Most Recent Blog Posts

• Why Health Care Reform May Fai

  • 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

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• Asthma Patients: Do They Take

  • From: dgianakos
  • Description:

    Not according to a recent study in the Mayo Clinic Proceedings.¹ In an observational study performed 2003-2005, good adherence was defined as taking 80% of prescribed doses of inhaled steroids.

    3.4% of asthma patients met good adherence criteria.

    3.4%!

    Note: The study involved patients covered by commercial insurance.

    What would the number look like for uninsured patients?

    I state the obvious: It’s time to change how we educate patients. It’s time to change systems of asthma care to address this remarkable problem.

    Reference

    Tan H, Sarawate C, Singer J, et al.  Impact of asthma controller medications on clinical, economic, and patient-reported outcomes. Mayo Clin Proc. 2009;84(8):675-684. doi: 10.4065/84.8.675.

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• Stimulus money: Get the facts

  • From: ElizabethWoodcock
  • Description:

    Looking forward to getting your hands on the $42,500 in federal stimulus package money for the EMR you’re buying? I’ve talked to too many physicians who seem almost bewitched by the idea of solving all of their information technology troubles with stimulus funds. Although the details of how money will be doled out are yet to be determined, there are several issues about which you should be aware:

    There are two pools of funds to which dermatologists will have access: Medicare (up to $42,500) and Medicaid (up to $63,750). The Medicare funds are capped at 75 percent of the Medicare allowed charges and doled out over five years. In order to access the $18,000 maximum initial-year bonus from Medicare, you’ll need to have billed at least $24,000 in Medicare allowed charges that year. If you’ve set your fees at 300 percent of Medicare, that translates into a minimum of $72,000 in gross Medicare charges. (Of course, fee setting varies by practice, and this example is for illustrative purposes only.) If you have less, you won’t qualify for the entire $42,500. To access to the $63,750 in Medicaid funds, you need to have at least 30 percent Medicaid patient volume (pediatricians are the only exception, but even they are required to have 20 percent). Importantly, you won’t have access to both funds – if you qualify for Medicaid, you can’t get the Medicare money too.

    The Medicare monies are for physicians only; your physician assistants and nurse practitioners won’t qualify for the stimulus money through the Medicare program. The Medicaid monies do include nurse practitioners, but, according to Section 4201, (3)(b) of the American Recovery and Reinvestment Act, physician assistants only qualify “insofar as the assistant is practicing in a rural health clinic that is led by a PA or is practicing in a Federally qualified health center that is so led.” 

    The Medicare ePrescribing program offers participating physicians a 2% bonus in the current year, as well as in 2010. If you decide to go for the EMR incentives, you give up access to the ePrescribing bonuses.

    Finally, it’s unlikely that either bonus—$42,500 from Medicare or $63,750 from Medicaid—could cover the cost of your entire system. Yes, you may be able to buy the software for less than either amount, but don’t forget that you’ll also need hardware, training, support—and most importantly, your time—to get your practice up and running with the EMR.

    Don’t get me wrong: I encourage you to implement an EMR. But, let’s stop believing in the myth that the implementation will be profitable for your practice because you qualify for the stimulus packing funding. Understanding the nuances of the stimulus package - and how it relates to your dermatology practice - will help you make better decisions as your practice embraces technology.

     

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• Dysfunctional Reimbursement: A

  • From: mpacker
  • Description:

    A friend of mine in London writes:

    “Hi Mark,
    Could you clarify something I was asked by a colleague yesterday, please? We were discussing anterior vitrectomy, and she asked if there was an additional surgical fee payable in the US for a pars plana approach above a limbal approach? I had no idea and wasn't keen to speculate! Thinking about it, I would assume that there is, and if so, then what order of magnitude is it? Thanks for your help.”

    Here is my answer.  First, a disclaimer: The reimbursement values for specific procedures vary with the Medicare “carrier,” that is, the company that administers the Medicare program in a specific region of the country. So, although there are 9 (I think) carriers in the United States, I am providing rounded-up dollar numbers based on our regional carrier in Oregon. Also, in this analysis, I am discussing surgeon fees only, not facility fees. (Reimbursement for the surgery center is separate, and does not really vary much in these different scenarios).

    The first principle of Medicare reimbursement is providing the CPT code. The second principle is “bundling” of certain codes together (only one code of several will be reimbursed if charged at the same visit). The third principle is that if two “unbundled” codes are charged on the same day, then the one listed first is reimbursed at 100%, the next is reimbursed at 50%. If a third code is listed, it gets 25%, and so on. (We always list the higher reimbursement first).  

