Top Favorite Blog Posts

• Practicing Ideal Primary Care Practicing Ideal Primary Care

  • From: jscherger
  • Description:

    Eight months ago I posted a blog here titled "Inventing a New Primary Care Practice Today."  Here is an update.  Our group is now providing ideal primary care, no joke.

    At Eisenhower Medicine Center in Rancho Mirage, California, every patient gets 5-star treatment.  This not-for-profit health system makes its margin on donations, not from medical practice, where it loses money every year on Medicare, its dominant payer.  With substantial reserves, Eisenhower is able to invest in whatever care it wants.  After 35 years of investing in specialty service lines, the system is now investing in primary care.  Not ordinary, brief visit, always-in-a-hurry, patients-wait-longer-than-they-see-the-physician primary care.  Ideal primary care.

    So what is ideal primary care?  We borrow the slogan from the Institute for Healthcare Improvement (IHI) in Boston: We give you the care you want and need, how, when and where you want and need it.  Patients get all the time they need with 30 and 60 minute appointments, longer if necessary.  Our group of 6 physicians (and growing) sees 5 to 6 patients each half day session.  Once the relationship is established, the access to dialogue with the patients is continuous on a secure communication platform, Relay Health.

    Ideal primary care is not only great service, it is also the best quality of care, based on current clinical evidence.  Our records are fully electronic, using a McKesson system, and linked with the hospital and specialists.  We have robust and growing Clinical Decision Support to guide our care.  We have transparency so that we can see at anytime how we are doing with our patients.  Rather than practicing episodic, reactive care that depends on the physician doing everything, our care is continuous, strategically proactive and empowers patients for greater self-management.  We are not perfect in all these areas yet, but we are getting there.

    So what does all this cost and who pays for it?  While Eisenhower is fronting the money, we have a sustainable business model.  In my previous blog, I indicated a fee of $365 a year paid for by the patients for all the nonvisit communication and care.  That works only if all physicians are instantly full with 1000 patients.  Since we are a growing practice and it takes 1 to 2 years for each physician to get a full panel, our annual fee is $595 a year with a $40 discount for couples and families.  We use the patient centered medical home hybrid payment model of billing for office visits taking Medicare and other insurance.  We are an advanced Patient Centered Medical Home, the bright future for primary care.

    Because half of our patients are seniors who require more time, we are capping our panel size at 900 patients per FTE physician.  With that we are able to have physician salaries start in the $200k plus range and that will grow based on the hybrid revenues. We bonus physicians based on quality of care and patient satisfaction.

    It is so much fun to practice ideal primary care.  I was getting to dread the frustrating challenge of seeing 12 patients each session, knowing that I was always in a hurry and shortchanging people's care.  Being able to sit back and get the entire patient story is such a reward.  The patient's regularly tell us they have never had doctors like us.  This is primary care the way is should be, and it is sustainable.  Do it!

  • Blog post
  • 4 years ago
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• Your Practice: A New Revenue S Your Practice: A New Revenue Stream

  • From: skern
  • Description:

    Congratulations! Your practice just became a revenue stream. Unfortunately, not for you, but for the federal government, various state governments, and the bounty hunters they are hiring to recover alleged Medicare and Medicaid overpayments.

    On March 10th, President Obama issued a directive expanding the use of “payment recapture audits” to identify and recover overpayments. What this means is that companies are being hired to audit your claims and seek return of payments made in excess of the amount the “auditors” decide you should have been paid. The reason for the expansion is simple. The cost of these audits is far less than the money the government realizes from them. In fact, the government can’t lose. They’ve taken a page from the trial lawyers and are paying their “auditors” a percentage of the amount they recover. So much for the fair, unbiased auditor.

    By calling the companies that audit on a contingency fee “auditors,” the government has turned the definition of an auditor on its head. Auditors are supposed to be independent and not rewarded or penalized depending upon their findings. Imagine the uproar if a bank or a Fortune 500 company paid its auditors based upon how much the audit enhanced the company’s bottom line or increased the value of its stock!

    Yet, in announcing the expansion of the audit program, the President highlighted Medicare’s Recovery Audit Contractor Program (RAC) as being particularly successful in identifying improper payments, and even boasted that the RACs are compensated on a contingency basis related to the recoveries they obtain.

    Obama also claimed that the RACs employ accounting specialists and fraud examiners using specialized technology to uncover overpayments. Yet, those of us who have had substantial experience with the RACs have a different perspective. Their “expertise” is often lacking, their objectivity highly questionable-- since they make their money only if they find overpayments--and their tactics often heavy-handed.

    Dealing with a RAC is not a job for an amateur or the faint of heart. It involves critical deadlines, complex procedures, medical and coding expertise, and a reputation for challenging their often erroneous presumptions and calculations. The amounts in controversy can be very large, and the potential for the audit to turn into a civil or criminal fraud case real.

    A RAC audit should be treated like an IRS audit. It could result in severe monetary penalties and trigger disciplinary actions and even criminal actions. If you have any doubts about your coding or documentation, get professional help immediately.

    Like most medicolegal issues, your ability to defend will depend in large part on the quality of your records. If you’ve yet to take the leap into electronic health records, this is yet another reason to do so. One of the advantages of many EHR systems is that they assure that the documentation matches the coding.

    States are now joining the federal bandwagon. New York State, for example, just increased the maximum civil penalty for persons who receive overpayments or otherwise inappropriate payments from Medicaid. The law now allows for penalties of up to $10,000 for a first offender and $30,000 for repeat offenders—for each item of care, service, or supply! If a Medicaid program audit finds more than 25% of the audited claims resulted in overpayments, the State can recover both civil penalties and the amount of the overpayment. If less than 25%, the State must choose between the amount of the overpayment and the civil penalty. Expect other states to follow with similar legislation.

    Steven I. Kern has served as Senior Principal with Kern Augustine Conroy & Schoppmann, P.C. (and its predecessor firms) for the last 30 years. In this position, he has provided counsel to physicians, nurses, and other healthcare professionals; numerous hospital medical staffs; state and county medical societies; and physician specialty societies. For the last 10 years, he has been General Counsel to New Jersey Physicians. Mr Kern has gained admission to both the New Jersey and the United States District Court - District of New Jersey bars.

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  • Blog post
  • 3 years ago
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• Right-sizing staff Right-sizing staff

  • From: jbee
  • Description:

    So the staff is driving you nuts? Young people today just don’t know how to work hard? The more staff you have, the more hassles you have and your manager is begging to hire more? Is that what’s bothering you, Bubbie? If so, take 2 ideas and call me in the morning.

    How many staff does one physician need? The frustrating answer is, always, it depends. The unspoken question is, “Do we need all these (staff) people?” That question surfaces in almost every consulting assignment. It is valid to ask the question because the largest bite out of overhead is staff pay and benefits. Rarely is there more budget available for additional staff, so the answer we are really asked is “How can I cut back?”

    The key to the right size staff depends on 3 things.

    Transaction volume

    The number of physicians in the office simultaneously is less important than how many patients a day check in and out at your front desk, regardless of the number of physicians. A mindful mix of physicians can actually save a position or at least cut one to only needed at peak times. The assumption that each physician needs/deserves one medical assistant is not always accurate. The style of the physician and the number of patients seen per day is what drives the number of required MAs. Two physicians who have longer appointments, using 2 exam rooms each, can share one MA successfully. One physician who has lots of short contacts with patients but uses the MA for education or treatments can be more productive by using 2 MAs and lots of exam rooms.

    The mix of interruptible and noninterruptible tasks

    Those who work at the front desk (nonclinical staff) are there to be interrupted by patients at the desk or on the phone. With a high volume of calls and patients, these staff should not be asked to do work that is difficult to interrupt.

    For example, the check-in person who greets 40+ patients per day and also answers some incoming calls cannot enter insurance demographics accurately because s/he does not have time to focus on one task at a time. This one error in task allocation causes lines at check in, long hold times on the phone, and crabby billing staff who have to fix the errors that occur in billing when the insurance/patient demographics are entered incompletely or poorly.

    These task combinations are so frustrating that it leads to lots of turnover at the front desk positions. None of the tasks are too hard, but the employee trying to do it all simultaneously will fail at one task if doing the other priority task well. Personally, I am glad that a worker can spot a bad job and move on before it ruins her attitude.

    For example, an MA is primarily responsible for keeping the doctor and the patients moving. When this person is also responsible for triaging medical calls, handling refills, making calls to patients for test results, and answering questions, the MA can choose one task and fail at the other. You can’t do both of these things well simultaneously. This problem is a combination of task conflict and unrealistic phone responsibilities.

    Unrealistic telephone responsibilities

    One person who makes appointments on the phone can handle 2 incoming lines and give reasonable service to callers. Assigning more than 2 incoming lines to a person gives you the ability to irritate more patients simultaneously. Basically, one person can handle the same number of lines as she has ears. If you can find staff with 3 or more ears, I might be persuaded to increase the ratio.

