The Obama administration unveiled new rules, today, specifying which preventive health services will be free to consumers under the new health law after Sept. 23. Mandated preventive care seeks to correct the problem of under utilization of preventive care services because of out-of-pocket expenses for consumers. Americans use preventive services at about 50% the recommended rate, according to research cited by the White House. Chronic diseases, which are often preventable, are responsible for 7 of 10 deaths among Americans each year and account for 75 percent of the nation's health spending.

Free preventive services are among the health insurance benefits that the White House is touting as it tries to show consumers that the health care overhaul has tangible benefits. The list of services likely to spark intense debate within the health industry over what's included and what gets left out.

• Children will get more than two dozen services, including vaccinations for influenza, diphtheria and tetanus, and screenings for hearing and vision impairment and autism.
• Women over 40 will still be able to get a mammogram screening every year or two.
• Colorectal cancer screening for adults over 50.
• Hepatitis B screening
• HIV screening for adults at high risk
• Depression screening for adults and adolescents
• Prenatal services including screenings for iron deficiency.
• Blood pressure screenings.
• Obesity screening and counseling for adults and children.
• Tobacco counseling for pregnant women

New health plans offered after September 23, 2010 must include these preventive services without a copayment or other direct costs for consumers on new health plans. However, these new health insurance plans are expected to be price higher than comparable old plans to cover the mandated services. Consumers who stick with their existing insurance plans won't benefit from the change, but it will become an individual health insurance comparison decision to determine if the new preventive benefits are worth the new health plan rates.

To determine which services qualify as preventive, government officials relied largely on existing recommendations by three groups, including the U.S. Preventive Services Task Force. The preventive services task force drew criticism last year for recommending that women delay annual mammogram services until age 50, instead of age 40. The health care law effectively ignores that recommendation, making mammograms a covered preventive service at age 40 under the law.

The doctor-patient relationship is moving online. With 68% of American adults now using the Internet to search for healthcare information, it's no surprise that many also want digital access to their doctor. Whether they have that option will depend heavily on doctors' ability to get paid for the service. As of last year, less than 5% of doctors communicating online with their patients were being paid to do so. That's slowly starting to change as big insurance companies, such as Cigna, Aetna, Anthem, and Humana, have begun to reimburse doctors for online clinical consultations.

Privacy Concern is the Primary Obstacle

Patients want to communicate with their doctor via e-mail, but there are security risks. Sending health information to a doctor through a private Gmail or Yahoo account isn't a safe. You have to find a way to ensure you're communicating with the appropriate person on the other end. You need a secure site that requires a log-in with a user name and password. Insurance companies require that online consultations or e-visits as they are called take place through a secure Web portal with high levels of encryption that comply with Health Insurance Portability and Accountability Act (HIPAA) privacy rules.

New Payment Mechanisms are on the Horizon

Currently, 12 states, including California, have laws on the books requiring health plans to pay for online medical services. E-visits generally fall under that umbrella. At the national level, a Center for Medicare and Medicaid Innovation has been formed to help facilitate technology that would let doctors meet with their patients through video chats, telephone checkups and in-home monitoring devices. And most recently, the Department of Health and Human Services issued $220 million in grants to 15 communities around the country for creating three-year pilot programs to test the adoption of healthcare technology, including e-visits.

E-Visit Technology Available Now.

Various types of technology are used for e-visits, including simple e-mail but also live online visits using Web-based video or phone through companies such as RelayHealth, American Well, MDLiveCare and SwiftMD. Aetna has a proprietary online consult program called webVisit, but only about 1% of their providers use it.

Follow the Money

Although insurers have started to recognize the value of e-visits, most still don't pay for them. Neither does Medicare. That makes e-mail communication just one more daily task that primary-care doctors are saddled with and not paid for. Growing consumer pressure will no doubt force the healthcare industry online, but, ultimately, it's the money that will lead doctors to their computer screens. There is no incentive for doctors to change at the current time.

Nearly a third of people living in the U.S. believe they have a food allergy, according to a recent study published in The Journal of the American Medical Association. But only 8% of children and less than 5% of adults have true food allergies. Experts say food allergies are definitely being over-diagnosed or in many cases erroneously self diagnosed. It's because people don't understand what really constitutes a food allergy and they often misuse the term.

You can't eat cheese, feel sick, and claim you have a food allergy, but then turn around and enjoy ice cream and feel OK. With a true food allergy, the trigger - milk protein in this case - does not change and the trigger will always set off the same immune system response.

A food allergy is a very specific immune system response involving either an immunoglobulin antibody IgE or T-cells. Both are immune system cells that react to a particular food protein, like milk protein. An IgE reaction occurs within minutes to an hour or so of either smelling, touching, or ingesting a particular food. The presence of the food triggers the immune system to over-react and interpret the food as harmful. Histamine is released, causing symptoms that range from mild to severe, including hives, itching, trouble breathing, wheezing, and anaphylaxis. Allergic reactions to food can be serious. About 30,000 Americans per year go to the emergency room due to catastrophic allergic reactions to food, and as many as 200 die every year from food allergies, according to the Food Allergy and Anaphylaxis Network.

Food intolerance is often confused as food allergy.

Food intolerance occurs when the body lacks a particular enzyme to digest that food. Two common examples are lactose intolerance and celiac disease, an autoimmune disorder in which the gastrointestinal tract cannot process gluten, a protein in wheat-based products such as cereal and bread. An intolerant person avoids the foods that trigger a reaction, but these reactions aren't caused by the immune system and they are not life threatening.

Most people who claim food allergies really have food sensitivity.

People with food sensitivity generally have an unpleasant reaction to certain foods - perhaps they develop acid reflux, nausea, or abdominal cramps - but these are not immune system reactions, and these reactions do not always occur in the same way when eating the food.

I think I have a food allergy, so I'll just avoid the offending food.

If you suspect you have a food allergy, just skipping the food that irritates you isn't enough. Unintentional food exposures occur, even in the most cautious individuals with true food allergy. The self-diagnosed individual is unlikely to be properly prepared to manage this potentially life-threatening reaction, such as use of an Epi-Pen." Epi-pen and Twinject are injectable forms of epinephrine.

Proper diagnosis of food allergy is essential.

Blood tests can also help diagnose a true food allergy by measuring IgE levels and determine whether there's a true food allergy. But blood tests can produce false-positives -- results that indicate an allergy when there isn't one -- in patients who have eczema, asthma, or other types of allergies because those people already have higher-than-average IgE levels. One accurate way to find out if you have a true food allergy is to visit your doctor and undergo a food challenge. The food challenge is managed by the doctor and done in a controlled environment at the doctor's office. It involves gradually giving higher doses of a particular food to see how much of that food is needed to trigger an immune system response. Another type of test -- the skin prick test -- can also indicate if the patient has a real food allergy by injecting a small amount of the allergen into the skin and checking whether the skin develops a bump or a rash.

What would happen if patients paid doctors whatever they thought a office visit was worth?

A handful of physicians decided, for one day only, to offer patients the option to pay only as much as they could as an experiment to see how people really value primary care. Physicians chose their own dates for a pay-what-you-can day and got the word out. On the day of the events, no insurance was accepted. Care was provided only to the uninsured, who were asked to pay what they could afford. Laboratory tests were provided at cost, and patients who needed additional services were referred to various public resources. Practices also handed out lists of generic medications available for reduced prices at large, discount pharmacies.

Overall, participating physicians said they learned that although patients valued the physician visit enough to pay something, the payments were below actual cost. Still, most valued it enough to pay something. Some patients were unemployed and paid nothing; some paid $100. Visits were as short as 10 minutes or as long as an hour. Some people scraped up $20, some paid $60 to $80. One patient, a waitress and college student, paid $80, mostly in singles. The doctor gave her $20 back.