    When a vitrectomy—any type—is unplanned (ie, occurs as a result of a complication during cataract surgery and was not listed as a planned procedure preoperatively), there is no reimbursement for it—zero. It is “bundled” with the cataract code (66984 for routine, 66982 for complex—meaning I used a capsular tension ring, iris hooks, or a pupil ring).

    Now, suppose I plan a vitrectomy (eg, I am going to place a secondary IOL for aphakia with vitreous prolapse). There are two ways I can do the vitrectomy.

    Scenario one—anterior vit: total $805

    66985 Secondary IOL $660 @ 100% = $660
    67005 Anterior Vit $410 @ 50% = $205

    Scenario two—PPV: total $1170

    67036 Pars plana Vit $840 @ 100% = $840
    66985 Secondary IOL $660 @ 50% = $330

    Suppose I want to decompress the vitreous in nanophthalmos prior to phaco in an eye with IFIS and then use iris hooks: total $1350

    66982 Complex Cat $930 @ 100% = $930
    67036 Pars plana Vit $840 @ 50% = $420

    Same scenario without iris hooks (Shugar-caine only): total $1175

    67036 Pars plana vit $840 @ 100% = $840
    66984 Routine Cat $670 @ 50% = $335

    It’s interesting—there is a higher value placed on PPV, but this has nothing to do with whether it is a “better” (ie, safer and more effective procedure) for removing vitreous in preparation for placing a secondary IOL. Similarly, I am paid more for using iris hooks, but in fact many eyes with IFIS do perfectly well without them, and the extra time involved in putting them in may eat up the extra reimbursement anyway. The reimbursements are determined by the RVUs (relative value units) assigned to each procedure—and these are determined by the work, practice expense, and professional liability related to the code, as well as the geography in which one practices.

    It would be nice if the personal financial incentives were actually aligned with better outcomes for patients. Doing that would require greater specificity in the coding, because an pars plana vitrectomy may be the best or only approach in one situation (vitreous decompression prior to phaco) but not as good in another (secondary IOL). In many cases, we don’t know which way is better because there is no definitive prospective randomized clinical trial data.

    Where do RVUs come from? The RVS Update Committee (RUC). Take a look at this page for more information: “The Resource Based Relative Value Scale.” The RVU is multiplied by a conversion factor each year to determine the reimbursement level for specific CPT codes. The Sustainable Growth Rate (SGR) formula used for determining the conversion factor is fundamentally flawed, and so each year leads to a significant drop in reimbursement. Every year Congress acts at the last moment to reverse the drop. This year, if allowed to occur, the reimbursement rate will fall over 20%.

    Congress may or may not permanently fix the SGR as part of “health care reform.” Some of us believe that the politicians don’t actually want to fix it because they raise huge amounts of money from the medical political action committees each year with the looming threat of whopping pay cuts. I wonder if anyone actually believes that Congress would cripple the health care system this year by removing all profit. To me, the whole process appears fundamentally dysfunctional.

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• Amyotrophic Lateral Sclerosis:

  • From: rkelley
  • Description:

    The various manifestations of what is termed “motor neuron disease” are primarily lower motor neuron involvement, primarily upper motor neuron involvement, primarily progressive bulbar paresis, or most commonly, the combination of upper motor neuron (long tract signs with spastic weakness and hyperreflexia) and lower motor neuron signs (atrophic weakness with fasciculations) often referred to as amyotrophic lateral sclerosis (ALS). The involvement of the bulbar musculature heralds a worse prognosis in terms of swallowing and speech difficulty as well as respiratory involvement. The diagnosis must be established with as much certainty as possible and involves not only a detailed history and thorough neurologic exam but also an electomyogram with nerve conduction velocities. This neurophysiologic study is vitally important and often requires considerable expertise.

    If there’s any question about the diagnosis, refer to a center with particular expertise in motor neuron disease because the implications of the diagnosis include death, often within several years from onset. However, this can very much depend on the manifestations and the level of supportive care warranted and requested. It is very important not to “give up” on the patient; monitoring the neurologic condition over time can provide considerable emotional support for both the patient and the family.

    The recent evidence-based review from the American Academy of Neurology (AAN) recommends considering riluzole to slow the disease progression, percutaneous endoscopic gastrostomy (PEG) to stabilize the patient’s weight and to prolong survival, and noninvasive ventilation (NIV) to treat respiratory insufficiency in an effort to prolong survival.¹

    In an accompanying article, the authors recommend referral to a multidisciplinary clinic should also be considered to improve the quality of life and to ensure that an extra effort is being made to address what can be considerable management needs. Refractory sialorrhea may respond to boxulinum toxin B or low-dose radiation to the salivary glands. Dextromethorphan and quinidine may prove helpful for pseudobulbar affect if approved by the FDA. The authors point out that the excessive fatigue which can be associated with use of riluzole, if counterproductive for the patient, should lead to consideration of its discontinuation. The authors also point out the importance of monitoring for cognitive and behavioral manifestations, including dementia. Despite the limited therapeutic options presently available for ALS, supportive measures and patients’ access to them must be kept in mind for this often devastating neurologic disorder.²

