AMEN!!!!!!!!  Waste and fraud are rampant, but gee, the ones who do it are great about covering it up!  AND the Recovery Audit Contracters (RAC) are paid big bucks to "find" that waste and fraud---if you underbill, it's just as bad as if you overbill. 

I say, Melissa for Secretary of HHS!  Redo ALL of CMS---it shouldn't be this hard......we've all discussed it here ad nauseum and come up with some really good plans. 

But no---it won't be done---none of it!  Keep carving out those exemptions and waivers to make that worthless "War and Peace" monstrosity even more of a joke......

You just keep being so eloquent Melissa---I'll be right behid you holding you up and swinging my bats.  Maybe between us we'll knock some sense into someone......

Thanks Sara,

I really appreciate your comments. The best thing we can do is to push this blog with all of your comments to every congress person we know. The least it will do is make them think and perchance, act in some responsible fashion when it comes to the real issues that will drive health care reform.

Melissa

Dr. Walton-Shirley:

Excellent perspective from a true clinician rather than doctors-wanna-be politicians advising the white house and CMS to be rewarded with some political managerial job. I think, like everything in this country, the pendulum sways too far on either side, before we realize it.  After we drive a lot of good talent away, and we suffer from an exodus, then we will realize that the solution is not a knee-jerk reaction as all the governments have done so far. What amazes me, is that the main sector that lead to the demise of our economy and drove us to the cliff (Financial industry), was resuscitated by the government and continues to run amok and totatlly unregulated with a revolving in-out door into our government. Their blunders are nothing to be compared with any blunder in the health care system. Unfortunately, our government seeks to remedy the system across the path of least resistance: the medical sector. Physicians have always been overpowered and can be easily targeted. May be it is time to really unionize and assert our rights.

Dear Doctor:I guess you  don't get it. 

We waste  a lot of money on medical spending. AND doctors show  inadequate interest

in the concept of cost effectivness 

Regarding the trauma  patient "after a loss of consciouness":. If it was AFTER  

   the  loss of consciousness ( PT NOW FULLY CONSCIOUS)  a CT of the head will be  negative because a traumatic cause of loss of consciousness implies a mass lesion in the brain. Mass lesions ( ie bleeds) big enough  to cause coma do not resolve quickly so someone who wakes up does not have a mass lesion (causing  the brief episode of unconsciousness). If the scan is positive it is an incidental  fiinding.

 Also calcium scdanning is   of dubious value. I  doubt mass  hunting for renal cell cancer would be

likely to be helpful  after all is said an done. Recent doubt placed on mammography and PSA

screening have actually  cast doubt on the general concept of preventive medicine. We have a limited amount of health dollars to spend . It's about time that physicans made their own decisions about wise spending because otherwise the government with do it for us. Yes,

malpractice reform would help....I grant you that .

PS: Being a Republican  will not prevent you from becoming  a thoghtful  physician.

Bill,

Thanks for your post. I love Republicans-Heck, I even married one!! Only a person who doesn't wear a bra or know anyone who does would say that mammography doesn't save lives. My sister in law is now 2 years out from a lumpectomy due to an abnormal mammo with calcifications that were absolutely not palpable.  I am so grateful for that discovery. I believe there is so much opportunityin America to find the funding to continue to look for the "needle in a hay stack" illness and have money left over if we approach medicine thoughtfully and carefully. It's not graft. I agree malpractice fears drive so much unnecessary spending.  See, like good Americans we can agree to disagree and still wish each other happy holidays!!!

The very first thing I'do is bring America out of the dark ages and make every public building smoke-free.  It's almost too embarassimg to admit that we are so far behind the rest of the industrialized world in worker protection. LEt's stop having to pay for preventable illness so often. 

Secondly, I'd map America and make PCI without SOS more accessable.

Third, I'd meet with health curriculum builders for elementary schools so that when each child reaches secondary school they know which side their gall bladder is on, the symptoms of appendicitis, what basic blood work can reveal, what drives heart disease,risl factors for glucose intolerance . Itis a shame how little human beings kmow about their bodies amd that ignorance drives the cost of health care.  actually, most folks WANT to know these things and it really would not be so difficult to teach that.

Fourth, I'd really like to bring blood pressure screening to the masses. Let's get real in  America. Provide tax incentives to beauty shops, barber shops and grocery stores where everyone congregates in order to get at stroke risk.

Provide incentives to hold nutrition classes on fat, carb and sodium education at the grocery where neighborhoods shop. The public really wants/needs this information at the point of contact where the food is purchased.

