CMS Stranglehold on Medical Testing and Diagnostics

The Centers for Medicare and Medicaid Services (CMS) is up to its dirty tricks continually. CMS may become the laughing stock of the medical care world if they continue to restrict what health care providers can do. The rules are becoming so restrictive that even the CMS employees cannot keep up with the changes. With this, is it any surprise, that Medicare is projected to be insolvent by 2026, only twelve years from now?

More from the bad news side: Medicare will not pay for more than one test a year that is not directly related to the illness currently being treated by the doctor. In addition, Medicare rules forbid your doctor to treat (and therefore to test for) more than one ailment per office visit. What is the patient to do? Many people using Medicare have more that one medical problem and often three or more.

In theory, the patient could pay for the additional testing, but if those tests are deemed “medically unnecessary,” your doctor could go to jail for writing that prescription if he or she bills Medicare for the test. And if she or he wants to discuss the results of the test and prescribe a course of treatment, all discussion and treatment must be about that original ailment, even if you’re now sick with bronchitis instead. I am only guessing, but this sounds like if you have more than one illness, then you will need to see a different doctor for each disease or illness. How ridiculous CMS is becoming!

If a product or diagnostic test is new, getting Medicare to create a new billing code for it can take a long time and cost doctors a significant amount of money in lost reimbursements. And if a billing code exists, Medicare must agree to pay for the service. Medicare has not been willing to pay for genetic testing, except in screening for compatibility for kidney and bone marrow transplants. And with genetic testing to help individualize and personalized medicine, Medicare is unwilling to cover the level of genetic testing need for this to become a reality.

Medicare won't pay for physicians to consult with patients by email or over the phone, even if the patient is old, disabled, or too ill to come to the doctor's office. Medicare will not pay for doctors to teach diabetics how to monitor their glucose levels or manage their diabetes in other ways. The same goes for other chronic illnesses.

Read about Medicare and their restrictions and follow the many links in this article.

Who Should Be in Charge of Medical Care?

This could be the $64 billion dollar question. I have been reading several blogs lately and each one seems to want to go in a different direction. Insurers are beginning to feel that they should have management control over health care. Doctors are beginning to push back demanding that they be in control. More patients are saying, “Now wait a minute, we would appreciate some voice in our treatment.” All of this may be out the window with government voicing more from the Centers for Medicare and Medicaid Services (CMS). They may drown out the other voices as they dictate more in what will be allowed and not allowed.

For many, having CMS wag the reimbursement tail and the insurance industry following lock-step will mean that neither doctors nor patients may have much hope of managing health care decisions. This may not be a good situation when insurers refuse to allow life saving procedures.

It was with some amusement that I read this by Dr. Pelzman in MedPage Today. Dr. Pelzman says, “A couple of years ago one of the major insurers got in touch with our practice and told us that they would like to come over to our office for a sit down, to talk about our patients and how we take care of them. When they arrived, the executive and his retinue of employees presented us with data that suggested that "we" were costing "them" a lot of money to take care of "their" patients. We went over the data they had, which showed it was costing them several million dollars more per year to take care of the panel of patients we shared than they collected in premiums from those patients.

Despite the fact that it appeared that much of the cost was due to several patients with acute leukemia who had massive unavoidable costs, they firmly came down with the recommendation that we find ways to take care of their patients with less cost.”

What follows is not a surprise as insurers want to make a profit and will take measures to ensure a profit. It is obvious that the practice Dr. Pelzman is part of felt they had to allow the insurer to install a care coordinator in their practice, even if this meant doing some practices that would literally exclude people based on their insurance status.

As patients, even we know the insurers have a purely financial interest in delivering care more efficiently and cheaply to patients. Then Dr. Pelzman goes where many doctors fear to go and says, “We should welcome the insurers to the table, as we continue building the patient-centered medical home, but it's time we as practitioners and providers of care seize the reins, take control, and start making some rules of our own. We are here to provide care for "their" patients, and ultimately we (hopefully) know best. We understand that they're worried about fraud, over-spending, over-testing, over-referring, but hopefully we can work together to build a more patient-centered way of taking care of these patients as our healthcare model changes in the 21st-century.”

