#I also need to get my pcp to send the hospital my blood test results since they need one but I JUST got a blood draw last week so

[venacoeurva]

ngl I did not expect to be handed a consent form like 30 seconds into actually being seen but it went so smoothly my appointment lasted less than like 10 minutes so I'll take it

[peachpride]

personal medical rambling...

i had to go to the er on saturday for really intense shoulder and side pain. like the worst pain i've ever been in (and i have chronic pain). so after hours of waiting and finally hearing back on the test results all i get is "well everything looks good! except one level is high, so you'll have to follow up with your pcp to get tested for autoimmune diseases!"

like?? okay the level is high, but how high?? and then they don't even send the blood work to my pcp, they just send the xrays that came back normal. i also can't look at the blood work through the hospital's chart site bc it's down for maintenance!!! i just want to know how worried i need to be and quickly i need to move!!

[stitch-n-time]

Topic of Conversation

The setup: I have ehler-danlos syndrome. My primary care physician (PCP) is the one that finally agreed to have the test run, after my seeing like 6 or 7 other doctors that just totally dismissed the idea. I love her. She's fabulous. Would recommend to at least most people. She's also gotten used to me over the past 3-ish years. She's told me in the past that she knows it's going to be an "interesting day" when she sees my name on the patient list. Everything from "my foot folded in half" to "I need you to help slice my toe open to fix this particular thing" to "I touched my leg and the skin split" to the latest one - "I woke up and my thumb was dislocated". All while having conversations that range from "we're going fishing tomorrow" to "haunted museum tours, you should totally bring your kid!" to "no no no... If you're still pregnant on Halloween, you should TOTALLY do the chestburster!" and a little bit of everything in between. So yesterday I go see her because... well, my thumb dislocated in my sleep. Like 2 weeks ago.  It hasn't been quite right since. It keeps subluxating (not quite dislocated, but not quite in the right spot), my grip strength is nonexistent, and it's becoming a problem. While there, I show her a ring brace that I think may help and ask her opinion. (Also about some supplements made specifically for people with conditions like mine, and she’s all gung-ho about my being a guinea pig for this particular one. Will update after they come in, and after taking them for a while.)

“I don’t know. I think it may help? But they’re also really expensive, and I don’t want you to have to spend that much without knowing more. Would you mind going and getting some x-rays? Maybe seeing a sports medicine specialist at the building I used to work in?”

me: “Sure! I would actually feel a little better getting a third* opinion on this, and having the images might help. It doesn’t feel like there’s bone chips or anything but still...”

Dr B: “OK. Let me print out a referral for you. And I’ll get the order for the blood test, so after you’ve taken those supplements for about a month, go ahead and get the bloodwork done. I want to see what happens there.”

me: “Yeah, great. That’s totally doable. And if anything happens with those, I’ll let you know and discontinue use.”

A little later yesterday, I get a phone call from her assistant. “Dr B told Dr D about you over lunch, and he said to go ahead and get just an over the counter soft brace for now. He’ll confirm when he sees you.”

Which... great. Now I know these two are friendly. Cool cool cool.

I call this morning to see if Dr D has openings for some point within the next couple of weeks. “Yeah, we’ve got an opening in about a half an hour. Can you be here?”

“Sure! I’m on the way home from work and haven’t passed that turn yet. Let’s go ahead and do it.”

Now, some important information here: I met Dr B while she was at the teaching hospital. I followed her from her observation, through where she was doing the observations, and into the new building where she works now. Dr D is currently at the teaching hospital, where he is doing the observation of upper level students who are working through their rounds and getting practice before being sent out into the world.

So I get there, go through the weight/height/blood pressure thing again, and go sit in a room. Student doctor comes and does an exam. She’s really taken aback by the whole “Yeah, Dr B had no idea either. But she was the first person to take me seriously. Mostly because she admitted that she had heard about ehlers-danlos but had never seen it, so she looked it up on the internet and essentially ran down the checklist while I listed off symptoms. Immediately ordered the test. Which, really? Just a simple blood draw? That could have been done years ago!” thing. Then we get to laughing about it.

SD: “Can you do that thing where you touch the ground, but with your hands flat? I can’t even touch my toes.” She demonstrates.

I laugh. “Yep!” Stand up, smack my hands flat on the floor and keep walking them back until my shoulders are behind my knees. “Want me to keep going?”

At this point she’s laughing, too. “What else can you do?”

“Touch my nose with my toes. Put one arm up and one arm down and grab my wrists behind my back. Before I had kids, I could bend backwards and put my heels on my chest. From behind. But I can’t do that anymore.”

Student doctor leaves. I can hear muffled conversation through the wall adjoining the exam room to Dr D’s office. Student doctor comes in. Dr D comes in, with a really amused look on his face. Introductions are made, he repeats the exam, checking a couple of things that student doctor didn’t know to check. He’s explaining why as he’s doing the exam. I’m nodding along, because this is familiar territory to me, thanks to previous work experience.

Dr D is doing the “Does it hurt here? Here? Here? What about if I do this?” thing while poking at the thumb and wiggling it around.

me: “No, not there. Pain receptors don’t quite fire correctly because of the EDS. The pain is specifically here, here, and here,” said while I put a finger on the spots.

Dr D: “Oh yeah. I forgot about that.” He leans back against the counter. “Honestly, you’re the first person I’ve ever actually seen with EDS. So a lot of my knowledge is more theoretical. What did you do that might have caused this with your thumb?”

me: “Slept?”

They both blink at me a few times. It takes a minute. 

Dr D: “No, no. I guess that makes sense. With your condition and all.”

me: “Yep. It just kinda happens. Now I know you talked to Dr B yesterday and approved a soft brace, but I want to show you something and get your opinion. Because I research everything. It’s what I do.” 

I pull out my phone and show him this:

“I’m more worried about the lateral movement than the hyperextension, since the hyperextension is something that’s happened ever since I can remember and has never been a problem.”