Well, I'd have to write for about a million more years to address all the practical opportunities we have for decreasing health care spending, 

Also, I dont think any cardiolgist would argue that elective PCI is life saving. It's "quality of life" saving. I suppose you should argue we should not set a broken arm? It's really NOT life saving after all and certainly therefore not worthy of our health care dollars, according to your logic.

Melissa

I feel the need to state that I am not "Part of the problem or solution?"  I know that I am not well liked on these blogs and do prefer to ignite my own fires.

Excellent comments however on both sides of the issue.  Should a frugal clinician achieving equal outcomes be somehow rewarded?  I think so because if our healthcare dollar is limited than those professionals are of greatest value to our society.  One thing I find interesting is the failure to recognize appropriate frugality while the usual is castigating failure to order tests.  Preprinted order sets for chest pain etc causes numerous unnecessary tests done often obviously not indicated when someone actually thinks about the utility.  I think there is an enormous amount of waste when one actually looks at what is ordered versus what is indicated.  I know in my hospital when I have looked at charts more than 50% of tests are either not indicated, not likely to make a treatment difference or probably aren't worth the money spent with regards to treatment value. Stress tests ordered as part of a routine 50 year old evaluation in an asymptomatic patient?  A regadenosan nuclear stress test done in an 85 year old patient as preoperative evaluation for a cataract?  Both ordered TODAY!  We are in part responsible for the cost of medicine and should acknowledge it.

Dr. K.

Your comments are appreciated (today! HA!). I would like to qualify the statement you made about the 50 year old with no symptoms.  I am certain you will agree that a 50 year old healthy patient on no meds who does not smoke, has no family history and no symptoms and whose lipids and glucose are normal has little business in our offices.  However, if that 50 year old lost their ovaries at age thirty three, of if they are on 100 units of insulin twice daily, or if their father died at age 47, then the landscape is drastically different.  I am in no way relieves by their lack of symptoms. It is not WHO you are (age 50), it is WHAT you are (dyslipidemic, smoker, etc) that counts in the world of risk assessment. I am sure you agree. We aren't just after the easy ones (sweaty folks clutching their chests). we are after the sneaky ones who look great and we read about them in the obituaries and everyone is so shocked (well, cardiologists rarely are. You can predict risk fairly well with a good history and some risk statifying tests).

As for you, Dr. or Mr. or Mrs. "Part of the problem"; not certain why you are in hiding but I'll take that question "what do you suggest?"

Innocent patients aren't being summoned by angiographers just to be placed on a conveyor belt in the cath lab.  They are referred for chest pain and risk assessment often by their internists or family physicians.   They are being referred by the "please cover my butt I want to operate on this guy's knee, gallbladder, hip, etc.docs", all of which (non cardiac procedures) are covered without one question by CMS and most of which are entirely elective.  I have great empathy for the surgical oncologists who are swimming around in a pool of hypercoagulability.  The risks for patients with a significant cancer burden are real and often much higher.  SOoooo, what is a cardiologists to do? Instead of just placing an envelope on my forehead like the great Carnack, I can do an echo to help the anesthesiologist know how to support their BP during induction. Neo for poor EF's or significant leaky valve folks and 2 liter bolus of NS for pristine EF's.If their is mild to mod ischemia, if there is room for beta blockers, I add them. If not, they get a cath and plumbing with a bare metal stent or CABG. If large territories of ischemia, they get a cath if the situation permits.  Other than approaching it this way, I really don't know what anyone else could expect.

As for your question about how to regulate the Crooks.  It's really not that difficult.  You look at other models in other arenas of fraud. You lay traps. You audit.  If you are running a PCI conveyor belt in your lab and you are subjecting innocent human beings to risk because of greed, you should be fined, jailed and in clear cut cases, your license to practice stripped.  If you document ischemia on a stress, a part of the audit should include a look at the actual stress exam. IF we  document progressive angina and the  the auditor should contact the patient to make certain the story is straight.  These extreme audits for the outliers would result in restitution.  They should be treated no better than Michael Jackon's wonderful cardiologist. 

Second answer: Malpractice reform. Enough said. Arguments against it are stupid and costly.

