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Radiology Imaging Tests: The Basics

By Carla Dellaporta |12/8/17
Director of Education, NeedyMeds

You’re out walking your dog, enjoying the fresh air and holiday decorations, when suddenly — bam! Down you go on a patch of black ice. Standing, you realize you can’t put weight on your ankle.

The doctor says she’s not quite sure how bad the damage is. To get a better idea, she wants to schedule what she calls a “radiology imaging test.”

Say what now? Isn’t radiology like, nuclear?

Medical jargon gets thrown around left and right these days. Thankfully this one’s pretty simple. “Radiology” is the branch of medicine that relies on technology to diagnose or treat diseases. And “imaging” means the technology involved to take pictures inside your body.

So your doctor is saying she needs to get a better picture—literally—of what’s going on inside you.

There are many radiology tests out there. They differ in terms of the technologies used to produce images of your body. Some common radiology tests requested by doctors include:

X-ray: Uses a small dose of radiation.

CT scan: Combines multiple X-ray images.

Ultrasound: Uses high frequency sound waves.

MRI: Uses magnetic fields and radio waves.

From 2000-2010, imaging services and costs grew at twice the rate of other healthcare technologies. One reason why may be what’s called “defensive medicine.” This term refers to doctors prescribing or recommending unnecessary tests to protect themselves from potential malpractice lawsuits.

A recent study estimated that unnecessary medical tests cost the U.S. nearly $7 billion dollars annually. Overly cautious medicine is a common practice that, unfortunately, comes at the patient’s expense. Don’t rush to get a test without having a clear idea of what your options are and whether or not you can afford treatment.

Below, we’ll cover some questions to ask before scheduling your radiology imaging test. That way you’ll know you’re getting the best bang for your buck.

Questions to Ask Your Doctor Before Scheduling the Test

Do I need this test? You’ll want to understand why you need a scan and how the results will change your course of treatment. If the doctor can’t justify how the results of the test would change the treatment course, then you probably can do without it. No use in wasting time or money on unnecessary tests.

Are there safer alternatives? A CT scan exposes you to much more radiation than a standard X-ray. An MRI, on the other hand, doesn’t use radiation at all. Because radiation can potentially cause DNA damage, you want to limit your long-term exposure. Ask whether there are any lower-radiation but still effective options.

How much will this test cost? Imaging fees vary widely between hospitals, private facilities, geographic location, etc. Always ask for the bottom line cost before scheduling a test. Keep in mind, there’s something called a “global fee” you’ll want to be aware of. This fee charges for the test itself as well as the professional interpretation of the results. Being aware of the global fee ensures you won’t be blindsided when the bill arrives.

How long before I get the results? Radiology test results are generally read on-site by a trained radiologist. However, it’s the doctor who usually delivers those results to the patient, and a variety of factors will influence when you’ll receive them. Ease your mind by asking up front how long this process will take. Consider calling if you haven’t received your test results after five days.

Some Final Cost-Saving Tips

Confirm which location(s) your health insurer considers in-network and how much they cover. Few people know that most of the time, imaging tests cost more when performed at a hospital rather than private facility. Contact your health insurance company directly to find out which facilities they consider in-network. By staying in-network, you won’t have to pay the for the full price of care. There’s a reason you have health insurance—let your insurer help cover the costs!

Ask for a cash discount or sliding scale payment plan. Paying out-of-pocket doesn’t mean you’re doomed to pay up-front and in-full. Most healthcare centers will work with your financial situation, but first you have to ask. A payment plan is a much more reasonable choice compared to putting the total fee on a credit card. You wind up paying a lot more money in interest if you can’t pay off your credit card bill immediately.

Check the credentials of the imaging facility. You know you can trust a facility if it’s been accredited by the American College of Radiology. That means the center has undergone a rigorous evaluation process led by experts in the imaging field. Generally, accreditation can tell you if the center’s radiologists are experienced, and whether or not the center’s equipment and staff meet/exceed nationally accepted standards. Obviously you want the best care for your money.

To learn more about the field of radiology imaging, our reviewers recommend RadiologyInfo.org as a great introductory resource. This website explains the various forms of medical imaging including their indications, complications, and relevant tips for patients undergoing tests. Read our full review for more information.

Why Prescription Drugs are Expensive and What We Can Do About It

By Mark A. Kelley, MD |11/28/17
Founder, HealthWeb Navigator

As the healthcare debate drags on in Congress, prescription drug costs continue to rise by almost 10% annually. It is the rare patient who is spared this expense.

Over the years, I have seen how these costs have affected my patients. At first, most patients had little in the way of co-pays. However, once the local economy deteriorated, co-pays skyrocketed as employers tried to curb their healthcare expenses. Now, monstrous co-pays are the norm for health insurance plans across the nation.

