Eastside Family Health Center: May 2011

Tuesday, May 31, 2011

The Wild Wacky World of Insurance: Part One

Why should I have insurance?

1in·sur·ance

a means of guaranteeing protection or safety

The economy has stretched everyone these days. Gas prices are a record high, food prices continue to increase and insurance premiums have done nothing but go up as well. It can be tempting to just not get insurance at all, or to cancel. However, all it takes is one illness that goes from bad to worse, and you’ll wish you had insurance. We have an example for you. But first, ever wonder, where did insurance come from?

How does insurance work and what do all those terms mean?

When you join an insurance plan, you essentially enter into a contract with the plan. Your physician also separately enters into a contract with your insurance plan. That relationship between you, your insurance plan and your physician is what determines how much you pay for office visits, tests, and more.

There are a lot of terms to know when dealing with insurance. For some of the common terms, visit our blog on EOBs here http://blogs.eastsidefamilyhealth.com/2011/05/understanding-insurance.html

What’s the big deal about not having insurance? I rarely get sick!

We all live in a world where accidents happen. Germs are everywhere and we have no ultimate control over how our body responds to everything it’s exposed to. Sometimes we do silly things, like miss the potato and cut our finger instead. Life is unpredictable. Health insurance provides reassurance that when Murphy does come to visit, you have a way to get the care you need, and to be able to afford it much better than if you don’t have insurance.

Insurance premiums do continue to rise and it can sometimes be a strain on the wallet, but let me present it to you this way – I will let the numbers do the talking.

Say you wake up one morning, with right sided abdominal pain and you have no insurance. Your doctor is great about giving a discounted rate for your office visits, but that does cost $75.00 when you arrive to the office (you have also called in sick to work, since the pain is so bad you are doubled over).

While there, the doctor tells you that you may have appendicitis. The only way to know for sure is an ultrasound or CT scan. Those tests range from $150-$1500. If your physician checks your blood, so you’ll get a bill from the lab. Tests there also have a range from $10 to $300, depending on how many and which tests. Oh, and the CT / ultrasound confirms it – you have appendicitis! You’re sent to the ER for hospital admission and surgery, lest you risk your life by not going. The cost of the ER visit, the labs, the surgeon, assistant surgeon, anesthesiologist (assuming you don’t want to be awake during surgery), the medication you’re given, the anesthesia you’re given…. I think you get the idea. It sure does add up!

A case of appendicitis may run you at a minimum of $2-3,000 and depending on the severity, etc. could go all the way up to $20,000. Now compare that to the cost of insurance…. Remember the opening definition for insurance? “A means of guaranteeing protection or safety.” While you cannot guarantee a life free of mishaps, at least with health insurance, you will can rest easy knowing you are protected financially.

Now, there are so many options for insurance plans. Do not let the search for the perfect one be so daunting for you! There are resources available and questions to help you in your search. Look out for our next blog addressing what some of those are.

___________________________________________________

Dr. Frank Marinkovich owns and operates Eastside Family Health Center in Kirkland, WA. Serving Kirkland and the Eastside, Seattle, Bellevue, Renton and the surrounding local communities. Specializing in Primary Care, Automobile Accidents and FAA physicals. Visit them online at Eastside Family Health Center or call them at (425) 899-2525.
LIKE us at Facebook!
FOLLOW us on Twitter!

Friday, May 27, 2011

So I was in a car accident but why do I need an attorney?

The story of a motor vehicle accident (MVA), or a car accident, as its most commonly called, usually starts out with something like this: So I was in a car accident but why do I need an attorney?

The story of a motor vehicle accident (MVA), or a car accident, as its most commonly called, usually starts out with something like this: “I was just sitting at the stoplight.” Let me tell you, though, the story does not always end well. It usually ends with a damaged car, physical pain and a lengthy process of recovery.