    For example, if a front desk person’s main responsibility is to answer incoming calls, how is that employee supposed to make outgoing calls for appointment confirmation, preauthorization, or request records from another office?

    So what is the answer to the question? Here are some rules of thumb, in case you have unruly thumbs.

    • One person at the front desk can handle check in and check out for up to about 75 patients a day PROVIDED she is not answering phones, entering extensive demographics, and doesn’t have to leave her station to take anything to another area of the office. If you handle much workers’ compensation business, the volume one person can handle is reduced. The extra paperwork and fact checking slows the flow at the front desk.
    • One MA can keep 6 exam rooms filled if she has very little preparation or discussion with the patients and no phone responsibility is required.
    • One person can check in and check out about 20 patients per day and answer 2 incoming lines before the wheels come off.
    • Reorganizing jobs so that the average person can accomplish them makes it easier to staff the positions, and it gives those working a sense of achievement for a job well done.

    I feel better; you?

  • Blog post
  • 5 years ago
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• Five Levers of Physician Profi Five Levers of Physician Profitability

  • From: RichardReeceMD
  • Description:

    One of the main purposes of this blog is offer specific information to help physicians improve performance (quality of care and outcome), productivity (number of patients seen), and profitability (cash flow and bottom line).
     
    To give physician readers a crisp summary of how these goals can be accomplished, I conducted the following interview with John McDaniel’s, president and chief executive officer of Peak Performance Physicians, a 21-year-old practice management firm in New Orleans with physician clients throughout the United States.

    Here is John’s advice, as crystallized into “five levers of profitability.”
     
    The first lever deals with reimbursement systems. Under that umbrella is coding: 80% of doctors still under code. They need to compare their coding against national established benchmarks. Also they need to look at the competitiveness of their fee schedule and their managed care contracts. Coding, competitiveness of fee schedule, and contracts with managed care, the three C’s if you will, are all reimbursement systems that need to be tended to.

    The second lever deals with billing and collection. It is about how to improve cash flow. The first place we look is at over-the-counter collections. How much are they collecting at the front window? If you’re a primary care doctors, 20% to 25% of your income will come from the front office in terms of co-payments, deductibles, outstanding balances, and any non-covered services. If you’re a specialist, 12% to 15% of your income will come from over-the-counter collections. In addition, we ask: how efficient is the practice in the initial billing of claims, their rebilling of claims, and how they managed denials and rejections – how quickly can they turn those claims around and rebill them.

    The third lever is accounts receivable management. For most doctors, it is their biggest asset. It exceeds the equity they have in their homes. It exceeds the equity they have in their pension plans. Basically in most practices, it is not that most accounts receivables are mismanaged; they are unmanaged. There are strategies for patient balance accounts and for collecting insurance accounts that are over 60 days old.
     
    The fourth lever is operations improvement. This includes everything within the four walls of the practice from staffing, to scheduling, to what type of ancillary services they could offer. These services may be a convenience to the patient as well as a revenue producer. We also look at the compliance processes to make sure they’re complying with coding, OSHA, CLIA, HIPPA and so forth.
     
    The fifth lever is practice growth. What are the doctors doing to increase his or her number of patients? If they are a primary care doctor, they only have to do two things: one, take care of their patients, and two, recall them on an annual basis. In my travels across the United States, I have yet to meet a practice who sends out notices that says it’s time for your annual visit. Your vet does it. Your dentist does it. Your optometrist does it. But not your doctor. Why not? First of all, it’s good medical care. Second, it generates business. If you’re a specialist, your primary care customer is the referring physician. Are you tracking the number of referrals you’re getting? Are they increasing or decreasing, and if so, why? I advise doctors to do simple zip code studies, where are your patients coming from. And are those the areas you want your patients to come from.
     
    To contact John McDaniel, call 800-279-0614, or email him at info@peakphys.com.

  • Blog post
  • 3 years ago
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• Medicare: Is It Time To Opt Ou Medicare: Is It Time To Opt Out?

  • From: skern
  • Description:

    With the new federal health reform law and recent announcements dramatically increasing the number of audits that Medicare will be conducting through its vigilante “auditors,” is it time to consider opting out of Medicare?

    To answer that question, you first need to know your options. Most physicians are participating providers with Medicare. That allows them to accept assignment and receive payments directly from Medicare. An alternative is to change to nonparticipating status. The advantage of this is that you can charge your patients additional fees, up to the Medicare limiting charge. However, Medicare will reduce the amount it pays you directly by 5% and, except on a case-by-case basis, you will not be permitted to accept assignment. That means that your patients will receive the check from Medicare for your services, and you will have to rely upon your patients to either endorse the check over to you, or to pay you directly for the care you rendered.

    For those physicians who believe that changing from participating to nonparticipating status will eliminate the ability of the government to audit your charges, no such luck. As long as your bill is submitted to Medicare, from any source, you are subject to audit.

    A third option is to completely opt out of Medicare. The rules associated with this process are somewhat complicated. By opting out, neither you nor your patient will receive any Medicare reimbursement. Because no Medicare monies will be involved, there should be no audits, but there can still be compliance issues with respect to whether or not you followed the complicated opt-out requirements.

    By opting out, a physician is not required to submit claims to Medicare on behalf of patients and is not restricted to the limits on charges for Medicare covered services. However, you cannot opt out selectively. If you opt out, even for one patient, you have elected to completely opt out for 2 years.

    In order to opt out, you need to enter into private contracts with Medicare beneficiaries. These contracts require Medicare beneficiaries to agree to give up Medicare payments for services furnished by the physician and to pay the physician without regard to any limits that would otherwise apply to what the physician could charge.

    There are a number of very specific items that these private contracts must include. Among other things, the contracts must

    • Be in writing
    • Clearly state whether the physician is excluded from Medicare under certain provisions of the Social Security Act
    • State that the beneficiary (or his legal representative) accepts full responsibility for payment of the physician’s charges for all services furnished by the physician
    • State that the beneficiary understands that Medicare limiting charges do not apply to what the physician may charge for items or services provided
    • State that the beneficiary agrees not to submit a claim to Medicare or ask the physician to submit a claim to Medicare
    • State the beneficiary understands that Medicare payment will not be made for any items or services furnished by the physician that would have otherwise been covered by Medicare if there were no private contract
    • State that the beneficiary enters into the contract with the knowledge that he has the right to obtain Medicare-covered items and services from physicians who have not opted out of Medicare, and that the beneficiary is not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have opted out
    • Be signed by the beneficiary and the physician.

    In addition to entering into a private agreement, the physician must file an affidavit notifying all Medicare carriers to which he would submit claims, advising each that he has opted out of Medicare.

    Physicians thinking about opting out should first consider the above requirements and weigh the potential benefits of opting out for their practice. If, after careful consideration, the physician decides to pursue opting out, he or she should contact a healthcare attorney to address all of the very specific requirements necessary to effectuate that decision.

    Steven I. Kern is a recognized expert on healthcare law and president of Kern Augustine Conroy & Schoppmann, P.C., a healthcare law firm with offices in Bridgewater, NJ, Lake Success, NY, and Philadelphia, Pa, and affiliates in Chicago, Illinois and Altimonti Springs, (Orlando) Florida.  Mr. Kern is a seasoned trial lawyer, having advised and represented thousands of physicians and other healthcare professionals in licensing matters and litigation from coast to coast.  He is a member of the Editorial Advisory Board of ModernMedicine.com and Medical Economics magazine, a member of the Editorial Board of New Jersey Lawyer, and a former Deputy Attorney General for New Jersey. He can be reached at kern@drlaw.com.

    [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.]

  • Blog post
  • 3 years ago
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• How We (Physicians) Get Paid: How We (Physicians) Get Paid: A Secret Revealed!

  • From: rgupta
  • Description:

    During the recent health care debates, I’ve noticed that the issue of physician reimbursement often tends to get overlooked. No matter what “reform” may take shape this year, how much a certain generalist or subspecialist is paid will eventually decide the future of health care in this country.

    How? Well, if primary care physicians were reimbursed sensibly, they could form the backbone of health care. Not only are primary care physicians gatekeepers to medical specialists, they also play a critical role in preventive care, including health promotion, disease prevention, and chronic disease management. If this field becomes financially unattractive, no graduating medical student would want to pursue primary care as a career, and health care expenditure would rise and rapidly get out of control to an extent unimaginable today.

    It is essential that physicians, especially those in primary care, have a basic understanding of their reimbursement. When we see a patient, we file a charge with certain codes--Current Procedural Terminology (CPT) codes--for the service. The CMS (Centers for Medicare and Medicaid Services) then utilizes a system to assign a Relative Value Unit (RVU) to the specific CPT code. These work RVUs are different for each CPT code and vary extensively. Generally, they take into account work, practice expense, and liability. Finally, RVUs are multiplied by a certain conversion factor to derive payment for that physician.

    Simple and fair, right? Well, not exactly. What you are paid depends on how much CMS values the CPT codes you submit. So who decides this? One of the main advisors is the American Medical Association’s (AMA) Resource-based Relative Value Scale Update Committee (RUC).

