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Month: June 2016

Choosing a Physician

By Mark A. Kelley, MD |06/27/16

Choosing the right physician is an important step.

First, let’s review a few definitions. All doctors are trained in a specialty like internal medicine, pediatrics or surgery. We term these doctors “specialists”. Beyond their specialty, some doctors have advanced training in fields such as cardiology, plastic surgery, pediatric intensive care, etc. These doctors are “sub-specialists”.

Here are some things to consider when choosing a physician:

1. What kind of doctor are you looking for?

Primary Care – If you want a doctor who can treat most common illnesses, a primary care physician is a good choice. These physicians are specialists in internal medicine, family medicine or (for children) pediatrics. You want your doctor to be nearby if you are sick. Therefore, most people prefer that their primary care physician be convenient to their home. Usually that doctor also has staff privileges at your local hospital.

Sub-specialty Care – (like joint surgery, cardiology) – most hospitals have sub-specialists in both surgery and medical fields. Your primary care physician will know them in your community and you can also ask around as suggested above. Be aware that some sub-specialists will only see patients referred by another physician.

What Most People Do: Choosing a primary care physician is good first step. He/she will get to know you personally and understand your needs. Shopping around for a sub-specialist for every problem is unnecessary if you have a good primary care physician. That doctor can handle most common conditions and will also refer you to a subspecialty expert if necessary. For recommendations about specific doctors, it can be helpful to ask friends (particularly those in health care).

2. How can you judge the quality of the doctor?

Finding information about physicians is easy, thanks to the Internet.

Finding the Doctor’s Practice Site – You can perform an online search for the doctor by name and find their office location and other details. Be sure to add the doctor’s degree to their name (usually “M.D.” or “D.O.”)

Credentials – all doctors have the same credentials: medical school, specialty training (residency), medical license and, in most cases, specialty board certification. You can find this information from their hospital’s website, the doctor’s practice website or from national listings.

Public Quality Reporting – there are ratings of physicians’ quality that come from the federal government. These reports are still under development and most experts feel that they are not yet very precise.

“Best Doctors” Ratings – some commercial companies publish listings of the “best doctors” in a region or across the nation, often for a subscription fee. These ratings concentrate on sub-specialists and are usually based on physician polling. These sources can vary in quality and consistency. In addition, many excellent doctors are not listed in these directories.

Consumer Ratings – consumers are now rating doctors through websites such as “Yelp”. This new movement is gaining some traction with consumers. Most of the feedback is focused on the doctor’s bedside manner and how the practice is organized. This is helpful in judging the “user-friendliness” of the practice. However, these ratings may not be reliable in judging the clinical skill of the physicians.

The Physician’s Professional Experience – As with all professions, experience matters in medicine. However, there are other issues to consider. A new physician may be more available and also more up-to-date in the latest medical advances. A senior physician who practices only part-time may not have as much experience as a younger colleague who practices full-time. Regardless of age, physicians who perform surgeries and other procedures must perform them regularly to maintain their skills.

What Most People Do: The most trusted source of information about a doctor still comes from a physician or a relative/friend. However, many folks will also check on the physician’s background from the online sources above. When you select a physician, ask the him/her about their experience, particularly in performing procedures. One rule of thumb: a practicing physician is usually good at what they are do now—not what they did years ago.

3. How can I see an expert at a famous medical center?

Most large medical centers are teaching hospitals with multiple missions: providing medical care, educating future physicians, and performing medical research.
Often, these hospitals are owned or affiliated with a university. This allows them to recruit experts in complex and challenging medical conditions.

Seeing such an expert may not be difficult. Many centers are open to self-referred patients although some still require a referral from your doctor. A good approach is to look at the hospital’s website and find the “How to Make and Appointment” section.

What Most people Do: – The process is easier if you use your own physician to recommend and orchestrate the referral. Sub-specialists at large centers are more likely to expedite physician referrals from physicians. With your permission your doctor will send your records to the medical center expert and help coordinate your care.

4. How do I know the doctor accepts my insurance?

Doctors accept most insurance plans but you should check the details. If you are looking for doctors who accept your insurance, contact your insurance company–either by phone or on their website. Most companies list their participating doctors on their website or in a printed directory

Once you select a physician, it is best to verify the insurance information by calling the doctor’s office. You do not want any surprises when you arrive at your appointment.

As noted in a previous blog, check to see if you insurance includes a “narrow network”. This means that you must see doctors within that network. If you get treated “out-of-network” you may have to pay extra charges out-of-pocket.

Some of these networks have a limited number of doctors and hospitals you can use. Others are “wider”, with more options. Your insurance company can provide this information.

Our Immune System Fights Infection – Is Cancer Next?

