Medicare Advantage – Great Insurance If You Are Healthy

It is open enrollment period through December 7, 2019 for those of us 65 years of age and older who are supposed to sign on to to choose our 2020 prescription drug plan Part D. This is also the open enrollment period for insurance owned and operated by private managed care Medicare Advantage programs. These plans preceded ObamaCare, or the Affordable Care Act, and are private managed care plans. They were designed to save the government money but, in fact, year after year are more costly per patient than traditional Medicare.

Let me repeat that, according to government auditors, MEDICARE ADVANTAGE PLANS COST MORE PER PATIENT PER YEAR THAN TRADITIONAL MEDICARE! If you sign up for one you will need to abide by the managed care company’s contracted panel of doctors and facilities. You do not get to choose the best doctor or hospital for your problem – just the best on your contracted panel. These insurers tell you it’s the same as Medicare but it is not. They will provide you with an insurance ID card colored and lettered to mimic Medicare but it is not Medicare.

It is great for healthy patients until they get sick. There are few, if any, monthly costs to enrollees. Generic drugs, inexpensive vision care, inexpensive hearing and dental care are often included. If you develop a complicated health problem and want to see the best it is usually OUT OF NETWORK. If you get sick out of your home area you may well be OUT OF NETWORK. These plans are immensely profitable to insurers.

They are so profitable that seniors are bombarded with mail advertising, full page newspaper advertising and constant prime time TV advertising using celebrity spokespersons. The ads encourage seniors to travel and fund their grandchildren with the savings they will reap from joining their plan.

They don’t explain what happens when mom has a new lymphoma and cannot go to MD Anderson or Memorial Hospital or Dana Farber for diagnosis and cutting-edge care. They don’t tell you about the experience of your contracted panel doctor to treat Grandpa’s throbbing headache caused by a brain vascular malformation because the regional neuro vascular interventionalist of choice is not on grandpa’s panel.

I have an idea. How about putting the cost of all the expensive enrollment advertising done by these private Medicare Advantage plans in to better benefits for their clients?  We all know the answer to that.

Changes in Florida’s Prescribing Medication Laws

In their ultimate wisdom, the Florida Legislature has decided that all medication prescribing shall be done electronically by computer beginning in January 2020.  As of November 1st, the Florida Medical Association has not informed its members of this but it was discussed briefly at a hospital staff meeting.

We were told that most pharmacies will no longer honor paper written prescriptions.  My office electronic health record system, which slows down seeing patients remarkably, has had electronic prescribing software which we have used for several years now.  The big change is that we will now be required to order controlled substances online electronically when in the past it was not permitted.

Since the opioid crisis struck Florida, physicians have been required to create an account with the State’s narcotics hotline named E-Forsce and check out the recipient prior to prescribing controlled substances for pain.  We then issued a written prescription.

It never made sense to me why if one is trying to track narcotic prescribing it wasn’t being done on computers from the beginning?  Nonetheless, this is a change which will require prescribers to download additional software and use two methods of identification as the legitimate prescriber before you can actually prescribe for your patients.

It will give you the freedom to prescribe from your phone or tablet when out of your office which is a convenience not available in the last few years. It will however mean more time in front of the computer screen, more user names and passwords to remember and less time actually listening, talking and communicating with patients.

40 Years of Service & a Misspelled Plaque – Thanks!

I attended my hospital’s medical staff quarterly meeting last week. At one time these meetings were mandatory.  If you missed a meeting, you were fined or even suspended.

Voting on major issues required a quorum of three quarters of the active staff.  Hospital employed physicians, or anyone being paid directly by the hospital, were not permitted to vote because they were felt to have a conflict of interest.   Much like the original Federal government which set checks and balances between the Executive Branch, the Legislative Branch and the Judicial Branch we had checks and balances between administration, medical staff and the community mission statement.   All of that is gone today. Meeting attendance is now voluntary.

For the most part, the only medical staff attending are hospital contracted physicians there to push an issue or vote which is beneficial to hospital administration. I have been a harsh critic of the loss of power of the community, and community doctors who support our hospital, but being a small fish in a large pond my thoughts and opinions are rarely considered because the bottom line is the bottom line and that seems to be all that counts in today’s health care environment.

