Medical markup

[wide]dollar health[/wide]The cost of medical care to consumers is nothing short of outrageous. A Houston cancer center billed a patient $7 each for alcohol prep pads used for injections, while a box of 200 is $1.91 online, according to a Time report published in February. And that’s just the tip of the iceberg of bill padding and fattening from both profit-making and so-called nonprofit institutions. Hospital administrators make multi-million-dollar annual salaries, and the labs and the manufacturers of medicines, medical supplies, devices and diagnostic equipment are getting rich from the high price of health care, all at the patient’s expense.

Even people who think they have good insurance can get hit with eye-popping amounts of money owed after medical care. Staggering bills from the briefest of hospital stays are based on nickel-and-diming everything that was provided. The charges for each line item are based on a huge computer file called a chargemaster — unique to every institution. Bills that are exorbitantly inflated to make up for all kinds of payers and non-payers are presented to all patients, regardless of their insurance status.

What Medicare pays for things gives us an idea of just how high that is. A hospital might bill a patient $333 for an x-ray while Medicare only pays $23.83 for the same thing, a very sizeable difference. On another bill described in the Time report, a patient was charged $6538 for three CT scans that Medicare would have paid $825 for. On another, a CT scan with radioactive dye to the tune of $7997.54 would have been paid only $554 by Medicare.

Online prices for medical supplies are telling as well. A patient having surgery may be billed $39 for the surgeon’s gown, or $32 for the use of a reusable blanket that goes for $13 new on eBay. Medicare either won’t pay for blood and urine tests or will pay $7 to $30 for them, but patients are billed $30 to $333 for them. Medicare won’t pay for incidentals that are part of other costs, but patients are billed for them anyway. It’s common for double- and triple-billing to occur, like when saline solution and oxygen or something normally included in the daily room charge are billed separately. An ICU kit can be billed as a unit and then each tool in it billed again.

Niacin tablets that cost about five cents each in drug stores go up to $24 when they appear on a hospital bill, and a Tylenol pill is billed for $1.50 when 100 pills go for $1.49 on Amazon, and often hospitals receive them for free from the maker.

IV solutions that you can buy online for $5.16 a bag are billed to patients at $84 to $134 per. Online you can get a box of diabetes test strips for about 55 cents each that hospitals bill $18 for. A patient was billed $13,702 for a dose of Rituxan that cost the hospital about $3000 to $3500. It cost the manufacturer only $300 to make it, test it and ship it to the hospital, a manufacturer whose CEO made a salary of over $11 million in 2011.

Safe sunscreens

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Photo by Robert S. Donovan
Photo by Robert S. Donovan

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I arrived at my son’s midday soccer game on a hot sunny day. I had remembered to pack the sports drink and snacks, and I even found the field (not always easy). But I was hatless and in tank-top and shorts, and I had forgotten to bring sunscreen for the two-hour stretch in full sun. I guess sunscreen season just kind of snuck up on me this year, and I forgot all about it.

Fortunately a fellow mom had some I could use. Although I forgot the top of my back and burned it, the rest of me was OK. There are those that say we should slather on sunscreen 24/7, 365 days a year, whether indoors or out, but I feel that for most of us some daily sun, when we can get it, is a good thing. The vitamin D and the warmth of it offer healthy benefits that include mood-lifting.

Gone are the days when we could blithely bake on the beach all day with nothing but a bikini, SPF-Nada tanning oil, and a reflective tanning screen, our sole goal by summer’s end to get as tan as humanly possible. I was like that.

Now we know that all that sun causes skin cancer. Most of us are closer to the happy medium of sun exposure, using protective lotions when outdoors for extended times. But there are different kinds of products with different ingredients and very different ways of protecting our skin. It should concern us that slathering our bodies with chemicals every two hours — exposing our largest organ to big doses of unknowns — may not always be the best thing.

I can’t tell you which are “good” and “bad” ingredients in topical products, but sunscreens are regulated by the FDA and subject to standards like medicines are.

Sunscreens are necessary for most of us who venture out our front doors. Most of these products get their efficacy from chemicals or minerals that protect the skin in different ways, usually by absorbing, reflecting or blocking ultraviolet light.

