Vol. 229 March 15, 2020 Beware the Ides of March

March 14, 2020

In Shakespeare’s play Julius Caesar, a soothsayer attracts Caesar’s attention and tells him:
            “Beware the ides of March.”
Caesar demands:

            “What man is that? Set him before me, let me see his face.”
When the soothsayer repeats his warning, Caesar dismisses him, saying:

            “He is a dreamer; let us leave him. Pass.”

When I started writing this blog a couple of days ago I was going to call it “A Politically Incorrect View of the Coronavirus” because I wanted to say that the virus will not be contained, that it will very shortly be community-wide,  and that we should marshall our efforts at monitoring, protecting, and treating the high risk people. But today, that is no longer “politically incorrect.” Many of our civic leaders and our leading medical scientists (Anthony Fauci, MD is my most famous medical school classmate, Class of ’66 Cornell Medical College) are now labeling COVID-19 as “community spread” , i.e. not containable through contact tracing since the sources are so numerous that we can not pinpoint a source, like the common cold and the flu.  We are now “mitigating” COVID-19, not “containing” it; just trying to “blunt the peak” on the graph of numbers of infected people.

The stakes are higher for COVID-19 (the name of the disease) then for the seasonal flu because it is more deadly to certain segments of our population. The name of the actual virus that causes COVID-19 is SARS-cov-2, and that is a real clue as to the nature of this virus given our experience with previous coronaviruses.

The good news is that the death rate is not expected to be as high as the past two coronavirus epidemics SARS (10% death rate) and MERS (35% death rate). SARS originated in Southeast Asia bats and civets (small, cat-like mammals) . MERS originated in Middle Eastern camels. SARS-cov 2 has been attributed at various times to be transmitted from bats, snakes, and now, pangolins (anteater-like reptiles with scales); all animals available in Southeast Asian “wet markets” of live animals. There is no evidence that implicates domestic dogs and cats as vectors for the virus. There is also no confirmed evidence that a mother can transmit it to her newborn during delivery.

As the number of identified cases increases (the denominator) we were hoping that the calculated death rate would decrease since the actual calculation =  #of deaths/#of cases. It appears now that the death rate could be between 1.6% (University of Bern, Switzerland estimate based on China’s CDC data) to 3.4% (WHO’s estimate from selected outbreaks), clearly at least 10 times the death rate for seasonal flu (0.1%). However, South Korea has the largest number of tested cases with cold symptoms (140,000) and their death rate is 0.6%. Of even more interest, of those 140,000 South Koreans with cold symptoms who were tested, only 4% were positive for SARS-cov-2, i.e. 96% of those with symptoms were infected with the flu virus or some other non-coronavirus.

The bad news is that about half of those in high risk populations who develop significant symptoms will require hospitalization.  80% of those hospitalized will be so sick that they will require ICU care for a number of days. The people at highest risk of requiring hospital-based medical care are those with underlying chronic diseases, called co-morbidities, like congestive heart failure, hypertension, diabetes, chronic obstructive pulmonary disease (COPD), chronic kidney disease, and those over 80 years old (a stage of life, NOT a co-morbidity thank you!).

Nearly 90% of COVID-19 cases have been in people between 30-79 years old. Less than 1% were in children under 9 years. Despite this fact that children are not the primary vector for this virus (unlike influenza), we are closing many elementary schools. In the swine flu epidemic of 2009 we closed 1300 schools for 7-14 days because of evidence that children were primary vectors for its spread. Despite the run on toilet paper resulting in empty market shelves, diarrhea is not a common symptom of the disease.

If COVID-19 is going to be as common as a cold or the flu, but has a lethal potential for select groups of people, how do we triage the people who think they have it while we wait for the coronavirus nasal swab test to become widely available?
The simplest triage diagram has just three branches in the decision tree:

  1.  If you have cold symptoms (but remember a runny nose is not a common symptom of COVID-19) — treat it like a cold with rest, fluids, and decongestants and try not to spread it to other people. (YOU wear the mask, not everybody else)
  2. If you have a fever over 101 and a cough — go see your primary care provider.
  3. If you have the above and feel weak or tired and are short of breath — the PCP may send you to the hospital.

How do people with COVID-19 die?  In the severe stage of the disease (called ARDS- Adult Respiratory Distress Syndrome) respirator machine support (a ventilator) in an ICU is usually needed. Another cause can be an overwhelming secondary bacterial pneumonia and sepsis later in the disease (similar to deaths caused by the flu) and, unexpectedly, some deaths have occurred without pneumonia or severe lung inflammation, particularly in patients with very high blood pressure or those on kidney dialysis.

