Health Insurance - the good, the bad and the ugly

In the US, healthcare is not a inalienable right. Many of you have health insurance either through employment or by paying yourself. Others are not so fortunate and do not have any coverage.

Healthcare insurance is viewed very differently from other types of insurance. Most people have auto insurance but don't expect that it will cover basic tuneups and preventive care so car owners take it upon themselves to get the oil changed, check the tire pressure, etc. Many view their health insurance as where their efforts to health begin and end. A healthy lifestyle is your best insurance but takes effort and responsibility.

So what are the pros and cons to health insurance?

Patients Perspective
Pros

• Peace of mind - just knowing that coverage is in place can be of comfort.
• You are more likely to seek medical care when you need it.
• If you are unlucky enough to incur large medical bills it may keep you from financial difficulty. Conversely - you are getting your money's worth

Cons

• It is not universal - having healthy neighbors makes you more healthy too,
• Those that cannot afford it generally do not seek medical attention when they need it.
• Insurance companies are purely profit driven and not an advocate for your health. They are in the business of denying benefits to increase profits. Insurance companies are making record profits and it is draining the pockets of America.
• They do not cover preventive medicine
• Actuaries are making health care decisions for you, not you, and not your doctor.
• Expense - many people cannot afford insurance and rely on the ER for their care; especially if you are healthy it can seem like money down the drain
• There is no incentive/reward for leading a healthy lifestyle
• Some things are not covered that you may want - massage, chiropractic...sometimes even naturopaths
• Deductible can make having insurance seem a waste of money

Physicians Perspective
Pros

• Increases the number of patients I see - those with healthcare are more likely to seek care

Cons

• As physicians we have an ethical and moral directive to help people in need. We also need to eat, pay our staff and student loans. I would love to provide healthcare to the best of my ability and not have to worry about whether someone has coverage or if I will be paid.
• Insurance companies are more likely to pay for a limb amputation than preventative medical treatment. Those without coverage don't even get that.
• Naturopathic treatments are more cost effective and yet there is no recognition of this.
• Massive amounts of paperwork.
• You are at the mercy of the actuaries.
• Time and money spent on following up on declined reimbursements
• You must agree to accept whatever the insurance company decides your services are worth
• Some appropriate treatments and diagnostic tests are not covered
• Practitioners must agree to charge the same amount for cash payers
• It is really a game and naturopaths do not really fit into the insurance model because we spend more time with patients
• They may only cover a certain amount of visits even though the patient would benefit from continued care
• Drives up the costs of healthcare - our healthcare is the most expensive in the world but not the best
• Many patients see insurance as their healthcare and don't accept their own responsibility making them difficult patients

Alternatives
For those that take an active roll in their health and lead a healthy lifestyle, a high deductible, low cost catastrophic insurance plan plus a health savings account for general health care might be a good alternative. This will save money overall if you remain healthy yet still provide coverage for emergent events. Perhaps we will see universal healthcare with the new US Government administration?

Further food for thought

• Michael Moore's film 'Sicko' - examines the state of healthcare in the US and gives glimpses of the national systems that other countries have in place
• Fast Food Nation - a humorous film that examines what happens when we feed ourselves with fast food. Changing diet to whole foods is great and tasty insurance.

How do ND's compare to MD's?

First, I would like to say that I consider Medical Doctors to be colleagues, not adversaries. I have good relations with many MD's and I recognize the need for all types of medicine.

How are we similar?
We all have the patient's best interests in mind when we make clinical decisions.
We both take insurance
We both use detailed history, physical exam, laboratory tests and imaging to diagnose.
We take the same basic science classes
We both spent a lot of time and money on education and carry huge student loan burdens
We both carry malpractice insurance
We both refer out for specialists opinions and treatment
We both can prescribe antibiotics and other pharmaceutical drugs
We both have national and state associations
We both take national board exams
We both have our scope of practice determined by our training and the state DOH
We both take the Hippocratic Oath.
We both must comply with ethical standards outlined by the state
We are both primary care physicians
We both have National Provider Identity numbers, DEA numbers, and business licenses

How are we different?
Our philosophies of health and healing are different
Our treatment modalities are usually different
Naturopaths generally spend more time with their patients
MD's pay higher malpractice because their treatments are usually of higher force
There are many more MD's in practice
MD's make more money in general
MD's can work at the hospital, ND's are in private practice
ND's cannot prescribe the most hightly addictive pharmaceutical drugs
ND's are largely not recognized by the US Federal Government and are not covered by Medicare/Medicaid

Please click on the following links to the Washington Association of Naturopathic Medicine for comparisons of:
Student candidate prerequisite requirements
http://data.memberclicks.com/site/wanp/ND%20&%20MD%20Prerequisite%20Education%20Comparison.pdf

Education
http://data.memberclicks.com/site/wanp/ND%20MD%20Ed%20comparison.pdf

What is Naturpathic Medicine and the Naturopathic Physician?

