Chicken pox is in the news around our parts:

4/21/12 – “The Oregon Corrections Department says two inmates at the state penitentiary have chicken pox…”

5/7/12 – Some online posts that NewsChannel 21 found read:
“I am a mother of a 5 year old son living in the Portland area, and I am looking to expose him to the chicken pox.”
“I have a 2 year old who woke up with chicken pox today. I live in Springfield, Missouri if anyone needs a playdate.”
“Pretty sure we had a successful party today. So be expecting them in Michigan soon.”
Some parents, however, have taken find chicken pox online to the extreme, and even sent items such as used lollipops and washcloths to parents, in order to spread the disease when no one can be found nearby. Not only can this be dangerous – it is illegal, and a federal offense to send a disease by mail.

Here is my brief science class on chicken pox.

The Latin name is Varicella, which would be a pretty name for a little girl, of course. “Chicken pox plus,” which appears later in life, is called Zoster, which would be a good name for a German-American farm family, if you ask me. “Go on down the road a piece, past the old Zoster place.”

The germ in question, the chickenpox germ, is a Herpes virus. There are a lot of different Herpes viruses. The major ones are chickenpox/shingles (varicella-zoster), “cold sores” above and below (herpes simplex), “mono” (Epstein-Barr and cytomegalovirus), and roseola (exthanthem subitum = “surprise rash”), the 3-day fever of infancy.

The word “herpes” means “creeping,” like a snake – for example, snake biologists are “herpetologists.” Snakes are meek and helpless (no limbs), and spend most of their time hiding out. Same with herpes viruses. They are so small and meek that the immune system would wipe them out immediately if it noticed them. So they creep away and hide.

What this means for humans is that when you catch a herpes virus, after the initial infection, the virus creeps away and hides out in your nervous system, where the immune system doesn’t patrol all the time. (It doesn’t patrol there all the time because you wouldn’t want constant inflammation of your brain and spinal cord.)

The virus lives there until the immune system is impaired or distracted for some reason – for example: you are under a lot of stress, you are sick with some other virus, you are taking steroids or getting chemotherapy, you have an immune system disorder.

If the immune system is impaired or distracted, a herpes virus may take that opportunity to creep out and party (multiplying and reproducing, resulting in symptoms).

If you could have a vaccine that would alert your immune system to the introduction of a herpesvirus, maybe you could prevent the whole active virus from creeping away into your nervous system and living there forever.

This is why I am in favor of chicken pox vaccination, even though I agree with parents that the chicken pox disease itself, although tough on adults and sometimes catastrophic for pregnant ladies and newborn babies, is not usually too terrible for little kids.

Often, when we think about shots for kids, we are only thinking about those individuals as babies or schoolkids.

But I am a family doctor – I take care of people of all ages, including many former babies and small kids who are now even older than I am (and I am as old as the hills).

A number of my patients, whose immune systems have been temporarily impaired or distracted, have developed shingles. Do you know what shingles are? You should, because if you are old enough to read this blog, you are old enough to get them.

They feel like an intense itching that turns into an intense burning, like a bee sting or a jellyfish sting. A couple of days later, the rash (usually) appears. It follows the path of the nerves coming out of the spinal cord by which it traveled. It is “exquisitely tender” (official medical term). This means that it feels like a burn from a cigarette held against your skin.

It lasts a while, and we hope it eventually goes away. Sometimes, however, the nerves sustain permanent (or semipermanent) damage, called “post-herpetic neuralgia.” This is worst when it occurs on the face.

Not only the skin can be involved; it is possible, for example, to get ulcerations on the cornea of the eye from the shingles, requiring long-term treatment with eye-immunosuppressant and anti-inflammatory drops, and so on. Ear involvement can cause long-lasting vertigo (“the spins”) and deafness. Do you think these are very unusual, unlikely, and freaky? I don’t – but I suppose I have a skewed vision of what is common, due to my occupation.

Sometimes people just have the nerve damage, and never get any blistery rash. This makes it pretty tough for healthcare workers to diagnose what is going on.

When we have a little baby, we don’t usually think of them as future senior citizens.

However, when we have a little baby, we do hear about somebody whose child was fine one day and autistic the next, and worry that shots must have caused it. (Ironically, we’re not usually as concerned that going to preschool that day, or digging in the garden that day, or kissing a puppy that day – each causing exposure to large numbers of multiple potent antigens at once – might have caused it… Note: nobody knows “the cause” of autism).

So we tend to think that a known quantity, like a traditional “childhood illness,” must be “more natural” and thus safer, than shots.

So – even if we do get our kids vaccinated against tetanus, maybe polio, maybe rubella – folks usually skip the chicken pox shot.

If you do get the shot, however, the virus does not go and live in your spinal cord; the shot consists of a weakened (“attenuated”) half-dead form of the virus, and it is not strong enough to do so.

I must say, I blame doctors primarily for the mystification around shots (and around medical care in general).