Watch out for advertisements of fraudulent cures or “protections” from COVID-19. The FDA has formally warned 7 companies, including the Jim Baker Show, that their advertisements for “silver solutions” to kill the virus must stop. There is no evidence that solutions of colloidal silver can kill the virus. Vitamin C is no help either. If Purell with alcohol can kill the virus some people think that alcohol by mouth could kill it. Unfortunately alcohol does not kill the virus. Soap and water or bleach does. Do NOT gargle bleach.

The AMA has responded quickly to the epidemic and filed a request for a rush approval of a CPT code for COVID-19 testing (necessary for insurance reimbursement, hence maybe the urgency of the request). AMA President Patrice A. Harris, M.D., M.A. has said,  “By streamlining the flow of information on novel coronavirus testing, a new CPT code facilitates the reporting, measuring, analyzing, researching, and benchmarking that is necessary to help guide the nation’s response to the public health emergency.” Also as I said, health insurance companies will be asked to pay for the test.

Two surveys released this week show that the Corona beer brand is suffering from a negative buzz. A 5W Public Relations poll of 737 beer drinkers in the U.S. showed that 38% of them wouldn’t buy Corona “under any circumstances”, and another 14% said they wouldn’t order a Corona in public.  However, Corona beer and seltzer sales actually increased in February.

 


Vol. 228 March 1, 2020 Physician Speeders, Roundup Off One Hook, and Don’t Shoot the Cows

March 1, 2020

“Many people believe medical specialty choices are associated with certain personalities
leading to driving behaviors, such as fast driving, luxury car ownership . . .
and leniency by police officers.”

 


“Do As I Say, Not As I Do” –  the physician’s mantra

A study of 14,560 speeding tickets issued to 5372 physicians in all specialities between 2004 – 2017 in Florida revealed that the average speed of the ticket receivers was 15-16 mph above the speed limit. The 25% of  MD tickets issued for speeding 20 mph over the limit were labeled “extreme speed” in this study; about the same percentage as in the general population of non-MD drivers.  “Extreme speeding” was most common among psychiatrists (31%), but otherwise similar (22-25%) across specialties. Among physicians who received a ticket for speeding, cardiologists were more likely to be driving luxury cars (41%), while emergency physicians, family physicians, and pediatricians (of course) were less likely to be driving a luxury car (20%). 11% of non- physician speeders drove luxury cars. Leniency by officers (“writing a ticket with a lower fine”) towards physicians pulled over for speeding was common, but did not vary by specialty, and was similar between physicians and non-physicians. Police tended to be more lenient to Ob-Gyn physicians, older, and female drivers.

The speediest driver was a general internist clocked at 70 mph.

Quite frankly, I am surprised by the low speeds of the ticket receivers, but not much else in this study. I am certain that the ticketed speed levels would be way higher on Route 3 to Boston any morning of the week. The authors did conclude their paper, I assume with tongues firmly planted in cheeks, with “the connection between the driving behavior of physicians and patient outcomes remains unknown.” (1)

Roundup May Be Off One Hook, At Least
A sharp decline in Monarch butterflies was noted around 2005 and in a 2012 paper the idea that milkweed loss in  Midwestern U.S. corn fields was the cause. The caterpillar stage of the butterfly requires the milkweed to develop. Each year Monarch caterpillars grow up on the milkweed between those rows of corn, and then the butterflies migrate all the way down to a specific forest in Mexico for the winter.  Our corn crops, genetically modified to resist Roundup, were thriving, but the Roundup was killing the milkweed. Hence, the story went, the Monarchs are declining due to Roundup. The evil and perils of Monsanto’s Roundup became a familiar story to us.