The meeting had some of the vestiges of past meetings including awarding scholarships to worthy young doctors in training, introducing new members of the medical staff and a speech about the future from our new CEO.  The elected Chief of Staff stopped after each introduction and posed for a picture with each scholarship winner and each new staff member.  It was a ritual performed for years at these meetings. The final discussions were about new rules and regulations starting January 1, 2020 regarding ordering of imaging tests and prescriptions. There was no discussion of the communication issues between physician to physician, no discussion of the new policy of nurses not accepting verbal orders from physicians either face to face or over the phone. No discussion of the impact of protocol medicine, one- size-fits-all on individuals with individual problems and needs.

The next morning a representative of the hospital’s marketing department arrived unannounced in our office. She comes monthly to make sure we aren’t having problems ordering outpatient tests at the hospital. On this day, after discussing nothing of earth-shattering importance, she turned to leave and then turned back and reached into her bag and pulled something out. “I almost forgot to leave this here for Dr Reznick.”

The item was incorrectly placed by my staff in my emergency message call box.  I saw it between patient encounters, lifted it up, turned it over and realized it was a plaque for me from Baptist Health System Boca Raton Regional Hospital.  There was a picture of the hospital and inscribed below was a message, “In recognition of 40 years of staff service providing care for the community.”

My name was spelled incorrectly using the spelling of a neurologist who is not on staff and practices 25 miles away.  For years now I have been complaining to no avail that my imaging and lab results are being sent to this physician in error. No one at Boca Raton Regional Hospital has done anything to correct the matter.  So, about twice a month I receive a middle of the night call from Mount Sinai Hospital in Miami Beach looking for their Steven Resnik (with an “R”) but mistakenly calling me (with a “Z”).

I did not ask for any recognition of my 40 plus years on the staff of Boca Raton Community now Regional Hospital.  Although a mention at the quarterly staff meeting, after they introduced the scholarship winners and the new members on staff, would have been nice.  And, receiving a plaque presented as an afterthought, by someone I do not know, with my name misspelled seemed rather disingenuous.

Taking BP Medications at Night More Efficacious Than in the Morning

The European Heart Journal published the Hygia Chronotherapy Trial which followed hypertensive patients in Spain for a decade between 2008 and 2018. There were 19,000 participants of whom 10,600 were men, all older than 18 and all being treated for high blood pressure.  The group was randomly selected to either take their blood pressure medications at bedtime or in the morning.  They were followed with frequent blood pressure checkups plus 48-hour ambulatory blood pressure monitoring to assess their sleep time blood pressures.

The study was performed only on Caucasian participants who went to sleep on what would be considered a normal day/night schedule.  The results were significant and important.

Those who took their blood pressure medications at bedtime saw the risk of dying from a heart or blood vessel related problem drop by two-thirds compared to those who took their meds in the morning.  Night time administration of blood pressure medications resulted in a 44% drop in heart attack risk, a 40% drop in the need for coronary artery revascularization, a 42% drop in the risk for heart failure and a 49% drop in stroke risk.  The overall reduction in risk for cardiovascular death was 45%.

This is a significant study which must now be performed in patients of color who tend to have higher night time blood pressures.  While these studies are in progress, it appears that taking your blood pressure medication before bed is the correct choice.

Healthy Aging – Adjustments for Living & Reality

For several years now my wife has been complaining that I do not hear her when she talks.  I have gone for regular ENT checkups with audiology testing and while there is clearly a drop in hearing certain frequencies, my word discrimination and comprehension put me in a position of delaying using hearing aids for another year.

I was aware I had trouble hearing my middle adult daughter’s voice frequency.  I was missing words on TV especially when foreign accents were present leading to the purchase of TV Ears which solved the problem.  Still I knew that without auditory stimulation your brain deteriorates at a faster rate.

Last year the ENT doctor sent me home with a pair of hearing aids to try.  “Your wife called and said that if you don’t try them she may find me and kill me in my sleep.”  I was so angry with my wife for interfering that I made a point of pretending not to hear her every time she addressed me and I had the hearing aides in.  Those hearing aids were returned within the 30-day trial period because I could not use my stethoscope with them in.

One year later I was back again and this time my hearing test showed some drop in my word discrimination. They suggested trying a blue tooth compatible pair of hearing aids and even took out a stethoscope to show me how my hearing was enhanced using the stethoscope thus eliminating my favorite argument.   I wore them home and frankly they are wonderful.

The next day I had an appointment for my six-month eye exam. My acuity was off and I suspected my visual field in one eye had diminished based on driving and athletic pursuits.  The test confirmed my suspicions with my ophthalmologist diagnosing “normal pressure glaucoma” in my right eye.  “We need to lower the pressure by 3% with the drops I am prescribing and if the pressure doesn’t decrease we will recommend a laser surgery procedure in three weeks.  You are not going blind, but we want to preserve your visual field.”