Our lab is busy with in -patient admits for chest pain, ST changes, leaking troponins, and progressive angina in out patients, not foks nabbed at Walmart for their body parts.  The fact is that most physicians are hard working and trying to serve the masses. To think that fraud is rampant in the cardiology world is ridiculous.  Let the non cardiologists who point fingers come into our environment of risk assesment as the "buck stops here" part of the  physician chain and they will sing quite a different tune,

Melissa

You should strive to implement the following evidence-based screening procedures in your practice:

Screen age>65 for AAA, especially male ex-smokers and smokers - screening saves lives

Screen age>65 for AF with an annual holter - anticoagulation saves lives and prevents catastrophic strokes in AF patients

Screen all patients over 40 for carotid plaque development - early detection can motivate powerful lifestyle changes (see US study from the Seychelles in Am J Preventive Med) 

Screen for a smoking history on all patients

Implement carbohydrate restriction (such Atkins diet) on all patients with even a whiff of overweight, obesity or visceral adiposity; elevated trigs or low HDL; elevated OGTT levels.

Screen for microalbuminuria and eGFR in anyone with hypertension or other risk factors for renal disease and implement ACE inhibition to prevent progression to dialysis, stroke and MI.  Please don't use an ARB in this setting (ORIENT, ROADMAP).

Get neighbours to do pulse checks and get BP screening implemented on the outside of the doctor's office - make BP cuffs as readily available in public venues as external defibrillators now are.

None of this is all that expensive, but you would save a fortune doing even some of this. 

Dan,

I love your suggestions but a annual holter would break the bank in our system in all 65 year olds. However, offering a holter to al patients with a positive family history of afib, +screen for sleep apnea, palpitations, sig valve disease or cardiomyopathy would be a great start. 

Part of the solution: mild-moderate ischemia or worse, not just mild ischemia, and it also depends upon how large the territory is. Works for me. In twenty years of doing pre-op evals, I've had two major ontraop complications.  One patient infarcted predictably because he had a brand new cypher and our anticagulants unmasked  aggressive bladder cancer.  We prepared his team for the very high likelihood of SAT, which DID occurr on the table resulting in a quick trip to the cath lab for a balloon only fix that thank GOD worked then resumed his bladder surgery.  The 2nd patient had moderate AS, long standing history of coronary artery disease and old mild ischemia with no angina. He arrested during a renal cell carcinoma surgery but walked out of the hospital.  

Make fun as much as you like.

Melissa

Melissa, the costs will come down for holter screening, particularly as the devices get smaller and easier to implement.  There is already RCT data on this. 

Screening versus routine practice in detection of atrial fibrillation in patients aged 65 or over: cluster randomised controlled trial.

I respectfully disagree.

Stress tests have NEVER been shown to be a useful population based screen for prognosis in asymptomatic patients.  It is a perpetuated myth of medicine that should be cleansed.  How many negative stress tests have "reassured" patients with early CAD who are then denied the benefits of aggressive primary prevention (props to Blanchett and McConnell here)?  Understand that that asymptomatic high risk 50 year old patient that you are advocating stress testing is being "screened" for the likelihood of requiring CABG for prognostic indications - because independent of the result there is no indication for PCI and aggressive medical therapy is indicated regardless. I would assert vanishing small potential benefit versus cost well documented in the Armed Services who do this routinely at age 45.  So please think about the implications of placing that recommendation in print as if it represents the standard of care - I would sooner see that patient medicated and educated and not invaded.  And is this subtle disagreement important - absolutely because patients at risk for an MI remain so after a normal stress test and that has enormous implications with regards to primary prevention, medicolegal understanding and population education.  Sorry I cannot let that assertion go unchallenged.

Dear Melissa,

I just want to offer you a word of support. I don't normally read these blogs but this one have caught my attention and I followed it through as it unfolded. I must say at the end I felt compelled to say something just to indicate that you are not alone out there and there are people who think just like you. As I was reading it I felt like you were attacked from all the directions by all these "blood thirsty" (I am sorry but at some point these attacks became pretty angry) "I know everything" wannabes when in fact you have outlined pretty accurately what the problems are, the complexity of the issue and reasonable steps to try and improve it.

I totally share your frustrations with the system and the ways administration sees the problem and tries to address it. All I can say if you want to have job done you hire someone who knows what he does and has done it before and not just throw someone to confront it. You get a plumber for a leaking sink and an electrician for your outdoor power point and not the other way around. 

I think we all could agree that nobody knows everything and what we know today maybe closer or further away from the truth depending on whether we took the right turning prior (ie correctly interpreted the "evidence" provided from yet again another randomized controlled study). So to all of you who throw some publications as the proof of their rightness I say.... just you wait, there will be another study that proves the complete opposite. 

