BE
Healthy ™
Sponsored by
Boston Public Health Commission
VOL. 4 • NO. 7
Te ap am re pr be su oa tt lts ch er in ca re
© March 2010
PATIENT POWER By all accounts, Donna Matthews is a “good” patient. As a diabetic, she checks her blood sugar level four to five times a day – and more if she does not feel well. She writes the numbers down in a log that she dutifully presents at each doctor’s appointment. Talk about patient empowerment. “I think I’m a little OCD (obsessive-compulsive disorder) now,” she admits. But that “OCD” serves her well. She can name each of her medications and the dosage. She asks questions; she writes things down. To say the least, Matthews is prepared — and clear on specific problems. The reason for her obsessiveness is also clear. “I don’t want to get any worse,” she said. The notion of patient empowerment — that patients take an active role in their care — is a growing concept. It’s not that patients are taking over; they’re just taking part. They weigh treatment options, learn about their illnesses and make decisions about their care. Research has shown that patients who interact with and have a good relationship with their providers not only receive better care but are happier with that care. If only all of Dr. Mark Drews’ patients were as good as Matthews. As an internist at Whittier Street Health Center, he averages
about 70 patients a week, and maybe he has specialists as well. twenty minutes with each of one of them. Dr. Eldrin Lewis, a cardiologist at Brigham and Women’s Hospital, admits he But a lot has to happen in those 20 minutes. spends more time in a visit compared to some. His visits also average 20 minutes but can Especially considering that primary care range as long as 40 minutes for new or comphysicians (PCPs) are increasingly being plex conditions. asked to do more with less time – and with fewer doctors. PCPs are becoming such a PH OTO BY TON Y IRVIN G rare commodity that in 2009 the Massachusetts Medical Society concluded that the shortage of doctors of internal medicine is “severe,” and that of family medicine is “critical.” Complicating the problem is that only 60 percent of family practitioners and a scant 44 percent of internists are accepting new patients, according to the society’s Physician Workforce Study. Donna Matthews (right), discusses her log of blood glucose levels with Dr. What’s worse, Mark Drews (left), a primary care physician at Whittier Street Health Center. on average, patients in this area have to Both Drews and Lewis agree that the time wait 44 days for an appointment. is better spent if patients come prepared. Although a 2009 report in the Archives “You wouldn’t think of visiting an accounof Internal Medicine found that visits with tant and asking if you’ll get a tax refund if you PCPs increased from an average of 18 minutes to almost 21 minutes, one thing remains have not provided the appropriate receipts,” Lewis said. “Why would you handle a doctor’s clear: there’s not much time behind those closed doors. visit any differently?” Time constraints pose a problem with Patient power, continued to page 4
The root of the problem Medical histories play an essential role in determining future lifestyles Thirty minutes had passed and Brenda Robertson had more questions than answers. She was trying to fill out her family tree — complete with medical histories — and she soon learned that the task was nearly impossible. Many of her relatives were dead and their medical histories — to the extent they were written down — died along with them. That didn’t deter Robertson. The information that she could collect was a good start — and changed her life. Both of her parents died from strokes, but it was her father’s history that particularly stood out. He had two strokes, and the second one was fatal. He was 44 years old when he died. Those genes were passed down. Already, Robertson’s older sister has had a stroke, as has one of her nephews. So far, Robertson has been spared, but she is not taking any chances. “I want to prevent these illnesses in myself,” she said. Knowing that strokes and diabetes run in her family, Robertson has changed her lifestyle
The value of family medical histories is enormous, largely because many illnesses are passed down from generation to generation. Many diseases, such as cancer, diabetes, high blood pressure and even mental illness, have a genetic link. So important is the family history that the Surgeon General in 2004 launched a Family History Initiative to encourage families to learn more about their inherited Knowing a family medical history can sometimes reduce the risk of health risks. The Surgeon inherited diseases through timely screenings and lifestyle changes. General designated to control those risks. Thanksgiving — a holiday when families She has substituted water for sugared gather — as National Family History Day. The beverages, reduced her portion sizes and eats Department of Health and Human Services has more vegetables. And she exercises. created a web-based tool at https://familyhis “I walk a lot now,” she said. tory.hhs.gov that allows users to enter, print out
and save the information. The family history tree is an essential tool for patient empowerment. In the 2004 HealthyStyle survey, the Centers for Disease Control and Prevention found that 96 percent of the respondents believe that family history is important for their own health; yet a paltry 30 percent reported that they actively collected necessary information. One difference was noted, however. Those with a personal history of type 2 diabetes were more likely to have collected information from relatives. The family medical history tree allows a doctor to assess risks for a certain disease, determine the type and time of screening tests and judge the risk of passing the conditions on to the next generation. For instance, women who have a history of breast cancer — especially when diagnosed at a young age — may require initiation of mammograms before the age of 40 as well as a concomitant MRI. Family history continued to page 4
Making every dollar count PH O TO : N AT IO N AL C AN C ER IN ST IT U T E
The beginning of the end of the national recession may be in sight, but financial experts say a full recovery is still a long way off. People should be cautious with their money and look for ways to reduce their spending. This includes health care costs. Stretching health care dollars is now more essential than ever. “Until the economy bounces back, people will be looking for ways to cut costs wherever they can,” said Dr. John Fallon, Chief Physician Executive at Blue Cross Blue Shield of Massachusetts (BCBSMA). “But when it comes to our health, we have to be smart about the decisions we make, including how we select and use our health care plans.” Whether you sign up for a health plan through work or on your own, being a smart consumer is key. Carefully evaluate all the options available to you to find the best care for your money.