    The RUC is accountable only to the AMA. In 2008, the CMS accepted 100% of the RUC’s recommendations. So who comprises the RUC, this so powerful committee which decides what you are paid (which is obviously not nearly enough for primary care)? It consists of 29 members, 23 of which are professional organizations and societies. Of the 23 professional organizations and societies, at least 11 are surgery-oriented; primary care is represented by 1 seat each from internal medicine, family medicine, and pediatrics. And by the way, there is a requirement that 2/3 of members accept any recommendation made by the RUC.

    Currently, the bulk of reimbursement funds are designed to be paid to the so-called procedure-oriented subspecialties. This explains why an ophthalmologist who spends the same time operating on a cataract as a primary care physician spends with a patient may make 7 or more times the pay of the primary care physician. This also explains why medical graduates may not find primary care to be very attractive. With more focus on preventive care and chronic disease management, it is obligatory to revise the current reimbursement formulas to reflect that focus.

  • Blog post
  • 4 years ago
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• Physician Alert: You Are Now t Physician Alert: You Are Now the FDA's Snitch

  • From: rgupta
  • Description:

    Effective May 11, 2010, if you are a healthcare provider in the United States, you have just been recruited by the FDA, whether you know it or not. The so-called Bad Ad Program is an FDA-sponsored program administered by the agency’s Division of Drug Marketing, Advertising, and Communications (DDMAC), in the FDA’s Center for Drug Evaluation and Research.  According to the FDA’s website, Phase 1 involves engaging health care providers at specifically-selected medical conventions and partnering with specific medical societies to distribute educational materials.¹ Phases 2 and 3 will expand the FDA’s “collaborative efforts” and update the educational materials developed for Phase 1. I am not sure what all this will mean for us since it is not clearly defined, and when things are not clearly defined, I tend to get nervous.

    As I understand it, the FDA wants you to do their job for them, sniffing out potential violators. In other words, whether you are attending a medical conference, listening to a national or local speaker, obtaining a brief from a pharmaceutical representative, or just viewing television with the family, the FDA now requires you to report any activity that you feel may be untruthful or misleading in prescription drug advertising. Not only are you required to make a report, but the FDA also wants you to disclose your name and other personal contact information that would help in ‘follow up’.²

    You must then ask the question: Is that it? Apparently not; the FDA also wants you to provide evidence, including the actual promotional materials or documentary evidence of oral statements, etc. While this level of involvement may make most of us uncomfortable, I’m sure a few would be willing to go through this ordeal if they were disappointed enough with an instance of untruthful or misleading advertising just to ensure that it doesn’t happen to them again or to one of their colleagues.

    Well, maybe that’s it, right? I have news for you. Your complaint will not undergo a bureaucratic review with a regulatory review officer deciding whether there will be an enforcement action or the FDA will just utilize this information for ongoing surveillance. If you have signed up to receive the FDA’s weekly enforcement reports, you will find that, over the years, there is a preponderance of recalls and field corrections rather than true punitive actions by the FDA to prevent similar future actions.³ In reality, all your hard work, time involved, and efforts spent—including divulging your personal information—will probably result in just the gathering of “interesting” data for the FDA to present somewhere.

    In real life, when I see a pharmaceutical representative or a speaker who is out of line, I usually point it out to them directly and immediately and it is usually never repeated again. Now you can judge which is a more effective and efficient method. Personally, I would recommend that the FDA ask for the authority to review all direct-to-consumer advertising of prescription drug products before the ads makes their way to the public, not afterwards. As a private citizen, I believe more damage to our health is being done by misleading advertising by the food and restaurant industry instead.

    References

    1. Truthful Prescription Drug Advertising and Promotion (Bad Ad Program). US Food and Drug Administration. Page last updated: May 14, 2010. Accessed August 17, 2010.
    2. Truthful Prescription Drug Advertising and Promotion: the Prescriber’s Role. US Food and Drug Administration’s Division of Drug Marketing, Advertising, and Communications. April 2010. Accessed August 17, 2010.
    3. Enforcement Reports. US Food and Drug Administration. Page last updated: March 3, 2010. Accessed August 17, 2010.

    Rahul Gupta, MD, MPH, FACP, is a Clinical Assistant Professor of Medicine at West Virginia School of Medicine; and Health Officer and Executive Director of Kanawha Charleston Health Department, both in Charleston, WV. He is an internist with a special interest in infectious diseases, HIV/AIDS, public health, and health policy.

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  • 3 years ago
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• Today’s Patients are Savvy and Today’s Patients are Savvy and Sophisticated; Talk with Them!

  • From: mpacker
  • Description:

    The following e-mail exchange (reproduced here with Protected Health Information redacted) was initiated through our practice's Web site "Contact Us" link at www.finemd.com.

    Dear Dr. Packer,

    By way of background, I am 53 years old. I was once very athletic, and still like to hit a tennis ball, go for a bike ride, walk and hike a bit, and swim. In addition, I write lengthy reports on the computer and read research journals. I send e-mails, use smart phones and like to read. During the Fall and Winter, I commute home after dark. I have never had prescription glasses, though have been using reading glasses the past few years, so I'm still getting used to glasses as a lifestyle.

    I'm presently in need of a cataract surgery on one of my eyes. I have a small cataract developing in my other eye, but it might be some time before it is ripe for removal. The challenge I've had is determining which lens to go with. My doctor originally suggested the ReStor lens (SN6AD1). After speaking with me further, he suggested the Tecnis lens (ZMB00 one-piece). He also was open to the Crystalens. I've also heard from a few doctor contacts of mine who still prefer the standard lens for their patients.

    You write on your office website that you feel the Tecnis is an overall better choice than the ReStor based on satisfaction levels despite the fact that it may have one line less acuity at the intermediate distance. Does Tecnis have less glare/halo or other advantages? Isn't the intermediate distance pretty important these days for computer usage? Does the loss of visual acuity and the probable side effects of the multifocals mean that the standard lens is still the sure bet? It seems some doctors are counting Crystalens out because they're not sure about how it works and the long run potential. As a monofocal, wouldn't this be a safer bet than the multifocals? And wouldn't it deliver a greater depth of focus than the standard lens? Should I wait for anything on the horizon?

    I apologize if these questions are way more than you have time to respond to. If that's the case, the short question is how do you feel about Tecnis(ZMB00)? As you can see, I like to do my due diligence up front before I decide on this important decision. Once I decide, I'm usually good to go. Perhaps you get these difficult questions all day long...

    John Smith

    Dear Mr. Smith,

    I have been intimately involved with the development of the Tecnis lens for the past ten years (now marketed by Abbott Medical Optics). I have also worked closely with the inventor/developers of the Crystalens (now Bausch & Lomb). I have not been so involved with ReSTOR (Alcon). Nevertheless, the ReSTOR is a very successful design. As far as the horizon goes, there is an innovative design called Synchrony which was acquired by Abbott last year and is likely to gain FDA approval within 12 months--but nothing is assured with the Agency. However, if I had only mild cataracts at this point I might very well wait for it, or consider a trip to Colombia and let Ivan Ossma implant them in my eyes (he has the most experience in the world with it).

    As far as what's available in the US today, I do favor Tecnis for anyone who does not want to wear glasses. The Crystalens does not have the multifocal image issues, it's true, but the chances are you'll still need reading glasses. And, the "halos and glare" really do diminish over time (about the same for Tecnis and ReSTOR). While it is true that "intermediate range" vision--about the location of your computer screen--is the weak point for Tecnis, I find that it's good enough and gets better over about 6-8 weeks. You may have to move the screen in and out at first to find a good focus, but it will probably settle down right where it started.

    I am doing a study right now in which I match the ReSTOR or the Tecnis to each eye based on the spherical aberration of the cornea (you may have read that these are aspheric lenses). I have a hunch that this might provide the best image quality and therefore the best acuity at all distances. Because of the design of the lenses, about 2/3rds of the population matches up with the Tecnis. One finer detail--I prefer the ZMA00 (three-piece lens). It has had more accurate outcomes than the ZMB00 in my experience.

    Best,

    Mark Packer

    Dear Dr. Packer,

    I have one remaining question and an intended course of action to run by you. You said the Tecnis lens tends to work best with two thirds of the qualifying population, while the ReStor lens tends to work well with the other one third. My understanding is that they are aspherical in different ways. It seems that one or the other might be better for me based upon the shape of my eye. Isn't that a preliminary determination? If my doctor first suggested ReStor and then suggested Tecnis for no other reason than I gave him more details about my activities and lifestyle, doesn't this negate the fact that one or the other might be best suited for me based on the characteristics of my eye? I did have a second impression from our discussion that you felt the Tecnis would be a good choice for me regardless. Maybe you could clarify this issue for me.

