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David Katzman, MD & Jennifer DeLaney, MD
Internal Medicine Specialists



Dear Friends,

The long, laid-back days of summer are here! Enjoy this magical time full of childhood memories spent with family and friends. Along with the sunny days and warmer weather, summer brings the risk of sunburn, allergies, bug bites and other potential health complications. We want all of you to enjoy a fun and safe summer by keeping informed about your health care. Stay up to date on the latest health and medical news and how health care policies in legislation may impact you. I hope you enjoy the articles in this newsletter that address some of these issues.
Don't forget to take care of yourself! Please call the office to schedule your annual physical or follow-up for a visit or conversation relating to a health concern that you have been putting off!

Tips for a healthy summer:
Get outside, get fit! Physical activity is good for mental health!
• Stay hydrated, drink water, and replace your electrolytes. Stay cool. Alcohol or caffeine are not effective against dehydration. Heat exhaustion can become very serious in the elderly or frail and can lead to heat stroke. Follow the link for signs and symptoms.
• Sun protection! Be good to your skin and eyes. Don't forget to wear protective eye wear for sun exposure and protection against injury while doing lawn work and playing sports.
• Take precautions to reduce risk of fire and heat related burn accidents. Stay at least 500 feet away from firework displays. Check your outdoor grill for leaks, cracks or dents before using.
• Fill your plate with more seasonal fruits and vegetables! Berries are especially anti-oxidant rich and high in fiber.
• Stress Less! Plant a garden, take a vacation, and relax with family and friends! It can lower your blood pressure, heart rate and stress hormones that lead to a widening waist and increased risk of heart disease.

The doctors and office staff wish you and your family a FUN and HEALTHY summer!


Please email me with any suggestions for newsletter ideas and topics.


AHCA-The replacement for the ACA
Jennifer Delaney, MD

The US House of Representatives just passed the AHCA (American Healthcare Act) and the Senate is set to vote on the BCRA (Better Care Reconciliation Act), a very similar plan. This legislation if passed by the Senate and signed by the President will fundamentally change Healthcare in the US. Who does it affect?

• The short answer is that it affects everyone, including those with insurance through their employers.
• Employers can choose which state’s requirements they want to comply with, meaning that if Alabama choses a waiver that doesn’t cover mental health coverage or maternity care, then your employer can choose not to cover them as well, even if they are not located in Alabama, according to the Wall Street Journal.
• Caps on benefits can now apply again, both for annual costs and for life time costs. So, if you develop a costly disease, like cancer or Crohn’s disease, you may run out of benefits. 59% of employers had a cap on benefits before the ACA (Affordable Care Act) was passed. This applies to all insurance, not just AHCA plans.
• Pre-existing conditions can now be considered in setting your premiums. The insurance cannot deny you coverage, but there is NO LIMIT to the premium that they can charge you if there is a lapse in your coverage due to late premiums or a job change or being new in an area. Estimates are that diabetic patients will have a premium surcharge of $5,000 a year, and cancer patient’s premiums may have a surcharge of over $100,000 a year.
• It is estimated that 27% of people under the age of 65 have a pre-existing condition that will increase their premiums.
• The ACA limited the surcharge that older people paid for health insurance to 3 times what younger people paid. The AHCA increases that surcharge to five-fold.
• States that allow waivers will have to establish a high- risk insurance pool. Missouri had one prior to the ACA. Average monthly premiums were $3,000 per individual.
• The Congressional Budget Office predicts that 24 million people who previously obtained insurance through Medicaid expansion and subsidized premiums through the ACA will no longer be able to afford insurance and will lose their coverage. 5 million of those people who will lose coverage are over 60 years of age.
• The AHCA will cut Medicaid funds by 25% or 880 billion dollars over the next 10 years. Medicaid provides insurance for impoverished children, people with disabilities and the elderly poor.
• The AHCA will cap the amount of money per Medicaid beneficiary. So, if you have a disabled person with high medical costs due to a condition like quadriplegia, they will run out of benefits.
• 64% of Nursing Home patients have their care paid for my Medicaid. The 25% reduction in funding for Medicaid will certainly affect this very costly care. 42% of Medicaid dollars are spent on Nursing Home care. Average nursing home care is $200 a day, or $73,000 a year. This is out of reach for most families to pay.
• Special Education is largely funded by Medicaid. The AHCA doesn’t mandate that states consider schools as Medicaid providers, meaning that schools will lose funding for Speech therapy, Behavioral Therapy, Physical Therapy and other services provided to the 16% of students who have special education needs. 1% of Medicaid costs goes for Special Education.
• The AHCA eliminates income based healthcare subsidies and replaces them with age based tax credits. The Kaiser Family foundation estimates this will lead to increased health care costs on average of $600-700 for most of Missouri, with the exception of Urban St Louis. Under the new congressional plan, estimated premiums will increase by $1,500-$7,000 for anyone over the age of 40.

