Outpatient Practice

Telomeres And Pulmonary Fibrosis

My stepfather was the quintessential short telomere syndrome patient. His hair turned gray in high school, his father died of idiopathic pulmonary fibrosis, his sister died of idiopathic pulmonary fibrosis, and then he too died of idiopathic pulmonary fibrosis, complicated by bone marrow failure from myelodysplasia. Last month, I attended an international conference on telomeres in lung transplant and the information from that conference has profound implications for treating our patients with these conditions.

Telomeres are repeating sequences of the DNA nucleotides, TTAGGG, that are on the ends of our chromosomes and serve to protect the genes inside those chromosomes from damage, kind of like how the plastic caps on your shoelace protect the shoelace from unraveling and becoming damaged.

We are all born with fairly long telomere segments at the end of our chromosomes but then as we age, our telomeres shorten, presumably making the genes underneath these chromosomes more more fragile and subject to damage. Thus, our telomeres start off about 11 kilobases when we are born but by age 80, they have shortened by two-thirds, to 4 kilobases.

The reason that we lose these repeating TTAGGG sequences is that when our chromosomes divide, about 50-100 base pairs of telomere DNA is lost from the end of one of the two chromosomes because of the way that a chromosome divides and then re-builds new twin strands of DNA to form the 2 new chromosomes.

Our cells can restore these lost telomeres by using a protein complex called “telomerase” that adds TTAGGG nucleotide groups to the ends of our chromosomes. But if there is a genetic abnormality in one of this group of proteins, then telomerase does not work properly and cannot fully restore the telomeres to their previous length. Thus, with each chromosomal division of mitosis, the telomeres get a little shorter. Telomeres are akin to a “molecular clock” in our cells and some people have postulated that if we can maintain normal telomere lengths, that we may be able to avoid the scourge of aging, in other words, create a Fountain of Youth. Although it is not clear if this is possible, it does appear prematurely shortened telomeres due to an abnormal telomerase protein gene results in the opposite, in other words, a “Fountain of Age”.

A patient with one of these abnormal genes will have telomeres that are shorter than normal people of their same age. This results in “short telomere syndromes”. In adults, the main short telomere syndromes are:

  1. Familial idiopathic pulmonary fibrosis
  2. Cirrhosis
  3. Aplastic anemia
  4. Myelodysplasia
  5. Prematurely gray hair

There are two ways to measure telomere length: a polymerase chain reaction (PCR) method and a fluorescent in situ hybridization (flow-FISH) method. The flow-FISH method is considerably more accurate than the PCR method. People can get a take-home telomere PCR test done essentially over-the-counter for about $100 through internet DNA companies. The flow-FISH method is only available at a few university laboratories, requires a physician order, and costs $400-800. I send my patients’ blood to be tested at one of these labs that use the flow-FISH method. The length of telomeres that indicates a short telomere syndrome is unknown but when the length is less than the lowest 1st percentile, I consider it highly likely. Since my clinical practice is primarily patients with interstitial lung diseases (including idiopathic pulmonary fibrosis), I end up seeing a number of these patients. Here is a telomere length test result on one of my patients with familial idiopathic pulmonary fibrosis, cirrhosis, and pancytopenia from a hypocellular bone marrow:

Idiopathic pulmonary fibrosis patients with short telomeres are different

There are some important differences in patients with familial idiopathic pulmonary fibrosis and short telomeres compared to everyone else with idiopathic pulmonary fibrosis. First, they do poorly with immunosuppressives. In the past, we used to use medications that suppressed the immune system to treat idiopathic pulmonary fibrosis, thinking (incorrectly) that inflammation was the genesis of the lung scarring that characterizes the disease. A number of years ago, there was a study sponsored by the National Institutes of Health comparing a treatment with the immunosuppressive medications azathioprine and prednisone with placebo. It turned out that the patients who got azathioprine or prednisone did a lot worse than those getting placebo. Recently, researchers went back and looked at stored blood samples of the patients who were in this study and it turns out that only those patients with short telomeres did poorly with immunosuppressive medications – patients with normal telomeres had the same outcome whether they received immunosuppressive medications or placebo.

Second, these patients do poorly after lung transplant. They are more prone to developing low white blood cell counts, presumably from being more susceptible to side effects of immunosuppressive medications. Also, they are more prone to getting devastating infections with cytomegalovirus (CMV) and aspergillus. Patients with short telomeres who get lung transplants can develop myelodysplasia or cirrhosis after lung transplant and those with liver transplants can develop myelodysplasia or pulmonary fibrosis after liver transplant.

More Questions Than Answers

Our understanding of short telomere syndromes and how to best medically manage these patients is still in its infancy. There is much that we do not yet know. For example:

  1. Which patients with idiopathic pulmonary fibrosis should undergo telomere length testing? Currently, I limit testing to those patients with a family history of idiopathic pulmonary fibrosis who also have a personal or family history of premature graying of the hair, unexplained cirrhosis, myelodysplasia, or unexplained cytopenia. Telomere length testing is not widely available and not always covered by insurance. If it only cost $25 and insurance covered it, I would probably order it on all of my patients with idiopathic pulmonary fibrosis. In addition, there may be other lung diseases associated with short telomeres. For example, pleuropulmonary fibroelastosis appears to be associated with short telomeres.
  2. Which patients with cirrhosis should undergo telomere length testing? NASH (non-alcoholic steato-hepatitis, aka fatty liver) is the most rapidly growing cause of cirrhosis due to the epidemic of obesity and diabetes in the United States. It seems like whenever there is no obvious cause of cirrhosis (such as hepatitis C or alpha-1-antitrypsin deficiency), then patients get labeled as having NASH cirrhosis by default. Many patients who carry a diagnosis of NASH cirrhosis likely have liver disease due to short telomeres.
  3. Should every patient with short telomeres be referred for genetic testing? Genetic testing is usually done in conjunction with genetic counseling by trained genetic counselors. Unfortunately, these counselors are in short supply and are mainly associated with pediatric hospitals and cancer hospitals. Furthermore, genetic testing is not cheap and typically costs around $800; most insurance companies will not cover it or will only cover it after a lot of physician effort doing denial appeals. The results of genetic testing in short telomere syndromes can be difficult to interpret – these syndromes can be associated with abnormal genes such as TERT and TERC but these genetic abnormalities can also be seen in some otherwise normal people.
  4. Should telomere length testing be done in all patients prior to transplant? One of the basic tenets of transplantation is to offer it to those patients who will most benefit by transplant. Since some studies indicate that patients with short telomeres have worse outcomes after transplant, should this affect their transplant eligibility? Could short telomeres be a relative contraindication to transplant?
  5. Should transplant patients with short telomeres get different immunosuppression regimens? Since it appears that patients with short telomeres do poorly with immunosuppressive medications, it may be that they need to have reduced doses of these medications when used to prevent transplant rejection. Or perhaps there are some immunosuppression regimens that are safer than others in patients with short telomeres. Once again, at this time, we just do not know.
  6. Should patients with short telomeres get combined lung and liver transplants? These patients are prone to getting both pulmonary fibrosis and cirrhosis and not infrequently does cirrhosis become apparent only after lung transplant for pulmonary fibrosis and vice versa. At the least, patients with known short telomeres undergoing liver transplant should probably be screened for interstitial lung disease and those undergoing lung transplant should be screened for cirrhosis. Most combined lung/liver transplants in the United States are done in patients with cystic fibrosis. Many centers have found that combined lung/liver transplant in other patients has a high mortality rate. One has to wonder whether a lot of these non-cystic fibrosis patients who have had combined lung/liver transplant actually had undiagnosed short telomere syndromes.
  7. Should patients with short telomeres undergoing transplant get a bone marrow biopsy? This is not part of the normal work-up for patients undergoing either lung or liver transplant. But the development of myelodysplasia or it malignant cousin, acute myelogenous leukemia, can be devastating in the post-transplant period. Clues to subclinical myelodysplasia can include unexplained macrocytosis (increased MCHC), leukopenia, or thrombocytopenia. No transplant physician likes a hematologic surprise after transplant.

One of the simultaneously frustrating and exciting things about medicine is that just when we think that we know everything, we realize that we don’t. Short telomere syndromes epitomize this axiom – clearly, we have much more to learn.

October 2, 2019

Inpatient Practice Outpatient Practice

Influenza Always Gets The Last Word

I am on this earth because of influenza. This is the 100th year anniversary of the influenza epidemic of 1918 that infected 1/3 of the word’s population and killed 1 out of every 10 people infected. One of those people was my grandmother’s first husband. She was a nurse at a hospital in Durham, North Carolina and after her husband’s death, she met a physician fresh out of medical school, my grandfather. So, if the influenza epidemic had not have occurred, she and my grandfather would never have married and I never would have been born.

All told in 1918, 675,000 Americans died of influenza; that works out to 1 out of every 150 citizens. It was particularly lethal for young persons with the result that the U.S. life expectancy dropped from 49 years to 37 years for men and from 54 years to 42 years for women. The influenza strain that swept the world in 1918 was H1N1, the same strain that caused the 2009 pandemic of influenza that also seemed to preferentially kill young adults.

