The Best Health Insurance - Can Save Your Life

The Sacramento Bee recently ran the following opinion piece below.  A couple of additional comments not published follow.  Enjoy. 

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It’s that time of year when most of us pick a health insurance plan based simply on cost. It’s a belief that is often perpetuated by friends, family, and advice dispensed by many articles in magazines and newspapers. As a practicing primary care doctor, I can tell you that the advice is frankly wrong.

Health insurance isn’t a commodity like auto insurance. It’s not just about the price. They aren’t all equally good at keeping you healthy and well. The recent annual report by the National Committee of Quality Assurance, which has been evaluating health plans for twenty years, continues to report tangible differences among health insurance plans across the country as well as in California.

In a ranking of 227 HMO plans nationwide in important areas like immunization rates for children, appropriate use of antibiotics, blood pressure and cholesterol control, cancer screening in adults for breast cancer, cervical cancer, and colon cancer, only two of nine California HMO health insurance plans ranked in the top 15 percent. The remaining seven were in the bottom half. If all health plans across the country performed at the level of the top 10 percent, 186,000 Americans would be alive today. They would have consistently and routinely received the preventive care and medical interventions that have proven to save lives.

Naturally, it is hard to believe that your choice of a health insurance plan might actually save your life. You often pick your insurance based not only on price, but also if your doctor is in the plan. As a patient, high quality care means your doctor sees you quickly when you are ill, he is always willing to listen and explain, and the fact that he actually knows you as an individual. As a result, he should know what to do to keep you healthy, even as research points to the contrary.

A recent study by the Journal of General Internal Medicine found that only 20 percent of doctors correctly screened patients for colon cancer, the second leading cause of cancer deaths. The doctors likely to do the right thing were younger, board-certified, and used electronic medical records. Those most likely to incorrectly screen or not screen at all were older, much like the fictional television doctor, Marcus Welby. He’s a doctor we would all feel comfortable with and we would trust to keep us well.

Who did better, a health plan or a doctor? The HMO health insurance plans in the top 10 percent of performance screened 72 percent of their enrollees appropriately for colon cancer, three and half times more than the doctors. The bottom 10 percent screened 47 percent of patients. The news for enrollees in the more popular PPO plans is more worrisome. Screening rates of these plans were only 54 and 39 percent respectively for the top and bottom 10 percent of plans.

It’s not obvious the reasons for this difference in performance among health plans or the difference between doctors and health plans. Do better health plans have systematic ways of keeping patients healthy or reminding doctors at the point of care? Is it that doctors who are better naturally gravitate to health plans that are focused on prevention? After all, the work of screening and providing the preventive interventions are done by doctors not by insurance companies.

As a practicing primary care doctor, I constantly balance the art of medicine, the bedside manner, and the science, the evidence based research. Before I joined with a high quality health insurance plan, I thought I was pretty good. The initial data showed otherwise. Over the past few years, I’m far better at keeping my patients healthy. With this insight I now know that given a choice, I would always start with health insurance quality first and then the doctors selection second. It doesn’t sound right. It doesn’t feel right. The science part of my medical degree says it is right.

The striking difference between health plan performance means that a choice most of us view as a simple formality or even an annoyance, picking a health insurance plan, is really a choice between getting the best care or not. A true choice between life and death. Intellectually this doesn’t make sense. Doctors take care of us. They are accountable to keeping us well, yet the data and research seems pretty compelling.

This year 186,000 Americans won’t have the opportunity to make the right choice because the health plan they had wasn’t high quality.

Will you make the same mistake this year?

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The two California HMO plans that were in the top 15 percent in the nation were Kaiser Permanente Northern California and Kaiser Permanente Southern California.  Each takes care of more patients than the entire top 10 HMOs combined.

Do I Need Cholesterol Medication? Is My Cholesterol High? The Simple Truth.

The New York Times recently ran a piece that wondered if doctors were treating patients with cholesterol lowering medication unnecessarily because a web-based calculator over estimated a person's risk.  The program was proudly sponsored by the pharmaceutical roundtable and was available at the American Heart Association.

