Wasting Taxpayers Money, Medicare Advantage and the RAC’s

My wife and I try to catch up on TV shows on Thursday evenings. We sit down with a cup of decaffeinated coffee on the couch together petting our dogs and watching mindless entertainment after a day at work. Now that the election is over, almost every commercial in my South Florida market is an advertisement for a Medicare Advantage Health Plan. We are nearing the completion of the “open enrollment” period between October 15 – December 7 when senior citizens can change their Medicare Part D Prescription Plan to one that covers their formulary of medicines and they can choose to leave the Medicare system and join a private health plan for a capitated Medicare Advantage Plan. These plans were initiated by the Center for Medicare Services (CMS) as a way to save money on the health care of seniors. The theory was that if they offered a product with a fixed monthly and yearly cost budgeting would be simpler and at least they would know what they are paying.

These programs are run by private insurance companies such as Humana, Blue Cross Blue Shield, and Aetna. Over the years, research has shown that they now cost the Medicare system more money per year, per patient, than the traditional Medicare system. The private insurers are probably making a great profit on this program because the money and energy spent on advertising to attract patients is relentless. I have been receiving multiple daily promotional letters in the mail for weeks now. Full page ads are run daily in major newspapers and magazines. Prime time television is filled with expensive ads with noteworthy spokespersons like basketball hall of famer Ervin “Magic” Johnson in addition to actors, actresses and former elected officials.

The insurers make their money by rationing and denying care provided by doctors and hospitals which agree to see patients in volume for a discounted fee. Patients have no deductibles; have no out-of-pocket expenses for physician care or generic pharmaceutical products if they stay in network. If they happen to get sick out of the service area, coverage is spotty and varies by program with the advice truly being “buyer beware.”

It seems to me that if these programs are actually more expensive per patient than traditional Medicare then why is CMS continuing them and allowing the millions of dollars spent on advertising to attract patients to continue? The information they need to choose a plan is available on the easy to use http://www.Medicare.gov website at no cost.

I open some non-critical advertisement mail as well. One letter from the Center for Medicare Services addressed to me personally as a patient, not as a physician, was extremely interesting. In December 2014 I was involved in a serious auto accident with my vehicle totally damaged due to the negligence of another driver. I was taken by ambulance to the local emergency room, examined, treated and released. At the time I was 64 years old and several months short of being eligible for Medicare. My auto insurance paid my medical bills. My private insurer Blue Cross Blue Shield was not billed.

The letter from CMS was a form letter saying that a claim from December 2014 had been investigated by them and although no payment was made on this claim, which was paid by Traveler’s Insurance (my auto insurer), they were now referring it to the Recovery and Audit Division for further investigation. The threatening nature of the letter suggested that if I was compensated by Medicare for this claim I would be required to pay back the money with interest and penalties. Considering I was not yet on Medicare, and considering the charges were billed by the local hospital health system, I am not quite sure why the letter was generated and forwarded to me?

Once again a government agency is spending taxpayer money on a frivolous item. How many more of these letters go out yearly at our expense?

The second letter I opened was from Social Security. It said that since I was still working and generating income, my wife and I would be required to each pay an additional fee per month for our Medicare health insurance and for our Medicare Part D prescription drug plan. This is in addition to the tax on my salary that goes directly to Medicare. I have been paying this tax on each paycheck since I started working at age 14 (I am now approaching 69). I read this letter just after hearing one of our elected officials to the Senate refer to Medicare as an “entitlement program.”

My Medicare bills now approach what private insurers charge patients for health insurance. I paid into this system for 51 years before I became eligible to use it. I hardly think the Medicare system is an entitlement.

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Statin Related Muscle Pain and Coenzyme Q 10

Statins are used to lower cholesterol levels in an effort to reduce the risk of developing cardiovascular disease. They are used after a patient has exhausted lifestyle changes such as changing their diet to a low cholesterol diet, exercising regularly and losing weight without their cholesterol dropping to levels that are considered acceptable to reduce your risk of vascular events.

Patients starting on statins often complain of muscles aches, pains and slow recovery of muscle pain after exercising. In a few individuals the muscle pain, inflammation and damage becomes severe. One of the known, but little understood, negative side effects of statin medications are the lowering of your Coenzyme Q 10 level. CoQ10 works at the subcellular level in energy producing factories called mitochondria. Statin drugs, which inhibit the enzyme HMG-CoA Reductase lower cholesterol while also lowering CoQ10 levels by 16-54 % based on the study reporting these changes.

The November 16, 2018 edition of the Journal of the American Medical Association published a review article by David Rakel, MD and associates that suggested that supplementing your diet with CoQ 10 would reduce muscle aches and pains while on statin therapy. Twelve studies were reviewed and the use of CoQ10 was associated with less muscle pain, weakness, tiredness and cramps compared to placebo. The studies used daily doses of 100 to 600 mg with 200 mg being the most effective dosage. Finding the correct dosage is important because the product is expensive with forty 200 mg tablets selling for about $25.

Since CoQ10 is fat soluble, you are best purchasing formulations that are combined with fat in a gel to promote absorption. As with all supplements, which are considered foods not drugs , it is best if they are UPS Labs certified to insure the dosage in the product is the same as listed on the label and that it contains no unexpected impurities.

