Been away for a while, I got very sick. Bronchitis, sinusitis, otitis, and finally, bilateral conjunctivitis to wrap it all up. I was a mess, seeing multiple doctors, taking time off from work and everything else, numerous antibiotics and prednisone. Not fun, felt so powerless. If anything, it strengthened my compassion for the sick, and made me take stock of the horror of my work treadmill. SO I stopped accepting new patients, cut my schedule down drastically. Took some time off.
I'm much better for it.
Thanks to my husband for giving me a butt kick and forcing me to stay still and to rest, being supportive all the way. We recently celebrated our 10th anniversary and went away somewhere quiet and beautiful.
It's Memorial Day. While I appreciate the day off and the "start of summer" moniker, I always think of the vets I treated, their stories, their humility and sense of humor, when I worked at various VA hospitals. They are true American heroes, I respect them with all of my heart.
It saddens me so much when I hear of deaths of our service men and women in the combat theaters around the world. What a giant waste. I don't need perpetual reminding of the waste of war. We need to use more diplomacy, and we need to leave the heathens to themselves more often than not. We give them money and weapons and then they turn it on us, 9/11. We're not going to "fix" Iraq/Afghanistan/Iran/Syria whatever...I am so tired of the constant warring. Just think for a minute of our people in their prime who have been destroyed by war.
Clear Stream
Monday, May 28, 2012
Tuesday, February 28, 2012
wow all insurance kinda sucks
I love it when I'm held to the highest, most stringent standard possible, but everybody else can do whatever, whenever, why-ever. And nothing happens to them. There are no consequences for the rest of the world for a big general f*** up, but for the doctors, NOOOOOOOOOOO. Hellfire and brimstone will come your way, doc! Make sure the HIPAA 5010 data box doesn't include a PO BOX in your address or you won't get paid. I'm not making this up. (see letter below from MGMA to Kathleen Sebelius regarding the 5010 f*** up).
Department of Health and Human Services
Room 445-G, Hubert H. Humphrey Building
200 Independence Avenue, S.W.
Washington, DC 20201
Dear Secretary Sebelius:
The Medical Group Management Association (MGMA) requests that you take immediate
action to address the payment disruption issues that have occurred as a result of the federally
mandated transition to HIPAA Version 5010 electronic transactions on Jan. 1. Medical
practices throughout the nation are experiencing significant challenges implementing these
new transactions, a situation that has led to considerable cash flow problems for physicians
and their practices. Problems are being reported with both Medicare Administrative
Contractors (MACs) and commercial plans.
Should the government not take the necessary steps, many practices face significantly
delayed revenue, operational difficulties, a reduced ability to treat patients, staff layoffs, or
even the prospect of closing their practice. As the transition to Version 5010 is a mandatory
step toward ICD-10 implementation, this raises even more concerns, understanding the
magnitude of ICD-10 is exponentially greater than Version 5010.
MGMA-ACMPE is the premier association for professional administrators and leaders of
medical group practices. Since 1926, the Association has delivered networking, professional
education and resources, political advocacy and certification for medical practice
professionals. The Association represents 22,500 members who lead 13,200 organizations
nationwide in which some 280,000 physicians provide more than 40 percent of the healthcare
services delivered in the United States.
Version 5010 Issues and Concerns
Physician practices have reported numerous problems across various areas of the United
States stemming from the transition to Version 5010. The most frequently reported problems
have involved:
Issues with practice management and/or billing systems that showed no problems
during the testing phase with their MAC, but once the practice moved into production
phase, found their claims being rejected
Issues with secondary payers
Rejections due to various address issues (pay-to address being stripped/lost from
claims; pay to address can no longer be the same as billing address; no PO Box
address)
Crosswalk NPI numbers not being recognize
Apart from the atrocious grammar and numerous typos, my spirit is simpatico to this letter and I agree the whole thing needs serious pushing back.