    I'm leaning in the direction of asking my existing surgeon the following questions:

    • Did he use the IOL Master to measure my eye?
    • Did he use the Corneal Topographer to measure the power of my cornea?
    • Did he use the Holladay II formula software to determine the power choice?
    • Does the Tecnis conform better than the ReStor to the shape of my eye?
    • Assuming that the Tecnis conforms best to the shape of my eye, would he put in the Tecnis three-piece IOL, instead of the one piece?

    If he answers in the affirmative, I'll proceed with him. I thought of switching, but it would mean starting over with the consultation and pre-op, etc. I would kind of like to move the process forward. If my doctor is not interested in dialoguing with me or he doesn't answer in the affirmative to my questions, then I would consider shifting.

    Thanks, JS

    Dear Mr. Smith,

    There are a few ways in which the ReSTOR +3D and Tecnis MF differ:

    1) Spherical aberration (important for quality of vision, contrast sensitivity, night driving performance)

    Tecnis is - 0.27 microns, ReSTOR is - 0.20 microns. The average cornea is + 0.27 microns. The cornea is measured with topography and then the measurement is translated into a polynomial series (one term of which is the spherical aberration) either automatically within the topographer or using software (VOL-CT from www.saavision.com/products.aspx). The target is zero total, so if your cornea is + 0.235 the Tecnis fits better (67% of the population is in this category). If < + 0.235, ReSTOR fits better.

    2) Near vision in dim light

    Tecnis MF is significantly better on average in the population (when no selection for spherical aberration is made)

    3) Material

    The ReSTOR is made from AcrySof material that often forms "glistenings." There is some small risk of these affecting vision in the future.

    My hypothesis, not yet proven but currently under investigation, is that matching the spherical aberration produces better function without glasses at all distances. However, in the absence of this determination, I prefer the Tecnis MF for the other reasons.

    Your questions are appropriate. By the way, the Lenstar and Immersion Ultrasound are equivalent to the IOL Master. Also, do find out the magnitude of your corneal astigmatism. If it is greater than > 0.5 diopter you may need relaxing incisions to reduce it.

    Best, Dr P

    Mark Packer, MD, CPI, FACS, is Clinical Associate Professor, Casey Eye Institute, Department of Ophthalmology, Oregon Health & Science University School of Medicine, and in practice with Drs. Fine, Hoffman & Packer in Eugene, OR. He serves on the Cataract Clinical Committee of the American Society of Cataract and Refractive Surgery (ASCRS). In 2005 he was elected to membership in The International Intra-Ocular Implant Club.

    [Editor's Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.]

  • Blog post
  • 3 years ago
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• Abortion: Separating fact from Abortion: Separating fact from fiction in health reform

  • From: jcopel
  • Description:

    At the last minute in the House of Representatives, Rep. Bart Stupak (D-MI) introduced an amendment to the Health Reform bill that would greatly restrict access to abortion services).¹ Up to now, the “Hyde Amendment” prevented Federal funding for abortions for many women. So, the military spouse I saw a while back who had a fetus with severe oligohydramnios from 16 through to 22 weeks, a small fetal chest indicating pulmonary hypoplasia, and fetal joint contractures? She had to pay for her abortion of a non-viable pregnancy out of pocket. Tricare, the federal plan for military dependents, wouldn’t pay.

    The Stupak amendment takes this several steps further. Basically women anywhere in a public option or exchange system, the two models being considered for increasing access to insurance for those who do not get coverage from their employers, will not be able to get coverage for abortion services if there is any federal money anywhere in the system.

    A team at The George Washington University School of Public Health, led by Sara Rosenbaum, estimates that such a rule for any public option will inevitably lead to reduced abortion coverage by private insurers.² They conclude that passage of the amendment will inevitably “have an industry-wide effect, eliminating coverage of medically indicated abortions over time for all women, not only those whose coverage is derived through a health insurance exchange.”

    Rosenbaum goes on to cite research from the Guttmacher Institute suggesting that 87% of health insurance plans include some level of abortion services and at least 46% of workers receive this coverage (the latter number may be an underestimate because 26% of respondents did not know if they had coverage).³

    So, in a nutshell, here is the dilemma. Is it better to expand health coverage overall at the expense of abortion coverage? There has not been any evidence that a market for “abortion riders” to policies can work. Half of pregnancies are unplanned and attempts to offer that kind of option have not been popular. In other words, the women who might need the coverage tend not to buy it. Also, remember I’m not just talking about elective terminations here, medically indicated terminations for lethal fetal anomalies would also lose coverage.

    At first my bias was to think that it’s better to expand health insurance to another 30+ million Americans. Those women don’t have ANY insurance now, let alone abortion coverage. First trimester abortions cost on average less than $1000 at Planned Parenthood according to the Kaiser Foundation, and the Guttmacher Institute report says that only 13% of abortions are directly billed to insurance (reimbursement for others may be sought by women afterwards).

    So, is health reform worth it if everybody loses abortion benefits? Or, is it better to get broad coverage for more working families who currently don’t qualify for public assistance and who don’t get coverage from their employers? Even as a staunch Pro-Choice advocate, I am torn.

    [Editor's Note: What's your take on abortion benefits? Log in and Comment in the box below.]

    References

    1. Affordable health care for America Act. Library of Congress; House of Representatives. Nov 7, 2009: p H12921.
    2. An analysis of the implications of the Stupak/Pitts amendment for coverage of medically indicated abortions. Washington, DC: The George Washington University Medical Center, School of Public Health Services, Dept of Health Policy. Nov 16, 2009.
    3. Guttmacher Institute Memo on Insurance Coverage of Abortion. New York, NY: Guttmacher Institute. July 22, 2009; updated on September 18, 2009.

  • Blog post
  • 4 years ago
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• New modifier for admitting phy New modifier for admitting physician: AI

  • From: ElizabethWoodcock
  • Description:

    On Dec. 14, CMS confirmed the new rules for inpatient admissions. This follows the surprising news that the CMS will no longer pay physicians for consultations, instead instructing you to bill a visit code.

    In the MLN Matters MM6740, CMS instructs: "The principal physician of record will append modifier 'AI' ['a' - 'eye'] Principal Physician of Record, to the E/M code when billed. This modifier will identify the physician who oversees the patient's care from all other physicians who may be furnishing specialty care. All other physicians who perform an initial evaluation on this patient will bill only the E/M code for the complexity level performed."

    The new modifier for the admitting physician will need to be appended to an initial hospital care code (99221-99223). Both the admitting physician -- and other physicians treating the patient in the hospital -- will use only one of the subsequent hospital care codes -- 99231-99233 -- for their services.

    Only one admission will be allowed per patient. If two physicians mistakenly use the modifier that designates the admitting physician, AI, one will be denied. If you're in this situation, you or your staff may have to get on the phone with the other physician(s) treating your patient to determine who made the mistake -- and hope that he/she will resubmit the corrected claim.

  • Blog post
  • 4 years ago
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• Why Health Care Reform May Fai Why Health Care Reform May Fail Again

  • From: rgupta
  • Description:

    With the debate over health care reform in the White House, both Houses of Congress, and in the public at large becoming more vigorous, I am curious about the lessons to be learned from the 1994 debacle—the nonpolitical lessons. I often wonder: What is the single most significant factor that led to the failure in 1994, and how can we, as a nation, work to address it?

    Recently, I came across a perspective comparing the public’s current views about health care reform with those of 1994.¹ There is a striking similarity. In both instances, although an overwhelming majority of Americans want health care reform, only about 40% support the Obama/Congressional plan or supported the Clinton plan in 1994. In both cases, the vast majority feels that neither will the quality of health care improve nor will the cost of health care decrease as a result of these reforms. On the surface, it seems like a poor job of marketing the package to consumers. But could there be something more?)

    One simple fact that has remained essentially unchanged and gone unnoticed in the past 15 years is the low levels of functional health literacy and overall literacy skills among US adults.² What this means is that a large number of Americans are unable to integrate 2 or more pieces of related information with reliable accuracy and consistency, especially in health context.

    Therefore, any government administrator or elected official who tries to convince the majority of their constituents of the validity of even a sound health reform agenda needs to ensure that those folks comprehend the message being delivered. Or else a majority of Americans will not be able to make good decisions and, as a result, will remain hostage to the agendas of various groups.

    So what’s the solution? There should be a concerted effort by all stakeholders to ensure that the public has the tools required to comprehend the basic principles of the proposed health care reform legislation and then debate it, not vice versa. In other words, we all need to do some homework! If not, there is a good chance that the well-meaning health care reform agenda will be derailed, again.

