ACP Internist Blog

Monday, April 16, 2018

Insurance companies and denial of emergency care

We live in an era of demonization. Political adversaries are not opponents, they are villains. Commentary that contrasts with our views is labeled ‘fake news'. Presumption of innocence? R.I.P. Civil discourse has become a quaint memory. Why would one debate respectfully when today's tactic is to talk over and demean your adversary?

On the morning that I prepared this post, I read an article reporting that one of Ohio's largest insurance companies, Anthem, is denying payment for non-emergency care provided at emergency rooms (ERs). In my view, this article was slanted, unfairly tilting away from the insurance company, an easy target to attack. I think that a typical reader would conclude that the company was greedily trying to claw money away from sick customers. An anecdote was offered describing a denial of payment for emergency care for abdominal pain that did seem improper, although there were no medical facts provided.

I felt that the journalist did not adequately present the insurance company's motive and point of view.

Of course, I expect true emergency care to be covered. And, I do not expect ordinary folks to reliably distinguish between a medical nuisance and an emergency. Patients are not doctors. But, there should be some standard in place. There should be a version of a reasonable person's belief that an emergency is present.

Consider the following points.
• Insurance companies are businesses and must be run responsibly, just like your business and my medical practice. You may believe you are entitled to every imaginable medical benefit, but someone has to pay for it.
• Many emergency room visits are clearly for non-emergent reasons. This wastes health care dollars, leads to medical overutilization and clogs up emergency departments.
• Insurance companies should object to paying for expensive ER care that could have been rendered elsewhere.
• A patient who presents to an ER with complaints such as a cough, a headache or stomach distress will likely undergo significantly more testing than would typically occur in a primary care physician's office without an improved outcome.
• Do we expect an insurance company to pay for an ER visit for a splinter?
• Do we expect an insurance company to pay for an ER visit to evaluate a child's cold?
• If a patient is offered an appointment at his physician at an inconvenient time, and he opts instead to proceed to the ER, should the insurance company be expected to pony up?
• What would our position on this issue be if we were insurance company administrators?

I read (but cannot verify) that $40 billion are spent each year in this country on unnecessary ER care. Do you think there might be a better use for these funds?

It's easy to vilify corporate America. The pharmaceutical and insurance industries have large targets on their backs. But, just because we can hit the target easily, doesn't mean that our aim is true.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

The importance of exercise

Exercise helps keep us healthy. Numerous studies document these benefits. Yesterday I tweeted another link, “For Heart Disease Patients, Think Exercise, Not Weight Loss.”

These studies do not expect vigorous exercise, but they do measure movement. Both movement and some resistance training help keep us healthy.

Here is another link, this one on, ”10 benefits of exercise.”

Readers know that I have become totally obsessed with exercise. I recently celebrated 2.5 years of Orange Theory Fitness. I go 4-5 times each week.

But one does not need to be as obsessed as I am. Moderate exercise works and works well. I have several friends who try to walk 4 or so miles each day – that is great moderate exercise. They also do some weight training twice each week. These are healthy men in their 70s. But thanks to this exercise, they function better than many 50-year-old men.

Exercise each day is better than an apple a day. Exercise (and I do recommend moderation even though I likely take it a bit overboard) will improve your quality of life, decrease the probability of many chronic diseases, and likely make you feel and look healthier.

I do not know of any drug as valuable as regular exercise. It certainly is less expensive than any newly developed medication.

(db refuses to step off the soap box, but does stop typing)

db is the nickname for Robert M. Centor, MD, MACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and the former Regional Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds regularly at the Birmingham VA and Huntsville Hospital. His current titles are Professor-Emeritus and Chair-Emeritus of the ACP Board of Regents. This post originally appeared at his blog, db's Medical Rants.
Friday, April 13, 2018

The gospel

I was told one thing. That your aortic heart valve was narrow and tight and that, just maybe, one day very soon you would need that valve replaced.

Aortic stenosis. That's what I was told. With clear certainty and not so much as an eye twitch or a blink. From his lips to my ears like it was the gospel. Aortic stenosis.

I entered the room alone. Armed with the gospel that I had been told about you. Aortic stenosis. I spoke to you for a few moments and talked about what was going on. “What is your understanding of what is happening with your heart valve?”