My business insurance policy wanted to have some outsourced guy come to the office to photograph the contents, and probably make sure I'm not some fraudulent business. Ok, fine. But this individual failed to show up at the appointed hour, and when called to check on why HE no-showed, some vague ministrations about a long day and so forth were made. We called again and left a message, nobody to actually speak to. This was 2 weeks ago. Today I get a letter from the insurance company that since I "refused" the mandatory inspection my policy would be cancelled. Holy hell!
My agent was sweating bullets and I let him have it. He will have to actually work for a living and attempt to correct this huge mistake. If this is how they do business, the policy will be cancelled. There is competition, still, God bless 'em.
I think there are so many things that have gone awry in the insurance industry that it's beyond repair. The norm is fraud. Therefore, they're on high alert and double check every tiny detail, even my tiny little office in a medical building.
Who knows where this poor outsourced shmo is. He probably quit and there's nobody else who will do this grunt work for minimum wage. Whatever.
Department of Health and Human Services
Room 445-G, Hubert H. Humphrey Building
200 Independence Avenue, S.W.
Washington, DC 20201
Dear Secretary Sebelius:
The Medical Group Management Association (MGMA) requests that you take immediate
action to address the payment disruption issues that have occurred as a result of the federally
mandated transition to HIPAA Version 5010 electronic transactions on Jan. 1. Medical
practices throughout the nation are experiencing significant challenges implementing these
new transactions, a situation that has led to considerable cash flow problems for physicians
and their practices. Problems are being reported with both Medicare Administrative
Contractors (MACs) and commercial plans.
Should the government not take the necessary steps, many practices face significantly
delayed revenue, operational difficulties, a reduced ability to treat patients, staff layoffs, or
even the prospect of closing their practice. As the transition to Version 5010 is a mandatory
step toward ICD-10 implementation, this raises even more concerns, understanding the
magnitude of ICD-10 is exponentially greater than Version 5010.
MGMA-ACMPE is the premier association for professional administrators and leaders of
medical group practices. Since 1926, the Association has delivered networking, professional
education and resources, political advocacy and certification for medical practice
professionals. The Association represents 22,500 members who lead 13,200 organizations
nationwide in which some 280,000 physicians provide more than 40 percent of the healthcare
services delivered in the United States.
Version 5010 Issues and Concerns
Physician practices have reported numerous problems across various areas of the United
States stemming from the transition to Version 5010. The most frequently reported problems
have involved:
Issues with practice management and/or billing systems that showed no problems
during the testing phase with their MAC, but once the practice moved into production
phase, found their claims being rejected
Issues with secondary payers
Rejections due to various address issues (pay-to address being stripped/lost from
claims; pay to address can no longer be the same as billing address; no PO Box
address)
Crosswalk NPI numbers not being recognize
Apart from the atrocious grammar and numerous typos, my spirit is simpatico to this letter and I agree the whole thing needs serious pushing back.
My business insurance policy wanted to have some outsourced guy come to the office to photograph the contents, and probably make sure I'm not some fraudulent business. Ok, fine. But this individual failed to show up at the appointed hour, and when called to check on why HE no-showed, some vague ministrations about a long day and so forth were made. We called again and left a message, nobody to actually speak to. This was 2 weeks ago. Today I get a letter from the insurance company that since I "refused" the mandatory inspection my policy would be cancelled. Holy hell!
My agent was sweating bullets and I let him have it. He will have to actually work for a living and attempt to correct this huge mistake. If this is how they do business, the policy will be cancelled. There is competition, still, God bless 'em.
I think there are so many things that have gone awry in the insurance industry that it's beyond repair. The norm is fraud. Therefore, they're on high alert and double check every tiny detail, even my tiny little office in a medical building.
Who knows where this poor outsourced shmo is. He probably quit and there's nobody else who will do this grunt work for minimum wage. Whatever.
Wednesday, February 15, 2012
Lead in lipstick
"Lead in lipstick!!" screams the headline, and in come the panicked patients....
The public needs to know that the lead is not an added ingredient in the lipsticks. Lead is a natural element that gets measured by the fact that it is present in the dyes used in cosmetics. These dyes are elements, and the lead is a contaminant in these inert powders that are used to confer color. That is why generally speaking, the sheerer the lipstick, the lower the lead level.
