DEAR DR. ROACH: My parents are in their 80s and have health issues that require careful monitoring, including diabetes and lymphoma. Their primary care doctor insists that Medicare only covers their blood tests every six months and that they would have to pay for any additional blood tests themselves. In the meantime, their medical specialists authorize blood tests as needed, sometimes just a few weeks apart.
I've never heard of this Medicare policy on restricting essential lab tests, and it seems dangerous and contrary to providing essential medical care. Is there any truth to what their doctor says, or should they find another doctor? -- M.M.
ANSWER: In the United States, Medicare does have limitations on some routine blood tests. For example, Medicare pays for an HIV screening once per year, a hepatitis C screening once per lifetime, and a diabetes screening twice per year.
However, if both your parents have diabetes, screening is no longer appropriate; instead, they need diabetes monitoring, which is normally recommended multiple times per year. Medicare does pay for laboratory testing when it is associated with a qualifying diagnosis for the purpose of monitoring a condition.
I suspect there is some missed communication going on here. I certainly have patients who want me to order more blood tests than I think is necessary. For example, most people don't need a routine complete blood count, but patients are used to getting them and understandably want to make sure that everything is OK.
From a physician's standpoint, it's a lot easier to order blood tests than it is to have a conversation about why they shouldn't be ordered. (The idea that a slightly abnormal routine lab test could lead to expensive, unnecessary, possibly invasive, additional follow-up testing is a difficult concept for many.) However, if your parents' doctor is making an untrue claim that the insurance won't pay for it, this is a cop-out at best and unethical at worst.
DEAR DR. ROACH: I am a petite 80-year-old female with a history of osteoporosis. I have never had children and have an intact uterus. My primary care physician does not believe in prescribing hormone replacement therapy (HRT) for someone my age due to the risk of cancer, yet I have been reading that HRT therapy is now being done for women with a history like mine.
I have a friend who is seeing a doctor at the University of California, San Diego, for this condition and is being treated with an HRT patch. Her bone health has improved dramatically with no adverse side effects. What is the current guidance on HRT and the cancer risk for older women like myself? -- Anon.
ANSWER: Estrogen is effective for the prevention of osteoporosis but is not as effective as other agents in treating established osteoporosis. In women with intact uteri, estrogen must be given with a progestin. This combination not only puts women at a higher risk for breast cancer, it also increases her risk of heart attack, stroke and blood clots.
The balance of risks and benefits in an 80-year-old woman, in my opinion, doesn't make estrogen the best choice. The long-term safety data on bisphosphonates like alendronate (Fosamax) is excellent when the drug is prescribed and monitored appropriately to a person who needs it.
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