September 19th, 2009 by Joseph Scherger, M.D. in Better Health Network, Health Tips
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I recently moved my work to the Palm Springs area of California. I am the Vice President for Primary Care at Eisenhower Medical Center in Rancho Mirage, California. My duties include starting a new primary care practice where I also work as a family physician. This week I developed a preventive medicine presentation I will be giving to groups of people, mostly seniors, in our area. I would like to share my key messages here.
Balance is the key to health in many ways. Our lifestyle choices play the major role in whether we are healthy or sick, outweighing our genetics and the bad luck of getting a disease for no apparent reason. There are four areas where lifestyle play a major role in our health. Do these four things and you are likely to be healthy:
Eat Right: We are what we eat, so what goes in our body is vital to our health. The mainstay of our nutrition should be vegetables and grains. We should avoid the saturated fats found in many animal meats and dairy, and the trans fats found in many fried foods and pastries. Eat healthy fats like those found in nuts and quality vegetable oils, such as canola and olive oil. We should avoid simple sugars that make us hungry and have protein at every meal (Nuts, low fat dairy, lean meats and fish). We should avoid excess salt. Do not eat many more than your body needs to maintain a healthy weight. See my other blogs since I write here about nutrition every month.
Be Active: Use it or lose it is a good rule for keeping our bodies healthy. Look for opportunities in your daily life to walk more, climb stairs and be active. Then, devote 5 of the of the 168 hours in a week to one or more physical activities of your choice. Being physically active is the best long term predictor of living a long and healthy life.
Sleep Well: We trained our children in how to sleep, but many of us forgot the lessons. Prepare for a good night’s sleep by winding down our daily activities, turn down the lights, and leave the problems of our day behind. Imagination is ok for adults to use to enter the world of sleep. As adults, 6 to 8 hours of refreshing sleep is usually enough to replenish our bodies.
Manage Stress: Stress can wear down even the healthiest body. Be aware of our stress levels at home and at work, and seek ways to reduce the stressors. Some of us thrive on a certain amount of stress, that is fine. We know when we are distressed because we are not at ease and not smiling as much. I like these three rules for handling stress: 1. Don’t sweat the small stuff, 2. Everything (just about) is small stuff, and 3. If you cannot fight, and you cannot flee, then flow.
Take a moment to reflect on these four “pillars” in your life and see what adjustments you can make to preserve your health.
*This blog post was originally published at eDocAmerica*
September 16th, 2009 by RamonaBatesMD in Better Health Network, Health Tips
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I’m sure I don’t see as many patients with common skin warts as my family practice or dermatology colleagues, but these patients still make it to my office. Sometimes it’s the primary complaint, sometimes it’s an afterthought. In reviewing the topic, it occurred to me that most patients don’t need to see any of us for this problem. They mostly need to accept the fact that the treatment takes TIME. So if you will persist, then you will often be successful without the expense of seeing a doctor. (photo credit)
Common warts (Verruca vulgaris) are caused by the human papillomavirus (HPV). Warts on the hands or feet do not carry the same clinical consequences of HPV infection in the genital area. It is estimated about 10% of children and adolescents have warts at any given time. As many as 22% of children will contract warts during childhood.
Common warts can occur anywhere on the body, but 70% occur on the hand. Often they will disappear on their own within a year. Even with treatment, warts can take up to a year to go away.
Before heading to the doctor, there are treatments you can try at home: salicylic acid or duct tape.
When using the 17% salicylic acid gel (one brand name: Compound W), it must be applied every day until the wart is gone. Only apply to the wart, not the skin around the wart. This treatment is enhanced by covering the wart with an occlusive water-proof band-aid or duct tape after applying the acid. It can also be enhanced by gently filing the wart with an emery board daily to remove the dead cells prior to applying the salicylic acid. Treatment can take weeks to months. Don’t give up early.
Duct Tape can take weeks or months to be effective. Apply the duct tape to the wart and keep it in place for six days. After removing the tape, soak the wart, and pare it down with a filing (emery) board. Repeat the above until the wart disappears. Once again, don’t give up early.