Ever read the ingredient lists? "FD&C red #7", "iron oxide #4" "aluminum lakes #8" and the like, are derived specifically for the FDA and no cosmetic in the US can be sold without these specific dyes, which have been vetted by the FDA and they continue to be. These dyes often have aluminum too, and though I'm not a chemist, the way I understand it is that these metals impart color fastness and stability, so the red lipstick will remain a red lipstick.
Lead has a very long and ancient history as a cosmetic dye because it makes the pigment more stable. Queen Elizabeth I wore a lead based facial paint to cover up bad facial smallpox scars. Supposedly she also suffered from lead poisoning along with untold others.
Currently lead poisoning affects children the most because their growing systems can't handle exposure to this substance, and the old flaky paint used before 1975 ( I think) shed lead particles nto the air. The lead dust can be inhaled and cause lead toxicity. But that's a whole other story.
In the past century there have been no cases of lead poisoning from a cosmetic in the US. In fact, pigment is what gives lipsticks their variable inherent SPF level. It has been shown that women have much lower rates of cancer of the lip vs. men because women tend to cover their lips with lipstick, and though not formally rated, the zinc oxides and pigment bases provide some level of ultraviolet protection. Lead is well known as a UV and radiation blocker, which is why you get a lead apron draped over you when you get Xrays at the dentist :-)
There are many flaws in the FDA's logic, namely that lipstick isn't a "food". They are lumping the lead risks from lipsticks together with the lead risk from other cosmetics, no other cosmetic gets ingested, only lipstick. Eileen, to answer your question, I believe the FDA has set the safe threshold for lead in a color additive at 20 parts per million, similarly Canada and the EU. All of these lipsticks tested on their list fall below 5 parts per million.
To conclude this long rant, knowledge is power. Nothing is perfectly safe in this world. Don't take anybody's word for it. You must educate yourself and form your own opinions about what you're willing to use and not use. It's your body.
However, if we wanted to be perfectly natural we'd wear zero makeup. But where's the fun in that?
The public needs to know that the lead is not an added ingredient in the lipsticks. Lead is a natural element that gets measured by the fact that it is present in the dyes used in cosmetics. These dyes are elements, and the lead is a contaminant in these inert powders that are used to confer color. That is why generally speaking, the sheerer the lipstick, the lower the lead level.
Ever read the ingredient lists? "FD&C red #7", "iron oxide #4" "aluminum lakes #8" and the like, are derived specifically for the FDA and no cosmetic in the US can be sold without these specific dyes, which have been vetted by the FDA and they continue to be. These dyes often have aluminum too, and though I'm not a chemist, the way I understand it is that these metals impart color fastness and stability, so the red lipstick will remain a red lipstick.
Lead has a very long and ancient history as a cosmetic dye because it makes the pigment more stable. Queen Elizabeth I wore a lead based facial paint to cover up bad facial smallpox scars. Supposedly she also suffered from lead poisoning along with untold others.
Currently lead poisoning affects children the most because their growing systems can't handle exposure to this substance, and the old flaky paint used before 1975 ( I think) shed lead particles nto the air. The lead dust can be inhaled and cause lead toxicity. But that's a whole other story.
In the past century there have been no cases of lead poisoning from a cosmetic in the US. In fact, pigment is what gives lipsticks their variable inherent SPF level. It has been shown that women have much lower rates of cancer of the lip vs. men because women tend to cover their lips with lipstick, and though not formally rated, the zinc oxides and pigment bases provide some level of ultraviolet protection. Lead is well known as a UV and radiation blocker, which is why you get a lead apron draped over you when you get Xrays at the dentist :-)
There are many flaws in the FDA's logic, namely that lipstick isn't a "food". They are lumping the lead risks from lipsticks together with the lead risk from other cosmetics, no other cosmetic gets ingested, only lipstick. Eileen, to answer your question, I believe the FDA has set the safe threshold for lead in a color additive at 20 parts per million, similarly Canada and the EU. All of these lipsticks tested on their list fall below 5 parts per million.