The implication was obvious. Simple tool determines an individual's risk for heart attack or death from heart attack.  It over estimates risk.  Patients treated unnecessarily.  To be also clear, the program did underestimate risk as well.


Unfortunately, the article missed an important point.  While the simplified calculator may not be as accurate as the more complex algorithm used by the National Cholesterol Education Program, the truth is doctors are likely to be overtreating patients not because the former program is presented by the pharmaceutical roundtable, but for another reason.

In my experience, doctors don't use any web-based tool.  Instead they use a simple rule - is the cholesterol over 200, which is even less precise than the vilified web calculator.

This is rather disappointing, yet occurs too often.

The public has been told erroneously that if your cholesterol is over 200 that it is bad.  Understandably to generate public awareness, a simple number is far easier to act on than the messier nuances determined by the Framingham heart study.  This classic and famous study found that total cholesterol and HDL (good) cholesterol, the age, gender, smoking status, blood pressure, and whether a person is taking blood pressure medication could provide an estimate of an individuals chance of having a heart attack or dying of one over the next 10 years.  In other words, it isn't just the cholesterol in isolation that predicts heart disease, but the profile of the whole person that does.


As a result of these calculations, some basic guidelines appeared.  Patient with a risk of greater than 20% over the next 10 years should be on cholesterol lowering medications like the "statins". Those with a risk of 10% or less should simply work on dietary changes, maintaining a healthy weight, and exercise.  Those between 10 and 20% should also adopt lifestyle changes and consider cholesterol lowering medication.

The decision tree is now far more sophisticated than simply treating a total cholesterol of over 200 with medication.

So when patients join my practice, particularly those who do not have high blood pressure, diabetes, or a history of heart disease, and who are on medication to lower cholesterol, I do this calculation with them.  Shockingly, many don't need medication. The only exception is patients with diabetes or heart disease where cholesterol lowering medication is a must. 


Though these patients are pleased, they are also somewhat reluctant.  Everyone else they know is on cholesterol lowering medication.  Bucking peer pressure, even when scientifically grounded, can be incredibly difficult.  It goes to show how powerful and effective the public service announcements have been to generate awareness.  It also shows how difficult it is to fight a perception, even when it is wrong, particularly when other doctors for expedience sake give patients what they think they want rather than what they need.  (Ever gotten antibiotics for a cold or viral illness instead of reassurance and TLC?)


So if your doctor tells you that you need cholesterol lowering medication, ask him how he reached that conclusion.  He might be doing a simple mental shortcut rather than taking a few minutes to determine your risk.  Ask him if he can quantify your risk over the next 10 years.  If you hasn't an idea what you are talking about,then ask him to Google "10 year risk calculator" to find the right test.

If you don't have diabetes or a history of heart disease and you do discover with a calculation that cholesterol lowering medication is prudent, the good news is there are a few excellent generic medications available to do the job.


Just don't ask for Lipitor the most widely prescribed cholesterol lowering medication.  It's very powerful yet most people don't need that level of potency to protect themselves from heart attack.  It's expensive as it isn't generic yet (Lipitor aka ATORVASTATIN went generic in 2012).  You probably will do just fine with the generic version of Zocor, simvastatin.  Don't take my word for it; that is the conclusion by medical experts for Consumer Reports.  If you are already on cholesterol lowering medication, don't stop until you check with your doctor to make sure it is safe to do so.


Remember, it isn't what you think you want; it's what you need.  Marketing of Lipitor or public service announcements about cholesterol can shape what you think you want.  Talking candidly with your doctor may actually help you determine what you need. Not only might this save you money, but also prevent you from being unnecessarily overtreated.

Life Line Screening - Worth the Money?

A patient brought in a flyer for Life Line Screening where for $129 an individual can have their carotid (neck) and peripheral (leg) arteries screened for blockage, abdominal aorta for aneurysm (swelling), and osteoporosis. The advertisement claims that "we can help you avoid a stroke" and their logo notes Life Line Screening - The Power of Prevention.

