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Monday, September 30, 2013

Affordable Care Act?

September 30, 2013 will probably not go down as a hugely memorable day in history. Yet, it represents   a pretty momentous confluence of events. On the one hand, there is the threat of an impending government shutdown based on partisan squabbling predicated on the defunding of the Affordable Care Act, or Obamacare, as it is widely known. We are on the brink of ......well, brinksmanship.

On the other hand, we are also on the brink of the inauguration of Health Exchanges-one of the cornerstones of the Affordable Care Act. The Exchanges represent a pretty grandiose social experiment. The goals of the Exchanges seem pretty laudable: reduce insurance premiums, allow those with preexisting conditions to get coverage, allow small businesses and families to have the same kind of leverage with insurers that large employers have.

There are many unknowns as to how, in fact, this will play out. And people should probably use a great deal of caution before chucking whatever plan they currently have. One of the gigantic question marks about the exchanges is a very practical one-how much will the insurance plans offered cost the consumer, and will that actually represent a savings over their current plan?

The fact that patients with pre-existing conditions must be allowed to purchase insurance on the exchange leads me to believe that insurance premiums are bound to go up rather than down. Obviously, if an insurer has a pool of insured people that are highly likely to use a large amount of medical services, they have to charge more to mitigate this risk.  In addition,somehow insurers must pay for the  laundry list of services that must be included for plans offered on the exchanges, such as prescription drug coverage and wellness services, somehow that must be paid for.

It is estimated that only a small portion  of the population will be using the exchanges. If you have existing insurance through your employer, you are only eligible for the exchange if your portion of the premium is over 9.5% of your income. Furthermore, Medicare recipients are not eligible. Further reducing the eligible pool of participants in the Exchanges, is that some states have elected to opt out of creating Exchanges. Those states who do not have an exchange will have a federally run exchange starting in 2014.  The exchanges will probably be applicable to only about 20 million people-more or less.

If you do not currently have health insurance, and you are eligible for the Exchange and you fail to purchase insurance, you will be fined $95. This fine will gradually escalate to $695 over the next few years.

So how will insurers try to keep down the cost of insurance plans offered on the exchanges? Physicians are very fearful that their reimbursement for work done under the auspices of insurance plans offered on the Exchange plans will go way down. One physician organization indicated that reimbursement was a low as 70% below more conventional insurance plans.

Tuesday, September 17, 2013

Colonoscopy Conspiracy?

Colonoscopy Conspiracy??

Don't get me wrong-I am not a conspiracy theorist....I am not one of those folks who is convinced that 9/11 was a government plot, or that the moon landings were a hoax. And, deep down, I really don't think that our government is really conspiring to phase out screening colonoscopy by trying to turn public opinion against it through the media. never know!!

I must confess, however, that my mind did start to wander about such possibilities when I happened to read two articles in large circulation newspapers(large circulation newspapers-that sounds like an oxymoron these days) that maligned colonoscopy. And interestingly, they were published only about 1 month apart. Coincidence? Maybe. Newspapers acting as a shill for government agenda-ie trying to curtail Medicare spending by convincing readers that colonoscopy is an unnecessary ripoff? Maybe.

If you are interested, one article was in the New York Times on June 2 of this year, while the other was in the Washington Post on July 20th of this year. I have attached the links below.

New York Times

Washington Post

Let's start with the New York Times article. The article is entitled: The $2.7 Trillion Medical Bill, with the subtitle:Colonoscopies Explain Why the US Leads the World in Health Expenditures.  Really?? Is it that simple? When the article starts out with that title, you know it isn't designed to present a balanced approach to the topic. The article goes on to discuss some anecdotal cases of patients who were stuck with some ridiculously exorbitant bills for their routine colonoscopy, and decries the overall cost of colonoscopy, quoting a figure of $10 billion per year in the US.  It goes on to quote Dr. Gilbert Welch, a Dartmouth professor as saying, “We’ve defaulted to by far the most expensive option, without much if any data to support it,” when discussing colonoscopy versus other screening tests for colon cancer.  The article failed to mention the fact that Dr. Welch has pretty much made his living over the last 20 years by bashing any attempts to achieve early detection of disease through screening tests. Hmmm, I wonder if he would discourage his mother or father from getting a screening colonoscopy. But, I digress. Oh, one more thing, Dr. Welch-there actually is plenty of data to support it.