None of the participating physicians collected enough money to make the concept financially viable over the long term, mainly because payments didn't match a typical day's collections from insurance and co-pays. Yet most say they want to do it again and enjoyed having one day free from insurance paperwork. Doctors found it was satisfying to be of service to people who have a need, even just for one day.

Physicians discovered an unanticipated and unintended benefit: Pay-what-you-can days can help build a practice. Local media coverage may increase a practice's profile, and patients from pay-what-you-can days might return when they do have insurance.
Pay-what-you-can days also brought an unexpected amount of goodwill to medical practices and produced public recognition within their communities, physicians said. Participating physicians say they have been stopped on the streets and in grocery stores by people thanking them for their efforts.

When a local newspaper ran a story about Will Conner, MD, a family physician in Matthews, N.C., holding a pay-what-you-can day at his Conner Family Health Clinic, one of his patients who was a nurse volunteered to help. Someone else dropped off a flower with a card that said Dr. Conner was "receiving this because you have done something nice. "The pay-what-you-can day "definitely got recognized. We know we did the right thing," Dr. Conner said. "It's not very practical to do every day, but it is good for the community, and good for patient care."

What can you possibly learn from your doctor that is not available on the Internet?

The Internet offers unlimited amounts of medical information. Now everyone can now Google primary data published in scholarly medical journals. One might ask, "What can you possibly learn from your doctor that is not available on the Internet?" Indeed, physicians are struggling to figure out how best to use this technology in the interests of their patients and themselves. The Internet is reshaping the content of the conversation between doctor and patient. Some of the past imbalance of power between patient and doctor is being equalized.

Thank God for the Internet

"Thank God for the Internet," a friend remarked after receiving a diagnosis of prostate cancer. He had been given the biopsy results by a urologist, who had offered to schedule a prostatectomy within 10 days. Concerned about incontinence and impotence, our friend searched the Web for outcome data on other treatment options. He made appointments with a radiation therapist, who advised him on the risks and benefits of treatment using implanted seeds as opposed to external-beam radiation, and a medical oncologist, who discussed the pros and cons of "watchful waiting." "I'm still thinking about it," our friend said. "And I'm reading more on the Internet."

I just end up scaring myself

But many patients have not fared so well. One woman with recently diagnosed lupus told us, "I really don't want to read what's on the Internet, but I can't help myself." Her condition is currently stable, but she finds herself focusing on the worst possible complications of the disease, such as cerebral vasculitis. Although her doctor gave her detailed information, she cannot resist going on the Web to seek out new data and patients' stories. "It's hard to make out what all of this means for my case," she said. "Half the time, I just end up scaring myself."

Novel Therapies and Junk Science

Other patients are drawn to online forums and Web sites that make unsubstantiated claims -- assertions that macrobiotic diets cure aggressive lymphoma, that AIDS can be treated with hyperbaric oxygen, that milk thistle remedies chronic hepatitis, and myriad other fallacious claims. Falsehoods are easily and rapidly propagated on the Internet: once you land on a site that asserts a false rumor as truth, hyperlinks direct you to further sites that reinforce the falsehood. Material is perceived as factual merely because it is on a computer screen. Doctors sometimes find themselves in the uncomfortable position of trying to dissuade desperate and vulnerable patients from believing false testimonials. Doctors may be perceived as closed-minded, dismissive, or ignorant of "novel therapies" when they challenge such Internet rumors.

Internet Self-Diagnosis to be Avoided by Hypochondriacs

Patients also consult the Internet in search of self-diagnosis. Sometimes, doing so leads them to seek medical attention rapidly and to suggest what turns out to be a correct diagnosis. But the Web is perilous for anyone prone to hypochondria. The differential diagnosis for backache, for example, led one of our neighbors to fret that he had an abdominal aortic aneurysm. After a sleepless week of worry, he mustered the courage to call his doctor. With a normal exam and repeated reassurance, the backache resolved.

A short, 27-item, questionnaire available free online is a valid and effective tool to help primary care doctors screen patients for four common psychiatric illnesses - depression, bipolar disorder, anxiety disorders and post-traumatic stress disorder (PSTD)

Just stressed or should you seek treatment? Check your mental health online with the M-3 Mood Monitor at www.mymoodmonitor.com

Primary Care Doctors Hold the Key

Primary care physicians hold the key to reaching more people suffering from undiagnosed psychiatric illnesses. For most people who suffer from depression, bipolar disorder, anxiety disorders and post-traumatic stress disorder (PSTD), their initial diagnosis is made by a primary care doctor, not by a psychiatrist. In addition, the majority of prescriptions for antidepressant medications are written by primary care physicians. For those reasons, a simple checklist that can screen for multiple disorders would be very helpful.

One in Ten with Psychiatric Illness Untreated

"About one in 10 Americans who suffer from depression and anxiety-related mental health disorders never receives treatment because they don't understand what's wrong, and when they go to their family doctor these treatable illnesses are too often missed," said Bradley Gaynes, M.D., M.P.H, lead author of the study and an associate professor of psychiatry in the University of North Carolina at Chapel Hill School of Medicine. "For these millions of people and their primary care providers, the M-3 screener is a tremendously helpful resource," Gaynes said.

Results Recently Published

Results of the My Mood Monitor (M-3) checklist study are published in the March/April 2010 issue of Annals of Family Medicine. The checklist was developed by M-3 Information of Bethesda, Md., and is available at www.mymoodmonitor.com.
To evaluate the M-3 checklist, Gaynes and study co-authors enrolled 647 adults age 18 or older who sought care at the UNC Family Medicine Center between July 2007 and February 2008. Each participant filled out a paper version of the checklist while waiting to see their doctor. Each participant's completed checklist was then given to their doctor, and the doctors used the checklist to discuss emotional health with their patients.

83% Effective in Screening Anxiety disorder

Researchers later interviewed each person who filled out the checklist, within 30 days of their doctor visit, and assigned final diagnoses after reviewing each interview with Gaynes. These diagnoses were then compared to the answers each participant gave on their checklists. The results showed that the M-3 was effective in screening for any mood or anxiety disorder 83 percent of the time and for a specific disorder in 76 percent of cases.

Self-Testing to be Studied

Gaynes said the research team is currently designing a second study to measure the effectiveness of the M-3 checklist when used by individuals to monitor their mental health status over time. The company has developed a mobile phone version of the checklist that will be released late this year.

CT scans sent by smart phones are clear enough for accurate diagnoses.

Let's say, your daughter is away on a school trip. she's having abdominal pain. The ER doctor at the local hospital suspects appendicitis, but wants a radiologist to look at the CT scan images. There isn't one available at the moment. Using a $19.95 iPhone app, downloaded from iTunes, the images are sent to the radiology department of a teaching hospital more than 300 miles away. Within minutes the appendicitis diagnosis is confirmed and the appendectomy performed without further delay.

Study Proves Accuracy

This scenario mirrors a recent study in which researchers (Asim Choudhri, MD, a fellow in neuroradiology at Johns Hopkins performed the study while at the University of Virginia) took CT images of 25 patients suspected of having appendicitis and sent them via iPhone to five radiology residents. Then, the residents were asked to make a diagnosis based on what they could see on their phones. Only one reader failed to make the right diagnosis. In every other case, the residents correctly determined that 15 of the patients were suffering from appendicitis and that 10 of the patients did not have appendicitis and did not need treatment.

Elliot Fishman MD,, director of diagnostic imaging at Johns Hopkins University, says ,"The promise is that we can look at anything anywhere. The technology can expedite diagnosis and, therefore, treatment."

There's a shortage of primary care doctors and it's getting worse. Sen. Chuck Schumer says he has at least a partial solution. He will introduce an amendment to the Senate health-care bill that would add 2,000 new medical residency slots.

