Here are the 3 most basic cancer screening rules:

1. Men and women, get a screening test for colon cancer starting at age 50. You can do the home test every year, and get a colonoscopy if it is abnormal (see below for more); or you can get a colonoscopy every 10 years; or you can get a “flex-sig” (like a mini-colonoscopy) every 5 years (but it can be hard to find a doctor who does many of these).
The home test checks for microscopic blood in the stool, and a colonoscopy uses a tiny camera to look at every inch of the colon.

2. Women, get Pap/HPV testing every 3 years, starting at age 21 if sexually active, and repeating sooner after any new possible exposure to HPV (the virus that causes cervical cancer, spread by wanted or unwanted vaginal penetration); stop at age 65.
A Pap test looks at cervical cells under a microscope to see if they are normal cells.

3. Women, get a mammogram every 2 years, starting age 50 and stopping age 75.
A mammogram is an x-ray looking for lumps you can’t feel.

The reason these are the most basic rules is that, at the community level, these are the commonest cancers, with screening tests in which we have the most confidence.
(At the individual level, if you have a higher risk for a particular cancer, you may need a different set of guidelines. If you have symptoms, you need fancier diagnostic testing – not basic screening.)

Other cancer screening issues:

~ We used to tell all men to get prostate cancer screening starting at age 50. Then, over the years, we found that screening might be causing more harm than good.
For example, a lot of “relative false positives” occur: you might indeed have a prostate tumor, but it may be unlikely to disable or kill you. A lot of prostate tumors will never make you sick. Screening tests can’t tell you whether you have a harmless tumor or a harmful tumor, so then you are obliged to have diagnostic testing.
Diagnostic testing (biopsy) and treatment (surgery, radiation) have their own serious risks, and shouldn’t be done if you don’t need them. So we don’t screen everybody anymore, but instead have long complicated conversations about all this, to help you decide if you want screening or not.

~ We used to tell everybody to get screened for lots of stuff, a lot more often than we do now, for exactly these same reasons. We used to have more confidence, as a society, that “It’s always better to know,” and that the “War on Cancer” was marching ever onward, saving more and more lives. We’re not as confident in these beliefs now.
If you have good and safe treatments for a cancer, then a little over-diagnosis, with possible unnecessary treatment, is acceptable. If treatment is risky, then it’s not.
Furthermore, we are finding that some cancers are very slow-growing, and it usually wouldn’t hurt you to just ignore them. However, if you test over and over again – while the cancer itself isn’t really changing – any differences you see in the results, may be due to the margin of error involved in your test – your x-ray machine, for example. This can lead to diagnostic testing and treatment that may turn out to be unnecessary, and not worth the risk.
Because of these problems, we keep re-adjusting the screening recommendations – to minimize the number of false positives (false alarms), without also missing true positives (dangerous cancers).

~ Some cancers can be very aggressive and dangerous, and do not cause symptoms until they are advanced and hard to treat, and we do not have screening tests for them, despite many decades of trying. Examples: lung cancer, ovarian cancer, pancreatic cancer. Tremendous amounts of research are still being done on these cancers – on screening (for those with no symptoms), diagnostic testing (for those with abnormal screens and/or probable symptoms), and treatment.

Inevitable, important questions about cancer screening:
If you have a negative (“normal”) screening test, does it mean you definitely don’t have cancer? (If it’s negative, the chances are very very good that you do not have a cancer.)

If you have a positive (“abnormal”) screening test, does it mean you definitely do have cancer? (If it’s positive, it could be a cancer, or it could be a false positive; you would need fancier diagnostic testing to find out.)

If you do have a cancer, is it the kind of cancer that will disable and/or kill you? (Some cancers are easier to characterize than others are. Breast cancer is relatively easy to characterize. Prostate cancer is notoriously difficult to characterize.)

If you get treatment for your cancer, will the treatment disable and/or kill you? (Most treatments for cervical cancer are very simple and effective, and don’t cause other problems. Treatments for many advanced cancers can be quite risky, although not as risky as the cancer itself.)

Whose fault is it that we can’t detect cancer very well?
(People who read biopsies and images, and primary docs who do screening according to the above basic guidelines, have a very high rate of being sued for “missing” a cancer, regardless of their actual skill and experience, and regardless of the inherent limitations of current screening tests. Here’s one example: a colon cancer that was “missed” by the home test, and a lawyer who suggests that only colonoscopies should be done. However, if a patient were to develop sepsis and/or die due to a colonoscopy-related injury, this lawyer could then, with equal justification, ask why a safer and less invasive test was not chosen. Or, if the patient could not afford the colonoscopy and simply did not go when it was recommended, then why wasn’t a more affordable test, with which the patient could comply, recommended, etc. It’s not necessarily the doctor’s/ radiologist’s/ pathologist’s fault – but the law may say that somebody has to pay.)

Whose fault is it that our cancer treatments aren’t very good?
(Cancer treatment still relies on burning, cutting, and poisoning, which is not only counter-intuitive as a means of preserving health, but entails serious risks. Here are some examples of practitioners in trouble, due to this issue. See also “Why haven’t we cured cancer yet?”)

Whose fault is it that we get cancer in the first place?
~ Might be the patient’s: they kept smoking and drinking; they kept eating meat (especially cancer-causing barbecue/grilled meat), instead of lots of fruits and vegetables; they became more and more obese, didn’t exercise, didn’t practice safe sex, and so on… even though they knew better.
(Insurance companies are starting to get more punitive about these factors – they don’t want to pay for the results, even though they’re happy to rake in the premiums every month.)
~ Might be the powers that be: environmental contamination, workplace carcinogens, lack of public health campaigns about risk factors (so people don’t know any better), etc.
~ Might be the luck of the draw: family history, age group, unrelated health condition that makes you vulnerable, etc.

In this context, here comes the latest CDC report.

It shows a lot of what you’d expect: a lot of folks aren’t getting basic screening tests in the first place, and screening and careful follow-up of abnormal results are shamefully poor among people of color, here in our white supremacist culture. (Doctors, including doctors of color, consistently deny that they treat people of color differently than ‘people of colorlessness,’ but the numbers reveal what actually happens.) I can’t get into the issues of white supremacy, unearned privilege, what-is-color/ what-is-race, or the medical one-drop rule, today. What stood out for me in this report was the results for screening that depend on cash money – greenback dollars – filthy lucre.

Among women who don’t have health insurance,
only 38% are getting screened for breast cancer.
Less than half what we’d hope for.
Among women who don’t have a primary care provider,
only 36% are getting screened for breast cancer.
Less than half.
[The consensus target for screening women for breast cancer
(and no, mammograms don't cause breast cancer)*
is that we'd like to screen at least 81% of women who need it.]

Among women who don’t have health insurance,
only 64% are getting screened for cancer of the cervix.
Two-thirds as many as we’d like.
Among women who don’t have a primary care provider,
only 65% are getting screened for cancer of the cervix.
Only two thirds of goal.
[The consensus target for Pap tests is that we'd like to screen
at least 93% of women who need it.]

Less than 25% of men and women got screened for colon cancer
if they had no health insurance, had no primary health care provider,
or had been in the US for less than 10 years.
About a third of goal.
[The consensus target for colon cancer screening is 70.5%.]

The authors remark, “Financial barriers to screening might explain some of the observed disparities in cancer screening rates…”

Ya think?!

If you, dear reader, have financial barriers to screening, please scroll to the bottom for some solutions.

The consensus targets above are from the “Healthy People 2020” program, launched in 2010, which, it turns out, also has targets for access to health care.
Wanted: 84% of people will have a primary care doctor in 2020.
(In 2007, only 76% of people had one. 10% improvement is the goal.)
Wanted: 100% of people will have health insurance in 2020.
(In 2008, 83% did. Universal coverage is the goal.)

What counts as screening?
How do we choose which cancers to screen for?
Why don’t we have more screening tests – or fewer?

Wiki: “Screening tests are performed on persons without any clinical sign of disease. The intention of screening is to identify disease in a community early.”

The condition should be an important health problem. There should be a treatment for the condition. Facilities for diagnosis and treatment should be available. There should be a latent stage of the disease. There should be a test or examination for the condition. The test should be acceptable to the population. The natural history of the disease should be adequately understood. There should be an agreed policy on whom to treat. The total cost of finding a case should be economically balanced in relation to medical expenditure as a whole. Case-finding should be a continuous process, not just a “once and for all” project. –World Health Organization

Considering all ages and races, in 2008 (most recent year these statistics are available):

146.7 men per 100,000 were diagnosed with prostate cancer (about one-and-a-half in a hundred), and 23 per 100,000, who were previously diagnosed, died from it.
(Screening = doctor exam +/- blood test. Problem: “The natural history of the disease should be adequately understood.” Our screening tests seem to find a lot of non-dangerous cancers that don’t necessitate immediate treatment – but we have trouble telling you whether yours is non-threatening.)

125 women per 100,000 were diagnosed with breast cancer (about one-and-a-quarter in a hundred), and 22.5 per 100,000, who were previously diagnosed, died from it.
(Screening = doctor exam and mammogram. Problem: “The test should be acceptable to the population.” I see a lot of women who are suspicious and/or fearful of mammograms, because they use x-rays.*)

59 men and women per 100,000 were diagnosed with lung cancer, and 49.6 per 100,000 died from it. That’s not a great cure rate, eh?
(No effective screening test has been found. All we can really do is look at major risk factors. Only about 1% of people who never smoked cigarettes get lung cancer. Exposure to radon gas, as the EPA estimates is found 1 in 15 homes, increases lung cancer risk by about 50%. Asbestos and air pollution are risk factors; for example, a 9/11 Ground Zero responder, a lifelong nonsmoker, died from lung cancer last year.)

45 men and women per 100,000 were diagnosed with colon cancer (colorectal, technically). 16 per 100,000 died from it.
(Screening = home test and/or colonoscopy. Many patients and doctors don’t know the details about the $7 home test; colonoscopy is heavily promoted instead, but as I mentioned, many people can’t afford it.)

8 women per 100,000 were diagnosed with cervical cancer, and 2.4 per 100,000 died from it.
(Screening = Pap and HPV tests.)

1.7 men and women per 100,000 were diagnosed with anal cancer, and 0.22 per 100,000 died from it.
(“Bionic Woman” Farrah Fawcett was diagnosed with this cancer in 2006, and died in 2009. Screening = anal Pap/HPV tests, especially for people with underactive immune systems. This is a pretty new technology and has not yet been well proven.)

You can see from these statistics that we have to look at pretty big chunks of the population – “per 100,000″ – because the incidence of these cancers is still small. For example, we often think of breast cancer as common – so common that we screen everybody for it – but still, only about one-and-a-quarter women, out of every hundred women, got that diagnosis in 2008.

Only about half a person (!), out of every hundred men and women, got a diagnosis of colon cancer in 2008. It’s common enough that we want to screen practically everybody for it, but it’s not that common, really, in the greater scheme of things.

(Don’t forget, cancer is diagnosed by diagnostic testing, not by screening tests – so these figures are telling us about cancers, not about screening tests. Screening tests can indicate a need for diagnostic testing; we hope in this way to catch a cancer at an early stage, if possible.)

The star of Bewitched died 6 weeks after her colon cancer diagnosis.

By the way, you can find out how many people get cancer in your county by choosing from the drop-down menus at this site.
For example:
Yearly from 2004-2008 (most recent stats available), my county had a higher incidence (rate of new diagnoses) of invasive breast cancer, than the nation as a whole (131 vs. 121 per 100,000).
Cervical cancer rates were so low that only a quarter of counties could analyze their numbers at all (which was true for all the other states I looked at, too).
My county had one of the lowest incidence rates (new diagnoses) of invasive colon cancer – lower than the national rate. Eleven other counties in Oregon had a higher-than-national incidence of colon cancer – almost a third of the counties.

Let’s talk about that “early detection” issue.

The CDC issued a report back in November of 2010, that looked at how many cancers – of the types we screen for – were found early, and how many were found late.
Early cancers are “localized.” They haven’t started invading everything around them yet.
“Late-stage” cancers are those that have already spread, and involve more complicated treatment – classified by “size, multiplicity, depth of invasion and extension to regional or distant tissues, involvement of regional lymph nodes, and distant metastases.”
Regional spread means, for example, that cancer cells are also found in nearby lymph nodes.
Distant spread means that new cancers have started in other areas – for example, cancer that started in the breast has spread to the bones, as well as to the lymph nodes.
(Like the report above, this one didn’t distinguish whether the pathway to diagnosis started with screening, or with symptoms.)