Anyhow, the article flashes eye catching highlights, like patients who got staggering bills of over $9000 for a colonoscopy. You have to dig a little deeper into the article, however to find that Medicare paid, on average, $531 for a colonoscopy in 2011. ( By the way-of this total, the physician's professional fee for performing the colonoscopy is approximately $220) Is this really why we lead the world in health care expenditures?

Let's move on to the Washington Post article. This one is another doozy. It is entitled, "How a Secretive Panel Uses Data That Distort Doctors' Pay". The article goes on to describe how an American Medical Association panel, supposedly behind closed doors, hatches a diabolical scheme to tilt the Medicare reimbursement process in the favor of physicians. They cite the case of colonoscopy, the Relative Value Unit(RVU)-which is the basic currency of Medicare reimbursement, is based on 75 minutes of physician time. The article then goes on to question how this can possibly be valid if some physicians are performing 12 or more colonoscopies in a day, i.e. there just aren't enough hours in a day How can colonoscopy reimbursement possibly be based on 75 minutes of physician time when the procedure often takes only 20 minutes or so, etc, etc. Like the New York Times article, it sounds like another example of how colonoscopy is a ripoff being perpetrated by the evil empire of medicine. 

These articles were very disturbing to me, and they should bother you as well. Colon cancer is the number three cancer killer in America. There are approximately 150,000 new cases of colorectal cancer diagnosed per year in the United States, and approximately 55,000 deaths per year. While there are other less expensive, less invasive tests to screen for colorectal cancer, colonoscopy is the only one that offers both early detection, as well as prevention(by way of detecting and removing precancerous growths). Screening colonoscopy has been shown to reduce deaths from colorectal cancer.

Sensationalist headlines blaming colonoscopy for America's healthcare woes, and portraying it as some elaborate scam only serve to discourage those who might be on the fence about getting a screening colonoscopy which might save their life. As a physician who performs colonoscopy, if the American Medical Association is distorting data to provide me windfall profits for performing a colonoscopy, then they are doing a poor job of it. As I mentioned above, the professional fee from Medicare for performing a colonoscopy is about $220. While the procedure may take only 20-30 minutes to perform, that is only the tip of the iceberg in terms of the man hours that are involved. The performing physician also routinely reviews the patient's medical record prior to performing the colonoscopy, speaks to the patient and family in the recovery area following the procedure, tracks down and evaluates results of any biopsies performed during the procedure, communicates those results to the patient, along with any further actions based on those results, and indicates when-if any-followup exam should be performed, and documents all of the above.  So is the RVU for colonoscopy based on 75 minutes of time really a distortion? If anything, it may be an underestimate.

Monday, August 5, 2013

Hemorrhoid Treatment

                                                   Hemorrhoid Treatment-Part 2

It is not Colonoscopy Chronicles’ intention to provide specific medical advice to users of its blog, instead we provide users with information to help them better understand their health, diagnosed conditions, and the current approaches related to treatment, prevention, screening, and supportive care. Colonoscopy Chronicles urges users to consult with a qualified health care professional for diagnosis and answers to their personal medical questions.

In our last post, we discussed treatment of hemorrhoids. As I indicated, I am a strong proponent of hemorrhoid banding in those patients in whom it is appropriate to treat their internal hemorrhoids. The technique I use involves the CRH System for hemorrhoid banding. The company that makes the equipment has a fairly helpful website that describes the equipment and the technique in some detail.

Having been involved in banding hemorrhoids for almost 25 years, I have found the CRH System the best one for my patients. First of all it is safe. Like any medical intervention, hemorrhoid banding has potential complications. The most common "complication" is the one that patients are usually the most concerned about-pain. Patient's, quite understandably, are worried about how painful the procedure will be. And in fact, with some techniques there can be a significant chance of pain after the procedure(32% in on published series from 2005). However, using the CRH system, the risk of significant pain after the procedure is less than 1% !!

