Addendum: “Why You Can Not Find a Doctor to Accept Medicare”

Center for Medicare ServicesOn April 14, 2015 the Senate, having returned from a recess, voted to repeal the SGR initiative thus halting a proposed 21% minimum payment reduction to health care providers (physicians). Under the new legislation sent to President Obama for approval, doctors will receive between a 0.5% to 1% annual increase in reimbursement through 2019. The measure proposes alternative pay structures which are designed to reduce overall health care costs and rate of health care cost growth. They involve paying one large entity which would then dole out pre-negotiated payments to its members delivering the services.

The American Medical Association as well as specialty medical and health groups are hailing this as a major victory for doctors and patients. I see it a bit differently.

Since 1977 the Congress of the United States has held practitioners at loaded gun point always threatening to reduce physician reimbursement without reducing physician costs or bureaucratic burdens in the least. Generations of policy advisors and elected officials have created a level of mistrust and uncertainty between themselves and providers while always painting the health care delivery teams as greedy money craving individuals more interested in their personal gain than the health of their patients. The result is that for years doctors have left the Medicare system and or retired early.

The current annual increase of up to one percent is accompanied by additional bureaucratic requirements having little or nothing to do with the doctor patient relationship. One percent will not keep up with the cost of inflation or the additional costs involved to meet the bureaucratic new requirements of CMS and policy wonks.

To hail this as a victory is like trying to sell Custer’s last stand at the Little Big Horn as a victory for the US Cavalry. The net result will be the destruction of small private practices, the growth of concierge medicine and the growth of enormous conveyor built corporate medical groups where patients are a product not a human individual.

Electronic Health Record System Down – Observations

EHROn Monday March 30, 2015 our Greenway Prime Suite electronic health record had a system wide failure at the level of the Edgemed Computer service center in New York State. It meant that I was back to using pencil and paper to interview patients and record the answers and physical findings. With much trepidation I began seeing patients with two sheets of white blank paper on a clipboard and my trusty BIC pen. To my surprise the sessions went by with ease. I was able to make much better eye contact with my patients, listen a bit closer and jot down the pertinent positive and negatives of the session to later enter into the computer record. My office visits are scheduled for 45 minutes each for routine follow up sessions and you need every second to be comprehensive and thorough and to check all the boxes and requirements imposed by government bureaucrats to comply with Meaningful Use and PQRS and Core Measure requirements. I found that without the computer it took at least ten minutes less time to see a patient and the visit was far more personal than with the magic box working.

Computerization was forced on physicians by the ARRA 2008 Congressional Law proposed and encouraged by the Bush administration to stimulate the economy and orchestrated further by the Obama Administration. Government grants and funds were set aside to computerize medical records, make the records more transparent and have data freely transmittable and reviewable from one system to the next. ARRA 2008 created a high tech committee which was funded at an extraordinary high salary level and staffed with the CEO’s and chief executives of the major health software manufacturing firms. If this sounds like asking the foxes to guard the hen houses you are beginning to get the picture. Their greed and self-serving interests led to multiple companies, with multiple products for sale most not designed or reviewed by practicing clinicians. Initially they were unable to communicate with any other competing systems and for the most part they still cannot. Interestingly when the 2014 Congress failed to refund the grants to the high tech committee this past session the CEO’s who ran it all resigned leaving the program rudderless.

The doctors and hospitals were promised a carrot at the end of the stick if you followed the ever changing rules but there was a financial penalty and reduction in reimbursement if you did not comply. The financial reward at the end of the stick in no way compensated an office for the work and trouble involved and was nowhere near the level of rewards the CEO’s who staffed the high tech committee actually received.

The computer software was supposed to be transparent and talking to each other by 2015. If this happens by 2020 it will be a true miracle. Yes the computer software corrects for illegible handwriting but not much else. Its costly, time consuming, expensive to maintain and it’s still difficult with the generic templates being used to determine if the patient the note is talking about looks like Haystacks Calhoun or Twiggy.

The system glitch was over by 4:00 p.m. that day and it took me about 3 hours to enter the patient visits into the system. My wife wondered why my “staff” couldn’t enter the data, but the vendors have not trained them for that function. So on Tuesday March 31, it is back to touch typing and computerized records so that the next President of the United States at his State of the Union Address can brag about how computers have brought down the rate of growth of spending on health care.

Why You Can Not Find a Physician Who Accepts Medicare

CMSSGR (sustained growth rate) is a policy and law put in place by the U.S. Congress signed into law four Presidential administrations ago and kept in place year after year by our non-creative elected Federal officials. It was designed to keep the costs of health care growth down by reducing payments to providers if they exceeded the health spending budget for the previous fiscal year. The problem is that health care spending has climbed continuously and it has never stayed within the budgetary guidelines legislated by Congress.