Now if he had urged bringing the patients into the discussion and making them part of the decision process, then the doctors and patients would have had more bargaining clout for dealing with the insurers. Yet most doctors refuse to consider patients as having any advantage other than providing them income in the practice of medicine.  Too often, we are thought of as non-adherent and incapable of following their ill thought-out instructions.

Medicare Again Aims to Harm Medicare Patients

How can I make this less painful? I think the best way is to just say it. The Centers for Medicare and Medicaid Services (CMS) is in the process of telling patients to bend over and prepare to be screwed. I don't mean just literally, but factually as well.

If you wonder why doctors will be cutting Medicare patients and moving many out the door, just read this blog by Dr. Jordan Grumet. Then read the press coverage of what the CMS has planned for 2014. The CMS intends to pay flat rates for Medicare visits to outpatient clinics instead of payments that vary with the severity of the patient's condition.

That's right, with the CMS proposed change, a healthy sixty five year old with a cold will lead to physician charges that are the same for a ninety five year old with congestive heart failure, emphysema, and out of control diabetes. What does this mean? Physicians, fatigued and overwhelmed with patient care, will be much more likely to avoid sickly seniors. It pays the same, why not select for the most healthy of the Medicare population? Yes, doctors will be forced into this and seniors with many comorbid conditions will be forced to use emergency rooms instead of seeing their doctor.

What upsets me even more is this is what CMS is doing to doctors, this parallels what the Affordable Care Act is doing to many doctors, and this will likely force many doctors out of the practice of medicine, as we know it today. This will cause many doctors to open contract medicine offices and not serve Medicare and Medicaid patients. Contract medicine encompasses “boutique”, “concierge”, “retainer”, and “direct care.”

For the present, hospital emergency rooms have been left untouched, but when CMS moves into this area, look out Medicare patients. Patients that have multiple medical conditions may be facing euthanasia because no doctor will be able to afford to treat people with multiple medical conditions.

This is serious enough that writing your members of Congress should be your goal in the month of December. It would not hurt to write letters to the editor of your local newspaper.

Activities of Our Diabetes Group

We are still attempting to have Hospice back to speak to us, but they have been busy. Even the county Public Health/Home Health Care person has been too busy. Both have been in contact with Barry and Allen according to Ben, but their time has been taken with clients needing attention. Allen even said that the speaker he wanted asked to hold off for the summer with the children being so busy.

We had one short meeting in June and have scheduled the next meeting for September, as several of our group will be on vacation for the month of August. Max and I were attempting to walk, but he is having a planters wart removed and the doctor has said no more walking than absolutely necessary. We agreed as this heat and humidity are making life difficult outside the air conditioning of our residences.

Allen is becoming very active online and is tackling a project that surprised the rest of us. He has become familiar with the FDA Patient Network and is doing correspondence with several people he met online there. Tim and I are attempting to help him when asked, but he has taken off on his own and is really into what he is doing.

Tim and I are attempting to monitor what is happening with the Medicare scandal and the CMS being sued for awarding non-approved companies contracts for medical supplies and medications. Not a fun task and I admit I am happy I have never dealt with any of the mail-order medical suppliers.

All of us must congratulate A.J. for being able to say goodbye to insulin and all medications. This extends to John as well, as both were able to be approved to stop all medications about the middle of July. I had a long conversation with A.J. when he said something, but he said the doctor had given him permission and since he is purchasing extra test strips on his own presently, the doctor just has him testing seven times per day. He and John are able to exercise each evening and John is happy to be off metformin.

Everyone is happy that four of our members are off medications and are doing very well with their new found freedom. Even Sue was happy to know that she and her husband were not the only ones off medications. Sue has asked for help, as her husband, Bob is having some troubles lately and his fasting is creeping upward. Barry told him to purchase some extra test strips and test on the frequency that A.J. is testing, and this seems to be the help he needed. A.J. also advised him to reduce his carbohydrate intake and cut more of the whole grains out of their food.

I loaned them my book, Wheat Belly to read and Sue said she is getting quite a lot out of the book. She and Bob do not like flax, so they are hunting other recipes. I sent the URL for Dr. William Davis blog site here. She said this has helped and they have ordered his second book Wheat Belly Cookbook. I also sent the following blogs for them to read starting with June 30 and then to explore more later. On the first – Fathead-Movie, I urged them to read the comments as there were often some great variations in the comments. On the second – Marks Daily Apple, I told them to explore and if that did not give them ideas, I would send some more.

