Sunday, June 30, 2013

Another "Wonder Drug" is on its way.


I've written before about how much I hate "me-too" drugs.

I think I've just found the worst offender of them all...and it hasn't even been released yet.

Two days ago, the FDA approved the "first" non-hormonal drug to treat hot flashes in menopausal women.  First- a bit of background.  Hot flashes are an extremely common symptom of menopause- it's estimated that up to 80% of women will experience them.  Hot flashes are caused by fluctuations in hormone levels causing blood vessels to dilate.  At best, hot flashes are a minor annoyance.  At worst, they are truly debilitating, happening several times an hour and interfering with work and sleep.

For decades, the mainstay of therapy for symptoms of menopause was hormone replacement therapy.  This consists of giving women small dosages of estrogen and progesterone, the two main "female" hormones that decrease during menopause.  Then, in 2002, the preliminary results of the Women's Health Initiative Study were released.  This showed a significant increase in the incidence of breast cancer in women who were on hormone replacement therapy versus women who were not.  Mass panic ensued.  Over the next few years, doctors wrote 70% fewer prescriptions for HRT.  As the years have passed, more information has be released and more data obtained, suggesting that the increased risk of breast cancer is not all that clear-cut.

However, the damage was done, and women have been suffering from hot flashes, afraid to try HRT.  This of course sparked an interest in finding non-hormonal treatments for menopausal symptoms.  Doctors have been using types of anti-depressants, SSRIs and SNRIs for years.  They work, a bit.  None of the studies have honestly been that impressive.  Some show a slight benefit, others are barely better than placebo.

I guess that a certain pharmaceutical company has decided that the combination of hot flashes and fear of HRT is a cash cow.  As I said above, on Friday the FDA approved the "first" non-hormonal medication to treat hot flashes.    The new drug is called Brisdelle.  Its generic name is paroxetine.  That's right.  Paroxetine.  Otherwise known as Paxil.  Paxil was FDA approved for treatment of depression in 1992 and has been generic since 2003.  It is available in 10 mg, 20 mg, and 40 mg tablets.

Brisdelle is a "novel" drug because it is available in a 7.5 mg dosage.  That's right, a whopping 2.5 lower milligrams that generic Paxil.  Is there ANY difference between taking 10 mg of Paxil and 7.5 mg of Brisdelle?  I sincerely doubt it.  I'd stake my medical license on it.

Even the drug company's own research was pretty pathetic.  Per the Times article, women on Brisdelle had an average of 6 fewer hot flashes, while women on placebo had an average of 5 fewer flashes.

Noven Pharmaceuticals has not yet released how much this new wonder drug will cost.  Well, here's a news flash for them.  If it is any higher than $2 a month, they're charging too much.  You can get generic paroxetine 20 mg pills for $4 a month at Walmart.  Break them in half and you've got 10 mg of paroxetine, which is basically what Brisdelle is.

I can't think of any scenario in which I would prescribe this drug.  To me, it appears to be expensive and ineffective.

Thursday, June 27, 2013

Big Brother is watching.

I'm willing to bet that most people think that what happens in the exam room is just between them and their doctor.

How wrong they are.

The Health Insurance Portability and Accountability Act (HIPAA), which came into effect in 2003, states:  "A covered entity (that's your doctor) may disclose PHI (Protected Health Information) to facilitate treatment, payment, or health care operations without a patient's express written authorization."

That means that all of your private health information can and is shared with your insurance company, pharmacy, and pharmacy benefits management company (like Caremark and ExpressScripts).  Don't think they're interested in what you're doing?  Wrong again.  I am constantly getting "helpful" communications from them regarding what you're doing.  Here's an example:


  
Not taking your medication?  Don't think I'm not going to find out!  Your pharmacy keeps track of how often you refill your pills.  They pass on this information to your insurance company.  They pass it on to me so I can...scold you?  Rap your knuckles?  Send you to bed without dessert?

I don't find these communications helpful.  I find them insulting to my intelligence.  I know people don't take their medications all the time.  No one does.  There's lots of research to back this up.  Because I know this, I monitor their chronic issues.  I bring them in for blood pressure checks.  I do lab work.  I do physical exams.  If something is not as it should be, I address it and work with my patients to make changes they can live with.  If everything is A-OK, we leave it alone.  I don't need to parent my patients.  That's insulting to them.  I'm an internist- I take care of adults.  If I wanted to treat people like children, I would have been a pediatrician.

So, I'll keep on adding on my own little check box that states "I find this communication to be useless." 

Even if Big Brother wants me to scold and nag.  

Thursday, June 20, 2013

Public Service Announcement: Your dog and pot. Just say no.

This is my dog.


The is the vet bill for my dog on drugs.




Any questions?