The majority of commercial sunscreens contain avobenzone, homosalate, octisalate, octinoxate, octocrylene or oxybenzone. The latter has been getting some extra bad press of late for effects on hormones — Google it — although some say you would have to put it on every day all day and use it for 30 years to get the effects the lab rats did. Vitamin A (retinyl palmitate) sometimes added for its anti-aging properties rather than its UV-screening abilities, has been accused of increasing the risk of skin cancer. It is seen less and less.

Often the active chemicals in sunscreens appear in some combination, because each one alone is not adequate to absorb the full spectrum of UV rays, or because some make the other ones work harder.

Driving with distractions

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Photo by Jhaymesisviphotography.
Photo by Jhaymesisviphotography.

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It’s likely we all know at least one person who didn’t make it through high school. For me, it was my classmate Scott Safer in Vermont in the late ’70s. He was a passenger in a car whose friend was changing a cassette tape while driving on an exit ramp. The car flipped over, and Scott didn’t survive. He was 16.

Avoidable fatalities caused by distracted teen driving cause thousands of hearts to break every year. Parents, family and friends find themselves devastated by the too-brief life senselessly snuffed out. It often seems to happen around now, prom time, just before graduation, a time that should mean new beginnings and new adventures for high-school kids.

Distractions that cause accidents, from drink or drugs to interactions with too many friends in the car, are many. The risk factor is exacerbated by the sense of invincibility that many young people have and compounded by their inexperience at driving.

But the deadliest factor, in 2013, is the telephone. Whether used for talking, surfing, reading or sending texts, it contributes to the vast majority of car accidents that claim lives. Text messaging is the worst culprit, creating a crash risk that is 23 times worse than normal driving, comparable to driving after four drinks or with a blood alcohol level of 0.8 percent, the legal limit. Texting while driving is responsible for eleven teen deaths every day in this country, according to the Insurance Institute for Highway Safety.

Even hands-free phones create a cognitive distraction from what the driver sees, hears and takes in about the conditions around him or her.

Statistics from 2011 say that 23 percent of crashes involved phones, and 21 percent of fatal ones involving teenagers between the ages of 16 and 19, were the result of cell phone usage. This percentage is growing as much as four percent every year. Eighty-two percent of 16- and-17-year-olds now have their own phone, 54 to 56 percent admit to talking on the phone while driving and 13 to 34 percent to texting.

The Centers for Disease Control report that nearly half of all U.S. high school students aged 16 years or older text or e-mail while driving. Students who text while driving are nearly twice as likely to ride with a driver who has been drinking and five times as likely to drink and drive themselves.

So far, the research indicates that the cognitive distraction of having a hands-free phone conversation causes drivers to miss the important visual and audio cues that would ordinarily help avoid a crash. Safe driving requires optimum visual, manual and cognitive attention from the driver. Eating, grooming, looking at a map or adjusting the radio take the driver’s eyes from the road or a hand from the wheel momentarily, reducing the effective attention on the task at hand. Using a cell phone diminishes all three: the eyes leave the road, a hand leaves the wheel, and the driver is thinking about something besides the road.

How to improve

Making Ulster County the healthiest county in New York State has got to be County Executive Mike Hein’s most well-publicized goal in the area of public health. But Hein, who first set the goal in 2009, has never specifically said how long it will take to achieve that worthy goal.

Ulster County Health and Mental Health Commissioner Dr. Carol Smith supports Hein’s goal. It’s the correct goal, she argues. Being number one should be Ulster County’s aspiration.

The nationwide county health rankings first published by the University of Wisconsin’s Population Health Institute four years ago is widely accepted as the standard for comparing county performance. In 2010 Ulster County ranked 33rd of New York’s 62 counties. In 2011 it dropped to 35th. In 2012 it improved to 29th, and this year its rank slid back down to 31st — the statistical middle of the state pack.

Both at last month’s board of health meeting and at the May 21 meeting for health professionals at Ulster County Community College in Stone Ridge, Smith complained about how this year’s results were skewed by the inclusion of a new category, “drinking water safety,” in which Ulster County was ranked very poorly — probably wrongly, according to her. She also expressed concern about the survey sample size — 500 Ulster County residents had been surveyed.

