Insurance Coverage and Pain Management

November 26, 2014December 3, 2014 / Thomas Cohn, MD

Every time someone goes to the doctor, they want to know if the visit and treatment is covered by insurance. Unfortunately, there is no simple answer to that question. In the distant past, care was much simpler and each visit with your family doctor had a small set cost that covered everything preformed.

Today it is a complex financial industry with thousands of players each getting paid, from the insurance industry, to the medical suppliers, to the manufacturers of every widget and needle to lastly, the physician.

The cost of everything gets itemized and factored into the cost of each visit and treatment. The insurance industry and Medicare have complex formulas to figure out how much every service is worth and what can be charged. Unlike going to an auto mechanic who tells you the cost of the parts and labor, the medical industry is very different. A physician can determine how much it will cost in order to provide a service, but each insurance company decides how much they are willing to pay on their end, and the doctor is stuck with that amount. Rarely is a medical service fully reimbursed to the provider; often it is at 30-40 cents on the dollar.

Am I Covered?

The first question on coverage is whether you have medical insurance. Every person now can qualify for insurance and there are a variety of plans available. Total cost and coverage are the remaining issues. The benefit of the Affordable Care Act (nicknamed Obamacare) is now everyone can get medical insurance and no one can be denied. Unfortunately, that means everyone needs to understand the insurance they have purchased, and realize every service provided is set by the coverage that you bought. Most physicians try to work with the patient and insurance to determine the best option in management of any medical problem. To stay in business, most physicians must have specialists in their offices to make sure they have the necessary prior authorizations in order to see and treat an individual.

The insurance industry has set a guideline that a service should be covered if it is deemed medically necessary. The amount of coverage depends on the individual plan, deductibles and co-payments required. Furthermore, the service may need to be approved by a primary physician in addition to the ordering physician, and it may need special approval by an insurance company’s medical expert.

Wait, What?

At this point, most people are totally confused and are concerned about the cost of seeing a doctor. If you have a problem that is not going away, then you should always start with your primary physician. A good history and physical exam should tell most physicians what is wrong and the treatment that will solve 90 percent or more of the problems without expensive intervention. If the problem does not resolve, then involving the next level of experts, tests and treatments may be necessary. Obtaining referrals, checking for authorizations and determining your copays and deductibles are now issues. Both your referring doctor and specialists can help explain the particular costs that may occur if you contact their business offices.

If you have insurance, the cost of your medical care is dependent on the insurance coverage, especially the amount each visit costs due to the deductible amount and copay required. Each insurance company sets a reimbursement rate for every conceivable medical service provided. The answer to how much anything will cost you can only come from a physician’s billing office and your insurance company. Unfortunately this is not a simple answer. If you ask a physician how much it will cost you, they will have no idea since they get paid at the whim of each and every insurance payer at different rates for the same services.

Doctor Ratings and the Importance of Communication

November 24, 2014 / Thomas Cohn, MD

Everyone wishes to have the best doctor available. In Minnesota there are multiple rating services available that score doctors, however, which rating systems are the best? Some services rate doctors on their compliance to medical guidelines such as those established for asthma and diabetes. Other services monitor the cost of a physician’s per patient billing to the insurance company, while others are patient reviews. The real question is, what will make you happy with your choice of physician?

Important qualities in a doctor includes their knowledge, skill, understanding of a patient’s condition and their communication skills. Almost every physician will have a good basic set of knowledge about any medical condition that they treat. In any profession, from car mechanics to teachers, 90 percent of the practitioners are good and 10 percent are exceptional and have a special talent in that field. Skill level is similar; most physicians have good techniques, but some just know the small things that make all the difference when doing any procedure, and are just better than others.

Understanding a patient’s condition is somewhat complex. First, a doctor must be prepared. This includes reviewing a patient’s medical record and knowing their history. This is ongoing, and the doc should know this information at each visit. Medical records are helpful, but personal notes may be needed in addition to fill gaps. Experience is also important, as is continuing to grow in their skill by attending conferences and seminars on a regular basis.