So if you ask me what we should use as a guide? I would say common sense, it never fails. And that common sense tells me that if we are to address an issue of malpractice and misuse we should use a model utilized commonly in the garden. Weeding is an efficient way of controlling the spread of unwanted species. And if you could ask your grandmother and I am sure you had one she would tell you that you pull out not all the plants and then decide which one were good and which ones weren't but only the ones that you specifically want to target. Trust me it works every time I go into the garden. 

I won't take anymore of your time, I really just wanted to thank Melissa for speaking out and tell her that she is not alone. 

And just one more thing, think simple. There is absolutely no need to try and reinvent the wheel every time we have to go somewhere. Complex solutions offer nothing but even more complex problems. Look around most of the times answers are just right in front of us we just have to look.

Keep it coming!  Your blog is the best.  I have been in practice in general and interventional

cardiology since 1979 and plan to keep going.  For all the points you appropritely raise it has still

been an amazing and gratifying ride. 

A question:   Why do you blame this new audit approach on the "White House"? 

 Is there any evidence that anyone in the White House actually proposed this? Exactly how did this program originate and by whom?

Personally, I'm getting really disgusted with people, especially Republicans and others who have an ax to grind, trying to blame every problem, whether real or perceived, on President Obama (which is what "White House" implies).

Mikhail and Michael,

Thanks so much for your kind comments.  I have a fairly thick skin and am an avid debater , but indifference to issues that impact mortality and morbidity, insulated with ignorance on behalf of our legislators is a painful reminder that our struggle to make a difference will be never ending.  In many  areans it will be futile. I am comforted however by the confidence that we can and should impact the immediate world around us.  I will not be deterred from that effort. It is one day at a time, one patient at a time. 

If i had one wish, I's hope that our president would sit down in a fire side chat situation amd address so many of the drivers of cost. I would be so impressed if he would address the nation on drunk driving issues, smoke free America, teen pregnancy, obesity, sedentary life style, cancer screening recommendations, etc. He should plan an hour, preceded by weeks of comversations with physicians and legislators to get a feel for the most pressing issues, then make specific recommendations as to how to make a positive impact at the ground level.   Our population is not getting this information in the office setting. A sore throat often gets only a prescription for Amoxicillin when the 58 year old male walks out the door with no recommendation for colon cancer screening. We tell them they should quit smoking but dont take the time to go through the various options, benefits, risks and costs of each modality.  

We can do better.  Conversations like these should help us all to think. I think they are sometimes good fodder for motivation!!!

Democrat: Whitehouse, administration, and congress when this medical program was passed into law.  Who would you have us blame?

As we can see, the more power and influence your give to the government or the more power and influence they take, the less freedom and freedom of choice we have in all aspects of our lives.

Allow physicians and patients to determine the best course for diagnosis and treatment, and offer better reimbursements for those physicians that get the best outcomes for the money spent.

 Dr. Walton-Shirley, please continue to speak out for your fellow physicians and more importantly for all of the patients out there.

Bill, I appreciate your post but I have to strongly disagree. Screenings and prevention would save tons of money. I cannot tell you how may renal failure pts I have worked with that are on dialysis and never knew they even had hypertension until it was to late. So a screening exam and possibly a $4/ month prescription could have saved us hundreds of thousands of dollars each year.

Genetic testing, carotid scans, calcium scoring test, etc...would all be much cheaper than having an Mi or stroke. Screenings are not expensive! Wellness is cheap when compaired to having an event.

Cindy,, 

Please see Cohen, Nejm 2008  358 661-663  for an in depth discussion of the issue

of  whether  prevention saves  "tons of  money".

  Many physicians   , nevetheless,like yourself, despite the evidence to the contrary , continue

to practice elaborate  unproven  and costly, preventive care practices. Why is this? 

My feeling is that prevention is  practiced by  many physicians because

practicing preventive  medicine  is far more  lucrative than treating sick, acutely ill people

which is a stressful , time consuming business, prone to malpracitice  risk, often requiring work at odd hours

interferng with famiily time  and sleep and it is work that is poorly reimbursed relative to

: work  done in  "preventive " medicine. Consequently, to stay  in business  and stay healthy

, doctors have to fall back on the preventive aspects of care.This is really not a criticism

just an observation. I think  on some level , the government , observant not blind, having cut funding to acute care,

now is going after the rest of the opportunties to cut costs:  prevention.

.  Our government is broke.Businesses are hurting due to health care costs

No efforts are being made to reduce the  national deficit  which is rising every single day.

This situation is not sustainable. 