This report showed the following:

~ Yearly during 2004-2006, among all men and women, about 1/2 of colon cancers, newly diagnosed, were already late-stage.
With treatment, the 5-year survival rate with localized colorectal cancer is 91%.
For late-stage cancers, the 5-year survival rate is 70% with regional spread, and only 11% with distant spread.

~ Among all women, about 1/3 of newly-diagnosed breast cancers were already late-stage.
~ 47% (nearly half) of cervical cancers were already late-stage.
The 5-year survival rate with localized breast cancer is 98%. For late-stage breast cancers, the 5-year survival rate is 84% for regional spread and just 23% for distant spread.
The 5-year survival rate for localized cervical cancer is 92%. For late-stage cervical cancers, the 5-year survival rate is 58% for regional spread and just 17% for distant spread.

This report also pointed out that “on March 23, 2010, the Patient Protection and Affordable Care Act” – which many Republicans, Libertarians, and insurance corporations are trying to repeal – “became law.”

How will the Affordable Care Act improve our success with cancer screening?
~ This act requires private health insurers and Medicare to cover the cervix and colon cancer screening tests described above, at no cost to insured patients.

~ The law also expands Medicaid coverage of screening tests, and increases the federal funding to help pay for them – and also funds expanded Medicaid eligibility. You don’t have to be absolutely destitute to get Medicaid – unless your state chooses to make it that way.

“Ensuring coverage of recommended cancer screening, in part by removing financial barriers, is a critical first step in increasing the number of persons in the United States who receive these services. An important next step is ensuring appropriate and timely follow-up of abnormal screening tests which requires a systematic approach to follow-up and surveillance.”
You can say that again.

Henrietta Lacks died from cervical cancer. She is
the most important woman in medical history.

Do you have financial barriers? Solutions:

Colon screening:
You can get a colonoscopy (every 10 years if normal) – for $3000 to 7000 out of pocket (+/- polyp removal and cost of anesthesia, and not counting cost of pathologist analysis of biopsies needed)…
or
You can get the home test (yearly, do it yourself and mail it in to the lab, get a colonoscopy if abnormal) – $7 through my office, thanks to my friendly local lab, for example.
(Ask your doctor if they would bill you for the “client fee” for the lab test. This means the lab sends the bill to the doctor’s clinic – about 30-50% what the lab would bill an insurance corporation. Offer to pay the doc’s office for the test in advance, or put down a deposit [no pun intended!], etc.)
You’d need to go through your personal primary care provider – doctor, nurse, PA, or whomever – for these tests. (You need to have a regular primary care provider.)

Women’s screening:
Although most Internets sources say that a Pap test should cost $25-60 out of pocket, actual people report fees of $75-165, for Planned Parenthood’s discount program, to $300-500+ in specialty physician offices. Actual people also report mammogram costs out-of-pocket of $500-1000, even though the generic “full price” quoted around the Internets is usually around $100.

If you don’t have insurance (or if your insurance won’t pay for screening) and are older than 40, the Oregon BCCP (Breast and Cervical Cancer Program) will provide a free physical exam, Pap test, and mammogram, as well as some basic labs, cholesterol etc. (Income limit examples: a family of 4 must earn $4,656 or less per month; a family of two must earn $3065 or less per month.) A friend of mine is providing these exams at a holistic clinic right up the street; our local independent radiologist does many, if not all, of their mammograms.

If you don’t live where I do, the CDC has a website that can take you to your own state’s or tribe’s lady-screening program: Here.

With women’s screening tests, if not eligible for the BCCP above (e.g., under 40 and no insurance), I do the exam (for cost of office visit), and have my favorite pathology lab bill me the “client fee,” and then I bill the patient for that, $75 for Pap + HPV, currently. (My favorite path lab reports the exact genotype and risk status of any HPV found, not just the two genotypes reported by the corporation down the road. In fact, they can also test for basic sexually-transmitted infections from the same sample, included in the same fee.)

Sometimes a person is able to pay in advance for the Pap/HPV; sometimes they pay me back later, and sometimes they don’t/can’t, for a while… and sometimes, due to a mixup, they get an additional bill from the lab, and get upset… But the primary thing is that we have access to these basic tests.

Our local independent radiologist (see above) charges $99 for a screening mammogram, if you have to pay out of pocket but can’t get into the BCCP.

*Mammograms, following normal screening and/or diagnostic guidelines, do not cause breast or any other cancer, despite what “Natural News” (specializing in spurious correlations and undocumented statistics, but offering $60 enema bags and $500 machines to give tap water “a super wetting hexagonal structure”) and “Dr Simone” (whose spotty resume and solicitation for “Cash Gifts, Bequests, Securities, Real Estate, Life Insurance, Art, Rare Books, Rare Coins, Rare Stamps” may be found on his “PROTECTIVE CANCER INSTITUTE” website) may assert – or any of the others profiting from, or simply manipulating, the hopes and fears of vulnerable people.

Hyperhidrosis (“HI-per-hi-DRO-sis”) is a condition where the sweat glands are overactive. It can affect the whole body, just the armpits or groin, or only the palms of the hands and soles of the feet. 1 to 3% of the U.S. population has it, and it usually runs in families.

I have several patients who have this condition. It can be pretty awful. One of them has a very hard time playing basketball, with his feet sliding around in his shoes. He twists his ankles a lot. Another one owns a restaurant, and always has to worry about glasses, dishes, the telephone, etc., slipping out of her grip.

There are actually 3 kinds of sweat glands in the body. The kind that is overactive in hyperhidrosis are eccrine sweat glands, which control “emotional sweating” and are concentrated in the palms and soles, with fewer in the armpits. These glands have an exaggerated reaction to normal emotional changes. Nervousness about having to shake hands or walk barefoot or stocking-footed in social settings makes this reaction even worse.

Here is what some folks say on the Internets:

“I hated giving high-fives as a kid.”
“I’m currently in college. I can’t take any notes because ill soak the page. I just sit there with my hands tucked away so no one sees.”
“Just simple things like typing on keyboards without sweat building in puddles, using iPhones, petting a cat, etc., can make all the difference.”
“I would always hold my drink in my right hand, this way if I were going to have to shake someone’s hand, my excuse for a cold wet hand was from the glass.”
“How can you tell someone you can’t hold their hand? I was always jealous of couples that could hold hands. I wanted that, but could never do it.”

There are some radical treatments that may be risky, have side effects, and may not even be very effective. These include Botox (botulism toxin) injections, to paralyze the glands, and surgery to cut the sympathetic nerve supply to the area (the “fight or flight” nerve supply). I do not recommend these unless every other option has already failed repeatedly.

Here are some less risky treatments to try:

1. Apply 20% aluminum chloride hexahydrate (prescription, brand names Drysol and Hypercare) nightly to dry skin. Cover (e.g., gloves and socks); rinse off in a.m. After improvement, may apply just twice weekly.

2. Topical glycopyrrolate (an anti-cholinergic medication that dries up secretions in general), 0.5 to 4% cream or solution, compounded in an acidic base. (You need a prescription that you can take to a compounding pharmacy, where they will make this preparation by hand. Insurance might not pay for compounded medications. A brand-name version is not available.) Apply nightly to dry skin and cover (e.g., gloves and socks); rinse off in a.m. May cause dry mouth (since it dries up secretions); stay well hydrated. Do not get in eyes (don’t touch face until gloves are on); causes blurred vision.

3. Oral medications might help, and may be chosen if they are needed for other conditions. Examples: indomethacin for gout or other inflammatory pain conditions; calcium channel blockers for high blood pressure; beta blockers for rapid heartbeat, hand tremors, or migraine prevention.

4. For palm-sole hyperhidrosis, iontophoresis (“eye-ON-toe-for-EE-sis”) can be tried.

~ Iontophoresis causes blockage of sweat ducts by directing a mild electrical current through the skin.
~ Once the sweat output is blocked or interrupted, sweat production on the palms and soles is, often suddenly and dramatically, “turned off.”
~ Iontophoresis appears to alleviate symptoms in approximately 83% of people with palm-sole hyperhidrosis, according to the American Academy of Dermatology.
~ It is safe and simple to perform.
~ The process is repeated every other day for 5-10 days, or until sweating is reduced to a comfortable level.
~ Once the desired dryness has been achieved, switch to a maintenance schedule of once every 1-4 weeks. ~ To maintain dryness, iontophoresis must be repeated as soon as sweating begins to return.
~ Most people report an improvement after 6 to 10 sessions.
~ The feet require a higher voltage than the hands.

~ In some locations, tap water may be too soft for iontophoresis to work. That is, it doesn’t contain enough electrolytes to help the electric current travel through the water and into the skin. Adding about a half-teaspoon of baking soda to each tray of water will correct of this.
~ If iontophoresis with plain water, or water with baking soda, doesn’t produce the desired dryness, glycopyrrolate (see above) can be added to the water. In the majority of cases this works.
~ Do not use iontophoresis if you are pregnant, have a pacemaker or metal implants (e.g., metal joint replacements), have a heart condition, or have epilepsy.
~ Remove all jewelry before iontophoresis.
~ If skin gets dried out, use moisturizer. Cover any scrapes, cuts, hangnails, and irritated skin with Vaseline before iontophoresis, to prevent irritation.

Iontophoresis machines can be purchased commercially ($500-1000) or made at home (~$30). Start by watching these videos that show how to make and safely use a home iontophoresis device:

One 8-minute version, new and improved from the original.

http://youtu.be/bOQfjZ9-Akw – Another version. (The author requested embedding the 10-minute video be disabled, but this is the link.)

Entertaining demonstration of use. Warning: contains a lot of swearing. Starts with about 18 volts (swearing), then reduces it to 12 (with good results).

Written testimony about these setups, from the Internets:

…I placed 3 batteries in a series like the video… When I placed my hands in the water it made me cringe. I guess the shock felt a little too much for me. I ended up only hooking up 2 batteries in a series, which was around 12.7 volts, and when I put my hands in the water I could feel the current, but only for about 2 seconds.
…To my surprise that evening my hands were 50% dry, and the next day stayed that way all day.
…The next day, probably 75% dry, even better than before.
Finally, after the 3rd day… my hands were about 90% dry all day and night.

I had the impression that one could not really treat armpits the same way.
E.g., “Idromed [commercial manufacturer] only recommends for 2mA [milliamperes] max, because of the risk of ventricular fibrillation. And with 2mA, I don’t think you will see great results.”

But I may have been wrong.

“At the moment I’m trialing the homemade ionto, and made up my own underarm devices. First I simply wrapped cotton wool around the wire. Then I started using sponge cloths folded over foil, with the alligator clips attached. If anyone attempts this make sure you only start with a 6-volt battery. I stupidly without thinking made the switch over from treating hands, and used 18 volts. I literally jumped out of my chair. Even 12V is uncomfortable.”
“Armpits require a lower voltage than the hands or feet.”
“For underarm treatments, you’ll need to be especially careful. Make sure that the alligator clips don’t come in contact with the skin. Remove all clothing material with metal, such as an underwire bra, before beginning.”

I am a nursing student… Touching a patient or putting on gloves was a nightmare for me… For 2 weeks, I have not sweat any more, neither my hands nor my feet… I am a totally different person.

It has now been months… I have a completely different life. I’m the same person, but even better. I have always been social, but now I feel unstoppable, because I can hug, shake hands and not worry… I hope those out there will have the chance to experience what a “normal” life is like. It’s amazing.

The stories that people have told about this condition are striking to me in that their suffering always centers around the estrangement they feel from others. To not be able to freely touch another person – stranger, friend, or lover – or to not be able to freely touch a beloved animal companion – is a tragic deprivation, keenly felt every day. To feel that one is irrevocably different – almost indecent, “clammy,” “slimy” – is such a stigma, that people will pursue practically any solution that might lessen it – no matter whether it is dangerous, uncomfortable, or prohibitively expensive. (Fortunately, safe and affordable options exist.)

It teaches us, again, that touch and companionship are essentials of life. They’re not small things.

