Thursday, January 31, 2019

Let Me In, Let Me In

Editor's Note: The following article is the third of six stories TMA's Healthy Vision 2025 advocacy plan, highlighting TMA's priorities for the 86th Legislative session. In this post,  Ray Callas, MD, explains the need to hold health insurers accountable so patients don't receive surprise medical bills. 

Beaumont anesthesiologist Ray Callas, MD, is tired of beating his head against the wall trying to get “in-network” with health insurance companies. And he’s tired of the surprise bills his patients receive when he can’t get in.

“If I’m out-of-network, but I’ve tried time and again to negotiate with networks and still can’t get in, I believe insurance should accept some of the responsibility for that bill,” he said.

And Dr. Callas is not an outlier.

TMA’s biennial physician survey shows 67 percent of physicians with no contracts who attempted to join a network received either no response or a “take it or leave it” offer. Thus, when physicians are not part of a network, it is generally because they either have no choice or no bargaining power.

And neither do their patients. Surveys show that as many as 60 percent of Americans have received a surprise bill from an out-of-network physician or provider. Many of them result from emergency medical care.

Especially in emergencies, it’s common for someone like Dr. Callas not to know if he’s in-network for the patient in front of him.

“My responsibility as a patient’s physician is to know the risks of administering anesthesia, not administering their personal insurance plan,” Dr. Callas said. “Frankly, educating patients regarding their insurance plan and what is and is not covered, and how to meet deductibles — that’s the responsibility of the plan. Don’t just hand them a 75-page booklet and tell them their benefits are described within.”

Narrow, inadequate networks can mean little or no access to critical services. The plans themselves determine how their networks are established and what physicians and providers will participate in those networks.

Physicians have a real and powerful incentive to be part of the insurance companies’ networks: Most believe they must contract with at least one commercial payer to have a financially viable practice.

Health plans, on the other hand, profit from skimpier networks.

“Insurance companies with narrow networks shame physicians into looking like the bad guy for billing for services rendered but unpaid, when the truth is I’ve tried to get in-network but have been offered less than desirable or even fair terms,” Dr. Callas said. “What other profession is expected to provide services regardless of the terms?”

Wednesday, January 30, 2019

It’s Going to Hurt All of Us

Editor's Note: The following article is the second of six stories TMA's Healthy Vision 2025 advocacy plan, highlighting TMA's priorities for the 86th Legislative session. In this story  Douglas W. Curran, MD, president of TMA, describes caring for an uninsured patient in her time of need so she can avoid a serious health condition and stay healthy, so she can continue to work and support her family. He says Texas' fiscal health hinges on helping physicians care for Texans' personal health.

In a rural Texas town where one-third of the patients admitted to the local hospital have no insurance, Athens family physician Douglas Curran, MD, does all he can to keep women like Rose (not her real name) out of the hospital.

Rose is part of what Dr. Curran calls “this massive group of working poor who have no access to care.” She doesn’t make enough to afford private insurance. She makes too much to qualify for Medicaid.

“She’s one of the strategic breadwinners in the family,” he said. “So when she’s not working, they’re struggling just to buy food.”

Rose just can’t afford to get sick, says Dr. Curran. And Texas can’t afford for Rose to get sick either. Not Rose and not the men and women who tend our ranches, build our office towers and highways, or serve our meals — the 4.5 million Texans who put our state at the top of the nation’s list of uninsured residents.

Video: It's Going to Hurt All of Us

TMA President Douglas Curran, MD, explains why good access to quality health care is crucial for the state economy.

“Right now, we have a state that’s really moving business-wise, a lot of things are happening,” he said. “If you keep people healthy, they’re producing, they’re generating, they’re keeping things going. But if that populace is not properly cared for and supported and empowered, then we’ll see the people that we really need to keep our business environment pristine begin to drift away. It’s going to hurt all of us.”

