Medicine Follow The Money

Michael_T said...
Prat, ...I was going to ask specifically what scan you're referring to...above Ken mentions the "Coronary Calcium Artery Score"--is that the one? ....If so, my PCP recommended against it since he had it had high doses of radiation.....

I am curious to know exactly which one Prat is referring to also.

Coronary Artery Calcium Score, is done in a regular CAT scan machine. The purpose is to score the calcification buildup in the coronary arteries. Essentially this is done to see how much plaque is built up in your arteries.

They hook up an EKG machine, and have software that recognizes when your heart is beating and the machine will not scan when your heart is beating.

Since the machine only scans in a timed pattern when your heart is not beating, I'm not sure how you could be getting much radiation. It seemed a good bit shorter time wise than the CAT scans of my head for sinus surgery.

I don't recall my score exactly (hundreds?) but I know the report said I was in the 25 to 50 percentile range for my age.

My wife (one year younger) had a score of zero. No plaque buildup at all.

My prescribing physician told me medicare and insurance would not pay and it would be out of pocket, so I knew that going in.

The echocardiogram I had was a color doppler ultrasound that reads motion, valves, flow, sealing of valves, estimates compression (sqeezing), etc. As I understand it, the echocardiogram shows how well your heart is functioning (in motion), while the Coronary Artery Calcuim Score tells you how much buildup of plaque you have in your arteries (that your heart is having to work extra to pump through)

IMO, people fifty and older would likely benefit from having both types of diagnostics of their heart and arteries.

To butress my point, this what I worry about:

>>>>>>>>>>>
Sometimes Going Fishing with the Doctor Isn’t So Much Fun
Posted: 09 Feb 2016 07:00 AM PST
BY A PATIENT OF MARK SCHOLZ, MD

When you go fishing, you can bring up all kinds of things besides fish—old rubber boots, pieces of a broken net and discarded trash. Once I caught an eel. You never know what you will drag in when you drop your line overboard.

The same analogy holds true for diagnostic testing in the medical world. Investigative studies can have unintended consequences. Of course the studies seem justified at the time. We presume that the doctor is being rightfully conscientious by using all the tools of modern medicine, “fishing” for the right answers.

Dr. Scholz asked me to relate the story of an extended medical fishing trip that started with my dermatologist for my annual, too-much-California-sun screening. While talking to my dermatologist, I mentioned some itching on my arms. He gave me a few samples of lotion and referred me to my internist for further evaluation and blood testing to “make sure” the itching wasn’t a symptom of something more serious. My internist ordered some lab work (which was normal) but recommended that I have a routine chest x-ray since itching can be associated with lung cancer. This suggestion may have occurred to him because he knew that lung cancer caused my mother’s death. Since I hadn’t had a chest x-ray in years, I thought, “why not?”

In retrospect, the chest x-ray may have been a mistake. Because that’s when the boat left the dock and the fishing really began in earnest. Two days later, the chest x-ray revealed a “suspicious” spot on my lung. So, to identify what it was, a CT was ordered. The spot was benign. “Whew!” It was only a bone artifact (the end of a rib visible due to the angle of the x-ray). But…. the CT scan showed a suspicious spot in the liver, which shouldn’t have been there and was large enough to be of concern. So, an MRI of the abdomen was ordered. The MRI revealed that the liver spot was nothing but a harmless hemangioma, a collection of blood vessels that are common and mean nothing. Another big relief. But…. guess what else the MRI found? At the top end of the scan in my lower neck, it showed some abnormalities in my thyroid “that could not be ignored.” So, a thyroid ultrasound was ordered. It revealed two nodules that looked benign and would have been ignored completely if there had only been one. But the only way to really know what types of cells the nodules consisted of was by doing a needle biopsy or an exploratory surgery.

Yikes! When would I get off this merry-go round? Who could imagine that simply mentioning some itching to a dermatologist would lead me face to face with the possibility of thyroid cancer. However, the doctor was kind enough to offer another alternative. Because of the known, slow-growth rates of typical thyroid cancers, active surveillance and re-testing at future intervals was also an option, and the one I have selected.

So, six months later, a second thyroid ultrasound—my fifth imaging test—showed no changes from the previous test. The fishing trip finally seems to be over. I am back in the waiting pool anticipating next year’s medical expedition, much the same as the next round of prostate screening tests I am scheduled to undergo early in 2017. Now, routinely surveilling my thyroid is going to be just like my prostate. If next year’s fishing trip doesn’t run down any new tributaries and is uneventful, I expect it may even be possible to extend by a year or two the time the frequency of testing.