“…What a ‘normal’ life is like. It’s amazing.”

Every heart sings a song, incomplete, until another heart whispers back.
Those who wish to sing always find a song.
At the touch of a lover, everyone becomes a poet.
– Plato

National: blackmail fails, so insurers forced by law to spend dollars on health care
The National Association of Insurance Commissioners (NAIC) voted unanimously Thursday to finalize new rules requiring insurance companies to dedicate more revenues directly to healthcare costs… The insurance lobby had fought hard to convince commissioners that the draft would harm consumers’ access to coverage.

…Making these rules work will require tough scrutiny of insurance companies’ spending to make sure they don’t use loopholes in the law to pass off overhead costs as health care.

State health insurance exchanges mandated by the health insurance reform law: Who will decide what is covered?
The U.S. Department of Health and Human Services is keeping its hands off what needs to be included in the essential benefit package for state insurance exchanges… The federal department released a bulletin stating that it would not create a prescriptive and detailed list of services that must be included in the package, as states had previously expected. Instead, the department has created four “benchmark plans” that are broad in scope .

…An “essential health benefits package”… includes health benefits and services that fall within ten categories: ambulatory patient services; emergency services; hospitalization; maternity and infant care; prescription drugs; mental health and substance abuse services; laboratory services; preventive services; rehabilitation services and pediatric services.

…The Department of Health and Human Services must create the list of services and benefits offered by the exchange to ensure that health plans being offered are not of lesser value than other options.

…Insurance exchanges are meant to be a one-stop shopping place for uninsured individuals and small businesses to find, compare and purchase affordable health insurance.

So how’s it going?
A nationwide study …closely examines the state laws passed to establish state exchanges set up so far and rates them on four key areas:
How accountable and transparent the exchange will be to the consumers and businesses that rely on it,
how it can negotiate for lower premiums and better quality,
how easy it will be for consumers and business owners to use,
and how stable it will be over time.

Oregon’s exchange earned a B- on the report’s scorecard. Weak points in the current exchange law include… Oregon’s law allows two seats on the exchange board to be filled by health insurance companies and other industry representatives with conflicts of interest. – The exchange is not yet sufficiently protected against the risk of “adverse selection”, in which it covers only less-healthy enrollees and premiums rise unsustainably.

In other news, partial success
Oregon insurance regulators received accolades this week from a U.S. Senate committee… The state stands out for its public involvement, the amount of information it requires insurers to submit and the extent to which it lowered proposed premium increases as a result, according to a recent survey by the General Accounting Office… The $1 million federal grant awarded to Oregon last year has helped lower health insurance premiums by about $25 million or $10 per member per month on average.

…Oregon was only among five states to earn that distinction. The report also found that just 14 states provided consumers with opportunities to be involved in premium rate oversight.

…The state used part of the grant funding to hold a rare public hearing for a proposed 22.1% increase on Regence BlueCross BlueShield individual plan holders in June [2011]. Last week, the Division announced it had reduced the rate increase to 12%.

The Aetna example: how to get fat by eating less
Back when it was the largest private health plan in the country, Aetna downsized its membership by millions but boosted profits… Now it looks to be making a similar – but smaller – move with a planned price increase for many of its customers in 2010.

The company figures it will lose between 600,000 and 650,000 members next year because of the price hikes.

…Simply raising prices probably would not get Aetna what it wants. That actually tends to result in sick people who are more “desperate” for coverage to keep it, and healthier groups to drop it. Instead, Aetna might change benefit designs, scaling back prescription drug coverage, for example, which sicker populations tend to value.

Same thing around here.
March 28, 2011 – Oregon health insurers covered fewer people and made more money [in 2010] than in recent years past… Compared to 2009, Oregon’s top eight health insurance companies covered 1.5 million people [in 2010] – down 14% – and made more than $207 million in net income – more than double what they earned previously.

…Mark Ganz, president and CEO of Regence BlueCross BlueShield, was the state’s highest paid health insurance executive. He earned… $1.38 million in total compensation. Ganz also earns a salary as head of the Regence plans in Utah and Idaho, however those financial records are not available to the public.

…Andrew McCulloch, regional president for Kaiser, earned more than $800,000, increasing his salary by 56 percent, while Jack Friedman, CEO of Providence Health Plans, was the third highest paid executive, taking home $678,013, representing a 33 percent increase.

…LifeWise was the only insurer to end the year in the red. It reported a $4 million deficit. LifeWise President Majd Fowzi El-Azma earned more than $400,000 in total compensation last year.

Regence gets fat
When state regulators approved a 12.8% rate increase for Regence BlueCross BlueShield earlier this year, they were aware that the insurer had dipped into its surplus account and given a $56 million dividend to its holding company just five months earlier. But they may not have known that some of those investment dollars were intended to develop a subsidiary company for Regence – known as Sprig Health… which is available to people without health insurance [and] allows them to book a medical appointment online, and pay using their credit card.

[...Regence’s holding company... recently changed its name from The Regence Group to Cambia Health Solutions.]

…It’s unknown whether any of the $56 million was used to bail out Kinetix Living Corporation, a customized fitness and nutrition company purchased by The Regence Group in March 2010 for $15 million – while its fair market value was assessed at $8.5 million. Then, the company spent another $4.3 million trying to keep it alive. Recently, Regence announced it was shutting down Kinetix because it didn’t generate enough sales.

…[In 2011,] Regence’s surplus actually grew to its highest level since 1998.

Regence eats less and gets fatter
Small businesses in Oregon will find themselves paying more for health insurance if a 4.5% rate request by Regence BlueCross BlueShield is approved by the Oregon Insurance Division.

…Regence has lost more than 11% of its enrollment since its last rate increase was approved in March 2011 that impacted when its enrollment reached 54,299 members.
Earlier this year, Regence asked small businesses to pay 10.8% in higher rates, but the Insurance Division reduced that request to 9.1%, which took effect in July.
The proposed increase could be as high as 8.5% or a decrease as much as 6.6%.

…Since April, Regence took in $229,643,974 in premiums and paid claims of $184,458,183 – and contributed $5,970,743, to its surplus… “The missing pieces include the cost of administration,overhead, premium taxes, portability charges, and assessments for the Oregon Medical Insurance Pool,” according to the filing. However, the specific costs of those expenses were not delineated in the filing, nor does the document say how much money went into Regence’s reserve account.

Details of Regence metabolism
The commissioner’s office learned that Regence BlueShield had been withdrawing insurance premiums from the wrong bank accounts, and, in some cases, those accounts actually belonged to people who weren’t even Regence members. Thousands of claims weren’t being paid on time, particularly for retirees who were members of the state’s Public Employees Benefit Board.
Regence had also caused distress among members who were scheduled for a surgical procedure within 72 hours, but learned the insurer had changed its mind and decided it would no longer pay for the operation .

Medicaid: Sharks start circling
States increasingly rely on private, managed care companies to cover Medicaid patients. With the health reform law expected to expand Medicaid to 16 million more Americans, insurers see a “potential bonanza.”

…The National Bureau of Economic Research published this month the first national report on Medicaid managed care and cost savings. Its verdict: moving Medicaid recipients into managed care “did not lead to lower Medicaid spending during the 1991 to 2003 period.”

…Seventy percent of Medicaid patients now receive coverage through a managed care plan, up from 11% in 1991. That there’s been so little academic work into whether this approach has delivered on its assumed goal startled me… You’d think we’d want to ask, have we been saving money?

Changes in the Oregon Health Plan (Medicaid) – What are “Coordinated Care Organizations”? Note that State employees will be sucked into them as well. View from a spokes.
Oregon has long been a health reform pioneer. In 1989, the state established the Oregon Health Plan (OHP), a way to expand Medicaid coverage by explicitly prioritizing certain conditions while providing fewer services.

Earlier this year, Gov. John Kitzhaber (himself a physician) and the Legislature approved another groundbreaking round of reforms. House Bill 3650 will move nearly one million OHP enrollees, teachers and government employees into so-called coordinated care organizations (CCOs).

…In the Oregon Health Plan today, we have roughly 40 managed care plans. Some provide physical health services; some are dental; some are mental health. The problem is we have very little, if any, coordination between them. You could have a Medicaid client who’s on all of those, maybe receiving some chemical dependency services through a county and then potentially be receiving what we call “open card” or “fee for service” insurance through the state. There’s no alignment right now… We’re also thinking about how we are going to develop a global budget and what outcomes and quality metrics we’re going to be looking at.

…If we were to set up a system that actually decreased emergency department use or decreased utilization in general, some may see that as cost savings. Others are going to see that as a revenue cut.

What we’re talking about is a bigger picture around managed care. We’ve got to bring all of this under one umbrella and work within a global budget.

More sharks circling.
Three of the state’s largest health plans that deliver care to the Oregon Health Plan population don’t want to be left in the cold when coordinated care organizations (CCOs) take over next July.

…Dr. Bob Dannenhoffer, CEO of Douglas County Independent Physician Association (DCIPA)… is confident his health plan, DCIPA, will become one of Oregon’s first coordinated care organizations… “We don’t see any way that there will be savings in the short run,” Dannenhoffer said. “We think the costs will increase.”

The massive overhaul of Oregon’s healthcare system under way is the result of House Bill 3650, approved earlier this year. It called for the creation of coordinated care organizations, which will integrate physical, mental and dental services for more than 600,000 Oregon Health Plan members starting next July.

More sharks.
Hospital representatives… want the opportunity to create coordinated care organizations (CCOs) that will transform the way Oregon Health Plan members receive health services. And, they don’t want that role left solely in the hands of the current managed care organizations (MCOs) delivering such services. .. However, some are saying that MCOs may be the best organization to organize and lead CCOs.

Is it mean to call them sharks? There are just so many of them, and they’re coming in so fast.
Provider groups worried they’ll be left out of the coordinated care organizations (CCOs) took their case to the Oregon Health Policy Board… The policy board is responsible for creating a business plan for the CCOs that will be presented to the Legislature in February, along with draft legislation that would allow the Oregon Health Authority to move forward with making CCOs operational throughout the state.

Entities displaying shark-like behavior who are not technically sharks
Public health officials are questioning how they’ll fit into the new healthcare delivery model for the Oregon Health Plan. …the CCOs… will be responsible for coordinating the physical, mental and dental health care of the Oregon Health Plan population in geographic regions throughout the state.

Not everybody wants a bite of the OHP – Regence is simply stuffed
Regence BlueShield is pulling out of the Medicaid market in Washington, after deciding not to bid on a new contract that takes effect in July… In the late 1990s, Regence BlueCross BlueShield withdrew from the Oregon Health Plan, saying it was no longer financially viable to participate.

…Regence’s decision came after the Health Care Authority announced new bid proposals for 2012… Under the new contracts, the number of people covered by managed care will increase to 737,000 lives (the current program covers approximately 700,000 people)… Under the new contracts, insurers cannot cap their Medicaid enrollments.

…In other news about Regence BlueShield, in 2010 it had the highest number of complaints among health insurers, according to a report released by the Washington Insurance Commissioner. There were 249 complaints, which reflected 25.12% of the market and represented $2 billion in premium dollars.

“Saving money”: anything goes.
Members of the Medicaid Advisory Committee vehemently voiced their concerns Wednesday about the state’s proposed cost-saving reductions to covered services for Oregon Health Plan patients… which would eliminate existing coverage for everything from incontinence to cochlear implants for children.

…”It’s not that something will go wholly untreated; [Medicaid doctors] will just find a more effective type of treatment for it,” [said a spokesperson for the state].

Some kinds of fat are unacceptable. (Primary care doctors are now obliged to submit written plans to prevent patients being penalized – at least that’s been my experience so far. Insurance companies excel at making doctors their enforcers.)
The Public Employees Benefit Board (PEBB) is on the verge of creating a health plan designed to encourage people to take greater responsibility for their health. The plan will be available to 150,000 state employees and their dependents… They may have to enroll in a smoking cessation or weight management program… Those who don’t follow through with the program’s requirements will be forced to leave and face higher out-of-pocket costs for their healthcare.

Comment:
I do not believe you mentioned the new out of pocket deductibles employees will be paying. $250 per person ! New Rx out of pocket $50 per person. Not to mention the Health premiums. Pebb’s quoted savings are at our expense.