    References

    1. Blendo RJ, Benson JM. The American Public and the Next Phase of the Health Care Reform Debate. N Engl J Med. published at www.nejm.org November 4, 2009 (10.1056/NEJMp0906394). Perspective.
    2. http://www.ncsall.net/fileadmin/resources/teach/environ_resources.pdf

  • Blog post
  • 4 years ago
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• Handling Staff—Tips From My Fa Handling Staff—Tips From My Father-In-Law

  • From: bbarankin
  • Description:

    The following are some tips from my father-in-law, who ran a pharmacy with over 20 employees for 25 years:

    1. Holiday/Christmas bonus - 1 week salary; he gave it every year despite the pharmacy head office telling him not to; he told them the head office that he does things his way, and that may be why his employee turnover rate was an industry low.
    2. If a good employee had a sick child, he'd still pay them for the day—the employee would typically work that much harder the rest of the week, and tell others how nice his boss was; as such, word also got out in the community that my father-in-law was a great employer, and so he never had to place an ad for a job posting.
    3. He always paid above minimum wage. His dad told him: pay someone $1 more, and they'll earn you $2 more.

    Benjamin Barankin, MD, FRCPC, is a practicing dermatologist, participating in group practice in Toronto, Ontario, Canada. He received specialized training in medical, cosmetic, and surgical dermatology and trained extensively with some of the best dermatologists in North America.

    [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.]

  • Blog post
  • 2 years ago
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• Would You Hire Her? Would You Hire Her?

  • From: jbee
  • Description:

    The resume came to our fax machine from a client. Their biller had given 2 weeks’ notice, and the new manager was already swamped getting settled in. The wife of a patient walked in the same day. She presented a resume and reams of glowing reference letters. Was this a gift from above???

    Maybe, but here’s the rub: If they hire her, they’re choosing her out of a universe of one. They don’t know if a better skilled and experienced person is available. A closer reading of the resume revealed a long list of relevant skills, but the candidate had only 7 months of experience and a recent certificate from a medical billing program. I suspect there would be a lot of training required of the time-pressed manager to bring this candidate up to speed.

    I know that recruiting is a pain—but do the work, and find the best you can. Actually, I told the manager that since they were in a huge pinch, they could hire the applicant on a per diem basis while they did the recruiting. Who knows? Maybe this person is a super star!! But won’t she and they feel better about confirming that?

    Judy Bee is a medical practice management consultant with the Practice Performance Group, La Jolla, CA. Since entering consulting in 1977, Ms Bee has developed a client reference list which numbers more than 700 physicians in 37 states of the United States.

    [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.]

  • Blog post
  • 2 years ago
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• Embezzling: Economic Indicator Embezzling: Economic Indicators?

  • From: jbee
  • Description:

    I have had my second call in a month about discovered embezzlement. As far as we know, the employees had not done this before. One was known to be in big financial trouble, living out of her car. The other had some vague hint of family trouble and perhaps some big psychotherapy bills to pay. In any event, the option of dipping into the practice income was too tempting.

    The first case concerned a manager who took collections made at the time of the service from 3 offices and deposited them separately from mailed-in checks. When trying to reconcile the income for end-of-year bonus distributions, the accountant discovered that income posted to the accounts did not match that deposited in the bank. If the accountant had received monthly payment summaries along with the bank reconciliations, this scam would not have worked. This lack of information is not unusual. Most profit and loss statements begin with what was deposited with no tie-in to what was collected. It is even worse when practices use Quick Books to create reports, and the CPA only sees them once a year at tax time.

    The second case was a bit different. The bookkeeper was overwhelmed, and she could not get all the work done. She refused help. Instead, she posted what she could and made the deposit equal the posting. What was missing was the number and amount of checks she didn’t post. Payment posters also make adjustments. It is too early to tell if she had a phantom bank account where she deposited the “extra” checks, making adjustments on patient accounts instead of posting the payment.

    How did the manager discover this problem? She was concerned about the “rat’s nest” in the billing office; so, while the bookkeeper was away, the manager started opening cabinets and drawers. She found many unposted checks, unposted EOBs, and overpayment refund requests from insurance companies hidden months’ prior. This bookkeeper also paid the bills! Big surprise, she “advanced” herself $1,500 when the manager was away. That was discovered at the end-of-the-year reconciliation with the payroll service account showing $1500 less than the expense summary for payroll.

    Moral: Get several people involved in opening the mail, totaling the checks, posting, and making the deposit. Make sure the CPA gets a summary by day of the collection posted to the computer as well as the bank rec. Recognize people in trouble and take the opportunity for creative solution.

  • Blog post
  • 3 years ago
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• Save $10,000+ on Your 2010 Tax Save $10,000+ on Your 2010 Taxes

  • From: skern
  • Description:

    As a change of pace, I’ve asked one of our tax consultants, David B. Mandell, JD, MBA, to assist in providing some thoughts what you can do now to save on 2010 taxes. Here are some ideas he suggests:
    
    1. Maximize the Tax Benefits of Your Qualified Retirement Plan (QRP)
    
    Nearly 95% of physicians have some type of QRP in place. These include 401(k)s, profit-sharing plans, money purchase plans, defined benefit plans, 403(b)s, or even SEP or SIMPLE IRAs, for these purposes (technically, IRAs are not QRPs). However, most of these plans are not maximized for deductions for the practice owner(s). The Pension Protection Act of 2006 improved the QRP options for many physicians. In other words, many owners may be using an “outdated” plan and foregoing further contributions and deductions allowed under the most recent rule changes. By maximizing your QRP under the new rules, you could increase your deductions significantly for 2010 and reduce your taxes on April 15, 2011.
    
    2. Implement a Fringe Benefit Plan
    
    While the vast majority of physicians have QRP’s in place, most have not analyzed, let alone implemented, any other type of benefit plan. Nonqualified plans or fringe benefit plans often enjoy favorable short-term and long-term tax treatment. We will examine 2 types of fringe benefit plans here.
    
    One plan has been in the tax code for decades, and the IRS has actually issued “safe harbor” rules so the plan can be implemented simply. This plan is governed under Section 79 of the tax code. Essentially, this plan allows a corporation to provide life insurance benefits to employees--which can be term insurance or permanent life insurance. Since permanent life insurance has an investment portion (called the “cash value”), taxpayers can build up significant values in such plans for retirement. In fact, some clients will accumulate well over $1 million in cash values for their retirement.
    
    Other elements of the Section 79 plan include:
    •    100% tax deduction for contributions to the plan
    •    Tax free-growth of plan assets
    •    In many states, the highest level of asset protection for plan funds
    •    Much higher potential contributions than with profit-sharing plans and 401(k)s
    •    The ability to carve out a “class” of employees for the plan
    •    59½ and 70½ age rules for qualified retirement plans do not apply
    
    Also, importantly, this plan can be offered in addition to a qualified retirement plan (like 401(k), profit-sharing plan) or SEP IRA. Thus, if you are already “maxed out” on your qualified retirement plan, the Section 79 plan can be an attractive option.
    
    Another fringe benefit plan is the provision of long-term-care insurance coverage for physicians. Again, this can be implemented so that there is choice among the physicians. Depending on the practice’s corporate structure, this plan, in addition to providing an important coverage for the physicians’ family, might reduce a physician-participant’s income taxes by thousands of dollars per year. Essentially, if the doctors may purchase such insurance anyway, why not get a tax break for doing so?
    
    If you are interested in reducing your 2010 taxes and have not considered these options, you should do so. These, and other techniques, can help you reduce your taxable income in 2010 significantly…and they can be put into place in a few weeks, so it’s not too late for 2010.
    
    
    Dave Mandell has also offered our readers a free copy of his book, FOR DOCTORS ONLY: A Guide to Working Less & Building More. If you would like a copy, contact David at mandell@ojmgroup.com.
    
    
    Steven I. Kern, Esq, is a recognized expert on healthcare law and president of Kern Augustine Conroy & Schoppmann, P.C., a healthcare law firm with offices in Bridgewater, NJ, Lake Success, NY, and Philadelphia, Pa, and affiliates in Chicago, Illinois and Altimonti Springs, (Orlando) Florida. Mr. Kern is a seasoned trial lawyer, having advised and represented thousands of physicians and other healthcare professionals in licensing matters and litigation from coast to coast. He is a member of the Editorial Advisory Board of ModernMedicine.com and Medical Economics magazine, a member of the Editorial Board of New Jersey Lawyer, and a former Deputy Attorney General for New Jersey. He can be reached at skern@drlaw.com.
    
    [Editor’s Note: Do you have any thoughts to share on this topic? Please Log in to use the Comment box below.]