Dr D: “Oh yeah, that will do everything I would hope for. Probably a little more. That looks better than anything I would have been able to recommend.”

me: “Perfect! I’ll see about ordering one, then. I was reluctant because of the price.” I stare at it for a minute. “Or maybe I’ll see about getting some sturdy wire and just making it my own damned self.”

Dr D: “I’m still going to send you for x-rays. I don’t think there’s anything there, but it’s a safety precaution in case of bone chips.”

me: “Yeah, Dr B and I talked about it yesterday, but I thought it would be a good idea to see you first. I don’t think there’s anything in there, but...”

Dr D: “You know we’re having lunch with Dr B today, right?”

me: “Yeah, I kind of figured. She fan-freakin-tabulous. Just don’t tell her I said so.”

Dr D laughs at me. “Yeah, we’re best friends. It may just slip. That happens sometimes. You already know we’ve talked about you, since her office called you yesterday.”

me: “More power to ya. Hell, if you want to talk about me to more people, let me know. Especially if there’s a new doctor you want to freak out a little bit. I’m an interesting case, and will absolutely tell them when they’re wrong.”

Dr D: “Oh. We are definitely going to be having a talk over lunch today...”

*third opinion, as she is confident that I have stupid amounts of self awareness, and actually know if something isn’t right before test results would show anything, so her confirmation counts as a second opinion when it’s just the two of us in the room

[fandoms-and-flute]

Post Occupational Therapy

I just finished 2 months of occupational therapy for my right hand, and as a flute player, maintaining physical health is essential to having a long-term career so here’s what I experienced and learned! and feel free to send any asks if you have any questions :)

How did you start going to Occupational Therapy? *warning this is a bit of a long explanation and US specific)

If you live in the US (specifically NJ) as a young adult, you will 100% relate that health insurance is a nightmare. I have the state insurance so for me to do anything (even go to the allergist) I need a referral from my PCP (primary care physician aka my doctor). 

When I started to notice how bad my hand health was affecting my playing the FIRST thing I had to do was go to my primary doctor, and he told me that I should first see a rheumatologist (aka hand specialist). Now you can’t just get a referral no no no-- you have to spend hours calling places to find out if they 1. take your insurance and 2. have an appointment available/take new patients. How do you find these places, you ask (with no evident sarcasm)? Well let me tell you: On the very shitty healthcare website that hasn’t been updated since originally published! 🙃

Once I found a rheumatologist, I then had to go BACK to my primary doctor to get a referral. Now I was very fortunate because I was able to get an appointment within a week (usually it could take a month or more!) so I really lucked out. At that appointment, I was checked for all different problems (carpal tunnel, arthritis, etc) - I had 5+ vials of blood taken for testing and X-rays done all on that day; and the rheumatologist was the one that told me I should go to occupational therapy. But it’s not that easy (of course it isn’t, it was so stressful).

When you have the basic health insurance, it is nearly impossible to get a hold of any therapy or pain management that takes your insurance. I had to call places several times - one place that could take my insurance actually flooded and so I was borderline mental breakdown. TWO WEEKS in (3 weeks of pain), I finally found a local hospital that had a rehabilitation center that accepted my insurance. Hooray. Except it was a bit more complicated than that. My advice is to just call as many places and ask “What insurance do you guys take/Do you take ____ insurance?” because co-pays are expensive so you want that covered as much a possible!

Now that I found a place that was accepting patients and took my insurance, I had to go back to my primary doctor (for the 3rd time) to NOT ONLY get a referral. I made that mistake - I went to my first appointment with just a referral and they could talk to me, but couldn’t run any tests. Why? Because you need a referral AND a prescription 😒so I got the prescription from my primary doctor (for those keeping score, 4 visits) and FINALLY I could go to occupational therapy for 12 visits. 🎉

tldr: I took me 3 1/2 weeks to finally find an occupational therapist (4 weeks if you count when I had my first official appointment). And was a super complicated process.

Why did you go to Occupational Therapy?

For a few years, I constantly felt like my technique was suffering because of my body’s inability to keep up with the demand of the flute. It peaked this semester when I had complete numbness and pain in my right hand (specifically the wrist and the ring and pinky fingers). 

Did you feel like Occupational Therapy was helpful?

Yes! I am hyper aware of my body at all times so I knew things were wrong, but I didn’t know what specifically (inside) was wrong or even how to fix it so OP helped me target specific problems and manage them. I learned stretches and exercises to manage my pain. It will still be an ongoing battle - you don’t just go to occupational therapy, do some work and then are OK for the rest of your life. It is being aware and constantly checking in and adjusting in order to manage the pain so if you are interested in going, just be aware that it is a very mentally tiring effort that will require your full involvement in order to see results.

What did you go to Occupational Therapy for?

As I said before I went for complete numbness and pain in my right hand (specifically the wrist and the ring and pinky fingers). I learned that I had carpal tunnel (which is the wrist) and cubital tunnel (which is a inflamed and pinched nerve in the elbow that affect the ring and pinky fingers). 

*also, when I went back to the Rheumatologist for my results (one month later), I learned that I have osteoarthritis (in my right hand thumb) - which has no cure and is super painful. This is the type of brace that I wear to support my thumb while playing flute:

What did you learn from Occupational Therapy?

Continuing from the above question, I started with learning about the wrist/elbow. I learned that I tend to hyper/over-extend my elbow. One of the first exercises I learned that I still use daily is:

I tend to have a high body temperature so I struggle to tell when my wrist or elbow is inflamed - this exercise had helped me focus on the area (I use my other hand to massage the tendon and through touch I have learned what it feels like when my carpal tunnel is flaring up). Icing also helps a lot!

An elbow exercise I learned was: 

This was targeted towards the cubital tunnel to help when I had wrist pain (on the side of the pinky/ring fingers). Because I hyper/over-extend my elbow, this exercise is targeted at activating my shoulders/trap muscles and (vocab word) serratus anterior!