As a Naturopathic Physician I am often surrounded by like-minded folk and I assume everyone knows what Naturopathic Medicine and Naturopaths are. Here is a short passage that will help others to understand who we are.

Naturopathic Medicine
Naturopathic medicine is much more than natural therapies. It is a system of health care - an art, science, philosophy, and practice of diagnosis, treatment and prevention of illness and health promotion. Naturopathic medicine is not defined by the substances used in treatment but rather by the principles which underlie and determine its practice. These principles include:

• First do no harm
• Find the cause
• Employ the healing power of nature (vis medicatrix naturae)
• Treat the whole person
• Pevention
• Doctor as teacher (docere)

All too often I see people falling into a trap by taking the result of a study or what a well-known figure says (insert Kevin Trudeau here) and applying it to their situation. Perhaps they get lucky and they find the appropriate remedy but there is a lot of misinformation in the public realm. More often their treatment does not work they are disappointed in natural medicine. This is not the Naturopathic perspective.

Only when we find the true cause of the illness (in the naturpathic sense) and apply the appropriate treatment will the correct therapy be selected. What is good for one individual may not be appropriate for another because the process that produced the illness may not be the same even though the symptom is similar. Pharmaceuticals and surgery are all appropriate naturopathic treatments if they are necessary and applied according to the Naturopathic Priciples. We endeavor to employ therapies that are rooted in nature and are of the least force that provides cure.

The Naturopathic Physician
There are approximately 4000 practicing naturopaths in the entire United States. We are scientists, artists, philosophers and teachers. We respect the natural wisdom of the body, the uniqueness of each person and the energetic being that makes us human. In general we spend more time with our patients with our first visits being around 1 hour and return visits 30 minutes. We use traditional and current methods of diagnosis including physical exam, laboratory analysis and imaging. We We have extensive referral networks that we use in the best interest of our patients.

In Washington State we are licensed as 'primary care physicians'. Many have a general practice and others work as specialists/consultants in natural medicine. Fourteen states currently license naturopaths and many more have ongoing legislative movements. As physicians in Washington we are included in the 'every category' of provider that mandates insurance policies be offered by insurance companies for medical coverage. Most naturopaths choose to contract with insurance companies and also accept cash patients at a discounted rate. Some have a strictly cash-based practice.

Naturapathic physicians tend to use a combination of herbal medicines, lifestyle modification, homeopathic remedies, therapeutic diet and nutrition, counselling, physical medicine and manipulation and vitamin and mineral supplements.

Our scope of practice is determined by our training and the state legislature. In November 2006 a large expansion of our scope was enacted giving the Naturopath the ability to prescribe most pharmeceutical drugs if the situation warrants. In addition this gives naturopaths the legal ability to manage the prescriptions that many of our patients are on already.

Naturopathic education is also modelled after conventional medical school. Students spend 4 rigorous years minimum recieving their academic training with a load often over 30 credits per quarter. Many choose to take 5 years. The first two years are spent learning the basic sciences, anatomy, physiology, pharmacology, histology, etc. This is followed by therapeutical and clinical training. Clinical training takes place at the school supported clinic treating members of the surrounding community and in private clinics with doctors throughout the region and beyond. Approximately 2/3 of each class continue to graduate with 1/3 either dropping out or failing to meet academic requirments.

All students must pass national board examinations over three days.

Traveler's Diarrhea

Description
Travelers’ diarrhea (TD) is a clinical syndrome resulting from ingestion of microbial contaminated food and water. It occurs during or shortly after travel, most commonly affecting persons traveling from an area of more highly developed hygiene and sanitation infrastructure to a less developed one. Thus, TD is defined more by circumstances of acquisition than by a specific microbial agent.