Doctor-Patient Communication

Communication between the doctor and patient is critical in quality of care. Most important is that communication is not one directional. To treat a patient, a doctor needs to know what is wrong, what are the symptoms, and what is actually working correctly. Since doctors often have limited time with each patient, they will need to guide the conversation to obtain the relevant information. Being honest is also extremely important. There are often multiple sources to confirm data, and if the information provided is not truthful, a doctor will likely be guarded in their care. Patients also need to ask questions about their condition and be open about their recovery.

Ratings of doctors are of limited value. The final rating that matters is how well you communicate with your doctor and whether or not you trust his ability and knowledge. Sometimes, you can find the right physician without any trouble. Other times, word of mouth and information from friends who know the practitioner is critical. Ratings on the web may be inaccurate or forums for the unhappy patient. No physician will be perfect, but finding the right physician may be a matter of how well both you and the physician communicate with each other.

The Health Conditions For Medical Marijuana in Minnesota

November 19, 2014 / Thomas Cohn, MD

As Minnesota moves toward the end of 2014, the medical marijuana laws are starting to take effect. Minnesota’s laws have very strict rules with regards to the use of marijuana for medicinal purposes. It is restricted to only certain conditions and only two forms will be available; Pill or oil for vaporization.

Health care practitioners will have a limited role in the Minnesota medical marijuana program. Patients will be strictly controlled and monitored, and only limited conditions have been approved for treatment. Furthermore, all medical marijuana will be controlled and distributed only through specific state controlled distribution sites.

Medical Conditions For Marijuana in Minnesota

Minnesota has legalized cannabis for only seven medical conditions. The conditions are cancer, glaucoma, AIDS, Tourette’s syndrome, ALS, epilepsy and Crohn’s disease. Medical marijuana is also available to individuals with a terminal illness with a life expectancy of less than a year who are experiencing pain, suffering, nausea or wasting. The Department of Health can add new medical conditions to the list, but the Minnesota legislature has the power to veto any additions. The first condition that should be added before any other condition is intractable pain. The Commissioner of Health would need to provide a report to the legislature on the reasons why it would qualify for cannabis use in order to add chronic or intractable pain to the list of approved conditions.

Medical providers in Minnesota are not required to participate in the marijuana program. However, a provider who does participate has multiple responsibilities under the law. A participating provider who certifies a patient must continue to follow the patient once they start the program. A patient cannot have a casual relationship with the provider; they must undergo a comprehensive evaluation, including history and physical exam, development of a treatment strategy, determination of a qualifying condition, and be counseled on the risks and benefits of medical marijuana, knowing full-well that this is an experimental treatment. The patient must give informed consent to all aspects of management and be followed regularly to determine if the treatment is effective. Furthermore, their medical records must be shared for research and tracking purposes with the Department of Health. The patient must be re-certified for the program annually.

Medical Marijuana Dosage

The cannabis derivative and dose will be determined by the pharmacists that are associated with the program. They will provide instructions to the distribution centers on the cannabis type and dose to be delivered. The pharmacists with the Department of Health will also be in charge of evaluating data on the forms of medical marijuana available, and the study of the patients and their response to treatment, as well as reviewing the existing scientific data on cannabis.

The program planned for medical marijuana in Minnesota will be a very rigid, structured program for the use of this compound. It is designed to limit the inappropriate use of marijuana for recreational enjoyment. It is also meant to use cannabis as a medication, and to study the patients and its effectiveness in a comprehensive management environment. Hopefully, the program can be implemented and be effective. For now, until more scientific evidence becomes available, chronic pain will not be included in Minnesota’s program.

How Obesity Makes Pain Problems Worse

November 17, 2014 / Thomas Cohn, MD

More information is now becoming available about how obesity can contribute to pain problems, sometimes in unexpected ways. Obesity is a known factor for osteoarthritis of the knees, and increased weight leads to mechanical stress on the knees, causing premature deterioration. Another factor is problems directly related to adipose tissue, fat, and products this tissue produces. Fat produces compounds that influence inflammation. These compounds can make weight bearing and deterioration worse.