Doctors:
1. Allowed the insurance industry to take over medical care, so that corporate executives now decide how much time a doctor will spend with their patients, how often they will see them, and how well they will know them – namely, not enough, hardly ever, and not well.
2. Chose to maintain physicians as an elite class (despite being actually demoted to corporate employees), perpetuating the mystification of all things medical without compensating for it with some sense of consumer solidarity. This has been the death of reliable “patient education” or what I’d consider skills-sharing.
3. Generally deal with their time pressure and sense of inadequacy by being abrupt and snotty to patients who are worried, which encourages people to privilege the information obtained from kindly, yet quacky, websites over anything endorsed by anyone with actual scientific training.

Many people I have met in person and read on the Internets believe that physicians have some sort of formal “kickback” relationship with manufacturers of vaccines. Nothing could be farther from the truth. Vaccines are monstrously expensive and a huge hassle to get ahold of and maintain – especially for small medical practices like mine (I have never been able to provide them).

Don’t even get me started on the truly crazy claims made about shots (e.g. FEMA vaccination prison camps, etc.), nor the truly strange assertions made about vaccine-preventable diseases (like CANCER for example) being more natural and safer than shots.

Just don’t let’s start.

former unvaccinated toddler

Although I respect the authority of parents and their responsibility to make health choices for their families, and I feel their deep concern – and often their anger – over these conditions, I also do know in my heart that immuno-science is the wave of the future in medicine.

Our own immune systems are so much more creative, flexible, and resilient, than all the poisoning, cutting, burning, and freezing to which we resort to prevent and cure illness, that it is just a tremendously exciting time to work on all this stuff – recruiting and strengthening and modulating the immune system, for human health.

For this reason, although I am not judging the decisions that parents make – we all try to do our best, after all, and they are the ones who must take responsibility for their decisions – I still wish folks were less afraid of shots, and more afraid of the disease germs that have injured, disabled, and killed so many people of all ages, who should otherwise have thrived – in our own backyards, and in my office, and all over the world.

What we need more of is science

Which brings me back to chicken pox.

You might think chicken pox is a benign childhood illness that mainly manifests as a daycare logistics problem for grown-ups.

But someday – possibly next year – when you get the shingles – particularly if you are unfortunate enough to get them multiple times – particularly if that terrible burning pain (“exquisite tenderness”) doesn’t go away – and you realize that, if the germ had never taken up residence in your spinal cord in the first place, this wouldn’t be happening – you might wish you had had the chicken pox shot, and not a chicken pox party, when you were a child.

another former unvaccinated toddler

Coda:
Isn’t there a shingles vaccine?
Yes! And shingles is such a significant problem (and costs so much, to our already-collapsing healthcare system, in diagnosis and treatment of older adults), that last year the FDA mandated that it be available ten years younger than before; it’s not mandatory, but you can get it anytime over age 50.

What kind of shot is it? Why, it’s the chicken pox vaccine. It doesn’t work as well as when it’s gotten during childhood, but it’s better than nothing. If you have ever had shingles, you’ll be willing to try “better than nothing,” rather than more shingles.

P.S.
But can’t kids get chicken pox from the shot, can’t they get shingles from the shot, can’t they get autism from the shot, can’t they turn into the incredible hulk* from the shot, etc?

The shot is safe. I hate to just state it so baldly, but the shot is safe. I know you might be looking at me skeptically, but…

You know, most of the symptoms of illness we experience, are less a direct effect of the germ, and more a direct effect of our own immune response. This is true when we get the flu, or when our finger swells up and turns red from an infected cut, etc.

Also true for reactions to vaccines: a kid who runs a fever, gets redness and swelling at the site of vaccination, and/or gets a few chicken pox blisters, as a result of vaccination, is showing a healthy immune response to the vaccine, which is a good thing. It indicates a vigorous constitution that will protect the child in the exposure-years to come.

That’s my story, and I’m sticking to it.

*“Vaccine Adverse Event Reporting System (VAERS)… reports can be entered by anyone and are not routinely verified. To demonstrate this, a few years ago I entered a report that an influenza vaccine had turned me into The Hulk. The report was accepted and entered into the database. Because the reported adverse event was so unusual, a representative of VAERS contacted me. After a discussion of the VAERS database and its limitations, they asked for my permission to delete the record, which I granted. If I had not agreed, the record would be there still, showing that any claim can become part of the database, no matter how outrageous or improbable.” - J. Laidler MD

More reading:
A nice review of varicella zoster herpesvirus, by the CDC:

http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/varicella.pdf

A recent news warning about chicken pox lollipops:

http://www.reuters.com/article/2011/11/12/us-chickenpox-lollipops-idUSTRE7AB0SW20111112

MC Hawking’s famous song “What We Need More of is Science”:

http://www.songfight.org/music/morescience/mchawking_morescience.mp3

“Moms who vax” is a pretty cool website:

http://momswhovax.blogspot.com/2012/02/moms-who-vax-pox-and-social-contract.html

Disclaimer, if “disclaimer” is the word I mean – maybe more like “testimonial”:
I had chicken pox as a child; the shot was not invented. My kids had chicken pox; two of them had it twice. The shot was not invented then, either. I probably would not have gotten it for them anyway, because I had never heard of shingles.

