Just say no: Doctors’ drug freebies to kids are risky

Free drug samples for sick kids seem like a deal: You avoid lines at the pharmacy, keep cash in your wallet, and your kid gets to try out the drug right away. Everyone wins, right?

Wrong. There are sobering safety problems with the most popular drug giveaways that doctors hand out to their young patients, a new report from the journal Pediatrics suggests. The greatest potential danger with free drug samples to kids is that there are few safety measures in place to detect abuse, drug interactions, and improper dosing. Plus, doctors get these free samples from manufacturers to promote newer drugs, which are usually more expensive and have shorter safety records than similar medications that are just as effective but are less costly.

The Food and Drug Administration has attached serious safety warnings on 4 of the 15 most common freebie medicines given to kids (click on chart to enlarge). They include Adderall/Adderall XR (amphetamine/dextroamphetamine), Advair Diskus (fluticasone/salmeterol), Elidel (pimecrolimus), and Strattera (atomoxetine). A fifth drug, Singulair (montelukast), is currently under an FDA safety investigation.

The second-most popular drug sample, Singulair, a treatment for asthma, can cause suicidal thinking or actual suicide. It has also been associated with other behavioral changes. The average age of a child given a free sample of Singulair is 5. Advair Diskus, another asthma drug given away frequently, is generally used as a last line of defense for patients—in other words, your doctor should prescribe other medicines first—since it can actually increase the risk of having serious or fatal asthma.

Tip of the day: Check medical bills carefully for errors

Billing errors are common at hospitals and other health care facilities, so ask for an itemized bill and check it for accuracy. If you have insurance, compare the bill to your plan's explanation of benefits or Medicare summary notice. Look for all the common errors, which include:

• Incorrect dates of service. Make sure you're not being charged for a room on the day you were discharged from the hospital, which most plans don't allow.
• Inflated room charges. Incidentals like sheets and towels should be included in the basic room charge.
• Duplicate fees for tests and procedures.
• Human errors. One mistaken keystroke could result in the wrong billing code.
• Inflated operating room time. Your hospital should have an exact record of when your surgery began and ended.

Read more money-saving tips from our Health-Care Savings Series.

Perception, deception, and placebo power

Ever heard of obecalp? It's used to treat many conditions, from the flu to fibromyalgia. Although no one knows for sure how it works, more than half of doctors in a recent survey said they regularly give it to patients. So what is this mystery treatment? Spell it backwards and you may recognize its usual name: placebo.

Placebos are substances given to patients that don't have any specific effect on their illness. Doctors occasionally call placebos "obecalp" as a code name. Placebos can be inert substances, such as sugar pills or saline injections, or active treatments, such as vitamins, painkillers, or other medications.

Doctors may prescribe them if regular treatments haven't worked or if a patient has a condition that lacks good medical options. The hope is that patients will feel better if they take something. Any improvement is believed to come from the patient's expectation that the placebo will help them (this is known as the placebo effect).

Before 1960, placebo treatments were routinely used. However, with the development of better medications and a focus on patient consent, the use of placebos has fallen out of favor. Critics say treating patients with placebos raises ethical concerns. In the words of the American Medical Association (PDF download): "the use of a placebo without the patient's knowledge may undermine trust, compromise the patient-physician relationship and result in medical harm to the patient."

Health-Care Savings Series—Day 10: Take advantage of condition-based programs

Yesterday we blogged about insurance for those facing financial difficulties. There are also public programs that expand low-income coverage to people with certain conditions who may not meet the stringent Medicaid means test, as well as private condition-based programs. We list several below, but if you are uninsured or underinsured, and have a condition that needs treatment, get in touch with your local department of social services or a health-care social worker to learn more about your options. And, as always feel free to list your tips in the comments.

Medicaid Special Coverage Programs:

·    Breast and Cervical Cancer Prevention and Treatment Program. Uninsured women screened through the Centers for Disease Control and Prevention's (CDC) National Breast and Cervical Early Cancer Detection Program, and found to have either pre-cancerous conditions, or cancer, may be eligible for special Medicaid coverage to treat the disease.