  • Blog post
  • 3 years ago
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• When and Why Refer to a Dermat When and Why Refer to a Dermatologist: A Checklist of Reasons

  • From: bbarankin
  • Description:

    Whenever I give talks and present CME events, the general practitioners often ask which patients they should be referring to me versus those they should be able to manage themselves. Here is my compiled list of when and why to refer to dermatology:

    • Patient demands to see a dermatologist
    • Common “big city phenomenon”
    • 2 strikes and you’re out: If your second attempt to treat a problem it hasn’t resolved or significantly improved it, the patient no longer trusts your diagnosis/treatment plan and future suggestions will be met with poor compliance
    • Moderate to severe eczema, psoriasis, alopecia, lichen planus, sun damage, etc.
    • If allergic contact dermatitis is in the differential, then refer to a dermatologist (not allergist) for patch testing
    • Phototherapy required: psoriasis, eczema, vitiligo, PLEVA, mycosis fungoides, chronic pruritus (eg, renal disease)
    • Patient requires oral medications &/or immunosuppressive medications, eg, methotrexate, soriatane, cyclosporine, biologics, Imuran, IVIG, cyclophosphamide, hydroxyurea, isotretinoin
    • Diagnosis is uncertain; rash or lesions recur
    • Severe psychosocial sequelae
    • Depression, anxiety, suicidal ideation
    • Patient needs to be great improvement for wedding or other major function in the very near future
    • Medicolegal protection: For complex or unhappy patients, having a specialist consultation letter on file shows you sought expert help and gave the patient the best/most comprehensive care
    • Improves compliance: If the specialist/dermatologist says so, it must be so
    • If you don’t have the sufficient equipment: Liquid nitrogen, hyfrecator, cantharone, chemical peels, Blu-U, laser, microdermabrasion, etc.
    • Cosmetic treatments
      • Patient requests or is interested in BOTOX, lasers, fillers, chemical peels, microdermabrasion, BLU-U
      • General skin measures and care of skin, new products
    • Medicolegal risks—don’t just tell patients to look for laser hair removal at any old med spa in the yellow pages; your “recommendation” can bite you in the a…
    • Diagnosis and treatment of skin cancers
    • If patient warrants Mohs surgery: Large skin cancers on face, recurrent skin cancers on face and neck, where tissue sparing is critical
    • Hemangiomas of infancy on the head & neck or genitals
    • Do I send this case to the allergist or plastic surgeon?
      • For allergies due to contactants (eg, perfume, nickel, occupational, etc)—patch testing by dermatologist (along with clinical correlation!)
      • For allergies, asthma and hay fever triggers—skin prick testing by allergist (along with clinical correlation!)
      • Is the lesion definitely a skin cancer—dermatologic surgeon or plastic surgeon
      • Does the person want or require major surgery (e.g. face lift, abdominoplasty, rhinoplasty, breast augmentation)—plastic surgeon
    • Full skin exams if numerous moles, multiple atypical moles, personal or family history of melanoma, personal history of BCC or SCC
    • Any uncertainty about diagnosis (we all need help; don’t get in over your head)
    • Any possible syndromes, eg, NF, TS
    • If cost is an issue for patients (derms are able to provide lots of samples or to convince drug companies to obtain compassionate products for free or greatly reduced price)
    • When treating ethnic skin
    • More complicated and medicolegally risky (eg, laser hair removal)
    • More dyspigmentation problems—watch out with the liquid nitrogen!
    • When treating the pregnant or nursing patient (more complicated and medicolegally risky)
    • Anything stubborn (diseases, patients)
    • If special testing required
      • KOH, fungal cultures
      • Immunofluorescence (bullous or autoimmune diseases)
      • Biopsies
      • Viral cultures
    • Blistering and autoimmune diseases: Bullous pemphigoid, pemphigus vulgaris, pemphigus foliaceous, paraneoplastic pemphigus, linear IgA disease, dermatitis herpetiformis, lupus, dermatomyositis
    • Leg ulcers
    • Rashes or lesions that are not resolving, growing or changing—cancers and infections grow!
    • Hair, nails, and oral problems (too poorly taught and understood by many doctors)
    • To see what may be new in the treatment of…(fill in the blank)

    [Editor’s Note: Do you have anything to add to this list? Login and Comment in the box below.]

  • Blog post
  • 4 years ago
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• Why Is There So Much Vitamin B Why Is There So Much Vitamin B12 Deficiency?

  • From: bgottlieb
  • Description:

    Is it my imagination, or does it seem like every other patient has vitamin B₁₂ deficiency? Is it because my patients, unlike myself, are getting older? Are there other factors to consider?
    
    As humans age the risk of developing a vitamin B₁₂ deficiency increases. Andres et al, report that more than 20% of adults 65 and older are deficient in this nutrient.¹ I have been taught to attribute this to poor absorption due to factors in the stomach, the small intestine, or both. We are all familiar with the consequences of B₁₂ deficiency to the hematologic and neurologic systems; every medical student memorizes the pathways that lead to macrocytosis, neuropathies, and spinal cord degeneration. There is increasing evidence that B₁₂ is a key piece of other common pathophysiologic puzzles including atherosclerosis and dementia.² Vitamin B₁₂ deficiency contributes to common psychiatric disorders including PTSD, panic disorder, depression, and obsessive compulsive disorders.^3,4 Vitamin B₁₂ is involved in the humoral immune response, and low levels have been associated with an impaired response to pneumococcal vaccine.⁵

    It does seem that B₁₂ deficiency is at least in part a phenomenon of “normal aging.” There are age-related changes in the stomach that reduce the availability of intrinsic factor. One might also argue that age alone can change the motility of the intestines, thereby altering the microflora, leading to poor absorption through the intestinal wall.
    
    However, the high prevalence of this nutritional deficiency among younger individuals suggests that there are other factors. For example, Mclean et al found high rates of vitamin B₁₂ deficiency among Kenyan school children⁶; others have documented high rates of vitamin B₁₂ deficiency throughout Africa and Asia, and among immigrant and refugee populations in the developed world who come from areas where this deficiency is endemic.^7-9

    Clearly diets that are deficient in animal-based foods--either because of religious or cultural beliefs or poverty--are known to be associated with vitamin B₁₂ deficiency. Worldwide, several common infections are also associated with vitamin B₁₂ deficiency. Chronic infection with Helicobacter pylori can lead to gastric atrophy, reduction of parietal cells and intrinsic factor, and impaired absorption of vitamin B₁₂.¹⁰ Intestinal parasites, including Giardia lamblia can lead to chronic malabsorption of many nutrients, including vitamin B₁₂.⁷ These infections are unfortunately more common in parts of the developing world where diets are marginal in animal-based foods, thus increasing the vulnerability of these populations to vitamin B₁₂ deficiency.

    Some of the things we do as physicians contribute to the problem. There has been recent attention to the association between vitamin B₁₂ deficiency and commonly prescribed medications, including H2 antagonists, proton pump inhibitors (PPIs), and now metformin.11-15 When I think about how many prescriptions I write in a day for H₂-blockers and PPIs, and the epidemic of obesity and diabetes, I have to reckon with the likelihood that I will be responsible for vitamin B₁₂ deficiency (or already have been) for a significant number of patients.

    Sturtzel et al call attention to a more obscure possibility in their compelling, although small study, of frail elderly patients in a geriatric home.16 Patients were randomized to an intervention group that received 5.2 g/d of oat bran mixed into their food, and a control group. Both groups were fed the standard diet of the facility, were followed clinically for constipation, and treated with laxatives as indicated. Baseline laxative use and serum vitamin B₁₂ and B6, and folic acid were the same. After 12 weeks, vitamin B6 and folic acid levels were unchanged. However, laxative use was reduced by 59% in the intervention group and only 8% in the control group, a difference that was statistically significant (P<.001). Vitamin B₁₂ levels decreased significantly in the control group (P<.05), but showed no significant decrease in the intervention group (P<.05). The authors point out that physicians often treat constipation in the elderly without regard to potential consequences to the microflora of the intestines. Selecting a regimen for preventing constipation, or a treatment that does not alter the microflora, may preserve normal levels of vitamin B₁₂ in this vulnerable population.

     

    Although the consequences of B₁₂ deficiency can be permanent, in many cases they are reversible over time. Many of the medication-induced causes of B₁₂ deficiency are also reversible over time. It is up to us to have a heightened awareness of the possibility of B₁₂ deficiency--to identify it early and treat before consequences develop.

    Equally important is to prevent its development in the first place. Here is my “note to self”:

    •    Ask a good dietary history. This is especially true of vulnerable groups--the elderly, immigrants, and refugees, the poor. (Also women of childbearing age, which is a whole discussion unto itself.)
    •    Test for H pylori—particularly among patients who come from areas of the world where this infection is endemic. Think about H pylori when a patient has vitamin B₁₂ deficiency.
    •    Think about intestinal parasites, and test when appropriate. If a patient seems to have been infected chronically, consider checking a B₁₂ level.
    •    Monitor B₁₂ levels regularly when patients take H₂ antagonists, PPIs, and metformin for extended periods of time.
    •    Since short term use of H₂ antagonists and PPIs does not seem to cause B₁₂ deficiency, use these medications carefully and for the shortest amount of time.
    •    Remember that preventing constipation is better than treating it once it develops.
    •    Remember that all medications can have consequences, particularly if they are used on a regular basis. Consider the mechanism of action of commonly used medications such as laxatives. Choose medications that are least likely to alter the body’s fragile microsystems, especially among the frail elderly.
    •    Finally, review all medications regularly, and discontinue them when they are no longer indicated.

