Controlling Health Care Costs. Continued

Controlling Health Care Costs—Continued

First, Retain all Employer Coverage.   Second, use tax credits to purchase from a variety of state sponsored plans that meets your needs and your wallet.  Third, maintain whatever coverage you have, no matter the amount, because you can then avoid any penalty by the Government for lack of insurance.  Fourth, combine Medicaid (able bodied peersons) with the refundable federal tax credit to enroll in a private insurance plan.  Fifth, support medicare reform that offers that offers a variety of plans and costs from competing insurance companies.  Sixth, Use Health Savings Accounts.  These are high deductible plans in which the patient pays for all routine medical care out of pocket but has coverage for major illnesses and operations.

All of these options offer an opportunity to individualize your health care costs and needs.  Patients are becoming more and more sophisticated about medical matters.  I have been lecturing to Lay groups for over 30 years about heart disease and I am amazing at the interest and the never ending questions.  People are very eager for health knowledge and search for physicians with whom they can discuss medical issues.  The Internet is awash in medical information of all kinds from very reliable institutions like the Mayo Clinic.  Physicians need to be prepared for patients who will be asking tough questions about their care.

Controlling Health Care Costs

HEALTH CARE COSTS

I believe the only way we are going to control health care costs is to put cost control in the hands of the patient.  “How can we control costs when we do not medical knowledge, the patient will ask?” The question is quite appropriate, but put your self in the doctor’s position.  He/she wants to please the patient and take good care of the patient and have a good reputation.  He will take more care in the ordering of tests and procedures if he knows the patient will have increased out of pocket expenses for whatever he orders.  Therefore the patient should tell the doctor that he wants to him to order whatever tests and procedures he thinks absolutely necessary, but to use his good judgment in the necessity for any test.  That information will be placed in the patient’s chart in case he is sued for failure to order certain tests.  I began medical practice in the 1960’s  before extensive insurance and Medicare.  I recall debating whether to order a $5 blood test because I knew the patient would have to pay and I wasn’t sure it would help in his care.

The  Government and the insurance companies thought they could control costs in the 1970’s by controlling hospital costs.  The patient would come in and say “hospitalize me Doc, my insurance will pay for it.”   Is that any different than saying, “order the test doc, Medicare will pay for it.”  When the patient does not have a role in controlling costs, costs will certainly increase.   

The Wall Street Journal published an article in the January 23, 2016 issue titled “Instead of ObamaCare :  Giving health care power to the people.”  The article was written by two independent investigators from reliable institutions located on both coasts.  The gist of the article was basically putting cost control in the hands of the patient through several different approaches.  Their suggestions are based on ObamaCare requiring all persons to have health insurance or be penalized by higher premiums if they do not have coverage.

To be continued on next blog

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Cardiac Arrhythmias

“Arrhythmia” is the term applied to abnormal heart rhythms and includes skipped beats, and conditions in which the heart beats too fast, >100 beats per minute, or too slow, < 60 beats per minute.  The patient may or may not be aware of these irregular beats.  The cause of many arrhythmias is difficult to determine because there are often contributing factors that must be considered, from fluid and electrolyte disturbances, such as serum sodium and potassium, to abnormal heart valves or coronary disease. 

As in all of medicine it is important to have the correct diagnosis before moving on to treatments.  A diagnosis of an arrhythmia is made by taking an ECG.  Once a diagnosis is made the doctor will try to determine a cause and how best to manage the arrhythmia.  A new cardiac subspecialist called the Cardiac Electrophysiologist has been developed by doctors who devote their entire careers to the diagnosis and management of arrhythmias.  Your Doctor may refer you to an electrophysiologist for treatment.

In general we have moved away from using medications to control and manage arrhythmias, with certain exceptions, because they tend to aggravate the arrhythmia rather than control it.  The trend has been to use mechanical devices such as pacemakers and internal defibrillators that are inserted into the heart.  A procedure called “ablation” has been developed by the electrophysiologists to deliver a radio-frequency charge through a catheter placed in a specific location in the heart to destroy a site responsible for starting an arrhythmias  I have had patients in whom their bothersome arrhythmias is completely cured with ablation.

Thus there are two separate and distinct systems to consider in managing the patient with heart disease.  The first is the circulatory system that carries fresh blood through the coronary arteries to sustain the heart muscle and the other is the electrical system that is necessary to drive the heart.  Both are essential to normal heart function and both must be considered and managed in all patients.

CARDIAC CHEST PAIN

As I talk to people about heart problems it appears there is confusion about what constitutes “heart” pain or chest pain of cardiac origin.  As a result an impending heart attack may not be recognized by the patient and getting medical help is delayed.    Heart pains also vary from patient to patient making recognition even more difficult for the patient as well as the doctor.  I will try to provide some guidelines to help with this problem.