Yeah.  I'll bet you have lots of questions- the main one being, "Marni, what the HELL are you talking about?"

So, here's my story.  Wednesday was a beautiful day.  I decided to go for a run when I got home- just a quick 3 miles.  As usual, I took Indy with me.  He loves a good run...usually.  However, I noticed that he was a bit slower than usual.  I didn't think too much of it, since he's been getting lots of exercise lately.  By the beginning of mile 2, he was really dragging.  By the time we got home, I was getting really worried.  I tried to give him water, but he just kind of slumped down into the water dish.  At this point I was well and truly panicked, as was Patrick.  He decided to take Indy to the emergency vet while I stayed with the kids.

After about an hour, he called me.  They were doing lots of tests but still weren't sure what was wrong.  Indy had a low-grade fever, was agitated, and was drooling.  He also couldn't seem to control his bladder.  At that point, the vet recommended having him stay there for overnight care, fluids, and further testing.

Patrick came home and I spoke to the vet about an hour after that.  She reviewed his lab work, which all looked pretty normal.  She then said to me, "This is a bit awkward to ask, but is there any possibility that Indy could have gotten into some marijuana?"

My initial response was a sound that was somewhere in between a snort, a choke, and a laugh of disbelief.  Here's the thing.  Those of you that are my patients, I'm sure, hope that I am a totally drug-free person.  Well, you can rest assured.  Those of you who know me on a personal basis can attest to the fact that I am one of the most straight-laced, boring people out there.  I've never smoked pot, or even a cigarette.  My good friends will tell you that the idea itself is laughable.

I turned to Patrick and asked him, "Hey, do you think any of the neighbors are growing pot?"  His response was similar to mine.  I asked the vet why she was asking this.  She informed me that Indy's presentation was really classic for marijuana ingestion.

I thought about it some more.  Here's the thing.  Indy spends a lot of time outside in the summer.  We live at the end of a nice, quiet cul-de-sac, and we do let him run around off leash.  He also gets to go to the beach and run around off leash there.  Like all labs, he has an unfortunate habit of eating anything that doesn't eat him first.  He once ate a 10 lb. bag of kibble.  He also ate some of my underwear.  So, in truth, it's entirely possible that my dog could have gotten into someone's stash, or at least ate a discarded joint.

Luckily, marijuana ingestion is rarely fatal for dogs, but it can make then quite sick.  I'm happy to report that Indy recovered well with IV fluids and some sedatives, and he's now back to his normal self.

I'm still smarting over the fact that my stoned dog cost me over $1000.

Just say no.

Monday, June 17, 2013

Ten things you might not know about me (or any of your doctors)


Here are ten things you might not know about me:

1.  I don't care if you shaved your legs before coming to see me.  We're not on a date.  However, I do appreciate it if you've bathed.

2.  There is nothing you can say that will shock or embarrass me. Nothing at all. I spent 4 years working in Greenwich Village in NYC.

3.  The chair with the wheels on it is mine.  I get antsy when someone else sits in it.  Get off of my chair- there are two others in the room for you!

4.  I like to hear what's going on in your life outside of your health.  It tells me a lot about you.  It helps set you apart from my other 4,000 patients.

5.  I know you don't always take your meds.  No one takes them all the time.  I'll also know if you're not taking them at all.

6.  I don't mind if you look stuff up on the internet.  However, I appreciate it if you listen to my point of view, too.  Even though my name is not Dr. Oz, I do occasionally know what I'm talking about.

7.  Sometimes, when I'm giving someone bad news or hearing about someone's troubles, it's all I can do to not cry.

8.  I'm not shifting around and looking jumpy because I'm impatient.  I just have to go to the bathroom.

9.  If you're a jerk to my office staff, I don't care about how nice you are to me.  You've already lost my respect.

10.  I have saved every "thank you" card that a patient has ever sent me.  Every single one.  If I'm having a bad day, I take them out, look at them and remember that it's all worth it.

Thursday, June 13, 2013

Swim-Bike-Run





A good friend of mine has convinced me to do a triathlon with her.  As is obvious from this blog, I'm a runner.  Not a particularly fast or talented one, but a dedicated one, nonetheless.  And, like many runners, I'm a one-trick pony.  Runners are notorious for loving running and having the firm opinion that all other forms of exercise are inferior.  

So I run.  Pretty much exclusively.  I'll occasionally throw in a yoga class out of some sense of obligation.  However, as I approach my 40's, I'll admit that all this running leads to more aches and pains than it used to.  I've had this nagging tendonitis in my foot that's been bothering me on and off for the past couple of years.  I get back pain now.  And so on.

So, I was already playing with the idea of adding in some cross training when Sarah brought up the idea of doing the triathlon.  My first response was, "No way, no how."  I run.  I know how to swim, I mean I won't drown or anything, but I'm not what anyone would call a good swimmer.  I know how to ride a bike. I even get on it at least once a year.  But doing a 15 mile ride, after a swim and following that up with a 5K run?  