    References

    1. Andres E, Affenberger S, Vinzio S, et al. Food-cobalamin malabsorption  in elderly patients: clinical manifestations and treatment. Am J Med. 2005; 118:1154-1159.
    2. Seshadri S, Beiser A, Selhub C,  et al. Plasma homocysteine as a risk factor for dementia and Alzheimer’s disease. N Engl J Med. 2002;346:476-483.
    3. Guzelcan Y, van Loon P. Vitamin B₁₂ status in patients of Turkish and Dutch descent with depression: a comparative cross-sectional study. Ann Gen Psychiatry. 2009; 8:18.
    4. Coppen A, Bolander-Gouaille C. Treatment of depression: time to consider folic acid and vitamin B₁₂. J Psychopharmacol. 2005;19:59-65.
    5. Fata F, Herzlich B, Shiffman G, et al. Impaired antibody responses to pneumococcal polysaccharide in elderly patients with low serum vitamin B₁₂ levels. Ann Intern Med. 1996;124:299-304.
    6. McLean E, Allen L, Neumann C, et al. Low plasma vitamin B-12 in Kenyan school children is highly prevalent and improved by supplemental animal source foods. J Nutr. 2007; 137:676-682.
    7. Stabler S, Allen R. Vitamin B₁₂ deficiency as a world-wide problem. Annu Rev Nutr. 2004;24:299-326.
    8. Rozgony NR, Fang C Kuczmarski MF, et al. Vitamin B(12) deficiency is linked to long-term use of proton pump inhibitors in institutionalized older adults: could a cyanocobalamin nasal spray be beneficial? J Nutr Elder. 2010;29(1):87-99.
    9. Benson J, Maldari T, Turnbull T. Vitamin B₁₂ deficiency: why refugee patients are at high risk. Australian Family Physician. 2010;39(4): 215-217.
    10. Kaptan K, Beyan C, Ural A, et al. Helicobacter pylori: is it a novel causative agent in vitamin B₁₂ deficiency? Arch Int Med. 2000;160:1349-1353.
    11. Ruscin JM, Page RL, Valuck RJ. Vitamin B (12) deficiency associated with histamine (2)-receptor antagonists and a proton-pump inhibitor. Ann Pharmacother. 2002:36(5):812-816.
    12. Rozgony NR, Fang C Kuczmarski MF, et al. Vitamin B(12) deficiency is linked to long-term use of proton pump inhibitors in institutionalized older adults: could a cyanocobalamin nasal spray be beneficial? J Nutr Elder. 2010; 29(1):87-99.
    13. Valuck RJ, Tuscin JM. A case-control study on adverse effects: H-2 blocker or proton pump inhibitor use and risk of vitamin B₁₂ deficiency in older adults. J Clin Epidemiol. 2004;57(4):422-428.
    14. Ting R, Sceto C, Chan M, et al. Risk factor of vitamin B₁₂ deficiency in patients receiving metformin. Arch Int Med. 2006;166:1975-1979.
    15. deJager J, Kooy A, Lehert P, et al. Long term treatment with metformin in patients with type 2 diabetes and risk of vitamin B-12 deficiency: randomized placebo controlled trial. BMJ. 2010;340:c 2181.
    16. Sturtzel B, Dietrich A, Wagner K-H et al. The status of vitamins B6, B₁₂, folate, and of homocysteine in geriatric home residents receiving laxatives or dietary fiber. The Journal of Health, Nutrition & Aging. 2010;14:219-223.
    
    
    Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health.
    
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• 2011 Medicare Physician Fee Sc 2011 Medicare Physician Fee Schedule is Released

  • From: rgupta
  • Description:

    Under the recently released Centers for Medicare & Medicaid Services (CMS) final 2011 physician fee schedule, improved payments are allowed for primary care services, which include patient coverage for wellness benefits with lower co-payments and a 10% incentive payment for primary care services. And as before, CMS will not make payments for consultation codes, only via E/M codes. However, this final rule for 2011 assumes that the current update will not be extended, resulting in a total scheduled reduction in Medicare payments to physicians of 25%, with the first cut of 23% beginning December 1, 2010, unless Congress once again intervenes as it has since 2002.

    Current law requires that CMS adjusts the Medicare physician fee schedule payment rates annually based on an update formula, which requires application of the sustainable growth rate (SGR). The formula has provided negative updates every year since 2002, and each year the cuts have been averted by Congress. Earlier this year, Congress provided a 2.2% increase in payment for June 1 to November 30, 2010.

    This begs the question: Why not fix the flawed SGR formula! A new payment system incorporating both the cognitive and procedural sides of medicine and includes quality measures that motivate, rather than force, providers to provide efficient care is both essential and would be timely. This new system should be independent of AMA's Relative Value Scale Update Committee, or RUC, and should contain adequate checks and balances rather than relying solely on an independent payment panel.

    Under the Patient Protection and Affordable Care Act (PPACA), the 2011 Medicare physician fee schedule implements provisions to expand beneficiary access to preventive services.¹ Medicare will cover certain preventive services that no longer will require out-of-pocket patient payment, including screening mammography and colonoscopy.

    The schedule also follows another provision of the PPACA to improve access to surgical services by providing a 10% incentive payment to general surgeons performing major surgery in areas designated by the Secretary as Health Professional Shortage Areas (HPSAs). It also allows physician assistants to order post-hospital extended care services in skilled nursing facilities. Another provision pays same Medicare rates to certified nurse-midwives as physicians. The final rule will appear in the November 29, 2010, Federal Register.

    Reference

    1. Final 2011 policy, pay changes in Medicare Physician Fee Schedule. Centers for Medicare & Medicaid Services Web site. Accessed November 19, 2010.

    Rahul Gupta, MD, MPH, FACP, is a Clinical Assistant Professor of Medicine at West Virginia School of Medicine; and Health Officer and Executive Director of Kanawha Charleston Health Department, both in Charleston, WV. He is an internist with a special interest in infectious diseases, HIV/AIDS, public health, and health policy.

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• Communicating Test Results (Sw Communicating Test Results (Swimming in the Quality Chasm)

  • From: bgottlieb
  • Description:

    I recently missed about 3 weeks of work for personal reasons. And my health center uses an electronic medical record (EMR) system to which, for better or worse (better for patients, worse for me), I have access 24-7. However, I was instructed to “REALLY TAKE TIME OFF. Someone will take care of your patients, review your results… anyway, when you’re distracted you’re liable to make important errors.”

    I am not indispensable. For the most part, my patients were taken care of and were fine during my absence. And it really was good to be freed up from patient care responsibilities. But when I returned, I realized that not everything was taken care of. The really urgent abnormal results were addressed—at least the first steps were taken. But in fact, many of the nonurgent abnormals were left behind, not to mention the normal results. I had to swim extra fast in order to catch up and keep up with the fast current of my resumed patient care responsibilities.

    In its landmark report, “Crossing the Quality Chasm, A New Health System for the 21st Century,” the Institute of Medicine established 6 aims for improving health care systems. The authors called for health care systems to be safe, effective, patient-centered, timely, efficient, and equitable.¹ If the IOM were to give me a report card for my communication of test results to patients in the past few weeks, I wouldn’t have received a passing grade; my personal quality chasm was very wide.

    I don’t have to be convinced that a physician’s handling of test results has major implications for patient safety, patient satisfaction, and avoidance of diagnostic errors. While many factors contribute to diagnostic error, it turns out that systems factors surpass cognitive errors on the part of physicians as well as so-called “no-fault” errors in which medical knowledge was insufficient to prevent the error.² Some sort of problem in handling test results is the most common systems problem contributing to diagnostic error. So lacking a clear system to handle test results in my absence was probably more dangerous than my presence might have been—even if I were very distracted. This is not good news.

    Luckily, most of my abnormal test results were handled appropriately, and in a relatively timely manner. Within a few days I caught up with some of the loose ends. No major harm seems to have occurred. However, my normal results were untouched. Pap tests, mammograms, glycosylated hemoglobins, lipid panels. How much does it matter that they get communicated?
    According to Boohaker, it is important to communicate patients’ normal as well as abnormal results.³ Those who don’t receive test results are less “activated,” less adherent, and, not surprisingly, have poorer outcomes. The IOM cautions strongly against the “no news is good news” approach to test results and encourages communication of all results as the standard.

    Electronic medical records have certainly made it easier to manage test results. However, Wahls and others warn that high rates of missed or delayed review and reporting of test results occur even when EMRs have advanced systems for flagging results to physicians and organizing results according to degree of abnormality.^4,5

    So, what does this mean for me? I typically spend more than an hour a day reviewing test results, communicating them to patients, and arranging the next diagnostic and therapeutic steps. It turns out that I am not unique. Poon, et al surveyed 168 internists about their practices for reviewing test results.⁶ Physicians with EMRs spend an average of 37 minutes per half day spent seeing patients reviewing and managing test results.

    Our EMR has the capacity to generate letters to patients. However, I rarely make use of this feature. Even though the letters can be written in both English and Spanish, many of my patients read at a third-grade level or lower, and their health literacy is also quite low. Often when they receive a letter announcing normal results they schedule an appointment—panicked that something is terribly wrong. They fear any letter that looks “official” because in their experience, official means bad news.