I am NOT a physician, however I am an RN and a cardiology patient AND a female.  This new audit policy of CMS frightens me.  We are battling the need for female cardiac sypmtoms to be recognized by cardiologists.  These symptoms DO NOT always include chest pain.  I would be DEAD now if my internist had not sent me for a "just in case" stress test based on my risk factors.  The stress test showed a "glitch" as the cardiologist described it.  Quote "probably nothing but artifact, but because of your risk factors I recommend a cath."  Had the cath, went from there to the OR for triple CABG because my LAD was 98% blocked and two blockages on my RCA > 96%.  My ONLY symptom was unrelenting fatigue - NO CHEST PAIN.  If the cardiologist was "threatened" by non-payment he probably would not have even done the stress test, much less the cath. 

Screening saved my life.  And for "hospitalistbill", I get the distinct feeling that you are a disgruntled "acute care" physician (your signature is a strong hint) that has seen your funding cut and now is looking to keep your volumn up.  After all, if preventative care becomes more affordable and prevalent, less people will become acutely ill and admitted to your service in the hospital.  If less people are admitted, then less hospitalists will be needed.  If less hospitalists are needed, well there you go.

Dr. Walton-Shirley is expressing the frustration of being micro-managed by people with no medical backgound or education.  As an RN, I have seen healthcare become more and more regulated by these non-medical persons.  First it was the HMO's, then different forms of "managed care groups", now the government is getting overinvolved.  When I go to a doctor, I want the doctor to draw upon his/her knowledge and experience to see me and help guide me and diagnose me.  I don't want a "cookie-cutter" response because CMS "threatens" non-payment.  If that is the goal, just have CMS issue a booklet to every person in the USA stating that these 25 symptoms we will pay for you to see a doctor, otherwise just stay home and die!  That is what micro-managing will lead to in the long run. 

Yes, healthcare is expensive, so AUDIT those that are displaying "warning" signs of fraud.  Don't throw the baby out with the bathwater.  Dr.Walton-Shirley is right on in my opinion.  Practicing physicians in regular private practice are the ones that should be "writing" or at least majorly consulted in making these healthcare reforms.  (Wouldn't hurt to have some practicing hospital bedside RN's - not advanced practice - in on the consultations as well for overall reform.  We are pretty observant and very creative.)

this is a comment to reply to CBS.

Dear CBS:

Thank you for your reply.  I agree with the indication  for  your heart cath .

You were SYMPTOMATIC and apparently had risk factors. Women have atypical symptoms for  coronary disease.

Was payment for the heart cath denied?

No, thank God.  This occurred before CMS instituted their recent changes.  I read about these changes earlier this month and immediately wondered if I would have fallen into the class that would be denied because "symptoms" are usually based on classic male symptoms.  So many women are denied treatment even when they are actively having an MI because they are not experiencing chest pain, or they are thought to be too young to be having an MI.  I fear that CMS is only going to make the process more difficult for women to otain quality cardiac care because they are presenting "differently" or are young. 

I don't expect to work for no pay and I don't expect my doctors to do so either. CMS is threatening more and more doctors with either no or severely reduced payment.  I firmly believe that the treatment of the physician should be paid for regardless of the diagnosis - if we only test for "sure things" then we are denying health care to a lot of people. 

While I am sure many persons you see as a hospitalist are already diagnosed, I am equally sure that you have ordered tests on a "hunch" and found something entirely different or new is occuring in your patient.  That hunch being based on your knowledge and experience. 

Many times, the primary or specialist in the office is starting from scratch - testing is required to rule out as well as rule in possibilities.  I see this new regulation as interferring with the doctor's ability to obtain needed facts, do his/her job completely and receive adequate (or even semi-adequate) payment for doing so.  If you work in the ED, then you probably face these same issues, but once the patient arrives on the floor, chances are some of these tests have already been run or a tentative diagnosis is already made. 

If we (government/CMS) take away the doctor's ability to receive payment for PCI, then we are effectively removing one of the better tools they use to get enough information to effectively treat the patient who may or may not be experiencing "recognized" symptoms, yet the "gut" of the cardiologist/internist is telling him/her to look a little further.

Medicine/health care has never been and should never become a cookie-cutter field.  Every person is different and symptoms vary by person.  If it ever does (and I see CMS and government involvement heading us in that direction,) then we can just produce machines that you stick your finger in, draw blood and poof!  diagnosis and treatment prescribed from an excell spreadsheet - no doctors needed. 

