Stop Paying Too Much For Common Medical Problems

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					                               Chapter 2
                             Sore Throat


                                   Key Points
• Avoid lab testing if possible.
• Strep tests cost money.
• The Centor criteria predict strep.
• A complete blood count adds very little to a diagnosis, so avoid this test.
• Call ahead. Your doctor might be able to treat you over the phone.
• Mononucleosis (a virus) may not be detected early on, so it’s okay to skip
  the mono test if you’ve been sick for only a few days.
• Generic antibiotics (costing $4) will work as well as expensive brand-name
  products.
• Let your doctor know if you are not improving.
• A sore throat lasting longer than two or three weeks may point to a more
  serious problem. See your doctor.


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        A sore throat is among the most common reasons to visit a doctor,
accounting for approximately 12 million clinic visits each year in the United
States, with patients and insurance companies spending an estimated $1.2
billion annually to address the problem. The average cost of a clinic or urgent
care visit for a sore throat is anywhere from $150 to $300, depending on what
tests are ordered. ER visits for sore throats are much more expensive.
Depending on where you live, an ER visit for a sore throat can cost an average
of $650.
        Sore throats have numerous causes. Sore throats can be serious enough
to warrant treatment or can heal on their own within a few days. The most
common cause of a sore throat is viral illness, such as a cold, the flu, or mono.
The next most common cause is strep throat, which is caused by a bacterium
(streptococcus). Dry air, heartburn or acid reflux, a runny nose with postnasal
drip, or seasonal allergies can also create a burning sensation or pain in the
throat. These are all possible causes a doctor will consider.
        Sore throats caused by viruses heal on their own, as do those caused by
allergies. Bacterial infections are usually treated with antibiotics. Failing to
treat a strep infection could result in rheumatic fever or rheumatic heart
disease. The end result can be damage to the valves inside the heart. This
condition is not seen very often, but for this reason (and to help patients
recover more quickly), U.S. doctors prescribe antibiotics for strep throat. Some
European doctors do not always treat strep throat with antibiotics.

Strep Throat

        Strep throat is a common illness, especially among school-age children.
Typical symptoms include a severe sore throat, fever, headaches, body aches,
swollen glands, nausea, and sometimes a rash. Young children might not
complain of a sore throat but might have headaches, stomach pain, or nausea.
        Some strains of strep cause pneumonia, ear infections, and sinus
infections. Others cause a contagious skin rash called impetigo. This rash feels
like fine sandpaper to the touch. The two most worrisome complications of
strep are rheumatic fever and glomerulonephritis (kidney inflammation). Not
all cases of strep throat cause these complications.

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        Most people visit a doctor for strep to get antibiotics to relieve
symptoms and to keep them from spreading the illness to family members,
friends, classmates, and coworkers. Antibiotics can prevent rheumatic fever but
have no effect in preventing inflammation of the kidneys.
Should You Be Tested for Strep?
        Not every patient complaining of a sore throat needs to have a strep
test. Your doctor will decide when to test, when it is okay to just treat with an
antibiotic, and when no medication is required. The most common testing
tool is the Centor criteria—four signs and symptoms that help predict the
odds that a patient has strep:

• Fever
• Swollen tonsils or tonsils covered with a white matter (called exudates)
• Swollen glands under the angular jaw (adenopathy)
• Absence of cough

       If fewer than two criteria are present, the risk of strep throat is very
low, probably less than 10 percent. Most doctors would recommend rest and
plenty of clear fluids and would suggest that the patient return if symptoms
don’t improve. If two to three criteria are present, most providers would swab
the throat and, if the patient tests positive for strep, prescribe an antibiotic. If
the patient meets more than three criteria, the risk of strep infection increases
to more than 50 percent. In this case, many doctors could prescribe antibiotics
and forgo ordering the strep test.
       Based on what your doctor sees in your throat, and on whether you’ve
been exposed to strep recently, you might be able to skip the strep test
altogether. If you have had close exposure to someone with strep throat or
have had strep throat before and feel the same way now, tell your doctor.
Rapid Test versus Follow-up Test
       Doctors can order two types of strep tests: a rapid strep test and a
follow-up test (either a throat culture or a strep PCR, a more reliable chemical
test).