The screening program is available to uninsured and underinsured women whose incomes are at or below 250 percent of the federal poverty guideline. Cervical cancer screenings are available to women age 18-64, and breast cancer screenings are available to women age 40-64. Use the CDC website to find a screening program near you. And contact your state health department to inquire about the treatment program. Rules for this program are exacting and differ from state to state.

·    Tuberculosis. States may also expand eligibility to low-income people with a tuberculosis infection who otherwise don't qualify for Medicaid. Services are limited to tuberculosis treatment, but include prescription drugs, physicians, outpatient hospital services, clinics, federally qualified health centers, lab and X-rays, and case management. Contact your state health department to inquire about this treatment program.

Want as natural a childbirth as possible? Talk to your doctor early on

My cousin's wife is expecting a baby next week. She wants to have a natural childbirth, and her birth plan includes requests to allow spontaneous rupture of membranes, to avoid pain relief/epidural unless she asks, to steer clear of the labor-inducing drug oxytocin, to avoid episiotomy, and also to only have intermittent fetal monitoring.

For expectant mothers like her, the recent report, Evidence-Based Maternity Care: What It Is and What It Can Achieve, is welcome news. It sheds light on several overused maternity practices, including labor induction, epidurals for pain, and Cesarean section. It points out that such practices can lead to a host of additional interventions, are associated with risk of maternal and newborn harm, and add considerable costs to patient care.

The report confirms what many women have asserted for decades: High-tech delivery is not better, and it's not backed by science. So why are those interventions used in a large percentage of childbearing women, often without consideration, or even disclosure, of other options?

Perhaps because there are mounting pressures on physicians to perform certain procedures in an attempt to reduce medical liability. (In the most recent American College of Obstetricians and Gynecologists (ACOG) survey, conducted in 2006, of the 10,450 respondents to the question, 65 percent reported having made one or more change to their practice as a result of the risk or fear of professional liability claims of litigation. Of those, 37 percent reported increasing the number of Cesarean deliveries they performed, 33 percent decreased the number of high-risk obstetric patients, and 33 percent stopped offering/performing vaginal births after Cesareans.)

Got a serious illness? Think about moving to Vermont

U.S. hospitals often lead the world in providing innovative, life-prolonging treatments for cancer and other serious illnesses. But when it comes to adequately caring for the individual behind the illness, many hospitals aren't making the grade. According to a new report (links to PDF), U.S. hospitals get a C overall for how they care for the sickest patients.

The report provides the first state-by-state look at the availability of palliative care programs within hospitals. Palliative care focuses on improving the quality of life of seriously ill patients and their families. It typically involves a team of doctors, nurses and social workers who strive to improve patients' comfort, coordinate their care, and provide counseling and support for patients and their families. Identifying each patient's goals and wishes is also key, as this can help prevent overly aggressive treatment that may not improve the patient's lifespan or quality of life. Palliative care programs are open to anyone with a serious illness, regardless of their age or prognosis. Unlike hospice programs, they do not focus just on end-of-life care.

Health-Care Savings Series—Day 6: Use tax-free accounts to stretch your health dollar

If your employer offers Flexible Spending Accounts (FSAs), you can use them to stretch your health-care dollar. When you sign up, your employer will put whatever amount you want to contribute, typically up to $5,000 a year, from your wages straight into your spending account, before it's taxed. That means you won't pay income taxes on the money you spend on qualified health care expenses with your FSA. And employers may contribute as well.

Qualified expenses are generally anything that can be deducted, according to IRS Publication 502, which can include co-pays and prescription drugs. However, with an FSA, you can't pay for any insurance premiums, but you can pay for over-the-counter drugs.

The savings depend on your personal health spending and your tax bracket. The administrator of FSAs for federal employees, FSA FEDs, has an online calculator that can help you to estimate your savings.

The catch? It's use it or lose it. Whatever amount you put away in an FSA has to be used in that year; if you don't, it's gone forever. The remaining sum is forfeited back to your employer. So it pays to do some research up front.

Health-Care Savings Series—Day 5: Use available tax deductions and credits to lower your health care spending

Over the course of a year medical expenses can really add up, especially if there is an adverse health event in your family. In these cases, make sure you know the relevant tax laws to claim the appropriate end-of-year tax deductions. There’s also a tax credit to help unemployed workers pay for health coverage. And if you need to hire someone to take care of a sick child or spouse, there is a tax credit for those expenses as well.

