Medicare Payment Figures Released

Center for Medicare ServicesThe Center for Medicare Services (CMS) parent organization of the Medicare program, released detailed raw data showing how much providers of Medicare services are paid. For many years, hospitals and physician organizations have battled to keep this information private from the media, the public and private health insurance companies. As a citizen I have no problem with transparency, but if in fact we are asked to show our payments from Medicare then I believe every other individual and business
should be required to have their federal payments revealed to the public and media as well.

The data revealed that a physician in West Palm Beach, who treats diseases of the eyes in the elderly, received 21 million dollars from Medicare during the time period reviewed, leading the country in individual payments. That physician claims that most of the payment was for a drug called Lucentis injected into the eyes of seniors with macular degeneration a potentially sight ending disease. The problem is that other experts claim that a less expensive drug, injected into the eye produces equal or better results for far less cost. If the less expensive drug produces equal or better results then why is Medicare still paying for Lucentis, except in cases where the patient is allergic to the cheaper alternative or where it has not worked? CMS has the ability to control its payments for ineffective products. It just chooses not to do so. The NY Times made a big splash headline of the fact that this physician made a sizeable political contribution to a political party and then asked elected officials to look into why he was being singled out for repeated Medicare audits? Yes Medicare has the right to review each chart and determine if the treatment was indicated, if it was provided, if it was documented and then billed per their extensive rules and regulations. CMS makes the rules. If the physician follows those rules then it is inappropriate to slander him and accuse him and ask the tabloids to do what CMS could not do because the physician was in fact playing by their rules!

At the same time that CMS released this data, organized crime continues to profit from Medicare fraud in south Florida, particularly in Dade and Broward Counties because it is less risky to commit Medicare fraud than it is to run drugs, prostitution, human trafficking and loan sharking. Maybe CMS should be trying to stop the flow of low hanging criminal fraud rather than releasing data on provider payment. As the storm clouds gather over the use of this data, ObamaCare seems to have reached its enrollment goals despite major startup problems. Despite this, Kathleen Sebellius, the CMS director resigned. Do you think it had something to do with the inappropriateness of the payment data release and the ultimate consequences?

Geriatric Fellowship Program with Model Senior Citizen Home for the Aged Needed

Nursing homeI have practiced general internal medicine and geriatric medicine in the South Palm Beach County, Florida area since 1979. I have seen the growth of the medical community from a sleepy seasonal coastal distribution of hospitals east of I-95 to a sprawling plethora of corporate and not for profit facilities sprouting in areas of population growth. While cardiac, stroke and trauma centers have evolved to meet the needs of the community; there has been no development of state of the art care for our aging and infirm seniors.

Yes there are many skilled nursing facilities in the area receiving patients from local hospitals following an acute illness or injury and attempting to rehabilitate the patients so they can eventually resume their lives. These facilities are paid primarily with Medicare funds if the patient has spent three nights in the hospital. The staffs of these facilities are numbered based on federal and state requirements. It is not unusual to see one registered or licensed practical nurse with a patient load of 20 or more patients. The nurses are assisted by aides, many of whom are paid minimal wages and who lack the language and training skills to recognize changes in their patients’ health conditions until those conditions have advanced to a critical level. They are not able to care for many of the simple day to day medical emergencies that we deal with at home on a daily basis such as cuts and abrasions, simple upper respiratory tract or gastrointestinal infections. Their mantra is “call 911 and send them to the ER while we copy the chart for transfer “(not always in that order). They are doing what they are told to do by administration and legal counsel and, frankly; their training and staffing does not allow them to do much else even if their hearts and souls feel differently.

We need the FAU Charles Schmidt College of Medicine or the University of Miami Miller School of Medicine or Nova Southeastern School of Medicine to partner with the Lynn School of Nursing at FAU and organize a geriatric fellowship program in medicine, nursing and care giving. The program would be taught at a model senior geriatric care center staffed by medical students, interns, residents, fellows in geriatrics, nursing students and graduate nursing students plus appropriate representatives of the other allied health supportive fields such as physical, occupational and speech therapy, nutrition and dietary and social services. Funding would come from philanthropic donors, federal and state grants, Medicare and Medicaid funds. The goal would be to train care givers to go out into the community and raise the bar and standard of care available to our senior citizens requiring acute rehabilitation or chronic custodial care while providing a local example of how excellent care can really be delivered. By raising the bar locally at a model facility we will be raising the bar throughout the region.