One of the recent exercises I learned was one to engage this serratus anterior - facing the wall, you have to have your feet shoulder width apart or slightly wider; elbows and wrist must be against the wall (also shoulder width apart), and keep the back straight. You can do this with or without a resistance band, move your arms up, back to initial position, and down (one arm at a time, and tiny movements) - it is to focus on using the lower traps instead of compensating with the elbows.

How did Occupational Therapy help/affect your music playing?

Every time before playing I would stretch for a minimum of 5 minutes. Doing any of the stretches mentioned above, plus just general body stretches- I would also take a few minutes to focus on breathing (doing a bit of the Breathing Gym, and if you aren’t familiar check this out!!). I would also take breaks any time I felt any pain and I always have ice and an ice pack with me. Primarily I would ice my wrist and elbow depending on the pain (and I would stretch). 

As previously mentioned, I wear a thumb brace when I play. However, when I’m just going about my day (typing, writing, sleeping) I also have to take care in order to maintain my hand’s health. This requires me wearing a brace for my carpal tunnel: 

I literally wear this anytime I sleep, write or type because it prevents me from curving my wrist in a way that causes inflammation. (General health throughout the day is connected and essential to maintaining playing health!!!).

Also, this is probably my favorite thing to come from OP, I present to you... the ELBOW PILLOW:

(Yes, that is a rolled up scarf that is tied with a hair tie.) This is a great way to engage the serratus anterior, rather than use my elbow (it must be held, it can’t be suspended by a strap or belt). And it reminds me to bring my elbow down and back. 

If you were to see my practice notebook, you would see me writing EVERY DAY the same posture mantra: shoulders down and back, elbows down and released, hips and shoulders even, and lift the neck. It is a huge learning curve that will take time to become habit, but right now I’m still fighting my body have better posture.

What was a regular appointment of Occupational Therapy like and how often did you go?

I went to OP only once each week (because I’m a very busy college student with no time for life outside of school), however, I was recommended to go twice a week! 

Every time that I went (after the initial measuring appointment), I arrived 10 minutes early to have paraffin wax on my hand and then I would sit with the paraffin and a HUGE heating pad for 10 minutes. In the beginning half of OP, I had the elbow, wrist, and forearm massaged to break up knots - and my therapist taught me how to find tension spots and how to break knots without hurting myself. In the later half of OP, I would do various exercises such as: 1. a noodle that I would have to bend up or down (to activate the shoulders/back instead of my elbows), 2. putty (yes actually putty) to smush with my fingers for carpal tunnel, 3. using a rolled up towel against my back (to be flat against) to pull back my shoulders, 4. modifications (next ask!), and 5. learning a bunch of different stretches.

What kind of modifications did you learn from Occupational Therapy outside of music?

For writing... I am a mess. I wear the carpal tunnel brace because my wrist wants to curve. I need to write at an angle to the desk (both my body and the paper). I have a pencil/pen grip that allows me to curve my thumb in rather than the hitch hiker thumb, and use my index finger. Also, I have to write at a slant using a binder to help my wrist’s angle. 

Before: (my thumb would go under my hand and I would rest the pen/pencil on the webbed part of my hand.. essentially no support).

After: (my wrist is forced to be straight by the paper being at an angle. The black thing on the pencil is the grip that has grooves for my fingers so there is more control) - and the pencil is no longer resting in the webbed part.

For typing... I am beyond a mess (I don’t know how this happened, I grew up with all those typing CD-roms... but I type with only 2 fingers, maybe 3 in each hand. I leave out the ring and pinky fingers...). The modification for this was to elevate myself above the computer/keyboard -  either a short desk, raise my chair or sit on a pillow (anything to get my forearms at a downward diagonal). Also, having a pillow/towel behind my back (flat back) with shoulders back rather than rounded forward. 

_____________________________________________________________________

There is a whole lot more that I worked on, but like I said just send asks if you have questions. I still have loads to work on, manage and be mindful of.

[your-dietician]

Primary care docs need to prepare for CGMs for type 2 diabetes

New Post has been published on https://tattlepress.com/health/diabetes/primary-care-docs-need-to-prepare-for-cgms-for-type-2-diabetes/

Primary care docs need to prepare for CGMs for type 2 diabetes

In the last year, Jai Smith has cycled through 13 primary care doctors. Ever since being diagnosed with type 2 diabetes in 1995, she’s tried her best to manage a disease that has devastated her family: Her grandmother and four uncles died from its complications.

But she’s struggled to find a doctor in her hometown of Little Rock, Ark., that will give her what she wants to manage the condition: a continuous glucose monitor. Like many patients with diabetes, Smith uses fingerprick glucose tests to help dose her medications. The 44-year-old was immediately interested when she heard about CGM, which uses an embedded sensor to collect a proxy for blood glucose around the clock.

“I’m already having to prick my finger three to four times a day,” she said. “Immediately I’m like, ‘OK, I should be a shoo-in, let me ask my doctor.’”

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But that doctor didn’t think it was a fit. Neither did the next one, or the one after that. Most, she said, gave her the same materials about nutrition and exercise, and occasionally tweaked her medications before sending her out the door with a follow-up appointment. Some told her that CGMs weren’t appropriate for people with type 2 diabetes; others told her there was no way the device would be covered by her Blue Cross Blue Shield insurance.

Smith’s frustration is becoming more common as CGM technology is exposed to patients with type 2 diabetes, the product of growing advertising budgets and a slowly growing evidence base. The job of fielding those requests falls mostly to primary care physicians, who lead care for patients with type 2 diabetes. But as demand grows, many of these doctors remain unprepared to interpret the evidence needed to prescribe them or navigate the minefield of securing insurance coverage.

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That’s because up until now, the devices have primarily been a tool of endocrinologists, specialists in hormone regulation who first used them to protect against dangerous dips in blood glucose in type 1 patients. Most patients with type 2 diabetes will never see an endocrinologist, though. In Smith’s long run of doctors, she’s only seen a specialist once.

