Affordable Care Act and Ramifications Discussion

Parent Cafe
1701

<p>“My D saw one mental health professional who didn’t seem to collect from her as she left, didn’t know what charges were “allowable”, didn’t seem to understand about deductibles.”</p>

<p>If my kid went to the doctor by herself, she would not know any of what you mentioned (in fact, I am grasping barely enough). So your D knows a lot more about this stuff than the common adult. Such knowledge comes from being practically involved in such matters.</p>

<p>“A very quick google showed many reputable institutions accepting the possible link between Heliobacter and stomach cancer. Maybe I’ll go look again.”</p>

<p>I am curious if I have a recurrence of ulcers, would anyone prescribe antibiotics these days? Trust me when I say Antacids are mostly useless against the pain.</p>

1702

<p>^ Ah! I think I see. I wrote down what she should say and ask. I sent copies of “EOB’s”. My office manager taught me that. You are right if you are saying a lot of people don’t seem to understand their benefits. But office staff should; no? They are losing a lot of money. Or maybe not.</p>

<p>And I just re- read post 1665, and the ones leading up to it. I didn’t see that you said co-pays where collected (I was supposed to be working my “day” job!). That is all we usually collect, unless we can find out about deductibles before the visit starts. Sometimes folks change their mind about being seen! </p>

<p>My D may have visited my office once in 15 years, to help paint.</p>

1703

<p>If you are talking about me, I don’t contend that doctors “don’t know what they are doing.” I do however think that they, like all of us, are vulnerable to cognitive biases that mean they make cognitive errors. And I’d like to see more standards and guidelines to rein in the fact that a lot of medical decisions are based, essentially, on medical fashion rather than medical facts. </p>

<p>If you Google “practice variation” you discover articles about how medical practice varies by location, in peculiar and unpredictable ways not explained by population variation. For example, surgery rates for certain procedures can vary by a factor of ten or more, depending on where the person lives.</p>

<p><a href=“http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/V/PDF%20VariationResearchSummary2013.pdf[/url]”>http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/V/PDF%20VariationResearchSummary2013.pdf&lt;/a&gt;&lt;/p&gt;

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1704

<p>Somehow from where I sit, that has as much to do with the market as it does cognitive bias. I am not that familiar with the decision making for those procedures, but I imagine when the risk-benefit ratios is okay, it’s covered, and it’s what everybody in your neighborhood or favorite forum is recommending, you pick your battles.</p>

<p>“Wide Disparities in ADHD Treatment Suggest Flawed Management of the Disorder”
<a href=“Wide Disparities in ADHD Treatment Suggest Flawed Management of the Disorder”>www.prweb.com/releases/2013/8/prweb10997025.htm</a></p>

<p>Fortunately, or not fortunately, I don’t mind tilting at a few windmills.</p>

1705

<p>CF- I actually refer to a trend in this thread, all along. From out to collect as much from us as they can, to unneeded surgeries on the elderly, to “medical fashion.” And more.</p>

<p>I get the point about practice variation, but believe we should also advocate for our own interests. I do worry about those unable to, unable to even broach many of the questions we’ve discussed on this thread. But here, we should be qualified to learn and question.</p>

1706

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I was under the impression that the antibiotic treatment was part of the current standard of care… but I might be mistaken. But all you have to do is look up the words “antibiotic” and “ulcer” on Google scholar and you can pull up an array of studies. From the title of one, it does look there is an emerging problem of antibiotic-resistant strains of helicobacter.</p>

<p>Here’s what I found on the CDC web site:</p>

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[The</a> Key to Cure | CDC Ulcer](<a href=“http://www.cdc.gov/ulcer/keytocure.htm]The”>http://www.cdc.gov/ulcer/keytocure.htm)</p>

<p>See also: [Peptic</a> Ulcer Treatment - Peptic Ulcer Health Information - NY Times Health](<a href=“Well - The New York Times”>Well - The New York Times)</p>

<p>Is it possible that you were tested for the presence of the bacteria and none was found? The piece that I didn’t mention is that a doctor would generally take a culture first before prescribing the antibiotics. </p>

<p>I’d note that I am not a doctor – my background is in law. I am offering this as an example of a situation where a treatment emerged for a common disease, but roughly a decade passed before there were enough controlled studies to lead to what I thought was a medical consensus. The point isn’t really to discuss pros and cons – in this particular example, I don’t even think it would have been an insurance problem, because the treatment involved common antibiotics. I doubt that insurance companies pay much attention to prescriptions for short-term antibiotics, given that they can be validly prescribed for all sorts of infections, and sometimes the antibiotic regimen is part of the process of diagnosis.</p>

