Insurance provider lists are full of lies

Posted December 18, 2014 by Dr. Roy
Categories: Pediatric Insider information

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The Pediatric Insider

© 2014 Roy Benaroch, MD

A goal that’s become The Major Talking Point about health care reform is to get more people into health insurance plans. There are XX million uninsured, they say, and this new scheme will help provide insurance to XX people. But just having insurance won’t make anyone healthier. Insurance has to allow access to health care providers in a timely manner.

Unfortunately, that isn’t always the case. A study just published in JAMA Dermatology demonstrated that many provider lists for health care plans are outrageously inaccurate, and greatly overstate the number of providers in health networks.

Researchers in California collected the currently-published physician directories for all of the Medicare Advantage plans available in their state. They looked at one specialty, dermatology, finding a total of 4754 total physician listings. About half of these were duplicate entries, with the same physician appearing multiple times in the same directory. They called every single one of the 2591 actual unique providers, and found that only half of those could be reached, were accepting patients in the plan, and could offer an appointment. For one of California’s Medicare Advantage plans, not a single dermatologist was available. Net for all plans, about 25% of the “listed dermatologists” in the plans could actually see you as a patient – and even then, the average wait time was 45 days.

Having health insurance is important, but it’s not the same as having health. Patients need to be able to see doctors; they also need to be able to get prescription drugs or ride an ambulance if necessary. And they need the cash to meet ever-growing deductibles. Cheap health insurance isn’t really very useful if you can’t use it. While this study doesn’t speculate on why the insurance booklets are so inaccurate, it’s obvious that if the insurance companies wanted accurate provider directories, they could make them. After all, in one quick phone call I can find out if a patient’s insurance covers a visit with me. Their computers know. But if you’re a health insurer, it’s better for you to misrepresent and obfuscate and over-state your networks. Their listings say 4754 dermatologists are in-network; but less than 1500 are really available to see you.

The goal of the insurance companies (and government-funded health care coverage bureaucracies) hasn’t changed. They want to spend as little as possible on your health care. Since they can’t exclude pre-existing conditions any more, they’ve come up with new ways to keep your premiums to make big profits. Tiny, limited networks are one trick. They make it very difficult to get an appointment, and care delayed is care they may not end up paying for. Even better for them: sometimes people become so frustrated that they see an out-of-network provider, paying with their own cash. You pay—you lose; you pay—they win.

EDIT: After I wrote this, a study was published looking at Medicaid — and found that about half of the providers on the lists were retired, dead, or not seeing Medicaid patients. Half is better than 25%, but both figures are terrible. Both private and public health insurers are way overstating their provider numbers.

The economic benefits of breastfeeding: A call for honesty

Posted December 15, 2014 by Dr. Roy
Categories: Nutrition, Pediatric Insider information

Tags: , ,

The Pediatric Insider

© 2014 Roy Benaroch, MD

Lookie here: I am a breastfeeding supporter. I regularly help new moms breastfeed successfully, and I even took special class to learn how to do a brief procedure to help babies overcome breastfeeding problems caused by tongue-tie. I’ve got a happy breast support sticker, right on my AAP card.

But I think honesty is (or should be) the breast policy. Some women and babies find nursing to be difficult, and some moms don’t want to nurse, and some moms, yes, don’t make enough milk to fulfill the health needs of their babies. Other moms or babies have their own health problems that prevent effective breastfeeding. Breastfeeding is not in any way an essential part of raising a healthy and happy kiddo—at least in the developed world, we’ve got great, healthful substitutes for mother’s milk. Babies do not have to be nursed to be loved and raised in a healthy manner, and moms who don’t nurse don’t need more pressure or guilt.