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        Rapid strep test: At many local clinics, a rapid strep test costs
$42._Rapid strep tests have a specificity of ?95 percent and a sensitivity that
varies between 65 and 90 percent. Translation: If the test is positive, it is 95
percent likely that you have strep throat. Sensitivity refers to how good a
particular test is at detecting what you want to find. No test delivers accurate
results 100 percent of the time.
        Follow-up test: If the rapid test is negative, most clinics will move on to
a follow-up test. Some clinics routinely run these; some don’t. Be sure to find
out what the policy is at your clinic and discuss whether a follow-up is
necessary. Depending on your doctor’s clinical suspicion, you might not need
that follow-up test. As a patient, you have the right and the responsibility to
decide what tests you want to have done. If the chance of strep throat is
exceedingly low, you can possibly cancel the follow-up test and avoid paying
for it. Certain chemical follow-up tests cost more than $100, and confirmation
of a negative rapid strep test with a throat culture is generally not necessary in
adults. There is some concern about certain strains of strep causing rheumatic
fever, but this is very unlikely in adults. Discuss testing options with your
doctor; be your own advocate.


Mononucleosis

        Mono is another common cause of persistent sore throat, fatigue, and
fever in young patients. Approximately 95 percent of adults between ages
thirty-five and forty have been infected with the virus that causes mono. Mono
is a viral illness but gives a similar clinical picture to strep: sore throat, white
matter on the tonsils, fever, and swollen glands. Mono can have some unusual
complications. For instance, the liver or spleen might swell due to mono
infection. Trauma or injury to the abdomen of someone with mono can cause
life-threatening internal bleeding. For this reason, doctors warn athletes with
mono not to participate in contact sports for six weeks.




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        Mono lasts anywhere from six weeks to three months, depending on
how well patients take care of themselves. Antibiotics are ineffective in
treating mono, but if you suspect you have mono, it’s advisable to get a
diagnosis so that you can take care of yourself, know what to expect in terms of
symptoms and healing time, and get a doctor’s note excusing you from sports,
school, or work if necessary. Patients with mono can spread the infection for
weeks, so avoid kissing others and sharing beverages.
        The mono virus remains dormant in a few cells in the throat and blood
for the rest of the affected person’s life. At times the virus can reactivate and
can be found in the saliva of infected people. This reactivation usually occurs
without any physical symptoms. Healthy people can carry and spread the virus
intermittently for life, making it nearly impossible to prevent the spread of the
virus and explaining why the majority of adults are infected.
Should You Be Tested for Mono?
        Mono testing is something to discuss with your health care provider. If
a sore throat has lasted longer than a week or if you’re exceedingly tired, you
may have mono. It is also possible to have mono and strep at the same time;
your doctor might want to test for both conditions. If you’ve been sick for only
a day, the mono test might show up negative, so you might need to repeat the
test later on. Talk to your doctor about the timing of the mono test to avoid
paying repeat lab and test fees.
Mono Tests
       The common test for mono is called a monospot. It costs
approximately $24, plus the lab fee to draw your blood. A complete blood
count (CBC) costs $35. If a doctor wants the lab to break down the different
types of white blood cells present, the cost jumps to $51. Add on top of that
lab fees. Clinics charge $15–$20 just to draw your blood and process the
specimens. As you can see, the total cost can be quite high—more than $250.
Additional tests include those that detect antibodies to the virus causing
mono. These tests might be useful when the diagnosis is uncertain, when
symptoms last longer than anticipated, or to determine if another virus or
condition is responsible for the ongoing symptoms.