I have had shingles myself three times, the first time during an immune meltdown involving “mono,” with high titers of Epstein-Barr and cytomegalovirus. (I was 36, struggling to support my family by working nights in an adolescent psychiatric hospital; I skirted the edge of Chronic Fatigue Syndrome, but did not quite fall over – that time.) When it first happened, I thought I must have broken a rib – I still had never heard of shingles.

When I learned in medical school that mainly the very elderly and people with AIDS get shingles, I thought my case must just be very weird. Now, however, I know that “98% of adults 20–49 years of age are at risk for herpes zoster. The lifetime risk of developing herpes zoster is about 30% and each year there are an estimated one million cases of herpes zoster in the United States.”

The last time I had them – recently, at age 49 – the nerve damage persisted for three months; now there’s only loss of sensation. I’m old enough now, thanks to the FDA’s new rules, for the shingles shot (which is the same as the chicken pox shot, scaled up in strength for grownup bodies) – but I can’t afford it yet (about $250, out of pocket).

So I know whereof I speak. Just saying!

First, some old-time history:

In 1848, the doctors of Charlottesville, Virginia, agreed to fix their prices above a certain minimum. Some examples:

Regular doctor visit, daytime, $1-2;
$2-4 for night visits.
Attendance on a sick patient through the day
(equivalent to minimal hospital care) $5;
through the night, $10.
Baby delivery, white mom $20; non-white mom, $10.
Difficult or forceps delivery, $20-100.
Amputation of arm or leg, $20.
Setting a fracture, $10.
Treatment of gonorrhea, $10; of syphilis, $20.
Catheterization or placement of a drain, $5.
Incision and drainage of an abscess, $1-2.
Tooth extraction, $1.

Here’s approximately what those dollar amounts might mean today:
Regular doctor visit, daytime; $30-55; $55-100, nighttime.
Attendance on a sick patient, all day, $140; all night, $275.
Baby delivery, white mom $550; non-white mom, $275.
Difficult or forceps delivery, $550-2800.
Amputation, arm or leg, $550.
Setting a fracture, $275.
Treatment of gonorrhea, $275; of syphilis, $550.
Catheterization or placement of a drain, $140.
Incision and drainage of an abscess, $30-55.
Tooth extraction, $30.

Also:
Administration of a medicinal enema, $55.
Pills (per dozen) or tincture/syrup/ointment (per ounce), $7-14.

This doesn’t mean a doctor couldn’t charge more – they just couldn’t charge less, except for charity, in which case the total bill had to be reduced, not individual parts of the bill. For example, the doctor couldn’t provide without charge “for charity” the cost of materials or the services of his helpers, while still charging for his own services.

Is it okay for doctors to fix prices? Nope, it’s against the law. Let’s fast-forward to some contemporary legal news around this topic.

In 2009, the Department of Justice issued a rule that restrains physicians from…
“(A) encouraging, facilitating, entering into, participating in, or attempting to engage in any actual or potential agreement or understanding with, between, or among competing physicians about:
any fee…
the manner [in which they'll] deal with any payer (i.e., insurance corporation)…
or any refusal to deal or threatened refusal to deal with any payer…

(B) communicating with any competing physician about:
the acceptability of any proposed or existing payer…
any proposed or existing term of any payer contract…
[or] the manner of resolving disputes between any parties to any payer contract.”

But why?

Here’s why.

In Idaho, 2006-2008, some local orthopedists “agreed not to treat most patients covered by workers’ compensation insurance… to force the Idaho Industrial Commission to increase the rates at which orthopedists were paid for treating injured workers.

“The Idaho Industrial Commission [a state agency] sets the fee schedule.” (For example, most orthopedic procedures are reimbursed at $88 each.)

They also “threatened to terminate their contracts, to force Blue Cross of Idaho to offer better contract terms to orthopedists.”

“The [DOJ's] proposed settlement prevents [them] from agreeing with their competitors on fees and contract terms… [and] prohibits them from collectively denying medical care to patients,
refusing to deal with any payer,
or threatening to terminate contracts with any payer.”

Now, that sounds right, doesn’t it? Those selfish, greedy orthopedists!

Read on.

It’s quite unusual for the Justice Dept’s Antitrust Division (for criminal cases) to prosecute such a case. Usually the federal Trade Comission (for civil cases) has done so.

“…The Justice Department has unambiguously stated that refusal to accept government price controls is a form of illegal ‘price fixing’… [and more ominously] has linked a refusal to accept government price controls with a refusal to accept a private insurance company’s contract offer.“

Basically, that means that refusing to accept an insurance corporation’s terms is treated like conspiring against the government.

“Even if there’s no evidence of direct communication between physicians, if a large number of physicians in a given market individually reject a government price control scheme or insurance company contract, the Antitrust Division can simply ‘infer’ the existence of a conspiracy.