I do not promise my patients that the technique is totally painless-since I would rather underpromise and overdeliver. I counsel them to expect a mild pressure-like sensation, or a slight pinching, which usually resolves within a few hours. Usually no intervention is necessary for such monir discomfort, however, I encourage patients to use Tylenol(acetominophen), or Advil(ibuprofen) as needed-as long as they are not allergic to those medications of have no other medical contra-indication. I always find it gratifying when we finish the procedure, and patients look at me in disbelief, and say"Is that it?

Bernal JC, Enguix M, López García J, García Romero J, Trullenque Peris R. Rubber-band ligation for hemorrhoids in a colorectal unit. A prospective study. Rev Esp Enferm Dig. 2005/01;97[1]:38-45

O'Reagan PJ. Disposable devices and a minimally invasive technique for rubber band ligation of hemorrhoids. Dis Colon Rectum 1999; 42(5): 683-5.

Sunday, April 14, 2013

Hemorrhoids It is not Colonoscopy Chronicles’ intention to provide specific medical advice to users of its blog, instead we provide users with information to help them better understand their health, diagnosed conditions, and the current approaches related to treatment, prevention, screening, and supportive care. Colonoscopy Chronicles urges users to consult with a qualified health care professional for diagnosis and answers to their personal medical questions. One of the most common findings at the time of colonoscopy is that of hemorrhoids. While it may seem like a simple topic, I believe that hemorrhoids are highly misunderstood! Let’s start by discussing what hemorrhoids are. They are simply engorged veins near the anal opening. Misunderstanding number one is that many patients are under the impression that it is mandatory to treat and/or remove all hemorrhoids. That is not true. Since hemorrhoids are really not linked to an increased risk of colorectal cancer, and do not necessarily lead to anything more sinister, there is no reason that hemorrhoids automatically need to be treated or removed. I tell patients that the main reason to be aggressive with hemorrhoids is if they are causing significant symptoms. Most people with hemorrhoids do not have symptoms. Those who do have symptoms must decide if the symptoms are bothersome enough to warrant doing something about them. That is really “in the eye of the beholder”. How much a patient is willing to put up with varies from person to person. The second major misunderstanding regarding hemorrhoids is “If it hurts down there, it must be hemorrhoids”. The fact is, that hemorrhoids can certainly cause discomfort. However what patients perceive as pain from hemorrhoids is often from other causes. For example, an anal fissure-which is a small cut in the skin at the anal opening-can cause severe anal discomfort. Likewise, irritation of the skin right around the anus, from eczema, dermatitis, or yeast infections can cause discomfort . Taking a good history of the patients symptoms and doing a good physical examination are critical to diagnosing the source of a patient’s symptoms. While it seems self evident, an accurate diagnosis is critical in providing the proper care for a patient with pain in the anal/rectal area. I have seen all too many patients who were treated for hemorrhoids-sometimes even surgically, when the underlying source of their symptoms was not actually their hemorrhoids. In addition to discomfort, hemorrhoids can also bleed. This bleeding is often minor, and does not necessarily mandate aggressive treatment. On the other hands sometimes the bleeding is persistent and severe enough to warrant intervention. Examples of this are when the bleeding leads to frequent soiling of clothing, or is extensive enough to cause the patient to become anemic. It is important that what is perceived as hemorrhoidal bleeding is not from something more sinister such as a malignant tumor of the colon or rectum. Evaluation with colonoscopy may be necessary in order to rule out tumors or other lesions as a source of the bleeding. Once it has been determined that hemorrhoids are the source of a patient’s problems, then next issue is how to treat them. Bleeding, in my opinion, is best treated with either band ligation or surgical hemorrhoidectomy. I favor trying band ligation first, since it is less invasive, and generally well tolerated and effective. The technique I use employs the O’Regan hemorrhoid banding equipment made by CRH. (