The two treatments (salicylic acid and duct tape) can be combined. Apply the salicylic acid liquid to the wart before bedtime. After letting it air dry for a minute or so, then apply the duct tape over the wart, completely covering the area. Remove the duct tape the following morning. Each time you remove the tape, you will be debriding some of the wart tissue. Repeat the application each night, until there is no remaining wart tissue. As with using only one treatment, don’t give up early.
If the above don’t work or you just don’t want to take the time, then you may wish to see your physician for removal. He can use cryotherapy to destroy the wart. This method may involve repeated treatment over several weeks. You can do the following to “get the wart ready for removal” and make the cryotherapy more effective:
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Every night for 2 weeks, clean the wart with soap and water and put 17% salicylic acid gel (one brand name: Compound W) on it.
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After putting on the gel, cover the wart with a piece of 40% salicylic acid pad (one brand name: Mediplast). Cut the pad so that it is a little bit bigger than the wart. The pad has a sticky backing that will help it stay on the wart.
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Leave the pad on the wart for 24 hours. If the area becomes very sore or red, stop using the gel and pad and call your doctor’s office.
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After you take the pad off, clean the area with soap and water, put more gel on the wart and put on another pad. If you are very active during the day and the pad moves off the wart, you can leave the area uncovered during the day and only wear the pad at night.
If none of the above work, then your wart may need to be removed surgically. Remember the above all take time, so give them time to work. Even if the wart disappears with any of the above treatments, it may recur later.
Sources
Treatment of Warts; Medscape Article, May 27, 2005: W. Steven Pray, PhD, DPh; Joshua J. Pray, PharmD
What Can Be Done About a Hand Wart That Keeps Reappearing After Removal?; Medscape Article, May 31, 2007; Richard S. Ferri, PhD, ANP, ACRN, FAAN
Duct tape and moleskin equally effective in treating common warts; Medscape Article 2007; Barclay L.
Duct Tape More Effective than Cryotherapy for Warts; AAFP, Feb 1, 2003; Karl E. Miller, M.D.
*This blog post was originally published at Suture for a Living*
September 9th, 2009 by DrRob in Better Health Network, Humor
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When you were last enraptured by my physical exam series, I was explaining the different directions doctors use to confuse themselves and everyone else. I am happy to leave that land of relativity and now re-embark on the actual human body. I am sure this relativistic view of direction was invented by some liberal anatomist intent on socializing the human body. It is a stop on the road to death panels, in my opinion.
It’s good to get that posterior to me.
My distraction (I get distracted, you know) happened as I was trying to explain how the shoulder works. Since the shoulder moves in so many directions and with such huge angles, I felt it was necessary to totally confuse you and so hide any chance you would pick up my ignorance. It’s always good to keep your readers snowed. So, after spending a whole post making poems about the shoulder (that will no doubt go down in the anals annals of poetry about joints) and another post about the confusing directions we doctors use to confuse other doctors, I will now talk about the actual exam of the shoulder.
As you probably have been taught, the shoulder is the joint that attaches your arms to your body. Some people refer to the top of their torso as their shoulders (as in “shoulder straps”), but this is not what I am talking about. The shoulder is supposed to be the joint between three bones:
- The humerus – which is the long bone in the upper arm, and got its name because of its habit of playing practical jokes on the ulna. The other bones are always inviting the humerus to parties.
- The clavicle – also known as the collarbone. This bone actually looks nothing like a collar, and it resents the implication.
- The scapula – called the shoulder blade. The collarbone is jealous because the scapula has a much cooler nickname. This causes the scapula to snicker often at the clavicle’s wimpy nickname.
Credit
Examining the shoulder Read more »
*This blog post was originally published at Musings of a Distractible Mind*
September 8th, 2009 by Dr. Val Jones in Health Tips, True Stories
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Ed Walker is 102 years old. I met him by chance on a steep hill in Lunenburg, Nova Scotia – not long after my husband blurted, “I hope you’ve got good brakes on that scooter!” Ed pulled up next to us (to demonstrate his brakes) and jubilantly announced his age, along with his suspected reason for it: “I have prostate cancer but chose to leave it alone.”
I chuckled to myself, thinking that he was probably right about his longevity-hospital avoidance connection.
Of course, the diagnosis and treatment of prostate cancer is being hotly debated these days. While no one likes the idea of leaving cancer untreated, slow-growing prostate cancer may be less of a threat to men at a certain age than the treatment required to cure it. And that’s a difficult truth to accept – especially for Americans.
My fellow blog contributors have noted the disconnect between scientific evidence and clinical practice in regards to prostate cancer. According to a recent study in the New England Journal of Medicine, PSA (a screening test for prostate cancer) testing has not made a difference in overall longevity. Urologists still favor testing (the American Urological Association guidelines recommend initiating PSA testing for all men starting at age 40) while family medicine physicians don’t usually recommend it. Is there a conflict of interest driving this difference in recommendation? Perhaps – though I suspect it has more to do with a surgical mentality (to cut is to cure!) than a conscious decision to protect one’s income. If you think there’s a shortage of urologic procedures to go around, then I’d recommend you simply consider the increasing age of the US population. It’s not as if the prostate gland is the only thing that needs work “down there.”
Perhaps Americans can take some cues from their elderly neighbors to the north – and try to accept that doing something is not always better than “doing nothing.” In the case of some prostate cancers, it’s cheaper, safer, and a lot less painful.
Just ask Ed Walker.
July 22nd, 2009 by Happy Hospitalist in Better Health Network, Health Policy, Primary Care Wednesdays
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What does that mean? Well. It means everything. And it means nothing. It is the enormous universe of numbered codes (CPT) that every physician must grasp in order to get paid for services provided. In order to remain a viable business, physicians must learn how to code. And they must learn how to code well so they aren’t accused of fraud.
The current coding system is ridiculously difficult and vague. So difficult and vague that audits by the Medicare National Bank (MNB) often result in multiple different opinions by the MNB auditors themselves.
Coding is a system of confusion. I am here to say the coding system is insane. Current coding rules are used by all third parties to determine the economic value of your care. To determine how much your encounter with the patient is worth. Ultimately, the coding system has become the most important aspect of a physician’s professional life because coding determines revenue. And revenue determines the viability of the business model. And that ultimately determines how much you take home to feed your family. Dr Kevin blogged about that here.
So let the games begin. The current coding rules are a futile attempt to bring rings of value to medical service. Services which are so vastly different and unique for every patient. I will attempt to walk you through an example of the payment system, and how it relates to relative value units (RVUs) and ultimately how that affects physician payment.
The number of codes is massive. For all imaginable procedures, encounters, surgeries. Any possible health care interaction. Hospitalist medicine is limited in the types of codes we use. So I only have to remember a few.
95% of my billing is based on about twenty CPT codes:
3 Admit codes (99221,99222,99223)
3 follow up codes.(99231,99232,99233)
2 critical care codes (99291, 99292)
5 consult codes (99251-99255)
7 observation codes (99218-99220, 99234-99236, 99217)
2 Discharge codes (99238, 99239)
There are a few others, but these twenty-two codes determine my very financial existence. Medicare says so. Imagine a surgeon, a primary care doc, and a medical subspecialist. Every single interaction has a code. There are codes for codes, modifiers for codes, add on codes, disallowed codes, V codes, M codes. It seems as if the list is endless. And you have to get it right. Every time. Or you don’t get paid. Or you are accused of fraud. It is an impossible feat. The process of taking care of patients has turned into a game of documentation. And that has drastically affected the efficiency of the practice of medicine.
Let me walk you through a 99223, the code for the highest level admit for inpatient care. A level three. There is no actual law, as I understand it, on the Medicare books that definitely defines the requirement for these Evaluation and Management (E&M) codes. There are generally accepted guidelines which carriers are expected to follow. 1995 and 1997 guidelines. Even the guidelines from different years are different. And you are allowed to pick and chose from both. More silliness.
The following is my understanding of what Medicare requires in order to bill a level three admit, CPT code 99223. You must have every one of these components or it’s considered fraud, over-billing or waste. Pick your verbal poison.
1) History of Present Illness (HPI) : This requires four elements (character, onset, location, duration, what makes it better or worse, associated signs and symptoms) or the status of three chronic medical conditions.
2) Past Medical History (PMH): This requires a complete history of medical (medical problems, allergies, medications), family (what does your family suffer from), social (do you smoke or shoot up cocaine?) histories.
3) Review of Systems (ROS): A 12 point review of systems which asks you every possible question in the book. Separated by organ system.
4) Complete Physical Exam (PE): With components of all organ systems, the rules of which are highly complex in and of itself.
5) High Complexity Medical Decision-Making: This one is great. It is broken down into three areas and you must have 2 of 3 components as follows; Pull out your calculator.
5a) Diagnosis. Four points are required to get to high complexity. Each type of problem is defined by a point value (self limiting, established stable, established worsening, new problems with no work up planned and new problems with work up planned). You must know how many points each problem is worth. Count the number of problems. Add up the point value for each problem and you get your point value for Diagnosis (5a). You must have four points to be considered high complexity.
5b) Data. Four points are required for high complexity. Different data components are worth a different number of points. Data includes such things as reviewing or ordering lab, reviewing xrays or EKGs yourself, discussing things with other health care providers (which I have never been able to define), reviewing radiology or nuclear med studies, and obtaining old records etc. Each different data point documented (remember you have to write all this down too) is given a different point value. You must add up the points to determine your level of complexity. Get four points and you get high complexity for Data (5b).
5c) Concepts. I call this the basket. Predefined and sometimes vague medical processes that are defined as high risk. This includes such things as the need to closely monitor drug therapy for signs of toxicity ( I would include sliding scale insulin in this category), de-escalating care, progression or side effect of treatment, severe exacerbation with threat to life or limb, changes in neurological status, acute renal failure and cardiovascular imaging with identified risk factors. There are too many categories that are defined as a high risk concept. I cannot remember all of them. If you have a concept considered high risk, you get credit for high risk in the concepts category (5c)
Now remember, out of 5a, 5b, and 5c, you must meet high high complexity criteria on two out of three to be considered high risk. Did you remember to bring your calculator to work? And once you’ve calculated your high complexity category, don’t forget to write down all the components required from HPI, PMH, ROS, PE to not be accused of fraud.
Folks, this is what I have to document every time I admit a patient to the hospital in order to get paid and not be accused of fraud. This is what the government (and all other subsequent third party systems) have decided is necessary for me to treat you as a patient. This is what I must consider every time I take care of you.
I always find myself wondering if I wrote down that I personally reviewed that EKG. I wonder if I wrote down that your great great grand mother died of “heart problems”. I wonder if I remembered to write down all your pertinent positives on your review of systems and whether I documented the lack of positives in all other systems that were reviewed.
And remember each CPT code is given an RVU value, the value of which is determined by its own three components.
- The work RVU
- The practice expense RVU
- The malpractice expense RVU
Then the MNB multiplies your total RVU (add the three components above) and attached a geographical multiplier (you get more RVUs in NYC than in Montana).
Then, they take that number of RVUs and they multiply it by the Congressional mandated value of the RVU (currently about $35/RVU). That value is currently determined by the political whims of politicians and is controlled by the irrational sustainable growth formula (SGR). That is the formula that is overturned every year because of the irrational economics it employs.
And that’s how a physician is paid. This is what determines whether physicians survive in the business of medicine. And whether they have enough money to pay the electric bill, the accountant’s fees and the matching contribution to their nurse’s 401K.
Oh yeah. I almost forgot, I have to do all this while actually taking care of your medical problems based on sound scientific principles.
This is coding in a nutshell. A 99223. This is what I think about when I’m admitting you through the emergency room. This is E&M medicine. This is Medicare medicine. This is how your government has decided the practice of medicine should be. To get paid, I must document what Medicare says I must in order to care for you, the patient. It doesn’t matter what I think is important to write in the chart. What matters is what is required to get paid and not be accused of fraud.
Like I have said before, the medical chart has become nothing more than a giant invoice for third parties to assert a sense of control on their balance sheet. It doesn’t matter who that third party is. They are all the same.. I’m telling you, it’s nothing more than a really inefficient game of cat and mouse. It is a terribly inefficient and expensive way to practice medicine.
And I might remind you, the exercise above was an example of just one patient on one day. I do this upwards of fifteen times a day. Every day. Day after day. Year after year. Oh yeah, and the rules are different for inpatient followup codes, discharge codes, critical care codes, and observation/admit same day codes. They all have their different requirements. And I have to get it right for every single patient I see. Every day. Over 2500 times a year. With the expectation of 100% accuracy.
Why? You see, in the eyes of Medicare, you are a nothing more than a 99223.
*This blog post was originally published at A Happy Hospitalist*