Please Contact your US Representative and Senator to voice your opinions on healthcare.



Sunscreens-what you need to know!
David Katzman, MD

Now that Summer is in full swing it is critical to protect our skin from the inevitable exposures that come from outdoor activities. Unprotected skin exposure does not just cause painful sunburn but also contributes to photo-aging of our skin. It is directly related to basal cell and squamous cell skin cancers which are often found on sun-exposed areas and contributes to perhaps 60-90% of Melanomas.
Ultraviolet (UV) radiation from the sun, mainly in the form of UVB, is the primary culprit. The application of sunscreen, which absorbs or reflects UV light, should be one of several strategies of protecting the skin--along with sun protective clothing, avoiding peak sun times, and seeking shade when possible
One should choose “broad spectrum” sunscreen, meaning it protects again both UVA and UVB radiation. The Sun Protective Factor (SPF) number represents how much protection is provided. For example, if a sunburn would be caused by 10 minutes of sun exposure, an SPF 30 should protect for 30 times that duration or 300 minutes. Most dermatologists recommend using SPF 30 as higher numbers mislead people into thinking they have more protection than they do and are not as protective against UVA.
Sunscreen should be applied at least 15 minutes prior to sun exposure  and reapplied every 2 hours.
The amount to cover the body should be about 1 shot glass or 9 teaspoons. One easy way to remember is 1 teaspoon for head and neck, 1 teaspoon for each arm, 2 teaspoons for front and back torso, and 2 teaspoons to each leg. Don’t forget the ears and feet!
A few other important issues. “Water Resistant” and “Very Water Resistant” products will generally maintain their SPF while swimming or sweating for 40 and 80 minutes respectively. Creams are generally felt to be more effective than sprays given the potential for an uneven spray. All antibiotics will make your skin sun-sensitive so be particularly careful when taking. Finally, skin types and sun sensitivities vary.

What you Need to Know About Tick-Borne Illness
Lauri Slyman, RN

Ticks are very effective transmitters of disease and in the United States, ticks are responsible for more human disease than any other insect. Ticks transmit illness by biting infected animals and later biting humans and transmitting the infection. At least 6 different human tick-borne diseases have been reported in Missouri: Rocky Mountain spotted fever, ehrlichiosis, tularemia, Q-fever, Lyme or a Lyme-like disease, and the southern tick-associated rash illness. There has been a five fold increase in the illnesses in Missouri in the last 10 years due to global warming causing changes in tick habitat. The two most prevalent tick-borne diseases in Missouri are Rocky Mountain spotted fever and Ehrlichiosis. The American Dog tick in Missouri is responsible for transmitting Rocky Mountain spotted fever. Symptoms of this illness develop about a week after the tick bite. The Lone Star tick is responsible for transmitting the bacteria that causes Ehrlichiosis. Symptoms of illness develop  around 1-2 weeks after exposure. See www.cdc.gov/ticks for picture identification and more info on ticks in your area.