By Mark A. Kelley, MD |06/20/16

Humans have been fighting disease for thousands of years. Until the 20th century, most people died young because they were exposed to deadly infections like small pox. However, smallpox survivors never experienced the disease again. The same is true for mumps, polio and measles. During these infections, our bodies create antibodies that recognize the virus as an alien invader and kill it before it can infect again. We have used this immune system to prevent infections and now we are using it against cancer.

The war against infections has been so effective that some infections are now rare. In fact, smallpox has been eradicated across the world. The reason is that we have developed vaccines that expose the body to proteins from viruses (like small pox) or bacteria (like tetanus) These proteins cause no infection but stimulate the body’s immune system to create antibodies that kill these organisms. Vaccines are among the most important discoveries in history and have saved millions of lives.

There are a few twists to this story. First, our immune system may need a “wake-up” call with a booster shot of vaccine. This revs up the immune system to create a fresh reserve of antibodies. A good example is the tetanus booster shot.

Second, viruses can change their appearance over time so that the immune system may not recognize them. For example, the influenza virus can change every year. Therefore, we need an annual flu shot to keep our immune system up-to-date.

In the past year, two different viruses, Zika and Ebola, have caused major epidemics. The Ebola virus is easily passed from human to human and has a high mortality rate. The Zika virus is transmitted by mosquito bites and rarely causes death or serious illness. The exception is unborn infants. For them, Zika can cause severe brain destruction leaving them disabled for life.

Both these viruses began in remote tropical areas of Africa and would have gone unnoticed before modern times. However, with larger cities and modern travel, diseases can rapidly infect people around the globe. Ebola, for now, has been confined to Africa, but Zika is steadily spreading across the Western Hemisphere.

These epidemics have awakened the world to the value of vaccines. There are now major efforts to create vaccines for these two dangerous viruses. However, it will take time to be certain that any new vaccine is safe and effective

The immune system is also becoming important in treating another major disease—cancer. Some cancers are linked to a viral infection. The best example is cervical cancer, which is associated with infection by the human papilloma virus. Vaccines against that virus, when given before puberty, reduces the risk of cervical cancer.

Cancer is a collection of abnormal cells that grow uncontrollably. Our immune system does not kill these cells because, on the surface, they look normal. If we could make these cells look abnormal, the immune system would destroy them quickly, just like any other invader. The effect would be dramatic. The immune system patrols the entire body and would hunt down every “strange” cancer cell.

Cancer research is now probing how to use our immune system to cure cancer. One approach is to make the cancer look like a foreign invader to our immune system. Another is to teach our immune system to use antibodies engineered to sabotage the growth of the cancer.

It may be a long time before we see results from this research … but we should be patient. It took decades to develop vaccines but the results have been spectacular. Our immune system is smart and ruthless in protecting us from infection. If we can train it to fight cancer, we will be moving closer to a cure.

What You Should Know About Health Insurance – The Details

By Mark A. Kelley, MD |06/15/16

Understanding Private Health Insurance – Part II

It is important to understand the coverage of your health insurance plan.
Previously, we covered deductibles, and premiums. There are other details that are important:

“Co-Pays”: These are fees that you pay whenever you receive certain services or purchase drugs or devices. The dollar value of co-pays varies by insurance plan and by the type of service provided.

The fee must be paid to the provider at the time of the service. In most plans, the co-pays are counted toward the deductible.

“Co-Insurance”:

Some insurance plans require you to pay a certain percentage of the cost of a medical service. For example, a 20% coinsurance for a procedure or hospitalization means that the insurance company pays 80% of the cost. You pay the rest. Plans with “co-insurance” usually have a lower monthly premium.

Some plans may include both co-insurance and deductibles. It is wise to contact your insurance company to learn these details.

“In Network”:

Insurance companies may offer a lower premium if you only use doctors and hospitals within a defined network. Typically, the insurance company has negotiated a discount with the network and passes some savings on to you.

To get this discount, you must stay in the network. If you go to providers outside the network, you may have to pay more for the service.

This arrangement should be very clear in your policy. If you are unsure, check with your insurer. If you already have a favorite doctor or hospital, check beforehand to see if they are in the network you are considering.

How to Manage “the Deductible”:

If you have a $1000 deductible, you are responsible for paying for medical services out-of pocket until the sum total of all such payments for the year reaches $1000. After that, the insurance company covers all costs.

Deductibles usually apply to visits to physicians or other health professionals; hospitalizations, procedures, diagnostic tests and prescription medications. It pays to know the exact details of your policy.

The insurance company will ask you to pay their usual cost, and no more. For example, if the company usually pays $50 for the doctor visit, you would pay that cost.

But there may be surprises. Some prescribed drugs and technologies have become very expensive, even for insurance companies. You may get sticker shock when you are handed some of these bills. If so, ask your doctor if there are less expensive alternatives.