In 2009, 12,000 people in the United States and a half million people worldwide died of influenza. The problem in 2009 was that the strain of H1N1 that emerged was one that had not circulated in humans for decades – about 1/3 of people over age 65 years had antibodies to it from past infection but few young adults had ever been exposed to H1N1 and thus few young people had any immunity at all. Most years, 80% of influenza deaths are in people over age 65 but in 2009, 80% of deaths were in people under age 65. The H1N1 pandemic was therefore notable not for the total number of deaths (which was actually rather low) but for the fact that most of the deaths occurred in young adults. Even in non-pandemic years, influenza kills thousands of Americans. For example, last year, the CDC estimates that 80,000 Americans died of influenza and its complications, the most deaths in 4 decades.

As of December 22, 2018, the epidemiology of this influenza season (red line in this graph from the CDC) is falling in-between that of the 2016-2017 season and the 2017-2018 season. Most of the influenza being seen this year is once again the influenza A H1N1 strain with a smattering of H3N2 and influenza B. The flu claimed its first celebrity of the season this week when 26-year-old Fox News commentator, Bre Payton, died the day after developing influenza.

Yet still there are people who fear influenza vaccinations and refuse to get a simple and inexpensive flu shot that can save their lives. Here are some of the reasons for not getting a flu shot that I hear from my own patients:

  1. “I always get the flu every time I get a flu shot.” It is impossible to get the flu from a flu shot as there is no live virus in the vaccine. You are no more likely to get the flu from a flu shot as you are to get pregnant from taking a birth control pill. Yet nevertheless, more than half of parents believe that their child can contract the flu from a vaccine.
  2. “I don’t need a flu shot because I never get the flu.” This is like saying that you don’t need to wear a seatbelt because you’ve never been in a car accident. These people probably have had the flu but just didn’t realize it and attributed their symptoms to a cold or other illness. No human in innately immune from influenza. If you inhale a bunch of influenza viruses, then you are going to get the flu.
  3. “I don’t want a flu shot because it causes autism.” Yes, and the earth is flat, unicorns are real, and the tooth fairy plays poker with Elvis and the Easter bunny every Saturday night. Conspiracy theorists love this one. 20 years ago, in 1998, Andrew Wakefield published a paper in the journal, The Lancet, suggesting that the measles, mumps, and rubella vaccine was linked to childhood developmental disturbances. It turned out that Wakefield was funded by attorneys who were suing the vaccine manufacturer for allegedly causing autism. Wakefield was later found guilty of fraud, he lost his license to practice medicine, and the journal retracted his article. But the myth lived on and in 2005, journalist David Kirby published the book Evidence of Harm – Mercury in Vaccines and the Autism Epidemic: A Medical Controversy that alleged that thimerosal in vaccines causes autism. That same year, class action attorney Robert F. Kennedy, Jr. wrote an article in the Huffington Post making the same allegation (presumably setting himself up to win the mother of all class action lawsuits). Celebrities bought into this, most notably actor Charlie Sheen and former Playboy playmate, Jenny McCarthy, who have become the voices of anti-vaccine activism. Most influenza vaccines do not contain any thimerosal (the preservative that contains mercury). Even those that do contain thimerosal have the same amount of mercury as is in about 4 oz of canned tuna HOWEVER, thimerosal is broken down in our bodies as ethylmercury whereas fish contains methylmercury – ethylmercury is relatively harmless compared to methylmercury. The science is very strong: vaccines do not cause autism.
  4. “I don’t need a flu shot because last year I got one and still got the flu.” Yes, it is true that influenza vaccines are not 100% effective in preventing the flu. However, by creating protective antibodies against influenza, your body will be able to fight it off better so that even if you get the flu, it will be a milder case and you will be less likely to die. A study this year by the CDC found that patients who were admitted to the hospital with influenza and had gotten a flu shot spent four fewer days in the hospital, were 37% less likely to be admitted to the ICU, and were 2-5 times less likely to die compared to those patients who had not received a flu shot.
  5. “If I go outside in the cold and wet air, I’ll get the flu whether or not I get a flu shot.” Influenza is not an environmental microorganism, it lives in people and is transmitted by people. You cannot get the flu (or a common cold) by going outside when the temperature is low or when it is raining. In fact, if you spent all of your time outdoors in flu season, you’d be less likely to get influenza than if you are inside a building in close contact with other people who have the flu.
  6. “I always wait until December to get my flu shot so that it will kick in when the flu seasons hits.” Although it is true that antibody levels will peak several weeks after getting an influenza vaccine, a person cannot predict when they are going to be exposed to the virus in any given year. Getting a flu shot on Monday will not do much good if you are exposed to influenza on Wednesday. A person is better off getting the vaccine as early as possible in the flu season, ideally before the end of October. That being said, it is not too late to get vaccinated, even in January or February, as influenza usually continues to circulate in the United States until March or April each year.
  7. “I don’t want to get a flu shot because I might be pregnant.” If I only had one dose of the flu vaccine in my office, I would save it for a pregnant woman. There is no risk to vaccinating pregnant women and in fact, in the H1N1 pandemic of 2009, pregnant women were among those who were most likely to die when infected with the virus.
  8. “I don’t want a flu shot because I might get Guillian-Barré syndrome.” Every year, 3,000 – 6,000 Americans get Guillian-Barré syndrome (GBS) but every year, 10,000,000 – 50,000,000 Americans get influenza. The vast majority of GBS is not related at all to influenza. However, in 1976, the swine flu vaccine did have an increase risk of GBS with the result that one out of every 10,000 people vaccinated developed GBS. Since that time, the increase in GBS has been about 1 case for every 1 million influenza vaccines. The mortality rate of GBS is 2.8% and the mortality rate of influenza is about 0.16%. If you do the math, there are about 150 influenza vaccine-related cases of GBS in the U.S. each year with about 4 of these patients dying. Therefore, you are about 10,000 times more likely to die of influenza if you are not vaccinated than you are to die of GBS if you are vaccinated. As a general rule, I am not a gambler but I’l take the 10,000:1 odds any day.
  9. “I can’t take the flu shot because I’m allergic to eggs.” Because many influenza vaccines are grown in eggs, these vaccines can contain a tiny amount of egg protein. Nevertheless, the CDC recommends that people with egg allergies should still get influenza vaccinations. Patients with anaphylaxis from eggs should be observed in a medical setting after getting a flu shot. However, studies of over 500 patients with anaphylaxis from eggs and who received influenza vaccines found that none of these people developed a serious reaction from the vaccine. People who can eat cooked eggs are very unlikely to have any reaction to influenza vaccines. For those people who are still afraid of the influenza vaccine because of fears of egg allergy, there is a recombinant influenza vaccine (Flublok) that does not contain any egg protein.
  10. “Flu shots are too expensive.” Most insurance plans cover influenza vaccination and if a person without insurance goes to the local pharmacy, that person will pay about $40 to get it out of pocket. On the other hand, we spend about $10 billion per year in the United States on direct costs of flu-related illness and have another $16 billion per year in lost earnings from flu-related illness. That works out to each case of influenza costing about $530. So, instead of looking at the flu shot as costing you $40 each year, look at it as saving you $490 each year.

At the time of writing this blog post, influenza is already widespread in many states. In the next few weeks, my hospital’s nursing units and ICU will be full of patients with influenza-related illness, and some of them will die. Those patients who survive the ICU are always the first ones to ask for a flu shot the next year. But for those who die, like Bre Payton, influenza always gets the last word.

December 29, 2018

Outpatient Practice Physician Finances

What Doctors Need To Know About Apple Watch EKG

The computer engineering geniuses at Apple have done it again. They’ve created yet another device that I’m probably going to have to buy. The new Apple Watch (series 4) has the ability for anyone to monitor their EKG (sort of). But what are we as physicians going to do with this data? Most electronic medical records permit patients to upload images to their patient portals for their physicians to have access to. Inevitably, some patients will overuse this system – some physicians are already drowning in dozens of Apple Watch rhythm strips being submitted by a single patient. But even for the patient who sends in a single suspicious rhythm strip, if the physician is going to make a clinical decision based on the strip, what are the implications? So, this presents several questions for physicians.

What is it?

The Apple Watch 4 can monitor the heart rhythm in two ways. First, it can measure the regularity of the heart beat by essentially taking the patient’s pulse; this can be reported as regular or irregular. Second, it can measure a single lead EKG reading and it is this latter feature that is really innovative. All EKGs are done by positioning 2 electrodes on different parts of the body and then measuring the electrical signal between those electrodes. A full EKG uses 12 electrodes and produces 12 different wave forms, or leads. The first three of these leads are the limb leads I – III. Lead I measures the signal between the left arm and right arm. Lead II is between the left leg and right arm. Lead III is between the left leg and left arm. The problem with a watch is that an electrode sensor on the back of the watch only has contact with one arm but by placing a second electrode sensor on the knob of the watch, a person can touch that second electrode with a finger from the other arm, thus generating a lead I EKG tracing by having an electrode in contact with both the left and the right arms simultaneously.