How to Pick a Plan Health plans are never one–size–fits–all. To choose wisely, evaluate your specific needs. • Who needs coverage? Are you single or married, or do you have a domestic partner? Do you have children who need coverage? • What are your health needs? Let’s say you’re healthy and rarely need to visit the doctor. You may benefit from a plan that couples lower monthly premiums with a higher deductible, the amount you must pay personally before insurance provides any coverage. If you have chronic illnesses requiring frequent care like diabetes, asthma, or heart disease, a no-deductible policy might be a better choice. • Are your current doctors in the network? Call or check online for which health plans your doctor accepts. • Do you pay a lot monthly for prescription drugs? A plan that has prescription drug coverage — or lets you opt out of it — may offer considerable cost savings. Some plans have tiers (groupings) of co–pays (set fees) for medications. Generic drugs are least expensive. Brand name drugs are grouped into increasingly expensive tiers. For example, a 30–day supply of tier–one generic high blood pressure pills may cost $10; tier-two brand name pills may cost $20; and tier-three brand name pills may cost $30.
Compare available plans during open enrollment periods. Carefully compare all available options during annual open enrollment periods (often in the fall); sticking with the same plan doesn’t always make sense. If you don’t anticipate needing to see the doctor frequently, it may be worthwhile to select a less expensive plan with higher co-pays or a higher deductible. Most health plans have formularies listing pre-approved drugs. Often, drugs are added (and sometimes dropped) annually. Remember to check formularies annually for medications you need. Staying informed — and keeping on top of selection deadlines — can save you headaches and cash. Compare additional incentives. Many plans offer discounts for health club memberships, smoking cessation, weight loss programs and preventive screenings. Discounts may even apply to accredited complementary care providers you visit, such as a dietitian, chiropractor, masseuse, or acupuncturist. Blue Cross Blue Shield of Massachusetts offers this through the Living Healthy Naturally Program.
Once you find the right plan, follow these tips to save on costs: 1. Investigate health savings accounts. If you’re under 65 and have a high-deductible plan, you can put a portion of pretax dollars into a Health Savings Account (HSA) to pay for eligible health expenses, thus lowering your tax bill. Unused HSA funds can roll over and accumulate year to year. Alternatively, a Flexible Spending Account (FSA) offered only through employers holds pretax dollars for eligible health or dependent expenses. FSA funds not spent by year-end are forfeited. If you already have an FSA, remember to submit 2009 claims for reimbursement by March 31, 2010. 2. Stay in network. Use doctors and specialists in your health plan’s network. Out-of-network care drives up your share of the health care bill. If you’re unsure if a provider is in your plan’s network, simply give your plan a call or check online. 3. Save on prescriptions. Always ask about generics, lower-cost brand name medications and over-the-counter options. Generics, which can be as effective as brand name counterparts, come on the market frequently (and big chains like Kmart, Sam’s Club, Target, and Wal–Mart price hundreds of generics under $5 for a 30-day supply). Find out if lifestyle changes — more exercise, better diet, stress reduction — might lower dosages or erase need for some medication. Always talk to your doctor or pharmacist before making any medication changes. 4. Dial a help line. Find out if your plan has nurse help lines to advise you on whether you should see a doctor or can self-treat using simple remedies like fluids, fever-relievers and rest. For example, members who have a plan under BCBSMA can call experienced nurses staffing the 24–hour Blue Care Line. Often a call can save an unnecessary trip to the hospital or doctor’s office—and your co-pay. Ask your plan what resources may be available to you. 5. Participate in wellness programs. Hit the jackpot with healthy choices. Exercising, losing weight and quitting smoking dramatically lower your risks for asthma, diabetes, cancer and heart problems, significantly improving your health while cutting your health care bills. Many health plans offer wellness program discounts, rebates and fabulous online tools like personalized weight loss or workout plans. Free and low-cost community programs may be available through the Boston Parks and Recreation Department, senior centers and community education centers.
