Category: Healthcare Industry

The American College of Physicians (ACP) appreciates that the final Medicare Physician Fee Schedule and the Quality Payment Program (QPP) rules for 2019 are responsive to many of the concerns that ACP raised with the Centers for Medicare and Medicaid Services (CMS).

“Internists appreciate CMS’ decision not to finalize changes in payments for evaluation and management (E/M) services until 2021. We are hopeful that the additional two calendar years leave time for physicians and other health care stakeholders to work together with regulators to develop and test alternatives that preserve higher payment for more complex, cognitive care,'” said Ana María López, MD, MPH, MACP, president, ACP. “We are pleased that CMS will be moving forward with plans to simplify documentation for such visits, with significant improvements going into effect next year, and with additional streamlined documentation options becoming available later.”

Under the final rule, starting in 2021, CMS will begin paying levels 2, 3, and 4 office visits the same flat amount; level 5 visits would continue to get higher payment, as they currently do, recognizing the greater work involved in caring for the sickest patients. The proposed rule would have paid them all the same amount, devaluing complex, cognitive care.

“While we are encouraged that CMS has recognized the principle that more complex, cognitive care should be reimbursed at a higher level by paying more for level 5, we have reservations about paying level 4 visits, the second most complex visits, at the same amount as levels 2 and 3 visits,” Dr. López continued. “We look forward to working with CMS on developing, piloting, and evaluating approaches that recognize the value of complex, cognitive care.”

ACP is encouraged to see CMS incorporate several of our recommendations in the physician fee schedule final rule; however, ACP also expresses continued reservations about some of the final provisions. ACP’s recommendations include:

• ACP is strongly supportive of provisions that would reduce documentation requirements for physicians, reducing unnecessary administrative burdens. ACP thanks CMS for eliminating redundancies and only requiring physicians to document changed information since the last visit for established patients-starting right away in 2019. Additionally, ACP is glad to see that the documentation changes would eventually allow physicians to choose between different options to best fit their practice needs, including enabling them to document based solely on medical decision making. However, these options will not be available until 2021—we would support CMS allowing them to be implemented sooner.
• ACP is pleased to see that, effective in 2021, CMS has allowed for add-on codes for level 2-4 visits in primary care and certain specialties and for extended visits to account for the value of cognitive work in treating more complex patients. ACP especially appreciates that the changes to the add-on codes equalize primary care payments to specialty payments.
• ACP is grateful that CMS is not moving forward with proposals to implement the Multiple Procedure Payment Reduction (MPPR).
• ACP is strongly supportive of payments for new codes for non-face-to-face visits that will be implemented in 2019. Virtual check-ins, e-consultations, and remote evaluation of patient images and videos will improve patient access to care and help control costs.
• ACP has long advocated for changes to the Physician Practice Information Survey (PPIS) and is extremely encouraged that CMS is considering updating the data source used to calculate indirect practice expenses to improve payment accuracy for physicians.

“ACP is thankful to see that CMS is moving forward, in 2019, with changes to reduce documentation burdens on these same codes. This effort is aligned with ACP goals in the Patients Before Paperwork initiative,” said Dr. López.

Additionally, ACP recognizes that CMS was responsive to feedback provided on the proposed QPP rule. Concerns on some provisions remain:

• ACP appreciates seeing CMS respond to our request for a Merit-based Incentive Payment System (MIPS) opt-in option for practices previously excluded under the low-volume threshold. This will expand participation without increasing burden.
• ACP supports CMS’ ongoing work to identify and remove low-priority, low-value quality measures and to continue working with stakeholders to focus on measures that offer the most promise for improving patient care while minimizing reporting burden on clinicians.
• ACP supports the 2015 Certified Electronic Health Record Technology (CEHRT) requirement and agrees that using updated standards and functionality can help improve interoperability; however, ACP is disappointed that CMS did not call out the need to provide physicians flexibility as they implement these upgrades over the course of 2019. Rushing implementation of these upgrades to meet a reporting deadline can have serious patient safety risks and is a major expense and burden, particularly to small practices.
• ACP is encouraged to see CMS continue the consistent risk threshold for Alternative Payment Models (APMs), which will provide consistency and predictability for model developers and will help APMs continue to grow. APMs are vital to the success of the transition to value.
• ACP is concerned that CMS’ finalized changes to the Cost Category, including adding several new episode-based measures despite concerns over low reliability ratings while simultaneously increasing the weight of the Cost Category from 10 percent to 15 percent, despite objections from ACP and other stakeholders. Clinicians should not have their MIPS scores negatively impacted by inaccurate measures.