After the first year of the law the General Accounting Office noted an 8% increase in health care spending above the budgeted amount. Congress was supposed to reduce health care payments to providers by 8% the next year, but the providers howled about an 8% reduction and the President and the Congress backed down. Instead of a reduction they gave providers a cost of living increase. The GAO showed that the increased spending was not due to physician pay increases or physician generated costs but due to increased usage and expense in areas outside provider control. Every subsequent year since the SGR became law, the Congress has backed down and granted a miniscule increase instead. The difference between what was budgeted and what was actually spent has accumulated from year to year and each subsequent Presidential administration and U.S. Congress has been reluctant to correct the SGR because the monetary difference would appear on their administration’s balance sheet and legacy. That continued until the Affordable Health Care Act (Obama Care) passed and signed into law before anyone who voted on it actually read it, made correcting the SGR part of the law.

On January 1, 2013 the SGR was due to be repealed by Congress and health care providers were due to receive an 18%- 45% reduction in fees for services. Congress kicked the can down the block until January 1, 2014 and again until December 31, 2014 when Obama Care made the reduction mandatory. The last Congress kicked the issue down the road until April 15, 2015. They were supposed to settle the issue before their spring recess but they adjourned for the spring recess with promises of passing new legislation upon their return on Monday April 13, 2015. That was yesterday when Conservative Republicans announced that after two weeks of consideration they had major problems with provisions of the legislation they had agreed to pass before their spring recess. Their delay will go beyond April 15th.

The Centers for Medicare Services or CMS decided simply to not process any bills or make any payments to health care providers until Congress makes up its mind. Since April 1st they have paid no one except themselves. If no legislation is agreed upon by midnight tonight, CMS will begin processing payments to providers retroactively to April 1, 2015 with a minimum 21% reduction in fees compared to the 2014 payment rates. Physicians are reacting just as expected. Many have decided to no longer see Medicare patients. Those that do see Medicare patients will require payment for services by cash or credit card at the time of service with payments up to 115% of the 2014 Medicare allowable rate for that service. Many will leave the Medicare system entirely.

Our office will continue to see Medicare patients at the current time under the existing payment systems and we will give this Congress an opportunity to fix the problem. When we refer you to specialty physicians we have no way of knowing who will be seeing Medicare patients and who will not. We suggest you ask that particular office before your planned visit so there are no surprises at the check in check out window.

American College of Physicians Rejects “Heart Screening in Adults at Low Risk”

Heart screeningI am often asked by potential new patients, “What do you consider a complete annual checkup?” When I tell them it is a detailed history session reviewing their personal medical history and family history followed by a comprehensive medical physical examination they inquire about testing. We generally perform a urinalysis and a blood panel measuring things such as the blood sugar, the cholesterol and lipid profile, kidney and liver function plus thyroid function. In addition to that we personalize the testing based on the information presented by the patient during the history session and exam. Despite having few risk factors for the development of heart disease, peripheral arterial vascular disease or cerebrovascular disease they ask how often they can have a nuclear stress test, an echocardiogram and imaging of their hearts and blood vessels. When I tell them they probably do not need such testing they tell me about their highly fit and athletic friend with no symptoms who just had a stress test and ended up with a three vessel coronary bypass procedure “saving“ their life.

An article in the Annals of Internal Medicine the American College of Physicians (ACP) supported that position saying that individuals with a Framingham cardiovascular risk assessment of <10% over the next 10 years should not be tested. “These recommendations are based on the lack of evidence showing that screening improves clinical outcomes.” They went on to say that screening has unclear effects on risk reclassification and the use of risk reducing therapies and noted that while abnormalities discovered via resting or exercise EKG were associated with an increased risk of subsequent cardiovascular events, they had no effect on clinical outcomes. According to the authors, “even if a cardiac abnormality is uncovered via screening, the most effective treatment may be adjustments in diet, exercise and other modifiable CHD risk factors that would be recommended regardless of screening results.”

I am frequently asked about the health conscious individual who had the testing and was found surprisingly to have critical disease requiring a lifesaving procedure. The ACP cited a thorough Coronary Artery Surgery Study in which cardiac catheterization on patients with “nonspecific“ or unclear chest pain revealed atherosclerosis in 40% of men and 24% of women, but only 3% of men and 0.6% of women had severe enough disease to benefit from a revascularization procedure.

The ACP paper cited the harm done by screening low risk individuals including excessive radiation exposure and the cost and morbidity of doing additional testing and or procedures to follow up false positive test results. The group stated that a nuclear stress test exposed an individual to an effective radiation dose that is twice the dose of an abdominal CT scan (15.6 mSV) which is the equivalent of ten years’ worth of chest x-ray irradiation. They also projected an increased risk of 2 -25 cancer cases per 10,000 nuclear medicine stress tests in people age 50 or older.

What is clear from the ACP recommendations is that the decision to perform cardiovascular screening should be based on the personal and individual patient history and physical exam findings which indicate a significant possibility of their being cardiac or vascular disease. If in fact the risk is low then testing for the sake of wanting to know causes more problems than solutions.

Generic Colchicine for Gout May Soon be Available on Local Markets

ColchicGout, Colchicineine has been the gold standard drug for the treatment of acute gout flare ups for generations. It is used additionally when physicians institute uric acid lowering therapy with allopurinol to prevent an acute gouty attack that can accompany any change of our uric acid level. It has additional uses in the treatment of the very rare Mediterranean fever.