Comment:
I believe this article omits the fee under PEBB’s plan that charges an additional surcharge to men with larger than a 40-inch waist. So it’s not just that you “have to try”, you’re going to pay every month until you get that skinny waist. Nor does it mention the fees if you don’t complete online classes on time. This plan is going to get you one way or another. It’s not a cost-saver, it’s a money generator.

Comment:
When you do not receive a pay increase for several years and then are confronted with the threat of a penalty that would more exceed the tiny cost of living adjustment finally conceded, the extorted response is very clear. Participate or suffer another financial hit. In that environment the rate of participation is clearly not reflective of satisfaction among those on which this has been imposed.

Response is overwhelmingly in favor of not going broke or being terminated
Close to 85% of state employees have chosen to participate in the Public Employees’ Benefit Board’s new health engagement model despite concern that the wellness program would tell people how to manage their health and invade their medical privacy.

…220 people chose not to enroll in a medical plan this year. That number jumped by 407%… many of the retirees that PEBB covers often choose not to have a medical plan.

…Nearly 9% of employees who smoke will pay a new $25 tobacco surcharge ($50 if their dependent smokes). About 8% percent of members will be charged a new $50 surcharge for covering their dependents.

Comment:
The way the email sounded at OHSU (Oregon Health and Sciences University), a lot of us thought we would be kicked off and have no health insurance if we didn’t participate. No one mentioned that we would merely be paying 20-35 dollars a month more to prevent insurance companies from looking at our health data.

Saving money the easy way: how patients reduce health care costs
A struggling economy, higher insurance deductibles, and the efforts by health plans and others to reduce utilization have altered patient patterns, perhaps permanently. Patients now often seek office visits – or any interaction with the health system – only when a problem can’t be ignored.

…A report… released Oct. 12… showed an 8% decline in office visits per full-time equivalent physician for September 2011 compared with a year earlier. It was the third consecutive month of declines compared with the same months in 2010, and the fourth decline in five months. Primary care was especially hard hit… We’re now up to nine consecutive quarters of physician office visits declining.

…Robert Kaufmann, MD, a solo Atlanta internist, said he has not seen a drop in patient volume… He sees about 40 patients a day… But Dr. Kaufmann has noticed that his patients are sicker when they come to him. They often have avoided visits because they still are paying their deductibles… “Sometimes they’ll get mad at me and say, ‘I wouldn’t have had this test if I had known that,’ but I say, ‘Listen, I can barely keep up with my own personal insurance – I’ve got a $10,000 deductible. I’ll trade with you.’ ”

Wrapup: cost shifting in health insurance
Patients, even those with insurance, avoiding spending cash on health care they think can be put off. “Patients are paying more, and they are getting less… We see people for economic reasons deferring important screening procedures or coming in less often for chronic conditions such as diabetes.” [ -President of the American Academy of Family Physicians]

…The number of uninsured grew by nearly 1 million in 2010, to 49.9 million, with 1.5 million losing employer-based coverage, according to the U.S. Census.

…Those who had employer-based insurance were paying more of their money for coverage and care.

…The insured are taking on larger deductibles.

…Consumers’ insurance and deductible costs are far outstripping wages. Insurance costs have doubled since 2001 while wages have gone up only 34%…The Census Bureau reported that wages are on the decline, with the median household income down $1,100 to $49,445 in 2010.

…Consumers are cutting back on care. A Consumer Reports study released Sept. 27 found that 48% of prescription drug users said they put off doctors’ visits or medical procedures, declined tests or ordered less expensive drugs from outside the United States.

…Health insurers are revising downward their health spending projections.

…People in the lowest 20% of income cut both insurance spending and care, while those in the second-highest 20% paid more for insurance but sliced out-of-pocket spending on care. The only income bracket to spend more on both was the top 20%.

“Updated findings from one of the largest studies of prostate cancer screening show that the commonly used P.S.A. blood test did not save lives.

“…Last fall, the United States Preventive Services Task Force concluded that healthy men should no longer be routinely screened for prostate cancer using the prostate-specific antigen, or P.S.A., blood test. That decision was based on findings from five well-controlled clinical trials, including a major American study… which studied P.S.A. testing in nearly 77,000 men ages 55 to 74.

“In 2009, the PLCO trial reported that although annual P.S.A. screening did detect more cancers, it didn’t save more lives when compared with a group of men who were given routine medical care and tested for prostate cancer only when a problem was suspected.

“But at the time, the investigators had only 7 to 10 years of data. Because prostate cancer can take several years to develop, the investigators continued to collect data after reporting the initial findings. In a new paper published today in The Journal of the National Cancer Institute, the scientists report that the additional follow-up time didn’t change the overall conclusion: that regular P.S.A. testing does not save lives and can lead to aggressive treatments that leave men impotent, incontinent or both.”

Please – before you get all hot under the collar – note that these issues are about screening tests, not tests performed on men who we are concerned might actually have a fast-moving prostate cancer.

“Screening tests are performed on persons without any clinical sign of disease. [Emphasis added.]

“…Screening can detect medical conditions at an early stage before symptoms present. [BUT]… Like any medical test, the tests used in screening are not perfect. The test result may incorrectly show positive for those without disease (false positive), or negative for people who have the condition (false negative).

“In particular when screening for a condition of low probability the absolute number of false positives may be high although the percentage of false positives is very low; if the incidence of a condition is one in 10,000 and the probability of a false positive is 0.1%, 9 out of 10 positive results will be false.”

That last part might be hard to read! Let’s go back a step.

So you may have to deal with the consequences of invasive testing and possibly treatment, which you never would have had ever in the first place, if you had not been (inappropropriately) screened, when you did not have any symptoms of cancer. “U.S. incidence data suggest overdiagnosis rates ranging from 29% to 44% of all prostate cancer cases detected by PSA screening.”

“Overdiagnosis” means misdiagnosis – misdiagnosis according to the best diagnostic tests we have available. It means that 29-44% of the time, when a PSA screening test seems to indicate a cancer, further testing and treatment does not save lives, usually because those cancers would not have caused death.

One man’s vignette:
“John Shoemaker visited six doctors in his quest to find the best treatment for his early stage prostate cancer – and only the last one offered what made the most sense to the California man: Keep a close watch on the tumor and treat only if it starts to grow.

“…Shoemaker is one of more than 100,000 men a year deemed candidates for it by a government panel. That’s because their prostate cancer carries such a low risk of morphing into the kind that could kill.

“The risk for them is so low, in fact, that specialists convened recently by the National Institutes of Health say it’s time to strip the name “cancer” off these small, lazy tumors.

“…Some 240,000 men a year in the U.S. are diagnosed with prostate cancer. Earlier this month, the NIH-appointed panel found that most have the low-risk kind, a legacy of using problematic PSA blood tests to screen healthy men for possible signs of this slow-growing cancer.”

See?

More bad news:
“Older men considering robotic surgery for prostate cancer shouldn’t trust the rosy ads promoting the expensive technology over low-tech surgery. That’s according to a new survey that found complaints about sexual problems and urinary leakage were equally common after the two procedures.”

Also, just as mentioned above, “One study found that more than 120,000 American men diagnosed with prostate cancer every year are ideal candidates for observation, or watchful waiting. Still, the majority of them end up having surgery, radiation or other treatment instead.”

Also:
“Doctors and anaesthesiologists at the Asian Heart Institute got the scare of their lives when the robot they were wielding to perform an advanced prostate cancer surgery went kaput… and stopped taking instructions from the surgeons manouevering it… The surgery had to be aborted and the patient revived from anaesthesia.”

And:
“A cloud has descended over research into a biomarker for prostate cancer – early prostate cancer antigen-2 (EPCA-2) – which was described as “amazing” and appeared to overcome some of the shortcomings of prostate-specific antigen [PSA]… A paper about the biomarker was published several years ago in Urology (2007;69:714-720), but was retracted in October 2011… ‘The article contains findings that may be unreliable,’ the study authors write in their retraction.”
< sad trombone noise >

And:
“Recently published in the journal, Cancer, significant findings link blood clots to hormone-targeted prostate cancer therapy… Hormone therapy has known links to bone loss, hot flashes, impotence, increased risk for diabetes, fatigue and memory loss. Now add potentially fatal blood clots… 15% developed one or more blood clots over a four-year treatment period, more than double the 7% of non-[hormone-treated] patients who developed clots.”

And:
Dendreon soared almost 40% in value, or $3.02 a share, in active trading on Thursday after announcing that fourth-quarter revenue from its Provenge prostate-cancer vaccine would exceed earlier forecasts… For full-year 2011, Dendreon said sales of Provenge would total approximately $228 million.

What is Provenge?
It’s “a therapeutic cancer vaccine for prostate cancer. It must be prepared specifically for each patient. In metastatic prostate cancer, it has extended survival by about four months. It costs $93,297.60 for a course of treatment” [three shots].

And in other news:
“Following a positive blood test for prostate cancer, men are often advised to undergo radiation treatment. However, prostate cancer cells sometimes become resistant to the effects of radiation. Yet a new study indicates that treating these cells with the antioxidant resveratrol may improve their sensitivity to radiation… Resveratrol is the antioxidant that has garnered red wine so much attention over the past few years.”

And:
“Soybeans, more specifically soy isoflavones, a natural, nontoxic component of soybeans, were found to be effective in the fight against prostate tumors, and now, even lung cancer tumors, according to Golda Hillman, PhD, professor of radiation oncology at Wayne State University’s School of Medicine and the Barbara Ann Karamanos Cancer Institute.”

And:
“If you develop prostate cancer, taking aspirin cuts your risk of dying from it by more than half, compared to people who don’t take it. How? Basically, aspirin throws the kitchen sink at the disease. It blocks COX-2 enzymes, which help many cancers grow. It also shrinks estrogen production or its effects, starving certain breast cancers. Plus, it seems to flip a biochemical switch that tells cancer cells to die, and to clean up genetic mutations before they turn cancerous.”

Oh, and by the way:
“The steroidogenic activity of primary human benign prostate stromal cells is significantly increased by exposure to a Hedgehog agonist or by transduction of primary human benign prostate stromal cells with lentiviruses that expresses active Gli2, a transcription factor that is triggered by Hh signaling… Hedgehog/Gli signaling may be a factor in acquired intratumoral steroidogenesis of a prostate tumor through its actions on stromal cells in the tumor microenvironment and an influence for the development of castration-resistant prostate cancer.
(Don’t ask.)

Have you ever had an MRI? Brief review: Magnetic Resonance Imaging uses a magnet – an very large “superconducting” magnet, using liquid helium. (Actually, not just even liquid, but cold liquid helium, about 455 degrees below zero [F]. That’s cold!) MRI basically looks at soft tissues. It’s good for looking at a tumor, or at your brain. Dye can be used to show blood flow in the area.

This is a cup of cold helium.

In my opinion, for most purposes, the sophistication of the results has outstripped our ability to interpret them. For example, it’s well known that people can have terrible-looking spine MRIs without chronic back pain or limitation in activity at all. Also, people with terrible daily back pain can have a very normal appearing spinal MRI. This shows that it is not a very good test for chronic back pain in most cases. I almost never order an MRI for any reason. If I think you have a brain tumor, I’m going to call a neurologist first (in a hurry!), and see what they think is the best way to investigate.

However, that is not what I want to tell you about.

Let’s just imagine that people are only getting MRIs when the MRIs are really truly going to produce important and accurate information that really truly will help us know how to fix a problem. Could getting this very-necessary test drive a family into the poorhouse?

Telephone interviews identified 639 patients whose illness contributed to bankruptcy: the debtor or spouse in 77.9% of cases; a child in 14.6%… At illness onset, 77.9% were insured… For patients who initially had private coverage but lost it, the family’s out-of-pocket expenses averaged $22,568.
…Nonstroke neurologic illnesses such as multiple sclerosis were associated with the highest out-of-pocket expenditures (mean $34,167), followed by diabetes ($26,971), injuries ($25,096), stroke ($23,380), mental illnesses ($23,178), and heart disease ($21,955).
…There is ample evidence that the financial burden of illness is increasing. [Note Elizabeth Warren as 3rd author.]

They were saying that back in 2007 – which for many of us were the economic “good old days”!