While well-intentioned, Schumer's idea seems unlikely to make much of a difference. There isn't even enough interest among qualified young docs to fill existing residency slots. Hundreds of slots went unfilled this year and graduates of foreign med schools filled many of the available positions.

Docs Tend to Follow the Money

Furthermore, doctors who go through residencies in internal medicine often choose do further training in a sub-specialty, rather than practice as primary-care internists. They do so, in large part, because many sub-specialties have higher pay, higher status and, in some cases, better hours. Adding more residency slots won't change that.

$50,000 Educational Loan Repayment Could Help

The shortage of primary-care doctors is especially acute in underserved rural areas. Doctors finishing up their residencies tend to gravitate to places where there are already lots of other doctors, not to places where physicians are scarce. Pointedly, there are other provisions of the health-care legislation that could encourage more young doctors to go into primary care and to move to the places where docs tend to be scarce. The Senate bill increases funding for the National Health Service Corps, which helps repay student loans for docs and other providers who work in underserved areas. Primary-care doctors who participate can get up to $50,000 of loans repayment.

How does this sound? - 24/7 access to your doctor, same day office visits, no waiting, more face time, and house calls. Like a nostalgic picture of medicine practiced in small town America 50 years ago? Nope. It exists today for some Americans willing and able to pay. It's called Concierge Medicine.

A new sitcom called Royal Pains, on the USA Network, will expose the medical concierge concept to the masses. Royal Pains' central character is Dr. Hank Lawson, a fictional ER doc who loses his job in a prominent New York hospital because he breaks rules to try to save a patient. While attending a ritzy party in the Hamptons, Hank brilliantly diagnoses the medical condition of one of the wealthy guests and provides lifesaving treatment on the spot. Overnight, he becomes the most sought after doc in the Hamptons social set.

Unheard of 10 years ago, concierge medical practices have grown to about 5,000 practitioners nationwide. Concierge practices are generally for the affluent but run the gamut in terms of what they charge for the privilege of membership. Perhaps the most obvious market for concierge medicine is the affluent elderly. But not necessarily, take Steven Knope, MD, for example. Dr Knope is a sports medicine internist. He's a four-time Ironman triathelete. His Tucson, AZ practice focuses on preventive medicine including a two-hour physical, nutritional analysis with a staff nutritionist, and fitness analysis with a personal trainer in his in-office gym. Dr. Knope's concierge patients pay an annual retainer of $6000 each.

The Concierge Medicine / LA practice in the Brentwood section of Los Angeles serves a wealthy clientele similar to that depicted in Royal Pains. Medical Director, Raphael Darvish MD, says that not all of his patients are wealthy. Some are just very health conscious. The practice has two other doctors in addition to Dr. Darvish serving about 1,000 patients. Memberships range from $2,000 to $10,000 annually depending on age and other factors. Concierge Medicine / LA features the presidential physical which is similar to the comprehensive physical Obama receives each year.

Concierge doctors say this style of medical practice is very rewarding to them in ways other than financial. The pace is relaxed and they get to build relationships with their patients.

The economy has tanked. People are getting laid off. Bank accounts are shrinking. We fear that it will get worse. All this is causing people to demand low-cost generic drugs and split pills, forgo recommended screening tests and delay elective procedures, perhaps even turn to home remedies. The number of people who have gone without a prescription or skipped a doctor's appointment for themselves or a child has increased since last year. In addition, this summer saw the first decline in prescription drug spending in almost a decade. Almost 20% of U.S. residents say they have trouble paying medical bills.

It's not just the uninsured who are affected. Even those who have group health insurance coverage are skimping because employers have raised their deductibles and copayments in order to cope with ever increasing health insurance cost. Increased out-of-pocket expenses for healthcare drive down utilization of health insurance benefits. Some that cutback in utilization is good because there was overuse of health benefits in the days of plush employer benefit plans, but there is a point where people's health will deteriorate because of forgoing preventive and routine care and result in bigger medical expenses down the road for treatment of serious illnesses.

My mother is 89 years old and suffers from advanced dementia so I'm perhaps more interested than most of you in new information about the aging brain. Having said that, I find fascinating the results of a recently published study published in the August 27, 2008, online issue of Neurology® - the medical journal of the American Academy of Neurology.

The study documents 30 years of testing of people's mental skills from age 70 to death. The study involved 288 people with no dementia who were followed from age 70 to death, with an average age at death of 84. The participants' mental skills were measured up to 12 times over a period of 30 years, and they were evaluated to make sure they had not developed dementia.

"These changes are different and separate from the changes in thinking skills that occur as people get older," said study author Valgeir Thorvaldsson, MSc, of Goteberg University in Sweden. "We found accelerated changes in people's mental skills that indicated a terminal decline phase years before death."

For instance, perceptual speed - measured by how quickly one can compare figures - begins declining 15 years before death. Spatial ability - everyday tasks such as finding one's way in the environment and learning the layout of a new environment - starts declining eight years before death. And verbal ability starts declining about six-and-a-half years before death.

Thorvaldsson noted that verbal abilities declined sharply in the terminal phase and did not decline significantly due to age only. "This indicates that people remain stable in their verbal abilities unless they are experiencing disease processes that also increase their mortality risk," he said. "A change in verbal ability might therefore be considered a critical marker for degeneration in health in older people."

How much longer will I live? While not frequently verbalized, this question is in all of our minds and one would assume that it's much more prevalent in those of advanced age. As I see it, this study's uniqueness lies in identifying specific declines in mental skills as markers of life expectancy.

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The recommendation is based on the fact that the average 75 year old American male will live less than 10 additional years and probably die of causes other than prostate cancer, So why risk the emotional and physical trauma of current treatment methods. Of course the decision to test or not is an individual one. For example, a 75 year old male in excellent health should live considerably longer than the average and will probably want to continue with PSA testing.

Retail walk-in medical clinics in pharmacies are proving more difficult to establish than initially thought. The clinics are more complicated and expensive to operate. It seems, operators and investors were overly optimistic in their return on investment estimates. The clinics are experiencing an 18 to 24 month break-even rather than the initial projections of a six month break-even. Much of the added cost is in marketing to make the public aware the service exists in each market and to gain acceptance. While the pubilc likes the convenience of the walk-ins, it takes a lot of users to make it pay.

While virtually all doctors (96%) agree that they should report incompetent colleagues, only 45% of them have ever done so. This according to a recently published study by Dr David Blumenthal from the Massachusetts General Hospital, Institute for Health Policy. Results were based on responses from 1,662 family practice, internal medicine, pediatrics, surgery, anesthesiology, and cardiology physicians between November 2003 and June 2004.

Another telling bit of information was that about one third of respondents said they would order unneeded MRI for back pain if a patient asked for it. See recent blog on the cost of unnecessary tests

West Nile Virus is hitting Californians hard. Four people have died of the virus in California and the disease is spreading. Governor Arnold Schwarzenegger recently designated the counties of Kern - with 60% of the state's 64 cases - Colusa and San Joaquin, to be in a state of emergency, giving them access to a 1.35 million dollar fund. The high season (August and September). is just starting and there are already three times as many cases as there were last year in California.

West Nile originated in the Middle East but is now usual in North America. Humans and animals get WNV from the bites of mosquitoes that have fed on infected birds. WNV cannot be spread by an infected human which is good becuase most infected people experience no symptoms at all. Those who do have symptoms usually show signs (fever and flu-like symptome initally, sometimes progressing to disorientation, convulsions, tremors, and loss of vision.The symptoms last several weeks. Less than 1% with WNV become seriously ill.

The American Medical Association (AMA) wants legislation to control the operation of retail clinics at the state and federal level. They will ask federal and state agencies to investigate retail health clinics that are joint ventures between retailers and pharmacy chains. The AMA contends that conflicts of interest exist because retail clinics increase prescription drugs sales and other product. The clinic is not independent of the store which sells the drugs the prescriptions, hence the conflict of interest according to the AMA.

