Health care by numbers, putting healthy people at risk

I was speaking to a patient today who was having some muscular problems and was concerned about.  He had just had his creatine levels checked (http://ezinearticles.com/?Creatine-Levels&id=405381) and the level was high.  Creatine levels that are high with cholesterol lowering drugs injestion is one of the reasons we need to be checked frequently when on these meds. I also suggested that some of his muscle stiffness and problems could be due to the drug.  When I asked him why he was having the problem, he said that his heart had a problematic valve which has likely been there all his life. When I asked him about his cholesterol levels, it was well under 200 which really is not high.

The important question is this:  Does the benefit outweigh the risk?  The patient has a known problem that is probably developmental.  Decreasing cholesterol levels that are near normal has no effect on heart function.  Taking cholesterol meds 5 times per week puts him at risk for liver and muscular problems, as well as adding medical costs to monitor him.  Since we are looking at a what if scenario which scares people because nobody wants a heart attack or a blockage to create a life threatening, what if we did nothing?  What if he got hit by a car tomorrow?

I know that is ridiculous but giving a perfectly healthy person dangerous (http://www.thepeopleschemist.com/view_learning.php?learning_id=11)  meds that potentially create problems he never would have had with constant monitoring makes little sense to me.  It is not preventative care, and has a detrimental effect, rather than a benefit over the short term. True preventative care prevents known outcomes such as foot problems creating back problems for instance, since it is mechanical and easily identifiable.  Shadow boxing with what if scenarios by physicians for dubious prevention of rare events is bad medicine.  Taking potentially harmful cholesterol lowering drugs that are likely to have no benefit but cause problems you do not have is not preventative, its foolish and a bad way to spend our health care dollars. Statistics show that statin's have a very small effect on extending ones life (http://www.dailymail.co.uk/health/article-432395/Statins-truth.html), and their benefits are way overstated. The best doctors question everything, including some of the practices of their own profession.  I have certainly done this as a chiropractor.  If you are a person who is on statins and has naturally low levels of cholesterol, but were advised these meds are a good idea, think about this article, the resources in it and have a fair and honest discussion with your doctor.  It is never about your doctors practice style, it is about your health and knowing the difference between prevention and an intervention that is good for your health vs. one that is not good for it.

What do you think, I value your opinion.

Can sitting shorten your life? A new study suggests it will.

I read an article today regarding sitting and how it can shorten your life (http://www.usatoday.com/news/health/2010-07-27-sitting-death_N.htm) .  In a 14 year study, they found that people who sit for longer periods of time (many of us do this at work for hours) are more likely to die from heart disease than those who get up and move around alot. Apparently, mixing alittle exercise with sitting did little to change the outcome.  Apparently, there was a sedentary physiology that develops with those who sit alot.  Please read the article.  Very interesting.

What's a nice doctor like you doing in a plan like this. The story behind why after only four months in ASHN's management of Cigna, we are leaving their network.

Ah, what is an ethical doctor to do?  Last January, we received a letter telling us that we can only continue our participation in Cigna Open Access Plus and the PPO if we become credentialed with a company called American Specialty Health Networks.  We did not accept the Cigna HMO since ASHN took over their network around 1999, when their other vendor went out of business because or the perceived reputation that ASHN had. I was not thrilled, since two years previous, I had helped save Cigna's previous HMO network who was also hurting chiropractors financially by underfunding a capitated plan and not communicating with Cigna that a problem existed.  Cigna historically likes to use vendors instead of administrating certain professions such as chiropractors directly.  We did credential with ASHN for a short time about 11 years ago and quickly left when we saw what was required of doctors in the network (reams of paperwork and faxes).  Over the last 10 years, Cigna had grandfathered us into their PPO without having to deal with ASHN which gave us the freedom to do what we thought was best for our patients.  A few years ago,A Cigna representative convinced us to join their Open Access Plus networks as well which we joined under the condition that we did not have do deal with ASHN.  Cigna's management under Open Access Plus and PPO plans was transparent and they allowed us to do what was necessary.  We had many patients in the expanding Open Access Plus network and it worked well for the past few years.

Fast forward to 2010, we felt compelled to credential with ASHN, despite their reputation among my colleagues as being a paper and payment nightmare because Cigna now said that we can only continue our participation by joining the network.  Some of my colleagues were exiting the network as I was credentialing however, I was willing to give it 6 months to try the network out.