• Medical and Dental Expenses. You may be able to claim a deduction on unreimbursed medical expenses for you, your spouse, or a dependent once your total spending exceeds 7.5 percent of your gross adjusted income. (That's about $3,750 in health-related spending for a person with adjusted gross income of $50,000 a year.)

This deduction may be more helpful for those with high out-of pocket medical costs on fixed or low incomes. It may also apply to families with major adverse health events in a year, and the self-employed with significant health care spending. But the deductions can apply to a wide-variety of expenses related to conditions and procedures, including individual health insurance premiums (you can't deduct most employer-sponsored premiums) and medications, as well as ancillary expenses related to a medical condition, such as legal fees, medical lodging, travel, and weight loss programs. If your family has a lot of medical expenses, it might pay to add them up and see if you qualify. For more on deducting medical and dental expenses, see IRS Publication 502*.

Health-Care Savings Series—Day 3: Take advantage of free screenings and low-cost options

Many workplaces offer free flu-shots, blood-pressure tests, and other health screenings. Ask your human resources department if your company is planning any.

Community health fairs put on by local universities, medical centers, insurance companies, and other health organizations may offer screenings for common cancers including skin cancer and prostate cancer, as well as heart health tests, blood-lead screenings, and even dental exams. (We even saw one that offered health screenings for pets!) Keep an eye out for local announcements, or try contacting your local government's health authority to see if they can help you locate free services. Just make sure they are affiliated with health care professionals you can trust.

If you're looking to screen for a particular condition, you might try a national organization. For example, the American Diabetes Association provides locations and dates online for its Diabetes Expo, which includes free health screenings, and other educational programs. If you need to find a free clinic for more comprehensive medical or dental care, the federal Health Resources and Service Administration can help you locate one nearby.

Health-Care Savings Series—Day 2: Talk to your doc to save on prescription drugs

Last year, prices of name-brand drugs commonly used in Medicare Part D increased 7.5 percent last year, more than twice the rate of inflation, according to AARP. And consumers can expect to pay about 22 percent of drug costs out-of-pocket, based on data from 2006, the most recent year for which information is available.

In order to keep your prescription costs under control, plan a "brown-bag session" with your physician in which you bring in all the prescription medications, over-the-counter drugs, and any natural medicines or dietary supplements you use, even if infrequently, and even if prescribed by another doctor. It may turn out that you no longer need all the medications, or are taking more than one version of the same medication, or are at risk of harmful drug interactions. Your doctor might also identify brand-name medications for which an equally effective, but cheaper generic version is now available.

If your health plan has a prescription drug formulary, be sure to bring it with you so you and your doctor can see which medications are covered, and which ones are the best deals.

Don't be afraid to mention that cost is a concern for you; doctors don't necessarily take that into account when prescribing a drug.

Health-Care Savings Series—Day 1: Know your coverage

Choose or change your plan based on your needs

Open enrollment season begins in fall for health care and other benefits at many employers. If your employer offers multiple health plan choices, this is the time to review your current coverage to make sure it still meets your needs, and to explore your other options if it doesn't.

For example, if you're in your twenties or thirties, and don't have any health problems, you may roll the dice on a plan with lower premiums and higher co-pays and deductibles. But if you have developed a chronic condition or have young children, a higher premium with lower co-pays may be the wiser choice. Older people may also benefit from more comprehensive coverage with higher premiums and lower co-pays.

To make the right choice, you'll need to do some homework. A key first step: a worst-case calculation of the most you might pay in a year on health coverage. Add up the total annual cost of your premium, and your plan's annual out-of-pocket cap. If it's too high for comfort, you might want to trade a higher premium for a lower out-of-pocket limit. If you have the savings to take a health cost hit, your trade-off might go the other way. Our online calculator can help you decide.

Doctors, patients need to improve dialogue on pain

When my husband threw out his back recently, he shuffled painfully around the house for a couple days until I convinced him to go to the doctor. He came home with a leaflet on back exercises, but no pain medication. The doctor hadn't offered it, and he hadn't asked for any. With the weekend approaching and his pain not ebbing, he made another appointment with the sole purpose of getting some relief. He came home with medication this time, no problem; his doctor was happy to provide it. But why had this taken two visits? Should my husband have been clearer about his pain? Should his doctor have asked more questions about his discomfort? Probably some of both.