A car accident can drastically change a person’s life. Your schedule now has to accommodate doctors’ appointments, physical therapy appointments, massage and chiropractic appointments. Sometimes, if the injuries are severe enough, there could be surgery and recovery time. If that is not enough, you’ll have the stress and emotions that come with juggling your appointments and work, and trying to go through “normal” life when even the way your body moves is anything but normal. It can be daunting just dealing with all of that. Now, add dealing with the car insurance company or companies and the other party, your stress level doubles and even triples.

All you want is for everything to be the way it was before the accident, right? For your body to be made whole, your car to be made whole... Sounds simple enough.

Car insurance is meant to protect you and to bring you back to wholeness. In another blog we looked up the definition of insurance which is a means of guaranteeing protection or safety. It is meant to protect you in case of harm: physically, by providing compensation for healthcare and financially, by paying for your vehicle repairs.

Your car insurance is meant to be your advocate. However, there are situations you may run into where you feel like things are not going well. The insurance company is trying to close your case and you don’t think it is time for that. Or your injuries are more extensive than your personal injury protection coverage will pay for. Will your car insurance agree to continue to pay for more treatment? Will the other party’s insurance? How will you know if what they are saying and what you are getting is fair? Are they thinking of what’s needed in the future or just closing your case? How do you know it’s time to close the case? Are you still in pain and still need medical care? Do you have more questions than answers (like this paragraph)?

We understand this process can be daunting, frustrating, and time consuming but we want to see you through the process and come out as healthy as you can. Sometimes, that means getting more help.

A lot of people cringe when they hear the word “lawyer” or “attorney”. All sorts of preconceived ideas come to mind. While seeing an attorney isn’t recommended at the beginning of a case, an attorney may be appropriate in cases with extensive physical injuries, a pre-existing injury is exacerbated by the accident, or when you come to a place where you are not sure if your car insurance or the other party are looking out for your best interests.
Not all attorneys are created equal though. A good attorney can be your advocate. If you are concerned about your recovery or if your car insurance is looking out for you, talk to your physician. Your physician may be able to refer you to a reputable attorney that they know and trust.

Confused about what to do if you’re in a car accident? For more details, visit this blog: http://blogs.eastsidefamilyhealth.com/2011/03/what-to-do-after-auto-accident.html

___________________________________________________

Thursday, May 26, 2011

Supplements: To Take or Not To Take?

A myth commonly believed by many is that vitamins and supplements make up for an unhealthly diet and lifestyle. This is far from the truth as supplements are designed to supplement the diet .

Experts recommend eating a well balanced healthy diet and the use of supplements to fill in the gap. Dr. Demetrius Albanes MD, epidemiologist at the National Cancer Institute states “vitamins are safe when you get them in food, but in pill form, they can act more like a drug with the potential for unexpected and sometimes dangerous effects.” We must be educated and aware that supplements taken in too high doses , such as the fat soluble forms of vitamin A, D, E, and K, can build up in the body and cause toxicity. Thus having an idea what the FDA recommendations of the upper and lower limits of vitamin and mineral doses is important in determining a supplement regimen.

I see many patients that are taking supplements on their own initiative or at the guidance of a provider and yet unaware how some of their supplements could be impacting their medical condition in a negative manner. Therefore, it is important that the provider review a current list of medications and supplements to identify any interactions and follow up with bloodwork to confirm normal values if necessary.

A good supplement baseline to get started for the young to middle-aged adult includes a multivitamin daily; Vitamin C 500mg daily as immune support therapy, not a treatment for cold viruses; Calcium 500mg up to two times a day depending on dairy food intake; and Vitamin D 1000-2000IU daily. This may need to be adjusted depending on the patient’s diet and current levels which can best be determined in consultation with your primary care medical provider.

___________________________________________________________

Wednesday, May 25, 2011

Hoarseness

Sounding hoarse lately? This refers to any change of voice. It can be higher, lower, huskier, or even breathless. This blog is to help think about the potential causes.

Voice is the result of interaction between the nose, mouth and a structure called the larynx.

Hoarseness can be caused by a number of factors. If the hoarseness is persistent it needs to be evaluated especially if there are no acute symptoms of infection or if has gone longer than two weeks. Tobacco use and alcohol are two worrisome coexistent risks for head and neck cancer. Unexplained weight loss, painful swallowing, difficulty swallowing or one-sided throat pain or ear pain needs to be evaluated.

