Medical Gluttony

Current Issue

Medical Autonomy

There has been some confusion in this era with Personal Health Records with getting the patient more involved in his or her own care. Some patients have interpreted this as going to any doctor they feel they need at the moment. They do not see their personal physician as being their managing partner—but just a person they can see when all else fails and they don’t know which doctor they should see next. They don’t feel that cost should be a factor. They have no concept of the costs involve. They consider it as just another office call with a new or different doctor. One patient this week said it didn’t matter since she had Tri-Care, which allowed her to seen anyone she desires without authorization. 

She had seen two new physicians since her previous evaluation. She had developed a cough with the phlegm clearing after a course of antibiotics. However, it did not clear her otherwise hacking cough. The allergist had done a pulmonary function test but she had no idea how well she did or what it showed. But she did begin allergy injections which over two months had no effect on her cough nor was it expected to do so in two months.  The printout from our HMO suggests that each consultation, which usually requires additional lab tests, x-rays, or procedures, adds $1500 to $3500 to that patient’s medical costs.

She also had two urgent care visits since her last evaluation in our office. Urgent care center evaluation is by another new physician who makes a stab at the diagnosis in the minimal amount of time without benefit of the patient’s medical records. Hence, these evaluations have minimal value depending on how many tests previously done have been duplicated. This is also a costly and essentially unnecessary expense.

She also had a hospital emergency room visit and was given another antibiotic. In the absence of any phlegm, this also had no significant effect on her cough. She developed nausea and vomiting the second day and call the Emergency Department. She was told there were no other antibiotics and she should see her personal physician.

The hospital Emergency Department visits start at $600 in our community but frequently can be as high as $9000. The ER doctor does not have the benefit of the patient’s medical file which may have been developed over the course of years with numerous tests, x-rays and probable procedures which the patient may not recall during an emergency evaluation, and even if recalled, is not able to give a medically verifiable result.

As a Pulmonologist I felt somewhat frustrated to not have basic pulmonary data to confirm my diagnosis to chart her treatment. Should I repeat the PFT or treat her empirically? Her cough of several months duration, persisting through two doctors, two urgent care centers, and one emergency room, had not stopped the coughing.

The diagnosis should have been obvious. In a lady with allergic rhinitis (hay fever) who develops a cough, it more likely than not is allergic bronchitis sometimes called cough variant asthma. Examination did confirm asthma. She did not have her albuterol inhaler with her and didn’t have any idea that she should carry it with her at all times.

So we used a new inhaler in our office. She was advised to exhale fully, open her mouth wide, and take a deep breath as I gave her an albuterol spray which she inhaled. I quickly reminded her that she must hold her breath for 30 to 60 seconds. If she exhaled the albuterol, it obviously would not do her any good outside her lungs. She was able to hold it for 45 seconds. She was then given the second inhalation of albuterol and was able to hold it for 60 seconds.

She had not further coughing during the remainder of her evaluation.

She was advised in the future to see her personal pulmonologist before the $10,000 to $15,000 she cost her insurance company over the past two months which are the ones who pay their Blue Cross premiums for such gluttonous use of health insurance which then increases their premiums unnecessarily. She already had an albuterol inhaler and we advised her to use every time she coughed. Hence, our $150 office call which required no further prescriptions was more effective than the $15,000 she had incurred.

We reminded her that we are always able to see established patients with 48 hours of their call and none of her health care visits were emergencies. In fact, none of her health care visits were effective.

She had not told any of these doctors who her personal physician was. Hence, we had no reports from any of them and so they were irrelevant to her. She was told to have a report in our office before her next visit from all her doctors or we would withdraw from her care. We would not be party to such a flagrant abuse of health care resources.

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Medical Gluttony

Previous Issue

Obama Administration: Largest Tax Hike since WWII

Recently, April 15th, so-called "Tax Day," served as a reminder that our federal government takes more of our money each year to fund a multitude of things not within its constitutional authority or purposes.

