In short, I’ve found the term “medical tourism” is something of a misnomer, often leading patients to emphasize the recreational more than the procedural in their quest for medical care abroad. Unlike much of the hype that surrounds contemporary health travel, Patients Beyond Borders focuses more on your health than on your travel preferences. Thus, throughout this book, you won’t see many references to the terms “medical tourism” or “health tourism.” In the same way business travelers don’t normally consider themselves tourists, you’ll begin to think more in terms of medical travel and health travel.

My research, including countless interviews, has convinced me: With diligence, perseverance, and good information, patients considering traveling abroad for treatment do indeed have legitimate, safe choices, not to mention an opportunity to save thousands of dollars over the same treatment in the United States. Hundreds of patients who have returned from successful treatment overseas provide overwhelmingly positive feedback. They persuaded me to write this impartial, scrutinizing guide to becoming an informed international patient. I designed this book to help readers reach their own conclusions about whether and when to seek treatment abroad.

So, why go abroad for medical care? Here are seven reasons.

1. Cost savings.  Most people like to get the most for their dollar. The single biggest reason Americans travel to other countries for medical treatment is the opportunity to save money. Depending upon the country and type of treatment, uninsured and underinsured patients, as well as those seeking elective care, can realize 15 to 85 percent savings over the cost of treatment in the United States. Or, as one successful health traveler put it, “I took out my credit card instead of a second mortgage on my home.” As baby boomers become senior boomers, costs of healthcare and prescriptions are devouring nearly 30 percent of retirement and preretirement incomes. With the word getting out about top-quality treatments at deep discounts overseas, informed patients are finding creative alternatives abroad. The costs listed in this table are for surgery (except as noted), including the hospital stay in a private, single-bed room. Airfare and lodging costs are governed by individual preferences. To compute a ballpark estimate of total costs, add $5,000 to the amounts shown in the table for you and a companion, figuring coach airfare and hotel rooms averaging $150 per night. For example, a hip replacement in Bangkok, Thailand, would cost about $18,000, for an estimated savings of at least $15,000 compared with the U.S. price. The estimates above are for treatments alone. Airfare, hospital stay (if any), and lodging vary considerably. Savings on dentistry become more dramatic when “big mouth-work” is required, involving several teeth or full restorations. Savings of $15,000 or more are common.

2. Better-quality care.  Veteran health travelers know that facilities, instrumentation, and customer service in treatment centers abroad often equal or exceed those found in the United States. Governments of countries such as India and Thailand have poured billions of dollars into improving their healthcare systems, which are now aggressively catering to the international health traveler. VIP waiting lounges, deluxe hospital suites, and staffed recuperation resorts are common amenities, along with free transportation to and from airports, low-cost meal plans for companions, and discounted hotels affiliated with the hospital. Moreover, physicians and staff in treatment centers abroad are often far more accessible than their U.S. counterparts. “My surgeon gave me his cellphone number, and I spoke directly with him at least a dozen times during my stay,” said David P., who traveled to Bangkok for a heart valve replacement.

3. Excluded treatments.  Even the most robust health insurance plans exclude a variety of conditions and treatments. You, the policyholder, must pay these expenses out of pocket. Although health insurance policies vary according to the underwriter and individual, your plan probably excludes a variety of treatments, such as cosmetic surgeries, dental care, vision treatments, reproductive/infertility procedures, certain nonemergency cardiovascular and orthopedic surgeries, weight loss programs, substance abuse rehabilitation, and prosthetics—to name only a few. In addition, many policies place restrictions on prescriptions (some quite expensive), postoperative care, congenital disorders, and pre-existing conditions. Rich or cash-challenged, young or not-so-young, heavily or only lightly insured, folks who get sick or desire a treatment (even one recommended by their physician) often find their insurance won’t cover it. Confronting increasingly expensive choices at home, nearly 40 percent of American health travelers hit the road for elective treatments. In countries such as Costa Rica, Singapore, Dubai, and Thailand, this trend has spawned entire industries, offering excellent treatment and ancillary facilities at costs far lower than U.S. prices.

4. Specialty treatments.  Some procedures and prescriptions are simply not allowed in this country. Either Congress or the Food and Drug Administration has specifically disallowed a certain treatment, or perhaps it’s still in the testing and clinical trials stage or was only recently approved. Such treatments are often offered abroad. One example is an orthopedic procedure known as hip resurfacing, a less expensive alternative to the traditional hip replacement still practiced in the United States. While this procedure has been performed for more than a decade throughout Europe and Asia, it was only recently approved in the United States, and its availability here remains spotty. Hundreds of forward-thinking Americans, many having suffered years of chronic pain, have found relief in India, where hip resurfacing techniques, materials, and instrumentation have been perfected, and the procedure is routine.

5. Shorter waiting periods.  For decades, thousands of Canadian and British subscribers to universal, “free” healthcare plans have endured waits as long as two years for established procedures. “Some of us die before we get to the operating table,” commented one exasperated patient, who journeyed to India for an open-heart procedure. Here in the United States, long waits are a growing problem, particularly among war veterans covered under the Veterans Administration Act, for whom long queues are becoming far too common. Some patients figure it’s better to pay out of pocket to get out of pain or to halt a deteriorating condition than to suffer the anxiety and frustration of waiting for a far-future appointment and other medical uncertainties.

6. More “inpatient friendly.”  As U.S. health insurance companies apply increasing pressure on hospitals to process patients as quickly as possible, outpatient procedures are becoming the norm. Similarly, U.S. hospitals are under huge pressure to move inpatients out of those costly beds as soon as possible. Medical travelers will welcome the flexibility at the best hospitals abroad, where they are often aggressively encouraged to spend extra time in the hospital post-procedure. Patient-to-staff ratios are usually lower abroad, as are hospital-borne infection rates.

7. The lure of the new and different.  Although traveling abroad for medical care can be challenging, many patients welcome the chance to blaze a trail, and they find the creature comforts often offered abroad a welcome relief from the sterile, impersonal hospital environments so often encountered in U.S. treatment centers. For others, simply being in a new and interesting culture lends distraction to an otherwise worrisome, tedious process. And getting away from the myriad obligations of home and professional life can yield healthful effects at a stressful time. What’s more, travel—and particularly international travel—can be a life-changing experience. You might be humbled by the limousine ride from Indira Gandhi International Airport to a hotel in central New Delhi or struck by the simple, elegant graciousness of professionals and ordinary people in Thailand, or wowed by the sheer beauty of the mountain range outside a dental office window in Mexico. As one veteran medical traveler put it, “I brought back far more from this trip than a new set of teeth.”

This article is based on excerpts from the second edition of Patients Beyond Borders (2008), the flagship of a landmark series of consumer guides to international medical travel that have helped thousands of patients plan successful health journeys abroad. Healthy Travel Media, publisher of the guides, has become a global clearinghouse for useful information about medical and wellness travel.

Copyright © 2008 U.S. News & World Report, L.P. All rights reserved.

Sept. 26, 2008-

Most of us believe that when a doctor orders screening tests, that’s a serious step toward keeping illness at bay. The screening test can find factors that place us at risk for diseases we might develop in the future or find hidden diseases. In either case, we will be treated.

Screening tests are considered a triumph of modern public health medicine. I only wish it was that straightforward.

It turns out that many of the commonly recommended screening tests fall far short on this promise. They fall so far short that no one should have them without first discussing them with their doctor.

