Transcript Self-Improving Patient Care with Ancillaries

Don Self
That’s
another
lie!
“The only benefit to
physicians regarding
PQRI is the 1% bonus
and you may or may
not get that!”
The Above is NOT true and if repeated often enough, some people will believe it
BE CAREFUL OF WHAT YOU BELIEVE!
“WE MAKE LESS
MONEY ON MEDICARE
THAN OTHER
PATIENTS”
“WHAT ARE THEY
COMPARING?."
THEY MEAN
WELL!
BE CAREFUL OF WHAT YOU BELIEVE!
“I DID NOT HAVE SEX WITH
THAT WOMAN, MS LEWINSKI”
THE DNA PROVED
HE DID LIE!
BE CAREFUL OF WHAT YOU BELIEVE!
“DURING MY TERM IN THE
U.S. CONGRESS, I TOOK THE
INITIATIVE IN INVENTING THE
INTERNET”
1977 – 1985 – HE
SERVED IN CONGRESS
INTERNET CREATED IN
1969 & NAMED IN 1972
BE CAREFUL OF WHAT YOU BELIEVE!
“I’M NOT A CROOK”
"If the president does it,
that means it's not
illegal."
REALLY????
BE CAREFUL OF WHAT YOU BELIEVE!
“READ MY LIPS – NO NEW
TAXES” QUOTE FROM 1988
1990 CONGRESSIONAL
BUDGET – HE RAISED
TAXES
99213 = $66.09
LET’S DO THE MATH TO SEE IF THEY
ARE RIGHT….
MEDICARE
PATIENT WITH
CHRONIC
DISEASE
99213
HEALTHY PATIENT
WITH A COLD
99214
WAIT A MINUTE! I CAN’T SEE 30
MEDICARE PATIENTS IN A DAY AS THEY
TAKE TOO MUCH OF MY TIME!
MAKE MORE MONEY
FOLLOWING PQRI
WITH 20 MEDICARE
PATIENTS THAN
SEEING 30 NON
MEDICARE PATIENTS
WORK SMARTER – NOT HARDER!
HAS MEDICARE CHANGED?
WHAT DOES MEDICARE
& THE OTHER
CARRIERS WANT &
WHY?
LOOK AT THE NUMBERS
1.
2.
3.
4.
How Many of YOUR
Medicare patients have
Chronic Disease?
What does Medicare want
you to do for those
patients?
What is Medicare willing to
pay for you to perform
those things?
What is your usual
Encounter
Reimbursement?
LOOK AT THE NUMBERS
1.
2.
3.
4.
What are you NOW doing?
Are you concentrating on
the number of visits?
Are you trying to perform
more procedures that are
being reduced in payment?
Have you adopted the
Evidenced Based Medicine
& Evidenced Based Value
philosophy shown in
PQRI?
WHY EVIDENCED BASED?
AHRQ, PQRI, PCFH –
ALL GEARED TO
EVIDENCED BASED
FOR A REASON
WHY EVIDENCED BASED?
•
•
•
•
•
•
8.3% of all Americans have diabetes
26.9% of those 65 & older have diabetes
33% of diabetics over 50 have P.A.D
33% of hypertensives over 50 have P.A.D.
23% of Americans 65 & older have P.A.D.
P.A.D. accounts for up to 90% of
amputations
• P.A.D. is the leading cause of amputations
1996 BALANCED BUDGET
ACT
If federal agency wants
to spend more in one
area – they have to
make reductions in
other areas….
17003 ↓ 39.4%
20550 ↓ 14.6%
20610 ↓ 21.6%
69210 ↓ 23.6%
91065 ↑ 229%
93922 ↑ 110%
94010 ↑ 37.6%
95921/22 ↑ 38.9%
WHERE HAVE YOU BEEN CONCENTRATING
YOUR EFFORTS?
AVERAGE ENCOUNTER FOR A 55
YEAR OLD MALE WITHOUT
DIABETES, HYPERTENSION OR
HYPERLIPIDEMIA = $74.00 BCBS
AVERAGE ENCOUNTER WITH A
MEDICARE PATIENT WITH DIABETES &
HYPERTENSION = $242.00
ARE YOU
FOLLOWING THE
PQRI, AHRQ,
MEDICARE &
CMS
GUIDELINES?