President Obama bragged recently that our deficits are coming down at the fastest rate in 60 years. And it is true: deficits as a percentage of gross domestic product (GDP) are falling faster under Obama than they have at any point since the end of World War II, says the Washington Examiner.

  • However, when the federal government's deficit fell from 30.3 percent of GDP in 1943 to a 4.6 percent surplus in 1948, the change was almost entirely due to deep spending cuts.

  • In 1943, federal government spending made up 43.6 percent of the economy. By 1948, that spending sunk like a rock to 11.6 percent.

  • And yet, despite forecasts of economic doom by Keynesian economists, the U.S. economy boomed after WWII.

  • Taxes actually fell during this period too, from 20.9 percent of GDP in 1944 to 16.2 percent in 1948.

Fast forward more than 60 years to today, and taxes are rising faster now under Obama than they have under any other president since WWII.

  • When President Truman came into office in 1945, federal taxes were 20.4 percent of the U.S. economy. When he left office in 1953 they made up just 18.7 percent.

  • President Eisenhower then lowered taxes even further to 17.8 percent by 1961, and President Kennedy lowered them further still to 17.6 percent.

  • President Johnson then raised taxes for his wars on Vietnam and poverty to 19.7 percent.

  • President Nixon then cut taxes to 17.9 percent by 1975, before President Ford raised them to 18.5 by 1977.

  • President Carter raised taxes even further to 19.6 percent, before President Reagan cut them to 18.4 percent and President Bush cut them to 17.5 percent.

  • President Clinton then raised taxes to 19.5 percent of GDP by 2001 before President Bush cut them to 17.6 percent in 2008. The financial crisis then sunk the economy, lowering tax collection to a post-WWII low of 15.1 percent.

  • President Obama's many tax hikes will send taxes as a percentage of GDP as high as 19.3 percent in 2015, before falling to 18.9 percent in 2017.

  • From 2009 to 2017, taxes as a percentage of GDP will have risen 3.8 points, a larger tax hike than any other American president since WWII.

Source: Conn Carroll, "Taxes Rising Faster under Obama than Under any Other President," Washington Examiner, August 7, 2013.

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Medical Gluttony thrives in Government and Health Insurance Programs.

Gluttony Disappears with Appropriate Deductibles and Co-payments on Every Service.

 

Medical Gluttony

Past Issue

Obama Administration: Largest Tax Hike since WWII

Recently, April 15th, so-called "Tax Day," served as a reminder that our federal government takes more of our money each year to fund a multitude of things not within its constitutional authority or purposes.

President Obama bragged recently that our deficits are coming down at the fastest rate in 60 years. And it is true: deficits as a percentage of gross domestic product (GDP) are falling faster under Obama than they have at any point since the end of World War II, says the Washington Examiner.

  • However, when the federal government's deficit fell from 30.3 percent of GDP in 1943 to a 4.6 percent surplus in 1948, the change was almost entirely due to deep spending cuts.

  • In 1943, federal government spending made up 43.6 percent of the economy. By 1948, that spending sunk like a rock to 11.6 percent.

  • And yet, despite forecasts of economic doom by Keynesian economists, the U.S. economy boomed after WWII.

  • Taxes actually fell during this period too, from 20.9 percent of GDP in 1944 to 16.2 percent in 1948.

Fast forward more than 60 years to today, and taxes are rising faster now under Obama than they have under any other president since WWII.

  • When President Truman came into office in 1945, federal taxes were 20.4 percent of the U.S. economy. When he left office in 1953 they made up just 18.7 percent.

  • President Eisenhower then lowered taxes even further to 17.8 percent by 1961, and President Kennedy lowered them further still to 17.6 percent.

  • President Johnson then raised taxes for his wars on Vietnam and poverty to 19.7 percent.

  • President Nixon then cut taxes to 17.9 percent by 1975, before President Ford raised them to 18.5 by 1977.

  • President Carter raised taxes even further to 19.6 percent, before President Reagan cut them to 18.4 percent and President Bush cut them to 17.5 percent.