Other causes of hoarseness include: acute laryngitis, chronic laryngitis, benign growths, cancer, nerve dysfunction, neurologic disease, or stress.

Acute laryngitis is common and self-limited condition lasting less than three weeks. This is usually due to a virus although can be bacterial. Laryngitis can also be caused by strain such as yelling or coughing resulting in bleeding from microtrauma.

Chronic laryngitis is typically due to irritants over time. Things such as acid reflux, fumes, chemicals, chronic voice strain, chronic alcohol use, chronic sinusitis, chronic post-nasal drip, or tobacco smoke. Some symptoms include throat clearing, heartburn, change of voice, sore throat, feeling like a lump in throat, or choking sensation. Asthma type symptoms may also present this way.

Normal Vocal Chords

As noted, there are benign growths that can occur on the vocal cords. Smoking can cause swelling of the cords called Reinke's edema resulting a husky low-pitched voice( sounds like a man). Polyps and nodules can also occur due to smoking, acid reflux or chronic vocal cord irritation.

This is Reinke's edema. Note the soft swollen irregular appearances (this was due to reflux).

Some may know of singer's nodes. This can be true but usually occurs with screamers. This is more common in women and children.

Now to the possibility of cancer. The vast majority of cancer is squamous cell. Major risk factors include alcohol use and smoking. This is usually heavy alcohol use such as up to 4-5 drinks per day. There are many other potential causes that have not been fully proved such as viruses, genetics and diet.

Cancer. Note the irregular appearing mass from the right vocal cord.

___________________________________________________

Friday, May 20, 2011

There's more to Psoriasis than meets the eye...

What is Psoriasis? Psoriasis is a chronic skin disorder which typically is characterized by plaques (patches of red raised skin) with a silver coat or scale. Recently, this skin disease has been associated with heart disease and can also be associated with life-threatening presentations. It affects men and women the same and is seen in all races. It peaks in age between age 20-30 with a second peak between 50-60. It is also interesting to note that psoriasis is even now being seen in children.

Who is at risk? Risk factors include family history (the disease is 100x more likely to occur among family members than unrelated people) but there are also many triggers. These include infections, stress- both physical and emotional, and as well certain medications. Several drugs are associated with worsening psoriasis such as beta-blockers, lithium, or ant-malarial drugs. Ibuprofen may but has not been fully proven. Smoking increases one’s risk of getting this skin disease. The worst kind of psoriasis, called pustular psoriasis is strongly associated with smoking. It also associated with obesity. In fact the greater the obesity, the worse the skin. This is also true of alcohol consumption. The greater the consumption, the worse the condition of the skin. A number of people also have nail involvement called psoriatic arthritis. The sun helps with the UV exposure.

Some Types of Psoriasis

Plaque psoriasisSa

The most common form of psoriasis is called plaque psoriasis accounting for about 80%. This is characterized by plaque in the scalp, elbows, knees, and back. The plaques are red with sharply defined margins that are raised. A thick silvery scale is usually present. Other areas are the intergluteal cleft and belly button.

Pustular psoriasis

A severe form is called pustular psoriasis. This can be severe and life-threatening. In addition to the usual plaques, there are sheets of superficial pustules (small elevation of skin filled with fluid called pus). It can associated with fever, weakness and diarrhea. It can be caused by pregnancy or the withdrawl of oral steroids, such as prednisone.

What causes it? We do not know what causes psoriasis but it likely immune related. This link has triggered breakthrough treatments. This is especially true of the newer family of drugs called biologics. Some patients after having undergone bone marrow transplantation have had a complete resolution of this disease.

What are other potential concerns if I have psoriasis? Even though psoriasis is a skin disease, it is also an independent risk factor for the heart attacks. The worse the skin condition, the higher the heart risk. This also makes psoriasis a higher risk of death. Certainly, this can be more than just affected skin! See your doctor to discuss this. It is important to have normal cholesterol numbers as well as blood pressure. Not to mention stop smoking and lose weight. It all goes together.