Retail health clinics are being installed in large retail chains like Wal-Mart, CVS, Walgreen and Rite Aid. About 1000 clinics are expected to be operational by the end of 2007.Nurse practitioners or physician assistants offer basic procedures and they charge less than a doctor's practice. The clinics are supervised by a physician who does not have to be on site.

AMA members, particularly primary care physicians, are concerned that the greater accessibility of retail clinics will cost them business.

When it comes to health care, there's no correlation between what we, our employers, or our insurers pay and the quality of care that we get. Where you live determines cost more than quality.

Take Pennsylvania for instance. The Pennsylvania Health Care Cost Containment Council recently published a report on hospital pricing and patient outcomes. Two Philadelphia area hospitals were the highest paid ($100,000 for heart bypass surgery) and had higher-than-average death rates. Some hospitals in other parts of the state had better outcomes (shorter hospital stays and lower death rates) at $20,000 for the same procedure.

A new home fertility test, the Fertell test, has recently been approved by the FDA. It tests the fertility of both men and women and can predict the likelihood of the couple conceiving with considerable accuracy. Men can test the quality of their semen in just over an hour. Women can measures FSH levels, a key predictor of female fertility.

While not as comprehensive as a physician's fertility evaluation, the Fertel test, can warn couples that something is wrong. The privacy factor makes it attractive so the test could be big. It sells for about $100 and is available at CVS and Longs pharmacies.

Visit the new Hospital Compare Web Site to compare hospital mortality rates for heart attack and heart failure at over 4,000 nationwide.

Once closely guarded, hospital mortality rates are coming out in the open. The Hospital Compare Web Site may include information on whether your local hospital's 30-day mortality rates (heart attack and heart failure patients who died for any reason within 30 days of admission) are better or worse than 4,000 other hospitals.

Drug companies maintain large sales forces that call on doctors and hospitals to promote the companies' pharmaceutical products. The New England Journal of Medicine published a survey recently measuring the extent of the physicians complicity. Of the physicians surveyed, 80% accept free drug samples or free food from their drug reps. Nearly 30% accept payments for services like promotional speeches and consulting.

One of the more remarkable activities of the pharmaceutical sales representatives is the promotion of "off label" uses of a drug. That is, influencing doctors to prescribe a drug for uses that do not have FDA approval. Take for example, Gabapentin - a drug manufactured by Parke-Davis and approved only for treatment of a specific type of epilepsy, Parke-Davis reps promoted Gabapentin for the "off label" treatment of migraine and certain psychiatric conditions (a broader market and larger sales potential than the FDA approved use). After the visits, almost half of the doctors told researchers* that they intended to prescribe Gabapentin more widely or recommend it to colleagues.

* Published in PLoS Medicine, Lisa Bero, PhD, University of California, San Francisco, the researchers said,

Wal-Mart Stores has announced that they will open retail health clinics in up to 2,000 stores over the next five years or so. Wal-Mart already has walk-in medical clinics in 75 stores across 12 states. Retail health clinics provide unmatched convenience. Wal-Mart's clinics offers walk-in appointments seven days a week. Nurse practitioners deliver preventive and routine care for $45 to $65 per visit.

I'm sure this is a good business opportunity for Wal-Mart, but there's no denying they are providing a service to customers in an underserved portion of the communities in which they operate. Most retail clinic customers are uninsured and in some cases would have used an hospital emergency room otherwise.

More parents are taking their children to walk-in retail medical clinics. For one reason the clinics are more plentiful - over 300 now with an additional 2,000 by the end of 2008. You can find them in Walgreens Drug Stores, and at some WalMart and Target stores. Parents who use them say it's more convenient than going to a doctor's office for minor stuff like routine tests and innoculations. Indeed, over 70 percent of parents wfo used the retain walk-in clincs said they wiould return. Health insurance generally covers the cost of these visits.

This trend is up for retail clinic care for children according to the National Poll on Children's Health conducted by the University of Michigan.

The walk-in clinics are typically staffed by nurse practitioners and physicians assistants, something that worrier Primary Care Doctors and Pediatritions. Most of the kids (89%) using retail walk-ins have an established physician. This does present a challenge to coordination of care. Until we have electronic medical records through our medical system, parents will have to be responsible for beiong the communication link between their child's primary physicians and the retail clinic.

A combination of two different migraine medications - sumatriptan and naproxen sodium - and releives migrain symptoms better than taking eother one alone. Combining two different types of treatment for migraine results in better symptom relief than taking either one of the medications, according to a study in the

About 3000 migraine patients at 118 U.S. clinical centers recieved a single tablet containing both sumatriptan (85 mg) and naproxen sodium (500 mg), or sumatriptan alone, or naproxen sodium alone or a placebo. The meds were used at the start of a moderate to severe migraine.

The sumatripan-naproxen sodium combination was more effective than placebo for headache relief at two hours after dosing. The rate of nausea was the same between sumatriptan-naproxen sodium and placebo. For sustained releif up to 24 hours, sumatriptan-naproxen sodium was superior to momotherapy.drug; NSAID) compared with placebo and single therapy with either of the drugs. ); or placebo, to be used after onset of a migraine with moderate to severe pain.

This is new inforamtion, results a study by Jan Lewis Brandes, M.D published in April 4 issue of JAMA. If you are being treated for migraine with either sumatriptan or naproxen sodium with less than wonderful results, talk to your physician about combination therapy.

Patients seeking treatments that might be controversial should learn about their medical options and choose physicians accordingly. Some medical professionals do not make their patients aware of all treatment options, including abortion, contraception, or even sedation for dying patients, that they oppose on moral grounds.

A bioethicist at the University of Chicago, Farr Curlin, submitted questionnaires to 2,000 physicians nationwide and received responses from 1,144. The answers provided by the participating physicians showed that 52% were opposed to abortion after failed contraception, 42% to providing contraception to minors without their parents’ consent, and 17% were opposed to "terminal sedation." Further, 8% felt under no obligation to present all the options, 86% believed they should, and 6% were undecided.

The study was prompted by the question of medical professionals who might refuse to provide care that conflicts with their moral or religious beliefs. This would include physicians and nurses who refuse provide an abortion or to prescribe contraception as well as pharmacists who decline to fill prescriptions for birth control or emergency contraception.

According to a survey published in the February issue of Consumer Reports, they polled 39,000 subscribers and 335 primary care physicians selected at random from a national list.

Patients said that their physicians failed to disclose the cost of medications or office visits, and one-third said that their physicians failed to discuss the side effects of treatments. About 19% of patients said that they could not make appointments with their physicians within one week, and 7% said that their physicians did not return test results promptly, the survey found.

Among physicians, 59% said that patients did not follow their advice "completely," and one-third said that many of their patients are not specific about their symptoms, the survey found. A number of physicians also said that patients do not make appointments as early as they should, according to the survey. About 40% of patients said that they researched information about their conditions on the Internet, and 41% of physicians said that such patients were misinformed, the survey found. According to the survey, almost 80% of physicians said that their patients asked for prescription drugs they saw advertised on television, and 40% said that they oppose direct-to-consumer advertisements for medications.

Generic-drug utilization exeeds 60 percent in Medicare Part D. The high generic dispensing rate in Medicare Part D is helping to keep Part D premiums and program costs lower than originally forecast. In recent months, numerous studies have shown the important role that increased use of generic drugs can play in lowering health care costs. In addition, competition from generic alternatives helped contribute to prescription drug-spending growth rate in 2005 slowing to its lowest growth rate in over a decade, rising just 5.8 percent.

