Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Saturday, October 17, 2009

Health Care for the Unemployed

Appended to a note about how much she enjoyed my book, a friend asks:
I'd be very interested in any thoughts you have about getting healthcare to the unemployed and uninsured. Do you have some?
If she means, "Do you have any thoughts about large structural changes in the delivery of health care that decouple it from employment and insurance status?" then the answer is yes. However in addition to being the topic of my next book, these thoughts by definition have no chance of actually helping any of the unemployed and uninsured -- two groups that frequently overlap, of course -- right this minute. If, on the other hand, she means "Do you have any thoughts about getting health care to the unemployed and uninsured this very minute?" then the answer is also yes. Furthermore, they fit into a blog post.

I'd like to make it clear at the outset that I'm not discussing primarily charity care. There are several local clinics and resources available that provide care at reduced rates. The thoughts I have are about making medical care more affordable by thinking outside the box and off the grid.

Medical Care

First, find a good family physician you can work with. By this I mean someone whose opinions and abilities you respect, and whose advice you will follow. The well-trained family doctor can care for 90% or more of the problems you may have, and can do so far more economically than the collection of specialists most people in this country have come to equate with "the best medical care in the world". You do not need an annual visit to a dermatologist/gynecologist/urologist/cardiologist to check your moles/pap/prostate/blood pressure, even though they may tell you that you do. This will also spare you from undergoing expensive, unnecessary testing: annual stress tests and echocardiograms do nothing for stable coronary disease; once you've had three normal annual paps, the frequency can be decreased to every 3-5 years; and so on.

Tell your family physician about your uninsured status. Plan to pay for your medical care, preferably at the time of service. Rates are often substantially less than you think they will be. My regular fees work out to about $200 per hour (ie, $50 for a 15-minute chronic care visit; $100 for a half-hour physical, etc.) Most doctors near me would probably charge about the same, or accept that amount upon negotiation.

Drugs

We are living in the golden age of generics. There are really surprisingly few patients who absolutely require expensive brand-name drugs. In addition to WalMart's $4 generics ($10 for 90 days), Target and Genuardis have almost identical lists. Many other pharmacy chains (Giant, Rite Aid, and others) will match prices, but you have to ask. Costco usually has the best prices. By law, you do not need to be a Costco member to use the pharmacy.

Labs

Laboratory studies are among the most overpriced components of medical care. The markups between what labs charge patients and their actual costs are truly sickening. I know this because their charge to me as a physician client is a fraction of the direct patient charge. By charging only a small markup for myself, patients end up paying less than half of what they would be charged by the lab. Additionally, there are assistance programs available. Then again, a qualified, thoughtful family physician (like me) will limit lab testing by doing only those tests absolutely necessary for appropriate diagnosis and treatment.

Imaging

There is a free-standing radiology center near me that offers fantastic service, and completely transparent pricing. If you call them up and say, "I don't have insurance. How much is a chest x-ray?" they will say "That will be $62." (Actually, a rep stopped by the other day and told me the price for a chest x-ray had actually decreased.) If you need to schedule an MRI, they will say, "Can you come over this afternoon?" Again, competent family physicians (like me) will only order imaging studies if they are absolutely necessary to diagnose and treat you appropriately.

Immunizations

Every county has a public health department that includes immunization clinics for adults and children. Some are free; some charge (VERY reasonable rates; I purchase vaccines and I know what they cost). Pride should not be an issue: this is not charity. You pay for it with your taxes. (Montgomery; Chester; others easily googled.)

(Hospital Care)

This could be a project for venture capital: a cash-only, insurance-free hospital with transparent pricing. In the meantime (apologies for continually tooting my own horn), a qualified family physician ought to be able to keep you out of the hospital, and especially the Emergency Department. Aside from major motor vehicle accidents and complex trauma, a good family doc can take care of many things for which you may think you need an ER. Call first.

Other Ways to Save Money on Health Care

I would be remiss if I did not include a discussion of things NOT to spend money on when funds for health care are limited.

Supplements & Vitamins

Stop purchasing and consuming assorted vitamins and supplements. Things like CoQ10, antioxidants of all descriptions, and substances purported to "support" any aspect of your health should be avoided completely. They are completely unnecessary for your physical health, and downright hazardous to your financial health. All essential nutrients are readily available in high-quality food. Use the money you save to increase your consumption of vegetables, fruits, and fish.