The look on my face advertised my disappointment.  “It’s not so bad, you have sent me hundreds of patients with this situation and we helped them all. Why are you so troubled over this?  Looking at your med sheet and problem list at least you aren’t complaining about ED.”    When I didn’t answer her there was a long pause and she said, “Oh, I am sorry if I brought up a difficult topic.”   The best I could mutter was that in geometry what was once an acute angle is now an obtuse one.”

I tried to sell the fact that my dermatologist had me on a short-term course of prednisone which was raising the ocular pressure, but she wasn’t buying that argument.  New glasses, nightly eye drops and hearing aides all in a 72-hour period.

Instead of being grateful and thankful that I had minor correctable issues, and I could afford to spend the $6000 plus dollars for hearing aides and new trifocal lenses, I was moaning and groaning about the trials and tribulations of healthy aging. It was like running into the ocean surf on a hot day preparing to dive in to the surf and cool off and an unexpected wave smacks you down and stuns you before you can dive below its crest and avoid the strong impact.  I was devastated.

It took about 72 hours to adjust.  At my regular Friday night dinner with friends my buddy said, “Steve you seem to be hearing much better tonight. We did not have to repeat anything. What are you doing?”   I told him I was wearing new hearing aids which he had not noticed.  I hear better through my stethoscope than I did before.  When I walk my dogs or take my daily walk I hear the birds chirping, the children playing, the sprinklers initiating their watering cycle. These are all sounds I had forgotten about.  At lectures and movies I am hearing clearer. The blue tooth connection to my cellphone makes calls easier to complete.  My new trifocals allow me to read up close far more easily and see distance much better.

As a physician and geriatrician, I stress eye exams, hearing tests and evaluations to determine our ability to stay independent and functional. I cannot explain why I was so resistant to applying the same principles to my own health.

My day-to-day life has improved markedly with the hearing enhancement and new glasses. I hope my patients and students will look at my stubbornness and reluctance to accept healthy age-related changes as an example of how hard we cling to our independence and how reluctant we are to give up pieces of it even when we know it is for the best.

Restorative Dental Surgery, the Elderly and Shared Decision Making

A wise professor of medicine always told me as a young physician, “Eighty-year olds are to be revered and not messed with.”   This is especially true for those 90 or older.  Here in South Florida there is always some senior citizen telling us today’s 80 is yesterday’s 60 and today’s 70 is yesterday’s 50.  It just isn’t so.  I see this erroneous belief of the elderly having the healing power of younger individuals   highlighted in the area of cosmetic and restorative surgery and dentistry in my affluent youth-seeking community.

We all want to look our best. In many cases this requires pulling teeth, placing implants and covering those implanted posts with crowns to produce that young smile and maintain a chewing surface. Most times it’s better to do less.

Pulling rotten teeth, obtaining dentures or using a bridge and practicing meticulous hygiene on the gums may be the better course.  Don’t tell this to 91 year old Hal who is mildly cognitively impaired, and his loving caring daughter who sent him for extensive dental surgery.   This gentleman had an artificial aortic valve placed by the less invasive TAVR method a few years back. He was required to take antibiotics before the procedure to prevent a heart valve infection as per the guidelines of the American Heart Association, American College of Infectious Disease and American Dental Society.

His former physician taught infectious diseases in a major academic center and felt he needed a longer course of antibiotics than the guidelines recommended.  Several weeks later he had intractable back pain and severe diarrhea. He was diagnosed with antibiotic related colitis and treated appropriately with oral vancomycin. The back pain was more problematic.  His daughter self-referred him to a physical therapist who could not find a way to obtain relief.

He came to me as a new patient with severe back pain and, after hospitalizing him for pain relief and with the assistance of an infectious disease expert, we were able to document an infection of the heart valve and an infection of the back disc space causing the excruciating pain. The infection originated with the disturbance of his gums and teeth during the dental work. He received 10 weeks of intravenous antibiotics and four months of physical therapy at a skilled nursing facility before he was able to return to his home with help.

At that point he and his family were advised to limit the dental work, follow antibiotic guidelines for the work being done and clear the work and antibiotic regimen with his internist and local infectious disease physician prior to undergoing non-life-threatening non-emergency procedures. It was no surprise however when I received a phone call from his aide saying he had diarrhea after a dental procedure and the daughter chose to use the prolonged antibiotic protocol that the former doctor had recommended years ago.  One of the aides had given the patient immodium several days prior to the call to me to slow down the diarrhea so now the body’s natural clearing response to a pathogen had been delayed by a medication choice.

