Medical Insurance Benefits 101

If you are a young person just coming off your parents' medical insurance or are starting a new job and need to decide what medical plan to choose during a benefit enrollment period, this primer may help explain some of the more esoteric terms you'll come across. 

Those dollar values and percent’s may not mean much to you when you signed up. I assure you they will when you are faced with a medical problem and find yourself confused as to why that lab test or procedure your doctor ordered was not "covered 100%".

I'll admit that even in my many years of medical training, through medical school, residency and fellowship, that I had no idea what a co-insurance, deductible, co-payment, or out-of-network doctor was! So don't feel bad.

Cost Sharing: 

Basically, you and the insurance plan agree to share the costs of your medical care.  Examples of cost sharing include deductibles, co-insurances, and co-payments. Cost sharing helps to keep your premiums lower. It doesn't apply to all things, so check your plan for costs of imaging, ER visits, screening tests like colonoscopy etc.  

Deductible: 

This is the amount you pay yearly before the insurance pays their share. If the cost is $3,000 and you have a $2,000 deductible, you pay the first $2,000. Thereafter you pay your share of the remaining $1,000 and the insurance company pays its share. 

Co-insurance: 

This is the percentage you pay based on cost the sharing agreement after you have paid your full deductible.  Most often the split favors you and you pay 20-30% while the plan pays 80-70%.   

Co-payment:

This is an upfront payment typically for routine office visits with a specialist or primary care provider. Co-payments also apply to medications. Your medical insurance card typically lists these amounts. These can usually range anywhere from $10-$50.

In-network:

The doctor or facility (provider) is contracted with your insurance plan. This means your provider takes your insurance and has pre-negotiated rates. 

Out-of-network:

Out-of-network benefits may be a part of your insurance plan. This allows doctors who are not contracted with your insurance plan the ability to bill your insurance. However, the fees paid by the insurance plan may be higher and thus your costs will be higher. Insurance plans typically will pass this on to you through a higher premium and cost sharing. With respect to cost sharing your deductible and co-insurance may be higher than the those for in-network providers. Some plans have no out-of-network coverage at all and you will not be able to see that provider unless you are wiling to pay cash and he or she will not be able to send bills to your insurance company for services rendered to you.  Its always best go to an in-network provider if you can. You must known the status of your provider with your insurance plan before you see them.  Actually, in the state of New York the provider must disclose this to you.

What's the deal with gluten-free (GF) food?

The majority of my patients come to me already with some vague knowledge about gluten-free (GF) foods. However, many do not know what gluten is or why GF items have been inserted into menus everywhere. I often spend time explaining how gluten causes disease in Celiac disease (CD) patients and why non-celiac disease patients feel better when they stop eating gluten. This conversation often leads further into a discussion of the difference between food allergy and food intolerance. The main misconception I have seen is that many patients without CD feel they have a food allergy when in fact they have a food intolerance.  

What is gluten?

Gluten is not that mysterious. It is a collection of proteins that are found in wheat, barley, and rye. Gluten is important clinically as it is the main cause of CD.  An individual with CD needs to completely avoid Gluten in order to heal from the disease. CD is an autoimmune disease.  Autoimmune diseases are characterized by an inappropriate activation of the immune system. Self or endogenous antigens (markers of self) are 'perceived' as foreign. Once activated, the immune system leads to the destruction of the absorptive surface of the small intestine. 

CD is common, found in approximately 1% of the population. I typically tell patients that it is less common than irritable bowel syndrome (1 out of 7), but more common than Crohn's disease (1 out of 500-1000 patients).

If it's only 1% of the population, why are gluten-free foods so ubiquitous? Well, certainly CD patients should be afforded the same rights to eat as safely as non-celiac patients. However, many people without celiac disease have found that removing gluten from their diets makes them feel less full, less bloated, and less fatigued. Clinically, this has been called non-celiac gluten sensitivity (NCGS). It is not clear if there is a distinct biological entity that results in pathological changes other than those seen in CD.

If these patients are ill but do not have CD, why do they feel better when they remove gluten? What is more likely happening is that people are responding to the removal of something from their diet that gluten is associated with, rather than the gluten itself. This has actually been shown in a clinical study. My bet is that these patients are responding to the FODMAPs found in foods made with wheat, rye, and barley. 

What are FODMAPS?

Fermentable Oligosaccharides Disaccharides Monosaccharides and Polyols. These are all forms of carbohydrates or sugars in varying shapes and sizes that are poorly absorbed or not well digested. FODMAPs are fermented in the colon by bacteria which results in the production of hydrogen gas (flatus, bloating, abdominal distention, pain), short chain fatty acids, and causes an osmotic effect to draw in water to the stool (diarrhea). 