Bob says he made the crust for the faux pizza and the paleo mayo and has really enjoyed the variety of sandwiches. He said that he had to make smaller sandwiches after the first time as he was over stuffed. He also commented that his blood glucose readings love the sandwiches. Sue commented that her blood glucose readings have come down as well.

Two of our members spent a couple of days in the hospital, but mainly it turned out to be for flu-like symptoms. Mostly the doctor said they were more dehydrated. Brenda is busy with her grandchildren for much of the summer.

Pilot Program on Food-Insulin Gap Helpful

This is great news and I hope hospitals are paying attention. Two articles on the same topic – here and here. Again communication is the key and this is often lacking across hospital departments as they think (more like don't) the other department is on top of things. It is surprising what a little cooperation does for the health of patients with diabetes. If you, as the patient, have been allowed to manage your own diabetes, then this study will not benefit you.

This also brings up an idea for another study while thinking about studies. I would like to see a study where the patients that are capable, emphasis on capable, are allowed to manage their own diabetes while in the hospital. Some hospital kitchens are capable of providing a list of the foods on the tray and the carb count of each food item. This would allow those on oral medications to medicate accordingly and those patients on insulin would be able to inject appropriately. This study could be done in hospitals that have an endocrinology department with specialists in diabetes employed by the hospital or attached to the hospital. I dare say that the patients would be more satisfied and not under the stress normally felt when the blood glucose is allowed to run above 180 mg/dl to 220 mg/dl that most hospitals allow.

Back to the study. Dr. Dace Trence, who was not involved in the study, carefully pointed out, “Hospitals may be motivated to do so because they could face penalties from Medicare if they do not. Hyperglycemia in the hospital is now a [national hospital inpatient quality measure], so you can imagine how important it is to try not only to prevent hypoglycemia, but also hyperglycemia."

Considering Dr. Trence's statement adds value to this study and may make hospitals consider this necessary. Shwetha Mallikarjuna, MD, an endocrinology fellow at Southern Illinois University (SIU), Springfield, presented the study at the American Association of Clinical Endocrinologists 2013 Scientific & Clinical Congress in Phoenix.

Often it is the simple interventions are the best medicine, like telling floor nurses that meals are on the way so they can coordinate insulin dosing for hospitalized diabetics.  The study demonstrated that patients received prandial insulin on time with significantly greater frequency when food service and nurses coordinated care (50.4% versus 35.5%). When patients are forced to let hospitals dictate when insulin is injected, the idea of injecting after a meal is a common practice and when a nurse can count carbs and know how many units to inject; this will help prevent a hypoglycemic episode. This is good for the patient and the hospital.

Mallikarjuna did note that their study was limited by a low sample size and low power. She said the study was also limited by poor patient matching. She said that a larger follow-up study is ongoing.

I see a few positives from this study and the potential for good being part of the penalty system being put in place by the Centers for Medicare and Medicaid Services. How much this will benefit patients still is to be determined.

Watch What Hospitals Do With MRSA

This is not unexpected. What was called MRSA for infections acquired by patients while in the hospital has now been termed HAIs (hospital acquired infections). I like the title given to the article in Medscape, “Medicare Reimbursement Change Spurs Prevention, Work-Arounds.” Work-arounds is what we can expect from hospitals so that they will be reimbursed for something Medicare has deemed non-reimbursable.

Approximately half of the hospitals participating in a report published in the May issue of the American Journal of Infection Control increased their attention of how such infections (HAIs) were coded for billing. Instead of doing increasing measurers to prevent HAIs, coding for other billable infections was where they paid attention. It is no wonder that people are concerned about hospital safety since the hospitals care only about the profits they can accumulate.

I quote from the article, “"Our findings were generally positive, suggesting the policies have led not only to an enhanced focus on targeted HAIs with greater efforts toward surveillance and education but also to changes in practice from front-line staff as reported by infection preventionists," the authors write.

