Sometimes Best Not To Know

The best thing that happened to Bob this week was he turned 84.

Otherwise this has not been a good week for him. Sometimes it's best not to know things. In spite of his limitations there's one thing he can do and that's find the results of his lab work on the computer. He had blood drawn this week before seeing his hematologist next week. He called me to the computer to see the results. There was a lot of red (low) on that report, more than usual. He's always kept his hematology reports clipped together but now he can't find them.  I would need to compare those reports with this last one to have a better idea what may be going on. Our biggest concern is the platelet count and it had dropped several points.

This is what I object to about immediately being able to see test results. As patients we think we have to know everything.  I don't think so. At least not immediately. Now here we sit with this report and no qualified medical person to explain it.

I have chosen not to worry until after he sees the doctor next week. Bob is concerned and there's not a lot I can do to ease his mind. We would have been better off not knowing before seeing the doctor. Bob may well be wasting a lot of good worry time.

The coffeemaker situation is still unresolved. He was no better operating the new coffee pot. That also ended in frustration. Daughter is sending him the least complicated Keurig made. Hopefully just off/on and press one button. I couldn't buy it because he would have been upset but she can send it to him as a gift and he'll think she's just wonderful.

He's flooded the new ice maker twice. It's hard to see the fill line. This morning I took a black magic marker and drew a line where he is supposed to stop with the water.

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It's possible to go without air conditioning here. We don't have too many really hot days. I'm just a wimp and choose not to run a chance on being hot.

Our jihadist recycling son who's busy saving the earth has chosen not to have air conditioning in their home. They use ceiling fans and other things but don't have an air conditioning unit.

Grandson has a cello lesson in the morning so I received a text from son asking if they could meet the teacher here for his lesson since it would be cool at our place.

I'm all for keeping the cello player cool but it means I've got to leave the house and entertain grandpa the duration of the lesson. My choice would be a coffee shop to relax, maybe read a newspaper or magazine. Sorry that won't work, Bob would be up in ten minutes wanting to know if it's all right for us to return home.

The only thing I've been able to come up with is grocery shopping. I try very hard to stay out of grocery stores on the week-ends to give working people space to shop. I may have to go against my convictions in the morning.

Prescription Drugs Price War

The cost of prescription drugs is a big issue in providing healthcare in America.

"The chief medical officer, Steve Miller, at Express Scripts, the largest pharmacy benefit manager in the U.S., has been essentially auctioning off his 80 million customers to the drug companies that will give him the best deal.

Express Scripts and its rivals including CVS/Caremark and OptumRX manage prescription drug coverage for insurers and employers.  They're trying to spark price wars among drug makers by refusing to pay for some brand-name medications unless they get a big discount.

The result is that average costs for many drugs are falling.  At the same time, consumers are being forced to change medications, sometimes to brands that do not work as well for them."

This year more than half of all patients will have a prescription excluded from coverage.

"Express Scripts pioneered a strategy two years ago, when it announced it would no longer pay for 48 brand-name drugs.  Right out of the gate it took on some big-name products, such as Advair - the blockbuster asthma drug made by GlaxoSmithKline, now known as GSK."

"Advair's price had risen more than 20 percent in 2013... Then on Jan. 1, 2014, Express Scripts tossed Advair off its drug list and moved its customers to rival asthma drug. Symbicort."

"The results were immediate.  Sales of Advair dropped $1.8 billion that year.  The prices of both Advair and Symbicort fell 20 percent in 2014 and are still falling.  Advair was restored to Express Scripts' formulary last year."

What would you suggest is the best way to bring the cost of prescription drugs down?

Medicare vs VA Drug Formularies

Well rats, the Republicans are having another tantrum, this one involving the president's proposed budget. I'd like to call your attention to a few things that affect senior citizens that they're refusing to consider.

The Center for Medicare Advocacy laid out the impact the president's proposed budget, if passed, would have on Medicare drug policies.  I'm using the short version posted on Time Goes by.

~ Restore drug rebates for brand name and generic drugs to beneficiaries who do not receive the Part D Low -income subsidy (LIS)

~ Greater transparency in drug pricing

~ Negotiate prices with drug manufacturers for biologics and high-cost prescription drugs covered under Part D.