The solution to this problem appeared simple. Drugs with expired patents are usually much cheaper for patients. Insurance companies encouraged physicians to prescribe these “generics” and used this practice as a metric to measure quality.

That strategy has indeed worked. Generic drugs now account for 89% of all prescriptions but only 26% of all drug expenditures.

Unfortunately, this success has not prevented drug inflation. Countless new drugs have emerged over the last thirty years. Some have been “blockbusters” that substantially change medical practice, but the rest have had much less impact. All of these new drugs, blockbusters or not, are protected by patents and promoted by aggressive marketing. They command high prices and subsequently drive up the average cost of prescribed drugs.

Recently, several events have given me a deeper appreciation of the reality experienced by our patients.

The first “surprise” was witnessing a 400 percent increase in the cost of the albuterol inhaler, an asthma product that has been around for decades. Because the inhaler propellant was changed, the manufacturer sold this product as a newly patented “delivery system.” This patent loophole is a common tactic in the drug industry. In this case, the FDA predicted that the loophole would cost consumers $8 billion before the patent expired in 2017.

The second revelation was a variation of the same theme. One of my patients watched the market price of a skin medication double in just four years. The reason was that the company’s drug patent was about to expire. The final price tag for the drug was $300 — for a six-week supply. This is another common industry tactic.

But the most surprising outcome has been the emergence of “competitive” generic drugs. Most generics have a low price point. However, if a large generic manufacturer has little competition, it can act like a monopoly and raise prices on its own terms.

A well-publicized example was the dramatic rise in the price of the “Epipen.” This pre-loaded injector of epinephrine can be life saving during severe allergic attacks. In 2007, one injection cost $50. By 2016 the price was $300 — for the same drug and injector. This tactic, termed “price gouging,” is now illegal in the state of Maryland. Other states may soon follow.

These pricing maneuvers have made drug prescribing more complicated for both patients and their physicians. Generics may no longer be “safe bets” for low costs. New and more expensive drugs may not be any better than generics. And drugs may have different co-pays, depending on the insurance plan.

How is one to know? The answer is simple: the patient and the doctor need to communicate.

I learned that lesson with my own new prescription. My doctor explained carefully why she preferred this brand-name product. When I picked up the prescription, the price tag was $420 for a 75-day supply!

When I mentioned this cost to my physician, she was even more astounded than me. She quickly changed the prescription to a generic product that cost $29 for the same duration of treatment. She felt the advantage of the first medication was minor compared to its overwhelming cost, which was 14 times more expensive.

Pharmacists have told me that this “sticker shock” is becoming more common among patients picking up their meds. But that situation is preventable. Doctors should know the prices and efficacy of the drugs they commonly prescribe, and patients should ask for the drug prices up front. In my case, both my physician and I should have done that homework. Thankfully, all that was needed to solve the problem was a painless follow-up discussion.

Drug price information is easy to find online, since pharmacies compete fiercely for business. The market price for most drugs is available via a simple Google search of the specific drug name with the term “price.” Here on HealthWeb Navigator, you can find several websites that help patients locate and compare drug prices.

If the drug is expensive (e.g. three digits for a typical 30 day prescription), the out-of-pocket cost (co-pay or deductible) is likely to be significant. If the local pharmacist has the patient’s insurance information, s/he can quickly quote how much the patient must pay. If the out-of-pocket cost is high, a less expensive yet effective drug may be preferable. If the patient cannot afford the drug, there are organizations such as NeedyMeds that can help with discounts.

Healthcare economics may be complicated, but drug cost is where patients and their doctors can team up. Patients want to be healthy but don’t want to go broke in the process. Informed doctors are in the best position to advise patients of the trade-offs between cost and benefit. Working together, doctor and patient can make an informed choice.

There is a lot of room for improvement. In a recent poll, 60% of patients feel their doctor is unaware of how much they pay for drugs. Doctors need to be better informed about drug costs and help patients deal with this challenge. 

If you are looking for a perfect model of patient-centered care, this is it. After all, as my own story illustrates, when doctors become patients, we face the same reality as everyone else.

Physician Burnout and the Battle for Time

By Mark A. Kelley, MD |11/10/17
Founder, HealthWeb Navigator

According to published reports, over 50% of doctors are burned out. The reason? They are overwhelmed by payment and quality rules as well as poor information technology.

It’s no secret that physicians spend long hours seeing patients. But as financial pressures have mounted within hospitals, doctors are forced to perform more administrative tasks. In fact, administrative tasks account for nearly a quarter of the average doctor’s schedule. That’s all time diverted away from patient care.