In general, any kind of chest pains or chest distress should make the patient think about a possible heart problem.  First, if that chest distress comes on with exertion such as climbing stairs, vacuuming, running, cycling, snow shoveling, etc, and then subsides with rest, should certainly raise the question of a cardiac origin of the pain.  Second, the heart is a midline, not a left chest structure, so heart pain will be in the middle of the chest.  The most common description is a dull, heavy, pressing, squeezing type of distress, “like an elephant on my chest.”  Sometimes it is described as an expanding ball of fire.  The pain may radiate up into the neck and jaws, and/or down the left arm.  The presence of sweating, particularly if sitting or lying down, in association with this type of chest pain, is heart in origin until proven otherwise by a physician.  Sharp, stabbing, fleeting, knife-like pains in the left chest beneath the left breast, are rarely an  indication of heart disease.   The most important thing for the patient to do is to maintain a high index of suspicion for possible heart disease and then get medical care if there is any question.  Let the physician sort through the various symptoms that are present.

Summary:   The typical chest pain associated with an impending heart attack is often described as a dull, heavy pain located in the middle of the chest, but there are many variations that only the physician can sort out.  The most important thing for the patient is to think of possible heart disease and get an evaluation.  Sharp, stabbing, fleeting pains in the left chest beneath the breast are rarely heart pains.

What are Nature’ Bypasses?

A friend wrote the other day and asked “What are nature’s bypasses?”  One of her male relatives began having chest pain and subsequently had a heart angiogram (heart catheterization) which showed an 80% narrowing of one artery and a second artery completely blocked near its origin from the aorta.  He had had a previous heart attack years before.  The heart cath showed the artery beyond this total blockage was being filled with blood from one of the other coronary arteries.  Normally blood in an artery passes through capillaries into the veins, but this was a direct artery-to-artery connection.  Direct artery to artery connections are rarely present anywhere else in the body.   The medical term for this finding is “collateral blood flow” and illustrates nature’s attempt to overcome the total blockage and thus reduce heart muscle damage.  Nature does amazing things. 

In reality this is what we do when we insert vein bypass grafts from the aorta to a  coronary artery beyond such blockages.  Vein bypass grafts carry a large amount of blood whereas collateral channels carry a relatively small amount of blood.  Never the less these collateral channels are important in helping heart muscle to survive, reducing the size of heart attacks.  Heart attack patients need all the help they can get and we all want as many collateral channels as possible.  These channels may be the difference, as in the case above, in determining whether we survive a heart attack or not.

Summary:  Nature’s bypasses are collateral artery channels that connect one coronary artery directly with another when one of the arteries is totally obstructed.  This is nature’s attempt to overcome obstructed coronary blood flow and reduce heart muscle damage when the patient suffers a heart attack.  There is nothing the patient can do to develop these channels other than to remain physically fit and active and follow preventive measures to avoid coronary heart disease.

Coronary Artery Anatomy:  A Primer

I have been lecturing on heart disease to lay groups for over 40 years.  The insatiable desire for knowledge about heart disease by lay persons has been one of the highlights of my career.  These lectures are often fun with never ending questions.  I consider this a sign of a health conscious country.

One area rarely touched upon is the normal anatomy of the coronary arteries.  The anatomy is very important because it explains many of the conditions that develop.   First of all it is important to remember that ALL arteries arise from the Aorta.  The aorta is a long, elastic tube that runs upward from the heart, curves downward at the neck, runs the entire length of the body, splitting at the level of the umbilicus to send the major arteries to the legs.  The aorta expands with each heart beat and then maintains artery flow, by virtue of the elastic recoil, while the heart fills for the next beat.  The first branches of the aorta are the coronary arteries and they arise just beyond the Aortic valve.  As a result the coronary arteries get the first and the freshest blood when the heart contracts.  The coronary arteries spread out over the surface of the heart sending their branches downward into the heart muscle.  Thus the coronary arteries are very accessible to the surgeon for any operation on the arteries.  There are two coronary arteries, a right and left, but the left quickly divides into two major branches, so we really think in terms of 3 major arteries.   The names are the left anterior descending (LAD), the circumflex (CIRC) and the right coronary artery (RCA).  Each of these three arteries is usually about 15 centimeters in length.

The majority of plaques develop in the first 3-4 cm of the artery origin from the aorta.  As a result the artery beyond 4 cm is usually relatively free of plaques and is suitable for inserting a vein bypass graft from the aorta.  The vein graft bypasses the bad plaques and brings fresh blood to heart muscle starved for blood due to obstructing plaques upstream. 

Summary:  The coronary arteries are on the surface of the heart and are readily accessible to the surgeon.  There are 3 coronary arteries, each of about equal length, that carry fresh blood to the heart.  Plaques develop near the origin of the each coronary artery leaving the area beyond the plaques uninvolved and suitable for a bypass graft.