What can it tell you?

Since the Apple Watch can only generate a single lead EKG, there are limitations about the amount of information it can provide. For example, you cannot diagnose a myocardial infarction from only one lead (you need all 12). The main information that the lead I tracing will give you is whether the patient is in sinus rhythm or atrial fibrillation. Apple claims that the Apple Watch is 98.3% sensitive and 99.6% specific for classifying atrial fibrillation. However, 12.2% of rhythms could not be classified by the Apple Watch EKG app. Although Apple only mentions atrial fibrillation on its marketing materials for the Apple Watch 4, any physician who looks at telemetry monitor strips in the hospital knows that there are other important rhythm abnormalities that can be identified from a single lead EKG tracing.

What should you do if the patient uploads a rhythm strip?

Although we all get trained in EKG interpretation in medical school, most physicians are not credentialed to read 12-lead EKGs. In most hospitals, physicians must apply for hospital privileges to interpret EKGs and generally, this will be limited to cardiologists; in smaller hospitals, it may be a general internist who has EKG interpretation privileges. Reading an Apple Watch rhythm strip is considerably less complicated than reading a full 12-lead EKG but nevertheless, physicians should know their own limits as to whether they can confidently identify atrial fibrillation (or some other abnormal rhythm) by a rhythm strip. So, for example, if you are a podiatrist or dermatologist and do not normally look at heart rhythm strips, you may want to tell the patient who uploads an Apple Watch rhythm strip to your electronic medical record that EKG interpretation is not part of your normal practice and that they should check with one of their other physicians. However, most primary care physicians are trained in the recognition of atrial fibrillation.

Can you bill for review of the rhythm strip?

The short answer is in 2018, no but in 2019… maybe. Lets take a look at the CPT code possibilities for Apple Watch rhythm interpretation.

  1. CPT code 93010 (Medicare reimbursement about $8.50). This is the CPT code for interpretation of a 12-lead EKG if someone else (usually the hospital) owns the EKG machine. It requires an order from a physician and a written interpretation. Since an Apple Watch rhythm strip is only 1 lead and since it is done by the patient’s initiation and not by the physician’s order, CPT 93010 cannot be used.
  2. CPT code 93042 (Medicare reimbursement about $7.00). This is the CPT code for rhythm strip interpretation of 1-3 leads of EKG tracings. Like the previous CPT code, this requires an order from a physician and a written interpretation. Although it is conceivable that 93042 could be used to bill for Apple Watch rhythm strip interpretation, I would be hesitant to bill it since the patient is submitting the strip without a physician order.
  3. CPT code G2010 (Medicare reimbursement about $6.50). This is the new CPT code for “Remote Evaluation of Pre-Recorded Patient Information” that was created as part of the 2019 Medicare physician fee schedule. This was designed for video or images such as photos of a rash, etc. that a patient creates and then sends to the physician for review. There are several restrictions when billing this CPT code, however. The physician doing the review of the pre-recorded information cannot have seen the patient for a regular evaluation & management encounter within the previous 7 days or within 24 after reviewing the images. Also, the physician has to interpret the image and communicate the findings to the patient within 24 business hours. We will not know for sure if Medicare carriers will accept CPT code G2010 for Apple Watch rhythm interpretation until the new fee schedule goes into effect after January 1, 2019 and we start submitting bills for it; however, it would seem like this CPT code would be the best fit.

Who should get one?

Since the main thing the Apple Watch EKG app does is tell whether there is atrial fibrillation, it will primarily be useful for patients at risk of atrial fibrillation or with a history of previous atrial fibrillation. Better identification of patients with intermittent atrial fibrillation really could save lives since about 15% of all strokes are the result of untreated atrial fibrillation. My suspicion is that a lot of other people with occasional PACs or PVC (premature atrial/ventricular contractions) will also be uploading rhythm strips to understand why they have occasional subjective “skipped heartbeats”. Although not designed for PAC or PVC identification, this could be a side benefit of the app. Similarly, ventricular arrhythmias such as non-sustained ventricular tachycardia may be identifiable. Bradycardic rhythms such as sinus bradycardia and various forms of heart block (1st degree, 2nd degree, and 3rd degree) may be identifiable. Even if these rhythms cannot be diagnosed with complete certainty, the tracings from the Apple Watch EKG app may be suspicious enough for the physician to direct the patient to seek medical attention where a full 12-lead EKG or a 24-Holter monitor can be performed.

I’ve never had atrial fibrillation or any kind of heart problem. So, am I going to get an Apple Watch 4 with an EKG app… well, yeah, probably.

December 20, 2018

Electronic Medical Records Outpatient Practice

Should A Physician Pre-Chart For Outpatient Visits?

There is a subtle difference between inpatient and outpatient medical practice that nobody ever talks about… time management. With inpatient practice, you see patients at your own pace during rounds and if you want to stop for a moment to have a cup of coffee or speak with a colleague, it doesn’t disrupt your workday. But with outpatient practice, you can work leisurely at your own pace before office hours and after office hours but during office hours, you are in a constant state of demand for time efficiency.

In my own practice, my office hours come in 4-hour blocks, either 8:00 AM to 12:00 noon or 1:00 PM to 5:00 PM. During those blocks, I schedule 15 minutes for return visits and 45 minutes for new patient visits – every minute is scheduled and the only way that there is a break is if one of the patients doesn’t show up for their appointment. During that 4-hour block, I have nurses, schedulers, and registration staff who all need to be working in order for the office to function in a financially viable way. But for them to stay constantly busy, I have to be constantly busy.

10 years ago, before we adopted an electronic medical record, each patient would have a paper chart and I would make a few shorthand comments on a piece of progress note paper and then at the end of office hours, dictate letters to the referring physician for each patient, clean up my orders for the day and fill out billing sheets. In other words, I “back-loaded” my work day with a couple of hours of charting after I was done seeing patents. Once we adopted an EMR, I tried to do a lot of that work while I was in the room with the patient. The result was that I didn’t have as much dictation and chart work after office hours but the EMR documentation encroached on the time that I was with the patients. I continued to allocate the same amount of office time per patient but I seemed to have fewer minutes just talking with my patients. And because the EMR results in the physician doing more of the work of documentation than in the past, I still was spending an hour or two at the end of the day finishing referral letters and closing encounters in the EMR.

This was reflected on my CGCAHPS patient satisfaction survey results. Patients were happy with the care that they got but they were not happy about the time they spent in the waiting room when I ran behind and they often commented that they didn’t get enough time to spend with the doctor once they were in the exam room.

So 5 months ago, I tried a different approach, pre-charting for my outpatient visits. The day before my office hours, I start my progress note for each patient by selecting the appropriate return visit note template (I have different templates for different diseases: one for interstitial lung disease, one for asthma, one for COPD, etc.). I pre-populate any new test results and pre-populate my final “impression” by pasting in the diagnoses that I manage for that particular patient from their previous note. For new patients, I insert the appropriate new patient template (again, I have different templates for different pulmonary conditions) and pre-populate the note with any test results, radiograph image review, pulmonary function tests, etc. that are available for that patient, either from our medical center or from other hospitals that I can access through the “CareEverywhere” function in our EMR (we use Epic). As a result, I spend about an hour prior to each 4-hour outpatient block pre-charting, sometimes longer if I have a new patient with a lot of records that require reviewing. After 5 months, I’ve found that there are advantages and disadvantages:


  1. I am less likely to get behind on my schedule and so my patients are spending less time in the waiting room.
  2. I have more time to spend just talking with my patients since I am not trying to furiously type into the EMR as much when I am in the exam room with the patient. As a consequence, I find that I actually enjoy my time in the outpatient clinic a lot more than I used to.
  3. I anticipate improvement in two of the CGCAHPS survey questions: During this visit did this provider seem to know the important information about your medical history? and During this visit, did this provider have your medical records?
  4. I finish the day’s work earlier because I do less charting at the end of the day by front-loading all of that charting before office hours.
  5. I have now started billing CPT code 99358 about 2-4 times a week. This code pays you for review of medical records prior to seeing the patient in the office, as long as you spend at least 31 minutes doing the review. In my own outpatient practice, most of my patients have already had pretty extensive evaluations and in about half of the new patients, I spend > 30 minutes sifting through office notes, lab tests, cardiovascular tests, chest CT images, pulmonary function tests, etc. This pays 3.16 RVUs (about $114 in Medicare reimbursement) and I now find myself getting paid for the work that I was previously doing for free. And this adds up… I estimate that my clinical receipts will increase about $13,000 per year from this CPT, alone.
  6. I have x-rays available when I see the patient. Most of my patients are sent to me from physicians at other hospital systems and so most of their chest x-rays and CT scan images are not in our hospital’s computer system. By pre-charting, I have been able to identify where those radiographs were done so that my office staff can contact that hospital’s radiology department and have the images sent over the internet before I see the patient – in the past, I often had to schedule a second visit with the patient just to go over x-ray images that I requested after I first saw the patient for an initial consultation.
  7. I have been able to do a “huddle” with the nurses just before the start of office hours to let them know about anything special that they will need to do to prepare for each patient’s visit.