“The blood rush over it in a way that's not normal. They heart valves don't open and close like they s'posed to.”

I nodded because, for the most part, that was true. It was. And I went into a description of what it all meant. Your tight and narrow heart valve. I said the words over and over again. “Aortic stenosis” this. “Aortic stenosis” that. You looked a little bit confused but when I asked if you understood you said, “I think so.”

I think so.

Next I pulled my stethoscope from my pocket. Slipping the rubber tips into my ears, I looked at you and smiled. You smiled back. Then I gave the diaphragm a vigorous rub with my palm remembering that a Grady elder had told me once: “Even though it don't do much to warm it up, something ‘bout seeing you try make me feel good.”

So I did that. And I do that. Most times, I do.

I close my eyes and place the instrument on your chest. I follow the map of listening areas taught to me as a medical student and quietly listen for the telltale sounds of aortic stenosis:

First a soft sssssssshhhh. Then it grows louder to a SSSSSHHHHH. Falling down quickly to the that soft hush again.

I know it when I hear it now. And so, instead of fighting to discern what it is, I am armed with experience. You patiently allow me to confirm what we both already know. My breathing slows. My hand glides with the stethoscope over your skin.

You are so cooperative and kind, I wish I wasn't alone and that a student could be beside me. To hear and learn right next to me. Aortic stenosis.

My eyes open.

Wait huh?

I am hearing sounds, yes. But they are NOT the ones I expect. I squint my eyes and listen harder (as if this changes what the ears hear.) “Can you hold your breath?” I ask. And you do.

Same thing.

A soft whoosh followed by what sounded like a deep sigh between heart sounds. Again and again I listen. And again and again, I hear the same thing.


“They told you your heart valve was small? Like tight and stiff?”

“They told me something. I don't know if it sounded like that.”

“What about a leaky valve? Did somebody say that?”

“I don't know, Miss Manning. Y’all be saying so much sometimes.”

And you're right. We do.

You don't have aortic stenosis. And while you do have an issue with your aortic valve, it isn't that. And though I am not a cardiologist, I can say that right now it doesn't look like you need surgery either.

You were gracious when I told you I was wrong. You shrugged and laughed a little. Like none of it was a big deal.

While my face burned hot like coals.

This happened a while ago. But what it taught me was that, like all gospels, I need to listen for myself, examine for myself and interpret for myself. Because even though a lot of times there is no discrepancy. . .sometimes there is. When telling someone life impacting information, it's good to have at least checked for yourself before talking.

Whew. Preach, pastor.

I also learned that there is a lot we say that gets missed. Yeah, so I work at doing a better job in that area, too. Explaining until you know so. Not just think so.


Last I checked, you hadn't had your aortic valve replaced. You were still doing well and seeing the cardiologists regularly. Today I am hoping and praying that you know exactly why. This is what I am hoping. And that the gospel you hear is the gospel indeed.


Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.

The disease delusion

I was privileged to speak on a panel, addressing the fundamental importance and powerful influence of diet to heart health, at a session of the American College of Cardiology conference in Orlando, Fla. The ACC is a large organization, and its annual conference is a big draw. The result is a rather massive meeting, inevitably housed in a cavernous convention center. Orlando was no exception.

My wanderings through that vast and labyrinthine building prior to my session took me through the exhibition hall, where I snapped the photo shown above. In a space that stretched to the limits of one's gaze in every direction were sleek displays, ranging from modest to grandiose, of drugs and more drugs, devices and technology and the instruments and procedures of revascularization. All of this vast display, and the implied, monumental mobilization of money, time, training, effort, pain, treatment, recovery, and resources of every description, were for a disease that virtually no one needs to get.

Make no mistake, with very rare, genetically-induced exception, coronary artery disease does not need to develop. In the spirit of all that's old being new again, this very revelation- rather than the barrage of popular nonsense- was the primary conclusion of Ancel Keys' famous Seven Countries Study. Keys was among the first to suspect, based on population-wide differences, that coronary artery disease was not an inevitable consequence of aging, as was widely believed at the time, but was induced by adverse exposures and lifestyle practices.