They send us a large credentialing packet on CD with all the plans, their fee schedules and most of what I needed to decide if this could work, since we handle many managed care plans.  The Cigna HMO fee schedule was quite low, if not below our cost of doing business however, the local rep assured us they would be fair but conservative. We were told that they would put us in a tier allowing us 5 office visits before any paperwork was necessary on their HMO patients.  We were also told that Open access plus and the PPO, who had similar fee schedules in their packets to the ones under Cigna directly did not require any paperwork.  In other words, things would not change other than who we bill through.

We officially joined as of 4/1/10 and had our first two HMO patients, and had programmed our computers to handle the fee schedules for their other plans as well under Cigna.  There was little training for their paperwork and the first two were problematic because they gave us far fewer visits than we asked for.  I finally spoke with the doctor in charge of the NJ reviews who stated that Cigna under ASHN's management is an acute only plan and does not cover any rehab.  He agreed to cover the 12 visits one patient had and the 8 visits the other needed and explained that the paperwork should have been filled out for the 1st visit, even though we do not need to submit it until the 5th.  We were told to fill it out after the 5th. After that conversation, all our Cigna HMO patients thereafter were required to sign an agreement saying they understand they can rehab, however, at their own cost.

We thought everything was fine until we did not receive any Cigna payments for their other plans for over two months.  When we received them, the payments were far less than we expected and then when we inquired about the Open Access Plus claims being paid improperly, we were given a different fee schedule than the one in the packet, that was markedly lower in many ways.  We also then found out that all their plans required certification, including non gaited plans (PPO and Open Access Plus) and we had been lied to or deliberately misinformed.  This meant we now had to scramble to do precertification paperwork on a bunch of people, some who could not fill out questionaires since they were no longer under care.  We submitted these care plans and they either denied increased treatment past 5 visits or gave us visits but reduced time frames that we billed within.  We called and their staff said to file for extensions which were of course denied.  I then requested that I speak with their medical reviewer who stated that during our last conversation in June, he believed that he was clear on the acute thing.  I said I was and then he could not believe we were misinformed by their staff,  offering little other than an apology and suggested more paperwork in the form of a continuing care paper form, to add to the other stuff we were already sending in, to get paid at less than were were paid before.

The final straw for us was a bounced check from ASHN, on services that we waited for payment for over two months.

As our patients know, I do my best for them.  Back injuries, neck injuries, shoulder injuries and other problem we see patients for all require rehab to get the problem corrected.  I believe it is wrong to tell someone that we will serve them half way for their co pay and then the rest is their problem. It just isn't right. It also is not right for an employer who to buys benefits that are advertised for up to 60 per year to have their employees find out it is limited it to 6 or 7. Bait and switch plans are not ethical.

Last night, after less than four months, I mailed and faxed in my resignation to ASHN.  They are indeed a nightmare.  They call themselves conservative.  I call them intrusive and overbearing.  I can now understand how they single handedly destroyed the economic viability for chiropractors who work in California, where they yield alot of influence.

For those of you who wish to continue under our care, we will continue to participate until the 60 days or so that are required have expired.  After that, we will be out of network as a provider for Cigna.  It is better that way and I believe our patients will find their out of network benefits are more beneficial without the interference of ASHN. For anyone else reading my blog, including other doctors in my profession, I am not suggesting any course of action, however, if your experience is similar to mine, you will have some thinking to do.

Was leaving the right thing to do?  I believe it was.  Working harder for less reimbursement and cheating patients out of their benefits was not what I signed up for.  In my office, it is quality or nothing.  In the case of the Cigna plans, I would rather be out of network where quality can exist. What do you think?  I value your input.

What's a nice doctor like you doing in a plan like this. The story behind why after only four months in ASHN's management of Cigna, we are leaving their network.

Ah, what is an ethical doctor to do?  Last January, we received a letter telling us that we can only continue our participation in Cigna Open Access Plus and the PPO if we become credentialed with a company called American Specialty Health Networks.  We did not accept the Cigna HMO since ASHN took over their network around 1999, when their other vendor went out of business.  Cigna historically likes to use vendors instead of administrating particular professions directly.  We did credential with ASHN for a short time about 11 years ago and quickly left when we saw what was required of doctors in the network (reams of paperwork and faxes).  Over the last 10 years, Cigna had grandfathered us into their PPO without having to deal with ASHN which gave us the freedom to do what we thought was best for our patients.  A few years ago, their representative convinced us to join their Open Access Plus networks as well.  Cigna's management was transparent and they allowed us to do what was necessary.  We had many patients in the expanding Open Access Plus network and it worked well.

