Recently a patient of mine expressed frustration with the presidential campaign, saying the other side wouldn’t listen to facts and just believed what they wanted to believe.
Knowing that she had repeatedly refused to get a flu shot, I asked her in that case if she’d like to get one, given that scientific studies have shown that the benefit outweighs the risk for most people. Although she hesitated, I unfortunately could not convince her.
As I previously discussed, a year ago we transitioned from the disease classification ICD-9 to ICD-10. That has been painful, but they keep making tweaks that require more work.
I guess the powers that be decided that more than 155,000 diagnoses were not enough when they recently changed many diabetes diagnoses (a day or two ago, at least, my organization implemented the latest edition). Now it’s no longer sufficient to say that someone has Type 2 Diabetes Mellitus with Diabetic Neuropathy [E11.40], for example, but I now have to specify in addition whether it’s with or without long term insulin use, or if it’s unspecified. That means all my carefully constructed Problem Lists on my patients no longer work. Every diabetic medication I reorder will have to be changed as they are associated with a diagnosis.
Across all my patients I’d estimate that’s close to 1000 changes I will need to make. Assuming it takes me 30 seconds each time (I’m probably a lot faster than most of my colleagues) that’s over 8 hours, so a full work day. Multiply that across all the primary care doctors and that’s a lot of time – about 1000 people working years! We have a shortage of primary care physicians and I think there are many better ways to spend our time.
I typed “type 2 diabetes mellitus” into my electronic medical record. I eventually scrolled to the bottom to see a message that there were 3158 diagnoses loaded, but that the results had been limited due to it being a common phrase! Many of these were synonyms, and one can save favorites, but I think it’s ludicrous that we have so many codes for just one disease. Those who promulgated moving to ICD-10 claimed the higher specificity would lead to all kind of advantages by being more precise, but in reality physicians can’t spend all day just to pick a diagnoses and they are going to pick something close that will satisfy the billing system. For many diagnoses you can’t even get precise agreement. There are various codes for uncontrolled diabetes, for example, but if you ask different doctors what that means, you’ll get different answers.
Patients with diabetes have to suffer from complications of their disease, increased medical costs, and being stuck more often for blood or injections. It’s too bad their physicians have to suffer more as well.
The New York times just ran a story about how Mongolia uses a system for their mail where each address consists of three words. A clever British start-up company What3Words divided a map of the world into 57 trillion pieces, each 9 square meters (about 10 x 10 feet), and assigned a 3 word combination to each one.
I checked the address of my office, and it’s crowned.tamed.raced. Given that each address takes up such a small area, I honed in on the map to where the actual rooms in my building are. Here are some of the address I came up with: remote.globe.puppy, patio.thin.ropes, living.quit.exit, castle.lofts.roses, famous.learns.cheek, and minds.agent.former.
I would say that as a geriatrician, living.quit.exit is a pretty good description of what I do, but from a marketing perspective, I’d have to go with remote.globe.puppy.
Bayer, the maker of Claritin, has a new product, ClariSpray. This is a good product, but with a confusing name. It has nothing to do with Claritin, other than they are both used for allergies (allergic rhinitis).
It’s actually fluticasone nasal spray, the same ingredient as Flonase, a prescription product, but now available over-the-counter.
Their website does takes pains to explain this, but there are some things things they don’t mention. They don’t say how it compares with Flonase or Nasacort. Although there are slight differences, and some people may prefer one over the other, they are basically similar, and just a matter of personal preference. Bayer’s website also doesn’t tell you that you shouldn’t take ClariSpray if you are taking Flonase or Nasocort, or one of the other nasal steroid sprays only available by prescription.
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.”
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.
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!
In 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!
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?!