So I have mixed feelings when I read studies like this one. Researchers in Great Britain published a study in October 2014, “Potential economic impacts from improving breastfeeding rates in the UK.” They used computer models to look at the savings reached by preventing diseases in children that have higher rates in formula-fed kids, including ear infections and GI problems ($17 million a year); they also added in savings from having to treat fewer women for breast cancer ($50 million a year, estimating current exchange rates). At first glance, those savings figures look modest—that’s because the effect of breastfeeding on preventing breast cancer and childhood infections in developed countries like Great Britain is really quite small. But let’s accept those figures as they are. The bigger problem I see is that the authors made no attempt to quantify the economic costs of breastfeeding.

We should be honest, here. We know that breastfeeding is the major risk factor for hypernatremic dehydration, which has been estimated to occur in about 2% of term newborns. This is caused by inadequate fluid intake in a newborn, and can cause seizures, brain damage, and death; it usually requires hospitalization to treat. And breastfeeding is also a major factor leading to health consequences from newborn jaundice, including hearing loss and later learning problems. The authors of this paper didn’t try to quantify the costs of these health problems, any more than they tried to look at the economic impact of breastfeeding on family finances or a woman’s career.

Like all pediatricians, I think it’s best for babies if they’re breastfed. But we’re not doing anyone any favors by exaggerating the benefits of nursing, either in terms of economics or health. We do need good social supports and laws to protect the rights of women to nurse in public and at their jobs; but we don’t need formula feeding to be a mark of poor parenting. Honest information is what parents need. Can we stop the hyperbole?

The holiday anti-shopping list: Things parents do not need

Posted December 11, 2014 by Dr. Roy
Categories: Pediatric Insider information

The Pediatric Insider

© 2014 Roy Benaroch, MD

Have money to burn and nothing useful to spend it on? Perhaps you, or someone you know, has a baby. With the holidays looming, it’s time to spend some cash on this year’s anti-shopping list of things no one needs!

#1: The Infant Helmet

51x2G1N-3SL._SX355_

The Thudguard, The Jolly Jumper, The Oopsie—I don’t know how you could choose just one! Probably best to have Junior wear all three, all the time. As long as there’s gravity, there are falls!

 

#2: Bottle sterilizers

download bottle sterilizer

Look: baby’s mouths aren’t sterile, mom’s boobs aren’t sterile. The world isn’t sterile. And that water in the sink? Heart surgeons wash their hands in it before they cut people open. Use tap water to wash your bottles or breasts—you don’t need to sterilize them.

 

#3: Nursery water

Hm. Water that’s virtually free, already fortified with fluoride, constantly monitored for safety and mineral content, and easily available in almost every room of your house; versus water that’s unregulated, contains whatever might be in there, and comes in environment-destroying plastic jugs you have to pay for and lug around. Just use tap water, please!

 

#4: Amber teething necklaces

A cord around Junior’s neck that could strangle him. Made of little beans that could choke him. That either (a) slowly releases the unstudied and unregulated chemical succinic acid into his body constantly, or (b) releases absolutely nothing and is entirely a sham. Or you could just go with, you know, a chewie ring or an occasional dose of Tylenol for teething—which, most of the time, doesn’t seem to bother babies at all.

 

#5: The Wee Block or Peepee Teepee

download wee block2

These little cup-shaped devices are supposed to be placed over a little boy’s weiner prior to diaper changes, so you don’t get whizzed upon. Seriously. It’s a real thing, and it comes in a bunch of colors, but oddly not in different sizes (no bragging, dads!) Some have little phrases on them like “lil’ sprinkler” or “tinkle tinkle little star” or “to pee or not to pee?” Ha! Shakespeare!

#6: Formula mixers

These come in handheld versions for six bucks, up through hyper-cool tabletop premium mixers for $160 (“Say goodbye to the time and hassle of manually preparing baby’s bottles, and say goodbye to 160 dollars!”) . Put formula into a K-cup, and then come talk to me.

 

#7: Ultraviolet pacifier and nipple sanitizer

binky sterilizer

OK, I admit violet is cool. So ultraviolet, that’s got to be ultracool. But you still don’t have to sterilize binkies, pacifiers, nipples, breasts, fingers, or anything else that goes into a baby’s mouth. Because, you see, it’s already not sterile in there. Clean, yes. Sterile? No.

