JustCare

Tag: Doctors

  • Schedule your doctor’s appointment early in the day 

    Schedule your doctor’s appointment early in the day 

    In 2011, a paper published in Proceedings of the National Academy of Sciences revealed that judges are more lenient on defendants early in the morning and immediately after lunch. They are less tired and less rushed. Not surprisingly, new research reveals that primary care doctors provide better care early in the day. Schedule your doctor’s appointments in the morning!

    Researchers at the Penn Medicine Nudge Unit looked to see when doctors ordered colon and breast cancer screening tests for eligible patients over the course of the day. They wanted to see if there were patterns. Did patients get better preventive care services at particular times of the day?

    They found the same pattern with almost all doctors. More patients who saw their doctors early in the day received orders for cancer screening tests than patients who saw their doctors at the end of the day. The data: 64% v. 48% for women eligible for breast cancer screenings and 37% v. 23% for men eligible for colonoscopies. These are preventive care services these patients should be getting.

    Similarly, patients who saw their doctors early in the day were more likely to have screening tests than patients who saw their doctors later in the day.

    In a separate study, the researchers detected patterns in doctor’s providing flu vaccinations. They found more vaccinations early in the day. Yet another study found that doctors who saw patients later in the day were more likely to prescribe unnecessary antibiotics and opioids.

    The researchers believe that “decision fatigue” may be one reason why patients appear to get better medical attention early in the day. People tend to make less good choices after they have had to make a lot of other choices. Doctors and patients both may suffer from decision fatigue at the end of the day. Rushed visits at the end of the day when a doctor’s or patient’s schedule is jammed up can also contribute to poorer medical care.

    The researchers suggest a couple of ways to correct this problem. Electronic health records can nudge doctors’ assistants to advise patients to get their screening tests and flu vaccines. A mailed reminder to patients can also be helpful.

    Here’s more from Just Care:

  • Why is your doctor prescribing costly drugs?

    Why is your doctor prescribing costly drugs?

    Recently Peggy, an Indiana woman and reader of this column, sent me a lengthy email about her 94-year-old mother who is rapidly spending down her minimal savings to pay for prescription drugs.

    Peggy didn’t hold out much hope that prices would come down before it was too late for her mom. But she succeeded in lowering her mom’s drug costs and what she learned along the way can be helpful to others strapped by high pharmaceutical bills.

    Her mother is typical of many women in old age who have only a tiny financial cushion to absorb the continual price hikes imposed by the drug makers.  She was raised during the Depression, didn’t work much outside the home, lived in a condo her son bought, and then moved to an assisted living facility almost two years ago.

    The facility’s $3,100 monthly fee plus drug copays bit into her savings, which totaled about $30,000 when she moved to assisted living.  Government benefits earned by Peggy’s father who served in the Korean War, a very small pension from a former employer, and Social Security benefits cover all but about $600 of the assisted living fee. The rest comes from her savings, which now are about half of what they were in 2017.

    While most of her mother’s drug copays and other out-of-pocket pharmaceutical expenses have been manageable, Peggy explained it was the $313 copay for a three-month supply of a well-known, heavily advertised blood thinner a cardiologist had ordered that was the biggest culprit causing her mother’s savings to shrink.

    That was the price her mom was paying when she hit Medicare’s infamous donut hole last year.

    Peggy said every time her mom visited the physician, the doctor told her she was lucky to take the expensive blood thinner instead of the other “stuff”, which he called “rat poison” implying a cheaper drug was inferior, even dangerous.  Peggy said at every visit he told her that she was fortunate to be taking something better.

    Then a family member discovered openpaymentsdata.cms.gov, a database maintained by the Medicare program that reveals the amounts of money pharmaceutical companies pay to doctors in speaking and consulting fees, in research fees and for food and drink expenses. Her mom’s cardiologist had received nearly $80,000.

    Peggy had a bad feeling about the doctor and switched her mom to another physician who kept her on the high-priced drug for a couple months. Then she was diagnosed with anemia, taken off blood thinners and prescribed low-dose aspirin.

    In the meantime, Peggy’s husband had a heart attack and developed a blood clot.  His doctor prescribed a low-cost blood thinner that’s been on the market for years.  She said he’s doing just fine on the “rat poison” disparaged by her mother’s first doctor. His cost: a $6 copay every 30 days.

    For a long time, impartial medical experts have thought that the choice of drugs and devices may be related to payments doctors receive from drug and device companies.

