Archive for January, 2015

Checklist for the Kidneys — a disease without symptoms

checklistIf your doctor says your kidneys are not working 100% …  is that a problem?  ABSOLUTELY!  You need your kidneys in order to stay alive and when blood tests begin to show kidney problems it means you have lost a lot of kidney function already — at least 50%.  So, the wise doctor and the informed patient need to run a checklist to do the right things.  If you wait until you have symptoms of complete kidney failure, it’s too late.

The main blood test for kidney function is serum creatinine — abbreviated Cr.  The kidneys have a large reserve capacity; in fact, a person can donate a kidney and still have the creatinine (Cr) blood test be “within normal limits”.

Many things can go wrong with the kidneys that range from the fairly simple to the terribly complex.  For instance, kidneys can be damaged simply by the bad effects of high blood pressure or by esoteric autoimmune diseases (“friendly fire” where the body’s defense against germs is accidentally directed at healthy kidney tissue).

You need to know 4 things to estimate your kidney function:

  1. Serum Creatinine (Cr) as measured on a blood sample.
  2. Your age (in years)
  3. Your race (black or not-black)
  4. Your gender (male or female)

Then you calculate another number called eGFR (estimated glomelular filtration rate) based on the items 1 – 4.  Often, this is automatically calculated by the lab — if not get the answer from many online web sites like the National Kidney Foundation eGFR calculatorThe normal value is 100 but it’s not considered abnormal until it is below 90.

STAGE eGFR DESCRIPTION TREATMENT (also see tables below)
1 90+ Normal kidney function but urine findings or structural abnormalities or genetic traits point to kidney disease. Observation, control of blood pressure.
2 60-89 Mildly reduced kidney function, and other findings (as for stage 1) point to kidney disease Observation, control of blood pressure and risk factors.
3A or3B 45-59
30-44
Moderately reduced kidney function Observation, control of blood pressure and risk factors.
4 15-29 Severely reduced kidney function Planning for endstage renal failure.
5 below 15 or on dialysis Very severe, or endstage kidney failure (sometimes called established renal failure) Dialysis or transplant.

Now to the checklist mentioned above (Clin J Am Soc Nephrol 9:1526-1535,2014.):  All is well if you have no known kidney problems, the eGFR is above 90, the urinalysis (U/A) is normal, and you have no genetic predisposition to kidney disease (like a family history of polycystic kidney disease). Otherwise, you have stage 1-4 kidney disease so check off the items below to make sure important tests and treatments are obtained.
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Slow the progression.

checked_checkbox Keep blood pressure below 140/90
checked_checkbox Check HbA1c and keep below 7% for diabetics.
checked_checkbox Every year check urine microalbumin/Cr ratio.
checked_checkbox If ratio is above 30 start ACE or ARB drugs.
checked_checkbox Work to stop smoking.
checked_checkbox Avoid NSAIDS (aspirin like products) or other toxins.
checked_checkbox Keep LDL cholesterol below 100.
checked_checkbox Get pneumonia vaccination every 5 years.
checked_checkbox Get Influenza vaccination each year.

Find and treat complications.

checked_checkbox Check hemoglobin and Iron — keep in satisfactory range.
checked_checkbox Check calcium, phosphate and PTH — keep in satisfactory range.

Referral to nephrologist.

checked_checkbox eGFR is below 30.
checked_checkbox Protein remains in urine despite initial treatment.
checked_checkbox Persistent elevated potassium.
checked_checkbox Can’t keep blood pressure below 140/90.
checked_checkbox eGFR falls by 30% in 4 months without explanation.
checked_checkbox Cause of kidney problems is unclear.
checked_checkbox Anemia needs treatment with erythropoietin stimulating drugs.
checked_checkbox Elevated phosphate or PTH.

So, this seems complicated?  TRUE.  That is precisely why a checklist is needed.  And, that is why the informed patient needs to go over this checklist with the primary care provider.  Print a copy of this post and take it with you to an appointment to start the discussion.

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It’s Your Life at Stake in the Hospital — speak up

cc-speakup

Hospitalization is dangerous because of your illness and because poor communication increases the risks.  The simple fact is:  patients who speak up get better care than those who are quiet and unassuming.  As Gomer Pile’s sergeant would say:  I CAN’T HEAR YOU!

A recent article in Consumer Reports (CR) February 2015 “How Not to Get Sick(er) in the Hospital” puts a focus on communication in the hospital and is worth reading.