The ABC’s of health insurance HMO, PCP, PPO, POS — feel like you’re wading through alphabet soup? Read on for translations of common terms. •
Health maintenance organizations (HMO) require you to choose a primary care physician (PCP), who coordinates all of your care, including visits to specialists.
• Preferred provider organizations (PPO) let you make your own choices from a network of preferred providers (in some plans, you can pay a higher fee for out-of-network care) and may not require you to have a primary care physician. • Point-of-service plans (POS) let you choose between receiving care from participating providers (you’ll be reimbursed more for this), or non-participating providers(you’ll be reimbursed less for this). Some plans offer lower premiums (monthly payments) in exchange for a higher yearly deductible (the amount you must pay personally before insurance provides any coverage). Some plans require co-pays, a set fee you pay for health care visits or medications. Others ask you to pay co-insurance, which means you’re responsible for a portion (20 percent, for example) of eligible expenses charged by a provider or the amount the insurer agrees to pay for specific services. Many plans require preauthorization or precertification for certain services, such as surgery or visits to a specialist. Some pick up the tab on preventive care services, such as flu shots, cholesterol tests, or colonoscopy. Most have formularies that list pre-approved, commonly prescribed drugs.
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Questions & Answers 1. Why is it so important to know exactly what medications you are taking and the dosage? The doctor must know all the medications you are taking in order to prevent unwanted or harmful medication interactions. In addition, the provider can better evaluate if the medications are beneficial or if a higher dose or different medication would be better.
You won’t learn the answer if you don’t ask the question Below is a list of questions you should always ask when the situation arises: 1. What is the test for? 2. How many times have you done this [procedure]?
Michelle Johnson, M.D. Internist Whittier Street Health Center
3. When will I get the results? 4. Why do I need this surgery? 5. Are there any alternatives to surgery?
2. Is the Internet a good source of medical information? The Internet provides good medical information on such sites as WebMD and MedlinePlus. However, you have to be careful because not all Internet sites are reputable. Look to see if the authors are experts on the subject and that the information is current. Check with your doctor if you have questions. 3. What’s the value of keeping a health journal? A health journal — a complete record of your health — allows you to present a complete and current medical history when visiting your doctor. The journal, which includes your illnesses, hospitalizations and medications, will expedite your visit and allow the physician more time to concentrate on other parts of the medical visit. 4. Can a patient safely assume that the doctor knows or remembers his or her medical history? No. Physicians treat many patients and sometimes do not see them for months at a time. It is difficult for them to remember all of their patients’ medical histories. Even with paper or electronic charts, a doctor can still lack certain information. It is always best to remind your physician of your medical history. 5. Is it necessary to mention herbal or over-the-counter (OTC) medications since they are non-prescription? Yes. Herbal medicines, such as Saw Palmetto (for prostate) and OTC drugs can be quite powerful. There is a common misconception that, because they are available without a doctor’s prescription, they are not really strong. However, many drugs now available OTC were prescription drugs at one time. Their ease of access has not necessarily reduced their potency. In addition, non-prescription drugs may counter the effect of a prescription drug, so it is important to mention all medications, whether or not they require a prescription.
