Prior authorization

 As I’m sure you know, before you can get treatment or medication your doc may have to convince your insurance provider that you need it. Prior authorization gives your insurance company more power than your doctor. If your prior authorization is denied, you have three options: pay out of pocket (not realistic); give up (this happens 80% of the time); or the doctor can go to bat for you.

One doctor says that she must get approval 95 percent of the time. Another doctor notes that she has four full-time employees whose sole focus is on obtaining prior authorization for medications to treat Crohn’s disease and ulcerative colitis. A frustrated pediatrician says, “I end up talking to someone who’s not even a physician—people who couldn’t pronounce the names of the drugs I was trying to prescribe.” Another says that the insurance company was giving her a hard time getting approval for chemotherapy for a patient diagnosed with lymphoma. “I was so emotionally exhausted. And that was just one patient.” By one estimate, the U.S. spends about $35 billion a year on the administrative costs of prior authorization.

Decades ago, prior approval was used sparingly to make sure that treatments and long hospital stays were necessary. The idea was to save us money. Now, it’s devolved into a system where treatments are denied for no reason. Even everyday medications, such as test strips for blood sugar and ADHD meds, require insurance approval.

The way insurance companies profit is to deny care. If they deny or delay care, that’s money they get to keep. Prior approval only serves to enrich the insurance companies: Cigna made $5.2 billion in profit last year; Elevance made $6 billion; United Health care made $22 billion.

I have never been turned down by my insurance providers (Medicare plus a supplement). But I have no idea if my physician has had to suffer on my account.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

GoFundMe: the go-to site for paying medical bills

 GoFundMe—a privately held, for-profit company—started as a crowdfunding site for underwriting “ideas and dreams.” Now, “medical expenses” is the most common category of fundraiser. People use it in desperation to pay medical bills.

In 2020, there were 200,000 medical-related GoFundMe campaigns in the U.S., which was 25 times higher than the number of such campaigns in 2011. Right now, there are more than 500 campaigns asking for help in paying for gene therapy for young children with spinal muscular dystrophy. (A single-dose treatment costs $2.1 million.)

The thing is, unless you’re famous or have lots of rich friends, the campaigns rarely help much. Almost all fall short of their goal, and some raise little or no money. The average campaign makes it to about 40 percent of the target amount, percentages that are getting worse over time. One woman, who was presented with $65,000 air ambulance bill (out of network), was able to raise only $1,400.

Apparently, this way of paying medical bills is becoming normalized. In some cases, patient advocates and hospital financial-aid officers recommend crowdfunding to people who can’t afford their medical bills. That’s sick.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Hierarchies and health

 A friend recommended a book titled The Nation of Plants, by Sefano Mancuso, a leading authority on plant neurobiology. The book discusses the eight principles that govern the lives of plants. One is the fact that plants are governed by decentralized “vegetable democracies,” rather than by hierarchical command centers. Instead of specialized organs, all their functions are distributed throughout their entire bodies.

Not only are our bodies organized in a hierarchical way—with brains at the top—but so are our societies. Our hierarchical organizations evolve bureaucracies in which commands coming from the top get transmitted throughout the levels of the hierarchy. Problems with hierarchical organizations include the Peter Principle (in a hierarchy every employee tends to rise to his or her level of incompetence), as well as Parkinson’s Law (bureaucracy expands as long as it is possible to do so, which, in fact, is usually between 5.17 and 6.56 per cent per year).

Hierarchical organizations can also be unhealthy. The Whitehall study in Great Britain examined more than 28,000 employees for ten years. They found that employees at the lowest level of the hierarchy had a mortality rate three times higher than that of employees at the highest level. Even when risk factors, such as low income, smoking, or on-the-job safety risks, were controlled for, employees in the lowest levels of the hierarchy suffered from cardiovascular disease at a rate that was 2.1 times higher than that of employees at the highest level. The cause of these discrepancies is the substantially higher stress levels at the lower levels of the hierarchy. Subsequent studies have confirmed such findings.

As you might expect, Mancuso recommends that we organize ourselves like plants do: in a diffuse model, in which consensus and authority derive from one’s own capacity to influence, rather than being conferred from above. Rather than having a single command center, decisions can come from the periphery where the needs are clearest, and information is more readily available.

One wonders: how’s the health of those folks we deal with at the DMV?

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Think twice about taking antibiotics

By now, I think most of us know to be cautious about taking antibiotics. Experts now estimate that 28 percent of antibiotics prescribed to children and adults are unnecessary. Not only that, but they can also do more harm than good. Here are some reasons for caution:

• Antibiotics are useful for only bacterial infections. They have no effect on viruses.
• They kill the beneficial bacteria in your gut (collateral damage).
• Disruption of good gut bacteria may lead to metabolic disorders such as Type 2 diabetes and autoimmune diseases.
• Antibiotics encourage bacteria to evolve drug resistant strains (“superbugs”) which can lead to antibiotic-resistant infections.

If you need an antibiotic, take the shortest course. Experts now agree that you don’t need to take all the pills prescribed. As Dr. Martin Blaser, the director of the Center for Advanced Biotechnology and Medicine at Rutgers University says, “After minimizing the biological costs of antibiotics for decades, medical scientists are finding that longer courses are more damaging than shorter ones.” In fact, shorter courses can be just as effective as longer ones. (For a urinary tract infection, two days of taking an antibiotic did the trick for me.)  Most cases of bacterial infections don’t require antibiotics for longer than five days. But for something like Lyme disease, take the whole course.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.

Red wine and sloppy science

More than 20 years ago, some scientists declared that drinking red wine was good for your heart, the idea being that it had “a flushing effect” that prevented clot-forming cells from clinging to artery walls. Drinking red wine was touted as the answer to why French people—lovers of pâté, butter, and triple crème Brie—had lower rates of heart disease than people in the U.S. The studies supporting the health effects of red wine have since been debunked. Many new studies are now saying that no amount of alcohol is good for your heart.

Who can you trust? Shoto David, a scientist with a PhD in molecular biology, quit his job to pursue his hobby of finding flaws in scientific papers and trying to get the errors rectified. So far, he has flagged about 2,000 error-riddled scientific papers, including those produced by the Harvard-affiliated Dana-Farber Cancer Institute in Boston. That Institute is retracting six research papers and correcting 31 more. In 2021, a surgeon at Columbia University quietly withdrew his cancer study because of flawed research. The fact that these papers appear in top scientific, peer-reviewed journals makes you wonder about the peer review process—and about research studies in general.

Nutritional research is plagued with credibility problems, partly because the world of scientific research is competitive. Grant money depends on getting research published. Journals select articles that make splashy news. In 2019, the often-quoted founder of the Food and Brand Lab at Cornell University was booted from his position because of academic misconduct, including “misreporting of research data.” His studies have been cited more than 20,000 times. Fifteen of those studies have been retracted.

So how about those cheese-loving French people and their healthy hearts? I’m just waiting for the nonsense about the dangers of saturated fat to be debunked.  

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.