  1. In the past, I defined my workday as being complete when I finished all of the work for the patients that I saw on that particular day and the administrative duties I had for that day. Because pre-charting is often relegated to the last thing that I do each day (since it is usually the least urgent), pre-charting becomes the task that keeps me at work an hour longer each day and so I now negatively associate it with being the thing that steals my time away from my family in the evening.
  2. I often have residents and fellows in the office with me. I worry that by doing the pre-charting, I am detracting from their experience of independently analyzing the patient. Personally, I believe that the trainees learn a lot about how to comb through old records for diagnostic clues efficiently by actually doing it themselves and when I pre-chart, I am depriving them of this opportunity.
  3. I’ve created this nagging sense that I am becoming obsessive-compulsive.

Every time management strategy in the outpatient clinic has a trade-off between advantages and disadvantages. I don’t think that pre-charting save me any of the total time I spend on any given week but I don’t think it requires any more of my time either – it just shifts some of the documentation time around from after the clinic hours to before the clinic hours. But I think that it makes both my patients’ experience and my experience with the time spent in the exam room a little better. So, for now, I’m going to keep pre-charting.

November 28, 2018

Outpatient Practice Physician Finances

Improving Your Outpatient Revenue: The CPT Codes You Forgot To Bill

In my last post, I lamented that Medicare billing will earn me $614 per hour reading pulmonary function tests but only $107 per hour in outpatient clinical practice. We all have the impression that outpatient medicine does not pay very well. But there are some ways to improve your outpatient billing by making sure that you bill all of the CPT codes that you can legitimately bill for. Here are 8 CPT codes along with the Medicare reimbursable amounts that you can bill in addition to your regular evaluation and management CPT codes that will enhance your outpatient revenue:

  1. 99497 – Advanced Care Planning 30 Minutes (2.39 RVUs; $86). You can bill this code when you are having face-to-face discussions about hospice and DNR status with the patient, family members, or surrogate. Time must be documented to be between 16-45 minutes. There is no limit to the number of times this can be billed in a given year. If you spend more than 45 minutes, then you can also bill CPT code 99498 for each additional 30 minutes of face-to-face discussion. I see a lot of patients with idiopathic pulmonary fibrosis, an ultimately fatal disease, and end-of-life discussions are common and always take >16 minutes so this is a useful code.
  2. 99358 – Prolonged Service Without Patient Contact (3.16 RVUs; $114). You can bill this code for reviewing patient records before or after an office visit with a patient. For example, if you are seeing a new patient with extensive medical records and documentation. Time must be documented and you have to have at least 31 minutes spend reviewing material to bill this code. Bill this code on the day that you review all of the records. Not only does it pay reasonably well, it can make you more efficient – by pre-reviewing all of the old records before the start of your office hours, you can spend more time actually seeing patients so that your office staff are not sitting around waiting for you to review records before putting the next patient in a room. Code 99358 is for 31-74 minutes of record review. If you spend 75-104 minutes, you can additionally bill 9359 (1.52 RVUs). Many of my patients come to me with multiple CT scans that require review of the various images, pulmonary function tests that require interpretation, lots of lab test, cardiovascular tests, hospitalization records, and outpatient notes from the referring physician. It is surprisingly easy to spend >31 minutes sorting through all of the records, doing my own interpretation of the CT images and PFTs, and documenting all of these findings in our electronic medical record.
  3. 99406 – Smoking Cessation Counseling 3-10 Minutes (0.41 RVUs; $15). Few things that we do in medicine can have as great of an impact on our patient’s health than getting them to quit smoking, and Medicare will pay us to do it! You can bill this in addition to your regular evaluation and management CPT code. You need to document what you discussed and the number of minutes (I use a “smartphrase” in our Epic electronic medical record). If you spend more than 10 minutes, then you can bill CPT code 99407 (0.79 RVUs). Be sure to add a -25 modifier to indicate that the smoking cessation counseling was done in addition to your regular evaluation and management service that day. Although this CPT code does not pay very much, we almost always spend at least 3 minutes talking to the patient when we are counseling about smoking cessation so this is one of the codes I bill frequently.
  4. 94664 – Inhaler Technique Training (0.49 RVUs; $18). I once read a study that found that 50% of patients use their inhalers incorrectly. This code pays us to do the right thing and ensure that all patients are using the proper technique with their inhalers. There are so many new inhaler devices on the market now that just knowing how to use one device does not necessarily mean that the patient will know how to use another device. We do not keep samples in our office except for inhalers which we keep purely for the purpose of teaching our patients when prescribing a new inhaler. Make sure you document that inhaler technique training was performed (another smartphrase). Interestingly, this CPT code is composed of a practice expense RVU and a malpractice RVU but it has no work RVU associated with it. That is because you (the physician) should not be doing the inhaler training – it should be your nurses who do this. Many pharmaceutical companies will provide demonstration inhalers that do not contain any medication – I find these less satisfactory because the patients need to know the feel and taste of the medication when it is delivered with proper technique. I bill this CPT code every time I start a patient on a new inhaler.
  5. 90460 – Intramuscular Injection (0.58 RVUs; $21). This is billed in addition to the CPT code for any vaccine that you administer in the office. In other words, there is one code for the actual vaccine and one code for the injection. I often see physicians only bill the code for the vaccine and so they are leaving a lot of money on the table. If you give 2 vaccines to the same patient during one office visit, use CPT code 90461 for the second injection (0.36 RVUs). We have this CPT code bundled in with common vaccinations (influenza, 23-valent pneumovax, Prevnar-13, etc.) so that it comes up anytime I order the vaccine.
  6. 99490 – Chronic Care Management 20 Minutes (1.19 RVUs; $43). Use this code when you or your staff spend at least 20 minutes per month managing patients with chronic illness when they are not in the office (paperwork, emails, phone calls, etc.). I confess: I’ve never actually billed this code because I never remember to document my time for all of the things that I do to take care of patients and the requirements are just to onerous. However, every practice has a handful of patients who occupy a disproportionately large amount of your staff’s time and your time (think about the patient who calls your office twice a week, every week). Here are the requirements:
    • Patients have to have 2 or more chronic conditions that you manage.
    • The chronic conditions are expected to last for at least 12 months or until death.
    • There is a reasonable probability of death/decompensation/exacerbation/decline if the chronic conditions are not actively managed.
    • The patient has to agree to a chronic care management plan with you (probably safest to get this signed in case of an audit but at the very least, document your conversation with the patient to this effect in the patient’s chart).
    • You (or your office staff) have to document a total of 20 minutes per month doing things like coordinating home health care, filling out various forms related to the patient and their chronic condition, phone calls with the patient, emails to the patient (preferably via your electronic medical record for HIPPA compliance), etc. That means that every time you have a phone call with that patient, you have to document the number of minutes you spent on the phone and then documenting the discussion and your staff have to document the number of minutes they spent filling out the patients FMLA forms.
    • Only one physician (or NP or PA) can bill this code for any given patient on any given month.
    • You can bill this code once each month
    • You have to adhere to the CMS scope of service for this particular CPT code including:
      • Care management including medication management and management of the patient’s medical, psychosocial, and functional needs
      • Access to care management services 24-hours a day
      • Continuity of care
      • Creation of a patient-centered care plan that is documented in writing or in the electronic medical record
      • Management of care transitions (e.g. admission to a SNF)
      • Coordination with home-based services such as home healthcare and hospice
      • Multiple ways for the patient or their care giver to contact the physician and/or the office staff (e.g. phone, electronic medical record, email)
      • Use of a certified electronic medical record that is available 24-hours a day to any physicians (or NPs or PAs) that provide cross-coverage
  7. 99495 – Transition Care Management Moderate Complexity (4.64 RVUs; $167) and 99496 – Transition Care Management High Complexity (6.55 RVUs; $236). The nurse practitioner who I work with oversees our pulmonary transition clinic that has been incredibly successful at reducing our hospital’s 30-day readmission rate for COPD. CPT codes 99495 & 99496 are perfect codes to cover this service. To meet the requirements of this code, there has to be contact with the patient within 2 days of discharge from the hospital (this can be by phone from your office nursing staff) and there has to be a face-to-face visit with the physician (or NP or PA) within 14 days of discharge from the hospital (7 days for 99496). The reason that these CPT codes are associated with a high RVU value is that the first office visit after discharge from the hospital is bundled into it. That first face-to-face visit is not billed separately and is included in the CPT code but any additional office visits in the 30 days after discharge can be billed separately. The transitional care can involve things like reviewing the discharge summary, following up on any pending test results, arranging follow-up testing, medication reconciliation, etc.
  8. 99354 – Prolonged Services (3.69 RVUs; $133). Use this CPT code when you spend an excessively long amount of time with an office visit. I find this code particularly useful when I am seeing a patient for the first that one of my partners has previously seen within the past 3 years (thus prohibiting me from billing that patient as a new patient visit and forcing me to use the return patient visit codes instead). The time associated with this code is 1-hour but that translates to 31-74 minutes in CMS language. Importantly, that is on top of the time it would take for a regular evaluation and management code. So, for example, if you are billing for a level 5 return visit (defined as 40 minutes by Medicare), then you have to spend at least 70 minutes with that encounter and then you would bill both the level 5 return visit CPT code plus the prolonged services CPT code.