Many physicians feel a loss of autonomy, a major factor in burnout. The National Academy of Science now sees burnout as a major threat to maintaining our physician workforce.

The key issue is how we want healthcare professionals to spend their time. Instead of asking them to do more, we should ask, “Do more of what …and why?”

Our current system is based on assumptions and technologies that are outdated and interfere with the delivery of modern health care. Three problems are clear:

• Physicians in the United States must provide exhaustive documentation to justify their services. No other health system in the world imposes such onerous rules.

• Health IT systems are designed primarily to support tedious billing documentation rather than clinical care. For practicing physicians, this issue tops the list of frustrations.

• Payers and other advocates have promoted different measures and incentives, leaving both physicians and patients searching for a single, meaningful quality agenda. That goal remains elusive, trapping physicians in many time-consuming quality tasks of dubious value.

These three problems have forced physicians to perform more tasks that take time away from patient contact. The result is the “ten-minute patient encounter,” during which the physician spends most of the time on a computer to document and bill for the visit.

This contrasts with how other professionals spend their time. Imagine if we expected airline pilots to sell tickets, load the baggage, and fill the fuel tank before flying the plane!

Several innovations would help solve these problems.

1. Modernize healthcare transactions to be efficient and understandable. Documentation has devoured clinical practice. Originally designed to curb costs and prevent fraud, the current system is an obsolete instrument. In businesses such as the credit card industry, electronic algorithms and analytics detect fraudulent behavior. Such technology should replace arcane documentation rules and their toxic effects on clinical practice.

Beyond the documentation problem, the healthcare industry operates an economic system that bewilders patients, providers, and most business experts. Private insurance rules vary widely by plan, location, facility, and provider. If health care were a consumer-based business, it would have been “out of business” long ago.

2. Focus IT on healthcare analytics. The depth and breadth of medical information is growing exponentially. To serve their patients, physicians must process complex data and perform multiple tasks rapidly. Well-designed informatics can save time, reduce errors, and distill information. Sadly, we are far from reaching that goal.

The current health IT systems are heavy on billing and documentation, and light on usability and analytics. While medicine has aspirations for using “Big Data” in patient care, its information systems are poorly prepared to do anything more than print reports and bills. The healthcare industry needs “smart systems” that make medical practice highly reliable, safe, and more efficient.

Outside of health care, new IT solutions are thriving. Patients can purchase a $50 voice recognition device to browse the internet, play music or news, and perform calculations. However, their doctors and hospitals are stuck with expensive billing systems that are clumsy at retrieving and organizing patient information. That embarrassment would end if healthcare IT focused more on patient care instead of billing.

3. Prioritize national quality goals that matter. Our nation needs to justify the assignments it imposes on physicians. The major advances in healthcare quality have been successful because both patients and physicians understood their importance. These advances, such as cardiac prevention, were planned and tested to blend into practice. Physicians will support important quality programs that meet these standards…but not low-impact measures designed in a conference room.

Medicine is the ultimate human service, whose value to the patient is quality time—time spent with the physician. That bond should not be threatened by putting “business” processes ahead of patient care.

If we lose that battle, both patients and their physicians will be casualties in the war to save medical professionalism.

Quality Reports for Hospitals and Doctors: Interesting but Flawed

By Mark A. Kelley, MD |10/18/17
Founder, HealthWeb Navigator

Every patient eventually asks the same question: “How can I find the best hospitals and doctors?”

The solution might seem easy, since we live in world where information is readily available on the internet. In a few clicks we can shop for goods, review consumer products, market ourselves on social media, and complete financial transactions instantly. You would think that health care, which accounts for 17% of the GDP, would have all these same features.

Think again. Healthcare information for consumers is woefully unsophisticated compared to other industries. Ask anyone who has ever attempted to find prices for healthcare services, interpret a medical bill, or schedule an appointment online.

Healthcare information is primitive because it focuses on finances rather than customers—that is, the patients. As a result, hospital and physician offices are skilled at sending bills but often can’t help patients with much else.

Federal regulations have helped improve online medical records and lab results. But information about healthcare quality is still lacking. The lack of standardization about what is important, credible, and measurable leads to confusion.

HealthWeb Navigator lists the most common online hospital rating websites. Unfortunately for patients, there is no consistency among these many rating tools. Research shows that hospitals ranked highly in one system often score poorly in another…and vice versa.

The reason? These rating systems all use different measurement criteria, as well as different statistics to compute results. Some are heavily influenced by reputation rather than clinical outcomes. Even Medicare’s rating system—Hospital Compare—isn’t very helpful since it’s hard to navigate and most hospitals come out “OK”. Many patients choose not to use these “quality” tools due to the inconsistency among them.