6. What are the possible complications? 7. Which hospital is best for my needs? 8. How do you spell the name of that drug? 9. Are there any side effects? 10. Will this medicine interact with medicines that I’m already taking? Source: Agency for Healthcare Research and Quality
www.ahrq.gov/questionsaretheanswer
Looking for reliable sources of health information? Here are a few... Government Agencies
Non–profit Organizations/HMOs
• National Cancer Institute www.cancer.gov
• American Cancer Society www.cancer.org
• MedlinePlus http://medlineplus.gov
• American Heart Association www.heart.org
• Centers for Disease Control and Prevention www.cdc.gov
• American Diabetes Association www.diabetes.org
• U.S. Department of Health and Human Services www.healthfinder.gov
• Blue Cross Blue Shield of Massachusetts www.ahealthyme.com
6. If you have bad side effects from a drug prescribed by your doctor, should you stop taking them? Not without your doctor’s consent. If you have bad side effects from a drug prescribed by your doctor, you should call your doctor’s office as soon as possible and inform him or her of your symptoms. Some side effects will resolve over time as you continue the medication. There are other side effects, however, which are potentially life threatening. It is always best to speak to your doctor about what the best course of action should be. 7. Should you talk to your doctor about life changes, such as stress, divorce or depression? Most definitely. Certain life changes can affect your overall health. For example, stress can worsen or trigger many problems such as heart disease, hypertension and obesity. The physician can evaluate you and refer you to get some help. 8. If the doctor’s office does not call a patient regarding test results, is it safe to assume that the tests were negative? You should never assume that everything is normal if you do not get a call from the doctor’s office. It is always best to contact the office yourself if you have not heard anything.
INHERITED RISKS There are several diseases that run in families and are passed down from generation to generation. A family history does not guarantee an illness; it raises the odds. Examples of inherited diseases are: • Prostate cancer • Ovarian and breast cancer • Colorectal and uterine cancer • Diabetes • Heart disease • Stroke • High blood pressure • High cholesterol
• Kidney disease • Depression and dementia • Alcoholism and other substance abuse • Miscarriage and stillbirth • Birth defects and infertility • Asthma • Alzheimer’s disease
The information presented in BE HEALTHY is for educational purposes only, and is not intended to take the place of consultation with your private physician. We recommend that you take advantage of screenings appropriate to your age, sex, and risk factors and make timely visits to your primary care physician.
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Tips for completing a family history medical tree: • Include at least three generations if possible • Note the relative’s age at diagnosis and the age and cause of death • Watch for a disease that occurs in more than one relative • Look for diseases that occur at an earlier age than expected • View death certificates, family bibles and family medical histories • Get input from as many relatives as you can • Continue to update and correct the tree as new information becomes available • Share the information with your doctor and relatives
Maternal Grandparents
Paternal Grandparents
Breast Cancer
Stroke Father
Aunt
Mother
Uncle
Keep in mind that your family history does not guarantee an illness — it indicates risk. You can reduce your risk by adopting lifestyle changes — not smoking, healthy diet and exercise. You can also often detect a potential problem by timely screenings or genetic testing. To develop your family history online, visit https://familyhistory.hhs.gov/fhh-web/home.action.
Breast Cancer
Stroke
Susan
Sister
Brother
Patient power continued from page 1
ing over-the-counter and herbal drugs, and vitamins; write a list of your symptoms and Medicines cause a major concern. Doctors complaints; and prioritize the three or four cannot prescribe a new drug without knowing most troublesome. what a person is already taking. “Less than The American Academy of Family Physione–third of patients will know what they cians recommends developing a health journal take,” Lewis said. “Others will have just a that includes a history of illnesses and injuries, general idea, but don’t know the name or dose hospitalizations, surgeries, allergies and drugs. of the drug. They assume that I know.” The second step is the actual visit. Discuss Drews agrees. your complaints; update the doctor of any Trying to get the details from some patients changes since the last visit, including life doesn’t always work. “The response — ‘The changes, such as divorce; answer questions heart doctor gave me a new pill. It’s white.’ — is honestly; ask questions if you do not undernot much help,” Drews said. “ ‘Let me call my stand and write down information. wife at home. She can read the label’ — is better. The third step is follow-up. Call if you But that doesn’t tell the entire story.” experience problems after the visit, such as He offers a solution: “Put all your pills in a side effects from medications, deterioration bag and bring them with you.” of your symptoms, or failure to receive the That helps in more ways than one. Not results of tests. only can he determine what you’re on, he can Lewis emphasizes the need for patients to determine what you’re no longer on. People take charge. “Most treatment occurs in between tend to keep medications they stopped taking doctor visits,” he said. “You have to understand — or they have three different doses of the what you’ve been told and then do it.” same medication, according to Drews. “It helps Be a part of the team. Ask why you’re takto have the actual bottles,” ing the