The question is whether having this Life Line Screening test is worth your money?

Short answer? No.

Although the flyer correctly indicates that 80 percent of stokes can be prevented, the National Stroke Assocation does not recommend ultrasound as a screening test. Preventing stroke includes quitting smoking, knowing your blood pressure and cholesterol numbers, drinking alcohol in moderation (if already doing so), regularly exercising, and ingesting a low sodium diet. Their is no mention of an ultrasound test. Why?

Because there is NO evidence that this type of ultrasound testing saves lives in individuals who are healthy and have no symptoms except for the following situations.

The United States Preventive Services Task Force (USPSTF) latest guidelines recommend only screening men between age 65 to 75 years old who have ever smoked to be screened for an aortic aneurysm. If you are in this group, ask your doctor for an ultrasound.

For women, osteoporosis screening should begin at age 65 years old and have a bone density test done. Among the "different bone measurement tests performed at various anatomical sites, bone density measured at the femoral neck by dual-energy x-ray absorptiometry (DXA) is the best predictor of hip fracture." It is unclear how accurate or how good ultrasound of the heel or wrist is compared to the bone density test. If you feel you have other risk factors, like family history, use of steroids for a long period of time, then check with your doctor to see if screening should be done sooner. Otherwise at age 65, all women should be evaluated not with an ultrasound but a bone density test.

USPSTF recommends against screening for peripheral artery / vascular disease (PAD) as well as carotid ultrasound.

Worried about either condition? Ask your doctor. For peripheral vascular disease, particularly when significant, individuals commonly have leg pain when walking. The blockage in the arteries decreases blood flow to the leg muscles when active causing pain. When the person stops walking, the pain resolves. A doctor can determine whether you have PAD by seeing if you have good foot pulses simply by placing fingers on the pedal pulses. If your pulses are normal, then you don't have significant PAD. If the doctor is concerned about your symptoms, he will order an ultrasound which will be covered by insurance.

There is a reason why Life Line Screening in small print writes that they do "not participate in the Medicare program and the cost of [their] screening services is not covered or reimbursable by Medicare" as well as they do "not file insurance claims and the cost of [their] screening services is your responsibility."

There is NO scientific evidence these tests can make a difference except in the specific situations listed above. Since insurance companies and Medicare only want to cover what is proven, Life Line Screening wants you to pay for an essentially unnecessary test.

Better use for your money? Check your blood pressure and your cholesterol. Quit smoking. Cut down alcohol use if you already drink. Maintain a low sodium diet. To prevent osteoporosis, women should take 1200 to 1500 mg of calcium per day as well as 800 to 1000 IU of vitamin D daily.

For $129? Get a really nice pair of walking shoes. Get a pedal exerciser for under your desk. Keep your muscles moving and maintain a healthy weight.

Oh, please don't spend too much money on multivitamins because they aren't worth the money either.

Want more helpful tips? Worry about whether you are getting the best medical care? Does your doctor seemed rushed? Not answering your questions? I have a solution for you!

The Decision Tree: How Smarter Choices Lead to Better Health - Really?

An article in Wired magazine called the "The Decision Tree" really got me thinking. In the book excerpt, the writer suggests that patients can get to the best decision using a simple tool, a flow chart. Making a good choice relies on the following:

• inputs - data that might affect our health
• process - an action we can take to change our outcome
• decision - a question that nudges us to make deliberate choices and
• end result - the consequence of the decision process

Certainly with the explosion of medical information and the ability to access that information quickly and easily because of the internet, anyone can read up and educate himself on the latest scientific research. A simple flowchart is a reasonable structure to organize a plethora of information so that it is usable and actionable.

What troubled me, however, was the implicit message that simply taking tests, like genetic testing for a fee, or getting a wealth of medical data and then using a decision tree could result in patients choosing the right care for themselves. The internet has allowed individuals to no longer rely on experts to book plane tickets or manage our investments. The author seems to suggest that in healthcare we've reached the time that patients can empower themselves in a similar manner.