Dr. Curran was on call the night Rose was wheeled into the emergency room. She was short of breath, had “big swollen feet,” and the oxygen level in her blood was dangerously low. He drained 50 pounds of fluid from her body and released her on aspirin and three generic medications —
 “three, $4 drugs” — to treat her congestive heart failure and high blood pressure.

Thankfully, Dr. Curran also was able to refer Rose for follow-up to a local, physician-run, volunteer clinic for the working poor.

“We take care of the people who can pay a little bit there,” he said. “They pay $15. It goes into the pot to keep the clinic going. The nurses are all volunteers. My wife’s an RN; she volunteers there a day a week. You do what you have to do.”

At the clinic, doctors and nurses can check Rose regularly to make sure the medicines are keeping her healthy — and to make sure the drugs’ side effects aren’t making her sicker. Without those check-ups, neither Dr. Curran nor any other physician could safely refill her prescriptions. Nor would they.

“Nobody’s going to refill those medicines, so she’ll re-accumulate that fluid, and she’ll be back in the hospital, and it costs $25,000 to get her back to a stable state on those $4 medications,” he said. “At the end of the day, that raises your insurance rates, my insurance rates, and everybody else’s insurance rates because she’s back in the highest cost place to get care there is (the emergency department).”

After passage of the Affordable Care Act in 2010, 33 states expanded eligibility for their Medicaid programs to include people like Rose. Texas did not, and all of the state’s top leaders remain strongly opposed to expansion.

Dr. Curran supports finding ways to get more Texans insured, but he says his practice can’t afford to accept too many Medicaid patients. With operating costs of $41,000 a day for 17 family physicians and Texas’ notoriously low payment rates for primary care services, Medicaid is a losing proposition.

“It’s not enough to pay my bills or to keep the lights on and to pay my employees,” he said. “A visit for a sore throat pays me about $27, and it costs me about $48 to see the patient in my office. I’d be better off [financially] giving a Medicaid patient 10 bucks and sending her to the emergency room.”

Tuesday, January 29, 2019

Stretched to the Limit

Editor's Note: The following article is the first of six stories TMA's Healthy Vision 2025 advocacy plan, highlighting TMA's priorities for the 86th Legislative session. This post details how Lisa Ehrlich, MD, reinvented her medical practice to reduce physician burnout and return more focus on her patients.

There came a moment when all the clicking on boxes, filling out forms, and waiting on hold was just too much for Houston internist Lisa Ehrlich, MD. The time and energy spent on all of these seemingly endless tasks meant she could not give nearly enough to her patients.

And after 19 years in private practice, with insurance companies and the government expecting her to care for 3,000-plus patients, she was burning out.

“I was really tired, exhausted,” Dr. Ehrlich said. “I did not want to go to work in the morning. … I was stretched to the limit.”

On the outside, her practice looked like the model of success. She earned recognition from the Health Care Incentives Improvement Institute for diabetes care, for asthma care, and for using health information technology. — an online physician rating system — regularly gave her its Patient’s Choice Award and Compassionate Doctor Recognition.

Dr. Ehrlich and her partner employed seven billing and clinical care staff, and could have used even more help. Meanwhile, payments were diminishing and electronic health records costs were exploding. “We were drowning,” she said.

“I was forced to begin limiting the time I spent with my patients and offload communications to my staff. I was spending more than half of my time on paperwork, haggling with insurance, and regulatory box checking.”

She worried that quality-improvement programs were doing little to keep her patients healthier or to hold costs down. She chafed at the forces that transformed the medical record — her patients’ charts — from a clinical instrument into a tool to satisfy third-party payers and government regulators. She seethed at wasting time with prior authorization phone calls that took her away from her patients.

“We were, and still are, in a constant exercise that’s really designed to save the middleman money,” Dr. Ehrlich said. “It’s not for the care of the patient, and it’s not actually really saving money. It’s a tax on our practices. It’s a tax on us.”


Houston internist Lisa Erhlich, MD, shares how she reinvented her medical practice to reduce physician burnout and return more focus on her patients.