Again, abuses need to be addressed - like the doctor in Tx. who, I believe, put 72 stents in one man's heart.  And maybe that wasn't an abuse situation, however I cannot blame CMS or any insurer for looking into that case further.  Investigate "red flags" that the cardiologists are well able to help CMS recognize if they were only asked.  I believe that by a significant majority our doctors are honest.  I do believe that a certain amount of CYA medicine is practiced - our litigious society has caused that.  Malpractice reform is greatly needed and deserved.  Let the physicians of the various specialties help CMS/government produce the list of "red flags" that warrent a more thorough investigation rather than treat all physicians as the third grade teacher does when she dictates punishment for the entire class because they won't tell who tripped little Karen. 

I don't know where healthcare reform is headed, I think some of what was included in the current reform is good, but mostly I think it was a hurriedly put together hodge podge of stuff that needs to be thoroughly evaluated in the "real" world of healthcare.  Limiting doctor's ability to receive payment for using tools to get adequate information to treat their patients is not the correct way to attempt cost savings.

Don,

I am a democrat but I vote for the "person" not the politician. I take our commander and chief at his word when he says, "the buck stops with me". Our president resides over all major government agencies, like CMS. If he doesn't know what is going on inside its walls, he should.  I am eternally optimistic that our voices are raised by having these discussions. In my naitivite, I believe eventually someone may relate the content of these conversations to someone of influence. If not, it's still great therapy.  

John,

In then US, pharmacies sometimes make a BP check device available, but there is no counseling option, no direct communication between the physician community and our pharmacists except for prescribing information. This is such a lost opportunuty and in the land of stroke and pump failure from poorly managed and undetected hypertension, incentives should be in place to encourage a seamless concerted effort at getting at this issue. The study this past year addressed putting the option in barber shops for BP checks and detection is increased.  I think Canada has it right on the issue of making the pharmacist at part of front line management and detection of hypertension. Lost opportunities abound here.

Dr. K

Our obituaries are full of asymptomatic individuals. Would you feel great about my long term prognosis as I proudly proclaimed that " I feel great", if I were an overweight smoker whose mom died of an MI at 54? Surely at this stage of cardiovascular medicine we are beyond symptoms.  Do you think that a patient would in a million years start a beta-blocker, asprin, mediterranean diet just on risk profile alone? Do we not gain anything by the knowledge that profound ischemia exists?  Believe it or not, a randomized controlled prospective trial is NOT required to support every decision in medicine. Common sense must be the cornerstone of every decision.  (collective gasp!). 30% of Mi's are "asymptomatic". Add to that OUR interpretation of symptoms further muddied by the patient's interpretation. All cardiologists have had to dig, conjecture and suppose on a daily basis in order to uncover the fact that indeed the TMJ the patient had for a while was no longer just TMJ, or the tums innocently added on today's intake questionaire in the office is really not treating indigestion but rather, it's angina. 

No thank-you, I will NOT worship at the tomb of the "asymptomatic patient". We have come too far and understand too much about risk to be reassured by our perceived lack of symptoms. Furthermore, by the tone of your posts, I believe that you are a thoughtful physician and do not believe for one second that you practice based upon "symptoms" alone.  Otherwise, we should just fold our arms and wait for folks to clutch their chests and fall down before we stand up to do anything. That's Not for me and probably not for you either when you get down to it.

Melissa

November 30, CMS issued a new directive that will allow nearly 15 million obese Medicare patients to see their primary care doctor for "free" up to 20 times in one year for face to face obesity counseling.

That's potentially 300 million doctor visits which is 100 million more office visits then Medicare patients see their primary doctor now for all reasons. (There are nearly 50 million Medicare patients who see their primary care doctor an average four times a year).  CMS set the reimbursement fee at $34 for each visit.

Do the math and this new unfunded benefit could potentially cost $10 billion.

Before CMS issued this ruling, they did no actual cost benefit analysis; no estimate of the total cost of the program or whether this new service can even be delivered. (Isn’t there a well known projected shortage of primary care doctors?)

The Affordable Care Act gave CMS the power to do this which rivals anything Soviet era central planning ever tried to accomplish.

How is this new CMS benefit any different than when the Central Committee set wheat production goals by fiat and then set the price of bread without any concern if the wheat could be grown or the price of bread could cover the cost of production?

The Affordable Care Act is an oxymoron if there ever was one.  Remember when Pelosi said the bill would have to pass before we could find out what was in it?  Surprise!

http://www.modernmedicine.com/modernmedicine/Modern+Medicine+Now/Medicare-to-reimburse-for-obesity-screening-and-co/ArticleStandard/Article/detail/752457?contextCategoryId=40158&ref=25

DEAR CBS

   TO CBS

I AM GLAD YOU HAD  YOUR MEDICAL CARE COVERED.