[We’re at a moment] when more data than ever lies within ready reach. Whether it’s personal genomics services like 23andMe or screening tests or self-tracking iPhone apps, each of us can draw on a wealth of personalized data sources that turn generic medical advice into customized health equations. And this is always-on data: Instead of checking in on our health episodically — when we visit the doctor or get lab test results — we can now tap into a constant stream of information and opportunity. We can minimize our uncertainty and maximize our control. We can build ever more sophisticated, and useful, decision trees.

If it was really that simple. There are significant nuances between the theoretical and practical, especially when it comes to genetic testing, which in many instances has not yet been proven to be an accurate predictor about one's future health. To understand the nuances take the simple routine cholesterol test. You already know to eat healthy, exercise, and maintain a healthy weight to achieve a lower cholesterol. Your question is whether your total cholesterol of 280 and a HDL (good cholesterol) of 35 is a problem? Do you need to take a cholesterol lowering medication?

The answer depends.

If the patient is a 40 year old man, who smokes, and otherwise healthy with a blood pressure of 120, then his risk of a heart attack is 21 percent over the next decade.

If the patient is the same man, but a non-smoker, his risk now is 5 percent over the same time of ten years.

If he is a non-smoker, but taking medication to maintain his blood pressure at 120, his risk for heart attack becomes slightly higher at 6 percent.

For the first example, the first thing the person should do is to quit smoking. The risk of heart attack drops by 75 percent. If he refuses, then his doctor should recommend starting a cholesterol lowering medication as well as suggesting taking an aspirin daily. In the last two examples, the risk is small enough that diet and exercise alone are adequate. Would a flowsheet have captured this difference in outcome?

While a decision tree and flowchart can be helpful and it is likely doctors are using a similar algorithm in our heads, the issue is who is interpreting the information. A flowchart for a critical health care decision may get the patient an end result. In situations where newer tests and technologies are involved, a review with a doctor who has the experience and expertise, will provide the framework for a candid discussion and a great result.

If this article demonstrated anything then it is that we as doctors have consistently failed to take the medical information available, interpret, translate, and then communicate clearly the risks, benefits, and choices personalized for an individual person. We can and must do better.

Coronary Calcium Scans Can Raise Cancer Risks

Interesting articles from the Annals of Internal Medicine and reported in HealthDay courtesy of Yahoo.

In summary, there is risk of radiation with using CT scan to determine if there are blockages in the coronary arteries. Note that from the article, "having such a screening test every five years would cause 42 additional cases of cancer among 100,000 men and 62 additional cases among 100,000 women."

Yet as one of the doctor notes it isn't proven that this screening test saves lives or is better at predicting who is at risk for heart disease than the usual measures of cholesterol, blood pressure, smoking status, age, and gender. (You can calculate your risk of having a heart attack or dying of a heart attack using the calculator provided by the National Cholesterol Education Program).

Interestingly, when hormone replacement therapy (HRT) for women in menopause was found to increase risk of cancer by 8 in 10,000 or 80 in 100,000, which is a little more than the increased cancer risk by this CT scanning, doctors and women essentially stopped using HRT. It was probably easier to do because there were alternatives to HRT.

Currently the US Preventive Services Task Force doesn't recommend it. The American Heart Association only suggests it for certain cases. Yet, unfortunately the state of Texas requires that the procedure be covered for all despite no evidence it works. Perhaps that is why a city in Texas was singled out as spending the most for medical care in a recent piece by physician author Atul Gawande in the New Yorker.

There are alternatives to using a CT scan to check the arteries to determine risk factor for heart disease. Until proven, it is best to stay away. Also, more importantly, quit smoking, stay active, maintain a healthy weight, control your blood pressure (ideally less than 120/80, but see your doctor if greater than 140/90), and control your cholesterol.

The entire article is here.