    References

    1. Miller RG, Jackson CE, Kasarskis EJ, et al. Practice Parameter update: The care of the patient with amyotrophic lateral sclerosis: Drug, nutritional, and respiratory therapies (an evidence-based review). Neurology. 2009;73:1218-1226.
    2. Miller RG, Jackson CE, Kasarskis EJ, et al. Practice Parameter update: The care of the patient with amyotrophic lateral sclerosis: Multidisciplinary care, symptom management, and cognitive/behavioral impairment (an evidence-based review). Neurology. 2009;73:1227-1233.

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• AACE/ACE Consensus Statement o

  • From: bgottlieb
  • Description:

    This will be a simple expression of gratitude. I have never been so happy to read a medical document as I was to read the recent AACE/ACE Consensus Statement on the treatment and control of type 2 diabetes.¹ [abstract]

    This 19-page document provides solid, practical, and simple guidelines for the evaluation and treatment of type 2 diabetes--a no-frills approach to this complex and prevalent disease. The panel consists of experts in the management of diabetes. They reviewed the available literature and established underlying principles for their recommendations and target levels for treatment endpoints. However, given the relative lack of randomized controlled clinical trials that evaluate combinations of medications, they also based recommendations on their extensive clinical experience, attempting to achieve consensus as much as possible.

    The authors make their underlying principles transparent and remain true to these principles:

    • Avoid hypoglycemia (the key guiding principle)
    • Lifestyle (diet and exercise) activities are the cornerstone of all treatment programs and should be encouraged at every opportunity
    • Fasting and postprandial control are treatment endpoints
    • Maximize safety and efficacy (safety and efficacy are valued over cost, since cost of medications is only a small part of the cost of care of type 2 diabetes)
    • Minimize weight gain
    • Consider all FDA-approved medication classes
    • Maximize simplicity of treatment regimens as much as possible
    • Anticipate the degree of patient adherence, and modify treatments appropriately
    • Consider cost of treatment to the individual and society (medications, monitoring, and the cost of complications)

    The treatment algorithm provides a useful guide to both the expert and the generalist. By focusing on the level of HbA1c and the expected lowering by particular drug classes, the provider knows what to expect and can provide realistic guidance to the patient as well. The recommendations include an aggressive, yet safe pace for lowering the HbA1c by monitoring every 2 to 3 months and stepping up treatment as indicated.

    The report is comprehensive. The provider is reminded to reinforce lifestyle changes at sentinel moments of treatment, such as when a new drug class is introduced. Similarly, the provider is reminded to reinforce the full range of risk reduction interventions: tobacco cessation, use of aspirin, ACE inhibitors or angiotensin receptor blockers, and statins. In addition, there is a brief review of the pharmacology of each class of drug and a practical guide to drug-drug interactions.

    Why am I so grateful? Not a clinical session goes by that I don’t have to face some sort of decision about diabetes treatment. However, the decision, the circumstances, the nuances are different for each patient. While the authors caution the practitioner to individualize treatment, this document provides a solid jumping-off point. I always tell my students that diabetes is a low-tech disease. What I mean by this is that diabetes is related to the most basic activities of life--what you eat and how much you eat, your exercise and physical activity, and the many social and economic factors that have an impact on these basic activities. Therefore, sadly, even with 8 major categories of medications and research and development seeking new and better pharmacologic pathways to exploit, the solutions to diabetes are, ultimately, low-tech solutions: lifestyle changes and treatment that is safe, effective, and sustainable. I now feel that I have a handle on how to achieve that low-tech objective with my diabetic patients.

    Reference

    1. Rodbard HW, Jellinger PS, Davidson JA et al. Statement by an American Association of Clinical Endocrinologists/American College of Endocrinology Consensus Panel on type 2 diabetes mellitus: an algorithm for glycemic control. Endocrine Practice. 2009;14:540-559.

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• Don’t Be Afraid to Refer Patie

  • From: bbarankin
  • Description:

    In my dermatology practice, I see many patients who are very frustrated with their primary care provider and vent to me how difficult it was to get a referral to see me. Although there is the gatekeeper value to primary care providers, it shouldn’t be a road block to referring patients whose medical condition is not improving. I have seen far too many patients who suffer with a skin condition month after month while various treatments are unsuccessfully tried at the personal and financial expense of the patient.

    I would argue that if the diagnosis is uncertain, the initial treatment has not worked, and/or the patient requests to see a specialist, the patient should be referred. I believe that prompt referrals in such situations are also medicolegally protective. Some of my most thankful patients are those whom I referred to a rheumatologist or other specialist.