DO YOU KNOW
WHAT OR
WHERE THEY
ARE?
www.donself.com
ARE YOU AWARE THEY
COME FROM YOUR
COLLEAGUES?
LET’S DISCUSS WHAT MEDICARE
WANTS YOU TO DO WITH THE
MEDICARE PATIENT WITH CHRONIC
DISEASE
NO – IT’S NOT A SECRET –
EVERYTHING IS ON CMS’
WEBSITE!
PHYSICIAN QUALITY REPORTING SYSTEM
HOW OFTEN DOES
YOUR PRACTICE
SEE DIABETIC
PATIENTS?
_8_ Diabetic Patients Seen Daily
A1c Quarterly – PQRI 1
(if controlled)
$8 or $4 or $1 Cost,
$14.00 Income
$6.00 Minimum Profit
__8___ x $6 x 5 x 52 weeks
= $12,480 a year NET
8 Diabetic Patients Seen Daily
LDL Quarterly – PQRI 2
(or up to 6 times a year)
$12 Cost,
$19.00 Income
$7.00 Minimum Profit
8 x $7 x _5_ x 52 weeks
= $ 14,560 a year NET
AUTONOMIC TESTING
ORTHOSTATIC BP – PQRI # 3
“ORTHOSTATIC BLOOD PRESSURE ON
EVERY DIABETIC PATIENT ROUTINELY”
412 ICD-9 CODES PAYABLE BY MEDICARE FOR
AUTONOMIC TESTING – WHICH INCLUDES
ORTHOSTATIC BP – TWICE A YEAR
$12 Cost,
$173.00 Income
$161 Profit
4 x $173 x _5_ x 52 weeks
= $ 167,440 a year NET
WHY DOES MEDICARE WANT AUTONOMIC TESTING?
Autonomic Nervous System Physiology
Autonomic
Nervous System Physiology
– The ANS maintains primary
neural control of the heart
– The ANS mediates
unconscious activity and
maintains homeostasis
– An inability to maintain
homeostasis may lead to
heart failure ,diabetes,
dehydration, hypoglycemia,
hyperglycemia, gout and
others
26
The ANS maintains primary neural
control of the heart
– The ANS mediates unconscious
activity and maintains
homeostasis
– An inability to maintain
homeostasis may lead to heart
failure ,diabetes, dehydration,
hypoglycemia, hyperglycemia,
gout and others
WHY ON
DIABETICS?
“Early Parasympathetic and Sympathetic
dysfunction (imbalance) signals the early
(asymptomatic) end-organ dysfunction.
Diabetic neuropathy is a debilitating
disorder that occurs in nearly 50% of
patients with diabetes… This nerve
disorder should be expected in all patients
who have had type 1 diabetes for more
than five years” ― 2005 - Evaluation and
Prevention of Diabetic Neuropathy - American Family
Physicians.
ADRENERGIC/CHOLINERGIC
ADRENERGIC =
SYMPATHETIC
CHOLINERGIC = PARASYMPATHETIC
You KNOW how these affect the ANS &
MEDICARE wants you to measure that effect
THE BALANCE OF MEDICATIONS
↓
↓
↓
• Medicine you
already know
• Now you can
objectively
measure your
patient’s
response
↓
↓
↓
WHAT YOU
ALREADY
KNOW
“Autonomic neuropathy causes changes in digestion, bowel and
bladder function, sexual response, and perspiration. It can
also affect the nerves that serve the heart and control blood
pressure, as well as nerves in the lungs and eyes. Autonomic
neuropathy can also cause hypoglycemia unawareness, a
condition in which people no longer experience the warning
symptoms of low blood glucose levels.”
SO – DIABETIC
AUTONOMIC
NEUROPATHY
SHOWS UP
WHERE?
• “Autonomic neuropathy
affects
• heart and blood vessels
• digestive system
• urinary tract
• sex organs
• sweat glands
• eyes
• lungs.”
NIH Publication No. 083185 February 2009
Protect Quality of Life (QoL) in
Your MEDICAREpatients!
Parasympathetic excess = low energy, depression, lack of interest in
anything, fatigue, and sleep disturbances
Sympathetic excess = palpitations, trouble sleeping, high HR,
hypertension, anxiety,
Both Require proper ANS Balance
ARE YOUR Medicare PATIENTS
SUFFERING MALAISE & DEPRESSION
BECAUSE THEIR ANS IS OUT OF BALANCE?