I AM UNABLE TO INTELLIGENTLY RESPOND TO YOUR COMMENTS ABOUT THE NEW CMS

CARDIOLOGY PAYMENT RULES AS I HAVE NOT REVIEWED THEM. I ATTEMPTED  TO FIND THEM BY LOGGIN ON TO THE CMS

WEBSITE BUT I FEEL THAT TRYING TO FIND USEFUL INFORMATION ON THAT WEBSITE IS LIKE

SCANNING THE NYC PHONE BOOK LOOKING FOR SOMEONE TO  MARRY.

IF YOU HAVE ACCESS TO THIS INFORMATION ( WHICH I AM SURE YOU DO

AS YOU HAVE VERY  STRONG OPINIONS ABOUT THE NEW RULES) THEN I WOULD

APPRECIATE  IT IF  YOU COULD  SEND ME THE REFERENCE. 

SINCERELY, HOSPITALIST BILL 

Ok, so screening by feeling the pulse works. So why the sudden leap to holter screening?

How much extra benefit does that produce, for how much effort and cost? Which many people cannot afford, even if they have basic insurance.

The trouble is that so many in the US have the belief that "if something is worth doing, it is worth overdoing" 

Thank you - one of the nicer replies that I still must disagree with but only on the preposition.

Risk factors (and perhaps adjunctive markers like coronary Ca+) should be the indication for education and appropriate prevention based intervention. Otherwise by the logic you propose you would reserve initiation of preventative therapies only for those who already had the disease as indicated by a positive stress test and deny it to those with a negative stress test.  So using a stress test to "screen" an aymptomatic patient would be expected to have vanishingly small benefit and potential harm if its utililty was misunderstood (not necessarily by well informed cardiologists as yourself but the physician most likely to arbitrarily order a stress test as part of a routine health exam).  So the question is does routine stess testing as a screening test at the age of 50 materially influence prognosis and the answer to that is no or at least not likely.  If you do a routine stress test at 50 when do you repeat it? Unfortunately when Medicare is going bankrupt sober conversations with regards to test utiltity need to occur and either physicians have realistic discussions or it will be left to a panel of beurocrats. Screening tests currently reimbursed by Medicare all have outcome data to support them.  Finally there is no benefit of revascularization in the vast majority of asymptomatic patients absent left main or perhaps proximal 3VD/LAD involvement so the screening stress test is looking for that frog to kiss.  Again I do not ignore these patients and quite likely overtreat them with preventative therapy.

Any symptomatic patient deserves evaluation which goes without saying.  Finding asymptomatic patients with high risk anatomy remains a challenge.  Since acute myocardial infarction occurs often on non-obstructive plaque there is every reason to question how effective even serial stress testing might be.  And the potential for abuse of any test exists - I have practiced in areas of the country where every six month nuclear stress tests were the norm and yearly nuclear stress tests on anyone who had even a low risk prior abnormality.  This stuff adds up and the argument that we will miss lives that could be saved needs some additional data - if we all lived in an ICU it would substantially cut the incidence of sudden death (not studied but I think a safe assertion). 

Cheers and have a wonderful holiday season. 

Dr. K

I agree that screening should not JUST include a stress exam. Simple Bp checks are a huge part of it. Calcium scoring is important as well, though I had my irst fakst Negative in a patient age 70 with left shoulder pain that remitted only after we PCI'd her RCA and it's been an ongoing process for months trying to treat her angina and to convince her to have a cath because her stress cine suggested inferior/post/lat ischemia with my least favorite results: "less than hyperdynamic response".

And remember: "You have to kiss a lot of frogs before you find your handsome prince!!!"    :}

Thanks for the holiday wishes and back at you!!!

Melissa

Melissa,

Take my comments with a huge grain of salt: I don't read holters, don't wear them myself, and don't explicitly know their cost (though I don't think it's that great - compared with some of the screening maneuvers we do - e.g. colonoscopy).

I do know there are new holter monitors that are basically the size of a large wrist watch (read that on cardioexchange.org - John Mandrola's blog), with are extremely convenient to wear.