The ranking system, its research supported financially by the Robert Wood Johnson Foundation, may have its methodological weaknesses, but in the field of American public health it is fast becoming the equivalent of what the Dow Jones Average is on Wall Street — that is, it’s widely followed, and it’s based on the best capsules of comparative data available.

The rankings of surrounding counties suggest the same up-and-down-within-a-narrow-range pattern as Ulster County’s. Neighboring Dutchess County was ranked 11 in health outcomes among the counties in 2010, 13 in 2011, 9 in 2012 and 9 again in 2013. Orange County ranked 21, 19, 20 and 22. Greene County was 59, 60, 52 and 55. Putnam County was ranked 1, 1, 1 and 4 among the counties, and Sullivan County a consistent 61 in all four years. Columbia County was ranked 45 in all years except 2011, when it temporarily moved up to 43.

As can be surmised from these numbers, results vary widely in the mid-Hudson region. What is more important than the rankings derived from the combination of various socio-demographic and medical variables is what they tell us about the pattern of public health care in our counties. What can be most easily improved? Where are structural changes most needed in our fragmented healthcare system? What are the relationships among the institutional players? What investments will yield the highest rate of return in terms of the improvement of overall public health?

The role of the hospitals in the rapidly changing community health systems is one of the big items the state health department is seeking to tackle this year. The county health departments are being required to prepare a four-year community health plan for submission to the state in November.

This is a tough time for people in health care who are comfortable with changing only one thing at a time. Americans are proud of having what we consider to be the best healthcare system in the world. Unfortunately it is by far the most inefficient, fragmented, disorganized and expensive healthcare system in the world as well, leading to our trailing many other nations in terms of outcomes and other results.

Joblessness and your health

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Illustration by Rick Holland
Illustration by Rick Holland

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For so many, losing a job can mean losing everything: family, finances, health, home and sanity.

According to Andrew O’Grady, executive director of Mental Health America of Dutchess County, there are, in the event of job loss, factors which predict worsening mental health and factors that predict the opposite.

“If someone defines their lives by their job, and then you lose that job, then you lose who are you when you lose that job and that’s a predictor of worsening mental health,” said O’Grady. “If family members criticize … for being jobless, or insinuate that your performance was an impacting reason for your unemployment, would also make it negative.”

O’Grady said that it’s common that when money gets tight, relationships begin to deteriorate and that causes more stress and depression. Therefore, the family structure, and how well supported the person is within it, is also an important predictor.

But, O’Grady said that not everyone who loses their job goes to Hades in a hand basket. He said it’s about what and how we spend our time, such as having routines and enjoyable activities to replace the job. O’Grady also pointed out that sometimes untreated mental health issues may have been an underlying cause for losing the job.

“There are physical symptoms for depression: headaches, back pain, difficulty sleeping, weight loss or gain, sleeping too much, physical pain,” said O’Grady. “That all happens.”

No money, fading health

For many, losing a job is a fast track to faltering health. Poughkeepsie-based oncology Nurse Practitioner Chris Egan said she notices that when someone loses their job a cancer diagnosis is quick to follow. Why? Egan’s personal opinion was that it’s about defenses; when a person takes a blow, such as sudden unemployment, their immune system begins to unravel with them.

William Bell of Middlehope has Crohn’s Disease, a chronic autoimmune condition in which the body’s immune system attacks the digestive system creating painful bouts of stomach pains, exhaustion, malnutrition and bleeding. In early May, Bell was told his job would be terminated as part of a corporate reorganization. “Initially I was devastated, I loved the job and the people I worked with, but eventually I started to think perhaps a new job, higher salary, closer commute could be a good thing — I was wrong,” said Bell.

As the summer progressed, Bell’s headhunters and recruiters at all the major agencies were turning up nothing, some explaining the job market was on hold until after Labor Day, not to worry, it would pick up. “As I began to worry about money, my health started deteriorating … My symptoms worsened as I began to get depressed about the unfortunate turn of events in my life. The symptoms became regular, daily, and more severe.”