CR makes some good points:

  • You should be treated as a partner with the health care team.  As a partner you should expect explanations in language you can understand.  You should expect to know the plan, when and why tests are done and what results mean.  If x-rays or blood tests are done ask the doctor “what was the result”.
  • You should not be a silent partner.  If you are not getting information or do not understand what is going on you are risking your life.  Be courteous but speak up and ask questions and get ANSWERS not platitudes like “you just need some rest”.  Reasonable questions are things like:  “why do I need a CT scan”, “why am I in intensive care”, “why do I have a fever”, “what did you find during surgery”?
  • The doctors or physician assistants (PA) or nurse practitioners (NP) are in charge — the nurses are not.  If you have questions about medical or surgical issues insist on talking the doctor or PA or NP.  If you need an extra pillow or help getting to the bathroom talk to the nurse.  If you ask your nurse about the result of a test expect a vague answer “it’s just fine, get some rest.”  However, the nurses know what medications have been ordered and what is available “if needed or PRN”.  If you have a headache ask “what has the doctor ordered in case I have a headache”?  “nothing — well please call the doctor now since I have a headache”.
  • You need “your people with you”.  Family or friends should be present as much as possible and they should make contact with the health care providers both doctors and nurses — at very least each time they visit they should introduce themselves to the RN at the desk to see how things are going.
  • Who is available day and night?  It is a very reasonable request to know the name of the nurse in charge or the name of the doctor on call and to have them contacted if there is a problem.   If you are under the care of Hospitalists they are in the hospital 24/7 so it is very reasonable to request to talk to one of them at any time if needed — even on the phone, if that is adequate.  “They are busy” is sometimes true but not for hours at a time.  The nuclear option is to ask to speak to the “hospital administrator on call”  — a request that always gets their attention.
  • In any healthcare setting:  you are not out of line to point out that a doctor, nurse or therapist failed to wash hands or use hand sanitizer.  “Please wash your hands”. You do not want germs from other patients brought to you on caregiver hands.
  • Doctors will spend more time with you and answer more questions if they are comfortable — ask them to “have a seat”.  A room with no seats is unacceptable — that, you can tell your nurse.
  • Choose the right hospital in the first place.  Check the ratings of hospitals on the CMS website called “Hospital Compare”.  Driving a hour to a better hospital is absolutely worth your time and may save your life.  This is not like going to a fast food restaurant.  At this point in 2015 there is still a huge difference between hospitals — advertisements do not  mean a hospital is good.
  • Keep a written record — if you have a test write it down and leave a blank to fill in the result.  You really don’t need all the details — “you had a blood count and it was normal” is a fine answer.  If asked about your notes just say you have some difficulty keeping track of what is going on since you don’t feel the best — if you felt your best you would not be in the hospital!

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Chronic Care Management — a patient guide

pnonenurseDoctors have long complained they don’t get paid to solve problems over the phone.  Now primary care providers (not specialists) can charge $40 per month for something called “Chronic Care Management.” (CCM)

If you have several long term and serious conditions like diabetes, congestive heart failure and chronic obstructive pulmonary disease then Medicare will pay $32 per month and you or your supplemental insurance will pay the rest for this service.  Many supplemental insurance plans have deductibles and co-payments — so many, if not most patients will be paying an extra $8 per month.

Who actually does all the work?  The office nurse.  The doctor supervises the decision making.

You will have to sign a consent for CCM in order for the doctor to bill you each month, so it is important to know what to expect.  Some doctor’s offices will make the service helpful but in other offices you may never know where the money is going.

If you can’t tell you are getting CCM then simply stop the service — revoke the consent with a letter “Dear Doctor, effective at the end of this month please stop “Chronic Care Management”.  I will continue visits as usual.”

In general, CCM is a good thing.  Here are some of the problems it solves:  Without CCM many doctors just don’t take the time to coordinate services except as part of an office visit — if you go to the emergency room the primary care provider would not act on recommendations until you actually go for an office visit.  If your visiting nurse suggests some course of action then you go for an office visit.  If you want to see a specialist you first go for an office visit.  If you get discharged from the hospital and need physical therapy you go for an office visit before it will be ordered.  With CCM the doctor gets $40 per month to coordinate care without always going for a face-to-face visit.

The minimum requirement for the provider is to spend at least 20 minutes per month working on your case without seeing you in person.  Here is a list of things providers of CCM are required to do (at no extra charge) and thus things you should expect:

  1. Transitional care management:  meaning admission or discharge from some medical service or facility (like giving orders for physical therapy after hospital discharge or providing full medical records to a rehab facility)
  2. Supervision of home healthcare.  The provider gives orders for home care with lists of medications, duration of treatment and goals of treatment.
  3. Hospice care supervision.
  4. Provide a limited number of end-stage renal disease services.