    Although we are always trying to help our patients as best we can, we need to realize that there are others in our midst who may have more specialized training or more experience with certain conditions. In the end, it’s not about our egos, but rather what is best for the patient.

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• Patient Handout: Popliteal Art

  • From: JKintec
  • Description:

     

    Patient Handout: Popliteal Artery Entrapment Syndrome

    What is Popliteal Artery Entrapment Syndrome?

    ·      It is a very uncommon syndrome in which the major blood vessel in the back of the knee becomes compressed by the muscle or tendon in the calf. The compression of this blood vessel can create a complete blockage of blood flow to the lower leg.

    How do I know if I have Popliteal Artery Entrapment Syndrome?

    ·      You may experience cramping, numbness, or sharp pain in the lower leg and foot

    ·      The lower leg and foot may look pale and feel cool to the touch

    ·      Pain may be experienced when sitting, standing or walking for extended periods of time

    ·      Relief from pain is felt immediately after stopping the exercise

    How is it commonly treated?

    ·      In order to feel relief from the symptoms, surgery in strongly recommended.

    How do I know if I need surgery?

    ·      If these signs and symptoms persist for any extended period of time it is recommended that you go see your doctor.

    ·      Your doctor will be able to use a physical exam along with different imaging techniques to diagnose the syndrome and its severity.

    ·      Surgery is recommended for all but minor cases.

    Is surgery a good idea?

    ·      There are risks associated with any surgery, but according to medical literature there is a high success rate in which normal blood flow within the vessel can be restored and maintained.

    When Can I return to Everyday Activity?

    ·      Patients are typically discharged the same day as the surgery

    ·      You will be able to return to your daily activities, including work, about 3 weeks after surgery

    How do I prevent reoccurrence following surgery?

    ·      Following surgery and recovery, most patients showed no reoccurrence of signs and symptoms of Popliteal Artery Entrapment Syndrome.

    ·      Patient follow ups have been performed up to 8 years following surgery in which patients have been able to sit, stand and walk for prolonged periods of time without pain. 

     

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• YouTube and You

  • From: skern
  • Description:

    Should an OB/GYN send his patients a “friend request” to become a friend on his Facebook Page? A Harvard law professor recently reported that one of her friends had received such a request, and it made her extremely uncomfortable. She felt that her relationship with her doctor had been a professional one, not a friendship.

    Since you are reading about this on a blog, chances are you know about Facebook. For those of you unfamiliar with Facebook and the social networking phenomenon sweeping the country (e.g. those without teenagers), a “friend request” is an e-mail inviting you to access a person’s Facebook page. That page, created by the person asking you to become a “friend” could include information ranging from his baby pictures to his latest article in JAMA.

    Even though a Facebook page may be completely professional, the notion of being invited to be a “friend” connotes a degree of familiarity that some may consider unprofessional. Certainly, the OB/GYN’s patient did not understand that the term “friend” is a term of art associated with Facebook. Then again, would this patient have felt the same way if the “friend request” had come from her dermatologist or cosmetic surgeon? Would she have felt the same if she were younger and a regular user of the social network? Probably not.

    Forty years ago, physician advertising was illegal. Then, the US Supreme Court ruled that blanket restrictions on advertising violated the First Amendment. Since that time, advertising by physicians, hospitals, and other health care providers has become pervasive. Social networking, however, will pose new challenges with new rules for physicians and other professionals who embrace this medium.

    Businesses are making social networking sites and their own YouTube channels part of their core marketing strategy. “Tweeting” one’s daily activities has become part of the daily routine of elected officials, professional athletes, and CEO’s. Yet when physicians use these same tools, they encounter unique challenges, legal issues, and sensitivities.

    Since patient reaction to social networking efforts may vary dramatically from patient to patient and may also depend upon the specialty of the physician sending the message. Careful thought and some test marketing should precede any social networking activity—be it Facebook, Twitter, or even a practice Web site.

    Conveying important information to your patients is a service that most patients would appreciate. Letting them know, for example, that you’ve received a supply of flu vaccine and giving them your recommendation as to whether they should receive the vaccine can be a valuable service. Expansion of office hours, the introduction of a new physician, changes in insurance plans with which you participate, and other information concerning your practice can provide patients with information that may make your practice more attractive. Telling patients about what you learned at a recent medical conference can let patients know that you continue to update your knowledge base, that you work hard to stay at the cutting edge of medical knowledge, and that new technologies, new drugs, or new procedures may offer benefits not previously available.