To conclude this long rant, knowledge is power. Nothing is perfectly safe in this world. Don't take anybody's word for it. You must educate yourself and form your own opinions about what you're willing to use and not use. It's your body.
However, if we wanted to be perfectly natural we'd wear zero makeup. But where's the fun in that?
Monday, February 13, 2012
Musings on happenings
A cold front came in yesterday and it's been in the 50's today, which is cold in FL. When the northeast gets a cold front it often pushes cold stuff all the way down.....Weird.
Every year I get bioterrorism training, the anthrax thing was diagnosed by dermatologists in New York City, people had sores on their hands and faces that weren't healing, they didn't go to the ER when they had just the cutaneous anthrax. The poor people who inhaled the spores and got sick right away obviously were in ER's first but nobody knew what they had until 3-5 days later when the cultures came back. So every derm conference is super pro active about the skin manifestations of every single bioterrorism agent, from nuclear skin burns to smallpox to anthrax to bubonic plague, which was used against Genoa in the 14th century as a bioterror weapon by flinging dead infected corpses over the city walls by the invaders du jour. I thought you'd like that tidbit.
There was a fantastic dermatologist speaker, the deputy surgeon general, Dr. Boris Lushniak. He had to go investigate the monkeypox epidemic in 2003 from people importing prairie dogs as pets. He showed up at this little rural clinic in Indiana in his full CDC protective headgear and full body white jumpsuit because they didn't know what they were dealing with, and he says,"you can imagine how big everybody's eyes got when I show up in my regalia and say 'now don't worry, you're fine, I'm from the government and I'm here to help' " and the whole audience roared in laughter just imagining this. Monkeypox turns out to be a fairly benign thing, not lethal, but when he was sent by the CDC they were thinking it was potential smallpox. The fear and panic such a thing would cause is unimaginable. I always pray that this never comes to pass again. The military gets vaccinated against smallpox as soon as they are deployed. Civilians still are not. We were vaccinated in the 70's and it turns out that it still confers some level of immunity but not the best. The gov't is stockpiling vaccines still, they aren't commercially available. The anthrax vaccine performs very poorly, you need so many booster shots to get immunity, most people would balk. He said only those high risk military get vaccinated, I presume the ones sent to Afghanistan, where it is endemic from sheep and goats. Needless to say I had so much food for thought, like I do after every derm meeting, it is a ton of info to process!
Tuesday, February 7, 2012
acne being shifted to cosmetic
Acne vulgaris is a terrible condition for teens--or anybody--to deal with. It's visible to all and afflicts many with shame, humiliation, low self esteem and confidence, etc. One of the mainstays of treatment has been benzoyl peroxide, which for decades has been proven safe and useful in controlling the pustules and papules. A big drawback is the irritation it causes, and one formulation in particular, Brevoxyl made by Stiefel Pharma, has been around since I was a resident. It had a micro-encapsulated delivery where the molecule would preferentially get into the pores and not sit on the surface of the skin leading to redness and irritation. I don't have a lab and can't attest to the biochemistry involved, but clinically speaking, it was wonderful and worked great.
A casualty of the current recession is Brevoxyl. Stiefel sold "the name" to another pharmaceutical company, apparently because it went off patent, so the product is still called Brevoxyl, but the teenagers I'm seeing have terrible flare-ups and complain that they're getting irritation and redness that they weren't before. One bright kid brought in the current Brevoxyl "kit" and pointed out that the stripes on the box are different colors and the wash runs out of the bottle like water instead of like a creamy lotion as it did before. SO-- the patients know that something is up.
I did a little sleuthing and Brevoxyl as we knew it in the past is no more. It's basically now a generic. Savvy money-hungry pharmacists are refusing to fill renewals and prescriptions and simply directing the patients to Aisle 4 where the Clearasil is located. Uh, hello, are you the doctor? Do you know what this person has and how to treat it? Do you know if the person is intolerant of Clearasil? It's absolutely appalling. Patients have been abandoned by their medication, it is simply no longer available. "Too bad, you figure it out" is the attitude.Mothers are calling me in tears.