Keys was right, as is now universally known, and this was the principal finding of his seminal study. He and his findings now have abundant company, spanning the spectrum of mechanistic research, intervention trials, and observational epidemiology at a grand scale.

In the world's five Blue Zones, people routinely live to be 100 in the absence of chronic disease, including coronary artery disease. This is attributable to lifestyle, which is in turn attributable to culture. But whatever the causes, and the causes of those causes of Blue Zone blessings, the fundamental message is perfectly clear: coronary artery disease as a mid-life rite of passage need not occur.

The same compelling message issues from the Bolivian Tsimane, the well-studied population of modern-day “hunter gatherers,” or foragers, in the Amazon. They have stunned researchers with their consistently pristine coronary arteries that show no signs of atherosclerotic degradation across the decades of their lifespan.

And there is evidence, too, that none of the above can be dismissed with a wave of the hand, and a reference to “good genes.” For one thing, the populations above are not genetically homogeneous; they are quite diverse, ranging from Ikaria, Greece, to Okinawa, Japan; from Costa Rica, to Loma Linda, California; and from Sardinia, Italy, to the Amazon. Immunity to coronary disease is courtesy of culture and lifestyle, not ethnicity or some lucky assembly of genes.

For another, it's perfectly clear that this immunity can be conferred. When Keys first began his work, the premature death rate from coronary disease in Finland was one of the highest, if not the highest, in the world. When the lessons of Keys' work were applied with fidelity in the North Karelia Project in that country, coronary disease rates dropped by over 80%, and average life expectancy increased by more than 10 years. Migration studies, such as Ni-Hon-San, involving the movement of people (in this case, Japanese) and their genes from one culture to another demonstrate the same: marked variation in disease rates as genes stay the same, but lifestyle and culture change.

America runs on coronary artery disease.

Coronary artery disease is fully embraced in our culture as a veritable rite of passage. If, at a certain age, you don't have a CABG scar for show and tell, or at least an anecdote about the particular intracoronary stent you've received, you are the odd man (or woman) out, the cultural anomaly. Real Americans, and increasingly real residents of all the world's developed countries, get stents! One is all but embarrassed not to have one.

This is as tragic as it is unnecessary.

My view of that exhibition hall, and the scale of that at-a-glance, cultural obeisance to an unnecessary disease of our own devising all but knocked the very wind out of me, and left me thinking of a single word in my momentary disequilibrium: delusion. The disease delusion.

Richard Dawkins, in his book, The God Delusion, points out (among other things) the many, fundamental inconsistencies both among and within the dogma of the world's major religions. Yet when culture demands faith and fealty rather than consternation and a furrowed brow, that's generally what culture receives.

More comfortably, perhaps, we might invoke the childhood parable of the Emperor's New Clothes. Or that ditty about a lump of peanut butter on the chin. The mundane, as readily as the divine, can be dispensed to us as cultural gospel, and we seem inclined to imbibe it accordingly.

But in this case, it is quite literally killing us. Heart disease is the leading, proximal cause of premature death among women and men alike in the United States. The distal, or root causes, are a lifestyle also subordinate to the dictates of culture, a culture that runs on Dunkin; peddles multicolored marshmallows as part of a complete breakfast; and conflates the Olympics with a trifecta of fast food, junk food, and sugar-sweetened beverages.

These human costs, years lost from lives, life lost from years, are what matter most. But for those inclined to count beans rather than lost blessings, the economic case is equally compelling. The most recent issue of JAMA is devoted to the absurdly high costs of so-called “health care” in the U.S., and the reasons for them. Left out of that inventory is the monumental prevalence of disease we need not get but choose to manufacture. The drug and device companies in that ACC exhibition hall are beneficiaries of so much coronary disease; so, too, are the many mainstays of our culture outside that hall that profit directly by its propagation.

In our one session at ACC 2018, we spoke of the power of diet and lifestyle to prevent, treat, and reverse coronary disease. Although our session was packed to capacity, standing room only, we were nonetheless a tiny and atypical island in the mighty currents of calamitous cultural norms.

The massively impressive aggregation of resources in that exhibition hall delivered the message loud and clear: go ahead and assault your coronaries like everyone else does. It's fine. It's normal. We've got drugs and devices and doctors for that.