Finally, there has been much discussion of an increased risk of cancer in individuals who have psoriasis. It is due to the immune process of the underlying disease or the treatment? Not known. But, if you have psoriasis it should mean getting it treated and seeing your doctor on a regular basis.

___________________________________________________

Monday, May 16, 2011

Understanding Insurance

What is an EOB? And More importantly, is it contagious?

Acronyms run freely about in the medical world. We have them for conditions, for procedures, for just about everything. So let’s throw one out there for discussion…

EOB… what is it? No, it is not a disease, body part or even some strange procedure with 30 letters if you were to write it out fully. EOB stands for Explanation of Benefits. It is simply a form you receive from your insurance company showing how they are processing a claim that your doctor submitted for the billing of your visit. It may also be referred to as EOMB.

What does it do? Simply put, an EOB takes the various codes used that tell what was done (procedure or visit) and the reason it was done (diagnosis) explains based on the benefits of your particular insurance policy what was paid by the insurance company, what part will be written off (or discounted) due to an agreement between the insurance company and physician, and what part the patient will be responsible to pay. Here are some terms you may see on an EOB.

What is a co-pay? A co-pay is usually a smaller payment that is paid at the time of service for office visits or tests by the patient. It is based on the insurance plan you select. The doctor is not able to waive or change the co-pay.

What is a deductible? A deductible is also part of the insurance plan agreement which a patient agrees to pay when they accept the plan. Deductibles are usually, but not always, the first amount to be paid. For instance, if the insurance processed $1000 in charges for a patient and the patient had a $500 deductible, the patient would pay the first $500 to fulfill their agreement of the deductible. More recently, there are some plans that allow for a certain amount of visits before the deductible is processed and expected to be paid.

What is co-insurance? Some plans have a certain percentage that when you accept that plan you are agreeing to pay that percentage as a patient. These percentages can vary from as much as 50% to 10%. They can also differ based on types of services, such as was it a skin biopsy or visit for a cold. Co-insurance is the amount the insurance sees as the patient’s portion of responsibility for that bill.

What is out of pocket? Most insurance plans have a maximum limit to the amount that a patient and/or family will pay each year. Every plan varies on what applies to that limit, but most typically it is the co-insurance amounts. For instance, when a patient’s coinsurance amounts for the year reach $10,000, the insurance plan will then pay the remaining bills at 100%.

What is an allowable? The allowable is the amount your insurance will pay for a visit or procedure. The physician services are billed off a fee schedule that is set for their office. The allowable amount for the insurance is typically lower than this amount as it is a discounted rate that the contract agreement between the physician and insurance plan . Per their contract, the physician will deduct the difference between the amount they billed and the allowable.

What are contractual adjustments? These are based on the allowable. Physicians are often in contract with insurance companies or networks and they agree to provide certain discounts to patients who are part of those plans. The contractual adjustments or discounts represent the amount of those discounts.

What is in network and out of network ? An In Network provider / facility is contracted with your health insurance. If you see someone NOT contracted, then they are Out of Network. Some insurance plans will allow you to see providers out of network but usually there is a higher portion that the patient is responsible to pay, in other words, you pay more co-insurance and/or deductible. Some plans, however, do not cover out of network providers. If you are unsure if a provider is in or out of network, check with the potential provider, or with your insurance plan.

What if something is denied or not covered? Contact your insurance company to find out why if it is not clear on the EOB. Typically they have a code that explains why. Sometimes the company is just waiting for a form or some additional information so they can process it. If that is not the case, you can always contact the physician’s office to see if they can assist you with it. There are some things that certain plans truly do not cover (these are called exclusions and can be found in your benefit booklet) and other times where is information that is needed. The physician’s office may be able to supply additional clinical information that will assist in seeing that you get the full coverage from your insurance that you are entitled to.