Most Over-the-Counter Medications

Stick to generic acetaminophen (Tylenol), ibuprofen (Advil, Motrin) and naproxen (Aleve) for pain and fever. Just about everything else is useless. Cold meds like decongestants, antihistamines, cough suppressants, etc. have been shown not to work in children under 4. Originally, they were banned under age 2. That age is going to keep creeping up until it is finally recognized that they don't do squat. Saline nose drops/sprays/neti pots work best for stuffy noses. Use plain honey for cough. (Locally produced honey can help with allergies, too.)

When you get sick, you really do need to rest, increase your fluid intake, and be patient; not "a patient" (noun), but "patient" (adjective). Wait it out at least a week. Almost all minor illnesses will be improving by then.

Avoid Chiropractors

Intelligent chiropractors recognize that they are providing a form of physical therapy. The ones who still believe there is a vital force flowing from your brain to your spinal cord and out to the rest of your body, and that all illness comes from spinal subluxations disrupting these vital forces, are dangerous pre-scientific quacks who are nevertheless persuasive and effective at separating you from your benjamins. Save your money.

Avoid "Alternative," "Complementary" and "Integrative" Medicine

The more accurate term for all these modalities is "quackery". Acupuncture, homeopathy, reiki, therapeutic touch, and all kinds of other so-called "CAM" practices are collections of pseudoscientific nonsense that have been well studied (with your tax dollars, thank you very much) and shown scientifically not to work. Their practitioners are compassionate and persuasive, but their ultimate interest is their pocketbook and not your health. When you win the lottery and have more money than you know what to do with, feel free to waste it as you please. But if you're unemployed, uninsured, and/or worried about how to pay for healthcare, it is unconscionable to throw your money away on these services.

Drop the Gym Membership

Get out and walk, either outside in fair weather or inside in foul. Thirty minutes a day, a little too fast to comfortably have a conversation if you happen to be walking with someone else, is all you need for metabolic fitness.

Quit Smoking

Now is the perfect time. Cold turkey is the most effective, as well as the cheapest way to go. At $5.00 per pack, one pack per day is $35/week, $150/month, $1,825/year. That should easily cover a year's worth of routine medical care out-of-pocket.

Quit/Cut Down on Drinking

Alcohol isn't cheap, and it isn't particularly good for you either. Decreasing or eliminating it will do you no harm at all. While on the subject of liquid refreshment, the latest nutritional recommendations for drinks for children are "nothing but milk and water." Given that soda and most fruit juices are nothing but sugar water packed with empty calories, that's pretty sound advice for adults too. "Water" means from the tap, by the way. Your taxes go to make sure that it's absolutely perfect. Bottled water is a waste of money.

Stay Healthy with the Basics

They're called "basic" for a reason:
  • Get plenty of sleep
  • Eat well
  • Exercise regularly
Nothing sexy, exciting, or expensive about any of it.

22 Comments:

At Sat Oct 17, 04:51:00 PM, Anonymous Anonymous said...

Well, until you made your uninformed statement about alternative medicine, I thought you were a pretty good doctor. But if my doctor ever admitted that she felt that way about these treatments, that would be the last time I would ever darken the door of her office.

Apparently you don't realize (or choose to ignore) the fact that big pharma can purchase "research" that will "prove" anything they want it to, including that alternative therapies don't work. I'm not saying there's never any quackery involved among alternative practitioners, but you are using a mighty broad brush to tar something that's helped many people, and that big pharma would love to see go away because it's a direct threat to their profits (of course, many alleopathic doctors would like to see it go away for the same reason, but I won't ascribe malice in your case because you don't strike me as that sort of person).

Yes, there are quacks, but there are also plenty of quacks among regular doctors (don't get me started on a certain local neurologist that must have got his license from a cracker jack box). The difference is that you aren't the target of a smear campaign concocted by a multi-billion dollar industry, probably because you welcome the drug reps who are pushing the latest expensive drugs when they come calling (and if you don't, far too many of your peers do).