<p>The point is, things are continually changing and there is not a wide body of research to support everything. It can take many years for the research to be done, and in some circumstances there isn’t anyone doing research because the condition needing treatment is too rare or unusual to gain attention.</p>

1707

<p>Doctors might prescribe different meds for patients with the same ailment because patients are different from each other. Maybe one is on other meds that interact badly. Maybe one has sensitivity to inactive ingredients. Or has trouble swallowing large tablets, or is deathly afraid of needles. Or needs to stay away from narcotics because of addiction issues. Or they can’t tolerate certain side-effects. Maybe they’re not compliant and won’t take meds as prescribed. The list goes on and on. That’s just meds. Now add in all the possible treatments and surgeries…</p>

<p>“The internet” doesn’t know an individual patient. In my case “the internet” provides the basis for some discussions with my doctors, but I don’t use it as a substitute for my doctor’s medical expertise. If I don’t trust a doctor’s expertise, I find another doctor! It’s up to me to do some research, listen to my doctors, and then make my own decisions about treatment and what I may or may not pay for out of pocket. And yes, I DO pay out of pocket for treatments I feel are appropriate if my insurance won’t pay.</p>

<p>And still, I may not be getting the “best” treatment, because nobody’s perfect, even me (shocking, I know! :D)</p>

1708

<p>I would want my doctor’s opinion on information I found on the internet too – but at the same time, I would also be skeptical if my doctor told me that she hadn’t heard of something or knew nothing about an emerging treatment when there was a lot of documentation available. When I refer to using the internet, I don’t mean WebMD or some blog – for a medical issue, I’d go straight to Google scholar or PubMed. </p>

<p>I’m not saying that I expect my doctor to know everything – but I want a doctor who is at least keeping up with new developments, or willing to look into something that I suggest or have a question about.</p>

1709

<p>Back on topic – Obamacare/ACA – Starbucks says that it’s employee insurance benefits are “non-negotiable” and will continue whatever added costs might be entailed under ACA. Money quote: “It’s not about the law. It’s about responsibility…” See: [Starbucks</a> CEO: We won’t cut benefits because of Obamacare - Aug. 27, 2013](<a href=“http://money.cnn.com/2013/08/27/news/companies/starbucks-obamacare-schultz/index.html]Starbucks”>Starbucks CEO: We won't cut benefits because of Obamacare)</p>

1710

<p>And I received the first ACA-related mailing from my provider- no rates, but the basic elements covered.</p>

1711

<p>"Is it possible that you were tested for the presence of the bacteria and none was found? The piece that I didn’t mention is that a doctor would generally take a culture first before prescribing the antibiotics. "</p>

<p>I don’t remember being tested for anything but did get lectured on standard types of foods I might be eating causing acid production. I write it up to being too busy to research doctors and ending up with a quack who was disdainful of my ethnicity (the gall of the guy the writing it off on my eating habits) back then.</p>

1712

<p>Well, here’s how it goes: ask if you were tested. If not, go for it.<br>
Don’t know what you tried, but one doc suggested antacids can be counter-productive. The brain senses the reduced acid levels and starts triggering. But it’s all complicated by the fact that so many things can cause or exacerbate. Find out if you were tested for the worrisome H Py that could be linked. </p>

<p>I agree PubMed is good, you can find the studies- some more informative than others.</p>

1713

<p>It was a very long time ago. I know for sure I was not and I was given over the counter prescriptions. These days I have a phobia about getting tested for anything!</p>

1714

<p>Shrinkrap says:

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<p>Yeah sure. Women in Redding are begging their doctors to take out their uteruses. Women in San Clemente are asking surgeons to lop off both their breasts. People in Watsonville, but not people in Lodi, are clamoring for unnecessary back surgery.</p>

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<p><a href=“http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/V/PDF%20VariationResearchSummary2013.pdf[/url]”>http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/V/PDF%20VariationResearchSummary2013.pdf&lt;/a&gt;&lt;/p&gt;

1715

<p>“Women in Redding are begging their doctors to take out their uteruses. Women in San Clemente are asking surgeons to lop off both their breasts. People in Watsonville, but not people in Lodi, are clamoring for unnecessary back surgery.”</p>

<p>Ouch. Is that what I said? My bad. My breasts and uterus are on the table. I didn’t see that in your examples! Are those procedures in the links? Glad I added the qualifier ( that wasn’t quoted.). I will withdraw my comment for now, until I get some sleep, and figure out if both your comment AND mine can be true. </p>

<p>FWiW, I DO appreciate someone else making the “rules” at times. Like the JV220 stemming the tide of the pressure to prescribe atypical neuroleptics for kids in foster care.</p>