[I know that conservatives dispute these numbers - see this by the group powered by Dick Cheney, Newt Gingrich, Ken "Enron" Lay, and their pals. They often don't believe that such misfortune happens often (it doesn't happen often to them, of course), and/or they can't understand how debts that they regard as nonsignificant can be insurmountable. However, I happen to know quite a number of former conservatives, who suddenly came to think otherwise - after the car crash, or after the diagnosis, or after the complications resulting from surgery.]

Anyway… how much does it cost to get an MRI, if you have to pay out of pocket for it?

Local sources (people that perform MRIs) tell me $1250-1500, for a lumbar spinal MRI, for example – double that, if contrast dye is used ($2500-3000). That includes the radiologist’s fee for interpreting the pictures. If you pay 20% on the spot, they will give you 10% off and a payment plan. Hope you have $600 in your pocket when you go there.

The Health Care Blue Book gives these estimates for our zip code:
Spine MRI (no contrast) – $517. Price includes the total amount for both physician (interpretation) and technical (imaging) fees.
Spine MRI (with and without contrast) – $753. Price includes the total amount for both physician (interpretation) and technical (imaging) fees.

In your dreams! The Blue Book’s prices for a lot of stuff do not correspond in any way to prices on the ground, unfortunately.

Would having a sit-in at the hospital bring the prices down? …Just kidding! People who actually need MRIs are too sick to sit-in anywhere.

Here are some data about why MRIs cost so much.

MRI machines can range in cost between $1 and $3 million. Construction of MRI suites can easily add another $500,000 to the total cost.

…The average annual salary for an MRI technologist ranges between $50,000 to $55,000… It isn’t uncommon for qualified repair engineers to earn salaries in the six-figure range.

How to buy a used MRI machine:
Have the MRI inspected… This will cost you somewhere between $1,500 – $3,000 but it is well worth the cost.

…Expect to spend around $10,000 for a deinstallation… The exit pathway is important and in many cases can be the biggest unexpected cost associated with an MRI purchase… First floor removals and rooms adjacent to exterior walls are the norm but there are exceptions. For a ‘normal’ removal, expect to spend approximately $10,000 – $12,000 to get it safely onto your truck! For a non standard removal… way more!

…It will need to move quickly to avoid excessive helium ‘boil-off’ once it is off power… Expect to spend around $5,000-$10,000 for overland domestic transport.

…The installation of your MRI is a complicated project… Expect to spend between $50,000 and $80,000 for a ‘typical’ installation.

Joke: Did you hear about the MRI that had to come out in little pieces?
Punchline: It’s in the basement.

American prices are not the same as prices in other lands.

NPR: Professor Yekagami, a health care economist in Japan… Do you know how much a MRI costs in Japan?

NPR: …They charge more here in the U.S. because we will pay more. How come? Well, I called a number of American hospitals and doctors and I got basically two reactions. The first and most popular: a shrug. We could never get those prices. That’s just how it is. And the second: some were surprised… Health care prices even to them are something of a mystery.

Comment on this story:
As a radiologist I read different types of MRI’s from many different facilities. Quality is all over the place. MRI scans from rural Texas are done by incompetent techs with inferior machines and are very difficult to interepret. I’m sure pathology is being overlooked. MRI’s done at the big medical center are state of the art and in the right radiologists hands can find disease. The problem with our system is that both scans get paid the same.

Per the Radiologic Society of North America (RSNA), using data from 2009: With a median salary of $454,205, diagnostic radiologists’ compensation increased by 3.7 percent in 2009, while interventional radiologists reported a median salary of $478,000, which was unchanged from the year before.

Radiologists and healthcare economist types discuss.
Radiologists have been content to live off the fat of the land, working bankers’ hours and outsourcing inconvenient night and weekend duties to teleradiology firms rather than taking call themselves. Even when they’re around, radiologists in general don’t do a good job of serving the physicians who refer to them, staying in their dark rooms and not being proactive or even responsive. As radiology groups are finding, if they demonstrate they’re not crucial to the success of a hospital on nights and weekends, that also makes a pretty good argument for why they’re not necessary during weekdays either. Once hospitals understand the truth they can dispense with the local, intransigent radiology group entirely.

Comment:
The quality of e.g. brain readings by any trained neuroradiologist in India is as good or higher than that of a general radiologist in the states, and since the images are easily transferable and are interpreted with the actual patient unseen, outsourcing is entirely doable.
Moreover, the technical component of radiologic exams (generating the actual images) are highly standardized, and if imaging facilities competed on price, studies would only cost a fraction of what they cost now.
…There is an easy bureaucratic fix that would allow us to keep all radiologic services in the country: just pay the radiologist the average time that it really takes him/her to interpret the pics and to generate a reading. Interpreting pics is not more stressful than seeing patients and should be compensated grossly similarly (of course one can make modest adjustments for education and risk of litigation).

Comment:
The handwriting is on the wall for academic medicine… This is nothing more than a plea to shift the money flow from private teleradiology firms competing in an open market to academic radiologists who can’t get out of their own way, and will be content to have residents read the work while they sit in their offices.

Comment:
The teleradiology I’m referring to is done by US board certified radiologists, though some of the commenters don’t seem to realize it. Many of these teleradiologists are in the US, but some are based overseas. Often the teleradiology companies hire radiologists out of fellowship and set them up in a remote time zone, e.g., in Australia or Hawaii. That way they can work during their day when it’s night in the US. It’s a pretty attractive gig… The issue of Indian or other low-cost radiologists is an interesting one but not addressed here. The US radiologists are managing to commoditize themselves quite nicely despite erecting guild-like barriers to entry.

We decided to check our local MRI prices. [Most likely Santa Clara, CA.] We called 5 hospitals and 5 outpatient imaging centers in our area asking for the full price for an MRI of the brain with dye.
Two hospitals were unable to give us the price (didn’t know!) and one outpatient center refused to divulge its cash prices over the phone.

MRI Price Range:
Hospitals (3) – $1750 to $2200
Outpatient Imaging Centers (4) – $700-$1000

…We called back and asked for a discount. Results:

Hospital 1 offered a 10% discount if paid in full
Hospital 2 offered to split payments in half
Hospital 3 asked us to “come to the Radiology department”

Outpatient center 1 refused to discount (price was $900)
Outpatient center 2 told us the “manager had to approve any discounts”. We left a message but didn’t hear back.
Outpatient center 3 gave us a 20% discount, reducing the price of the test from $1000 to $800.
Outpatient center 4 offered to give us a discount but only if we faxed in the doctor’s order.

Comment:
I am an Aussie living in America (18 months) and have unfortunately had the ‘opportunity’ of using the American Health system… Wow, what an absolute calamity! In Australia, the cost to the public is around $10 to $20… We just got a bill for (wait for it…) $1,800! …Heaven help us all, if we ever need to rely on the US health system for something serious.

Comment:
I hurt my back at a water park in Ukraine and went to a private hospital… The cost of my doctor consultations and a spinal MRI came to $90! That’s NINETY DOLLARS!

Comment:
I’m from Italy and I lived in USA. Weeks ago I needed a breast MRI, hospital asked me to pay almost 8000! It’s a shame, I came back to Europe and I had the MRI for 65 Euros in 3 days. [Approx $83 US.]

Comment:
I live in small town Texas… No imaging centers here so I was told by my (most horrible insurance company in the world) insurance company it would cost over $3000 because I had to meet my $1300 deductible first then pay 20% and of course I have an out of pocket max per year of $2500 and on and on and on, and when I ask what that means, I get – you pay it all… This is getting worse and worse. Pretty soon we will all be just like in George Orwells 1984 or Solyent Green or better still Red Dawn. What has happened to our world? We cannot afford the things they are telling us we have to pay for and our doctors tell us they cannot help us unless we do what they tell us to do. Unless I give up everything I have (left) and go on welfare, I cannot afford to live and I do mean live. One day, I will probably die from not getting treatment because I cannot afford any of the tests needed to help me. Pretty soon I will not be able to afford the drugs either like so many other poor people in America. What has happened? I’m not some kind of radical. I am a 61 year old grandmother who can’t get a job any more. Something has to change.

How to find out the price of an MRI or other medical tests:
1. Start with finding out the CPT code of the test your doctor has ordered. This stands for Current Procedural Terminology and is a unique identifier for every medical test that exists… Try Googling for this info… Note that a test that requires the use of contrast dye is a different CPT code than a test that does not require contrast dye.

2. It’s always easier to get prices from the stand alone radiology facilities or basically any center that is not directly owned by a hospital… Call the imaging center and ask the person that answers the phone how much a person who has to pay out of pocket will pay for such-and-such a test… If your doctor has requested that the test include contrast dye be sure to tell them that as well.

3. To get the price from a hospital you really must have the aforementioned CPT code… Ask for either the Cashier’s Office or the Billing Office… If the first place you reach doesn’t have the info, ask to be transferred to the other office. Also ask about the physician’s reading fees… but don’t be surprised if the person you are speaking to doesn’t know the answer. It’s not their fault. Frequently physician’s fee billing is done through the physician’s private office.
Also, always ask if there is a discount for self-pay patients, and how to qualify for this discount, as sometimes this entails additional paperwork.

How can we occupy healthcare?

The idea of Occupy is really that incremental change is happening way too slowly for people’s health or safety. Many people now have nothing left to lose. Others are very aware that they soon, or with one false step, also will have nothing left to lose. They may not be sure how to fix the problem. All they may know is that they can’t wait.

From my perspective, in one of the save-the-world professions, is that people are literally getting sick and dying right now, right down the street – with chest pain when they go up a flight of stairs, with uncontrolled seizure disorders, with enormous quantities of pain medications, with severe blood loss anemia, unable to sleep or work due to lung disease, becoming skeleton-thin from intractable vomiting – not because of political problems, but because of medical problems. But if they are to navigate the current healthcare system and get the evaluation and treatment they need, they really need to have a ton of energy, determination, ingenuity, education, and cash. Which they often do not have. Note: these people do not look different from anybody else. You can not identify their predicament by looking at them. They are your relatives. They are your neighbors.

We can’t wait. I think the politics of MRIs – how much the machine costs here and elsewhere, how much radiologists are paid and why, how difficult it is to even find out how much the test costs, and what happens to people after they leave the doctor’s office with the order in their hand – these give us a little snapshot of something very important.

They show us that the system – the elected officials, from city council to the white house, hospital and insurance administrators, drug and “medical device” corporations, economists and the talking heads who report on teevee every night that “the recovery” might be “stalled” – is dangerously out of touch.

The danger is palpable. The danger is directly to someone’s health and safety. Many of my patients are too sick to “Occupy.” But they, too, have nothing left to lose.

You may say to yourself, Well then, Dr. Leigh, what are you doing about this terrible situation? Short answer: I’m being a doctor in a particular way.

My biggest wish, if I could make a magic wish, would be for my patients to be organized, to “Occupy Healthcare” and make their voices heard – before it’s too late.

I know an adult who broke a rib with this kind of cough (but had to keep coughing with the broken rib. Made it hard to work). I know someone who had a prolapsed – well, you don’t want to think about the details. Suffice it to say, plenty of folks have weeks of incontinence with this kind of cough.

Click here for Dr Leigh’s “Pertussis Facts” handout (all ages).
Click here for a visual guide on how to diagnose a cough (all ages).

Click here, here, and here, for guidance on how to recognize “vaccine-preventable diseases” in children. If you don’t give your kids shots, it’s your responsibility to know how to spot, for example, whooping cough, measles, pneumonia (from HiB and/or pneumococcus), etc.

Why do I say, “your responsibility”? Isn’t that what doctors are for?

The reason we even have vaccinations is because those particular illnesses are difficult or impossible to treat. Your doctor needs to know as early as possible in the course of the illness, what is going on. Your doctor is also required by law to help keep track of epidemics*, and they can’t do that, if you didn’t tell them your suspicion.

Your doctor almost certainly did not receive training in the signs, symptoms, diagnosis and treatment of vaccine-preventable diseases – your doctor will have to look up and review that information. (Note: your doctor knows more than really seems reasonable about the microbiology and micro-patho-physiology of these critters – but that’s not the same as knowing how a baby looks when they have pertussis, knowing about proper nursing care for a kid with rotavirus, or knowing specific danger signs, beyond any physician’s simple “Hmmm, could this be encephalitis?”)