ACP was pleased to see that the Hospital Outpatient Perspective Payment System (HOPPS) rule, released this morning, finalized site-neutral payments for clinic visits. Equalizing payments across facility types is a longstanding goal of ACP.

“Currently, CMS often pays more for the same type of office visit in the hospital outpatient setting than in the physician office setting, resulting in higher out-of-pocket costs to patients and unnecessary spending by Medicare. ACP agrees with CMS that there is no justification for patients and the Medicare program paying more for a visit to a doctor when the service is provided in an office owned by a hospital than it would for the same type of visit in an independent physician practice,” said Dr. López. “This will increase the sustainability of the Medicare program and improve quality of care for seniors.”

ACP recognizes that these are promising steps in the right direction, and is encouraged that CMS expressed interest in working with ACP and other physician organizations on these issues, in particular, the E/M changes.

“ACP will continue to advocate on behalf of the patient care that internal medicine specialists provide to ensure they are adequately valued for their instrumental role in driving high-value care and will look for continual reforms to the QPP to maximize positive patient outcomes while minimizing clinician burdens,” concluded Dr. López.

Provided by:
American College of Physicians

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In 1816, a French doctor, Rene Theophile-Hyacinthe Laennec, discovered a way to improve the diagnosis of cardiovascular disease. While more sophisticated methods that have been invented since, the stethoscope remains a weapon in most doctor’s arsenal. Occasionally, the tubing on the stethoscope must be changed because it has become brittle or has been cut or for some other reason. It is less expensive to replace it than to buy a new one.

• Buy new tubing. You can find ready-made tubing for your stethoscope at any medical supply house, or you can purchase it online. Expect to pay up to $30 for the tubing, much less than most doctors invest in their stethoscopes. If you are interested in lengthening your stethoscope, you’ll need to add about 6 inches for the binaurals, or listening devices. Tubing comes in an array of colors and you must make sure that it will accommodate the dimensions of your hardware. Also, if your diaphragm is reversible, remember there are two places where you must install the tubing.

• Remove to old tubing. Simply twist the tubing from both of the binaurals and the diaphragm. Occasionally, this will not be possible, particularly if the tubing is old and dry. Carefully cut away the old tubing; and with a rag soaked in rubbing alcohol, remove the remnants of the tubing on the both binaural and the diaphragm.

• Replace with your new tubing. Gently twist the tubing on both binaurals and the diaphragm. Once done, your stethoscope will be like new. Some manufacturers provide new binaurals with the new tubes, but they will cost more.

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An ECG (also known as EKG or electrocardiography ) machine is used to identify what kind of electrical activity (rhythm) the heart is producing. With this information a doctor can make the right decision on how to treat the patient’s cardiac issues. Although ECG machines vary in look, set up (3 lead up to 12 lead styles) and operation, all perform the same way by capturing a picture of the electrical current your body naturally produces through heart function. ECG’s come with a manufacturer’s manual to aid in using specific machines, but the basic steps of usage are universal.

Things You’ll Need

• ECG
• Monitor

• ECG electrodes
• ECG leads

• Ensure ECG is plugged in for a steady power supply (most machines have a battery operated backup, but it is not good practice to rely on the battery first in case it dies during operation).

• Check the connection between the ECG machine and the monitor. Set the ECG machine to test mode (this checks for function of both the ECG and the monitor).

• Enter the patient’s demographic information when prompted by the ECG machine, for quality assurance. This information prints out on the telemetry strip and is used in discerning one patient’s readings from another. The amount of leads you are using will now be identified. There are three types: 3-lead, 5-lead and 12-lead.

• Set the machine to read the right amount of leads (either 12-lead, 5-lead or 3-lead). The machine has a turn dial that designates the type of lead input being used. Each lead type relays different information to the monitor, which is then printed out on the strip.