If you are not convinced you will be advantaged by having the test, why bother?

Let me illustrate this with three of the commonly recommended tests. I will explain why I have never let anyone check my cholesterol or my PSA, and why I have submitted to colonoscopy once, and never again.

Blood Cholesterol
Blood cholesterol level is a risk factor for heart and other blood vessel diseases — but not much of a risk factor. If you have the worst LDL and HDL cholesterol we find occasionally in the population, you have a year or two of life expectancy at risk.

For nearly all who are told they have “high” cholesterol, the amount of time on earth that they are risking is measured in months. I’m not sure we can even measure such a small risk, or that I care.

But if you do, the next question is crucial. Can we do anything to my cholesterol that reduces the risk? That’s not the same question as can you lower the cholesterol? We can do that very well, and we do lower the cholesterol of millions of Americans thereby reducing the risk factor. But does that reduce the risk?

There are scientific studies asking this question. The treatment does not reduce the risk of dying from heart disease. The most optimistic analysis of these scientific studies leads to the following conclusion: 250 people who have not had a heart attack would have to swallow a statin drug every day for five years to spare a heart attack.

Do you believe we can even measure such a tiny effect? Is it worth your while to take these pills for years? Would it be worth it if you had to pay out-of-pocket?

PSA Testing
PSA stands for Prostate Specific Antigen. It’s a normal protein in the prostate. A small amount gets into the bloodstream normally.

Greater amounts get into the bloodstream if the prostate is inflamed by infection. Prostate cancer is another cause of more PSA getting into the bloodstream.

Prostate cancer is a normal part of aging; by age 70, essentially all men have prostate cancer. Furthermore, nearly all men will die with their prostate cancer and not from it.

The challenge for screening is not to find prostate cancer, but to find the prostate cancer that will kill a man before his time. That’s a tall order, and one for which PSA screening is a double-edged sword. After all, if you want to be sure you will not die from prostate cancer before your time, you will have to submit to a procedure, usually a major surgical procedure that offers a 15 percent likelihood of incontinence and more of impotence.

In a clinical trial in Scandinavia, a great number of aging men were divided into two groups. Those who were offered and opted for surgery for their elevated PSA gained very little for the experience compared to those who were not offered surgery. They gained too little for me to opt for the surgery if my PSA was elevated. Therefore, I won’t let anyone check my PSA. You need to have this discussion with your doctor before you opt to have a screening PSA.

Colonoscopy
A few rare families and rare diseases aside, colon cancer is another disease of the sunset years.

Like prostate cancer, it is slow to grow and slow to spread but it is far less common than prostate cancer. The treatment, surgical removal, has far less likelihood of complications than prostate surgery.

The screening is not a blood test; it’s hunting for the cancer directly. More and more, this is done by inserting a tube into the colon and looking inch-by-inch. It’s not a perfect test, requiring patience as much as dexterity.

And it has complications, many of which relate to the removal of polyps which are grape-like growths on a stalk that have very little potential for harm (if they develop into cancer at all, it takes decades).

So we are back to our critical question. The issue is not whether one can find a cancer and remove it, but whether one can find and remove the cancer that is likely to cost me time on this earth.

I don’t care if I develop colon cancer in my 80s; something else is likely to kill me long before it can. I don’t care if I develop colon cancer in my 70s either, for the same reason. Furthermore, screening me in my 40s is largely an exercise in futility; colon cancer is so very, very rare in 40-year-olds that the chances of a complication of colonoscopy far outweighs the chances of finding the rare cancer. It’s in the 50s and 60s that finding and removing the rare colon cancer is likely to be meaningful to that person and worth the risks to all those who don’t have colon cancer.

Hence, I had my one colonoscopy. In fact, I settled for a partial look (flexible sigmoidoscopy) because that was good enough risk assessment for me and the procedure is gentler and safer.

I am not alone in realizing the limitations of these tests and others such as mammography or even the annual physical examination. Many a researcher has been recruited to the task of improving screening tests. However, until we have much better screening tests, no person should be screened unaware of the limitations of the test.

Dr. Nortin Hadler is professor of medicine and microbiology/immunology at the University of North Carolina at Chapel Hill, and an attending rheumatologist at University of North Carolina Hospitals. He is the author of Worried Sick: A Prescription for Health in an Overtreated America and The Last Well Person.

American presidents generally don’t like to talk about their health problems. Few people knew, for instance, that during their presidencies, Woodrow Wilson had suffered a massive stroke that left him partially paralyzed or that John F. Kennedy was taking as many as eight medications a day to deal with extensive back pain, digestive problems and the hormonal disorder known as Addison’s disease.

As the 2008 presidential race heats up, two University of Michigan medical historians argue in the June 4 issue of the Journal of the American Medical Association that given the poor track record of past presidents to share medical details and the already strong interest in the health histories of nominees Sens. John McCain and Barack Obama, Congress should appoint an impartial panel to evaluate presidents and presidential candidates’ health.

We asked one of the authors, Dr. Howard Markel, director of the Center for the History of Medicine at the University of Michigan, to explain the concept and who it will really help.

Howard Markel:  If you’re healthy, nothing. If there’s something slightly there, you don’t want to give your opponent or opponent’s spinner any kind of leeway to knock you down. With the era of the permanent campaign, instant communication and the 24-7 news cycle, no one wants to give out information that might hurt [his or her] chance to win an election. We have found out that anything can and will be used against them.

Should a president’s or presidential candidate’s health be of concern to the public?

Absolutely. The president is the most powerful person on the planet. Their mental, physical health and well-being, really does effect the global market, war, peace, political legislation–all sorts of things with the stroke of a pen. The caveat is that you really can’t predict based on a medical evaluation today what’s going to happen a year from now. You could be cleared as completely healthy and a year later have a debilitating heart attack. But it’s important for people to know. We make decisions based on where people go to worship, their income, where they went to college. From my perspective, as a physician and historian of medicine, this is a big piece of data we want to know.

Why do you think there currently isn’t a method to assure impartial, candid health evaluations for future presidents and presidential candidates?

It’s all about control. It’s only gotten worse with each successive campaign cycle. You have to control the information getting out that might hurt you, even information you don’t think would hurt you. Sen. [Barack] Obama smoked cigarettes. There’s no evidence he has lung cancer or heart disease. But in this era, smoking cigarettes is looked down upon much more negatively than when FDR was running for president and had a cigarette in his mouth.

Explain the method you propose.

Once somebody is president, he needs to be examined on a regular basis, annually or more frequently. We want nominees to be examined too. And it’s critical that they’re not examined by their own physicians. If I’m physician to the president I’m probably going to like that job. There’s a conflict of, do I do something that will get the president upset enough to fire me?

An independent panel would be appointed by Congress with all sorts of doctors, dermatologists, neurologists and cardiologists, so that [everything] is covered, but also other experts, such as lawyers and ethicists, to help in terms of publication of such a report. They would be independent umpires who don’t have a dog in the race.

It’s also critical that nominees and presidents are evaluated because the 25th amendment of the U.S. Constitution … is vague in how it defines disability. How it’s defined today compared to 1967, when the amendment was ratified, has changed markedly. We need clear definitions.

At the annual checkup, nominees could voluntarily say there are categories they want to opt out of disclosing. They may have a genetic screening and carry a trait … that they don’t want reported. They may say they want to talk about that with their children, but it has no bearing on their ability to govern.

