Notes from a doctor with a laptop, a housecall bag and a fountain pen
It’s been a while since I recorded a series of videos, explaining common diagnoses and medical concepts.
I would love to hear readers’ ideas of topics/non-personal questions for a new round of videos here and on Substack (link is funny, you may have to hit “back” if you get an error message). Post a comment if you have suggestions. And thank you…
Finally, the Fed is catching on and proposing a way to stop the private Medicare Advantage plans from siphoning money in fraudulent ways. This is a quote from a recent article in The New York Times:
The change in payment formulas is an effort, Biden administration officials say, to tackle widespread abuses and fraud in the increasingly popular private program. In the last decade, reams of evidence uncovered in lawsuits and audits revealed systematic overbilling of the government.
The instrument that was designed to help Medicare budget by getting more precise diagnoses is called Hierarchical Condition Categories, or HCC. The more specific my diagnosis coding is for each patient, the more accurately Medicare can predict their cost. Compared to the average cost for a patient, a diabetic without complications is 10% more expensive, and one with kidney disease is predicted to cost 30% more to care for. This HCC coding translates into what is called a risk adjustment factor, RAF. This is expressed as 0.105 or 0.302, which is added to the universal, healthy person’s RAF of 1.
There is a huge push to get providers to code this way, and it is starting to make some difference in how much money our clinics make, but so far it is in the form of bonuses or “shared savings”. But for Medicare Advantage plans, this is cold hard cash. And this has caused a feeding frenzy.
The instrument for collecting this data is our billing codes. At least once a year, every diagnosis that is worth more because of a risk adjustment factor greater than zero, should be billed. If I forget to use the code for morbid obesity (which is only a BMI of 35 or more if you have a condition like hypertension that may be related to it) or amputation status, Medicare will underestimate the cost to care for that patient and I will look like I overcharged and overtreated a healthy person.
And, again, I may not see the benefit or punishment my coding theoretically causes, yet, although I probably will see more and more of this effect as time goes on. But the Medicare Advantage plans have benefited handsomely from this.
Two things have happened.
One is that providers like me get letters, in some cases with promises of a $100 payment, asking me to verify diagnoses my patient appears to have, based on claims data.
The other is that the Advantage plan sends a Nurse Practitioner or an MD to the patient’s home to conduct an Annual Wellness Visit and submit a bill to CMS so that the plan gets credit for all those diagnoses.
They want this so badly that they’ll still pay me for doing my own Wellness Visit with my patient.
Quoting from The New York Times:
But numerous studies from academic researchers, government watchdog agencies and federal fraud prosecutions underscore how the insurers have manipulated the system by attaching as many diagnosis codes as possible to their patients’ records to harvest these bonus payments.
Four of the largest five insurers have either settled or are currently facing lawsuits claiming fraudulent coding. Similar lawsuits have also been brought against an array of smaller health plans.
And apparently (I don’t have a TV, but I read about it) now the Medicare Advantage plans are running TV ad campaigns that insinuate CMS is trying to cut member benefits, when all they are doing is trying to clamp down the plans’ abuse of the system.
There are actually two kinds of abuse by the Medicare Advantage plans going on, overcharging the government and shortchanging their patients by refusing to pay for expensive testing, like CT scans, necessary to diagnose cancer and other life threatening diseases.
Out of 2.5 million people in this country with opioid use disorder, a chronic condition with an annual mortality rate of 10%, only 278,000 (11%) are receiving treatment. Consider this: For every patient in Medication Assisted Treatment (MAT), there is one other person who dies.
In 2020, only 10% of primary care physicians had the “X-waiver” to be able to prescribe buprenorphine for substance use disorder. This requirement has now been dropped (although electronic medical records generally have not yet been updated to make this possible for doctors without such a waiver). But in 2020, only 24% of those who had the waiver actually used it to prescribe buprenorphine.
So, how do we get more people into treatment?
Under the waiver restrictions, buprenorphine prescribers were limited in how many patients they could treat, depending on how long they had been qualified and whether they worked in a substance abuse clinic. Back then, many clinics tried to build a “hub and spoke” model, where patients would get induced and stabilized in the hub and then transition out to their primary care provider to continue treatment. But community providers were reluctant to take on these patients. I heard worries about the “clientele” disrupting the waiting room and other such prejudices.
So, even with the waiver gone, I hold little hope that primary care practices that don’t have their own clinics will welcome even stable buprenorphine patients for this part of their continued recovery.
I think for those of us who treat opioid use disorder, the most realistic way to move forward is to try to find ways to take on more patients. But there are restrictions, imposed by insurers, Medicaid in particular. You have to have a certain number of therapists in the recovery group depending on the number of participants, and in order to pay the doctor for prescribing and overseeing the medical aspect, there has to be a face-to-face encounter. And you can only do so many in whatever time your group is scheduled for – in my case 90 minutes.
But, strictly speaking, other reimbursement mechanisms may be available. There are grant monies that could move us away a little bit from the face to face with the prescriber and, just like in other areas in medicine, there could be scribes. We also have peer counselors and medical assistants who can gather information, do drug tests and so on.
As much as I enjoy and value the therapeutic aspects of my long term relationships with relatively stable MAT patients, I am starting to feel that maybe I could see them less often in order to make room in my schedule for new patients. Given the fentanyl crisis, and given the statistic that as soon as an addict enters a MAT program, their risk of dying from an overdose drops by 38-59%, perhaps we are not using ourselves as a resource in the most effective way possible. After all, we are in a crisis. Are we in enough of a crisis mode for the situation we are in?