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The Complete Blood Count

         If your doctor suspects you have strep or mono, her clinic might require
her to order a CBC. The CBC measures the quantity of certain types of blood
cells, including white blood cells, red blood cells, and platelets (the sticky
things in blood that stop bleeding by producing clots). Not every patient
benefits from having a CBC drawn. Providers should not order this test by
default. While it does provide some information in certain clinical situations,
such as abdominal pain or fever without a known cause, the utility of a CBC
for a patient with a sore throat is minimal at best. The CBC with differential
is a more comprehensive breakdown of the various types of cells, with a
particular focus on different types of white blood cells. Bacterial infections can
cause an increase in white blood cells called neutrophils and in immature
neutrophils called bands. This increase can be a sign of more serious illness.
White blood cells called lymphocytes, or lymphs, often increase due to viral
infections.
         Ask your doctor how having a CBC will change the management of
your illness. Usually, the test does not change anything. For example, if you’ve
already had a positive strep test, there’s really no benefit in knowing your white
cell count on top of it. You’re going to receive antibiotics to treat the strep
regardless of the CBC results.
         A CBC can be helpful if there’s some question about whether an illness
is viral or bacterial, but the medical literature is full of evidence that a CBC is
unlikely to predict the presence or severity of a particular illness. For instance,
I’ve seen plenty of cases of acute appendicitis in which the patient’s white
blood cell count was normal. Disease processes don’t always follow the medical
textbooks.
         The cost of a CBC with differential is usually $50 at minimum. Add
the lab charge of another $15–$20, the doctor’s office visit charge, and a
prescription, and the cost adds up quickly. In short, avoiding unnecessary tests
provides the greatest cost savings.




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Sore Throats and Antibiotics

        Patients with sore throats often ask, “Can’t I just get an antibiotic?”
The reality is that if your sore throat is from a virus, an antibiotic is not going
to do anything to make you feel better. It may give you side effects, and it is
certainly going to waste your money. Taking an antibiotic unnecessarily also
contributes to antibiotic resistance. The bugs (bacteria) are getting smarter and
are able to resist many of the antibiotics doctors use. Limiting unnecessary
antibiotic use is one of the best ways to address this growing problem.
        There are many choices for antibiotic treatment of strep throat.
Penicillin, amoxicillin, and Keflex are all available for approximately $4 for a
course of treatment at most large retail pharmacies. (See appendix A, “Online
Resources.”) Many other choices work well, but the cost difference is
significant. Zithromax is a convenient and short course of therapy—taken once
a day for five days—but it costs $24.84. If you are allergic to a certain
antibiotic, ask your doctor and pharmacist to help you determine an affordable
alternative. Apply your new knowledge of antibiotic choices to keep more of
your health care dollars in your own pocket.


Other Options

        You might be able to deal with your sore throat over the phone.
Perhaps several of your children have strep. Maybe you’re a teacher with a
strep outbreak in your classroom, and you have fever, sore throat, and white
stuff on your tonsils. Ask your doctor if you can come in for a throat swab only
and not a face-to-face visit. Your cost savings will be huge. (Note that this is
not a service provided by the majority of urgent care clinics.) You can also call
a nurse helpline; look on the back of your insurance card or check the
company’s website for the phone number.




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SIDEBAR


                                Savings Opportunity
Tests Your Doctor Might Order
Rapid strep test: $42
Strep PCR follow-up: $130
Mono test: $24
CBC: $35
CBC with differential: $51
Antibiotic Choices
Penicillin; amoxicillin; Keflex: $4
Augmentin: $60.32
Ceftin: $27.99
Omnicef: $82.99
Zithromax: $28.84


Real-World Cases

Case 1
       A mom brings her ten-year-old daughter, who has a sore throat, to the
urgent care clinic. The girl’s symptoms developed after she shared a water
bottle with a teammate who had been diagnosed with strep throat the day
before. The doctor could just treat the girl for strep, assuming the exam
findings suggested strep, or he could order some tests. In this setting, with
only a day or two of symptoms, a mono test would be unlikely to help, and a
CBC would be unnecessary. By skipping those two tests, the patient saves
nearly $100.
Cases 2 and 3
        John goes to see Doctor X with a fever of 101, a sore throat, swollen
tonsils, no cough, and swollen glands under the jaw. Based on the Centor
criteria, John has a greater than 50 percent chance of having strep. Based on
what he sees, Doctor X decides that no lab tests are needed. She prescribes an
antibiotic. John walks out the door with a prescription for penicillin at cost of
$4.