What do you say to people who feel this is too big an invasion of the president’s or candidates’ privacy?

We offer patients confidentiality, and that’s critically important for regular patients. But let’s face it: The president of the United States and the nominees for president of the United States are the most public patients in the world. They have long since given up any elements of privacy. We know whether they like hot dogs or the Yankees. With health, it’s just too important.

What about those who might argue that disclosing information about the president’s health could affect global politics?

If the president has a serious illness, like let’s say a stroke, that’s serious. We need to know about that right away. The vice president needs to be put in place by the 25th amendment. If it’s a long-standing [health problem], you’ve got a little bit more leeway.

I would argue it’s a bigger threat to national security by hiding it than by disclosing it. Transparency is way better than opaque policies–that’s one thing history teaches us again and again.

Similar lawsuits have been filed in several states which have led to the halting of executions in Texas, Delaware and New Jersey.

The men in these articles have tortured, raped and killed innocent people.  What gives them the right to life? They took a life, if not, several.  What about the rights of the victim’s family to see justice for the loss of a loved one?

What kind of message would we be giving criminals?  By halting executions, are we telling “would be” criminals to fatten up to commit heinous crimes so that they may not face the death penalty?  I don’t think the victims of these men had a choice in the way their lives ended so abruptly!

Here are the articles, if you would like to read them…   

http://www.cnn.com/2008/CRIME/08/25/death.penalty.fat.ap/index.html

http://abcnews.go.com/TheLaw/story?id=3684431

By Robert Winnett, Deputy Political Editor

The National Institute for Health and Clinical Guidelines (Nice) has ruled for the first time that saving a life cannot be justified at any cost, in a review of its ethical guidelines.

The ruling - made by the board of the controversial organisation - contradicts advice it received from its own ‘Citizens Council’ which offers advice from a representative sample of the general public.

Nice is facing growing criticism over the number of drugs it is now rejecting which are available throughout Europe and in America. Last week, it refused to sanction four kidney cancer drugs which can double life expectancy.

It has now rejected the so-called “rule of rescue” which stipulates that people facing death should be treated regardless of the costs. The rule is based on the natural impulse to aid individuals in trouble.

In a report on “social values judgement” the regulator says: “There is a powerful human impulse, known as the ‘rule of rescue’, to attempt to help an identifiable person whose life is in danger, no matter how much it costs. When there are limited resources for healthcare, applying the ‘rule of rescue’ may mean that other people will not be able to have the care or treatment they need.

“Nice recognises that when it is making its decisions it should consider the needs of present and future patients of the NHS who are anonymous and who do not necessarily have people to argue their case on their behalf…The Institute has not therefore adopted an additional ‘rule of rescue’.”

The ruling contradicts the advice of Nice’s Citizens Council, which said that a rule of rescue was an essential mark of a humane society. The report said that where individuals are in “desperate and exceptional circumstances” they should sometimes receive greater help than can be justified by a “purely utilitarian approach”.

Doctors have also criticised the ruling. Tony Calland, chairman of the ethics committee of the British Medical Association, said: “We would be opposed to ignoring a rule of rescue when it introduces a degree of flexibility around extreme cases. So what if you waste a few pounds if you are doing your best for humanity?”

Nice defended its ruling last night saying that the Citizens Council provided useful input to its decisions but that the organisation’s role was to determine how best to allocate the health service’s limited resources.

Nice is facing increasing accusations that it is giving undue weight to financial considerations - rather than medical benefits - when making decisions on whether to allow drugs or other treatments on the NHS. Doctors and patients have alleged that they are treated with contempt by the organisation and that life-saving drugs are being unfairly denied.

The Daily Telegraph disclosed yesterday that Nice is preparing to offer patients advice on the medical benefits of drugs that are not available on the NHS. The disclosure is likely to anger patients who face paying tens of thousands of pounds for expensive drugs which may prolong their lives.

By MARILYN ELIAS
USA TODAY
Aug. 15, 2008—

Multiple combat deployments to Iraq are increasing serious mental health problems among soldiers, triggering drug and alcohol abuse and contributing to record suicide levels, suggest reports out Thursday at the American Psychological Association meeting in Boston.

In a typical unit headed to Iraq, 60 percent are on their second, third or fourth deployment, lasting about a year each, says U.S. Army Col. Carl Castro, who directs a medical research program at Fort Detrick, Md.

More time in Iraq means heavier exposure to violence, which leads more soldiers to develop symptoms of post-traumatic stress disorder (PTSD) and depression, Castro told the psychology meeting. By their third tour to Iraq, more than a quarter of soldiers show signs of mental problems, such as PTSD, and it’s about 1 out of 3 for those exposed to heavy combat, according to a U.S. Army Surgeon General report in March on more than 2,000 soldiers.

In another report at the meeting, deployment correlated with more heavy drinking and illegal drug use, according to anonymous questionnaires given to about 34,000 active duty troops, Reservists and National Guard members. Deployed Reserve troops had the highest traumatic stress symptoms and rates of “seriously considering suicide,” according to the Defense Department-funded study by RTI International, Research Triangle Park, N.C.

National Guard and Reservists sent to Iraq and Afghanistan are disproportionately represented in returning veteran suicides, according to a Departmentof Veterans Affairs analysis. There were 115 Army suicides and 935 reported attempts in 2007, a record high, show Army reports.

“There are concerns about the reserves,” says Lynn Pahland, a health promotion policy director in the Defense Department. But the military is increasing efforts to prevent, identify and treat troubled troops,she adds.

At a crisis hotline for veterans, about 75 percent of the 400 calls a weekcome from Reserve and National Guard troops or their families, says Shad Meshad, president of the National Veterans Foundation (1-888-777-4443), which runs the line. “Many have been sent back three or four times,” he says.

On Wednesday, a Texas Reservist going to Iraq for the fourth time called “in a hysterical state” because his house is being foreclosed on, and his wife is taking the kids and leaving him. Says Meshad: “We’re just trying to help him out with the financial stuff and keep him from hurting himself.”

Copyright © 2008 ABC News Internet Ventures

By SUSAN DONALDSON JAMES
Aug. 6, 2008 —

The news from Barbara Wagner’s doctor was bad, but the rejection letter from her insurance company was crushing.

The 64-year-old Oregon woman, whose lung cancer had been in remission, learned the disease had returned and would likely kill her. Her last hope was a $4,000-a-month drug that her doctor prescribed for her, but the insurance company refused to pay.

What the Oregon Health Plan did agree to cover, however, were drugs for a physician-assisted death. Those drugs would cost about $50.

“It was horrible,” Wagner told ABCNews.com. “I got a letter in the mail that basically said if you want to take the pills, we will help you get that from the doctor and we will stand there and watch you die. But we won’t give you the medication to live.”

Critics of Oregon’s decade-old Death With Dignity Law — the only one of its kind in the nation — have been up in arms over the indignity of her unsigned rejection letter. Even those who support Oregon’s liberal law were upset.

The incident has spilled over the state border into Washington, where advocacy groups are pushing for enactment of Initiative 1000 in November, legalizing a similar assisted-death law.

Opponents say the law presents all involved with an “unacceptable conflict” and the impression that insurance companies see dying as a cost-saving measure. They say it steers those with limited finances toward assisted death.