Note: I am speaking about family doctors. Pediatricians, no doubt, have superpowers to detect vaccine-preventable diseases and their complications. Unfortunately, if you do not give shots to your kids, you may already have been kicked out of your pediatrician’s practice.

Headlines from the internets this morning:

The rise in pertussis, or whooping cough, has reached the level of breakout in at least one New Mexico county.

As of Oct. 27 there have been 129 confirmed cases of pertussis,” said Dr. Gary Goldbaum, health officer and director of the Snohomish Health District. This is a drastic difference from the 25 reported cases in 2010. [WA]

Just across the [Oregon] border in Washington, 6.2% elected not to vaccinate [in 2011] – one of the highest rates of non-medical exemption rates in the country after Alaska (9%), Colorado (7%) and Minnesota (6.5%). Oregon’s exemption rate rose to 5.6%, up from 5.2. (The percentages refer to kindergarten students.)

*FYI – Only a few of the things your doctor is required by law to report to Public health:
Immediately, day or night: Measles, Rubella, Diphtheria, Polio
Within 24 hrs: HiB (causes pneumonia and meningitis), Bacterial meningitis
Within one working day: Pertussis, Mumps, Hepatitis A, Tetanus
…Also, of course, Rabies, Plague, Syphilis, Tuberculosis, Mad Cow Disease, etc.

Because of it, I have been learning a lot about “metabolic syndrome” – what it truly is, how it works, what we can do about it. I’ve been talking to a lot of you about this stuff in the office. You may have heard me say, “Inflammation is the most basic function of our immune system, and whenever we have a system like inflammation, we have another system to tone it down, because you don’t want inflammation getting out of control.” Right? And I’m talking to you about it in the context of metabolism – how we break down and use the foods and other stuff we take into our bodies.

So in the course of reading about “immunometabolism,” I found this review article that intrigued me, not only because it uses fabulous words like “nonphlogistic recruitment” (remember phlogiston? the fire within?) and “efferocytosis” (Latin, “to take the dead cell to the grave”), but also because it describes the condition of inflammatory obesity in terms of (to me) high drama.

Imagine, if you will, the micro-world…

high drama

In the micro-world, a human being (or a chocolate labrador, or a lab rat, or any other complex creature) is not the master or director of conditions; they are, instead, the universe. Their activities (skipped breakfast, chased ducks at the lake, was injected with an experimental drug) are undectectable, except insofar as they provide the ambient temperature, the shifts in water acidity, the relative amounts of nutrients and pollutants, and are self-correcting to a greater or lesser extent, locally.

There are TONS of players in any ecosystem; I am only going to mention the ones that particularly interest me today, so please don’t scold me for neglecting to mention the key roles played by T-cells and nitric oxide and leptin, insulin and cortisol and ghrelin, etc.

The micro-world is full of players. The ones I’m thinking on today are certain cells.

fallopian tube: this way in

When you imagine “a cell,” you might imagine a bacterium or an ameoba – a blob with an eye, crawling around. That’s pretty close.

Cells are born as baby cells and are small and simple, and they develop skills and identities and finally have a characteristic look. A bone cell looks like one thing (spiky). A muscle cell looks like another thing (bamboo). A nerve cell looks like another thing (a tree). A skin cell looks like another thing (a brick). A fat cell looks like another thing (a water balloon).

A lot of cells congregate together and form rows and walls and layers, tissues – like muscle tissue, brain tissue, fatty tissue.

layers

Cells talk to each other the same way cats talk to each other – with a look, a smell, an attitude – sometimes a show of force, sometimes a strategic withdrawal, sometimes a sort of invisibility. Cats talk to each other through air and light. Cells talk to each other in the dark, under water.

Cells make chemicals that indicate things. I am trying to find a better vocabulary than we use in the hard sciences. For example, a ripe banana makes a chemical, due to being ripe. If a fruit-fly or a monkey or a bird notices this chemical, they might seek, find, and eat the banana. If they used a nose to detect the chemical, then we call the chemical a smell or a scent or a fragrance or an odor. What if they don’t have a nose? We might call it a chemoattractant – not a very poetic term. What if the smell is bad? If a nose is involved, it’s a stink. Without a nose, what is it? Something else.

l’eau de cytokine

Here’s another notion. In 1788, somebody imported rabbits to Australia, where they had no ‘natural enemies.’ The rabbits had a bazillion baby rabbits and basically ate up every green thing growing on the land, because nothing could stop them except running out of clover. They are making Australia a desert. But it’s not the rabbit’s intention to do so – they are just going on about their normal rabbit business. One could say that the rabbits are “sending a signal” that isn’t being received or responded to properly by the “environment.” Usually “the environment,” receiving the “signal,” would fix the situation (hawks and foxes and cats would eat the rabbits).

Similarly, something weird might happen to a cell, so that it just keeps growing, out of control. Weird cells have an effect on the environment. The “signals” they send may or may not be properly “received.” The immune system may or may not send its hawks and foxes and cats to wipe them out, or at least to keep them in check. The environment will either seek balance, or adjust to the new normal. As with the rabbits in Australia, we personally may or may not be pleased with the results.

like with kudzu

Unfortunately, in the science of the micro-world, we do not have a very good vocabulary to describe this. We say things like,
“Cells exchange signals to maintain their phenotypes and to optimize their functions. When a cell receives a signal, it sets off complex cascades that trigger and modulate the activities of numerous genes and proteins.”

Sheesh! I suppose it’s accurate, but it’s not evocative. It evokes nothing, except a stuffed shirt. These are living organisms, in functional ecosystems. Just because they’re teensy doesn’t mean their lives aren’t complex.

jelly jelly

I usually make cells sound like creatures, even though, like jellyfish, they have no central nervous systems. I imagine their “nervous system” – the patterns which enable them to get things done in a coordinated way – is more like a communications network (or a zeitgeist), than a specific individual goal-driven or teleological set of behaviors.

So imagine, if you will, this micro-world. Here is a fat cell – an “adipose” cell.

belly belly

Adipocytes look like water balloons. That’s not the prettiest picture. Here’s a nicer one:

As babies, they lived in the walls of the blood vessels that run through the fat tissue. When high amounts of nutrients ran through the blood vessels, the baby fat cells started growing up, and moved out into the adipose tissue – a forest of fat cells, all crowded together – next door.

As babies, they looked like regular cells, with one eye (a nucleus) and the usual internal organs, but as they started their normal job of absorbing and storing droplets of oil, they expanded bigger and bigger, so the eye and the internal organs got squished off to one side. This is why, as grownup cells, they look like water balloons.

You might wonder how we can take pictures of these cells, and why they are these various colors. Normally, they are so small that to our eyes, they are basically see-through. What we do is grab some (via blood test, biopsy, scraping, etc.), stain them with colors, and put them in the kind of environment they started out in. (If you looked at them in dry air, they’d be like collapsed balloons.)

a biggish blood vessel.

Why do adipose cells have this job?

Droplets of oil are fatty acids and triglycerides. They can be used as emergency fuel when there’s not a lot of blood sugar around, but they also can be toxic and harmful to most cells in general. All cells absorb fats, but adipose cells soak up more.

You don’t want a buildup of fatty acids, inside your blood vessels (atherosclerosis), your liver cells (steatohepatitis), your pancreas that is supposed to be making insulin (pancreatic steatosis).

That acid doesn’t belong there, and those cells have to work hard to detoxify it and get rid of it, taking energy away from what they normally should be doing. Sometimes they aren’t able to detoxify it, and the heart muscle, liver, and pancreas cells get sick and weak.

bluck

Luckily, there are adipose cells – starting as babies in the blood vessel walls, sensing excessive amounts of nutrients in the blood – that will soak up and store these acids, and keep them away from other cells.

Adipose cells, like all cells, need a supply of oxygen to stay alive. They are just single cells; they do not have a heart or blood vessels of their own. Oxygen, riding on red blood cells through the bloodstream, simply falls off the red blood cells and leaks through the blood vessel walls, into the adipose cells. However, as the adipose cells collect more and more oil, and get bigger and bigger, eventually it’s just too far for oxygen to travel, and a lot of cells that are far away from blood vessels become starved for oxygen, and start to die.

It’s like blood in the water: the sharks come out. When cells are dying, other cells start coming around to eat up the debris.

Sharks? Macrophages. From the Greek, “macro,” big, + “phagos,” glutton. They literally eat stuff – odds and ends of sugars and proteins, dead cells, etc. Here’s one, in a 30-second movie. It’s chasing a bacterium around, in and out amongst some red blood cells. (A neutrophil is like a macrophage for bacteria.)

Like sharks, macrophages travel from far away to gather in bunches – once again, not talking to one another through light or air, but communicating underwater and in the dark, through a smell, a change in temperature, a flavor, however you want to imagine the “chemical signals” they possess. Remember, like the ripe banana being eaten by the fruitfly, they don’t necessarily choose or intend to set in motion a chain of events – it’s just a natural outcome of their normal behaviors and life cycles.

mac.

How do they get to where the action is? They float around in the bloodstream until something attracts their attention, and then they wiggle out into the tissues – like diving off the freeway into the jungle. Another way of looking at it is, they float along until something grabs them, like someone in a flood getting yanked out by the leg.

If you ask me, this is tricky. You don’t want to be punching a hole in the side of the blood vessel, you don’t want the blood vessel seams to be loose and flimsy – they’re under blood pressure, and could spring a leak. But macrophages – like T-cells and other kinds of white blood cells – do squiggle out into the tissue, following whatever trail they are following. Here’s a 40-second reenactment.

Macrophages will behave in certain ways – and even look certain ways – depending on the environment around them. They have superpowers of being able to function in low-oxygen conditions. When they are attacking stuff, in an inflammatory way, spraying poisons around and eating up debris, we call them by the unromantic name “M-1.” Like attack elephants, they can be indiscriminate, and cause a lot of extra damage.

However, they relieve the pressure. The oxygen content starts to improve. If all goes well, the ecosystem starts to re-balance. The macs start to change in character and become “M-2.”

“Macrophages downregulate their proinflammatory activity and shift their function towards local resolution of inflammation and tissue repair.”

This really does mean making new tissue, new cells to replace the ruined ones, new blood vessels. Now the previously-rampaging elephants pitch in to rebuild walls, clear roads, and generally make things better than they were before.

Some will change up even further, and become “M-res” macs – “resolution” macrophages. These carry away the dead. When cells die, you don’t want them to just suddenly explode – for example, if they’re fat cells, they would spray fatty acids everywhere; if they are immune cells (like neutrophils), they’re full of bleach and peroxide and other other nasty bacteria-killing stuff. The “resolution macrophages” engulf these dead cells whole, and carry them away out of the area.

At any given time, tissues have a certain number of macs that hang around. Under healthy conditions, most of them are the friendly, helpful M-2s. But if things go haywire, you get a higher population of strong, savage, attacking M-1s. What if this happens without an obvious suspect, like a staph germ in your lung, a tapeworm in your belly, or a tumor in your gut? Then the attack just generally creates mayhem wherever it happens to occur. You get chronic inflammation, to a greater or lesser degree.

When we are looking at the micro-world to find out how inflammatory obesity occurs, we are looking at immunometabolism. Let’s review:

baby fat cells, with tiny droplets

Baby fat cells, in the walls of tiny blood vessels, are bathed in floods and floods of nutrients, because we eat too much (too much starch and sugar and fat and protein), for most of our lives. They gather together, they encourage one another, they coordinate activities to form fatty tissue, to store away the strong stuff – the overload, day-in-day-out, of acidic oil, one of the main results of your egg-and-pancake breakfast, your deluxe burrito lunch, the snickers snacks, the mac and cheese, etc.

They gather in bigger and bigger crowds – far from the blood vessels carrying oxygen. They fill up fuller and fuller with oil – they crush their own internal organs under the weight, trying to sequester all that oil.

Some die. Some spring leaks. Free fatty acids float around in the tissue. And it’s strong stuff.

“The response of the adipose vasculature and stroma to adipose expansion is often insufficient, leading to hypoxia and overcrowding… This perturbs adipocyte integrity and function and may lead to apoptosis and necrosis… resulting in the spill-over of free fatty acids into the circulation. Excess circulating free saturated fatty acids are harmful to the vasculature and also [build up] in numerous organs, including liver and muscle. Insulin resistance and lipotoxicity ensue.”