The U.S. has a shortage of geriatric care physicians, in part because salaries for the field are lower than for other specialties. There are fewer than 7,000 geriatricians in the U.S. About 14,000 are needed to meet demand, according to experts. The shortage is expected to worsen as baby boomers age and require care. Annual salaries of geriatricians average about $150,000, while other specialists, such as radiologists or orthopedists, can earn more than $400,000 per year.

In addition, many medical schools have inadequate training in geriatrics because often they have assumed students learn about geriatrics by treating older patients on hospital rounds. As a result, some physicians do not understand the different needs of an elderly patient. With the shortage expected to worsen, geriatricians will likely be reserved for seniors with the most complicated problems, and "nternists and family practice physicians will continue to serve most old people.

Despite the claims that tv ads play an educational role, they contain limited information about causes and symptoms of their target illnesses, their prevalence and risk factors. They also show people that have lost control over their social, emotional or physical lives without the medication; and they minimize the value of health promotion through lifestyle changes. The ads have limited educational value and may oversell the benefits of drugs in ways that might conflict with promoting public health.

We're seeing a dramatization of health problems that many people used to manage without prescription drugs. The ads send the message that you need drugs to manage these problems and that without medication your life will be less enjoyable, more painful and maybe even out of control.

Should we consider banning direct to consumer tv advertising of prescription drugs altogether?

Patients treated at the top 5% of U.S. hospitals are 28% less likely to die and 5% less likely to experience complications than those treated at other facilities in the nation, according to a study released on Monday by HealthGrades.

For the study, researchers analyzed mortality rates for 26 medical procedures and diagnoses -- such as bypass surgery, angioplasty and heart attacks -- among almost 39 million patients treated from 2003 through 2005 at all 5,122 U.S. hospitals not operated by the federal government. The top 5% of hospitals reduced their mortality rates by an average 11.7% over the three-year period, the study found.

According to the study, in the event that all hospitals provided the same quality of care as the top 5% of facilities, 158,264 fewer patients would have died over the three-year period, and 12,409 fewer would have experienced major complications. Samantha Collier, senior vice president of medical affairs at HealthGrades, said, "The continued gap between the nation's top and poorest-performing hospitals continues."

Most primary care physicians say that they accommodate their patients' requests for drugs they have seen in TV ads, according to a survey published in the February issue of Consumer Reports. The survey questioned 335 doctors and 39,090 U.S. residents. It found that 78% of PCPs received patient requests for specific drugs they have seen advertised on television and that 67% reported they sometimes grant the requests.

In addition, the survey found that 41% of doctors feel patients are poorly informed. According to Robert Thompson, a professor of popular culture at Syracuse University, direct-to-consumer drug ads "have completely turned around the old relationship when the doctor was this godlike character and you used to go in there all deferentially." Consumer Reports urges readers to "ignore drug ads" and cautions that the drug industry "spends billions of dollars a year trying to get you to pester your doctor for expensive, new brand-name drugs".

Separately, health insurance carriers often point to direct-to-consumer drug ads s one of the significant causes of increased prescription drug costs.

See full story from Atlanta Journal-Constitution, TV drug ads influence doctors' orders

Walgreen has opened 50 in-store clinics in five markets since last year and plans to operate 250 nationwide by August. They have 5,584 stores nationwide. "The clinics over time will help lower health care costs," CEO Jeffrey Rein said.

Walgreen hopes the in-store clinics, which offer treatment for minor ailments and are operated by nurse practitioners, will boost prescription drug sales and encourage customer loyalty. Walgreen is moving forward carefully with the expansion in an effort to avoid alienating doctors.

CVS, Wal-Mart and Target in the past three years also have opened in-store clinics. I applaud this trend given the growing shortage of Family Practice physicians.

Consumer Reports conducted the survey in three phases last year. The survey of about 39,000 patients and 335 primary care doctors appears in the February edition of Consumer Reports.

These tips from Consumer Reports might get you better care:

Get referrals. Friends, co-workers, or relatives can provide recommendations.

Research carefully. When gathering health information, consider the quality of the source.

Make an agenda. Before your appointment, set priorities about what you want to discuss with your doctor.

Ask about email. If you don't have time to cover everything in your appointment, ask if you can follow up by email.

Bring someone with you. A friend or relative can help you get your questions answered and remember what the doctor tells you.

Tell it like it is. Be frank, honest; and don't be shy. Bring up any conditions bothering you.

Follow your doctor's advice. For example, don't stop taking medications without talking with your doctor.

Be persistent. Work with your doctor to find the right treatment.

Switch doctors, if necessary. Not happy with your doctor? There are others out there.

Keep drug ads in perspective. If you ask your doctor for a drug you saw advertised, understand he may or may not agree its the right drug for you.

Weight loss, or bariatric, surgery was nine times more common in 2004 than in 1998 in the U.S. - 121,055 in 2004 - most of those operations were gastric bypass surgeries.

"This report shows that more Americans are turning to obesity surgery and that an increasing number of younger people are undergoing these procedures," says AHRQ Director Carolyn Clancy in an AHRQ news release.

"As the rate of obesity continues to climb, the health care system needs to be prepared for continued escalation in the rate of this surgery and its potential complications," Clancy says.

Bariatric surgery can have complications, but the report shows a drop in the hospital inpatient death rate. In 2004, 230 patients died in hospital stays in which bariatric surgery was performed, down nearly 80% from 1998.

A new federal database makes public for first time statistical data that compares health insurance costs among the nation’s largest cities and other geographical areas. A warning: this is a government website so user friendly it is not.

Some highlights from the new data for the 20 largest metro areas:

Average premiums for family coverage were highest in New York ($11,244) and lowest ($8,521) in the Riverside, California metro area, which includes San Bernardino and Ontario.

Premiums for single coverage were highest in San Francisco ($4,185) and lowest in Riverside, ($3,012).

The data include statistical averages from the following cities and surrounding areas: New York, Los Angeles, Chicago, Philadelphia, Dallas-Fort Worth, Miami, Houston, Washington, DC, Atlanta, Detroit, Boston, San Francisco, Riverside, Phoenix, Seattle, Minneapolis, San Diego, St. Louis, Baltimore and Tampa.

The estimates, which are from AHRQ’s Medical Expenditure Panel Survey for 2004 -- the most current data -- show large geographical variations in how much Americans pay for family coverage and individual coverage as well as how much employers contribute to workers’ health insurance premiums. We already know that the quality of health care can vary significantly according to geography. These new data highlight local cost variations.

This is all part of the US Department of Health and Human Services drive for health care transparency. Looks like they are getting some traction.

Pharmacies are allowed to make and sell their own drugs. The practice, known as compounding, has long been accepted as a way for physicians to tailor drug therapies to individual patients—say, by instructing a pharmacist to turn pills into liquids for someone who has trouble swallowing. Such products can be sold without FDA approval, provided the pharmacist has a prescription from a doctor. But once a compounding pharmacy starts mass-marketing its own recipes, via the Web or other means, the FDA can regulate it as if the pharmacy were a commercial drug manufacturer.

A pharmacy called Med4Home advertises on the Internet and TV. They target Medicare recipiants, promising to deliver medications to the door and file their Medicare claims for them. But what Med4Home actually delivers are reformulated versions of the brand-name medicines. Med4Home's parent company, home health-care provider Lincare Holdings Inc., (LNCR ) is being investigated by the Food & Drug Administration. In August 2006, the agency sent a warning letter to another Lincare affiliate that makes the drugs Med4Home delivers. The FDA blasted the affiliate, Reliant Pharmacy Services, for making drugs at "ineffective or dangerous dosage levels," maintaining poor quality-control practices, and in some cases sending patients non-FDA-approved copies of commercially available drugs without getting clearance from their physicians.

See full story at BusinessWeek.com, Is Your Medicine The Real Deal?