“News of payment denial is tough enough for a terminally ill person to bear,” said Steve Hopcraft, a spokesman for Compassion and Choices, a group that supports coverage of physician-assisted death.

Letter’s Impact ‘Devastating’
“Imagine if the recipient had pinned his hope for survival on an unproven treatment, or if this were the first time he understood the disease had entered the terminal phase. The impact of such a letter would be devastating,” he told ABCNews.com.

Wagner, who had worked as a home health care worker, a waitress and a school bus driver, is divorced and lives in a low-income apartment. She said she could not afford to pay for the medication herself.

“I’m not too good today,” said Wagner, a Springfield great-grandmother. “But I’m opposed to the [assisted suicide] law. I haven’t considered it, even at my lowest point.”

A lifelong smoker, she was diagnosed with lung cancer in 2005 and quit. The state-run Oregon Health Plan generously paid for thousands of dollars worth of chemotherapy, radiation, a special bed and a wheelchair, according to Wagner.

The cancer went into remission, but in May, Wagner found it had returned. Her oncologist prescribed the drug Tarceva to slow its growth, giving her another four to six months to live.

But under the insurance plan, she can the only receive “palliative” or comfort care, because the drug does not meet the “five-year, 5 percent rule” — that is, a 5 percent survival rate after five years.

A 2005 New England Journal of Medicine study found the drug erlotinib, marketed as Tarceva, does marginally improve survival for patients with advanced non-small cell lung cancer who had completed standard chemotherapy.

The median survival among patients who took erlotinib was 6.7 months compared to 4.7 months for those on placebo. At one year, 31 percent of the patients taking erlotinib were still alive compared to 22 percent of those taking the placebo.

“It’s been tough,” said her daughter, Susie May, who burst into tears while talking to ABCNews.com. “I was the first person my mom called when she got the letter,” said May, 42. “While I was telling her, ‘Mom, it will be ok,’ I was crying, but trying to stay brave for her.”

“I’ve talked to so many people who have gone through the same problems with the Oregon Health Plan,” she said.

Indeed, Randy Stroup, a 53-year-old Dexter resident with terminal prostate cancer, learned recently that his doctor’s request for the drug mitoxantrone had been rejected. The treatment, while not a cure, could ease Stroup’s pain and extend his life by six months.

Playing With ‘My Life’
“What is six months of life worth?” he asked in a report in the Eugene Register-Guard. “To me it’s worth a lot. This is my life they’re playing with.”

The Oregon Health Plan was established in 1994 and the physician-assisted death law was enacted in 1997. The state was recently hailed by a University of Wisconsin study as having one of the nation’s top pain-management policies.

The health plan, for those whose incomes fall under the poverty level, prioritizes coverage — from prevention first, to chronic disease management, treatment of mental health, heart and cancer treatment.

“It’s challenging because health care is very expensive, but that’s not the real essence of our priority list,” said Dr. Jeanene Smith, administrator for the Office of for Oregon’s Health Policy and Research staff.

“We need evidence to say it is a good use of taxpayer’s dollars,” she said. “It may be expensive, but if it does wonders, we cover it.”

The state also regularly evaluates and updates approvals for cancer treatments. “We look as exhaustively as we can with good peer review evidence,” she said.

The health plan takes “no position” on the physician-assisted suicide law, according to spokesman Jim Sellers.

The terminally ill who qualify can receive pain medication, comfort and hospice care, “no matter what the cost,” he said.

But Sellers acknowledged the letter to Wagner was a public relations blunder and something the state is “working on.”

“Now we have to review to ensure sensitivity and clarity,” Sellers told ABCNews.com “Not only is the patient receiving had news, but insensitivity on top of that. This is something that requires the human touch.”

Sellers said that from now on insurance officials will likely “pick up the phone and have a conversation,” he said.

But a 1998 study from Georgetown University’s Center for Clinical Bioethics found a strong link between cost-cutting pressures on physicians and their willingness to prescribe lethal drugs to patients — were it legal to do so.

The study warns that there must be “a sobering degree of caution in legalizing [assisted death] in a medical care environment that is characterized by increasing pressure on physicians to control the cost of care.”

Cancer drugs can cost anywhere from $3,000 to $6,000 a month. The cost of lethal medication, on the other hand, is about $35 to $50.

Advocates for the proposed Washington law say that while offering death benefits but not health care can be perceived as a cost-cutting, “respectable studies” say otherwise.

“The reason is that hospice care, where most patients are at the end of life is relatively inexpensive,” Anne Martens, spokesman for Washington’s Death With Dignity Initiative, told ABCNews.com.

But even those who support liberal death laws say Wagner’s predicament is reflective of insurance attitudes nationwide.

Case Is Not Unique
“Her case is hardly unique,” said Michigan lawyer Geoffrey Fieger, who defended Dr. Jack Kevorkian’s crusade to legalize physician-assisted deaths. “In the rest of the country insurance companies are making these decisions and are not paying for suicide,” Fieger told ABCNews.com. “Involuntary choices are foisted on people all the time by virtue of denials.”

“I am surprised there hasn’t been a revolt in this country,” he said. “It happens every day and people are helpless.”

Indeed, one executive suffering from a rare and potentially fatal form of liver cancer is fighting his insurance company for coverage. Oncologists from a major teaching hospital in New York City have prescribed Sutent — a medication that costs about $4,000 a month and could extend his life expectancy.

“Most of my objections are that some second rate guy on the staff of the insurance company is second-guessing one of the foremost authorities and trumping his judgment,” said the 57-year-old executive, who didn’t want his name used to protect his privacy.

“I am fortunate to have the financial resources and the ability to fight these people who would rather these you die,” he told ABCNews.com.

Dr. Jonathan Groner, clinical professor of surgery at OSU College of Medicine and Public Health in Columbus, Ohio, said some patients may want to prolong their lives for a life-cycle event, like a birth or wedding.

“A course of chemo would not cure, but would subdue the cancer long enough to be meaningful,” he told ABCNEWS.com. “There are many people with slow-growing but nonetheless metastatic cancer for whom death, while inevitable, is many years away.”

“The problem with the Oregon plan is it sounds like administrators, not physicians, are making treatment decisions,” he said. “And if a patient can get assisted death paid for but not cancer treatment, the choice is obvious.”

Derek Humphry, founder of the Hemlock Society and author of “Final Exit,” who helped write the Oregon Death With Dignity Law, said only about 30 people a year choose an assisted death, which must be approved by two doctors.

“It’s purely optional and the patient and doctor can walk away from it,” the 78-year-old told ABCNEWS.com. “It’s not the mad rush our enemies predicted and for our residents it has worked out well.”

His own wife, Jean, was diagnosed with fast-growing breast cancer in 1975 and asked him to help find drugs to help her die. At 42, she chose to take them and ended her life.

Humphry says the Oregon Health Plan’s approach to coverage is sound.

“People cling to life and look for every sort of crazy cure to keep alive and usually they are better off not to have done it,” he said.

Meanwhile Wagner has faith in her medicine, not assisted death. Now, at the request of her doctor, the pharmaceutical company Genentech is giving her Tarceva free of charge for one year.

“The doctor did say it would put a lid on the cancer and I am hopeful,” she said.

Wagner’s daughter Susie May says her mother is a fighter. “I think we all knew that this is her last hope,” she said.