Report cards about doctors are not much better. Medicare’s Physician Compare suffers from the same problems as its hospital-focused counterpart. The average visitor has difficulty sorting out the information most valuable to them. Some websites promote doctors who pay to be listed on the website. Others feature those doctors with regional and/or national reputation. This approach is common in regional publications magazines like Boston Magazine that list the “best” local specialists.

Finally, the newest “report card” for hospitals and doctors is the popular website Yelp. Reports featured on Yelp remain controversial, as they are based on consumer opinions rather than a more data-driven methodology. Despite the flaws, Yelp reviews are extremely popular among consumers.

In the midst of all this confusion, how can someone find a good hospital or doctor?

Most physicians, including me, think that the best source is still a recommendation from a trusted friend, preferably a health professional. Those in health care usually have a network of helpful contacts. Of course many other factors can influence patient choice. Most patients prefer medical care that is conveniently close to home. Others, especially those with complex conditions, may prefer to see a specialist in a large medical center far from home.

Once a hospital recommendation is made, the patient and their family can examine the hospital’s website to evaluate its staff and their credentials. Some hospitals publish their staff’s expertise and experience in certain specialties. Such voluntary public reporting is becoming more common among hospitals that perform at a high level. If a hospital does not list such metrics, it is worth asking for them.

As for doctors, you can check out their background on several websites featured in our “Physicians” section. Most hospitals list the educational credentials of their medical staff, including board certification.

Clinical experience is highly important when choosing a physician. That information may not be listed on a website, but every physician can and should be able to summarize their experience to interested patients. HealthWeb Navigator covers how to choose a doctor in more depth on a previous post.

In summary, publicly reported hospital and physician “scorecards” are interesting and sometimes helpful—but not necessarily authoritative. We have a long way to go before “public reporting” in health care represents an accurate reflection of clinical performance in ways that consumers can understand.

In the meantime, the best approach is to contact a trusted source, especially a physician or nurse. Ask them where or to whom they would send their loved ones in times of need. That recommendation is bound to be reliable.

Rising Costs: The Greatest Threat to Health Reform

By Mark A. Kelley, MD |9/21/17
Founder, HealthWeb Navigator

The main character in the popular film Groundhog Day is caught in a time loop where he must repeat the same day over and over again.

The U.S. Senate is now having its own “Groundhog Day” moment as it debates (yet again) a law to replace the Affordable Care Act. To add to the drama, Senator Bernie Sanders (I-Vt.) is promoting his single payer alternative popularly branded as “Medicare for All.” In a recent TV interview he raises many of the same points I raised in my previous post.

Meanwhile, the average person watches their health care costs spiral out of sight, something our elected officials seldom discuss. How did that happen? Who is to blame?

The answer is no one…and everyone. Human history is full of examples when humans exhausted their resources. This is believed to be the reason why Easter Island’s inhabitants disappeared, eradicated by their own unchecked “ecocide.”

In North America, humans wiped out 50% of the large animal population in the geologic blink of an eye. Of course no one planned these extinctions. But we humans seem to have trouble learning that excessive demand eventually devours resources.

We have the same problem when it comes to health care. Over the last 40 years, health care has become one of the most innovative and profitable sectors of our economy. However, its costs are now taking big bites from the budgets of government, industry, and private citizens.

Until recently, this toxic effect was hidden behind spectacular successes in medicine: new technologies and cures, improved public health, better quality of care, etc.

For businesses, the success has been equally impressive. Health care has been profitable for insurance companies, hospitals, device manufacturers, and the pharmaceutical industry. These sectors thrived because the government and employers could afford to pay the costs, very little of which was passed on to patients.

But those “good times” ended a decade ago when health costs pushed the U.S. auto industry into bankruptcy. After the
Great Recession of 2008, most companies faced the same challenge and were forced to cut their health benefits to stay afloat.

As a result, employees now pay more for health care out of pocket, while the average worker’s income has flatlined. You don’t have to be a math major to figure out that health care will soon be too expensive for most people. Meanwhile, the big business of health care has shown few signs of slowing down. Nearly all companies remain profitable.

However, there are some cracks in the armor. The profits of some hospitals and systems have dropped off, and several have closed as a result. Physician incomes are stable, but the pressures of practice are becoming intolerable. Many physicians are suffering from burnout, causing them to leave practice.

Health care is a major sector of the economy, accounting for 17% of the GDP. It is a field with many powerful constituents who support—and wield substantial influence over—members of Congress. That fact alone makes legislative reform difficult.