Further studies in 2017-2019 using satellite imagery, analysis of chemicals in butterfly bodies , and more accurate counts revealed that only 2 out of 5 Monarchs came from those cornfields and that butterfly counts were stable in the Midwest summer but were declining in the Mexican winter forest. That suggested strongly that something was killing the butterflies en route. Maybe it wasn’t just the Roundup in the corn fields. Even the original “milkweed-loss” proponent backed off a bit. Currently a major study by 120 people monitoring 235 sites along the migratory route is underway to identify what is now considered the multi-factorial causes of Monarch decline. Meanwhile, the federally preserved wildlife area in the U.S. has been reduced by nearly half since 2007, and the Mexican winter-home forest has been reduced by surrounding logging operations and climate change to the size of a soccer field. Science, if not the Monarch butterfly, marches on. (2)

Don’t Shoot the Cows . . . Just Reduce Their Antibiotics.
Carl Sagan was probably the first to point out that methane gas in our atmosphere was really the only sign of true life on earth to any observer from space. We later were told that the chief source of methane on earth were cow farts, and that methane was a greenhouse gas (“bad”) enhancing climate warming. Of course, we all know that manure is an excellent fertilizer. It helps a lot of good green things to grow; good plants that grab carbon dioxide (another “bad” greenhouse gas) out of the air and trap it in organic matter. Soil stores twice as much carbon dioxide as the atmosphere can. Another plus for cows and their solid output.

A curious, enterprising,  and probably not-so-social graduate student measured the amount of carbon dioxide released into the air by different mounds of cow manure over several months. It was a sophisticated, but understandably messy, project whose methodological details are not important here. He found that the manure from cows that had not been given antibiotics released less carbon dioxide into the air, and had an overwhelming positive effect on plant growth. The manure from cows treated with antibiotics released much more carbon dioxide, and resulted in soil much less beneficial for plant growth. In fact, the type of antibiotic given to the cows made a big difference; up to a two-fold increase of carbon dioxide release by one type of antibiotic. Since U.S. livestock contributes 13 million kilograms of antibiotics a year to the environment, it is not exactly a moot point. Picking a different antibiotic might enhance the carbon-capture benefits of manure fertilizer which could help mitigate some climate change. (3) For another unintended consequence of antibiotics on wildlife check out the story of diclofenac and declining vultures in India.

References:
1. British Medical Journal, “The Need for Speed; Observational Study of Physician Driving Habits”, Harvard Medical School, Dec. 18, 2019
2. Scientific American, What’s Happening to the Monarchs, March 2020
3. Scientific American, Manure Problems, March 2020


Vol. 226 February 1, 2020 Current Controversies . . . other than impeachment.

February 1, 2020

The Battle of the Best Diets
Low-carb? Low fat? Keto? Intermittent fasting? Paleo? Gluten-free?
“The science of nutrition is confusing and contradictory. How are we supposed to figure out what to eat?”

A Stanford nutritionist’s study of 600 people, half on low carb diet and half on low fat diet for a whole year, not only found no difference in weight loss between the two groups, but also revealed wide variations in weight change in individuals within each group. Some members in each group actually gained 10 to 20 pounds! Furthermore the researches had no success in predicting which individuals would do better on one or the other diet.

“With diets, there are too many dry drunks around – people who have found a way to drop some weight and now want to force everyone else to see the light.” The only consensus about the best diet is:
1. 
reduce or eliminate added sugar.
2. reduce or eliminate refined grains, processed carbs, and processed meats.
3.
eat as many green, leafy vegetables as possible (avoid white potatoes).
(Neil Swidey, Boston Globe magazine, August25, 2019, pg. 17-20)

Vaping Illness Epidemic
“In 2019 so far there have been six deaths in the U.S. connected to vaping, as compared with more than 10,000 gun-related deaths. That can mean only one thing: EXPECT IMMEDIATE LEGISLATION RESTRICTING VAPING.”
(
Brian Pomodore, Letter to the Editor, Bos Globe September 13, 2019)

Nap for Heart Health
A Swiss study tracked 3,462 healthy adults for five years and found that those who took a nap once or twice a week had about half the risk of a heart attack or stroke. More frequent naps and naps over an hour provided no additional protection. The researchers admit they have no idea how napping provides that benefit, but speculate that it might be “stress relief”.
(Nadine Hauser, NBCNews, September 2019)

Vitamin D Supplement Does Not Strengthen Bones
Canadian researchers studied 311 healthy adults from the “land of lesser sun” (Calgary and Alaska) taking vitamin D supplements daily for three years and discovered that supplemental Vitamin D actually was associated with a decline in bone density: 1.2% decrease in those taking 400 units daily, 2.4% in those taking 4,000 units, and 3.5 % in the 10,000 units a day group. (The official Canadian recommendation for Vitamin D is 600 units a day)
(Burt, JAMA 2019 August 27;322)