However, the results also include persuasive evidence of hospitals "gaming the system," according to Peter Pronovost, MD, PhD, director of the Armstrong Institute for Patient Safety and Quality and Johns Hopkins Medicine Senior Vice President for Patient Safety and Quality, Baltimore, Maryland.”

It is disturbing as a patient to see statements like “gaming the system.” This means that the coding is apparently working for them to obtain reimbursements they would otherwise be denied by Medicare. Read the article here.

I will now get into another even more disturbing aspect that this causing. I had intended on writing about this from another perspective. However, this does explain why the hospitals have through the American Hospital Association, sent a formal letter to the Centers for Medicare and Medicaid Services asking that delays be granted in meeting the “Meaningful Use” criteria that is scheduled to begin later this year.

The “Meaningful Use” came into existence as apart of a government program (the American Recovery and Reinvestment Act of 2009 (ARRA)) in which billions of dollars were set aside to aid medical providers shift from paper records to electronic records. When the providers could prove they had reached certain stages of meaningful use, they would receive reimbursement from the government to cover the expense of implementation.

During stage one of meaningful use providers needed to demonstrate that an interface was in place so patients could access their own medical records, via the internet, securely and privately. For hospitals, that access needed to be provided within four days of a patient's discharge. Read the AHA communication here in a PDF file. (Adobe Reader required)

Now that it is almost ready for stage two (starts Jan 2013), patients have asked for quicker access, meaning within at least 24 hours for theirs, their spouses, or their childrens records. We want to know what took happened, with whom, and how it happened. This is important if post discharge problems occur and we want to discern where the problems may have arisen from and who may be responsible. However, the American Hospital Association if attempting to delay these provisions and has asked for a 30 day limit for patient access. The AHA also wants three years to each stage instead of the two years currently mandated.

Fortunately, it is easy to figure out why they want the 30 day window. They want the extra time to “doctor” the records to “game the system”, prevent things from being available to the patients, and thus their lawyers, for events that should have been reported, but weren't. They need time to hide these and more. Yes, the hospitals are nefarious for misdirection and covering up what should have been reported. This is why when you are hospitalized, if you are able, record everything, or have another family member record what they observe. Hospitals count on this not happening because they know most patients do not have this mind-set.

Hospitals also need the time to recode and balance bill. They are sure to increase a number here and there for items seldom, if ever counted. Hospitals also have become adept at changing a coding number to get more money than should be charged. Therefore, if they deliver the records to you as soon as you are discharged, they will not have time to make all the changes they want. Plus an event that needs to be hidden may be in plain site. If by chance, the AHA request for 30 days is denied, you may end up in the hospital for a day or two more than normal while they adjust your records. Excuses for additional time in the hospital can be easily fabricated. Remember, the profit margin needs to be met for each patient as well as preventing future problems from your records.

Read the article here by Trisha Torrey. Then follow the links provided by here to others that are pointing out problems. I must also encourage you to read this blog from The Health Care Blog. This also takes you to other blogs that you should read.  Carefully follow the link to the letter from Trisha's blog.  I admit I cannot get it to work for me otherwise.

If you do not follow Regina Holliday, she has a lot to say about the current disaster in our hospitals and obtaining the medical records for her deceased husband. Her situation should make you desire to take action. Read these three blogs by Regina, one, two, and three.

If it takes some time to read all this, then you should have had time to consider your course of action. I have sent my emails to my congressional people.

A Campaign for All of Us

A problem faces all of us, whether we are type 1, type 2, or any other type. How much longer are we going to put up with the Centers for Medicare and Medicaid Services (CMS) setting the limits for how many test strips we can be reimbursed for and that we can use? Yes, we will be taking on a strong arm of the government, but the need is there to do this. We cannot continue to allow them to take away our testing supplies.

Why the CMS? Because they set the limit and private insurance follows their lead. It is time what we notify our senators and congressional representatives to explain to them what is happening. How many test strips do we need? Definitely more than we are currently being allowed.

People with type 1 definitely need more that 4 or 5 test strips per day. Some days when they are going from a high to a low, they go through many test strips. And, if this happens often, where do they get the additional test strips. Many have to buy the extra test strips on their own. People with type 2 on insulin face the same problem.