    Since 2014 the Physician Payments Sunshine Act requires drug and device makers to report to the government the payments they make to doctors. The Medicare database is a treasure trove of some 11 million payments to physicians.

    The online publication ProPublica found that drug and device makers gave more than $1 billion to doctors and hospitals from August 2013 to the end of 2016.  Some of them have received payments totaling millions of dollars.

    However, the drug and device database may be one of health care’s best-kept secrets.

    A study published in the British Medical Journal (BMJ) found that only about 3 percent of respondents said they knew if their own doctor had received payments from the medical industry. Unlike Peggy’s family, they had no idea that Medicare’s Open Payments database existed.

    Most Americans don’t readily switch doctors, sometimes – even in the face of overwhelming evidence that the doctors performed badly. The Lown Institute, a Boston medical think tank, reporting on the BMJ study, concluded, “maybe we should be more open to switching doctors based on their relationship with industry.”

    Peggy had some advice of her own: “Do the research. Did the doctor receive money to push the drug? Ask questions?  How much does the drug cost? Is it really a better alternative?”

    This piece was published on Tarbell.org  on 3/27/19 and originally published as part of Rural Health News Service series, “Thinking About Health”, on 3/26/19.

    Here’s more from Just Care:

  • Which medical sources can you trust?

    Which medical sources can you trust?

    A new Pro Publica and New York Times investigative report reveals that many of the country’s leading medical journals are publishing articles by doctors with ties to the health care industry–who may stand to financially benefit from their articles–without disclosing these ties. Because of these potential conflicts of interest, it would be a mistake to trust articles from these medical journals. So, which medical sources can you trust?

    Evidence abounds that individuals and organizations who take money from the health care industry are more likely to speak favorably about the products of the health care companies who fund them than individuals and organizations who are free of these financial ties. Health care corporate money corrupts people, including doctors, in all kinds of insidious ways. But, a large number of doctors take the money and fail to recognize its corrupting influence, let alone to disclose their financial relationships. In the process, they aid corporations in selling more of their products.

    The journals that publish these articles have done a poor job of ensuring appropriate disclosures. Even the highly regarded New England Journal of Medicine has allowed the president-elect of the American Society of Clinical Oncology, Howard A. Burris III, to publish 50 articles without disclosing his industry ties and with a declaration that he had no conflicts of interest. He apparently did not believe that nearly $8 million in pharmaceutical industry research money to his employer, the Sarah Cannon Research Institute, amounted to a conflict.

    Dr. Robert J. Alpern, the dean of the Yale School of Medicine, wrote a positive article in the Clinical Journal of the American Society of Nephrology about an experimental treatment, without disclosing that he was a member of the board of directors of the company that had developed the treatment, that he owned stock in the company, or that the company had paid for the clinical trial.  

    Almost ten years ago the Institute of Medicine recommended ways that health care journals could do a better job of reporting conflicts of interest. But, little has changed at these journals since then. One recent study reported that only 37 percent of articles by the 100 most highly paid doctors by medical device makers reported their conflicts of interest.

    In September, Memorial Sloan Kettering Cancer Center’s chief medical officer, Dr. José Baselga, resigned after an investigative report revealed his undisclosed ties to industry.

    One doctor recently argued in JAMA that researchers who do not disclose their financial ties should face charges of misconduct. Without these disclosures, their research cannot be trusted. They are effectively “falsifying” information. And the International Committee of Medical Journal Editors may decide to recommend that the institutions that hire researchers who do not disclose financial ties look into whether they should be charged with research misconduct.

    For now, you can find trustworthy research on Cochrane, an independent non-profit research institute. You also should seriously question all research that may have been funded with corporate dollars. And, you should beware of medical advice from the mainstream media.

    Here’s more from Just Care:

  • Don’t rely on Medicare Advantage plans to cover care from doctors you can trust

    Don’t rely on Medicare Advantage plans to cover care from doctors you can trust

    There is not a lot of good information available to help you choose a doctor, whether the doctor is a primary care doctor or a specialist. Yet, particularly when you’re ill or injured, it is important to be able to count on good primary care doctors and specialists. Unfortunately, you cannot rely on Medicare Advantage plans–commercial health plans that contract with the federal government to provide Medicare benefits–to cover care from doctors you can trust, let alone from the doctors you want to see.

    A recent Pro Publica report highlights how a Medicare Advantage plan had a neurosurgeon in its network who was critically harming and sometimes killing his patients. Lesson learned: It is a mistake to assume that Medicare Advantage plans ensure the quality of the doctors with whom they contract to provide in-network care.