Denied for lack of prior authorization? What is prior authorization and why do I need one? A prior authorization is simply an approval from your insurance company to proceed with getting a certain test or procedure done before you get it done. A prior authorization must be obtained before certain services are covered to ensure medical necessity ( a fancy term that means according to the insurance plan guidelines they view the test and/or procedure as appropriate and needed for the symptoms and diagnosis that you have). If a service is performed without prior authorization, it may not be paid by your insurance plan. Common tests that usually require prior authorization are CT, MRI, Nuclear diagnostic studies and even some medications. Your physician’s office will take care of getting the prior authorization processed for you if they ordered the test, but you may have to wait to schedule your test. However, if you were referred to a specialist, make sure to clarify which physician (the specialist or your primary care doctor) will be obtain authorization and communicate with that office regarding the authorization.

So you have a received an EOB from your insurance company. What is next?

First, the EOB is not a bill. It is simply a statement showing how the insurance applied your plan to the bill. Your physician’s office will either send a statement if you owe a balance or you can contact them to pay any difference if you do not want to wait for the bill. Secondly, if something does not appear correct or make sense, call your physician’s office to get further explanation, or if you have a visit bring in a copy to review with someone.

Always check to see which provider the EOB is referring to. For instance, if you have an office visit where your blood is drawn, you will have an EOB from your medical doctor, and one from the lab. Your doctor cannot correct or modify the information on the EOB from the lab. If you have a question regarding your account with the lab, you should call them first.

___________________________________________________

Tuesday, May 10, 2011

Carpal Tunnel Syndrome

What is carpal tunnel syndrome? Carpal tunnel syndrome (CTS) refers to the pain, numbness, and sometimes, but less commonly weakness which is caused by the compression of the median nerve as it travels through the wrist. Carpal tunnel syndrome is one of the most common causes of hand numbness seen.

What are the symptoms? The classic symptoms include numbness and tingling limited to the median nerve innervated fingers (or fingers that contain nerves that are supplied stimulation through the median nerve), but there is wide variability. The pain and numbness may be localized to the wrist or involve the entire hand. It is also not uncommon for the symptoms to radiate into the forearm, and as well, less frequently to radiate above the elbow to the shoulder. So, the hand symptoms described could be carpal tunnel or radiating pain from the neck.

These symptoms are often provoked by activities that involve extending the wrist, such as raising the arm while driving, reading, writing, typing, or holding a phone.

It is good to know that CTS often presents bilaterally (in both hands), up to 65% of the time.

Carpal tunnel may follow an alternating pattern with periods of remission and exacerbation. In some cases, there is progression from intermittent to persistent that may even advance to motor loss (strength). In the most severe cases, motor loss involves difficulty holding onto objects, turning keys or doorknobs, or buttoning clothes. One may even see atrophy.

How is it diagnosed? The diagnosis is a clinical one determined by a physician based on some testing and symptoms. The most important clue is nighttime pain or numbness. Standard symptoms include: dull, aching discomfort of the hand, forearm, or upper arm; numbness in the hand, weakness or clumsiness of the hand, any symptom in median distribution.

Some provoking factors include symptoms occurring in the sleep and repetitive actions of the hand. A test called an EMG which is a series of electrodiagnostic studies are needed to make the diagnosis. The EMG results in combination with the physical exam and the clinical history all lead to the diagnosis.

Who is at risk? Risk factors for CTS: obesity, female gender, pregnancy, diabetes, rheumatoid arthritis, diabetes, hypothyroidism, connective tissue disease( ex: lupus), pre-existing CTS, genetic predisposition, use of HIV meds, or workplace factors such as cold temperatures, vibrating tools, or repetitive hand use. As an interesting note, most studies do not support the association between computer usage and developing carpal tunnel.

What is the treatment? Treatment includes splinting, stretches, physical therapy, yoga, injections into the carpal tunnel and finally surgery. For sure there are many treatment options, the success of which usually depends on the severity of the compression. Ask your doctor to discuss the risk and benefits of each. Not all carpal tunnel needs necessarily end in surgery! As well, there are potentially other causes of it other than just overuse.