Vitamin D Supplements Do Not Reduce Falls, Fractures or Improve Bone Density

Much has been written about the benefits of supplementing Vitamin D in patients. The World Health Organization sets its normal blood level at 20 while in North America it is listed at over 30. Under normal circumstances when your skin is exposed to sunlight your kidneys produce adequate amounts of Vitamin D.

Over the last few years low vitamin D levels have been associated with acute illness and flare-ups of chronic illness. The Vitamin D level is now the most ordered test in the Medicare system and at extraordinary expense. Supplementing Vitamin D has become a major industry unto itself.

The October 4th edition of the Lancet Diabetes and Endocrinology contained an article written by New Zealand researchers that looked at 81 randomized research trials containing almost 54 thousand participants. “In the pooled analyses, researchers found that Vitamin D Supplementation did not reduce total fracture, hip fracture, or falls – even in trials in which participants took doses greater than 800 IU per day.” Vitamin D supplementation did not improve bone mineral density at any site studied (lumbar spine, hip, femoral neck, forearm or total body).

They concluded that there is little justification for the use of Vitamin D Supplements to maintain or improve musculoskeletal health, and clinical guidelines should reflect these findings.

Sleep and Cardiovascular Health

Several recent publications and presentations of data on the relationship between sleep patterns and vascular disease occurred at the recent meeting of the European Society of Cardiology. The PESA (Progression of Early Subclinical Atherosclerosis) study performed by Dr Fernando Dominguez, MD, of the Spanish National Center for Cardiovascular Research in Madrid talked about the dangers of too little or too much sleep.

The principal researcher, Valentin Fuster, MD PhD, looked at 3,974 middle-aged bank employees known to be free of heart disease and stroke. They wore a monitor to measure sleep and activity. Interestingly, while only about 11% reported sleeping six or fewer hours per night, the monitor showed the true figure was closer to 27%. They found those who slept less than six hours per night had more plaque in their arteries than those people who slept six to eight hours. They additionally looked at people who slept an average of greater than eight hours.

Sleeping longer had little effect on men’s progression of atherosclerosis but had a marked effect of increasing atherosclerosis in women. Researchers then adjusted the data for family history, smoking, hypertension, hyperlipidemia, diabetes and other known cardiovascular risk factors. They found that there was an 11% increase in the risk of diagnosis of fatal or non-fatal cardiovascular disease in people who slept less than six hours per night compared to people who slept 6-8 hours per night. For people who slept an average of greater than eight hours per night they bore a 32% increased risk as compared to persons who slept 6-8 hours on average. Their conclusion was distilled down into this belief: “Sleep well, not too long, nor too short and be active.”

In a related study, Moa Bengtsson, an MD PhD student at the University of Gothenburg in Sweden presented data on 798 men who were 50 years old in 1993 when they were given a physical exam and a lifestyle questionnaire including sleep habits. Twenty one years later 759 of those men were still alive and they were examined and questioned. Those reporting sleeping five hours or less per night were 93% more likely to have suffered an MI by age 71 or had a stroke, cardiac surgery, and admission to a hospital for heart failure or died than those who averaged 7-8 hours per night.

While neither study proved a direct cause and effect between length of sleep and development of vascular disease, there was enough evidence to begin to believe that altering sleep habits may be a way to reduce future cardiovascular disease.

Shortening the Discomfort of Sore Throats

There has been a strong movement in the United States to limit resistance to antibiotics by insuring that we prescribe them appropriately for bacterial infections only and make sure we educate our patients to complete the course of the antibiotics to prevent the bacteria from surviving and developing resistance patterns. We have been taught that a “strep throat” is rarely seen in adults unless they are caring for children age 2-7 that are sick with a sore throat.

The patient should have a fever, swollen glands in the neck and an exudate on the tonsils or oropharynx. This constellation of findings and symptoms represents “Centors’ Triad” which conveys a high probability that a quick streptococcal assay or culture will be positive. For all other sore throats we are taught to treat it with lozenges, warm fluids and time. There is a definite and distinct effort to train doctors to not prescribe an antibiotic or a “Z Pack” for these non-beta hemolytic streptococcal sore throats.

It is with this background or preamble that I report on an article out of the October 17, 2018 International Journal of Clinical Practice that discusses the use of an experimental throat lozenge versus a placebo throat lozenge. The experimental troche contained a small dose of an antibiotic, tyrothricin plus benzalkonium chloride and benzocaine (an anesthetic). Tyrothricin is an antibiotic used overseas to treat gram positive organisms. It is incorporated into lozenges designed for children with non-streptococcal sore throats. This antibiotic has not demonstrated any issues with bacteria developing resistance yet.

In a clinical trial, patients 18 years of age and older with a painful sore throat which was not due to “strep” were randomly assigned to the study drug or placebo. The results were striking with more relief of pain at two hours in the study group than placebo, less difficulty swallowing and more resolution of symptoms at three days with the study drug than a placebo.