Fast forward to 2010, we felt compelled to credential with ASHN, despite their reputation among my colleagues as being a paper and payment nightmare.  Some of them were exiting the network as I was credentialing however, I was willing to give it 6 months.

They send us a large credentialing packet on CD with all the plans, their fee schedules and most of what I needed to decide if this could work, since we handle many managed care plans.  The Cigna HMO fee schedule was quite low, if not below our cost of doing business however, the local rep assured us they would be fair. We were told that they would put us in a tier allowing us 5 office visits before any paperwork was necessary on their HMO patients.  We were also told that Open access plus and the PPO, who had similar fee schedules in their packets to the ones under Cigna did not require any certifications.  In other words, things would not change other than who we bill to.

We officially joined as of 4/1/10 and had our first two HMO patients, and had programmed our computers to handle the fee schedules for their other plans as well under Cigna.  There was little training for their paperwork and the first two were problematic because they gave us far fewer visits than we asked for.  I finally spoke with the doctor in charge of the NJ reviews who stated that Cigna under ASHN's management is an acute only plan and does not cover any rehab.  He agreed to cover the 12 visits one patient had and the 8 visits the other needed and explained that the paperwork should have been filled out for the 1st visit, even though we do not need to submit it until the 5th.  After that conversation, all our Cigna HMO patients thereafter were required to sign an agreement saying they understand they can rehab, however, at their own cost.

We thought everything was fine until we did not receive any Cigna payments for their other plans for over two months.  When we received them, the payments were far less than we expected and then when we inquired about the Open Access Plus claims being paid improperly, we were given a different fee schedule than the one in the packet, that was markedly lower in many ways.  We also found out that all their plans required certification, including non gaited plans (PPO and Open Access Plus) and we have been lied to or deliberately misinformed.  This meant we now had to scramble to do precerts on a bunch of people, some who could not fill out questionaires since they were no longer under care.  We submitted these care plans and many of them did not give us what we needed, or ended care prematurely either by visit or by date.  We called and their staff said to file for extensions which were of course denied.  I then requested that I speak with their medical reviewer who stated that during our last conversation in June, he believed that he was clear on the acute thing.  I said he was and then he could not believe we were misinformed by their staff, and offered little other than an apology and suggested more paperwork in the form of a continuing care paper form, to add to the other stuff we were already sending in, to get paid at less than were were before.

The final straw for us was a bounced check from ASHN, on services that we waited for payment for over two months.

As our patients know, I do my best for them.  Back injuries, neck injuries, shoulder injuries and other problem we see patients for all require rehab to get the problem corrected.  I believe it is wrong to tell someone that we will serve them half way for their co pay and then the rest is their problem. It just isn't right.It also is not right for a company to buy benefits that are advertised for up to 60 per year and limit it to 6 or 7 and then tell the patient sorry, while I need to fan the flames of someone who was sold a bait and switch plan.

Last night, after less than four months, I mailed and faxed in my resignation to ASHN.  They are indeed a nightmare.  They call themselves conservative.  I call them intrusive and overbearing.  I can now understand how they single handedly destroyed the economic viability for chiropractors who work in California, where they yield alot of influence.

For those of you who wish to continue under our care, we will continue to participate until the 60 days or so that are required have expired.  After that, we will be out of network as a provider for Cigna.  It is better that way and I believe our patients will find their out of network benefits are more beneficial without the interference of ASHN.

Was leaving the right thing to do?  I believe it was.  Working harder for less reimbursement and cheating patients out of their benefits was not what I signed up for.  What do you think?  I value your input.

What's a nice doctor like you doing in a plan like this. The story behind why after only four months in ASHN's management of Cigna, we are leaving their network.

Ah, what is an ethical doctor to do?  Last January, we received a letter telling us that we can only continue our participation in Cigna Open Access Plus and the PPO if we become credentialed with a company called American Specialty Health Networks.  We did not accept the Cigna HMO since ASHN took over their network around 1999, when their other vendor went out of business.  Cigna historically likes to use vendors instead of administrating particular professions directly.  We did credential with ASHN for a short time about 11 years ago and quickly left when we saw what was required of doctors in the network (reams of paperwork and faxes).  Over the last 10 years, Cigna had grandfathered us into their PPO without having to deal with ASHN which gave us the freedom to do what we thought was best for our patients.  A few years ago, their representative convinced us to join their Open Access Plus networks as well.  Cigna's management was transparent and they allowed us to do what was necessary.  We had many patients in the expanding Open Access Plus network and it worked well.