___________________________________________________

Monday, May 9, 2011

Colon Polyps

Colon cancer is one of the leading causes of death for both men and women. For the most part, death is avoidable with by using the very good screening tool we have called the colonoscopy. The colonoscopy is a procedure where a probe is inserted into the colon (commonly known as the large bowel) which allows the physician to view inside the colon for abnormalities as well as take samples of these to determine what the nature of these abnormalities are. This blog is about an announcing growth that needs investigation referred to as a precursor growth in the colon called the polyp.

Normal Colon Colon polyps

There are all different types of colon polyps, some pre-cancerous and some not. The most common polyps seen are called non-neoplastic polyps which include those called hyperplastic. Even though hyperplastic polyps are benign (or noncancerous), consideration must be given to their appearance, such as some (serrated forms) may have the potential for cancer. As well, there are some hyperplastic polyps which occur in large numbers together; a syndrome called Hyperplastic polyposis syndrome. This syndrome requires more intense screening due to increased risk of cancer development.

There are other polyps associated with other conditions such as Crohn’s disease or inflammatory bowel disease (IBS) which are both other diseases of the bowels. These types of polyps typically occur in multiples and need to followed closely by a physician.

Another important category of colon polyps are adenomatous polyps. These are by definition pre-cancerous. Nearly all colorectal cancers arise from adenomas, but only a small minority of adenomas actually progress to cancer( about 5 %). Risk factors for getting this type of polyp include older age( starts at age 50), obesity, and being a man. Adenomas can go through a process from low grade to high grade to cancer, or can present as high grade. You just don’t know where it is without looking under the microscope!

Adenomas have different shapes. Tubular adenomas account for about 80% of colon adenomas. Another type of adenoma is called villous adenoma. These polyps grow at variable rates, thus, when to repeat colonoscopy is based on size of the polyp. Adenomatous polyps bigger than 1 cm are a risk factor for containing cancer. If the adenomatous polyp is has a villous pathology( fingerlike under the microscope), the risk one whether one will develop cancer is also based on size( more than 1 cm, risk is up to 30% for that polyp to develop cancer).

So, it is very important to get screened for colon cancer. How often and when to begin depend on multiple factors including family history. This is a good topic to discuss with your doctor. There are some factors to prevent colorectal adenomatous polyps have been studied: diet—low in fat, high in fruits and vegetables as well as fiber. Maintaining normal body weight, regular exercise, dietary calcium intake, and avoidance of tobacco and excessive alcohol intake, especially beer are recommended.

___________________________________________________

Tuesday, May 3, 2011

Melatonin for Sleep

Melatonin is a hormone made by the pineal gland in the brain that controls the sleep/wake cycles. Our body has an internal clock that dependent on the time of day will control how much melatonin is produced. As insomnia can be a common symptom among patients, one of the recommended treatments for the often requested “natural” alternative is the dietary supplement melatonin.

Studies suggest that melatonin supplements may help people with disrupted circadian rhythms (such as people with jet lag or those who work the night shift) and those with low melatonin levels (such as some seniors and people with schizophrenia) to sleep better. Melatonin supplement doses can range from 0.3 mg to 80mg.

Melatonin is a dietary supplement and therefore it is not federally regulated. Thus the dose listed on the bottle may not be congruent to the dose contained inside. The timing of the dose can also be tricky as some sources recommend taking Melatonin up to 30 minutes before sleep while others suggest increasing the time by 30 minutes to as much as 6 hours to have an optimal effect on shifting the internal biological clock.

Melatonin has been found to be more effective on people that have already natural low levels of melatonin such as the elderly. Thus it is recommended that it be taken in the day time when low internal levels of melatonin already exist. It has also been found that the best method for delivery of melatonin is sub-lingual (under the tongue) or trans-dermal (through skin usually creams or patch) for better absorption.

All in all, the effectiveness of melatonin in treating insomnia is questionable and very individual. It is good to be aware that beta blockers and anti-depressants can suppress or reduce melatonin levels and thus may impact the effectiveness of the supplement as well. If insomnia becomes a chronic issue, it is recommended that you see your primary care provider for evaluation and treatment.

___________________________________________________________________