Is Dark Chocolate Good For Your Heart?
The Mayo Clinic says that the beneficial ingredient in chocolate is flavanol which which acts as “an antioxidant that can reduce cell damage implicated in heart disease, helps lower blood pressure, and improve vascular function.” The problem, of course, is to get the flavanol benefit you would have to eat about seven average chocolate bars a day! The flavanol in cocoa is actually bitter and has to be masked with fats and sugar to make delicious-tasting  commercially available chocolate; consumption of which can lead to weight gain  and increased risk of associated diseases. Many of the “favorable studies” of the effect of chocolate have been industry-funded so “should be taken with a grain of salt, , , and not another square of chocolate.”
(Unsavory Truth: How Food Companies Skew the Science of What We Eat, Marion Nestle, NYU Professor of Nutrition and no relation to the candy maker, Bos Globe 10/27/19, A28)

Does Smartphone Screen Time Effect the Sense of Well Being?
Not really. A rigorous meta-analysis of 226 studies involving 275,000 people showed no significant link between depression and suicide and increased screen time. There was a tiny effect; about the same effect as wearing glasses. Many studies were based only on “time spent onscreen” with no data on “screen content”. It seems clear that heavy use of social media can be associated with harmful effects, but concern over average use of social media technology is overblown. One must remember that “association” does not prove “cause and effect”. Radio, video games, television, and even comics have caused consternation in the past about the harmful effects of technological innovation. in fact, Socrates bemoaned the new tradition of writing for fear it would diminish the power of memory. He was wrong about writing, but was prophetically correct about cell phones and our memory of phone numbers.
(Lydia Denworth, Scientific  American, November 2019, pg. 49)

Is Reading Printed Books with Children Better Than Reading Digital Books?
Yes. Reading printed books with children increased the mutual, reciprocal interactions between parental reader and the child when compared with reading digital, tablet-based books. Control and intrusive behavior on the part of both parent and child were decreased when reading printed books.

Is Red Meat Bad For You?
The Annals of Internal Medicine just “ corrected” (retracted) its publication of a 2019 study saying that most people could continue eating red and processed meat at their average consumption level without bad health effects. That report went against the prevailing scientific view that red or processed meat consumption is bad for you because of high amounts of saturated fat. The retraction was caused by the discovery that the principal author failed to disclose that he had received a sizable grant from Texas A&M AgriLife. It raised questions about conflict of interest and the researchers’ agenda “to make saturated fat look benign or beneficial”.

Benefits of Probiotics?

 

 

 

 

 

 

Enuff said.


Vol. 225 January 15, 2020 Hubslist’s 2019 Recap – Part II

January 13, 2020

Click on date to read the whole blog.

June 1: Juuling and Schooling  -All vaping solutions contain nicotine despite the label that says “contains no nicotine”, or even more cleverly “contains no nicotine tar”, which means of course “no tar”. Juul (jewel) is the most successful vaping company, so successful that it has become a verb, as in “Do you Juul?, Lets Juul.” Tobacco companies are investing in vaping because they know that the younger a person is when nicotine is introduced the more likely they will become a life-time tobacco user.

June 15: Hospital Readmission Reduction Program – At first blush it looked like this Medicare cost reduction program actually worked because “preventable” readmissions decreased for cardiac disease and pneumonia, but further analysis revealed five reasons why that wasn’t true.

July 1: Public Opinion About High Health Care Costs –Two-thirds of the U.S. public thinks that reducing health care costs is a top priority for both President Trump and Congress in 2019.  The expert opinion consensus is that the over $500 Billion (yes, that’s a “B”) cost of “unnecessary services”, “inefficient delivery” , and “excessive administrative cost” is a significant cause of the high cost of our health care, but only 23% of public poll respondents thought so.  The U.S. remains unique as the only developed nation lacking universal health care insurance for its people.

July 15: Tidbits for Summer Cookouts Fitbits- People walking only 4,400 steps a day (not the recommended 10,000 steps a day) had a lower “premature death rate”. Where did the 10,000 steps a day target come from?— a 1960 marketing campaign by a Japanese pedometer manufacturer that recognized that the Japanese character for 10,000 resembled a man walking! Screen Time – Research by Nielsen found that Americans aged 35 to 49 used social media 40 minutes more each week than millennials.  A researcher interviewing elementary school children uncovered a lot of complaints from the kids about prying their parents away from their screens. “Parents”, she sighed, “are the worst.”