“It’s just a numbers game,” said Steven Edelman, an endocrinologist at the University of California, San Diego. There are only 8,000 or so working endocrinologists in the United States, and 34 million Americans with diabetes — about 30 million of whom have type 2 diabetes. Like Smith, about 90% of them receive their care from a PCP. As the evidence and demand for CGMs in type 2 diabetes grows, those physicians will need the resources and tools to get sensors into the right arms and bellies.

It’s only in the last few years that doctors have even considered CGM a viable option for patients with type 2 diabetes.

The tides began to turn in 2017, with the publication of the Dexcom-funded DIAMOND randomized, controlled trial. It looked at the effect of real-time CGM use for people with type 2 diabetes who were on an intensive insulin regimen: daily background injections, plus extra doses at meal times. Their A1C levels, a measure of average blood glucose, dropped by 0.3% more than those using standard blood glucose strips over six months — a small but statistically significant change.

Around the same time, devices from Dexcom and Abbott were getting smaller, cheaper, and more convenient to use. Patients with type 1 diabetes, who are especially at risk of dangerous low bouts of blood sugar, had been willing to put up with the finicky technology because it could save their lives. But the easier the devices got to use, the more it made sense to test their use in type 2 diabetes.

Medicare started covering CGMs for patients on intensive insulin in 2017, and by now, many endocrinologists will prescribe CGMs for type 2 patients who take multiple daily injections of insulin or use an insulin pump. The devices seem to help these patients keep their A1Cs in a healthier range — and prevent acute complications, just like with type 1. Recent claims-based research funded by Abbott has shown that six months of the company’s FreeStyle Libre, a “flash” CGM that collects readings with a swipe over the sensor, can reduce emergency visits and hospitalizations for type 2 patients using insulin.

“The people with insulin are the low-hanging fruit,” said Irl Hirsch, an endocrinologist at the University of Washington.

Research is also beginning to show that CGM could help type 2 patients on longer-acting basal insulin, who take their medication just once or twice a day. Earlier this month, researchers reported results from the MOBILE study also funded by Dexcom, a randomized, controlled trial of CGMs for people with type 2 diabetes on basal insulin. Unlike past studies which looked at patients being treated by endocrinologists, this study recruited patients from primary care doctors, who were then advised by diabetes specialists.

“They drew the population from primary care, because that’s really where these people are being managed in the real world in America,” said Thomas Martens, medical director at the International Diabetes Center and lead author of the study, which saw a statistically significant decrease in A1C over eight months with CGM compared to traditional fingerstick monitoring — a 1.1% drop instead of 0.6%.

Another study this month looked at real-world outcomes and found that CGM use among patients with type 1 and type 2 diabetes who used insulin was associated with lower A1C levels and lower rates of emergency department visits and hospitalizations for hypoglycemia.

“Perhaps most telling is that people with type 2 had greater improvement than those with type 1,” said Revital Nimri, an endocrinologist at Schneider Children’s Medical Center of Israel, during a session focused on primary care CGM use at the annual meeting of the American Diabetes Association. “Nevertheless, only 1% of the type 2 population got access to CGM, compared to 61% of those with type 1.”

But their effect in the real world will depend on whether — and how — primary care physicians are able to deploy them.

The first barrier is simply awareness. “I have some primary care colleagues who are very comfortable prescribing the FreeStyle Libre and telling patients the basic instructions to get it started, and I have some folks who have pretty much not even heard of a CGM or wouldn’t really know the first step,” said Tejaswi Kompala, an endocrinologist at UCSF and Livongo’s director of clinical products.

But the public is growing more familiar with CGMs, thanks in part to free device trials and ads like Dexcom’s multimillion-dollar Super Bowl spot featuring Nick Jonas.

“Even though this was geared toward patients, it was seen by doctors too,” Hirsch said, adding that he started getting emails from colleagues in primary care about prescribing CGMs; Kompala, too, began receiving more inquiries from patients before she could bring up CGMs herself in visits.

Companies are also ramping up direct outreach. Dexcom has targeted its education initiatives at primary care doctors who prescribe a lot of insulin to their patients with diabetes; more than half of patients on intensive insulin, type 1 or 2, are treated in a primary care setting. “[If] you look at the penetration of CGM in the endocrinologist community, it’s so much higher than the primary care community,” said Dexcom CEO Kevin Sayer. “We are a business, so we’ve got to look for new customers, and that’s where a lot of the patients reside.”

Primary care physicians will also need to be confident in how to best prescribe and manage their patients’ care on CGMs. “It isn’t that you just stick a device on someone and they get better,” said Anne Peters, an endocrinologist at University of Southern California’s Keck School of Medicine and co-author on the MOBILE study. “You put a device on someone, you work with them, and you improve outcomes.”

“The bad news is the primary care providers are not trained for this yet,” said Hirsch. “They don’t have a good infrastructure for looking at data. They don’t have a good infrastructure for dealing with all the hassles of getting the patients their devices.”

The problem isn’t so much that CGM data is inscrutable, but that primary care doctors aren’t often trained to read the standard format for the information, which is called an ambulatory glucose profile and shows several measures of a patient’s blood glucose activity. “If primary care doctors are educated on how to read a CGM, it’s amazing how much they can focus in on the major problem within 30 seconds,” said UCSC’s Edelman.

During the pandemic, Hirsch led a continuing medical education module on best practices for telecare in diabetes, including CGM use. After the session, 86% of the attendees said they intended to change elements of their practice — mostly by incorporating CGM data or advocating for coverage with insurance providers. But that kind of change requires an investment of time that PCPs rarely have.

“If you ask a primary care provider: Do you think that people with diabetes that you’re seeing in your clinic might benefit from CGM? They’d probably say, ‘Probably, but I don’t have the time,’” said Mahmood Kazemi, Abbott’s chief medical officer.

