High Deductible Plans

Now that we are 8% into 2013, many people are feeling first-hand the effects of new payment formulae for healthcare. Patients are responsible for a larger part of their medical bills and this is taking many by surprise.

Every January we note that the office visit copay for many plans increases – I am not surprised at $40 per visit. Not everyone has a copay anymore. An increasing number of employers have signed on for large deductible plans.  In this case, the office files a claim with the insurer on behalf of the patient and once we receive the explanation of benefits that delineates the patient responsibility we bill the patient. Patients usually have some notion of how much the office visit will cost. What many people finding upsetting are the charges that they previously did not see, such as laboratory fees. The lab too will bill the insurance company first, but if the deductible is not yet met the patient will get a bill.

Many patients find that large deductible plans give them more freedom. If a patient is unlikely to reach his deductible ($2500 to $5000) he may not feel limited to only using doctors “on plan.” When sick, a patient can have an office visit with the doctor of her choice since she will be writing a check for the visit no matter what. If a major illness does occur the maximum monetary exposure will be the amount of the deductible.

The large deductible plans do require a bit of budgeting. We budget money to change the oil in the car and we can take our cars to the dealer (“on plan”) or to the neighborhood shop. Healthcare is not so different. 

The 'Common' Cold

The average adult has two to four colds per year; young children have six to eight. Most colds last seven to ten days but symptoms may linger up to three weeks. Rhinovirus is the most common cause, accounting for 30 to 50 percent of all respiratory tract infections. Currently, no antiviral medications are available to treat the common cold.

The main goal of care is to treat symptoms. Most over the counter (OTC) products are combinations of medications and are suitable for adults. In 2008, the US Food and Drug Administration recommended that over the counter medications not be given to children younger than two years and ‘cough and cold’ preparations are among the top ten substances involved in the injury of children younger than five years.

In general, I prefer single ingredient medications. If one takes more than one combination product (such as a cough, cold and fever reducer) there is the risk of mistakenly taking too much medicine. Many of the OTC products have significant amounts of acetaminophen (Tylenol) that can be toxic to the liver, especially if there is alcohol use. Products with ibuprofen (Motrin) can cause gastrointestinal upset. One of the best treatments for the common cold is breathing up steam (such as from a hot cup of tea or in the shower). The body’s natural defense mechanisms work best when the mucosa is wet – a stuffed nose can lead to mouth breathing that will dry out the airways.

My preferred OTC medication is guiaifenisen, which thins secretions thereby making it easier to mobilize them. Guiaifenisen is available as a single ingredient (Humibid, Mucinex) as well in combination with other medications. Once again, I prefer the single ingredient product.

More information on guiaifenesin.

An outstanding recipe for chicken soup.

Where Did I Put My Glasses?

Patients often wonder if they are mentally ‘losing it.’ They will forget why they have walked into a room or wonder what it was they were supposed to buy at the market. The overwhelming fear is developing dementia.

The thirty second test for dementia: it’s not remembering where you put your keys, but rather looking at the keys and wondering what they are for. It’s not quite a simple as that but physicians do have tools to assess cognitive function. When assessing a patient it’s important to take into account the underlying intelligence – the proxy for this is years of education. We expect better test scores from a Ph.D than from a grade school graduate. Also, patients who don’t feel well or who are in an unfamiliar environment may not score well.

Even patients who score well on a cognitive assessment panel may have difficulty with everyday tasks such as handling money or finding their way around familiar streets. Information from family or friends is helpful, particularly when determining fitness to drive. Such collateral history may be needed in judging executive function. The inability to self-regulate and plan may be a clue to specific underlying brain disorders.

One cannot do a cognitive self assessment: the people around the patient will notice a problem. Since medical problems may present as cognitive decline, it’s important to obtain a complete medical evaluation. 

A special report from Johns Hopkins Press.

The Flu - Once Again

Most of the country is now experiencing flu – the levels are similar to peak levels in moderately severe seasons in the past. Nationally, the levels of hospitalization for influenza and pneumonia are just below the epidemic threshold. So far, Connecticut has been spared the burden of disease, but we are surrounded and it’s only a matter of weeks (or days) before our levels increase. The rate of infection for children younger than age 4 is increasing far faster than for the other age groups.

There is plenty of flu vaccine available and the shot can be obtained as a walk-in in many pharmacies. Immunization is important for anyone with a chronic medical condition, including those who are very obese (body mass index greater than 40). Children younger than 5 and adults older than 50 are considered high risk for complications and should be immunized.

There is a high-dose flu shot for people older than 65. Human immune defenses become weaker with age, which places older people at greater risk of severe illness from influenza. Also, aging decreases the body's ability to have a good immune response after getting influenza vaccine. A higher dose of antigen in the vaccine is supposed to give older people a better immune response and therefore better protection against flu.

To learn more: flu.gov

Happy New Year

My New Year’s resolution last year was “less but better.” I like it enough to use it again this year.

A good friend of mine gives wise advice on how to eat an elephant: one bite at a time. I would add my two cents – don’t make the bite so large that you choke. Take baby steps when making a change for the better. Smoke one less cigarette. Have only one scoop of ice cream. Park at the far end of the row and walk to the store. Looking at the big picture can be too overwhelming. Don’t worry about the forest, just look at the tree standing in front of you.

Don’t beat yourself up over what has already happened. Move forward. Try not to make the same mistake again, but if you do, move on. Sometimes it just takes a while to catch on.

I wish everyone a healthy and happy new year.