I sometimes see even supposedly seasoned clinicians taper a person off one SSRI like escitalopram (Lexapro) and then starting from scratch with another SSRI like sertraline (Zoloft).
In my experience, this is almost never necessary. Think about it, the SSRIs hit the same receptors. Each drug has a somewhat different personality; some are sedating, some a little energizing and so on. You would also have to consider the half life, like fluoxetine (Prozac) has a long one and venlafaxine (Effexor) a short one. Switching between a long acting and a short acting one may require a wait period or a partial taper. But the main action is similar enough that tapering completely off one and on to another is more likely to cause unpleasant reactions (SSRI withdrawal) than a straight one-day switch. I do the same when switching from an SSRI to an SNRI like venlafaxine or duloxetine. I just ballpark the SSRI potency of the two drugs and, wham, we’re done.
So, as long as you hit the same receptor, it’s not a whole lot more complicated than going from Corona to Bud Light. You might want to consider the potency, and to some degree the drug half life, but it’s not quite rocket science.
I have written many times about how I have made a better diagnosis than the doctor who saw my patient in the emergency room. That doesn’t mean I’m smarter or even that I have a better batting average. I don’t know how often it is the other way around, but I do know that sometimes I’m wrong about what causes my patient’s symptoms.
We all work under certain pressures, from overbooked clinic schedules to overfilled emergency room waiting areas, from “poor historians” (patients who can’t describe their symptoms or their timeline very well) to our own mental fatigue after many hours on the job.
My purpose in writing about these cases is to show how disease, the enemy in clinical practice if wou will, can present and evolve in ways that can fool any one of us. We simply can’t evaluate every symptom to its absolute fullest. That would clog “the system” and leave many patients entirely without care. So we formulate the most reasonable diagnosis and treatment plan we can and tell the patient or their caregiver that they will need followup, especially if symptoms change or get worse.
Martha is a group home resident with intellectual disabilities, who once underwent a drastic change in her behavior and self care skills. She even seemed a bit lethargic. A big workup in the emergency room could only demonstrate one abnormality: Her head CT showed a massive sinus infection. She got antibiotics and perked up with a ten day course of antibiotics.
A month later, her condition deteriorated again. It was on the weekend. This time she had a mild cough. Her chest X-ray showed double sided pneumonia. She got antibiotics again and started to feel better.
When I saw her in followup, she was still coughing a little, and she wasn’t her usual happy self. Her lungs were clear. I asked her caregiver if they had done a head CT the last time she was in the ER. I saw no mention of it in the ER report.
“I’m pretty sure they did”, he said.
I retrieved it from the statewide Maine Health InfoNet site. It described that all the sinuses were infected and only slightly improved from the earlier study.
Martha is now on a much longer course of antibiotics, because a sinusitis often takes a lot longer to clear up than most pneumonias. I sometimes compare this to getting the contents of an egg out through a tiny hole in the shell (I never did learn how that is done). And, a sinusitis can sometimes cause pneumonia because of postnasal drip.
I saw another case the other day where I think I was able to piece things together.
Gretchen had seen another provider for headaches. She had migraines in her youth but they stopped after she had her first child. My colleague ordered a brain MRI to make sure there wasn’t something more malignant going on. It showed what the radiologist described as a possible migrainous angiopathy.
By the time I ended up seeing her, she had had the migraine for over a week and she had taken daily doses of over-the-counter remedies, so I figured that she now had an element of withdrawal headache. Normally I prescribe prednisone in such cases, but Gretchen told me she has had severe psychiatric side effects from steroids before.
I asked her to wean off the OTC medications and started her on topiramate. Gradually her headaches got better. Then, a few days later we got a phone call, saying her migraine had come back with a vengeance. It was late in the day and she had been vomiting. She went to the ER and they gave her IV fluids, metoclopramide and something for pain.
I saw her in followup and she was better but very worried, telling me her headache was starting to build again.
Then she told me something that jolted my brain I to action.
“Whenever I start to hurt on the side of my nose where I had the surgery, the headache comes on.”
“What kind of surgery”, I asked.
“I had a big cyst removed, se-ba-cious I think it was called.”
“Can you take your mask off”, I asked. I had not seen her uncovered face before.
She did and there was a big scar.
“What kind of pain do you have there”, I asked. Is it steady or, like, pulsating?”
“It’s like jabs and jabs, like someone is sticking needles in there.”
I pulled the monofilament from my pocket and started touching her over the three branches of the trigeminal nerve on each side of her face.
“Does this feel the same on both sides of your face?”
“No, it’s different.”
I took a deep sigh and explained:
“This looks like a nerve pain, a neuralgia, in the nerve that reaches the skin outside your sinus there, and also in the other two branches that go to the forehead and the jaw. It’s called the trigeminal nerve and it comes directly from the brain. I wonder if that is what has made your migraines come back after all these years.”
“Can you stop this from getting full blown”, she asked.
“I probably can’t stop the neuralgia very quickly. Most neuralgia medications take a while to,start working, but I’ll send in a prescription for Imitrex. Take one as soon as you get home and you can take one more later today if you have to. Then call me tomorrow and let me know how you are doing.”
The next day she told me she was headache free after just one Imitrex, and the neuralgia was barely noticeable.
I’m curious how she will do in the long run, and I’m curious if the trigeminal neuralgia is somehow related to the surgery she had there.
Like I’ve said before, curiosity is a powerful antidote to burnout.
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