Etiology - cause
There is considerable diversity in etiologic (causative) agents. Bacteria are the most common cause of TD and are responsible for approximately 80%-85% of cases, parasites about 10%, and viruses 5%. These organisms enter your gastrointestinal tract and overwhelm your defense mechanisms and normal gut microbes, resulting in signs and symptoms of traveler's diarrhea. A similar but less common syndrome is toxic gastroenteritis, caused by ingestion of pre-formed toxins (ie botulism). In this syndrome, vomiting may predominate, and symptoms usually resolve within 12-18 hours. Often residents of less developed nations have become used to the bacteria and developed immunity to them.

Signs and Symptoms
Definitions of TD that rely on rigid criteria for frequency of loose stools in a 24-hour period are commonly used in clinical research studies but are not relevant to the clinical syndrome as it affects travelers.

The most common signs and symptoms of traveler's diarrhea are abrupt onset of:

• Increased volume and weight of stool
• Frequent loose stools — usually about four to five loose or watery bowel movements each day
• Urgency
• Abdominal cramps
• Nausea
• Vomiting – up to 15% of those affected
• Fever
• Bloating

Travelers’ diarrhea is generally self-limited (resolves without treatment) with significant improvement in 3-4 days and resolution in 1 week, but persistent symptoms may occur in a small percentage of travelers. A small number of cases involve moderate to severe dehydration, bloody stools, persistent vomiting or a high fever. If you or your child experiences any of these signs and symptoms or if the diarrhea lasts longer than a few days, it's time to see a doctor.

SIGNS OF DEHYDRATION – in need of IV rehydration

• No urination for >8 hours
• Sunken eyes
• Lethargy
• Confusion
• Skin does not return after pinching
• Dizziness or light-headedness
• Crying without tears
• High pulse rate and respiration rate

Prevention
For travelers to high-risk areas, the CDC recommends the following conservative approaches, which can minimize but never completely eliminate the risk of TD:

• Wash hands with soap and water prior to eating or meal preparation.
• Probiotics, such as Lactobacillus and Saccharomyces boulardii – daily ingestion of supplement or possibly yogurt helps to keep your intestinal bacteria healthy.
• Care in selecting food and beverages for consumption may minimize the risk for acquiring TD. The following comprises a conservative approach, your disgression will need to weigh several factors about the country you are visiting .
• AVOID
  Drinking non-potable water and reconstitued beverages – even brushing teeth and ice cubes
  Drinking water in the shower
  Foods washed in non-potable water – ie salads
  Street vendor food
  Undercooked or raw meats, fish and shellfish
  Buffets
  Reheated prepared foods
  Unpasteurized dairy products
• CONSUME
  Freshly cooked hot meals
  Bottled, boiled, chemically treated (iodine) or microfiltered water
  Sealed carbonated beverages
  Dry foods – ie breads. pastries, cereals, nuts
  Fruits and vegetables that you can peel – bananas, oranges, avocados

Treatment - allopathic (conventional)
Antibiotics are the principal element in the allopathic treatment of TD, although they are often not needed. Adjunctive agents used for symptomatic control may also be recommended.

ANTIBIOTICS
Bacterial causes of TD far outnumber other causes, so treatment with an antibiotic directed at bacterial pathogens of the intestines without testing remains the best allopathic therapy for TD. The effectiveness of a particular antimicrobial depends on the etiologic agent (bacteria, parasite or parasite) and its antibiotic sensitivity. First-line antibiotics include those of the fluoroquinolone class, such as ciprofloxacin or levofloxacin. Increasing microbial resistance to the fluoroquinolones may limit their usefulness in some destinations such as Thailand, Nepal and others. An alternative to the fluoroquinolones in this situation is azithromycin. Rifaximin has been approved for the treatment of TD caused by noninvasive strains of E. coli.

The standard treatment regimens consist of 3 days of antibiotic, although when treatment is initiated promptly, shorter courses, including single-dose therapy, may reduce the duration of the illness to a few hours. Antibiotic use should be follwed by use of probiotics to reduce the chance of sequelae (irritable bowel syndrome, dysbiosis)

ANTI-MOTILITY AGENTS
These agents include:

• Loperamide (Imodium)
• Diphenoxylate (Lomotil)
• Opiates (Paregoric and codeine)

These provide a prompt decrease in stool frequency by reducing muscle spasms in your gastrointestinal tract, slowing the transit time through your digestive system and allowing more time for absorption. These agents should not be used by travelers in diarrheal illness associated with high fever or blood in the stool, rather they should seek medical attention. They are not recommended for children <12>

ORAL REHYDRATION THERAPY
Fluid and electrolytes (minerals) are lost in cases of TD, and replenishment is important, especially in young children or adults with chronic medical illness. In adult travelers who are otherwise healthy, severe dehydration resulting from TD is unusual unless persistent vomiting is present. Nonetheless, replacement of fluid losses remains an important adjunct to other therapy.