    The manner in which that information is conveyed, however, is all important. You wouldn’t call a patient at work to chat about your recent medical seminar, no matter how interesting it may have been. Providing that same information through a social network may be viewed as similarly intrusive if not handled appropriately. As such, though the content of a Facebook page may be professional and informative, the very request to join as a “friend” could convey a message which is anything but professional. Often, it’s not what you say, but how you say it.

    Before you decide to enter the social networking market consider your patient population and your specialty. Ask your patients what they think of the idea. If they are receptive, initially send friend requests to a few select patients who you believe will be open to the idea. Have your office follow-up and see what kind of response you receive. If the response is favorable, consider first sending a note to your remaining patients letting them know that they may receive a friend request. Explain that the request is simply an invitation to access professional information that may be of interest to them, as a “friend of the practice.” By taking the time and effort to explain your purpose, you may avoid unintended negative reaction or even charges of unprofessional conduct.

    In addition to assuring that your patients are receptive to the idea of having your practice as part of their social network, it is equally important to assure that the content of your communication is appropriate. A number of hospitals, including some of the nation’s most prestigious institutions, have already recognized the benefits of these new methods of communication. Their Web sites include information for patients concerning their areas of specialty, awards they’ve won, and patient information ranging from directions to the hospital to information on cancer and heart disease. However, hospitals also have legal departments that review content before it is distributed through the web. Among the things they watch for is any potential breach of patient confidentiality and videos which may portray their physicians and employees in a less than professional light.

    For example, videos mocking patients or their complaints, videos of professionals drinking at social events, dressed in costume for a skit, or acting silly may be fine to share among colleagues. However, patients generally do not want to perceive their physicians in this way. Their vision of a physician is that of a consummate professional—a person they can respect, confide in, and trust. They don’t want physicians to be their drinking buddies!

    Maintaining patient confidentiality is another imperative. Pictures of patients, distributed without their consent, can violate HIPAA. Even pictures of a portion of a patient’s body, which do not readily identify the patient, can cause problems, if the patient realizes that the picture is of his body part, and he has not given his consent to its use.

    Physicians contemplating using social networks should keep certain guidelines in mind. Do not merge your personal social site with your professional site. Your personal site should be limited to your close friends and not be accessible to patients or others. Even then, remember that today’s friend could be tomorrow’s competitor. Don’t post anything on your personal site that you wouldn’t want your spouse or your employer to see.

    Your professional site should be just that—professional. Post your vacation photos on your personal site, not your professional site. Limit your professional site to medical and practice information that your patients can use to their benefit. Be sure that the information you provide is accurate and does not breach any patient confidentiality. And, be sure that it is tasteful.

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• Medicare Stops Payment for Con

  • From: ElizabethWoodcock
  • Description:

     

    As announced in the October 30, 2009 press release, “CMS is also finalizing its proposal to stop making payment for consultation codes…” CMS has increased the RVUs for new and established patients by six percent and for initial and subsequent hospital visits by two percent, thus making the change budget neutral for them.  Primary care physicians will benefit greatly from the increased RVUs for office and hospital visits; however, specialists who rely on consultation codes will take a significant hit to their bottom line, as the consultation codes paid far more than the new patient codes. Consultation codes have not been eliminated from the 2010 CPT® Manual, although new commentary has been added about “transfer of care”. You’ll need to check with your commercial payers to determine the status of reimbursement.

     

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• Post Weight Loss Converts To C

  • From: feplasticsurgery
  • Description:
    
    
    What need do weight loss adherents have of Tummy Tuck or liposuction?.
    
    “Indeed, many people after following a strenuous weight loss routine, although succeeding in losing weight are predominantly unhappy over the new shape their body has acquired”.
    
    After a rigorous regimen and succeeding in losing weight one thinks they would be happy. Not apparently. They succeed in losing the fat but after that they find that the skin becomes loose and begins to hang.
    
    “Once the fat disappears the skin does not automatically drape around your new body and you face a new problem that is excess skin. But procedures exist today said an Orange County Tummy Tuck specialist, where a tone can be acquired that is pleasant to the eye and the efforts of the weight loss are pronounced and made prominent”.
    
    Sometimes the body may not respond to weight loss techniques and fat may acquire at local pockets. Then a particular method or a mix of existing procedures including liposuction are selected to make one realize the full potential and reflect the results of his or her efforts said an Orange County Liposuction specialist.
    
    “It is one thing for one to lose weight and acquire a new body and it is another to keep it going through a healthy diet and continuous exercise. Ultimately the onus lies on the individual to keep his body fit and many procedures exist today for this purpose said a Newport Beach Cosmetic surgeon.
    