Those that are also type 2, but on oral medications are allowed a maximum of two test strips per day. People with prediabetes are not allowed any test strips. To become more empowered patients and manage diabetes effectively, we need the limit removed or at least increased to a reasonable number of test strips. This is true after diagnosis, as learning is taking place about what foods can do to our blood glucose levels.

Yes, we also need to rattle some doctors, as they often do not want patients testing at all because they do not wants patients to become depressed when they see the results. Others will not fight for their patients to get them more test strips. This amazes me as doctors are supposed to do no harm. Their attitude is definitely doing harm to their patients.

What these doctors do not realize is that the patients need support and training to manage their diabetes. They do not need to be told not to test when they need to know what their blood glucose levels are to learn how to manage diabetes. Why increase the anxiety level in these patients that the doctors do not want them to succeed in managing their diabetes.

To the patients that have doctors like these, seriously consider finding a doctor that will work with you to help you manage diabetes. Since the doctors cannot hold your hand 24/7, you need one that will give you the tools to use on your own.

It is unfortunate that people do not understand why they need to test. Shortly after diagnosis, people need to understand what the food they are eating is doing to their blood glucose levels. Some are immediately concerned and do not want to eat, but by being able to test their blood glucose levels about one hour after eating. Many are surprised at the increase in blood glucose levels from before eating to approximately one hour after, or up to two hours after eating.

They can see an increase of 60 up to 100 mg/dl (3.3 to 5.6 mmol/L of blood glucose increase. They need to be concerned about the quantity of food consumed as well as the nutritional quality. If your blood glucose happens to be 109 (6.0 mmol/L) before eating, you do not want to see a blood glucose level above 149 (8.3 mmol/L) one hour after eating or a maximum increase of 40 mg/dl (.2.2 mmol/L).

Most people that have managed their blood glucose levels for some time do not want the see an increase above 140 mg/dl (7.8 mmol/L). For the newly diagnosed, they still must work through this trial period and learn what the different foods do to their blood glucose levels.

Even those of us that have managed our blood glucose levels effectively, still need more test strips to assist us in getting through times when we have problems because of illness, stress, or unforeseen circumstances. So it is necessary for all of us to protest the restrictions for test strips CMS is placing upon us.

CMS Threatening More Euthanasia?

This is being opposed by the medical profession with vigor and by the rest of us as well. Although this is only a proposal at this time, what it could do is create an environment that means if you are, for example, involved in an severe auto accident, your chances of being treated properly will go away. This will force hospital emergency departments to make an evaluation as to whether they can treat you or not.

In other words, if the injuries are too severe, they will be forced to make you comfortable and let you die instead of using technology to find the source of injuries and treat all injuries. The current proposal will be for computed tomography (CT scans), magnetic resonance imaging (MRIs), and ultrasound scans and will mean cost cutting measures so that CMS will only reimburse in full for a head scan, but only at 50 percent for any other needed tests on the rest of your body that requires scanning resulting from the same accident.

Sound like Obama's death panels? If this proposal gets put into effect, that is essentially what this will be. This will force hospitals to say that it will cost too much and that treatment is denied. So if the accident is that serious, better hope that you die at the scene, so all insurances can be collected for your family.

Sound harsh? This is what we are facing if CMS (Centers for Medicare and Medicaid Services) has its way. At least 61 members of Congress have seen the folly and intent of CMS and has called for this to end. But this is still not a majority of both houses to stop this action. At stake also is the 29.5 percent across-the-board reduction in physician pay that Medicare's sustainable growth rate formula will trigger on January 1, 2012. Organized medicine is counting on Congress to postpone this cut before year's end, as it has with other cuts going back to 2003.

Many of the medical professionals call this proposed cut in CMS reimbursements “Blind Cost-Cutting” and arbitrary. Please read this article thoroughly and follow the links to see what you can do.

Now having said all this, I am not giving hospitals and doctors a clean pass, as many times to avoid even the chance of a lawsuit, too many medical tests are ordered for no justifiable reason and only because they can be reimbursed by Medicare or Medicaid. This is a practice that needs to be stopped, but the wording of the proposed CMS rules will hurt more people than actually prevent unwarranted tests. Somewhere there needs to be some common sense applied which is sadly lacking on both sides of this issue.