August 1: Parenting “Unconventional Wisdom” – Breast feeding – The benefits of breast feeding infants are generally found in studies of mothers with a higher IQ and in a higher educational and economically class than non-breast feeding mothers. “So what is the real cause of breast-feeding benefits?” Sleep training – Many studies of sleep training show sizable improvements in maternal depression, family functioning, and no negative effects on infants. Working Moms – There is very little data about the pros and cons of mothers working outside the house except for the evidence supporting longer maternity leave which is beneficial to mother and infant in those first months.

September 1: Understanding Medical News About Famous People What is the prognosis for Andrews of the Patriots (pulmonary embolism) and Ginsburg of the Supreme Court (multiple cancers)? It is relatively save to say that Andrews will not play NFL football this season and that Ginsburg, a champion statistical outlier for 86 years, will probably be sitting on the bench when the Supreme Court resumes in October. After that, who knows? Doctors may guess, but they really don’t know either.

September 15: Vaping and Fatal Pneumonia – There are so many additives in vaping solutions that it is not absolutely certain that vitamin E acetate oil causing lipoid pneumonia is the culprit, but some of the counterfeit vaping solutions used by recent respiratory-distress patients contained more than 50% vitamin E oil!  Who would guess that we would ever say, “It appears to be much safer to just smoke a joint!”

October 1: Vitamin supplements – Here’s more evidence-based skepticism about the benefits of both vitamin C and vitamin D supplements. I have cautioned against vitamin E . . .at least the inhaled form. Is there a vitamin F supplement to continue my alphabetic progression? Yes.  Vitamin F is an outdated term for omega-3 and omega-6 fatty acids,  but I think I’ll let that subject “sleep with the fishes” for the moment.

November 1: Vaping Disease, Medical Marijuana, and CBD –  Pathologists from the Mayo Clinic in Scottsdale, Arizona found no expected microscopic hallmarks of lipoid pneumonia in patients with vaping lung disease, but did find a chemical “burn” or reaction to a toxic gas. Medical marijuana resulted in minimal decrease of pain, little improvement in sleep, and virtually no effect on anxiety or depression. Despite the fact that patients were told by the sellers that there was CBD in the purchased product one third of the study patients had NO detectable CBD in their urine!

November 15: Climate Change Deja Vu from 1996 – “We are still a long way from stabilizing the global climate, a far more complex challenge than repairing the ozone layer. Even with quick action, some greenhouse gases will linger in the atmosphere for centuries. Still, close observers note that a climate of hope has crept into negotiations recently. Insurance companies, small island nations, and others with major interests in a stable climate have re-shaped the diplomatic playing field. Finally, the time for serious policymaking may be at hand.” (1996 Report)

December 1: Top 10 Dangerous Toys and Hazardous Vaping Pods – Though not lethal, yet, if ingested by toddlers the concentrated pods of marijuana for vaping devices can cause significant ICU stays for them. The even more concentrated forms of MJ in edible “dabs” (up to 90% THC) can really cause trouble. Ingesting the concentrated nicotine in vaping pods can actually be lethal to toddlers.

December 15: Changing My Medicare Health Insurance Plan Is Just like Placing a Bet  –  “Youse pays your money and youse takes your choice.” Or as one of my medical student buddies said when we were a lot younger, “Life insurance? You lose (die), you win ($). You win (live a long life), you lose ($).” Did I make the right choice in changing plans?  I’ll know in a year if I won the bet, or the house did.

 


Vol. 224 January 1, 2020 Hubslist’s 2019 Recap – Part I

January 2, 2020

Click on date to read the whole blog.

January 1: Hemp, MJ, THC, and CBD . . . Wha.a.a.a?     Hemp and marijuana are both cannabis plants. But they are not the same. CBD is being actively promoted for its “wellness” effects.The largest marijuana-producing company in Canada (Canopy) is planning to distribute hemp-derived CBD-infused “sports” beverages in the U.S.  Vogue magazine calls CBD wellness products one of the top 10 trends in 2018. The stock price of Canopy January 2019: $28.11  Stock price a year later:$19.28. The 2019 high: $52.70

January 15: Updates
In the U.S. both the average man and the average woman gained 24 pounds from 1960 to 2002. The latest independent estimate of immigrant children held in 9 U.S. centers is 15,000. Most of the children are held for 104 to 240 days in large centers with up to a thousand children. Daily low dose aspirin provided NO benefit to the elderly against all types of deaths, cancer-related deaths, dementia, physical disability, or cardiovascular events.