    So, for the most part, I call my patients. I have to say that they love it. LOVE IT. They are surprised and honored that I call them. If they have any questions, I can answer them right away. If there are misunderstandings, I can clear them up without generating unnecessary visits and phone calls. Activating patients? I never called it that, but when my patients say “Oh—my cholesterol is normal, so I can stop the medicine,” I can encourage them to keep on taking their medication because it is working. Or when I report a normal Pap test, I can remind them when their next one is due. To me, this is the meaning of the IOM’s 6th aim—that health care must be equitable, specifically, that quality “doesn’t vary because of personal characteristics such as ethnicity, geographic location or socio-economic status.” This letter-generating enhancement of our EMR doesn’t provide equity. I have to do that on my own.

    However—doing this is very time-consuming. And, one might argue, not the best use of my expensive time. I agree. But I haven’t found an alternative strategy, and even if I did, it would likely require a person in addition to information-systems changes. Maybe that person will eventually be part of the Medical Home team, but right now that person is me.

    Yet, even with my system, who is to say that I don’t miss important results or cause medically-significant delays in reviewing and acting on results? In Poon’s study, 83% of respondents reported at least 1 test result in the previous 2 months that they wished they had known about earlier. Eighteen percent of respondents had 5 or more such delays.

    Wahls points out that the handling of test results is complex and likely requires innovations on multiple levels, including information technology, clear policies and procedures to address predictable gaps such as absences, and activating patients’ expectations of receiving test results as a fail-safe. One of the strategies for “activating” patients is to provide direct access to their own test results through the electronic record. This is not new—but it is new for my health center.

    There is no doubt that EMRs have improved patient care in countless ways. However, I am a bit wary: So far, each enhancement to our EMR (including the EMR itself) has added to my work. Patient access to parts of the electronic record raises particular challenges when the patient population has low literacy and limited access to computers.

    So, with any new enhancement, I ask: Will this enhancement be a good thing or a bad thing for my patients? Will they acquire the skills and access that this enhancement requires, or is it one more thing that will bypass them? Is this enhancement guided by the goal of equity, or does this strategy preclude other potential strategies that might have been more equitable, but have been put aside in favor of this? Or will I, and others who care for poor and low literacy patients continue to have to find our own ways of ensuring equity and closing the quality chasm?

    References

    1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press, 2001.
    2. Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005:165:1493-1499.
    3. Boohaker EA, Ward RE, Uman JE, McCarthy BD. Patient notification and follow-up of abnormal test results. A physician survey. Arch Intern Med. 1996:156:327-331.
    4. Wahls T. Diagnostic errors and abnormal diagnostic tests lost to follow-up: a source of needless waste and delay to treatment. J Ambul Care Manage. 2007;30:338-343.
    5. Singh H, Thomas EJ, Sittig DF, et al. Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain? Am J Med. 2010;123:238-244.
    6. Poon EG, Gandhi TK, Sequist TD, et al. “I wish I had seen this test result earlier!” Dissatisfaction with test result management systems in primary care. Arch Intern Med. 2004;164:2223-2228.

    Barbara R. Gottlieb, MD, MPH, is Assistant Professor, Harvard School of Public Health; Associate Professor, Harvard Medical School; and as Associate Physician, Brigham and Women’s Hospital, and Faulkner Hospital, Boston, Mass. She is a primary care internist practicing in the Brookside Community Health Center in Jamaica Plain, Mass, with special focus on women’s health.

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• Doctor-Patient Communication a Doctor-Patient Communication and EMR: Benefits of Technicians as Scribes

  • From: mpacker
  • Description:

    In a recent article, Pauline Chen, MD, discusses some of the challenges of maintaining and optimizing doctor-patient communication with the introduction of electronic medical records (EMR).¹ She cites a recent report from The Center for Studying Health System Change that raises the concern EMR systems may both “help and hinder” patient communication.²

    In ophthalmology, there has been a long-standing practice of utilizing scribes in the exam room to improve efficiency and to permit the physician to speak directly with the patient without having to interrupt the dialogue to create documentation. Prior to implementation of our EMR System for Ophthalmology (GE Centricity), we did not employ scribes, but we realized that the requirements of on-screen documentation would require the physician to sit at a desk, with his back to the patient, typing. To avoid that situation, we decided to train our technicians to serve as scribes (rather than dictate to voice recognition software or hire a couple of new full time employees to work as scribes).

    I see important benefits coming from having our technicians work as scribes.

    Improving Quality of Care

    The scribe serves as a second professional in the exam room, paying attention to both the doctor and the patient, while keeping a record of the interaction. When I dictate to the scribe, I am reformulating the patient’s description of his or her symptoms, and I am pushed to be concise and correct to simplify the scribe’s task and make the medical record clear The scribe who is paying close attention will often ask me a question to clarify my meaning, and this helps prod me to be both more specific and more accurate (especially regarding symptoms, findings, and diagnoses).

    In this way my interaction with the scribe improves both the quality of care and of the medical record. In addition, the scribe may pick up on something the patient has said that I have missed, increasing the likelihood that we will correctly diagnose and treat the problem. Sometimes the scribe will appropriately suggest a test or procedure (“Do you want an HRT with that visual field?”) which I have omitted. Occasionally, the scribe’s intuition about a particular patient’s concerns will help to move the decision-making process forward. Finally, the scribe serves as witness to the interaction in the exam room and makes sure that the conversation is correctly represented in the medical record.

    Focus and Efficiency

    When the scribe is entering data and recording my interaction with the patient, I am free to focus entirely on the patient. Lots of important information gets transmitted because I don’t have to try to do two things at once, that is, talk to the patient and fill in the form simultaneously. I can take my time to explain the problem and treatment plan, feeling confident that the important information is getting where it needs to go—in the record.

    There are several ways in which we are realizing the efficiency gained by techs functioning as scribes. First, data is entered at the same time the history and exam are performed. This process is faster than my performing the exam and then entering the results. Second, if a question arises during the exam (“What is the wearing Rx for the ‘old’ glasses she likes best?”), the scribe can take charge of getting the answer. This occurs commonly with lab results, with omissions or errors that are noted in the work up, with insurance information, with communications with other doctors’ offices, with scheduling. Third, once I am done communicating with the patient, the scribe can finish up the medical record, fax the prescriptions, or do whatever else is needed so that I can move on to the next patient (also, in the less-usual situation where additional information is needed, the tech can find me and carry an answer back to the patient).

    Learning by Listening

    The tech/scribe has an opportunity to learn a great deal from listening to my explanation of diagnoses and treatments for multiple problems. The tech/scribe who pays close attention will recognize the indications for each of the different refractive procedures we offer, including presbyopia-correcting IOLs (and the reasons one type is recommended over another for a given patient). He or she will learn about the benefits and risks of all the procedures we offer and will understand the process of communicating these to the patient.

    There are times of stress in the doctor-patient relationship (for example, when a difficult diagnosis must be discussed, or when a complication has occurred and must be addressed) when learning to be present while continuing to function represents an incredibly valuable experience that is really a part of the best medical training. There are also times of joy and laughter (following great surgical results, or when empathy is received)—these times are a great reward for all of us for doing our work well. These opportunities for education and growth are a direct result of working as a scribe.

    Patient Benefits

    There is a benefit to the patient also, not only from all the preceding factors but also from the fact that the particular tech/scribe who was present during the most recent exam has a thorough understanding of that patient’s situation. He or she can now be a resource for phone or e-mail questions—as well as a familiar and friendly face when the patient returns.

    Through this process of scribing, we are all sharing much more with each other than we did previously. My therapeutic relationships with my patients have become fully transparent to the tech/scribes—and the working relationships between the tech/scribes and me have become transparent to our patients. This heightened visibility creates an incentive for all of us to be our best selves, always. Our work environment encourages us to grow personally and professionally and to take on important challenges in our lives and our work. For all these reasons I am impressed by the benefits of having techs function as scribes.

    Incidentally, this model is available to physicians in any specialty. In fact, my own primary care doctor utilizes scribes in a similar manner.

    References

    1. Chen P. An unforeseen complication of electronic medical records. New York Times. April 22, 2010. http://www.nytimes.com/2010/04/22/health/22chen.html?src=me&ref=health.
    2. O’Malley AS, Cohen GR, Grossman JM. Electronic medical records and communication with patients and other clinicians: Are we talking less? (Research Briefs). Center for Studying Health System Change. Issue Brief No. 131. http://www.hschange.org/CONTENT/1125/

    Mark Packer, MD, FACS, is Clinical Associate Professor, Casey Eye Institute, Department of Ophthalmology, Oregon Health & Science University School of Medicine, and in practice with Drs. Fine, Hoffman & Packer in Eugene, OR. He serves on the Cataract Clinical Committee of the American Society of Cataract and Refractive Surgery (ASCRS). In 2005 he was elected to membership in The International Intra-Ocular Implant Club.

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