Recent studies have shown that weight and thus mechanical stress is a main cause of knee degeneration. The majority of the patients that have knee degeneration are significantly obese. Other factors for knee arthritis often include multiple injuries and repetitive trauma from activities like sports or running. Running can be especially damaging with the impact on hard surface. That said, conversely, losing weight can actually relieve symptoms in patients with knee osteoarthritis. Managing knee pain is closely associated with managing your weight.

Hand Pain and Obesity

Unlike knee arthritis, hand arthritis is not typically related to mechanical stress of weight. Studies have found in these cases, the chemical factors related to inflammatory compounds have significant impact on these joints. The relationship between inflammatory compounds and hand joint deterioration have confirmed that hand arthritis is more common in the obese. Research has now begun to identify the chemical compounds that are increased in obese individuals with arthritis to determine how their presence can best be deterred.

Obesity causes mechanical stress and now we know fat releases chemicals that cause inflammation and pain. Reducing weight does decrease mechanical stress on joints. It may also decrease the amount of available inflammatory compounds that also cause damage to joints. Pain has many causes, but since individuals can have significant control over their own weight, managing it is one of the best ways to decrease your likelihood of developing arthritis in your joints.

Can Alternative Medicine Really Help Your Back?

November 12, 2014 / Thomas Cohn, MD

The following is a guest blog post from our friends at North American Spine.

If you’re experiencing mild or chronic back pain, there are a variety of traditional and alternative treatments that can both ease the pain and help address the root cause. When most patients complain of back pain, their doctor’s first reaction may be to refer them to an orthopedic or osteopathic surgeon. However, there are other options that have been effective in treating patients for centuries. These include:

Acupuncture

A diet rich in anti-inflammatory foods

Myofascial release

Physical manipulation

Back-strengthening exercises

Yoga and meditation

A Physical Medicine Pain Doctor

Help a Bad Back by Sticking Needles in It

That’s right. Acupuncture, which is the art of inserting thin needles into certain parts of your body to help reduce or relive discomfort, is an effective drug-free method for relieving back pain. Although the results are not long-lived, treatments help when pain medicine and other therapies have failed.

Scientists are still working to understand how acupuncture relieves pain and stimulates endorphins. Acupuncture is endorsed by the American Pain Society, the American College of Physicians and the National Institute for Complementary and Alternative Medicine. In fact, one of the main reasons people choose acupuncture is because it’s been so successful at treating back pain. If you’re worried about being stuck with needles, don’t be. Patients rarely feel pain. If anything, it’s more of a slight tingling sensation.

Rest, Relaxation and Less Pain

Myofascial release is another type of therapy that uses pressure to effectively loosen the tension and tightness that contributes to upper and lower back pain. Myofascial techniques are often included in massage therapy and chiropractic care. When done correctly, these techniques can both decrease pain and increase your range of motion.

Down Dog Your Way to Less Back Pain

Yoga is a unique method for treating back pain because it stimulates the mind AND the body. Breathing and meditation coupled with low-impact exercises calms the mind and relieves the stress that is caused by chronic pain. With help from cushions, certain yoga poses are great for stretching and strengthening the back.

A 2011 study conducted by the National Center for Complementary and Alternative Medicine found that 12 weekly yoga classes improved function and mobility for patients with recurring or chronic back pain better than traditional therapies.

Eat Better, Feel Better

Just as certain medicines relieve inflammation, a healthy diet can reduce the swelling that may cause back pain in the first place. A good anti-inflammatory diet includes vegetables, fruits, fish, high-fiber foods and certain spices. North American Spine recently talked about the correlation between your diet and your back in a back pain eBook.

If possible, try to shy away from eating too many carbohydrates, as they affect insulin levels and promote inflammation. The same holds true for dairy, eggs and wheat—especially if you’re sensitive to these foods. The key to a healthy back is a healthy diet, so be sure to eat foods rich in zinc, iron and fiber and less rich in hydrogenated oils and fats.

The goal of alternative treatments is to increase mobility, reduce pain and lessen your dependence on medications. Above all, these simple methods should encourage you to take an active role in your care.