Even Wagner’s ex-husband, Dennis Wagner of Springfield, has weighed in on the ethical dilemma.

“My reaction is pretty typical,” he told ABCNews.com. “I am sick and tired of the dollar being the bottom line of everything. We need to put human life above the dollar.”
Rana Senol of ABC News Research contributed to this report.

A growing chorus of discontent suggests that the once-revered doctor-patient relationship is on the rocks.

The relationship is the cornerstone of the medical system — nobody can be helped if doctors and patients aren’t getting along. But increasingly, research and anecdotal reports suggest that many patients don’t trust doctors.

About one in four patients feel that their physicians sometimes expose them to unnecessary risk, according to data from a Johns Hopkins study published this year in the journal Medicine. And two recent studies show that whether patients trust a doctor strongly influences whether they take their medication.

The distrust and animosity between doctors and patients has shown up in a variety of places. In bookstores, there is now a genre of “what your doctor won’t tell you” books promising previously withheld information on everything from weight loss to heart disease.

The Internet is bristling with frustrated comments from patients. On The New York Times’s Well blog recently, a reader named Tom echoed the concerns of many about doctors. “I, as patient, say stop acting like you know everything,” he wrote. “Admit it, and we patients may stop distrusting your quick off-the-line, glib diagnosis.”

Doctors say they are not surprised. “It’s been striking to me since I went into practice how unhappy patients are and, frankly, how mistreated patients are,” said Dr. Sandeep Jauhar, director of the heart failure program at Long Island Jewish Medical Center and an occasional contributor to Science Times.

He recounted a conversation he had last week with a patient who had been transferred to his hospital. “I said, ‘So why are you here?’ He said: ‘I have no idea. They just transferred me.’

“Nobody is talking to the patients,” Dr. Jauhar went on. “Everyone is so rushed. I don’t think the doctors are bad people — they are just working in a broken system.”

The reasons for all this frustration are complex. Doctors, facing declining reimbursements and higher costs, have only minutes to spend with each patient. News reports about medical errors and drug industry influence have increased patients’ distrust. And the rise of direct-to-consumer drug advertising and medical Web sites have taught patients to research their own medical issues and made them more skeptical and inquisitive.

“Doctors used to be the only source for information on medical problems and what to do, but now our knowledge is demystified,” said Dr. Robert Lamberts, an internal medicine physician and medical blogger in Augusta, Ga. “When patients come in with preconceived ideas about what we should do, they do get perturbed at us for not listening. I do my best to explain why I do what I do, but some people are not satisfied until we do what they want.”

Others say the problem also stems from a grueling training system that removes doctors from the world patients live in.

“By the time you’re done with your training, you feel, in many ways, that you are as far as you could possibly be from the very people you’ve set out to help,” said Dr. Pauline Chen, most recently a liver transplant surgeon at the University of California, Los Angeles, and the author of “Final Exam: A Surgeon’s Reflections on Mortality” (Knopf, 2007). “We don’t even talk the same language anymore.”

Dr. David H. Newman, an emergency room physician at St. Luke’s-Roosevelt Hospital Center in Manhattan, says there is a disconnect between the way doctors and patients view medicine. Doctors are trained to diagnose disease and treat it, he said, while “patients are interested in being tended to and being listened to and being well.”

Dr. Newman, author of the new book “Hippocrates’ Shadow: Secrets from the House of Medicine” (Scribner), says studies of the placebo effect suggest that Hippocrates was right when he claimed that faith in physicians can help healing. “It adds misery and suffering to any condition to not have a source of care that you trust,” Dr. Newman said.

But these doctors say the situation is not hopeless. Patients who don’t trust their doctor should look for a new one, but they may be able to improve existing relationships by being more open and communicative.

Go to a doctor’s visit with written questions so you don’t forget to ask what’s important to you. If a doctor starts to rush out of the room, stop him or her by saying, “Doctor, I still have some questions.” Patients who are open with their doctors about their feelings and fears will often get the same level of openness in return.

“All of us, the patients and the doctors, ultimately want the same thing,” Dr. Chen said. “But we see ourselves on opposite sides of a divide. There is this sense that we’re facing off with each other and we’re not working together. It’s a tragedy.”

With gas prices hovering around $4 a gallon, my patients are cutting back on medical care.

A 59-year-old woman decided not to have a mammogram this year. At her age, she should be screened for colon cancer, too, but she is holding off until she becomes eligible for Medicare at 65.

Despite having some medical insurance as a self-employed cleaning woman, she is pinching pennies by scrimping on preventive care. If she develops cancer of the colon or breast she won’t have saved anything. This year she is taking her chances. 
 
Rising deductibles, stiff drug co-payments and increasing prices for just about everything are forcing some hard choices about health. Care that doesn’t strike patients as critical is getting delayed. As the economy squeezes my patients, they are showing up sicker.

A patient quit smoking so he could afford gas for the 40 mile commute to work in a packaging plant. He has been living paycheck to paycheck for years and his rent just went up. I was glad that something finally motivated him to stop smoking.

The bad news was that he came to the office with severe pneumonia two days after refusing to let an E.R. doctor admit him to the hospital. My patient was afraid of the expense and all the time he would go without pay from work.

To make matters worse, he didn’t fill the antibiotic prescription he was given either. The $50 co-payment was unaffordable, he said. This is a case when an insurer would have been better off picking up the antibiotic tab to avoid a larger expense. But there’s no easy way for a doctor to override a plan’s co-pay or to let an insurer know its rules are about to make something very expensive happen.

When the patient came to see me, his condition had deteriorated. I persuaded him to let me admit him to the local hospital. He was in such bad shape that he was soon transferred to the ICU of a large medical center. His care will end up costing tens of thousands of dollars.

It was no surprise to me to read recently that claims severity and costs for health insurers took an unexpected jump this year. Many patients are not able to bear even a moderate expense to save their insurance companies the cost of major claims.

A 53-year-old patient couldn’t avoid a trip to see me when his finger was fractured in a log splitter. After X-rays and having his fingertip sutured together, the man required several trips to the office for dressing changes and monitoring for infection.

He’s been unable to work as a laborer in the month since he got hurt. With no money coming in, he’s racked up $200 in office co-payments for visits that his insurance won’t be covering. We’re carrying his balance until he can get back to work.

He isn’t the only one in arrears. As a result of lean times, accounts receivable from uninsured patients in my practice is trending up. About 5% of our patients are uninsured.

Patients are still having babies at the same rate. But elective procedures, preventive exams and compliance with prescriptions are all down.

Some of my patients are taking themselves off medications. Just last week I encountered patients who stopped their cholesterol medication and urinary incontinence medications. I’m getting fewer refill requests for E.D. drugs, like Viagra, too.

I noticed an uptick in patients canceling appointments and just not showing up over the last few weeks. More people are asking for advice over the phone and trying to avoid an office visit.

Many of our patients travel 20 or 30 miles to see us, and I think gas prices are affecting no-show and cancellation rates, particularly with low income patients.

My total number of office visits is off 5% from last year. Another indication of the slowdown is that I’m getting my nursing home rounds done. I’m pretty well caught up on my daily deluge of paperwork, too. When things are busy, I almost never get those things accomplished.