If only my very limited insurance would pay for some alternative treatments, I'd try them, and if they do absolutely nothing I'd be the first to say so (I attended a fundamentalist church for many years and yet I thought most of the faith healers that came through were charlatans and quacks, and therefore came off like the skunk at the garden party on more than one occasion). But a lot of folks in particular seem to think that acupuncture and Reiki and similar treatments are helpful. My Dad had chelation treatments (back in the 70's, I think) and while I don't know if they extended his life by all that much, they certainly seemed to improve his overall health.

The thing is, and pardon me for being blunt about it, but I think it's just ignorance and arrogance that causes most "regular" doctors to dismiss alternative treatments. And seriously, if my doctor ever said to me what you just said, they would not be my doctor anymore, because I could never trust them and would always be suspicious that perhaps they were just pushing pills for big pharma!

 
At Sat Oct 17, 05:15:00 PM, Blogger Resident Anesthesiologist Guy (RAG) said...

Like many alt-med junkies, it seems that Anon believes that anyone who decries it is purely ignoranr. Whatever.

Good sound advice, Dino. Unfortunately that requires personal accountability that a great deal of unemployed/ uninsured seem to lack - from my limited experience at least.

 
At Sat Oct 17, 06:38:00 PM, Anonymous Anonymous said...

Well, there you go… if you don't buy into the big pharma propaganda, then you must be an "alt-med junkie" (despite the fact that the only "alternative meds" I buy are Aspirin tablets and a cheap store-brand Vitamin D supplement, the latter only because I live in a cold climate and don't get out in the sunlight nearly as much as I should, plus I have previously been diagnosed with solar keratosis, which kind of means I should stay out of the sunlight).

But it's exactly that sort of comment that makes me distrust the medical profession. You folks just aren't open to anything you didn't learn in medical school, and that's fine if you want every condition to be treated with drugs. But I don't, and a lot of other people don't. Why aren't we allowed to make that choice without being marginalized and put down by "medical professionals?" Why is everyone supposed to just acquiesce to the bought-and-paid-for "research" that tells us that drugs are good for us, and any alternative treatment that doesn't involve drugs is bad/ineffective (despite the fact that many people who've had alternative treatment have had a positive outcome)?

 
At Sat Oct 17, 06:46:00 PM, Blogger chartreuse said...

Vitamin D is the important exception to the no-supplements rule, and anybody living in an area that has winter should be taking it. It's dirt cheap, though.

 
At Sat Oct 17, 08:16:00 PM, Anonymous Anonymous said...

The other thing the alt med junkies are is "often in error but never in doubt." The medical profession believes in science. If there's no science--and there's not, there's no proof of benefit. Great advice, Dino. We should all take it.

 
At Sun Oct 18, 10:17:00 AM, OpenID behlerblog said...

I have to admit that had I not done research in alternative options for a book I was writing, I would have been of the same opinion as most docs. It makes sense, doesn't it? These techniques can't be scientifically proven. Furthermore, there is no guarantee that what worked for one will work for another.

Doctors have a duty to their patients to practice sound medicine that works every time. Antibiotics for an infection - it's a no-brainer. Reiki? Who knows?

Having said that, I had some very odd and profound things happen to me during my research phase, and my docs can't explain any of it. Yah, I do believe Reiki had a profound effect on my health - so much so that I couldn't tolerate my meds. Once I was off them, test were done and the conditions were no longer there.

I know, it sounds like a church revival meeting, doesn't it? But something very concrete happened to me. Having said that, there is no way I'd ever stop going to my doc, and I would never rely solely on anything other than science. I look at Reiki as a means to obtaining total relaxation - nothing more.

However, I know that when I get a headache or sore throat, nine times out of ten, a quick blast results in my not getting sick or the headache disappearing within minutes. Even my aspirin takes longer.

But docs would be irresponsible to prescribe a blast of Reiki over migraine meds. I still find it an interesting dynamic.

 
At Sun Oct 18, 11:17:00 AM, Anonymous Dick Carlson said...

I'd love to hear your suggestions on just how I find "a good family physician you can work with."

We recently moved across the country, and I've spent two years trying to find recommendations from friends, web reviews, bloggers, and other resources. When I call an office on the phone I'm treated like dirt if I'm not a current patient.

I'm then told the Doctor "doesn't do interviews" and I have to make an appointment to come in for a problem.

The two I've tried seem competent, but are very focused on just getting me in and out, handing me a scrip or sending me for some expensive (and non-conclusive) testing. I understand they've got a business to run, but it doesn't do much for me.