How many people do you know who take vitamin C and echinacea to prevent colds, melatonin for insomnia, or St. John's wort for depression? More than 60% of Americans use herbal and dietary supplements, yet the Food & Drug Administration (FDA) has virtually no authority over these so-called safe and natural wares. Reputable study after study has failed to show that these remedies are effective. The only supplements with unqualified support are calcium and vitamin D for women at risk of osteoporosis, folate for pregnant women, and fish oil, containing omega-3 fatty acids, for lowering cholesterol and blood pressure. Multivitamins, taken by more than half of all adult Americans, have been largely dismissed by the National Institutes of Health.

A new book just published by author, Dan Hurley, Death, Lies, and Politics in America's Vitamin and Herbal Supplement Industry, is an angry and detailed exposé of the largely unregulated field of natural remedies. Hurley has gathered considerable data on the steady flow of deaths, disfigurements, and injuries linked to this $21 billion-a-year business.

There are excellent cosmetic surgeons throughout the world. However, Americans seeking surgery abroad requires homework. Consider establishing a relationship with a local board certified plastic surgeon before going on your trip. Then, if complications arise when you return home, a qualified surgeon will be familiar with your goals and procedures.

Unless you have met the surgeon on a prior visit, and have seen the surgery facility, how do you know that you will be comfortable with him or her, and feel secure in proceeding with surgery? Remember, a successful; doctor-patient relationship is based on confidence and trust, not on perceived savings and price. Make sure you are fully comfortable with the surgeon providing your care.

What are the risks of long flights and any additional land travel before and after surgery? Will travel have an impact on my surgical outcome? Will I have to stay longer at the tourist destination to decrease the risk of post-surgical deep vein thrombosis (DVT) before I get on a plane?

Is there an increased risk of DVT in the legs, or pulmonary embolism (blood clots in the lungs) associated with long air travel before and after surgery?

What is the surgeon's training?

Be sure that your physician has specific training in cosmetic surgery procedures through an accredited plastic surgery residency program and/or fellowship. What specialty certification does the surgeon hold? The International Society for Aesthetic Plastic Surgery is a good source for finding qualified cosmetic surgeons.

You've probably seen those TV commercials for Requip (ropinirole), the first drug approved to treat "restless leg syndrome", a condition whose signature feature is creepy-crawly leg sensations that interfere with sleep and rest in nearly 1 of every 10 adults.

But if taken too long, the drug can actually backfire, causing symptoms to worsen, say doctors who specialize in treating the condition. At this point, you can't just up the dose. The drug is part of the problem. They say that treatment that rotates through different types of medications may be needed for many patients

In the wake of FDA approval for Requip and Mirapex (pramipexole), along with the attendant heavy advertising, It's important for both primary care physicians and patients alike to understand the risks of relying on these medications for too long.

Most U.S. adults say they are in good or excellent health, according to a new Gallup poll. Of those polled, 79% rated their physical health as "excellent" or "good," while 21% said it was "only fair" or "poor." Self-ratings for mental health were even higher: 86% said their mental health was "excellent" or "good," while 14% rated it "only fair" or "poor."

Are Americans really as healthy as we claim? That's not clear. The poll didn't include specific health questions -- such as "What is your blood pressure?" -- and participants weren't asked for medical records for confirmation.

As for demographics, the analysis shows that younger adults, Republicans, men, people with higher incomes, whites, and churchgoers are most likely to rate their physical and mental health highly.

Toyota will build a $9 million medical clinic for employees and their families at its new San Antonio truck factory. The clinic will provide primary care including eye care, dental services, pediatrics, laboratory tests and physical therapy. The decision to offer more comprehensive services onsite means the company likely will spend more for primary care and prescription drugs, but the additional costs should be offset by a drop in more expensive hospitalizations and specialty care. Toyota will measure the success of the clinic by monitoring employees' health indicators, such as smoking cessation rates and blood pressure levels, and by tracking expenses. Toyota will not require employees to use the clinic but will charge higher copayments and deductibles for workers who seek care elsewhere.

See full story in Detroit News, Toyota's health cost cure: A clinic at the plant site.

U.K. doctors Hangwi Tang and Jennifer Hwee Kwoon Ng find that their patients often use the popular Google Internet search engine to try to diagnose their own illnesses.

They wondered if it works.

To test the strategy, they took advantage of a feature in The New England Journal of Medicine. Every week, the journal offers doctors the chance to hone their diagnostic skills by presenting a puzzling case history.

So Tang and Ng gave Google a chance to solve 26 of the puzzles.

The two doctors selected three to five search terms for each case history. They then typed them into Google and looked over the first five pages of search results for a diagnosis.

Google came up with the correct diagnosis 58% of the time, Tang and Ng report in the current online issue of BMJ, formerly the British Medical Journal.

"Our study suggests that in difficult diagnostic cases, it is often useful to 'google' for a diagnosis," the researchers conclude.

The catch: Tang and Ng are doctors, and their combined expertise was needed to choose the most likely search result.

"Patients doing a Google search may find the search less efficient and be less likely to reach the correct diagnosis," they note. "We believe that Google searches by a 'human expert', a doctor, have a better yield."

More than 150,000 Americans undergo spinal fusions for lower back pain each year. The process involves using bone grafts with or without surgical implants to fuse two or more vertebrae. Among Medicare recipients, spinal fusion surgeries quadrupled to a rate of 12 per 10,000 in 2003 from 3 per 10,000 in 1992, according to a report last month from researchers at Dartmouth Medical School.

Recent European studies have raised questions about the benefits of spinal fusion in general.
A head-to-head study in Britain last year found spinal surgery offered no clear advantages over intensive rehabilitation therapy for patients with chronic lower back pain. This year, a Norwegian study found spinal fusion was no better than physical therapy in patients who had undergone previous back surgery.

In the latest report, researchers from the University of Washington, found that two years after surgery, about 60% of patients remained disabled. The high rate of long-term disability in all of the patients suggested that spinal fusion was of little benefit.

See Los Angeles Times story, Spinal surgery devices questioned

Both U.S. and international studies show that the more a healthcare system relies on primary care, the better the outcomes and the lower the cost. But American medicine is heavy on specialists and getting heavier. In just the last eight years, the number of graduates of U.S. medical schools choosing careers in family practice and adult primary care has plummeted by more than half.

About one-third of medical spending is now devoted to services that don't appear to improve health or the quality of care and may make things worse. This means that the U.S. is wasting more than $650 billion a year on unnecessary and often harmful care. The facts show that these enormous expenditures may be buying us the best amenities in medical care — but not the best health.

Even though Americans spend twice as much per person on healthcare as the other 21 wealthiest countries, data from the World Health Organization show that we live the shortest amount of time in good health — 2 1/2 years less than the average in the other countries (69.3 versus 71.8 years).

From LA Times OpEd Piece, November 3, 2006 Healthcare Code Blue By John Abramson, a clinical instructor at Harvard Medical School, and the author of "Overdosed America."

People with HIV can get 24 extra years of life from modern treatments at a total cost of $618,900 in 2004 dollars. Initially, monthly treatment costs about $2,100. The cost of drugs is nearly three-fourths of the lifetime expense. Unfortunately, 25% of people with HIV don't find out until their immune system collapses. The cost of treatment started at this late stage averages $4,700 per month. That's because hospital costs rise to almost half the lifetime expense. Of course, the least expensive option would be to prevent the estimated 40,000 new HIV infections that occur each year in the U.S.

That finding comes from a Cornell/Johns Hopkins/Harvard/Boston University research team that analyzed the costs and benefits of modern HIV treatment. Schackman and colleagues report their findings in the November issue of Medical Care.

Young people aged 15 to 24 get about half of the world's new HIV infections. We often blame them for being ignorant, for their notoriously bad judgment, and for their impulsivity. Or we let them off the hook for lack of access to condoms and lack of sex education.