• Apply the leads as directed by your machine’s literature. The 12-lead ECG is the preferred type of monitoring, giving the best electrical activity picture. The name “12-lead ECG” can be misleading (there are only 10 cords) and is the most difficult to set up. With this set up you will use the patient’s arms, a leg and chest, applying one lead to each arm, one lead to a single leg and one lead to the right clavicular line. All other leads go into a triangular pattern on the left chest area. The 3-lead type is used primarily in field transport by emergency medical responders to get a quick readout for the transfer to the hospital emergency room. The 3-lead is easier and only takes a few seconds, by applying one lead to the right clavicular line, another to the left clavicular line; the third is the ground, to be placed anywhere in between the other two. The 5-lead type, which is rarely used, is a little more time consuming than the 3-lead, and just as effective.

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Acetaminophen and aspirin, although two different drugs indicated for different conditions, can be taken together to treat pain and inflammation. Acetaminophen, an over-the-counter pain reliever, treats fevers and body pain and can be found in the brand name Tylenol. Aspirin reduces inflammation and treats pain by reducing a substance similar to a hormone in your body that causes initial pain. Aspirin can be found in brand names Bayer and St. Joseph. These drugs are not harmful when taken together and can serve to support each other in the treatment of inflammation, fever, and pain.

• Purchase over-the-counter acetaminophen and aspirin tablets. Popular brands that produce these drugs are Bayer, for Aspirin, and Tylenol. You also have the option of purchasing tablets that already combine these two drugs, such as Excedrin Extra Strength, Excedrin Migraine and Vanquish.

• Read carefully the suggested dosage on the back of the bottle. Do not take more than the amount prescribed for each drug, as an overdose of either acetaminophen or aspirin can be dangerous. Do not take more than 8 tablets in a 24 hour period.

• Take your acetaminophen and aspirin tablets at the same time with a glass of water. This makes it easier to keep track of when you have taken your pills, and thus avoid an overdose. Likewise, it will prove more effective for overall pain relief.

Tips & Warnings

• If you are having any kind of surgery during which you will undergo general anesthetic, alert your doctor to the drugs that you are taking.

• Do not overdose on either acetaminophen or aspirin, as an overdose of aspirin can cause serious harm to your liver.
• Do not drink alcohol while you are on this medication, as it is potentially harmful to your liver.
• Do not take this medication if you are pregnant without first consulting your physician. Likewise, if you are nursing a child, consult your doctor before taking acetaminophen or aspirin.
• Never give aspirin to a child under the age of twelve or a child or teenager who has a fever or flu symptoms, as this could result in a potentially fatal condition called Reye’s Syndrome.
• Stop taking acetaminophen and aspirin tablets if you experience any kind of allergic reactions and immediately consult your physician.

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Veins are the blood vessels that carry blood toward the heart. Most of the time you can see veins through the skin, especially where they cross over bones. Veins are most visible in the arms and resemble small tubes. Sometimes because of weight, temperature, or a skin condition veins may not be readily visible through the skin. In these situations, palpation can help locate a vein using your sense of touch. This skill is useful in the health care profession when attempting to gain intravenous access.

• Wash your hands or use an anti-bacterial disinfectant before making physical contact. This is to prevent the spread of germs.

• Inspect the area in which you are trying to locate a vein. The arms, hands and feet are the easiest areas to locate veins where they run over bony processes.

• Steady the area you have chosen to palpate for the vein. You can do this by gently grasping the area with one hand.

• Extend your index finger.

• Push down on the site using gentle pressure. When you feel a firm, spongy bounce back you have located a vein.

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Doctors, hospitals and pharmacies use a system to keep track of pharmacy representatives. This can be a database or some form of record keeping that contains contact information. You can find lists through professional magazines and associations, networking with other pharmacy professionals and on the Internet.

• Navigate your browser to the SK&A Pharmacy Mailing List website (See Resources). This is a service provider that offers a list of more than 100,000 pharmacy representatives. Fill out the information boxes to the right of the Web page. The requested information includes contact information, e-mail, the state you are working in, pharmacy title, location and type of service. Add any comments and then click “Get Quote Now.” You will receive further information and the opportunity to request free reports with information pertaining to pharmaceutical representative lists.