What do the macrophages see? Dying cells, toxic crud, low oxygen levels… could be a staph infection. Could be a tapeworm. Could be a tumor. They see red. And if they’re in stressed, wounded, sick adipose tissue, they see it everywhere they go.

clear lipid, red macs

“In lean, healthy mammals, macrophages account for approximately 10% of adipose tissue cellularity and are interspersed between adipocytes” – mostly M-2, build-and-repair macs.

“Obesity is accompanied by a robust influx [of] M1 macrophages… reaching 40% of adipose tissue cellularity. These staggering statistics exemplify the concept of an inflamed adipose tissue.”

Did you see those numbers? When the little village was small and efficient, one in ten citizens was a beat cop, helping folks out, jumping dead batteries for people.

When it became a crowded, polluted, crime-infested urban area, four in ten citizens was not just a cop, but an armed thug, jumping people for batteries.

Is that too much of a stretch? Try this instead:

When my belly fat was just a regular layer of warm insulation over the muscles, a few of the cells in there were build-and-repair macrophages, cleaning up any debris from micro-injuries and wear and tear.

However, when my belly fat became as big and heavy as three grocery bags full of food, almost half the cells were inflammatory macrophages… doing, ominously, what they do.

“The inflamed adipose tissue of obesity resembles an organ chronically infected by an intracellular organism, despite the absence of any pathogen.”

Your body – in the micro-world – is a universe of individual cells, coordinating their activities as appears appropriate given environmental conditions, and/or wreaking havoc for one reason or another.

Even if you could somehow command the actions of one of the individual players, it wouldn’t make any difference… you must instead seek to be influential over the whole situation.

How can you – your brain, your soul, your pure intention, and what you do – influence this ecology?

Further reading:

Macrophage transformations: http://www.frontiersin.org/inflammation/10.3389/fimmu.2011.00049/full

Then I was gently told that no, they can’t allow any discounts for patients who pay out-of-pocket, except for HIV tests (provided to them for free by the state), and that if I needed an interface between the lab and my electronic medical record, that would be $300 please.

So naturally I took my business to the other lab in town, which provides same-day service for my homebound patients, sends results to my secure email, and provides a hefty discount for all out-of-pocket labs – and what else? They’re really nice. They remember who I am, despite my small practice providing almost no business to them. My lab rep and I commiserate about adjusting to western Oregon, since we both moved here the same year, from very different climates. When I have weird questions about arcane lab tests (as a recovering biochemist), we conduct chatty email conversations about them.

(This is also why I send Paps and biopsies to a particular pathology lab; they have a ridiculously extravagant commitment to both cutting-edge science and full accessibility, including rock-bottom prices for out-of-pocket payers. Oh, and that independent radiologist in town, with the advanced training in women’s imaging? I send him all the business I can, too.)

However, sometimes a patient (with insurance) prefers to go to the giant corporation instead, where they always went before. And that’s okay. Shouldn’t be any problem.

So three weeks ago, a patient dutifully got blood drawn at the “old branch” of the giant corporation, downtown near her work. It was just a routine cholesterol screening. She was getting frustrated because I never sent her any results.

However, I never received notification of the test, or any results, by fax or by snail, even though I have received (from them, for other patients) prior records, specialist reports, warnings not to prescribe certain drugs, and plenty of advertisements for their glossy new facilities and their amazing new specialists – both by fax and by snail.

So I called the “old branch” downtown. The operator transferred me to medical records and put me on hold. Ten minutes later, I was told they had no records of the patient since 2009. (I explained that her insurance company had already paid for it and sent her a receipt, however.) I was told to call the “new hospital” medical records department “which is the main one.”

Here I was given the option of pressing 1 to ask for a release of records, 2 to get their fax number, or 3 to hear their hours. (Why is there never “Press 666 if you are a doctor in a hurry”?) Then I had the option of leaving a voicemail.

Eventually heard back. Was told by the medical records-keeper, who was looking at his computer screen, “I can see the patient, but I can’t see the lab test, because it’s an outside physician.” He asked, “Who are you with again?” I replied, “Nobody – I’m a family doctor in private practice,” and he said under his breath, “Ohhh, you’re not with anyone…” Finally he decided to connect me directly with the lab itself, who could straighten it out directly.

Here I spoke to a somewhat embarrassed lab tech who said, “I’m so sorry, this is just a draw station, I don’t know why they sent you here!” She told me I needed to call Client Services, because “only they have that kind of information.”

Called Client Services, where they promised to fax the results immediately. I asked if the original results had been sent to some other doctor, but no, it was my name and contact information on the original lab order. So what happened? (You need to understand, dear reader, that lab orders always-always emanate from a doctor and then results go to a doctor. They never-never just float around homeless in limbo – theoretically.)

The Client Service person explained that even though she could see that my fax number has been active in the files since 2009, it was, nevertheless, chronically in the inactive stack, and the backup system of telephoning-the-doctor-with-results was simply never activated.

I went, “Huh?” …and I may be reporting this conversation incorrectly, because it was such a complex set of stacks and piles and lines and actives and inactives that I’d never heard of before.

This person was clicking many buttons and saying, “Huh. But why – That’s weird… Huh. I don’t know… Hmmm.” Her final solution was, “I’m gonna print up the lab slip, hand-write a note on it that this fax number is the correct number, and send it back in, so somebody can re-enter your information into the right part of the system.”

So maybe soon, after this hour-long process, I’ll be getting this lab result that I didn’t even know was drawn (three weeks ago), even though I am “an outside physician.” Yes, here I am, “outside,” pressing my nose against the glass, looking in at the big shiny information network reserved for the “inside” doctors, who are on the payroll…

By the way, earlier this year, the giant corporation (note to self: stop calling it “heartless”) did break down and start offering lower prices to people paying out of pocket. A few of these prices are lower than those offered by the lab I usually use. Most are not. If you are insured but obliged to pay out of pocket (for example, with a high deductible policy), the price is generally about 300% higher than it could/should be. This, of course, is not sustainable for most of the folks I know. (I can’t be more specific, because doctors are not allowed to discuss fees or prices specifically, by law; see here, and scroll to the bottom for last year’s Justice Department ruling.)

Do you also want to hear the story about how a long chain of command amongst the corporate doctors led to a friend paying full price for an MRI of her child’s wrist, with inconclusive results, leading them back to doing the simple office exam, for a common harmless condition, that they should have done in the first place? Do you want to hear how I spoiled the Christmas of a rural family by sadly telling them their child really will have to have a belly CT, which they had to pay cash for, to make sure it’s not a ruptured appendix? Why aren’t we occupying medical corporations?

You know, the main reason I originally gravitated to the corporate lab was that it had once been founded by nuns, and I like nuns. The founder, Sister Francis Clare (nee Margaret Anna Cusak) was an Irish proto-feminist who once said, “I do not believe in offering the gospel of talk to starving people.” This was at the end of the second Irish Famine, which killed a million people – about 1 in 8. She also said: “What kind of liberty of conscience is it which tolerates, or rather encourages, oppression in one place and cries with wild shrieks of rage against what is a simple matter of duty?” She ended up quitting, finally, as her order’s website describes, “sick and disillusioned with a patriarchal Church.”

I have to wonder what Mother Clare would be saying about the heartless corporation today. In an article this year about the disappearance of nuns from leadership roles in Catholic – often charity – hospitals, one 73-year-old nun-boss said, “We can’t be maudlin about this… I mean, yes, we are a dying breed. We are disappearing from the face of the earth and all of that. That being said… there is this thing called Presence,” explaining that she was trained to see Jesus in the face of every patient, “and I think that’s the piece that is lost.”

Her replacement states that he will be “trying to drive more efficiencies in the system.”

“It is almost six years since Katrina. Charity sits empty.”

So anyway… Waiting for those lab results, and wishing for the thousandth time that socialized medicine would reduce the temptations of filthy lucre to people of conscience.

So now the White House (my Facebook friend), is soliciting comments about “what $40 means to you.” Because, they explain, if the Payroll Tax Cut is not extended – and the Republican majority has zero interest in extending it – that’s the amount by which a ‘typical’ paycheck would be short.

Typical?

Forty bucks is the amount that someone would lose on a biweekly (twice a month) paycheck if they earned $50,000 per year.

People who earn $50K per year are part of “the 75%,” but most of the cardboard-sign-holders are not $50K/year folks.

Even if they did get lucky and find a full-time job, it would have to be as an accountant, or a psychologist, or a biologist, for a few examples – to be part of “The 75%.” And the folks who are commenting on the Facebook page – and most of the comments are simply hateful – but the few folks who do answer the question, they’re almost never $50K/yr people. Just like the cardboard-sign holders.

“$40 would mean I wouldn’t have enough for groceries for the next two weeks or transportation to work & school.”
“I could give up my internet access or having a phone.”
“Losing $40.00 would mean not being able to buy school lunch for my child, for three weeks.”
“$40 is my whole food budget for a week. Or fuel for my car to get to work for 2 weeks.”
“Medical bills… I have made a contract with these clinics for $50.00 a month.”
“$40 = week of gas.”

The White House has a little calculator that can tell you what you’d stand to lose, or what you’d stand to gain, if the Payroll Tax Cut were rescinded, versus if it were expanded by another 1.1% as it says in the proposed American Jobs Act – whether you are a single-income or a multiple-income family.

Let’s compare these numbers to the population figures we looked at before.

“The 75%” = People in the US who make $50K or less per year.
If you make $50,000/year before taxes, you lose $1000/year when the Payroll Tax Cut ends.
If the Jobs Act were passed, you’d keep your $1000 and raise it by $550, for an “extra” $129 per month ($1550/yr).

“The 66%” = $40K or less per year.
If you make $40,000/year before taxes, you lose $800/year.
(Examples: plumber; math teacher; or drug rep married to a part-time preschool teacher; or truck driver married to a floral designer, etc.).
Pass the law, keep your $800 and raise it by $440, for an “extra” $103 per month ($1240/yr).

“Since I already don’t have health insurance this means an increasingly unhealthy diet as well.”
“40 bucks would be 20 for gas and 20 for a past due bill.”
“$40 = month of communication for cellphone.”"
$40 is a healthy, home-cooked Monday-Friday dinner for my family.”
“You know, $40 a paycheck isn’t going to hurt my bottom line so much. It’s a dinner out for my family, a months worth of school lunches for my kids. We could stretch it out and cover those expenses. But that’s just us, we are blessed.”

“The 55%” = $25K or less per year.
(Example: military rank E4 (Corporal, Specialist, Petty Officer 3rd Class, Senior Airman).
If you make $25,000/year before taxes, you lose $500/year.
Pass the law, keep your $500 and raise it by $275, for an “extra” $65/month ($775/yr).

“The 33.5%” = $15K or less per year.
If you make $15,000/year before taxes, you lose $300/year (Example: full-time cleaning lady, bouncer, part-time dental hygienist).
Pass the law, keep your $300 and raise it by $165, for an “extra” $39/month ($465/yr).

“The 25.4%” = $10K or less per year.
If you make $10,000/year before taxes, you lose $200/year.
(Examples: full-time minimum wage worker in Wyoming or Georgia, $5.15/hr; or part-time $10/hr worker, working 50 weeks per year).
Pass the law, keep your $200 and raise it by $110, for an “extra” $26/month ($310/yr).

“Dinner and a movie with friends. Or I could cut down on my 401k contribution.”
“1/2 a textbook for next semester!”
“$40 is the cost of school lunches for 2 weeks for 2 kids.”
“1 case of diapers or a case of formula for my newborn twins.”
“Gas for my car for the month.”
“Don’t have a paycheck to take $40 from. Hanging on by a frayed thread.”

People in “the 66%” pay the same prices for groceries & heat & blood pressure pills & cell phones & diapers as people in “the 33.5%.” But some will get an extra $100, and others only $40, per month, and that only if we, the people, pass the Jobs Act.

Lose the Payroll Tax Cut instead, and now the math teacher will lose $67/month, while the lady who cleans his house will lose $25/month. (They still both pay $40/month for gas or cellphone or school lunches or 1/2 a textbook.)