“…The DOJ has a number of tools the FTC does not, including the self-granted power to award amnesties from criminal prosecutions to the first ‘conspirator’ to step forward and provide evidence against one’s competitors… And if that doesn’t work, the DOJ can always seek wiretaps of physicians’ phones and computers, a power awarded the DOJ during a 2006 renewal of the Patriot Act.”

You remember the USA-PATRIOT act: the letters stand for “Uniting (and) Strengthening America (by) Providing Appropriate Tools Required (to) Intercept (and) Obstruct Terrorism.”

So now, complaining about insurances to another doctor can be in the same category as conspiring to commit an act of terrorism. Wouldn’t it be crazy if insurance corporations could use the Patriot Act and the Feds to put doctors out of business (or in prison), if they resisted corporate control? That would be so crazy, right?

Another doctor’s letter to the DOJ, three years earlier, regarding a similar case:

“Physicians were forced to react to anti-competitive behaviors by Cincinnati insurers because the Department of Justice did not enforce antitrust principles against those insurers.

“The DOJ allowed a monopsony of insurers to impose unrealistic contract terms on obstetricians and to fix prices below fair value…. which created an unsustainable financial loss for those doctors.

(A monopsony is like a monopoly; all the local doctors are forced to accept whatever the one or two major insurance corporations are willing to pay them, because those corporations are the only game in town.)

… “The actions of the doctors are inaccurately described as a ‘conspiracy to artificially raise fees by healthcare insurers’…The doctors were actually trying to partially reverse the artificial depression of fees resulting from the concerted, unopposed and unwarranted fee depression by the insurance monopsony in Cincinnati.

… Antitrust rules are supposed to prevent huge corporations from taking advantage of consumers (patients) and small businesses (doctor offices). The large insurers in this case and similar cases use the DOJ as a weapon against physician resistance to unfair contracts to increase insurer profits.”

Not quite the same idea as selfish greedy doctors denying care to patients in search of exorbitant fees.

Three years before that, in a review of 21 prosecutions by the Bush Administration:

“Each of these cases presents a similar scenario:
~ A group of independent physicians band together to deal with the administrative and regulatory burdens imposed by managed care.
~ The group negotiates contracts with various HMOs, PPOs, and employer-based plans.

… “Permitted exceptions are for so-called “risk sharing” models… [such as] capitation and withholding.”

Okay, I know your eyes are starting to glaze over, but this part is important. These legal-beagle details really help to answer the questions of why our health care system is so broken, why you’re having so much trouble finding a primary doctor, and why medical attention costs so damned much.

~ “Capitation is the basis of most managed care organizations: The insurer pays a fixed price per service… regardless of the actual cost to the physician. Thus, if a physician receives $5,000 to treat a heart attack patient, but the physician’s actual cost of treatment is $8,000, the physician must absorb the loss.

… “Both of these models shift risk from the insurer to the physician while simultaneously distorting the price paid by the ultimate consumer. It is illegal for consumers to know the true cost of health care and for the physicians to take any action that might enable services to be produced more efficiently.

I’ll repeat that: “It is illegal for consumers to know the true cost of health care and for the physicians to take any action that might enable services to be produced more efficiently.

“The only beneficiaries are the third-party insurers, which are cartels exercising the state’s authority by proxy.”

[I talk to my patients about capitation all the time; I didn't know about withholding. (I suppose in the context of an employee doctor's employment contract, it has some other name, like "bonus incentive plan" or something.) The conversation we generally have is about Medicaid. See below for the Medicaid implications of these rules.]

A lot of angry doctors on the internets – a group of very privileged and politically conservative people overall – are now blaming all of this on “Obamacare,” although the laws of concern were established in like 1993, and mainly started being used to attack doctors during the Bush II administration. These folks see the current government’s teensy little dip-a-big-toe-into-the-pool effort at universal medical care coverage as the long arm of the law.

Whatever. If the citizenry gets together and declares in its wisdom that every doctor should accept Medicare prices for all services, so be it; it’s a democracy. But what I find absolutely horrifying is that the rules and tools of democracy are being employed for the benefit of the most voracious profiteers in our system today – private insurance companies, feeding off the vulnerability of the suffering, with their profit margins enforced by the Department of Justice.

One last note: about a possible exemption allowing physicians to talk to one another about insurances, and what it means in the context of Medicaid.

One recent review stated that Accountable Care Organizations might be one way physicians can speak freely to one another about medical-economic conditions, without being presumed to be in a Standard-Oil-style monopoly-establishing conspiracy.

What are ACOs? Same old, same old: capitation and witholding, obliging doctors to do the insurance company’s work of denying services, unless they agree instead to go broke.

How do they affect physican free speech? It changes their status, so they can not be presumed to be “competing” against one another any more. Now they are all employees, working for the same corporate masters.

So they can complain all they want. It won’t make any difference.

What did the State of Oregon recently get a big fat grant to establish? Yup, Accountable Care Organizations to administer Medicaid.