They also often don’t have the technical setup to easily ingest CGM data. Patients can share their data with physicians through the manufacturers’ portals or aggregators like Tidepool and Glooko, but that still requires toggling between screens during a visit that’s already short on time. To record that data in EHRs, providers still have to manually type in glucose metrics, and some resort to screenshots or even printouts to scan back in.

“The truth is endocrinology clinics, they’re set up to get access to the data; they’re sort of primed for this,” said Martens. “Primary care, not so much.”

Some providers and device manufacturers see a solution in better interoperability. Martens’ International Diabetes Center just launched a pilot with Abbott that directly integrates its data into the practice’s EHR. “This is really key for adoption in a primary care setting,” said Kazemi.

There’s only so much that simple data porting can do to help, though. “The thing that’s missing in a lot of these platforms is suggested therapeutic interventions,” said Edelman, which could help primary care providers navigate the ever-growing list of diabetes medications and nuanced insulin dose adjustments. Experts said it could be valuable to feed CGM data directly into EHRs to inform clinical decision support for primary care physicians. “The real dream is artificial intelligence to help guide insulin-based therapy,” Martens said.

Before all that, though, primary care doctors must jump a high hurdle: getting CGMs covered.

Currently, CGMs are easily reimbursed for patients with type 1 diabetes, but Medicare coverage for type 2 diabetes requires meeting a long list of criteria. The Centers for Medicare and Medicaid Services recently stopped requiring patients to measure their blood glucose four times a day in order to qualify, but three-times-daily insulin injections are still a requirement. And primary care physicians have far less experience navigating the rules so their type 2 patients don’t get hit with hundreds of dollars in additional expenses each month.

Many patients, meanwhile, are relying on primary care providers to help jump through all those hoops and prescribe CGMs when appropriate, which they aren’t always willing to do.

“I know it’s probably a small chapter in the medical book about diabetes,” said Smith, who is still waiting for her monitor. “But if you were a doctor and you have 300 patients and 275 of them are diabetic, you don’t want to go a step further for your own patients? That’s the part that I just can’t understand.”

Six months ago, she finally found a doctor she’s willing to stick with, who took her off most of her medications, including insulin, to start from scratch. With most commercial insurance following Medicare’s lead, she won’t qualify for CGM coverage any time soon.

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[anniekoh]

elsewhere on the internet: yes, medicare is that complicated

So I’m down with Medicare for All as a banner slogan, but as many folks have pointed out, part of the problem with the American health care system is its preposterous complexity and Medicare is part of that complexity. Here are a few articles at KevinMD.com I found useful in thinking through what I don’t know about Medicare.

[High cost of medical procedures in the U.S. chart. Source: Washington Post, 2013]

Fix the pay imbalance between specialists and primary care physicians ZACHARY JANOWSKI | AUGUST 27, 2017

Medicare’s current system for paying physicians dates back to the early 1990s. To fix the historical-prices problem, Congress ordered the creation of an elaborate price-setting formula based on the relative value of procedures (not the value to the patient, but the value of the inputs). Hsiao worked with hundreds of doctors, economists, and other experts to develop the resource-based relative-value scale (RBRVS). Hsiao measured how doctors spent their time—and the intensity of that time. This so-called “work value” accounts for about half of what a doctor is paid by Medicare. The other half covers practice costs. Medicare also pays for malpractice-liability insurance, but this accounts for only a small fraction of fees. Medicare adjusts what it pays doctors based on geography and uses a conversion factor to determine how much to pay doctors for each diagnostic code. Until 2014, there were more than 10,000 codes. With the implementation of ICD-10, an update to the World Health Organization’s medical-classification conventions, that number has exploded to 140,000.

Measuring a doctor’s time and effort takes its own share of time and effort. The George H.W. Bush administration didn’t want the government to play that role, so the American Medical Association assumed it. The AMA created a committee of doctors heavy on surgical specialists. Thirty-one doctors help Medicare set prices for every doctor in the country.

…. Berenson coauthored a 2007 study showing that the gap between primary care and specialty income had grown from a little more than $80,000 in 1995 to more than $135,000 in 2005, meaning specialists earned nearly twice as much as generalists. The same study, which appeared in the Annals of Internal Medicine, cited a study showing the share of medical school graduates going into family medicine fell from 14 percent to 8 percent between 2000 and 2005. “Although incomes of primary care physicians are far higher than the earnings of most persons in the United States, and the public has little sympathy for physicians who cry poor, the lower income of primary care physicians is a major factor leading U.S. medical students to reject primary care careers,” Berenson and his coauthors wrote.

[Photo of medical bill from Tucson News story on facility fees]

Facility fees are ruining quality care NIRAN S. AL-AGBA, MD | MAY 1, 2017

Medicare pays double the amount for office visits at hospital-owned clinics as compared to private physician offices, according to 2012 and 2014 reports by the Medicare Payment Advisory Commission (MEDPAC), an agency that guides Congress on Medicare spending. For example, Medicare paid $453 for an echocardiogram at hospital-owned facilities, yet the same test performed at an independently owned physician office costs, on average, $189, according to the 2014 report. In its 2012 report, MEDPAC found Medicare paid 80 percent more for a 15-minute visit at a hospital-based clinic compared to one at a private practice.

Hospital-based clinics tack on “facility fee” charges, which are separate from the bill for the doctors’ services, for the use of the room in which the patient was seen. One hospital administrator told me to think of it as “room rental.”

Eliminating the facility fee and setting hospital reimbursement equal to that of independent physicians for 66 procedure groups, results in $900 million per year in savings on Medicare costs. However, eliminating the charges has proved daunting, for $3 trillion “reasons.”

[MRI prices by state, Alaska averages $3,169 and Washington State averages $1,743. Source: USA Today]

The chargemaster is health care’s most evil component DR. SAURABH JHA | JULY 26, 2017

Whatever the morality of deductibles — and they are a trade-off between higher premiums for healthy Peter and higher out of pocket expenditure for sick Paul — a deductible is short-lived if decimated, for example, by a single visit to the emergency department (ED) for vague chest pain which leads to a triple rule out CT angiogram. This is because the charges imposed on the patient before insurance kicks in are the list charges — the dreaded, illogical, evil and, frankly, stupid chargemaster rates. This is not like drinking premium whiskey in a premium hotel. It’s worse.