Fast forward to 2010, we felt compelled to credential with ASHN, despite their reputation among my colleagues as being a paper and payment nightmare.  Some of them were exiting the network as I was credentialing however, I was willing to give it 6 months.

They send us a large credentialing packet on CD with all the plans, their fee schedules and most of what I needed to decide if this could work, since we handle many managed care plans.  The Cigna HMO fee schedule was quite low, if not below our cost of doing business however, the local rep assured us they would be fair. We were told that they would put us in a tier allowing us 5 office visits before any paperwork was necessary on their HMO patients.  We were also told that Open access plus and the PPO, who had similar fee schedules in their packets to the ones under Cigna did not require any certifications.  In other words, things would not change other than who we bill to.

We officially joined as of 4/1/10 and had our first two HMO patients, and had programmed our computers to handle the fee schedules for their other plans as well under Cigna.  There was little training for their paperwork and the first two were problematic because they gave us far fewer visits than we asked for.  I finally spoke with the doctor in charge of the NJ reviews who stated that Cigna under ASHN's management is an acute only plan and does not cover any rehab.  He agreed to cover the 12 visits one patient had and the 8 visits the other needed and explained that the paperwork should have been filled out for the 1st visit, even though we do not need to submit it until the 5th.  After that conversation, all our Cigna HMO patients thereafter were required to sign an agreement saying they understand they can rehab, however, at their own cost.

We thought everything was fine until we did not receive any Cigna payments for their other plans for over two months.  When we received them, the payments were far less than we expected and then when we inquired about the Open Access Plus claims being paid improperly, we were given a different fee schedule than the one in the packet, that was markedly lower in many ways.  We also found out that all their plans required certification, including non gaited plans (PPO and Open Access Plus) and we have been lied to or deliberately misinformed.  This meant we now had to scramble to do precerts on a bunch of people, some who could not fill out questionaires since they were no longer under care.  We submitted these care plans and many of them did not give us what we needed, or ended care prematurely either by visit or by date.  We called and their staff said to file for extensions which were of course denied.  I then requested that I speak with their medical reviewer who stated that during our last conversation in June, he believed that he was clear on the acute thing.  I said he was and then he could not believe we were misinformed by their staff, and offered little other than an apology and suggested more paperwork in the form of a continuing care paper form, to add to the other stuff we were already sending in, to get paid at less than were were before.

The final straw for us was a bounced check from ASHN, on services that we waited for payment for over two months.

As our patients know, I do my best for them.  Back injuries, neck injuries, shoulder injuries and other problem we see patients for all require rehab to get the problem corrected.  I believe it is wrong to tell someone that we will serve them half way for their co pay and then the rest is their problem. It just isn't right.It also is not right for a company to buy benefits that are advertised for up to 60 per year and limit it to 6 or 7 and then tell the patient sorry, while I need to fan the flames of someone who was sold a bait and switch plan.

Last night, after less than four months, I mailed and faxed in my resignation to ASHN.  They are indeed a nightmare.  They call themselves conservative.  I call them intrusive and overbearing.  I can now understand how they single handedly destroyed the economic viability for chiropractors who work in California, where they yield alot of influence.

For those of you who wish to continue under our care, we will continue to participate until the 60 days or so that are required have expired.  After that, we will be out of network as a provider for Cigna.  It is better that way and I believe our patients will find their out of network benefits are more beneficial without the interference of ASHN.

Sincerely,

William D Charschan DC,CCSP .

 

Right to die with dignity - NJ sees a new billboard campaign

I read an article the other day about right to die groups and how they are getting out their message (http://www.nj.com/news/index.ssf/2010/07/national_campaign_guiding_ill.html).  Apparently, there are many groups that are taking Dr. Kevorkians message and putting their own spin on people being able to be allowed to die if the conditions warrant it.  In my opinion, many people die in hospitals, with tubes out their body in misery.  There have been many instances where these same people have been given an overdose of a medication to put them out of their misery, however, this is considered illegal.  I agree that is someone is terminal, and miserable, and has an extremely poor quality of life, they should have the option to end it.  Many religions oppose this because the value of life is too great.  In reality, many of these religions have been around for thousands of generations, long before we had the equipment to keep the near dead alive.  Statistics show that we consume at least 1/3 of all our health care costs at the end of life, with the end being the same.  When did it become ethical to torture the dying?  We not only torture them, but we drain them and their family financially, emotionally, without having a rational alternative unless a living will is present. The outcome, statistics show is the same;  death, which is a normal part of our lifecycle.  We should educate ourselves about how to prepare and take a healthier view during the emotional end of a loved one, rather than try things that decrease the quality of life at the end and worsen the suffering.