ACOs are a hot topic in the health-profiteer press these days – there’s a lot of gushing. For example, “The success of an ACO will depend on how they will land within the “sweet spot” of not cutting too many services and getting enough bonuses and if they can influence their decision-makers (the individual clinicians!) to provide only reasonable services and referrals that will increase quality.”

“Success,” I suppose, means financial success, although it’s politically correct in these settings to tip the hat to ‘quality care’ or ‘outcomes’ in a way that is reminiscent of actual concern for actual patient wellness. The “sweet spot” mentioned above is one in which doctors are willing to deny care in exchange for a bonus. The bonus, I suspect, actually consists of avoidance of “withholding” penalties – but they make it sound nicer. Yippee.

Will ACOs really make doctors immune from prosecution for complaining about crummy insurance rules? That remains to be seen. Personally, I doubt it – why should they? The insurance industry has already been reassured that the Justice Dept. and the FTC would “review an ACO with a 50% or greater share of any common service that two or more independent ACO participants provide to patients in the same primary service area.”

“Review” = well, all of what I just discussed.

Meet the new boss. Watch your step.

Here are some home remedies with stuff the average kitchen might have on hand – for when you are unable to go, or send anybody, to the drugstore, grocery, or health-food store. These are for urgent/stopgap use only, not for every day, and are not usually preferable to the remedies you could otherwise obtain from your drugstore, grocery, or health-food store!

Also please be aware that many groceries and pharmacies do deliver, and will bring you over-the-counter remedies, not just the typical items, if you need them and can pay a little extra for the service. Call and ask.

Please also make sure that somebody knows you are sick, and will check on you every 24 hours. If you were to suddenly become too weak to care for yourself, you would need help.

Vomiting:
~ Ginger tea +/- honey – sip to quell nausea. Can use dried ginger powder; it will be spicy.
~ Important: If you are vomiting, you are losing electrolytes. If your urine is bright or dark yellow, you need fluids. Make oral rehydration solution:
1 qt water + 2 Tb sugar + 1/2 tsp salt
(+/- 1/2 c orange juice +/- pinch of baking soda [bicarbonate]).
Drink this instead of plain water. Don’t worry if you throw it up again. Keep drinking.

Diarrhea:
~ Applesauce with lots of cinnamon. Not apple juice – apple sauce. Make your own applesauce by grating or chopping whole scrubbed apples and cooking over low heat until they form a sauce. What’s a lot of cinnamon? As much as you can tolerate. (Don’t do this: http://bit.ly/y8qO44)
~ BRAT diet: bananas, rice, applesauce, toast. BURNT toast. The charcoal helps.
~ Blackberry tea: blackberries grow like crazy where I live. Pick leaves, dry them in the oven, crumble them up, make a strong astringent tea. (Raspberry leaf works, too. Make it strong.)

Constipation:
~ Coffee: are you a coffee drinker? Caffeine is laxative. Try 3 cups, if you tolerate coffee.
~ Prune juice: 1/2 cup nightly to prevent constipation; 1 quart (4 cups) to treat it. Takes time to work. Apparently works because it is high in sorbitol. Some folks chase it with apple juice (apple juice, not apple sauce).
~ Mineral oil: 3 Tb by mouth. May combine with something else, like juice. May take 6-8 hrs to work. Mineral oil is also known as baby oil. Not the same as machine oil. (Can try any kind of vegetable oil as well – e.g., olive, coconut, cooking oils. Mineral oil is preferred because it is not digested, but travels all the way through the intestinal tract without breaking down, acting as a lubricant.)
~ Enema:
If you have a bulb syringe, a turkey baster, or a water bottle with a squirter top (use sandpaper and/or a lighter to soften and smooth the end), and some lube (e.g., shortening), you can give yourself an enema.
Remember that the bowel tissues are delicate, and do not use anything harsh.
Try a booty-up or a side-lying position, with strategically-placed towels.
Allow the solution to stay inside for as long as you can (5-15 minutes).
BE CAREFUL. BE GENTLE.
Recipes:
- – - Saline enema: 1 Tb salt + 1 c warm water
- – - Milk and molasses enema: 1 c milk + 1 c molasses
- – - Soapsuds enema: 1 quart water + 1 tsp castile soap (liquid or shaved and dissolved, e.g. Dr. Bronner’s or Kirk’s). Any other soap can be used, including dish detergent and baby shampoo, but I recommend using a much smaller amount if it has additives (colors, scents, surfactants, etc.) – approx. 1/2 tsp per quart of water.

~ Oral magnesium: for people with completely normal kidney function only! If the kidneys can’t clear the magnesium, overdose can be life-threatening.
Take one dose per 24 hours. Don’t take it over and over. It’s strong stuff.
- – - Epsom salts (magnesium sulfate): 8 oz warm water + 2 tsp epsom salts (approximately 1975 mg elemental magnesium).
- – - (or) Magnesium citrate (If you happen to have it around): 150-300 mL adult (1440-2880 mg elemental magnesium).
- – - (or) Magnesium pills: If you have magnesium supplement pills (e.g., “Slow-Mag”), you can crush up enough to equal approximately 2000mg elemental magnesium. (This is likely to also give you 3000+ mg calcium. Stay hydrated, and skip your vitamin D supplement, to prevent calcium overabsorption.)