How will change occur? Possibly, though not ideally, from America’s most common instrument of change—a national crisis.

Despite what many experts believe, health care is not “too big to fail.” It has few price controls and bears no resemblance to a free market. The industry cannot survive without employer and government subsidies. As a nation, we have become gluttons for health care that is inefficient and becoming prohibitively expensive. There is no clearer path toward extinction.

Left unchecked, healthcare prices will continue to rise. Unless those costs are subsidized or controlled, more consumers will choose to be uninsured and seek care in hospital emergency rooms, leaving other patients to foot the bill.

If employers retreat from health insurance, the consequences will be catastrophic. The uninsured will flood the country’s delivery system of doctors and hospitals. Without federal bailouts, the system will bleed itself dry and suffer a full-blown meltdown.

That may happen no matter what Congress decides in the coming months. If Congress reduces current federal subsidies, more Americans will find themselves instantly uninsured, triggering a political and financial crisis. But even if the subsidies survive, costs will continue to rise, eventually resulting in catastrophe for all.

Unwittingly, with health care we have created a game that the public simply cannot win. The time has come to change the rules in our favor.

The Affordable Care Act: Moving the Public Closer to “Medicare for All”?

By Mark A. Kelley, MD |8/30/17
Founder, HealthWeb Navigator

The Affordable Care Act (ACA) debate resumes when Congress returns from its summer recess on September 4th. In the meantime, the debate has already had major effects on public opinion.

A recent report describes how Americans currently view the ACA. According to national polls, over 90% of Americans would change the current law. Most Democrats would expand ACA coverage while most Republicans would reduce ACA benefits or rewrite the law completely. Only 8% of those polled would repeal the ACA without a replacement.

The most surprising result is the public’s response to the following statement: “It is the responsibility of the federal government to ensure that all Americans have health coverage.”

Last year, 51% of Americans agreed with that statement. In 2017, the approval rate jumped to 60%. It appears that a government health insurance option is gaining popularity.

Meanwhile, contrary to some reports, the ACA program is stable. Most regions of the country still have private insurance plans available through the ACA. Many insurers increased premiums to cover losses, but that one-time intervention seems to have stabilized the markets.

The reality of health insurance is that it must be profitable to cover unexpected losses. The insurance company has several tools to ensure a profit: charge high premiums, select consumers with low risk, or limit the services and/or payments of coverage.

The ACA eliminated most of these options. High-risk consumers could not be denied coverage or be overcharged. Further, every health plan was required to pay for a standard portfolio of services.

To offset losses, the federal government has provided supplements to cover costs on a year-to-year basis. The ACA has proven even more expensive than anticipated because the uninsured have been much sicker. The ACA had plans to offset these costs but they have had no major effect to date.

To force Congress to pass a new law to replace the ACA, President Trump has threatened to stop its federal supplements. That threat has already caused some insurance companies to leave the ACA. Congress, however, does not favor this action since it would leave millions of Americans without health insurance.

This situation has exposed the major weakness of the ACA — its financial fragility.

• The ACA required all Americans to purchase health insurance to create a new funding source. That plan failed because the law was poorly enforced. Now the ACA has no consistent source of revenue to offset costs.

• On the costs, the ACA is also vulnerable. The ACA insurance plans are managed by the private insurance industry. As long as insurance companies can rely on federal subsidies, they have little incentive to reduce costs.

• The bottom line is that the federal government must continue to subsidize the ACA.

This challenge is not new. With Medicare for the elderly, the federal government has a long experience with publicly supported health insurance. Medicare is a popular plan that is predictable, understandable, and accepted across the nation. Because it controls national pricing, Medicare has kept inflation low compared to private insurance.

“Medicare for All” was popular with some voters during the 2016 presidential campaign. Many now wonder why they cannot have the same federal insurance plan as their parents and grandparents.

That is a timely question. For most Americans, employee health insurance has become too expensive and unwieldy. Our U.S economy rewards workers who have geographic mobility and job flexibility. For such employees, finding health insurance in differing local markets can be a nightmare. A national health plan, like Medicare, solves that problem.

Companies see the rising cost of employee health insurance as a threat to the bottom line. Many businesses pass these costs to their employees through higher deductibles, co-pays, and co-insurance. That maneuver may reduce company costs, but it puts economic stress on employees and does little to curb medical inflation.

Americans are beginning to understand these issues and envision a future where the federal government ensures access to health care for everyone. During the ACA debate, voters sent several strong signals to Congress:

• Do not repeal the ACA without a replacement plan in place.

• Do not reduce current benefits.

• Do not interrupt or threaten any current insurance.