Signs and Symptoms of Illness:
* Vary among individuals and differ according to the bacteria introduced
* Sudden onset of a high fever or fever
* Headache, can be severe
* Malaise
* Chills
* Muscle pain
* Nausea, vomiting, diarrhea or anorexia
* Rash in some cases (mostly seen in RMSF around day 5 or 6)

Treatment:
* Clinical suspicion of any of these diseases is sufficient to begin treatment. The treatment of choice is the antibiotic Doxycyline. Delay in treatment may result in severe illness and even death.
* History of a bite is not required! If you were exposed to a tick habitat
(brushy or wooded areas) in the past 14 days and experience any of the symptoms of tick-borne disease please contact your physician to begin treatment and to be properly tested for identification of the illness causing bacteria.

Prevention:
Ticks don’t jump, fall or fly! Instead they climb up shrubs, tall grasses and brush and are generally found within 3 feet of the ground. They are attracted to carbon dioxide (exhaled while breathing), heat and movement. They wait until a host brushes up against the vegetation and then seek a place to latch on for a blood meal. Ticks travel upward and favorite places to hide are around the head, neck, underarms, behind the knees and groin.
* Check yourself often! Disease can be transmitted after only 4 hours of being imbedded.
* Wear light colored clothing so ticks can be seen easily
* Wear light weight long pants tucked into socks or boots
* Tightly woven socks protect best against tiny seed ticks
* Shower immediately after being outdoors in a brushy area-use a washcloth to help dislodge any crawling ticks.
* Wash clothing immediately-leave shoes outside and consider spraying with repellent (see below)
* Remove any imbedded tick immediately! See www.cdc.gov/ticks for tips on proper tick removal
* Avoid folklore remedy for tick removal such as using heat, Vaseline, or nail polish to make the tick detach from the skin 
* Kill the tick by immersing in rubbing alcohol
* Mark the day on your calendar when you found tick 
* Make sure to wash area with soap and water and to position tweezers as close to the skins surface as possible around the tick’s mouthparts. Then use a slow, steady upward motion when pulling tick from skin. Do Not Twist because this could break off the mouthparts

Use of insect repellent:
Using an insect repellent allows you to continue to play and work outdoors while helping prevent tick and mosquito-borne illnesses such as West Nile virus. It is the only way to protect exposed skin.
* It is recommended by the CDC to use a repellent that contains at least 20% DEET on exposed skin and will last several hours. The American Academy of Pediatrics approves use of 10-30% DEET in children over 2 month of age.
* Permethrin can be used to treat clothing, shoes, socks, and tents. This should never be used directly on your skin and should be applied to your clothing and allowed to completely dry before wearing
* Please read all labeling for proper use and for more info, see http://cfpub.epa.gov/oppref/insect/
* Treat dogs and cats as recommended by your veterinarian.
* For tips on insect-safe landscaping, see http://www.cdc.gov/lyme/prev/in_the_yard.html

When to call the Doctor:
It is important to note that the use of prophylactic antibiotic treatment after a tick bite is NOT recommended as a means of prevention. There is no evidence this practice is effective. Instead persons who experience a tick bite or was exposed to a tick habitat should be on the alert for symptoms of illness and consult your physician right away if fever, chills, headache, malaise, rash or other symptoms of concern develop.

On a personal note and firsthand experience with the tick-borne disease ehrlichiosis, I feel it is important to be educated on the illnesses ticks can cause. In the past, I hated using any chemical insect repellent on my skin but always made sure to do a thorough skin check after being outdoors in brushy areas. Several weeks ago my complacency with insect protection combined with a little bit of bad luck caught up with me. My son and I were enjoying a hike in St. Genevieve and it was there that I earned the respect of a very small, but powerful Lone Star tick. The Lone Star tick is Missouri’s most common tick and a very aggressive biter. It can detect the footsteps of a potential host and start running towards it in a matter of seconds. The tick latched on behind my knee and was embedded at least a day before finding him. I didn’t think much about it because I didn’t develop any swelling, redness, or rash at the bite site. About 10 days later I ended up in the ER with a 103 degree fever, chills, severe headache, muscle pain, diarrhea, and dizziness. I was sent home later that night with diagnoses of GI virus. I kept getting sicker and 2 days later I was admitted to the hospital for IV antibiotics. I recovered fully but be aware of one side effect that some people experience after being bitten by a Lone Star tick- the development of a red meat allergy. Make sure to ask your doctor if you should be tested for this allergy after a tick bite. Tick-borne disease can become a very serious illness if not treated promptly and correctly. Don’t let a little insect put a damper on your summer! Enjoy the warm weather and outdoor activities by being educated, prepared and armed with the necessities for insect bite protection!