It occurred to me in an idle moment that I would be a lot busier if the $600 government stimulus checks had been spent on a basket of basic primary care services. That would have paid for 130 million people to have had most of their health needs met for a year. Instead, folks around here seem to be spending more on $4 gas.

http://online.wsj.com/article/SB121675678304374527.html?mod=2_1566_topbox

By JULIE APPLEBY
July 14, 2008

States, the federal government and private insurers are experimenting with an idea to cut costs and make patients happier: Paying primary-care doctors extra money to oversee and coordinate patients’ care.

The pay boost rewards doctors who reshape their practices to recreate an era when a trusted family physician helped patients through hospitalizations, coordinated specialist care and provided routine screenings. Such efforts may save money by reducing hospitalizations, ER visits and disease.

Dubbed “medical homes,” the concept is a modern twist on an idea first promoted in the 1960s. Under most pilot projects being tested, primary-care doctors who have established medical homes will receive additional fees ranging from just a few dollars a month per patient to more than $35,000 a year per doctor from states, Medicare or other insurers.

Medicare this year will choose eight states to test whether paying primary-care doctors more per month to treat patients with chronic illnesses in medical home settings results in better care and lower costs than traditional practices.

The concept aims to change rushed doctor’s appointments and fragmented specialist care by creating patient care “teams,” which could include nurse practitioners, nutritionists or other medical staff. Medical homes also offer longer office hours, electronic medical records and same-day appointments.

The idea is that patients would turn to a trusted adviser, either the doctor or another team member, for preventive and routine care and rely on that person to help coordinate needed screenings, specialist visits and other care, says Terry McGeeney, head of TransforMED, a subsidiary of the American Academy of Family Physicians that helps doctors create such practices.

While health maintenance organizations and managed care companies aimed for such coordination, many didn’t pay doctors adequately for it, instead rewarding them financially for restricting care, says McGeeney. Under medical homes, he says, doctors won’t prevent patients from seeing specialists or ordering tests.

It’s not clear how well such plans will work. North Carolina saved $231 million in 2002-03 by setting up medical homes in its Medicaid program.

Joseph Antos, an economist at the conservative American Enterprise Institute, says no one argues with the goal, but: “If all we’re doing is rearranging the deck chairs on the medical Titanic, and spending more money, that’s clearly not something we want to do.”

The idea appeals to doctors such as Joseph Mambu, who set up his Pennsylvania practice as a medical home. They recreate “the old-fashioned doctor who has the time to get to know you,” he says. “This is our last, best hope to save primary care.”

Copyright © 2008 ABC News Internet Ventures

By Kay Lazar
Globe Staff / July 8, 2008

A long-awaited report concludes that 12 cents of every $1 paid for health insurance in Massachusetts goes toward 26 state-mandated benefits, from maternity and mental healthcare to infertility and diabetes services.

Graphic Estimated spending on mandated benefits
Statewide, the price tag is $1.3 billion a year, says the report released yesterday by the Division of Health Care Finance and Policy. It was commissioned in 2006 as part of the state’s near-universal health insurance law.

Insurers and small business groups said the findings show that mandates are helping to drive up costs, making coverage unaffordable as many businesses and workers struggle. The business groups said the mandates translate to roughly $1,300 annually per employee in a family healthcare plan.

But some mandates are also required under federal law, the report said, meaning that employers would have to offer those benefits even if the state mandates were not in place. Excluding such benefits, the report concludes that the cost of the state’s mandates would be no higher than $687 million a year, or roughly 6 cents of every $1 paid for health insurance.

State lawmakers are now considering proposals that could require employers to add more benefits, including expanded mental healthcare coverage.

“It’s getting harder and harder for both employees and employers to pay healthcare costs,” said Dr. Marylou Buyse, president of the Massachusetts Association of Health Plans, which represents most of the state’s health insurers.

“We believe there should be a moratorium on all new mandates until healthcare costs rise at the same rate as general inflation,” she said. “Right now, healthcare costs are about two to three times the rate of inflation.”

The report’s authors reviewed health studies about the various mandates and estimated that most of them are cost-effective. But they suggested that regulators may consider removing some that are not considered the standard of care, such as bone marrow transplants for treatment of breast cancer. The report also noted that just five of the mandates - maternity, mental health, home health, preventive care for children, and infertility services - account for 80 percent of the total cost of the mandated benefits.

Advocates for universal health coverage said these conclusions show that regulators and lawmakers are not going to be able to wring significant cost savings from slashing existing benefits.

“Healthcare costs are going to require serious grappling of root causes of cost inflation, which are not these mandated benefits,” said Brian Rosman, research director at Health Care for All, a nonprofit that lobbies for affordable healthcare and pushed for the state’s 2006 landmark health insurance overhaul.

The law included a moratorium on adding mandated health benefits until the state published a report detailing the costs of existing mandates. The report released yesterday effectively lifts that moratorium.

The report did not calculate the cost of mandatory prescription drug coverage, which is being phased in this year.

Small business owners say that that mandate alone is likely to boost costs by another 3 to 4 percent.

“Legislators think companies are all big businesses who can afford to pay, and that’s not true,” said Bill Vernon, state director of the National Federation of Independent Business, which represents small business owners.

Vernon said small business owners are bearing the brunt of the state mandates because most larger companies are exempt from state insurance rules under federal law.

He said healthcare costs are typically the second- or third-largest employer expense and that mandates make it tough for small companies to tailor their coverage to the benefits that would most help their employees.

“Perhaps the employees want something else, like higher pay or more 401K contributions,” he said. “It’s the [lack of] flexibility that really irritates small business owners.”

WASHINGTON (AP) — The Bush administration said Monday it will delay paying doctors for treating Medicare patients in early July to give Congress more time to block a scheduled 10.6 percent fee cut.

The move by the Centers for Medicare and Medicaid Services doesn’t block the cut, scheduled to take place Tuesday. It’s up to Congress to decide that.

But to give Congress more time to act, the agency will instruct its contractors to delay the processing of any physician or non-physician Medicare claims for health care services given during the first 10 business days of July. Claims for services received on before June 30 will be processed as usual.

CMS will not be making any payments at the 10.6 percent reduced rate until July 15, at the earliest, agency spokesman Jeff Nelligan said. The delay in processing claims probably means that claims that would have been paid in mid-July will be delayed up to a week, the agency estimates.

Another option would have been to issue on-time payments at the lower rate and pay the rest later after Congress fixes the problem.

Congress, facing the prospect of millions of angry seniors at the polls in November, will be under tremendous pressure to act quickly when it returns to Washington the week of July 7 to prevent the cuts in payments for some 600,000 doctors who treat Medicare patients. The cuts were scheduled because of a formula that requires fee cuts when spending exceeds established goals.

But Senate Republicans and the White House are in a standoff with Democrats seeking to cut subsidies to insurance companies that provide Medicare coverage to “pay for” easing the payment cuts to doctors. There’s no guarantee the standoff will be broken soon.

Lawmakers on all sides promise that if the impasse goes on and doctors receive the lower payments, they’ll get repaid retroactively through automatically reprocessed claims. That’s more difficult than it sounds, given the millions of Medicare claims that have to be processed every day. A comparable situation that occurred in early 2006 took six months to fully fix.

HHS Secretary Mike Leavitt had promised Friday that his agency “will take all steps available to the department under the law to minimize the impact on providers and beneficiaries.” On Monday, the department used its administrative tools to delay implementing the scheduled 10.6 percent cuts.

