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.