Any hints or tips?

 
At Sun Oct 18, 11:54:00 AM, OpenID crankylitprof said...

Why couldn't you compel/force doctors to perform a certain number of hours of free service at clinics for the poor, unemployed and uninsured?

Lawyers have to do a certain amount of pro bono work every year to maintain their good standing and license. Why not make the doctors do the same?

/Devil's advocate, waiting for the feces to hit the ventilating device.

 
At Sun Oct 18, 11:58:00 AM, Blogger Shay said...

The thing is, and pardon me for being blunt about it, but I think it's just ignorance and arrogance that causes most "regular" doctors to dismiss alternative treatments.

No, what causes "regular" doctors to dismiss alternative treatments is the fact that none of them have ever been able to pass clinical trials. Sen. Harkin and his pet alt-med project have spent almost 10 years trying to find CAM treatments that work and failed miserably.

 
At Sun Oct 18, 12:12:00 PM, Blogger The MSILF said...

Heh, you beat me to this. I was working on a post comparing what I do when I'M sick as opposed to what patients get and/or expect (the chest x-rays, the useless antibiotics, the decongestants, the referrals to ENT, etc). But now you said it so much better.

And I was going to say sinus wash/neti pot, and cited the cough suppressant vs honey study too!

 
At Sun Oct 18, 01:30:00 PM, Anonymous Anonymous said...

Sweet advice, Dino; much of it even applied to those of us who already have an established relationship with a primary care doc.

Funny, though, how the alt-med types seem to think that clinical trials published in peer-reviewed journals are all hoaxes perpetrated by pharmaceutical companies to sell us more of their products while failing to notice just how much money the quacks and woomeisters are pulling hand over fist out of their pockets. But then they also don't seem to understand the placebo effect, either.

 
At Sun Oct 18, 03:13:00 PM, Blogger The Hatchling said...

This comment has been removed by the author.

 
At Sun Oct 18, 03:18:00 PM, Blogger The Hatchling said...

crankylitprof -

Many of my Emeritus professors supervised a free clinic our medical school provides that is completely student run and funded. Then one got sued by a free clinic patient and they stopped coming for fear of more lawsuits.

IMHO reduced liability for free care would improve access to uncovered patients.

I'm quite sure the situation is different in the legal profession but if the door were to open to allow anyone exposed to lawyers to call for a lawsuit due to harm caused b the contact I'm sure their pro bono practice would change.

 
At Sun Oct 18, 04:30:00 PM, Blogger Drew said...

I work in a hospital in a non-clinical position, but in a field that affords me daily opportunity to work with a number of clinical professionals. I enjoy the work and have developed a bit of an addiction to MediBlogs, because part of my work involves coordinating emergency operations procedures (and as a result, H1N1 has been on my radar for a while now) and I find it interesting.

A great deal of what post I agree with. There are--without a doubt--a number of "cures" and "treatments" that are designed to cure nothing while at the same time, running up credit card balances. I stay away from things that promise to assist me in losing; "30 pounds in 30 days," while claiming that the program will allow me to eat, "ANYTHING", I want.

All of that stated (and shame on the manufacturers of snake oil, packaged exclusively for those who are desperate to cure what ails them, AND on those who are gullible enough to actually buy--both figuratively and literally--such suspect claims) I am not sure that all of the alternative therapy/treatment products/regimens should be equally dismissed.

For example, despite your disdain of acupuncture (which you include in your list of waste of time treatments) there appears to be some traditional research based evidence indicating that acupuncture can be very effective in treating post surgical nausea/vomiting, in particular in those suffering from cancer related treatments/surgeries.

Information from the Mayo Clinic
http://podcasts.mayoclinic.org/2009/02/16/acupuncture-for-nausea/

as well as from Duke University
http://www.sciencedaily.com/releases/2004/09/040922070424.htm

doesn't show research being done by a group of wanna-be doctors, but rather, by what appear to be respected members of the traditional medical community.

In that I am not a doctor, I'll leave it up to those far more qualified than me to debate the merits of the information provided.

Nevertheless, it appears that at the very least, there are those in the non-quack medical community who are embracing at least the possibility that something like acupuncture might reduce post-operative nausea and vomiting.

Thanks--and I really enjoy this Blog.

 
At Sun Oct 18, 09:07:00 PM, Anonymous Anonymous said...