Democrats on Capitol Hill say that the administration is following existing anti-fraud rules that require a two-week delay before most Medicare payments to doctors can be paid anyway. Republicans say the real issue is processing of claims, not the payment of them.

Almost every year, Congress finds a way to block the automatic Medicare cuts. But last week the Senate fell just one vote short of the 60 needed to proceed to legislation that would have stopped the cut.

In a particularly vitriolic exchange, Democrats and Republicans blamed each other for what Dr. Nancy H. Nielsen, president of the American Medical Association, said has put the country “at the brink of a Medicare meltdown.”

“Seniors need continued access to the doctors they trust. It’s urgent that Congress make that happen,” the AMA said in ads taken out in Capitol Hill newspapers read by members of Congress and their aides.

Doctors have complained for years that Medicare payments have failed to cover rising costs.

This year, majority Democrats homed in on cutting the Medicare Advantage program, which is an ideological issue for both parties. The Bush administration and Republicans like Medicare Advantage because it lets the elderly and disabled choose to get their health benefits through private insurers rather than through traditional Medicare. Democrats argued that government payments to the insurers are too generous.

The White House warned that President Bush would be urged to veto a bill that contained cuts to Medicare Advantage.

That didn’t stop the House last Tuesday from approving the legislation 355-59, well above the margin needed to override a veto. Every Democrat supported it, and Republicans, bucking their president, voted 129-59 for it.

Associated Press writers Kevin Freking and Andrew Taylor contributed to this report.

CHICAGO - Some health insurance companies rate doctors on their performance. Now doctors are turning the tables.
The American Medical Association issued its first health insurance report card at the group’s annual meeting Monday. The primary focus is on how quickly and accurately doctors get paid.

“Physicians are spending 14 percent of their total revenue to simply obtain what they’ve earned,” said Dr. William Dolan, an AMA board member.

The report card is an effort to reduce the cost of claims processing to doctors and help them as they negotiate contracts with insurance companies, he said. The report card will help patients if it reduces wasteful administrative costs, Dolan added.

The report card compares Medicare and seven national commercial health insurers on the timeliness and accuracy of claims processing. It is based on a random sample drawn from 3 million claims.

There are no grades like A, B and C, and many of the technical measures may not mean much to most patients. But business leaders and health policy makers are interested in cutting an estimated annual $210 billion in wasted administrative claims processing costs, AMA leaders said.

Four years ago, Dr. Marcy Zwelling got so frustrated with the time and cost of making sure she was paid accurately by insurers that she stopped dealing with them. She now runs a so-called “boutique” practice. Most of her patients pay her an annual fee out of their own pockets.

“The best thing is, I get to be a doctor” instead of a claims processor, said Zwelling, of Los Alamitos, Calif. She says she doesn’t make any more money than she did when she accepted insurance, but she has more time with patients.

UnitedHealthcare had the lowest rate of contract compliance, according to the AMA report. About 62 percent of medical services billed were paid by UnitedHealthcare at the contracted rate, compared with 71 percent for Aetna and 98 percent for Medicare.

UnitedHealthcare spokesman Gregory Thompson said doctors and their billing services share responsibility for prompt payment. “Data show there is often a significant lag time between when services are provided and physician claims are submitted,” he said.

He said UnitedHealthcare has improved its electronic claims systems and noted the AMA gave the company higher ratings on other measures.

Medicare performed better than the private insurers in most areas, said Dr. Lawrence Casalino, a University of Chicago health economist and former physician. Commercial insurance plans compete by promising employers that they are tough on holding down the cost of claims, he said.

“There’s no question that administrative costs for doctors and the country would be a lot lower in a single-payer system,” Casalino said in an interview after the meeting. But a market-based system has advantages of competition, choice and innovation, he said. “Are the benefits enough to justify the cost?”

Peter Lee of the Pacific Business Group on Health welcomed the report card, but said he hoped the AMA would look at a broader range of areas that would be helpful to consumers.

“Increased payments to physicians means increased premiums and increased costs in a system that is spiraling out of control,” Lee said.

Susan Pisano, a spokeswoman for America’s Health Insurance Plans, said that for claims to be processed accurately and quickly it takes two parties: insurers and doctors.

She complained that while insurance companies that rate doctors generally share the information with doctors before they make it public, the AMA did not share its report with insurers before releasing it online Monday.

In other action Monday:

• The delegates voted to lobby for legislative changes that would allow pilot studies to find out if offering financial incentives would increase the number of organs available for transplant from deceased donors. According to the AMA resolution, pilot studies involving payment are barred under the National Organ Transplantation Act.

• Delegates took a step back from endorsing programs that use undercover patients to evaluate the performance of doctors and their staffs. The delegates sent the matter back to the AMA ethics council. Doctors were concerned that these sham patients, used by some hospitals and clinics to evaluate health care performance, take time away from real patients.

___

Report Card: http://www.ama-assn.org/go/cureforclaims

It wasn’t the boy I had a problem with. It was his mother.
 
We had met a few months earlier, when I gave her 14-year-old son a diagnosis of mild asthma. I didn’t mind her tough questions, but her tone of voice put me on edge. She seemed suspicious, almost angry. Still, in the end I decided she was just a smart, assertive parent, and I let it go.
 
This time, she was more confrontational. She complained she had been “forced” to bring in her son for a physical because his school needed a doctor’s clearance before he could play sports. What kind of racket did we doctors have with schools? Why did she have to bring in her son when she knew he was healthy? I was taking her money for doing this?

I bit my tongue and tried to tell her why I thought they belonged here. Yes, he was probably very healthy. But an annual checkup could help him learn to take charge of his own health as he grew up, and it would give me a chance to encourage healthy choices and to get a good sense his emotional health during these challenging years. Finally, I pointed out, he was due for a tetanus booster.

She was unimpressed. “I don’t believe in preventive care,” she said. “I’ll treat him for tetanus if he needs it.”

The rest of the visit went more smoothly, mainly because Mom left the room so I could examine her son. But before they left, she again accused me of taking her money, saying I hadn’t done anything different from their previous visits. Before I could reply, her son politely confirmed that this visit had been more comprehensive.

I have had my share of difficult patients and parents. But putting up with this lady had taken more time than it was worth, and it interfered with my taking care of her son. I wasn’t sure I wanted to do it again.

I considered my options. I could be stoic, do my job and keep the boy in my practice. I could call his mother and ask her to keep her opinions to herself so I could focus on her son, though my instincts told me that this wouldn’t stop her. Finally, I could decline to see her son, and therefore her, ever again. In other words, fire my patient.

The physician-patient compact basically states that a doctor will care for a patient in exchange for compensation and that the patient will heed the doctor’s advice. Patients who disagree with their physicians, or just dislike them, are free to go elsewhere.

By the same token, this mutual contract gives a doctor the right to dismiss a patient. The most obvious reasons are failing to pay or missing multiple appointments. Refusing to adhere to treatments can lead to dismissal. So can being abusive to the medical staff.

Of course, we need to exercise this option sensibly. Doctors cannot fire a patient in dire straits like severe pain, bleeding or a life-threatening situation. And of course, we cannot refuse to see patients because of their race, age, sexual orientation and so on.

But could I fire a patient because I didn’t like his mother? Colleagues who had studied the ethics and legal issues told me that the answer wasn’t clear-cut. Obviously, I couldn’t just abandon them. Yet like a lot of legal jargon, the word “abandonment” is open to interpretation. I decided it meant that as long as I wasn’t leaving anyone out to dry with a serious, immediate medical problem, that I gave a patient reasonable notice and provided options about where to continue getting care, I was within my rights.