If you or someone you know has responded to a Gluten-free diet make sure they see a gastroenterologist to learn whether they in fact have an intolerance to foods containing gluten or have CD.  CD can be tested by obtaining measurements of circulating antibody markers. Those that have excluded all gluten from their diet will need to be re-challenged with it for 6 weeks with at least 1-2 slices of bread a day. This is because patients with CD lose the diagnostic serum markers of the disease while on a gluten-free diet.  If markers are positive, confirmation will be needed by obtaining small intestine biopsies during an upper endoscopy.

What markers are most sensitive and specific?  In the presence of normal serum IgA levels, I have found that the IgA anti-tissue transglutaminase antibody is most sensitive and specific. Others tend to have low positive predictive values. 

Is there a genetic test? Yes and no. The test is only useful to exclude celiac disease. I utilize HLA DQ2/DQ8 allele testing when results of testing are ambiguous, or their is a high suspicion despite conflicting test results (i.e. positive markers, negative biopsy). A positive test (presence of both alleles) is seen in 99.9% of CD patients while only 40-50% of the general population tests positive. Thus, a positive value does not diagnose CD. Rather, it is the absence of these alleles (negative result) that excludes CD. 

What's causing my abdominal pain? When size does matter!

Abdominal pain is a common reason to visit a gastroenterologist's office.  The most common scenario I encounter is a patient presenting with right sided abdominal pain after eating.  The intensity and temporal relationship to their meals often allows me to more easily determine the cause. Patients often report pain within 30 minutes to 1 hr of eating.  They find the discomfort peaks after meals and then decreases towards the start of the next meal. They often wake up feeling well. The pain is also often described as a discomfort rather than pain.  Patients often do not have associated symptoms of reflux such as heartburn or regurgitation.  Warning signs such as vomiting, weight loss, diarrhea, prompt a different conversation and work up.

In the absence of warnings signs or signs suggestive of a peptic process or reflux I typically find these patients are over-eating and/or are eating too quickly. Many have a history of anxiety, depression, or other mood disorder.  I will typically have patients try a proton-pump inhibitor for 2-4 weeks and if there is no improvement I have them focus on portion size, time spent eating, and have them reduce the fat and carbohydrate contents of their meals. 

I hypothesize that many of these patients have visceral hypersensitivity. They further have anxiety and busy jobs that require long hours and little time for relaxation.  These factors lead to overeating and rushing. Latenight overeating is also a factor so I encourage each of these patients to take a good look at the quality of their life and encourage them to take more time for themselves.  I remind them to eat protein and complex carbohydrate rich breakfast (fruits , granola, and yogurt) and to have a good sized lunch. They should be cautious to eat slowly and to chew well. I recommend smaller portions at night so they avoid eating large heavy meals prior to laying down. Avoidance of seltzer and sodas is also helpful.

If medication, life-style changes, or dietary modifications do not help I will obtain an abdominal ultrasound and upper endoscopy to assess for organic causes.  There are a select group of patients who have already had these tests so I do not repeat them.  If these tests are unrevealing I will recommend a 4-8 week trial of a tricyclic antidepressant, which will treat the underlying visceral hypersensitivity by modulating the output of the enteric nervous system to the central nervous system. Signals representing stretching of the walls of the digestive tract will dampen and patients will have less discomfort with meals. 

 

Practical Information for someone with Acute Diarrhea

What is acute diarrhea? 

Acute diarrhea is a diarrheal illness occurring for up to two weeks. Once diarrhea lasts beyond 2 weeks it is called Persistent Diarrhea. If diarrhea persists beyond 4 weeks it is called Chronic Diarrhea.

  1. What causes acute diarrhea? Acute diarrhea can be caused by one of many food-borne pathogens due to ingestion of undercooked foods such as beef and poultry. Some bacteria create bacterial toxins which result in rapid onset of symptoms after ingestion of toxin-containing foods. Other infectious agents includes particular viruses, parasites, travel-related bacteria diarrhea. Non-infectious agents include simple food intolerances. Typically, a careful history taking such as recent travel, use of antibiotics, sick contacts, 
  2. When should you seek medical attention?: If your diarrhea becomes bloody this may be a sign of dysentery caused by Shigella bacteria or the amoeba E. histolytica. Severe signs of illness include fever > 100.3, abdominal pain, nausea or vomiting. If you develop fever, abdominal pain, or inability to tolerate oral hydration immediately seek the assistance of a gastroenterologist or internal medicine provider.  As an alternative, there are a number of urgent care centers around New York City. The doctor will ask you to provide stool samples to perform a stool culture which can take 2-3 days to result.  
  3. What is the possible outcome from acute diarrhea? Most cases of acute diarrhea resolve spontaneously and are difficult to attribute to a single pathogen or cause. Acute bloody diarrhea should be promptly evaluated for Shigella species and Entamoeba Histolytica
  4. Is it safe to use imodium? This question is best answered by a physician that can completely evaluate you by history, physical exam, and blood/stool testing. Once infectious etiologies are rule out by stool testing it may be safe to use imodium or other anti-diarrheals. Be sure to check with your doctor before starting any medications. 
  5. What is safe to eat when dealing with diarrhea? Its best to avoid products containing dairy, high fat content, or rich foods. Its most important to stay well hydrated to keep up with losses of fluids in the stools. The BRAT diet is typically suggested.

