McCamy Taylor
McCamy Taylor's JournalA Sleep Revolution is Coming in Public Health
In the 19th century, people knew that their water was clean. They could tell by looking at it. Sniffing it. Tasting. Then Louis Pasteur showed them what they could not see, smell or taste---microbes that caused disease. Once we became aware of the danger, we were willing to invest in sanitation services, sewage treatment, water filtration.
In the 21st century, people know that they get a good night's sleep. They go to bed at 11 pm. They set the alarm for 7 am. They lose consciousness for the next eight hours. They wake up feeling tired, achy and groggy, but that is just caffeine withdrawal kicking in. After a cup of java, they are good to go--for a couple of hours. Boy, age sure has crept on them. They sit at a desk all day, but they are always hungry. None of their old clothes fit. When they get home, they don't want to do the dishes. They don't even want to go out. They just want to pop a pizza in the microwave, fall asleep on the couch watching TV---and then go to bed at 11 pm, ready for that good night sleep that will make all the difference.
In the 19th century, people did not know that what they could not see, smell or taste could kill them. That's because they could only see it with a microscope. In the 21st century, people do not know what happens when they are unconscious can kill them. That's because it only happens when they are unconscious.
By now some of you know that I am talking about sleep disorders. More of you know that I am writing about sleep disorders than members of the average population would know if forced to read this. You are reading this because it has the words "public health" in it, and therefore you have an interest in health. Since those reading this have an interest in health, 100% of you should know all about sleep disorders, one of the most common chronic medical conditions in our society today. 100% of you should know how you sleep, whether you snore or stop breathing, whether you grind your teeth, whether you kick all night, because you will have made a point of asking friends and family---it is very important that we know how we sleep.
Sadly, more of you probably know your ldl cholesterol than know about your own sleep. More of you have probably asked your significant other "Are there any funny looking moles on my back that might be cancerous?" than have asked "Do I show signs of restless leg syndrome?"
Sleep disorders are one of those tricky medical conditions that do not announce themselves with a great big billboard, the way that--say--angina from coronary artery disease does. When you are carrying the groceries in the house and suddenly a bull elephant is sitting on your chest and you have been transported from sea level to the top of Mount Everest and your head is swimming and you feel like puking---when all that happens, you listen.
Sleep disorders are more like high blood pressure. Sometimes you get symptoms, more often you don't. Once upon a time, no one knew their blood pressure. Now, you can get it checked in the grocery store. Almost every adult knows that blood pressure is important. So is cholesterol. So is blood sugar. So is not smoking. If you want to avoid a heart attack, you pay attention to these things---and heart disease is the number one killer in this country right now.
Pop quiz. Name another independent risk factor for heart disease. You said obesity, didn't you? Close. Sleep apnea. Name a risk for car wreck--besides DUI. Blindness? I guess so. But most blind people know not to drive. People who are sleep deprived do not know that they are sleep deprived, because they were unconscious when their body was failing to get restful, restorative sleep.
Our current insurance system, which offers many of us essentially no insurance between the ages of 40 and 65---too many pre-existing conditions to get individual policies and not yet old enough for Medicare---has contributed to the sleep apnea crisis. When folks reach 40 and the sleep disorder they inherited from Mom kicks in, they do not know that they have a sleep disorder. They know that they have high blood pressure, depression, fibromyalgia, erectile dysfunction, low back pain, migraine headaches---and they can no longer perform the necessary functions of their jobs so they make mistakes and get fired.
Once they start working as a cashier at Quickee Mart, they no longer have health insurance, so even if they begin to suspect that there is something wrong with their sleep, they can not see a doctor and get tested. But most of them do not suspect. They know that they can not work and so they file for Social Security Disability. They are turned down because high blood pressure, depression, fibromyalgia, erectile dysfunction, low back pain, migraine headaches can not keep a person from working--the judge knows this. If the people appealing their disability denial could bring in the results of a pulse oximetry test done overnight or a sleep study showing that they stop breathing 60 times an hour, the judge would exclaim "You have sleep apnea! No wonder you can't work! Here's your Medicare. Get that treated!"
No, this is not a fairy tale. I have lost track of the number of patients whom I treat at a public health clinic for the uninsured who lost their jobs and insurance due to a sleep disorder that their old doctors never suspected and who are able to successfully appeal their disability denial and get Medicare---insurance!---once they prove to the judge that there really is something wrong with them. I have lost count of the number of people who think that I am psychic, because I look over their medical record and ask "Do you snore or stop breathing at night?" No, I am not psychic. I just have first hand experience with what it is like to have an unrecognized sleep disorder that costs you your career in the prime of your life.
Now, on to the revolution. This is not how it should be. People who develop sleep disorders in middle age should not lose their memory, their energy, their concentration and finally their jobs because doctors are so bad at diagnosing sleep disorders. This should be one the first things that their doctor screens them for when they first go in saying "I can't remember things. My driving sucks. I can't get an erection. I hurt all over." They should not go into their doctor's office unaware of their own snoring, apnea, restless leg jerks and bruxism, since---being educated professionals---they keep track of their own health. They should not be forced out of the professional job market and into the hourly minimum wage job market just when their professional skills are at their best. They should not have to leave the job market altogether---in effect, retire---in order to get their sleep disorder treated. If they and their doctors recognized the first clues about a sleep disorder and started treatment while the patient was still employed with insurance and did not carry the stigma of long term unemployment, a big chunk of the American workforce would continue to be productive beyond Medicare retirement age---and we would never have to worry about Medicare and Social Security going bankrupt.