The provider must have 5 capabilities and use those capabilities as needed:

  1. Keep your records in a computer
  2. Create a care-plan — an outline of goals and actions the provider will follow to meet those goals.  Like “keep blood sugars in control — by weekly phone contact”. The provider should give you a copy of the plan — it should be specific to you and not a standard form applicable to anyone.
  3. Provide phone access to talk to a someone associated with the office 24 hours per day (they should be able to look at your computer record).  Provide office visits as needed (presumably same day for urgent problems and within a week for non-urgent problems)
  4. Facilitate transitions in care.  Like provide prescriptions and orders for therapy after discharge from a hospital or providing medical information to specialists for each visit.  Or, keeping orders for home oxygen up to date.  Or, immediately sending outpatient medical records to the hospital where you are admitted.
  5. Coordinate care.  This does not mean providing all care, it is not a wall around you.  If you need to see a specialist the provider makes sure all your medical data is transmitted to that specialist and makes appointments for you.  And, follows the instructions of the specialist (as medically reasonable).  Engages therapy such as home visits by nurses, physical therapy, occupational therapy or social service.  And, makes efforts to meet the care needs outlined by those therapy services (as medically reasonable).

CCM does not eliminate office visits but it makes sure loose ends are dealt with and it obligates the provider charging CCM fees to provide access to someone that can look at your chart 24 hours per day.  It also means the ER can call the primary care provider office and get up-to-date medical information about you in an urgent situation.

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Disclaimer:  the rules and fees for this program are in a state of flux.  What is true today may not be accurate tomorrow.  So, discuss the meaning of CCM with your primary care provider.  Give them a copy of this article as a place to start a discussion.  Here are some additional helpful links:

CMS – Medicare.gov

PBS Newshour

 Pershing Yoakley & Associates

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Fee for Counseling Service — another CPT code

cptwowWow, you could have had a CPT code and $60.  While fee-for-service is widely excoriated for excessive cost what is CMS doing?  They want primary care providers or someone to have another fee-for-service.  The fee is for “counseling” about lung cancer CT screening and “counseling” about weight loss.  Both things that are currently part of an office visit with no additional CPT code — just good patient care.

Both topics could easily be covered on YouTube in several languages but NO — lets do this the old fashioned way and spend a zillion dollars for each provider to reinvent the discussion each time.   CMS:  don’t be so lazy — make the patient education video and tell primary care providers the URL!  And, update the video every 6 months.

The bottom line:

  • Lung Cancer CT Screening:
    • Don’t do it if the patient can’t have surgery
    • Don’t do it until the patient has 30 pk yrs accumulated (number of packs per day times number of years)
    • Don’t do it if the patient is less than 55 or over 80 years old.
    • Don’t do it if the patient quit smoking more than 15 years ago.
  • Weight-loss counseling:
    • Say in a loud voice “you weigh too much” then say “eat less”.  (that was not so hard!)
    • Doctors have been doing this for decades without sustained  results.
    • There are 20,000 books about diets to loose weight without sustained results.
    • This is not going to work — at least be honest.

Follow the money:  

Counseling fees for CT scans is an incentive to do the CT scans.   The primary care provider makes money, the x-ray office makes money and the radiologist makes money.  A better idea is to have the radiology office pay the primary care provider for the counseling out of CT revenue so this is a no-sum-gain.  Better yet — make it a provided service under an ACO plan!

Counseling fees for intensive weight-loss is an incentive for lots of repeat visits or a referral.  The Primary care provider makes money (and changes from a primary care provider to a specialty provider).  The incentive reduces the pool of available visits for primary care with little if any benefit to the vast majority of obese people.  A better idea is not to add another CPT code.  If the patient needs more time — make another appointment!

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States with Poor Health Care — the bottom 13

2014overallbystatePoor healthcare exists in the United States and there are 13 states to prove it (*).  The map at the left is from the Commonwealth Fund and it is an aggregate of many measures of healthcare quality.  Mississippi is the worst — perhaps the State should be listed as a 3rd world country!

So just to make the point a little sharper here is the list of States in the bottom quartile and the Governors.

State Governor Party
Alabama Robert Bentley R
Arkansas Asa Hutchinson ** R
Illinois Bruce Rauner** R
Indiana Mike Pence R
Kentucky Steve Beshear D
Louisianna Bobby Jindal R
Mississippi Phil Bryant R
Missouri Jay Nixon D
Ohio John Kasich R
Oklahoma Mary Fallin R
S. Carolina Nikki Haley R
Tennessee Bill Haslam R
W. Virginia Earl Tomblin D

So, how to look at the data?  Do the above States just have a lot of health problems or just ineffective State government.   Sadly, the answer is both.

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*D.C. Radley, D. McCarthy, J.A. Lippa, S.L. Hayes, and C. Schoen, Results from a Scorecard on State Health System Performance, 2014, The Commonwealth Fund, April 2014.

** New Governors just elected for 2015

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