The chargemaster is a hospital’s list price which hospitals use to show how much charity work they’re doing.

“Look we just did $3000 of charity by giving away ten $100 saline drips, which only cost us $2, for free. Can we keep our Mother Teresa … I mean non-profit status?”

Hospital administrators, in clandestine meetings, use the chargemaster to negotiate with insurers reimbursement for medical services.

Let’s revisit their imaginary, though not unimaginable, conversation.

Tom: $10,000 for CT angiogram for uninsured Abdul. For the rich people your plan covers, all I ask is $1000.

Price: No, $200. Take it or leave it.

Tom accepts, but his ego is bruised. Once bitten, twice shy. Tom returns with a vengeance.

Tom: $15,000 for MRI/ MRA of the brain. That’s what we charged Abdul, that uninsured cab driver straddling the 400 percent Federal Poverty Level (FPL). For your Goldman Sachs’ bankers, all I ask for is $2000.

Price: No, $200. Take it or leave it.

Tom: Did I tell you we’re merging with three other hospitals in New York?

Price: OK, can we make it $1800?

“Thou shalt not charge un- or underinsured more than Medicare rates for services rendered in any hospital which accepts Medicare.”

#Medicare4All won’t fix the problem SHANNON TAPIA, MD | JULY 13, 2017

For a medical analogy, I’ll use one we geriatricians think a lot about: the prescribing cascade. A relatively healthy 60-year-old starts taking Aleve (or any NSAID) regularly for her osteoarthritis. It’s over the counter, and it works. She continues her Aleve for years until she sees a new PCP at age 65 and is found to be hypertensive. Lisinopril is prescribed, but it’s not enough. Hydrochlorothiazide is added. Eventually, she’s placed on a PPI for reflux symptoms. She later develops a hot, swollen toe and is started on allopurinol for gout. All of these medications were started appropriately relative to the symptom, however medical providers don’t stop to ask if perhaps there is something at the beginning that caused the cascade of medication pile on. NSAIDs cause reduced perfusion to kidneys, which leads to elevated blood pressure, particularly with chronic use. Hypertension must be addressed. But the BP meds have side effects (like thiazides can cause gout). Likewise, the NSAID causes a more acidic stomach, and then a patient needs a medicine to fix that. Chronic PPI use is associated with higher infection rates. It goes on and on. But the doctor or provider who sees the whole picture and appreciates the value of the long-haul would dig deeper before prescribing the first anti-hypertensive and question what the patient takes over the counter. In doing so, they would remove the NSAID and suggest safer pain management along with lifestyle interventions. The initial base treatment for her primary issue needs to be reformed, because it no longer makes sense. It’s also causing a cascade that ultimately will lead to earlier morbidity and mortality for her if the reflexive approach of only treating symptoms is continued.

Medicare uses the “relative value unit” (RVU) to determine what they deem is valuable from physicians and thus decide our pay. However, the formula for the RVU prioritizes procedures and high-volume patient turnover to time-based care. Essentially, Medicare does not pay doctors for their time and knowledge.

In applying the same RVU schema and formula to all types of doctors, Medicare has now steered physicians away from primarily time and knowledge-based fields, like primary care, geriatrics and general internal medicine, and into the specialties that only have to focus on one body system and also have lots of procedures. It takes a lot more time, mental energy and documentation if you have to think about all systems interacting including the patient’s preferences than to focus on one system.

How to game medical coding isn’t why I became a doctor FRED N. PELZMAN, MD | AUGUST 9, 2017

Take, for example, the recent push to expand our use of Risk Adjustment and Hierarchical Condition Category (HCC) Coding (a mouthful in more ways than one). This somewhat contorted initiative was created to ensure that we adequately represent the severity of the medical conditions we are providing care for, by trying to get providers to always include the codes that increase the risk factor coefficient at which a patient is billed.

When I got my report back, two auditors from our department came to my office and went over my charts with me, and showed me where I had opportunity to use higher codes to bill, to increase the risk factor score for these patients, to improve the reimbursement rate the institution receives for the care of these patients.

The auditors’ idea is that somehow by including all of the medical conditions that a patient has and classifying them at the highest level of risk, they can accurately reflect and reimburse for the complexity of the care each of our patients requires. While this makes sense from a certain standpoint, this is never been the way we’ve been taught to think about billing.

Billing in the electronic health record, even going back to paper charts and the paper bills we used to send out, was always related to the symptoms a patient presented to see us with that day, the diagnoses we made that day, the medical conditions we managed that day, and the medical conditions that interacted with the diagnoses made that day that were somehow complicating them or affecting how we managed them (such as diabetes with foot cellulitis, or COPD with upper respiratory infections).

That day. To include medical conditions we didn’t manage that day that had absolutely nothing to do with the visit, was anathema to our thinking, and was even considered billing fraud.

Just because the patient had heart failure, if you didn’t manage it that day, if it was in the purview of some other provider, in no way impacted your medical care that day, and you included it in the billing, well, you were up to something no good. Padding the bill.

In fact, when this sometimes inadvertently happened, such as when a medication that was refilled was linked to a problem, patients would see this reflected on their bill and often complained, saying, “I wasn’t there to see you that day about my heart failure; why am I getting a bill about this?”

It makes sense to do what we can to get reimbursed accurately and adequately for the care we provide — nothing more, nothing less. But I kept telling them that this is not how I was trained; this is not how we think; this is not doctoring.