I have heard of this happening in other fields--certain chemotherapies where the manufacturers simply ceased operations, some FDA half-hearted investigations happened, with no conclusions. I cannot imagine the hell those patients and their oncologists have been put through.
Turns out Panoxyl is the new benzoyl peroxide OTC made by Stiefel but no "wholesaler" will get it for the patients because of order minimums and that's right, it's now OTC. Patients can order it from amazon.com or drugstore.com. if they so choose.
But for the most part, now it's back to the drawing board for many patients. The nice balance they achieved and the good control has been upset. They're red, irritated, and pimply. They need to be come in, be examined by me and we need to start at square one and get them on different therapy to manage their acne.
A casualty of the current recession is Brevoxyl. Stiefel sold "the name" to another pharmaceutical company, apparently because it went off patent, so the product is still called Brevoxyl, but the teenagers I'm seeing have terrible flare-ups and complain that they're getting irritation and redness that they weren't before. One bright kid brought in the current Brevoxyl "kit" and pointed out that the stripes on the box are different colors and the wash runs out of the bottle like water instead of like a creamy lotion as it did before. SO-- the patients know that something is up.
I did a little sleuthing and Brevoxyl as we knew it in the past is no more. It's basically now a generic. Savvy money-hungry pharmacists are refusing to fill renewals and prescriptions and simply directing the patients to Aisle 4 where the Clearasil is located. Uh, hello, are you the doctor? Do you know what this person has and how to treat it? Do you know if the person is intolerant of Clearasil? It's absolutely appalling. Patients have been abandoned by their medication, it is simply no longer available. "Too bad, you figure it out" is the attitude.Mothers are calling me in tears.
I have heard of this happening in other fields--certain chemotherapies where the manufacturers simply ceased operations, some FDA half-hearted investigations happened, with no conclusions. I cannot imagine the hell those patients and their oncologists have been put through.
Turns out Panoxyl is the new benzoyl peroxide OTC made by Stiefel but no "wholesaler" will get it for the patients because of order minimums and that's right, it's now OTC. Patients can order it from amazon.com or drugstore.com. if they so choose.
But for the most part, now it's back to the drawing board for many patients. The nice balance they achieved and the good control has been upset. They're red, irritated, and pimply. They need to be come in, be examined by me and we need to start at square one and get them on different therapy to manage their acne.
Wednesday, January 25, 2012
dry winter skin
Despite the fact that my profession has me spouting off the wonders of regular emolliation of the skin, I often neglect my own needs until it's crunch time. My skin was alligator-like on my legs, rough and peeling on my fingertips from repeated hand washing with industrial strength antibacterials. I followed my own advice and have been using Cetaphil cleanser in the shower, Cetaphil cream frequently on my hands and Cetaphil cream after my shower. Amazing changes, the dry flaking itchy skin is a heck of a lot better. The stuff is wonderful and I'm glad it hasn't changed in decades. Please keep it this way, Galderma Inc.!!!!
I'm not an insurance agent
The new year, new horizons, new challenges...and a new year for pateints' copayments, deductibles, and calendar year activity. This is an especially painful time. Patients don't know what their plans cover. They don't know what they're paying for. I blame the agents and the plans themselves, for perhaps providing information, but not providing understanding. Patients also have the ostrich-head-in-the-sand attitude, they don't want to know anything until they get a bill, then they start screaming. Literally. I am the face and the bricks-and-mortar location where they can walk in and scream. One lady looked like she was going to burst a blood vessel in my waiting room she was THAT agitated. Um, your plan didn't pay anything because you have to spend $5000 first before it kicks in. There are 800-numbers on the backs of their cards but the patients do not call and verify anything. Their agents sit back and demand payment for the policy and they can't (won't) answer any questions about the products they sell. They refer them to the 800 numbers on the back of the insurance card!