 

#8: The Bumbo Floor Seat

If your baby’s too young to sit up on his own, he’s probably… too young to sit up on his own. Sure, you can make him do it, with the help of this thing—but it restricts movement and can hurt his motor development. Still, it does come in nice colors.

 

#9: Walkers

Walkers” delay motor development and can cause injuries and death—the AAP has called for them to be banned since 2001. Trust me, this is the only walker that’s safe to be around your baby.

 

#10: Mr. Milker

breast fed man

The “#1 breast feeding device for men” – as you can see in the picture, you CAN be a cowboy, and breastfeed too! Still, hopalong, you might want to adjust the hold on that baby in your right hand. Giddyup!

 

OK, now, before you all get all mad at me in the comments for making fun—I know, you bought that amber teething thing for your child and it’s great and he hasn’t been strangled even once, and you like convenience of making infant formula from K-cups, and blah blah how insulting I’m never visiting this blog again… I apologize in advance to everyone for everything I’ve ever done. That should about cover it. Happy holidays!

 

Some bad news about flu this year

Posted December 8, 2014 by Dr. Roy
Categories: Medical problems

Tags: , , , ,

The Pediatric Insider

© 2014 Roy Benaroch, MD

We could be in for a rough influenza winter.

First, data just released from the CDC shows that a lot of the flu circulating in the USA isn’t a good match for the strains in this year’s flu vaccines. About 82% of flu since autumn is a type A H3N2, one that historically has been associated with more-severe illness. Of those, only about half are closely related to the A/Texas/50/2012 strain that was chosen in February to be included in the vaccine. Unfortunately, current methods of vaccine production take a long time, and manufacturers have to commit early—months ahead of time—to what will be included in the vaccines. In February, when the World Health Organization made their recommendations for the Northern Hemisphere 2014-2015 flu vaccine, they chose the H3N2 that was then in circulation. Since then, it’s “drifted”, or changed, to a related but non-identical type.

What this means is that the current vaccine is well-matched to only about 40% of circulating flu. The vaccine will probably offer some protection against the other 60%– illness will be milder and shorter—but a lot of people who got their flu vaccines are still going to get the flu, and spread the flu. Now, some protection is still better than none, so I’d still go and get that flu vaccine now if you haven’t gotten it already. An imperfect (or, honestly, far-less-than-perfect) flu vaccine is better than none. But it isn’t looking good this year.

And it gets worse. It’s becoming increasingly clear that Tamiflu, the anti-viral medication we rely on to help treat influenza, doesn’t work very well. As summarized by the Cochrane Collaboration earlier this year, studies show that Tamiflu is only modestly effective in reducing the length of influenza illness, and may be only slightly effective at reducing complications. If it does work for treatment of flu, it works best when started very early in the course of the illness. The FDA labeling calls for it to be started within 48 hours, but honestly it seems to barely work if started that late. Better to get it started within 24, or even better, 12 or 6 or 2 hours.

In practice, Tamiflu really doesn’t seem to do much of anything for most of the flu patients seen in hospitals and doctor’s offices, because we usually see patients too late. It does have a role in helping family members at risk for flu. They can start it immediately, at the first symptoms, and will probably get more benefit.

Tamiflu can also be used as a prophylactic, or preventive, agent in people exposed to flu with no symptoms, though again, the benefits are modest at best. Crunching the numbers, we probably have to treat about 33 people on average for just one person to benefit from prophylaxis. That’s not very good, especially considering that all 33 people will have to pay for it and risk the side effects.

And Tamiflu does have some significant side effects. Nausea and vomiting are quite common, but the scarier reactions are depression, hallucinations, and psychosis. Neuropsychiatric side effects are most common in people of Japanese ancestry.