Is that Z Pack for the Cough Safe? Do Antibiotics Trigger Arrhythmias?

Azithromycin“Hello Dr Reznick, this is JP, I have a runny nose, a cough productive of yellowish green phlegm, a scratchy throat and I ache all over. My northern doctor always gives me a Z Pack or levaquin or Cipro when I get this. I know my body well and I need an antibiotic. Saul and I are scheduled to go see the children and grandchildren next week and I want to knock this out of my system. Can you just call in a Z-Pack? I don’t have time to come in for a visit.”

This is a common phone call at my internal medicine practice. Despite the Center for Disease Control and the American Academy of Infectious Disease Physicians running an education al campaign on the correct use of antibiotics, patients still want what they want , when they want it. The Annals of Family Medicine , March/April issue contained a study by G. Rao, M.D., PhD of the University of South Carolina in Columbia which examined whether a Z Pack (azithromycin) or a fluroquinolone (levaquin) can cause arrhythmias and an increased risk of death. Their study was a result of a 2012 study in the New England Journal of Medicine that proved that macrolide antibiotics were associated with a higher cardiovascular death risk and rate than penicillin type antibiotics such as amoxicillin. To examine this issue closely, Rao and associates examined data from U.S. veterans who received outpatient treatment with amoxicillin (979,380 patients), azithromycin (Z Pack 594,792 patients) and levofloxacin (levaquin 201,798 patients). These were patients in the VA health system between 1999 and April 2012. Their average age was 56.5 years.

The patients were prescribed the antibiotics for upper respiratory illnesses (11 %), chronic obstructive pulmonary disease (14 %) and ear- nose and throat infections (29.3 %). The azithromycin was administered as a Z Pack and the risk of an arrhythmia or cardiovascular death was increased for the 5 days the patient took the medication. For every million doses of azithromycin administered there were 228 deaths at five days and 422 at 10 days. For levaquin there were 384 deaths at five days and 714 deaths at 10 days per million prescriptions administered. Ampicillin showed far lower numbers with 154 deaths at 5 days and 324 deaths at 10 days per million prescriptions.

The overall risk of arrhythmia and cardiovascular death was quite low with all the medications but clearly levaquin carried a higher risk than azithromycin or amoxicillin. The risk of arrhythmia with levaquin was about the same with azithromycin.

This study points out another danger of taking antibiotics inappropriately or indiscriminately. We usually point out the dangers of antibiotic resistance and antibiotic related colitis when explaining to a patient why we do not want to prescribe an antibiotic when none is warranted. We can now add arrhythmias and sudden cardiac death to the list. This doesn’t mean we shouldn’t take an antibiotic when appropriate. It does mean we may want to avoid certain antibiotics in patients who have cardiovascular risk factors.

Glucosamine Study: “It Doesn’t Work”

C. Kent Kwoh, M.D., of the University of Arizona in Tucson reported results of a study to examine whether individuals who take glucosamine showed evidence of structural benefits in the treatment of their knee arthritis on MRI scans and in biochemical markers of cartilage deterioration. The study appeared in the online version of Arthritis & Rheumatology.

GlucosamineThere is a big retail market for glucosamine with more than one in ten U.S. adults using it for relief of arthritic pain. Many studies have been done but most were sponsored by manufacturers of glucosamine so the results are felt to be reliable. Worldwide sales of glucosamine top $2 billion dollars per year.

To evaluate the substance, Dr. Kwoh found 201 volunteers from his community with chronic knee pain. The patient’s mean age was 52 years old. More than 50% were women. Their body mass index averaged 29kg/m2 indicating they were not grossly overweight. They were randomized and blinded into two groups one receiving 1500mg of glucosamine hydrochloride (Reganasure) or a placebo in a 16 ounce bottle of a diet beverage. They then followed the patients for six months recording their pain evaluations, their changes on MRI images of their knees and noting any difference in the levels of C-terminal telopeptide of type II collagen – a marker of collagen deterioration. The results showed no differences between the glucosamine and placebo group.

Joanne Jordan, M.D., Chief of Rheumatology University of North Carolina noted that the study showed that glucosamine at this dose and for this length of time does not alter or help arthritis sufferers. “Nobody wishes it worked more than me.” said Nancy E Lane, M.D., director of the Center for Musculoskeletal Health at the University of California Davis in Sacramento. “It doesn’t work. There’s a group of patients who get a reduction in pain when they take glucosamine because glucosamine is a sugar and sugars can be analgesic to some people.”

