Lack of communication among emergency room staff, poor configuration of information on the patient's electronic health record and diminished focus on patient safety were three of the main deficiencies of Texas Health Presbyterian Hospital in Dallas where a man infected with the Ebola virus was misdiagnosed last year and died, according to an independent report released by the hospital Friday. The hospital asked the five health-care officials on the expert panel to review the events surrounding Thomas Eric Duncan, the Liberian emigre who arrived at the hospital Sept. 25, 2014, and who, hours later, even after his fever reached 103 degrees, was sent home with a diagnosis of sinusitis.
Inch by inch, two doctors working side by side in an operating room guide a long narrow tube through a patient's femoral artery, from his groin into his beating heart. They often look intently, not down at the 81-year-old patient, but up at a 60-inch monitor above him that's streaming pictures of his heart made from X-rays and sound waves. The big moment comes 40 minutes into the procedure at Morton Plant Hospital. Dr. Joshua Rovin unfurls from the catheter a metal stent containing a new aortic valve that is made partly out of a pig's heart and expands to the width of a quarter outside the catheter.
Being more physically active on days when patients with either rheumatoid arthritis or osteoarthritis are feeling especially fatigued buffers the negative effect of fatigue on positive mood, the Dunedin Fatigue Study suggested.
Medicare's wellness codes were launched with great fanfare, but despite the potential largess for primary care, physicians have been slow to submit claims, data shows. From MedPage Today.
A huge victory in primary care doctors' quest for better Medicare payment came Jan. 1, 2011, or so they hoped.
That's when six pages of the Patient Protection and Affordable Care Act kicked in, authorizing three novel billing codes so that as many as 33 million beneficiaries enrolled in Medicare Part B could receive "annual wellness" visits to help them thwart disease. Nationally, the amounts are significant, paying from $118 to $174 for each code, and possibly more in some locations.
That's billions of dollars worth of care physicians couldn't bill before. It pays not for dealing with patients' symptoms but for reviewing their screening tests and immunizations, family history, cognitive and physical abilities, risk for falls, and for designing a "personalized prevention plan" for every beneficiary.
It is, said, Reid Blackwelder, MD, board chairman of the American Academy of Family Physicians, a time "for patients and doctors to take a breath, and focus on looking ahead at risks they need to be aware of. It's a different mindset about care."
Better still, there's no 20% co-payment required as in normal Part B services.
Doctors already provided some of this care, but often in a choppy, haphazard way, squeezing admonitions about extra pounds, smoking, or alcohol use during other office visits.
But despite this potential largess for primary care, physicians have been slow to submit claims. For the third year of the new codes, only 12% of eligible beneficiaries had Medicare billings for these services, according to 2013 data from the Centers for Medicare and Medicaid Services.
"There's a lot of money and services being left on the table because of the way Medicare has structured this," said Joseph Scherger, MD, vice president for primary care at Eisenhower Medical Center, a 48-physician practice in Rancho Mirage, Calif., that struggled to make the codes work for them.
"That's because these visits are different and separate, instead of being integrated into the flow of care. Now, there's this awkward separatism that offices have to work around. Patients want to talk about their medical problems, but that ends up violating the intent of wellness visit," Scherger said.
The reasons doctors give for the poor uptake are many. Peter Lipson, MD, an internist in Southfield, Mich., who blogged about his concerns in Forbes in October, explained that when patients take time to see a doctor, they "expect they'll be able to tell him or her about their gout or sore arm."
"When patients start to do that, you have to redirect them. You have to say horrible things to them like, 'We can't talk about your arm right now. I know it hurts but you'll have to come back to talk about that.'"
"That's always a problem with patients," said Philip Webb, MD, a family physician in Ranger, Texas. "Just as you're walking out the door, they'll say 'Oh doctor, I have this chest pain.' And now you have to stop and address that."
Even with non-emergent complaints, Webb said he tries to manage those then and there, at the end of the wellness visit, "depending on my schedule, and how far behind I am that day." But usually, he doesn't have time, and just says, "I'll be happy to talk with you about that during another visit."
Some doctors find that problematic and don't bother billing these wellness codes because of the confusion and scheduling problems they can cause, even occasionally annoying and angering the patients. Or, they combine them with regular evaluation and management visits that can take nearly an hour.
"To say to a patient, 'I'm sorry, I can't talk about that' -- I can't do that to my patients," said Paul Speckart, MD, an internist in San Diego. "Their daughter takes the day off to drive them -- and they expect everything to be addressed."
Though he believes Medicare's new preventive care codes "are good medicine all around," Speckart said his practice combines the wellness exam "with the elements of the good old yearly physical," because patients shouldn't have to, and often won't, come back for a second, separate exam. While the new Medicare codes "look good on paper, they don't work out in practice" when services are separated this way.
Scherger said his practice has started to turn over the wellness visit to the "lead nurse who does all the intake and gets the targeted history, and goes over all prevention care and immunizations." The physician sees the patient briefly and just at the very end.