I am SO BEYOND FED UP. I am not an insurance agent, adjuster, nor processor. I do not magically know what your policy will and won't cover. I resent SO MUCH being in the middle of this tug of war and being attacked for doing my job. We have now started charging a nominal fee for doing "prior authorizations".
What is a prior authorization? Well, firstly it is a complete misnomer. It sounds like it would be something you do prior to seeing the patient to authorize some service. Nope. It is an ex post facto thing that I, the "prescriber" must do when the pharmacy calls me and states that Mr. Smith's drug is not being paid for by his insurance plan. I then need to speak to someone at Mr. Smiths' pharmacy benefit office, someone normally with a minimum of a high school education, who then screens my call and a staff pharmacist will then call me back. A day or two later, the pharmacist FROM THE INSURANCE COMPANY will interview me as to why Mr. Smith needs this drug. My doctors' degree, NPI, DEA, state license, etc are not sufficient to ensure that I know what I'm doing. This all a delay tactic to NOT pay for Mr. Smith's drug. I then have to fax the records and letters to get the insurance company to pay for the drug. After all this, they usually deny it and the patient must foot the bill. Meanwhile I have spent hours with this back-and-forth and my staff has spent untold time on this issue for which we are not being paid.
A bank charges $40 for a bounced check. Medical offices need to charge for employee and staff time, faxes and the toner, paper, etc. in dealing with essentially a negotiation to try to get a drug paid for a patient. This has gone beyond the pale. I am being continually harassed by all the above involved parties--patients, pharmacies (why do they care where the money comes from, whether it's the insurance plan or the patient? aaah vested interests mesh tightly....), and insurance plans to do this thing where, as far as I am concerned, my responsibility has been vacated. I interviewed, examined, and diagnosed the patient. I discussed treatment options and recommended a plan for the patient's disease. This continual snowball of responsibility has not been curtailed by the physicians' representatives/lobbies, the AMA has done the most piss-poor job on the planet of voicing the concerns and issues of the physicians. All they care about is selling the new ICD-10 coding book.
I am SO BEYOND FED UP. I am not an insurance agent, adjuster, nor processor. I do not magically know what your policy will and won't cover. I resent SO MUCH being in the middle of this tug of war and being attacked for doing my job. We have now started charging a nominal fee for doing "prior authorizations".
What is a prior authorization? Well, firstly it is a complete misnomer. It sounds like it would be something you do prior to seeing the patient to authorize some service. Nope. It is an ex post facto thing that I, the "prescriber" must do when the pharmacy calls me and states that Mr. Smith's drug is not being paid for by his insurance plan. I then need to speak to someone at Mr. Smiths' pharmacy benefit office, someone normally with a minimum of a high school education, who then screens my call and a staff pharmacist will then call me back. A day or two later, the pharmacist FROM THE INSURANCE COMPANY will interview me as to why Mr. Smith needs this drug. My doctors' degree, NPI, DEA, state license, etc are not sufficient to ensure that I know what I'm doing. This all a delay tactic to NOT pay for Mr. Smith's drug. I then have to fax the records and letters to get the insurance company to pay for the drug. After all this, they usually deny it and the patient must foot the bill. Meanwhile I have spent hours with this back-and-forth and my staff has spent untold time on this issue for which we are not being paid.
A bank charges $40 for a bounced check. Medical offices need to charge for employee and staff time, faxes and the toner, paper, etc. in dealing with essentially a negotiation to try to get a drug paid for a patient. This has gone beyond the pale. I am being continually harassed by all the above involved parties--patients, pharmacies (why do they care where the money comes from, whether it's the insurance plan or the patient? aaah vested interests mesh tightly....), and insurance plans to do this thing where, as far as I am concerned, my responsibility has been vacated. I interviewed, examined, and diagnosed the patient. I discussed treatment options and recommended a plan for the patient's disease. This continual snowball of responsibility has not been curtailed by the physicians' representatives/lobbies, the AMA has done the most piss-poor job on the planet of voicing the concerns and issues of the physicians. All they care about is selling the new ICD-10 coding book.
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