Abdominal wall pain considered
I commend ACP Internist for its excellent article, “Abdominal wall pain as its own diagnosis,” in the September 2017 issue, as well as its placement on the front page. Throughout my career, I have successfully identified several patients with chronic abdominal wall pain by the methods the article described. The longest sufferers had experienced this condition for more than seven years. They had undergone extensive, repetitive testing, including multiple radiation-exposing scans, invasive endoscopies, even laparoscopies, all while the diagnosis was “at hand.”
I would like to point out that when performing the Carnett sign, the patient must be instructed to raise the legs high enough that the examiner can feel the muscle become taut under their examining hands. Otherwise, the examination will lose specificity.
Gregory A. Hood, MD, MACP
The article “Abdominal wall pain as its own diagnosis” in the September 2017 ACP Internist was of great interest, yet omits something very important that I have seen several times over the years. Have the patient point out the spot of pain, put an ink mark there, have him or her stand up, and stick your finger on the ink. It is amazing how often you will find a hernia there, and fixing it will cure the pain.
Melvin J. Breite, MD, ACP Member
Pricing for profit
As a new primary care physician, I was very pleased with the insights of Ira D. Stein, MD, FACP, in the Letters to the Editor section in the September 2017 ACP Internist. I wanted to add that there has been some compelling investigative journalism to support the systematic, typically exorbitant, and highly variable “cash” or “no coverage” pricings for labs, equipment, procedures, and imaging as a means toward maximizing every parties' profits at each billing cycle. I refer chiefly to the TIME magazine article “Bitter Pill: Why Medical Bills Are Killing Us” by Steven Brill, published in 2013.
As Dr. Stein speculated in his letter, the little bits of obtainable proof strongly suggest that our current scheme of health insurance is intentionally overpriced. This is by no means “open market,” as is frequently claimed to defend high prices as “market rate.” It is a system that is underregulated and hidden behind charge-master price lists that differ between every insurer, lab, hospital, clinic, and servicer. To the best of my knowledge, these price lists are often protected under trade-secret copyrights and restrictions and are unviewable by the public.
According to Mr. Brill's explanation, it breaks down to private companies using Medicare repayment as the benchmark, then setting up whatever “cash/no coverage” price is necessary to end up with a final charge, co-pay, and repayment at the level of Medicare's once parties involved have made their individual profits off the inflated price. This elevated price can then be written off, likely at no cost to anyone involved. It suggests that everybody (except patients, and, I argue, most physicians, who get little to no access to any of this information) is more focused on the business of health care profits, either actively or implicitly, when participating in this scheme.
I'm not trying to be an alarmist outright, but for all the talk and discussion over how to fix health care, my observation has been that this issue gets pushed aside or simply ignored. Access to care is important, of course, but what are people getting when they do get care? High copays, vanishing coverage, and little or no information on actual costs, with insurers claiming they must continuously raise prices due to the growing risk pool, low-quality care, and utilization issues? If that's the case, it's time for every major insurer to start backing their claims up with public disclosure of all of their business.
This is the core issue of “insurocracy”: The setting and changing of prices involve a loosely regulated, behind-closed-doors system that minimizes payouts and coverage whenever it can, inflates as much as it legally can, and claims to offset costs the public cannot access, all while claiming to be an open-market system.
Chadwick Richard, MD, ACP Member