The message seems clear: most Americans want Congress to improve the ACA and move forward—not backwards. The only institution with the experience, power, and resources to lead the way is the federal government. If that happens, the country will be on the path to a “public option” like Medicare where the federal government is the insurer.

That option was proposed for the ACA in 2010 but was withdrawn due to political pressure from the insurance industry. Reviving the public option will likely provoke the same industry reaction. However, if voter support continues to grow, the public option could prevail. That will be a game-changer.

Planning for the End of Life: What Baby Charlie Can Teach Us

By Mark A. Kelley, MD |8/7/17
Founder, HealthWeb Navigator

Charlie Gard was a one-year-old boy who had a rare genetic disease leaving him blind, comatose, and unable to breathe on his own. This metabolic disorder can be fatal and has no known cure.

Charlie’s parents wanted him treated with experimental drugs in the hope that a miracle would happen. As reported in the press, the British medical and legal community considered this care futile and blocked it.

This sad story created a flurry of public discussion about ethics, end of life care, and patient and parent autonomy. Experts debated the wisdom of the parents’ decision. The discussion centered on whether the experimental therapy would help Charlie or make him suffer more.

These “end of life” issues have evolved during medicine’s successes over the last 50 years. Thanks to life-saving advances, premature infants have been saved. Organ transplants have given new life to patients with failing lungs, heart, kidneys, and livers. Many cancers are now curable.

However, there are limits to what medicine can do. Full recovery is rare among patients who have multiple-organ failure or advanced chronic disease. This raises the important issue of length of life versus quality of life.

As an intensive care physician, I have treated many patients facing this challenge. These situations are exceedingly difficult for everyone: patients, their families, and their medical teams. Emotions are magnified even more when the patient is young and/or cannot speak their wishes.

The major question for a critically ill patient is, “What happens next?” Sometimes, nature sends clear signals: the patient does not respond to maximum therapy, or there is no sign of brain activity. But more often the situation is uncertain. The patient may enter the twilight zone of the “chronically critically ill.” Such patients, who are often comatose, can be kept alive by machines that inflate the lungs, pump the heart, and dialyze the blood—all in the hope of a major recovery.

Research has shown that patients who need such advanced life support for many days have a grave prognosis. Those few who survive and leave the hospital usually die within one year and most never achieve full function. Physicians and families find it hard to know how aggressively to treat such patients without understanding their wishes.

This situation is preventable. While 90% of patients feel that they should discuss end-of-life plans with their family, only 27% actually do so. Knowing such plans in advance is invaluable for developing a treatment plan that respects the patient’s wishes. However, unless patients tell their families beforehand, how can anyone know?

Fortunately, progress is being made, thanks to public support and resources such as The Conversation Project. This advocacy program encourages everyone to “have the conversation“ with family when there is no pressure to make a hasty decision. The group’s website has helpful information and tools to guide the discussion. As some experts have written, we make plans for our estates—why not include our end-of-life wishes?

Charlie Gard’s parents were in a very difficult situation. They had to make a decision about his care and initially defied the medical/legal community by choosing aggressive therapy. Many supporters, including Pope Francis and President Trump, rallied to endorse the parents’ position.

That was before the medical facts became clear. According to published reports, experts agreed that Charlie’s disease had permanently damaged his brain and that he would never awaken or breathe on his own. The experimental therapy would not reverse his current state of suffering but could possibly make it worse.

Once they understood these facts, Mr. and Mrs. Gard chose to remove their young son from life support, and he died peacefully. We can sympathize with their painful and loving effort.

The Gard story has a message for us all. As a comatose child, Charlie could not speak about end-of-life decisions—but, as adults, we can. It is important to remember that the end of life is inevitable and that we will all experience it some day.

Having “the conversation” can relieve our loved ones from a responsibility that rightfully belongs to us. It may be the most important gift we can give them.

How to Effectively Manage Appointments with Your Doctor

By Mark A. Kelley, MD |7/12/17

Everyone in health care is busy these days. Most doctors have full schedules and patients often can’t afford to take time off from work.

Neither patients nor doctors are satisfied with this situation. However, once you and your doctor get together, there are ways you can make the visit more valuable.

Doctor appointments fall into two different categories:

• Urgent visits: For true emergencies, you should seek immediate medical attention. For a problem that is not an emergency but worries you,  the best approach is to contact your doctor’s office. Your doctor may be able to solve the problem by phone or work you quickly into the office schedule.

• Routine planned visits: These visits are usually for a new consultation or a follow-up for a known condition. You can get more from these scheduled visits if you do some preparation.

The New Consultation

You can take a few steps to ensure a new consultation goes as smoothly as possible.