[simplelittlebrowngirljae]

Becoming an advocate

I have lived with chronic illnesses since I was a child. While they were mild, I faced some challenges in learning to deal with the fact that my life was different. At age 7, I started breaking out in hives and these weren’t your ordinary hives either. They were so massive, almost the size of a large tomato. And they were all consuming. We would spend days and hours going back and forth to doctors and Emergency Rooms and never found answers. My mother kept pushing and doctors were stumped. And then this mysterious cough came and took the place of the hives. And for months we back and forth to doctors and specialists and nobody could figure things out yet again. It wasn’t until my mother, who had been pushing and pushing got my PCP to give us a referral to another specialist and what happened next was beyond mind blowing.

We went to see an Ear, Nose and Throat doctor and literally within moments he was able to diagnose me….I had asthma. He knew that cough very well and gave me a referral to an amazing pulmonologist. And that doctor was just as awesome and gave us some great resources to learn to manage this condition.

I know that none of that would have happened if it wasn’t for my mother continually pushing for answers and the ability for us to see multiple doctors and specialists and have tests ran. The reality is that many people are unable to access healthcare nor effectively manage their chronic conditions.

Let us fast forward many years and me having to go through almost similar situations again. This time it started with my feminine pain and issues and me desperately seeking to be heard and diagnosed. It took me 13 years and 13 doctors to end up being diagnosed with Endometriosis. I was blown off, dismissed and had so many door shut in my face that it discouraged me and made me feel like I was insane until I finally found a doctor who believed me and was able to help. And I wish it stopped there. But it never does. Also during this time I developed so many other symptoms and had to seek out other doctors and the same thing happened. It would take me years to find someone who understood what I was going through and receive not only a proper diagnosis, but proper treatment as well.

And once again, I wish I could stop there but that isn’t how life works right? Right. I have had to go through all of this yet again, but with my parents and let’s just say it is much harder this go round. Something about having to do this while still fighting my own battles just makes this beyond exhausting. But if I don’t step in and help, then what will the outcome be? Who will be the one the assist them? I will tell you what will happen because I just went through this.

My father was to have a two day surgery about a week ago on his back. He went in for the first part of his procedure and that went fine. He was in his room when he started to crash. His b/p and other vitals began to drop rapidly and the rapid response team was brought in. They got him stable and then noticed a pool of blood in his bed. They also noticed his catheter bag was empty. Over a several hour period he had not voided any urine. They removed the catheter and tried to place another one. Same situation happened. He had lost more blood and his bladder hadn’t drained. They tried to cath him again and had no results. We went through this several more times and then eventually the urologist came and they got a good cath. His urine finally drained and it was filled with blood. He had also lost quite a bit of blood at this point.

The doctor came in the next morning and told my mother and father that he could not do the second part of the surgery because he had lost too much blood. At this point I was on my way to the hospital to see what the hell was going on. I found out his blood level were so low and he was basically at transfusion level. However, they wouldn’t transfuse him. He also still had quite a bit of blood in his urine and on top of that he was a bit disorientated and wasn’t eating. He also had these severe hiccups and was not getting the medications ordered for him. Because all of this was going on, I requested the Patient Advocate, Nurse Manager and the Hospitalist. They didn’t send any of these people, just assistants and at this point he was not doing well. So we filed a complaint with the hospital. He was discharged with a catheter, blood in his urine, not eating and dangerously low blood levels. We know that this occurred 1.because nobody wanted to take responsibility for what had happened post operatively with the catheter which was the cause of most of his problems 2.because he was a patient of color and 3. Because nobody really wanted to address these issues.

My mother and I spent days pushing and advocating for his care and yet nothing happened.  Even after his discharge we are continuing to push for things to be addressed and for the continuity of care as he should have it. However, this is more of an uphill battle than we have ever experienced. And the sad part is, the resources are there, the doctors that need to be ordering these services are simply not doing it. However, about a week out of the hospital we did see a glimmer of hope…his primary care doctor was able to finally fully review all that transpired and not only was she upset at the chain of events, she was able to order some things that would help him comfortably recover at home. Praise God for a great Primary Care because without her I don’t think that we would have made any progress. She also has made a complaint about his care and it is documented that she has great concerns with how he was treated during his inpatient stay.

So here is the other harsh reality: many patients do not have advocates and the ways our healthcare system is set up, if you don’t have someone who can serve as your voice when you are unable to speak, then it is almost as if you are doomed. And this a shame. We live in a society that if you don’t have insurance or if you are of a certain socioeconomic status or even of a certain race, then these factors predetermine the level of care you received and that isn’t right. And if these things cannot be changed, then it is necessary to have someone pushing for you to get the best care that you can receive. And even if you have insurance or you are from a privileged background, you still have to keep pushing to get the best care because if not they will leave you to perish.

I the coming weeks, I know I will continue to stretch and strain myself to help my mother care for my father, and also ask the tough questions at his appointments. And I know his providers may not have the answers we are looking for but as an advocate, at some point they will need to come up with the answers and that is the honest truth. And the same goes for those who work in hospital administration and with the insurance companies and any other aspect of the healthcare industry. When we know better we do better!

[optometrist0]

Retinal Eye Exam

Contents

New algorithm examines retinal fundus images

Left … and specialists are scarce

Eye exam phoenix can

Explains how even today most hospitals

Does accept vision

A new algorithm examines retinal fundus images of eyes (left … and specialists are scarce and people otherwise wouldn’t have easy access to in-person eye …

Alexander Valley Healthcare's diabetic retinal eye exam rate for. QIP/HEDIS measure for the first quarter of 2017 was 23% and increased to 40% as of the third quarter of 2017. This is due to. AVHC purchasing a retinal digital camera in order to do screenings in house. At AVH, in house retinal exams were implemented in …

The eye exam phoenix can be used to determine problems through technology. Eye exam AZ aims to find & treat problems by using retinal imaging in our office.

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At my most recent yearly eye exam I was asked if I wanted to pay more and not have my eyes dilated for the retinal exam. I declined, had my eyes dilated and all was well.

