Tuesday, March 27, 2012

What is Diabetes?

Diabetes(diabetes mellitus) is a metabolic disease where there are high levels of sugar (glucose) in a person's blood. Type 1 diabetes is caused by the pancreas not producing enough insulin and Type 2 diabetes occurs when the cells do not respond to insulin to metabolize sugar. Type 2 diabetes is more common, is often genetic,  and there is an epidemic if this type of diabetes occurring because of high obesity rates. Gestational diabetes occurs in pregnant women who do not usually have diabetes. It usually resolves with the birth of the child but must be treated because of potential harm to the fetus from elevated glucose in pregnancy.

 Diabetes affects more than 20 million Americans and is the leading cause of blindness and kidney failure.

 Many people with Type 2 diabetes do not know they have it because it develops slowly over time. Diabetes is easy to diagnose with blood tests.  If a patient has two fasting blood glucose tests over 126, the diagnosis of diabetes is confirmed.  Another test called Hemoglobin A1c confirms that the glucose has been elevated over time if the level is 6.5% or higher.   Diabetes is dangerous for the body because it affects the microvasculature (blood vessels) in the body. High Cholesterol, diabetes,and hypertension are considered a "triple threat" and greatly increase the risk of heart attack and stroke.

 There are complicated interactions between organs, hormones, cells and molecules in the body that are disrupted by extra fat cells and obesity. New evidence also points to inflammation as a culprit.  Low levels of inflammation in the body activates immune cells and causes insulin resistance. New diabetic medications mimic hormones from the small intestine and allow interactions between the brain, pancreas and cells to help reduce blood sugar.  Diabetes is not a simple disorder and researchers  are learning new chemical interactions in the body that will help with effective treatment in the future.

 The main treatment for type 2 diabetes is exercise, strict diet and weight loss. Losing weight to a normal BMI can completely manage the disorder in a majority of people who are overweight.  But many people with type 2 diabetes are of normal weight and many obese people do not develop diabetes so genes play a big role in the disease.   Exercise helps lower glucose without medication and aids in weight loss.

 If you are diagnosed with diabetes or pre-diabetes is is essential to understand the disease and see a nutritionist to learn about healthy eating and diet.  There is a wealth of information about diabetes from the American Diabetes Association and a diagnosis of diabetes is so serious, full blown education and action is needed.    We physicians have been too casual in allowing people to have elevated glucose levels  because diabetes causes more deaths a year than breast cancer and AIDs combined!!!

 For more information, this website is filled with great information and tips for dealing with diabetes.

If you or a loved one is diagnosed with diabetes, get educated right away and treat it like you would treat a diagnosis of Cancer or another life-threatening disorder.  Get your treatment plan going by visiting The American Diabetes Association  and get your family and friends involved in your recovery.

Sunday, March 25, 2012

This is what gastroenteritis looks like

Good news:  It only lasts a day

Spots on the Scrotum

The answer to yesterday's Image Challenge was #2 - Fordyce's angiokeratomas.

Like many unusual medical names, the condition was first described by John Addison Fordyce in 1896.
These tiny blood vessels (capillaries) are under the superficial dermis and can be found on both men and women in the scrotum and vulva area.  They are painless and appear in the 2nd and third decade and may continue to appear as the person ages.

Fordyce's angiokeratomas should not be confused with warts, herpes or other conditions.  They are completely benign and require no treatment.

There are a number of chat rooms on-line where men are concerned about these lesions and want them removed by laser.  That can be an expensive and time consuming treatment and there is no guarantee that they will not recur. 

 The best treatment is awareness and acceptance that every body is varied and Fordyce angiokeratoma is just another appearance.

Thanks everyone for your guesses and great diagnostic acumen!

Thursday, March 22, 2012

Image Challenge

 What is the diagnosis?
 You be the doctor.  This 32 year old man wonders about the raised spots on his testicles.  They are non-tender and non itchy.  (click on the image for a close-up view)

1. Beta-galactosidase deficiency
2. Fordyce's angiokeratomas
3. Radiation dermatitis
4. Scabes
5. Varicocele

The answer will be posted tomorrow so be sure to check back.  Make your guess in the comments section.  The winner gets bragging rights.

Wednesday, March 21, 2012

Goal Play Leadership Lessons

My blog friend,  Paul Levy,  former CEO at Beth Israel Deaconess Medical Center in Boston,  was the first hospital CEO to create a blog ("Running a Hospital")  that became famous for it's honesty and look into a hospital's inner workings.  He is now embarking on the next chapter of his life with the publication of his new book," Goal Play - Leadership Lessons from the Soccer Field."   Who knew that being a soccer coach for his daughter's team would provide him with a new platform to use in communicating his wisdom?

Paul has taken his considerable leadership skills and uses his Soccer experience to show us how to communicate, handle adversity and fix problems.  One wouldn't think of soccer coaching and running a hospital as having similar issues, but Mr. Levy skillfully weaves his experiences with both and shows that leadership knows no boundaries.  It is not a book about soccer...it is a book about how to be the best leader we can be by using self examination, honesty, courage and vision.  It is about helping others be the best they can be too.

I have been a fan of Paul Levy ever since I read his "Running a Hospital" blog on the internet.  He talked openly about union strikes, quality at the hospital, patient safety and employee complaints.  I had never heard of a CEO lifting the hood to expose such things.  Yet by exposing them honestly and coming up with solutions, he improved the atmosphere and dialog about health care in a way that was quite unique.  He came to the position when the organization was in crisis and used his considerable skills to "turn it around".  He opened up an era of transparency that is slowly being embraced by others.

In Goal Play, Paul gives us a tutorial about how to "coach" and be a great leader by empowering others. He transverses the worlds of soccer and corporate medicine and shows that building a team and helping that team collaborate on a plan is the measure of success for both.

I recommend "Goal Play" for everyone who wants to improve their own effectiveness, whether it is with coaching a kid's team or improvment in the workplace.  Leaders in Medicine will find it particularly interesting to read the challenges that faced the author and will be inspired to improve their own organization. 

"Goal Play" should be on the bookshelf of anyone who leads teams of people. That is a lot of people who could benefit from reading this outstanding book.  

( click on the link to order directly or go to Amazon)

Sunday, March 18, 2012

How Doctors Get Paid

Medical economics is more confusing than "advanced derivatives" and the entire banking industry collapse.  Have you ever wondered how doctors get paid?  I will try to give a brief tutorial.  Consider it "Doctor Reimbursement 101".

First of all, all payments made by Medicare or Insurance companies are based on a weird rating called the Relative Value Scale.  A group of mainly specialty dominated physicians have been appointed to an "expert panel" called the Relative Value Scale Update Committee (RUC) and they assign value ratings to the work a physician does.  For example, the RUC might proposed that an office visit is worth 2.53 value units while placing a catheter is worth 23.5 units.   Each procedure gets a value rating and through a complicated formula these value ratings are converted to actual money $. 

 This committee meets 3 times a year and their work is secret.  Their recommendations are accepted, rejected or modified by CMS (Medicare).   Only 13% of the members of the RUC represent primary care or cognitive specialties.  The remainder, 87% are made up of specialists like urologists, radiologists, heart surgeons and anesthesiologists.  With a fixed annual budget from Medicare, how the shrinking pie is divided is decided upon by this specialty dominated committee.

Is it any wonder primary care is so grossly underpaid in the United States?

After the RUC recommends the value scale for a piece of work,  CMS assigns a dollar amount based on a complicated formula that includes location, malpractice fees and presumed office expenses.  Medicare has determined that in 2012 the fee for a routine office visit for a Medicare provider is $84.30.  The Medicare reimbursement for a hip replacement is $1,459.34.   The Medicare physician fee schedule is 1,235 pages long.  Most doctors in a specialty have no idea how much another doctor in a different specialty gets paid by Medicare.

Medicare fee schedules are important because private insurers based their payments to physicians on these fees.  Some pay percents more and some  less.  Large groups or hospital consortia  have more bargaining power with insurers than does an isolated doctor.  Consequently solo or small group practices are fast becoming dinosaurs in the U.S.  The trend for physicians to join large groups or become employees of hospitals is on a rapid upward trajectory.

A few primary care physicians have opted out of the Byzantine payment structure by going "concierge".  In this structure a patient pays an up front annual fee to cover office visits, prescription refills, phone calls and access to medical care.  The patient still needs insurance to cover tests, surgeries, medications and hospitalization but the preventive and routine visits are usually covered by the fee, as is the coordination of care.  The primary care doctor gets out of the "billing" side completely.

The fee for concierge medicine can range between $1500 - $20,000/ year.  At the higher range, the concierge physician limits his practice to a few hundred patients.

Hospital charges do not include physician charges so patients often get bills separately from the radiologist, the surgeon, the hospitalist, the emergency room physician and the anesthesiologist.  Some of them contract with your insurance company and take an assigned fee.  Some do not and the charges can be quite a shock on top of the hospital bill.

Is it any wonder that our payment scheme is unsatisfactory for both patients and doctors?

Tuesday, March 6, 2012

Electronic Health Records Don't Cut Costs

A new study was published in the Journal Health Affairs that reports computerized patient records are unlikely to cut health care costs and might encourage doctors to order more expensive tests.

Save your research dollars, Health Affairs...I could have told you that!

The electronic health record gives doctors information about the patient instantly and helps coordinate care between specialists who are on the same system.   Communication and patient safety are improved.  Some are built to allow the patient access to their test results and to even make on-line appointments with their doctors.  The EHR should create a more accurate record and allow complex data to be aggregated in a way that is understandable.  It should create a more efficient system but it will never lower the cost of health care and here is why.

The technology itself is very very expensive.  The cost to an individual doctor to install and maintain the EHR can be tens of thousands of dollars a year and  large health systems spend $billions converting from paper to electronic.  The promise of eliminating file clerks and paper pushers has been replaced with even more people to enter data, maintain and upgrade the system,  and act as scribes for the busy doctor.   Doctors are training now for the new specialty of  Medical Informatics and these young physicians will never treat patients...they will deal with data and maintenance of the digital record.  It is a booming and richly paid field.

Even the fasted, most facile physician spends more time with the EHR than she did with a paper chart.  The documentation is better  and more comprehensive, but it is not cheaper.  Different systems do not talk with each other and the lack of interoperability is costly.  Paper reports still need to be scanned into the EHR and that takes time and money and extra staff.

The EHR should eliminate duplicate ordering of tests when doctors can see what others have done.  But there is a culture in medicine where physicians don't "believe" the tests that another doctor or hospital ran.  Sounds crazy but it is true and it drives me crazy when I send the results with a patient and the consultant repeats the tests.   The second $2500 MRI or $600 round of blood panels is rampant in medicine...even when the doctor has the results of a test done that week.   (Tip: Patients should refuse a 2nd test if they just had it by a referring doctor) 

 There is nothing about digital records that would drive down the cost of ordering more and more expensive tests that are not needed.  That is where the cost is.   There is nothing that eliminates expensive, futile end of life care or reduces admissions to intensive care units for patients that will never leave the hospital alive. 

Technology can improve the practice of medicine.  We are too fragmented and inefficient and the EHR is an important step for patient safety.  Anyone who thinks it will lower costs is living on another planet.  There is ample proof that it is more expensive than a paper and pen.


Saturday, March 3, 2012

Spam Comments on EverythingHealth

Dear Readers,
I am seeing more and more comments on EverythingHealth that are not real but are simply there to drive readers to commercial webpages, advertisers or porn. 

All bloggers love comments and the dialog that goes with social media.  That is why we blog and I never delete controversial comments or criticisms.  Most commenters are respectful and very thoughtful and I learn a lot from my readers.  I read all comments and reply when warranted.

I am going to add a function to the blog where I will approve comments before they are posted.  This will allow me to delete the spams early as they are showing up on my old posts also.  We'll see how this goes!

Please comment on any subject that stirs your interest. 

Thursday, March 1, 2012

Embezzlement in Doctors Offices

I just read an article that talked about more medical practices being victims of embezzlement.  In a 2009 survey of members of the Medical Group Management Association (MGMA), 83% of 945 respondents said they had been the victim of employee theft.  I guess this means I can come out of the closet now.  I have always been ashamed that my practice of 5 Internal Medicine doctors was embezzeled by our trusted long-time book keeper.  It made me feel so stupid and I didn't know how prevalent the problem is.

Our medical practice was a small business with about 100-150 patient visits a day.   Each of us ran an individual business with shared overhead and employees.    At that time patients paid small copays of $5-20,  mostly in cash.  We thought we had good record keeping but Medical Practices are actually easy to rob from because doctors have no idea what they are getting paid for a patient visit.  The documented visit charge is seldom paid in full by the insurance company.   Partial payment arrives months later...or not at all.  Many charges are "written off" when it is clear no-one is going to pay it.  The partial payments are not standardized so a $80 visit could be paid $12.53 or $45.01 or $62.33 and there was no way to know.  The lag in payment not only kept us on the edge financially, it lent itself to fraudulent practices.

I thought I could tract accounts receivable by getting monthly reports from the bookkeeper but the holes in payment are just too big.   How can disparities between billing and collections be identified when there is no standard payment for a charge?

I tracked overhead expenses, signed all checks personally when attached to an invoice and did not use credit cards for office expenses.  I often opened my own mail and spot checked insurance payments and denials. I thought I had a handle on the business of Medicine.

All of us were working very hard and our incomes were pretty poor.  But as primary care doctors, we were used to that.  I went years without self-funding a retirement account (much to my dismay now that I'm older!)

I can't remember how we uncovered the fraud but our trusted bookkeeper, Steve, had a separate account at the bank where he was depositing money for himself.  He took the cash co-pays from all of us.  Not enough to be noticed,  but enough to add up to tens of thousands of dollars over time.  We never knew how much cash was stolen.  He also deposited insurance checks and patient checks into his own account and reconciled the books so we never saw it.  That amount totaled over $180,000 that we knew about...meaning there was much, much more that we will never be able to discover.   Why the bank allowed a business check to be deposited into his personal account we will never know.

Did we prosecute?  Yes,  but the judgment we got against him never amounted to any reimbursement.  The money was long gone.  He never served jail time and is probably out there somewhere working in another medical practice.

Embezzlement can happen to anyone in business and apparently happens frequently to doctors in private practice.  some say it cannot be prevented and given the crazy way medicine is reimbursed I would have to agree.

When to Use Urgent Care

We all know that Emergency Departments are over-crowded with long waits and exorbitant fees.  Free standing Urgent Care is a great solu...