"It's kind of like when you get your teeth cleaned by a dental hygienist, and the dentist comes in to take a look at your mouth before you leave. You really have to treat it that way medically if you want to make this work."
If the patient raises a critical problem then, the doctor may reassess, asking "how bad are you right now? Let's get your medical visit scheduled right away," maybe later that afternoon or the next day.
If the doctor can review the new complaint the same day, the practice can add a second visit service to the wellness visit claim with a modifier that enables payment for both, explained Barbie Hays, coding and compliance strategist for the American Academy of Family Physicians.
But the modifier pays less than a separate evaluation and management service visit would. In addition, the physician usually schedules just 10 to 20 minutes for the wellness visit, while a new symptom complaint can take 30 to 45 or longer to evaluate.
Though it has taken a few years to get started, Webb and some other doctors are learning to love the new wellness codes. Webb said they help him "feel better about spending extra time with patients to discuss all these extras, like have you had your colonoscopy and your bone density tests."
Likewise for Michael Richter, MD, an internist in Rego Park, N.Y., who started billing the codes three years ago. "I think it's good for the patient, helps to screen for things that end up causing problems like depression, falls, dementia, and gets advance directives in the record. These are all very valuable things, and ultimately save healthcare dollars."
But these visits are not typical "physicals," or head-to-toe exams, which is what many patients expect when they come to the doctor, and what the physician is used to providing, although some have questioned their benefit in otherwise healthy patients. The patients usually do not even undress.
Not getting a "physical" confuses some patients, and requires time for physicians and their office staffs to explain -- often to uncomprehending 90-year-olds -- what the wellness visit is, and what it isn't, several physicians acknowledged. In fact, as CMS policies clearly say, Medicare never covers "routine physicals."
"That's where there needs to be communication at the front office and scheduling level as to what kind of visit patients are actually wanting, because Medicare does not cover physicals," said Hays. Patients also need to be informed what is a preventive exam, which they do and don't co-pay for, and what is a routine exam, including ordering of lab tests. "We all know we're dealing with elderly patients who aren't always familiar with their benefits," Hays said.
Robert Ostrander, MD, a family practice physician in Rushville, N.Y., said Medicare "made a paradigm shift, but ... made no effort to clarify that it wasn't a physical when they said they were offering this wonderful annual wellness service."
So Ostrander's practice took it upon itself to produce an explanatory letter to beneficiaries. The office also combines the wellness piece and the regular chronic disease management visit, "and anything else the patients want to address." That means patients will get billed a co-pay for the non-wellness part of the visit, and some "do gripe, because people want stuff for free. But most of my patients realize that primary care is woefully underpaid."
Some of Medicare's requirements are silly, Ostrander said. "It's moronic to discuss fall risk and watch someone walk across the room who was in the woods the day before splitting firewood. I don't need to do that screen. But for the wellness visit, Medicare says I do."
But overall, the codes have really been a good thing so far, Ostrander said. The visits have revealed problems he wasn't aware of, like a patient's depression that went unnoticed during regular complaint visits. "I was doing these things before, but for free. And for a lot of doctors it wasn't getting done at all."
Low uptake of the codes is a problem, acknowledged Blackwelder. And doctors need to be educated about "a culture shift" from what doctors are used to providing, which he termed "volume hamster-wheel medicine. It's a way for them to say to the patient 'you don't have to be sick to see me.'"
"And that's a very big difference. In fact I want to keep you from being sick, so let's set up time to look at your behavior, your lifestyle, and your end of life planning, these things that aren't addressed when you're trying to cram everything into one visit."
The burden now is on physicians to explain this to patients in a better way, and be more proactive, which the AAFP is trying to do for its members, "because obviously these codes have been around for awhile and we're not using them," Blackwelder said.
But Medicare should share more responsibility as well, Blackwelder said: "It needs to figure out the best way to communicate with patients" to let them know the value of these new codes, and that they too should request these visits from their doctors.
The government moved Thursday to strengthen protections against discrimination for women, transgender people, the disabled and others who receive care throughout the health-care system, including those who buy insurance under the Affordable Care Act and providers that receive federal funding. The ACA already bars discrimination based on sex and other factors, but the long-delayed proposed regulation issued Thursday explains how the protections will be applied to insurers and health-care providers, such as hospitals and doctors who receive Medicare and Medicaid payments, and it clarifies the standards federal officials would use in implementing the law. The proposed regulation comes as social attitudes about sexuality and gender are undergoing major shifts.
In 2002, medical giant C.R. Bard recruited Kay Fuller, a veteran regulatory specialist, to help secure FDA clearance for its Recovery blood clot filter, after the agency had turned down a previous application. The Recovery, a one-and-a-half-inch metal trap, was designed to sit inside a major vein, the vena cava, and block blood clots from traveling to the heart or lungs, where they could be deadly. In an exclusive interview with NBC News, Fuller said that she had serious concerns about the Recovery. A small human clinical trial raised red flags, and the company did not give her important safety performance test results. But when she voiced her concerns, Bard officials didn't seem to want to hear them.