If you take too much? More than 9000 mg can produce over-relaxation of your whole system, including flushing, headache, lethargy/somnolence, slowed heart rate, and abnormal heart rhythms. Too much calcium can give you kidneystones and lots of other issues.

Once again – these are remedies for adults who are usually in normal health (not pregnant, not small children, not with chronic illnesses on multiple medications), who are stuck at home and sick without help, not for every day. Now obviously, the BRAT diet and ginger tea are not going to hurt you… What I am saying is, if and when you can obtain more specific care and more specific remedies, you should.

From a brief stroll around the Internets:

I was recently diagnosed with having an Ovarian cyst after having extreme lower, right abdominal pain and nausea and being admitted to the hospital to rule out appendicitis. Can someone give me information on this?

I had an ovarian cyst. It was painful, so I had it removed. The ultrasound ruled out any bad possibilities. While I could have opted to not have surgery, the cyst really hurt so I wanted to end the pain.

Here is my understanding.

“Ovarian cysts” should not even be called “cysts.” If you are told you have an “ovarian cyst” and then go home and look up “cyst” in any online dictionary, you will be afraid. Very afraid.

~ “A stage in the life cycle of certain parasites.” Uh, maybe keep reading.
~ “A pathologic space in bone or soft tissue containing fluid or semifluid material.” Gross.
~ “…See cystic ovarian disease.” – Wait, disease!?
~ “Most cysts are harmless but they occasionally may change into malignant growths.” WHAT?
~ “Four main types: retention cysts, exudation cysts, embryonic cysts and parasitic cysts” [followed by list of 58 kinds of cysts, including 'chocolate cyst' and 'sterile cyst' which, alarmingly, "fails to produce brood capsules"]. WTF?

If you look up “ovarian cyst” in one of the very long lists, you are referred to “follicular cyst,” which is then defined as “one formed by enlargement of a graafian follicle as a result of accumulated transudate.”
…Annnnd now you’re done.

Okay, forget all that. Reframe.

There’s that cute Dr. Graaf, inventor of the graafian follicle, circa 1670.

As you know, during your fertility cycle, your ovaries make a lot of estrogen, while an egg develops in the ovary. I know this is boring, but stay with me. This is actually happening in your actual body.

The egg matures inside a weensy little water balloon* which floats to the surface of the ovary and then pops. When it pops, the water balloon* starts shrinking (and the egg wanders away). That tissue turns into a temporary endocrine gland, making progesterone (which thickens the uterine lining and does a lot of other premenstrual stuff). (If no fertilization and no new placenta making new hormones, the system resets = menses.)

Another detail: “We begin with up to 7 million oocytes [eggs] and by menarche [first menses] we have only 400,000. By age 30, we have only 100,000. In our lifetime, a woman will ovulate only 450 oocytes or 0.1% of those she had at puberty. What happens to the rest?”

Well, all we have are theories, really. The point is, during each cycle, many water balloons* develop, and usually, only one pops. The other ones have to shrink as best they can.

*The “water balloon” is an ovarian “cyst.” We all make many, many of them every cycle. They are normal.

Attractive rendering of an ovary with several healthy looking fertile bubbles in play.

How can they cause pelvic pain? Several ways are possible.

1. Thanks to hormones, many bubbles develop at once. This makes the ovary bigger. This can cause some temporary stretching and crowding, potentially producing pain. Although it is painful, it is not abnormal. Sometimes it takes them longer to shrink than at other times, prolonging the stretching and crowding.

2. Some cycles, a bubble can be extra-large. When it pops (ovulation), a lot of fluid comes out, and if a little blood vessel is nearby and also leaks, you get a bunch of fluid +/- blood leaking out into the pelvis. This is just generally “irritating” – medicalese for ‘painful.’ The body naturally reabsorbs the fluid/blood, but it does take a few days. Although it is painful, it is not abnormal.

This is the ovary of a daylily. It looks very much like yours.

3. If multiple bubbles and/or an extra-large bubble make the ovary very large, it can actually twist on its ligaments, cutting off its own blood supply. This is a special, excruciating, sudden and persistent pain that is a medical emergency. (A tubal pregnancy – a fertilized egg caught in the tube – also causes excruciating, sudden and persistent pain that is a medical emergency, usually 5-8 weeks after the last period.)

4. “Polycystic” ovaries are ovaries which are under the influence of a lot of estrogen, and make tons of fertile bubbles. This makes the ovaries bigger, with the mechanical problems described above. This issue can be on a spectrum from mild to extreme. Medical science so far usually only diagnoses and treats extreme cases, so far, but in my humble opinion this will be changing shortly.