Coronary Calcium Scans Can Raise Cancer Risks
HealthDay Reporter by Ed Edelson

Mon Jul 13, 11:48 pm ETMONDAY, July 13 (HealthDay News) -- When weighing whether a coronary calcium scan is worth the risk, a new study suggests that arriving at an answer won't be clear-cut or easy.

A team of researchers from the U.S. National Cancer Institute and Columbia University found that the average range of radiation exposure from having such a screening test every five years would cause 42 additional cases of cancer among 100,000 men and 62 additional cases among 100,000 women. However, given the wide range of radiation doses seen in the study, the increase could be as low as 14 cases and as high as 200 cases among 100,000 men, and as low as 21 cases or as high as 300 cases among 100,000 women.

This is an issue of growing importance on the American medical scene, said Dr. Andrew J. Einstein, director of cardiac computed tomography research at Columbia University, and a member of a team that reports its findings in the July 13 issue of the Archives of Internal Medicine.

"There has been great interest recently in computed tomography, owing to the fact that the number of CAT scans has grown tremendously in the United States," Einstein said. "The National Council on Radiation Protection & Measurement estimates that 70 million are done per year."

The study in which Epstein took part looked at a form of computed tomography that scans for calcium deposits in heart arteries. CAC scanning, as it is called, is one of the lesser-done forms of computed tomography, but a private organization, Screening for Heart Attack, Prevention and Education, has proposed that it be done annually on 50 million Americans, and a new Texas law mandates health insurance coverage of the procedure.

The new study looked at what a dose of radiation in a single CAC scan would be, and found an enormous variation. There is no single protocol -- set of rules -- for such a scan, which can be done on a variety of equipment, Einstein said. "This was first proposed in 1990, and CT scanner technology has changed, so it is not clear what the protocol might be," he noted.
The study found roughly a 14-fold difference in radiation dosage among the various CAC scan protocols. Eliminate two or three "outlying" readings, and the difference is still threefold, Einstein said.

But those estimates are suspect, said Dr. Thomas G. Gerber, an associate professor of medicine and radiology at the Mayo Clinic, and co-author of an accompanying editorial, because it is based on extrapolation of the damage done to people exposed to high doses of atomic bomb radiation at Hiroshima and Nagasaki.

"At the very low doses used in medical imaging, there is a huge controversy about whether there is an increased risk of anything," Gerber said. "Estimates of increased risk are based on a linear no-threshold hypothesis. There is even a theory that chronic exposure to low doses of radiation might be beneficial."

There is equal cloudiness on the benefit side of the equation, said Gerber. "I am not a strong proponent of screening," he added.

"The risk of cardiac events increases if calcium is present in the arteries," Gerber said. "But you can't pick up blockages before they are 70 percent or more. There is some debate about whether the risk predicted by coronary calcium screening is incremental [adds to] the risk predicted by conventional risk factors. It stands to reason that it might be, but that is not proven."
The U.S. Preventive Services Task Force recommends against using CT scans in screening programs, and the American Heart Association says they should be used for "selected individuals" at intermediate risk.

So what do physicians do about CAC scanning in the real world?

"I like using it for patients at intermediate risk of coronary disease, when I do not know how aggressive therapy should be," Einstein said. "For such patients, it is a fantastic test."

"In my practice I use it for patients with no symptoms but an unfavorable risk factor profile," Gerber said. "If there are risk factors but they are adamant about not changing their lifestyle or taking coronary medication, I think it sometimes helps patients realize their coronary atherosclerosis [hardening of the arteries] has begun."

A definitive study of the risk-benefit ratio of CAC scanning is unlikely, Einstein said. The people in question are not at high risk of heart disease, and "the rarer an event is, the larger the sample size that is needed," he said. "A randomized controlled trial would require hundreds of thousands or millions of patients, with adequate follow-up."

More information
For more on coronary calcium scans, go to the U.S. National Heart, Lung, and Blood Institute.

What's the Best Medicine / Treatment? Doctors Don't Know

Fascinating article from the Associated Press titled, "What's the best medicine really?" in which a government panel will try to determine which therapies and medications are better than others in a study of "comparative effectiveness". Funded by the stimulus package passed by Congress, about $1.1 billion will be spent understanding this.