If you've ever visited a stroke ward, a rehab hospital, or a neurology clinic (or an emergency room on any given day), you will know that AF-related stroke is the single biggest cause of stroke disability, mortality and costs - that much I do know. It is also the most preventable form of stroke (anticoagulation is extremely effective; warfarin abolishes 85% of all cardioembolic strokes, and 68% of all strokes). Screening only patients with known cardiomyopathy, known valve disorders or palpitations will pick up a tiny fraction of the preventable a.fib.-related strokes whom I see post-event.  I agree widespread screening is not ready for prime time - maybe our technology is still lagging and our costs are too high.

Dan,

I worked summers as a nursing assistant at Cardinal Hill Rehab hospital in Lexington Ky back in the day. My areas were the spinal cord and stroke units. I learned at an early stage of my career what devastation occurrs as a result of these maladies. There are characteristics that are associated with stroke and I think a large trial would get at the answer fairly easily.  Perhaps now that Dabi, Rivoraxaban and apixaban companies are looking for patients (instead of generic warfarin), they might sponsor a trial to look at who ELSE needs anticoagulation.  Ideally the NIH SHOULD sponser thos trial. And dont think anyone will hurt my feelings if they "steal" my trial idea. I've got enough to do, so I'd love it if someone would help us understand how to mine the goldmine of information we waste daily that could be used for stroke prevention from occult afib.

For patients in sinus rhythm who get an echo for what ever reason: chest pain, palpitation, syncope, dyspnea, ---If their LA is dilated, why not holter them?  We know those patients already dont hold sinus post cardioversion very well, so why not holter them prospectively to see if we can catch them up to no good BEFORE we meet them on the stroke ward?  (egg on my face if this trial has already been performed-I am unware of it).  OR sit on the front steps of a grocery, walmart or some large gathering place and offer a free echo to all comers age 65--for those with LAE, holter them (If they will agree of course! HA! might get arrested if we try to force the issue LOL!)This would decrase selection bias of those who get an echo for wymptoms, but I think both populations should be studied.  Ideally a study to look at CRP's might be a good querry and holter those patients as well to look for occult afib and cost effectiveness of screening that population. 

Melissa

Melissa,

Glad we see eye to eye on this important issue.  Yet the vast majority of cardioembolic stroke patients I see only get their holter and echo post-stroke.  Thus while it's nice to think that going from a determination of LA size on an echo performed for other reasons (eg chest pain, SOB) will pick up a huge amount of silent AF patients on subsequent holter, we clearly need a better strategy to screen patients for occult AF than performing these two tests in tandem (which is logistically difficult at a population level). 

You are looking at it from the cardiologist's office perspective - your echos are already done and read.  I am looking at from the stroke clinic's perspective - most of these patients have never had an echo or a holter, or else the echo was done years and years ago (before their problems developed). 

I honestly believe that holtering large segments of the elderly population in a relatively unselected fashion will pick up a huge burden of unsuspected AF.  In conjunction with CHA2DS2-VaSc scoring and anticoagulation, this will prevent many strokes.  AF is present in 1 in 10 over the age of 80, and I am seeing many devastating strokes in elderly women in particular from this disease.  I like your idea of offering it in the grocery store, but I would honestly skip the echo - many studies have suggested it's virtually useless for work-up of potential cardioembolic stroke anyway (unless it's done transesophageal), and increased LA size is neither sensitive nor specific for predicting AF as a clinical routine.  Since this can't be done in everyone, I would suggest holter be performed in anyone with a CHA2DS2-VaSc score of 2 or more (still a huge population).  And yes we need a trial to prove it.

Dan

The plan is NOT to micromanage cardiac care from the White House for everyone. NO NO NO.

Only white folk.

The other America will be exercizing the Cadillac of HealthCare plans.

Don't you know there are two America's/

White America

and everyone else.

I agree that health care should be delivered without bias to every sector of a population. We will have solved the issue when we no longer consider the complexion of the individual with regard to dispersement of funds, but respect the physiology of race as well as gender that requires individualized approaches to therapy.

Melissa

Very interesting observational piece  DR MELISSA WALTON-SHIRLEY. Here is my priceless opinion....Let all lawmakers and their assistants in charged of managing and appropriating tax money(chasing health care cost instead of advocating transparency of fair profit margin on all items involved in treating old people...drug companies, device mnuf. hospitals, health insurance providers, includes mds as well....are all health care providers) Md pcp and specialitst are singled out for SGR. WHY? LAW MAKERS CONCERN AND THEIR ASSISTANTS SHOULD GO TO MED SCHOOL AND PRACTICE IN THE RURAL AREAS WITH WHERE OLD POLKS AS PATIENTS THEN TAKE THESE JOBS TO MANAGE HEALTH CARE. Thank you...My opinion.