Office News

Office Will Be Closed Tuesday, July 4th for the Holiday:
We will resume normal office hours on Wednesday, July 5th 8:30 am-4:30 pm

Vaccine Updates for your College Student: 
While your college student in the practice is home for the summer, please call ahead to make sure they are up to date on all vaccines needed before heading back to school in the fall. We can order the appropriate vaccines and schedule an appointment. Your college student should receive 2 doses of the meningitis B vaccine. Even if your child has been vaccinated for meningococcal disease, they may not be vaccinated against Meningitis B. Before 2014 there were no approved vaccines in the US for Meningitis B. The CDC recommends that a Meningitis B vaccine be given to adolescents and young adults. Currently most insurance carriers do not cover this, but please check with your individual plan. The out of pocket cost for the vaccine is $164.00. 
There have also been mumps outbreaks at several US colleges. If your student attends one where there is an ongoing outbreak, they should get a booster of the MMR vaccine. Please call the office to find out what to do! 


Client Portal Update:
The office staff and our IT team have been working on getting our new client portal up and running. We appreciate your patience and please pardon the delays! We want to make sure all of the bugs are out and it is as user friendly as possible for everyone! We will be implementing the portal by starting with our clients who have appointments scheduled in the next month. Then, we will begin mailing out the enrollment information to all clients over the following few months starting at the beginning of the alphabet. The information that will be sent for enrollment should answer most questions you may have and of course please feel free to email or call the office with any questions or concerns you may have!

Insurance Cards for 2017: Please CONTINUE to let us know if you have received a new insurance card recently! We must have the correct information to obtain approval for your medications, ordering labs and scheduling diagnostic tests. We will continue to check and update all cards at your office visit. 
This will allow us to expedite your services in a more timely manner. 

Billing Concerns and Questions: Tonya would like to thank everyone for referencing the invoice number on their check. Please continue to reference invoice numbers on every check, and it is ok to pay more than one invoice on one check as long as they are from the same doctor. Tonya can be reached via e-mail and she is available to return your calls on Tuesday afternoons and Wednesdays. 

Please visit our website if you missed past newsletters. The newsletter archives can be found by hovering your mouse over the "Medical Links" tab. 

Apps, Blogs, and Podcasts to help plan quick and healthy meals:

Fooducate app: Free and easy to use. Grades and offers pros and cons of each food item you search or UPC code you scan along with healthier alternatives.
Nutrition Diva podcast: Founded by Monica Reingel, MS, LD/N, CNS. Her goal is to sort the food facts from fiction. Shares tips to make your eating more healthful. Nutrition Diva podcast on iTunes, nutritionovereasy.com
Love & Lemons* blog: Award winning blog featuring mostly vegetarian recipes including vegan and gluten free. Step by step instructions that feature fresh, seasonal ingredients.
American Heart Association website: Features quick, simple and delicious recipes that’s good for your heart-Healthy for Good Recipes. AHA can also be followed on Pinterest.

*Blog can be followed on Facebook, Pinterest, Twitter and Instagram.

Free Health Lectures and Screenings in Your Area

Missouri Baptist Medical Center Community Education

Community Events Sponsored by Barnes-Jewish West County Hospital

Community Events Sponsored by Barnes-Jewish Hospital



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