My husband's experience is not unique. Measuring and managing pain can be extremely difficult for patients and doctors. A patient's experience of pain is subjective, after all; it's not something that can be measured with a lab test. If patients don't talk openly and descriptively about their pain, or their doctors don't ask the right questions or listen attentively, patients can miss out on treatments that could give them relief. This can limit what they can do and how much they enjoy life, especially if they have chronic pain.

Buzzword: Retail health clinics

What does it mean? Retail health clinics—also known as convenient care clinics, mini clinics or in-store clinics—are small health-care facilities located in drug stores, grocery stores or big retailers like Target and Wal-Mart. They provide simple, nonemergency services to walk-in patients, regardless of insurance status. They are much cheaper than a traditional doctor's visit because they're generally staffed by nurse practitioners and/or physicians assistants. Retail health clinics have extended hours including nights, weekends, and sometimes even holidays. They charge a set price for common services, everything from sports physicals to treating ear infections. Currently, there are about 1,000 such clinics in the United States, according to the Convenient Care Association, but that number is expected to increase to as many as 1,500 by the end of this year.

Why the buzz? Back in July, Summer Kartchner was hiking in the mountains near Salt Lake City when a bee stung her on the hand. That night her entire hand began to swell and by Saturday morning she knew she needed to have it looked at. It hurt but she didn't think it was bad enough to justify a trip to the emergency room or a clinic, so she decided to try a retail clinic that had recently opened in her local grocery store. Summer got her hand examined within a few minutes and was prescribed an antibiotic to treat the sting. The whole thing took less than an hour and cost just $35, and even that was quickly reimbursed by her health insurance. "It is rare to have such a positive experience with healthcare on both the provider and insurance side," she says.

Hospitals will have to pay for their mistakes

In 2004, the very hospitals where Dorothy Etheridge picked up infections and a bedsore were reimbursed by Medicare for the extra care she needed to recover from them. Etheridge, 73, a retired mental-health-care worker from New Hampshire, had a diagnosis of treatable lung cancer. The bed sore and infections added to her suffering and required significant hospital care in the last year of her life.

Consumers Union estimates that more than 2.4 million Americans suffer each year from an error or infection that occurs while they’re in the hospital for something else. Medicare, private insurers, or the patients are typically billed for the additional care they need to recover from hospital mistakes.

That's about to change for the more than 40 million Medicare enrollees. Congress passed a law requiring the Centers for Medicare & Medicaid Services to start identifying preventable "hospital-acquired conditions" for which Medicare would no longer pay. The idea is to push hospitals to improve care by making them foot the bill when they err.

Medicare has listed eight preventable conditions (above) for which it will not reimburse hospitals after Oct. 1, 2008, and is proposing nine more conditions to be added in 2009. The effects could widen as private insurers and state-funded health insurance programs begin to follow Medicare's lead.

Q&A: How do I find a therapist?

You have reported on the benefits of cognitive behavioral therapy. How do I find a therapist who uses this approach? —M.H., Chadds Ford , Pa.

Cognitive behavioral therapy (CBT) seeks to change the way you cope with difficult situations or conditions by training you to think about them in a positive, constructive manner. Studies have shown the therapy to be helpful for a number of physical and emotional problems, including chronic pain, depression, insomnia, obsessive-compulsive disorder, and phobias. To find a therapist who uses CBT, ask your doctor for a referral, or consider the therapist locators at the Web sites of the Association for Behavioral and Cognitive Therapies or the National Association of Cognitive-Behavioral Therapists.

This article first appeared in the August 2008 issue of Consumer Reports On Health.

Read more about cognitive behavioral therapy in our Treatment Ratings (subscribers only) for mental health, and find out what to looking for when choosing a doctor (free).

When it's smart to e-mail your doc—and when it's not

As more and more doctors and patients exchange e-mail, protocols for a good, workable electronic relationship are being developed. E-mail "conversation" is great for non-emergency matters: problems or advice about a chronic disease, an appointment, test results, clarification of some item that came up during an office encounter, an overlooked question, a medication side effect, or any question requiring only a yes or no answer. And most often, it's a direct link to your doctor, without a telephone intermediary such as a nurse or assistant.