    It is also a mistake to assume that Medicare Advantage plans offer you the choice of doctors you want to see. A Kaiser Family Foundation report found that more than one in three Medicare Advantage plans offer narrow networks, meaning less choice of doctors and hospitals. They typically include fewer than half of all doctors in a region.

    Medicare Advantage plans also typically cover care at only half the hospitals in their area, according to the Kaiser Family Foundation. What’s particularly troubling is that they too often do not cover care at centers of excellence. Even when there is a national cancer institute in the area, more than 40 percent of Medicare Advantage plans do not cover care delivered in that specialty hospital.

    Fewer than one in four Medicare Advantage plans offer broad networks, covering care in 70 percent of area hospitals.

    It’s critical to do your homework before deciding to join a Medicare Advantage plan. Traditional Medicare may require higher upfront costs than Medicare Advantage plans–particularly for people who need to buy supplemental coverage. But, traditional Medicare offers coverage from a wide range of doctors and hospitals throughout the country; and, you do not need a referral from a primary care doctor to see a specialist. Moreover, with supplemental coverage, you generally have no or small out-of-pocket costs for covered services. Out-of-pocket costs for in-network care in a Medicare Advantage plan can easily reach $6,700 a year for people with costly conditions. And, the sky’s the limit on your out-of-pocket costs if you use out-of-network care.

    No matter which Medicare plan you are enrolled in, be sure to choose your doctors carefully, a challenging task. Keep in mind that hospitals may employ surgeons who are not fit to be practicing medicine. They may not report surgeons who they know to be hurting their patients. And, these doctors may do serious harm.

    Here’s more from Just Care:

  • How much are drug companies paying nurses?

    How much are drug companies paying nurses?

    Not that long ago, Congress required pharmaceutical and medical device companies to disclose the value of their cash and gifts to physicians. Beginning in 2020, StatNews reports that Congress may require these drug and device companies to disclose how much they are paying nurses and other health care providers.

    If the bi-partisan opioid bill passes, which it looks like it will, pharmaceutical companies and device manufacturers will have to make public the amounts they spend on nurse practitioners, including clinical nurse specialists, nurse anesthetists and nurse-midwives, as well as physician assistants. We already know that the drug and device makers spend more than six billion a year on doctors and hospitals for “consulting” services, “speaking fees” and other services. These payments often lead these providers to promote the companies’ products and otherwise look favorably upon the companies.

    We do not have a good handle on how much the drug and device companies spend on nurses and other health care providers. Often it is not the physicians but the nurse practitioners who fill out the prescriptions and make decisions about the drugs and other medical products patients use. So, it is likely that they do receive cash and other gifts from industry.

    Senator Claire McCaskill tried to include a provision in the opioid bill that also would have required the drug and device companies to disclose the amount of money they contribute to advocacy groups. Unfortunately, that provision is not in the bill before Congress. This information would be helpful to know. Many advocacy groups that might appear to be independent, such as most of the large disease organizations, actually receive significant support from industry.

    Pro Publica has a tool that allows you to learn whether your physician takes money from the drug industry, Dollars for Docs.  Kaiser Health News has a tool that allows you to learn about some of the patient advocacy groups that take money from the drug industry, Pre$cription for Power.

    Here’s more from Just Care:

  • Why you might want a female doctor

    Why you might want a female doctor

    Tara Parker-Pope writes for the New York Times that people who have a female doctor appear to have better health outcomes. The evidence from several studies suggest that it could be that both men and women do better with female doctors because they are better listeners. 

    A recent study published in the Proceedings of the National Academy of Sciences (PNAS) finds that female heart patients live longer when treated by female doctors. Female heart patients have greatest risk of death if treated by male doctors, but their risk of death is reduced when the male doctors have worked with female doctors or treated a lot of female patients.

    Researchers looked at over 580,000 heart attack patients in Florida over 20 years. They saw that male and female emergency room patients were less likely to die when the treating doctor was female.

    A 2016 Harvard study had similar findings. The researchers looked at 1.5 million Medicare patients who were in hospital. They found that the male and female patients who had female doctors had a reduced risk of death as well as a reduced likelihood of being rehospitalized after discharge than patients treated by male doctors. While the difference in risk of death was small–around 0.5 percent–if male doctors had the same outcomes as female doctors on the total Medicare population, it would mean 32,000 fewer people dying each year.

    Based on the data, one explanation for better outcomes with female doctors is that they rely a bit more on the evidence when treating patients and hew more closely to the clinical guidelines.