~ Close the Part D doughnut hole in 2018 - two years earlier than under current law.

This NYT article, titled "The Reason Medicare is a Lousy Drug Negotiator" is worth reading.

"The real problem is that Medicare can very rarely say "No way" to a drug company.  Medicare beneficiaries wanted the program to cover most drugs that older people would want to use.  So Congress put in place rules that strengthen the hand of the drug companies in negotiations."

"The government does have one program that can say "no" to drug companies, and it gets much better deals than Medicare.  The Department of Veterans Affairs negotiates hard with drugmakers. But it is also bound by fewer rules than Medicare, and one result is that it covers far fewer drugs."

From personal experience we have found the drug formulary for the military to be very different from the formularies of Medicare and private insurance companies.

Last year when Bob's twin was dying he needed a drug that was prohibitively expensive, more than $5,000 a month.  It was not covered by Medicare or his insurance company.  Fortunately he had served in the Navy and qualified to go to a veterans hospital.  He got the drug there for free. What if it had been his wife that needed that drug, where would she have turned for help?

I find all this troubling.  How about you?

Medical Titles

I don't know about you but I'm confused about who is treating me these days when I see my doctor.  In days of old it was more simple, there were nurses and there were doctors. I did not know enough to check education, certifications, and exams.

I had read about Physician's Assistants (PA) and thought that was a good move given the predicted shortage of physicians.  I am okay with seeing a PA for my little aches and pains.  They are also good for monitoring chronic conditions, and that is what I see when I go to one of the urgent care clinics.

Then the day came when I was told my appointment would be with a Nurse Practitioner (NP).  Something new, how different was that from a Physician's Assistant (PA)?  Hard to say.

Next I noticed name tags with Medical  Assistant (MA).  Who were they?

I decided it was time for me to do a little investigative work. I can only give a brief amount of information in this space but perhaps it will be enough to assist you in doing your own research.

Physician Assistant (PA)
Must have a master's degree, or a doctorate of some kind. They are qualified by taking a national certification exam and practice under a trained physician.  They only work when a trained physician is on site to supervise.  They're great in clinics and urgent care, one physician can supervise several.

Nurse Practitioner (NP)
Also must have a master's degree, or doctorate of some kind. They also are qualified through national certification exams. Nurse practitioners are generally more focused to a specific population, such as pediatrics or geriatrics.  They can also carry out some tasks of healthcare without supervision. They can work alone in certain settings.

Bachelor of Science in Nursing (BSN)
Have completed a bachelor's degree with training in leadership, management, and administrative roles in addition to courses required to become an RN.  Must pass the national NCLEX test.

Associate Degree in Nursing (ADN)
Must have completed a two year associate degree in Nursing from a college or university program or a Diploma of Nursing from a hospital-based nursing program.  Must pass the national NCLEX test.

Licensed Practical/Vocational Nurse (LPN)(LVN)
Most programs are provided by vocational schools or community colleges.  Programs generally require one year of full time study to complete.  Must pass The National Council Licensure Examination. They do not work independently, but are supervised  by a Registered Nurse (RN).  Physicians and RNs determine courses of patient care.  The LPN/LVN assists in carrying out these instructions.

Medical Assistant (MA)
This one confuses me.  There appears to be two tracks for this one.  The two year associate degree program opens up the widest path to future advancement but there is also a one year program. Must pass the Registered Medical Assistant Exam(RMA).  Most clinics are moving to fewer RNs and more MAs.  The salary for an MA is much lower than for an RN.

Certified Nurse Assistant (CNA)
Training lasts approximately eight weeks.  Programs usually offered through vocational schools and community colleges.  Upon completion of program must register as a nurse assistant with their state health department and pass a written competency examination.  These are the people we are familiar with in the hospitals that we refer to as nurses aides.

I have only listed a few, perhaps the more common ones you see around clinics, hospitals, and labs but the list goes on and on.

Scarcity of Geriatricians

This week Ronni Bennett wrote about The Scarcity of Geriatricians on the Time Goes By blog. After reading her post I feel grateful we were able to get Bob under the care of a geriatrician.  Apparently they are not easy to find and their practices are full if you do find one.  She refers to an interesting article in the New York Times.