    An increasing number of women find it a convenient way to reshape themselves in a way which pleases them and their close ones too said an Orange County breast augmentation specialist.
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  • 3 weeks ago
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• Breast Augmentation: When Indi

  • From: feplasticsurgery
  • Description:
    
    
    When a relationship even if albeit a commercial one turns sour should one be indiscrete? The recent allegations and counter allegations of the contestant Prejean and the hosts of Miss California pageant only strengthen the adage that discretion is the best part of valor. Prejean was stripped of her title because of her controversial statements and the acrimony began between her and the hosts.
    
    “The hosts revealed the fact that she had a breast augmentation for which they are incurring the wrath of Prejean. I think it is more of a question of ethics”, said the Orange County breast augmentation specialist.
    
    It is heartening to know that breast augmentation is pursued by the glamorous.
    
    In recent times innovative procedures are being implemented in the field of liposuction. The beauty conscious would do well to keep abreast of the developments.
    
    Medical weight loss is fast finding its way into the terminology of the figure conscious said the Orange County Tummy Tuck specialist. “Now a days people are resorting to tummy tuck after first trying out medical weight loss where surgeons are playing more and more important role. The sheer multitude of recipes and experts are actually confusing the people”.
    
    “Liposuction is the younger cousin of tummy tuck and has its distinct role and necessity. Development in lasers is finding its way into liposuction where the accumulate fat is first melted before removal. The other methods of softening up the accumulated fat is by use of ultrasound in Vaser Liposelection and Body Jet Liposuction where jets of water are used”, said the Orange County Liposuction specialist.
    
    “Zerona is a procedure where laser rays are used without a surgical operation to melt the fat. The frequency of this treatment is about thrice a week but the procedure is still under study and is being evaluated”, said the Newport Beach Cosmetic surgeon.
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• Cosmetic Surgery : Discovering

  • From: feplasticsurgery
  • Description:
    
    
    Life would be meaningless if we do not search for youthfulness. That does not mean we do not accept the inevitability of the aging process. One is shocked when people go to lengths to decry “altering God given looks”. “Did anyone say you should not try to regain the looks of your past when it is feasible and affordable?” , said an Orange County Tummy Tuck specialist.
    
    “A mild harmless incision that disappears subsequently will leave you with radiance of look and happiness of feeling, , said a Newport Beach Cosmetic surgeon who has put many people through rediscovering their good looks.
    
    “The things some people do to discourage an innocent indulgence is equally hilarious. Like alternative methods like breast slapping which are ridiculous and scientifically or otherwise unproven. Modern breast augmentation has become available after detailed and deliberate scientific principles have been tested and put into practice said an Orange County breast augmentation specialist. “Some celebrities who take vicarious pleasure in announcing that they will not have this implant or that should realize it is a matter of choice for many. Today they may revel in the limelight but it is tomorrow which will test their resolve”.
    
    “Like all modern medical treatments that have made life easier to cope with, liposuction is an innocent expression of wanting to regain the past good looks that age tries to quietly take away”, said an Orange County liposuction specialist. “A variety of methods are available today for selection like surgery”.
    
    Ultimately one should look at the happy people.
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  • 3 weeks ago
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• Living Through an Epidemic

  • From: jscherger
  • Description:

    We have all read about epidemics.  History makes them sound like there was panic in the streets.  The Influenza epidemic of 1917-18 killed as many as one in four persons in many locations.  Truly devastating.  Then when you read things like the political history of the time, the epidemic is not even mentioned.

    We are now in an epidemic of H1N1 "swine flu."  On college campuses, 95% of students are infected and so are our schools.  Everywhere people are getting sick.  Fortunately, as of today (10/26/09), only 1000 persons have died in the U.S.  Life goes on.  I will head to work just the same as any day.

    As we live through this epidemic, there are two problems: the flu itself and the hysteria that some people get.  Emergency rooms are overcrowded.  Los Angeles County reports up to a 24-hour wait to be seen.  Unless you are really sick and need life support, how dumb is waiting 24 hours in an emergency room?

    I recently wrote a blog, "Getting Sick is Good for You," about the benefits of natural immunity.  I still maintain that the luckiest people today are those getting a mild infection.  I hope that I get a subclinical infection as many will.  Get long term immunity and never get sick!  Do we report how many people that is happening to?  I have received my seasonal flu shot and am waiting for my H1N1 vaccine, but I still hope I get a mild case that will give me the most protection for later exposure.

    We need balanced reporting of infectious diseases, including the benefits of milder cases.  I still remember the "chickenpox parties" of my youth to expose children to the illness so they could get the sickness early when it was less severe than in an adult.  I'm not sure those were wise, but I'm also not supportive of the panic and rush for drugs that a case of chickenpox causes today.

    We should be celebrating how mild this current epidemic has been to date, with appropriate recognition to the lives that have been lost, comparable to any peak flu season.  Our modern lifestyle, with clean water, adequate food, and sanitation go a long way in keeping these infections from becoming to severe in the population.  Things could get a lot worse, but I for one am not going to worry too much and will go about my business, including reassuring as many patients and families as I can.