Outpatient practice can be challenging because there is a lot of time outside of the patient’s actual office visit that is required to care for the patient. Using these codes will not make you rich but they can at least partially pay for all of the non-compensated time that you have been providing in order to manage your outpatients.

October 13, 2018

Outpatient Practice

The Silent Victims Of The Opioid Crises: Physicians

Last week, I delivered the opening introduction to the annual Addiction Studies Institute, an annual conference sponsored by Talbot Hall, the addiction recovery hospital at our medical center. This is the 28th year of the conference and was attended by more than 1,000 health professionals, clergy, educators, and criminal justice professionals who had one thing in common: dedication to the treatment and prevention of addiction disorders. The key note speak was Dr. Jerome Adams, the Surgeon General of the United States. He had a powerful message about our current opioid crisis and that it takes people from many professions to combat it. I left the conference energized and ready to help do my part in curing society of this scourge.

And then I came back to my world in the hospital, to learn that yet another one of our physicians had been physically threatened by a patient because of refusal to prescribe opioids.

Currently, 1-2 people in Columbus, Ohio die every day from drug overdose. Nationwide, 64,000 people die of an overdose every year. The reasons for our current opioid crisis are complicated but are largely due to the confluence of three key factors:

  1. Over-prescription of opioid pain medications in the 1990’s and 2000’s

  2. Lowered costs of heroin imported from Mexico

  3. Availability of high-potency, low cost fentanyl over the internet from China

There have been several initiatives to battle the opioid crisis, particularly to reduce the excessive prescription of opioid pain medications that have caused many people to unwittingly become addicted. Here in Ohio, for example, there has been the creation of the OARRS database, where pharmacists upload records of all opioids dispensed in Ohio by a doctor’s prescription; prescribers are required to check the OARRS database prior to every opioid prescription to ensure that patients are not getting opioids from multiple physicians. The state medical board limits the number of days that a patient can receive opioids for post-operative surgical pain. There has been a state-wide effort to use non-opioid pain medications whenever possible, including the approval of a new medical marijuana law here in Ohio.

The result of all of this is that it is harder for physicians to prescribe opioids and by prescribing opioids, physicians increasingly put themselves at risk of sanctions by the state medical board, including loss of their medical license if they don’t follow all of the regulations exactly. Consequently, many doctors in Ohio are reluctant to prescribe opioids and patients who have become addicted get desperate.

Recently, we had a very good physician resign from our hospital because a patient threatened the doctor with death if the doctor would not prescribe opioids. The patient had initially been treated with opioids for cancer pain but with effective treatment, the cancer was cured. Since the cancer was cured, the cancer-related pain should also have resolved and when the doctor said that it was time to taper the opioid pain reliever off, the patient became irate. This was a doctor whose professional life had been dedicated to relieving pain and suffering, particularly of those people with cancer but to the doctor, it was not worth the risk to life nor the fear of walking through the clinic parking lot alone every morning.

This week, a patient called and threatened another one of our doctor’s lives – the doctor had not even seen the patient for 3 years but another prescriber, had told the patient that they were no longer able to prescribe an opioid pain medication to the patient and somehow the patient got it in his head that it was all the original doctor’s fault.

As physicians, we take these threats very seriously because sometimes patients act on these threats. On July 26, 2017, in South Bend, Indiana, Dr. Todd Graham (a physiatrist) refused to write a prescription for an opioid pain medication for a patient and later that afternoon, the patient’s husband shot and killed him. Every pain management physician knows about this case and thinks about it every time they de-escalate an opioid prescription or decline a request for a new opioid prescription.

Sometimes the threats are more subtle and play more to the physician’s emotions rather than making physical threats. I had a patient who I prescribed oxycodone-containing cough suppressants who, when told that I was not going to prescribe them anymore, told me that he would just have to buy opioids on the street and that my failure to continue to prescribe the cough suppressant was going to turn him into a street drug addict. He said that his impending use of heroin was going to be all my fault… I still said no.

Sometimes the threats are not so much physical or emotional but the threat of inconvenience. As an example, we had an inpatient who wanted an opioid pain medication and the hospitalist did not find a justifiable indication for it and refused to prescribe it. The patient threatened that if the doctor didn’t prescribe him Percocet, that the patient was going to report that the doctor was intoxicated. The doctor refused and so the patient called the medical staff office to report the hospitalist was drinking on the job. We had to pull the hospitalist off of rounds and sequester the doctor in the administrative offices until we could get the lab director to do an alcohol breath test. It was, of course, negative, however, the time of sequestration put the hospitalist behind in her rounds and so she ended up working a couple of hours later than her normal shift in order to finish her patient care duties… and the patient never did get the Percocet.

There are some tangible things that we can do to protect our physicians so that they do not need to either feel guilt for not prescribing opioids or feel that their lives are at risk for not prescribing opioids. Here are 11 things that we can do as medical leaders:

  1. Don’t ignore the doctors’ concerns. If they tell you that they are worried or fearful, take it seriously. When it comes to your perception of their safety and their perception of their safety, their perception is what is really important.
  2. Set clear expectations when initially prescribing opioids. All patients receiving more than a few day’s of an opioid for post-operative pain or a bronchitis-related cough should have a written pain contract that the patient signs. The pain contract should specify the purpose of the opioid, that regular drug testing will be done to ensure that they are not taking other controlled substances and are not diverting (selling) the opioids being prescribed to them. It should spell out that violations of the pain contract will result in a non-negotiable cessation of opioid prescription.
  3. Secure vulnerable practice locations. Using badge-reading locks to doors leading to high-risk clinics such as pain clinics or palliative medicine clinics can provide a sense of security to the physicians.
  4. Locate vulnerable practices in areas with security. Once again, pain management practices and palliative medicine practices are best suited in either a hospital location or in large, multidisciplinary clinic building where the size of the facility warrants having on-site security personnel. This is much safer than locating these practices in small, isolated office buildings.
  5. Consider panic buttons. If a patient threatens a physician, there usually is not enough time to pull a cell phone out and call for help. In large office buildings or hospitals, there may not even be good cell phone service in the interior rooms. A panic button that alarms directly to on-site security can provide a lot of reassurance to the physician.
  6. Consider chaperones. When a doctor is in a closed exam room with a patient, they can feel very vulnerable. Having a second health care worker in the room, especially for those patients who the doctor anticipates conflict over opioid prescribing, can help maintain an atmosphere of control and can run out to get help in event of patient threats.
  7. Make opioid addiction treatment available. Most patients who are addicted to opioid pain medications do not really want to be addicted to them but they cannot see any way out. Any physician who prescribes opioids needs to know where to refer patients who are addicted in order to get help, ideally some place where the patient can go directly from the physician’s office to initiate evaluation and treatment for addiction.
  8. If you are the medical director, be willing to be “the bad guy”. Many times, a well-meaning doctor will prescribe opioids for a chronic condition like a painful non-healing wound or a cancer but once that wound or cancer is cured, the doctor finds him/herself still prescribing an opioid. The doctor has spent months or years being that patient’s advocate and healer and is often reluctant to disrupt that doctor-patient relationship. Sometimes it is easier for that doctor to tell the patient “I want to help you but my medical director says I have to stop prescribing your opioids.”
  9. Do not penalize physicians for doing the right thing. It was not too many years ago that we were told that “pain is the 5th vital sign” and failure to treat pain (with opioids) was akin to not treating patients with hypotension from septic shock. It was only last year that CMS still incorporated how well pain was treated as a component of the HCAHPS surveys of patient satisfaction. Patients who do not get the opioid prescription that they want are often angry and vindictive. We have to accept that those patients are going to fill out HCAHPS and CGCAHPS surveys unfavorably and will rate doctors low on on-line rating services. Hospital leaders have to be willing to accept theses ratings and not hold them against physicians who refuse to prescribe opioids unnecessarily. We cannot be the facilitators of patients who would hold their doctors hostage to prescribing habits.
  10. Beware of physicians who accept payments from pharmaceutical companies that market opioids. A study published in JAMA Internal Medicine by Dr. Scott Hadland this year found that 7% of physicians who prescribe opioids accepted payments from pharmaceutical companies for non-research opioid payments (speaking fees, meals, honoraria, consulting fees, education, travel, etc.). 1.7% of these physicians received > $1,000 in benefits from pharmaceutical companies regarding opioids. Those physicians who received payments from opioid-producing pharmaceutical companies were less likely to reduce opioid prescriptions to patients than physicians not receiving pharmaceutical payments. In fact, every meal received by a physician from a pharmaceutical company increased opioid prescriptions by 0.7%.
  11. Give the doctors other options. There are a lot of other ways to treat pain than opioids. Often, a non-steroidal anti-inflammatory drug, physical therapy, or an interventional pain procedure can be more effective that an opioid. We need to be sure that these methods of treating pain are just as easy to order and arrange as a prescription for Vicodin.