February 1: Things That Threaten
Repeats
from 2010 include: Watching TV increased chance of a cardiac death by 18%; Tanning Booths increased chance of malignant melanoma by 75%; Cell phone use in cars increased risk of accident by 400%; Toy injuries caused 251,000 visits to  ERs in 2018; Sleep apnea increases the chance of a driving accident by about 100%; No evidence for Brain cancer from cell phones in 2010, but i 2019 a Swedish study found that very heavy cell phone users had an increased incidence of acoustic neuroma (non-cancerous growth on hearing nerve); Many herbal supplements for sexual enhancements, body building, or weight loss had incorrectly labeled ingredients and/or unlabeled contaminants.
“New” threats: Gun Violence – Two previous blogs (2015 and 2018)  compared the story of the frog complacently sitting in the gradually boiling water with our pace of achieving gun safety. (“By Degrees”, Markerelli.com) Climate Change (try to stifle your yawn here) “Climate change is already adversely affecting human health and health systems, and projected climate change is expected to alter the geographic range and burden of a variety of climate-sensitive health outcomes and to affect the functioning of public health and health care systems.” (NEJM editorial)

February 15: Valentine’s Day  Using the Arons Protocol of 36 questions caused a journalist to promptly fall in love on one of her dates, and she wrote it up, “To Fall in Love With Anyone, Do This”, her most widely read column according to the NY Times.

March 15: Jargon Update:
Elderly” is OUT – Few “older adults” want to be called “elderly”. “Seniors” is acceptable, even though it implies that those under 65 are “juniors”. “Perennials”, in contrast with “millennials”, implies that one may not need to be replanted every Spring. The Boston Commission on Affairs of the Elderly changed its name to the Age Strong Commission, becoming a candidate for “Best New Politically Correct Term of the Year” award.
“Organic”, “natural”, “healthy” – All still remain relatively undefined by the U.S.  Department of Agricultural, so any company can put those labels on almost any food.
“Moral injury” is a substitute term for “burn out” of our physicians.  “The increasingly complex web of medical providers’ highly conflicted allegiances. . . results in the moral injury . . . of not being able to provide high-quality care and healing in the context of health care. . . . Electronic health records track productivity and business metrics, but significantly reduce face-to-face interactions.”
Sexual orientation is “who you go to bed with. Gender is who you go to bed as.”
“Safe-school officers” are combat veterans wearing body armor while carrying a 9mm Glock handgun and a sawed-off automatic rifle roaming the halls of the Manatee School for the Arts in Palmetto, Florida. The principal hired the combat veterans because “I don’t want this to be the first time they’ve had someone shooting at them.”

April 1: Alzheimer’s: There’s an App For That – Dr. Atul Gawande, CEO of Haven, the new healthcare-innovation company, announced that their first “new model of care” is an app for patients with Alzheimer’s. The app’s name is “FIGAWI”, after that ancient Indian tribe that gets lost in the fog on the way to Nantucket from Cape Cod every Memorial Day weekend . I’d give you the website where you can download it, but I can’t remember it.

April 15: A Modest Proposal to Eradicate Measles: Measles was declared “eradicated” in 2000. Since January 1, 2019 the U.S. has had 465 cases in 19 states. One way to get things done in America – to effect change – is to sue somebody—your spouse, your neighbor, the police, the National Enquirer, the President, whomever. We should sue an anti-vaxxer, the parent of an unvaccinated child who spreads measles to other people for civil damages!

May 1: Extend the Modest Proposal to Tetanus: Oregon reported its first case of tetanus in thirty years in 2017. An unvaccinated 6 year old developed tetanus and the total bill for his care exceeded $1 million. What if the parents of the Oregon tetanus-afflicted child were sued by the tax payers in Oregon to “recover” those medical care costs that they paid for?

May 15: Fake nutritious food- Foods that sound healthier than they really are include: veggie sticks, rice cakes (arsenic?), spinach wrap, protein powder, turkey burgers, bran muffins, instant oatmeal, and granola. Most have high sugar or high salt or both.

Part II in two weeks.