In response, she staged her own revolution. Twenty-five years after graduating medical school, she eschewed joining forces with a big hospital system and instead reinvented her practice. Even though the personalized care model she implemented means she is accessible to her patients nearly 24/7, Dr. Ehrlich says she is happier — and saner. She’s still clicking and haggling, but on behalf of only 600 patients, all of whom she knows well.

“This arrangement has put the joy of practicing medicine and really caring for patients back in my life,” she said.

Her patients have a deeper, personal relationship with their very own physician, who is almost always on call. “This can be life-saving,” Dr. Ehrlich said, describing one case where her intimate knowledge of a patient’s medical history led her to arrange immediate treatment for necrotizing fasciitis — more commonly known as “flesh-eating bacteria.”

Or there’s the long-time patient who called her with unusual chest pains on Labor Day weekend. With his normal lab results and electrocardiogram, Dr. Ehrlich says, most emergency rooms would have released him with no further work-up.

“But I just did not like the way he looked.”

Acting on instinct, she persuaded a cardiologist to perform an angiogram.

“He ended up having a 95-percent blockage of the left main artery, which we call the ‘widow maker,’” she said. “He was admitted immediately for bypass surgery and is a healthy survivor. In my old model, I would have had a 25-percent chance of being on call that day.”

Friday, January 18, 2019

Navigating Growth Spurts in Teens

By Alexandra Bicki, MD, MPH
Pediatric Resident at the University of Texas at Austin Dell Medical School
Member, Texas Medical Association

We can all remember a certain grade school classmate — maybe even ourselves — who was a “late bloomer.” Whether it was the boy who didn’t make the basketball team, or the girl who was last to buy her first bra, this can be a stressful time for both child and parent.
Many families bring their children in for annual check-ups, or well-child checks, wondering how their child’s height stacks up to their peers. The most important thing that determines how tall a child will be is how tall the biological parents are, and how each parent went through puberty. Math formulas that use parents’ height can help calculate a range of what we might expect for the child, but race and weight play a part as well. For example, Hispanics, African-Americans, and overweight children tend to start puberty a bit earlier than Caucasians or Asians.

A girl’s growth spurt typically starts at age 11 or 12, while a boy’s growth spurt tends to happen at age 13 or 14 — with lots of variation in between. On average, the main growth spurt lasts two years. Because the arms and legs tend to grow before the spine, some parents actually notice their child looks a little disproportionate or lankier before their child’s overall height starts to change.

A child may feel “abnormal,” or simply out of control, as this “natural” process takes its time. Although some mood changes are a normal part of puberty, don’t be afraid to raise your concerns with your doctor if your child seems stressed, withdrawn, nervous, or suddenly doesn’t want to do certain activities he or she used to enjoy.

An adolescent can feel self-conscious having to shop in the kids’ clothing or shoes section while their close friends wear older teen clothes because their bodies are changing more rapidly. At home, if there are siblings of various ages, genders, or with different parents, they can be reminded over and over again of how different they feel.

There's no exact cut-off date to when a child should grow.
A girl's growth spurt starts around age 11 or 12, while boys
 grow around age 13 or 14 - with variation in between.
Many families wonder if there is a medicine that can speed up the process. Before deciding if that is an appropriate course for your child, your doctor might start by taking a single x-ray of the child’s hand, a “bone age” study. The x-ray helps show how your child’s development compares with other kids their age. If your child’s development is not on track, there are hormone-related medications pediatric endocrinologists can prescribe, but as with every medicine, these may have side effects and risks.

It is important to remember that growing too fast and too early is not necessarily a good thing. The fastest gain in height is during puberty, so if a child’s growth spurt occurs early, he may be the “tall kid” in middle school, only to have his growth slow down later on — just as his peers’ growth starts to speed up.

If a child is growing at her own pace, and especially if her parents were also “late bloomers” themselves, it is often safe to let nature run its course. During this time, parents can help by encouraging positive eating and exercise habits, which helps provide all the right ingredients the body needs to keep growing in a healthy way.