So: the flu vaccine, this year, will probably offer only modest benefits. And Tamiflu really has very limited usefulness. It looks like we’d better prepare for a rough winter, and keep in mind some of the old-fashioned ways to keep from getting the flu:

  • Stay away from sick people.
  • If you’re sick, stay home.
  • Keep your mucus to yourself—sneeze into your elbow, or better yet into a tissue. And then wash your hands.
  • Don’t touch your own face. Flu virus on your hands doesn’t make you sick until you help it get into your body by touching your eyes, nose, or mouth.
  • Wash or sanitize your hands frequently, and especially before touching your face or eating.

Not everything is an illness

Posted December 4, 2014 by Dr. Roy
Categories: Medical problems

Tags: ,

The Pediatric Insider

© 2014 Roy Benaroch, MD

A thought provoking article in the November, 2014 edition of Pediatrics highlights a growing problem with modern medicine: just because we can make a diagnosis doesn’t mean we should.

The article, titled “Overdiagnosis: How our compulsion for diagnosis may be harming our children”, has been made available for free to everyone. It’s fairly dense and technical, but if you’ve been following this blog I think you can handle it. The article challenges a lot of assumptions we’ve gotten used to making. It turns out that early detection and diagnosis of scary things like cancer is not always a good idea, because sometimes these conditions improve on their own. And making these sorts of diagnoses can cause a lot of harm, including the costs and worries and medical risks of invasive testing and the side effects of medications. The drive to finding diagnoses early may be increasing the number of people with health conditions without actually improving anyone’s health.

“Overdiagnosis” is the term used when an abnormality is found, but detection of that abnormality doesn’t actually benefit the patient. Some examples:

Skull fractures after head trauma – Simple, isolated skull fractures have an excellent outcome without any intervention. Yet children who are diagnosed with skull fractures often are hospitalized and have multiple CT scans.

Increased cholesterol – A 2011 guideline suggests screening lipid panels for children starting at age 10. Following those guidelines, about 200,000 children would be found each year who would qualify for treatment, though there are no studies of the long-term risks and benefits of treating most cases of increased cholesterol in children.

Food allergy – About 17% of children, overall, will show “sensitization” to at least one food on testing; but only about 2.5% of children are actually allergic to food. In other words, most children who test positive for “allergy” to foods are not allergic and don’t need to change their diet.

GERD – “Gastroesophageal reflux disease” is very often diagnosed in babies, especially fussy babies, despite their being very little evidence that reflux causes fussiness or that reflux medication helps in most cases.

Neuroblastoma – This scary, potentially devastating cancer of early childhood can be diagnosed very early by screening urine tests. But early screening in this manner picks up lower-stage cancers that can regress without therapy. Studies of mass screenings for neuroblastoma show that screening does not reduce in the incidence of end-stage cancer or mortality.

What’s the harm in overdiagnosis? There are physical effects—the dangers posed by further medical testing and treatment. These diagnoses sometimes lead to a cascade of confirmatory tests and invasive procedures. There’s also the psychological cost of worry, and of children and parents falling into a belief that their family is vulnerable and unhealthy. And the financial strain can be considerable, potentially diverting resources from genuine health needs that should have been addressed.

As I’ve said many times, doctors need to be humble. What we think we know may not turn out to be right, and more and more screening and diagnosing may not always be what’s best for our patients. We’re not the only guilty ones—there are plenty of worthless pills pushed by alt-health providers and pharmaceutical firms, and plenty of “non-diagnoses” being made by quacks eyeing your wallet. Sometimes the hardest thing to do is nothing, and the hardest diagnosis to make is “you’re fine.” That’s why it’s up to physicians to do it right.

Food allergy testing: Do those big panels work?

Posted December 1, 2014 by Dr. Roy
Categories: Medical problems, Pediatric Insider information

Tags: , , ,

The Pediatric Insider

© 2014 Roy Benaroch, MD

Theresa asked about eczema (see last post), and also asked about food allergy panels. Does all of that testing help?

Well, usually, no.

It turns out that allergy testing (whether done by skin scratches or blood tests) doesn’t even test for allergy. We sort of smudge through that distinction, because it’s complicated. But it’s time for someone to spill the beans about this kind of testing, and here at The Pediatric Insider, we’re all about telling you guys “the real deal”—the inside info that docs typically keep to ourselves. Here’s something you may not want to hear: “allergy” testing is, well, just not very good.