Educate yourself beforehand: Understand the reason for the consultation from your referring doctor. Have you read up on your particular problem? Have you checked the credentials and experience of the new doctor? Is this new doctor affiliated with a hospital that you like? Does the doctor accept your insurance?

Bring your medical records, drug list, and results of any lab/radiology studies: This step can make a major difference in your first visit. Medical records provide a clear picture of your health history. The doctor can read faster than you can talk, and this written information frees up time for the doctor to have a better conversation with you. The information may also reduce the need for more tests, allowing the doctor to focus on a diagnosis and treatment plan.

Prepare a list of questions in advance: Make a list that you can share with the doctor. This conversation will help you to understand the medical issues involved, as well as help the doctor understand your concerns.

Ask a close relative or friend to accompany you on the visit: This has several advantages. Your relative may remember something about your medical history that you forgot to mention. They may also be helpful in remembering specific details that the doctor mentions. Additionally, it is always comforting to have a close companion with you to provide support.

Ask the doctor to summarize their findings and recommendations for you: Then, in your own words, repeat the summary back to the doctor. This will help you remember details and ensure that you and your doctor are on the same page regarding your problem and action plan. Don’t be shy about asking questions. Doctors want their patients to be well informed.

Understand the plan and goals before the next visit: These may include any new medications, tests, procedures, or therapies. For each one, consider asking the following questions: How does this test or therapy work? Why do I need it? How long will I need it? What are its benefits? What are its risks? For a new medication, what side effects should I look for? Will it interfere with my current medication? If I have a problem, who should I contact?

Ask for a printout: Request hardcopies of any diagnosis, medications (especially new ones), or tests before you leave the office. You can also ask the doctor to send you a written summary of the visit for your records. By law, you are entitled to this information, and physicians are usually glad to provide it.

Learn more about your condition: Although you may have read about the subject beforehand, your doctor may direct you to other helpful resources. The information may come in the form of written materials or online resources. HealthWeb Navigator can direct you to the most trustworthy, independently reviewed health websites online today.

The Follow-Up

Follow-up visits are scheduled so that the doctor and patient can monitor progress together. You should expect to discuss the following issues with your doctor:

• Are you feeling better or worse?

• Are there any problems to report? If so, let the doctor know early in the visit. They can evaluate whether this issue is serious and/or related to other conditions.

• Are you taking your medicines as prescribed?

• Have you had any new tests or other doctor visits recently? The doctor may not have the results but should be able to get them quickly.

• Do you have any questions about your condition?

• Do you understand the treatment plan? Before you leave the appointment, be sure you receive written summaries and instructions.

Based on my decades of practice, this preparation makes the office visit more productive for doctor and patient alike.

Final Tip

Sometimes routine follow-up visits become “too routine.” Physicians know that patients spend a lot of time and money on medications and doctor visits. If you are doing well and everything has been under control, you may want to pose the following questions to your doctor:

• Can I cut back on any of my medicines (or even stop them)?

• Can I reduce the number of routine follow-up visits?

• Can some of these follow-ups be done by phone or email?

Physicians are modernizing their practices to suit your needs. I suspect that most are more than willing to discuss these requests.

Firearm Fatalities – What Are the Issues?

By Mark A. Kelley, MD |6/22/17

The recent shooting at a Congressional baseball practice is another example of firearm violence. When such crimes grab headlines, it is helpful to review the national statistics concerning guns and safety.

According the Centers for Disease Control, 33,000 Americans die from gun injuries annually. About 65% of these deaths are from suicides. Easy access to firearms, especially in the home, is associated with higher rates of suicide.

Because self-inflicted gun injuries are highly lethal, most suicide attempts by this method are successful. However, patients with unsuccessful suicide attempts rarely succumb to suicide later. Therefore, keeping these patients away from guns is life-saving.

The second major cause of firearm death is homicides (33%). Nearly all of these deaths are in the home or among people who know one another. Random shooting fatalities are rare.

The final cause of firearm deaths is accidental shootings, usually in the home, and often involving children. These deaths account for 2% of firearm fatalities.

Mass shootings, such as at the Sandy Hook Elementary School in 2012, are heart-breaking tragedies. From 2007-2016, the national fatalities per year from mass shootings ranged from eight to 67 victims. Over that decade, the nation averaged 38 deaths per year, or 0.3% of the total gun-related homicides.

Firearm mortality statistics can be summarized as follows:

• The majority of Americans who die from gunshot wounds are the victims of suicide.

• Most other fatalities are due to domestic violence or among people who know one another.

• Mass shootings, while dramatic, are a very small part of this problem.

In all these scenarios, easy access to firearms increases the likelihood of a fatal outcome.