The medication used in the study is not currently available in the USA. If it is as successful as this study implies then when will it be introduced in the USA for symptomatic relief of those uncomfortable non-strep sore throats?

Commercial Air Travel is Really Safe

For the last 25 years I have had the privilege of being a designated airman medical examiner by the Federal Aviation Administration. To earn that privilege, it required flying to FAA headquarters and taking a one week training course followed by refresher training material every three years.

The FAA grades medical examiners annually by our judgment and decision-making. The nature of the questions we are required to ask the pilot candidates, and the exam, have been dictated by the rigors of being a pilot and reflect the stresses unique to flying a plane safely. Many of them were created after a plane crash, fatality and the resulting National Transportation Safety Board (NTSB) investigation revealed a health reason involved in the crash.

I attended my refresher course in Washington, D.C. this past week over a three-day period. Physicians designated by the FAA fly to the event and stay at their own expense. By law, the FAA is not permitted to pay for food, coffee or any expenses. Over 50% of the attendee physicians are pilots who fly to the conference in their own private planes. There are about 2,800 physicians performing these exams around the world and, judging by the grey hairs, and canes in the crowd; they are getting significantly older reflecting the same process in the physician population in our country.

This was the first time I attended this meeting and I saw a significant number of women physicians in the audience which makes me believe there is diversity in the physician examining population as well. The speakers on medical topics are first rate. We heard from leading doctors at the best places, all leaders in aerospace medicine and research in cardiology, neurology, psychiatry, otolaryngology, ophthalmology, fatigue and sleep medicine. I learn a great deal of general medicine to bring back to my medical practice medicine at these sessions.

Performing FAA exams for pilots is not a particularly lucrative proposition. You see 3 classes of candidates including the commercial pilots for class 1 exams, navigators for class 2 exams and general aviation or civilian private pilots for class 3.

As our pilot population continues to age, domestic airlines are now retiring them at age 65. If perfectly healthy, a class 1 pilot starts getting EKGs annually at age 39 and they are then seen every six months at a minimum. The exam and paperwork takes 45 minutes at least and must be transmitted back to the FAA by computer. If you detect a problem either by your taking a history, or performing an exam, there is a further investment of time and research to provide the FAA safety experts with the medical records they need to determine if the pilot is healthy enough to safely fly a plane.

I would say the vast majority of examiners charge only $175 or less for these exams. Try getting that time, attention and value when you go to most physicians for an exam.

The reward for being a designated airman medical examiner is being part of a team that keeps the skies safe for the flying public. Seeing accident and mortality rates decrease year after year brings an extraordinary sense of satisfaction. I get to work with extraordinarily talented and dedicated employees of the FAA, from the staff at my Regional Flight Surgeons headquarters in Atlanta, and the professionals in Oklahoma City and D.C. who read, train and study so when I fly from place to place, I arrive there intact after an uneventful flight. There you have it. Commercial air travel is really safe.

Consumerism and Convenience Gone Wild in Health Care

I have received several phone calls in the last few weeks from young adults requesting information about their last vaccinations. They are travelling to areas of the world that suggest or require certain vaccines and do not remember if they had them or not. Others are applying for positions of employment which require travel and the employer’s human resources department needs the patient’s updated vaccination records.

When we tell them that we only have a record of the vaccinations we have given them in the office they act surprised. “You mean XXX hasn’t sent you a copy of my tetanus booster shot?” Others inquire if the travel health service they went to sends us a record of the vaccines they administered. The answer is “sometimes”.

The State of Florida instituted a website called Florida Shots for immunization records a few years back which is incomplete at best. At one time you received all your vaccinations and immunizations in the doctor’s office and a record was then maintained.

In the new world of consumer convenience first, pharmacies are paid by insurers for administering vaccines while the same shot given in your doctor’s office is not a covered service. In some cases, we have the childhood vaccination records from a pediatrician and a college health form updating us on meningitis and hepatitis A and B vaccines. Those adults out of college for more than seven years who do not have a copy of that form are just out of luck. This is a prime example of consumerism and convenience gone wild for no good reason

Another example is the creation of the BasicMed program allowing non-commercial pilots to obtain a medical certification to fly instead of going to a highly trained certified FAA Airmen Medical Examiner Physician (AME). If you have a driver’s license and pilot a plane for 6 or less passengers, which will not fly faster than 250 knots, or ascend above an altitude of 18,000 feet; you can go to any doctor with your driver’s license and be certified to fly.

Why would a pilot go to BasicMed rather than to a trained and certified and recertified physician in aerospace medicine? Probably because they are concerned that the trained physician will not pass them based on their health and the non-certified doctor will either go easier on them or just miss the problems that an AME might investigate.

 

This law was the result of lawsuits against the FAA by pilots not meeting the standards and resulted in Congress passing this private pilot friendly law. In recent years, expensive private flight schools have become the pathway for a student to eventually become a commercial airline pilot. They are replacing the previous pathway of hiring former military pilots who are more experienced, more disciplined and usually older and more mature than flight school candidates. This new breed of air transport pilot will now be sharing the skies with private civilian pilots receiving their medical clearance from less physicians with less aerospace medical knowledgeable. Is this not also convenience and consumerism gone wild?