Cyclospora on the rise as cause of watery diarrhea

The CDC just announced that gastrointestinal infections with Cyclospora are on the rise.  

Patients with acute diarrhea, or diarrhea that persists beyond 2 weeks should be tested for this pathogen. 

Doctors need to keep in mind that Cyclospora must be requested specifically as typical stool examinations for ova and parasites do not test for it.

Symptoms of Cyclosporiasis include watery diarrhea that can be profuse, along with bloating, nausea, fatigue, weight loss and flatulence. Other symptoms can include fever, muscle aches (myalgia), and vomiting. The parasite is transmitted from contaminated food or water. Symptoms occur about 7 days after ingestion and can last for a few days to months if left untreated. Treatment is with Bactrim(trimetoprim/sulfamethoxazole), a sulfa drug. Unfortunately, according to the CDC, if you are allergic to sulfa drugs you will need to be monitored for recovery and provided supportive treatments.

FODMAPs in The Press!

I am pleased to see news coverage of the low fodmap "diet."

Many of my patients that I have diagnosed with either Irritable bowel syndrome (#IBS), bloating, or chronic diarrhea have found it helpful.

The term "diet" in association with fodmaps is a misnomer. I feel more like this is a road map to reducing symptoms and improving quality of life. It's important to follow this road map closely with the help of both your gastroenterologist and a dietician experienced in it. 

Keep in mind that anyone with symptoms of bloating, diarrhea, abdominal pain should seek a diagnosis first before assuming they have IBS, as its diagnosis remains at this time one of exclusion. There is no diagnostic test. A physician must first rule out other causes through careful exam and history taking. In some, blood work, imaging, and colonoscopy or endoscopy may be required. 

A Diet Low in FODMAPS Can Improve Symptoms of Bloating in Irritable Bowel Syndrome: Go Low FODMAP!

Irritable bowel syndrome (IBS) affects 1 in 6 people and is characterized by chronic abdominal pain associated with a change in bowel form or frequency. Typically pain or discomfort related to IBS is relieved with bowel movements. Bloating is often a common symptom and one of the many reasons patients come to Gotham Medical Associates. About one third of patients with IBS have a form of IBS in which they are constipated most of the time (IBS-C), while another third of patients have frequent loose stools (IBS-D), the remaining group has mixed symptoms (IBS-M).

The exact causes of IBS are unclear but likely include genetics, environment, stress levels, and diet. If you or someone you know suffers from IBS you may deal regularly with the discomfort of bloating, increased flatus, and irregular bowel movements. All of this can occur despite eating what is considered to be a “healthy diet”. The purpose of this inaugural newsletter is to introduce our patients at Gotham Medical Associates to the FODMAPS, particularly those patients with symptoms of bloating and or those who have been diagnosed with IBS.

What are FODMAPS? FOMDAPS are a group of sugars collectively called Fermentable Oligosacharides Disacharrides, Monoscharrides, and Polyols. These sugars and sugars alcohols vary in size, length and shape. They are ubiquitous in our diet and include the common Disaccharide, lactose, the Monosaccharide fructose, and well as sugar alcohols including sorbitol, xylitol and mannitol. Other less knowns FODMAPS include the fructans, which are longer molecules. 

How do FODMAPS cause symptoms? When FODMAPS are undigested, unabsorbed, or over-abundant they reach the colon and are fermented by the colonic bacteria. In the process of fermentation hydrogen gas and lactic acid are produced. This ultimately leads to bloating, loose stools, and abdominal pain.  For some, and for unclear reasons, this results in constipation and bloating.

Is Gluten a FODMAP? No, in fact, Gluten is a group of proteins found in wheat. It is hypothesized that ingestion of wheat (containing gluten) results in bloating as a result of coincidental FODMAPS found naturally within wheat. 

What is a Low FODMAP diet? The Low FODMAP diet is based on research conducted by the Monash University in Australia. A strict interpretation of the diet would be to exclude all high FODMAP-containing items from the diet for 4-6 weeks and then a “re-challenge” phase whereby foods are reintroduced one-by-one to systematically determine which foods are culprits. This strategy can be restrictive on the diet due to possible excessive dietary exclusions, and the long term risk of FODMAP exclusion is not known, thus it should only be attempted under the guidance of a nutritionist with expertise in this area. Gotham Medical Associates can link its patients up with qualified nutritionist if needed.

Visit Gothammedicine.com for more details on the Low FODMAP Diet. 

If you are interested in obtaining a consultation with one of our Gastroenterologists please call 212-227-3688. Our staff will be happy to assist you, your friend or family member!