Mass shootings are a relatively new phenomenon in our country. Many hypotheses have been raised to explain this change. Among them are the expansion of social and news media, the availability of automatic weapons, and weak gun control laws.

These who commit these crimes share some common characteristics. In many cases, they do not know their victims. Most of the perpetrators act alone, have no plans for escape, and die violently, often by their own hand. Many obtain firearms legally.

Why motivates such people? Psychologists have suggested that this violence stems from rage at society because of some grievance. The result of this anger is mass casualties and usually the shooter’s own death by gunfire, often self-inflicted.

This raises several issues. Are mass shootings a form of public suicide? If so, will they occur more often? While no one has the answers, one fact is clear. The behavior behind these shootings is highly abnormal and suggests serious mental health problems as the root cause of the violence.

Our society has two problems that are closely linked—lethal weapons and mental health. Those with mental health issues and violent intent are more likely to harm themselves or others if they have access to guns. However, gun control is only a partial solution.

The major challenge is early recognition and treatment of mental illness. We need to help mentally ill patients well before their depression or rage reaches the breaking point.

Our elected officials are now considering cuts to healthcare benefits, particularly in mental health. Such cuts would be a major public policy mistake. In this era of gun violence, public safety requires that we make mental health one of our top priorities.

What Can We Expect From the Proposed American Health Care Act?

By Mark A. Kelley, MD |6/1/17

Our last blog focused on the political movement to replace Obamacare. Since then, the U.S. Senate has been busy revising a new healthcare bill passed by the House of Representatives called The American Health Care Act (AHCA). Some of the specifics of the bill have been clarified.

The Facts to Date

If the AHCA replaces Obamacare, the Congressional Budget Office (CBO) predicts the following outcomes:

• 14 million Americans would lose their coverage within the next two years. Most of them have little or no income and have serious healthcare challenges.

By 2026, over 51 million Americans would be uninsured compared to 28 million if Obamacare remained in place.

By 2020, insurance companies would be able to exclude those with pre-existing conditions. As a result, millions of sick Americans could lose their current health insurance.

The AHCA also cuts taxes for the rich, and reduces federal revenue by $700 billion over ten years. The impression is that health care is being sacrificed to help the top 1% of wage earners in the nation.

The Key Issues – Insurance Availability and Cost

Most Americans are focused on two health insurance issues: availability and affordability. There are reasons to worry on both counts.

Insurance Availability: The AHCA cuts Medicaid and threatens other forms of insurance coverage. Obamacare defined the benefits for all health insurance, including no penalty for pre-existing conditions. The AHCA offers “waivers” for insurance companies to “customize” these features to reduce cost. These waivers could include denying coverage for pre-existing conditions or any future expensive illness. In a worst-case scenario, pre-existing conditions might include common problems like hypertension, asthma, and obesity that affect many Americans.

Insurance Affordability: The AHCA may lower premiums by limiting benefits or covering only low risk patients. However, this would deny health insurance from those who need it most.

Even more worrisome is a long-standing problem of national healthcare costs. The reality is that cost inflation continues to drive higher premiums and threatens the national economy. There has been little attention paid to that major challenge.

Can we afford to cover more people when health care cost inflation continues to rise? The answer is “No”…unless we change the current status quo.

Health Care Cost Inflation – A National Problem

The cost problem can only be solved through a national system that has a budget, reliable revenue, and the tools to control costs.. The best example is Medicare, which covers the elderly. With the advantages of national price and policy controls, Medicare has begun to curb the rate of medical cost inflation.

Why is this example important? Medicare is a federal insurance plan that sets prices, controls costs, and covers its beneficiaries through taxes. Private health insurance is different. It is an industry that operates as a free market, like any other type of insurance. No country has successfully used the free market to provide health care for its citizens. The reason is that many people cannot afford to buy private health insurance. Only a government program can help them.

Obamacare was a major step forward. The law standardized benefits and offered subsidies to help cover the cost of private insurance. The result was that over 14 million Americans were newly insured.

But that plan will fail without a system that has enough predictable revenue to cover everyone and has the power to control costs. That is a task that only the federal government can manage.

We have already started down that pathway. The federal government manages, directly or indirectly, more that half of all U.S. health care expenditures: Medicare, Medicaid, the Veterans Administration, and the Armed Forces. In effect, we have a large national health portfolio supported by taxes.

Voters are becoming weary of the politics of health care. Soon they will wonder why they cannot enjoy the same benefits as their parents on Medicare. If that bandwagon gains momentum, politicians will scramble aboard.

The process may take time but as Winston Churchill quipped, “You can count on Americans to do the right thing…after they have tried everything else.”

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