I don't think so.

But the idea stayed with me.  So, last week, I got into the pool (brrrrr!) and swam the quarter mile.  44 boring laps in my pool.  And it was pathetic.  Took me 19 minutes, I'm embarrassed to say, although at least 3 minutes of that was spent clinging to the side of the pool, huffing and puffing.    The next day, I got on my bike.  I got to the end of the driveway and realized that air in the tires would probably be helpful.  After I put air in the tires, I went for a 6 mile ride.  And it was hard.  And I felt like I would die at the end.   But I didn't.

The next day I was sore.  But it was a good kind of sore- they kind you get from a good workout.  And I realized, I haven't been sore like that in a while.  And while I was sore, my nagging tendonitis and back pain hadn't been aggravated the way they are after a run.  

So, I've decided to go for it.  And I've put it out here so that there is no chance that I'll chicken out.  For anyone that cares to join me- it's the Kingston Triathlon on August 11th.  

Monday, June 10, 2013

Physicals, Billing and Insurance: Coding 101


The "annual physical exam" is somewhat sacrosanct. It's also a bit contentious. Often doctors and patients swear by its importance, while lots of research shows that the annual physical does not really show any evidence of contributing to better health.

I'm not going to talk about the values of the annual physical today- that would be a post for another day. What I am going to talk about is how we charge for an annual physical and how an insurance company pays for it.

First off- it is imperative to understand a bit about how we charge for medical visits.  We do this by a process called coding.  Every diagnosis under the sun is assigned a "code."  There are literally tens of thousands of codes.  The code for an annual physical is V70.0.  Every time I see someone in the office, I have to write down the codes for all of the diagnoses that I am dealing with at that visit.   Then, based on the complexity of the visit, I assign an "evaluation and management code" to the visit.  This basically grades the complexity of the visit on a scale of 1 to 5, with 5 being the most complex.  How I reach that number is totally complicated and nuts, but again, that's a post for another day.

Physicals are billed using a V code.  V codes signify that medical care is taking place that does not involve an E&M level.  Preventative care, such as the annual physical, falls into this category.

What does all of this blather mean?  It means that an annual physical is purely a "wellness" visit.  Coding guidelines specifically state that there are "no complaints" for an annual physical, meaning that the patient is healthy and only preventative care is being discussed.

Why is this important?  Most insurance companies, and Medicare, pay for an annual wellness physical with no copay and no out-of-pocket expenses.  There is no deductible for most plans.  However, the only thing covered is the wellness exam.  Technically, if you have an acute complaint the day of a physical, one of two things should happen.  Option one- the appointment is no longer a physical and should be charged as a regular office visit and assigned an E&M level.  Option two- the appointment is still a physical and is charged as a physical with what is called a modifier code.  A modifier code allows both a physical and an acute office visit to be charged at the same time.  With either option one or two, you are going to have your regular copay and deductible apply, because it is no longer just a routine physical.

I don't usually take option two.  If someones acute complaints are severe enough for me to consider either of these options, I take option one.  The visit becomes a regular office visit, and we re-schedule the annual physical to another day.

Here's an example.  Let's say someone schedules an annual physical with me.  While reviewing their general health, I find out that they've had uncontrolled thirst and urination for a month.  I check their blood sugar and it's 300.  They have new-onset diabetes.  At this point, this is no longer a routine wellness visit.  I need to get lab work, start medications, and educate the patient regarding diabetes.  This needs the patient's full attention, and mine, and it deserves a visit all of its own.

Here's another example.  A patient comes in for an annual physical.  She is visibly anxious.  She just found a breast lump and is very concerned because her mother died of breast cancer.  Again, this is no longer a routine annual physical.  It is now an acute visit for a breast lump.  The patient needs some tests, possibly a referral to a surgeon, and counseling.

Get it? Here's the crux of the matter.  Just because you want a physical doesn't mean you're going to get one.  Just because you booked a physical doesn't mean you're going to get one.  What you are going to get is appropriate medical care.  The rest is just semantics.  However, if you get appropriate medical care that is NOT a routine physical, chances are your insurance company is going to want you to pay your copay and deductible.

And that's not my fault.  I don't make these Byzantine rules, but I do need to follow them.  My job is to provide the correct medical care.  My contract with your insurance company requires me to bill them appropriately.  So, DO NOT ask me to bill an acute visit as a routine physical so that your insurance will cover it.  That's called fraud.  And I won't do it.  Period.  End of discussion.  Even if you're my favoritest patient in the whole wide world.  No matter how much I love you, I won't commit fraud and risk prison time for you.  Sorry.