  • President Clinton then raised taxes to 19.5 percent of GDP by 2001 before President Bush cut them to 17.6 percent in 2008. The financial crisis then sunk the economy, lowering tax collection to a post-WWII low of 15.1 percent.

  • President Obama's many tax hikes will send taxes as a percentage of GDP as high as 19.3 percent in 2015, before falling to 18.9 percent in 2017.

  • From 2009 to 2017, taxes as a percentage of GDP will have risen 3.8 points, a larger tax hike than any other American president since WWII.

Source: Conn Carroll, "Taxes Rising Faster under Obama than Under any Other President," Washington Examiner, August 7, 2013.

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Medical Gluttony thrives in Government and Health Insurance Programs.

Gluttony Disappears with Appropriate Deductibles and Co-payments on Every Service.

 

Medical Gluttony

Past Issue

Frequently not recognized by patient, family, hospital, or physician

The perspective of a pulmonary consultant occasional provides an overview of medicine. Recently a patient was referred for consultation of an emergency room evaluation. The family was very concerned over the report of a very abnormal chest x-ray.  The report indicated right middle lobe collapse, interstitial infiltrates, calcified pleural plaques, and possible pneumonia. 

I remembered him from previous consultations. He looked like a robust 70 year old Eastern European. He didn’t appear ill and looked about as I had remembered him. The son, who also served as the interpreter, re-expressed the concern of a serious and grave illness. Since his chart had been retired after five years of inactivity, a search of our computerized files found our previous consultations of 2001 and 2008.

As I perused my previous consultation, I read aloud my concern about his abnormal chest x-ray in 2001, how the patient had recalled that he had a similar abnormality of his middle lobe in Hungary in 1981, he had had a bronchoscopy which revealed a narrowed bronchus to the middle lobe, that biopsies were obtained and no cancer was found obstructing the middle lobe which is a common presentation of a middle lobe lung cancer. “But is the x-ray the same?” I stated that it is impossible to ascertain if they are identical without seeing the x-ray side-by-side on my viewing box, but that considering one radiologist reading the films in 2001 and a different radiologist reading the film in 2013, it would certain appear that they were describing essentially similar films.

“But dad is so much more short of breath,” he said. “Well then, why don’t we measure his pulmonary function and determine why he’s so short of breath.” I found his old PFT on my laptop and printed it out showing a mid-expiratory flow rate of 14% of normal, and then did a current PFT which showed the same flow parameter at 12% of normal. The son immediately mentioned that his dad had obviously gotten 2% worse. I pointed out that this was probably within the standard deviation of testing and was really the same value. The son breathed a sigh of relief and the patient just smiled broadly as if he never had any concern.

Looking over the 41 pages of emergency room testing, it was apparent this was well beyond the usual average of $9,000 for an emergency room visit and was more like a $20,000 relatively “non-transparent” charge. How can these costs be controlled? This has occurred over a long period of government meddling into physician work hours, giving ER evaluations greater latitude in charging Medicare, and lack of patient copayments and deductibility, all previously discussed in this column.  

Since the initial complaint was chest pain, and the initial electrocardiogram was normal, a 20% copayment on a $200 ECG may have satisfied the family that he wasn’t having a heart attack. If they had stopped the testing at this point when their 20% copayment was $40, it would have save Medicare more than $20,000 in costs. If the patient had gone to the same hospital emergency room where his first 2001 tests had occurred, the initial $250 chest x-ray could have been compared to the previous one and the 50 copayment may have satisfied the family and the $20,000 in hospital costs could have been contained. If the patient would have come to the same consultant in the office that saw him in 2001, a clinical diagnosis could have been made of no change. If the family anxieties could have been relieved at that point, then the whole $20,000 cost could have been contained. Continuity of care may be the biggest restrainer of health care costs increases.

But as long as the medical illiterate control the White House, the Congress, and the AMA, reason will never prevail.

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Medical Gluttony thrives in Government and Health Insurance Programs.

Gluttony Disappears with Appropriate Deductibles and Co-payments on Every Service.

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