    Researchers at Johns Hopkins Bloomberg School of Public Health conducted a meta-analysis of studies of doctor communications. They found that female primary care doctors do a better job of listening to their patients than their male counterparts. The female doctors spent two more minutes with each patient, which amounts to 10 percent more time with them.

    If you have a male doctor you like, you still should make sure the doctor is a good listener, who takes you seriously. It’s important your doctor pay attention to you, not interrupt you precipitously and show an understanding of your health needs. You also need to be good at speaking up for yourself. Good communications is a very important element of good health care. Doctors will good listening skills are better able to understand symptoms, which can be important, especially for heart patients.

    Here’s more from Just Care:

  • Why you should ask your doctor if you can review your medical records

    Why you should ask your doctor if you can review your medical records

    If you’re like most of us, you’ve never seen the notes your doctors take during a visit. So, it’s hard to imagine what happens when doctors share their notes. It turns out to be a good idea. Here’s why you should ask your doctor if you can review your medical records if you have not done so.

    Today, 120 health care systems throughout the US use “Open Notes,” an initiative in which doctors open their notes to patients. It’s a new and growing trend in this country but a practice that is common in other parts of the world. Now, patient advisory groups in this country are asking doctors to share their notes.

    As Mara Gordon reports for NPR, for doctors, sharing medical records can be a bit of a challenge. For one, they cannot use acronyms like SOB, shortness of breath, or their patients will not be able to understand the notes. Moreover, their patients may question or object to their entries.

    One patient felt her doctor had betrayed her trust when she read in her doctor’s notes that she and her child were not in a good place. The doctor made the entry to remind himself and other doctors that this patient did not have a health care buddy to join her at her doctors’ appointments. But, the patient felt she had shared the information with her doctor in confidence, not to share it with other doctors.

    A study of 105 doctors with 19,000 patients receiving primary care at Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in rural Pennsylvania, and Harborview Medical Center in Seattle, reveals that information is power for patients in the health care arena. OpenNotes allows patients to partner with doctors in conversations about treatment options. Patients who see their doctors’ notes have a better sense of their health issues, and they report better medication compliance.

    Results from another OpenNotes study, letting patients see their doctors’ notes, also show it can help improve patient “satisfaction, trust and safety.” The majority of patients who read their doctors’ notes felt the same about their doctors after reading them, and almost four in ten, 37 percent, felt better about their doctors. No doctors who shared their notes reported ordering more tests or more referrals. And a slim majority said they believed their patients were more satisfied with their care and trusted them more.

    While it’s still not customary for doctors to share their notes with their patients, it is a growing trend. Doctors and nurses believe patients benefit from seeing these notes. They can be more engaged in decision-making about their care. That can mean better health outcomes. And, if there are mistakes in patients’ records, patients can catch and correct them.

    Major funding is now in place for 50 million more Americans to access OpenNotes. We’ve come a long way since the Seinfeld episode in which Elaine struggles without success to see her doctor’s notes. Check out this short clip below.

    And, if you’re wondering whether it’s time to find a new doctor, here are four questions to ask yourself; there are several reasons you need a good primary care doctor.

    Here’s more from Just Care:

  • People shouldn’t need to shop for health care

    People shouldn’t need to shop for health care

    Austin Frakt reports on a new NBER study that finds that only one in 100 Americans shop for lower-cost health care, even when it comes to simple elective procedures like MRIs. Rather, they go where their doctors direct them even when they could save money going elsewhere. The study does not consider people’s desire for quality care.

    Last September, Kaiser Health News reported on similar findings published in Health Affairs. While comparison shopping could lower your out-of-pocket costs for some tests and procedures, here are six reasons why people should not need to shop for lower-cost health care. Note that people with traditional Medicare do not need to shop for health care to save money; it’s only people with commercial health insurance.

    1. First, continuity of care is important for better health, and we should not be moving from one doctor to another based on the cost of a particular treatment.
    2. Second, as a general rule, when we visit the doctor, we often receive a battery of services that we could not have predicted. So, even if our doctor charges more than another doctor for the treatment we plan to receive, the other doctor may provide additional services we could not predict that end up costing us more.
    3. Third, all doctors and hospitals are not created equal. So, paying less may not mean saving money. And, it could mean getting poorer care. At this juncture, we still have little clue about differences in health care quality among doctors or hospitals. It’s smart to see doctors who come highly recommended, because they have experience and a good reputation for treating people with your condition. Finding these doctors is not always easy, but if you can find them, paying more upfront, could mean paying less later on. (Here are some tips for choosing a doctor.)
    4. Fourth, 60 percent of hospital spending is for non-elective services, for which we are unable to shop around, be they emergency services or services in hospital over which we have virtually no control. So comparison shopping is out of the question. We are saddled with bills at whatever level the hospital, in collaboration with our health insurers, is able to set them.
    5. Fifth, many people have cognitive impairments and other functional limitations that prevent them from comparison shopping. It’s wrong for our health care system to penalize them.
    6. Sixth, most of us are busy working all day, without the time or flexibility to shop around for lower-cost services.