  • Blog post
  • 3 weeks ago
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• Hooray for Herae: Software for

  • From: jbee
  • Description:

    I learned something today. We always attend our local Medical Group Management Meetings (MGMA) if we are in town. This one was great. The topic was office efficiency tools. We did a round table of managers who had experience with new things that help.

    Herae (sounds like her’ray), http://www.herae.com/, is a company that converts explanations of benefits (EOBs) into a consistent format and can allow you to do auto posting as you do with Medicare’s auto remittance software. This software helps you analyze the payment and saves you time otherwise spent copying what is on an EOB into your billing software.

    I also learned about Remit EZ Medicare software. It allows you to track an EOB in process before you get the check and creates an EOB with one patient on it so you can use it for billing secondary insurance and comply with HIPAA. And, it’s free from your Medicare vendor.

    Moral of the story? Join your local MGMA, go to the meetings, and stop reinventing the wheel.

  • Blog post
  • 4 weeks ago
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• Fatigue And You

  • From: jcopel
  • Description:

    Several years ago, as we all know, the New York legislature, acting in response to the death of Libby Zion, mandated work-hour restrictions for residents. This has been adopted nationwide and now applies to fellows in training as well.

    This week in JAMA, Rothschild and colleagues take a look at attending surgeons and complications after nighttime surgery.¹ The study [abstract] evaluated complications after surgeons and Ob/Gyns had performed surgery the previous night and calculated the time spent from the end of the overnight surgery until the start of the next day’s case as a crude measure of how much sleep the surgeon might have gotten. It’s not perfect, but you know if there was less than 6 hours between the two, that’s the most that the surgeon could have slept. We don’t know if there was a longer interval whether the surgeon slept or not, and that could have made the data less able to detect effects of sleep deprivation.

    It is clear to me that if we require 30-year-old residents to limit their hours, we really need to be consistent and do the same for older physicians. While I no longer take night call, the last few years that I did it was very obvious that I didn’t seem to bounce back from a bad night as quickly as I used to.

    So I think it’s time for us to take the plunge. It won’t be easy, especially for those in small group settings, but I predict that there will be more and more research in this direction, suggesting that fatigue is real, and that we have to get sufficient rest to take good care of our patients. It will be important for practices and hospitals to develop realistic and functional ways for handoffs to occur, since it’s also quite clear that the flip side of mandating rest periods is the need for more frequent handoffs. At the same time, air traffic controllers can hand of thousands of planes to each other every day; surely we can find a way to do safe and effective handoffs.

    In complicated issues like this, perhaps the simplest way to find the best answer is to ask what is best for our patients. A well-rested doctor is always the right answer to me.

    Reference

    Rothschild JM, Keohane CA; Rogers S, et al. Risks of complications by attending physicians after performing nighttime procedures. JAMA. 2009;302:1565-1572.

  • Blog post
  • 4 weeks ago
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• Medicare payment fix in the wo

  • From: MorganLewisJr
  • Description:

    A bill introduced last week in the U.S. Senate may eliminate the flawed payment formula used for physicians who accept Medicare patients.

    Senator Debbie Stabenow, (D-Michigan) introduced the “Medicare Physician Fairness Act of 2009” on October 13 which would terminate Medicare’s Sustainable Growth Rate (SGR), which is a component of the formula Medicare uses annually to calculate physician fee schedule. The SGR was intended to be a budgetary restraint on Medicare’s total expenditures to maintain budget neutrality. Every year since 2002, the SGR called for payment reductions. In 2003, Congress stepped in to avert those cuts and has repeated the intervention annually. Years of deferred cuts has created $245 billion in debt, according to the American Academy of Family Physicians. Without Congressional intervention, physician fees will shrink 21 percent in 2010.

    SGR reform was not included in the Senate Finance Committee’s massive health reform bill, which it approved last week, leaving many physicians concerned cuts would finally be enacted in order to pay for the legislation.

    Physician groups quickly embraced the bill.

    “Health care reform really does require that we address the flawed current formula for Medicare payments,” says AAFP President Lori Heim, MD, in a statement on the AAFP News Now web site. “This would give us the basis for that fix.”

    “There is widespread agreement that Medicare physician cuts will harm seniors’ access and choice of physician,” says American Medical Association President J. James Rohack, MD, in a statement. “Congress can no longer put a band-aid on the problem. As we undertake an historic effort to improve the health system, it’s time for permanent repeal of the Medicare physician payment formula.”

    There has been no formal action on the bill since last week. Senate Democrats were scheduled to have a cloture vote on October 19 – a move that would limit the debate of the bill and avoid a Republican filibuster – but instead lawmakers agreed on October 16 to work out a compromise.

