That s another lie! The only benefit to physicians regarding PQRI is the 1% bonus and you may or may not get that!

Transcription

1 Don Self

2 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

3 BE CAREFUL OF WHAT YOU BELIEVE! WE MAKE LESS MONEY ON MEDICARE THAN OTHER PATIENTS WHAT ARE THEY COMPARING?." THEY MEAN WELL!

4 BE CAREFUL OF WHAT YOU BELIEVE! I DID NOT HAVE SEX WITH THAT WOMAN, MS LEWINSKI THE DNA PROVED HE DID LIE!

5 BE CAREFUL OF WHAT YOU BELIEVE! DURING MY TERM IN THE U.S. CONGRESS, I TOOK THE INITIATIVE IN INVENTING THE INTERNET HE SERVED IN CONGRESS INTERNET CREATED IN 1969 & NAMED IN 1972

6 BE CAREFUL OF WHAT YOU BELIEVE! I M NOT A CROOK "If the president does it, that means it's not illegal." REALLY????

7 BE CAREFUL OF WHAT YOU BELIEVE! READ MY LIPS NO NEW TAXES QUOTE FROM CONGRESSIONAL BUDGET HE RAISED TAXES

8 99213 = $66.09 LET S DO THE MATH TO SEE IF THEY ARE RIGHT.

9 MEDICARE PATIENT WITH CHRONIC DISEASE HEALTHY PATIENT WITH A COLD 99214

10 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!

11 HAS MEDICARE CHANGED? WHAT DOES MEDICARE & THE OTHER CARRIERS WANT & WHY?

12 LOOK AT THE NUMBERS 1. How Many of YOUR Medicare patients have Chronic Disease? 2. What does Medicare want you to do for those patients? 3. What is Medicare willing to pay for you to perform those things? 4. What is your usual Encounter Reimbursement?

13 LOOK AT THE NUMBERS 1. What are you NOW doing? 2. Are you concentrating on the number of visits? 3. Are you trying to perform more procedures that are being reduced in payment? 4. Have you adopted the Evidenced Based Medicine & Evidenced Based Value philosophy shown in PQRI?

14 WHY EVIDENCED BASED? AHRQ, PQRI, PCFH ALL GEARED TO EVIDENCED BASED FOR A REASON

15 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

16 1996 BALANCED BUDGET ACT If federal agency wants to spend more in one area they have to make reductions in other areas.

17 % % % % % % % 95921/ % WHERE HAVE YOU BEEN CONCENTRATING YOUR EFFORTS?

18 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

19 ARE YOU FOLLOWING THE PQRI, AHRQ, MEDICARE & CMS GUIDELINES? DO YOU KNOW WHAT OR WHERE THEY ARE? ARE YOU AWARE THEY COME FROM YOUR COLLEAGUES?

20 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!

21 PHYSICIAN QUALITY REPORTING SYSTEM

22 HOW OFTEN DOES YOUR PRACTICE SEE DIABETIC PATIENTS?

23 _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

24 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

25 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, $ Income $161 Profit 4 x $173 x _5_ x 52 weeks = $ 167,440 a year NET

26 WHY DOES MEDICARE WANT AUTONOMIC TESTING? Autonomic Nervous System Physiology Autonomic Nervous 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

27 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

28 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 Evaluation and Prevention of Diabetic Neuropathy - American Family Physicians.

29 ADRENERGIC/CHOLINERGIC ADRENERGIC = SYMPATHETIC CHOLINERGIC = PARASYMPATHETIC You KNOW how these affect the ANS & MEDICARE wants you to measure that effect

30 THE BALANCE OF MEDICATIONS Medicine you already know Now you can objectively measure your patient s response

31 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.

32 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 February 2009

33 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

34 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!

35 Autonomic Activity (normalized, bpm 2 ) 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 AND IT IS ASYMPTOMATIC!!!

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! 36

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! 37

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! 38

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! 39

40 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

41 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

42 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

43 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

44 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

45

46 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, $ Income $99 Profit 2 x $99 x _5_ x 52 weeks = $ 51,480 a year NET

47 Medicare has been Increasing Payments for ABIs

48 Determine Patient Need When you realize how many of your Medicare patients have P.A.D. you may be surprised!

49 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.

50 NATIONAL INSTITUTES OF HEALTH

51 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 ; Dallas. DO YOU KNOW WHICH OF YOUR MEDICARE PATIENTS HAVE P.A.D.?

52 P.A.D. MEDICARE PATIENTS ARE THE LARGEST AGE GROUP

53 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, Circulation. 110: 2004;

54 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.

55 TYPICAL ROI FOR ABI TESTING $5 Cost, $ Income $99 Profit 2 x $99 x _5_ x 52 weeks = $ 51,480 a year NET

56 G0438 = $ ANNUAL WELLNESS VISIT G0439 = $103.88

57 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.

58 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 & 96120

59 $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

60 A simple & easy test for seniors CPT CODES & 96120

61 PLEASE TOUCH THE STACK OF PANCAKES ON THE SCREEN CPT CODES & 96120

62 PLEASE TOUCH THE DONKEY ON THE SCREEN CPT CODES & 96120

63 PLEASE TOUCH THE AIRPLANE ON THE SCREEN CPT CODES & 96120

64 PLEASE TOUCH THE ONE YOU MAY HAVE FOR BREAKFAST CPT CODES & 96120

65

66

67 DO YOUR MEDICARE PATIENTS HAVE: IBS Abdominal Bloating GERD Lactose Intolerance Diarrhea Due to Dietetic Abdominal Pain 789.0# Flatulence, Abd. Distention WHO DOESN T?

68 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

69 . 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%)

70 2012 = $96

71 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

72 YOU CAN MAKE MONEY BY GIVING GOOD MEDICAL CARE

73 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

74 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.

75 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.

76 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.

77 I WAS LIED TO! PQRI & MEDICARE REALLY ARE PROFITABLE

78 THEY ARE MORE PROFITABLE IF I WORK SMARTER IF I PROVIDE GOOD MEDICINE

79 DON SELF & ASSOCIATES, INC CELL