 

 


Vol. 223 December 15, 2019 A Health Insurance Premium Is Just A Bet

December 15, 2019


“Private insurance is a defective product. Their business model is based on collecting premiums, avoiding sick people, and denying coverage for expensive services whenever possible. Insurers boast in their reports to shareholders about their low “medical loss ratio” (MLR), the low share of premiums they pay for for care.”
-David Himmelstein, MD and Steffie Woolhandler, MD,
Hunter College and Harvard Medical School

I have been covered by Medicare for 15 years and have no complaints about it. Medicare has been “berry, berry good to me”. For 15 years I have also purchased a Medicare Supplement policy and a Part D prescription drug coverage policy from a private insurance company. The combined premium for those two private insurance policies is about $1700 a year. This year, having been attracted by the ads for Medicare Advantage HMO plans providing the same coverage for zero ($0) premiums and being a low utilizer myself  of medical services and prescription drugs, I decided to explore joining a zero premium Medicare Advantage HMO plan.

How hard could that be? I like my primary care physician and the few specialists I go to; my local hospital and the tertiary hospitals I favor all participate in Medicare Advantage plans;  I am a physician, a retired medical care administrator, and I have actually served on the board of a health insurance company so I am familiar with insurance jargon; and I don’t have diabetes, cardiac disease, or chronic pulmonary disease, so I suspect that I will look like a good candidate to an insurance company.  I anticipated that I could readily figure out if joining a Medicare Advantage HMO would save me money while providing the excellent coverage I have grown accustomed to.

It was NOT easy.

I focussed on only two private companies, Blue Cross and Harvard Pilgrim, both reputable companies in Massachusetts. I ignored the other companies that sent me all sorts of spam and junk snail mail during the limited enrollment window. So, why was it not so easy to figure out?

First, I needed to confirm that all my doctors participated in any plan I joined , i.e. would they be reimbursed by either company? When I called my doctor’s office to do that I was told to call the insurance company. Two phone calls later (one to each company) my physicians’ participation was confirmed. The good news was that I avoided lengthy “holds” on the phone calls since during the open enrollment window (deadline of December 7) both companies had an abundance of marketeers ready to answer my questions. My second phone call to both companies was to confirm that my specific prescription medicines were in their formulary, i.e. their cost would be covered. Some of my medicines were in Tier 1 and some in Tier 2 (different copays for each Tier), and there were slight differences between the companies. The short news here is that none were in Tiers 3 and 4 (the much higher copay Tiers), but two of the drugs would need “pre-authorization” of medical necessity by my physician (actually the same requirement as my current policy).

So far so good, but, of course, one never knows what medications you might need in the future, so the first whiff of being in a gambling game wafted into my mind. When I then delved into the morass of copays, deductibles, and co-insurance percentages (all of which are different kinds of “out-of/pocket” payments by the subscriber, i.e. i n addition to the premium ), I really felt like I was in front of a roulette wheel or at a craps table. I didn’t feel at all like I was playing Black Jack where the odds are so well known that  books have been written about how to “beat” them.

In each plan some physician visits had a $20 co-pay, some had $40 a visit. A Medicare-approved outpatient surgery could have a $150 or a $250 copay. An “inpatient” hospital stay was $150 or $360 a day for the first 5 days (no information available on “observation status” or “ER overnight stay”  which are other kinds of hospital stays). Diagnostic X-ray had a $20 co-pay unless it was for an MRI or CT scan and then it was 20% “co-insurance” which means, I think, I would pay 20% of whatever the MRI charges are (I assume both facility and physician charges are counted). One plan dropped the MRI 20% coinsuranse for a straight $200 copay. Chemotherapy medications and “Other Part B Prescription Drugs” (drugs ordered and administered by a physician ) also had 20% coinsurance payments.

Reeling from this game of variable numbers, which I am not good at (remember I’m just a pediatrician), I then went on to compare some of the “perk” benefits like coverage for eye exams, eyeglasses, hearing exams, hearing aid purchase (from $699 to $999 copay), selected dental, Over-the-Counter allowances, and finally the “wallet benefits” (reimbursements for “qualified health and wellness benefits”). Some were included in one company’s policy and not in the other. There were different copays and different “annual limits” between perks and also between companies. . . . Ahh, “annual limits” ??

So where did I place my bet? I decided it was worth saving $1700 premiums a year to go with a Medicare Advantage Plan with a $0 premium for continued Part A and Part B Medicare coverage while also providing prescription drug coverage and Medicare supplement coverage.