Let’s start basic. An “allergy” is an adverse reaction (a bad thing, some kind of symptom) triggered by an exposure to something, and caused by a reaction of the immune system. It requires symptoms of some kind, and requires the symptoms to be caused by an immune reaction of some sort.

A broader term, “adverse reaction,” includes allergies but also non-immunologic reactions to things. For instance, many people get bloaty and gassey after ingesting milk. That’s typically caused by lactose intolerance, an inability to digest milk sugar that has nothing to do with any allergy. Still, lactose intolerance and gluten sensitivity and many other reactions are sometimes lumped in with allergies. They’re not allergic, and no “allergy testing” of any kind could possibly identify non-allergic reactions.

Also, allergy – an allergic reaction – requires some kind of symptom, and the symptom ought to be reproducible after exposures. Allergy “testing” often reveals “positives” to foods or other things that upon exposure doesn’t actually trigger a reaction. If eating a food you’ve tested positive for doesn’t cause a reaction, you are not allergic to the food. Period. Allergy requires symptoms.

And that’s the biggest issue with allergy testing—because these tests don’t test for allergy. They test for “sensitization”. They show that your immune system has the capacity to react to the substance, but that doesn’t necessarily mean that you will react to the substance.

I can’t tell you how many times I’ve heard from families who tested positive for food XX, though they’ve never had a reaction to XX—and in fact, they used to eat XX all the time. If your child eats peanuts routinely and doesn’t have a reaction, it doesn’t matter what the allergy testing shows. He is not allergic. The test shouldn’t have been done in the first place.

There are other problems with allergy testing. Though individual tests can fairly accurately say who is sensitized, each test does have a chance of a false result. If the rate of an incorrect test is, let’s say, 5%, that might sound pretty good. But what if you do a panel of 40 foods, each of which has a 5% chance of a false result? There’s a 88%* chance you’ll get at least one false positive. If the panel is large, you’re going to get false results. The larger the panel, the more wrong answers you’ll get. What then?

Another problem: there are a lot of ways to do allergy testing, and they’re not all the same, and I most families have no idea what they’re getting into. The current, most reliable blood testing for sensitivity is called a Cap-RAST or ImmunoCap, and it tests for specific IgE molecules. Older tests are far less accurate, and some still in wide use are as worthless as flipping a coin. If you are going to do allergy testing, you should at least do the best one. Skin testing, too, has different reagents and methods, and it can be difficult to know if what’s being done is the most-reliable testing.

About skin tests: they’ll be unreliable if the patient has been taking antihistamines, and they’ll be less reliable if the patient has a skin condition like eczema, which causes high overall IgE levels and a sort of overall hypersensitivity that leads to many false positives on both skin and blood testing. Testing children with eczema is fraught with peril, which is one reason many dermatologists aren’t keen on addressing the possible allergy-eczema connection.

Still, allergy testing can sometimes help, if you keep these points in mind:

  • Consult with a board-certified, genuine allergist. Many companies market allergy kits and tests and things for general practitioners and ENTs and who knows who else. They’re a big money maker, but we really don’t know what we’re doing with them or how well they work. Please stay away from alt-med practitioners who claim to be able to diagnose allergies by holding your hands or waving vials about or using some kind of elecromagnetic hyperscience quantumconfusionating walletemptier.
  • Test only for foods or other allergens that might be causing a reaction. Foods that are eaten routinely without problems are NOT allergies (and testing will lead only to confusion); foods that always do cause a reactions ARE allergies, and don’t have to be tested. Only test the grey-zone, “maybe” foods, or you’re asking for trouble.
  • Test a limited number of foods. Almost all food allergies are to a small number of candidates: milk, egg, wheat, soy, shellfish, fish-fish, peanuts, and treenuts. Tests for mustard and plantain and okra and lamb are unlikely to yield useful results, and might upset the lambs.
  • Think of allergy testing as a starting point, for clues to what might be a real allergy (positive tests), and clues for what are probably not causes of allergy (negative tests.) Under most circumstances, unless there’s been a life-threatening reaction, you have to confirm ‘allergy testing’ with deliberate exposures. And if there has been a life-threatening reaction, you probably already know what the trigger was—so why do the test?