Yet it's found that social influences are what really determine young people's sexual behavior. These influences fall into seven key themes. And the same themes are seen in every culture in the world. The themes are:

Young people decide whether to have risky sex based on whether they see their partner as "clean" or "unclean." This determination is largely based on social position and behavior perceived as socially appropriate.

The nature of a young person's sexual partnership influences not just their condom use, but their sexual behavior in general.

Condoms are stigmatizing and associated with a lack of trust.

Gender stereotypes determine social expectations and behavior. For example, men are expected to be sexually experienced while women are expected to be innocent -- yet women also are expected to be responsible for pregnancy prevention.

Society offers both penalties and rewards for sex. For example, an unmarried pregnancy can stigmatize a woman -- yet it can also offer escape from her parents' home.

Reputations and social displays of sexual activity or sexual abstinence are important.

The finding comes from an analysis of more than 250 studies of teen and young-adult sexual behavior by Cicely Marston, PhD, and Eleanor King, MSc, of the London School of Hygiene and Tropical Medicine. The study appears in the Nov. 4 issue of The Lancet.

Brand-name drugs that account for about $30 billion in annual sales are expected to lose patent protection this and next year. Generic prescription drugs are getting a bigger role in many people's health care spending as competition among retailers drives down generic prices and the selection of those drugs becomes more plentiful. Consumers can save 30% to 80% by switching from brand-name drugs to generic versions. The uninsured and those covered by the Medicare prescription drug benefit are expected to benefit most from the wave of new generics.

Wall Street Journal, Badal, (10/22).

As employers increasingly seek to encourage people to look for lower-cost medical services, workers will need to know what their medical services cost. According to a survey by Harris Interactive for employee benefits provider Great-West Healthcare, 68% of respondents did not know the cost of treatment until it was received and 11% said they never learned the cost. Respondents guessed that a routine doctor's office visit costs $95, when it typically costs $200. For emergency department visits, respondents estimated average costs of $680, when the actual costs totaled $400, according to the poll.

See Washing Post story, Before You Get Sick, Shop Around

A growing number of Americans (500,000 last year) are traveling to countries like India, Thailand, Costa Rica and Malaysia for medical care. Perhaps they are put at ease by the number of U.S.-trained doctors abroad and an increasing number of hospitals that are certified by U.S. insurance companies - Blue Cross Blue Shield Association includes an India hospital in its network of participating hospitals; California insurer Health Net contracts with clinics in Mexico; and West Virginia's Legislature is considering a bill that would encourage state employees to have non-emergency surgeries performed abroad. Medical tourism in recent years has expanded from primarily plastic surgery to include more medically necessary procedures like heart bypasses and orthopedic surgeries.

A recent episode of the television show Boston Legal featured the story of an HMO patient who was sent to India for a heart bypass. At the center of the plot was the fact that the patient had no choice about where she was treated. This is of course fictional, but I wonder if this might not become something to worry about for people who worry about things that might happen in the future.

One of the best ways to reduce your health care costs is by using generic drugs when possible. Order your expensive brand-name drugs from Canada. My family has been using CanadaDrugs.com for years with excellent results. You can also split your drugs. For instance, medications may come in 20 and 40 milligram tablets for the same price. It's wise for patients to buy the 40 milligram tablets for the same price and make them last twice as long by cutting them in half. Check with your physician though, because not all drugs can be split.

When it comes to insurance, look for insurance with a high deductible and lower premiums if you're healthy and don't expect your costs to meet the deductible anyway. Those with expensive health problems should look for lower deductibles but higher premiums, assuming their costs will easily surpass the deductible.

Those without insurance can consider Medicaid and state subsidized health plans. The Healthcare Options Matrix will show you what's available in your state. These plans are often restricted to children and individuals with children.

Health insurers are learning that they can save medical costs by getting people to have dental care at the right time in their lives. Aetna and the Columbia University College of Dental Medicine released a two-year study of 144,000 insured patients that finds early periodontal treatment reduces overall medical care costs by 9% for diabetes, 16% for coronary artery disease and 11% for strokes.

Another study, published in the Journal of Periodontology, finds that early treatment of pregnant women with serious gum disease reduces preterm births by 84%.

Aetna has expanded dental coverage offerings for enrollees who would most benefit -- such as pregnant women and people with cardiac disease -- to include such services as an additional third cleaning per year and scaling and root planing to remove plaque around the tooth root.

Aetna, Wellpoint and other insurance companies are offering free generic drugs and are waiving copays for members. Other insurers, including Blue Cross and Blue Shield of Illinois, are "stepping up direct-mail marketing of generics to consumers to combat direct-to-consumer ad spending on television and magazine ads by brand-name manufacturers. Aetna is paying to install vending machines in medical offices that allow doctors to dispense up to 30 days of free generic drugs. The machines track what drugs have been dispensed and send an alert when they need to be refilled.

The campaigns by insurers come during a year in which brand-name drugs representing an estimated $20 billion in sales are losing patent protection. The brand-name drug industry spends billions marketing drugs to doctors and the general public, and health insurers are now "fighting back" by promoting generic drugs.

Privately insured consumers seeking treatment for mental health and substance abuse problems still have to pay more out-of-pocket than do patients receiving other medical services.

Researchers compared what consumers paid out-of-pocket for psychotherapy, behavioral counseling, medication management and other outpatient mental health services with what they paid for medical care between 1996 and 2003. They found that consumers' out-of-pocket expenses for mental health was 35 percent versus 21 percent for medical treatment. They note that state mental health parity laws cover only a fraction of privately insured patients and relatively few employers voluntarily moved to full parity.

"Coverage for Mental Health Treatment: Do the Gaps Still Persist?" was published in the September 2006 issue of the Journal of Mental Health Policy and Economics.

You may havve heard about walk-in medical clinics in chain stores, supermarkets and shopping malls. They are remarkably consumer friendly. The walk-in clinics require no appointment and little or no waiting for treatment of minor ailments such as flu, bladder infections and sprains. They're open nights and weekends. Prices are posted, and the bills are surprisingly reasonable. More insurance plans are covering retail clinics because the clinics charge less than doctors' offices. The insured patient is charged the plan's co-pay. The uninsured patient pays an average of $50 to $80.

Doctors don't like it. They're afraid this will drive the Family Practice doctor out of business. They complain that the clinics are staffed by nurse practitioners not doctors. However, a landmark 2000 study in the Journal of the American Medical Association found that nurse practitioners performed as well as doctors in a primary-care setting. Researchers randomly assigned 1,316 patients to a doctor or a nurse. After six months, health outcomes and patient satisfaction were comparable in the two groups.

Consumers like it. Among adult clinic patients, 80 percent are satisfied with the cost, 89 percent with the care and 92 percent with the convenience, according to a Wall Street Journal Online/ Harris Interactive poll.

Some doctors are charging $1,500 to $1,900 a year, to give patients telephone access at all times, same-day appointments and, in some cases, house calls. Concierge practices typically limit the number of patients to no more than 600. That contrasts with as many as 3,000 in a traditional internal medicine practice.

Patients in these practices generally fall into two categories. One is busy, successful executives who want personalized care around their schedule. The other is retirees with multiple medical problems who are frustrated with the Medicare system.

For patients who can afford the service, having a doctor readily available offers peace of mind. It is comforting to know that a doctor who knows you best is just a quick phone call away.

MDVIP, an association of doctors who have this type of practice, maintains an online provider directory.

I had a routine physical a couple of weeks ago, something I do every 3 years, and I was back at home before I realized I hadn't asked my doctor several questions that had been on my mind for months. Apparently, I'm not alone. Research shows that although most people claim to want as much information about their medical conditions and treatments as they can get, even the most confident are struck dumb (even with their clothes on) when talking to doctors.