For more severe fluid loss, the CDC recommends replacement with oral rehydration solutions (ORS), such as World Health Organization ORS solutions (labelled WHO-ORS), which are widely available at stores and pharmacies in most developing countries. WHO-ORS is prepared by adding one packet to the appropriate volume of clean water (see packet for instructions). Once prepared, solutions should be consumed or discarded within 12 hours (24 hours if refrigerated). If vomitting is present, begin with sips of fluid and work up to larger volumes as tolerated.

TREATMENT FOR CHILDREN
In older children and teenagers, treatment recommendations for TD follow those for adults, with possible adjustments in dose of medication.

Macrolide antibiotics such as azithromycin are considered first-line antibiotic therapy in children, although some experts are using short-course fluoroquinolone therapy with caution for travelers younger than 18 yo. Rifaximin is approved for use starting at age 12 yo. Antimotility agents, loperamide and diphenoxylate, are not recommended for children <12>

Treatment – naturopathic

The mainstay of naturopathic treatment is preventive and then oral rehydration with electrolytes, natural antimicrobials, immune modulation and bulking of the stool to increase the time it takes for food to transit through the intestines (similar to antimotility agents).

ORAL REHYDRATION – if WHO-ORS unavailable

• 1 Qt (or 1 Liter) water (clean)
• 1/2 tsp salt
• 1/2 tsp baking soda
• 2 Tbsp sugar or 1 Tbsp honey or 2 Tbsp rice powder
• 1/4 tsp potassium chloride (salt substitute – if available)
  Sip every 15 min for a total of 1 C every 90 minutes as tolerated.

Alternatives if unable to gather the above ingredients

• Sauerkraut juice (1Tbsp) in tomato juice (8oz) – give 1-2 tblsp every 15 min until see red in stool, then back off to every 30 min.
• Vegetable broth – even from a boullion cube

You or your child can drink the solution in small amounts throughout the day as a supplement to solid foods or formula, as long as dehydration persists. Small amounts reduce the likelihood of vomiting. Breast-fed infants also can drink the solution, but should continue nursing on demand. If dehydration symptoms don't improve, seek medical care. Oral rehydration solutions are intended only for urgent short-term use.

NATURAL ANTIMICROBIAL AGENTS

• Oregano oil – 3-5 drops in a small ammount of water
• Grapefruit seed extract (450mg per day) – aslo available in liquid which can be added to oregano oil
• Echinacea angustifolium or purpura, Hydrastis canadensis (goldenseal), Baptisia tinctora (baptisia) – equal parts; a classic tincture combination; ½ dropperful with a little water every 2 hours
• Glycyrrhiza galbra (licorice root) – great tasting
• Berberis aquifolium (oregon grape) – 50mg/kg/day (1lb = 2.2kg)
• Garlic
• Vitamin C – 1000mg 4-6 times daily (adult) or 250-500 mg 4-6 times daily (child 4-12yo)
• Activated charcoal – absorbs bacterial toxins in gut to reduce vomitting and diarrhea; take 1 dose after each bowel movement (8 tablets = 4 capsules = 1 Tbsp); may use burnt toast in a pinch; will darken stools

OTHER NATURAL TREATMENTS

• As your diarrhea improves eat mashed bananas, applesauce, bland cereals, crackers, clear soup, weak tea, dry toast or bread, rice
• Bulking agents – psyllium seed husk (1 Tbsp soaked overnight and followed by a glass of water); applesauce and carob powder (1/2 tsp carob in applesauce twice daily)
• Probiotics - Lactobocillis or Sacromyces boulardii; to help repopulate the intestines with friendly bacteria

See a Doctor When:

• Bloody diarrhea
• Fever in a child >102 degrees F
• Significant dehydration (see symptoms above)
• Persistent vomitting
• Vomitting after a head injury