Bill Postmus whines for the established outpatient oncology industry:

What has happened is that with Medicare reimbursement cuts, profitability of treating patients in the office has allegedly zeroed out.  Private clinics that used to rake in obscene profits 20 years ago, and comfortable profits 10 years ago, now not quite struggling but certainly doing marginally until the current sequester, are lobbying heavily to keep the cash cow going for outpatient cancer treatment.

Who would deny cancer patients their treatment?  I think that the same horrible people who deny gun control “for the children,” taxing the rich even more, or decry spending ourselves into oblivion ought to think about the big picture here.

Certainly cancer treatments that meaningfully offer a chance for cure and prolong a useful life are important.  Lance Armstrong offered a great example of a famous person cured of metastatic cancer.  We might blame some of his choices after the cure on chemo-brain, but that would be stretching it.

However, if you look at the meat and potatoes of how most chemotherapy providers make their money (and where most Medicare cancer dollars go), you will find that a whole lot of money is being spent that does little to improve the quality or quantity of life for most who receive it.  There are two types of cancer treatments:  curative and palliative.  I’m not going to touch palliative therapy in this discussion other than to say balancing quality of life of a patient and the insurance reimbursement you can squeeze out of treating a dying patient should not be but sadly can be an equation considered in most oncology out patient practices.

In my experience, most patients  embark on adjuvant treatment -an effort to cure an otherwise incurable cancer – with little understanding of the real odds they’ll derive any benefit from the treatment.  Sometimes they are goaded on by providers or family to “do something” when if they realized they had a 19 out of 20 chance of just getting sick and wasting a lot of time at the doctors, not to mention money, and still die when they would have without therapy, they might choose to not receive chemotherapy.

Adjuvant treatment for breast cancer for high-risk patients does reduce the risk of recurrence in about one fifth of patients treated. That means that 80% of women who receive third generation combined modality therapy either don’t need it or don’t benefit from it (if you define cure as your benefit).  Aromatase inhibitors can make life hell for patients with fibromyalgia-like symptoms, and they are “just hormone treatments” commonly used in Medicare-aged patients with about one out of seven benefit.

In colon cancer resected with involved lymph nodes the number of folks who benefit from adjuvant treatment is less, maybe about one out of eight in the highest risk groups.  Its much less for many who ultimately do choose therapy.

In lung cancer, about one out of twenty folks who receive adjuvant treatment after resection live significantly longer without recurrence.  Prolongation of life in those not cured is usually measured in one or two month intervals.

Yet in my experience, when cancer patients are offered adjuvant chemotherapy treatments, these are not the statistics they hear.  Usually its something like “we can reduce your risk of recurrence by 50%.”  BIG difference in emotional impact, same studies, same data.

I recommend that if we are going to re-up reimbursement for outpatient chemotherapy, we should demand that the patients hear the blunt published data regarding benefit from therapy versus no therapy in terms that describe the chances they have of meaningful benefit from the treatment (e.g., you have an 80% chance of not benefiting from this treatment), the expected short and long term side effects and quality of life, and that they have at least two days to ponder their decision before embarking on a treatment regimen.  I bet we’d get a significant reduction in Medicare costs for cancer treatment without reducing payment to providers.

Setting the Standards

One of the many interesting aspects of the totally NewSpeak-Named Affordable Care Act of 2010 is that is sets the United Stated Preventive Service Task Force as the entity that establishes Standard of Care that all insurers are required to provide coverage (without patient co-pay).  You can bet that if insurer’s are required to pay for it, that physicians will be required to abide by these recommendations or risk professional and economic censure.  The implementation of EMR’s simplifies the ability for DHHS and AHRQ to data-mine and identify outlying practitioners for what I assume will be the new industry to supersede CME:  MPRC – Medical Provider Re-education Camps.

The USPST was established in 1984 to advise primary care providers how to implement preventive care practices.  Ironic, isn’t it, or is it, that this government task force established under Ronald Reagan has become the DHHS and AHRQ weapon to wield against independent health care practice in the USA?

The Task Force in comprised of “volunteers” who represent the vanguard of progressive preventive health interests in government, higher education and industry.  Their initial forays into recommendations have evolved into a complex industry of making recommendations for further funding of research that not surprisingly encompasses the research that they and their close colleagues themselves make their bread and butter performing.

Some of their recommendations have been quite controversial, but relatively reasonable from my perspective.  But look at the areas they are now recommending be researched so they can be added to preventive health practices that all providers will soon find themselves required to perform and document in the EMR:

High-Priority Evidence Gaps for Behavioral Interventions

Below are three areas from the fields of behavioral intervention and health promotion that the USPSTF has prioritized as having critical evidence gaps that may be addressed through research and that if filled are likely to result in important new recommendations:

  1. Moderate- to Low-Intensity Counseling for Obesity
    The importance of obesity as a health problem in the United States is increasingly apparent. According to recent data, when obesity is defined as a body mass index of 30 kg/m2 or more, 30 percent of American men and women are obese. Being obese is associated with health problems such as an increased risk of coronary heart disease, type 2 diabetes, various types of cancer, gallstones, and disability. In addition, obesity is associated with increased risk of premature death and decreased quality of life. In 2003, the USPSTF concluded that the available evidence supported recommending high-intensity interventions for obese adults and that the evidence was insufficient to make a recommendation about the use of moderate- or low-intensity counseling together with behavioral interventions to promote sustained weight loss in obese adults. In 2010, the USPSTF recommended screening and intensive counseling for obese children ages 6 years and older. The Task Force is currently completing an update of its 2003 recommendation for adults. Future research is needed in many areas concerning screening and counseling for obesity in children and adults. Continued development and testing of counseling and behavioral interventions with better and longer followup are needed, especially to understand the potential contribution of moderate- and low- intensity counseling. Additional research should also examine the long-term outcomes and effects of interventions delivered to overweight children and adults.
  2. Interventions to Prevent Child Abuse and Neglect
    Approximately 1 million abused children are identified in the United States each year. Despite the dedication and hard work of people in many sectors, no one has discovered an effective role for the primary care system and primary care professionals in preventing child abuse and neglect. The Task Force recognizes that the solution to this issue will include many other efforts and hopes that needed research to find effective interventions initiated in primary care will be conducted. Early research suggests that clinician referrals to home visitation by nurses during pregnancy and early childhood may reduce child abuse and neglect in selected populations, but additional research is needed. Future research must examine both the potential benefits and the potential unintended harms of interventions aimed at preventing child abuse and neglect.
  3. Screening for Illicit Drug Use
    Illicit drug use and abuse is a serious problem in the United States and ranks among the 10 leading preventable risk factors for years of healthy life lost to death and disability in developed countries. In 2008, the Task Force found that there was insufficient evidence to make a recommendation about screening for illicit drug use in primary care practices. Studies are needed to determine whether interventions found effective for treatment-seeking individuals with symptoms of drug misuse are equally effective when applied to asymptomatic individuals identified through screening. In addition, observational studies are needed to establish more clearly the effects of treatment on long-term health outcomes, including morbidity and mortality.

And these are areas the Task Force is highly interested in at the end of their 2012 report to Congress:

  1. How do primary care professionals incorporate new evidence to change their practice?
  2. What are the most effective strategies to assist primary care professionals in the translation of evidence-based clinical preventive services into practice?
  3. How can primary care professionals share evidence with their patients to empower patients and families to make health care decisions about prevention?
  4. How can health information technology, including electronic health records and personal health records, be utilized to increase the number of Americans receiving recommended clinical preventive services?
  5. How can the USPSTF continue to improve its work to better meet the needs of primary care professionals and their patients

To start at the bottom and work your way up, note that they are particularly interested in how best to get “primary care professionals” (who used to be doctors but now include all sorts of licensed and unlicensed individuals) to change their ways to their point of view.  Don’t let #5 fool you.  It comes right after #4.

Screening for illicit drug use.  It certainly is a serious issue.  It is also quite expensive and time consuming just to ask the questions, not to mention perform body secretion testing.  But since the government will now be studying this intensively, you can bet they’ll be requiring a lot of primary care professionals to be documenting in their EMRs not only if patients have been screened for illicit drug use, but just what the drugs used, amounts and frequencies as well.  All that information will be indelibly entered into each patient’s EMR.  Does that bother ANYONE?

Interventions to Prevent Child Abuse and Neglect.  Again, a serious issue we can all agree seems important to study.  Note, however, that up to now even the Task Force agrees there has been no identified benefit of primary care efforts in PREVENTION of abuse.  So they hope that engaging the PCP’s to identify folks to send nurses out to their homes to investigate might be a good thing.  Unfortunately to me, this sounds all to likely to be adopted as one new form of SWATing.  Not right away, mind you, but if you look at what is happening in the UK now, you can see what happens with this kind of interventionism.

Moderate to Low-Intensity Counseling for Obesity.  They want to look into the potential benefits of PCP counseling regarding weight issues.  Of course, that means we’ll have to not only record the weight in every chart, which is already done, but use diagnosis codes delineating the patient’s BMI in their chart, so we can track them better.  More goodies, that like e-mail, are forever in the wonderful world of electronic records.

My real concern is that up until relatively recently doctors were expected to rely on their training, experience and interaction with colleagues to determine just what they did and did not do when providing health care to their patients.  In the past ten years, that has changed.  Now its about to get a WHOLE LOT WORSE.  What has been a decentralized imposition of standard of preventive care practices by insurance formularies, State-generated directives and Federal directives through Medicare, Medicaid, the VA, Public Health Service, Indian Health Service and military health services will now be standardized through the DHHS’s USPST.

But don’t worry.  Big Brother only has your best interests at heart.  Just remember your best interests are what’s best for the corrupt and insolvent Federal US government bureaucracy.

The Obamacare World is Out There, Not in Here

Physicians and all other health care providers are evolving into unmindful data collectors solely responsive to the third-party/government financial officers who have replaced the yank on their fiscal and professional leashes with a shocking electronic medical records collar.

No longer Masters of Our Fate, we find this Invisible Fence is built to keep us from straying outside the boundaries prescribed by our Masters of State.

We are being trained first to document as we interact with people seeking health care, at the cost of our human interaction.

Providers find themselves entering the examination room with a bean-counter with a stopwatch.

We are constantly asked to second guess our treatment decisions (not yet our diagnostic ones, but I am sure that is coming) by non-clinical government and insurance workers asking us to consider different and cheaper medications, if not to consider discontinuing them entirely.