IF PARASYMPATHETIC EXCESS (PE) IS THE
PROBLEM – IT IS EASILY TREATABLE!
Autonomic Activity (normalized, bpm2)
Autonomic Changes with Age
ANS dysfunction is
asymptomatic
Autonomic neuropathy
presents up to 20 years
earlier with Chronic
Disease!
Early intervention can normalize ANS decline
DAN presents
CAN presents
Autonomic decline is a normal part of aging, but it can be accelerated by
chronic disease …A N D I T I S A S Y M P T O M A T I C ! ! !
HOW MANY PATIENTS
A DAY DO YOU SEE
WITH THESE
DIAGNOSIS?
USUAL COVERED
DIAGNOSIS FOR
AUTONOMIC TESTING
CARRIERS PAYS FOR THESE
DIAGNOSIS FOR A REASON!
36
HOW MANY PATIENTS
A DAY DO YOU SEE
WITH THESE
DIAGNOSIS?
USUAL COVERED
DIAGNOSIS FOR
AUTONOMIC TESTING
CARRIERS PAYS FOR THESE
DIAGNOSIS FOR A REASON!
37
HOW MANY PATIENTS
A DAY DO YOU SEE
WITH THESE
DIAGNOSIS?
USUAL COVERED
DIAGNOSIS FOR
AUTONOMIC TESTING
CARRIERS PAYS FOR THESE
DIAGNOSIS FOR A REASON!
38
HOW MANY PATIENTS
A DAY DO YOU SEE
WITH THESE
DIAGNOSIS?
USUAL COVERED
DIAGNOSIS FOR
AUTONOMIC TESTING
CARRIERS PAYS FOR THESE
DIAGNOSIS FOR A REASON!
39
HOW MANY PATIENTS
A DAY DO YOU SEE
WITH THESE
DIAGNOSIS?
USUAL COVERED
DIAGNOSIS FOR
AUTONOMIC TESTING
CARRIERS PAYS FOR THESE
DIAGNOSIS FOR A REASON!
40
HOW MANY PATIENTS
A DAY DO YOU SEE
WITH THESE
DIAGNOSIS?
USUAL COVERED
DIAGNOSIS FOR
AUTONOMIC TESTING
Disorder of autonomic
nervous system (ANS) function
CARRIERS PAYS FOR THESE
DIAGNOSIS FOR A REASON!
41
HOW MANY PATIENTS
A DAY DO YOU SEE
WITH THESE
DIAGNOSIS?
USUAL COVERED
DIAGNOSIS FOR
AUTONOMIC TESTING
CARRIERS PAYS FOR THESE
DIAGNOSIS FOR A REASON!
42
CONGESTIVE HEART FAILURE
32% OF CHF PATIENTS ARE
OVER BETA BLOCKED (Journal
of American College of Cardiology
02/2008)
• Patients are tired, weak and fatigued
• Depression
• Sleep Difficulties
• Lack of Sex Drive
Autonomic Testing can help
you know when and how
much to titrate to return
QUALITY OF LIFE
Syncope
“Orthostasis is a common cause of syncope”
eMedicine – WebMD Oct 22, 2010
“Orthostatic Hypotension is the number one
cause of syncope” American Family Physician –
Oct. 15, 2005
“Orthostatic hypotension has been observed
in all age groups, but it occurs more
frequently in the elderly” (AAFP) 12/15/2003
8 Diabetic Patients Seen Daily
FOOT & ANKLE – PQRI 126
“Peripheral Neuropathy – Neurological
Evaluation ”
184 ICD-9 CODES PAYABLE BY MEDICARE FOR
ABI TESTING – ONCE A YEAR
$5 Cost,
$104.00 Income
$99 Profit
2 x $99 x _5_ x 52 weeks
= $ 51,480 a year NET
Medicare has been Increasing
Payments for ABIs
Determine Patient Need
When you realize how many of your Medicare
patients have P.A.D. you may be surprised!
NATIONAL INSTITUTES OF HEALTH
• Smoking is the main risk factor for P.A.D.
• On average, smokers who develop P.A.D. have
symptoms 10 years earlier than nonsmokers
who develop P.A.D.