The drug was always generic and exceedingly inexpensive until 2010 when the FDA granted Takeda Pharmaceuticals copyright exclusivity production it put its version known as Colcrys through the rigorous testing and trials the FDA demands. Before Takeda engaged in the testing and evaluation of Colcrys, all of our colchicine in the USA was produced overseas in small generic factories that had no oversight or inspections by the Food and Drug Administration (FDA). As a reward for going through the oversight process to insure that our colchicine was safe and pure, Takeda Pharmaceuticals received an exclusive distribution right while the other foreign products were removed from the market. The cost of colchicine produced by Takaeda USA soared to $6-$10 per pill. This made a month’s supply too expensive for many users.

Last month, under encouragement from the FDA and consumer groups, Takeda Pharmaceuticals USA gave permission to Prasco Laboratories to distribute Colcrys as a generic product at a much lower cost. It will be sold under the Prasco name. As of 03/19/2015 it has not yet arrived in the South Palm Beach County Florida market but should be there shortly.

Study Reveals No Deterioration of Kidney Function …

NSAIDSAs we age and try and keep moving we notice the severe aches and pains from wear and tear and osteoarthritis that we feel at the start of a day. To relieve those feelings we often reach for the over the counter bottle of Advil ( ibuprofen) or Aleve ( naproxen sodium) knowing full well that the medication will help the aches and pains but may irritate our stomach or contribute to the downfall of our kidneys.

The problem and decision making in prescribing NSAIDs is even more critical in patients with Rheumatoid Arthritis. A recent scientific publication in the Annals of Rheumatic Disease 2015:74: 718-723 authored by B Moeller MD of the Unselspital-University Hospital, Bern, Switzerland looked at this question. They “found reassuring data regarding preserved renal function despite long-term NSAID use in Rheumatoid Arthritis (RA) patients.” Kidney function was followed on 4101 RA patients between 1996 and 2007. 2739 patients used NSAID while 136 2 patients did not.

They assessed and followed kidney function by the accepted methods of calculating the Glomerular Filtration Rate ( GFR). Their results revealed that there was no decline in kidney function in patients who had less than stage 4 Chronic Kidney Disease at the start of the study. They went on to recommend that if a patient’s eGFR or glomerular filtration rate was less than 30 ml per minute they should not take NSAIDs to treat their aches and pains from RA because of the high risk of these medications exacerbating their already compromised kidney function.

The study included medicine from two different classes of NSAIDs, both the “coxib” and “rofecoxib” class. With this data it is safe to say that individuals with arthritic aches and pains can take NSAIDs without fear of kidney deterioration as long as they do not already have severe chronic kidney disease.

Disagreement Over Optimal Nursing Staff Ratios Continues

NursesIn an ongoing disagreement, nursing unions and their supporters believe that the number of patients per nurse during inpatient hospital care is a major indicator of the quality of care provided in a hospital. The current argument involves staffing in critical care areas such as intensive care units where the norm has been a one nurse to one patient staffing ratio or at worst one nurse for two patients. The decision on number of patients per nurse is based on the severity and acuity of care required on the individual patient.

The state of Massachusetts passed a law mandating this staffing ratio in critical care areas as of September 2014. Hospital lobbying associations dispute the need to staff at this ratio. The state of Minnesota was supposedly conducting a research study to answer the question of the relationship between how many patients a nurse was caring for and quality but only one of the State’s 39 hospitals cooperated by providing support and data.

The ratio of nurses to patients in critical care areas and emergency areas is one question but the same question applies to care on the general medical and surgical floors. When I first started practicing in 1979 the ratio stood at four patients per nurse. That figure has ballooned to 5 – 8 patients per nurse today with the patient population being older, sicker and more complex. In those days the nurses worked an 8 hour shift. Today’s staffing schedules have nurses working fewer days but working 12 hour shifts. There are those experts who believe that most of the errors in care and medication that occur in a hospital setting occur in hours 9 – 12 on a nurse’s shift. The extra day off created by working the longer hours is well appreciate by staff on the 12 hour schedules, but is it as safe for patient’s as the eight hour shift?

As a practicing physician in a community hospital it is very clear to me that the quality of care provided in a hospital is directly related to the quality of the nursing service provided. Having quality and experienced doctors is important but not nearly as important as caring and experienced nurses. They are the eye s and ears of the medical staff when the doctor is not at the bedside. They are the ones who first become aware of a problem or recognize a change in the patient’s condition and have an opportunity to sound the warning. When they are asked to care for too many patients it limits their time and exposure to the patient’s clinical situation.

On a daily basis the public is bombarded with advertisements from hospitals and hospital systems touting the excellence of care they provide. How many patients think to ask about the number of patients per nurse? How many philanthropic individuals think about donating towards an extra nurse per shift instead of a bricks and mortar type donation like a piece of equipment or a room or object? The improvement in care with an extra nurse per shift may be far more significant than a remodeled waiting area in the emergency department.



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