If you’re a libertarian, that probably sounds fair… until you consider that it means the math teacher has $3266/month left over, while the cleaning lady has $1225/month left over. Which one has a better shot at buying the gasoline, diapers, school lunches, and blood pressure medicine they need every month?

It’s your basic flat-tax problem. Imagine if each were taxed, for example, a “fair and equal” 50%. The math teacher would still have $20K to live on for a year; the cleaning lady would only have $7,500 left to live on for a year. The difference in their “fair and equal” life chances is immediately evident. This is why we tax higher incomes at higher rates – it’s not as big an ultimate bite for those who are wealthier.

(Before you ask, my libertarian friend, no, the cleaning lady making $15,000/year is not eligible for “welfare” or Medicaid. She could, of course, get $16 a month – yes, that’s sixteen dollars – in Food Stamps [based on $400/month rent]. The math teacher would basically not qualify for anything, not even for $16, unless s/he were supporting five dependents.)

Why on earth is this discussion appearing in a doctor blog?

… Because I can prescribe an albuterol inhaler to treat your asthma, but I can’t buy it for you. It costs about $45/month. What if you decide your kid needs it more than you do? You’re not filling that prescription.

… Because I can prescribe birth control pills, but I can’t buy them for you. They cost about $30/month, unless you get fancy (then maybe $250/month). If you can’t afford them, then Plan B may be $50 – if you happen to have $50, right when you need it.

… Because a good antibiotic might be $30, so you might decide it’s better to wait and see if the cough and fever go away by themselves. (You didn’t have $100 for a chest x-ray, so we’re kind of guessing, anyway.)

… Because I’d like you to get a blood count and a metabolic panel (about $25 out of pocket), and also to take three basic supplements (multivitamin with minerals; vitamin D; fish oil – about $20 at the discount store), for your disabling fatigue and body aches. (Most doctors would shudder at what bare-bones medical care that is; some might consider it approaching malpractice, for failing to do a complete workup.) However, a one-month bus pass to get to work costs $50. You can’t buy both, so I just never hear back from you.

… Also, of course, because you can’t pay your doctor bill – either your $30 co-pay, or else your $50 out-of-pocket office visit. Maybe this means you don’t come in until you’re so sick you have no choice, but you still can’t pay me. This means I’m looking for a third moonlighting job. Without one, I won’t be able to afford to see you, either.

It’s not only about what $40 per paycheck means to me and my Facebook friends. It’s that an economic collapse is also a health problem – seriously, a BIG one – and I don’t have the tools I need to help you.

You know those cardboard-sign holders in the park? The ones the City Council just decided to disperse, by fair means or foul? We’d better get down there and join them.

Resources:
American Jobs Act/Payroll Tax Cut calculator:

http://www.whitehouse.gov/economy/jobs/we-cant-wait

Food Stamp benefit calculator for Oregon:

https://apps.state.or.us/fsestimate/

Nationwide Food Stamps income limits, based on household size:

http://www.fns.usda.gov/snap/applicant_recipients/eligibility.htm#income

To find your own “percentile”:

http://www.ssa.gov/cgi-bin/netcomp.cgi?year=2010

For your state’s minimum wage laws:

http://www.dol.gov/whd/minwage/america.htm#content

To see military pay scales:

http://www.navycs.com/2011-military-pay-chart.html

Estimated salaries:

http://www.simplyhired.com/a/salary/home

Income by race:

http://www.census.gov/compendia/statab/2012/tables/12s0701.pdf

Neither they nor I are big fans of using prescription medication to do these things. They don’t want to take a weight-loss pill three times a day, an antidepressant, two blood-sugar pills three times a day (or three insulin shots a day), an ACE inhibitor and a diuretic, a statin, a narcotic and an NSAID (+/- a muscle relaxer), plus the stool softeners and antacids to counteract the effects of the pain meds, and a sleeping pill (or two) every night. They don’t even really want to take a handful of vitamins and “natural” supplements, three or four times a day. They just want to be well.

And very often they will say wistfully, “Gosh, I’d do anything to be healthy again.”

And I have taken to saying, “Anything? You would do anything?”

The reading I have done recently, and the patients I’ve talked to, at length (since most of my office appointments are an hour long, with plenty of time to talk), have convinced me that in many cases it is possible to improve health overall by making a very minor change in a person’s diet.

That change is, eliminating animal-based foods.

Here is my reasoning.

It appears that diets high in animal-based foods, even if they also contain some fruits and vegetables (and none of us really eat as many fruits and vegetables as we think – food diaries always suprise us!), produce a kind of generalized low-grade inflammation throughout the body.

What is inflammation? It is the most basic function of the immune system. In the popular military motif, the immune system “attacks invaders” to “defend the body.” (Of course the story is more complex that that – more like the complex relations between trees and grasses, fungi and worms, mammals and reptiles, birds and fish, all interacting within the same ecosystem. In this case, the ecosystem is a person’s own body.)

This interpretation of inflammation tells us that, among other things, the immune system over time tends to “mistake fatty deposits for intruders.” An alternative interpretation may be that, within the immune system, certain elements function to reduce excess/unnecessary fat cells, or to reduce the amount of lipid stored in fat cells. One of the effects of inflammatory cytokines, after all, is to produce “sickness behavior,” which includes loss of appetite. The whole story undoubtedly includes both, for complex organisms tend to have systems that both “attack” and “nuture.”

It appears that animal-based foods – meat, poultry, fish, milk, eggs – contain a fair amount of inflammatory mediators themselves. They are also very high-calorie, promoting obesity. The evidence is pretty good that a person, by not eating animal foods, can attain a healthy weight, normalize their body’s responses to nutrients (including cholesterol compounds and blood sugar), and reduce the effects of stress responses.

Of course there is plenty of anecdotal evidence of this. Witness the personal transformation of the average patient (overweight, with high blood pressure and cholesterol, and just not feeling very well) seen in the documentary about nutritionists leading the research in this field, Forks Over Knives. I myself know several people (and am married to one) who were surprised that, when they switched to a plant-based diet, they not only lost weight, but felt so much better than they had expected. Better energy. Better sleep. Better mood. And if they were under medical supervision, their doctors were likewise surprised and pleased.

My young and glamorous spouse notes, for the record, that he not only quit eating animal foods – he also quit drinking soda and eating chips and candy bars. He doesn’t smoke cigarettes, and never overdrinks. He doesn’t need to take any prescription medications or even vitamins, and he pretty much eats as much as he wants.

Is it difficult to quit eating animal foods? Depends. I have shopped and cooked for vegans for more than 15 years, in several different geographical locations (urban to rural), in several different family structures (all ages), and at several different income levels, including on food stamps. I developed some flexible strategies, and am currently putting together a cookbook to share them. But here are some basics:

~ If you live where I do, the stores and restaurants are all full of vegetarian versions of regular American fare, from vegan pizzas to vegan pot pies. There are 8 kinds of vegan milk, from soy to hemp, for your granola, not to mention a million soy yogurts. You may eat better than you ever have in your life.

~ If you live in an area that does not have so many options, you will probably want to concentrate on recipes from Asian, Mexican, and Italian traditions, leaving the meat out of the recipes, or substituting something, like tofu or mushrooms, for the meat. You’ll want to have a sandwich before you go out to a restaurant with your “meater” friends – because you may very well be limited to salad for supper. Forget about restaurant breakfasts, unless you love oatmeal and fresh squeezed OJ (yum).

~ If you are on a budget, rice and beans will be your mainstay for a while. Did you know you can make your own veggie burgers at home, from rice and beans (and other ingredients)? Frozen veggies are cheaper than fresh, and they keep better. (Skip the organic vegetables until you can afford them.)

~ Maybe you are on a budget, and do not have much time to spend in the kitchen. Get a new-used crockpot from the Salvation Army store – throw in a rice cooker, if you find one. (You can cook lots of things in it, not only rice.) Also look for plastic food storage containers, and buy a Sharpie (permanent marker, to date frozen foods.) You will be able to throw together soups and sauces before work or school, and they’ll be ready at the end of the day. Many of us cook a double recipe, and freeze half for another day. Canned beans, by the way, are instant, as opposed to dried, and they’re still cheap.

~ Does your family hate the whole idea? Too bad! Think about how much it will cost you – and them – to take 20 pills a day, because that’s where many of us are headed. Imagine how nice it would be, to feel strong and energetic again. Just because your family prefers to be less healthy doesn’t mean you should enable them. However, to ease the transition, you can temporarily commit to spending a little more on “meat substitutes” (like “garden burgers” and “tofu pups”). Put the soymilk in a pitcher or a reusable glass milk bottle, in the fridge. Put the vegan margarine in a butter dish or butter-crock. Be patient. It usually takes about 3 weeks for kids, and 8 weeks for grownups, to completely adjust to the change.

I wrote this article because, when I was telling my (meat-eating, soda-drinking) dad about my ideas, he said, “Is this just something you made up, or do others say the same thing?” I did a 20-minute Internet search on PubMed, the national scientific research database, and found these abstracts below (emphasis added). I got all excited. I hope you will, too.

The effects of a low-fat, plant-based dietary intervention on body weight, metabolism, and insulin sensitivity.
Barnard ND et al. Am J Med. 2005 Sep;118(9):991-7.
Department of Medicine, George Washington University School of Medicine, Washington, DC, USA.
This study investigated the effect of a low-fat, plant-based diet on body weight, metabolism, and insulin sensitivity, while controlling for exercise in free-living individuals. In an outpatient setting, 64 overweight, postmenopausal women were randomly assigned to a low-fat, vegan diet or a control diet based on National Cholesterol Education Program guidelines, without energy intake limits, and were asked to maintain exercise unchanged. Dietary intake, body weight and composition, resting metabolic rate, thermic effect of food, and insulin sensitivity were measured at baseline and 14 weeks.
RESULTS:
Mean +/- standard deviation intervention-group body weight decreased 5.8 +/- 3.2 kg, compared with 3.8 +/- 2.8 kg in the control group (P = .012). In a regression model of predictors of weight change, including diet group and changes in energy intake, thermic effect of food, resting metabolic rate, and reported energy expenditure, significant effects were found for diet group (P < .05), thermic effect of food (P < .05), and resting metabolic rate (P < .001). An index of insulin sensitivity increased from 4.6 +/- 2.9 to 5.7 +/- 3.9 (P = .017) in the intervention group, but the difference between groups was not significant (P = .17).
CONCLUSION:
Adoption of a low-fat, vegan diet was associated with significant weight loss in overweight postmenopausal women, despite the absence of prescribed limits on portion size or energy intake.

Diet and cancer
Drew, J. World J Gastrointest Pathophysiol. 2011 August 15; 2(4): 61–64.
Rowett Institute of Nutrition and Health, University of Aberdeen, Greenburn Road, Bucksburn, Aberdeen, AB21 9SB, United Kingdom.
Obesity and associated reduced consumption of plant derived foods are linked to increased risk of colon cancer as well as a number of other organ specific cancers. Inflammatory processes are a contributing factor but the precise mechanisms remain elusive. Obesity and cancer incidence are increasing worldwide, presenting bleak prospects for reducing, or preventing, obesity related cancers. The incidence of these preventable cancers can be achieved with greater understanding of the molecular mechanisms linking diet and carcinogenesis. Janice Drew has developed a research program over recent years to investigate molecular mechanisms related to consumption of anti-inflammatory metabolites generated from consumption of plant based diets, the impact of high fat diets and associated altered metabolism and obesity on regulation of colon inflammatory responses and processes regulating the colon epithelium. Comprehensive strategies have been developed incorporating transcriptomics, including the novel gene expression technology, the GenomeLab System and proteomics, together with biochemical analyses of plasma and tissue samples to assess correlated changes in oxidative stress, inflammation and pathology. The approaches developed have achieved success in establishing antioxidant and anti-inflammatory activity of dietary antioxidants and associated genes and pathways that interact to modulate redox status in the colon. Cellular processes and genes altered in response to obesity and high fat diets have provided evidence of molecular mechanisms that are implicated in obesity related cancer.

Again, that was a very simple twenty-minute internet search, not even using any special doctor resources! There is lot of data to support this approach. My mission is to spread the word, and give you ideas on how to make it easy. Because if you say, “I would do anything,” I’ll take you up on it!

Stay tuned for Dr Leigh’s “inflammation transformation” cookbook, appearing here sometime soon (ish).