Doctors ALREADY provide a lot of charity care--it's called public aid and not only are we paid less than it costs to see the patient, we have to pay a staff member to file the claim.

 
At Mon Oct 19, 01:29:00 AM, Blogger AmyB said...

When I lost my high-end insurance policy that covered everything at no charge to me, and I had to change to a lesser policy with co-pays, I switched to all generic drugs and dropped Nasacort (for dust mite allergy) in favor of a neti pot. The generics work just fine, and the neti pot does a better job than Nasacort ever did.

 
At Mon Oct 19, 02:16:00 AM, Anonymous med(stud)ent said...

That post was some damn good common sense!

 
At Mon Oct 19, 06:23:00 AM, Blogger Dragonfly said...

Best medical advice ever!!
Like you said about the well trained family doc, in my experience they provide the "best medical care in the world". Here in Australia a referral to a gynae for a Pap smear is as rare as hens teeth. It only happens if the lady has massive anatomical abnormalities or a massive and significant history. Even the women being followed up after Lletz procedures etc, with HPV and CIN III in their PMHx get their paps done by their friendly local GP and the results cc'ed to their gynae.
I have worked with some of these GPs and they are awesome. (They tend to say the same things you do, including re the chiros for back manipulation but not for the treatment of brain cancer et al).

 
At Mon Oct 19, 11:08:00 AM, OpenID crankylitprof said...

Ah. So real medical reform, access issues for the unemployed and the poor alike), would be greatly improved by...tort reform. Because tort reform is a key element of any effort to hold down the costs of health care.

Of course, The trial lawyers' political action committee is the second-largest donor to Democrats' federal campaigns, and lawyers gave $127 million to Congressional candidates in the 2008 political cycle--more than doctors and health professionals, hospitals and nursing homes, pharmaceutical companies, and HMOs, combined.

Even Howard Dean admitted that, "The reason why tort reform is not in the bill is because the people who wrote it did not want to take on the trial lawyers."

 
At Mon Oct 19, 10:01:00 PM, Anonymous red rabbit said...

Great post. I may just print it into a poster and hang it in my clinic.

Oh, and angry altmed anon? Byah! Don't let the door hit you on the ass on the way out!

 
At Wed Oct 21, 10:53:00 AM, Anonymous Anonymous said...

mostly, I agree with Dino, but I try to keep an open mind.

1) I note that several of the commenters mention studies of alternative medicine (at that point, if successful, is it no longer considered alternative?) such as acupuncture, which demonstrate effectivity.

2) the honey and neti pot could be considered homeopathic, along with other unmentioned home remedies which have been passed down in various cultures.

3) as noted- vitamin D is a good supplement to remember for many. We have a national study showing many people are deficient. Better than the skin cancer risk of tanninng for those of us who are pale.

4) eating no processed foods (ie cooking and eating fresh foods and veggies) I still would have a hard time getting all my recommended nutrients within the calorie limit doing nothing but walking for 30 minutes a day. There's no harm in a gym membership. Additionally, the endorphin release from more strenuous activity is a mood booster.

 
At Thu Oct 22, 05:27:00 AM, Blogger The MSILF said...

My standard line, borrowed from Carl Sagan, about "alternative" medicine is that there is no such thing. Plenty of medicines and interventions are unexplained, but PROVEN to work in randomized controlled (preferably blind) trials, or even lesser types of clinical trials.

If it works in a blind trial, it's medicine. The theory behind it doesn't matter. If it doesn't work, it isn't medicine. Period. There is no "conventional" and "alternative" and "natural" and any other term you want. If it works, explained by a theory or not, it is medicine I am willing to practice. If not, it isn't.

So, while some might say that the honey for cough is "homeopathic" or whatever (works by theory X), all I say is that it is shown to work in an RCT. Lubrication? Hyperosmolarity pulling out fluid and thinning secretions? Local allergens? Who the fuck knows?

So that's my take, it seems respectful (I'm totally open to anything that works) and avoids the either-or mentality. Which is ridiculous anyway, because you could certainly say that, say, vinca alkaloids are "natural," yet for some reason, people still run off to laetrile.

Hopefully when I'm bigger and have more gray hairs and people listen to me (sigh, if I only could have been a man), I'll be more able to take stuff head on.

 

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