drug. If you are on he said. three different medications He makes a larger for apparently the same point. “This is a national diagnosis, ask why. When safety issue,” Drews said, you have your blood presreferring to the thousands sure taken, write down the of accidental overdoses results. “That’s a patient’s and allergic reactions to all job,” he said. types of drugs. He finds that some Lewis agreed that people are a little bit more involved in their care, but he prefers to see the medications directly and not as much as he’d like to see. People of African not rely solely on the American descent, he medical record. “It could noted, tend to not ask quesbe wrong,” he noted. He knows his time is tions as often. Eldrin Foster Lewis, M.D., M.P.H. limited. In those 20 minutes One thing he stresses. Cardiologist Lewis must hear and inter- Brigham and Women’s Hospital If you and your doctor have pret a patient’s problems, a relationship that works, ask questions, perform a physical examination that goes a long way. “You don’t have to be and develop strategies for treatment. “You friends, but you should feel secure that he or don’t want to lose ten minutes trying to figure she has your best interest,” he said. “If not, find out medications,” he remarked. another doctor.” Both doctors mentioned pet peeves or Apparently, Matthews’ fastidiousness and irritations that impede good care: not taking her close working relationship with Drews medicine but thinking that you’re going to have paid off. She sees the improvements. get better; not telling the doctor when you “My A1C — a test that reflects the averdon’t understand; being too embarrassed to age blood sugar level for the past two to three raise an issue; showing up late for appointmonths — used to be in the 9’s,” she said. ments; relying on a family member’s advice “Now it’s in the 6’s.” instead of the doctor’s. It is recommended that the A1C for diaFor his part, Drews does his homework betics not exceed 6.9. to make the most of his time and he expects Matthews is living proof of several studthe same from his patients. During the visit, he ies that suggest that African Americans can expects participation and good interaction from improve blood glucose levels when in strong his patients. He encourages questions. And he partnership with their doctor. expects honesty. Hiding information and proShe relies on her doctor for expertise and viding just part of a picture can be detrimental. support but relies more heavily on herself to He welcomes a family member or friend at the follow through with “her” health plan. visit to help fill in the gaps. She says that Whittier Street Health For the patient’s part, it takes three Center is good at calling her to inform her of steps to achieve the ultimate visit. The first test results. If they didn’t, she explained, she is preparation. Don’t go to the doctor emptywould anyway. handed. Take your drugs with you — includ“I’d be too scared not to,” she says.
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Ovarian Cancer
Stroke
Susan’s Family Tree Stroke runs in Susan’s family and strikes young, as noted in her younger brother. Ovarian and breast cancers — which are linked — are also found. Susan will probably be advised to have regular mammograms, which can catch breast cancer in the early stages.
Who’s in charge here?
You are
It is your responsibility to get the appropriate screenings at the appropriate time based on your age, gender, race, risk factors and family history. If your doctor does not offer the tests, ask for them. You’re the one who ultimately pays — in poor health. Condition
Frequency*
High blood pressure High cholesterol Type 2 diabetes Breast cancer Prostate cancer Colorectal cancer Cervical cancer
Yearly Every five years Every three years Yearly Yearly Every one to ten years Every one to three years
Starting age* 20 20 45 40 50 50 21
*Frequency and starting age will differ by risk factors. For instance, if you have prostate cancer in your family, you will probably start screening at age 40 or 45. Sources: American Cancer Society, American Heart Association, American Congress of Obstetricians and Gynecologists
Family history
continued from page 1
“The biggest concerns are cancer and heart disease, especially in the young,” said Dr. Mark Drews, an internist at Whittier Street Health Center. “If you’re 40 and your brother died of cancer at 40, you should know which cancer. If it was prostate cancer, you need to start screening now. If it was lung cancer and he was a heavy smoker, there is less concern.” An ideal family history includes at least three generations. Primary relatives — parents, children and siblings — are most important. But grandparents, aunts, uncles and cousins should not be overlooked. What should trigger attention is a disease that occurs at an earlier age than expected, a disease in more than one close relative, a disease that is atypical for that gender — for instance breast cancer in a male — and certain combinations of diseases, such as breast and
ovarian cancer. It takes a bit of detective work to complete the history. Ask questions, review death certificates and available medical records. Determine age of diagnosis and age and cause of death. List ethnic backgrounds as well. The history is a work in progress and should be corrected and edited as new information comes to light. Most important is to pay attention to what’s been revealed. Lifestyle changes — healthy diet, exercise, and smoking cessation — will not change your genes, but can reduce the risk of the diseases. The fact that your family has a certain history is not a guarantee that you will likewise be afflicted. Originally from the West Indies, Robertson readily admits she is not through with her history. “I’m going home this year,” she said. “I can get more information from my family then.”
Comments on Be Healthy? Contact Health Editor Karen Miller at kmiller@bannerpub.com.