Del Meyer, MD, Pulmonary Medicine

MedInfo Health Line

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2007

Medical Tragedy

A patient developed pain in the pit of his stomach with nausea and vomiting associated with gastro-esophageal reflux disease. This began shortly after he entered the service at age 19. A clinic physician prescribed Tagomet, an acid H2 blocker, with refills. He improved while the refills lasted for about a year and then the pain in the pit of his stomach with nausea and vomiting recurred. He had a gastroscopy and was told he had some esophageal scarring but nothing else was found. He was stressed because his wife was pregnant and he was being shipped to Japan. TUMS, an antacid tablet, gave transient relief. A year or so later he was evaluated at a regional Air Force Medical Center and had a second gastroscopy. He was told everything looked good but he had some scarring and should avoid spicy foods to keep that from progressing. On leaving the service, he obtained a truck-driving job. He enjoyed his new job. He did well for years. Then the pain in the pit of his stomach recurred. Some days he couldnít drive his truck. He was sent to a psychiatrist who placed him on antidepressants. However, he was not depressed; he just hurt. The pills didnít help. They made him feel worse. He was fired from his truck-driving job because he called in sick too often. Since he couldn't work, he applied for disability benefits and began receiving them. The pain in the pit of his stomach persisted and he had a third gastroscopy at a private regional medical center. He was told that his esophagus was scarred and narrowed and they passed a rubber tube to open it. He undoubtedly was talking about a dilatation. He was given Protonix. It helped relieve the pain until the refills ran out. The pain in the pit of his stomach recurred. His wife changed insurance plans and he came in for a medical evaluation.

When first seen for the pain in the pit of his stomach, he had been unable to work for about 10 years and was on disability. The heartburns occurred after each meal and he took an occasional TUMS with some relief. He awakened during the night, essentially every night, with the pain. As he was thinking about this, he said that he had been awakening with the this pain nearly every night for at least 10 years and possibly since he went into the service 20 years ago. He had not been asked this question regarding this classic symptom of peptic ulcer or reflux disease. I gave him a Prevacid, which I had readily available, and a Gaviscon chewable antacid pill. By the conclusion of the exam, he was feeling better. I told him to purchase the formerly $5.00 purple pill that was now generic and available at Walmart or Cosco for 50 cents. I advised him to take it at least before breakfast and dinner and at bedtime if he still had heartburns. He was told to buy large bottles of antacids and to take a large swallow of it after each meal and at bedtime and during the night if he had heartburns. He was told that he could return to driving a truck in a month or so and was advised to have a bottle of antacids next to him and to take a large swallow every couple of hours and whenever he had heartburns. He and his wife were incredulous and mentioned their doubts and disbelief. He was disabled and the thought of returning to work seemed to frighten both of them.

When seen again in a month, he was a different man. He hadn't experienced heartburns or pain in the pit of his stomach, he slept through the night, had no nausea or vomiting, and was looking into driving a truck again. His outside records at this time confirmed that
he had a negative H. Pylori titer and thus not a reversible cause of GERD. His gastroscopy reports were rather remote and did not become available.

Here is a patient who had 20 miserable years, ten on disability, and a distraught wife and daughter. It was all reversed by a caring physician simply listening to his story. He stated that most of my questions had not been asked before. Of critical importance was the fact that he received his first dose of an acid inhibitor and acid neutralizer while in the office so he was better by the time he got home. This, of course, gave him the impetus to drive to Walmart or Cosco to obtain the Prilosec and antacids at OTC prices.

Other observations of relevance in our health care milieu are important. This man was seen in three sophisticated medical systems. He had three invasive procedures, all of which he did not need. What he needed was simply a physician or a nurse practitioner who would do a medical interview and a medical examination. Pressing on the pit of his stomach confirmed that it was on fire from all the acids burning his esophagus and pylorus. Hence, it was apparent that the fire could easily be put out with antacids. It was.

In addition to the unnecessary health-care costs, and cost on his family, there was also the unnecessary cost of disability payments and the loss of a job he really missed. Government medicine would not have been better. One of the three medical systems that saw him was the Federal Government. Doctors no longer are given the time to explore the medical history on which three fourths of all diagnosis are based. They immediately proceed to unnecessary procedures and then donít take the time to explain the findings in terms the patients can understand. This happens in all the systems of health care. But the answers are evolving. Stay tuned to MedicalTuesday.net to keep posted.


Private Hospital Care vs Integrated Hospital Care

The high-tech hospital is extremely important for the complicated and seriously ill patient. However, as this conference repeatedly pointed out from acquired infections to simple blood transfusion, it is an increasingly hazardous environment. The consequences extend far beyond the hospitalization into the ambulatory care arena. As hospitals lose much of their volume from inpatients, they have increasingly resorted to outpatient medicine. However, it has repeatedly been shown that outpatient hospital medicine is far more expensive than similar treatment in a doctor's office - sometimes on the order of two or three-fold. It also depends on the system and reimbursement mechanisms.

In the average hospital, the goal is increasing revenue, which is how they stay in business. But it is increasingly costly and maybe gluttonous. A recent example surfaced.

There is a great emphasis on pulmonary rehabilitation in recent years. Medicare reimburses for this. I had a patient that enrolled at the local hospital and he stated that Medicare was billed about $2500 for the two-week program. There were about 20 COPD patients in his group and he figured that the hospital revenue for providing one respiratory therapist for two hours a day to lead this group netted the hospital well over $50,000 for what he estimated at 25 hours of work.

I also had some Kaiser Permanente patients in my research group that went to pulmonary rehabilitation at KP three days a week for 10 or 15 years. There was no charge in this integrated health care system. I made a visit to the rehab unit and spoke with the respiratory therapist. He stated that KP provides these facilities and saves considerable moneys by preventing hospitalizations. He had the figures to prove that when patients dropped out of the program, they were more likely to go to the emergency room and be admitted.

The key difference is that the private hospitals make money on such programs and also make money on the failure of such programs, which then requires admission to their high-cost center.

KP, being an integrated health care system with the three arms of Kaiser Foundation Hospitals, Kaiser Foundation Health Plans, and The Permanente Medical Group, work in concert with each other to reduce health care costs. They are connected through electronic medical records that allow any Permanente physician to access a patient's medical record from any computer terminal within the system. It appears to be a winning combination. They feel that this is the answer to the insurance dilemma.