My medical fishing trip was not much fun. Personally, I’d rather spend my time working, biking or walking, or doing almost anything besides waiting for the next set of results from the last odd thing that showed up unexpectedly. But life goes on and it isn’t possible to know precisely how it will end. My recommendation—Give careful consideration to your doctor’s invitation to go fishing. Take control over your medical destiny and ask you doctors if close surveillance is an alternative to further testing.


>>>>>>>>>>>>>>>>

Mel

Tud:

Maybe a more extensive ct scan.

mel

The below is a medscape article in conjunction with the Mayo clinic.

medscape said...
Who Should (and Shouldn't) Have a Calcium Score

Dr Pereira: How do you use coronary calcium scores in your practice? There
are always some gray areas. Can you illuminate some of those?

www.medscape.com/viewarticle/842348#vp_3

This link is to page three.

If someone has an interest in the procedure, what's, why's, and where to fore's they will probably want to read from page one.

Michael BTW, what happened with your echocardiogram today?

@JNF, you are right it's ridiculous how they bill. When I had stents put in, they billed $92,000!!! The insurance company paid $52,000. Still ridiculous but why bill $92,000?

Didn't cost me anything, but I was so annoyed, I tried to get the name of the CEO, no success, nobody even knew the name (Empire BCBS. And the person I spoke with told me that it would do know good, because it happens all the time, and they all laugh when they see the amounts. Like its a joke.

I wonder who at the hospitals is giving h**d to who at the insurance companies.

compiler said...
Prat:

I just noticed this thread. I would be most hesitant to recommend that everyone over 45 get that scan.

How about a full body scan?

Maybe it makes sense, but I'm hesitant. Meanwhile, we have those who are against PSA testing, which is how 90% of us were dx. I would advocate PSA testing, but to recommend the CT Scans, I remain to be convinced.

Mel

Mel, the value of the CT Heart scan is that when one gets a score high enough to show they have, or are well on their way, to coronary artery disease, which is pretty much irreversible, and progressive, they will be more willing to make the lifestyle changes necessary to stop the progression. BEFORE they need stents or worsen have a heart attack.

If you have access to Netflix, (I've heard it streams for free elsewhere as well, maybe google it) watch the documentary ""The Widowmaker" it is eye opening. I truly wish I had access to this test when I was 45 or 50. I would have stopped this thing in its tracks way earlier in the cycle.

Here's how the money works:

The insurance company defines what each 'thing' will be billed at. In the example given, for simplicity they tell the hospital/doctor that the sort of stents put in should "cost" $92,000. This is the book price. Then, when BCBS pays $52,000 they can publicly state they "saved" $40,000. And, in the days before managed care came into being along with PPO's and "networks" and all that other BS, the billed cost for the procedure would have been, guess what? : $52,000.

So, in this system, the same entity (insurance company) is both the buyer and the seller, who defines what the true seller gets paid AND determines what the seller can sell. It's crazy.

Prat, I'm waiting to hear the results of the echo. It does sound like it won't necessarily tell me the entire picture though.

If you don't mind me asking, since you had the full monty radiation wise, what is your next step? Do you get retested eventually to see if the number has done down or have your stents taken care of the biggest issues and you treat with diet going forward?

Michael_T said...
Prat, I'm waiting to hear the results of the echo. It does sound like it won't necessarily tell me the entire picture though.

If you don't mind me asking, since you had the full monty radiation wise, what is your next step? Do you get retested eventually to see if the number has done down or have your stents taken care of the biggest issues and you treat with diet going forward?

Michael, forgive me if any of this is repeating myself, I seem to not remember what I've posted and what I haven't lately. I think I'm on too many forums.

So, not EXACTLY sure of how things will go. But I approached this in a similar way to the way I approached PC (thank you HW). I've done a lot of reading, still some confusion, but I found a forum that's been a great help. It led me to a visit this morning with a Cardiologist at NYU Tisch Men's Health Center. He is also Board Certified in Integrative Medic e, and director of Integrated Medicine for the Center, which is an executive style facility that is multi faceted. Urology, gastro, cardio, etc.