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       Jane has identical symptoms. She has same chance of having strep
throat (greater than 50 percent) as John. Doctor Y decides to order a CBC
with differential and a rapid strep test. The rapid test is positive. The CBC
with differential doesn’t change the outcome of anything, except the clinic bill
is now $51 higher. Jane’s lab tests cost a total of $93. She receives a
prescription for Augmentin at a cost of $60.32.
       The cost difference between John’s and Jane’s strep throat: $150.32.


Conclusion

         Strep throat is treated with an antibiotic and generally responds quickly
to treatment. Viruses don’t respond to antibiotics; they will run their course
and resolve with commonsense care. The Centor criteria can help predict
whether a patient has strep throat. Mono is a viral illness and is self-limited—
it goes away with supportive care. But mono can have serious consequences if
the patient has a swollen spleen or liver and participates in contact sports. Be
sure to discuss these issues with your doctor. He will determine if something
else is causing your sore throat. Always let your doctor know if your symptoms
are not improving.


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                               Table of Contents

Introduction                                Chapter 6: Back Pain
                                            Key Points
Chapter 1: Emergency Room versus            Back Pain Basics
Urgent Care Clinic                          X-rays, CT Scans and MRIs
Key Points                                  Red Flags
Types of Care Centers                       Treatment
Reality Revealed                            Real-World Cases
Decision-Making Guidelines                  Conclusion
Real-World Cases
Conclusion                                  Chapter 7: STDs and Contraception
                                            Key Points
Chapter 2: Sore Throat                      STD Testing
Key Points                                  STD Complications
Strep Throat                                Options for Finding Care
Mononucleosis                               Treating STDs
The Complete Blood Count                    Real-World Cases
Sore Throats and Antibiotics                Conclusion
Other Options
Real-World Cases                            Chapter 8: Influenza (the Flu)
Conclusion                                  Key Points
                                            Real-World Cases
Chapter 3: Ear Pain and Infections in       Conclusion
Children
Key Points                                  Chapter 9: Dental Issues
Signs and Symptoms                          Key Points
Treatment Options                           The Importance of Dental Care
Ear Tubes                                   Life-Threatening Oral Infections
External Ear Infections                     Costs of Dental Care in the ER
How to Avoid an Emergency Room Visit        A Visit to the Dentist
Savings                                     Narcotics and Diversion
Real-World Cases                            Community Resources
Conclusion                                  Real-World Cases
                                            Conclusion
Chapter 4: Pinkeye
Key Points                                  Chapter 10: Prescription Medications
Bacterial Conjunctivitis                    Key Points
Viral Conjunctivitis                        Beware of Samples
Allergic Conjunctivitis                     Look for Prescription Coupons
Tests                                       Investigate Your Options
Treatment                                   Beware of Your Insurance
Returning to Day Care, School or Work       A Word about Prior Authorization
Real-World Cases                            Conclusion
Conclusion
                                            Chapter 11: Electronic Medical and
Chapter 5: Urinary Tract Infections         Health Records
Key Points
UTI Symptoms                                Appendix A: Online Resources
Kidney Infections (Pyelonephritis)
Testing                                     Appendix B: Key Points Summary
Who Needs Testing?
When to Visit the Clinic                    About the Author
Treatment Options
Real-World Cases
Conclusion




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Description: Chapter from my book: As ER Doctor's Guide. Complete title available on Amazon or from the publisher.
Mitchel Schwindt Mitchel Schwindt M.D. http://MitchelMD.com
About Emergency Physician, author and endurance sport fanatic.