Without being morbid, I do believe in advanced directives, and I believe it is wrong to keep dying people alive artificially, to prolong their suffering.  We surely do not usually do this with our pets who may die with more dignity when the terminally ill pet is put to sleep painlessly. 

These groups have a valid point.  We should have the option if we are terminal and have poor quality of life to end our own suffering. That is my opinion because it is humane.  Regarding the use of billboards, this makes a big statement.  Sometimes these types of statements are offensive however, often if you have not offended someone, you really did not get your point across effectively.  BTW, the ensuing articles published by the newspaper on these signs is great marketing and PR.

What to you think? I always value your opinion.

Dr C

Dis ease - the idea of diseases as the cause of what ails us

Wikipedia describes disease as follows:

A disease is an abnormal condition of the body of organism that is not comfortable for it. It is often construed to be a medical condition associated with specific symptoms andsigns.^[1][2][3] It may be caused by external factors, such as infectious disease, or it may be caused by internal disfunctions, such as autoimmune diseases.

In humans, "disease" is often used more broadly to refer to any condition that causes pain, dysfunction, distress, social problems, and/or death to the person afflicted, or similar problems for those in contact with the person. In this broader sense, it sometimes includes injuries, disabilities, disorders, syndromes, infections. Isolated symptoms, deviant behaviors, and atypical variations of structure and function, while in other contexts and for other purposes these may be considered distinguishable categories. A diseased body is quite often not only because of some dysfunction of a particular organ but can also be because of a state of mind of the affected person who is not at ease with a particular state of its body.

Our health care system is built upon the concept and the Merck Manual, a commonly used guide for diseases is used by doctors worldwide.  Disease is regularly used in languages throughout the world and in many cultures, since this is the way we are used to describing a series of symptoms, sometimes with a known cause of pathogen, or sometimes it is just a series of symptoms, named after someone that they described as a new disease or ailment that afflicts us, as well as most living things.  Disease has also been used by drug companies to sell product (eg: seasonal effective disorder, restless leg syndrome).  

In the chiropractic world, using this definition, back problems can be classified as diseases too, however, this is because it is dis  ease or as described above it is a medical condition of specific symptoms of signs.  The problem I have with this is that often, using the term disease describes an affliction, without promoting understanding.  Too often, diseases have been treated with medications to relieve the dis ease, without understanding why the problem exists.  Knee problems are a perfect example of this. We diagnosed meniscus disease, kneecap tracking disease which in no way describes what the condition is or how it got there.  We have trained people to treat these dis eases who could care less why it went bad.  The reason it went bad is the problem.  We teach them to throw therapies and solutions at the symptom which is knee pain which leads to tests and interventions, without the understanding of what we are treating. In the realm of musculoskeletal medicine, this is problematic, expensive, can be disabling (knee replacements gone bad with their thousands of dollars in implementation and rehab.  What the dis ease moniker does not do is promote understanding.  Lack of understanding currently leads to tests, questionable interventions and expensive solutions of limited benefit (knee replacements, which my mother had just undergone can last 10-15 years and then need to be redone). A better paradigm which is functionally based, rather than dis ease classified would lead to better prevention of many of the so called dis eases. Of course, there are many entities in our healthcare system who are profiting handsomely from the dis ease philosophy being used in the musculoskeletal system.  It has lead to unbelievable high costs of treatment, mediocre rehab based on a paradigm that is not meant to promote understanding , unneeded testing and human misery.  Managed care promised to hold the line on these costs but instead has tried to clear a profit without helping the paradigm change to a functionally correct one.  As they have failed, like the government, they simply pass the bill on to us as higher insurance premiums which has lead to more people underinsured with higher out of pocket costs and a health care system very far from cost effective and effective when compared to the rest of the world.

My recommendation is that at least in the musculoskeletal realm, we move away from the dis ease idea and move toward one of function, which will yield to lower costs from better care and more effective treatment and better preventative care.  Other diseases should come under the microscope too since we try to classify things we really do not understand into bite size pieces and then throw therapy regimens about the symptoms so the dis ease process is no longer noticed (not necessarily resolved).