Having all of your child’s height and weight measurements in the same place is one reason taking him or her to the same doctor’s office every year can be helpful. Tracking the growth over time can help your health care team decide whether your child’s pattern looks suspicious, or if he or she is simply following in the parents’ footsteps.

Wednesday, January 16, 2019

The Prevention of 5 Percent of All Cancers in the World is Two Shots Away: The Case for the Anti-Cancer HPV Vaccine

By Lois Ramondetta, MD

Gynecological Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center; member, Texas Medical Association

Editor’s note: January is Cervical Cancer awareness month. The human papillomavirus (HPV) vaccination for preteens and teens can prevent most cervical cancers. Physicians also recommend regular screenings for women.

The Houston Chronicle previously published a version of this article, co-written by Dr. Ramondetta with Hagop Kantarjian, MD. Dr. Kantarjian also is a TMA member.

Scientists have developed a way to prevent 5 percent of all cancers with little more than two shots. It is called the human papillomavirus (HPV) vaccine, and in 2006 the Food and Drug Administration approved it for use.

The following year, Australia was one of the first countries to introduce a national HPV vaccination program. The nation dedicated itself to preventing cervical cancer associated with the virus. It worked. A study published in October 2018 estimated that — as a result of high rates of vaccination and screening — Australia will nearly eliminate cervical cancer by 2028.

It is time for the United States, and especially Texas, to use the Australian experience as a roadmap to potentially prevent and eliminate cervical cancer.

To grasp the scope of the problem, it is important to understand that HPV is a group of approximately 200 viruses, several of which are responsible for more than 43,000 cases of cancer this year. More than 80 million Americans are currently infected with HPV, and 14 million new infections occur each year. About 45 percent of American adults have been exposed to HPV infections, which cause genital warts. While HPV infections often resolve spontaneously or with therapy after six to nine months, some high-risk HPV strains can cause cancers decades later. The number of HPV-related cancers has increased drastically in the past 15 years, from 30,000 in 1999 to 45,000 in 2015.

January is Cervical Cancer Awareness
These high-risk strains cause virtually 100 percent of cervical cancers. More alarming is an almost epidemic rise of HPV-related cancers of the oropharynx — the back of the throat, tongue, and tonsils.

Unfortunately, Texas lacks significant educational policies to encourage and promote the HPV vaccination of children to protect them from the risk of developing HPV-associated cancers later in life.

Despite a decade of solid scientific evidence confirming the value and safety of the anti-cancer HPV vaccine, there has been resistance to its broad implementation. This hesitance is driven mostly by three misperceptions: The vaccine may be ineffective; it may promote increased sexual activity; it may have serious side effects.

Of course, none of these is true.

The prevalence of HPV infections in the United States has fallen significantly since the vaccine was first introduced. The percentage of girls infected decreased from 12 percent in 2003-06 to 4 percent in 2009-12. Clearly the vaccination is working.

Furthermore, HPV vaccination and education are not associated with a change in sexual behavior. A study of the school-based state Youth Risk Behavior Surveillance System saw no substantive association between HPV legislation and adolescent sexual activities.

Finally, an extensive review after the U.S. Food and Drug Administration approved the vaccination has not shown any serious risks. Eight years of data have only helped confirm what doctors already knew — preventing HPV prevents cancer.

It is a knowledge that needs to be spread in Texas. Our state is ranked 44th for HPV vaccination rates.

The HPV vaccine is available for people up to age
26, but it could soon be available for men and
women up to age 45. 
But things are changing. Since 2011, as knowledge of the anti-cancer benefit of the vaccine has penetrated communities, vaccination rates, especially among boys, have risen rapidly.

However, even though the HPV vaccine has been available for a decade, only two states (Virginia and Rhode Island) and the District of Columbia have laws requiring vaccination for school entry. Rhode Island requires all seventh-grade students to be vaccinated. Virginia and the District of Columbia require sixth-grade girls to be vaccinated, but allow parents to opt out.