I thought about our conversation on the tetanus booster, when the mother said she didn’t believe in preventive care. I’m a pediatrician — prevention is in my DNA. If I accepted her view, I’d be compromising my conscience and my professional ethics. I couldn’t do that.

I wrote a letter addressed to my patient’s mother and sent by certified mail. I kept it brief: “Sometimes, a patient or family and doctor aren’t compatible. … Therefore, I will be dismissing you from my practice.” I went on to advise them how they could get a new pediatrician and told them that until they found a new doctor, I would continue to care for her child’s mild asthma.

Two weeks later, I received notice that they had gotten it. The child had signed for it, which made me feel bad because I didn’t have anything against him. Checking his chart, I saw that his mother had chosen a new pediatrician, a colleague of mine. They hadn’t seen him yet.

I considered telling my colleague about my experience. Perhaps warning him so he could remember to take extra care would help get them off to a better start. On the other hand, perhaps I would unfairly bias him against this child and his mother.

I decided to keep quiet. After all, it could have just been me. 

Rahul K. Parikh is a physician in Walnut Creek, Calif. He writes about medicine for Salon.

Check other readers comments:  http://community.nytimes.com/article/comments/2008/06/10/health/views/10case.html

http://cosmos.bcst.yahoo.com/up/player/popup/?rn=3906861&cl=8111503&ch=4226723&src=news

WHERE CAN I GET THE BEST PRICES ON PRESCRIPTION DRUGS?

First of all, whether you are 25, 45 or over 65, prescription costs can be a bear. Some carriers won’t cover certain drugs, some drugs haven’t been in wide spread use long enough to be approved by various carriers, some are excluded due to sheer cost….. but there is help!

There are many avenues to saving money if you don’t have a health plan that covers your particular medication needs - or if you don’t have a plan at all.

First….. doctor’s samples. Almost every prescription that a doctor can write has been given to him in sample form, by pharmaceutical reps. If nothing else, a doctor should be able to give you a two week to two month supply of samples. Some doctors have kept patients going indefinitely on samples.

Second….. ask if the prescription comes in a generic form. It is surprising how many doctors just write out the prescription for the brand name, even when there is a generic.

Third….. if you take a medication that is in a breakable tablet form, ask your doctor to write it for double your usual strength with the instructions to break it in half. The price difference between 20 and 40mgs of a drug is often less than 20%. Sometimes, there is no difference.

Fourth….. shop around! Many of the stores have those wonderful $4 generics. For the most part, the least expensive retail store I have seen for brand name is Costco. Go to www.costco.com and check out any of your prescriptions - you may be surprised by some of those rates.

Fifth….. I have never heard a horror story about prescriptions filled in Mexico but, since those factories are simply independently contracted and Canada’s are owned and operated by many of the manufacturer’s themselves, I would tend to trust Canada more…

Sixth….. Canadian mail order. For some reason, some folks think this isn’t around anymore. The only ones complaining about Canadian mail order are all the “middle men” involved in the distribution of prescription drugs who won’t get their “cut” if you buy your prescription outside the US. By the time a medication leaves the factory and gets to your drug store, it goes through about six distribution points, each with their own fee tacked on. Try www.candrugstore.com. Once on this very easy-to-use website, use Promo Code 898 and your first order will get free shipping, even if you have ordered in the past. Or call 866-444-6376 to place your order - again, reference Promo Code 898. Note: they do not, never have and never will order from China due to quality control issues.

Also, the patent on brand name drugs is only good in the US. Many of the same companies who

manufacture prescription drugs in the US make them in Canada also -  in their own facilities and

in a generic form. This is true - and the cost, ordering through Canada, is anywhere from 35% to

75% less the cost of the brand name equivalent.

Seventh….. if you are low income or simply have some really costly meds, you can contact the manufacturer directly and ask if they participate in any prescription assistance programs. Many do and none advertise this. All it takes is for you and your doctor to fill out a form and send it in. Many drugs costing in the $75 to $300 range are dispensed at little or no charge by the manufacturers.

Bear in mind, too, that many brand name and some generics, are manufactured in China, regardless of where you are buying them. There have been some recalls of prescription drugs manufactured in China that contain heparin. The Internet is a valuable tool is keeping up with this type of information. 

The above tips are for everyone - not just the over-65, the unemployed, the disabled…. everyone.

Docmos is a company I have recently founded with several other people that tackles a fundamental problem in health care:  Providers do not compete on the value (i.e., quality over cost) they deliver to the end consumer.  This, of course, creates the situation where costs can spiral out of control.   

Our company has chosen to target the radiological services industry (which cost US health care more than $100 billion last year).  Rather than competing just on quality, through our company radiology facilities will be able to compete on cost in order to attract patients.  This is fundamental change and truly a step closer to an “open market.”   Please take a look at our website, www.docmos.com, to see value proposition.

Sincerely,

Herb Singh, MD, CEO

Docmos http://www.docmos.com/

The Internet search giant’s service, Google Health, at www.google.com/health, is the latest entrant in the growing field of companies offering personal health records on the Web. Their ranks range from longtime online health services like WebMD to the software powerhouse Microsoft to start-ups like Revolution Health.

The companies all hope to capitalize eventually on the trend of increasingly seeking health information online, and the potential of Internet tools to help consumers manage their own health care and medical spending.

Google enters the field of personal health records with a leading online brand, deep pockets and a wealth of technical skills. In a two-month trial this year, the Cleveland Clinic found that its patients were eager to use the Google health records.

The pilot project, limited to 1,600 patients, was quickly oversubscribed, said C. Martin Harris, the Cleveland Clinic’s chief information officer. Dr. Harris also said that when the clinic’s online health records, introduced in 2004, were linked to the Google record the clinic’s records were used more frequently by patients. “It positioned our personal health record more into an activity that they use every day,” Dr. Harris said.

The Google record, he said, allows the user to send personal information, at the individual’s discretion, into the clinic record or to pull information from the clinic records into the Google personal file.

The ability of patients to send information, in particular, can be helpful to clinic doctors, Dr. Harris said. For example, if a person sees specialists outside the clinic and receives a drug prescription from an outside doctor, it raises the risk of harmful drug interactions. “Until now, if a patient doesn’t remember to tell me,” he said, “I don’t know about drugs prescribed outside the Cleveland Clinic system.”

In the Cleveland trial, patients apparently did not shun the Google health records because of qualms that their personal health information might not be secure if held by a large technology company.

In Google Health, as in the pilot project, the company is not selling advertisements. And what information is shared with doctors, clinics or pharmacies is controlled by the individual, said Marissa Mayer, Google’s vice president of search products.

More than two dozen companies and institutions announced that they are partners with Google Health, including Walgreens, CVS, the American Heart Association, Quest Diagnostics, Beth Israel Deaconess Medical Center and the Cleveland Clinic. The partnerships are not exclusive arrangements.

Cleveland Clinic, for example, is also talking to Microsoft. “As these online services become available, we expect to connect to them all,” Dr. Harris said.

Google Health, Ms. Mayer said, represents a “large ongoing initiative” by the company, which she said she hoped would eventually include “thousands of partners and millions of users.”