• Go to NAPRx (National Association of Pharmaceutical Representatives) website on the Internet (See Resources). NAPRx is a website dedicated to the trade association for pharmaceutical representatives. Comprehensive information is provided on different fields of pharmaceutical reps, magazines, memberships, news and company contacts. Sign in to the “Membership Area” to the left of the screen to utilize this service.

• Visit the Rep Association website (See Resources). This will show you a national directory of regional professional sales rep associations. This list is not comprehensive, but it does provide an excellent resource to obtain pharmaceutical representative lists. You can subscribe to this site by clicking the “Subscribe Now” button to the left or you can scroll through their lists of representatives to create your list. They provide the name, address, contact information, phone number and e-mails. The list is divided by state to make your search easier.

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Whether you want to assemble a new Prestige brand stethoscope or you are cleaning and repairing the one that you already own, you can put it together in a matter of minutes.

Things You’ll Need

• Two earpieces
• Chest piece
• Binaural stethoscope spring with ear tubes

• Snap-on stethoscope diaphragm
• Stethoscope tubing set
• Stethoscope rim and disc assembly

• Insert the earpieces on the ends of each ear tube. These tubes are connected to a binaural spring.

• Connect the stethoscope tubing set to the bottom of each ear tube.

• Screw the chest piece to the single-tube end of the tubing set.

• Snap the stethoscope diaphragm to the side of the chest piece.

• Attach the rim and disc assembly to the opposite side of the chest piece.

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During your physical exam your doctor makes use of several different doctor’s tools such as a blood pressure monitor which is designed to measure your blood pressure; an ophthalmoscope which is used to examine the eyes; a thermometer which the doctor will use to measure your temperature; a stethoscope which a doctor uses to listen to the patient’s heart, lungs and abdomen, and an otoscope which your doctor will use to examine the inside of your ears, nose and mouth.

In addition to these, there are many more doctor’s tools that are used in different specialized areas of medicine, to diagnose and observe and monitor a variety of more complicated medical conditions.

This doctor’s tool is a major symbol of the medical profession. Its beginnings can be traced all the way back to Laennec, the French doctor, who was the inventor of a crude model in 1819. Many modifications have occurred since then. The original version consisted of a wooden box in which the doctor heard the sounds within the patient’s chest cavity.

The modern version is composed of two earpieces that are connected by a piece of flexible tubing to a diaphragm. A doctor makes use of this tool when he wants to hear the low-volume sounds that are put out by the heart, intestine and the fetal heartbeat.

An otoscope is another commonly used tool in health exams. It has a cone-shaped attachment on the end called an ear speculum. It is used to examine a patient’s ear canal. The doctor is able to peer into the ear canal in order to check whether the eardrum is red or has fluid behind it; this is indicative of an ear infection. A pneumatic otoscope delivers a small puff of air to a patient’s eardrum to see if it vibrates. This vibration of the eardrum is completely normal. An otoscope examination can also detect a wax build-up in the ear canal or whether the eardrum is punctured or ruptured.

Measuring blood pressure calls for an instrument named sphygmomanometer which measures the blood pressure in the arteries. There are basically two types of these instruments. One kind is a mercury column and the other consists of a gauge accompanied with a dial face. The sphygmomanometer which is most commonly used today is the gauge which is attached to a rubber cuff. It is then wrapped around the patient’s upper arm and is inflated in order to constrict the arteries. When the cuff is fully inflated with air, the doctor places a stethoscope over the brachial artery in the crook of the patient’s arm. As the air in the cuff is slowly released, the first sound the doctor hears through the stethoscope is the systolic pressure. As the air continues to be released from the cuff, another point is reached when the doctor no longer hears any sound. This marks the diastolic blood pressure.

A thermometer is one of the most commonly used tools by doctors. It is a doctor’s tool that measures the body temperature. They come in the following types:

Oral and rectal thermometers: A conventional oral or rectal thermometer consists of a sealed glass tube containing a liquid like mercury. Imprinted on the tube is a temperature scale. When the temperature rises or falls, the mercury will expand or contract, causing the mercury to move up or down the thermometer’s tiny passageway. If the mercury moves up the scale, before it is used again, the thermometer will have to be “shaken down.” In order to get an accurate reading, the patient must keep this instrument in contact with her body for approximately four minutes in order to obtain an accurate reading. The rectal thermometer is typically a little more accurate than an oral thermometer.