5. It is possible to have a growth in the ovary that is not a fertile bubble. You can have a blood blister (from a broken small vessel in there, in which case the blood is reabsorbed over time, like any other blood blister) or a dermoid cyst (which is more like a skin cyst – not infectious, but full of goosh), or several of the others on the 58-item list in the dictionary (including endometriosis, in which a speck of uterine lining gets established outside of the uterus, and responds to the hormone cycle by filling up with blood and then leaking/shedding). These, however, are not diagnosed as “an ovarian cyst.” If you had one of these, your gynecologist or radiologist or whomever would have called it by those names, not called it a “cyst.”

Note: Ovarian-fertility related pain is usually felt starting a week or so after the last period ended. Once again, terrible pelvic pain several weeks after a missed period, especially with a positive pregnancy test, needs medical attention.

Also note: Pelvic pain is not necessarily due to water balloon/”fertile bubble” development! There can be other causes. This discussion is only about “cysts.”

Multiple ovaries in the belly of the earth. How cool is that!

When should you seek medical attention?
~ If you are unable to care for yourself due to pain which is not responding to reasonable at-home treatments.
~ If you have fever, shaking chills, vomiting, or other alarming medical problems that could indicate a tubal pregnancy or a pelvic/uterine/or bladder/kidney infection.
~ If you missed a period and then had terrible pain.

If you have a personal physician, of course, you should just email them or call their cellphone, whenever you simply are concerned and would like advice from someone who knows you well, to figure out how worried to really be.

At least, that’s what my patients usually do.

Many people reading all this will think their situation is different from what I am describing, because they have already been told that they have a big ovarian cyst, polycystic ovaries, or other grave “ovarian cyst” problems possibly requiring surgery.

Now, I’m not a gynecologic surgeon… but unless you are having ovarian cyst pain that is worsening and persisting (like a solid [not bubble] dermoid cyst that is growing and growing), or is sudden and severe (like a big ovary getting twisted on its ligaments) – you might want to treat it medically rather than surgically. Are these different? They are.

~ You can work on ways to stop having ovary/pelvic pain on a cyclic basis, for example by temporarily suppressing your ovulatory processes.
~ You can support your body’s natural clearance and healing process while reabsorbing pelvic fluid and reducing associated inflammation.
~ You can rehab the pelvic pain and the likely microscarring involved.

If you look up images for “ovarian cyst,” you are going to see a lot of worst-case scenarios that are posted on the internet specifically because they are rare. They are going to freak you out. Combined with the alarmist terminology and the surgical bias of a specialty, they can give you a completely distorted idea of what is going on. And it is very, very well known that “catastrophic thinking” directly and dramatically worsens the perception of pain.

It was many decades ago that women recognized that the medicalization of women’s health – childbirth, for example – resulted in unpleasant, harmful, and often dangerous attitudes and practices. We also recognized that these attitudes and practices were intellectually offensive, because they perpetuated false and mystifying notions. I feel the same is true of the way gynecology conflates many normal processes with grossly pathologic processes, including ovarian “cysts.” I am not saying ‘fertile bubbles’ aren’t sometimes a huge pain in the pelvis. I am simply saying, recognize them, interpret them, and manage them – claim them and take charge, same as we did for the also sometimes-challenging but always-astonishing normal processes of menstruation, birth, nursing, and menopause.

Don’t let the bubbles get you down.

Image modified for extra graafian mystique from ittybittiesforyou at Flickr.

If you are totally sure you are totally healthy, you do not need to go see your doctor.

But if you had an issue your doctor had some suggestions about, last time, and you haven’t seen the doctor for a while, it’s a good idea to check in, because things can change.

~ Your doctor might have changed their mind about what they said before.
~ Your doctor might have new information that didn’t exist before.
~ Your doctor might have new resources for you that weren’t available before. You never know!

…So I went to a week-long doctor conference, and it was okay.

It’s Oregon, not New York, and mostly family practitioners (docs, nurses, PAs), not radiologists/ cardiologists/ surgeons. (I imagine their conferences are held on yachts, over caviar and champagne.) So the crowd had a huge preponderance of ponytails, fringey scarves, fleece vests, and sandals-with-socks.

What the screen says: “Punch versus shave.” Scintillating stuff, folks. No, really.

A lot of women brought their knitting, and I missed mine. I was impressed that all the knitters were working on advanced-level projects, using fine yarn, throwing with their left hands, and doing intricate color and texture patterns. Well done!

During the classes, a fair number of folks were reading the newspaper (sports or money sections), reading novels, or playing Angry Birds on their phones. I frowned upon this. Even on the first day of medical school, doctors always try to appear above listening to lectures. Personally, I’m delighted to hear an expert talk about what they dig.

My home sweet home, in the International Hostel. Cozy and fun!

Here are some of the things I went to interesting classes on:

Thyroid disease:
~ “Apathetic hyperthyroidism” (causing weight loss, depression, and palpitations
~ “Amiodarone-induced thyrotoxicosis,” in which heart-attack medicine, containing “therapeutic overdose” of iodine, backfires
~ Why “natural” thyroid, from pig glands, typically causes overdosing of one form of thyroid hormone and underdosing of the other. (Hint: storage form is not same as circulating form, in humans, physiologically.)
…and much more.