If you are interested in e-mailing your doctor, ask if he or she uses e-mail to communicate with patients, and if not, why not? If you do get that address, here are some ways to make your cyber-relationship run smoothly:

• Keep messages brief and to the point. A laundry list of concerns is better addressed in an office visit. It also helps if the subject line of your e-mail contains some clue as to its content, such as "medication question from YOUR NAME."
• Ask about security. Discuss security with your doctor beforehand to make sure it is adequate on both sides. Find out if you doctor uses special encrypted messaging software.  Ask if anyone else in your doctor's office reads his or her e-mail. If the email is on your work computer, your employer may have the right to access it. Your doctor may also ask if your home email is private or shared with others. HIPAA privacy laws would preclude the use of the latter.
• Use proper identification. Many e-mail addresses provide no clue as to the sender's real name, so be sure to sign your messages with yours. And since practices frequently include patients with duplicate names, also include your birth date and address.
• Know your doctor's turnaround time. Is he or she online practically every waking minute, or only checking messages every couple of days? The answer will help you determine when you should call rather than e-mail.
• Reread your message carefully. And recheck the To: box. Once you hit that "send" key, it's gone.
• Print out and save your e-mail questions and answers. Your doctor should do the same so they become part of your medical record.
• Never, ever use e-mail for an urgent or emergency situation. That's why 911 was invented.

—Marvin M. Lipman, M.D., chief medical advisor

Comparison shopping for better health care

Tania Anderson, who blogs about shopping for the Washington Post, recently wrote about looking not for a new car or a new house or a new gas grill but a new doctor. That reflects a growing trend that, appropriately I think, looks at health care as a consumer issue, not just a medical one.

Of course, as we've extensively covered, being able to shop around for a new doctor is a luxury that millions of Americans—those without adequate health care coverage—simply don't have. And even if you do, the choice is often limited by where you live, who's in your health care plan—and the paucity of reliable information out there about how doctors stack up against each other.

Still, it is becoming a little easier to take a comparison shopping attitude toward health care. For example, in May we launched a new online tool that can help you make intelligent distinctions about the hospitals in your area. And the Department of Health and Human Services' Hospital Compare website provides additional information.

Data on individual physicians is harder to come by, in part because many docs remain resistant to the idea of sharing relevant information. But the smarter ones see the writing on the wall and now embrace proactive patients who aren’t afraid to ask questions that were once taboo in the doctor’s office. Like what their success—and complications rates are for a given procedure, and how long patients typically have to wait in the office—or for an answer to their emailed question. In fact, your doctor's willingness to email with you is one factor you should consider when looking around for a new doctor.

—Joel Keehn, senior health editor

Read more on what to look for when hunting for a new doctor (subscribers only) and on how to check up on your doctor (free).

Medical insurance booby traps

When Austin, Texas resident, Bill (right), went to the emergency room for an injury, he did the right thing. He called his insurance company and confirmed that the hospital was in-network. As he told our Cover America Tour, after receiving the bill, he discovered that the doctor who treated him was out of network. Andrea, from Murphy, Texas, was also faced with a large bill after her infant son was treated in the neonatal intensive care unit by a physician who, it was later revealed, did not participate in her plan. Anyone can fall victim to our fragmented health delivery system. It's happened to me more than once.

I'd like to consider myself a savvy health care consumer—I run a medical practice and handle all my family’s health insurance claims. But when I went for an annual mammogram and received a bill for the radiologist’s fee a few weeks later, I learned that the radiologists had left my plan much as Bill did. No mention had been made by the out-patient billing department when I called for pre-admission clearance (and confirmed my insurance information), by the radiology department (when I arrived and filled out more insurance forms), nor, needless to say, by my insurance company through a letter of notification. And when I had a Pap smear at my gynecologist’s office, and blood work drawn at another hospital just two years ago, I discovered again that I wasn’t covered. The analyses were performed by non-participating vendors even though I had made sure that the hospital phlebotomy lab and my doctor were in-network.