Tag: Ed Pullen

Does Medicare Have it Right in 2011?

Starting in 2011 with the regulations required by the PPACA Medicare will mandate copay and deductible free preventative services for our older Americans.  This is great news for primary care physicians.  I’m a family physician, and have struggled for years with the fact that just about every private insurance plan covers an annual physical exam, but Medicare did not.  What this anti-intuitive dichotomy accomplished was bringing in my relatively healthy 30-something patients for a physical exam each year, while for my 70 year old for whom far more preventative services were recommended by the United States Preventative Services Task Force was not covered for a preventative exam ever.  Not annually, not every 3 years, just once at age 65 to last their lifetime.

As primary care physicians we tried to our best to squeeze preventative care into visits primarily for other complaints.  At a visit of my diabetes patients every 3 months I’d try to focus on the diabetes and save enough time to review immunization status, assure breast and colon cancer screening was up to date, help med decide if they wanted prostate cancer screening, ….   I’m looking forward to being able to ask my seniors to schedule a preventative care visit annually now and being able to focus on these issues without having to eke out time in a problem oriented visit.

Still I have to say if the goal is to provide incentive to older Americans to go to their physicians for services that will really make a difference in the health of the Medicare population problems I think congress has it wrong.  If we want to prevent unnecessary hospitalizations and expensive complications from neglected medical problems, and have the biggest impact to reduce the burden of expensive medical complications and I believe the most efficacious preventative services we can offer in health care are secondary prevention and disease management.  I’d love to think that by primary prevention, education, and physical exams I can help patients improve their health and subsequently reduce costs and get better outcomes.  The problem is that there is little evidence that this is the case. This new regulation, offering a free once annual preventative care visit may find some early cancers, improve immunization rates and make us feel like we are being proactive.

Continue reading…

Is My Canadian Online Pharmacy Really in Canada?

Maybe Not.

I practice in Washington State, and have a number of patients who travel to Canada to purchase their medications.  Why drugs are so much less expensive in Canada than in the US is primarily related to the single payer system in Canada, where drug companies have to negotiate prices with the Canadian health plan.

In the US with so many different insurers none have the where-with-all to negotiate steeply discounted prices because to remain competitive they have to offer all the popular drugs or risk losing patients to plans that do offer those drugs.  This leads to a situation where many patients simply cannot afford some of the expensive branded drugs that they are prescribed.  Admittedly we have a nice variety of inexpensive generic medications for most conditions, but in some situations there is no good alternative to expensive drugs.  Don’t think the Discount Drug Coupons are going to save you in the long run.

Of my patients who get drugs from Canada, many of them see a physician there who does a brief evaluation and re-prescribes the medications prescribed for them by me or other US physicians.  Others find pharmacists who will fill prescriptions written by US doctors.  At the border crossing coming home rarely patients  are searched and have their prescriptions confiscated, but the prices in Canada are enough less than US drug prices that it is worth the trip and risk of confiscation that patients using expensive branded meds find the trip worthwhile.   I don’t have a big concern for these patients.  I have no reason to believe that the drugs dispensed in Canada by pharmacists to visiting Americans are not the same medications they get in the US.

Continue reading…

What if All Americans Had at Least Catastrophic Health Care Coverage?

Picture 9I really dislike the term healthcare reform. I think our system needs to be changed not reformed. I assume that I am not the only person who suspects that the recent health care reform act is not going to be the final solution for America’shealth care problems. The cost of healthcare is not really addressed at all, and even if it works better than expected some Americans will not have even catastrophic health carecoverage.

This post is really just my first shot at suggesting a way I think makes sense to address the problem of the large number of uninsured people in America, while at the same time leaving lots of choice and personal responsibility that seems to be needed and a part of the American culture. I am certain that I have not thought through all of the gritty details, and really don’t profess to have the talent or knowledge to write legislation, but I think this basic tenant might be a starting point.First my assumptions:Continue reading…

How Would Modern Medicine have Helped our Early Patriots?

On Independence Day I thought it would be interesting to look at the causes of death of some of our famous Revolutionary era patriots. When I started researching this I anticipated early deaths from infections and untreatable chronic diseases like diabetes and hypertension.  Interestingly many of the famous early Americans lived to a ripe old age, and died of causes that even today may well have been their demise.

George Washington: Washington is an exception to the comment above. Washington died at age 67, likely of a pharyngeal infection, possibly streptococcal disease.  Today he would likely have received antibiotic treatment and survived this illness.

Continue reading…

Medicare To Cover Preventative Care

A nice surprise buried somewhere  in the Health Care Reform Bill is that starting next year Medicare patients will be able to get annual preventative care exams that are paid for by their health insurance. It may come as a surprise to those of you with commercial insurance who think of  coverage of an annual exam as a routine thing for insurance to cover, but up to now Medicare has only covered a “Welcome to Medicare” exam in the first year after turning 65.  From then on no physical exams at all are covered, and many preventative services like colonoscopy and mammography were either not covered, or subject to fairly high copays and deductible costs.  As a physician this has always seemed like this is backwards. I can make a pretty good argument that a physical exam for a 27 year old man is not needed annually, but it is essentially always a covered benefit in any plan the young insured patient has through an employer. Older adults are far more at risk for cancer, heart disease, diabetes, hypertension, depression, and safety at home issues than young adults. I am pleased that better preventative services coverage for our older and more vulnerable adults will be a paid service starting in 2011. This is discussed nicely in a recent NY Times article by Leslie Alderman in his Patient Money column.

Starting Sept 23, 2010, 6 months after the signing of the bill, all new insurance plans, or current plans which make certain changes will be required to cover preventative services recommended by the United States Preventative Services Task Force as category A or B ratings (A = conclusive evidence and B = very strong evidence showing benefit of receiving the services) and beginning Jan. 1, 2011 Medicare will also cover these services with no copay or deductible applicable.

This is good news for our seniors and should make it much easier for their physicians to convince our seniors, some of whom now have to choose between shelter, food or medicine on their poverty level fixed incomes, to receive preventative care.

Ed Pullen, MD, is a board certified family physician practicing in Puyallup, WA. Dr. Pullen shares his viewpoints on medical news and policy from a primary care physician’s perspective at his blog,

APSO needs to replace SOAP in EMRs

Electronic medical records (EMRs) have a bad reputation among many physicians for generating progress notes that are so verbose and filled with standard phrases that they are nearly useless to other physicians, and even to the physician who produced the note in the first place.  This is in part because rather than engineering the EMR to produce a note intentionally efficient and effective for users looking at the note on a computer monitor, many EMR users choose to create a record familiar to them from years of use of paper charts.  A note documenting a patient visit really serves only 3 purposes.  First it is a clinical note documenting the patient’s history, findings on exam, and the assessment and plan of care.  This is ideally efficient to generate, easy to review, and have the information needed in future visits in an easy to see and understand format. Secondly the note is a legal document, providing documentation of care and advice provided, and needs to be useful in case of a legal challenge.  Third it needs to document the care done to justify billing and assure payment by third party payers.  A good note does all of these things.  In many EMR systems the last two are done well, but the clinical usefulness of the note is very poor.

Most EMR notes do a great job of documentation to assure payment. The ability to easily enter the information needed to justify a level of billing is sometimes too easy, and EMR users have been criticized for overbilling as a result.  From a physician’s point of view, being easily able to enter the information required by payers without doing a long and costly dictation is a big plus of EMRs.Continue reading…