<p>Rhetorical question. Don’t answer. This is not the place. </p>

<p>And I do get patients calling “clamoring for back surgery” , coming for mental health clearance, or after. I do not accept them if I can avoid it, because I don’t know what to say. Cardinal Fang, what would YOU say? They are suicidal. They are hopeless. They feel what they have been offered won’t work. Are you are saying they have been misled or coerced?</p>

1716

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Well, a bacterial culture is pretty simple. They actually have a breath test for this particular bacteria. Here is a link to a New York Times article announcing FDA approval of the test back in 1996: <a href=“http://www.nytimes.com/1996/09/25/us/new-breath-test-for-ulcer-causing-bacterium.html[/url]”>http://www.nytimes.com/1996/09/25/us/new-breath-test-for-ulcer-causing-bacterium.html&lt;/a&gt;&lt;/p&gt;

1717

<p>I find these discussions fascinating, and enjoy the added vantage of a physician’s perspective.</p>

<p>I will say this, because something shrink rap said to me really resonated:</p>

<p>When I was dx’d with the facet joint syndrome I mentioned previously, which by that point had cause a lockup that inflamed all my ligaments from my spine to my right ankle and also triggered non-stop sciatica pain, I literally wanted to put a gun to my head. I honestly could not form a rational thought through the pain. I could not walk upright without a cane. At first, nothing reduced the spasms.</p>

<p>If the osteosurgeon had told me to have both legs amputated, I would have. I actually WANTED surgery, because I reasoned that the removal of these bone growths in the channel would stop the lockups. </p>

<p>The surgeon very carefully expressed his reservations about the risks of the surgery, which he said was very long and complicated due to the multitude of locations, and actually directed me to the research that showed whether it worked or not would be a crap shoot, and the newer research that suggested alternate approaches.</p>

<p>He’d said in ten years, he expected that less invasive and risky procedures would be available (and he’s right, but now I don’t need them…it’s still nice to know they’re there.) Now, this guy was Harvard-trained and top in his field. And he was nearing the end of his career in terms of age, and talked about his experience and seeing unsuccessful outcomes after surgery. If he’d not been such an “authority” on the subject, I might have balked more and pushed for surgery.</p>

<p>So I can certainly see where physicians are influenced by patient demands under duress, because I almost resembled that remark :)</p>

<p>Unintended consequences seems to be a wiley undercurrent in healthcare. On one hand, you can’t be a Luddite in the face of new treatments or said treatments never have a chance to show efficacy. heliobacter py being an awesome example. On the other hand, its gotta be difficult to sort the poppy seeds from the dirt in terms of the plethora of seemingly disconnected and offten funder-influenced medical research.</p>

<p>ACA seems to be attempting to bring some uniformity to access that may inadvertently also bring some uniformity to actual approaches in care in terms (hopefully) of both efficacy and cost-efficiency. But uniformity does mean that outlier treatments and situations can suffer and damp down an innovative thrust in treatment.</p>

<p>As a taxpayer, I’m not sure what to think. I don’t want to pay for ineffective stents, but I do want to pay for antibacterial treatment for digestive conditions :slight_smile: I want to see innovation in the system, but I’d also like to see more conservatism in the “first do no harm” arena :slight_smile: I don’t know what it would take to get there.</p>

1718

<p>Cardinal Fang (post 1690): my point (and obviously I should have been more clear) was that expensive new-fangled treatments can be long-term cost-savers. Rituxan in 2000 was considered a treatment of last resort because of the cost (at least, that was the case in my husband’s oncologist’s practice at the time). My husband demanded it and got it despite our 20% co-payment (so we went out of pocket for thousands of dollars). It was a decision we haven’t regretted. He does, however, mildly regret the adriamycin (which was an old-line “standard” treatment that was given as an adjunct) because of the lung damage it caused.</p>

1719

<p>kmcmom, I understand that you wanted back surgery or anything that would make the pain go away. But you haven’t explained to me why back surgery is twelve times more prevalent in Watsonville than in Lodi. That looks like doctor fashion to me.</p>

<p>That desperate patients come in asking for surgery is about the patients. That twelve times more patients in Watsonville get these iffy back surgeries is on the doctors, not the patients. That some places have over five times as many coronary bypasses as other places is because not patients in those places are five times more likely to ask for them.</p>

1720

<p>Watsonville. [Watsonville</a> residents top state for back treatment rate | Center for Health Reporting](<a href=“http://centerforhealthreporting.org/article/watsonville-residents-top-state-back-treatment-rate1118]Watsonville”>http://centerforhealthreporting.org/article/watsonville-residents-top-state-back-treatment-rate1118)</p>

<p>I still say it is important to look for perspective. It’s a short article, but includes this: “In recent years, however, the number of procedures done locally has dropped markedly. According to state hospital data, physicians in the county performed 84 of the procedures in 2008; that dropped to 31 in 2011.”</p>