    UPDATE (10/21): The “Medicare Physician Fairness Act of 2009” has been shelved indefinitely today as Senate Democrats could not land the 60 votes necessary to move the bill forward.

     

     This afternoon, the AMA issued a statement:

    “The AMA is deeply disappointed that the Senate today blocked consideration of S. 1776, legislation … Permanent repeal of the Medicare physician payment formula is essential to comprehensive health system reform,” Rohack is quoted.

    SGR reform may see new life during debate over the health care reform legislation, or afterwards, according to Senate Majority Leader Harry Reid (D-Nevada), who indicated that next year’s expected 21 percent Medicare physician fee cuts will likely, again, be averted.

  • Blog post
  • 4 weeks ago
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• Patients Complain? Thank Them

  • From: ElizabethWoodcock
  • Description:

    In difficult economic times, it seems like more patients are grumpy, if not downright irritable. Although many patients present valid complaints – a long wait or a rude receptionist, perhaps – some patients seem to just like to criticize just for the sake of it. Either way, how you handle complaints will form the patient’s impression of your overall customer service. On the one hand, you could respond with a rebuttal to the complaint – the wait wasn’t that long, the receptionist was just having a bad day – or, you can thank the patient.

    Thank a patient for complaining, you say? Yes, express gratitude: “Thank you for bringing that to our attention, Ms. Jones.” Style counts when handling irritated patients. Make eye contact and use their name. And, never, ever laugh, even if the complaint is ridiculous.

    For greater impact, follow through with an apology: “I’m sorry that we didn’t meet your expectations.”

    If time allows during an in-person contact, pull out a notepad and offer to write down the nature of the patient’s complaint so you can “review it with a supervisor.” After you document the complaint, ask the patient if he/she wants to be called by the manager about the situation.

    A ‘thank you,’ an apology and recording the complaint can transform a frustrated customer into one who walks away impressed with your practice.

    For more tips on customer service, see my column.

     

     

  • Blog post
  • 4 weeks ago
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• Cellulite and Liposuction

  • From: DrDavidAmron
  • Description:

    Ah, the old question of cellulite with liposuction, whether it improves or not. This is my feeling about it and my representation of cellulite with liposuction. Although there is definitely no guarantee that cellulite itself can improve with liposuction, typically if the liposuction is performed in a certain way, cellulite usually improves, although there is no guarantee. And what I mean by this is well-done superficial liposuction, which tends to loosen some of the fibrous bands occurring in the superficial fat layer which contributes to cellulite in women. Personally, I have never in 14 years seen cellulite get worse in my hands with liposuction. So, if it is done properly it is very likely the cellulite will not get worse. I would not necessarily expect it to get better, although usually it does if it is done properly. The way I represent it to patients is do not do liposuction for cellulite alone, but do it because you are trying to balance your body out and create a more proportioned shape. And if the cellulite improves, and usually it does, it is a bonus. So once again, it would be very unlikely for it to get worse if it is done properly. It may get better, but it may not. But, once again, you are not doing liposuction for the cellulite alone but target areas of genetic disproportion. With regard to swelling and pain, this still is a surgery and typically there is a little bit of soreness that can go on for several days or several weeks. In terms of the patients being healed up well enough to be able to get back into a bathing suit or go on a trip, typically it is three weeks. My point of when to do the surgery before a vacation would be three weeks prior. At that point, most of the swelling is down, all the bruising has gone away and typically any soreness has greatly subsided.

  • Blog post
  • 4 weeks ago
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• Massive data loss by insurer

  • From: ElizabethWoodcock
  • Description:

    Earlier this month, Blue Cross Blue Shield Association (BCBS) revealed that a laptop stolen from one of its employees in late August contained unencrypted identifying information for every U.S. physician contracted with a Blues-affiliated insurance plan.
    But wait — it gets worse. Out of the 850,000 physician records on the laptop, nearly 200,000 had used their Social Security numbers as a tax identification or NPI number.
    Although the BCBS plans were notified a week after the incident, there have been delays in notifying the physicians who were impacted. The association is offering a year’s worth of credit monitoring automatically for physicians whose Social Security numbers were in the file, as well as to any other physicians who request the service through their local BCBS plan.
    The potential problems that this data loss could cause are enormous, particularly for those of you who use your Social Security number as your tax ID or NPI number. Make it a priority to contact your local BCBS provider representative. Put your request for assistance in writing.
    Consider this a lesson for you and your staff. Never, ever transport confidential information on a laptop or USB drive. When and if you must work from home on the office network, be sure to have a secure, encrypted method for logging in. Follow other security rules, such as changing passwords regularly and never share passwords.

  • Blog post
  • 1 month ago
  • Views: 332