• If you have P.A.D., your risk for coronary artery disease, heart
attack, stroke, and transient ischemic attack (“mini-stroke”) is
six to seven times greater than the risk for people who
don’t have P.A.D.
If you have heart disease, you have
a 1 in 3 chance of having blocked leg arteries.
•
http://www.nhlbi.nih.gov/health/dci/Diseases/pad/pad_what.html
NATIONAL INSTITUTES OF HEALTH
P.A.D.
“ 23% of Americans age 65 and older (4.5 to
7.6 million) have PAD. As the population
ages, the prevalence could reach 28% in
those age 70 and older” American Heart
Association. Heart Disease and Stroke Statistics—2004. 2004;
Dallas.
DO YOU KNOW WHICH OF YOUR
MEDICARE PATIENTS HAVE P.A.D.?
P.A.D.
MEDICARE PATIENTS ARE THE
LARGEST AGE GROUP
PREVALENCE
• “20% of Caucasian Americans, 50 &
Older have Peripheral Arterial Disease”
• “25% of Black Americans, 50 & Older
have Peripheral Arterial Disease”
• “25% of Latino Americans, 50 & Older
have Peripheral Arterial Disease”
Prevalence of and risk factors for peripheral arterial disease in the United
States. Results from the National Health and Nutrition Examination Survey,
1999–2000. Circulation. 110: 2004; 738-743.
Quotes from: PQRI Measure #126: Diabetes Mellitus:
Diabetic Foot and Ankle Care,
• “Evaluation of neurological status in patients with
diabetes to assign risk category and therefore have
appropriate foot and ankle care to prevent ulcerations
and infections ultimately reduces the number and
severity of amputations that occur.”
• “Treatment of infected foot wounds accounts for up to
one-quarter of all inpatient hospital admissions for
people with diabetes in the United States.”
• “Approximately 45-60% of all diabetic ulcerations are
purely neuropathic”
• “Over the age of 40 years old, 30% of people with
diabetes have loss of sensation in their feet.”
TYPICAL ROI FOR ABI TESTING
$5 Cost,
$104.00 Income
$99 Profit
2 x $99 x _5_ x 52 weeks
= $ 51,480 a year NET
G0438 = $155.19
ANNUAL
WELLNESS
VISIT
G0439 = $103.88
1. Establish or update the individual’s medical & family
history.
2. List the individual’s current medical providers and
suppliers and all prescribed medications.
3. Record measurements of height, weight, body mass
index, blood pressure & other routine measurements.
4. Detect any cognitive impairment.
5. Establish or update a screening schedule for the next
5 to 10 years including screenings appropriate for the
general population, and any additional screenings
that may be appropriate because of the individual
patient’s risk factors.
6. Furnish personalized health advice & appropriate
referrals to health education or preventive services.
CHECK OUT ONE OF THE
COGNITIVE AND DEPRESSION
SCREENING TESTS THAT
RESULTS IN YOUR OFFICE
INCREASING THE INCOME BY
ANOTHER $134.00! CHECK OUT
CPT CODE 96103 & 96120
$134 is a lot for a Nurse Visit
• THE AWV IS NOT A PHYSICAL
• THE AWV CAN BE
PERFORMED BY YOUR
LICENSED NURSES, PER
MEDICARE
NO DEDUCTIBLE – NO COPAY
A simple & easy test for seniors
CPT CODES 96103 & 96120
PLEASE TOUCH THE STACK OF
PANCAKES ON THE SCREEN
CPT CODES 96103 & 96120
PLEASE TOUCH THE DONKEY
ON THE SCREEN
CPT CODES 96103 & 96120
PLEASE TOUCH THE AIRPLANE
ON THE SCREEN
CPT CODES 96103 & 96120
PLEASE TOUCH THE ONE YOU
MAY HAVE FOR BREAKFAST
CPT CODES 96103 & 96120
DO YOUR MEDICARE
PATIENTS HAVE:
•
•
•
•
•
•
•
IBS 564.1
Abdominal Bloating 787.3
GERD 530.81
Lactose Intolerance 271.3
Diarrhea Due to Dietetic 787.91
Abdominal Pain 789.0#
Flatulence, Abd. Distention 787.3
WHO
DOESN’T?