Which of the two private Medicare Advantage HMO plans did I choose? — The one with an annual Out-of-Pocket Limit of $4500 rather than the almost identical . . . I think . . . plan with an Out-of-Pocket limit of $6700. I figured that if I bet wrong on all those deductibles, copays, coinsurances, medication eligibilities, and hospital inpatient days, or if my good health odds really tanked, I would lose $2200 less while trying to save $1700. At least I wouldn’t lose the whole pot. Illness and medical bills contributed to two-thirds of all personal bankruptcies in 2007 (three quarters of those medical debtors had private health insurance).

So, as one saying goes, “Youse pays your money and youse takes your choice.” As another saying goes, this one from one of my medical student buddies when we were a lot younger, “Life insurance? You lose (die), you win ($). You win (live a long life), you lose ($).”

So, did I make the right choice?  I’ll know in a year if I won the bet or the house did.


Vol. 222 December 1, 2019 Annual List of Hazardous Toys

December 1, 2019

World Against Toys Causing Hazards (W.A.T.C.H.) has just published  its 2019 “Top 10”  list of most dangerous toy “nominees” in time for holiday buying. (I’m not sure an actual vote is ever taken, but they still call them “nominees”) . As in the previous 47 years the choking hazards of small parts, the presence of long strings or wires with strangulation potential, and potential eye injuries from flying parts caused several toys to be listed. Here is a summary of some of the more interesting toys . Pictures of the toys and more details are available on the WATCH website.

NERF Ultra One– “furthest flying NERF dart ever” ; 120 feet – potential eye injuries
YETI – a”cuddle” toy with easily pulled out long hairs that can be ingested or cause ligatures around fingers, toes, and other protuberant organs.
NICKELODEON FROZEN TREAT SLIME – Made with a variety of hazardous chemicals, it has a DO NOT EAT label on the package, but looks like mint chocolate chip, berry smoothies, and soft serve.

 

 

 

 

 

 


ANSTOY ELECTRIC TOY GUN-

(no further comment necessary on this realistic looking submachine gun)

 

POWER RANGERS ELECTRONIC CHEETAH CLAW– “Use the strength of the claw to take on enemies. . . but don’t hit or swing at people.”

WATCH added an additional caution about buying toys online, which they predict to be about 60% of total toys bought this holiday season. An analysis of over 2000 toys on Amazon revealed that 64% did not have the choking hazard warnings that the same toys did on Target.com.

The independent federal Consumer Product Safety Commission logged 257,000 toy-related injuries in 2017. “One child is treated in a U.S. emergency room every 3 minutes for a toy-related injury.” (That child must be really accident-prone and  very tired – drum roll of rim shots!) In the last two years over 1.2 million toy units were recalled after lead paint poisonings, lacerations, or strangulations. However, toys are getting safer. In 2008 the CSPC issued 172 recalls (not units) while there were only 12 recalls in 2019.

The Toy Association, a toy industry trade group that represents most of the toy makers named on the list, dismissed the annual list as misleading. It suggests parents should always purchase toys from reputable stores and online sellers. “By law, all toys sold in the United States must meet 100+ rigorous safety tests and standards,” the organization said in a written statement. That sounds a lot like Dan Ackroyd as the toy salesman pitching a bag of broken glass on a classic SNL Christmas skit. (Ackroyd’s comeback was a pitch to buy an accompanying bag of toy bandaids.)

Additional serious hazards for small children this holiday season are liquid nicotine and marijuana pods for vaping devices.

Delivered in high doses, nicotine can be lethal.  Exposure to liquid nicotine found in e-cigarettes has resulted in thousands of calls to poison control centers in recent years.  Liquid nicotine poisoning can occur in three ways: by ingestion, inhalation, or absorption through the skin or eyes.  For small children, coming into contact with even a small amount of a highly-concentrated liquid nicotine product can be fatal.

The CSPC is responsible for enforcing a key provision of the Child Nicotine Poisoning Prevention Act of 2015 that requires any nicotine provided in a liquid nicotine container sold, offered for sale, manufactured for sale, distributed in commerce, or imported into the United States to be in “special packaging”.  This packaging, in layman’s terms, must be designed to prevent children from accidentally accessing and ingesting liquid nicotine, and must restrict the flow of liquid nicotine under specific conditions.

Though not lethal, yet, concentrated pods of marijuana for vaping devices if ingested by toddlers can cause significant ICU stays for them. The even more concentrated forms of MJ in edible “dabs” (up to 90% THC) can really cause trouble if ingested by toddlers.

 


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