Ten percent of Americans over 40 have a sleep disorder. 80% of them do not know it. Among them are professionals like me, a family physician. Society lost ten years of my medical skills, because neither I nor my doctors knew what was wrong with me for years after I retired. And then, after I figured it out and got treatment, I had to scramble to find a way to get back into a workforce that does not trust those who have been out of it, it would rather see you stay on disability and Medicare, just to be safe.
As we move closer to the goal of Cradle to Grave Insurance for all of us, those who pay the bills will have an incentive to keep us healthy. As it stands, Blue Cross would just as soon see your sleep apnea go untreated--if it means you lose your job and your insurance. If Blue Cross is going to pay your medical bills whether you can work or not, Blue Cross wants you as healthy as possible---because people with undiagnosed sleep disorders accumulate thousands of dollars a year in unnecessary medical tests and treatments, and if you have Cradle to Grave insurance, Blue Cross will have to pick up that bill. Blue Cross (and United and Aetna and Medicaid and Medicare) will realize that increasing physician and public awareness of sleep disorders will keep you healthier and save them money.
Eventually, you will see pamphlets like the ones that the American Cancer Society used to hand out with the 10 warning signs of cancer. Yes, once upon a time, people did not know that rectal bleeding could be a sign of cancer that could be treated and cured if found early. One day, they will know that snoring can be a sign of a serious medical condition that is treatable--if found before you die in a car wreck or of a stroke. Eventually, High School Health classes will teach sleep hygiene. Eventually, no one would dream of NOT telling you "You snored and stopped breathing last night" anymore than they would dream of NOT telling you "Don't eat that potato salad. It was left out all night. There is no telling what kind of bacteria are growing on it."
Raise sleep medicine awareness. Keep our roads safer. Keep middle aged workers at their jobs longer. Reduce the strain on Social Security and Medicare. It's gonna happen. The only variable to the equation is when.
And, as before, if you want a free Word document copy of "Life After CPAP" send me an email at McCamyTaylor@earthlink.net
Damaged Care Redux: "They're Back!"
In 1999, under my maiden name I published a short book about so called managed care---"Damaged Care" as it was sometimes called at the time. HMOs or Managed Care failed due to physician and patient concern that they were damaging the doctor-patient relationship and leading to poor quality care. In particular the idea of paying doctors NOT to provide care or to turn away SICK people did not set well with many people---including doctors. Laws were passed to prevent HMO abuses. Most people dumped their HMO for a PPO--a plan that provided better payment for in network providers but had an out of network option as well.
Well, don't look now, but the economic forces that lead to the creation of HMOs are in play again. Insurers now must take all comers, regardless of pre-existing conditions. They can no longer "cherry pick" healthy people in the individual markets. If your aunt on dialysis wants to sign up for United Health, she can. If your brother who is on a liver transplant list decides to pick Blue Cross, Blue Cross is stuck with him.
Since insurers make money in only one way---by collecting more in premiums than they pay out in benefits--the ACA puts them at tremendous risk. And risk is something that the health insurance industry does not want. In order to cut its losses, the industry will try to do what it did in the 1990s---limit care, drive away the sick, make it difficult for doctors to care for those who need care the most. Their goal is to make all the sick people abandon ship while keeping the healthy members happy. Their ultimate goal is to force all the "sick" people on government funded Medicare and Medicaid while collecting federal payments for healthy people. How do they hope to accomplish this? The same way they did it back in the 1990s.
Some things have changed from the 1990s, but some are all too familiar. People who are trying to use their shiny, new silver plated insurance for the first time are discovering that their specialists are NOT on their plan (they were promised that they would be). If they belonged to an HMO in the 1990s and if they had read my book back then, they would not be surprised, because they would know that "Member Services Always Lies." They are beginning to realize that finding doctors and providers on their new insurance can be difficult if not impossible. There are new rules and regulations that make so sense. Barriers to care are thrown up that seem to serve no purpose except to frustrate and frighten patients--and that is exactly what they are trying to do. Scare away "sick" people while keeping the "healthy" folks happy. Insurers have found new ways to reward doctors for treating only the healthiest patients--they call it "Pay for performance". And since "poor" often equals "sick" in this country, one way they can limit their liability is by having only a limited number of doctors and providers that serve in poor or minority areas.
After reading about some early bad experiences that people are having in California, I decided to revise and update "Damaged Care" for the 21st century. Some parts are left out. Some are modified. New sections have been added to address issues that are unique to the ACA. The book, "Damaged Care Redux" is now available in electronic form now for FREE at Amazon at http://www.amazon.com/...
If you do not have a Kindle and can not download Kindle books on your computer, send me an email at McCamyTaylor@earthlink.net and I will send you a Word manuscript at no charge. If you want a copy of "Life After CPAP" I can send that, too.
I am a family physician with a Master's Public Health. I work in a public clinic for the uninsured but I see a lot of so called Medicare Advantage Plan patients too, because their insurance does not have enough doctors to meet their needs. Pretty sad when someone with insurance has to rely on a clinic for the uninsured to get care.
Remember, an informed consumer is a healthier consumer.
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