    Unlike Medicare, our current commercial health care system permits irrational pricing and price-gouging and offers people very little information to make informed health care choices, even when they have the time and wherewithal to make them.

    With improved Medicare for all, we wouldn’t need to worry that our doctors and hospitals were gouging us. Prices would be set, as they are with Medicare. And, in a humane health care system, we all would be able to afford needed care. Traditional Medicare comes closest to that system, though you need supplemental insurance coverage to budget for your care.

    Here’s more from Just Care:

  • There may soon be a female Democratic doctor in the House

    There may soon be a female Democratic doctor in the House

    Erin Mershon of StatNews reports that, over the last almost 60 years, there have been 49 physicians who have become members of Congress. Of that group, only a few have been Democrats and only two have been women. None has been a Democrat and a woman. A grassroots organization is working to change history and put some female Democratic doctors in the House and Senate.

    A group of 8,000 Democratic doctors who are women, led by Dr. Ramsey Ellis, is supporting eight female Democratic physician candidates for Congress this year. Dr. Ellis was a grassroots organizer for Hillary Clinton. Now, she is heading Physician Women for Democratic Principles in order to help ensure there are more women and more physicians governing our country and leading the public debate on health issues.

    Imagine how Democratic physician women policymakers might have shaped and improved on Medicare, Medicaid and the Affordable Care Act had they been our representatives in Congress when these major pieces of legislation were being debated. Only two Republican female physicians have ever served in Congress, Reps. Nan Hayworth of New York and Shelley Sekula-Gibbs of Texas. Today, there are 15 physicians in Congress, all are men and 13 of them Republicans.

    With one third of the physicians in the US female, it seems reasonable that five physicians in Congress would be female. Similarly, about half of physicians are Democrats. If the physicians in Congress reflected the national pool of physicians, seven or eight of them would be Democrats, not just two of them.

    Stat interviewed several Congressional candidates who are physicians to understand why they were running for office. Their primary reason: To solve the health care problems presented by the Affordable Care Act. Candidates who are members of Physician Women for Democratic Principles want to strengthen the ACA and Medicaid. Not surprisingly, Republican physician candidates want to repeal the ACA and slash Medicaid funding.

    Here’s more from Just Care:

  • What to do if your in-network doctor goes out of network?

    What to do if your in-network doctor goes out of network?

    It used to be that our health care system valued continuity of care. Insurers covered care from virtually any doctor or hospital, and we could stick with our doctors over our lifetimes. And, that’s still the case with traditional Medicare. But, if you’re in a Medicare Advantage plan or virtually any other health plan, you are at risk of losing that continuity of care if your doctor pulls out of the network or you’re forced to switch plans. What can you do if your in-network doctor goes out of network mid-treatment?

    When you’re mid-treatment, it can be critical to stick with the doctors who have been treating you. They know your condition through and through. They know which treatments work and which don’t. And, you and they have developed a bond, a trust, that can be as valuable as the medical treatments you’re receiving. But, the cost of out-of-network care from the doctors you know and trust, can be astronomical. So here’s what to do:

    • If you are enrolled in a Medicare Advantage plan, call your State Health Insurance Assistance Program for help. You can find the number online at www.eldercare.gov or by calling 1-800-677-1116. You may be able to get your health plan to continue to cover your care from the doctors who have been treating you. Also, the Centers for Medicare and Medicaid Services (CMS) may grant members of a Medicare Advantage plan the right to switch plans as a result of a “significant” change in a health plan’s provider network.  CMS does not define “significant.” But, according to Kaiser Health News, it has been granting this right to some health plan members who have seen changes in their provider networks.
    • If you are not yet enrolled in Medicare, contact your state department of health or department of insurance to find out your rights. Some employers and some state laws allow–or are considering allowing–people with chronic, acute or terminal conditions to stick with their doctors for as long as a year (and longer for terminally ill patients), even if their doctors are no longer in their networks. Their new health plans must cover care from their providers so long as those providers are willing to accept the health plans’ payment rates.

    Here’s more from Just Care: