Healthy Snacks

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I was pleasantly surprised to see this sign at the edge of the produce department. Good job, Fred Meyer!!

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The Medical Paperwork Reduction Act

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Painting in the Mauritshuis Museum

Today, in a rare moment of bipartisanship, Congress passed the Medical Paperwork Reduction Act. It states that administrative requirements will be decreased to the minimum required for good medical care and billing. The Department of Labor estimated that this will reduce the average physicians paperwork by 1.7 hours a day, and that for primary care physicians, it will be closer to 3 hours a day. That in turn is expected to significantly decrease the primary care physician shortage, as they will be able to see more patients a day, and lessen unnecessary emergency room visits. Doctors’ morale is expected to improve with improved job satisfaction, leading to less early retirement, decreased physician suicide, and a lower divorce rate. Despite an increase in administrators and clerical staff seeking unemployment benefits, the Congressional Budget Office estimates a net benefit to the economy of 17.2 billion in the first year. “This is a special day. I never dreamed of seeing this,” said AMA spokesman Jonathan Dreckle, “not in a million years.”

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Trump the Bureaucracy

About 6 weeks ago I referred a patient of mine with a knee problem to an orthopedic surgeon in my group. He ended up seeing someone else in the same group about 3 1/2 weeks later, and the doctor prescribed a knee brace.

A few days ago my patient said his insurance company wanted me to do a new referral, because I had referred him to a different physician than the one he ended up seeing. Even worse, he still did not have the brace because they required his primary care physician (that’s me) to write them a letter saying the brace was necessary.

I did write a letter saying that I’m not qualified to say whether or not the brace is necessary, and that if they wouldn’t approve it, then their medical director should contact the orthopedic surgeon to explain why not.

Physicians have far better things to do with their time than waste it on unnecessary paperwork. If we could only channel our collective anger and frustration with the system, as Donald Trump has been doing in the realm of politics, maybe we could spend more of our time treating patients, rather than placating the government and insurance companies.

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Gluteus Maximus

I ordered atorvastatin (generic Lipitor) for one of my patients with high cholesterol and Medicare Part D coverage. It was denied. We then appealed it (prior authorization). A fax from Maximus Federal Services said their decision was, “UNFAVORABLE.” They said the patient had not tried and failed one of the preferred generic statins (lovastatin or simvastatin). They did note that we could appeal to an Administrative Law Judge.

In fact the person had tried simvastatin, which I had noted on the prior authorization. However the cost savings is minor. According to Goodrx, a 90 day supply of atorvastatin is as low as $19.25 around where I work.  For the equivalent dose of simvastatin it’s $10.06.

Yes, it’s almost half the price, but it’s still a pretty small amount, especially in my patient who had already had a heart attack, and the difference will only get smaller as Lipitor has not been generic for all that long. Contrast that with the staff time wasted dealing with this on both ends. Dealing with this is a pain in the Gluteus Maximus!

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Disabled Parking and Needless Paperwork

Date and Place SignedIn Washington State, if you want a disabled parking permit you need your doctor to fill out a form. Effective 7/1/15, a new law also requires a written prescription to help combat forgery. Physicians already have to deal with far too much paperwork. Their latest form ridiculously asks us to write down the place signed. As the photo above shows, I made up a stamp that has the latitude and longitude of my office. They want to know where I signed it? They got it!

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An ICD-9 Story

Medical billing and epidemiology relies on a classification of diseases maintained by the World Health Organization. On the first of October, 2015, we will transition from ICD-9 to ICD-10, a major change that increases the number of available diagnoses from some 17,000 codes up to more than 155,000. In a strange cosmic twist, that’s the same day that most retails need to install readers for credit cards with chips or be liable for bad purchases.

With that in mind, I present a short story in ICD-9, with a translation into English.

It was E900.0. That, combined with E904.1 and E904.2, not to mention V69.4, is what led to 780.2. I admit it, I have V69.0 and V69.1. I usually sleep well, but that night was different, thanks to 780.55 due to 780.92. That morning I understandably drank 969.7, leading to 785.1. During E924.2 while E013.0 I felt 780.4. Stepping out I had 368.45 before I 780.2.When I was V49.89 after my E884.9. I had a 784.0, as if I had a 305.00. I used my E011.1 to call work to say I’d be late and hoped to avoid V62.1. He greeted me with a 784.42 indicating 300.4.

Last year I V49.89. The flights are arduous, subjected to E918 or being in V01.9 with a 780.92 E979.6 at E902.0. After landing I’m 780.79 due to V69.4 and 780.55, leading to excessive 786.09.

I was in 309.29. At least, thank to the ubiquity of E849.6, I didn’t have to suffer from 292.0.

If you think this makes for 315.00 and is a 729.1 to read, just wait for ICD 10! Ever see a V91.07XA?!

It was too hot. That, combined with lack of food and water, not to mention lack of sleep, is what led to my fainting. I admit it, I don’t exercise or eat right. I usually sleep well, but that night was different, thanks to interrupted sleep from my son’s crying all night. That morning I understandably drank one too many cups of coffee, leading my heart to skip a beat. During a hot shower I felt lightheaded. Stepping out my vision narrowed before I passed out. I awakened after my fall to the floor. I had a headache, as if I had a hangover. I grabbed my cellphone to call my work to say I’d be late and hoped I wouldn’t be in trouble with the boss. He greeted me with an edge to his voice, indicating he was wasn’t completely happy.

Last year I traveled to foreign countries. The flights are arduous, subjected to being squeezed in with other passengers, or being next to a crying, germy child at altitude. After landing I’m worn out due to lack of sleep and jet lag, leading to excessive yawning.

I was in culture shock. At least, thank to the ubiquity of vendors, I didn’t have to suffer from caffeine withdrawal.

If you think reading this is difficult and is a pain in the butt to read, just wait for ICD 10. Ever see a burn due to water-skis on fire?!

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Going Viral is Bad for Your Health

A few days ago CNN hosted the 2nd Republican presidential debate. Unfortunately, the topic of vaccines came up. Donald Trump had previously suggested that vaccines can cause autism. When asked about this he responded, “You take this little beautiful baby, and you pump — I mean, it looks just like it is meant for a horse, not for a child, and we had so many instances, people that work for me, just the other day, 2-years-old, beautiful child went to have the vaccine and came back and a week later got a tremendous fever, got very, very sick, now is autistic.”

He went on to say that he’s not against vaccines, but just thinks the same total dose should be given in smaller doses and spaced out more.

Donald Trump is not a doctor, so why is he giving medical advice? Republican presidential hopeful Dr. Ben Carson, a retired pediatric neurosurgeon, said, “We have extremely well-documented proof that there’s no autism association with vaccinations. But it is true that we are probably giving way too many in too short a period of time.” Although he at least discredited the theory that vaccines cause autism, he agreed with an alternative dosing schedule. Fellow debater Senator Rand Paul, who is also an ophthalmologist, said, “I’m all for vaccines, but I’m also for freedom. I’m also concerned with how they’re bunched up.”

The American Academy of Pediatrics put out a statement saying there is no alternative dosing regimen. Based on lots of scientific literature and much expert opinion, the current schedule was designed to optimize benefit versus risk. Delaying vaccinations increases the risk that children will catch the disease before they have been protected. It’s also psychologically more traumatic. Studies have shown that a child is just as traumatized if they get one shot or three shots at one visit, but 3 visits with a shot at each one is worse than one visit where they get 3 shots. Spacing out the vaccines also means more cost, and more exposure to sick kids each time they are brought for a vaccination.

So where did this idea of spacing out vaccines come from? Pediatrician Dr. Sears published “The Vaccine Book” in 2007 that proposed alternative vaccination schedules.  But that was just his opinion, and was not based on studies to show that it’s safe and effective.

The belief that vaccines can cause autism came from a study published in 1998, that has since been retracted because it was found to be based on fraudulent data. Some people still choose to believe it.

You might argue that spacing out the vaccines is better than nothing. That’s true, however that’s like saying that only wearing seat belts every other day is better than nothing. That’s true, but it’s still much better to use it the way you’re supposed to.

Republicans don’t have good record when it comes to vaccines. Four years ago Rep. Michele Bachmann (R-Minn.) attacked Texas Governor Rick Perry for mandating that young women get HPV (human papilloma virus) vaccine. He later backed down. That vaccine prevents women from getting cervical cancer.

I may not agree with politicians when it comes to issues regarding such things as  immigration, taxation, use of the military, domestic spying, or abortion, but those are legitimate areas for politicians to debate and legislate. They can even debate the wisdom of the Affordable Care Act (ObamaCare), but they should stay out of the science of medicine. That includes politicians who happen to be physicians, unless they are stating medical facts, rather than pandering to what their constituents want to hear.

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Medicare Audits – Or How I Spent Part of Labor Day Weekend

Copyright 2105 Daniel Ginsberg PhotographySome weekends I go to my office to try and catch up on paperwork. This Labor Day weekend I had to ‘labor’ away part of it to satisfy a Medicare requirement.

I received a fax from a medical supplier saying that Medicare had sent them an, “additional documentation request” for diabetic supplies for a patient of mine from June 2013. I didn’t see her on the date of service they listed, nor even see that I prescribed any diabetic testing supplies then, though it’s possible I filed out a faxed form and it wasn’t saved to her chart.

They requested that I include copies of the patient’s blood glucose testing logs. I do not routinely scan those into the chart, so I don’t know how that’s supposed to happen.

They also say to verify that the records contain the following other items, though it could be considered fraud to go back and add them now:

  • Patient’s Diagnosis and Prognosis
  • Patient’s Testing Frequency
  • Condition and Treatment History
  • Quantity and Day Supply Prescribed
  • Physical Limitations Due to Condition
  • A1c Lab Report
  • Insulin/Non-insulin
  • Insulin Injections/Pump
  • Medication lists

In addition, they want all documentation from 6 months before the service date up to the present day, and they want it, “ASAP.” That’s 2 years and 9 months of documentation, all for a few diabetic test strips I prescribed (which I don’t make any money from, for the record)!

What’s more, it says that we are not allowed to charge the supplier or the beneficiary (the patient) for providing this information.

That’s your government, hard at putting us primary care doctors to work.

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Asinine Associations

As I previously wrote, when physicians place orders, they have to associate diagnoses. This is becoming even more painful as we move towards ICD-10, of which I’ll have more to say later.

I’m sure this was an attempt by the government to save money, but in the vast majority of cases the ordering physician has no secondary gain, and they order the test because they think it’s the right thing to do. I can understand it for some expensive tests or procedures, but many are just plain obvious.

I think lawmakers should have a taste of their own medicine. When they need office supplies, they should have to give a reason. Here, I’ll help them out with a few items to help them understand how it works:

StaplesTo attach separate pieces of paper.

NotepadTo write down information.

PenTo apply in conjunction with a notepad to convey information.

ChairTo help counteract gravity to prevent leg and back pain and fatigue.

Laser Printer TonerTo print out things using a laser printer.

Light BulbTo counteract darkness.

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Sesame Chicken

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I often suggest my patients use smart phone apps to help them with their diet, in particular Lose It! or MyFitnessPal. Both progams have the ability to scan a bar code of a food item, which will then show the amount of calories, protein, fat, carbohydrates, etc for a given portion size. Not having any food in my exam rooms, I grabbed the box of tissues to show how to scan the bar code. Lose It! identified it as Sesame Chicken!

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