Virginia Teas Gill, a medical sociologist at Illinois State University, said, "Some patients show up to a scheduled appointment with a fistful of questions, and that’s fine. But, to get them answered, write the questions down beforehand, and say at the outset of the office visit: ‘I’ve got some questions. When would be the best time for me to ask them?’ That alerts the doctor — who has to keep an eye on the time — to what the patient’s agenda is, so that the two can prioritize what to cover and decide whether they’ll need a follow-up meeting".

The internet is already transforming many medical encounters. Some patients now come armed with journal articles and printouts, and demand specific treatment. Doctors may give in to a patient’s request, if it is made in an assertive manner. (They don't like confrontation any more than the rest of us.) But the patient may lose the advantages of the physician’s experience. You may end up getting what you want, not what you need.

I recommend a book, You: The Smart Patient: An Insider’s Handbook for Getting the Best Treatment,” published this year. Written by two physicians — Michael F. Roizen and Mehmet C. Oz — the book helps patients cut through medical jargon, find a good surgeon or hospital, get a second opinion and navigate health insurance problems.

I have been buying my wife's prescription drugs at CanadaDrugs.com for a couple of years now and have been very satisfied with the price, quality, and service.

Buyers must beware, though, because not all prescription drug web sites using the name Canada are selling genuine drugs. Some are not even in Canada. The FDA just released (Aug. 31, 2006 ) the following list of companies selling fake drugs and recommends that people who have bought drugs from these web sites not use them because they may be unsafe.

www.RxNorth.com
www.Canadiandrugstore.com
www.Rxbyfax.com
www.Northcountryrx.com
www.Canada-pharmacy.com
www.My-canada-pharmacy.com
www.NLRX.com
www.Canampharmacy.com
www.Canada-Meds-For-Less.net
www.Canadian-safe.com

These web sites are owned by or have orders filled by Mediplan Prescription Plus Pharmacy or Mediplan Global Health in Manitoba, Canada.

Brace yourselves, according to a recent Los Angeles Times article doctors are billing for things like prescription refill requests, copies of medical records, phone consultations, family medical leave forms, medical disability forms, waivers of insurance premiums, waivers for handicapped plates. Other physicians, notably pediatricians, charge patients for after-hours calls, passing on the $15 or $20 per call that they're billed by the answering service.
Almost unheard of five years ago, the practice has disgruntled some.

The article quotes, Arthur Levin, director of the New York City-based Center for Medical Consumers, "It shows that healthcare is like any other enterprise: It is revenue-driven”. Duh! Where has he been? Of course, healthcare is revenue driven. "In the old days, we just did it, it was part of doing business and doctors would absorb the cost," says Dr. Richard Lander, a New Jersey pediatrician who currently charges $5 for school, camp or athletic participation forms. "But in today's climate with so much paperwork involved, doctors feel they can no longer give services for free." Lander recalls the reaction when he first started asking for the fee five years ago. "People were astonished. They were incensed. I had a few patients who left my practice," he says.

My opinion? This practice does not bother me. First of all we're not talking about a lot of money and secondly, I'd rather pay for the administrative services I request than being overbilled for medical services to pay for someone else's paperwork.

How do you feel about it?

I've talked about medical cost transparency (clearly stating the cost of medical services) by hospitals and doctors previously. While doctors and hospitals continue to drag their feet, the federal government and some insurers have begun to respond. Last week, President Bush signed an executive order requiring four federal agencies to compile and release information about the quality and price of health care provided to people they cover. Medicare now posts on its website how much it pays for 30 medical procedures in each of the nation's counties, along with data on how many of the treatments each hospital performed last year. In general, the more experience a facility has with a procedure, the better the outcome for the patient, studies show. Aetna, which covers 30 million beneficiaries, will make physician-specific information on fees, clinical quality and efficiency available to its members in seven states.

Consumers wouldn't think of buying a new car without knowing the sticker price and gathering some information about reliability, yet they'll go ahead with a knee replacement with little thought of the actual cost of treatment, and with virtually no information about their hospital's track record with that procedure. Patients who try to ask about price are unlikely to get a straight answer. "It depends" is how most hospitals will reply because they have sliding scales of fees based on a patient's insurance, discounts negotiated by health plans, and potential complications in treatment. Bills are incomprehensible.

Are you aware of other instance of medical cost transparency that you'd like to share?

Now that I'm paying a bigger share of my healthcare costs. (I have a high-deductible PPO plan and a Health Savings Account), I am more careful about reviewing bills from doctors and hospitals than I was back in the day when my employers health plan paid for everything. Even though I'm in the healthcare business, it's very difficult to for me know if there is a mistake in a bill. That's because everything is coded, making it practically incomprehensible for the lay person.

If you're faced with a huge hospital or doctor's bill, it may be worth getting an advocate to help you. There are a growing number of medical billing advocates to help people deal with healthcare billing issues. Fees for services can run from less than $50 an hour to more than $200. In some cases, advocates take a percentage of the amount they recover. Here is a good place to start: Medical Billing Advocates of America, 540-387-5870 Online Advocates Directory

Psychology Today has a Find a Therapist Website that's worth visiting. I put in my ZIP code and instantly viewed 22 psychotherapists. You get a picture and profile of each therapist.

You may have heard the term "consumer directed healthcare" recently. The idea behind the term is this: smart consumers can decide how and where to get the best medical and financial outcomes for ourselves within the guidelines of our health insurance plans.

In the days of employer provided health insurance, plans covered everything with only nominal costs to the consumer, there was no need for smart shopping. Today, it's more likely that we have a high-deductible health insurance plan, meaning less insurance cost to us and our employer, but more out-of-pocket expenses for us. Now it's our money that we're spending and it's time to pay more attention to costs.

Unfortunatley, we are just beginning to get access to the kind of information we need to make informed decisions. Our health insurance carriers need to give us access to their negotiated rates with providers. For instance, my insurance company will pay 80% of the negotiated rate for an MRI. But there is no way to know what the negotiated rate for Provider A is versus Provider B. So how would I know which diagnostic provider is going to be cheaper for me. The difference can be huge. I had an MRI on my knee a couple of years ago and the hospital bill (retail price) was $1700. My insurance company had negotiated a discounted rate of $800. Great deal right? But what if I could have shopped other providers of MRI services in the area? I probably would have saved money.

Some data is now available for comparing hospital costs, so that we can compare the retail price range for comon proceedured between hospitals - check out Healthia (free), or My Healthcare Advisor ($24/yr) as examples of hopeful signs for the future. This kind of comparing lends itself to the internet and no doubt there'll be tools available to make us smarter consumers of healthcare.

How do you go about choosing a doctor? Most people rely on the recommendations of non-medical friends and acquaintances. If someone asked me, I'd recommend my doctor. I've been seeing her for about 10 years and I think she's a good doctor. But I'd also have to say, she's a lousy manager because her office staff sucks. You can't get through on the phone. They loose stuff. So if you asked me, I'd tell you about the good and the bad.

There's a website called RateMDs.com, that let's you rate your doctor for all to see. It's still relatively new, so you may not find much information about docs in your area yet. This type to website depends on community involvement. That's one of the reasons I want you to check it out because I want it to succeed. I really need a place like this to recommend to my clients and friends who are looking for help in choosing a doctor. Oh by the way, it's FREE.

Let's say you need back surgery (Discectomy and Laminectomy). How would you go about picking the hospital that would give you the best chance for a satisfactory outcome. If you're like most, you'd probably select a hospital close to home with a good reputation. You might not be making the best choice.

You might find as I did that the local big-name hospital, 10 miles from your home, does only half as many of these procedures as a lesser known hospital 45 miles away. The lesser known hospital also had fewer patients with complications from this procedure. You can even compare charges - prices range from $10,400 to $213,300. Quite a range.

I recommend My Healthcare Advisor.
For an annual subscription of $24, you can sign up for your own personal access to My Healthcare Advisor. Well worth it.