• 38% of patients who met Rome 2 criteria for IBS had
fructose malabsorption – easily treated if diagnosed
(JAG 11/2008) 46% of IBS cases result from small
intestinal bacterial overgrowth (JAG 11/2008)
GLucose hydrogen breath tests (GHBTs) were
given to 450 consecutive patients 200 with
gastroesophageal reflux disease (GERD) who were
taking PPIs (median 36 months) 200 with the
irritable bowel syndrome (IBS) who had not taken
PPIs for at least 3 years, and 50 healthy controls.
• The GHBT was used as an indirect, surrogate test for
SIBO, and all patients completed a gastrointestinal
symptom score evaluation. The IBS patients were also
classified as diarrhea (40%), constipation (40%), or
mixed (20%) subtypes Overall, SIBO was suggested by
a positive result on GHBT in 50% of patients receiving
PPIs, 24.5% of patients with IBS, and 6% of controls
• . Rifaximin 400 mg 3 times daily for 14 days
was given as an open-label treatment.
Eradication was achieved in 87% of the PPI
group and in 91% of the IBS group (P = NS).
There was no apparent difference in the
success of eradication and length of use of
PPIs. Following eradication, absence
was reported for bloating (90%),
diarrhea (94%), and abdominal pain
(92%)
2012 = $96
Breath Hydrogen Testing
THIS DEVICE IS LESS THAN $4,000!
1 Patient = 1-3 Tests
$5 Cost,
$96 Income
$91 Profit
2 x $91 x 5 x 52 weeks
=$
47,620 a year NET
YOU CAN MAKE MONEY
BY GIVING GOOD MEDICAL CARE
I want to take the opportunity to publicly give thanks to Don
for all of his wonderful advice. Reluctantly i began arranging
Annual wellness visits for our Medicare patients and much
to my surprise it has been a good experience for the
following reasons: I did not appreciate how many Medicare
clients I have & the response from the patients has been
very positive. We are being reimbursed $167.00, we have
improved the history documentation for the clients and we
are capturing opportunities to call patients in for first time
additional diagnostic studies including ekg, Ansar,
vestibular and pulmonary functioning. Once again Don has
demonstrated in a clear and concise way how to improve
patient care all the while improving the financial health for
medical practices. Thank you very much Don.
MICHAEL BENAVIDES, D.O. – DALLAS - JUNE 2, 2012
Having known you for many years and thinking I
never "needed" your services I attended a lecture
you gave and what heard made me feel like I was
falling behind in my approach to managing my
office.
After a visit to my office and
implementation of a few suggestions, within 6
months I had realized over a 30% increase in office
revenue which has allowed me to add new
employees and more diagnostic equipment which
will continue to increase my office bottom line.
Jeffrey Lindenbaum, D.O.
A little more than 6 years ago, (2006) we met in
your seminar and since then, we have been
following your advice. You have always willingly
answered our questions and helped us with billing
and ancillary services. We have told others how
much you have helped us and in the almost 6 years
since we have been using your recommendations,
we have increased our annual income by more than
$200,000 a year.
J Michael Holder, D.O.
Here is a little feedback on your breath hydrogen unit that has
been a great piece of equipment, from the financial aspect it is
relatively inexpensive, not expensive to run and VERY good
reimbursement. Bloating and heartburn patients are plentiful in
my practice and it is amazing to see patients who have had CT
scans, ultrasounds, EGD's along with the GI consultation and
still they are miserable and told to “live with it”. A simple test
with the breath hydrogen and you identify the underlying
problem, usually meaning a short course of antibiotics or more
likely avoidance of certain foods. Patients come back crying with
joy and relief that they finally have their problem solved. I have
had multiple scenarios played out in my office and when it comes
to the bloating/burping indigestion patient, I have not found a
patient yet that we could not solve their problem. If anyone treats
these Patients I strongly recommend Don’s unit as it is very costeffective and you will have patients that think you are a genius
for solving their problem.
Orrin McLeod D.O.
I WAS LIED TO!
PQRI & MEDICARE REALLY ARE
PROFITABLE
THEY ARE
MORE
PROFITABLE
• IF I WORK SMARTER
• IF I PROVIDE GOOD MEDICINE
DON SELF & ASSOCIATES, INC
WWW.DONSELF.COM
[email protected]
903 372-7529 – CELL