No one has shown that glucosamine is harmful to anyone. It would be helpful if the study ran for more than six months since arthritis is a long term episodic disease. The investigation of supplements and alternative treatments is long overdue so this scientific study is welcome. It just needs to be continued for a longer period of time to satisfy those who use the product and have gotten relief.

New Knees and Hips Cut Heart Risk

Heart DiseaseAt the annual meeting of the American Academy of Orthopedics in New Orleans, Bheeshma Ravi, M.D., an orthopedics resident at the University of Toronto, reported that patients who underwent knee and hip replacements were able to dramatically reduce their risk of a heart attack or stroke over a seven year period. He followed 153 patients who were high risk for cardiovascular disease and noted the major risk reduction.

Some of the improvement in risks were assumed to be due to the increased mobility and increased activity the recipients were able to enjoy. The increased physical activity improves cardiac health. While physical activity is one explanation, the reduction in pain, stress, use of painkillers and inflammation is another set of potential reasons. With pain comes use of more nonsteroidal anti-inflammatory medications which have been implicated in the development of acute heart attacks.

In our medical practice we often see senior citizens who are healthy enough to undergo a joint replacement but are too fearful to proceed with the surgery. This particular study provides additional evidence that replacing the inflamed joint and resuming activity is the correct choice to make.

The Business of Medicine Should Not and Can Not Replace Care and Compassion

Compassionate CareWell over a year ago I advised my 80 something year old patient and her children that due to progression of her Parkinson’s disease, and her frail nature, she needed a higher level of assistance and care if she wished to remain in her home.  She was extremely unsteady walking and several courses of physical therapy had not improved the situation. The patient was feisty and would only allow help to come for 4 hours per day despite having a long term care policy that paid for significantly more.  She lost her balance recently, fell and landed on her back. She could not get up or get to a phone or her alert bracelet and was found seven hours later on the floor by her aide arriving for work.  In the Emergency Room x-rays revealed several acute fractures of her vertebrae that accounted for her severe pain with movement and inability to stand, bear weight or walk.

I hustled over to the ER and examined her and called the interventional radiologist to see if he could perform a procedure called a kyphoplasty that would cement the fractures and remove the pain. It was early Friday afternoon and the traditional back specialists were unavailable until the next day.  The radiologist came promptly, was professional and very pleasant explaining that he could do the procedure but because she took a baby aspirin for prevention of stroke, he would not perform it until the aspirin wore off in 5 – 7 days because of fear of excessive bleeding around the spinal cord.  He suggested we send her home with pain medications and round the clock assistance or keep her in the hospital until the aspirin wore off and he felt comfortable performing the procedure.  He was courteous and a credit to any profession. 

Since the patient was in great pain with any movement, I chose to admit her to the hospital while we sorted things out.  I admitted her as an inpatient because she is extremely elderly and frail with medical conditions that led to this injury which an expert had just told me required surgery to fix. She could not walk or transfer to a chair or wheelchair to get food, water or get to the bathroom. She had no arrangements for additional help at home to assist her. She could not, in my professional opinion, go home safely at this point.  

The next day I was making rounds late in the day for me at noon, reviewing the situation with the patient and her son when the physician’s assistant (PA) for the back surgeons, Andy, walked in and introduced himself. They had not seen her Friday evening or Saturday morning and this was their first contact with the patient.  My consult request and phone call had been quite clear. I wanted to know how they viewed the injury and what options did they feel were best to fix the problem. I additionally asked them how their approach would differ, if at all, from the approach of interventional radiology.  I had seen Andy around the facility and said “hello” but never formally met him so it was an introduction for me as well. 

“Hi, my name is Andy, and I work for Doctors Y and Z.  We have a little problem with your insurance.  You have a Medicare Advantage plan and we are not part of that plan. Most of the time, about 95% of the time, we eventually get paid for our services but we need to know how we will get paid for performing a procedure on you to fix your back before we proceed further. In these situations we usually ask the patient to pay the bill up front ($1000 – $1200) and then we submit the charges to your insurance company. If we get reimbursed from the insurance we return the money to you.”  