“To relieve pain and suffering” is at the core of what makes us doctors. But then so is the tenet of “first, do no harm”. The problem with opioids is that they can relieve pain but they can also cause harm, to the patient but also less directly to the physician. It is incumbent on all of us to create treatment environments where physicians can feel safe from being the ones who are harmed by the opioid epidemic.

August 2, 2018


Outpatient Practice

Why Do People In Ohio Smoke So Much?

This month, the CDC released the preliminary results of the National Health Interview Survey for 2017. The great news is that the percentage of American adults who smoke dropped nearly 2 percentage points from last year, from 15.8% to 13.9%. This is the lowest number in more than 50 years. But in Ohio, the percentage of people who smoke did not change; in fact, it is going up.

Smoking has notable demographics. Men are more likely to smoke than women (15.8% versus 12.2%). White Americans are more likely to smoke (15.7%) than Black Americans (15.1%) or Hispanic Americans (9.7%). People living in a rural area are more likely to smoke (21.5%) than people living in small cities (15.6%) or large cities (11.4%).

On January 11, 1964, Dr. Luther Terry, the Surgeon General of the United States, released a report concluding that smoking causes lung cancer and chronic bronchitis. That year, 42% of Americans smoked and the average per capital U.S. cigarette consumption was 4,300 per year (another way of stating this is the average American smoked 215 packs of cigarettes per year). The number of cigarettes smoked immediately began to fall. The science behind this report was solid but there were a lot of “smoking-deniers” who refused to believe it and so in the mid 1970’s, the per capita cigarette consumption in the U.S. rose. Over time, most of the deniers either changed their mind or died so that now, 54 years later, only a few Americans doubt the relationship and the per capita cigarette consumption has been steadily falling every since the mid-1970’s.

Over the past 20 years, the percentage of Americans who smoke has fallen an average of 0.5% per year. At that rate, in 26 years, no Americans will smoke. Therefore, in 26 years, three jobs that you don’t want to have are: tobacco farmer, cigarette maker, and pulmonologist. Alas, my medical specialty is going to go the way of the blacksmith, slide rule maker, and telephone operator.

From a health economics standpoint, cigarettes are actually a very effective way of government cost-control. The average woman who smokes a pack a day will live 11 years less than a non-smoking woman and the average man who smokes lives 12 years less than a non-smoker. If you do the math, it works out to losing 14 minutes of life for every cigarette a person smokes. Since smokers die so much earlier than non-smokers, they consume a lot less Social Security benefits. With more Americans not smoking, we’ll see more people living long enough to be on Medicare and Social Security.

But Ohio is different. From a report by the United Health Foundation, for the past three years, the prevalence of smoking has gone up rather than down and in 2016 (the most recent data year available for the state), 22.5% of Ohioans smoked. So then, why is the prevalence of smoking going up in Ohio whereas it is going down in the rest of the country? If you examine the data carefully, then demographically, Ohio smokers are different than the rest of the country:

  1. Age. Similar to the rest of the country, the older you are in Ohio, the less likely you are to smoke. However, young Ohioans (age 18 – 44) are far more likely to smoke (26.4%) than in the rest of the country (18.1%).
  2. Race. Nationwide, Hispanic Americans are the least likely racial/ethnic group to smoke but 22.3% of Hispanic Ohioans smoke, double the national average. Ohio has the dubious distinction of being one of the most equal opportunity states for smokers with about the same percentage of white, black, and hispanic Ohioans smoking.
  3. Education. For many years, there has been a significant inverse relationship between education and the prevalence of smoking – the more education a person has, the less likely they are to smoke. But in Ohio, for those people with less than a college degree, these differences are amplified. Thus, if a person doesn’t finish high school in Ohio, that person is far more likely to smoke than a high school dropout in the rest of the country.
  4. Income. Not surprisingly, the relationship of smoking with income tracks that of education. But once again, in Ohio, the effects of income are amplified.
  5. Rural versus urban. Nationwide, Americans living in rural areas are less likely to smoke than those in large cities. But Ohio is different. People living in Ohio’s large cities have the same prevalence of cigarette smoking as those who live in rural Ohio.

So what does all this mean about Ohio? For starters, 25 years from now, Ohio will be one of the last hold-outs for smokers in the United States. If you live in a large city, have lower income, or have a lower education level in Ohio, then you are more likely to smoke than in the rest of the country. With the average price of cigarettes at about $6.50 in Ohio, the Ohioan who smokes spends about $2,300/year on cigarettes – for the 39% of Ohioans earning less than $25,000/year who smoke, than means that they are spending 1/10th or more of their entire annual income on cigarettes. Many in Ohio complain about the loss of good-paying jobs over the past 15 years. Part of our problem in Ohio is that because we spend so much more money on cigarettes than the rest of the country, once you factor in the cost of those cigarettes, our take-home income is less for the same job as the rest of the country. Clearly, we have a lot of work still to do in Ohio when it comes to tobacco education and control. Our high rate of tobacco smoking puts Ohio at a competitive disadvantage to other states

As a pulmonologist, this unfortunately means that I will still have a job in Ohio when I am well into my 80’s, long after my peer pulmonologists in the rest of the country are out of work.

June 28, 2018

Outpatient Practice

Should Men Be Screened For Prostate Cancer With PSA?

Identification of cancers in early stages when they are surgically curable has resulted in an overall reduction in cancer death rates in the past 20 years. Where cancer screening has been most effective is in colorectal cancer, cervical cancer, and breast cancer. Prostate cancer screening has been much more controversial with several recent studies suggesting that screening with serum PSA levels may not have much impact on overall survival. The most recent study showing no benefit by PSA screening was published in this month’s JAMA. This was a powerfully large study that involved 415,357 men age 50 – 69 years old followed for 10 years. The overall conclusion of the study was:

“…there was no significant difference in prostate cancer mortality after a median follow-up of 10 years but the detection of low-risk prostate cancer cases increased. The findings do not support single PSA testing for population-based screening.”

In other words, they found more cancers but finding them did not result in men living any longer. The idea is that by screening, you find very low grade cancers that would never pose a risk to a man with a normal life expectancy. And the implication is that by screening, we’d do a lot of unnecessary prostatectomies on men who really don’t need them. So, does this mean that we should stop screening men for prostate cancer? Well, we shouldn’t condemn the PSA too fast.

First, the study took place in England and Wales – notable because one of the major risk factors for prostate cancer is being African American (at least in the United States). In the U.S., 12.3% of the population is black whereas in the U.K., only 3.0% of the population is black. Therefore a significant at-risk population was underrepresented in the study. It is likely that different screening strategies should be employed for higher risk men, such as those who are black and those with a family history of prostate cancer. This would be analogous to doing mammography at an earlier age for women with BRCA genes and strong family history of breast cancer or doing more frequent colonoscopies in people with familial polyposis.

Second, the study protocol was a single PSA test with prostate biopsy for those men with a PSA > 3.0 ng/ml. I would question the value of a single PSA test, especially if it is only minimally elevated, for example 3.0 – 5.0 ng/ml. Instead, it may be more predictive to look at the PSA trajectory over time with men at the highest risk of more aggressive prostate cancer having the steepest trajectory in PSA levels.

Third, if you look carefully at the data from the recent study, although there was no overall significant difference in the mortality from prostate cancer between the men who got usual care (control) versus those that got the single screening PSA (intervention), by 14 years, the curves were starting to separate and I question whether there would be a significant difference in mortality if the groups had been followed for 18 or 20 years. The implication of this is that for men with a long life expectancy, PSA screening may be appropriate.

So, what is my personal take on whether we should be doing PSA screening for prostate cancer? I believe that we should do it but that screening should be personalized based on life expectancy and risk factors. Here are my thoughts on it:

  1. Be sure that the PSA test is accurate. There are many things other than prostate cancer that can cause a moderately elevated PSA level, such as age, prostatitis, urinary tract infections, and benign prostatic hypertrophy (BPH). But there are also other conditions that can cause mildly elevated PSA levels and these need to be taken into consideration when considering the timing of the blood draw for the PSA test: constipation, riding bicycles (particularly those with the sharp-angled, pointed seats), recent ejaculation, recent foley catheter placement or urinary tract surgery, and digital rectal exam. Because the half-life of PSA in the blood is 2-3 days, we should caution men to avoid these things for 3-4 days before getting their PSA level drawn so that the the risk fo false positive tests are minimized.
  2. Screen only those men who are otherwise likely to live at least 12 years. There is no need to get a PSA test on a patient who has advanced COPD, who has severe heart failure, or who is 85 years old. On the other hand, it may be reasonable to screen a very healthy 60-year old man with a family history of everyone living into their 90’s.
  3. Men with risk factors, such as having family histories of prostate cancer or being black, should be managed differently, with a lower threshold for doing PSA screening.
  4. Follow the PSA trajectory. Every child has their height plotted on a growth curve as they get older – we should do the same with PSA and then those men whose curve deviates from the expected increase in PSA with age should be the ones that we target for doing more detailed cancer testing such as prostate biopsy. A single PSA is just one point in time and what may be more important is the change in PSA over time.