The HPV vaccine is currently available for people up to age 26. However, in October the FDA approved the HPV vaccine for men and women up to 45 years of age. That broader HPV vaccine eligibility becomes official if the Advisory Committee on Immunization Practices (ACIP) approves it next month. (ACIP is a national group of medical and public health experts that develop recommendations on vaccines.)

Other than the hepatitis B vaccine, which may reduce the incidence of liver cancer, the HPV vaccine is the only vaccine that can prevent several types of cancer. This two-shot HPV series is the best way to protect our children for decades from developing a disease associated with 5 percent of all cancers.

Physicians can also do their part to raise further awareness about the HPV vaccine. They should be talking to patients about the vaccine during every screening for HPV cancers and during routine tests like pap smears. These conversations should be a two-way street. Patients diagnosed with an HPV disease should ask their physicians how to get involved in HPV advocacy. Survivors can join support groups to further educate themselves about HPV and receive help.

We can change the culture on HPV awareness and prevention if we each step up and do our part. The time to act is now.

Dr. Ramondetta is a professor in the Department of Gynecologic Oncology and Reproductive Medicine at The University of Texas MD Anderson Cancer Center. Dr. Kantarjian is a nonresident fellow in Health Policy at Rice University’s Baker Institute and is chair of the Leukemia Department at The University of Texas MD Anderson Cancer Center.

Thursday, January 10, 2019

Protect Yourself From Bacterial Meningitis

By Kevin Francioni, MD
Pediatric resident physician at The University at Austin Dell Medical School
Member, Texas Medical Association 

Meningitis is a serious infection of the tissues surrounding your brain and spinal cord. It can result in serious neurologic impairment, or even death, if not treated adequately or promptly. As pediatricians, we often worry about this serious infection in tiny babies who have fever, but meningitis is an illness that can affect people of all ages. Meningitis can be caused by a viral, fungal, or bacterial infection, the latter of which is my focus here.

Bacterial meningitis is very serious, and can kill someone in as little as a few hours. Patients also can suffer brain damage, lose their hearing, or experience learning disabilities.

Symptoms of meningitis include new fever, severe headache, stiff neck, nausea, vomiting, and photophobia (eye pain from bright lights). Physicians can diagnose the condition with a lumbar puncture known as a spinal tap. During this procedure, a doctor inserts a needle between two bones in your lower back to remove and study a sample of cerebrospinal fluid, the fluid that surrounds your brain and spinal cord.

The bacteria that commonly cause meningitis in teens and young adults are known as Neisseria meningitidis and Streptococcus pneumoniae. Meningitis is often spread by close contact with others who have it in their body. Simply coughing on or kissing someone can pass the infection, through saliva, or spit. It often occurs among people living in close quarters like dormitories. That is why Texas law requires new or transferring college students up to age 22 to get a meningococcal vaccination and show proof before moving onto campus. In fact, according to a new study published recently in the Pediatrics medical journal, college students are more than three times as likely to contract meningococcal disease serogroup B (MenB), one type of bacterial meningitis, than other young adults aged 18 to 24.

Several vaccines help prevent meningitis. It's best to ask your
physician which shot is right for you and your child. 
Thankfully, several vaccines help prevent meningitis. They have names such as pneumococcal vaccine (PCV), Haemophilus influenzae (Hib), meningococcal conjugate vaccine (MCV) and the serogroup B meningococcal vaccine (MenB). Doctors recommend specific shots for certain ages of patients, so it’s best to ask your physician which shot is right for you or your child. Some vaccines to prevent meningitis can be given to infants and children, while others are best for college-age and older people. (Again, I suggest you ask your physician which vaccine is best for you.)

You also can help prevent the spread of meningitis by washing your hands often, and avoiding close contact with people known to have meningitis.

You can even take antibiotics if you have been in close contact with someone with specific types of bacterial meningitis (you would need to consult with your physician about this, too).

For more information on meningitis and vaccinations, please see this Texas Medical Association fact sheet (in English and Spanish) or visit the Centers for Disease Control and Prevention website:

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