I took a deep breath and wondered if maybe I was overreacting to the brusque inappropriate presentation to a groggy senior who had been given a narcotic 30 minutes before for pain and was really in no condition to listen to any presentation or sign away informed consent.  I cut Andy off in the middle of a sentence and reminded him that I had requested an opinion. The son, an attorney by trade took up the fight and reminded the PA just how inappropriate his initial remarks were and that in this case money was not a problem but the manner of dealing with an elderly confused patient was.  I played mediator at this point and got the PA to explain that his employers had done several thousand of these procedures and handled many more complications than most interventional radiologists and that their success record spoke for itself.  He outlined a slightly different approach and once we got him talking about the reasons for his invitation onto the case, justified calling his group.

I am all in favor of physicians being paid for their professional services. This could have been handled differently by calling me first and informing me that they had concerns about payment and insurance and letting me address the issues. It could have been handled far gentler by answering the questions asked first and suggesting options and then reviewing the problems with the insurance. Had the gentleman performed a history and or exam rather than rely on the ER PA’s evaluation the day before, he would have seen that the patient was not in a position to comprehend what he was saying or sign for a procedure.  

This is not a criticism of PA’s or Nurse Practitioners. It is a criticism of any practitioner who does not answer the questions asked by the referring physician or question the referring physician about payment before arriving for the consult if they have questions about getting paid for their time and expertise.

The post script is that the son wisely chose to use this group based on their talents and experience and put aside the rude and insensitive communication by the PA. The surgery went well and the patient will go home after spending three nights in the hospital. 

There is still one obstacle to overcome. The hospital ignored my written order to make her status inpatient and made her status observation which will prevent her from receiving any post-surgery therapy or care which is paid for by her insurance. I will fix that. Keeping the phone number on my phone contact list of the Office of the Inspector General who investigates Medicare irregularities opens doors in situations like this. It does not change the fact however that as practitioners we need to be much more thoughtful when we discuss financial issues before medical issues if we wish to continue to be considered a profession rather than another business.

HDL Cholesterol: The Good Cholesterol Can Go Bad

CholesterolWhen discussing lipids and cholesterol the public, in particular, has been educated to the fact that the cholesterol is divided into several different types based on where it settles in a test tube after being spun in a centrifuge. The good cholesterol or HDL (high density lipoprotein) is said to be healthy and protective while the LDL (low density lipoproteins) are felt to be detrimental to your health. For years now we have been striving to lower the LDL cholesterol by eating correctly, exercising and when necessary taking medications such as statins.  At the same time we are trying to raise our HDL, or protective cholesterol, by exercising.  The higher your HDL cholesterol is, and the lower your LDL cholesterol is, your risks of not having a cardiovascular event improve.

In reality we know that HDL cholesterol carries bad cholesterol away from the blood vessel walls and deposits it in the liver where it is broken down and removed.  HDL is like a convoy of trucks ferrying your cholesterol away from vital places. The LDL cholesterol does just the opposite, carrying unwanted lipids to the vessel walls and depositing them there. 

 Just when we were getting comfortable with this concept, researchers at many institutions were able to break the LDL or bad cholesterol down into even more discrete groups. Apparently the large fluffy type of LDL is now considered beneficial. At the same time they have broken the HDL or protective cholesterol down into smaller divisions with some types being “broken” and causing inflammation in the artery walls leading to heart attacks and strokes. 

 Dr. Stanley Hazen, MD of the Cleveland Clinic’s Lemer Research Institution is one of the cardiologists promoting the concept of existing “broken” HDL which is damaging to our vessels and bodies.  Hazen’s research shows that in people with heart disease, about 1 in 5 HDL particles in the artery wall are dysfunctional.  People who have more of this dysfunctional HDL are at higher risk of heart disease, independent of the well-known risk factors such as age, diabetes, smoking and blood pressure.  This dysfunctional HDL is very hard for a lab to detect. 

 Dr. Hazen was part of a team that developed the MPO or myeloperoxidase blood level as a marker of plaque buildup in artery walls as a result of dysfunctional HDL and other risk elements.   High myeloperoxidase levels are associated with inflammation and damage to the vessel walls resulting in increased risks of heart attack and stroke.  The MPO test is licensed and copyrighted to the Cleveland Clinic and only available through the Cleveland Heart Labs program.

 We offer the Cleveland Heart Lab panel of tests as part of the cardiovascular risk assessment we present to individuals who do not have cardiovascular or cerebrovascular disease.  It is the only panel of tests that offers the Myeloperoxidase Level.  If interested please ask about this panel at your next visit.

Follow

Get every new post delivered to your Inbox.