I won't cover ground here that she covered in her blog but I encourage you to read her post.

What I want to talk about here is what we have experienced with care under a geriatrician as opposed to a regular family practice physician.  A geriatrician is a physician already certified in internal or family medicine who has completed additional training in the care of older adults.

Bob's geriatrician is a woman from Slovenia so there is perhaps some cultural influence in the care she gives.  Here are just a few things I have noticed that are different about her care.

1) She is not in a hurry.  You get as much of her time as you need.  That said, you pay for this by sometimes waiting a while to see her.  She's often not on time but you know when she gets to you she will give you her full attention.

2) She has a different approach to medications.  Medicines sometimes act differently in older people.  She talks about studies of senior adults taking a drug, not studies of the general population taking it.

3) There is a psychological difference in how she approaches the patient.  More awareness of what may be going on mentally in an older patient.

4) She believes in what she calls "a tincture of time."  She uses that phrase often.  She believes "a tincture of time" is often good medicine. That may be cultural but I use that term often myself.  I also believe "a tincture of time" takes care of a lot of things.

5) She believes in keeping it simple, no more than is necessary.  Too many medications and you often  get additional problems.

6) She speaks in a loud clear voice, mindful older people often have hearing issues.

7) Her nurse calls to follow up.  Once Bob was in the emergency room and we got a call from her office the next day when the ER report reached her office.

8) The first time Bob saw her was shortly after the death of his twin.  She took both Bob's hands in hers and told him she was sorry about him losing his brother and knew he was grieving.  Said there was not a pill she could give him for being sad but he would begin feeling better.

Keep in mind she is in our community hospital owned clinic, not in private practice.  Geriatricians are a good thing, we need more of them.

Medical Contact Center

It seems the harder I try the behinder I get in keeping up with new developments in the world of medicine.  This morning I picked up a copy of The Hillsboro Tribune, a local paper I seldom stop to read.  This article jumped off the page, a 400-employee 'contact center' is coming to my town.

It seems Kaiser Permanente is responsible for this facility that will house all of the region's appointing and advice nurse services, as well as a physician-led virtual care team.  That's a lot of stuff.

They seem to think bringing all these services together in one facility will give their members a seamless experience whether they are calling for an appointment, need to talk to a nurse, or schedule a virtual visit with a physician.

I was most interested in how these virtual visits with a physician will take place.  It seems an ambulance service will dispatch paramedics for nonemergency visits to the patient's home where the paramedic will facilitate video consultation with the physician stationed at the contact center.

No in-person services will be provided through this center.  If you wish to speak face-to-face with someone you will still need to visit a medical facility.

First I have heard of such a thing.  Makes my brain spin.  What are the people up the chain of command at Kaiser Permanente up to with such a service? No doubt they expect it to bring down medical costs.

Now about that virtual visit with a physician, what do you think that will cost?  Doesn't sound cheap to me.  Is that cheaper than an ER visit?  Better than an ER visit?

We don't have coverage with Kaiser Permanente but I think it is kind of everything in one package.  This will no doubt work for them.  Would it work for us with our insurance coverage, I do not know. I question if it would pay for a virtual visit with a physician but maybe so.

Keep your eyes open, change is happening all around us.  What do you think of this kind of center?

Obamacare Meetings

A few months ago I received a phone call asking me to meet with a group of medical providers, hospital staff, and patients to discuss the Affordable Care Act's requirements and how they were being implemented by our community hospital.

As you can imagine I found that exciting and it was more fun than I could ever have imagined.  We meet every three months to discuss different issues and hear a report on the progress made on prior issues we've discussed.

This is education in the fast lane for me.  It gives me a chance to see the Affordable Care Act through the eyes of the hospital and what they're doing to meet the requirements.  Very interesting.

I get to see through the eyes of clinic and hospital staff the issues they're dealing with every day.  Many of those issues have nothing to do with the Affordable Care Act but the discussion then turns to anything in the Affordable Care Act that might help in managing those issues.