He was examined and found to have a mildly tender abdomen. A digital rectal exam identified microscopic blood in his loose stools.   A stool evaluation identified clostridia difficile as the causative agent of his antibiotic related colitis. He is now back on medications for this entity and hopefully it will control the disease while we keep him hydrated and out of the hospital again.  More is not always better. The frail elderly need to be revered and not messed with. Palliative rather than aggressive therapy may be best in this patient population.

Mrs. Sommerville is another example. A beautiful mid-eighties woman, she looked years younger. She signed up for pulling all her teeth on her lower jaw and recreating her smile with implants. She was given an opioid medication for pain control. Post-surgery she ran a fever for several days.  After taking the opioid for pain relief she fell and hit her head. She was referred to a hospital ER where she was noted to have a subdural hematoma from the fall (blood on the brain) and positive blood cultures from the oral bacteria which seeded the bloodstream during her dental procedure.  I suggested transferring her to a facility that had the neurosurgical capabilities to treat the complications of a subdural hematoma. The patient did not want to be transferred and, in the era of shared decision making, the consulting neurologist was comfortable obtaining serial MRI scans to observe the brain bleed and follow its course.  The MRI’s didn’t get done on a timely fashion because the patient had just had hair extensions placed by her hair stylist and the metal clips were not permitted in the magnetic range of the MRI machine. The patient refused to allow anyone but her hair stylist to remove the extensions and his schedule didn’t permit his visit to the hospital for 48 hours.

Both situations exemplify the zest for life and vitality human beings exhibit. In both cases, less would have been preferential.

I suggest that as we get older before considering cosmetic procedures, we discuss it with our medical doctors and review the pros and cons and alternatives. I am not accusing the dentists of being too aggressive but maybe too accommodating with no real geriatric training to help them in their clinical decision making.

Hypertension Guidelines Versus Life Experiences

One of the advantages of practicing clinical medicine, and seeing patients daily for many years, is you develop your own long-term study regarding certain medical health issues. In the area of hypertension, I have been taught by the best since my internship with pioneers such as Eliseo Perez Stable and Barry Materson at the University of Miami affiliated hospitals, Jackson Memorial Program, ensuring that their trainees were up to the task.

The goals and guidelines have changed. Lifestyle changes including salt restriction (sodium chloride), weight reduction, smoking cessation, reducing alcohol intake and regular exercise will always be mainstays of non-pharmacologic treatments.  We used to be taught to keep the systolic blood pressure at less than 140 and the diastolic blood pressure at less than 85.  These numbers have changed over the years, having been lowered, with everyone over 120 systolic now being classified as having some degree of increased risk of cardiac, cerebrovascular or vascular disease and hypertension.

We originally were taught to start with a diuretic and keep raising the dosage until the blood pressure was controlled or the patient developed adverse effects. We learned that when we used one medication, pushing it to its limit inducing adverse effects along the way, patients just stopped taking their medications. This resulted in a change in strategy to using several medicines each with another pathway to controlling blood pressure but all at a lower dosage which did not produce any ill feeling adverse effects.  The downside of more medications was additional costs and more pills to remember to take.  As hypertension experts pushed us to lower systolic blood pressure to 120 or less in our geriatric population I was concerned that lowering the pressure that much would again create adverse effects which were as or more troublesome than the risk  of having a BP between 120 and 140 systolic.  An article in JAMA Internal Medicine looked at this issue. They looked at patients over 65 years of age who were hospitalized for non-cardiac related problems and whose blood pressure was over 120. They studied these patients at Veterans Administration hospitals over two year period. Patients with elevated blood pressure above 120 were given more medications and higher dosages to bring their pressure down to meet the more stringent guidelines. The result was that there were no fewer cardiac events than anticipated and no better blood pressure control at a year.  In addition, these patients suffered from an increased number of re-admissions to the hospital and “serious“ adverse events within 30 days.

The new guidelines for blood pressure control may be applicable in a younger healthier population.  In the geriatric population we may need to readjust our goals to account for the physiologic changes that occur in men and women who age in a healthy manner. More specific data on why there were more re-admissions and what serious adverse effects occurred needs to be made public to determine if the effort to tightly control blood pressure is to blame.