The deductible “resets” to zero at the end of every year. If you are planning an elective procedure, like joint surgery, check the calendar. If you have paid many medical bills in the calendar year already, you may have reached your deductible. In that case, the insurance company would pay for all the cost of the surgery…provided it happens before the end of the year.


Good News/Bad News – there are limits to your out-of-pocket costs –but not your premiums
.

The Affordable Care Act limits out-of-pocket health costs. For an individual, the annual cost cannot exceed $6850 for an individual; or $13,700 for a family. These costs include, co-insurance, copays, and deductibles. For some plans the limits may be lower.

The limits are helpful but for those with modest incomes, these are still impressive sums. The other flaw is that these limits do not include the costs of premiums to purchase health insurance.
The federal government provides an excellent overview of these issues.

The Health Insurance Checklist:

In evaluating a plan, here are some things to consider:

1. Does the plan include your favorite doctors and hospitals? This is very important for those who are already receiving medical care. Some hospitals and doctors are more expensive and that cost may be passed on to you.

2. How much insurance can you afford? You must decide how much premium you are willing to pay to offset the risk of the deductible. Remember, by law, there are absolute limits on your out of pocket costs.

3. What is included in the coverage? Most common medical and surgical conditions and procedures are covered by insurance plans. However, check into the detials since the coverage can vary for:
Nursing home care, rehabilitation, medical equipment and devices,
Mental health services
Travel in other states or countries
Special drugs like chemotherapy, transplant.

4. Customer Service – health insurance is complex and you may need help to understand your coverage and your bills. Do not hesitate to contact your insurer for advice or questions. These companies must have good customer service to compete for your business. You can check consumer ratings of the companies in your region.

What You Should Know About Health Insurance – The Basics

By Mark A. Kelley, MD |06/10/16

Understanding Private Health Insurance – Part I

By law, everyone must have health insurance. If you qualify, you can use the government plans: Medicare, Medicaid, or Veterans Affairs insurance. If not, you must be covered by a private insurance plan. Read more about health insurance plans at Consumer Reports.

In these next two blogs, I will explain the key points and offer some tips about private health insurance.

Private health insurance is not free and has many different features:

The Monthly Premium:
Health insurance is a contract between you and the insurance company. The cost is billed monthly and you must pay it or lose your coverage. Like all insurance, the more coverage you buy, the higher the monthly bill (premium).

If your employer offers health insurance, you may pay only some of the premium cost. If you do not have employer insurance, you must buy it yourself and pay the full monthly premium. If you go through state or federal health exchanges, you may qualify for a discount if you have a low income. You can find the exchange in your state by going to Healthcare.gov.

Health Insurance Resembles Auto Insurance (Sort of)

The health insurance industry has redesigned its plans to include “deductibles”
This arrangement is familiar to all car owners. The deductible is what you pay out of pocket before the insurance kicks in. For example, if your car is damaged, a deductible of $500 means that you pay the first $500 of the repair bill before insurance pays anything.

To lower your premium, you can buy a higher deductible plan. That means you will have to pay more of any repair bill.

For example, if you choose a $1000 “high deductible” plan, you will pay less for insurance premiums compared to a “low deductible plan” of $500. However, in the event of an accident, you would pay the first $1000 of any collision repairs.

Many health insurance plans have a deductible, which is like a big bucket that fills up with medical bills. You pay every bill yourself until that bucket is filled to the deductible limit. If your deductible is $1000, you must spend that amount on medical care before the insurance begins to pay bills. The deductible applies to most health services and medications that you use during the year.

High or Low Deductible – Your Choice

A very healthy person may figure that the risk of any illness is low. Therefore, that individual might choose a plan with a low monthly premium and a high deductible (like $3000). Of course, an unexpected illness or accident could run up a bill of $3000 but the insurance would cover anything else for the rest for that year.

Those with existing medical conditions may already use medical services frequently. In that case, they might choose to pay a higher premium with a low deductible (like $1000) so that out of pocket costs are limited to $1000.

Obviously, the choice is up to you. The important factors to consider are:

–What is the annual cost of your insurance premiums?
–What is the likely cost of your medical bills next year? (Think carefully—are you planning elective surgery? do have an ongoing serious medical condition or recovering from one?)
–How much of that estimated cost will fall into your deductible? (If you don’t know, assume most of it will)

The major decision is whether you want a lower monthly premium and are willing to accept more risk for medical bills (a high deductible). If you anticipate many medical bills, the insurance company will cover more of the cost, provided you pay a higher premium.

The bottom line is to match your health insurance to your needs.

Only you can make that call.

Next Week – Part II: Understanding (and Using) Private Health Insurance – Details Matter

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