I’m not ready to give up on recommending prostate cancer screening on the basis of the most recent study. But I am ready to commit to screening more strategically and making sure that my patients are better informed about the test.

March 22, 2018

Outpatient Practice

Making Your Outpatient Practice More Efficient

It is hard to make a huge salary with a purely outpatient medical practice, in fact, it is hard to just break even without support from a hospital or some other institution. American medical financing is structured in order to preferentially reward physicians who do procedures, who have high-volume inpatient practices, or who are subsidized by a hospital. But there are some tangible things that the outpatient physician can do to improve the operational efficiency of an outpatient medical practice to optimize revenue and improve income.

Why you can’t make a living off of wRVUs alone.

First, you have to understand the current medium of exchange in physician financing, the RVU (relative value unit). Every service and procedure in medicine is assigned a number of RVUs based on the average time it takes to perform that service or procedure, along with the complexity and degree of training required to do it. Each total RVU is composed of 3 subcomponents: the work RVU (that represents physician effort), the expense RVU (that represents the typical overhead expense to provide that service or procedure), and the malpractice RVU (that represents the average expense to cover the malpractice premium to perform that service or procedure). Medicare pays physician based on the number of RVUs that they bill – currently about $36 per RVU. Medicaid typically pays less – around $22 per RVU and commercial insurers pay more (around $40 – $60 per RVU, depending on individual physician contracts with specific commercial insurance companies). Uninsured patients typically pay little to nothing per RVU. We often focus on the work RVU (wRVU) as a measure of physician productivity. Therefore, in an outpatient medical practice with an average overhead expense, the amount of money that the physician takes home should equate to the number of wRVUs that he or she generates per year times the average revenue per RVU generated by Medicare, Medicaid, and all of the various commercial insurance companies that cover the patients in that medical practice.

So, in theory, if you generate 1,000 wRVUs and you get paid an average of $36/wRVU, then your income should be $36,000. But reality doesn’t work that way. The 2017 Medscape salary survey indicates that the average pulmonologist makes $310,000 per year. If you add to that 25% benefits, then you need $388,000 to cover a year’s worth of salary and benefits. To generate this much money, you’d need to generate 10,764 wRVUs per year. However, the average pulmonary/critical care physician only generates 5,768 wRVUs per year. The MGMA does a deeper analysis of compensation per wRVU and found that the average pulmonary/critical care physician brings in $58 per wRVU.

So, how do you improve your compensation per wRVU?

The simplest way to get to the $58/wRVU number is to restrict your practice by not taking uninsured patients and Medicaid patients and putting a limit on the number of Medicare patients that you see in order to load up on the higher paying commercially insured patients. There are a lot of physicians who do just this. But most physicians can’t or won’t limit their practices to patients with commercial insurance. However, there are some things that the physician can do to improve their average compensation per wRVU:

  1. Negotiate a higher compensation per wRVU. If you are a solo practitioner, you have zero negotiating power with commercial insurance companies but if you are in a large group practice or affiliated with a hospital with a lot of financial clout, then you can negotiate for higher rates then the “standard fee schedule” that the insurance company offers. Also, if you are affiliated with a hospital, then you can often negotiate a higher payment per wRVU from the hospital with the assumption that the hospital will make enough in downstream revenue from your patients that they can afford to subsidize your practice.
  2. Buy your own testing equipment. If you have sufficient procedural volume to justify purchasing an EKG machine, a point-of-care lab testing machine, or a spirometer, then you can add to your overall revenue. As an example, if you purchase a spirometer for $1,500 and you get paid $34/test (Medicare rate), then you need to do 44 tests to cover your initial costs and every test over that is profit.
  3. Negotiate coverage of hospital activities. Hospitals are required to have a physician available for things like cardiac rehabilitation, anticoagulation clinics, and hyperbaric oxygen treatments. Most of the time, these require very little physician work except on the rare occasions that a patient has a medical problem while participating in these programs. So, negotiate for an hourly coverage fee – you can still be seeing patients in the office at the same time as long as the office is in the same building as the hospital-based program.
  4. Reduce your clinic expenses by improving your operational efficiency.

Improving operational efficiency in the outpatient clinic

Medicare doesn’t pay you by the wRVU, it pays you by the total RVU. So, if you can reduce the amount of money that you have to spend on overhead expense, you increase the amount of money that goes to the physician’s salary. Lets take a hypothetical service with a total RVU of 2.22. Of that total RVU, there is 1.00 wRVU, 1.00 peRVU (practice expense RVU), and 0.22 mRVU (malpractice RVU). At $36/RVU Medicare rates, the assumption is that you will need $36 to cover the overhead expense of providing that service and there will be $36 toward the physician salary for that service. But, if you can reduce your expense to $18 for that service, then you will have $54 to go toward the physician’s salary, thus converting $36/wRVU into $54/wRVU.

Optimizing clinic efficiency can reduce the overhead expense for the medical services you provide. Most of the overhead expenses that a medical practice has on any given day that the practice is open are fixed expenses: the cost of rent, the cost of the nurses and registration staff, and the cost of your billing staff. If the physician had to do everything on their own (registration, scheduling, checkout, billing, answering the telephone, vital signs, etc.), then the physician would probably only be able to see a very small number of patients per day. Strategically, the physician should just do the components of medical practice that only a physician can uniquely do and the practice should employ other people to do the more routine things. By hiring office staff and nursing staff, you can improve the number of patients seen per day, up to a point. The trick is to hire just enough staff to match the physician’s peak productivity – too few staff, and the physician either has to do non-physician tasks (reducing productivity) or cut back the number of patients seen and too many staff, and the physician can’t generate enough work to keep all of the staff busy. According to the MGMA, the average number of staff in a physician-owned medical practice is 1.24 business operations support staff, 1.48 front office support staff, 1.82 clinical support staff, and 0.78 ancillary support staff per physician in a multi specialty practice. In a hospital-based clinic, the numbers of staff per physician are generally lower. It is a lot like the Starling curve that defines cardiac output and preload.

As an example, lets take a look at what happens if you change from scheduling return visits at 20 minutes per visit to scheduling them at 15 minutes per visit. Lets assume that you bill all of your return visits as level III returns and get paid Medicare rates of $36 per RVU. And lets say that your overhead expense for your practice is $272,000 per year. By simply dropping from 20 minutes per visit to 15 minutes per visit, you can double the physician income:

  • 3 patients/hour increases 33% to 4 patients/hour
  • 24 patients/day increases 33% to 32 patients/day
  • Net revenue $408,000 increases 33% to $544,000
  • Physician income $136,000 increases 100% to $272,000

This is because if the overhead expense is fixed, everything that the physician generates above the overhead expense is profit to the physician. In reality, overhead is made of of both fixed and variable expenses, particularly if things like billing are outsourced where billing expenses are usually charge based on the volume of bills rather than a fixed annual amount. Nevertheless, you can see that small changes to clinic visit times can have a huge impact on physician salary revenue.

Other things that can reduce expenses and improve clinic efficiency:

  1. Don’t hire an registered nurse to do a medical assistant’s job. RNs are expensive and MAs salaries are lower. Make sure that you are not over loading the clinic staff with people who are over qualified for typical duties. You don’t need an RN to do vital signs and schedule tests.
  2. Work the staff at the top of their license. This is an extension of #1 above. The physician should delegate those tasks such as maintaining the past medical history and calling in prescriptions rather than trying to do everything him/herself.
  3. Avoid canceling clinics. Even though the physician and the patients aren’t there, the office staff are still there and you still have to pay rent. In large practices or hospital practices, rather than having all of the staff sit around idle, a different physician should be seeing patients if the normally scheduled physician is on vacation.
  4. Convert phone calls into paid office visits. On a typical Monday, I’ll have around 15 – 20 patient phone calls and email message via our electronic medical record. I prescribe a lot of medications over the phone and give out a lot of advice over the phone. And all of it is free since phone calls and emails are not reimbursable. By saving 15 – 30 minutes at the end of each day for sick call visits, you can convert a lot of that free medical care that you provide into paid medical care that you provide.
  5. Use the entire office hour time. I know some physicians who don’t start seeing patients until 9:00 even though the office staff start at 7:30. That is a lot of idle time. Ideally, the physician should be present and seeing patients during the entire time that the clinic is open and then reserve meetings, phone calls, etc. to a time of day that you are not paying your office staff to be present.
  6. Spend 15 minutes prepping for the day’s patients. By scanning the patients’ charts you can identify things for your office staff to do in order to improve the efficiency of the clinic visit, whether that is locating test results that aren’t in the chart or pre-ordering an office EKG or spirometry that you know that you are going to need. The goal is to have the patient spend only the amount of time needed for the office visit in an exam room and to avoid having the patient waiting in the exam room while the physician or nurse tracks down the results of the CT scan that the patient is there to discuss with the physician.
  7. Do a pre-clinic huddle with the clinic staff. This follows from #6 above. If the staff know what to expect with the patients scheduled for that day, they can prepare and optimize flow.
  8. Double book strategically. As a rule, I don’t like to double book – if both patients show up, then both of them only get half of the time that they deserve or I end up putting the rest of the day’s schedule behind. However, if you can anticipate which patients are less likely to show up, then double booking those patients can average out to a normal schedule in the long run. In my practice, new patients referred from the emergency department or referred as hospital follow-ups frequently don’t show. Also, return patients with a history of not showing in the past are likely to not show in the future. Demographically, in many practices, uninsured patients and Medicaid patients are more likely to not show.
  9. Schedule patients strategically. In every medical practice, there are some patients that you know are going to take longer than others. For example, in my practice, a pulmonary nodule follow up or an annual asthma check up take less time than a return visit for a patient with multiple medical problems who is close to entering hospice. Also, there are some patients that always seem to need more time – maybe because they have lower health literacy, because they require a translator, or because they just need to talk more. Schedule these patients at the end of the day.
  10. Organize patient flow efficiently. You need to really look at the patient movement through the clinic: where the physician charting area is located, where the nursing charting area is located, where registration and check out are located. Often, patient flow is determined more by where the rooms were located when you first rented your office space – by making small adaptations, you can often greatly improve efficient flow.
  11. Make your electronic medical record work for you. I’ve posted a lot about EMRs but the reality is that I like our EMR. But it is easy to not take advantages of the efficiencies that it can bring to the table. Getting refresher training can improve your utilization of note templates, increase your use of smart phrases, reduce your number of mouse clicks per encounter, and improve how you navigate between different EMR windows.
  12. Don’t forget reimbursable services that you probably already perform. Remember that smoking cessation counseling is an add-on billable service to the regular office visit service. Also, if you prescribe inhalers for asthma or COPD, inhaler technique training is a billable service (but it should be done by the office staff, not the physician).
  13. Get the right number of exam rooms per physician. Once again, there is the equivalent of the Starling curve for exam rooms – you can increase productivity up to a point but beyond that, productivity does not increase with increasing number of exam rooms (but your square foot rental expense does continue to increase). The right number of rooms varies by medical specialty and by individual physician. A cardiologist may only need 2 exam rooms whereas a dermatologist may need 4.

Even with peak efficiency, it is hard to get a physician in an office practice up to the $50 – $60 per wRVU that it takes to cover the physician’s salary so physicians are increasingly becoming hospital-employed in order to get access to hospital subsidies that would not be available in a physician-owned practice due to Stark laws and anti-kickback laws. As the medical director of a hospital, my responsibility is to ensure that the hospital-associated outpatient medical practices continue to use the tenets of practice efficiency to prevent the hospital from running a deficit and going out of business.

February 24, 2018

Inpatient Practice Outpatient Practice

Should Your Hospital Hire Locum Tenens Physicians?

It is a vexing question that most hospitals and medical practices face eventually: when you have an expected or unexpected physician vacancy, do you bring in a temporary substitute? Locum tenens is a huge business – rarely a day goes by that I don’t get a phone call or an email from a locum tenens company asking if I’d be willing to cover a pulmonary practice for a few weeks or do a few ICU shifts in some community in the Midwest.

There are a lot of very legitimate reasons why bringing in a locum tenens physician makes sense. The local physician could be out on an extended medical leave or maternity leave. A doctor in the National Guard could be called up for active duty. Maybe there was an unexpected death or retirement and the replacement physician can’t start for a few months. There could be unexpected physician resignations or an unexpected growth in clinical demand and hiring just can’t keep up.

In nursing, we call those temporary workers “travelers”. In business, they are often called “temporaries”. When it comes to physicians, we call them “locum tenens”. The word comes from Latin meaning “placeholder”. I’ve seen these employees work both ways. For example, when I was the treasurer of our Department of Internal Medicine, we brought in a temporary administrative director to oversee our revenue cycle department and she brought in a wealth of knowledge and experience – we were able to capitalize on her objective analysis of our operations as an outsider looking in so that we were able to greatly improve our billing and collection efficiency. On the other hand, I have seen hospitals bring in temporary physicians who did not perform clinically as expected and resulted in a deterioration in the quality of care in those hospitals.

Many hospital medical directors and hospital credentials committees remember the bad experiences and forget about the good experiences and thus try to avoid locum tenens doctors. This month, in JAMA, we finally have some objective data to help us to decide whether bringing in locum tenens physicians is safe. In an article from Harvard, investigators looked at 1.8 million Medicare admissions covered by an internist between 2009-2014. They found that 2.1% of the admissions were covered entirely by a locum tenens physician. In addition, 9.3% of the non-locum tenens primary admitting physicians were covered by a locum tenens physician at some point during the hospitalizations.

The key finding was that there was no difference in 30-day mortality between the locum tenens physicians (8.83%) and the non-locum tenens physicians (8.70%). There were some interesting differences, however. Patients treated by locum tenens physicians had higher costs of hospitalization ($1,836 versus $1,712), longer length of stays (5.64 days versus 5.21 days), and lower readmission rates (22.80% versus 23.83%) compared to patients treated by non-locum tenens physicians. In summary:

  • No difference in mortality
  • Longer length of stay
  • Higher cost of hospitalization
  • Lower readmission rates

There were also some interesting demographic differences. Locum tenens physicians were more common in Southern and Western United States. They were also more common in smaller rural and suburban hospitals (as opposed to urban hospitals) and in public hospitals (as opposed to private hospitals).

A recent survey of healthcare organizations indicated that 85% use locums tenens at some time. Although you might think that locums tenens primarily attracts younger, more mobile physicians, it turns out that 75% of locum tenens physicians are over age 51, that is, toward the end rather than at the beginning of their careers. When considering hiring a locum tenens physician in your hospital, it is important to understand the doctor’s motivation to do locum tenens work – there are “good” reasons and there are “bad” reasons:

The Good Reasons For Being Locum Tenens:

  1. Desire to visit different parts of the United States or to visit family members residing in different parts of the country.
  2. Desire to try out a hospital practice or a part of the country before committing permanently (like dating before committing to marriage).
  3. Wanting to scale back clinical practice as a bridge to retirement.
  4. Flexibility in scheduling and ability to have extended time off during the year.
  5. Preferred lifestyle.
  6. Enrichment of professional experiences by practicing in multiple locations to improve clinical abilities.
  7. Better pay.

The Not So Good Reasons For Being Locum Tenens:

  1. The physician does not get along with other people and cannot maintain lasting relationships.
  2. The physician has substandard practice and cannot hold a job for a long period of time.
  3. The physician does not want to be invested in the long-term success of an organization.
  4. Better pay (this can be either a good reason or a bad reason, depending on the circumstances.
  5. The physician has become burned out and is just trying to stay employed.

When considering a locum tenens physician, the hospital will most often be dealing with a locum tenens company as an intermediary. It is important that the hospital stick with its usual credentialing process to vet the physicians – there can be a tendency to delegate some of the credentialing steps to the locum tenens company with the assumption that they are as thorough or have as high of standards as the hospital’s credentials committee. However, that is not necessarily the case. The locum tenens company is selling you a product, namely the doctors on their list and they will be motivated by trying to make a sale rather than by trying to improve your hospital’s quality of care. There is also the belief that because the locum tenens physician will only be there a short while, that the hospital can live with lower standards than they would require for a regular permanent physician. However, remember, it is always harder to get someone off of the medical staff than to put them on in the first place and if that physician decides to stay in the area and now has regular medical staff privileges, he/she could decide to continue to practice at the hospital long-term. Also, a bad doctor can do a lot of damage to your hospital in a short period of time. There is also the issue of cost – locum tenens physicians will usually be more expensive than a regular, permanent physician.

Some large physician groups will have an internal locum tenens group in order to fill temporary vacancies at the various practice locations that they have. Although you can be a bit more sure of what you are getting in this circumstance (since these locum tenens physicians are actually employed by the physician group), they still require the regular vetting you use for any other new physician, including contacting references from past locations where they have practiced.

The use of locum tenens physicians is becoming more and more common. Most hospitals in the U.S. will be using at least some locum tenens physicians in the next year. The new study indicates that the overall quality of care by locum tenens physicians is good. However, the hospital still need to be sure that the individual locum tenens physician’s motivations for his/her career choice will mesh with the hospital’s culture and goals.

December 7, 2017