~ Lung cancer screening, pap tests, new drug warnings. Just gangs of stuff.

Family doctors purely love oatmeal, everywhere you go. Offered every morning.

I am a shy person who did not know anybody there, so I mainly eavesdropped during mealtimes and breaks. There were some interesting themes. For example, “Medicaranoia” (my term) – lots of theorizing and dire predictions about what is going to happen with the trifecta of aging baby boomers, the primary care shortage, and the fact that Medicare reimbursements are lower than most docs need to stay in business.

Some or all of this is expected by Oregon office-based family docs:

1. Congress won’t allow Medicare reimbursements
to become commensurate with other medical care
payors.
(For me, it’s about 1/3 of what insurances pay.)

5. Doctors will just quit. And that will be the end of
family practice, as physicians are replaced with nurse
practitioners.
(That 2009 survey found that 1 in 5 family docs were planning
to quit by 2014 anyway.)

I heard a phrase I hadn’t heard before, and I heard it several times: “the worried wealthy.” These are the people whom doctors reassure themselves will make up for their Medicare burden. The “worried wealthy” will come in to the office once or twice a year, for a physical exam or a mole check, and the resulting reimbursements will make up for the 10 yearly visits of one MCare patient with diabetes [and glaucoma and underactive thyroid and chronic bronchitis and migraine headaches and acid reflux and ringing in the ears and high blood pressure and depression and needing to pee ten times a night - absolutely not exaggerating].

These doctors were not talking about actual wealthy people. (If they had been, they’d have been doing it over caviar and champagne on that yacht.) They were referring to people who have what used to be considered normal health insurance.

Even in this already-gloomy context, there was a lot of resentment amongst older docs regarding the high turnover of younger docs. At one table there was a long series of exchanges about communities where new doctors moved in, didn’t join the doctor club properly or at all, performed poorly, and left abruptly. (Of course, this is a phenomenon that’s been going on since forever; the typical first primary-doctor job lasts a year, and the job-changing rate yearly is about 10% across all specialties.)

These docs mainly blamed “bean-counters” and clueless administrators at giant group practices, for offering bad jobs, with hidden pitfalls, to gullible youngsters.

In some cases, they noted that their communities – Oregon is mainly composed of small communities, thickly sprinkled over the Western half of the state, it seems to me – were just too conservative for the newbies. In others, they noted that patients aren’t comfortable with anyone who has brown skin or an accent. It was easy for them to openly discuss this, since in all (by my count), there were just one brown skinned person and ten Asian looking people at the entire conference. I really didn’t hear any accents.

One of the things that surprised me most at this conference was considerable contention about statins. Statins are medications used to lower blood cholesterol, in hopes of thereby reducing risk of heart attack or stroke. I heard them discussed, in no uncertain terms – conflicting, but never uncertain – at five different classes (on cholesterol management, heart disease, how to read an EKG, obesity, and drug safety).

About a third of the time, people gave strong cautions, warning of the terrible things that could happen as a result of taking statins (muscles fall apart and byproducts kill kidneys; people get diabetes).

Another third of the time, people stated shortly and firmly that statins are perfectly safe. “They ought to put them in the water.”

Another third of the time, people gave very elaborate debunkings of the scaremongering around statins, with the take-home message: statins are safe, and here’s a ton of science why. (For example, study results showing muscle pain is mainly seen in people with vitamin D deficiencies; ditto, in people with underactive thyroids.) It’s nice to hear some interesting science amongst all the opinionating, but wouldn’t you think that same science would have already unified the field?

I know patients always suspect that doctors probably are given ten$ of thousand$ of greenback dollar$ by Big Pharma to say nice things about dangerous drugs. In this case, however, I doubt it. There were only about six drug-company vendors, with folding tables set up in the afternoon snack area (cupcakes!) – they offered pamphlets and, I believe, some pens. They looked a little bored and lonely. They were dressed much more nicely than the doctors. I bet they wished they’d been assigned to the radiology/ cardiology/ surgery conference on the yacht instead.

So, in any case, I went to a week-long doctor conference, and it was okay.

If you haven’t seen your doctor for a long time, it’s worthwhile checking in, because you never know, your doctor might have some new suggestions for you about…
~ Taking azithromycin for chronic bronchitis (and not because it’s an antibiotic)
~ Getting off of thyroid medicine (half of people with mild low thyroid regain normal function after 3 years) – and off of dessicated pig thyroid in particular
~ “Blister beetle juice” for plantar warts
~ Drinking only very expensive fine imported or microcrafted wines – if you have a fatty liver
~ Staying away from “no-flush niacin” (it’s not actually niacin!)
~ Using lidocaine gel to deal with unpleasant pelvic (and/or prostate?) exams
~ The proper use of lube – to reduce friction in relationships

Hurrah for lifelong learning!

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.