Digital thermometers: Today thermometers are available that have digital displays. It is much easier to read the temperature this way. A beeper signals when the thermometer has finished registering the temperature. These thermometers come with flexible tubes that resist breakage.

Ear thermometers: Eardrum thermometers are very precise and read infrared radiation that emanates from the eardrum tissue.

Basal thermometers: These thermometers measure minor changes in temperature in a woman’s body to indicate to her whether ovulation, or when an egg has been released from a woman’s ovary, has taken place. A woman’s temperature may rise slightly when ovulation occurs and will not return to a normal temperature until the beginning ogf menstruation. Basal thermometers are quite sensitive and will monitor even the slightest temperature change.

One very important tool used by a doctor is an ophthalmoscope, which examines the interior portion of the eye including the retina, optic nerve and lens.

A common clinical ophthalmoscope, which can be found in your family physician’s office, consists of a concave mirror along with a battery-powered light that is housed within the handle. The doctor peers through one monocular eyepiece into each eye of the patient. This tool has been developed with a rotating disc of lenses which permits the eye to be examined at different magnifications and depths. For a doctor to use this tool efficiently, a patient may have to have eye drops that will dilate the pupil as well as enlarge the opening into the eye’s inner structures.

The ophthalmoscope has been an invaluable tool in many medical fields including cardiology, hematology, genetics, neurosurgery, family medicine, internal medicine, diabetes, medical genetics, rheumatology, neurology, pediatrics and geriatrics.

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Adding computers or going electronic can make everything from billing to keeping track of patient records quicker in a hospital, but computers also bring disadvantages to the hospital environment. As technology and computers become more advanced, additional elements will appear in the hospital setting, but whether the advances are really improvements is open for some debate.

Cost

• One of the biggest drawbacks of adding computers to hospitals is the cost. Computers cost money, and a large hospital needs many computers to keep the system running smoothly. Creating a network to transfer medical records or keep track of billing is an additional initial cost. Unlike paper records, which simply require a few more copies, electronic record keeping requires constant upkeep of computers, computer software and other electronic elements, which can cost even more.

Security

• If your doctor or hospital is switching to computers or electronic record keeping, you’re probably worried about the security of your medical records. Paper records are kept in a doctor’s office or a warehouse, but once computers are added to a hospital, electronic record keeping typically follows. Once electronic record keeping is begun, medical information is usually added to a closed computer network, but as long as an Internet connection comes into the network, the system is vulnerable to outside sources, opening the debate to questions about patient privacy and medical record security.

Lack of Standardization

• From a hospital point of view, one of the biggest disadvantages of adding computers and electronic records to a hospital is the lack of standardization through the medical field. Different hospitals use different shorthand abbreviations or symbols on medical records than others. Even the codes called out during emergencies don’t always mean the same thing in every hospital. If a medical record is transferred from another hospital or the system becomes open so hospitals can share information, the lack of standardization in hospital notes and records could cause problems when it comes to a medical professional’s understanding of the medical record.

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Hospice care can provide comfort, medical attention and daily-living help in an ideal setting for patients who choose this type of care. Many people seek hospice care when their current disease has a terminal prognosis. However, hospice care can also provide services to individuals who need extra emotional support, or who decide to discontinue treatment in order to stay in a more relaxed environment at home.

Lifetime Illness

• Illnesses where there is no current cure qualifies patients for hospice care. Examples are cancer, heart failure and emphysema.

Low Life Expectancy

• A patient may also qualify for a hospice care if a physician considers life expectancy to be low, usually within 6 months or less.

Discontinued Treatment

• Patients who wish to discontinue treatment and stop any restorative treatment may qualify for hospice care.

Comfort Measures

• Many patients have wonderful turnaround rates when comfort measures are provided along with medical treatment. Patients may qualify for hospice care in order to seek mental and emotional comfort.

Residential Restrictions

• In order to qualify for hospice care, most patients must reside within the regulated residential region of the service area.

Goal Agreement

• A goal must be made between the patient and the hospice care as to what exactly the care will entail. An agreement form must be signed before care can begin.

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