And, I get to hear other patients experiences, some good and some bad.

In March we will discuss patient medications.  Oh my, what a nightmare.  I can promise you no solutions will come from that meeting but we'll gnaw around on the topic for a while.

The Affordable Care Act is an enormous piece of legislation with so many pieces it would be impossible to put the puzzle together to see the whole picture.  I know of no one who thought this legislation was all that it needed to be at the time it became law.  It's a working piece that will hopefully become better with time.

It's in everyone's best interest if we work together to make healthcare work in this country.  When I see congress voting as many as fifty times to repeal this legislation I get angry.  The reason I get angry is these people know when they call these votes that their vote will be vetoed by the president and they don't have the votes to override his veto.  Wouldn't it be smarter to spend their time looking for ways to make the current legislation work better?  Healthcare should not carry a political party label.

Concierge Medicine

I noticed our family practice doctor had become frustrated and angry with the financial side of medicine in this country.  At the time I didn't think too much about that but I should have stopped right there and changed physicians.

We liked this young man, or at least we had at one time.  It became apparent once he went into private practice he was not capable of managing an office.  He began to blame others for his problems.  He felt he had been misled into family practice medicine when specialists were making a lot more money than he was seeing in his practice.  He was angry about Medicare, and insurance companies in general.

In time I received a phone call from his office inquiring if we would be interested in retainer fee/membership medicine.  Next came the letter informing us our doctor was changing his practice to this kind of medicine.

The thing that quickly grabbed my attention was he would no longer accept any forms of insurance.  Medicare/Medicaid claims cannot be filed by the patient so even if we'd been inclined to stay with his practice that alone would have been a deal breaker.

For a retainer fee he would be offering some services each year but anything above that the patient would pay up front and file their own insurance.

Knowing this young doctor I knew he was all about a more lucrative practice for himself but I also knew he preferred to practice preventive medicine.  He did not enjoy treating chronic conditions.

While I have no doubt the frustration level among doctors is high over insurance and Medicare I did not see the masses rushing to concierge medicine.  Doctors in our medical community were puzzled over our doctor's decision.

At this point I lost respect for our doctor.  I also felt bad for him because I felt his choices were going to disappoint him and lead to more anger and frustration.

If his choice worked he would have set up the following things:

1) Set in motion a two-tiered system that favored the wealthy.
2) He would no longer see the elderly or the poor as he would not accept Medicare/Medicaid.
3) His practice would be smaller allowing the time needed to care for his retainer patients.
4) He would not see patients with chronic illnesses as they must rely on insurance.  Why go to him and have to file your own when doctors' offices all over town file insurance for you?

We're now some two years out from all this.  His practice has gone bankrupt and my understanding is he's left the area.

My next post will be about choosing a new doctor.

Aging Eyes

When I was about six years old both my parents came home wearing new glasses.  I was impressed and made wearing glasses one of my life goals.

By the time I reached forty wearing glasses was no longer one of my goals in life but they began printing paper items in smaller fonts and I was forced to take a look at non-prescription reading glasses. I loved them.  I had them in many colors and in every room in the house.  I could push them up into my hair when not in use.

Then things got serious, no more reading glasses, it was trifocals time.  For the next thirty or so years I wore those, and they were not nearly as fun as wearing reading glasses.

Eventually aging eyes caught up with me and it was time for cataract surgery.  I learned if I paid the $1,000 Medicare would not pay on a lens to correct my astigmatism I could almost certainly go back to non-prescription reading glasses.  I was excited.

I had myself a good time at the $1 store in those early days after surgery.

Then I became more selective.  I like the very narrow ones. I was no longer shopping at the $1 store.

Then it was on to some online shopping.

The difference these days is I can no longer remember where I laid my glasses and my hair's now too thin to hold them if I push them on top my head.  I lost a pair I'd stuck in a vest pocket.  I've now ordered this item to wear when I leave the house that will hopefully keep my glasses safe when not on my face.

I've also realized it's too much effort to keep up with multiple pairs of glasses.  Most of these are now relaxing in a drawer waiting for the opportunity to be passed on to someone else having cataract surgery.
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A fun article: Jon Favreau, Speechwriter