Anyway, his approach is multi faceted - nutrition, exercise, stress relief, etc. And his words to me were that for me, anxiety was as big an issue and potentially as harmful as diet. (Apparently, he read me easily, just like the guys on HW did when came here) He explained that anxiety is a chemical response that causes inflammation which creates more plaque. This is similar to the Ornish approach, EXCEPT he completely disagrees with Ornish diet approach in that he believes in low carbs, NOT low fat, thinks fat is not harmful (as long as it's not transfat)

So anyway, the goal is to stop progression, because it's the non calcified soft plaque that can hurt me, and eventually the soft plaque turns to hard plaque, which is actually protective. If I stop the progression, the soft plaque will eventually calcify and since I'm not producing new plaque, I will be left with mostly harmless calcified plaque.

Ok I'm getting off track, so... Next steps....

He took blood, being sent to a lab in Boston, to do something called a Boston Health Lab Panel. It looks at Lipids, but drills,down to different types, and things like small particales vs large particles, and it looks at many other proteins. This will give him info on what foods and medicines I might be resistant to and which ones might harm me, based on my makeup. He says everyone is different.

Those tests take about two weeks, and so I scheduled in three weeks, what he calls a "wellness" visit, which I think is where we discuss the test results, and a plan of action.

Also, he referred me to a high end nutritionist, as well as a Psychologist who will work with me (if I choose) on biofeedback, to help control my anxiety. I looked her up and she works with athletes, and business people, to control anxiety and enhance performance. I am going to meet with her, and then I'll decide, because it would run $1500-2000 and it's all out of pocket. I have to be really convinced that it will help to spend that money.

He also gave me the name of a well known meditation expert, who trains in meditation. Not sure I'll do this yet, one thing at a time,plus I just don't know if I can buy into the idea. On the other hand, I will consider it. An alternative is one of the many meditatin apps available for download.

As far as testing, we haven't gotten that far yet. I intend to ask him on my next visit. He did only an EKG today. I'm guessing I'll have annual heart scans (the lower rad dose variety) to determine CAC score and monitor progress.

I hope this works. I just think it's better than the other three Cardiologists I have seen including my PCP who initially diagnosed me, who all were basically just telling me,stop being so nervous, your fine, just take the pills and see me in three months. I Need to be more proactive than that.

All I need to figure out now is how to tell my PCP/Primary Cardiologist, that I'm going to fire him as my cardio but would he please let me stay as a primary care/internal Medicine patient. But I'll figure that out.

Anyway, sorry , I probably answered a lot more questions than you asked.

Prat, that was very helpful and I very much appreciate the detailed response. I was aware of various aspects of what you're doing (I'd been following your Ornish thread, although didn't participate), but this response was more comprehensive. For what it means, what you are doing sounds imminently reasonable and very thoughtful. I wish you the best on this.

In my case, I haven't thrown myself at this like I did PC since I have no idea if I have any heart-related issues or not. That said, I'm not the bastion of health I should be. I'm on statins, which controls my cholesterol, and I'm taking blood pressure medicine, which seems to be controlling my blood pressure (although not as much I'd like--the diastolic number hangs around the mid 80s).

And mainly because I'm in my mid-50s and I know I need to eat better and exercise more. I've been pretty good about since last October and have lost 10 pounds and my energy level (which has never been the same after my HT) is somewhat better. But this is very much a work in progress--I'm 5' 10" and 185 pounds and I'd like to get down to 170 over time. Hope this isn't too off track on this forum--you, BillyBob, Ken and others have been very helpful to me as I've lurked on some of these discussions.

Michael, you are in a good position, i think. Hopefully, your echocardiogram comes back negative. Once that happens, at age 50, the fact that you know you could eat better and lose a few pounds, is a big step. Do it. Don't let it slide for a few days, then a few weeks they turn into a few months and years of being lackadaisical, which is what i was until i turned 60. But by then the disease had progressed, although i didnt know it until last year.
I'm glad my post was helpful, reach out on here or via email, any time. I'm no expert, but learning every day.
And thanks to the mods (and everyone else) for being tolerant of what sometimes turns into a heart discussion rather than a prostate issue.
We've sort of got nowhere else to go with this, and it is a common problem among much of this forums population

*disclaimer* I have only read the first couple of posts - which if I'm interpreting correctly are essentially talking about the bias of money on healthcare decisions. Bias exists in every segment of our economy. The practice of medicine relies on the Hippocratic oath that doctors take, along with other processes to ensure bias is minimized, but it still happens. I just read this article earlier today on bias with IMRT in PCa treatment as an example:

www.bloomberg.com/news/articles/2012-11-06/prostate-patients-suffer-as-money-overwhelms-optimal-therapy

Food for thought to be sure.