* It has been a long time since I did statistics. What I did was figured the 5% chance of a false result on one test means that 19/20 times the test will be correct. So if you’re doing that 40 times I figure the chance of 40 correct tests in a row is 19/20 raised to the 40th power = ~ .12, and the chance of that not happening is 1-.12 = 88%. Am I even close? At The Pediatric Insider we welcome comments that point out boneheaded mistakes. Be gentle.

Allergies and eczema: Are they related?

Posted November 24, 2014 by Dr. Roy
Categories: Medical problems, Pediatric Insider information

Tags: , ,

The Pediatric Insider

© 2014 Roy Benaroch, MD

Theresa wrote in, “I’d be interested in seeing an article about the connection (or lack thereof) between food allergies and eczema. Also interested in the helpfulness (or lack thereof) of large blood panels for food allergy testing.”

Two good topics—and I’ll get to food allergy panels in the next post. First: What’s the connection between allergies and eczema?

Eczema is by far the most common chronic skin condition pediatricians see. It’s present in about 1 in 3 young children, or maybe more if you count the milder cases. In fact, if you look closely enough, just about every child has at least some eczema. It’s usually mild, and improves nicely with good skin care and the occasional use of low-strength topical steroids.

What causes the itchy, scaly, red rash? Many things seem to contribute: dry skin, rough fabrics, and scratching all make eczema worse. It often runs in families, and often occurs in the same children who later go on to have allergic rhinitis (hay fever), asthma, and food allergies (those conditions, as a group, are called “atopic.”) Eczema is also called “atopic dermatitis”—atopic referring to inflammation and sensitivity, typically caused by an allergic trigger. These conditions are all interrelated, and often co-exist. So is eczema, the rash, caused by a specific, identifiable, and avoidable allergic trigger?

There’s the controversy.  If you ask allergists, they’ll say “probably yes.” They stress identifying and avoiding specific triggers, typically one or more foods. Sometimes their advice is guided by allergy testing, or sometimes just by history, and sometimes by trial and error. Just avoid food X, and if that doesn’t work, avoid food Y. If there is an allergic food trigger, it’s probably one of the common food allergies, like egg, milk, wheat, soy, fish, or peanut. Maybe try avoiding those.

But it’s hard to avoid all of those foods—and “testing” will often lead to false positive or negative results. If food allergy does trigger eczema, it does it slowly, so it may take several days or weeks of restrictions and reintroductions of multiple, overlapping foods to figure this out. Meanwhile, Junior is still itchy. So the dermatologists take a different approach.

If you ask dermatologists if eczema is caused by food allergy, they’ll say “probably no.” They stress taking care of the skin (using good bathing techniques, moisturizers, sometimes topical antiinflammatory medications, and sometimes agents to reduce bacterial colonization.) Just treat the skin, that’s the dermatologists’ motto. We can make this better, and quickly, without anyone going hungry.

Now, if you ask pediatricians if food allergy causes eczema, we’ll say “sometimes.” Though some of us are probably more allergy-focused than others, most of us probably favor practical advice: for mild-to-moderate eczema, it’s usually best to focus on good skin care, and treat the eczema, and get Junior feeling better. IF initial, safe therapy doesn’t work, or if the eczema is severe, then we’ll also try to identify food triggers—though we’ll keep up the good skin care at the same time. One approach doesn’t mean you can’t also follow the other. And, in fact, the best dermatologists and allergists will also recommend this kind of middle-of-the-road, practical advice.

What about those food allergy panels Theresa asked about? Short answer: They don’t work, at least not if your goal is to figure out what your child is allergic to. More in the next post.


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