Visiting an eye care professional for a comprehensive retinal exam is an important part of maintaining healthy vision. A retinal exam involves dilating the pupils and …

The eye doctor and the patient will discuss the patient's health, eyes and vision. Following this case history, there are three primary types of clinical eye tests performed in a regular exam: An external eye health evaluation, a refraction (or acuity) test, and a retinal examination. A thorough eye health and visual analysis  …

Other Eye Tests. In some cases, besides these common tests performed during a standard comprehensive eye exam, your eye doctor may recommend other, more specialized eye tests. Often, such tests are performed by other eye doctors, such as retinal specialists, on a referral basis.

Dec 29, 2017 … A retinal examination — sometimes called ophthalmoscopy or funduscopy — allows your doctor to evaluate the back of your eye, including the retina, the optic disk and the underlying layer of blood vessels that nourish the retina (choroid). Usually before your doctor can see these structures, your pupils …

Some have never had an eye exam," he said. "The bill penalizes the 41.3 percent … Baker said staff members at the Paducah Retinal Center, where he works, are currently doing clinical research on technologies that can identify eye …

BW Primary Care is pleased to announce that we are now offering Diabetic Retinal Eye Exams right in the office. Can't remember when your last ophthalmology exam was?

The fact that disease can be spotted in the retina isn’t a surprise. Doctors often …

On the basis of the site, the market is segmented into sclera, retina, uvea, and others. On the basis of the diagnosis, …

A healthy retina is essential to maintaining clear vision and overall eye functioning.

Diabetes can harm your eyes. It can damage the small blood vessels in your retina, or the back of your eye. This condition is called diabetic retinopathy.

Find Your Nearest JCPenney Optical and Schedule an Eye Exam Today!

Annual comprehensive dilated eye exams are … the exam may show yellow deposits called drusen or clumps of pigment beneath the retina. In some cases, the exam may …

Last dilated retinal eye exam_____ Assessment. Diabetes mellitus _____With Complications _____Without Complications _____At goal for glucose control _____Less than optimal control . Lipids _____At or near goal for LDL _____ Less than optimal lipid management. Blood Pressure _____At or near target goal _____Less than optimal BP …

He explains how even today most hospitals consider it risky to transport eye …

A retinal exam combined with an eye exam can tell your eye doctor a lot about your eyes and overall health and is critical to preventing eye and health diseases.

Eye exam — Overview covers definition, what to expect and results of vision testing.

June 2017. Diabetic retinal eye exam. As you may know, national guidelines and the National Committee of Quality Assurance (NCQA) recognize the importance of screening people with diabetes annually for diabetic retinopathy through its inclusion in one of the Comprehensive Diabetes Care (CDC) measures. Similarly  …

Jan 28, 2017 … Retinal imaging is a relatively new eye test that can detect many diseases in the eye. WedMD explains what the test is.

These AMD-related changes tend to cause deterioration of a small area of the retina called the macula, which is needed for sharp, central vision. A comprehensive dilated eye exam is also critical for detecting glaucoma, a disease that damages the optic nerve, which carries information from the eyes to the brain. In a person …

A dilated eye examination should be performed to rule out an associated tear or detachment. … Floaters, Retinal Tears, and Retinal Detachments. Back to: …

Eye care professional report for Dilated Retinal Eye (DRE) exam. Use this completed form to communicate results to your patient's primary care provider. Patient name. ID #. DOB. Health plan. PCP. Phone. FAX. Chief complaint(s). Right eye. Left eye. Tonometry Date of exam. mmHg. mmHg. Retina. Diabetic retinopathy. Yes.

What to Expect at Your Retinal Exam. Retina Your initial examination and testing will be comprehensive. Since we endeavor to complete all tests and make recommendations based the results at the time of your examination, please allow several hours for your first visit (2-3 hours).

To diagnose retinal detachment, your doctor will ask you questions about your symptoms, past eye problems, and risk factors. The doctor will also test your near and …

Retinal Eye Exams . … retinal eye exam during the current or previous calendar year. This measure includes members with diabetes

[edit]. Fully dilated pupil prior to ophthalmoscopic examination. Examination of retina (fundus examination) is an important part of the general eye examination. Dilating the pupil using special eye drops greatly enhances the view and permits an extensive examination of peripheral retina.

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Visiting an eye care professional for a comprehensive retinal exam is an important part of maintaining healthy vision. A retinal exam involves dilating the pupils and looking into the eyes with a bright light and a special microscope to visualize the retina, optic nerve and blood vessels that are at the back of the eye. During a …

Aug 7, 2016 … Another device called a slit lamp is used to see the clear surface of the eye ( cornea). The doctor may take photos of the back of your eye to get a more detailed exam. The eye doctor may use a special camera to take photos of your retina without dilating your eyes. The doctor then views the photos and lets …

More than half (59 per cent) do not know what the pupil does and 42 per cent have …

Cpt retinal eye exam — PageLink google chrome keeps freezing with windows 10 link a Smart Appliances Market to.

The retina is a thin layer of tissue that lines the back of the eye. The retina receives light focused by the lens, and converts the light into neural signals to send to the brain for visual recognition. What is Retinal Imaging? Retinal imaging takes a digital image that shows not just the retina, but also the optic disc – the foremost …

Services & Procedures Retinal Exam and Consultation. A healthy retina is essential to maintaining clear vision and overall eye functioning. A retinal exam may be …

Comprehensive diabetes care: retinal eye exam. This measure examines the percentage of adults ages 18-75 with diabetes (Type 1 and Type 2) who had a retinal eye exam to screen for diabetic retinal disease. The frequency of the exam is determined by the results. Qualifying eye exams. • A retinal or dilated eye exam by …

A retinal exam combined with an eye exam can tell your eye doctor a lot about your eyes and overall health and is critical to preventing eye and health diseases .

New technology! The Optos Retinal Imaging machine will improve your eye exam . Learn more, here.

Learn about digital retinal imaging eye exams available at local MyEyeDr. optometry offices and eye care centers near you.

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