Naturally, all parties involved have a stake in this because there will be losers. Although the article states that it is a secret that newer medications don't need to be better than older proven therapies, that isn't true. It's that the public is unaware that for FDA approval, medications only need to be better than placebo.

Pharmaceutical companies rarely do comparative effectiveness studies because they can backfire. Note how Bristol-Myers Squibb compared its cholesterol lowering medication PRAVASTATIN (PRAVACHOL) against Pfizer's ATORVASTATIN (LIPITOR) in the PROVE-IT study. Bristol-Myers sought to prove that its medication was better than the newer one, LIPITOR. They were wrong and it cost them.

The real challenge isn't just understanding what works better than others. The real challenge is how to get this information to doctors consistently and in a timely manner. Research shows that on average it takes 17 years for medical research and findings to be practiced routinely in the community doctor offices. Whether the internet and information technology shortens this time frame remains to be seen. As a result, all the studies in the world are meaningless unless those at the front lines - doctors and patients get this information.

I am skeptical that any study will ultimately help manage healthcare costs.

What's the Best Medicine / Treatment? Doctors Don't Know

Fascinating article from the Associated Press titled, "What's the best medicine really?" in which a government panel will try to determine which therapies and medications are better than others in a study of "comparative effectiveness". Funded by the stimulus package passed by Congress, about $1.1 billion will be spent understanding this.

Naturally, all parties involved have a stake in this because there will be losers. Although the article states that it is a secret that newer medications don't need to be better than older proven therapies, that isn't true. It's that the public is unaware that for FDA approval, medications only need to be better than placebo.

Pharmaceutical companies rarely do comparative effectiveness studies because they can backfire. Note how Bristol-Myers Squibb compared its cholesterol lowering medication PRAVASTATIN against Pfizer's ATORVASTATIN (LIPITOR) in the PROVE-IT study. Bristol-Myers sought to prove that its medication was better than the newer one, LIPITOR. They were wrong and it cost them.

The real challenge isn't just understanding what works better than others. The real challenge is how to get this information to doctors consistently and in a timely manner. Research shows that on average it takes 17 years for medical research and findings to be practiced routinely in the community doctor offices. Whether the internet and information technology shortens this time frame remains to be seen. As a result, all the studies in the world are meaningless unless those at the front lines - doctors and patients get this information.

I am skeptical that any study will ultimately help manage healthcare costs.

Secrets to Preventing Heart Disease

I recently gave a talk to discuss how to keep the heart healthy and avoid heart disease. February is designated as heart health month. Heart disease is the leading cause of death in both men and women. Yet within our country, there are doctors who consistently treat their patients to the latest research such that for their patients, heart disease is no longer the leading cause of death! In fact, their patients chance of dying from heart disease is 30% less than those of other doctors and hospitals in the same communities.

Their secret? Knowing your numbers and then treating them. Risk factors for heart disease include the following:

Age
Gender
Cholesterol
Blood Pressure
Smoking Status

The older you are, the more likely you will have heart disease. In terms of gender, men will tend to have heart disease at an earlier age. Women will see their risk gradually increase after menopause (average age of menopause is age 51).

Cholesterol is a risk factor, but needs to be determined in the context of the above risk factors. An excellent heart risk calculator is the 10 year risk calculator. Punch in your numbers. (Patients who have diabetes or a previous history of heart disease don't use this calculator because you should already be on cholesterol lowering medications called "statins"). The calculator is from data generated from the Framingham heart study, the nation's longest heart study.

Those with < 10 % risk, continue lowering your risk by dietary changes and exercise. Those with 20% or great risk, contact your doctor immediately and find out if you should start taking cholesterol lowering medications, blood pressure medications, or quit smoking as a 1 in 5 chance of dying from a heart attack or having one is pretty high! Those between 10 to 20% should see their doctor and ask what more can they do to lower risk.

Need more? Here's the secrets to preventing heart disease courtesy of Kaiser Permanente.